impact of an increase in family planning services on the teenage population of Philadelphia, The

Family Planning Perspectives, Mar 1995 by Hughes, Mary Elizabeth, Furstenberg, Frank F Jr, Teitler, Julien O

This perspective indicates a need to explore patterns of selectivity in clinic use. An important factor in this issue may be the nature of teenage sexual experience in the United States. Unsurprisingly, teenagers, who lack cognitive and emotional maturity, not to mention resources, appear to have at least as much difficulty practicing contraception as older persons do. The situation is further complicated by the transitional nature of teenagers' sexual lives, which makes sex more difficult to anticipate and manage. Furthermore, this transition occurs in a social context that glamorizes sex yet counsels teenagers to "say no".(10) Amidst these conflicting and confusing messages, barriers to clinic use such as location, inconvenient hours and lack information may prove insurmountable for all but the most motivated teenagers.

If these speculations are correct, what type of programs might be most effective at bringing down U.S. teenage fertility rates? One strategy, consistent with our data, is to focus on changing what is considered normal behavior for teenagers through intensive public health campaigns akin to those focusing on smoking. Although our analysis found no evidence of change within the target areas, we did find evidence of more widespread change over time. During the study period, there was a barrage of information from various sources about responsible sexual behavior; the fact that we detected change over time suggests that the sheer proliferation of messages may be slowly changing teenagers' ideas. Although the changes in attitudes toward sex and contraception were in general stronger than changes in behavior, such normative shifts should not be underplayed. Even if teenagers are only parroting socially acceptable answers, the fact that they increasingly care about giving a "correct" answer is an indication that behavioral norms may be shifting toward abstinence and safer sex.

A second potentially useful approach to increasing program impact may be school-linked health centers. Recent evidence indicates that under certain conditions, these programs can be effective at delaying sexual initiation and promoting contraceptive use among those who are already sexually active.(11) School-linked services have the advantage of targeting smaller, more circumscribed populations, thereby focusing the dosage of the program and enabling more concentrated efforts. If a clinic is in or near a school, it represents less of an alien environment to teenagers and increases clinic visibility and access. Because schools are communities in which social norms are formed, social contagion may increase the number of young persons who are indirectly affected by the programs. Changes in the behavior of just a few adolescents may alter norms sufficiently to influence the behaviors of nonprogram users.

Our results may be discouraging to the RESPECT providers and, perhaps, to other providers as well. We would like to emphasize again that our findings do not imply that clinics do not affect the lives of their clients or that they should close their doors. Although investigating population impact is relevant, it is a very stringent test of clinic effectiveness. Furthermore, our results are predicated on a certain level of services already being in place; they imply only that changing services in the way the RESPECT project did would not affect the entire teenage population. If existing services were cut, teenage fertility rates would likely increase unless program participants were provided with alternative resources. Finally, while our study showed none of the expected impacts of the RESPECT clinics, neither did it show any adverse efverse effects, such as an increase in sexual activity in the target areas.