JOURNAL OF ADOLESCENT HEALTH 2003;32S:79 –90
SUPPLEMENT ARTICLE
Meeting the Reproductive Health Care Needs of
Adolescents: California’s Family Planning Access,
Care, and Treatment Program
CLAIRE D. BRINDIS, Dr.P.H., LORI LLEWELYN, M.P.P., KATE MARIE, M.P.A.,
MAYA BLUM, M.P.H., ANTONIA BIGGS, Ph.D., AND CATHERINE MATERNOWSKA, Ph.D.
Purpose: To examine the effect of the California Office
of Family Planning’s Family Access, Care, and Treatment
Program (Family PACT), which was established in 1997
to provide comprehensive, reproductive health services
for low-income adolescents and adults. Program evalua-
tion was used to measure access to services, develop a
profile of users, identify service utilization patterns, and
assess the sensitivity of the health care system to the
needs of adolescents.
Methods: Data sources include baseline data on Cali-
fornia’s previously established family planning services,
enrollment, and claims data for the first 4 years of Family
PACT, client exit interviews, and on-site observations.
Results: Adolescents represented 21% of all clients
served by Family PACT in fiscal year 2000 –2001 (FY
2000 –2001). Adolescent clients served increased from
100,000 in FY 1995–1996 to more than 260,000 in FY
2000 –2001(161% increase). The proportion of males has
increased from 1% to 11%. In FY 2000 –2001, Hispanics
comprised 50% of adolescent clients, followed by 32%
white, 9% African-American, and 6% Asian, Filipino, or
Pacific Islander. Over one-half were aged 18 or 19 years,
42% were aged 15 to 17 years, and 5% were aged younger
than 15 years. Contraceptive methods most often dis-
pensed were barrier methods (55% for females, 72% for
males), oral contraceptives (44%), contraceptive injec-
tions (16%), and emergency contraceptives (7%); 57%
received sexually transmitted infection screening.
From the Center for Reproductive Health Research and Policy
Studies, University of California, San Francisco, California
Address correspondence to: Claire D. Brindis, Dr.P.H., University of
California San Francisco, 3333 California Street, Suite 265, San Fran-
cisco, CA 94143-0936.
Manuscript accepted February 19, 2003.
© Society for Adolescent Medicine, 2003
Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010
Conclusions: By linking eligibility determination to
the delivery of services, removing cost barriers, increas-
ing the numbers and types of providers offering publicly
funded services, and ensuring confidentiality, greater
numbers of adolescents obtained needed reproductive
health care, thus ensuring an opportunity to reduce
unintended pregnancies and sexually transmitted
infections. © Society for Adolescent Medicine, 2003
KEY WORDS:
Adolescent reproductive health services
Confidentiality
Publicly funded family planning services
Over the past decade, the United States has experi-
enced rapid declines in adolescent pregnancy, reach-
ing its lowest rates since initially recorded in 1975.
This decline was from 117 in 1985 to 94 pregnancies
per 1000 females aged 15 to 19 years in 1997, repre-
senting a 19% reduction [1]. A parallel trend has been
documented for the U.S. teen birth rate, which in-
creased from 51.0 births per 1000 teens in 1985 to 62.1
in 1991 [2]. However, throughout the 1990s, the teen
birth rate declined steadily, falling to a record low of
45.9 births (preliminary data) per 1000 teens in 2001
[3].
Although the United States continues to have one
of the highest adolescent pregnancy rates compared
with those of other industrialized countries, several
significant factors appear to have contributed to the
decline in teenage pregnancy and births: delayed
sexual activity, more conservative attitudes among
1054-139X/03/$–see front matter
doi:10.1016/S1054-139X(03)00065-X
80 BRINDIS ET AL
adolescents about casual sex and out-of-wedlock
childbearing; fear of sexually transmitted infections
(STIs), especially acquired immunodeficiency syn-
drome (AIDS); increased condom use especially at
first intercourse; increased use of more effective
long-acting hormonal birth control methods, espe-
cially contraceptive injections; an emphasis on child
support enforcement; and a stronger economy, with
better job prospects for young people [4,5]. Contin-
ued reduction in adolescent pregnancy rates will
require federal and state policies that promote ado-
lescent pregnancy prevention messages, supporting
responsible sexual behaviors, along with access to
confidential reproductive health care.
Over the past 30 years, states have expanded
minors’ authority to consent to health care, including
care related to sexual activity [6]. This policy recog-
nizes that, although parental involvement is desir-
able, many minors will remain sexually active but
will not seek services if parental consent is required
[7]. Thus, adolescents need to have the ability to
readily access available reproductive health services
through a variety of channels [8]. A recent study
documents that most sexually active adolescent girls
would stop using all reproductive health services, or
delay testing and treatment for STIs and human
immunodeficiency virus (HIV), if their parents were
informed that they were seeking prescribed contra-
ceptives [9].
Furthermore, almost all the girls (99%), regardless
of all races and ages studied, reported that they
would remain sexually active, even if they stopped
using the reproductive sexual health care services
because of mandatory parental notification. The
likely outcome of mandatory parental notification for
prescribed contraceptives would be an increase in
teen pregnancies and the spread of STIs [9]. Thus,
key to the continuation of promising trends in the
reduction of too-early childbearing is the availability
of federal- and state-subsidized confidential and
comprehensive reproductive health services to ado-
lescents. Family planning providers are in a unique
position to offer education, counseling, and clinical
services to help adolescents develop healthy relation-
ships and make responsible decisions about their
health and well-being that will have a lasting effect
on their lives.
The State of California has a long and distin-
guished history of providing comprehensive and
confidential family planning services to low-income,
uninsured adolescents, women, and men of repro-
ductive health age who are in need of care. From
1974 to 1997, the Office of Family Planning (OFP) in
JOURNAL OF ADOLESCENT HEALTH Vol. 32S, No. 6S
the California Department of Health Services (DHS)
contracted annually with public and private, non-
profit family planning agencies throughout the state.
Under this Clinical Services Contract Program
(CSCP), which was funded through a limited budget
from California’s General Fund, these agencies de-
livered family planning services to low-income
women and men. By fiscal year (FY) 1995–1996, 142
agencies with 450 sites participated in the CSCP, and
funding was capped at $47 million from the state’s
general fund [10].
Client demand for services far outstripped the
limited funding available under CSCP. In an effort to
increase access to care, the California State Legisla-
ture approved an expanded DHS family planning
initiative, the Family PACT (Planning Access, Care,
and Treatment) Program, with phased-in implemen-
tation beginning in January 1997 [11]. This innova-
tive program represents the first effort in the country
to establish a legal entitlement to state-funded ser-
vices and supplies for both female and male low-
income residents [11]. The new program was devel-
oped in collaboration with a number of stakeholder
groups, including the American College of Obstetrics
and Gynecology, the California Academy of Family
Physicians, the California Family Health Council, the
California Medical Association, the California Pri-
mary Care Association, the California Women’s and
Children’s Health Coalition, the Planned Parenthood
Affiliates of California, and a number of CSCP con-
tractors [10].
Family PACT is administered by DHS/OFP, re-
sponsible for program policy (including determina-
tion of the scope of services), program monitoring,
quality improvement, and evaluation. Program mon-
itoring and evaluation of the Family PACT program
are currently conducted by the Center for Reproduc-
tive Health Research and Policy in the Department of
Obstetrics, Gynecology, and Reproductive Health
Sciences and the Institute for Health Policy Studies,
University of California, San Francisco, under an
interagency agreement with DHS/OFP.
Family PACT is designed to improve access to
comprehensive family planning reproductive health
services by removing cost barriers, increasing the
types and numbers of providers, and ensuring con-
fidentiality. Confidential, comprehensive services
are provided to adolescents at no cost and without
parental consent. Eligibility for adolescents is based
on personal income and health insurance, not par-
ents’ income or insurance coverage. Furthermore,
clinics can also apply for separate funding for the
TeenSmart program that operates in more than 50
June 2003 MEETING THE REPRODUCTIVE HEALTH CARE NEEDS OF TEENS
family planning agencies throughout California, en-
abling them to provide more in-depth counseling
services to adolescent clients.
In addition, direct marketing to adolescents in
counties with high pregnancy rates, notably the “It’s
Up to Me” multimedia campaign (which includes a
toll-free telephone number to facilitate setting up
geographically convenient appointments), increases
awareness about teen pregnancy prevention for both
teenagers and their families. Incorporating these
types of strategies is especially important because
adolescents have unique characteristics that place
them at heightened risk of unintended pregnancy
and STIs. In addition to confidentiality concerns,
adolescents often have difficulty accessing services
owing to costs, lack of transportation, and a lack of
knowledge about where to obtain services [8,12].
Compared with adults, adolescents often need addi-
tional time for counseling and education; may be
more fearful of pelvic examinations, blood tests, and
the side effects of birth control; and may be less likely
to follow up on referrals [8,12]. In the following
section, we present background information on the
Family PACT program.
Background
Ensuring that high-quality family planning services
are available to meet the needs of California’s low-
income citizens is a public health priority, as well as
an important contribution to meeting personal health
needs. Over the next three decades, California’s
population is expected to grow by 55% (from 33
million to more than 51 million), a rate of growth
higher than that of any other state [13]. Fueling this
increase is a 34% increase in the number of adoles-
cents aged 10 to 19 years between the years 1995 and
2005 [14]. Although some of this population increase
will result from immigration, most of it will be owing
to births to California residents. Many of the ex-
pected births will occur among the state’s poorest
women: teenagers and women with family incomes
at or below 200% of the federal poverty level. This
group makes up 38% of California’s women of
reproductive age but accounts for nearly two-thirds
of California’s births [15].
Although some low-income women can receive
family planning services through Medi-Cal (the
state’s Medicaid program), many other low-income
women cannot access or do not qualify for this
coverage and, thus, face significant financial barriers
when they attempt to obtain such services. Adoles-
81
cents face an even greater array of barriers to such
services. In addition to unintended pregnancies, mil-
lions more experience STIs. In California, STIs con-
stitute two-thirds of the communicable disease re-
ported, and the state’s adolescent population is
particularly affected, because approximately 35% of
chlamydial infections occur among adolescents [16].
In response to this epidemic, Family PACT has
redesigned its benefits package to include a new
array of STI-related services.
In an effort to increase access to family planning
reproductive health services beyond the limitations
of the CSCP, the Family PACT program was devel-
oped and implemented in 1997. Eligible clients in-
clude all persons residing in California who have an
income at or below 200% of the federal poverty level,
are at risk of pregnancy or causing pregnancy, and
have no other source of health care coverage for
confidential family planning services. Adolescents
are considered a family of one and have the legal
right to consent to their own reproductive health
services.
Family PACT differs from its predecessor in sev-
eral key respects. First, the provider base has been
significantly expanded to include private providers,
pharmacies, and laboratories. Before 1997, Califor-
nia’s family planning program included publicly
funded providers, such as county health depart-
ments, and private, nonprofit providers, such as
community clinics and Planned Parenthood clinics.
In 1997, Family PACT also invited private, for-profit
providers, that were already Medi-Cal providers, to
participate in the Family PACT program. Pharma-
cies, as well as clinics, are distribution sites for
over-the-counter and prescription drugs and contra-
ceptive supplies. As a result of these changes, the
number of providers participating in the state family
planning program expanded from approximately
450 clinic sites under CSCP in FY 1995–1996 to 1432
in Family PACT in FY 1997–1998 and 1929 in FY
2000 –2001. A 5-year Medicaid 1115b Waiver Dem-
onstration Project allocating matching funds for fam-
ily planning services was approved in December
1999 by the federal Health Care Financing Adminis-
tration, now known as the Center for Medicare and
Medicaid Services. As part of the demonstration
project, OFP has the opportunity to demonstrate the
effect of this California model on three hard to reach
populations: adolescent women, low-income men,
and low-income women living in areas of high
unmet need.
Second, client eligibility determination and enroll-
ment occur at point of service, designed to reduce
82 BRINDIS ET AL
barriers to client participation and to ensure timely
access to sensitive services. A variety of prevention
and health promotion services, which for many are
their only source of health care, is also available.
Family PACT client enrollment data is self-reported
on an OFP form at the clinic or doctor’s office at the
time of enrollment. The enrolling provider uses the
information to determine eligibility, and clients are
issued a Health Access Program card, which allows
them access to services. The client enrollment card
and the point-of-service determination were the only
new concepts incorporated into the provision of
services.
Third, Family PACT is a fee-for-service family
planning program with reimbursement rates consis-
tent with those of Medi-Cal, in contrast to the previ-
ous program in which providers were reimbursed
flat rates for bundled services. Previously, OFP re-
imbursement rates were about 80% of the reimburse-
ments paid through the Medi-Cal program. Family
PACT providers can also render and bill for itemized
services for all eligible clients.
Providers enroll by signing a formal application
and agreement specific to upholding required ad-
ministrative practices or program standards. Family
PACT policies and standards set forth the scope,
type, and quality of family planning services re-
quired under the program, as well as the terms and
conditions under which the services will be reim-
bursed. The Family PACT standards address in-
formed consent, confidentiality, availability of op-
tions, linguistic and cultural competence, access to
care, clinical and preventive services, and education
and counseling.
In an effort to promote and ensure the delivery of
services consistent with Family PACT standards,
quality improvement activities are an ongoing re-
quirement of the program. Quality improvement activ-
ities focus on topics related to comprehensive family
planning services, including screening, initiation, and
maintenance related to contraception; prevention, de-
tection, and treatment of STIs; reproductive health
education and counseling; and participation of ancil-
lary staff members in sensitive services. To support
quality improvement efforts, DHS/OFP provides a
range of resources. Providers are reached through a
variety of mechanisms, including statewide and re-
gional conferences and workshops, regional provider
forums, technical assistance and support by telephone
or on site, newsletters, websites, and technical bulletins.
As adolescents represent a special population within
the program, these efforts assure that the type of care
adolescents receive is of the highest quality.
JOURNAL OF ADOLESCENT HEALTH Vol. 32S, No. 6S
Table 1. Scope of Services Available Through Family
PACT
Clinician services
• Provision and maintenance of contraceptive methods
• Periodic health screening, including a comprehensive health
history: physical examination; cervical and breast cancer
screening: STI screening; and examination of breast, vulva,
uterus, and ovaries
• Female and male sterilization
• Limited infertility services
• Diagnosis and limited management of cervical dysplasia
• HIV screening and STI diagnosis and treatment
• Education and counseling pertaining to selection, initiation,
and continuation of a contraceptive method; reproductive
anatomy and physiology; preconception guidance and
pregnancy planning, options following pregnancy testing;
cervical dysplasia; STI/HIV prevention; nutrition and
preventive care; communication; partner relationships; and
decision making
• Referrals for services not available from the clinician
provider (including surgical procedures) and for medical
and psychosocial conditions not covered by the program
• Management of complications related to contraceptive
methods or other covered services
Medication and supply services
• Contraceptive medications and devices, including birth
control pills, intrauterine devices, contraceptive injections,
implants, and patches
• Emergency contraception
• Barrier methods and supplies, including female and male
condoms, diaphragms, cervical caps, spermicides,
lubricants, basal body thermometers, and other supplies
• Noncontraceptive medications, including antibiotics for the
treatment of STIs, urinary tract infections and vaginitis;
conjugated estrogens; antiviral drugs; antiemetics, topical
treatments for genital warts, and hepatitis B vaccine
Laboratory services
• Screening before starting contraceptive methods, STI/HIV
screening and diagnostic tests, cervical cancer screening,
pregnancy testing, urinalysis, fertility assessment, and
surgical pathology
The Family PACT program offers a comprehen-
sive package of clinical family planning services (See
Table 1). The full range of family planning methods
are offered, including all contraceptive methods ap-
proved by the federal Food and Drug Administra-
tion, surgical sterilization, and limited infertility ser-
vices. The provision of STI services within the Family
PACT program greatly expands the opportunity for
early detection and treatment to a population partic-
ularly at risk of STIs and their complications. The
program covers the screening, diagnosis, and treat-
ment of STIs and screening for HIV; it does not
provide treatment or care for HIV or hepatitis. Fam-
ily PACT does cover pregnancy testing and options
counseling, but it does not cover abortion services or
other services related to pregnancy.
June 2003 MEETING THE REPRODUCTIVE HEALTH CARE NEEDS OF TEENS
Additionally, services to protect the reproductive
spectrum include evaluation, screening for cervical
cancer, and treatment for cervical dysplasia. Family
PACT covers education and counseling concerning
method selection, STI prevention, pregnancy test
options, and other reproductive health issues. Males
now have access to a range of services comparable to
female services. Previously limited male services
were expanded in 1998 to include HIV testing and in
2000 to include all STI services.
The article presents initial evaluation results on
the effect of Family PACT on comprehensive, confi-
dential reproductive health services for adolescents
addressing the following questions:
• Has Family PACT increased access to family plan-
ning services for adolescents in California?
• What are the social and demographic characteris-
tics of adolescent clients?
• What are the service utilization patterns for ado-
lescents?
• Are Family PACT providers sensitive to the needs
of adolescents?
Methods
To provide a multifaceted profile of the effect of the
Family PACT program, the evaluation synthesizes
and integrates data from multiple sources, covering a
variety of years. Data sources include summary data
for CSCP (FY 1995–1996) to establish a baseline,
enrollment and claims data for Family PACT (FY
1997–1998 through 2000 –2001), and data from client
exit interviews and on-site observation for Family
PACT (FY 1997–1998). All research protocols were
approved by the University of California’s Office of
Human Research.
Summary data for the last full year of the CSCP
Program (FY 1995–1996) provided baseline data on
clients served, the number of participating providers,
and the demographic profile of clients. Enrollment
and claims data for the first 4 full years of the Family
PACT program (FY 1997–1998 through 2000 –2001)
provided an overview of Family PACT’s evolution in
these same areas, as well as a profile of providers and
service utilization.
Enrollment and claims data for the CSCP were
collected and managed by OFP, primarily for pur-
poses of contract management and reimbursement
allocation. Participating providers kept records of
clients served and services provided on OFP forms,
and data were forwarded to OFP on a monthly basis.
Summary data were available for counts of clients
83
served and client demographics, whereas the distri-
bution of race or ethnicity specific to adolescent
clients was not available. In this analysis, we as-
sumed that the distribution of race or ethnicity for
CSCP adolescent clients in FY 1995–1996 was the
same as for all clients. For the Family PACT pro-
gram, client enrollment data are collected at each site
and forwarded to DHS for processing and analyses.
DHS/Medi-Cal collects and maintains both Medi-
Cal provider enrollment data and Family PACT
provider enrollment data. All provider records are
maintained by Medi-Cal provider number. Because
provider numbers are assigned to billing units, a
provider number may represent a single physician or
nurse practitioner, a clinic with multiple clinicians,
or multiple clinic sites. Given available data, it is not
possible to distinguish between these different types
of provider organizations. All references to “provid-
ers” herein refer to entities with one Medi-Cal pro-
vider number. The count of enrolled Family PACT
providers for a given fiscal year includes any pro-
vider for which Medi-Cal provider status was “ac-
tive” and Family PACT provider status was “en-
rolled” for part or all of the year.
Family PACT claims data provide information on
service utilization, as well as the numbers of clients
served and provider activity. Two elements of claims
data provide information about contraceptive ser-
vices: primary diagnosis codes (specific to Family
PACT) and procedure codes (standard industry-
wide Current Procedural Terminology, or CPT-4). A
limitation of claims data is that it is based on pro-
vider billing behavior, which may differ from actual
services rendered.
Two additional sources of data were used to
assess the sensitivity of Family PACT clinician pro-
viders to adolescents’ needs: client exit interviews
and on-site observations. Provider sensitivity to the
needs of adolescents was measured in terms of
overall adolescent satisfaction, as well as the degree
to which providers addressed adolescents’ special
needs for STI education and counseling, confidenti-
ality, and on-site provision of contraceptive methods
and prescriptions. As part of a larger study of client
satisfaction (1398), 239 adolescents completed client
exit interviews in five counties. In addition, clinic
visits were observed, and clients were surveyed at
the conclusion of their visit. Of the 306 clinical and
counseling encounters conducted, observations were
conducted on a subset of 48 adolescent clients.
In this article, we focus on analyzing enrollment
and claims data specific to adolescents and conduct
further descriptive analyses comparing the profile of
84 BRINDIS ET AL JOURNAL OF ADOLESCENT HEALTH Vol. 32S, No. 6S

Table 2. Race/Ethnicity and Primary Language of

Family PACT Clients, FY 2000 –2001
Population and Language Adolescents Adults
Characteristics (n ⫽ 260,213) % (n ⫽ 1,009,067) %
Race/Ethnicity
Hispanic 50 71
White 32 16
African-American 9 5
Asian, Filipino, and 6 4
Pacific Islander
Native American and 4 3
Other
Primary Language
Figure 1. Growth in number of adolescent clients served. Spanish 28 61
English 68 34
Other 4 5
adolescent and adult program users. Statistical anal-
yses were conducted using SAS-PC [17]. Descriptive
statistics are also used to summarize the data for the
nia in 1997 [18]. On the basis of increases in the
client exit interview and on-site observations. Where
population of California women in a similar age cohort
possible, the most recent data are presented, unless
(averaging about 2.8% per year) [18], we estimate that
otherwise noted.
there were about 582,000 adolescent women in need of
services in 2000. Family PACT provided contraceptive
Results services to 203,000 adolescent women in FY 2000–2001,
thereby meeting the needs of a significant proportion
Has Family PACT Increased Access to Family (about one-third) of the state’s adolescent women in
Planning Services for Adolescents in California? need. It is not to be expected that Family PACT would
Adolescents consistently represented 21% of all cli- meet 100% of this need, as a subset of this population
ents served in the first 4 years of Family PACT, a has other sources of coverage, such as Medi-Cal or
slight increase from 19% in the last year of CSCP. private insurance. (In addition to the 203,000 adolescent
However, the numbers of adolescent clients have women provided contraceptive services, another
increased substantially since the implementation of 28,000 were provided services related to pregnancy
Family PACT, from 100,000 in FY 1995–1996 to more testing, STIs, or fertility evaluation.)
than 260,000 in FY 2000 –2001 (See Figure 1). This
represents an increase of 161% compared with 137%
for adults in the same time period. What Are the Social and Demographic
Although the number of adolescent clients has Characteristics of Family PACT Adolescent
increased dramatically, the demographic profile of Clients?
these clients has remained largely the same. White Of the 260,000 adolescent clients served in FY 2000 –
adolescents increased at about the same rate as 2001, 53% were aged 18 or 19 years, 42% were aged
adolescent clients as a whole (167% compared with 15 to 17 years, and 5% were aged younger than 15
161%), whereas Hispanic adolescents increased at a years. Most were female (89%), but male participa-
slightly slower rate (144%). African-American and tion has increased from 1% in FY 1995–1996 to 11% in
Asian, Filipino, and Pacific Islander adolescents had FY 2000 –2001.
the greatest rates of growth in program participation One-half (50%) of all adolescent clients identified
(355% and 293%, respectively), although they con- themselves as Hispanic, 32% as White, 9% as Afri-
tinue to make up less than one-sixth of all adolescent can-American, and 6% as Asian, Filipino, or Pacific
clients. Unlike adolescents, growth in the number of Islander. Sixty-eight percent reported English as
Hispanic adults participating in the program (216%) their primary language; 28% reported Spanish as
far outpaced that of adults from other ethnic groups their primary language. Compared with adult cli-
(160%). ents, adolescents were less likely to be Hispanic (50%
According to estimates by the Alan Guttmacher compared with 71%) and were less likely to report
Institute, there were 536,000 female adolescents in need Spanish as their primary language (28% compared
of publicly supported contraceptive services in Califor- with 61%) (See Table 2).
June 2003 MEETING THE REPRODUCTIVE HEALTH CARE NEEDS OF TEENS 85

Among the adolescent clients, 81% had never Table 3. Contraceptive Services for Female Family PACT
given birth, 16% had had one birth, 3% had had two Clients, FY 2001–2001
births, and 1% had had three or more births. Male Clients Who Were Provided the
adolescent clients were more likely than their female Methoda
counterparts to be African-American (15% male vs. Adolescents Adults
8% female) and less likely to be white (22% vs. 33%). Contraceptive Services for (n ⫽ 231,838) (n ⫽ 903,198)
They also tended to be somewhat younger than their Females % %
female counterparts; 53% of males were aged Oral Contraceptives 43.8 38.4
younger than 18 years, compared with 46% of fe- Contraceptive Injections 15.5 13.8
Contraceptive Implants ⬍0.1 0.1
males.
Intrauterine Contraceptives 0.3 1.6
Barrier Methods 55.0 43.5
Tubal Ligation ⬍0.1 0.4
What Were the Family PACT Clinical Service Emergency Contraceptives 7.1 2.3
Utilization Patterns Among Adolescents a
Columns may not add to 100% because some clients may be
Adolescents were more likely than adults to seek served under more than one method type.
services from community clinics (48% to 33%),
equally likely to seek services from other public or
nonprofit providers (28% and 27%), and less likely to 4). Adolescent female clients were also more likely
seek services from private providers (28% to 46%). than adults to receive “pregnancy testing only” ser-
(One client may be served by more than one vices (15% and 10%, respectively).
provider type.) Adolescent utilization patterns re-
flect female behavior because 9 in 10 adolescent
Are Family PACT Providers Sensitive to the
clients are female. In contrast to their female
Needs of Adolescents?
counterparts, male adolescents are just as likely to
seek services from community clinics as they are Two sources of data were used to assess the sensi-
from other public or nonprofit providers or private tivity of Family PACT clinician providers to adoles-
providers. cents’ needs: client exit interviews and on-site obser-
The contraceptive methods most frequently dis- vations. Results indicate that Family PACT providers
pensed to adolescent female clients were barrier were sensitive to the needs of adolescent clients in
methods (55%), followed by oral contraceptives several key areas, including the provision of contra-
(44%), contraceptive injections (16%), and emergency ceptive methods and prescriptions, pregnancy tests,
contraceptives (7%). Less than 0.5% of adolescent STI counseling and education, confidentiality, and
female clients received intra-uterine contraceptives, client satisfaction.
contraceptive implants, or tubal ligations (0.3%,
⬍0.1%, ⬍0.1%, respectively).
Barrier methods were the contraceptive method On-site Provision of Contraceptive Methods
most frequently dispensed to adolescent male clients and Prescriptions
(72%). Adolescents aged younger than 18 years were Adolescents often have difficulty following up on
somewhat more likely to receive barrier methods referrals and can often best be served in a “one-stop”
than older adolescents (74% for adolescents aged manner. It is generally considered preferable to take
younger than 18 years vs. 70% for adolescents aged care of all their contraceptive dispensing and pre-
18 –19 years). scription needs on site rather than requiring them to
Patterns of contraceptive service utilization are
somewhat different for adolescents and adults. Both
female and male adolescents were more likely to be Table 4. Contraceptive Services for Male Family PACT
Clients, FY 2000 –2001
dispensed barrier methods (55% and 72%, respec-
tively) than adults (43% and 62%). Adolescent female Clients Who Were Provided the
Method
clients were also more likely to receive emergency
contraception (7%) than adults (2%) and less likely to Adolescents Adults
receive intrauterine contraceptive (adolescents, 0.3%; Contraceptive Services (n ⫽ 28,375) (n ⫽ 105,869)
for Males % %
adults, 1.6%). Both female and male adolescents were
less likely to have sterilization procedures (both Barrier Methods 72.4 62.4
Vasectomy ⬍0.1 1.1
⬍0.1%) than adults (0.4% and 1.1%) (See Tables 3 and
86 BRINDIS ET AL
pick up their prescriptions in neighborhood pharma-
cies. In Family PACT in FY 1997–1998, 4 of 5 adoles-
cents received their oral contraceptives on site, and
nearly 9 of 10 received contraceptive supplies (pri-
marily condoms) on site. This finding demonstrates
that clinicians are making special efforts to ensure
that adolescent clients easily receive the methods and
supplies they need.
Pregnancy Testing
Adolescents receiving negative pregnancy test re-
sults are at high risk of pregnancy and benefit from
immediate interventions, such as same-day educa-
tion and counseling and on-site dispensing of a
contraceptive method [19]. Sixty-one percent of fe-
male adolescents received one or more pregnancy
tests during the course of FY 2000 –2001. The major-
ity of adolescents (82%) who had a pregnancy test
also had either one-on-one counseling or an ex-
tended clinical visit on the same day as indicated by
claims data. The client exit interviews indicate that 9
of 10 adolescent clients were counseled on the full
range of choices related to their pregnancy test
results. Evaluators performing on-site observations
found that in 85% of the 28 pregnancy counseling
sessions, the adolescent clients received “unbiased
information from which an informed choice about
the pregnancy or future contraceptive needs” could
be made. The findings suggest that this sample of
providers is aware of the importance of providing
comprehensive services to adolescents seeking preg-
nancy tests.
STI Counseling and Education
Approximately one-third of female adolescents who
have chlamydial or gonococcal infections have no
symptoms [20]. Given the high rates of STIs among
adolescents, many of which are asymptomatic, as
well as the Centers for Disease Control and Preven-
tion (CDC) recommendations that adolescents be
screened each year, it is appropriate for providers to
both test and provide counseling and education on
STIs more frequently among adolescents than among
adults [21]. In addition to contraceptive services, 57%
of adolescent clients received one or more STI tests in
FY 2000 –2001. Client exit interviews found that
providers were more likely to offer STI testing to
adolescents than to adults (59% vs. 50%). They were
also more likely to talk about STI prevention with
adolescents than with adults (64% vs. 54%).
JOURNAL OF ADOLESCENT HEALTH Vol. 32S, No. 6S
Confidentiality
Evaluators performing on-site observations found
that during 91% of the counseling sessions, the
adolescent’s confidentiality and privacy were ade-
quately protected. This protection included provid-
ing a physical space that allowed for visual and
auditory privacy and a means for returning confi-
dential messages. Although most adolescents were
certain that the Family PACT services they received
were confidential, approximately one of three were
not “very sure” that this would be the case. Adoles-
cents are likely to have varying definitions of confi-
dentiality, and it is incumbent on the provider to
specify its meaning (e.g., explaining to clients
whether test results will be sent to their homes).
Close to one-fourth of adolescent clients surveyed as
part of on-site observations thought (erroneously)
that their medical charts could be released without
written permission.
Client Satisfaction
Findings from client exit interviews indicate that the
majority (83%) of adolescents were “very satisfied”
with the family planning services they received.
Ninety percent of adolescents who participated in
the Family PACT client exit interviews reported no
difficulties in obtaining family planning services
during the year. Among those who did encounter
problems, the most frequently cited problems were
the cost of services, difficulty getting to the appoint-
ment, and concerns about confidentiality. Close to
90% felt that the staff “counseled in a language that
they could easily understand” and that the counselor
“completely understood what the client needed.”
The majority (94%) reported that they were able to
ask all the questions that they wanted to ask. Ado-
lescents were also satisfied with the education they
received about their birth control method, with al-
most 90% completely satisfied with explanations
about how the method worked and its effectiveness.
However, nearly 20% felt that providers did not
“completely” discuss potential problems related to
their method.
Discussion
California’s Family PACT program has resulted in a
dramatic increase in use of publicly funded family
planning and reproductive health care services
among adolescents in California. In just 5 years, the
number of adolescents served through the state
June 2003 MEETING THE REPRODUCTIVE HEALTH CARE NEEDS OF TEENS
program has surged 161%, from approximately
100,000 in FY 1995–1996 to more than 260,000 in FY
2000 –2001. In large part, this growth has been driven
by the program’s innovative “one-stop” model link-
ing eligibility determination to the delivery of ser-
vices, the removal of cost barriers, and the significant
expansion of the provider network.
The provider mix made available through the
Family PACT program likely contributed to an in-
creased number of clients being served through a
variety of channels, given that different adolescents
are attracted to different modes of service delivery. It
is important to provide teenagers with a variety of
service delivery gateways. Adolescents were more
likely than adults to seek services from public and
nonprofit providers, such as community clinics
rather than private providers.
The implementation of the Family PACT program
has also facilitated a dramatic increase in the number
of low-income and ethnically diverse communities
able to access care. The large increase among all
racial and ethnic groups, as well as women across the
continuum of the reproductive years, speaks well to
the responsiveness of the program. For example, the
large number of Hispanic adolescents enrolled in the
Family PACT program illustrates the cultural sensi-
tivity of the program. Hispanic adolescents represent
the ethnic group with the highest teenage childbirth
rates in the state (97 births per 1000 compared with
68.1 among African-American, 25.2 among Whites,
and 19.8 for Asians and Pacific Islanders). As a
group, they have a disproportionate number of ad-
olescents living in poverty, have a pattern of poor
contraceptive use, and have the strongest likelihood
of experiencing the negative health outcomes of early
childbearing [22]. Thus, the availability of Family
PACT services may be a key point of early interven-
tion.
A limitation of the evaluation data is that they
only reflect the experiences of adolescents who suc-
cessfully sought care and do not lend insight into the
experiences and perceptions of nonusers. Although
the program emphasizes free and confidential care,
many nonusers may not be necessarily convinced of
this message. As additional providers are enrolled in
the program, decreasing potential transportation
barriers, and greater numbers of adolescents refer
their peers for services, the program may increas-
ingly be able to enroll the next, more challenging tier
of adolescents in the program, including adolescents
who engage in multiple risk-taking behavior, home-
less youth, and youth in foster care. Throughout each
87
of these efforts, the availability of confidential care is
paramount.
Evaluation results, including increased access, di-
verse client characteristics, expanded service utiliza-
tion, and service provider mix, illustrate the impor-
tance of using the financial base of the Family PACT
program judiciously. It also reflects the importance
of the focused investment of existing resources on
underserved communities, as well as the importance
of providing high-quality and culturally sensitive
care to reduce existing access disparities. California’s
OFP has played a key leadership role in this arena by
targeting its adolescent pregnancy prevention efforts
where there has been a lack of access to care and
where the incidence of adolescent childbearing is
highest. This targeting is especially important as
adolescents who have access to contraceptive care
do, in fact, use them to avoid early childbearing.
About 750,000 to 1.25 million pregnancies are
averted annually in the United States by sexually
active adolescents who use contraceptives [23]. Fur-
thermore, an estimated 40% of high school students
in California are sexually active [14], thus there is an
ongoing need to expand efforts to reduce adolescent
childbearing.
Findings from the Family PACT program further
demonstrate that given the means, adolescents are
capable of taking responsible action to avoid unin-
tended pregnancies. California’s significant reduc-
tion in the adolescent birthrate, from a high of 74.4
births per 1000 females aged 15 to 19 years in 1991 to
a low of 48.1 per 1000 females in 2001, is testimony to
this responsibility [24]. However, although Califor-
nia’s teen birth rate has reached a record low, it still
remains high: 1 in 20 female adolescents aged 15 to
19 years gave birth in 2000 [25]. Thus, continued
efforts aimed at adolescent pregnancy prevention are
key.
The State of California has clearly demonstrated its
commitment to this vision through the creation of a
state-driven portfolio of preventive programs that com-
bine family life education through a wide network of
community-based organizations, the provision of com-
prehensive family planning services, special clinic
counseling programs directed at adolescents
(TeenSMART), and a statewide media campaign,
including billboard and television ads. Family life
education efforts are provided through a network of
school and community-based organizations that use
a continuum of strategies: from abstinence-only to
approaches that combine comprehensive family life
education with youth volunteer service, mentoring,
and cultural heritage. OFP’s Community Challenge
88 BRINDIS ET AL
Program, the Male Involvement Program, and the
Information and Education Program focus on pri-
mary pregnancy prevention, whereas the Adolescent
and Family Life Program, under the auspices of the
state Maternal and Child Health Program, focuses on
pregnant and parenting adolescents as a means of
preventing a second birth. Additionally, OFP is
working to establish stronger referral and program-
matic links between teenage pregnancy prevention
programs in the community and clinical family plan-
ning services for pre-sexually and sexually active
adolescents. As part of the FY 2002–2003 evaluation,
an assessment of current strategies to integrate these
efforts is being conducted. In some sites, this effort
may be further enhanced, because the sponsoring
agency provides both family life education in com-
munity settings, as well as Family PACT care.
Linkages between clinical and community-fo-
cused efforts are especially timely given the signifi-
cant increase (34%) expected in the number of Cali-
fornia adolescents aged 15 to 19 years between the
years 1995 and 2005. The anticipated growth will
occur primarily among low-income adolescents who
are often at greatest risk of an unintended preg-
nancy; although they make up approximately 40% of
the adolescent population, they account for 83% of
teens who give birth and 85% of those who become
an unmarried parent [26]. Even at the current teen
birth rate, this growth could translate to 63,462
annual births in 2005, a 17% increase over the 52,966
births in 2001, due solely to demographic changes
[26].
A number of program ingredients, including the
provision of confidential, free, and comprehensive fam-
ily planning reproductive health services, along with
the ability to enroll clients in the program at the point
of service, greatly contribute to the acceptability of
Family PACT among both male and female adoles-
cents. Although the Family PACT program has made
important inroads in meeting the need for adolescent
reproductive health services, increasing the proportion
of California’s adolescents enrolled in the program will
continue to be a priority in subsequent years.
Although the architects of the Family PACT pro-
gram have responded to the commonly identified
barriers to the provision of reproductive adolescent
services, clearly there are additional cognitive, inter-
personal, and other contextual factors that interfere
with the early adoption of contraceptive methods
among many pre-sexually and sexually active ado-
lescents. However, it is noteworthy that significant
progress has been made in the earlier adoption of
contraceptive methods by adolescents, specifically
JOURNAL OF ADOLESCENT HEALTH Vol. 32S, No. 6S
condoms, at the time of their first intercourse. Still,
additional reinforcement (by partners, family mem-
bers, and providers) is needed, as too many adoles-
cents continue to be inconsistent in their contracep-
tive compliance. New and existing contraceptive
methods, including patches, rings, and injections,
hold great promise for adolescents, because they can
be disassociated from the actual sexual act and can
be hidden, although many of these methods do not
protect adolescents from STIs.
This profile points to the need by family planning
clinics and teenage pregnancy prevention programs
to continuously strive to recognize the myriad of
additional factors that may interfere with consistent
contraceptive use. These factors can range from
adolescents’ lack of communication and contracep-
tive negotiating skills; concurrent alcohol and drug
use; the special needs of marginalized groups of
adolescents at risk of early childbearing, including
homeless, runaway, and youth in foster care; adoles-
cents experiencing ambivalence about childbearing;
and those affected by the stigma that is often associ-
ated with contraceptive use. An additional important
barrier has been the lack of focus and inclusion of the
adolescent male. Although the provider community
can play a significant role in responding to these
issues, the complexities associated with early sexual
experience among adolescents, including unin-
tended pregnancy and STIs, requires that a more
comprehensive approach, such as the aforemen-
tioned portfolio of California’s multiprong approach,
is made even more widely available to encourage
young people to delay sexual activity. A combination
of successful academic experiences, strong connec-
tions between adolescents and their families, schools,
and communities, as well as meaningful alternatives
to early childbearing are as important in helping
adolescents to delay childbearing as is the option of
access to contraceptive care.
Although males currently comprise only 11% of
total adolescent clients served in the Family PACT
program, it is noteworthy that this number has grown
steadily over the past 5 years. The number of males
receiving care increased 10-fold between FY 1995–1996
and FY 2000 –2001. It is likely that these trends will
continue to increase if the care received by the initial
program adopters encourages a strong, but informal,
word-of-mouth referral for both males and females.
An expanded focus on providers will help to
ensure that the challenges of working with adoles-
cents are met. This focus is especially crucial in the
area of STI screening and treatment, given the
known poor reproductive health outcomes associ-
June 2003 MEETING THE REPRODUCTIVE HEALTH CARE NEEDS OF TEENS
ated with such infections. STIs are frequently associ-
ated with adverse and expensive outcomes such as
ectopic pregnancy, HIV transmission, and infertility.
In 1994, the cost of STIs (including HIV infection) in
the United States was estimated to exceed $17 billion;
direct medical costs annually for STI treatment in the
United States is estimated to be at least $8.4 billion
(this does not include nonmedical indirect costs, such
as lost wages and productivity, out-of-pocket costs,
or costs related to transmission to infants). Many of
the direct costs result from a failure to detect and
treat the infection in its initial state [21]. More than
70% of chlamydia cases among females occur among
those aged younger than 25 years; most of these
cases are among 15- to 19-year-olds [16,20].
Although the incidence of gonorrhea and syphilis in
California have been brought to historic lows, chla-
mydia remains an epidemic, with adolescents and
young adults aged younger then 25 years having the
highest rates of new infections. Family PACT exit
interviews indicate that adolescents were highly satis-
fied with their care and felt that providers were sensi-
tive to their needs for STI testing, education, and
counseling, yet the proportion of sexually active ado-
lescents screened for chlamydial infections (57%) was
lower than the CDC recommended guidelines of yearly
examinations for sexually active adolescents [21].
Thus, although most Family PACT providers sam-
pled in this study offered quality care to adolescents
consistent with Family PACT’s standards, this was
one area that clearly demonstrated poor compliance.
In response, OFP is working closely with providers
to ensure that such standards are followed, evi-
denced by the increase from the 48% of adolescents
screened in the program’s first year. Additionally,
the large proportion of adolescents who receive
barrier contraceptive methods through the program
(accounting for 55% of all methods dispensed to
females and 72% to men) are anticipated to meet the
needs of many of California’s adolescents, one-third
of whom are estimated to have a chlamydial infec-
tion. By serving larger numbers of sexually active
male and female adolescents and providing inte-
grated STI and reproductive health care, teenagers in
California’s Family PACT program will have the
opportunity to decrease the high incidence of STIs.
California OFP’s Family PACT program has made
substantial inroads in meeting the diverse needs of
adolescents through the implementation of a flexible,
responsive, and accessible program. Initial findings
reflect that the provision of confidential reproductive
health services for adolescents can be successful in
decreasing their unmet need for care. With its mul-
89
tifaceted approach to adolescent pregnancy preven-
tion, including comprehensive family life education,
media campaigns, as well as teen-friendly family
planning services, California has clearly demon-
strated its leadership and commitment to improving
the lives of its young people.
We gratefully acknowledge the California Department of Health
Services, Office of Family Planning for their support of this evalua-
tion, especially Ms. Anna Ramirez, M.P. Chief, OFP, Ms. Jan Treat,
PHN, M.N., Chief, Clinical Services, OFP, and John Mikanda, M.D.,
M.P.H., Research Scientist. We also thank Mary Bradsberry, Denis
Hulett, and Diane Swann at University of California San Francisco
for data management and programming support.
References
1. Ventura SJ, Mosher WD. Trends in pregnancy rates for the
United States: 1976 –1997: An update. Washington, DC: Na-
tional Vital Statistics Reports, June 2001.
2. Ventura SJ, Mathews TJ, Hamilton BE. Births to teenagers in
the United States, 1940 –2000. National Vital Statistics Reports;
Vol 49. Hyattsville, MD: National Center for Health Statistics,
2001, , No 10..
3. Martin JA, Park MM, Sutton PD. Births: Preliminary data for
2001. National vital statistics reports;Vol 50. Hyattsville, MD:
National Center for Health Statistics, 2002, , No 10.
4. Donovan P. Falling teen pregnancy, birthrates: what’s behind
the declines? Guttmacher Rep Public Policy 1998;10:1–4.
5. Wertheimer R, Jager J. State Policy Initiatives for Reducing
Teen and Adult Nonmarital Childbearing: Family Planning
and Family Caps. Washington, DC: Urban Institute, 2000.
6. Boonstra H, Nash E. Minors and the right to consent to health
care. Guttmacher Rep Public Policy 2000;3:4 –8.
7. Ford C, English A. Limiting confidentiality of adolescent
health services: What are the risks? JAMA 2002;288:752–3.
8. Brindis CD. Advancing the adolescent reproductive health
policy agenda: Issues for the coming decade. J Adolesc Health
2002;31(Suppl): 296 –309.
9. Reddy DM, Fleming R, Swain C. Effect of mandatory parental
notification on adolescent girls’ use of sexual health care
services. JAMA 2002;288:6710 –4.
10. Brindis CD, Darney PD. California’s Family PACT Program:
Program and Evaluation Report. Submitted to the State of
California, Department of Health Services, Office of Family
Planning. San Francisco: University of California, January 2000.
11. Fiscal Year 1996/1997 Budget Trailer Bill, Assembly Bill
(AB)3483, Section 24000 of the Welfare and Institutions Code.
[provided additional state funding to expand the clinical
family planning program, thus establishing the Family PACT
Program].
12. Armstrong K, Stover M. SMART START: An option for
adolescents to delay the pelvic examination and blood work in
family planning clinics. J Adoles Health 1994;15:389 –95.
13. California Department of Finance, Demographic Research
Unit. Actual and projected births by county, 1970 –2008, with
births by age of mother and fertility rates. Sacramento: State of
California, December, 1999.
14. Clayton SL, Brindis CD, Hamor JA. Investing in adolescent
health: A social imperative for California’s future. San Fran-
cisco: University of California, San Francisco, National Ado-
lescent Health Information Center, 2000.
90 BRINDIS ET AL
15. Braveman P, Egerter S, Marchi K. The prevalence of low
income levels among childbearing women in California: Im-
plications for the private and public sectors. Am J Public
Health 1999;89:868 –74.
16. California Department of Health Services, STD Control
Branch. Sexually transmitted disease in California, 2000. Sac-
ramento, CA: Author, 2000.
17. SAS Software Release 8.2. Cary, NC: SAS Institute, Inc., 2001.
18. Frost J, Ranjit N, Manzella K, et al. Family planning clinic
services in the United States: Patterns and trends in the late
1990s. Fam Plann Perspect 2001;33:113–22.
19. Zabin LS, Clark SD, Jr. Adolescents with negative pregnancy
tests: An accessible at-risk group. JAMA 1966;275:113–7.
20. Biro FM, Rosenthal SL, Kiniyalocts M. Gonoccal and chlamyd-
ial genitourinary infections in symptomatic and asymptomatic
adolescent women. Clin Pediatr 1995;34:419 –23.
21. Centers for Disease Control and Prevention. 1998 guidelines
for treatment of sexually transmitted diseases. MMWR Morb
Mortal Wkly Rep 1998;47:53–9.
JOURNAL OF ADOLESCENT HEALTH Vol. 32S, No. 6S
22. Driscoll AK, Biggs MA, Brindis CD, et al. Adolescent Latino
reproductive health: A review of the literature. Hisp J Behav
Sci 2001;23:256 –326.
23. Kann JG, Brindis CD, Glei D. Pregnancies averted among U.S.
teenagers by the use of contraceptives. Family Plann Perspect
1999;31:29 –34.
24. State of California, Department of Finance, Demographic
Research Unit. Actual and projected births by county, 1970 –
2110, with births by age of mother and fertility rates. Sacra-
mento, CA: Author, August 2001.
25. Alan Guttmacher Institute Issues in brief: Teenage pregnancy and
the welfare debate. New York: Alan Guttmacher Institute, 1995.
26. California Department of Health Services, Maternal and
Child Health Branch, Epidemiology Section. Teen birth
rates, 1990 –2001. Sacramento, CA: California Department
of Health Services, 2002 Available at: http://www.mch.
dhs.ca.gov/epidemiology.htm. Accessed September 30,
2002.