Precede-Proceed Phase 1: Although we have seen pregnancy rates decline in the past two
decades, substantial health disparities remain in both social and economic aspects for teenagers
that are at risk. Many individuals are affected nationwide directly and indirectly, from being the
teenagers who face unplanned pregnancies to lost tax revenue. Both social and behavior factors
exist and have a major impact on teenagers living in the United States. Many teenagers are
easily influenced by their peers, but they also serves as targets of the media. We must improve
adolescent reproductive health in central San Diego by improving the behaviors with
encouraging positive attitudes, extracurricular activities, and offering counseling services.
Strategies used in sex education courses at high schools can be improved by including
information about health services that are offered in the community and not only encourage the
delay of sexual intercourse, but also provide education on the risks associated risky sexual
behavior. There are many studies that have been conducted on sex education and teen
pregnancy. Our health promotion program and plan will incorporate the most effective strategies
Precede-Proceed Phase 2 (National Level): “Despite declines since 1991, the teen birth
rate in the United States remains as much as nine times higher as in other developed countries”
(Pazol, et. al. 2011). This is unusual for being such an industrialized, developed country. “Each
year, teen childbearing costs the United States approximately $6 billion in lost tax revenue and
nearly $2 billion in public expenditures” (Pazol et. al, 2011). According to Jessica Pika,
Assistant Director, Communications for The National Campaign to Prevent Teen and Unplanned
Pregnancy Organization states, teen pregnancy is a major issue for the U.S. because it not only
affects pregnant teens, but their family, friends, and people they have never met (i.e., taxpayers
who pay for “teen childbearing costs” (personal communication, November 20, 2012). Teen
pregnancy affects everyone (J. Pika, personal communication, November 20, 2012). Since teen
pregnancy can be prevented, this is a lot of money that the country is losing annually.
“Approximately one third of the teenaged females in the United States becoming pregnant and
once pregnant, are at risk of becoming pregnant again” (Basch, 2011). Getting pregnant once
during one’s teenage years raises the risk of conceiving again. In a recent interview with Marcy
Clayson an Engagement Specialist at Planned Parenthood a statement she made advocates for
Basch’s belief about teen pregnancy risks of conceiving again, she stated, “A lot of our teen
moms are children of teen parents. That is a common factor. It’s almost a social norm in their
communities. We make sure that our teens know that they can prevent an unplanned for a second
pregnancy once they’ve graduated and received further education.”
Precede-Proceed Phase 2 (State Level): On the state level, in 2005, teen pregnancy of
Californian girls, ages 15-19 years old, according to The National Campaign to Prevent Teen and
Unplanned Pregnancy (2012), was 96, 490. The 2005 California teen pregnancy rate for girls of
the same age range (i.e., 15-19 years old) was 75 compared to the United States (U.S.) teen
pregnancy rate of 70 (The National Campaign to Prevent Teen and Unplanned Pregnancy, 2012).
The number of California teenage girls who gave birth in 2010 ages 15-19 years old was 43, 149
(The National Campaign to Prevent Teen and Unplanned Pregnancy, 2012). Furthermore,
during 2010, the number of Californian “girls under 15” who gave birth was 433 (The National
Campaign to Prevent Teen and Unplanned Pregnancy, 2012). The 2010 California “teen birth
rate” for girls ages 15-17 years old was 16.4 while girls ages 18-19 years old was 53.4 (The
National Campaign to Prevent Teen and Unplanned Pregnancy, 2012). The “number of teenage
births” data in California was further narrowed down to “race/ethnicity” (The National
Campaign to Prevent Teen and Unplanned Pregnancy, 2012). Therefore, “Hispanic girls” in
2010 had 31, 580 teenage births (The National Campaign to Prevent Teen and Unplanned
Pregnancy, 2012). This population had the highest “number of teenage births” than other
ethnicities (e.g., “Non-Hispanic White girls” had 5, 800 teenage births and “Non-Hispanic Black
girls” had 3, 737) (The National Campaign to Prevent Teen and Unplanned Pregnancy, 2012).
Furthermore, “Hispanic girls’” 2010 California “teen birth rate”, 48.1, also had the highest rate
than other ethnicities (e.g., “Non-Hispanic White girls” had 14.1 and “Non-Hispanic Black girls”
had 37.7) (The National Campaign to Prevent Teen and Unplanned Pregnancy, 2012).
Precede-Proceed Phase 2 (Local Level): With a teen population of 709, 916 in the city of
San Diego alone, according to the County Health Ranking, statistics within the past year, there
have been 26,385 teen pregnancies. (County Health Rankings. 2012) In a city with such a diverse
group of ethnicities it has been found that when it comes to teen pregnancy, San Diegans with
Hispanic background tend to have a higher pregnancy rate. Pregnancy and birth rates among
teenage Latinas are actually high nationwide and locally. Rates among Latina teens have failed
to decline as rapidly as rates among other ethnic groups. While Latinos comprise just over a
third of the teenage population in San Diego County, Latinas account for more than three-
quarters of teen births in the area. (National Campaign to Prevent Teen and Unplanned
Precede-Proceed Phase 2 (Risk Factors at the National Level): It is commonly found that
teenagers, who live in areas where their community has a lower socioeconomic status, have a
greater risk of risky sexual behavior and getting pregnant. “Many studies show that adolescents
who live in disadvantaged communities with high poverty rates are more likely to have sex,
become pregnant, and give birth. In contrast, teens who live in more affluent communities are
less likely to engage in risky sexual activity” (Manlove et. al, 2002). Unfortunately, it has also
been shown that “teen childbearing also perpetuates a cycle of disadvantage; teen mothers are
less likely to finish high school, and their children are more likely to have low school
achievement, drop out of high school, and give births themselves as teens” (Pazol, 2011).
According to Talia Perez, a Community Engagement Specialist from Planned Parenthood of the
Pacific Southwest, Planned Parenthood has a program called Teen Success. The national average
of teens that have a second pregnancy is 20%. Perez explains that Teen Success is for pregnant
or parenting teens and helps these individuals prevent a second pregnancy by helping them focus
on school, graduate from high school, and seek secondary education. Teen Success started in
1990. For teens enrolled in Teen Success, only 4% have a second pregnancy, which is
significantly lower than the national average. There are many risk factors associated with teen
pregnancy and risky sexual behavior. These not only include gender, age, race and ethnicity but
also the following: attitudes (i.e. peer pressure, social acceptance), the adolescent’s family, and
involvement in activities. According to a study conducted on teen pregnancy and the risk
factors, “Teens whose parents talk about sex and birth control with their children, and
communicate strong disapproval of sexual activity, are more likely to have positive reproductive
health outcomes” (Manlove, et. al, 2002). To support this statement, Jessica Pika, Assistant
Director, Communications for The National Campaign to Prevent Teen and Unplanned
Pregnancy Organization states, open and honest and communication between parents and teens
will help increase awareness about how to prevent and reduce teen pregnancy because teens are
knowledgeable about the options of abstinence, having safer sex with the use of contraceptives,
or having unsafe sex with a higher risk of becoming pregnant (personal communication,
November 20, 2012). Parents who also talk to their teens not only on sex, but also love, dating,
and good relationships increase their teens’ awareness on sex and relationships (J. Pika, personal
communication, November 20, 2012). In addition, it also has to do with social acceptance, the
teenagers’ attitudes on sex, and the perception of sex among their peers. One major factor is,
“those who believe sexual experience will increase others’ respect for them are also more likely
to have sex” (Manlove, et. al, 2002). Another report shows that school involvement and/or
involvement in extracurricular activities play a significant role. “Adolescents’ engagement and
performance in school, religious activities, and sports (among girls) are all associated with more
positive reproductive health behaviors, which indicates that involving teens in positive activities
may help them avoid other risk-taking behaviors” (Manlove, et. al, 2002).
Precede-Proceed Phase 2 (Risk Factors at the State Level): No single state has the same
number of racial/ethnic populations. Therefore, teen pregnancy may affect different racial/ethnic
populations differently. In the state of California, African American and Latina teens have the
highest number and risk for teen pregnancy. Many studies have not shown any genetic risk
factors associated to teen pregnancy yet. However the risk factors that greatly affect teenagers,
such as Latina teens who reside in California, are behavioral and environmental. According to
MedlinePlus (2012), “poor academic performance” and poverty can be both behavioral and
environmental risk factors that increase the risk of teenage girls becoming pregnant. For
example, “poor academic performance” can be both behavioral and environmental because some
teenagers do not believe that education is important or they may have to fill in the role of a
parent to a younger sibling if they live in a single parent household, which in turn leads them to
not have education as their number one priority (MedlinePlus, 2012). Furthermore, where a
teenager lives may not have the best schools/universities, hence “poor academic performance”
(MedlinePlus, 2012). Latina teenagers have the risk factors that MedlinePlus listed. To support
this claim, Frost and Driscoll (2006) explain, “Latinas’ higher rates in poverty and lower
educational attainment place them at a higher risk of teen pregnancy and also translate into fewer
resources to cope with the difficulties of teen parenting” (as cited in Biggs, Antonia, Ralph,
Minnis, Arons, Marchi, Lehrer, Braveman, Brindis, 2010, p. 78). From this quote, having fewer
resources is an environmental risk factor for teenagers regardless of their race/ethnicity because
they have fewer coping and educational methods if they have disadvantaged lives. Another
behavioral risk factor that increases the risk of teen pregnancy is having an “older male partner”
(MedlinePlus, 2012). In California, Latina teens “are more likely than teens of other
racial/ethnic groups to choose partners who are significantly older, placing them at higher risk
for early childbearing” (Darroch, Landry, & Oslak, 1999 as cited in Biggs et al., 2010, p. 79).
An environmental risk factor that increases the risk of teenage girls becoming pregnant is
experiencing “gangs and gang activity” in their neighborhood (Richardson & Nuru-Jeter, 2012,
p. 69). “Studies show that adolescent involvement with gangs is associated with risky sexual
behavior, including lower use of condoms” (Richardson & Nuru-Jeter, 2012, p. 69). Thus, teen
girls (e.g., Latinas) whose partners are affiliated with a gang have a high “incidence of
pregnancy” (Richardson & Nuru-Jeter, 2012, p. 70).
Precede-Proceed Phase 2 (Risk Factors at the Local Level): Latino teens in fact share
many of the same common goals and concerns with those of other ethnic backgrounds.
However, it is still clear that there are also differences as well. Young Latina mothers are likely
to face different circumstances than those of non-Hispanic mothers. Latinos not only have lower
educational and income levels throughout San Diego, but they are also more likely to be located
in high poverty neighborhoods (e.g., Skyline, Lincoln Park, Paradise Hills, Barrio-Logan, Logan
Heights, etc.) (Murphy-Erby, 2011). The types of contraception used by Latinos also contribute
to higher pregnancy rates. Latino teens are less likely than other ethnic groups to use condoms
and are less likely than white teens to use birth control pills. Furthermore, Latino teens are more
likely to use less effective approaches, such as the pull out method as well as the rhythm methods
Precede-Proceed Phase 3 (Predisposing, Enabling, and Reinforcing factors): One
predisposing factor of teen pregnancy is not having the knowledge of contraceptives. Some teens
have never been educated about contraceptives where they are available. Another predisposing
factor is the glamorization of teen pregnancy on television/movies. An enabling factor of teen
pregnancy low income/ underserved teens do not have “access to health care facilities” because
they are not aware that they can utilize their community health clinic services (Mckenzie,
Neigor, & Thackeray, 2009, p. 22) Another enabling factor is resources are not available, such as
health care facilities and social support from family and friends, without these resources teens
have a higher risk of risky and unsafe sexual activities. One reinforcing factor of teen pregnancy
is peer pressure. Having an older partner or being in a long-term relationship, a teenage girl
might be pressured to have sex without protection. Another reinforcing factor is some teens do
not have parents that discourage risky and unsafe sexual activities because parent-teen they do
not have an open and honest parent-teen relationship
Precede-Proceed Phase 4 (Goal, Objectives, and Interventions) are listed below:
The teen pregnancy rates have declined nationally but at state and local areas, there do still exist
issues. This is especially the case among Latino adolescents. Our goal is to reduce the teen
pregnancy rates within the Latino community in central San Diego County. San Diego Teen
Pregnancy Prevention Program (STEPPP) will help lower the teen pregnancy rate in central San
Diego by incorporating new curriculum in the high schools’ sex education course. Students will
be offered the chance to enroll in the sex education course upon parental consent. We will pilot
test STEPPP in the central San Diego area to compare between STEPPP at Garfield High School
and the current sex education course at Lincoln High School, using the quasi-experimental
1.1 Process Objective: STEPPP would be pilot tested at Garfield High School and Lincoln High
School (control). Program staff members and volunteers will disseminate informational
brochures on how to prevent and reduce teen pregnancy. In addition, there will be flyers listing
resources that are available at local community health clinics. The information will be targeting
25% (target: entire freshman class) of high school students when they are taking a sex education
course (upon parental consent).
1.1 Activities/Strategies: The informational brochures and flyers will be available at schools and
other facilities such as the following locations: YMCA, school nurse’s office, school
advisor/counselor’s office, and where parent-teacher conferences are generally held. The
information would not only reach our target population but also parents and others in the
2.1 Learning (Awareness) Objective: After listening to guest speakers, half of the students in the
sex education course would be able to identify multiple risk factors of teen pregnancy that
individually affect them.
2.1 Activities/Strategies: Guest speakers (e.g., pregnant teens, teen mothers, family and friends
of pregnant teens, health care workers who work with pregnant teens and their families) will
visit and share personal experiences with the students enrolled in the sex education course. The
students will be able to have open discussions with the guest speakers after they have made
2.2 Learning (Knowledge) Objective: During the group discussions, 2 out of 4 high school
students will be able to explain the risk factors of teen pregnancy and how those risk factors
impact their life in an ecological perspective.
2.2 Activities/Strategies: The class will be divided into small groups to complete an assignment
through discussion. The instructor(s) will have handouts for the students. These handouts will
include teen pregnancy topics in an ecological perspective. Each group will also be given a
script/scenario to role-play/act out in front of the class. Role-playing in certain scenarios can
help students learn more about teen pregnancy and how they can protect themselves. Incentives
(e.g. gift cards, movie tickets, etc.) will be given after the completion of the group
2.3 Learning (Attitude) Objective: After the completion of the sex education course, 50% of
students would pledge to refrain from unsafe sexual activities.
2.3 Activities/Strategies: Pledge cards will be handed out to the students and they will have the
opportunity to make their pledge individually.
2.4 Learning (Skill) Objective: Upon completion the sex education course, at least 75% of
student can demonstrate resistance strategies to having unsafe sexual activities.
2.4 Activities/Strategies: Pre- and post-test assessments/surveys will be given to Garfield high
school students to gather information and data to see if they are grasping the concepts and other
learning objectives of the course. Handouts and pamphlets on teen pregnancy prevention will
be given to the students. Multiple group discussions will be held in the duration of the sex
education course to help the students further understand the risk factors and potential
disadvantages of those directly/indirectly affected by teen pregnancy.
3.1 Action/Behavioral: By the end of a semester, the majority of the students who complete the
sex education course will comply with their pledge to refrain from unsafe sexual activities.
3.1 Activities/Strategies: Pledge cards will be handed out to the students and they will be given
the opportunity to make their pledge individually.
4.1 Environmental Objective: During the sex education course, a majority of students will have
access to newly built-in/placed condom dispensers in the advisor/counselor’s and school nurse’s
4.1 Activities/Strategies: Newly built condom dispensers will be installed in the school advisors
and school nurse’s offices.
4.2 Environmental Objective: As part of the sex education course, 100% of the students (those
with parental consent) will participate in a field trip to local community health clinics, which will
allow them to learn more about the facilities and their services.
4.2 Activities/Strategies: Field trip to local community health clinics; access to community
resources. Each community health clinic will have a tour guide (staff member who works at the
facility) to show students the different areas of the clinic. The tour guide will also explain to the
students the different services and classes that are offered to teenagers. The students will have
the chance to make appointments or sign up for classes if they so choose to and ask questions
during the field trip.
4.3 Environmental Objective: During the sex education course, 100% of students will have
access to the newly created student Facebook page (co-partnered with local community health
clinics through community organization and community building) that will include not only the
upcoming events of the high school, but links to local community health clinics and their
upcoming events. This will serve as a resource for students, parents, and others in the
community. Instructors and other staff members can encourage students to visit the high school’s
Facebook page to access information. On the Facebook page, there will be public service
announcements (PSAs) that students can watch.
4.3 Activities/Strategies: The students will have a classroom activity that includes browsing the
Internet for local community health clinics. The Facebook page will serve as one of the internet
resources and as a social media tool for the students. There will be public service announcements
for students to watch.
5.1 Outcome: To lower teen pregnancy rates among the Latino population in central San Diego
by 10% within a year time span.
Activities/Strategies: Implementation of the objectives’ activities and strategies listed above into
the sex education course.
Precede-Proceed Phase 5 (Implementation): STEPPP will be pilot
tested/implemented at Garfield High School and compared the current sex education course at
Lincoln High School. This will begin January 2013 for the spring semester of the academic year.
Precede-Proceed Phase 6 (Process Evaluation): Key informant interviews from local
community health clinics will be conducted prior to the start of STEPPP. Data will also be
gathered from internet sources and other agencies/organizations associated with teens and teen
pregnancy prevention in the community. In order for the pilot testing to begin, it must be
presented to and be approved by the stakeholders. During the pilot testing, the program will take
effect and be available to students at Garfield High School. The program will include multiple
group activities that will help reinforce making healthy choices. By implementing new strategies
into the sex education course, we can better equip each generation with tools to make healthier,
safer decisions in life. In addition, collaboration with local community health clinics will help
with facilitating field trips and other activities. For satisfaction evaluation of STEPPP, we can
include questions in the pre- and post test assessments. Many of the interventions will be
measured through the pre- and post test assessments. Evaluators will be assigned to sit in the sex
education class during key classroom activities (those mentioned in the Learning Objectives) to
observe the interactions between students and instructors. Surveys will be given to students after
each key classroom activity for the evaluators to interpret and prepare for monthly staff
meetings. Monthly meetings will be held for program staff members to assess the quality and
effectiveness of the current methods used as the learning objectives of STEPPP.
Precede-Proceed Phase 7 (Impact Evaluation): According to McKenzie, Neiger, and Thackeray
(2009), “impact evaluation relates to changes in behavior, and, in some cases, changes in
awareness, knowledge, attitudes, and skills” (p. 359). As program planners of STEPPP, we will
evaluate these changes (i.e., behavior, awareness, knowledge, attitudes, and skills) in high school
students through observations and pre- and post-test assessments/surveys. There will be a weekly
assessment of number of people accessing student Facebook page by using a website counter.
Program staff will observe students throughout the course of the sex education program. As for
the field trip, we will assess the number of participating students who signed in the sign-in sheet.
They will observe the students’ behaviors through the various activities/strategies implemented,
such as visiting guest speakers, group discussions, and role-playing scenarios. Changes in the
students will also be evaluated through pre- and post-test assessments/surveys. These pre- and
post-test assessments/surveys will have both closed and open- and closed-ended questions. An
agency will be assigned to evaluate, analyze, and interpret the results.
Precede-Proceed Phase 8 (Outcome Evaluation):
Outcome: By the end of program the evaluating consultant will identify that the quasi-
experimental design was implemented throughout STEPPP. With our target population mainly
aimed towards Latino teens to the Central San Diego region we concentrated our focus on two
specific schools that we felt would benefit most with the program (Lincoln High School and
Garfield High School.) Both schools we’re chosen due to their location and student population.
Garfield High School is well known for taking in troubled teens as well as teen moms/soon to be
teen mothers throughout the San Diego county, therefore implementing the program into the
school would give those students who need it the most the proper education and allow them to be
aware of different available resources that are open for their taking. Lincoln High school was
also chosen because of a Regional Occupational Program (ROP) that they already have
implemented into their school. We felt that by being able to compare Lincoln High School’s
ROP to STEPPP would improve education to the teens in the future.
Reporting: After one academic school year, the results of STEPPP will be presented to
the program staff, Garfield High School’s officials, Lincoln High School officials, parents, the
San Diego County Office of Education, the community, the local community health clinics, and
the County of San Diego: Health and Human Services Agency. The STEPPP results will be
reported to these stakeholders in order to evaluate and improve the quality and effectiveness of
the program for future endeavors (McKenzie, Neiger, & Thackeray, 2009, p.336). Further
explanations and presentations will be given to show how much of an impact the program has
made on the students at Garfield High and the possibilities that could arise if implemented to
Lincoln High School as well. Key informants will also be brought back to emphasize on the
different area’s they found would be beneficial to implement within the STEPPP program, to
further explain the thought process and reasoning as to why certain activities were chosen. A
display of numerous activities (pre- and post tests, surveys, field trip sign in sheets etc.) that were
done by the students would be displayed for the viewers to see and take note on the progress
STEPPP has made in educating them. STEPPP continues its program at Garfield high, and is
also implemented at Lincoln the following year. Other local schools in the Central San Diego
region are open to partake in the STEPPP and eventually will be open to all of San Diego in the
Basch, C. (2011). Teen pregnancy and the achievement gap among urban minority youth.
American School Health Association. 81(10), 614-618.
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Brindis, C.D. (2010). Factors associated with delayed childbearing: From the voices of
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