A Statewide Policy Advocacy Intervention in California : The No Time for Complacency Initiative

California has made substantial progress since 1991 in reducing its teen birth rate, and its rate reduction now leads the nation. Yet more than 50,000 Californian teens continue to give birth each year, and many more became pregnant. And due to changing demographics and the recent reversal in the last decade’s poverty rate declines, California’s improvements are at risk. The No Time for Complacency (NTFC) initiative is a policy advocacy intervention designed to promote effective statewide teen pregnancy prevention policy and funding in California. This initiative employs legislative-district data analysis to provide a politically compelling organization of teen birth data, cost analyses to heighten the societal relevance of teen births, policy analysis to identify promising and effective state policies, and media advocacy to focus attention on these issues in all regions of the state. The process and results described show how it was possible to achieve impacts on state-level health policy and program funding. © 2006 Californian Journal of Health Promotion. All rights reserved.


Introduction
California has made substantial progress since 1991 in reducing its teen birth rate.While all 50 states have experienced declining teen birth rates during this period, California's rate reduction leads the nation.In spite of these improvements, the teen birth rate in California remains high by international standards, in fact higher than the rates for every other industrialized country.In 2004, more than 50,000 teens gave birth in California -one out of 25 young women aged 15 to 19 -and many more became pregnant.And due to the changing demographics of the California adolescent population, combined with a recent reversal in the poverty rate declines of the last decade, California's improvements are at risk.
California has been a national leader in several important policy areas related to statewide teen pregnancy prevention.The only state to have consistently declined Section 510, Title V, abstinence-only-until-marriage federal funds, California avoids this program's matching funds requirements and its prohibition of comprehensive sexuality education.In addition, the State of California has made substantial bipartisan investments in funding communityand school-based teen pregnancy prevention programs and services.Additional long-term investments have been made by several philanthropic foundations, led by The California Wellness Foundation.The estimated total state and philanthropic investment during recent years has been approximately $60 million for programs and activities focused directly on teen pregnancy prevention.In addition, approximately $68 million annually of combined state and federal funds comprise the 21% adolescent share of FamilyPACT, California's Medicaid demonstration project waiver to provide comprehensive reproductive health services to low-income women and men (more details on specific program characteristics and funding levels are provided in Constantine & Nevarez, 2003;2006).
In 2002, an unprecedented state budget crisis was gathering steam.The governor's 2003 proposed budget included extensive cuts in teen pregnancy prevention program funding, and calls were growing for California to reverse course and accept federal abstinence-only-untilmarriage funding.As a result, what we initially had viewed as a proactive opportunity to advocate for improved policy and expanded funding in California evolved into a more reactive need to ensure continuation of funding for key programs, and protection and clarification of positive legislation.During this time, the fragmented and inadequate implementation of comprehensive sexuality and HIV/AIDS prevention education in many California school districts was formally documented by two statewide school district surveys (Friedman et al., 2003;Burlingame, 2003), confirming in-the-field reports from California Department of Education district compliance reviewers (personal communication, Chris Berry).

Evidence-Based Policy Advocacy
Policy advocacy interventions increasingly have been recognized as essential strategies for public health (e.g., Brindis & Ott, 2002;Schwartz, Goodman, & Steckler, 1995).Defined by Altman et al. (1993) as "the active espousal of a cause or principle and actions that lead to a goal considered worthwhile by the people involved," advocacy offers promise to address some of society's most important public health challenges.
Research findings and data can provide a strong foundation for evidence-based policy advocacy.Although research results alone do not typically affect public policy directly, research can have a greater impact when it becomes part of advocacy for a preferred position (Weiss, 1991).Four kinds of research evidence have been identified as potentially impacting program and policy decisions -descriptive data, analytic information, evaluation, and policy analysis (Weiss, 2001).These types of evidence can be used individually or in combination, but for evidence to prevail in policy making it must be persuasively used.As Weiss advises, "Whispering in the ear of the powerful will no longer be enough.Researchers and data providers of all types will need to alter their ideas about what it takes to get a hearing for evidence and to master the arts of communication to multiple audiences.Their findings will have to inform and convince a wide swatch of the public if policy is to be truly evidence-based."(2001, p. 291).(Constantine, Slater, & Carroll, in press), an explanatory case study of the state's teen birthrate decline, and a statewide telephone survey of parental support for comprehensive sexuality education across five California socialgeographic regions.This article describes the process and results of the initial 2002-2003 phase of the NTFC initiative.

The No Time
The primary message of this initiative can be summarized as "no time for complacency."This message has three parts, and is challenging to work with due to its complexity.The first part is that California has been doing something right.Appendix A shows the dramatic decline in California's teen birth rate during the decade from 1991 to 2001 (these were the most recent data available at the time of the 2003 release).This improvement in rates becomes more compelling when compared to the more modest national decline, and to the anemic decline in Texas, a state with many shared sociodemographic and population characteristics but dramatically different prevention policies and funding levels.
The second part of the message is that in spite of its considerable improvements, California needs to do more.A comparison of California and U.S. teen birth rates to rates for other industrialized countries was employed to illustrate this need.Historical teen birth rates for developed countries were compiled by Singh and Darroch (2000).Across the 45 countries for which recent data were available, teen birth rates for 1995 ranged from a low of 3.6 in Japan to a high of 56.2 in Armenia (see Appendix B).The comparative U.S. rate (for 1995) was 54.4, second highest after Armenia.
The last part of the message is that if more isn't done, there will be negative consequences and costs.Due to demographic shifts among the adolescent population as well as other factors, the progress of the last decade is at risk.Appendix C shows actual numbers of teen births for each year of the decade up to 2001 on the left, and California Department of Finance (CDOF) projections for the following decade on the right.(These were the most recent data available in 2003, CDOF projections have since been reduced, and a less dramatic reversal over time is now projected.)Data analyses, including legislative-district teen birth data analyses and cost analyses, provided an empirical foundation for the initiative's message (all analysis methods are detailed in Constantine & Nevarez, 2003).California's 40 state senate districts were mapped to zip codes, and senate district teen birth rates and counts were computed using zip-code level teen birth counts provided by the California Department of Health Services, together with U.S. Census Zip Code Tabulation Area (ZCTA) population data.Cost analyses employed a rigorous algorithm developed by Maynard and colleagues (1997), adapted to California and adjusted for inflation.This allowed for estimation of taxpayer and societal costs associated with adolescent child bearing in California.Finally, as presented in Appendix D, the legislative district data analyses were combined with the cost analyses to yield cost estimates by legislative district.(A similar births and costs analysis was completed for California's 80 assembly districts.)Comparing these district data to the international data provided in Appendix B further illustrated that every one of California's 40 state senate districts had higher teen birth rates than, for example, Japan (3.6), Netherlands (5.8), Italy (6.9), France (10.0), Germany (13.2), and Ireland (15.0).
An integrated set of professionally designed and produced materials provided a primary vehicle for the NTFC message.This included the 40page policy report (Constantine & Nevarez, 2003), an eight-page executive summary, individual fact sheets for each of 40 state senate districts, supplemental charts, and two websitesone public and one password-protected for media use during the pre-release embargo (all materials are currently available on the publicuse web site, http://teenbirths.phi.org).The policy report examined consequences and costs of adolescent childbearing, trends of the last decade, statistical projections for the future, and California policies and program investments, and included a detailed set of policy recommendations.A press release was developed, as part of a press kit also containing an NTFC fact sheet, spokespersons list, key findings summary, recommendations, and other related information.
Throughout the initiative, the focus was kept on our primary audience, state legislators, and our supporting audience, policy influentials such as legislative staff, journalists, and advocates.The print news media was used extensively with the help of a media communications firm.This involved making personal contacts and providing press kits and other content and logistical support to individual journalists to promote wide coverage in every newspaper market in California.Similarly, personal contacts were made directly with legislators and their staff.For example, on the day before the media release, each of the 40 state senators' offices were personally visited and provided with copies of the executive summary, the district fact sheets for their district, and the web site address for further information.Among other benefits, this helped ensure that policy makers would be prepared to respond to the media questions that began the following day.Critical partners were recruited and supported at both the local and state levels.Local community partners were primarily advocates associated with community-based agencies.These were key to providing community perspectives for local journalists, as well as providing grass-roots advocacy and legislator support within their own legislative districts.Local partners were provided with media training, conference calls, web-based support materials, referrals, and opportunities for networking.State partners were also recruited, including several legislators' offices and caucuses, and statewide advocacy groups such as Planned Parenthood Affiliates of California, American Civil Liberties Union, Hispanas Organized for Political Equality, and California Alliance Concerned With School-Aged Parenting and Pregnancy Prevention.

Results
The project achieved all of its intended intermediate outcomes together with several longer-term policy impacts.Intermediate outcomes included wide-spread media coverage, extensive use by advocates, and considerable attention by policy makers and others.The coordinated release of the 2003 NTFC report and associated legislative district fact sheets was covered in 22 newspaper articles and editorials across large and small media markets throughout the state, with a combined circulation of more than 4.5 million, and readership of more than nine million (see Appendix E).Most articles were written around a local connection to the NTFC message, and many provided in-depth coverage of the issues.Unanticipated national media coverage was obtained in the Washington Times, and Latina Magazine.The report's findings and recommendations also was covered by national and California health policy daily reports, such as the Kaiser Daily Reproductive Health Report, and the California Healthline.Brindis et al., 2004;Foster et al., 2004).Other state-funded programs are more challenging to evaluate and generally did not yield such compelling evidence of effectiveness.Another delicate balance was required to acknowledge the existence of these evaluations and at the same time their limitations, and to avoid overinterpreting inconclusive results.
The complexity of working effectively with the media to support the initiative's goals presented a third challenge.Addressing this challenge demonstrated the critical value of partnering with a professional media communications firm early in the initiative.In spite of these and other challenges, the NTFC experience demonstrated the potential power of a statewide public health policy advocacy intervention combining legislative data analysis, cost analysis, policy analysis, and media advocacy.

Current Activities
The primary goals of NTFC have shifted to implementation and protection.This includes helping ensure that the provisions of SB 71 are fully communicated, understood, and implemented, monitoring the threats to SB 71 from potential ballot initiatives and new legislation, monitoring and analyzing state funding trajectories for teen pregnancy prevention programs, and promoting the integration of teen pregnancy prevention with adolescent HIV/STI prevention.
As part of this process, a working partnership has been formed with the California Adolescent Sexual Health Workgroup.This is a standing workgroup composed of program managers from the California Department of Education and California Department of Health Services who are committed to working more effectively to address the sexual and reproductive health of adolescents in California.The Workgroup's vision is "to create a coordinated, collaborative, and integrated system among government and non-governmental organizations to promote and protect the sexual and reproductive health of youth in California."The Workgroup has agreed to serve in an advisory capacity to this project, and to facilitate the provision of contributed services, such as incidence data access and customized reports.Specific current activities for 2006-2007 include providing SB 71 implementation support to state and local agencies and community groups, producing a series of bi-annual policy reviews on the adolescent sexual health policy environment in California (see, e.g., Constantine & Nevarez, 2006), producing a new NTFC report focusing on STI rates and costs by California counties, and conducting and publicizing a representative statewide survey of parental support for comprehensive sexuality education and services across five California regions.