Programs that Work
Self Center (School-Linked Reproductive Health Services)
Healthy and Safe Children
Youths abstaining from sexual activity or not engaging in risky sexual behavior
Age of Child
Type of Setting
Health Care Provider
Type of Service
Health Care Services
Type of Outcome Addressed
Teen Sex / Pregnancy
Evidence Level (What does this mean?)
The Self Center (School-Linked Reproductive Health Services) program was established to provide year-round contraceptive and reproductive health services and education to middle and high school students in Baltimore, Maryland. Funded and evaluated as a three-year program, it began in November 1981 and provided services through June 1984.
In the program model, a social worker/nurse team provided students with in-school support and education as well as helped them to obtain free reproductive and contraceptive health services and counseling at a health clinic adjacent to the schools. Within-clinic services included pregnancy testing, contraceptives, treatment for sexually transmitted diseases (STDs), and ongoing education and counseling services. The school-based component included counseling and education services, with teams conducting homeroom and classroom presentations at least twice yearly, and a presence on-site in school health suites for several hours daily to facilitate small group discussions and informal individual counseling. The curriculum emphasized behavioral skills development, sexual abstinence, and contraceptive and sexuality/STD/HIV/AIDS education. A student resource team assisted staff with outreach.
The program study included all seventh through twelfth grade students at one middle school and one high school in Baltimore, Maryland. Students came from low-income, inner-city, African-American neighborhoods with high rates of sexual activity and teen pregnancy.
The research study compared 1,700 students from the two schools participating in the program over a three-year period (1981 to 1984) with 1,950 students from similar backgrounds in schools not participating in the program. Students in the comparison group participated in their schools' standard sex/health education curricula. The evaluation design included both pre/post measurements and intervention/control groups.
Student questionnaires were used to evaluate the following indicators: changes in knowledge, attitudes, and behaviors, including the percentage of students having sexual intercourse; the percentage of students using contraceptives; and the percentage of students becoming pregnant or causing a pregnancy. Student knowledge and behaviors were assessed before the program began and annually for three years.
In addition, an evaluation was done assessing the distribution of utilization of the various curriculum components, for example, the percentage of students accessing in-school services only, the percentage of students accessing both in-school and clinic services, and the percentage of students accessing small group versus individual counseling services.
Key Evaluation Findings
The study by Zabin et al. (1986) found that, compared with students in the nonparticipating schools,
- Significantly more girls in the program schools were likely to delay the start of sexual intercourse; the median delay was seven months.
- Both boys and girls showed a significant increase in contraceptive use at last intercourse. This effect was greatest among the younger, sexually active girls and boys whose use of contraception was minimal at the start of the program.
- Significantly more students in the program schools attended a health clinic before becoming sexually active and during the first months of sexual activity.
- By the program's third year, the pregnancy rate dropped 30 percent among the high school girls in the program schools, while it rose 58 percent among students who were not in the program schools.
- Pregnancy rates among younger teens in the program schools decreased slightly, while the pregnancy rates for younger teens that were not in the program schools increased dramatically.
This program could be implemented in partnership among public schools, social services, and health care professionals.
Program services were funded by the Educational Foundation of America. The Ford Foundation and the W. T. Grant Foundation funded the evaluation.
- The program linked contraceptive and reproductive health services to school-based educational services.
- Clinic services were located in proximity to the participating schools in a place that was easily accessible to teens.
- Students had access to year-round, free, high-quality clinic services.
- The program was facilitated through commitments from the school superintendent, school principals, the health committee, and the health department.
- Clinic and school-based services were provided by the same staff in order to facilitate and encourage clinic attendance.
- Program staff had considerable expertise in education and/or health education.
Self Center staff provided full-time, year-round support to teens through a combination of in-school and adjacent clinic-based services. Each of the program schools were assigned a Self Center team, which was made up of a social worker or nurse midwife, who were particularly interested in adolescent health. An educator experienced in sex education was made available intermittently. For the in-school component, Self Center staff made at least one presentation a semester to every homeroom to introduce the program and to discuss student value definition, decision-making, and reproductive health. In addition, Self Center staff members were available on-site in the school health suite several hours daily to facilitate informal group discussions and individual counseling. These sessions allowed students to access information on topics such as relationships, physical development, drug use, and parenting. Furthermore, 12 students in each school served as spokespeople for the program in its last two years, creating visual aides for use around the schools. Parents were also informed about the program prior to its initiation, and a parental advisory committee was formed for the duration of the program.
The same Self Center staff team provided year-round contraceptive, reproductive health, and other services at a clinic adjacent to the schools. Gynecologists from Johns Hopkins University provided needed medical care at the clinic. Teens requiring additional medical or psychological care not available through the clinic were given appropriate referrals. Discussion groups, educational videos, and pamphlets were also available to students waiting for clinic appointments. Individual and group counseling were offered through the clinic as well. Clinic services were available to teens on weekday afternoons and during school vacations.
Additional details on program implementation, as well as on the day-to-day work of the social workers and nurses, are available in Zabin et al. (1988a).
The Self Center program does not have a prescribed curriculum.
Issues to Consider
This program received a "promising practice" rating. The research, conducted over three years, was implemented according to rigorous standards and included an experimental group of 1,700 teenagers and a comparison group of 1,950 teens.
One possibly significant variable not clearly included in the program evaluation was the level and importance of involvement of Johns Hopkins University. The evaluation indicates that professionals from Johns Hopkins Medical Center offered their services in cooperation with the program and that resources (facilities, supplies, support, and such) were shared; however, there is no elaboration as to the degree of collaboration or analysis of what impact the involvement (such as saved or added costs) had on the function and viability of the program. The possibility exists that the cooperative partnership with a major university or medical center was an important contributor to the success of the Self Center program.
The cost of the Self Center program was evaluated in Zabin et al. (1988b). The average cost of the program per student was $122, but this cost was not equally distributed; females were on average four times more costly to serve than males. Forty percent of the program budget was used on the school-based components, while the remaining budget was used in the medical clinic.
A frequent objection voiced in response to aggressive and direct sex-education programming in schools involves the opinion that such programming, and the ready availability of birth control, will result in increased and earlier sexual activity among teens. Findings from the Self Center evaluation indicating a delay of first sexual intercourse as a result of the program counter this concern. For example, results indicate that approximately two-thirds more of the girls had become sexually active by age 14 before the program began as compared with after three years of exposure. This is a significant reduction in sexual initiation and supports the notion that rather than fostering new sexual activity among teens, exposure to the program is in fact reducing such activity. Because sexual exposure during early teens is associated with the highest risk of unintended conception, this created delay is of real importance.
In addition to reducing the number of teenagers who become pregnant or create a pregnancy, the program also affects the emotional and psychological well-being of participants through its focus on group and individual counseling and a focus on judgment and decision-making skills.
Dr. Laurie Schwab Zabin
School of Hygiene and Public Health
Johns Hopkins University
615 N. Wolfe Street, Room W4503
Baltimore, MD 21205
Tel.: (410) 955-5753
Fax: (410) 955-0792
Detailed information and materials needed to establish, implement, and evaluate the program, as well as to obtain parental consent, have been published in Zabin et al. (1987).
In addition, a Self Center program package developed by the Sociometrics Corporation includes a user's guide, program manual, educational pamphlets, evaluation materials, parental notification form, directory of evaluation consultants, and telephone technical support for a year (1-800-846-DISK).
Frost, Jennifer J., and Jacqueline Darroch Forrest, "Understanding the Impact of Effective Teenage Pregnancy Prevention Programs,"
Family Planning Perspectives,
Vol. 27, 1995, pp. 188-195.
Hardy, Janet B., and Laurie Schwab Zabin, Adolescent Pregnancy in an Urban Environment, Baltimore, Md., and Washington, D.C.: Urban & Schwarzenberg and The Urban Institute, 1991.
Zabin, Laurie Schwab, and Marilyn B. Hirsch, Evaluation of Pregnancy Prevention Programs in the School Context, Lexington, Mass.: Lexington Books, 1987. (Note: This book is available from Dr. Laurie Schwab Zabin. See Contact Information above.)
Zabin, Laurie Schwab, Marilyn B. Hirsch, Edward A. Smith, Rosalie Streett, and Janet B. Hardy, "Evaluation of a Pregnancy Prevention Program for Urban Teenagers," Family Planning Perspectives, Vol. 18, 1986, pp. 119-126.
Zabin, Laurie Schwab, Marilyn B. Hirsch, Rosalie Streett, Mark R. Emerson, Morna Smith, Janet B. Hardy, and Theodore M. King, "The Baltimore Pregnancy Prevention Program for Urban Teenagers: I. How Did It Work?" Family Planning Perspectives, Vol. 20, 1988a, pp. 182-187.
Zabin, Laurie Schwab, Marilyn B. Hirsch, Rosalie Streett, Mark R. Emerson, Morna Smith, Janet B. Hardy, and Theodore M. King, "The Baltimore Pregnancy Prevention Program for Urban Teenagers: II. What Did It Cost?" Family Planning Perspectives, Vol. 20, 1988b, pp. 188-192.