Proof - Community Readiness Assessment

opportunity. uninterrupted.

COMMUNITY READINESS ASSESSMENT FOR DALLAS COUNTY, TEXAS December, 2018

Presented by: Melissa Ugland, MPH Principal Consultant, Ugland Associates melissaugland@me.com 414-916-4402

ACKNOWLEDGEMENTS

T

HE NORTH TEXAS ALLIANCE TO REDUCE TEEN PREGNANCY, or Ntarupt, is grateful for the participation of the 45 people who agreed to be interviewed for this community readiness assessment. Ntarupt appreciates their generous contribution of more than 80 hours of interviewees’ time and their willingness to share their unique insights into teen pregnancy issues in the community. Ntarupt is glad to have so much support for its vision, which is that every young person in our community has the opportunity to set goals, plan an education and a career, and become self-sufficient before becoming a parent.

Parents of teens ages 16-20 in Dallas County Youth ages 16-20 in Dallas County Alley’s House Atmos Energy Big Brothers Big Sisters Lone Star Texas Centro de Mi Salud Dr. Tom Chapman City Square City of Dallas Mayor Mike Rawlings The Concilio Concord Dallas Cox Insurance Group Dallas City Council Dallas City Hall Staff Dallas County Judge Clay L. Jenkins Dallas County Staff Dallas Independent School District (DISD) Dr. Sandra Lozano Regina Montoya, Chair of Dallas Taskforce on Poverty Nurse Family Partnership Parkland Health and Hospital System Texas Recycling, Inc. Trinity River Mission Planned Parenthood of Greater Texas Resource Center Real Live Connection United Way of Metropolitan Dallas University of Texas Southwestern Medical Center Youth First Texas Youth Revive

TABLE OF CONTENTS ACKNOWLEDGEMENTS.............................................................................................................. 2 EXECUTIVE SUMMARY................................................................................................................4 TEEN PREGNANCY ISSUE BACKGROUND.......................................................................... 5 NATIONAL TEEN PREGNANCY TRENDS ����������������������������������������������������������������������������� 5 TRENDS IN TEEN PREGNANCY IN TEXAS �������������������������������������������������������������������������� 8 TRENDS IN TEEN PREGNANCY IN DALLAS COUNTY, CITY OF DALLAS............. 10 COMMUNITY READINESS MODEL BACKGROUND.........................................................13 COMMUNITY READINESS ASSESSMENT IMPLEMENTATION..................................... 14 QUANTITATIVE RESULTS OF COMMUNITY READINESS ASSESSMENT................ 16 STAKEHOLDER GROUP SCORES........................................................................................... 16 QUALITATIVE RESULTS..............................................................................................................18 THEMATIC ANALYSIS DISCUSSION ..................................................................................... 19 RECOMMENDATIONS.................................................................................................................27 SUCCESS STORIES: MILWAUKEE, WISCONSIN............................................................... 30 CONCLUSION ��������������������������������������������������������������������������������������������������������������������������������32 APPENDIX A: COMMUNITY READINESS ASSESSMENT INTERVIEW SCRIPT.....33 ENDNOTES......................................................................................................................................38

EXECUTIVE SUMMARY Teen pregnancy1 in the United States has been on a steady decline for the past 30 years. This decrease, however, has not happened equally across all parts of the country: disparities remain.

Some ethnic and racial groups’ teen birth rates are declining at a slower pace than other groups, particularly African Americans and Hispanics. Other factors, such as family socioeconomic status, peer group and community norms, and a lack of access to comprehensive sexuality education and contraceptives contribute to persistently high teen pregnancy rates in some communities.

Nationally, the teen birth rate has decreased to 20.3 births per 1,000 teens. In Texas that rate is 31.0, placing it fourth highest in the nation. Additionally, Texas has the highest repeat teen birth rate in the country. Some Dallas zip codes are between three and five times the national rate, ranging between 72 and 123 births per 1,000 teens, and rising. These persistently high rates limit future possibilities for the teens who give birth, the children they give birth to, and the communities in which they reside. The North Texas Alliance to Reduce Unintended Pregnancy in Teens (Ntarupt), the City of Dallas, local elected officials, and several community partner organizations have spent considerable time examining the issue of teen pregnancy prevention in the Dallas community. Partnerships and the understanding of this issue continue to grow in a positive way throughout the community.

This Community Readiness Assessment report discusses the Dallas community’s level of readiness to prevent teen pregnancy. Forty-five community members gave generously of their time to complete one-on-one phone interviews with trained interviewers, following a standard script. Some interviews were conducted in Spanish. This report shares the qualitative and quantitative data that emerged from these interviews. The information that is summarized in this report will enable Ntarupt and its community partners to take steps to increase the community’s readiness to address teen pregnancy prevention in Dallas.

Using the standardized scoring rubric that is part of the Community Readiness Model, the community scored at “Stage Three: Vague Awareness.” Hallmarks of this stage are that a few community members have at least heard about local efforts, but know little about them. Community leaders and community members believe that this issue may be a concern in the community, but most of them show no immediate motivation to act. Community members have only vague knowledge about the issue.

The Dallas community has begun to dedicate significant resources to reducing teen pregnancy in the area and currently enjoys support from a federal grant, but much work must still be done. Few issues touch as many parts of a young person’s life as teen pregnancy. From school completion, to future income potential, to health outcomes, delaying parenthood benefits parents, children, and the community at large. Dallas has the potential to positively impact tens of thousands of lives by reducing its persistently high teen pregnancy rates, and the community is poised to address this topic immediately and with a broad base support. As one faith community leader interviewed said when asked about reducing teen pregnancy, “I don’t think that we grasp the degree to which it’s all our responsibility.”

1

Teen pregnancy and teen births are both down nationwide; Ntarupt’s mission is to reduce teen pregnancies.

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TEEN PREGNANCY ISSUE BACKGROUND NATIONAL TEEN PREGNANCY TRENDS

Teen pregnancy, an issue that impacts the entire nation, has been declining in recent years. In 2015, 229,715 babies were born to women aged 15 to 19 years, for a birth rate of 22.3 per 1,000 women in this age group.

This represented a decline of 8% since 2014. While the reasons for this decline is not entirely clear, the available evidence suggests that these declines are due to more teens abstaining from sexual activity as well as an increase in those teens who are sexually active choosing to use birth control compared with previous years. , Teen birth rates, however, remain stubbornly high in the United States when compared with other western nations. Disparities between ethnic and racial groups, as well as differences by geography, also persist.

BIRTH RATES PER 1,000 FEMALES AGES 15-19,

BY RACE AND HISPANIC ORGIN OF MOTHER, 1990-2016 120 100

116.2 100.3

Hispanic

80 60 40

Black 59.9

Total

42.5

31.9 29.3

White

20.3 14.3

20 0 1990

1992

1994

1996

1998

2000

2002

2006 2004

2008

2010

2012

2014

2016

Martin JA, Hamilton BE, Osterman, M.J., Discoll, A.K., and Drake, P. (2018) Births: Final data for 2016. Hyattsville, MD: National Center for Health Statistics.

According to the Centers for Disease Control and Prevention, the overall birth rate to teen moms ages 15 to 19 was 20.3 per 1,000 women (down from 22.3 in 2015). Between 2015 and 2016 teen birth rates declined for all races except American Indians/Alaskan Natives. Hispanics also saw a decrease in teen birth rates. The teen birth rates for 15- to 19-year-olds changed accordingly for the following ethnic and racial groups: · · · · · ·

-9% for all teens nationwide (down from 22.3 to 20.3); -44% for Asian/Pacific Islanders; -8% for non-Hispanic African Americans; -9% for Hispanics; -11% for non-Hispanic whites; and +37% for American Indian/Alaska Natives (AI/AN).

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A

persistent disparity has been observed in the Hispanic community, where in 2015, the teen birth rate was still more than two times higher than the rate for nonHispanic white teens. The birth rate of non-Hispanic African American teens was almost twice as high as the rate among non-Hispanic white teens, and American Indian/Alaska Native teen birth rates remained more than one and a half times higher than the non-Hispanic white teen birth rate. Geographic differences in teen birth rates also persist, both within and across states. Within some states with low overall teen birth rates, individual counties have high teen birth rates. Less favorable socioeconomic conditions, such as low education and low income levels in a teen’s family, may also contribute to high teen birth rates.

According to the Power to Decide, formally the National Campaign to Prevent Teen and Unplanned Pregnancy, only 51% of teen moms earn a high school diploma compared to 89% of female students who did not give birth as a teen.

Among the youngest mothers, just 38 percent of teen girls who have a child before they turn 18 have a high school diploma. Risks also carry over to young men or boys who father children during their teenage years. They have a 25-30% lower probability of graduating from high school than their non-parenting peers., Babies born to teen mothers are more likely to: · · · · · · · · ·

have a higher risk for low birth weight and infant mortality; have lower levels of emotional support and cognitive stimulation; have fewer skills and be less prepared to learn when they enter kindergarten; have behavioral problems and chronic medical conditions; rely more heavily on publicly funded health care; have higher rates of foster care placement; be incarcerated at some time during adolescence; have lower school achievement and drop out of high school; give birth as a teen; and be unemployed or underemployed as a young adult.,

There are several risk and protective factors that may contribute to teens’ likelihood to become parents before they are fully prepared. In needs assessments conducted in 2016 and 2017 by Texas Woman’s University on behalf of Ntarupt, adolescent sexual health was studied in a holistic manner to identify different levels of influence from family, peers, communities, and the youth themselves.

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INDIVIDUAL LEVEL FACTORS PROTECTIVE FACTORS:

· Delay in initiation of sex · Consistent use of contraception during intercourse · Good school performance, school connectedness, and future plans for higher education · Religiosity and religious affiliation RISK FACTORS: · Race (particularly youth who are Latino/Latina or African-American) · Teens involved in substance use and delinquency · Experiences of anxiety, aggression, and suicidal behaviors

FAMILY LEVEL FACTORS PROTECTIVE FACTORS:

· Family connectedness, parental monitoring, good adolescent-parent relationships · Effective parent-child communication about sexual activity and contraceptive use RISK FACTORS: · Low socioeconomic status · Unstable family life · Poor parent-child communication about sexual activity and contraceptive use

PEER LEVEL FACTORS

PROTECTIVE FACTORS: · Friends who have prosocial behaviors and attitudes · Discussing condom and contraception use with peers and partners RISK FACTORS: · Perception that their friends are already sexually active · Friendship group includes delinquent peers or teen parents · Having an older sexual partner is associated with early sexual debut, less contraceptive use, and high pregnancy risk

COMMUNITY LEVEL FACTORS

PROTECTIVE FACTORS: · Residing in a community with a sense of connectedness, including monitoring and support from adults in the community · Feeling connected to the community RISK FACTORS: · Residing in a poor community with little access to resources and services, few employment opportunities, high crime rates, and poor schools with high drop-out rates · Residing in a community where teen pregnancy is a community norm

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WHY IS TEEN PREGNANCY DECLINING IN MOST PLACES IN THE USA? Teen pregnancy has declined in most places around the country in the past 30 years. A variety of factors have contributed to this decline. The National Survey of Family Growth documented the percentage of teens who reported that they had ever had sex declining from 51% in 1988 to 44% between 2011-2013. Teens also reported greater use of contraceptive methods if they were sexually active. Between 1995 and 2012, the use of contraceptives at last sexual intercourse rose from 66 to 86%. While the share of teens who reported using contraception has not changed overall, there was an increase in emergency contraception use (Plan B), from 8% to 22% between 2002 and 2011-2013. Teen pregnancies and abortions have declined during the measurement period, with teen pregnancies decreasing by 38% and abortions decreasing by 51% for the same age group during the measurement period. Other contributing factors, such as television shows like “Sixteen and Pregnant”, may have helped lower teen pregnancy rates, but there is disagreement about whether or how much these shows help reduce teen pregnancy. Please see the figure that follows for a summary of related data. \

U.S. teen pregnancy, birth and abortion rates reached historic lows in 2011 Rates per 1,000 women 15-19

120 100 Pregnancy Rate

80 60

Birthrate Abortion Rate ‘73

‘78

‘83

‘88

‘93

‘98

‘03

40 20

‘08 ‘11 0

TRENDS IN TEEN PREGNANCY IN TEXAS

Teen pregnancy is a public health crisis in Texas. State Medicaid data shows that births to teens on Medicaid (under 15 to age 19) cost more than births to non-teens on Medicaid for the last five years. The percentage cost difference is small at the individual birth level: $133 more on average than to non-teen Medicaid births. Multiplied by the 151,696 births to teens between 2012 and 2016, these births cost $18,658,608 more on average than births to non-teen counterparts. Not only are delivery costs more expensive, but these young mothers will often continue to need significant financial assistance after their children’s births. The number of teens who gave birth in Texas in 2016 was estimated at 29,765, according to Power to Decide. Of this total, 26,811, or 90% of teen mothers, were on Medicaid at the time of delivery. Compared with the rest of the population in Texas, which has a Medicaid enrollment rate of just 16%, teen mothers are 560% more likely to be on Medicaid than the general population.

Teen childbearing in Texas cost $1.1 billion as recently as 2010 according to the National Campaign to Prevent Teen Pregnancy. In addition to the direct costs associated with prenatal care, delivery, and the costs associated with delivery complications, teen parents are more likely to rely on financial assistance programs such as Medicaid, Supplemental Nutrition Assistance Program (SNAP), and/or Women, Infants and Children (WIC). As their children grow up, they are more likely to experience being placed in foster care, being the victims of child abuse and neglect, or becoming incarcerated.

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Deliveries to Mothers on Medicaid, Texas, FY 2012-2016 AGE GROUP DELIVERIES

FY2016

Under 15

FY2015

FY2014

FY2013

FY2012

390

429

391

452

495

15

1,029

1,152

1,251

1,360

1,491

16

2,465

2,640

2,866

3,230

3,406

17

4,581

4,891

5,155

5,608

5,919

18

7,428

8,041

8,487

8,919

9,507

19

10,918

11,374

12,133

12,569

13,119

Subtotal – Teen Mothers

26,811

28,527

30,283

32,138

33,937

Non-Teen Mothers (age 20+)

183,761

181,688

182,970

174,920

170,385

Total - All Deliveries

210,572

210,215

213,253

207,058

204,322

DELIVERY COST

Under 15

$1,251,923

$1,329,446

$1,221,663

$1,396,992

$1,433,106

15

$3,254,811

$3,614,956

$3,893,657

$4,246,676

$4,404,979

16

$7,845,869

$8,199,799

$8,890,570

$9,907,224

$9,984,573

17

$14,511,307

$15,232,971

$16,079,284

$17,220,688

$17,362,956

18

$23,610,246

$25,131,434

$26,296,962

$27,616,446

$28,130,794

19

$34,586,223

$35,382,565

$37,432,665

$39,002,564

$38,660,376

Subtotal - Teen Mothers

$85,060,379

$88,891,171

$93,814,801

$99,390,590

$99,976,783

Non-Teen Mothers (age 20+)

$564,102,736

$540,640,504

$542,519,930 $515,918,213 $485,799,561

Total - All Deliveries

$649,163,115

$629,531,675

$636,334,731 $615,308,802 $585,776,345

AVG. DELIVERY COST

Under 15

$3,210

$3,099

$3,124

$3,091

$2,895

15

$3,163

$3,138

$3,112

$3,123

$2,954

16

$3,183

$3,106

$3,102

$3,067

$2,931

17

$3,168

$3,114

$3,119

$3,071

$2,933

18

$3,179

$3,125

$3,098

$3,096

$2,959

19

$3,168

$3,111

$3,085

$3,103

$2,947

Avg. Cost -Teen Mothers

$3,173

$3,116

$3,098

$3,093

$2,946

Avg. Cost - Non-Teen Mothers

$3,070

$2,976

$2,965

$2,949

$2,851

Average Cost - All Deliveries

$3,083

$2,995

$2,984

$2,972

$2,867

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TRENDS IN TEEN PREGNANCY IN DALLAS COUNTY, CITY OF DALLAS While teen pregnancy rates have declined nationally, they have fallen more slowly in Texas than in other places in the country. Texas also leads the nation in repeat teen births.

Dallas County, and more specifically, the City of Dallas, continue to experience higher teen birth rates than the rest of the state. Encouragingly, teen pregnancy rates are on the decline at the city and county levels in most areas.

Some areas of the City of Dallas, however, are increasing at a time where many places are seeing a sharp decrease.

Teen Birth Rates (per 1,000), Ages 15-19 70 60 50 40 30 20 10 0

2 012

2 013

2 014

State of Texas

2 015

Dallas County

2 016

City of Dallas

City of Dallas Zip Code Teen Birth Rates (per 1,000), Ages 15-19 140 120 100 80 60 40 20 0

752 40

75227

752 19 2 012

75228

752 17

2 013

752 31

2 014

752 16

2 015

752 03

75172

752 15

2 016

As noted with an asterisk (*) in the table above, six of the ten City of Dallas zip codes that have the highest teen birth rates actually had an increase in their teen birth rates from the previous measurable year, the most recent years for which zip code data is available. While Ntarupt works to address teen pregnancy across a range of communities, these areas are of special concern.

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FOCUS GROUP & SURVEY DATA: DALLAS, TEXAS The Texas Woman’s University needs assessment that identified the preceding risk and protective factors discussed earlier in this report also conducted focus groups or surveys with educators, services providers/health educators, religious leaders, and medical providers. Summary data from each group is provided below.

EDUCATORS: SUMMARY INFORMATION ·

46% of Dallas teachers, administrators, counselors, and case managers surveyed said that teen pregnancy was an issue on their campuses

·

23% of this group said they had “often” been approached by a student needing sexual health advice

·

39% of this group described sex education at their schools as “received information too late” and “abstinence is emphasized”

·

15% felt that their school’s sex education was “enough to meet the needs of youth”

·

77% cited lack of contraceptive use as the greatest risk for unintended pregnancy

·

69% cited lack of education about contraceptive use as the greatest risk for unintended pregnancy

·

Lack of supportive partners and lack of self-efficacy regarding contraceptive use were cited as risks among 54% of the group

·

Lack of access to contraception and lack of career/education goals were cited by 46% as the greatest risk for unintended pregnancy

·

Educators were also concerned that their students lacked: financial literacy, information about being a parent, healthy relationship information, and sex education

·

A lack of confidential health care services and a lack of knowledge about existing services were both concerns of educators

SERVICE PROVIDER/HEALTH EDUCATORS: SUMMARY INFORMATION ·

Health care and health education service providers (for teens and/or parents) primarily referred teens to city/county health clinics, Planned Parenthood, or other clinics (81.9%)

·

78% cited lack of contraceptive use as the greatest risk for unintended pregnancy

·

88% cited lack of education about contraceptive use as the greatest risk for unintended pregnancy

·

Lack of access to and self-efficacy regarding contraceptive use were cited as risks for unintended pregnancy among 72% of this group

·

60% felt that a lack of career/education goals put teens at greatest risk for unintended pregnancy

·

Providers wanted to see better education, better healthy relationship information and support, better parental support, and better sex education for youth

·

A lack of parental support keeps health care service and education providers from reaching youth

·

Lack of transportation was frequently cited as a barrier to accessing health care services

·

Lack of funding was also cited as a barrier to accessing services, or adding more services

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RELIGIOUS LEADERS: SUMMARY INFORMATION ·

Most religious leaders felt that churches play an important but limited role in Teen Pregnancy Prevention. For some, this limitation was doctrinal.

·

96% of religious leaders “strongly agreed” that their community needed more efforts to prevent teen pregnancy

·

82% of religious leaders said that they/religious groups should be doing more to help prevent teen pregnancy

·

Many religious leaders expressed concern about teen pregnancy, saw it as a problem and a big community issue that needed to be addressed

·

Religious leaders frequently expressed an opinion that parents are leaving child-rearing to peers and the media

·

Leaders cited a lack of educational materials and the education needed to use them as obstacles to conducting sexual education in a church setting

·

Religious leaders were most likely to cite a “lack of career and educational goals” as the biggest risk for unintended pregnancy (78%), followed by a lack of contraceptive use (52%) and a lack of knowledge about how to use contraceptives (52%).

·

A full 73% of religious leaders said they were “very comfortable” discussing healthy relationships with teens

MEDICAL PROVIDERS: INFORMATION SUMMARY ·

Providers cited a lack of transportation as a significant challenge for teens trying to access health care services

·

Lack of contraceptive use (92%), lack of education about contraceptive use (86%), lack of supportive partners (78%), and lack of self-efficacy regarding contraceptive use (76%), lack of career/ education goals (67%), and lack of access to contraception (61%) were all cited as the greatest risks for unintended pregnancy.

There is significant overlap between the nationally identified risk and protective factors for teen pregnancy and the concerns expressed by the local professionals who interact every day with teens in Dallas, Texas. Questions of access to health education, health care services, and enabling teens to develop a familiarity with and comfort around these issues are all potential hindrances to teen pregnancy prevention. Further, religious leaders aspire to take a greater role on this issue, and would prefer to partner with the whole family in doing so.

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COMMUNITY READINESS MODEL BACKGROUND In early 2018, Ntarupt engaged with Ugland Associates in Milwaukee, Wisconsin to complete a community readiness assessment for the Dallas community around teen pregnancy prevention. A community readiness assessment uses the Community Readiness Model (CRM), developed by the Colorado State University Tri-Ethnic Center. It is an evidence-based tool that draws from diverse community experiences to inform appropriate interventions for a specific issue. The model is adapted from the Transtheoretical Model of Behavior Change, also called the Stages of Change Model, which aims to determine an individual’s readiness to change a specific behavior and maintain that change.

Similarly, communities have a collective readiness to change their attitudes, beliefs, and behaviors regarding specific issues. Readiness is the degree to which a community is prepared to take action on an issue. For a given issue, a community will fall somewhere on a continuum of readiness (pictured below) with 1 being no awareness that the issue exists, and 9 being a high level of community ownership and awareness of the issue. The tool results in a community readiness assessment that offers an inexpensive and easy way to measure the community’s readiness on an issue and develop stageappropriate strategies. It has been used internationally, nationally, and at the local grassroots levels, typically for health-related topics but also for other focus areas.

This community readiness assessment helps gather baseline information about the readiness of the Dallas community to address issues related to teen pregnancy prevention.

The goal of this assessment was to answer the question: “What is the Dallas community’s level of readiness to address the issue of teen pregnancy through prevention?” The readiness score is determined based on interviews using a structured script, conducted across key stakeholder groups (for the interview script, see Appendix A). The selection of stakeholder groups ensures the inclusion of multiple voices in the community, leading to community-informed strategies that are tailored to Dallas’s own level of readiness.

The CRM uses a survey tool consisting of open-ended questions asked to each stakeholder interviewee. The questions address five dimensions of community readiness: · Community Knowledge of Efforts: How much does the community know about current programs and activities? · Leadership: What is the leadership’s attitude toward addressing the issue? · Community Climate: What is the community’s attitude toward addressing the issue? · Community Knowledge of the Issue: How much does the community know about the issue? · Resources: What are the resources that are being used or could be used to address the issue?

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COMMUNITY OWNERSHIP

THE COMMUNITY READINESS MODEL DEFINES 9 STAGES OF READINESS

EXPANSION/CONFIRMATION

STABILIZATION

INITIATION

PREPARATION

PREPLANNING

VAGUE AWARENESS

DENIAL/RESISTANCE

NO AWARENESS

STAGES OF COMMUNITY READINESS

Each interview is given an overall readiness score as well as a score on each of the five dimensions. These scores are averaged across stakeholder groups, giving the community an overall readiness score for the issues, stakeholder group-specific scores, and dimensionspecific scores. This quantitative data allows us to identify the community’s particular strengths and opportunities, and obstacles we may encounter as we move forward. The five dimensions of community outlined earlier in this section. For the purpose of this assessment, “community” refers to Dallas County. Interviewees had to work, live, attend school or be parenting a child who attends school within the county to be eligible for interviewing.

The scores are then analyzed to characterize the community into one of the following nine stages of readiness: (1) No awareness, (2) Denial/resistance, (3) Vague awareness, (4) Pre-planning, (5) Preparation, (6) Initiation, (7) Stabilization, (8) Confirmation/Expansion, and (9) Community ownership. Please see the following figure for their sequence.

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NO AWARENESS

DENIAL/RESISTANCE

VAGUE AWARENESS

PREPLANNING

PREPARATION

INITIATION

Each stage comes with recommended actions that best serve to influence change at each level of readiness.

Ntarupt will use these results, discussed later in this report, to develop an action plan to move the community forward on readiness spectrum to work toward the prevention of teen pregnancy.

STABILIZATION

EXPANSION/CONFIRMATION

HIGH LEVEL OF COMMUNITY ONERSHIP

COMMUNITY READINESS ASSESSMENT IMPLEMENTATION

Between May and September of 2018, three interviewers completed 45 interviews with individuals across nine stakeholder groups. Interviewees were identified as individuals or representatives of organizations who have an interest or direct role in addressing Dallas’ teen pregnancy crisis. Each person interviewed was asked the same questions. (For a copy of the interview questions, see Appendix A.) Interviews typically took around one hour, though they varied in length. Some interviews were conducted by Ntarupt staff in Spanish, using a translation of the original interview transcript from English into Spanish. Additional demographic information follows.

GENDER IDENTITIES OF INTERVIEWEES

MALE FEMALE

ETHNIC & RACIAL BACKGROUNDS OF INTERVIEWEES • African American • Asian American • Caucasian/ White • Latino/Latina • Brazilian

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Once the interviews were completed, the transcripts were de-identified and scored by two trained scorers who work outside of Ntarupt. The scorers also met to discuss scoring discrepancies and establish inter-rater reliability.

The interview transcripts were analyzed by two individuals for overarching themes, and these individuals also met to establish agreement on themes. Scores and themes are discussed in greater detail later in this report.

QUANTITATIVE RESULTS OF COMMUNITY READINESS ASSESSMENT

The Dallas community had an overall readiness score of 3.28, or in the lower range of the “Vague Awareness” stage. By dimension, however, some scores were a bit lower or a bit higher. Each of the five dimensions is listed in the table that follows, with an explanation and analysis of what each dimension means. There were nine different “stakeholder groups” identified by Ntarupt staff as having an interest in or being impacted by teen pregnancy in the Dallas community: 1) 2) 3) 4) 5) 6) 7) 8) 9)

Health Care Community-Based Organizations Parents of Teens Elected Officials/Policymakers Teens/Young Adults Educational Professionals Faith Community Leaders Lesbian, Gay, Bisexual or Transgender or Queer/Questioning People (LGBTQ) Business Leaders/Business Owners

SCORES BY GROUP AND DIMENSION Stakeholder Group

Community Knowledge of Efforts

Leadership

Community Climate

Community Knowledge of Issues

Resources

Stakeholder Group Totals

Health Care

3.15

3.50

3.95

3.45

3.95

3.60

Community-Based Organizations

2.79

3.93

3.71

2.79

3.21

3.29

Parents

1.83

2.42

3.58

2.75

1.33

2.38

Elected Officials/ Policymakers

2.45

4.00

4.90

4.70

4.55

4.53

Youth

3.00

3.88

3.31

2.50

4.06

3.35

Educational Professionals

4.50

4.00

4.90

4.70

4.55

4.53

Faith Community Leaders

2.38

3.19

3.81

2.88

3.50

3.15

LGBTQ

1.75

3.38

3.75

2.06

3.63

2.91

Business

2.20

3.50

3.95

2.55

2.40

2.92

Dimension Totals

2.67

3.63

3.90

2.93

3.28

Overall Readiness Score 3.28

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SCORES BY DIMENSION Dimension

Score

Community Knowledge of Effort

2

Community Climate

2

Explanation & Analysis Denial/Resistance: “We can’t (or shouldn’t) do anything about it!” ·

Leadership and community members believe that this issue is not a concern in their community or they think it can’t or shouldn’t be addressed.

·

Community members have misconceptions or incorrect knowledge about current efforts.

·

Only a few community members have knowledge about the issue, and there may be many misconceptions among community members about the issue.

·

Community members and/or leaders do not support using available resources to address this issue.

Leadership

3

Vague Awareness: “Something should probably be done, but what? Maybe someone else will work on this.”

Community Knowledge of Issues

3

·

A few community members have at least heard about local efforts, but know little about them.

·

Leadership and community members believe that this issue may be a concern in the community. They show no immediate motivation to act.

Resources

3

·

Community members have only vague knowledge about the issue (e.g. they have some awareness that the issue can be problem and why it may occur).

·

There are limited resources identified that could be used for further efforts to address the issue.

Most scored group information shows that scores are clustered between stages two (2) and three (3), or “Denial/Resistance” and “Vague Awareness.” These calculations put the scores of the interviewees overall at stage three: Vague Awareness. Vague Awareness is characterized by some community members having at least heard about local efforts, but knowing little about them; leadership and community members believe that this issue may be a concern in the community but they show no immediate motivation to act; community members have only vague knowledge about the issue (e.g. they have some awareness that the issue can be problem and why it may occur). Resources may be limited to address the issue at the community’s current level of awareness and interest.

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QUALITATIVE RESULTS:

THEMATIC ANALYSIS OF INTERVIEW TRANSCRIPTS The overall themes back up the level of readiness in the nine stakeholder groups that were interviewed. Thematic analysis was completed independently initially, then reconciled twice to achieve a high level of agreement. Themes are supported with direct quotes from those interviewed across the nine stakeholder sectors.

There were eight overarching themes that emerged as part of the community readiness assessment. Each is presented below, then discussed and supported with quotes pulled directly from interview transcripts.

THEME 1: Leadership is limited on teen pregnancy prevention. Vocal leadership has come from Mayor Rawlings, County Judge Clay Jenkins, Regina Montoya as Chair of the Mayor’s Task Force on Poverty, and some City Council members, but community members are generally unable to identify other individuals at work on this topic.

THEME 2: Community members and leaders are generally focused on other priorities such as homelessness or education. Teen pregnancy prevention was not seen as a community priority unless it directly affected families or communities, or unless someone was involved in working to prevent it.

THEME 3: There is a low level of awareness of teen pregnancy as an issue, it

is rarely mentioned in the media, and the public is not discussing it.

THEME 4: Many people, particularly in some churches, feel that comprehensive sexuality

education should not be taught in schools, and that doing so will lead to more teens having sex.

THEME 5: Religious leadership has a big influence in the community, which is

seen by some to hinder teen pregnancy prevention efforts, while others see it as a possibility for some of them to step up and become leaders on this issue.

THEME 6: Teen pregnancy is viewed by many people as something that

primarily affects communities of color or low-income families, and in some families is multigenerational and perhaps seen as normal or expected.

THEME 7: There is a lack of basic knowledge about contributing factors to Dallas’s high teen pregnancy rate, and the short- and long-term effects of teen pregnancy are not yet widely understood in the community. Community members are unsure whether comprehensive sexuality education is offered in Dallas Independent School District (DISD) high schools or middle schools.

THEME 8: Efforts to address teen pregnancy prevention, such as those undertaken by

Ntarupt and Planned Parenthood, are seen as effective when people have heard of them.

Funding is limited, and transportation and geography limit the reach of these programs.

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THEMATIC ANALYSIS DISCUSSION THEME 1: Leadership is limited on teen pregnancy prevention. Vocal

leadership has come from Mayor Rawlings, County Judge Clay Jenkins, and some City Council members, but community members are generally unable to identify other individuals at work on this topic.

Though some individuals could name visible leaders and their leadership roles, most interviewees were not able to name leaders or think of times that they’d seen local leadership addressing teen pregnancy.

QUOTES THAT SUPPORT THIS THEME:

“I think as a whole, our leaders should be doing more.” – Business Community Interviewee “I think a lot of people see what is going on and it’s affecting more and more people each day. They just need to take action.” --Youth Interviewee “…I don’t think they (leaders) are too concerned. I think they are concerned with other issues and when they are not focused on the need to bring in more money to develop a program to be able to help the teenagers, especially the Latinas.” –Health Care Organization Interviewee “The Dallas Mayor has a task force on poverty, and Regina Montoya is the leader of that, and she’s talked about it and the linkage she makes of course is that when these young girls make a decision to become moms—or maybe they don’t make the decision, they just are moms—that that almost certainly locks them into a life of poverty for them and their children, especially if they’re not able to finish high school because of that decision, and they’re confined to low-wage, low job skills. So, the kind of economic well-being of the whole family is really threatened, or challenged at least, when these young girls become pregnant.” --Elected Official/Policymaker Interviewee

“I think our community leaders are just looking for someone with a plan, and if it’s a plan that everyone can agree on, I think it would be very well received.” –Faith Community Interviewee “From the council meetings and events that I’ve attended, I’ve seen maybe a few people who are in leadership roles that I’ve seen actively participate and vocally support it, so yeah, I would say there’s some initiative there, but it’s like few to some (leaders).”--Community-Based Organization Interviewee “I think (leaders support programs) passively, to the extent that they understand the problem, understand the opportunity they have, and are presented with a clear path in terms of what they can do.” --Faith Community Interviewee

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THEME 2: Community members and leaders are generally focused on other priorities such as homelessness or education. Teen pregnancy prevention was not seen as a community priority unless it directly affected families or communities, or unless someone was involved in working to prevent it.

The Dallas community faces a number of issues of high concern to residents and leaders alike. Teen pregnancy prevention is mainly a high priority to people who are currently involved in organizations working on it, or in families affected by it.

QUOTES THAT SUPPORT THIS THEME: “It has to be on their radar, but I think they’re more focused on early childhood development. They’re more focused on homelessness. There are a lot of issues that are ‘sexy’ and teen pregnancy is something we don’t like to talk about, especially since nationally the rates have gone down.” --Community-Based Organization Interviewee “There are not a lot of programs to prevent teen pregnancies. The programs I put my kids in is only for ages 6-14 years old. There needs to be a program for older teens, too. Maybe I haven’t looked enough.” –Parent Interviewee

“I would say that it is of less interest to most community citizens because they are not…if they are not touched by it and if they don’t have to see it, it can be out of sight, out of mind...” –Business Community Interviewee “I feel like teen pregnancy can be… similar to teen homelessness or something, that sometimes with people in power it gets talked about a lot so they’re focused on awareness but not necessarily making an actual impact, so that’s why it seems like it’s…not an actual priority.” --LGBTQ Community Interviewee “I think it’s a mindset of… ‘It’s not affecting my family or my daughter; I really am not concerned.’” --Faith Community Interviewee “We barely know, we only know because of people like you (Ntarupt) give us classes.”--Parent Interviewee 6.4: “Because we live in Dallas County, we live in a space where there are an insurmountable amount of issues and problems that are affecting our young people.

Teen pregnancy… gets thrown in the mix. And there’s a level of resiliency, on the positive side, or almost complacency… feeling like it’ just a part of the reality that we live in. So, often times community members with a lot of these social problems, they throw them all in a bunch and they say it’s just a part of the environment. It’s just something that happens or something that we’re used to.” -- Educational Professional Interviewee

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THEME 3: There is a low level of awareness of teen pregnancy as an issue, it is rarely mentioned in the media, and the public is not discussing it.

People don’t see the issue being discussed in the public forum, be it on television, in print media, or on social media.

QUOTES THAT SUPPORT THIS THEME: “We haven’t had a good public dialogue about this. I haven’t seen it in the media or a lot of conversations about it. But if there was a good communications strategy out there, I think it would be.” --Elected Official/Policymaker Interviewee “Generally speaking…the problem is that if you’re working on it (teen pregnancy prevention) you think there’s a lot of visibility for it. But if you’re just out there in the community, you know it’s not really a topic of conversation. And you need awareness but also action. Awareness is wonderful. Action is what you need. There is a reasonable awareness, but there’s not a strong action side to it, because there’s so many competing priorities in our society.” --Business Community Interviewee “The biggest group of young women having babies in Dallas are Hispanic young women. I don’t think their parents think that they’re involved with boys, but it’s the other girls, not theirs.” --Elected Official/Policymaker Interviewee “I see so many girls that are pregnant and are my age or even younger than me, so I don’t know if they are concerned about it. I don’t see anything done about it, I guess I’m trying to say here. Some type of mentoring or information, I don’t see that here, at least where I live.”--Youth Interviewee

“Teens, even adult parents of teenagers, don’t know where to necessarily find these programs and resources. It’s not to say that they’re not out there. It’s just people aren’t aware.” --Faith Community Interviewee “Being a service provider… from my interaction with folks and engaging with our donors, they seem to be very surprised when they learn about the teen pregnancy rate in Texas and Dallas specifically. So, I think it’s a lack of awareness and not necessarily a lack of concern.” --Health Organization Interviewee “Compared to where we are statistically, it’s definitely a lack of information available. I don’t see a lot of billboarding. I don’t see a lot in the paper or the news. So, for it to be the health crisis that it is, we have not done enough in this area.” --Educational Professional Interviewee “I think if you asked an elected official, they would all agree it needs to be addressed, but… I grew up in a family that thought actions speak louder than words, so you can say all day long that it’s an issue, but what are you putting behind it?” --LGBTQ Community Interviewee

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THEME 4: Many people, particularly in some churches, feel that comprehensive sexuality

education should not be taught in schools, and that doing so will lead to more teens having sex.

Religious belief systems in some parts of the Dallas community do not support comprehensive sexuality education. This is tied to a belief that by offering this education, more teens will become sexually active.

QUOTES THAT SUPPORT THIS THEME: “There’s a taboo talking about sex and pregnancy and people don’t want to be stigmatized.” –Community-Based Organization Interviewee “There isn’t a gray area for (the people against comprehensive sexuality education), that’s the problem, and they can’t get their arms around that, that there’s something between abstinence-only and Sodom and Gomorrah.” --Elected Official/Policymaker Interviewee “It’s a conservative state, and it’s very often the abstinence approach and not so much where schools are teaching like how to have safe intercourse and how to have safe choices.” --Community-Based Organization Interviewee “I think that the misconceptions (about the programs) are that all of them are geared toward trying to expand abortion, and that they encourage promiscuity among teens as opposed to being necessary healthcare options for teens, and women in general, not just teens.” – Faith Community Interviewee

“…A lot of the times what the school districts are teaching aren’t comprehensive. And parents would like to have more knowledge sometimes.” --Health Organization Interviewee “There are some who believe that if you have these efforts, you are encouraging the girls to have another baby or it’s okay instead of not knowing that the girls are being educated and learning how to be a good mom and to not repeat the same cycle.” –Faith Community Interviewee “So, a lot of people would (say) it’s easier to just make abstinence the rule and not deal with it, because it’s controversial to talk about sex with young people. So, that’s a big obstacle, trying to get people to change the perception of sex education and our children and their relationship to their sexuality. Depending on their parent, religious could be part of it. Parents, for religious purpose, don’t want their kids engaged in anything talking about sex and sexuality.” --Educational Professional Interviewee “I think there’s that educational component that is missing all the way around. Which is why it’s important that these efforts are taking place. (There is a misconception) that we are giving kids the okay to have premarital sex. That we are giving kids the okay, the green light to be teen parents. Some people, I think the misconception is that education is a go-ahead.” --LGBTQ Community Interviewee

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THEME 5: Religious leadership has a big influence in the community, which is

seen by some to hinder teen pregnancy prevention efforts, while others see it as a possibility for some of them to step up and become leaders on this issue.

Religious/Faith communities are an important part of life in Dallas for a large amount of the population. They are recognized as powerful institutions that can make or break initiatives like teen pregnancy prevention efforts.

QUOTES THAT SUPPORT THIS THEME:

“We have these big African American megachurches with 3,000 members. Now the Catholics will never buy into it, but the Black pastors in town, there’s a handful, a dozen or so, if you got them to adopt a curriculum in their youth ministries. And African American parents would just be more inclined to have their kids taught in church than in Dallas ISD public school.” --Elected Officials/Policymakers Interviewees “Very (few) people are interested in helping, just churches help and give classes.”--Parent Interviewee “I feel like a lot of the church leaders, like the megachurches, are like really concerned with building their congregation or building their facilities. I feel like city leaders are more concerned with building their constituency. I feel like they’re just more concerned with gaining power for themselves. I really don’t know about their concern for youth.”--Educational Professional Interviewees “There are some people who just don’t support these types of programs. I went to a church in like the southern sector of the city, and actually the preacher, the head of the church, talked about how they were leaving this really great program they were a part of because the program started including safe sex and the church could only support abstinence (only).” –Educational Professional Interviewees “I don’t see, when you look around and you see what’s in the newspapers, that’s sort of the tone of the community, and I read the newspapers, it’s not discussed.

Not at church and it’s not in the newspaper, so it’s my general perception of the visibility of the topic to the community.” –Business Community Interviewees

“Some people in the community oppose efforts like this (Ntarupt’s) on religious and moral grounds.”

--Elected Officials/Policymaker Interviewees “Adults don’t like thinking of their young people having sex. And I think that’s a lot of the time going to be a barrier to people. A lot of the barriers come from people that are conservative and/or religious in their thinking about sex education.

They may have one narrative about how they want to have that conversation versus a secular parent. I think getting all parenting adults to have a conversation about these access to these resources is going to be really vital. Adults focus on the act of sex more than focusing on all that goes into being a good person and living as a happy and healthy individual. --LGBTQ Community Interviewee

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THEME 6: Teen pregnancy is viewed by many people as something that

primarily affects communities of color or low-income families, and in some families is multigenerational and perhaps seen as normal or expected.

Teen pregnancy is not yet seen as an issue that affects a broad swath of the community, which may hinder collaboration efforts to prevent it.

QUOTES THAT SUPPORT THIS THEME: “The misconception is that so many people are always wanting to do things in the African American and Hispanic community. And I think they have great intention, but I think they’re missing the mark at times. Because in that message what you may hear, or it gives the assumption that white girls aren’t having as much sex and Black girls and Hispanics. So, it looks like kids in these communities don’t have the same set of morals. It gives this whole racist view of the issue, where it might actually just be these white girls have more access to the resources so they don’t have the same prevalence of births as this neighborhood over there. These white girls are having just as much sex.

They just have different circumstances.” --Health Organization Interviewee “I went to this middle school right near Love Field Airport, and probably like 90% of the girls that went to that middle school got pregnant later on. So, like we find out through Instagram, ‘Oh, they’re pregnant, and oh, look, they went to the same middles school as us.’” –Youth Interviewee “It’s a norm, so that’s the only way that I think some of the people would (tolerate teen pregnancy). Because they’re so used to seeing it and having it.

And that’s why so many grandmothers are raising their grandchildren. And I know grandmothers in their early 40s and 50s. I know someone who is a greatgrandfather and he is only 63.” --Elected Officials/Policymaker Interviewee

“Some people feel like, ‘Oh, it only happens in very lowincome (communities)’ when it really has no discrimination with economic status.” – Educational Professional Interviewee “Students ask why I didn’t have kids as a teenager. It’s thought of as a good thing, and there aren’t negative implications. So, I think that needs to change.

And I guess health and child development is an aim of that, but I don’t know if the implications are explained to the students. And honestly, I think it needs to be taught in middle school, because I’ve had a lot of students who had babies when they were in middle school.” --Educational Professional Interviewee “I think the negative is that some portions of the population are ignored because they feel like the gay, lesbian, bisexual or transgender kids aren’t going to get pregnant. So, people in that community, a lot of the sexuality is fluid. Just because they identify as gay doesn’t mean they won’t have sex with someone that could lead to pregnancy. So that’s a huge barrier and a stumbling block to make them realize that this is a population you need to address also.” --LGBTQ Community Interviewee

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THEME 7: There is a lack of basic knowledge about contributing factors to Dallas’s high teen pregnancy rate, and the short- and long-term effects of teen pregnancy are not yet widely understood in the community. Community members are unsure whether comprehensive sexuality education is offered in Dallas Independent School District (DISD) high schools or middle schools.

The causes and effects of teen pregnancy are not yet widely understood, in part due to a lack of widespread comprehensive sexuality education access in public schools. Most community members are unsure whether sexuality education is available in schools.

QUOTES THAT SUPPORT THIS THEME: “I have a daughter so I’m worried. They don’t know the consequences that come after having a baby.”--Parent Interviewee

“I feel like most people know the basics. You know, how to put on a condom and general birth control. They don’t know that it’s places you can go to get free birth control.” –Youth Interviewee “The school district, even though the (it) isn’t a health provider, they have a lot of pregnant teens going to school, so they handle the results of the problem.” –Elected Official/Policymaker Interviewee “I have a daughter who is in high school. There was a young lady in her school that had no clue whether she was pregnant or not.” --Parent Interviewee “I think people are very unaware of the loss in terms of production, human and economic and social product that we get from our citizenry because of the girls who have babies and the families that have to support them. And the babies themselves, you know, needing (more, but) having inadequate resources. There’s a huge economic and cultural impact to this that I think people are pretty clueless about.” –Faith Community Interviewee “(People) have little understanding of the financial and logistical ramifications of having a child. That teenager will have to totally change their lives for their kids. Or the sad part is that they don’t change their lifestyles and the child that’s born suffers as a result. So, they don’t understand the consequences, the lifelong ramifications, the financial burden on other people. Or how it almost destines them to a life of poverty.” –Educational Professional Interviewee “I think people get how, but they don’t understand the full complexity on teenagers and why that occurs on such a level. What can be done to prevent it, what conversations parents and parenting adults can have to prevent it…Teen pregnancy itself is a doubleedged sword because it’s rooted in racism and classism, because what teens are we trying to keep from getting pregnant? The reality of this that for a lot of these teens, it’s generational. If we don’t stop and see the world from those people’s viewpoints and perspectives, we won’t be able to delay pregnancies.” --LGBTQ Community Interviewee

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THEME 8: Efforts to address teen pregnancy prevention, such as those undertaken by

Ntarupt and Planned Parenthood, are seen as effective when people have heard of them.

Funding is limited, and transportation and geography limit the reach of these programs.

Numerous external forces may present challenges to teen pregnancy prevention efforts in Dallas, particularly elated to resources and spreading the word about programs.

QUOTES THAT SUPPORT THIS THEME:

“I think especially being in Texas and the lack of sex education provided to youth, coming up with creative ways to engage and provide that information to them outside of school has been a challenge.” --Community-Based Organization Interviewee “I think on the surface, (people) know it’s an issue and a problem. They know it’s not a good thing. But overall, teens having unprotected sex and bringing a child into the world, they don’t know about that. People aren’t taking the time to consider it unless they’re in the situation or it’s someone really close to them.” –Faith Community Interviewee “I think they (the community) don’t know more because it’s still very new. Organizations like Ntarupt and Teen Pride are still very young and when you start out very young like they have, funding is very limited, and resources have to be there in order to be able to reach the masses.” –LGBTQ Community Interviewee “Sometimes schools don’t have enough money to handle the issue. And it depends on what area of town you live in. Some areas of the metroplex are more privileged than others, and so they have avenues for delivering information to teens about teen pregnancy, whereas other areas of Dallas County don’t.” --Elected Official/Policymaker Interviewee “…They (leaders) understand the pressure it puts on publicly funded programs to service these people (teen parents and their children). It sounds cold to say they don’t care about individuals, but it’s the aggregate cost of servicing these children.” --Business Community Interviewee “Transportation is always a barrier, when the resources are available. So, for example, you know you have kids who unfortunately are also working adult to a degree or have activities that they’re doing and that sort of things. So, when it’s available to them can be a barrier.” –Health Care Organization Interviewee “Having money to do things and people to be able to go to different neighborhoods about what they’re doing. I think there’s not enough.” –Health Care Organization Interviewee “I don’t think that teen pregnancy prevention and sex education are widely supported in this community. I think that comes from the lack of interest and the constant war on funding at both the state and federal level.” --Business Community Interviewee

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RECOMMENDATIONS “In Texas, we don’t like to talk about sex, and parents don’t like to talk to kids about sex.

And this teen pregnancy thing is going to be one of those sort of taboo subjects, but I’m afraid we’re going to take this… ‘just say no’ approach and we’re not going to really… because we need to look at these five zip codes in Dallas that have these alarmingly high teen pregnancy rates, and that is just abject poverty there. And these young women and men have grown up in that whole kind of toxic stress environment.

And that, in my opinion, we haven’t talked about the environment that these kids are growing up in, the stress they’re subjected to, you know where they’ve got a family member incarcerated, food insecurity, gunshots going off in their neighborhoods at night. We haven’t talked about the kinds of conditions that are creating this high teen pregnancy rate, and if we let thought leaders think that these are just kids that are bored getting pregnant, that’s not the real issue here.” – Elected Official/Policymaker Interviewee The Dallas community has a low level of awareness of the issue of teen pregnancy, but that doesn’t mean there is a low level of concern among community members. As one faith community leader interviewed said, “I don’t think we grasp the degree to which it’s all our responsibility.” The highest levels of teen pregnancy and repeat teen pregnancy tend to occur in the same communities, even the same geographic areas, which can be an advantage in outreach and prevention work.

The Dallas County community’s overall readiness level, as discussed earlier in this report, is at Stage Three, or Vague Awareness (an overall score of 3.28). In two of the five dimensions, however, the community scored at Stage Two: Denial/Resistance. The most successful campaigns to move a community toward readiness to act and engage must focus on community stakeholder groups that appear to lag behind others, or focus on the dimensions which scored lowest in the assessment. The recommendations for engaging at these levels are outlined below, drawn from the Colorado State University’s Tri-Ethnic Center’s Community Readiness Model Handbook.1 Stage Two: Denial/Resistance ·

Continue actions from previous stage.

·

Put information in church bulletins, club newsletters, respected publications, Facebook, etc.

·

Distribute media articles that highlight issue in the community.

·

Communicate strategically with influencers and opinion leaders.

Stage Three: Vague Awareness (Dallas community’s stage of readiness) ·

Continue actions from previous stages.

·

Present information at local community events and unrelated community groups.

Don’t rely on just facts. Use visuals and stories. Make your message “sticky.”

·

Post flyers, posters, and billboards.

·

Begin to initiate your own events to present information on this issue. But they must be fun or have other benefits to potential attendees.

·

Publish editorials and articles in newspapers and on other media with general information but always relate the information to the local situation.

Ntarupt and community partners can move to increase the Dallas community’s readiness to prevent teen pregnancy through the following steps, drawn from the themes as well as the scoring outlined elsewhere in this report.

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DEVELOPING LEADERSHIP IN KEY COMMUNITY GROUPS STEP 1) Create a leadership team that consists of a broad base of community stakeholder group representatives, and train them thoroughly on the ways that teen pregnancy can impact individuals, families, and communities. Setting numeric goals informed by local public health professionals will help measure successes. Integrating the leadership team into an ongoing strategic plan will also ensure momentum and accountability to the public.

STEP 2) Parents scored lower than any other group among community stakeholders, but are in a unique position to influence the future of teen pregnancy in the Dallas community.

Ntarupt and community partners can train parent “ambassadors” who can help host parentspecific events or who can attend parent-focused events within community organizations or faith communities. These events could offer parent-to-parent training for parents about teen pregnancy prevention. Parents can talk to each other about how to have difficult conversations with their children about delaying sexual activity or having another plan to delay parenthood until they have accomplished their educational and career goals.

STEP 3) Utilizing “Popular Opinion Leaders” is an evidence-based strategy used widely to advance public health knowledge and understanding. By identifying local leaders who have the trust of community members, or who have connections with hard-to-reach communities, messages can reach more of the intended population. Leaders can be both formal and informal leaders, and may be especially helpful when they involve youth and parents of youth in key roles.

OUTREACH & COMMUNICATION STEP 1) The two dimensions that had the lowest scores were Community Knowledge of Efforts and Community Knowledge of the Issues, so some basic outreach to increase knowledge of teen pregnancy as an issue and what the community is already being done to address it could be done in tandem. At the level of readiness of Stage Two or Three, one-on-one or small group meetings will help to gradually build relationships, awareness, and impact.

STEP 2) To the extent that it is economically feasible, all program materials online or on paper should be made available in Spanish. All parent interviews were conducted in Spanish, and the level of English language ability among parents may not yet be at the level of their children, so it is vital that materials be available in Spanish wherever possible.

STEP 3) Information can be shared more broadly where people regularly find information that informs them about the community, such as in church bulletins, local newsletters or newspapers, on social media sites like Facebook or Instagram, or other social media sites frequented by Dallas residents. Posting to a person’s individual social media sites ensures a broader distribution of information about events, educational materials, or other resources.

STEP 4) Individuals who were part of the community stakeholder groups that scored higher—health care organization staff, elected officials and policymakers, and educators/ administrators—can be asked to share in their professional and personal communities.

Individuals already at high level of buy-in for preventing teen pregnancy could be asked to write opinion pieces or letters to the editor. This would further expand messages to raise the level of community knowledge about teen pregnancy prevention.

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RESOURCES & PARTNERSHIPS STEP 1) Resources from the federal level have been secured but are nearly always time-limited. Significant resources have been allocated by the Dallas City Council, a marker of strong leadership for and support of preventing teen pregnancy. By cultivating additional funding sources, the sustainability of the work can be secured and the city can continue its overall progress toward reducing teen birth rates.

STEP 2) This community readiness assessment drew 45 participants who gave generously of their time and expertise by agreeing to be interviewed. The community does not yet have a high level of awareness about teen pregnancy, but there is a general concern about the conditions in which many young people are living. Ntarupt and a leadership team can look for “sister organizations” that focus on families and youth, complementing what they do by forming partnerships. Agencies can strengthen each other in their outreach and messaging, agreeing to promote each other’s missions and visions.

STEP 3) Dallas Independent School District (DISD) has been revising its implementation plan for sexuality education. Ntarupt can continue to offer technical assistance, training, and other resources to ensure that Dallas students have the best evidence-based, comprehensive education available. Ntarupt can also offer information on national examples of programs and services that have helped other urban school districts’ successful teen pregnancy rate reductions.

FAITH COMMUNITY LEADERSHIP STEP 1) Dallas residents have strong ties to their faith communities and are more likely than many other urban communities around the country to identify a strong faith affiliation.

Leaders in these faith traditions—particularly Evangelical Protestant, Mainline Protestant, and Catholic denominations—have the potential to reach significant proportions of their congregations should they become involved in teen pregnancy prevention. Each church or other faith community must decide for itself whether or how to become involved, but the potential is there for greater pastoral and lay leadership in the prevention of teen pregnancy.

STEP 2) Many faith communities have health fairs or other community events to which Ntarupt or partners or parent ambassadors could be invited. Faith community leaders who become part of the leadership team can help identify ways for information about teen pregnancy prevention to be presented at its events, be it through information tables or more formal presentations. Materials for parents can also be distributed through family ministries or outreach efforts, particularly in communities where there is already a high level of teen pregnancy.

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SUCCESS STORIES: MILWAUKEE, WISCONSIN In 2006, the City of Milwaukee confronted an ugly truth: one out of every 20 girls gave birth to a child. Health department epidemiologists, academics, and United Way of Greater Milwaukee and Waukesha County staff came together to set a goal to reduce teen pregnancy. The initial, highly ambitious goal was to reduce teen birth rates by 46% by 2015. In 2013, the United Way’s Teen Pregnancy Prevention Initiative announced that it had met its initial goal two years early. It then established a new goal, to reduce to 11.4 births per 1,000 teens ages 15-19 by 2023. The program has become an award-winning, national example of a successful community-wide effort to decrease teen pregnancy.

The initial campaign was started because of a community-wide belief that “Teen pregnancy profoundly, and in most cases negatively, affects the lives of those involved while costing the community millions of dollars through direct care, ancillary services, and the overall drain on the workforce. Most alarming is the connection between Milwaukee’s teen pregnancy epidemic and vicious, cyclical poverty.”

The United Way and partners committed to: ·

Bringing together representatives from business, government, education, the medical field, the faith community, law enforcement and other nonprofits to create a focused, cumulative effort. A Teen Pregnancy Prevention Oversight Committee meets every eight weeks, and has since 2006.

·

Investing hundreds of thousands of dollars in the Healthy Youth Initiative program to fund a wide variety of youth-focused efforts designed to educate youth about the consequences of teen pregnancy and teach skills needed to cope with social pressures, with the goal of delaying sexual activity and avoiding pregnancy.

·

Maintaining the BabyCanWait.com web site to provide medically accurate age-appropriate information on preventing pregnancy and promoting healthy relationships for youth.

·

Encouraging parents/guardians to talk to the youth in their lives by distributing the Family Communication Toolkit, available free of charge in English and Spanish.

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Working with Serve Marketing, a local marketing and communications firm, to develop a robust public awareness campaign

·

Regularly presenting to and communicating with the public as milestones are reached.

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The Teen Pregnancy Prevention Initiative has engaged in a wide variety of attention-grabbing, sometimes controversial campaigns. They have included topics such as: 1) You’re Too Young to be a Grandparent dramatizing how teen pregnancy can affect a whole family and asking parents to have the awkward conversation with their teens now instead of dealing with the consequences later.

2) You Think Your Life Won’t Change with a Baby? showed how life could change after having a baby as a teen.

3) Pregnant Mannequins featured partnerships with four local prom dress stores that agreed to display pregnant mannequins that featured tags that had simple messages like “A prom date is better without a due date.”

4) Rats and Snakes tackled the touchy subject of older men preying on younger teen girls, with the message “What kind of man preys on underage girls?” ·

Your Baby’s Not A Baby showed teens crammed into high chairs, car seats and strollers with the headline “Your Baby’s Not a Baby Anymore.”

The ads directed parents to talk to their kids about sex with assistance of BabyCanWait.com which offers a download of the Let’s Talk Toolkit.

5) If Age Is Just a Number was a campaign highlighting the harsh consequences of statutory rape, and discouraging anyone 18 and over from preying on younger teens.

6) Get At You video campaign combined honest messages and social media to reach out to the young men of Milwaukee with positive advice. Milwaukee guys talked candidly about many topics ranging from; their fears of being a young father, thoughts about older men dating younger women, things they wish they had known growing up, what they would tell their young self about being a father, why it’s good to use a condom, and why you should respect women.

7) 2028 was a movie promotion for the seemingly real, teen suspense thriller, called 2028 was nothing but a hoax to get teens to stop and hear a message warning them about the harsh realities of getting pregnant as a teen.

There were more than a dozen other campaigns or special events that were designed to address specific aspects of teen pregnancy prevention.

Serve Marketing worked closely with the United Way and community groups to ensure that messaging was targeted and effective.

The Teen Pregnancy Prevention Initiative is ongoing and is co-chaired by a retired physician and the immediate past president of the Milwaukee Journal-Sentinel, Milwaukee’s largest newspaper. Its Oversight Committee brings together public health and medical professionals, youth workers, educators, elected officials, business leaders, faith community leaders, and additional individuals with a vested interest in healthy youth development.

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CONCLUSION There is growing recognition of teen pregnancy as a crisis in the Dallas community, but public awareness and leadership must still grow significantly to address the issue. Reductions in teen pregnancy in Dallas are only being experienced by some parts of the community. Ten zip codes remain at persistently high rates of teen pregnancy, and of those ten, six had an increase in teen births at least measure. There are numerous challenges to the community climate around preventing teen pregnancy, such as the belief by some community members that teaching comprehensive sexuality education will encourage teens to engage in sexual activity.

There is tremendous potential to raise the public’s interest in this topic, and there are significant life social and economic savings that could be realized through reducing the rate of teen pregnancy. Every community sector has the potential to play significant roles in this important work, but parents, youth, and faith community leaders may have the biggest reach into their own networks.

By forming a strong leadership team and implementing a multi-year, multi-sector strategic plan, Ntarupt and its partners can reduce teen pregnancy much like other communities around the country. Success will depend on the dedicated leadership of representatives of the nine stakeholder groups interviewed for this assessment as well as the community at large. There is growing recognition of teen pregnancy as a community priority for the Dallas community. By focusing on the current level of readiness of key community groups, and taking a stepwise approach, the community can become more aware of and more united in its campaign to reduce teen pregnancy in all areas of Dallas.

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APPENDIX A: COMMUNITY READINESS ASSESSMENT INTERVIEW SCRIPT First Contact (by phone or email): North Texas Alliance to Reduce Unintended pregnancy in Teens, or Ntarupt, is hoping to get some feedback from community members like you on preventing teen pregnancy in Dallas County. The results of these surveys, called a Community Readiness Assessment, will help us figure out how to help Dallas County prevent pregnancy in teens, ages 15 through 19. I’m contacting you today because you were identified as someone who has information that will be helpful to this project. Would you be willing to be interviewed for this project? We anticipate the interview lasting approximately 30-45 minutes and will be conducted by phone.

QUESTIONNAIRE Just to remind you, I’m interviewing you today as part of a Community Readiness Assessment on preventing teen pregnancy in Dallas County. As you may know, there are lots of parts of the community that can play a role in preventing teen pregnancy. The teen birth rate in Texas is the fifth highest in the nation, and Texas has the Country’s highest repeat teen birth rate. The North Texas Alliance to Reduce Unintended Pregnancy in Teens (Ntarupt) is working on a comprehensive and community-driven plan to reduce this rate.

You were identified as someone who has information that will be helpful to this project. Before we begin the questionnaire, I would like to ask you just a few questions that will help us make sure we are getting a broad range of people in Dallas County for our survey. Please keep in mind that you will not be identified by name in reports or summaries of these results.

Basic information: (ask left-handed column items and fill in right-handed column items) Age: _____________________________ Location: _____________________________ Ethnicity: ________________________

Date: _________________________________

Gender: __________________________ Time of Day: _________________________ Language Spoken: __________________ Interviewer: ___________________________ Thank you for sharing that information with me. The next several questions I will ask are about teen pregnancy and teen pregnancy prevention in Dallas County. (This refers to prevention efforts only, not efforts to support teens who are already parenting.) I will read each question, then I will type up your answers as you share them with me.

If at any time you would like to stop the interview, or if you would like to skip a question, please do not hesitate to let me know. We are not asking any personal questions in this interview, only your views of the community’s knowledge, climate, resources, programs and services.

A. Community Efforts and B. Community Knowledge of Efforts 1. For the following question, please answer keeping in mind your perspective of what community members believe and not what you personally believe.

On a scale from 1-10, how much of a concern is teen pregnancy to the community of Dallas, with 1 being “not a concern at all” and 10 being “a very great concern”?

Can you tell me why you think it’s at that level?

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COMMUNITY KNOWLEDGE OF EFFORTS I’m going to ask you about current community efforts to address preventing teen pregnancy in Dallas County. By efforts, I mean any programs, activities, or services in your community that address this issue.

2. Are there efforts in Dallas County that address preventing teen pregnancy?

If Yes, continue to question 3; if No, skip to question 15.

3. Can you briefly describe each of these?

4. How long have each of these efforts been going on?

5. Who do each of these efforts serve (e.g., a certain age group, ethnicity, etc.)?

6. About how many community members are aware of each of the follow ing aspects of the efforts - none, a few, some, many, or most?

How many… · Have heard of efforts? · · · · ·

Can name efforts?

Know the purpose of the efforts?

Know who the efforts are for?

Know how the efforts work (e.g. activities or how they’re implemented)?

Know the effectiveness of the efforts?

7. Thinking back to your answers, why do you think members of your community have this amount of knowledge?

8. Are there misconceptions or incorrect information among community members about the current efforts? If yes: What are these?

9. How do community members learn about the current efforts?

10. What are the obstacles to individuals participating in these efforts? (Is everyone able to participate regardless of income, transportation, geography, gender, or other factors?)

11. What are the strengths of these efforts?

12. What are the weaknesses of these efforts?

13. What planning for additional efforts to address preventing teen pregnancy is going on in Dallas County?

Only ask #14 if the respondent answered “No” to #2 or was unsure.

14. Is anyone in Dallas County trying to get something started to address preventing teen pregnancy? Can you tell me about that?

LEADERSHIP I’m going to ask you how the leadership in Dallas County perceives preventing teen pregnancy. By leadership, we are referring to people who could affect the outcome of this issue and people who have influence in the community and/or who lead the community in helping it achieve its goals.

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15a. Using a scale from 1-10, how much of a concern is preventing teen pregnancy to the leadership of Dallas County, with 1 being “not a concern at all” and 10 being “a very great concern”?

Can you tell me why you say it’s a _____?

15b. How much of a priority is addressing this preventing teen pregnancy to leadership?

Can you explain why you say this?

16. I’m going to read a list of ways that leadership might show its support or lack of support for efforts to address preventing teen pregnancy.

Can you please tell me whether none, a few, some, many or most leaders would or do show support in this way? Also, feel free to explain your responses as we move through the list.

How many leaders… · · · · ·

At least passively support efforts without necessarily being active in that support?

Participate in developing, improving or implementing efforts, for example by being a member of a group that is working toward these efforts?

Support allocating resources to fund community efforts?

Play a key role as a leader or driving force in planning, developing or implementing efforts? (prompt: How do they do that?)

Play a key role in ensuring the long-term viability of community efforts, for example by allocating long-term funding?

17. Does the leadership support expanded efforts in the community to address preventing teen pregnancy?

If yes: How do they show this support? For example, by passively supporting, by being involved in developing the efforts, or by being a driving force or key player in achieving these expanded efforts?

18. Who are leaders that are supportive of addressing this issue in your community?

19. Are there leaders who might oppose addressing preventing teen pregnancy? How do they show their opposition?

COMMUNITY CLIMATE For the following questions, again please answer keeping in mind your perspective of what community members believe and not what you personally believe.

20. How much of a priority is addressing teen pregnancy to community members?

Can you explain your answer?

21. I’m going to read a list of ways that community members might show their support or their lack of support for community efforts to address preventing teen pregnancy.

Can you please tell me whether none, a few, some, many or most community members would or do show their support in this way? Also, feel free to explain your responses as we move through the list.

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How many community members… · · ·

At least passively support community efforts without being active in that support?

Participate in developing, improving or implementing efforts, for example by attending group meetings that are working toward these efforts?

Play a key role as a leader or driving force in planning, developing or implementing efforts? (prompt: How do they do that?)

·

Are willing to pay more (for example, in taxes) to help fund community efforts?

·

Are willing to support local schools in implementing comprehensive health curricula?

22. About how many community members would support expanding efforts in the community to address preventing teen pregnancy? Would you say none, a few, some, many or most?

If more than none: How might they show this support? For example, by passively supporting or by being actively involved in developing the efforts?

23. Are there community members who oppose or might oppose addressing preventing teen pregnancy? How do or will they show their opposition?

24. Are there ever any circumstances in which members of the community might think that teen childbearing should be tolerated or encouraged? Please explain.

KNOWLEDGE ABOUT THE ISSUE 25. On a scale of 1 to 10 where a 1 is no knowledge and a 10 is detailed knowledge, how much do community members know about teen pregnancy in Dallas?

Why do you say it’s a ____?

26. Would you say that community members know nothing, a little, some or a lot about each of the following as they pertain to teen pregnancy? (After each item, have them answer.), in general (Prompt as needed with “nothing, a little, some or a lot”.) · · · · · ·

the prevalence or amount (or how this shows up in the community) the causes or risk factors

the consequences (of teen pregnancy)

how much preventing teen pregnancy occurs locally (or the number of teen parents in your community) what can be done to prevent teen pregnancy

the effects of teen childbearing on teens, children of teens, family and friends?

27. What are the misconceptions among community members about teen pregnancy, for example, why it occurs, Dallas teen birth rates, or what the consequences are?

28. What type of resources or information is available in Dallas County about preventing teen pregnancy (e.g. reproductive healthcare for teens, clinics, sexuality education for teens, information for parents, newspaper articles, brochures, posters)?

If they list information, ask: Do community members access and/or use this information?

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RESOURCES FOR EFFORTS (time, money, people, space, etc.)

If there are efforts to address the issue locally, begin with question 29. If there are no efforts, go to question 30.

29. How are current efforts funded? Is this funding likely to continue into the future?

30. I’m now going to read you a list of resources that could be used to address preventing teen pregnancy in your community. For each of these, please indicate whether there is none, a little, some or a lot of that resource available in your community that could be used to address preventing teen pregnancy? · · · · · ·

Volunteers?

Financial donations from organizations and/or businesses?

Grant funding from foundations, government, or other sources?

Experts?

Space?

Nonprofits?

31. Would community members and leadership support using these resources to address preventing teen pregnancy? Please explain.

32. On a scale of 1 to 5, where 1 is no effort and 5 is a great effort, how much effort are community members and/or leadership putting into doing each of the following things to increase the resources going toward addressing preventing teen pregnancy in your community? · · · · · · ·

Seeking volunteers for current or future efforts to address preventing teen pregnancy in the community.

Soliciting donations from businesses or other organizations to fund current or expanded community efforts.

Writing grant proposals to obtain funding to address preventing teen pregnancy in the community.

Training community members to become experts.

Recruiting experts to the community.

Supporting local independent school districts in their efforts Raising Awareness

33. Are you aware of any proposals or action plans that have been submitted for funding to address preventing teen pregnancy in Dallas County?

If Yes: Please explain.

Thank you so much for sharing your time with me today.

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Endnotes

Martin JA, Hamilton BE, Osterman MJK, et al. Births: Final data for 2015. National vital statistics report; vol 66, no 1. Hyattsville, MD: National Center for Health Statistics. 2017. <?> Santelli J, Lindberg L, Finer L, Singh S. Explaining recent declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use. Am J Public Health. 2007;97(1):150-6. <?> Lindberg LD, Santelli JS, Desai, S. Understanding the Decline in Adolescent Fertility in the United States, 2007–2012. J Adolesc Health. 2016: 1-7 <?> Sedgh G, Finer LB, Bankole A, Eilers MA, Singh S. Adolescent pregnancy, birth, and abortion rates across countries: levels and recent trends. J Adolesc Health. 2015;56(2):223-30. <?> Reduced Disparities in Birth Rates Among Teens Aged 15–19 Years — United States, 2006–2007 and 2013–2014, MMWR 2016 <?> Martin JA, Hamilton BE, Osterman MJK, et al. Births: Final data for 2015. National vital statistics report. <?> Ibid. <?> Reduced Disparities in Birth Rates Among Teens Aged 15–19 Years — United States, 2006–2007 and 2013–2014, MMWR 2016 <?> Penman-Aguilar A, Carter M, Snead MC, Kourtis AP. Socioeconomic disadvantage as a social determinant of teen childbearing in the U.S. Public Health Rep. 2013;128(suppl 1):5-22. <?> Finer LB and Zolna MR, Declines in unintended pregnancy in the United States, 2008–2011, New England Journal of Medicine, 2016, 374(9):843–852, http://nejm.org/doi/full/10.1056/NEJMsa1506575. <?> Covington, R., Peters, H. E., Sabia, J. J., & Price, J. P. (2011). Teenage fatherhood and educational attainment: Evidence from three cohorts of youth.

Retrieved from http://resiliencelaw.org/wordpress2011/wp- content/uploads/2012/04/Teen-Fatherhood-and-Educational- Attainment.pdf <?> Fletcher, J. M., & Wolfe, B. L. (2012). The effects of teenage fatherhood on young adult outcomes. Journal of Population Economics, 25, 201-218 <?> Hoffman SD, Maynard RA, editors. Kids having kids: Economic costs & social consequences of teen pregnancy. Washington, DC: Urban Institute Press; 2008. pp. 92–74. <?> Quick stats: Birth rates* for teens aged 15–19 years, by state—United States, 2009. Morbidity and Mortality Weekly Report, 60(06), 183. <?> Markham, C. M., Lormand, D., Gloppen, K. M., Peskin, M. F., Flores, B., Low, B., & House, L. D. (2010). Connectedness as a predictor of sexual and reproductive health outcomes for youth. Journal of Adolescent Health, 46(3), S23-S41. <?> Mmari, K., & Blum, R. W. (2009). Risk and protective factors that affect adolescent reproductive health in developing countries: A structured literature review. Global Public Health; an International Journal for Research, Policy and Practice, 4(4), 350-366. <?> Markham, C. M., Lormand, D., Gloppen, K. M., Peskin, M. F., Flores, B., Low, B., & House, L. D. (2010).

Connectedness as a predictor of sexual and reproductive health outcomes for youth. <?> Viner, R. M., Ozer, E. M., Denny, S., Marmot, M., Resnick, M., Fatusi, A., & Currie, C. (2012). Adolescence and the social determinants of health. The Lancet, 379(9826), 1641-1652. <?> Cavazos-Rehg, P., Krauss, M. J., Spitznagel, E. L., Schootman, M., Bucholz, K. K., Peipert, J. F., et al.

(2009). Age of sexual debut among US adolescents. Contraception, 80(2), 158-162. <?> James, S., Montgomery, S. B., Leslie, L. K., & Zhang, J. (2009). Sexual risk behaviors among youth in the child welfare system. Children and Youth Services Review, 31(9), 990-1000. <?> Crittenden, C. P., Boris, N. W., Rice, J. C., Taylor, C. A., & Olds, D. L. (2009). The role of mental health factors, behavioral factors, and past experiences in the prediction of rapid repeat pregnancy in adolescence. Journal of Adolescent Health, 44(1), 25-32. <?> Markham, C. M., Lormand, D., Gloppen, K. M., Peskin, M. F., Flores, B., Low, B., & House, L. D. (2010).

Connectedness as a predictor of sexual and reproductive health outcomes for youth. <?> Akers, A. Y., Schwarz, E. B., Borrero, S., & Corbie‐Smith, G. (2010). Family discussion about contraception and family planning: A qualitative exploration of black parent and adolescent perspectives. Perspectives on Sexual and Reproductive Health, 42(3), 160-167. <?> George, C., Alary, M., & Otis, J. (2007). Correlates of sexual activity and inconsistent condom use among high school girls in Dominica. The West Indian Medical Journal, 56(5), 433. <?> Browning, C. R., Leventhal, T., & Brooks-Gunn, J. (2005). Sexual Initiation in Early Adolescence: The Nexus of Parental and Community Control. American Sociological Review, 70(5), 758–778. <?> Pilgrim, N. A., & Blum, R. W. (2012). Protective and risk factors associated with adolescent sexual and reproductive health in the English-speaking Caribbean: A literature review. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 50(1), 5. <?> Salazar, L. F., Crosby, R. A., DiClemente, R. J., Wingood, G. M., Lescano, C. M., Brown, L. K., Harrington, K., Davies, S. (2005). Self-Esteem and Theoretical Mediators of Safer Sex Among African American Female Adolescents: Implications for Sexual Risk Reduction Interventions. Health Education & Behavior, 32(3), 413–427. <?> Pilgrim, N. A., & Blum, R. W. (2012). Protective and risk factors associated with adolescent sexual and reproductive health in the English-speaking Caribbean: A literature review.. <?> James, S., Montgomery, S. B., Leslie, L. K., & Zhang, J. (2009). Sexual risk behaviors among youth in the child welfare system. Children and Youth Services Review, 31(9), 990-1000. <?> Salazar, L. F., Crosby, R. A., DiClemente, R. J., Wingood, G. M., Lescano, C. M., Brown, L. K., Harrington, K., Davies, S. (2005). Self-Esteem and Theoretical Mediators of Safer Sex Among African American Female Adolescents: Implications for Sexual Risk Reduction Interventions. . <?> Markham, C. M., Lormand, D., Gloppen, K. M., Peskin, M. F., Flores, B., Low, B., & House, L. D. (2010).

Connectedness as a predictor of sexual and reproductive health outcomes for youth. <?> Helitzer, D., Hollis, C., de Hernandez, B. U., Sanders, M., Roybal, S., & Van Deusen, I. (2010). Evaluation for community- based programs: The integration of logic models and factor analysis. Evaluation and Program Planning, 33(3), 223-233. <?> Sieving, R. E., Resnick, M. D., Garwick, A. W., Bearinger, L. H., Beckman, K. J., Oliphant, J. A., . . . Rush, K. R. (2011). A clinicbased, youth development approach to teen pregnancy prevention. American Journal of Health Behavior, 35(3), 346. <?> Retrieved on 10-16-18 from: https://www.cdc.gov/nchs/data/databriefs/db209.pdf <?> Lindberg, L., Santelli, J., Desai, S. Understanding the Decline in Adolescent Fertility in the United States, 20017-2012. Journal of Adolescent Health 59 (2016) 577-583. <?> For a full report on rates of pregnancy, birth and abortion among adolescents between 1973-2013, see these tables: https:// www.guttmacher.org/sites/default/files/report_downloads/us-adolescent-pregnancy-trends-2013_tables.pdf <?> Melissa S. Kearney & Phillip B. Levine, 2015. “Media Influences on Social Outcomes: The Impact of MTV’s 16 and Pregnant on Teen Childbearing,” American Economic Review, American Economic Association, vol. 105(12), pages 3597-3632, December. <?> Jennifer Stevens Aubrey, Elizabeth Behm-Morawitz & Kyungbo Kim (2014) Understanding the Effects of MTV’s 16 and Pregnant on Adolescent Girls’ Beliefs, Attitudes, and Behavioral Intentions Toward Teen Pregnancy, Journal of Health Communication, 19:10, 1145-1160. <?> Retrieved on 10-6-18 from: https://hhs.texas.gov/about-hhs/records-statistics/data-statistics/healthcare-statistics <?> Retrieved on 10-6-18 from: https://wonder.cdc.gov/natality.html <?> Retrieved on 10-6-18 from: http://files.kff.org/attachment/fact-sheet-medicaid-state-TX <?> Retrieved on 10-15-18 from: https://powertodecide.org/sites/default/files/resource-primary-download/fact-sheet-texas.pdf <?> The National Campaign to Prevent Teen and Unplanned Pregnancy. (2013). Counting it up: The public costs of teen childbearing: key data. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy. <?> Retrieved on 10-20-18 from: https://www.vera.org/publications/price-of-prisons-2015-state-spending-trends <?> E.R. Oetting, B.A. Plested, R.W. Edwards, P.J. Thurman, K.J. Kelly, and F. Beauvais. Community Readiness for Community Change: Tri-Ethnic Center Community Readiness Handbook. 2nd edition. Fort Collins, CO. Tri-Ethnic Center for Prevention Research; 2014. http://triethniccenter.colostate.edu/docs/CR_Handbook_8-3-15.pdf <?> Prochaska JO, DiClemente CC, Norcross JC (1992). In search of how people change. Applications to addictive behaviours. Am Psychol 47:1102. <?> Retrieved on 10-15-18 from: http://triethniccenter.colostate.edu/docs/CR_Handbook_8-3-15.pdf <?> E.R. Oetting, B.A. Plested, R.W. Edwards, P.J. Thurman, K.J. Kelly, and F. Beauvais. Community Readiness for Community Change: Tri-Ethnic Center Community Readiness Handbook. 2nd edition. <?>

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“THE NUMBERS ARE JUST SHOCKING. TEEN CHILDBEARING IS ONE OF THE REASONS SO MANY CHILDREN ARE GROWING UP IN POVERTY IN DALLAS. IT IS BOTH A PERSONAL AND STRATEGIC ISSUE.” – MAYOR MIKE RAWLINGS

624 N. Good-Latimer Expy, Suite 100 | Dallas, Texas 75204

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