FROM THEORY TO ACTION: FRAMEWORKS FOR IMPLEMENTING

COMMUNITY-WIDE ADOLESCENT PREGNANCY PREVENTION

STRATEGIES

Claire Brindis, Dr.P.H.

Deborah Sattley, Ph.D.
Laura Mamo, Ph.D.

Bixby Center for Reproductive Health Research & Policy,

Department of Obstetrics, Gynecology & Reproductive Sciences
and the
Institute for Health Policy Studies
University of California, San Francisco
SUGGESTION CITATION:

Brindis, C.D., Sattley, D., Mamo, L. (2005). From Theory to Action: Frameworks for
Implementing Community-Wide Adolescent Pregnancy Prevention Strategies. San Francisco,
CA: University of California, San Francisco, Bixby Center for Reproductive Health Research &
Policy, Department of Obstetrics, Gynecology & Reproductive Sciences, and the Institute for
Health Policy Studies. http://crhrp.ucsf.edu/
H

PUBLISHED BY:

Bixby Center for Reproductive Health Research & Policy,

Department of Obstetrics, Gynecology & Reproductive Sciences,
And the Institute for Health Policy Studies
University of California, San Francisco.
3333 California Street, Suite 265, Box 0936
San Francisco, California, 94143-0936
Website: http://crhrp.ucsf.edu/
H
FROM THEORY TO ACTION:
FRAMEWORKS FOR IMPLEMENTING COMMUNITY-WIDE
ADOLESCENT PREGNANCY PREVENTION STRATEGIES

Claire Brindis, Dr.P.H.

Deborah Sattley, Ph.D.
Laura Mamo, Ph.D.

Bixby Center for Reproductive Health Research & Policy,

Department of Obstetrics, Gynecology & Reproductive Sciences,
and the Institute for Health Policy Studies
University of California, San Francisco
FROM THEORY TO ACTION: FRAMEWORKS FOR IMPLEMENTING
COMMUNITY-WIDE ADOLESCENT PREGNANCY PREVENTION
STRATEGIES

TABLE OF CONTENTS

Acknowledgements

I. INTRODUCTION TO THEORETICAL MODELS

Why are theoretical frameworks important for my program?
What is the role of theoretical frameworks in my work?
A Brief Historical Context: Understanding Teenage Pregnancy and Prevention
Activities

II. BRINGING THEORY INTO ACTION: THEORETICAL FRAMEWORKS AND

PROGRAM MODELS
Theories and Models: Does One Size Fit All?
How Do Theoretical Frameworks Help Program Planners and Providers?

III. THEORY INTO PRACTICE

Selecting the Level of Program Intervention
Evolution of Teen Pregnancy Prevention Program Interventions
Description of Theories
1. Developmental Assets/Resiliency Theory
2. Transtheoretical Model
3. Health Belief Model
4. Theory of Reasoned Action/Theory of Planned Behavior
5. Social Learning Theory
6. Attribution Theory
7. Protective Motivation Theory
8. Self-Regulation Theory
9. Relapse Prevention Theory
10. PRECEDE Framework
11. Psychosocial Model
12. Social Ecology Theory
13. Theory of Gender and Power

IV. SYNTHESIZING THEORIES AND MODELS TO FIT YOUR COMMUNITY’S

TEEN PREGNANCY PREVENTION GOALS
Theoretical Models and Their Application to Health Promotion Practice
Theoretical Models within an Adolescent Development Framework
A Shift from Individual to Interpersonal and Social Structural Pregnancy
Prevention Approaches
Modifying Factors Associated with Adolescent Pregnancy
-Poverty
 -Adolescent Development
-Family Attitude and Behavior toward Sexual Activity
-Sexual Abuse and Violence
-Policy and Social Context

V. PUTTING IT ALL TOGETHER

Incorporating Theory-Based Factors into Adolescent Pregnancy Prevention
Programs

VI. SUMMARY

VII. REFERENCES

CASE STUDIES
1) Applying the Transtheoretical Model to the Adoption and Use of Condoms by a Male
Teenager
2) Applying Theory to Programs: The School/Community Model and Sexual Risk
Reduction

LIST OF TABLES

Table 1: Theoretical Models and their Primary Focus: Individual, Familial/Community

and Structural Level
Table 2: Summary of Theories: Focus and Key Concepts
Table 3: Personal and Environmental Domains Incorporated in Behavioral Theoretical
Frameworks
Table 4: Transtheoretical Model of Behavior Change and its Application to Condom Use
Table 5: The Theory of Gender and Power on Women’s Health and Pregnancy
Table 6: Modifying Factors to Consider Building Into the Development and Evaluation of
Adolescent Pregnancy Prevention Programs
Table 7: Theory-Based Factors to Consider Incorporating Into Program Planning by
Theoretical Models of Behavioral Change
Table 8: Theory Based Factors to Consider in the Development and Implementing of
Adolescent Pregnancy Prevention Interventions

LIST OF FIGURES

Figure 1: Comprehensive Adolescent Pregnancy Prevention Components and Strategies

Figure 2: The Stages of Change Linear Model
Figure 3: The Circular Model of the Transtheoretical Approach
Figure 4: Health Belief Model
Figure 5: Theory of Reasoned Action
Figure 6: Protective Motivation Theory
Figure 7: Self-Regulation Theory
Figure 8: Relapse Prevention Theory
Figure 9: The PRECEDE Framework
 Acknowledgements

The authors would especially like to thank the many dedicated people without whose
assistance this monograph would not have been possible. We are especially grateful to
Michael Dalmat, previous Director of the CDC's Teenage Pregnancy Prevention Initiative,
for his vision, insights, and helpful assistance throughout the development of this
monograph. We are also thankful for the valuable input and comments provided by Dr.
Doug Kirby, ETR Associates (Scotts Valley, California), Dr. Susan Philliber, Philliber and
Associates (Accord, New York), and Adrienne Paine-Andrews, Ph.D., The University of
Kansas (Lawrence, Kansas), for their careful review of earlier drafts of this paper. We are
indebted to the William and Flora Hewlett Foundation and The California Wellness
Foundation for supporting the development and publication of this monograph. We are
especially grateful to Steve Snyder and Annie Larson for their editorial assistance in
preparation of this volume.

We hope that this monograph is found to be useful to program developers, funders,

researchers, and others as they attempt to develop theoretically-driven prevention
programs aimed at improving the lives of young people throughout this country. We also
hope that this monograph will be useful for training practitioners and researchers in the
prevention of adolescent pregnancy prevention.
 FROM THEORY TO ACTION:
FRAMEWORKS FOR IMPLEMENTING COMMUNITY-WIDE
ADOLESCENT PREGNANCY PREVENTION STRATEGIES

I. Introduction to Theoretical Models

Over the past three decades, the American public has increasingly recognized the challenge of reducing
the United States’ high incidence of adolescent childbearing. During this period, researchers documented
key ingredients prevalent in the most effective pregnancy prevention strategies, as well as factors that
serve as antecedents to this challenging issue. Ingredients for program success include a strong anchoring
in a theoretical framework, depth and duration of program exposure, and well-trained, committed, and
enthusiastic staff.1 The purpose of this paper, From Theory to Action: Frameworks for Implementing
Community-Wide Adolescent Pregnancy Prevention Strategies, is to begin a collaborative process among
theorists and program planners and staff members. While it is our intention to assist program planners
and staff members in integrating theoretical models into their programs when and where they may exist, it
is also our goal to have program staff feel comfortable in constructing and adapting appropriate
theoretical frameworks for their adolescent pregnancy prevention efforts. That is, it is our belief that
theory and practice mutually inform one another.

For the past thirty years, theory and practice have mostly been viewed as separate undertakings within the
field of adolescent pregnancy prevention. This document serves as a guide for program planners and
other staff to integrate theory into practice. Doing so requires several steps:
1) Identifying the theoretical assumptions reflected in their programs,
2) Developing program interventions that fit these assumptions or testing these assumptions with
their current programs, and
3) Constructing new theoretical and programmatic understanding of what works and does not work
in teenage pregnancy prevention.

This document also aims to support program planners and direct service providers in assessing theoretical
frameworks that are relevant to the issue of adolescent pregnancy prevention and the types of
interventions that they provide in their communities.

7
Why are theoretical frameworks important for my program?

In reviewing the extensive literature produced by pregnancy prevention programs across the last three
decades, it is clear that theory has played an important role in the development of some of the most
effective approaches, including such well-known programs as “Reducing the Risk” and the “Teen
Outreach Program.”1 Nonetheless, these programs, like many others burdened by the everyday work of
delivering services, are often unable to fully document, and at times, articulate the theoretical concepts
upon which their interventions are based. As a result, program planners are not able to review what the
theoretical underpinnings of various pregnancy prevention programs are, which ones have demonstrated
to be most effective, and which most represent their own program priorities, mission statements, resource
capabilities, and/or theoretical positions. In contrast, other program staff may not be even aware of
theoretical frameworks and their use in helping to develop more effective programs that take into account
what psychologists, sociologists, and other researchers have been able to document as influencing human
behavior and relationships.

What is the role of theoretical frameworks in my work?

In conducting this review, we recognized that program planners and direct service providers have an
enormous range and number of theoretical frameworks to work with in their quest to develop and
implement programs that will proactively influence positive behaviors among young people within the
context of their own communities. This monograph brings together in one place a full range of
contemporary theoretical frameworks that serve as program models, thus enhancing their accessibility to
planners and providers. While all health promotion practitioners who are involved in some way with
programs that aim to change such complex behaviors as too-early childbearing incorporate theoretical
ideas into their practices, they do so to different degrees and with varying levels of understanding and
acknowledgement.

It is our objective to assist practitioners, where necessary, in identifying the theoretical assumptions they
use and developing a clear understanding of how these theories, and the program models that are built
from them, can be advantageous to their work. While it is our goal that this document will streamline
these choices and provide guidance on which theories are most appropriate for any given program, this is
one of many goals. We also hope to recognize program planners and direct service staff members as
theorists themselves. It is these individuals who are most able to evaluate the ways a given program and
its theoretical assumptions make sense. And further, to assess how to adapt the programs themselves and
the theoretical assumptions upon which they are based to better serve the larger communities and
programs working with the shared goal of ameliorating unintended teenage pregnancies.

8
A Brief Historical Context: Understanding Teenage Pregnancy and Prevention Activities

As researchers and programs planners have increased their understanding of the multiple “antecedents” to
teenage pregnancy2 greater focus has been devoted to creating programs that effectively respond to these
contributing factors. Antecedents include both “risk-factors” that increase one’s chances of becoming
pregnant and “protective factors”2 those that reduce one’s chances. While identifying antecedents does
not predict pregnancy outcomes, it does provide an understanding of the social lives, context, and
behaviors of adolescents and what they need in order to delay early childbearing. Antecedents, by
definition, are correlated with outcome behaviors2 such as initiation of sex, use of contraception, and
pregnancy. Some of the common antecedents relate directly to sexual activities (e.g., teenagers’
knowledge, attitudes, and beliefs about sex), and others do not (e.g., levels of poverty, academic success
or failure, and parents’ level of education).

In the search for pregnancy prevention programs that work for adolescents, a great variety of approaches
have been tried—many of which followed the first wave of programmatic efforts aimed at helping those
adolescents who were already pregnant or parents. In the 1960s and 1970s, professionals pursued family
life education strategies for primary prevention, reflecting their assumption that all adolescents were “at
risk” based on a lack of sufficient knowledge. Thus, the first generation of pregnancy prevention efforts
addressed antecedents by providing adolescents an expanded knowledge base. The knowledge base
included teaching adolescents about different methods of birth control and the need for protection against
STDs, and also sought to inculcate positive attitudes towards the use of birth control. Interventions based
on this approach were typically restricted to presenting information on adolescent physical development
and methods of birth control.

From the mid-1980s to the early 1990s, the narrow focus of these efforts proved to have only limited
results, and attention turned to developing skills-based curriculum programs that emphasized social
interactions over individual capacities.2 These programs emphasized improving the communication and
negotiation skills of adolescents. Such skills were intended to help teenagers remain abstinent, or, in the
case of those who were already sexually active, to help them negotiate the use of birth control with their
partners and to locate and access contraceptives. Some of these programs were abstinence-only programs,
others were more comprehensive programs that discussed both abstinence and contraceptive use. Absti-
nence-only proponents assume that exposing young people to contraceptive information would dilute or
nullify the abstinence message and may encourage sexual activity. The debate as to whether adolescents
should be exposed to both messages continues to be argued in local communities, states, and at the federal
level. Interestingly, several of the most successful curricula, such as Reducing the Risk and the Teen

9
Outreach Program, have demonstrated that adolescents are able to reconcile a dual message: one of
delaying sexual relations wherever possible and one of adopting the use of protection if they do engage in
sexual relations.2 Regardless of whether a program curriculum is abstinence-only or more comprehensive
in nature, research has clearly shown that, while knowledge is important, knowledge alone is usually
insufficient to create or sustain behavioral change. Programs that are skills-oriented and theory-driven
have been shown to be more likely to succeed.

Along with early educational efforts to tackle the issue of teen pregnancy in the 1970s and 1980s, a
parallel focus was adopted based on the premise that some adolescents were at higher risk than others for
early childbearing. Thus family planning programs were designed to specifically address the needs of
sexually active teens in an effort to reduce the incidence of adolescent pregnancy.2 Similarly, this
approach depended on both improving the knowledge base of teenagers and increasing access to birth
control services. While improved access to contraceptive care (particularly condoms and the birth control
pill) has had a significant impact on reducing the incidence of adolescent childbearing, a large number of
adolescents continue to remain at risk2 either because they do not use birth control at all, they select
ineffective methods, or they use contraceptive methods ineffectively and/or inconsistently.3 In this
respect, adolescents are not that different from adults in terms of planning for childbearing; nearly two-
thirds of adult women do not plan their pregnancies, compared to 85% of teenagers.4

In the early 1990s, a third generation of efforts consisted of attempting to bolster the motivation of
adolescents to delay childbearing by expanding and improving the life choices and future opportunities
open to them. Generally identified by the term “youth development,” these programs address non-sexual
antecedents and attempt to provide teens the skills and opportunities they need to secure greater life
options and play meaningful roles in their communities. These programs often consist of mentoring
programs to bolster adult-adolescent relationships, service learning or volunteer community service
programs, and vocational training to increase adolescent career options. The idea behind incorporating
such programs into or linking them with pregnancy prevention programs is to help teenagers begin to
develop a fuller sense of self and a greater exposure to wider horizons, in the hope that early childbearing
will become a less attractive option. Evaluations have clearly documented that the programs reduce
sexual activity and teen pregnancy.5

Used as a pregnancy prevention strategy, youth development has received growing attention, though
clearly it also takes longer to fully implement those types of interventions than more traditional ones in
the field of family planning, such as comprehensive family life education. Moreover, although many

10
communities have a variety of recreation programs, Girls’ and Boys’ Clubs, YMCAs and YWCAs, and
other youth-oriented organizations, more needs to be done to connect these programs in an effort to
deliberately construct adolescent pregnancy prevention strategies. Strategies need to include family life-
related information, skill building (e.g., negotiation, refusal, planning), and access to contraceptive
services. Girls, Inc.6 represents an important example. The program goal is to motivate girls to make
smart choices—either choosing to postpone sex or, if not, using effective protection against pregnancy
and disease. The program incorporates a developmental and sequential approach to adolescent pregnancy
prevention, with curricula first introduced in the elementary school, additional learning experiences in
middle school, and a high school-based program that also recognizes that some of the participants may
also need referrals to health services. Girls, Inc. complements these educational program components with
additional activities structured to expand the life opportunities of young women. For example, their
“OpSmart” program teaches science, math, and relevant technology to girls. What makes Girls Inc.
unique is its age-phased program that provides appropriate skills, personal tools, peer support and
complete information as girls become developmentally ready for additional skills. In early years, they
teach communication skills and move into self-reliance, and as older teenagers, they provide information.
The program is based on theories of developmental stages, research, and the realities of girls’ lives.
Furthermore, the program builds on research that has clearly demonstrated the protective quality of
adolescents who feel a sense of connectivity to adults in their lives.7

As the issue of adolescent pregnancy prevention continues to be one that often evokes controversy,
communities are often tempted to pursue youth development strategies that are devoid of family life
education and/or contraceptive access. However, proponents believe that all three components (e.g.
equipping young people with knowledge and skills, including messages regarding both abstinence and
contraceptive information, and ready access to teen-sensitive clinical services ((including STI and
HIV/AIDS screening and care)), and offering a wide range of such youth development strategies as
school-to-work transition programs, mentoring programs, and community volunteer placements8) are
needed in order to have the greatest positive impact. Thus, beginning in the late 1990s, many in the field
of adolescent pregnancy prevention recognized the need to combine all these strategies into a
comprehensive package.

Communities have also come to realize that the complexity of the issue, and the comprehensive strategies
needed to address it, requires a collaborative effort; no single agency or organization can mount the wide-
ranging effort that is truly needed to make more than a dent in the problem. New community-based
interventions are directed at engaging a wider group of stakeholders, including representatives from the

11
business sector, faith-based institutions, schools in the community, parents, and—not least—teenagers
themselves.9 In casting a wider net, the hope is that a broadened sense of “ownership” of the adolescent
pregnancy prevention issue leads to the development of widespread, inclusive, and viable solutions that
are more specifically tailored to the unique needs and resources of the adolescent, as well as his/her
community.

The underlying assumption in this new generation of programs is that combining concurrent strategies
and programs will create a synergistic effect. For example, the multi-year adolescent pregnancy
prevention program, developed by Dr. Michael Carrena and sponsored by the Children’s Aid Society in
New York City, combines: 1) a semester-length course on skills-based family life education, 2)
comprehensive health care, including mental health and reproductive health services and contraception, 3)
individual academic assessment, tutoring, help with homework, preparation for standardized exams and
assistance with college entrance, 4) a work-related intervention that includes a job club, stipends,
individual bank accounts, employment and career awareness; 5) self-expression through a culture and arts
program, 6) recreation and sports activities, and 7) scholarships for a college education for participants
who graduate from high school. This synergy of different components is intended to produce the kind of
sustained effort thought to be needed to have any real effect on the complex syndromes that surround
adolescent pregnancy.11 The program provides a clear message about avoiding unprotected sex and early
pregnancy. A rigorous evaluation of the program in six different sites showed that among girls the
program significantly delayed the onset of sex, increased the use of condoms and other effective methods
of contraception and reduced pregnancy rates, although the program did not reduce sexual risk-taking
among boys.11

Community-focused approaches—rather than a singular program specific focus—holds the key to the
next generation of adolescent pregnancy prevention efforts. By combining and making available a diverse
set of coordinated strategies within the community, different segments of the adolescent population—
each with its own set of needs—should be reached, with a greater likelihood of changing specific social
norms and practices. Furthermore, this synergistic approach emphasizes focusing on the assets of youth,
in direct contrast to more traditional program concepts that have often stressed reducing or “repairing”
their deficits.12 Rather than define teenagers as a risk-taking “problem group,” program staff attempt to
identify and nurture the strengths of their adolescent clients in an effort to reinforce an individual sense of
responsibility for their own actions. In addition, there is increasing recognition of the valuable role young
people who are adequately nurtured and trained can have in shaping the development (and even staffing)
of new programs and strategies.8 These and other more comprehensive approaches to adolescent

12
pregnancy prevention are being examined through the application of rigorous evaluation studies. Figure 1
delineates comprehensive adolescent pregnancy prevention components and strategies.

As reflected in this monograph, several different generations of program efforts sometimes co-exist
within the same community, although formal linkages between different types of pregnancy prevention
programs traditionally do not. This fragmented approach (which often reflects adult ambivalence
regarding adolescent sexuality and contraceptive use) contributes to the “mixed messages” young people
receive in our society today. Unfortunately, most adolescents do not receive clear and consistent messages
from their families, schools, community-based organizations, and policy makers about their value to the
community, and of the importance of delaying the onset of sexual activity, or about being contraceptively
responsible, if they are already engaged in a sexual relationship.

Figure 1. Comprehensive Adolescent Pregnancy Prevention Components and Strategies

Interventions Strategies
Skills-based Knowledge
Attitudes, Beliefs and Values
Family Life Education Building Relationships and
Communication
Religious Community
Cultural Competence

Contraceptive Services Family Planning Education,

Counseling and Services
STD/HIV Clinic Services
Condom Distribution Programs

Mentoring Programs
Youth Development Academic Remediation
and Life Options Case Management
Youth Groups and Peer Education
Community Service
Job Training & Support
Entrepreneurial Development
Talent Identification and
Development
Sports

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II. Bringing Theory Into Action: Theoretical Frameworks and Program
Models
In this section, we present the theoretical frameworks we found to be most clearly relevant for teenage
pregnancy prevention programs. These theoretical models were extracted from various sources studied in
the course of a wide-ranging review of the professional literature, including a recent textbook edited by
DiClemente, Crosby and Kegler.1,14,15,16,17,18

Although various theoretical frameworks have been available for a number of years and used in
psychological and sociological studies to gain greater understanding and insight into human behavior,
their practical application to developing more effective interventions, such as programs focused on
adolescent pregnancy prevention, has rarely been fully explored. When these frameworks have been
applied, it has often been with the goal of influencing behaviors by working at the individual level (e.g.,
adolescent self-esteem, knowledge of and motivation to delay sexual activity or to use contraceptives).
Furthermore, relatively little effort has been to direct program strategies at the antecedent factors that
shape individual behavior. For example, academic failure has been well documented as a risk factor for
early childbearing, yet few programs focus on linking their efforts with school tutoring or academic
remediation efforts.

Today, many planners and providers are recognizing the need to expand the focus of their efforts not only
at the individual client level, but also at the broader familial, community, and social context in which
adolescents live. This expansion is based on understanding the non-sexual antecedents that influence
adolescent sexual, contraceptive, and pregnancy behavior (e.g., family structure, adult support, parental
attachments, etc.) as well as community and social context (e.g., availability of contraceptive services for
teenagers, policies pertaining to the type of sex education offered in schools, etc.).
Interventions aimed at the familial/community level, reflective of the young person’s social and
environmental context, are conceptualized as providing cultural models and norms that support and
sustain protective behaviors, thereby promoting individual behaviors that reduce pregnancy risks. Finally,
we recognize the importance of working to ameliorate teenage pregnancy at the structural level.
Ameliorating poverty, gender inequalities, employment opportunities, and assuring greater access to
educational and health resources will promote the social equality necessary to reduce the incidence of
teenage pregnancy.

In fact, many theorists and program providers recognize that it is the interactions among individuals,
families, communities, and social structures that shape human behaviors and that is where interventions

14
need to be targeted in order to have a major effect. Yet, far too few efforts have been made in the past to
consciously plan and implement programs that incorporate what is known about human behaviors and
social structures and how best to influence those behaviors and structures at individual, social and
environmental levels.

As Kirby1,2 has argued, it is accepted that:

1) Individual characteristics of teens themselves affect their chances of becoming pregnant as
teenagers, but so do the characteristics of their partners, peers, families, schools, communities,
and states.
2) Since so many factors affect teen pregnancy, a program that addresses only one factor is unlikely
to have a dramatic impact on teenagers. To make a significant impact, one or more programs may
need to concurrently address multiple risk and protective factors at the same time.
3) Some of the most important risk and protective factors related to adolescent pregnancy involve
sexual beliefs, attitudes, and skills, but many others do not even involve sexuality (e.g., plans for
the future, life opportunities, level of family income).

Thus, it is generally agreed that to maximize positive behaviors and reduce risk behaviors, program
impact must occur not only at the individual/behavioral level, but also at the familial/community and
broader social structural level as well. Prevention programs must be championed by additional
stakeholders and at levels that go beyond individual behavioral interventions to other areas that influence
young peoples’ lives.

Too many programs that are designed to produce individual behavioral change have forfeited important
opportunities to maximize the success of their outcomes. Many programs, of course, serve as examples of
theory-action integration. What they share is an explicit theoretical understanding of the assumptions they
make about “the causal chain linking interventions, risk and protective behaviors, and sexual risk
taking.”1,16 Important examples include various youth development programs that have integrated
developmentally appropriate family life education, for example, the Girl’s Inc.6 or the Junior League that
originally established the Teen Outreach Program, a service-learning community program that integrates
family life education in its curricula,5 the Children’s Aid Society/Carrera Program in New York City,11
and the California Adolescent Sibling Pregnancy Prevention Program.12

Although it is not realistic to expect that basing programs on theoretical frameworks will ensure total or
automatic success, program models that rest on a firm theoretical footing have a better chance to succeed.

15
The sheer complexity of influencing complex human behavior requires that we try to design, fund,
implement, and evaluate the strongest possible programs built on sound theoretical frameworks.

This monograph concentrates on two primary areas:

1) A description of the theoretical frameworks that appear to be most relevant to adolescent
pregnancy prevention, and
2) The application of these theoretical constructs to the development of comprehensive prevention
programs.

Finally, the overall intent of this analysis is to aid the process of raising the quality, and thus the
effectiveness, of both new and existing programs through the application of relevant theoretical
frameworks.

Theories and Models: Does One Size Fit All?

No one theory can provide the “best” solution for designing, delivering, and/or evaluating effective
adolescent pregnancy prevention programs. Programs often and appropriately rely on several theoretical
assumptions when designing and providing services; however, relatively few adolescent pregnancy
prevention efforts have incorporated important theoretical frameworks in an explicit and prescribed
manner. Some intervention components implicit in the theoretical frameworks that we will discuss have
been applied more than others and some theories have received greater testing than others. On the whole,
the application of theoretical frameworks to the complexities of adolescent pregnancy prevention remains
largely undocumented and untested. Exceptions can be found in such programs as Reducing the Risk,20
Safer Sex, 22 Cognitive-Behavioral Interventions,23 and Teen Talk,24 where the use of theoretical
frameworks to support skills-oriented program strategies has been found to be more effective than
programs that merely impart information to their adolescent clients.24 Other programs that effectively
integrate theory and program design can be found in HIV education and teenage pregnancy prevention
efforts such as Plain Talk, 25 Project Action, 26 and Project RESPECT 27 among others.

That there are theories that have yet to be tested simply underscores a primary message of this document:
while pregnancy prevention initiatives often do employ theoretical frameworks in their program models,
they do so with a variety of levels of continuity of understanding by managers and direct service
providers on just how the intervention supports their theoretical assumptions. In addition, once programs
are delivered, program planners and service providers rarely reassess the theoretical ideas and
assumptions upon which their program rests. More than ever, we must make our efforts count, and turn

16
our energies to developing more effective and targeted interventions, enhance our theoretical
understanding of teenage pregnancy prevention, and test these approaches to learn what works and why.

How Do Theoretical Frameworks Help Program Planners and Providers?

When delivering an intervention, assumptions are made about the social problem at hand. These
assumptions represent one’s theoretical position on the causes and consequences of the social problem. In
academia, a theory is a set of interrelated concepts, definitions, and propositions that presents a systematic
view of events or situations by specifying relations among variables, in order to explain and predict the
events or situations.28 Academics aside, all programs hold assumptions about the problem and design
their interventions accordingly. These assumptions usually include causal understandings of the health
outcome of interest; in this case outcomes include sexual behaviors and/or pregnancy and HIV/STD
prevention. What is often lacking, however, are articulations of those assumptions, the antecedents
addressed, and continuous re-evaluations of those assumptions in light of the degree to which a designed
program is effective in reaching its goals.

As described earlier, three “ideal-types” of theoretical frameworks exist: individual level,

familial/community level, and structural level. In general, theoretical perspectives divide rather clearly
between those concerned with large-scale characteristics of social structure and social position (i.e. macro
perspectives related, for example, to the impact of poverty and class on the incidence of adolescent
childbearing) and those concerned with person-to-person encounters and the details and meanings of
human interaction and communication (i.e. micro perspectives related, for example, to the type of parent-
child communication that exists regarding sexual behavior, the impact of a sibling who is a teenage
parent). This does not mean however, that synergy and interaction among these theoretical levels of
analysis does not occur. In fact, many theoretical perspectives are concerned with the interactions among
social structures, social positions (race, class, and gender), and social interactions.

What is important is to recognize that all theories hold certain assumptions about human nature, human
behavior (or action), and the degree to which institutions and cultural norms constrain and enable human
action. Furthermore, each theoretical perspective more appropriately addresses specific antecedents. For
example, for the antecedents at the structural or the social environment level—such as community
poverty level, social institutions, neighborhood resources, and social capital (e.g., level of mutual trust
and sharing of resources)—a structural level theoretical framework with its associated interventions will
better match one’s goals than an individual level approach. 1 Theoretical perspectives that aim at

17
predicting both human behaviors and social life are most able to identify intervention points where human
behaviors are susceptible to influence and change.

Table 1: Theoretical Models and their Primary Focus: Individual, Familial/Community and
Structural Level
Individual Familial/Community Structural
Developmental Assets/Resiliency
Health Belief Model (3) Social Ecology Model (12)
Theory (1)
Transtheoretical Model (2) Social Learning Theory (5) Theory of Gender and Power (13)
Theory of Reasoned Action/
Theory of Planned Behavior (4)
Attribution Theory (6)

Protective Motivation Theory (7)

Self Regulation Theory (8)

Relapse Prevention Theory (9)

PRECEDE Framework (10)

Psychosocial Model (11)

Which specific theoretical level of intervention or combination of levels of intervention to use will largely
depend upon a great number of different factors. These factors include:
• The target antecedents (e.g., social/structural environment, familial/community social network, or
individual adolescent knowledge, beliefs, and behaviors).
• The target population the program is intended to serve (e.g., males, females, pregnant teens,
parenting teens, sexually active and not yet sexually active teens, parents with children and
adolescents, specific age groups, specific racial or ethnic groups, etc.).
• The desired program outcomes (e.g., enhancing the life skills of young people, postponing the
initiation of sexual activity, decreasing the number of sexual partners, improving the consistent
and correct use of birth control methods, improving the economic environment of young people
in a community).
• The types of resources and interventions that are actually feasible for and available to the target
population (e.g., youth-serving organizations willing to link their activities to a pregnancy
prevention agenda, staff who are trained in the program curriculum and who are enthusiastic
about working with adolescents, availability of a comprehensive family life education curriculum,

18
 counseling in a teen-friendly family planning clinic, business sector concerns and investment in
young people as an alternative to early childbearing).
• The community and cultural context that determines which strategies will be accepted by the
target population (e.g., Do community norms encourage the use of a variety of strategies to delay
early childbearing, including the role of parents as the primary source of sexuality education,
mentoring, and job skills development for their children? Will the community comfortably accept
explicit discussion of condom use in school settings?).
• Community capacity (e.g., Do the families, teenagers, and other community members appear to
have the capacity to mobilize for action? For example, do they have the capacity to improve
neighborhood conditions and advocate for safe neighborhoods or to work for current and future
education and employment opportunities for young people?).
• The economic conditions in the community (e.g., level of poverty and unemployment, economic
opportunities, types of economic resources available).
• The availability of the media resources needed to communicate to and within the community
(e.g., television, community cable access, radio, internet, billboards, and local community and
school newspapers).

III. Theory into Practice

The theoretical frameworks presented on the following pages were selected for review according to the
following criteria.
• Their potential utility in explaining complex behavior;
• Their potential for immediate and relative ease in applicability;
• Their acceptance by a broad range of experts in multiple disciplines; and
• Their inclusion in a thorough review of the literature in terms of their actual application to other
major public health or related problems.18,28

The theoretical frameworks selected for extensive discussion are:

1) Developmental Assets/Resiliency Theory
2) Transtheoretical Model
3) Health Belief Model
4) Theory of Reasoned Action/Theory of Planned Behavior
5) Social Learning Theory
6) Attribution Theory
7) Protective Motivation Theory

19
 8) Self Regulation Theory
9) Relapse Prevention Theory
10) PRECEDE Framework
11) Psychosocial Model
12) Social Ecology Model
13) Theory of Gender and Power

While other frameworks, such as Consumer Information Processing, and Diffusion of Innovations
Theory, were also examined, their applicability to adolescent pregnancy prevention did not meet our
selection criteria. We discuss 13 potentially applicable theoretical frameworks at length. Some, such as
the Developmental Assets/Resiliency Theory model and the Transtheoretical model, focus more on the
interpersonal level and behavioral levels, while others are geared more to the social structural level. It is
our goal that program evaluators, planners, and providers will begin to recognize the synergy among these
levels of programmatic effort.

Our intention is that this analysis can serve to encourage evaluators, planners, and providers to explore
which theoretical framework (or combination of frameworks) best fit the populations they serve, as well
as their own program assumptions and goals. While there are information gaps in the research field
regarding the applicability of each theory to community-wide adolescent pregnancy prevention strategies,
their potential utility for improving the types of programs that need to be developed is not in serious
doubt. We urge the reader to examine all 13 frameworks to ascertain how appropriate each might be
(keeping in mind that components from different frameworks can often be extracted for combined use)
for different groups of adolescents (e.g., males vs. females, urban vs. rural, younger vs. older, different
racial or ethnic groups, etc.), and to consider how these frameworks help to shape the types of strategies
pursued.

In the field of adolescent pregnancy prevention, the lack of a theoretical base has resulted in part from
information gaps that arise when researchers do not have the opportunity to help programs understand the
potential application of theory-based findings both to existing interventions and to the creation of new
ones. In addition, program developers and providers often lack the training, the time, or the incentive to
alter existing program practice by incorporating theoretically-based research and findings that are relevant
to their programs. This information gap frequently results in a mismatch between research findings and
the types of programs that are currently available to adolescents and their families through community
settings. The failure to apply theoretical frameworks to programs for adolescents may also stem from

20
 stereotyping teenage behavior as irrational and impulsive, and thus not suitable to the application of
rational theoretical models. Adler et al. have demonstrated that adolescents do in fact make rational
decisions and are an appropriate target population to which theoretical frameworks can be applied.29
Table 2 lists each theoretical framework, its level of intervention and focus, and key concepts.

Table 2: Summary of Theories: Focus and Key Concepts

Level Theory Focus Major Concepts

Familial/ Health Readiness for action stems from an • Perceived susceptibility
Community Belief individual’s estimate of the threat of • Perceived seriousness
/Individual Model illness and the likelihood of being • Perceived benefits
able, through personal action, to • Perceived barriers
reduce that threat. • Cues to action
• Self efficacy
Individual Attribution Describes the behavioral processes of • Seek to understand causes of:
Theory explaining events and the behavioral o Internal factors
and emotional consequences of those o External factors
explanations. o Circumstances
o What to do to avoid problem in the future
Individual Protective Actions are based both on threat • Motivation a function of:
Motivation appraisal and coping appraisal. o Severity of consequences
Theory o Probability of consequences
o Effectiveness of recommended action
o Internal rewards
o External rewards
Individual Trans- Modification of behavior involves • Precontemplation
theoretical movement through stages of change. • Contemplation
Model • Preparation
• Action
• Maintenance
Individual Relapse Modification of habitual patterns of • Initiation
Prevention behavior through the use of self- • Modification
Theory management and self-control • Cessation
techniques. • Maintenance of cessation
• Relapse
Individual Gender & Economic and educational • Reduction of inequalities by gender, race, or class
Power opportunities. • Addresses division of labor, division of power, and
Theory Social and institutional gender norms. division of cathexis (i.e. social norms and affective
attachments)

21
 Level Theory Focus Major Concepts
Individual Theory of Behavior predicted by individual’s • Own evaluation of consequences
Reasoned intention to perform the behavior. • Own attitude and beliefs about protective action
Action/ The dimension of perceived control • Others attitudes and beliefs about protective action
Theory of was later added and called the Theory • Normative beliefs and expectations of others:
Planned of Planned Behavior. o People I love
Behavior o People I value
o Providers
o People who set policies and laws
• Motivation to comply
• Perceived control
Familial/ Social Behavior a result of “reciprocal • Reciprocal determinism
Community Learning determinism,” the continuing • Skills, including goal-directedness, emotional
Theory interaction between a person, the coping, and problem solving
behavior of that person, and the • Expectations
environment within which the • Intent
behavior is performed. • Motivation
• Self-efficacy
• Observational learning
• Norms
• Reinforcement (intrinsic and extrinsic)
• Social support
• Structured opportunities for change
Individual Self Individual’s operate like feedback • Feedback system of self regulation
Regulation systems, constantly regulating their • Coping procedures
Theory relationships to the environment in • Problem solving
order to bring their current states
closer to their goal states.
Individual Develop- To enable youth to participate in • Support (Family, friends, school and community)
mental socially useful tasks so that they • Empowerment
Assets/ become healthy adults in spite of • Motivation
Resiliency adversity, and demonstrate positive • Boundaries
Theory results in self-esteem and moral • Expectations
development. • Provision of opportunities
• Educational commitment
• Positive values
• Social competencies
• Positive identity
• Positive school climate
• Activities (extra-curricular, religious, and community)
Individual PRECEDE Systematic planning process which • Predisposing factors (provide motivation or reason
Framework empowers individuals with behind a behavior)
knowledge, motivation, capacity and • Reinforcing factors (provide continuing rewards or
involvement in community affairs so incentives for a behavior)
that they can change their behaviors, • Enabling factors (make it possible for a motivation
policies, and regulations which to be realized)
influence their behaviors resulting in
an improved quality of life.

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 Level Theory Focus Major Concepts
Individual Psycho- Individuals strive to combat • Goodness of fit
social disequilibrium between themselves • Reduction of problems and stress
Model and their environment. • Shaping of environment
• Modification of individual constructs
• Enhancement of self-esteem and perception
• Past has effect on present
• Significant others’ opinions and values
Structural Social Individual is embedded in and • Multiple domain health intervention integration
Ecology influenced by numerous systems or (home, school, community, and political settings)
Theory groups. • Cultural change (transformation of norms, values,
and policies)
• Individual’s perception of support or neglect
• Opportunities for safer behaviors

Selecting the level which program developers want to target will help them choose the theoretical
framework(s) best suited to their program.

Selecting the Level of Program Intervention

On the individual level, many pregnancy prevention programs employ interventions aimed at changing
cognitive, behavioral, and psychosocial characteristics that are shown to directly impact sexual
antecedents, such as the number of sexual partners, onset of sexual activity, and the level of contraceptive
use. These interventions are often curricular-based, such as HIV/AIDS and sex education (including
abstinence-only programs), and aim to improve teenagers’ knowledge, attitudes, and beliefs about
sexuality and teen pregnancy. These programs may also include other components, such as sex and HIV
education targeting parents and families and reproductive health programs designed to improve access to
condoms and contraceptives.

Interpersonal Level Interventions

The interpersonal level includes familial, peer, and other social relationships. At this level it is
understood that such factors as relationships with family members, teachers, peers and significant others
influence peoples’ feelings and actions. Programs at this level of analysis often include peer support and
connections with mentors and other adults.

Social Structural Level Interventions

The social structural level emphasizes social and community factors, such as access to and distribution of
financial and cultural resources, including family income, education, employment opportunities, and
extra-curricular activities. Programs at this level of analysis often include cultural norms, access to care,
and inequalities in educational and other community resources.

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 Evolution of Teen Pregnancy Prevention Program Interventions

Recognizing the limitations of the past, pregnancy prevention programs are shifting from a singular focus
on knowledge, attitudes, and belief-based interventions and/or interventions focused on access, to services
that emphasize multifactorial, multilevel approaches to teen pregnancy. As the field acknowledges a
clustering of risk factors, programs are being developed accordingly—addressing the antecedents to teen
pregnancy (e.g., academic failure) as well as preparing young people with the tools to navigate their
adolescent years pregnancy-free. Despite this shift, many programs continue to emphasize individual-
level attributes and, thus, are directed at impacting sexual behavioral antecedents exclusively and do not
pay attention to non-sexual antecedents, such as cultural norms and need for service learning, vocational
education and employment opportunities, and adult connections. That is, few programs aim to shape
interventions based on what we know from theoretical research about the complexity of changing health
risk behaviors and increasing protective behaviors. We contend that if programs are able to gain clarity on
theoretical options, types of antecedents, and intervention choices, more effective interventions are
possible. In fact, many of the theoretical frameworks presented in Table 2 include both personal (or
internal) and environmental (or external) factors, and the interaction between the two (Table 3 illustrates
this well).

Table 3: Personal and Environmental Domains Incorporated in Theoretical Behavioral Frameworks

Theory is made up of personal and environmental factors, and the interaction between the two:
Personal Factors (Internal):
• Knowledge
• Attitudes, beliefs and values
• Skills
• Intent and motivation
Environmental Factors (External):
• Social support
• Social norms
• Availability of programs and services
• Opportunities for youth development

Although a given program may be successful with one target population, the same intervention may not
necessarily be successful with the same general target group in other communities, or in communities or
settings with different target populations.28 To implement effective interventions, the intervention must
target the appropriate outcome variables that are specific to the needs and assets of the target population
and to the individuals within that population. It is also important to recognize whether the intervention is
directed towards internal or external factors, or both. For example, if many adolescents in a community

24
are sexually active at an early age and have poor education and social outcomes, and the desired program
outcomes are to: 1) increase the number of adolescents who remain abstinent, 2) increase the number of
sexually active teens who use effective contraceptive methods and 3) increase school graduation rates,
then the program’s planners must consider: 1) when and how often to intervene (at what age or grade in
school), 2) the type of curriculum and/or other intervention(s) needed and the requisite level of
reinforcement, and 3) the level at which the intervention(s) (personal, inter-personal, and/or
environmental) is directed.

The target population’s level of knowledge about such matters as sexuality and reproductive health, as
well as career development, is an important underlying aspect of most theoretical frameworks, since that
level of knowledge is a crucial element in shaping individual behavior and decision-making.
Furthermore, the community needs/assets assessment that must precede intelligent program design and
implementation should seek to assess what adolescents of different ages and their parents actually know
(or think they know) before interventions are developed and tested to meet their needs. An obvious
example of this process is to determine the level of knowledge adolescents in the community possess
about pregnancy and pregnancy prevention, sexually transmitted diseases, and contraceptives, as well as
their awareness concerning the importance of completing high school and the pursuit of higher education
to fulfill career goals.

Although not all the theoretical frameworks discussed in this monograph have thus far been incorporated
into tested or evaluated pregnancy prevention programs, they do provide insights into the kinds of
potential strategies and the level to which they could be targeted (i.e. personal and/or environmental) that
could be included in various programs and approaches. A close examination of these theories promises
ample validity and utility for planners and providers who wish to benefit from their application in
designing new interventions or re-conceptualizing existing programs. Related topics to assess in
adolescents also include:

1) Their perceptions concerning their future employment opportunities,

2) Their feelings about early childbearing,
3) Their perceptions of the accessibility and acceptability of existing family planning and other
social service and community-based organization resources in their community,
4) Their behavioral intent to abstain and/or use birth control protection in their future, and
5) Their intent to seek viable alternatives to early childbearing within a youth-friendly community
context.

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Description of Theories

A detailed description of each theory, along with a schematic framework and its potential application to
adolescent pregnancy prevention efforts, follows. It is important to remember that these theoretical
frameworks are not unchangeable, and are in fact continually evolving as ongoing research applies these
theories to different research questions. As research continues, elements that might have been omitted
from a given theory’s initial conceptualization might emerge as that theory is applied to different target
groups. To cite a simple example, a given theoretical framework, or elements of that framework, may
prove more applicable to younger adolescents than to older ones. For this reason, theoretical frameworks
should be reviewed and updated regularly to ensure their applicability to the program that is being
developed, implemented, and tested, and to the population or group for which the program is intended.

1. Developmental Assets/Resiliency Theory

The Developmental Assets/Resiliency Theory represents a shift away from viewing youth as “problems”
(the problem, or deficit, paradigm) that somehow must be “fixed” or “repaired.” Instead, this theoretical
framework looks at youth in terms of the positive assets and resources that either reside within young
people themselves, or that can be enlisted in support of youth in the broader community as positive
change agents (resiliency/prevention paradigm). The problem paradigm focuses on individual
weaknesses and limitations, and overlooks the value in—and thus restricts the opportunities for—
encouraging young people to participate more fully in their community. The developmental assets
paradigm, on the other hand, incorporates youth service as a key element in prevention planning. The
theory represents a compelling argument that teenagers who participate in socially useful tasks (paid and
volunteer) become healthy adults and show positive results in self-esteem and moral development, even
among those raised in adverse environments.30 This links with pregnancy prevention in that it encourages
young people to focus on positive assets, such as education, and therefore to protect themselves from
pregnancy risks.

Developmental Assets/Resiliency Theory can be divided into two primary dimensions: external assets
and internal assets. External assets are the factors that surround adolescents with the support,
empowerment, boundaries, expectations, and opportunities that guide them to make sensible choices and
behave in healthy ways.8 These assets can be provided by various people and social institutions,
including families, friends, neighbors, schools, and faith and community organizations. Positive support,
communication, monitoring, mentoring, discipline and involvement represent a sample of the kinds of
assets that various people and institutions can offer to young people.

26
Internal assets are defined as values, skills, and self-perception. They are assets that must be taught,
encouraged, and nurtured so that teenagers can learn to guide their behaviors and choices in positive, self-
nurturing ways.30 They include a commitment to learning, positive personal and social values, social
competence, and a positive social identity. Some specific examples of internal assets include a
motivation to achieve, educational aspirations, caring about themselves and others, honesty, a sense of
responsibility, self-restraint, a desire for non-violent conflict resolution, respect for and familiarity with
other cultures, and a sense of purpose. All these assets represent qualities that are desirable if teenagers
are to be convinced that avoiding too-early childbearing is in both their short- and long-term self-interest.
Youth service—the active participation of young people in community service—draws upon both external
and internal assets, and is an important component of Developmental Assets/Resiliency Theory. The
literature emphasizes five reasons for incorporating youth service into prevention programs.31 Youth
service:

1) Promotes healthy psychological, intellectual, and social development;

2) Helps teenagers learn how to assume adult responsibilities;
3) Draws upon the energy and creativity of youth to address present and future problems;
4) Builds linkages between school and community, thus enhancing the relevance of education to
life, and experience to education; and
5) Helps fill the large unmet need experienced by most communities in voluntary and other
community service positions that often go unfilled for lack of volunteers.31

This model stresses that families, businesses, peers, education and health institutions, community-based
organizations, and the faith community must work together to foster the positive personal and social
development of young people. Also important is the availability of community services, activities,
support programs, and opportunities for youth development which foster a greater sense of
“connectedness” between adolescents and adults in the community. The pregnancy prevention
community models that employ a variety of concurrent strategies (e.g., the Children’s Home
Society/Carrera Model) draw upon various community resources to develop and reinforce the inherent
assets of teenagers. This “social inoculation” approach attempts to prevent vulnerability to an unintended
pregnancy.32,33 By marshaling the resources of teenagers and their families, as well as the faith, school,
and business sectors of the community, more adolescents can be supported in their efforts to act in a
personally responsible manner. The goal is to help young people become capable of being responsible
not only to themselves, but to a community that demonstrates it cares about their welfare as well. This
theory, then, exists in between the behavioral/individual level and interpersonal levels of analysis.

27
2. Transtheoretical Model

The Transtheoretical Model was developed to understand the underlying structure of behavior change.
Thus, this theory is firmly situated in a behavioral level theoretical framework. The Stages-of-Behavior-
Change Model was previously noted as a separate model, borrowing from the Transtheoretical Model.
Due to their almost identical nature, only the Transtheoretical Model has been included in this
review.,34,35,36,37

A core concept of the Transtheoretical Model is that modification of behavior involves movement through
stages of change. This model applies to individuals who seek professional help and to those who choose
self-change. Both groups have been found to go through varied processes, depending upon the stage of
change they were initially in, and the stage they are in when seeking assistance. An individual can enter
or exit the stage of readiness to change at any point through any of the stages. Although originally
conceptualized in linear terms, with the individual progressing sequentially from one stage to the next
(Figure 2), the course of change that is more characteristic for many clinical problems tends to follow a
circular pattern (Figure 3). The stages represent distinct but related periods of time, marked by different
actions in each stage.

These stages consist of pre-contemplation, contemplation, preparation, action, and maintenance. In the
pre-contemplation stage, individuals are either unaware of having problems, or they are not thinking
seriously about changing a behavior that results in a problem. Although the individual may not
acknowledge the problem consciously, persons in his/her environment are often aware that there is a
problem. As applied to a pregnancy prevention intervention, this stage may describe an adolescent who is
sexually active, but who ignores, or is not aware of the risk, of an unplanned pregnancy or a sexually
transmitted disease. It may also describe the teenager who is abstinent, but who may not be conscious of
the stages of thinking that will help him or her to maintain their resolution to remain abstinent.

Contemplation is the stage where individuals become aware that a problem exists. At this stage, there is
serious thinking about the situation, but not yet a true commitment to change. During this stage,
individuals often weigh the pros and cons, as well as the solutions to the problem, struggling with their
evaluations of the problem behavior, and the amount of energy, effort and loss it will cost to overcome the
problem. At this stage, adolescents realize the risk of pregnancy, and, if abstinent, seriously consider how
they might successfully communicate to their partners their desire to remain abstinent. At the same stage,
the sexually active teen may be considering adopting a method of birth control. However, both groups
may avoid further action out of fear that the effort would be too complex or difficult. Maintaining

28
continued abstinence in the face of peer pressure to initiate sexual activity, or negotiating condom use
with a partner, may seem nearly impossible to many adolescents.

The third stage consists of preparation, when the individual begins to make a plan for change. He or she
may have unsuccessfully attempted some action during the past year and intends to take action in the next
month or the very near future. Although some movement to deal with the problem may have occurred,
truly effective action has not yet been taken. At this stage, adolescents may have experimented with a
birth control method or a plan to use birth control in the very near future. They may use contraception
inconsistently at this stage, and may only proceed to the next stage if they or a friend have been faced
with a pregnancy scare. For the adolescent who wants to remain abstinent, or for the teen who may
already be sexually active with the intention of becoming abstinent, he or she may be in the process of
considering which steps might be necessary to achieve these goals.

The next stage is the action stage, when people change their overt behavior to overcome their problems.
This requires an alteration of problem behavior, and the implementation of new behavior. Self-esteem
tends to be high in the action stage, when individuals feel capable and confident of acting on their beliefs.
Others, too, may notice the change, and provide recognition or support for the person who has reached
this stage. To continue our examples of the teenager who chooses to abstain, or the teen who is sexually
active, he or she at this stage has consistently abstained or has been consistently practicing safe sex, for up
to six months. Both feel good about their decisions and their ability to fully put into practice their desired,
more responsible behavior.

The final stage, maintenance, is where the individual works to continue the gains achieved during the
action stage, and to prevent relapse. Maintenance can be viewed as a continuation of the relatively newly
adopted behavior change. In the maintenance stage, individuals must remain free of their problem
behavior for more than six months, and can remain in this stage for the rest of their lives. The chief
hallmarks of maintenance are stabilizing behavior and avoiding relapse. At this stage, our adolescent
examples have been consistently abstinent or practicing safe sex. To remain in this stage and avoid
relapse, he or she will continue to do so, both in current relationships or in new ones as they emerge36,37
Figures 2 and 3 show the frameworks from a linear and a circular approach. While a teenager may
proceed from one stage to another, life circumstances, such as a new relationship or a stressful situation,
may accelerate or delay progress from one stage to another.

29
 Figure 2: The Stages of Change Linear Model
Precontemplative→ Contemplative → Preparation → Action → Maintenance
(Source: Prochaska, J., & DiClemente, C., 1984)

Figure 3: The Circular Model of the Transtheoretical Approach

Maintenance Action

Relapse Contemplation

Enter
Here

(Source: Prochaska, J., & DiClemente, C., 1984)

The Transtheoretical Model requires different interventions for different stages. Individuals who do not
meet the criteria for effective action in a given stage may remain in their current stage for a short time, or
relapse to a previous stage. The amount of time spent in each stage varies with the individual, although
the tasks required in each stage are assumed to be unvarying. By ascertaining an individual’s current
stage, and hence his or her readiness for change, the appropriate intervention can be implemented
accordingly.

The Transtheoretical Model focuses primarily on the individual, and does not explicitly address
environmental factors. So, while it is informative and helpful that the health educator or counselor know
which stage the adolescent is in to target an intervention, they must also discern what kind of action the

30
adolescent may be ready to take. If, for example, the adolescent is at high risk for becoming pregnant and
is still in the pre-contemplative stage, she is either unaware of or in denial of any potential problem; she is
not explicitly considering any change in behavior. The counselor must then begin to educate the
adolescent about the likely risk of pregnancy, and counter her belief that she is somehow immune to
becoming pregnant. Until she realizes and accepts her own vulnerability, she will most likely not practice
effective contraceptive use. The adolescent who desires to remain abstinent may need to develop a
repertoire of skills to successfully communicate with his/her partner in order to maintain their choice.

The most important factors to accentuate in the application of the Transtheoretical Model are the
assessment of which stage the individual is in, his/her readiness to change (or attempt to change), and the
specific strategies the provider can use to help guide the adolescent through the stages. Asking questions
about perceptions of risk, previous experience with contraceptive use if appropriate, and barriers to
implementing new behaviors are helpful to incorporate into the process. The educator or counselor may
also explore at what stage the adolescent is in relation to creating a sense of direction for their own future.
Reexamining an adolescent’s past decision to become sexually active or not, as well as discussing the
option of a return to abstinence, could also be valuable. (See Case Study 1).

Case Study 1: Applying the Transtheoretical Model to the Adoption and Use of Condoms By a
Male Teenager.
Tom is a sexually active 16-year-old who has never used condoms or considered using them. At the start
of his junior year, he participates in a 10-week sexuality education program that emphasizes the use of
condoms to prevent pregnancy and STIs. Two weeks after completing the program he purchases a
package of condoms. The next weekend he goes to a party, thinks briefly of the condoms he forgot at
home, and proceeds to have unprotected sex in his car. Was the sexuality education program
unsuccessful? Our first reaction may be that it was not successful—after all, Tom continued to engage in
unprotected sex. However, he did purchase the condoms—presumably with the intent of using them—a
measure he had not even considered prior to the program. While this outcome might frustrate us as
sexuality educators, proponents of the Transtheoretical Model of behavioral change would say that helping
Tom move one step closer to practicing safer sex should be defined as a success.

Although teenagers are likely to progress through these stages in a linear fashion, this framework (see
Figure 3) allows for the possibility of skipping stages, as well as moving back and forth between them.
For example, an adolescent may move from Pre-contemplation directly to Action (this would have
reflected Tom’s progression from one stage to the next had he actually used the condoms). Or, there may
be movement from Ready for Action/Preparation back to Pre-contemplation. For example, if Tom’s
parents found the condoms and didn’t allow him to go to the party, fear of discovery might carry more
concrete, immediate risk for Tom than the more abstract risks of unprotected sex. Proponents of the
Transtheoretical Model believe that the regression exhibited by Tom should not be viewed as a failure,
since people often learn from their mistakes. Forward progress for Tom may well be easier the next time
around, depending upon his willingness to accept greater responsibility in his relationship and a more
candid dialogue with his parents.

Beyond matching interventions to the adolescent’s stage of readiness, the Transtheoretical Model suggests

31
that we should target the individual’s perceptions of the pros and cons of the behavior in question. The
ratio of the perceived pros to perceived cons is referred to as the individual’s Decisional Balance.
Adolescents in earlier stages are likely to perceive more cons related to a behavior such as condom use,
while those in advanced stages, such as Action, are more likely to perceive more pros. The theory further
suggests that moving an adolescent from Pre-contemplation to Contemplation is best accomplished by
attempting to increase perceived pros, while a move from Contemplation to Action or Maintenance is
more likely to result from efforts to reduce perceived cons.

Health educators and other service providers recognize that normally they have only brief contact with
program participants who are also subject to other strong influences, such as their peers and the media.
Moreover, most educators have little if any opportunity to assess long-term change. Instead, assessing
Stages of Change may be one way that they can demonstrate the positive effects of programs, even when
drastic changes in behavior are not apparent or long-term follow-up is not possible.

A basic tenet of this model is that interventions should be “stage matched”. The adolescent’s stage of
readiness for change must be determined, since targeting the wrong stage would have little or no impact.
For example, demonstrating proper use of condoms may be useful for moving a teenager from
Contemplation to Action. However, the same strategy is not likely to influence the individual who is in
the Precontemplation stage, and who is not even considering the use of condoms. Instead, this individual
might benefit from a discussion of the protection condoms can provide.

What is particularly challenging for a classroom health educator is that in all likelihood, they will be
working with adolescents at different stages of both change and development. However, these differences
in development and readiness for change can actually be used as an effective teaching approach in
classroom or group settings. If they are exposed to differences among their peers, those adolescents who
are less mature and/or less ready to accept change are likely to become more aware of alternative options
or different ways of thinking.

The provider should also be aware that the individual teenager may require very specific behavioral
strategies to progress from stage to stage. While educational interventions per se are not behavioral alone,
consciousness-raising, might mean providing information about the behavior in question. Another, self-
efficacy strategy, might be employed to help an adolescent develop sufficient confidence to actually
perform the behavior. Finally, the Transtheoretical Model defines “temptation” as the intensity of the urge
to perform or not to perform a given behavior. Thus, Tom’s opportunity to have sex may be the stronger
motivator even though his intentions are to use condoms when he has sex. Together, all these components
of the model provide directions for improving services for adolescents, as well as for adults.32

32
Table 4: Transtheoretical Model of Behavior Change and its Application to Condom Use

Stage General Definition Condom Use

Pre-contemplative Not currently performing behavior Not currently using condoms; does not
and does not intend to do so; may be intend to do so in the future.
unaware of risk or benefit of behavior.
Contemplation Not currently performing behavior, Not currently using condoms; intends to do
but intends to do so eventually. so in the future, within six months.
Ready for Not currently performing behavior, Not currently using condoms; intends to do
Action/Preparation but intends to do so immediately so in immediate future, within one month.
Action Currently performing behavior for a Currently using condoms, for a period of
short period of time and intends to time less than six months; intends to
continue doing so. continue doing so in the future.
Maintenance Currently performing behavior for a Currently using condoms for a period
long period of time and intends to longer than six months; intends to continue
continue doing so. doing so in future.
(Source: Vickberg, 1999)

3. Health Belief Model

The Health Belief Model affirms that readiness for action stems from an individual’s estimate of the
threat of illness or, as applied to a pregnancy prevention intervention, pregnancy and sexually transmitted
diseases. This readiness for action also assumes the likelihood of being able, through personal action, to
reduce that threat. Specifically, the Health Belief Model considers the individual’s perceived suscepti-
bility (a person’s subjective perception of risk of contracting a condition); perceived severity (death,
disability, pain, or other feelings about the relative seriousness and consequences of contracting illness, as
well as effects on work, family or other social consequences); perceived benefits (beliefs about the
relative effectiveness of various actions that could be taken to reduce the threat); and perceived barriers
(the potentially negative aspects of a particular health action, including expense, danger, side effects, and
pain).39

A fifth category, other variables, might also influence an individual’s health-related behavior and should
be taken into account as well. These other variables include demographics. For example, the younger
adolescent who is at a cognitive state of concrete reasoning may not realize the true risk of pregnancy, or
might perceive the side effects of some birth control methods as posing a greater danger than pregnancy
itself. Figure 4 delineates the relationships among the five categories of variables postulated by the
Health Belief Model.

33
 Figure 4: Health Belief Model

Individual Modifying Factors Likelihood of Action

Perceptions
Demographic variables Perceived Efficacy
(Examples: age, sex, race, benefits of expectations
ethnicity, etc.) preventive
Sociopsychological variables action

Perceived Likelihood of taking

susceptibility to Perceived recommended
Disease " X ' threat of preventive health
Perceived Disease " X "
action
seriousness (severity)
of Disease " X "

Cues to action
(Examples: Mass Media
Campaign, Advice from others,
Reminder postcard, Illness of
family member or friend,
Newspaper or magazine article)

(Source: Becker, M. H., Drachman, R. H., & Kirscht, J. P., 1974)

The Health Belief Model proposes that individuals consciously consider and weigh all the different
variables in deciding the actions they will pursue. A kind of “cost-benefit analysis” is thought to occur in
which an individual weighs opposing or conflicting options. The cost side consists of susceptibility and
severity factors, while the perceived benefits of taking action and the ability to overcome perceived
barriers to action make up the benefit side. Other variables can affect either costs or benefits. Individuals
are most likely to take action when they believe they are susceptible, when the condition is severe, when
the available course of action is beneficial in reducing susceptibility or severity, and when the costs of
inaction outweigh the benefits. Also inherent in this theory are the concepts of self-efficacy and outcome
expectancy: individuals must not only believe a specific action will lead to a particular desired outcome,

34
but they must also believe they will be able to initiate the behavior required to produce the outcome.
Thus, an adolescent who desires to graduate from high school and proceed to college will need to weigh
the pros and cons of being involved in a relationship that might result in an unplanned pregnancy that
might well interfere with their life plans.

A concept that was not originally part of this theory, cues to action, has become a prominent component
of the Health Belief Model. Put simply, cues to action activate and stimulate behavior. For example, a
negative pregnancy test may give an adolescent such a scare that she begins to practice effective and
consistent contraceptive use from that point on or may opt to become abstinent. An adolescent may also
model behavior he or she sees through the media. For example, if sexual situations presented in a
television show do not include contraceptive cues, or effective negotiating skills to delay or abstain from
sexual intercourse, a unique opportunity to help shape behavior has been missed.

In applying this theoretical framework to a pregnancy prevention intervention, a counseling component

might be included that stresses cues to action and personal perceptions of the negative consequences of an
unplanned child or a sexually transmitted disease, particularly in relation to the adolescent’s education
and career aspirations. Counseling should also address such perceived barriers to action (an important
factor in the Health Belief Model) as poor communication between the partners about delaying sexual
relations, or using birth control if they do have sex. The Health Belief Model emphasizes personal goals
and optimism about the future, self-efficacy, threat appraisal, and problem-solving and decision-making
skills, all of which could be incorporated into educational interventions that feature counseling, youth
development, and mentoring components.40,41,42

4. Theory of Reasoned Action/Theory of Planned Behavior

The Theory of Reasoned Action proposes that willful behavior is predicted by an individual’s intention to
perform a behavior. The intention to perform the action is influenced by two forces: 1) attitude toward
performance of the behavior (e.g., whether engaging in the behavior is considered good or bad) and 2) the
individual’s belief in the subjective norms that dictate societal expectations regarding that behavior (e.g.,
what the individual believes family and friends think they should do). Furthermore, attitudes and
subjective norms are each comprised of two components. Attitude toward the specific behavior is a
function of the individual’s set of beliefs concerning the possible consequences for taking the action,
weighted by an evaluation of the importance of the outcome. Subjective norms are determined by an
individual’s beliefs about what salient others (e.g., family and friends) think he or she should do regarding
the behavior, weighted by the individual’s motivation to conform to others’ wishes.

35
 Figure 5: Theory of Reasoned Action

General attitude
(Beliefs of consequences)
towards
multiplied by
protective
(Value of consequences)
behavior

Intention to
Performance
engage in
of behavior
behavior

(Perception of others desires) General social

multiplied by expectations
(Motivation to comply with desires) regarding behavior

(Source: Ajzen, I. & Fishbein, M., 1980)

While behavioral intention is a cause of behavior, it is not usually sufficient in itself to predict behavior.
Background, personality, and other social and psychological variables influence attitude and subjective
norms. Attitude and subjective perceptions of norms have an effect on intention. In turn, intention
influences behavior.43,44

Following his conceptualization of the Theory of Reasoned Action, Ajzen later proposed a Theory of
Planned Behavior, which is an extension of the Theory of Reasoned Action.45,46 A third conceptually
independent variable (the first being attitude, the second subjective norms), perceived behavioral control,
was added to the Theory of Planned Behavior. Perceived behavioral control is defined as the perceived
ease or difficulty of performing the behavior, and is factored into the person’s intention to perform the
behavior.

As applied to an adolescent pregnancy prevention intervention, factors from this theoretical framework
that should be emphasized include attitudes (e.g., whether adolescents view having a child early in life as
a positive or negative event), perceived norms (e.g., what adolescents believe their family and friends
think they should do regarding delaying sexual activity and pursuing further education), and perceived
personal control (e.g., whether adolescents feel they have the negotiation skills to delay having sexual

36
intercourse). Other factors to emphasize in educational, counseling, and media interventions include
perception of consequences, perception of barriers to taking protective action, and perceived support from
other people who matter to the adolescent, such as his/her partner. Threat appraisal, in the form of
personal vulnerability to pregnancy or decision-making skills, should also be stressed in the intervention.

5. Social Learning Theory

Social Learning Theory posits that behavior is the result of “reciprocal determinism”—the continuing
interaction between a person, the behavior of that person, and the environment within which the behavior
is performed. The constant interaction between these factors is such that a change in one has implications
for the others. Behavior can result from the characteristics of a person or an environment, and it can be
used to change that person or environment as well. Behavior is viewed not in isolation, but rather as the
outcome of the dynamic interaction of personal and environmental variables.

The two most important variables that Social Learning Theory takes into account are self-efficacy and
modeling. Self-efficacy, or the confidence in one’s ability to successfully perform a specific type of
action, is considered by Bandura (the “father” of Social Learning Theory) to be the single most important
aspect of the sense of self that determines one’s effort to change behavior.46 That people learn not only
from their own experience, but from the actions and reactions of others as well, is defined as imitation or
modeling, a basic premise of Social Learning Theory. Other important variables include knowledge,
skill, problem-solving, expectations, self-control, emotional coping, perception of the environment,
attitudes, beliefs, intent, and motivation. The term “personal variable” refers to an objective notion of all
the factors that can affect an individual’s behavior that are physically internal to that individual.
“Environmental variables” include observational learning (modeling), reinforcement, family members,
peers, friends, opportunities and norms—in short, all the factors that can affect a person’s behavior that
are physically external to that person.47

In applying Social Learning Theory to adolescent pregnancy prevention, a major component would be
modeling: adolescents imitate behavior from others in their environment through observational learning.
It is often the job of health educators and counselors to help adolescents recognize that different,
sometimes conflicting, social norms may well exist in their community or environment. The messages
they receive about sexual behavior from the media, from their peers, or from family members, religious
leaders, and others, will almost inevitably be different to some extent. By providing adolescents with an
increased awareness of the influence of other significant individuals in their lives, as well as knowledge
and negotiation skills about abstinence and contraceptives, the chances of an unplanned pregnancy can be

37
lessened. In addition, by utilizing observational learning, adolescents can learn and practice appropriate
pregnancy prevention behaviors through guidance from mentors, parents, friends, teachers, community
role models, and the media. The greater the reinforcement across all these sectors, the greater the
likelihood of successful transmission and acceptance of the message. These personal and environmental
variables are examples of factors that should be emphasized by the program staff as part of their
education and counseling efforts.

6. Attribution Theory

Central to Attribution Theory is the assumption that people ask the question “Why?” to ascribe causes and
make sense of the world. Attribution Theory describes the behavioral process of explaining events and
the behavioral and emotional consequences of those explanations. Assignment of causes to conditions
(the situations and individuals’ experience) is believed to make effective management possible and guide
future action. Internal attributions (those that are the result of the individual’s own actions) and external
attributions (those that are due to luck or chance), personal forces, and environmental factors all operate
on the individual. The balance determines the attribution of responsibility that the individual ascribes to
his or her own ability to influence change.

The kinds of attributions individuals generate have significant implications for subsequent thoughts,
expectations, feelings and actions. Internal attributions for failure, such as failing to seek a volunteer
opportunity in the community or to use a contraceptive because it was inconvenient or would “spoil the
mood,” result in deficits in self-esteem. In contrast, external attributions for failure, such as the inability
to find any community opportunities to develop computer skills or to obtain contraceptives, do not result
in deficits in self-esteem.

Individuals are in some part information seekers who try to lessen ambiguity in their lives. Attributions
render the world predictable and controllable. Individuals are especially motivated to conduct
attributional searches when faced with ambiguous, extraordinary, or uncontrollable situations (e.g.,
illness) and ask “Why me?” They then attempt to explain why something did or did not happen.
With regard to adolescent pregnancy, the factors that bear emphasis within this theoretical framework
include self-efficacy and conviction about one’s ability to take corrective action, e.g., giving an
adolescent the tools and sense of self-confidence and capacity to delay early childbearing. The adolescent
could also be counseled concerning their perceived perceptions of the consequences of an unintended or
mistimed pregnancy, emotional coping responses, and learning from past experiences. For example, a
family planning counselor might wish to emphasize how the adolescent was feeling as she was waiting

38
for pregnancy test results, and encourage her to consider how she can avoid this anxiety in the future. Or,
the counselor could emphasize how much the adolescent had expressed a desire to go to college, and how
raising a child at this point in her life would interfere with that dream.

7. Protective Motivation Theory

Protective Motivation Theory emphasizes cognitive processes in mediating attitudinal and behavioral
change (Figure 6). Motivation to act is based on threat appraisal (an individual looks at the severity and
magnitude of an event and the probability that the event will occur to them) tempered by coping appraisal
(the individual assesses the efficacy of a protective action and his/her ability to cope with stressors). A
self-efficacy component is built into the model. Individuals must believe that they have the ability to
adopt a new behavior and ward off the perceived threat. Information about the threat provides the
impetus for action and changes in beliefs.

As applied to pregnancy prevention, Protective Motivation Theory posits that individuals are most likely
to avoid pregnancy if: 1) they believe there is a good chance of becoming pregnant (or impregnating
someone), and if 2) they protect themselves (either by abstaining or using an effective method of birth
control). Reinforcement is also built into the model; internal and external rewards increase the likelihood
for action.50

In applying this theoretical framework to the development of an adolescent pregnancy prevention

program, the perception of consequences and external rewards are factors that should be emphasized. For
example, a teenager who presently wants to delay having a child so that they can go into vocational
training will seek avoiding pregnancy and thus reflect on the perceptions of the potential consequences if
the pregnancy does occur. External motivating rewards should also be emphasized in counseling
teenagers, for example, considering how much more supportive their relationship with their family will be
if they pursue future aspirations that don’t involve being a teenage parent.

Other important components of Protective Motivation Theory are perceived barriers to taking protective
actions, achievement motivation, and self-control. These three variables all affect attitudinal and
behavioral change, and their messages can easily be incorporated into a variety of settings, including
schools, recreational settings, and media campaigns.48 For example, a counselor can help an adolescent
understand situational factors, such as being alone with a boyfriend and drinking, that threaten her ability
to protect herself against the risk of pregnancy or an STI (alcohol may present a barrier to taking self-
protective action). It is particularly useful for the adolescent to learn not only how to identify these

39
situational factors herself, but to have the ability to control them (self-control to avoid alcohol particularly
when she is alone with her boyfriend), thus protecting herself from the possibility of pregnancy and
failure to complete school, reflecting achievement motivation.

Figure 6: Protective Motivation Theory

Communication Specific Beliefs Acceptance

Factors

Magnitude of Appraised
Noxiousness Severity

Intention to Adoption of
Probability of Expectancy Protection Adopt protective
Occurrence of Exposure Motivation Recommended behavior
Response

Efficacy of Effectiveness
Recommended of Coping
Response Response

(Source: Rogers, R.W., 1975)

8. Self-Regulation Theory

This model acts on the principle that individuals operate like feedback systems, regulating their
relationships to the environment (Figure 7). They establish goals, generate methods for meeting these
goals, and then establish criteria for monitoring progress toward their goals. The information gleaned
from this monitoring process is used to alter coping techniques, establish new criteria for revising goals,
and evaluating responses. Individuals are viewed as active problem solvers who attempt to bring their
current state closer to their goal state. This model specifically includes an emotional component,
acknowledging that emotional responses to threats may be perceived differently than cognitive responses.
The individual’s sense of efficacy, the belief that they can plan and act in a certain manner, generates
emotions which affect their coping reactions.

Leventhal, Meyer, and Gutmann (1980)49 contribute the following notable components of the Self
Regulation Model:

40
• Extracting information from the environment.
• Generating a representation of the danger of the illness to oneself.
• Planning and acting (including imagining response alternatives to deal with problems and the
emotions they generate, then taking actions to achieve specific effects).
• Monitoring or appraising how one’s coping reactions affected the environmental problem and oneself.

In the application of this theoretical framework to adolescent pregnancy prevention, threat appraisal,
problem solving, and achievement motivation should be stressed. How adolescents view becoming
pregnant or impregnating their partners is an obvious example of threat appraisal, and how to demonstrate
love for one’s partner without the fear of pregnancy is an example of problem solving. In addition,
achievement motivation, such as how to delay childbearing will help adolescents achieve mutual goals, a
component that can also be stressed and reinforced by parents, counselors, teachers, and other mentors.
Other factors of importance include personal perceptions of consequences, perceived barriers to taking
protective action, personal goals, self-efficacy, decision making, emotional coping responses, personal
power, and self control.

Figure 7: Self-Regulation Theory

Current State Goal State

Reassessment of gap between current and goal states

Coping
techniques
altered

Criteria for
Goals Progress of
meeting goals Goals met
established goals
established
monitored

New criteria for

revising or
meeting goals
established

(Source: Levanthal, H., Meyer, D., & Gutmann, 1980)

9. Relapse Prevention Theory

Relapse Prevention Theory is less a theory than it is a generic term referring to a broad range of strategies

41
designed to help individuals anticipate and cope with lapses in appropriate behaviors. In achieving
behavior change, individuals typically go through the stages of initiation, modification, cessation of the
old behavior, and maintenance of cessation. Relapse can occur at any time during this cycle. An
individual who has “relapsed” has experienced a breakdown or failure to alter or change a specific habit
pattern and has returned to previous habits. Further, the individual’s beliefs about the course of
behavioral outcomes and causes of relapse affect outcome behavior. For example, individuals who
believe they will not be able to avoid becoming pregnant and as a result don’t use effective protection,
will likely engage in sex without protection and become pregnant. On the other hand, individuals who
understand that the outcome of relapse (pregnancy) necessitates an active behavior of abstinence or
utilizing effective birth control, and then acting on that understanding, are less likely to become
pregnant.51

Figure 8: Relapse Prevention Theory

Decreased
Coping Increased
probability of
Response self-efficacy
relapse

High-risk
situation

Decreased
self-efficacy

Positive
outcome Guilt and Increased
No coping experiences Initial use of
perceived probability of
response (for initial substance loss of relapse
effects of control
substance)

(Source: Marlatt, G. A., & Gordon, J.R., 1985)

Three high-risk situations are primarily associated with relapse: negative emotional states (the individual
is in a bad mood, frustrated, angry, anxious, lonely, depressed or bored); interpersonal conflict (a recent

42
or ongoing conflict with a partner, friend, family member or employer); or social pressure (the individual
is responding to another person or group who influence the individual to perform the negative behavior).
Implemented primarily in programs that address addictive disorders, Relapse Prevention Theory focuses
on changing habitual patterns through the use of self-management and self-control techniques. As applied
to pregnancy prevention, self-management/self-control techniques might mean avoidance of sex without
contraception. The concept of self-efficacy (e.g., belief in one’s ability to prevent pregnancy) is an
important component of Relapse Prevention Theory. Avoidance of addictive patterns (e.g., unsafe sex)
depends on an individual’s measure of self-efficacy, with the likelihood of relapse dependent upon the
strength of that measure.

10. PRECEDE Framework

Largely a heuristic framework, PRECEDE is presented as a planning model rather than as a formal
theory. The overriding principle of this model is that behavior change is voluntary in nature. This
framework seeks to empower individuals with knowledge, understanding, skills, motivation and
community involvement to improve their quality of life. As applied to pregnancy prevention, individuals
have knowledge and understanding of their sexual behavior, the skills to avoid pregnancy-risk behaviors,
the motivation to want to avoid these behaviors, and the community involvement to change policies and
regulations which influence pregnancy-risk behaviors.

PRECEDE is the acronym for “predisposing, reinforcing and enabling constructs in educational diagnosis
and evaluation.”52 Three classes of factors have been identified as “pre-behavioral” (antecedents to
behavior) and as having the potential for affecting health behavior:
1. Predisposing factors or personal preferences (attitudes, beliefs, values, perceptions) that provide
the motivation or reason behind the behavior change. Although self-efficacy is included as a
construct, demographic characteristics were dropped from this category as they are not readily
susceptible to intervention or change and are reflected in other constructs of all three pre-
behavioral factors of PRECEDE.
2. Reinforcing factors or rewards or reinforcements refers to the feedback individuals receive from
others and the environment. These incentives, such as praise, social support, or alleviation of
symptoms contribute to repetition or persistence of behaviors.
3. The final pre-behavioral construct, enabling factors, includes objective characteristics of
individuals, communities and environments that support or hinder behavioral change. Enabling
factors include objective, not perceived barriers. Perceived barriers fall under the category of
predisposing factors. Enabling factors allow individuals to overcome objective barriers by

43
 providing the means to act on their predispositions by means of available resources, supportive
policies, assistance and services.

Figure 9: The PRECEDE Framework

Predisposing
factors:
knowledge,
attitudes, values
and perceptions

Health Enabling factors:

education availability of
components of Behavioral Quality of life
resources, accessability,
health causes
referrals and skills
program

Policy
Regulation
Reinforcing factors:
attitudes and behavior of
health and other
personnel, peers,
parents, employers, etc.

(Source: Green, L. W., Kreuter, M. W., Deeds, S. G., & Patridge, K.D, 1980)

The factors to emphasize in an adolescent pregnancy prevention program include predisposing, enabling,
and reinforcing factors. Predisposing factors provide the impetus or rationale for a behavior (e.g.,
choosing to continue with one’s education instead of having a baby) and enabling factors provide the
means for people to act on their predilections (e.g., ready access for adolescents to good educational
institutions and transportation and supplies). Reinforcing factors provide ongoing rewards or incentives
that contribute to repetition or persistence of behaviors (e.g., earning good grades and continuing with
one’s education as a viable alternative to early childbearing).52

11. Psychosocial Model

Based on Systems Theory, the Psychosocial Model posits that people have problems in living due to the
disequilibrium between themselves and their environments. Dealing with a multiplicity of psychological,
family, and social forces at work, individuals try to find a “goodness of fit” between themselves and their

44
environments. In striving toward this goodness of fit, individuals attempt to change aspects of themselves
or conditions in their environments.

This model attempts to help individuals better shape their environments and to enhance their self-esteem
and perception. Individuals are not expected to merely adjust to their systems; rather they learn to
negotiate them. Once individuals learn behaviors, they can use what has been learned to solve future
problems.53

The Psychosocial Model asserts that an individual’s current functioning is influenced by his or her past,
as well as current events. For example, a female adolescent who has not practiced effective contraceptive
use in the past and has not yet become pregnant may mistakenly believe she will never get pregnant.
Also, a past pregnancy may influence later pregnancies. In fact, research has demonstrated that young
women who become pregnant before the age of 20, often become pregnant a second time due to a
confluence of different factors. An adolescent who has experienced academic failure is likely to be
impacted in her future efforts to improve her academic standing, even if an academic tutoring program is
actually available.54

In addition to past and current events, other external factors, such as the opinions, statements, and actions
of a significant other will influence an individual’s perceptions. An individual does not react to the
environment as it exists, but rather, as he or she sees it. For example, misperceptions are not due to an
individual’s personality alone; rather they may result from direct experience (past and current) and also
the opinions of trusted others. The power of a trusting relationship can be used positively, as when
parents communicate with their children about their future goals and dreams. Conversely, trusting
relationships can have a negative influence, as when peers provide misinformation (“You can’t get
pregnant the first time,” etc.). This trusting relationship can be utilized on a broader level in the form of
incorporating responsible community social norms concerning sexual activity, implementing more
mentoring programs, and creating more adult relationships with youth.

This model stresses that behavior must be viewed from a multiple-level approach.53 Five levels of
influence have been identified regarding health-related behaviors, including:
1) Intrapersonal, or individual factors, including an adolescent’s knowledge and skills regarding their
options, including abstinence and the use of birth control;
2) Interpersonal factors, such as communication skills between adolescents and their partners and
families;

45
 3) Institutional or organizational factors, such as the availability of tutoring and academic enrichment
programs, summer jobs, mentoring opportunities, as well as contraceptive services through
community clinic and outreach workers;
4) Community factors, such as a established norms or a community-based media campaign aimed at
supporting youth and their life options; and
5) Public policy factors, such as the availability of government-subsidized youth programs and
services provided to adolescents.

All five levels of factors must be taken into account when planning a health promotion intervention.

12. Social Ecology Theory

Using this theoretical framework, health promotion, and specifically pregnancy prevention, is viewed not
only from an individual perspective, but rather more broadly, as the individual is embedded in and
influenced by numerous systems or groups. Whether an individual feels supported or neglected by these
systems also impacts behavior. Thus, if social institutions do not invest in young people’s futures, preg-
nancy becomes an attractive alternative where personal meaning is gained through becoming a parent,
even prematurely.55

Social Ecology Theory was developed as a response to the severity and complexity of chronic health
conditions that are rooted in a larger social, cultural, political and economic fabric.56 Traditionally, the
emphasis on risk for unhealthy behaviors that can lead to pregnancy has been placed on individual
factors. As a result, the majority of health promotion programs often focus solely on changing individual
characteristics, rather than seeking to change environments, laws or policies. Social Ecology Theory
understands and addresses the fact that behavior does not occur in a vacuum. This theory incorporates
environmental resources and interventions as an adjunct to interventions that are solely targeted to the
individual level.

Social Ecology Theory assumes that the effectiveness of health promotion (i.e., pregnancy prevention)
can be enhanced through multilevel intervention packages that combine both behavioral and
environmental modification strategies.55 The current wisdom in health promotion holds that ignoring
behaviors beyond those at the individual level will produce less of an impact on health status.
In applying Social Ecology Theory to pregnancy prevention, two key elements must be emphasized.
First, it is important to integrate health promotion interventions across multiple life domains, such as the
home (family members practice open communication concerning values related to education, personal

46
responsibility, delaying sexual activity and /or supporting contraceptive use), the school (including
comprehensive school-based family life education curriculum and academic enrichment programs, tutor-
ing, and job shadowing), the community (employment and recreational opportunities for youth,
mentoring, and health services that are affordable and accessible in the community), and in political
settings (including legislation addressing poverty issues). The second key element, opportunities for
enhancing community well-being, can be realized through cultural change. For example, through the
transformation of norms, values and policies regarding the need to invest in young people, social support
for comprehensive youth programs can be strengthened.

13. Theory of Gender and Power

The Theory of Gender and Power is a social structural model that seeks to understand women’s risk as a
consequence of different social structures.57 According to this theory, three major structures characterize
gendered relationships between men and women: The sexual division of labor, the sexual division of
power, and the structure of cathexis.58 These three overlapping structures serve to explain how and why
many people assume gender roles. These structures exist at the societal level and at the level of social
institutions. Examining structural inequalities in these areas enable one to assess the exposures and risk
factors of all three structures as they interact to cause an adverse impact on women’s (and men’s) health.

Table 5: The Theory of Gender and Power on Women’s Health and Teenage Pregnancy
Societal Level Institutional The Social Exposures Risk Biological Disease
Level Mechanisms Factors Factors
Sexual Division of Work Site Manifested as Economic Socio-
Labor School unequal pay, which exposures economic
Family produces economic Risk factors
inequities for women
Sexual Division of Relationship Manifested as Physical Behavioral Douching HIV
Power Medical imbalances in control Exposures Risk Pregnancy
System which produces Factors Contraceptive
Media inequities in power Use
among women
Structure of Relationships Manifested as Social Personal
Cathexis: social Family constraints in exposures risk factors
norms and affective Church expectations, which
attachments produce disparities in
norms for women
(Source: Wingood and DiClemente, 2002)

In applying the theory of gender and power, it is assumed that gender-based inequities and disparities in
cultural expectations that arise from each of the three structural components produce differing risk factors
that shape teen risk for unintended pregnancy and STIs. Risk factors here are understood as external to

47
teens that may influence their sexual risk taking behavior and subsequently, their likelihood for
unintended pregnancy. In the theory of gender and power, each structure can not be examined without
also examining the others because each structure constitutes different risk factors and exposures that
increase young women’s vulnerabilities. Thus, it is imperative that all three structures are examined as
overlapping.

IV. Synthesizing Theories and Models to Fit Your Community’s Teen

Pregnancy Goals

Theoretical Models and Their Application to Health Promotion Practice

In reviewing various theoretical frameworks, it may appear difficult to choose the correct model when
planning a specific intervention or when re-conceptualizing or making changes in an existing program.
The choice of which theoretical framework to apply (or which combination of elements from one or more
theories) will depend on: 1) the specific level at which change is targeted (e.g., individuals, groups,
organizations, and/or overall communities), 2) the desired change, and 3) the type of behavior your
program or intervention seeks to address.

Public health problems must be approached from multiple levels. In addition to education and
counseling, interventions aimed at behavior change must also include such components as planning,
community support, and organizational change. These components must be addressed by whatever
theoretical frameworks are adopted. There are three primary levels at which to develop and implement an
intervention: individual, interpersonal, and community. The individual level is the most basic level of
health promotion practice, where the focus is on behavioral factors such as knowledge, attitudes, and
beliefs and skills, motivation and past experiences regarding academic success, sense of future, and
sexual activity, contraception and pregnancy. Adults must also consider their own behavior and modeling
in these arenas and whether or not they exhibit responsible behavior, for example, in planning for their
own lives, including thinking about their education plans, delaying childbearing and protecting
themselves against STDs. The viable alternatives to early childbearing they and their communities
provide to adolescents must also be considered, including opportunities for adolescents to connect with
and strengthen the one-to-one relationships with meaningful adults in their lives.

At the interpersonal level, people interact with the beliefs, advice, and support of others concerning life
opportunities, the impact of sex and pregnancy, and help model their own feelings, behaviors and health.
Family, peers, co-workers, and others in the individual’s environment can and do influence individual

48
behaviors. The interpersonal level also includes factors related to the individual’s perceptions of and
interaction with their environment.

Community health promotion practice goes beyond the individual and addresses environmental influences
and interpersonal relationships through some kind of comprehensive effort. Programs and policies that
support youth assets, such as interventions that combine mentoring, academic tutoring, recreation,
mentoring, life skills training, and health and mental health care, are important elements that must be
included in community-level pregnancy prevention programs. It is also important to note that many of
these programmatic elements are not relevant solely to adolescent pregnancy prevention, but to the
prevention or amelioration of other adolescent risk-taking behaviors, such as drug and alcohol use, as
well.

Finally, at the social-structural level, people’s exposures to organizations, institutions, and cultural
expectations and patterns are considered as shaping people’s actions and meanings applied to those
actions. Access to education, job training, cultural resources, and other means of moving one out of
poverty and low educational attainment situations are understood as capable of reducing risk.
All the theoretical frameworks discussed in this document can be classified according to either the
individual, interpersonal, or social-structural level of intervention. However, some theories do not
necessarily fit neatly into one level, and instead intersect at two levels. For example, while the Health
Belief model primarily addresses individual factors regarding behavior change, external rewards are built
in as well. Thus, environmental influences do interact with individual characteristics.

Which theoretical frameworks or combination of theories to apply to a specific pregnancy prevention

program or community-wide adolescent pregnancy prevention initiative depends upon where the change
is directed. The premise that underlies most current thinking is that comprehensive, multifaceted
interventions are needed at all three levels: individual, interpersonal, and community. Thus, as program
planners consider which frameworks to apply, they should consider the overall approach they are
planning to pursue. One particular agency does not need to be responsible for offering interventions at all
levels. In fact, collaborative efforts among different agencies and stakeholders may very well help
mobilize the multiple concurrent efforts that are needed and directed at both the individual and the
community levels.

The Transtheoretical Model, for example, directs the level of intervention primarily at the individual.
This model focuses on various stages of individual change with very little mention of the surrounding

49
environment. Using the Transtheoretical Model, a program may first attempt to present knowledge to
adolescents concerning their risk for pregnancy as a means of motivating them to shift from the pre-
contemplation stage into contemplation, where direct service providers are then in a position to affect and
reinforce behavior change. Concurrently, the counselor may also incorporate aspects of the
Developmental Assets/Resiliency model that emphasize the role of self-efficacy in supporting the
individual’s sense that she or he does have the needed control over their own lives to mobilize knowledge
for constructive action, including the pursuit of education and employment opportunities as viable
alternatives to early childbearing.

Theoretical Models within an Adolescent Development Framework

An adolescent’s developmental process should also be taken into account when developing and
conducting program interventions. The adolescent’s stage of development must be carefully assessed:
providing information in too abstract a format will be ineffective with teenagers who are unable to foresee
future consequences for themselves. An adolescent who looks physically mature may be treated as an
adult by a counselor or other provider. But the young teenager who looks mature may actually still be
thinking in concrete terms and may be unable to apply abstract concepts (such as the risk of pregnancy) to
his/her own life. That adolescents who have often not matured beyond concrete thinking are treated as
abstract thinkers is problematic, because adolescents who are still thinking at the concrete level have a
narrow view of reality. They pay attention only to the immediate effects of their own actions and are not
cognitively able to consider future events. In contrast, adolescents who are abstract thinkers are able to
anticipate future events and can mobilize their efforts to prevent negative outcomes.

Erroneous perceptions of a teenager’s cognitive stage of development may well prevent reaching him or
her in the most appropriate and effective manner. Health messages and recommendations must be
conveyed in a way that is developmentally appropriate for the adolescent if they are to be truly
understood and acted on. Providers also need to recognize that adolescents who are capable of abstract
reasoning may revert back to concrete reasoning when dealing with personally challenging issues, such as
whether or not to become sexually active or encourage their partner to use a contraceptive method.
Strengthening coordination efforts across or within programs that offer both education and counseling
interventions may best facilitate the reduction in teen pregnancy. Ideally, family members, peers, teach-
ers, and other adults in the lives of adolescents would also reinforce messages of responsibility and help
provide them with the nurturing and support they need in their transition to adulthood. Program planners
also need to consider how they can develop community-wide interventions that respond to negative or

50
counterproductive forces in the social and economic environment as a means of providing viable
alternatives to early childbearing.

A Shift from Individual to Interpersonal and Social Structural Pregnancy Prevention

Approaches

Thus far, we have primarily covered individual-level approaches to adolescent pregnancy prevention
because historically these interventions have accounted for the great majority of programs. However, at
this point in the evolution of pregnancy prevention programs, we can expand our focus to interpersonal
and community-wide approaches that emphasize structural components, even though we have far less
programmatic and evaluation experience in these domains. At the interpersonal level, individual as well
as social/environmental factors must be taken into account. For example, Social Learning Theory posits
that behavior is the result of the continuing interaction between an individual, the behavior of the
individual, and the environment within which the behavior is taking place. At the interpersonal level of
intervention, an adolescent pregnancy prevention program should not only take into account personal
variables, but also structural/environmental variables that shape both behaviors and access to structural
supports, such as poverty reduction, better schools, access to resources, and community economic
development. Through links with other programs, the intervention can be aimed both at personal
characteristics (e.g., attitudes, skills, values, knowledge) and the adolescent’s interpersonal environment
(e.g., family relationships, peer contacts, mentoring, etc.).

The third level, social structural intervention, is potentially the most far-reaching. Here, interventions in
school settings, future vocational training, and educational opportunities serve as protection for teens.
Combined, productive individual and environmental interaction is further bolstered by developing an
interpersonal climate in which positive adolescent behavior is promoted and reinforced. For example,
interventions that combine decision-making skills as applied to abstinence and/or contraceptive use
(individual factors) with exposure to positive role models and affirming life experiences (environmental
factors) will produce a more comprehensive and reinforcing set of messages. This backed by an array of
institutional services, such as job training and educational opportunities that promote gender, race, and
class equity, may further ameliorate and reduce the burden of teenage pregnancy. This kind of individual
and environmental synthesis is likely to result in more effective adolescent pregnancy prevention
programs. However, arriving at a community consensus that will support and affirm both those
adolescents who are and who are not sexually active, and encourage health-promoting behaviors, requires
concerted effort. This means a consensus-building effort that involves a wide range of community
stakeholders, including young people themselves, their parents and families, as well as teachers, health

51
providers, the business sector, the faith community, community-based organizations, the media, and
policymakers.

Modifying Factors Associated with Adolescent Pregnancy

Beyond the psychological foundations espoused by theoretical frameworks that attempt to explain why
individuals practice (or fail to practice) health behaviors related to adolescent pregnancy prevention, there
are other significant modifying factors involved as well. These modifying factors are psychological and
sociological variables that also contribute to or are associated with teenage pregnancy. These variables
should not be considered as separate factors whose sole purpose is to fill in the gaps in the theoretical
frameworks; rather, these modifying factors are often intertwined with the theoretical variables previously
discussed. For example, the individual characteristics of biological, cognitive, emotional and social
development listed as modifying factors can greatly influence the adolescent’s readiness for change and
movement to the next stage, as postulated by the Transtheoretical Model. Some of these modifying
variables have already been discussed as aspects of the theoretical frameworks, but deserve special
additional emphasis. Others, such as the powerful influence of the media, and community norms on early
childbearing, can also have a great impact on teenage prevention efforts.

There are many modifying factors that influence the incidence of adolescent pregnancy, including
educational background, family characteristics, income level, and religion. By recognizing the influence
of these factors within planned interventions, practitioners can attempt to combat or lessen their impact or
their outcomes. Populations who exhibit greater numbers of sociological risk factors, such as poverty or
low educational achievement, will most probably benefit to a larger degree from a greater intensity of
program interventions tailored to their specific needs.

Another way to combat negative modifying factors is for planners and practitioners to be creative in
intervention approaches. While a counselor or other service provider may not be able to change certain
negative family characteristics that affect the adolescent, he or she can still provide an effective
intervention. If a teenager has a drug-addicted mother and an absent father, that doesn’t mean the child is
doomed to fail. In fact, this young person can still graduate from high school or college and be a role
model to siblings, although formidable challenges must be overcome. The process of adolescent self-
actualization does not have to come from being student body president at school, and health educators and
providers can help emphasize the point. Acting as head of the household and taking care of the family
can draw out a positive sense of self-actualization too. It is the job of the provider to first identify the

52
modifying variables involved, and if they are “deficits,” they can then help the adolescent understand how
strengths (assets) can arise from deficits, and place more emphasis on the assets side of the ledger.

Table 6 shows a list of modifying factors, all of which have been associated with an increased likelihood
of adolescent pregnancy.1 The modifying factors were collected from a review of the literature that has
identified those factors which have been shown to have the greatest influence with regard to the behaviors
that are known to be related to adolescent pregnancy. Although many of these factors are powerful in and
of themselves in explaining human behavior, they should not be seen as directly causal.

Although all of the modifying factors are important and should be considered as potential points for
intervention, health behavior and pregnancy prevention research have consistently found four factors to
be particularly influential: poverty, adolescent development, family variables, and incidence of sexual
abuse. These four modifying factors therefore are given particular attention in this section. While a
formal body of research continues to be developed in the field of adolescent pregnancy prevention, there
is nevertheless a growing awareness of the relationship and co-variance between modifying factors and
adolescent pregnancy. Profiles of adolescent risk-taking behavior that include sexual activity and tobacco,
drug and alcohol use have documented the clustering of these modifying factors.59

Poverty

Many social structural variables are correlated with each other, further compounding the likelihood of
pregnancy. For example, a low income level and low educational attainment, two risk factors for
unintended pregnancy, are highly correlated. In fact, low income is related to almost all of the risk factors
for pregnancy, including ethnicity, parental education level, family structure, having a mother who was a
teenage parent, living in foster care, doing poorly in school, having low aspirations, and already being a
teenage parent. Many risk factors antecedent to early childbearing are far more prevalent in adolescents
from low socioeconomic backgrounds and are often the result of living in poverty.1 For example, an
individual who does poorly in school is likely to have low aspirations and as a result drop out of school,
have a low education level and a low socioeconomic status. This fact underscores the importance of
including psychological and social structural variables in pregnancy prevention strategies, as well as
considering important points of intervention that result from these factors.

For example, while resolving the problem of poverty altogether may not be fully possible, recognizing
and addressing some of the causes of poverty (such as poor education, lack of access to job training
programs, and structural inequalities), as well as the effects that poverty has on adolescents is possible.

53
Building some tangible alternatives into the portfolio of program interventions allows for more effective
outcomes. While it is not realistic for a family planning clinic to contemplate establishing a youth
employment or academic tutoring program, memoranda of understanding and active referral relationships
can be established with programs in the community that do provide these opportunities and services.
Thus, the family planning clinic can play an active role in screening and triaging clients for other services
it cannot provide. Although some family planning counselors may view this as an extra burden, they
need to recognize the interrelationships between personal motivation, a sense that a decent future is
possible, and the likelihood of increased contraceptive compliance.

Adolescent Development

Biological, cognitive, social and psychological factors make up adolescent development. Precocious
biological development is related to early sexual behavior and pregnancy. Early biological development
often results in a gap between biological and cognitive development. An adolescent who is biologically
ready for sex may lack the cognitive ability to assess the risk of pregnancy or to seek contraceptive care in
a timely manner. This gap between physical and cognitive maturity often contributes to the high inci-
dence of unintended teenage pregnancies, particularly among younger adolescents. The older the
adolescent at the time of sexual debut, the greater the likelihood that the adolescent will be using a
method of birth control.1

At this period of development, adolescents are often trying to determine their role in life and find their
identity.59 In this struggle for identity, teenagers often strive for independence. In their attempt to prove
that they are adult, they may engage in sexual activity, mistakenly believing that it will make them more
mature. Social pressures and wanting to fit in with their peers may also strongly impact an adolescent’s
behavior. Peer pressure is often a factor mentioned as a reason for engaging in sexual activity.1

Family Attitude and Behavior Toward Sexual Activity

At the interpersonal level, the pregnancy status of teenage girls is strongly related to the family’s
(particularly the mother’s) attitudes and behavior concerning sex. Teenagers whose mothers were
sexually active at a young age are often sexually active at a young age themselves. Daughters of mothers
who themselves were teenage parents are more likely to bear a child during adolescence. Researchers
have found that among whites, daughters whose mothers had teenage births were more than twice as
likely as daughters of older mothers to have a teenage birth. Among blacks, daughters of young mothers
were about one-third more likely to do so. Those whose mothers have permissive attitudes about teenage
and premarital sex also begin sexual activity at a younger age. Other factors that place their daughters at

54
high risk for pregnancy include lack of an adult role model, lack of support and affection, lack of su-
pervision, and a sibling who is a teenage mother.1

By ascertaining which adolescents come from homes where the adolescent’s mother or sisters were them-
selves teenage mothers, at-risk teenagers can be identified and targeted with special types of
interventions. For example, the younger siblings of teenage pregnant or parenting adolescents could
receive case management services that include special counseling, tutoring and recreational activities.
Such services could represent an especially important tool for delaying early childbearing among this
particularly vulnerable population and have been shown to be effective.60

Sexual Abuse and Violence

A history of sexual abuse is also a factor in adolescent pregnancy. Studies have found that sexual abuse
may affect a child’s or adolescent’s cognitive, psychological and emotional development.61 Here gender
and power theory clearly has a role to play as young girls are often threatened with sexual abuse and
violence. Factors that affect development can also lead to interference in adaptive functioning, including
effective use of birth control. In an empirical study, when compared with non-victimized teenagers,
victimized teenagers (those who experienced molestation, rape and sexual abuse) began intercourse one
year earlier than their non-victimized counterparts.61,62 Understanding how sexual abuse can affect an
adolescent’s childbearing behavior enables a program to address specific issues and build into it
additional safeguards against unintended pregnancy. Because of reporting requirements, this is a
particularly sensitive area that requires special training and preparation of counseling staff.

Apart from sexual abuse, youth violence was not viewed until recently as a modifying factor that was
related to adolescent pregnancy, although professionals in the field are now reporting their observation of
the correlation between violence and adolescent pregnancy. Violence can range from abuse experienced
by dating and/or pregnant adolescents at the hands of their partners, to the pressure some adolescents feel
out of fear of their own early demise to have a child before it is too late.63

55
 Table 6: Modifying Factors to Consider Building Into The Development and Evaluation of
Adolescent Pregnancy Prevention Programs

Some high-risk psychological and sociological factors to consider including in a

program development that may not be included or emphasized in theoretical models:
Structural Issues:
• Socioeconomic status (particularly poverty, lack of education, and underemployment)
• Cultural Opportunities (access to resources)
• Violence
• Gender Inequalities
• Ethnicity
Interpersonal Issues:
• Family structure and functioning
• Family stability
• Educational attainment of parents
• Adult role model
• Peer pressure
• Affection
• Supervision
• Mother’s attitude toward sex and sexuality
• Mother a teenage parent herself
• Pregnant/parenting sibling
• Number of siblings
Individual Characteristics:
• School performance and attendance
• Future aspirations
• Already a teenage mother
• Prior coercive sexual encounter
• Age of initiation of sex
• Frequency of sexual intercourse
• Use of cigarettes, alcohol and /or illicit drugs
• Number of partners i F

• Knowledge, Attitudes and Beliefs

• Early and delayed biological development (physical development)
• Cognitive development49
• Emotional development50
• Psychological development
Other Characteristics:
• Accessibility to programs and supplies
• Use of contraceptives
• Desire to become pregnant
(Source: Kirby, 2001)
It is important to include strategies to address the psychological and sociological variables encountered by
pregnancy prevention programs, and to make decisions about important points of intervention that might
counteract these modifying factors.

56
Policy and Social Context

Beyond the important modifying factors described above, adolescent pregnancy and prevention
intervention are also highly affected by the social and policy contexts that exist. Although all of the
theoretical frameworks incorporate environmental factors to some extent, two important environmental
influences that are not clearly addressed by many theories are funding and policy directives. Three of the
theoretical frameworks, Developmental Assets/Resiliency, the Psychosocial Model and Social Ecology
Theory, include administrative and policy diagnosis as a means of assessing the need for and availability
of community and organizational resources, as well as the existence of barriers and supports. Social
Learning Theory notes that the environment, including poverty level, welfare and unemployment, impact
the behavior of the individual, and readiness to change, but this theoretical framework doesn’t explicitly
make any statement about the influence of funding or political directives.

The failure to include policy directives in theoretical frameworks that drive program implementation is a
major oversight; these influences are in fact instrumental in shaping the environment and the options
available to individuals. Public policies affect programs, which in turn affect the options made available
to individuals.64 Even when individuals are highly motivated to change their behavior, they may be
limited in the steps they take due to funding and policy constraints. For example, a teenager with
ambitious educational aspirations, but whose high school lacks advanced placement courses, is at a strong
disadvantage compared to peers in better funded schools. Similarly, the teen who would otherwise be
motivated to use contraceptives, but who lives in a community that lacks teen-friendly services, may not
seek appropriate care. Policy is an integral component of effective pregnancy prevention programs, yet it
is often overlooked or inadequately considered in the development of program interventions.

The existence of concrete, highly prioritized policies that ensure the availability of youth programs and
services are key factors that have been shown to be important in affecting the incidence of adolescent
pregnancy. Sufficient funding to ensure ready access to a wide range of comprehensive programs and
services is also important. For example, classes that teach adolescents how to communicate with their
parents and partners, as well as classes that teach parents of adolescents how to communicate with their
child, can be an important component of the portfolio of approaches that a community may decide to
pursue. By offering classes to all three target populations, communication, particularly about sensitive
topics, has a greater likelihood of taking place. Social norms that promote open communication and
responsible behavior must be encouraged and reinforced by a broad range of stakeholders, including
families, schools, the media, and other community institutions. Policies and programs to improve
educational opportunities and academic success, youth service programs that concentrate on the transition

57
from school to work, and a stable financial base for adolescents and their families, are also urgently
needed. Much like a feedback loop, policy often shapes attitudes and behaviors, and in turn attitudes and
behaviors shape policy. If pregnancy prevention programs are to result in their intended outcomes,
policies and funding that support the social context of adolescent life, and that provide access to
medically accurate information and health services on an as-needed basis, must also be given highest
priority.

V. Putting It All Together

Incorporating Theory-Based Factors into Adolescent Pregnancy Prevention Programs

Program planners know that the results of a needs and assets assessment often determine many of the
actual specifics of an intervention (e.g., who receives the intervention, for how long, and what specific
strategy will be implemented). Less widely known is that theoretical frameworks can significantly
determine both the kind of information gathered through the needs/assets assessment process, as well as
in the subsequent planning and evaluation of interventions. Theoretical frameworks can also furnish the
necessary conceptual structure, as well as many specific concrete components on which to build and
implement an effective pregnancy prevention program that is aimed not only at the individual level, but
also recognizes the significance of important individuals with whom adolescents interact, and the broader
social environment.

Many different factors are embodied in the 13 theoretical frameworks we have selected as relevant to
adolescent pregnancy prevention, each with its own special level of emphasis. A selection of the most
common key attributes across these frameworks are delineated in Table 7. It is important to note that
self-efficacy, perceived barriers to taking action, and personal perception of consequences are
thematically highlighted in each of the theoretical frameworks. Threat appraisal, and perceived support
from others that matter, are noted in a subset of theories, while honesty and personal responsibility are
found in a smaller subset.

Program planners and direct service providers have a number of components to choose from when
creating pregnancy prevention interventions aimed at attitude and behavioral change. Table 8
summarizes theoretically driven factors at the individual level, including knowledge, attitudes, beliefs,
values, skills, intent, and motivation. At the interpersonal and social structural levels, the table includes
social support, social norms, the availability of programs and services, and opportunities for youth
development. Table 8 also lists prominent theory-based program components to consider incorporating

58
into adolescent pregnancy prevention interventions, including family life/sex education, peer education,
mentoring, academic remediation, media, youth groups, case management, family planning services,
community service, job training and support, and entrepreneurial development. As we have already
discussed, a formula that is comprised of family life knowledge, access to care, and youth development,
when implemented within a comprehensive strategy, can be important in successfully combating
adolescent pregnancy.

Program planners and direct service providers can include any number of different components in their
prevention programs. For example, intervention components such as family life education, family
planning services, and programs aimed at improving life options for youth all depend on such personal
factors as knowledge, attitudes, beliefs and values, skills, intent, and motivation.

A given message can be delivered by a multitude of different intervention approaches. For example,
personal goals and a sense of purpose concerning the future, which are important attitudinal factors for
adolescents who want to avoid pregnancy, can be stimulated by means of a number of different
interventions or components, including family life education, peer education, mentoring, academic re-
mediation, media messages, youth groups, community service, job training and support, and
entrepreneurial development. This is important because not all programs will be able to include all
intervention components. The important thing is to impart a consistent and reinforced message across and
through different program and adolescent pregnancy prevention initiatives. In this way, the message is
still transmitted to the adolescent, even though a specific intervention component may be absent from any
one program within a given comprehensive model of adolescent pregnancy prevention. By affirming that
a broad portfolio of possibilities exists in the community, through which adolescents receive messages
concerning abstinence, contraceptive responsibility, and a positive sense of future, planners and providers
can offer a better chance of success for at-risk adolescents, even though the pathways to successful
outcomes may be different for different segments of the population. Case Study 2 provides an example of
theory into practice in a school and community risk-reduction model applied in South Carolina and
Kansas.

Although practitioners should consider theory when designing programs, they do not have to be wedded
to using one theoretical framework only. The most effective pregnancy prevention program will perhaps
consist of providing linkages among individual, interpersonal, and social-structural interventions. One
program may not emphasize each on their own, but can create synergies with other community programs.

59
TABLE 7: Theory-Based Factors to Consider Incorporating into Program Planning By Theoretical Models of Behavioral Change

TABLE 7 MODEL AND/OR THEORY

THEORETICALLY-DERIVED Health Attri- Reasoned Social Protective Self Trans- Relapse Devel. PRECEDE Psycho- Social
Belief bution Action Learning Motivation Regulation theoretical Prevention Assets & Frame- social Ecology
FACTORS Resil. work
PERSONAL FACTORS
KNOWLEDGE:
Reproductive development
Menstrual cycle
Conception
Consequences of teenage pregnancy for all
involved
Development of relationships √ √ √ √
Family formation √ √ √ √
Contraception and reproductive health
Availability of programs for youth √ √ √ √
Availability of services for youth √ √ √ √
Availability of support for youth √ √ √ √
Availability of opportunities for youth √ √ √ √
ATTITUDES, BELIEFS, AND VALUES:
Gender roles and relationships √ √ √ √ √ √ √ √
Teenage childbearing
Perceived threat: can get pregnant from
unprotected sex
Personal perceptions of consequences √ √ √ √ √ √ √ √ √ √ √ √
Personal perceived benefits of abstinence
and contraception
Perceived barriers to talking and
√ √ √ √ √ √ √ √ √ √ √
maintaining protective action
Perceived expectations of others that
√
matter about abstinence and contraception
Balance between “here and now” and the
√ √ √ √
future
Personal goals and sense of purpose √ √ √ √ √ √ √ √ √
Optimism about the future √ √ √ √ √ √ √ √ √
Perception of self-worth (self-esteem) √ √ √ √ √ √ √
Confidence in own abilities (self-efficacy) √ √ √ √ √ √ √ √ √ √ √ √
Perceived support from others that matter √ √ √ √ √ √ √ √
Perceived value, access, and affordability √
√ √ √ √ √ √
of programs and services

Key: √ = Yes Blank Space = No or Not Directly Applicable 60

TABLE 7: Theory-Based Factors to Consider Incorporating into Program Planning By Theoretical Models of Behavioral Change

TABLE 7 MODEL AND/OR THEORY

THEORETICALLY-DERIVED Health Attri- Reasoned Social Protective Self Trans- Relapse Devel. PRECEDE Psycho- Social
Belief bution Action Learning Motivation Regulation theoretical Prevention Assets & Frame- social Ecology
FACTORS Resil. work
Ability to learn from past mistakes/lessons
√ √ √ √ √ √
learned
INTENT AND MOTIVATION
Personal power: “control over things that
√ √ √ √ √ √ √ √ √ √ √
happen to me”
Achievement motivation √ √ √ √ √ √ √ √ √ √ √
Self-control: Personal regulation of goal
√ √ √ √ √ √ √ √ √ √ √ √
directed behavior or performance
Conviction about one’s own ability to take
√ √ √ √ √ √ √ √ √ √
corrective action
Internal rewards √ √ √ √ √ √ √ √
Public recognition of the achievements and
progress made by: youth, family, √ √ √ √ √ √
neighborhood, school, and community
Readiness to change or maintain behavior √ √
ENVIRONMENTAL FACTORS
SUPPORT:
Family: love, safety, communication,
involvement, advocacy, clear boundaries
√ √ √ √ √ √ √ √
established, monitor whereabouts, high
expectations, clear rules
Other adult relationships: positive role
√ √ √ √ √ √ √
models, long-term involvement
Neighborhood: safety, caring neighbors,
√ √ √ √ √ √ √
monitoring neighbors’ behaviors
School: caring, encouraging, safe, clear
√ √ √ √ √
rules and consequences, high expectations
Peers: friends model responsible behavior √ √ √ √ √ √
SOCIAL NORMS:
Opinions/perceptions of the general public, officials, other leaders, service providers, parents, and peers about:
1. The value of youth to the community √ √ √
2. Teenage pregnancies and childbearing
3. Abstinence before marriage
4. The completion of schooling √
5. Use of contraceptives by sexually
active youth

Key: √ = Yes Blank Space = No or Not Directly Applicable 61

TABLE 7: Theory-Based Factors to Consider Incorporating into Program Planning By Theoretical Models of Behavioral Change

TABLE 7 MODEL AND/OR THEORY

THEORETICALLY-DERIVED Health Attri- Reasoned Social Protective Self Trans- Relapse Devel. PRECEDE Psycho- Social
Belief bution Action Learning Motivation Regulation theoretical Prevention Assets & Frame- social Ecology
FACTORS Resil. work
6. Access to contraceptive education
7. Access to contraceptive services
Media coverage and editorials √ √ √ √ √
Institutionalized norms: policies, laws √ √ √ √
AVAILABILITY OF PROGRAMS AND SERVICES:
Family life, abstinence and contraceptive
education, counseling, services and
supplies
Mental health √
Academic assistance to achieve potential √
Sports/clubs √ √
Job skills development √ √
Entrepreneurial skills development √ √
Mentoring, tutoring and coaching √ √
Meet real and perceived needs of youth √ √ √
Perceived quality √ √ √ √
Youth friendly location(s), times, staff,
√ √ √ √
environment
Affordable √ √ √ √
Physically accessible √ √ √ √
Culturally attuned √ √ √ √
Sufficiency: number of youth that can be
√ √ √ √
accommodated in relationship to need
OPPORTUNITIES FOR YOUTH DEVELOPMENT:
Community service starting in elementary
√ √
school
Systematic approaches to identifying talent
√ √
of youth starting in elementary school
Talent nurturing and development (e.g.,
√ √
arts, sports, academics)
Peer community: sense of belonging,
√ √ √ √
positive purposes
Geographic community: sense of
√ √ √ √
belonging
Employment opportunities √ √

Key: √ = Yes Blank Space = No or Not Directly Applicable 62

TABLE 8: Theory-Based Factors to Consider in the Development and Implementation of Adolescent Pregnancy Prevention Interventions

TABLE 8: Factors To Include As Family Peer Mentoring Academic Media Youth Case Family Community Job Entre-
Life/ Sex Education Remediation Groups Mgt. Planning Service Training preneurial
Part of Intervention Components Education Service & Support Dev’t.
PERSONAL FACTORS
KNOWLEDGE:
Reproductive development √ √ ? √
Menstrual cycle √ √ ? √
Conception √ √ √ √
Consequences of teenage pregnancy for all
√ √ √ √ √
involved
Development of relationships √ √ √ ? √ √
Family formation √ √ √ √ √
Contraception and reproductive health √ √ √ √
Availability of programs for youth √ √ √ √ √ √ √ √ √ √ √
Availability of services for youth √ √ √ √ √ √ √ √ √ √ √
Availability of support for youth √ √ √ √ √ √ √ √ √ √ √
Availability of opportunities for youth √ √ √ √ √ √ √ √ √ √ √
ATTITUDES, BELIEFS, AND VALUES:
Gender roles and relationships √ ? ? √ √ √ √ √ √
Teenage childbearing √ √ √ √ ? √ √
Perceived threat: can get pregnant from
√ √ √ √ ? √
unprotected sex
Personal perceptions of consequences √ √ √ √ ? √ √
Personal perceived benefits of abstinence
√ √ √ √ ? √
and contraception
Perceived barriers to taking and
√ √ √ ? √ √ √
maintaining protective action
Perceived expectations of others that
√ √ √ ? √ √
matter about abstinence and contraception
Balance between “here and now” and the
√ √ √ √ √ √ √ √ √ √
future
Personal goals and sense of purpose √ √ √ √ √ √ ? √ √ √
Optimism about the future √ √ √ √ √ √ ? √ √ √
Perception of self-worth (self-esteem) √ √ √ √ √ √ √ √ √
Confidence in own abilities (self-efficacy) √ √ √ √ √ √ √ √ √ √
Perceived support from others that matter √ √ √ √ √ √ √ √
Perceived value, access, and affordability
√ √ ? √ √ √ √
of programs and services
Caring: places high value on helping
√ √ ? ? √ √ ? ?
others

Key: √ = Yes ? = Could Apply Blank Space = No or Not Directly Applicable 63

TABLE 8: Theory-Based Factors to Consider in the Development and Implementation of Adolescent Pregnancy Prevention Interventions

TABLE 8: Factors To Include As Family Peer Mentoring Academic Media Youth Case Family Community Job Entre-
Life/ Sex Education Remediation Groups Mgt. Planning Service Training preneurial
Part of Intervention Components Education Service & Support Dev’t.
Integrity: acts of convictions and stands
√ √ ? ? √ ? ?
up for beliefs
Honesty: tells the truth even when it is not
√ √ ? ? √ ? ?
easy
Responsibility: accepts and takes personal
√ √ ? √ √ √ √ √ √ √
responsibility
SKILLS:
Communications and other interpersonal
competencies: empathy, sensitivity, √ √ √ √ √ √ √ √ √ √
friendship skills
Cultural competence: comfort with
√ √ √ √ √ ? ?
diverse people
Threat appraisal √ √ √ √ √ √ √
Problem solving, planning, and decision
√ √ √ √ √ √ √ √ √
making
Negotiation: relationships, abstinence,
√ √ √ √ √ √ ?
contraceptive use
Resistance √ √ ? √ √ ? ?
Emotional coping responses, including
√ √ √ √ √ √ √ ? ?
stress management
Studying, learning, and testing √ √ √ √ √ √ ? √
Entrepreneurial and job skills ? √ √ ? ? √ √ √
Time management and constructive use of
√ √ √ √ ? √ √ √ √
time
Learn from past mistakes/lessons learned √ √ √ √ ? ? √ √ √ √ √
INTENT AND MOTIVATION:
Personal power: “control over things that
√ √ √ √ √ √ √ √ √ √
happen to me”
Achievement motivation √ √ √ √ √ √ √ √ √
Self-control: Personal regulation of goal
√ √ √ √ √ √ ? √ √ √ √
directed behavior or performance
Conviction about one’s own ability to take
√ √ √ √ √ √ √ √ √ √
corrective action
Internal rewards √ √ √ √ √ √ √
Public recognition of the achievements and
progress made by: youth, family, √ √ ? ? √ √ ? √ ? √
neighborhood, school, and community
Readiness to change or maintain behavior √ √

Key: √ = Yes ? = Could Apply Blank Space = No or Not Directly Applicable 64

TABLE 8: Theory-Based Factors to Consider in the Development and Implementation of Adolescent Pregnancy Prevention Interventions

TABLE 8: Factors To Include As Family Peer Mentoring Academic Media Youth Case Family Community Job Entre-
Life/ Sex Education Remediation Groups Mgt. Planning Service Training preneurial
Part of Intervention Components Education Service & Support Dev’t.
ENVIRONMENTAL FACTORS
SUPPORT:
Family: love, safety, communication,
involvement, advocacy, clear boundaries
√ √ √ √
established, monitor whereabouts, high
expectations, clear rules
Other adult relationships: positive role
√ √ √ ? ?
models, long-term involvement
Neighborhood: safety, caring neighbors,
√ ? ?
monitoring neighbors’ behaviors
School: caring, encouraging, safe, clear
√ ? √ √
rules and consequences, high expectations
Peers: friends model responsible behavior √ √ ? √
SOCIAL NORMS:
Opinions/perceptions of the general public,
officials, other leaders, service providers,
parents, and peers about:
The value of youth to the community √ √ √ √
Teenage pregnancies and childbearing √ √ √
Abstinence before marriage √ √ √
The completion of schooling ? √ ? ?
Use of contraceptives by sexually active
√ √ √
youth
Access to contraceptive education √ √ √
Access to contraceptive services √ √ √
Media coverage and editorials √
Institutionalized norms: policies, laws √
AVAILABILITY OF PROGRAMS AND SERVICES:
Family life, abstinence and contraceptive
education, counseling, services and √ √ √ √
supplies
Mental health √ √ ?
Academic assistance to achieve potential √ √ √ ?
Sports/clubs √ √
Job skills development √ √ √ √ √
Entrepreneurial skills √ √ √
Mentoring, tutoring, and coaching √ √ √ √ √

Key: √ = Yes ? = Could Apply Blank Space = No or Not Directly Applicable 65

TABLE 8: Theory-Based Factors to Consider in the Development and Implementation of Adolescent Pregnancy Prevention Interventions

TABLE 8: Factors To Include As Family Peer Mentoring Academic Media Youth Case Family Community Job Entre-
Life/ Sex Education Remediation Groups Mgt. Planning Service Training preneurial
Part of Intervention Components Education Service & Support Dev’t.
Meet real and perceived needs of youth √ √ √ √ √ √
Perceived quality √
Youth friendly location(s), times, staff,
? √ √ √ √ √
environment
Affordable ? √ ?
Physically accessible √ √ √
Culturally attuned √ √
Sufficiency: number of youth that can be
√ √ √ √ √
accommodated in relationship to need
OPPORTUNITIES FOR YOUTH DEVELOPMENT:
Community service starting in elementary
√ √
school
Systematic approaches to identifying talent
√
of youth starting in elementary school
Talent nurturing and development (e.g.,
? √ √ √
arts, sports, academics)
Peer community: sense of belonging,
√ √ √ √
positive purposes
Geographic community: sense of
√ √ √ √
belonging
Employment opportunities √ ? ? ? √ √

Key: √ = Yes ? = Could Apply Blank Space = No or Not Directly Applicable 66

 Case Study 2: Applying Theory to Programs: The School/Community Sexual Risk
Reduction Model

An example of a successful program that has incorporated both a theoretical framework and multi-
component school and community-based strategies to reduce adolescent pregnancy was originally
developed in South Carolina and replicated in several communities in Kansas.65 This comprehensive
strategy seeks to forge alliances among parents, teachers, the faith community, community leaders, and
young people themselves. These alliances are designed to reinforce sexual abstinence, help promote
healthy decisions by youth and support access to contraceptives for those adolescents who are sexually
active. Key components include the following:

• Provide teachers with graduate level education about sexuality.

• Strengthen age-appropriate, comprehensive, sexuality education in public schools.
• Survey adolescents’ sexual behavior.
• Involve the faith community in facilitating communication within families about sexuality issues.
• Implement school- and community-based counseling programs.
• Enhance access to health services for adolescents.
• Engage peer support and education.
• Offer skill development activities as alternatives to early parenthood, including alternative
activities for youth provided by schools, religious organizations, and community organizations
such as city parks and recreation programs.
• Involve the entire community, including parents, young people, the faith community, businesses,
health and community-based organizations, and the media in facilitating social and environmental
change to reduce adolescent pregnancies.
• Mobilize the media to increase community awareness and involvement.

The model builds on a set of theoretically-based principles from the Social Learning Theory and Health
Belief models. Implicit in this model is a recognition that, in order to be successful, interventions must
take into account both the social context of the adolescents’ lives, and the development of their own skills
and abilities. The intervention is designed to:

• Equip the adolescent with the assertiveness, communication, problem-solving, and decision-
making skills needed to resist peer, societal, and cultural pressures to engage in unhealthy
behaviors.
• Improve the self-esteem and the future educational and employment opportunities of all young
people through the provision of mentoring and job opportunities.
• Enhance the health and lives of children and families by increasing access to a variety of
preventive health care services. This includes increasing access to contraceptive services for
those adolescents who are sexually active.
• Enhance the knowledge, attitude, and skills of adolescents concerning reproductive health,
contraception, and the prevention of pregnancy.

67
 • In coordination with the local school district, implement a continuous and multi-pronged
approach for the provision of educational programs directed to all members of the community to
enhance their knowledge and communication skills.
• Involve all community members in forging alliances to facilitate social and environmental change
to reduce adolescent pregnancies (e.g., establish interagency councils and networking).

A basic premise of this model is that the risk factors associated with adolescent pregnancy are numerous,
interrelated, and not easily remedied. The model’s hypothesis is that the more changes are made in
school and community contexts related to the mission of decreased adolescent childbearing, the greater
the likelihood of success. The aim of the model is to facilitate appropriate doses of multiple interventions
directed to the general population and higher doses of targeted programs to at risk-risk youths.65

A multi-component school- and community-based approach requires the full cooperation and
collaboration of the many varied segments that comprise the community. The common denominator is
the recognition that a great many factors contribute to early childbearing and other public health
problems, that long-term solutions will be achieved only by frankly acknowledging that the problem
exists, and that the mobilization of community resources directed at every segment of the local population
will be required.

Source: Paine-Andrews, Vincent, Fawcett, Campuzano, Harris, Lewis, Williams, and Fisher, (1996).

68
VI. Summary

The United States has the highest teenage pregnancy rate of any developed nation.53 To ensure a more
effective response to this challenge, educational efforts (including support for abstinence, as well as
access to contraceptive care) and youth development (including a focus on assets messages) could be
enhanced by integrating theoretical frameworks aimed at behavioral change. In turn, positive changes in
community norms will be more likely to occur. Conversely, focusing on broader community norms can
in turn impact individual behavior. Previous interventions have focused primarily on the individual level,
and have traditionally been geared to changing the attitudes and increasing the knowledge of adolescents
about pregnancy prevention. While changes in attitudes and knowledge are important, they often result in
only modest, short-term changes or no behavioral change when they do not also focus on environmental
factors (i.e., interpersonal support and social-structural components) and the individual’s behavior within
that environment.

Expanding our knowledge of what it takes to create behavioral change does require the application of
theoretical frameworks as an integral part of adolescent pregnancy prevention interventions. As part of
the needs and assets assessment, important modifying variables, as well as funding and policy directives,
must also be taken into account. By enhancing the adolescent pregnancy prevention intervention with
strong behavioral components, whether the intervention is school-based or implemented within the
broader context of the entire community, at-risk adolescents may have a better chance to develop their
capacity to set and meet goals, thereby generating the motivation for a greater understanding of and
control over their behavior, ultimately leading to behavioral change. Sufficient knowledge and access to
services, as well as the enrichment that comes from well-conceived youth development programs, can
engender the motivation necessary to delay early childbearing. For maximum effectiveness, prevention
strategies need to incorporate the theoretical components which have been shown to be crucial in creating
a climate for behavioral change. Finally, the use of a variety of concurrent, theory-driven strategies will
help to ensure that adolescents will have the maximum opportunity for success. Community-wide
interventions that bring all of these ingredients together will have the best chances for successful
outcomes.

The theoretical frameworks, and the psychological, sociological and policy factors we have discussed,
have many implications for the development of effective preventive interventions. For optimal behavioral
change, interventions that incorporate theories, that respond to high-risk factors, and that address the

69
policy environment must be combined. When interconnected, they not only have a greater predictive
capacity to impact individuals, but they may also lead to the development of interventions with far greater
practical power to stimulate and sustain individual behavior change, as well as changes in community
norms. Teenage sexual behavior and the incidence of pregnancy and births are determined by multiple
influences. Interventions must therefore simultaneously target multiple individual, community, and
societal factors. If they are properly balanced and sufficiently comprehensive, combined interventions
should produce a greater degree of synergy, thereby increasing the likelihood of an effective impact on
adolescent behavior, as well as on the communities in which adolescents mature. Thus, these theory-
driven approaches must then be further evaluated to ascertain which interventions work best with which
kinds of individuals and population groups, and under what circumstances. Theoretical frameworks, taken
together with their modifying psychological and sociological factors, provide professionals with viable
choices for designing potentially far more effective interventions and community-wide initiatives.

70
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