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Report to Congressional Requesters: 

United States Government Accountability Office: 

GAO: 

October 2006: 

Abstinence Education: 

Efforts to Assess the Accuracy and Effectiveness of Federally Funded 
Programs: 

GAO-07-87: 

GAO Highlights: 

Highlights of GAO-07-87, a report to congressional requesters 

Why GAO Did This Study: 

Reducing the incidence of sexually transmitted diseases and unintended 
pregnancies is one objective of the Department of Health and Human 
Services (HHS). HHS provides funding to states and organizations that 
provide abstinence-until-marriage education as one approach to address 
this objective. 

GAO was asked to describe the oversight of federally funded abstinence-
until-marriage education programs. GAO is reporting on (1) efforts by 
HHS and states to assess the scientific accuracy of materials used in 
these programs and (2) efforts by HHS, states, and researchers to 
assess the effectiveness of these programs. GAO reviewed documents and 
interviewed HHS officials in the Administration for Children and 
Families (ACF) and the Office of Population Affairs (OPA) that award 
grants for these programs. 

What GAO Found: 

Efforts by HHS and states to assess the scientific accuracy of 
materials used in abstinence-until-marriage education programs have 
been limited. This is because HHS’s ACF—which awards grants to two 
programs that account for the largest portion of federal spending on 
abstinence-until-marriage education—does not review its grantees’ 
education materials for scientific accuracy and does not require 
grantees of either program to review their own materials for scientific 
accuracy. In contrast, OPA does review the scientific accuracy of 
grantees’ proposed educational materials. In addition, not all states 
that receive funding from ACF have chosen to review their program 
materials for scientific accuracy. In particular, 5 of the 10 states 
that GAO contacted conduct such reviews. Officials from these states 
reported using a variety of approaches in their reviews. While the 
extent to which federally funded abstinence-until-marriage education 
materials are inaccurate is not known, in the course of their reviews 
OPA and some states reported that they have found inaccuracies in 
abstinence-until-marriage education materials. For example, one state 
official described an instance in which abstinence-until-marriage 
materials incorrectly suggested that HIV can pass through condoms 
because the latex used in condoms is porous. 

HHS, states, and researchers have made a variety of efforts to assess 
the effectiveness of abstinence-until-marriage education programs; 
however, a number of factors limit the conclusions that can be drawn 
about the effectiveness of abstinence-until-marriage education 
programs. ACF and OPA have required their grantees to report on various 
outcomes that the agencies use to measure the effectiveness of 
grantees’ abstinence-until-marriage education programs. In addition, 6 
of the 10 states in GAO’s review have worked with third-party 
evaluators to assess the effectiveness of abstinence-until-marriage 
education programs in their states. Several factors, however, limit the 
conclusions that can be drawn about the effectiveness of abstinence-
until-marriage education programs. Most of the efforts to evaluate the 
effectiveness of abstinence-until-marriage education programs included 
in GAO’s review have not met certain minimum scientific criteria—such 
as random assignment of participants and sufficient follow-up periods 
and sample sizes—that experts have concluded are necessary in order for 
assessments of program effectiveness to be scientifically valid, in 
part because such designs can be expensive and time-consuming to carry 
out. In addition, the results of efforts that meet the criteria of a 
scientifically valid assessment have varied and two key studies funded 
by HHS that meet these criteria have not yet been completed. When 
completed, these HHS-funded studies may add substantively to the body 
of research on the effectiveness of abstinence-until-marriage education 
programs. 

What GAO Recommends: 

To address concerns about the scientific accuracy of materials used in 
abstinence-until-marriage education programs, GAO recommends that the 
Secretary of HHS develop procedures to help assure the accuracy of such 
materials used in programs administered by ACF. HHS agreed to consider 
this recommendation. HHS also provided information on steps it takes to 
assure accuracy, which we have incorporated into the report, as 
appropriate. 

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-87]. 

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Marcia Crosse at (202) 
512-7119 or crossem@gao.gov. 

[End of Section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

Federal and State Efforts to Assess the Scientific Accuracy of 
Materials Used in Abstinence-until-Marriage Education Programs Have 
Been Limited: 

A Variety of Efforts Have Been Made to Assess the Effectiveness of 
Abstinence-until-Marriage Education Programs, but a Number of Factors 
Limit the Conclusions That Can Be Drawn: 

Conclusions: 

Recommendation for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: HRSA's Technical Assistance Contract for Abstinence 
Education: 

Appendix II: Methodology for Identifying and Reviewing Research 
Studies: 

Appendix III: Comments from the Department of Health and Human 
Services: 

Appendix IV: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Definition of Abstinence Education: 

Table 2: Funding Provided by HHS for the Three Main Abstinence-until- 
Marriage Education Programs: 

Table 3: ACF's Reporting Requirements for the State Program and the 
Community-Based Program, Fiscal Year 2006: 

Abbreviations: 

ACF: Administration for Children and Families: 
AFL: Adolescent Family Life: 
ASPE: Office of the Assistant Secretary for Planning and Evaluation: 
CDC: Centers for Disease Control and Prevention: 
FAR: Federal Acquisition Regulation: 
HHS: Department of Health and Human Services: 
HIV: human immunodeficiency virus: 
HPV: human papillomavirus: 
HRSA: Health Resources and Services Administration: 
NAC: National Abstinence Clearinghouse: 
NIH: National Institutes of Health: 
OMB: Office of Management and Budget: 
OPA: Office of Population Affairs: 
RFP: request for proposal: 
STD: sexually transmitted disease: 
TANF: Temporary Assistance for Needy Families: 

United States Government Accountability Office: 
Washington, DC 20548: 

October 3, 2006: 

Congressional Requesters: 

Preventing sexually transmitted diseases (STD) and unintended 
pregnancies among adolescents is an important public health challenge. 
Although pregnancy and birth rates among female adolescents in the 
United States have been declining since the early 1990s, the rates 
continue to be high when compared with those in other industrialized 
nations. The Centers for Disease Control and Prevention (CDC) reports 
that about 141,000 children were born to girls 17 years old and younger 
in the United States in 2003. CDC also reports that STDs 
disproportionately affect adolescents, with adolescents and young 
adults ages 15 to 24 acquiring almost half of the estimated 19 million 
new infections each year. 

Reducing the incidence of STDs and unintended pregnancies among 
adolescents is an important objective for the Department of Health and 
Human Services (HHS), which identifies as one of its goals the need to 
reduce major threats to the health and well-being of Americans. Among 
the efforts it supports to reduce the incidence of STDs and unintended 
pregnancies among adolescents, HHS funds abstinence-until-marriage 
education programs. Abstinence-until-marriage education programs, also 
referred to as abstinence-only education programs, teach adolescents to 
abstain from sexual activity until marriage in order to avoid risks of 
unintended pregnancy, STDs, and related health problems.[Footnote 1] 
The content of federally funded abstinence-until-marriage programs is 
required to be consistent with several principles, such as teaching 
that a mutually faithful monogamous relationship in the context of 
marriage is the expected standard of human sexual activity, and that 
abstinence from sexual activity is the only certain way to avoid STDs. 
Abstinence-until-marriage education programs are delivered by a variety 
of entities, including schools, human service agencies, faith-based 
organizations, youth development groups, and pregnancy crisis centers. 
Instructors can incorporate a variety of educational materials into 
their abstinence-until-marriage education programs, including 
textbooks, student manuals, brochures, slide presentations, and videos. 

The three main federally funded abstinence-until-marriage programs are 
the Abstinence Education Program (State Program), which is administered 
by HHS's Administration for Children and Families (ACF); the Community- 
Based Abstinence Education Program (Community-Based Program), which is 
also administered by ACF; and the Adolescent Family Life (AFL) Program, 
which is administered by HHS's Office of Population Affairs (OPA) 
within the Office of Public Health and Science. Funding provided by HHS 
for the three abstinence-until-marriage programs increased from about 
$73 million in fiscal year 2001 to about $158 million in fiscal year 
2005. 

Recent studies have raised concerns about the accuracy of educational 
materials used in abstinence-until-marriage education programs and 
about the effectiveness of these programs. These studies have reported 
that some of the materials used in abstinence-until-marriage education 
programs contain, for example, scientifically inaccurate information 
about anatomy and physiology as they relate to reproductive health as 
well as misleading information about contraceptive failure rates and 
STDs.[Footnote 2] State and federal agencies have also documented 
inaccuracies in abstinence-until-marriage educational materials. 
Further, studies examining the effectiveness of these programs have 
reported varied results. For example, some researchers have reported 
that abstinence-until-marriage education programs have resulted in 
adolescents reporting less frequent sexual intercourse or fewer sexual 
partners, while other researchers have reported that these types of 
programs did not affect the frequency of sexual intercourse or were 
ineffective in delaying the initiation of sexual intercourse.[Footnote 
3] 

You asked us to describe certain aspects of the oversight of federally 
funded abstinence-until-marriage education programs. Our objectives 
were to report on (1) efforts by HHS and states to assess the 
scientific accuracy of materials used in abstinence-until-marriage 
education programs and (2) efforts by HHS, states, and researchers to 
assess the effectiveness of abstinence-until-marriage education 
programs. You also asked us to describe how HHS selected a contractor 
for the abstinence-until-marriage technical assistance contract that 
was awarded in September 2002. This information is provided in appendix 
I. 

To describe the efforts by HHS and states to assess the scientific 
accuracy of materials used in abstinence-until-marriage education 
programs, we reviewed published reports, program announcements, Federal 
Register notices, agency Web sites, and other documents related to 
abstinence-until-marriage education. We focused our review on efforts 
related to the three main federally funded abstinence-until-marriage 
education programs administered by HHS, as well as efforts to review 
the accuracy of scientific facts included in abstinence-until-marriage 
education materials. We did not assess the criteria used to determine 
the scientific accuracy of education materials or the quality of the 
reviews. We interviewed officials from ACF, the Health Resources and 
Services Administration (HRSA), OPA, and CDC. We also interviewed 
officials from the 10 states that received the largest share of federal 
funding (together accounting for 51 percent of the total funding in 
fiscal year 2005) through the State Program for abstinence-until- 
marriage education.[Footnote 4] 

To describe efforts by HHS, states, and researchers to assess the 
effectiveness of abstinence-until-marriage education programs, we 
focused on efforts that examined the extent to which these programs 
achieved their program goals. In general, these goals include teaching 
adolescents to abstain from sexual activity until marriage in order to 
avoid unintended pregnancies, STDs, and related health problems. As 
part of our review, we compared these efforts to the design 
characteristics that experts have identified as important for a 
scientifically valid study of program effectiveness.[Footnote 5] We 
reviewed journal articles and other published reports, agency budget 
submissions, program announcements, agency and grantee performance 
reports, Federal Register notices, agency Web sites, and other 
documents related to abstinence-until-marriage education. (For a more 
detailed description of our literature review methodology, see app. 
II). We also interviewed officials from ACF, HRSA, OPA, CDC, the 
National Institutes of Health (NIH), the Office of the Assistant 
Secretary for Planning and Evaluation (ASPE), and 10 states that 
received the largest share of federal funding for abstinence-only 
education through the State Program in fiscal year 2005. We also 
interviewed individuals from the National Campaign to Prevent Teen 
Pregnancy, The Brookings Institution, ETR Associates, The Heritage 
Foundation, and Advocates for Youth, and researchers from Case Western 
Reserve University and Columbia University to obtain general 
information regarding the state of the research on abstinence-until- 
marriage education. We focused our review on efforts to assess the 
scientific accuracy of materials and the effectiveness of the programs 
during fiscal year 2006, and also reviewed the administration of the 
programs back to fiscal year 2001. We also attended conferences 
organized by ACF and OPA to learn about training that is provided to 
grantees on scientific accuracy and program evaluations. 

To describe how HHS selected a contractor for the abstinence-until- 
marriage technical assistance contract that was awarded in September 
2002, we reviewed the Request for Proposals and other related contract 
documents. We also interviewed officials at HRSA, ACF, and the National 
Abstinence Clearinghouse about the technical assistance contract. We 
performed our work from October 2005 through September 2006 in 
accordance with generally accepted government auditing standards. 

Results in Brief: 

Efforts by HHS and states to assess the scientific accuracy of 
materials used in abstinence-until-marriage education programs have 
been limited. This is because ACF--which awards grants through two 
programs that account for the largest portion of federal spending on 
abstinence-until-marriage education--does not review its grantees' 
education materials for scientific accuracy and does not require 
grantees of either program to review their own materials for scientific 
accuracy. In addition, not all states that receive funding through 
ACF's State Program have chosen to review their program materials for 
scientific accuracy. In particular, 5 of the 10 states in our review 
conduct such reviews. Officials from these states reported using a 
variety of approaches in their reviews. In contrast, OPA does review 
the scientific accuracy of AFL grantees' proposed educational materials 
and any inaccuracies found must be corrected before the materials can 
be used. While the extent to which federally funded abstinence-until- 
marriage education materials are inaccurate is not known, in the course 
of their reviews OPA and some states reported that they have found some 
inaccuracies in abstinence-until-marriage education materials. For 
example, OPA has required that a grantee correct several statements in 
a true/false quiz--including statements about STDs and condom use--in 
order for the quiz to be approved for use in its curriculum. In 
addition, one state official described an instance in which abstinence- 
until-marriage materials incorrectly suggested that HIV can pass 
through condoms because the latex used in condoms is porous. 

HHS, states, and researchers have made a variety of efforts to assess 
the effectiveness of abstinence-until-marriage education programs; 
however, a number of factors limit the conclusions that can be drawn 
about the effectiveness of abstinence-until-marriage education 
programs. To assess the effectiveness of their abstinence-until- 
marriage education programs, ACF and OPA have required their grantees 
to report on various outcomes that the agencies use to measure the 
effectiveness of grantees' abstinence-until-marriage education 
programs. For example, as of fiscal year 2006, states that receive 
funding through the State Program are required to report annually on 
four measures of the prevalence of adolescent sexual behavior in their 
state, such as the rate of pregnancy among adolescents aged 15 to 17 
years. To assess the effectiveness of both its State and Community- 
Based Programs, ACF also analyzes trends in adolescent behavior, as 
reflected in national data on birth rates among teens and the 
proportion of surveyed high school students reporting that they have 
had sexual intercourse. OPA requires grantees of the AFL Program to 
develop and report on outcome measures that demonstrate the extent to 
which grantees' programs are having an effect on program participants. 
In addition, other HHS agencies and offices--ASPE, CDC and NIH--are 
making efforts to assess the effectiveness of abstinence-until-marriage 
education programs. Further, 6 of the 10 states in our review that 
receive funding through the State Program have worked with third-party 
evaluators to assess the effectiveness of abstinence-until-marriage 
education programs in their states. Several factors, however, limit the 
conclusions that can be drawn about the effectiveness of abstinence- 
until-marriage education programs. Most of the efforts to evaluate the 
effectiveness of abstinence-until-marriage education programs that we 
describe in our review have not met certain minimum criteria--such as 
random assignment of participants and sufficient follow-up periods and 
sample sizes--that experts have concluded are necessary in order for 
assessments of program effectiveness to be scientifically valid, in 
part because such designs can be expensive and time-consuming to carry 
out. In addition, the results of efforts that meet the criteria of a 
scientifically valid assessment have varied and two key studies funded 
by HHS that meet these criteria have not yet been completed. When 
completed, these HHS-funded studies may add substantively to the body 
of research on the effectiveness of abstinence-until-marriage education 
programs. 

To address concerns about the scientific accuracy of materials used in 
abstinence-until-marriage education programs, we recommend that the 
Secretary of HHS develop procedures to help assure the accuracy of such 
materials used in the State and Community-Based Programs. To help 
provide such assurance, the Secretary could consider alternatives such 
as (1) extending the approach currently used by OPA to review the 
scientific accuracy of the factual statements included in abstinence- 
until-marriage education to materials used by grantees of ACF's 
Community-Based Program and requiring grantees of ACF's State Program 
to conduct such reviews or (2) requiring grantees of both programs to 
sign written assurances in their grant applications that the materials 
they propose using are accurate. 

In commenting on a draft of this report, HHS agreed to consider 
requiring grantees of both ACF programs to sign written assurances in 
grant applications that the materials they use are accurate. In 
addition, HHS noted that all federal grant applicants attest on a 
standard form that information in their applications is correct. 
However, it is not clear that this serves the purpose of assuring the 
scientific accuracy of the educational materials. Further, the 
curricula to be used are not required to be included with states' 
applications. HHS's written comments also stated that ACF requires that 
the Community-Based Program curricula conform to standards that are 
grounded in scientific literature by requiring certain types of 
information. However, the inclusion of certain types of information 
does not necessarily ensure the accuracy of the scientific facts 
included in the abstinence-until-marriage materials. In addition, HHS 
noted in its written comments that we did not define the term 
scientific accuracy and stated that it disagreed with certain findings 
of the report because it was difficult to precisely determine the 
criteria employed by GAO in making the recommendation as to scientific 
accuracy. However, the objective of our work was to focus on efforts by 
HHS and states to review the accuracy of scientific facts included in 
abstinence-until-marriage education materials and not to perform an 
independent assessment of the criteria used or the quality of the 
reviews. With regard to effectiveness, HHS agreed that it may be too 
soon to draw conclusions about the effectiveness of ACF's and OPA's 
programs. 

Background: 

Recent statistics from CDC show that many high school students engage 
in sexual behavior that places them at risk for unintended pregnancy 
and STDs. In 2005, 46.8 percent of high school students reported that 
they have ever had sexual intercourse, with 14.3 percent of students 
reporting that they had had sexual intercourse with four or more 
persons. The likelihood of ever having sexual intercourse varied by 
grade, with the highest rate among 12th grade students (63.1 percent) 
and the lowest rate among 9th grade students (34.3 percent). CDC also 
has reported that the prevalence of certain STDs--including the rate of 
chlamydia infection, the most frequently reported STD in the United 
States--peaks in adolescence and young adulthood. According to CDC, in 
2004 the chlamydia rates among adolescents 15 to 19 years old (1,579 
cases per 100,000 adolescents) and young adults 20 to 24 years old 
(1,660 cases per 100,000) were each more than twice the rates among all 
other age groups. 

HHS's current strategic plan includes the objectives to reduce the 
incidence of STDs and unintended pregnancies and to promote family 
formation and healthy marriages. These two objectives support HHS's 
goals to reduce the major threats to the health and well-being of 
Americans and to improve the stability and healthy development of 
American children and youth, respectively. Abstinence-until-marriage 
education programs are one of several types of programs that support 
these objectives.[Footnote 6] 

The three main federal abstinence-until-marriage education programs-- 
the State Program, the Community-Based Program, and the AFL Program-- 
provide grants to support the recipients' own efforts to provide 
abstinence-until-marriage education at the local level.[Footnote 7] 
These programs must comply with the statutory definition of abstinence 
education (see table 1).[Footnote 8] 

Table 1: Definition of Abstinence Education: 

Abstinence education refers to an educational or motivational program 
that:

A. has as its exclusive purpose, teaching the social, psychological, 
and health gains to be realized by abstaining from sexual activity. 

B. teaches abstinence from sexual activity outside marriage as the 
expected standard for all school age children. 

C. teaches that abstinence from sexual activity is the only certain way 
to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and 
other associated health problems. 

D. teaches that a mutually faithful monogamous relationship in context 
of marriage is the expected standard of human sexual activity. 

E. teaches that sexual activity outside of the context of marriage is 
likely to have harmful psychological and physical effects. 

F. teaches that bearing children out-of-wedlock is likely to have 
harmful consequences for the child, the child's parents, and society. 

G. teaches young people how to reject sexual advances and how alcohol 
and drug use increases vulnerability to sexual advances; and. 

H. teaches the importance of attaining self-sufficiency before engaging 
in sexual activity. 

Source: Social Security Act, § 510(b)(2) (codified at 42 U.S.C. § 
710(b)(2)). 

[End of table] 

The State Program: 

The State Program, administered by ACF, provides funding to its 
grantees--states--for the provision of abstinence-until-marriage 
education to those most likely to have children outside of 
marriage.[Footnote 9] States that receive grants through the State 
Program have discretion in how they use their funding to provide 
abstinence-until-marriage education. Some require that organizations 
apply for funds and use them to administer abstinence-until-marriage 
education programs. Others may directly administer such programs. At 
their discretion, states may also provide mentoring, counseling, and 
adult supervision to adolescents to promote abstinence from sexual 
activity until marriage. 

The Personal Responsibility and Work Opportunity Reconciliation Act of 
1996 established the State Program, and states were awarded grants 
beginning in fiscal year 1998.[Footnote 10] Funds are allotted to each 
state that submits the required annual application based on the ratio 
of the number of low-income children in the state to the total number 
of low-income children in all states. States are required to match 
every $4 they receive in federal money with $3 of nonfederal money and 
are required to report annually on the performance of the abstinence- 
until-marriage education programs that they support or administer. In 
fiscal year 2005, 47 states, the District of Columbia, and 3 insular 
areas were awarded funding.[Footnote 11],[Footnote 12] 

The Community-Based Program: 

The Community-Based Program, which is also administered by ACF, is 
focused on funding public and private entities that provide abstinence- 
until-marriage education for adolescents from 12 to 18 years old, with 
the purpose of creating an environment within communities that supports 
adolescent decisions to postpone sexual activity until marriage. The 
Community-Based Program provides grants for school-based programs, 
adult and peer mentoring, and parent education groups. The Community- 
Based Program first awarded grants in fiscal year 2001.[Footnote 13] 
Grantees of the Community-Based Program are selected through a 
competitive process and are evaluated according to several criteria, 
such as the extent to which they have demonstrated that a need exists 
for abstinence-until-marriage education for a targeted population or in 
a specific geographic location. Grantees are required to report to ACF, 
on a semiannual basis, on the performance of their programs. For fiscal 
year 2005, 63 grants were awarded to organizations and other 
entities.[Footnote 14] 

The AFL Program: 

The AFL Program supports programs that provide abstinence-until- 
marriage education.[Footnote 15] The primary purpose of these programs 
is to find effective means of reaching preadolescents and adolescents 
before they become sexually active in order to encourage them to 
abstain from sexual activity and other risky behaviors. Under the AFL 
Program, OPA awards competitive grants to public or private nonprofit 
organizations or agencies, including community-based and faith-based 
organizations, to facilitate abstinence-until-marriage education in a 
variety of settings, including schools and community centers. 
Established in 1981, the AFL Program began awarding grants in fiscal 
year 1982. AFL Program grantees include school districts, youth 
development groups, and medical centers. Grant applicants are evaluated 
based on several criteria, such as the extent to which they provide a 
clear statement of mission, goals, measurable objectives, and a 
reasonable method for achieving their objectives. Grantees are required 
to conduct evaluations of certain aspects of their programs and report 
annually on their performance. As of August 2006, OPA funded 58 
abstinence-until-marriage education programs, and most of these were 
focused on reaching young adolescents from the ages of 9 to 14. 

Funding for Abstinence-until-Marriage Education Has Increased: 

Funding provided by HHS for abstinence-until-marriage education 
programs has increased steadily since 2001 (see table 2). For the three 
main programs combined--the State Program, the Community-Based Program, 
and the AFL Program--the amount of agency funding increased from about 
$73 million in fiscal year 2001 to about $158 million in fiscal year 
2005. Nearly all of this increase was for the Community-Based program; 
funding under this program increased by about $84 million from fiscal 
years 2001 through 2005. In fiscal year 2005, agency funding for the 
Community-Based Program constituted the largest share of the total 
funding (about 66 percent) for the three main programs combined. 

Table 2: Funding Provided by HHS for the Three Main Abstinence-until- 
Marriage Education Programs: 

Dollars in millions. 

Fiscal year: 2001; 
State Program[A,B]: $43; 
Community-Based Program: $20; 
AFL Program: $10. 

Fiscal year: 2002; 
State Program[A,B]: 43; 
Community-Based Program: 40; 
AFL Program: 12. 

Fiscal year: 2003; 
State Program[A,B]: 44; 
Community-Based Program: 55; 
AFL Program: 13. 

Fiscal year: 2004; 
State Program[A,B]: 41; 
Community-Based Program: 75; 
AFL Program: 13. 

Fiscal year: 2005; 
State Program[A,B]: 41; 
Community-Based Program: 104; 
AFL Program: 13. 

Sources: ACF, OPA, and HRSA. 

Notes: Figures are rounded to nearest $1,000,000. Funding levels 
represent the total amount of grants awarded and funding for program- 
related support, such as technical assistance and evaluation. 

[A] States that receive funding are required to match every $4 they 
receive of federal funds with $3 of nonfederal money. 

[B] The amount of funding provided by HHS for the State Program has 
generally varied by year because the states that have applied for 
funding each year have varied. 

[End of table] 

Within each of the three main abstinence-until-marriage education 
programs, the amount of individual grants varied.[Footnote 16] In 
fiscal year 2005, the State Program's annual grants ranged from $57,057 
to $4,777,916 and the median annual grant amount was $569,675. That 
same year, the Community-Based Program's annual grants ranged from 
$213,276 to $800,000 and the median grant amount was $642,250. In 
fiscal year 2006, the AFL Program's annual grants ranged from $95,676 
to $300,000 and the median grant amount was $225,000. 

Federal Agency Responsibilities Related to Abstinence-until-Marriage 
Education: 

Five organizational units located within HHS--ACF, OPA, CDC, ASPE, and 
NIH--have responsibilities related to abstinence-until-marriage 
education. ACF and OPA administer the three main federal abstinence- 
until-marriage education programs. CDC supports abstinence-until- 
marriage education at the national, state, and local levels. CDC, ASPE, 
and NIH are sponsoring research on the effectiveness of abstinence- 
until-marriage programs. 

ACF: 

ACF is responsible for federal programs that promote the economic and 
social well-being of families, children, individuals, and communities. 
ACF administers and provides oversight of both the State Program and 
the Community-Based Program by, among other things, awarding grants, 
providing training and technical assistance to grantees, and requiring 
annual performance reporting from grantees. ACF has been responsible 
for the State Program since June 2004 and the Community-Based Program 
since October 2005. HRSA previously administered these programs. 

OPA: 

OPA has responsibility for advising the Secretary of HHS on a wide 
range of reproductive health topics, including adolescent pregnancy and 
family planning. The office is also responsible for administering 
programs that provide services for pregnant and parenting teens and 
prevention programs, such as abstinence-until-marriage education 
programs. OPA administers and provides oversight of the AFL Program by 
awarding grants, providing training and technical assistance to 
grantees, and requiring annual performance reporting from grantees. 

CDC: 

CDC is primarily responsible for the prevention and control of 
infectious and chronic diseases, including STDs. CDC provides funding 
to state and local education agencies in their efforts to support 
comprehensive school health education and HIV/STD prevention education 
programs, and CDC officials told us that some of these are focused on 
abstinence. CDC also provides funding to several state education 
agencies to implement various abstinence projects, such as 
collaboration-building among agencies to increase the impact of their 
efforts to encourage abstinence. Further, CDC develops tools to assist 
state and local education agencies with their health education 
programs. CDC provides funding to several national organizations to 
build the capacity of abstinence-until-marriage education providers. 
Organizations' activities include, but are not limited to, the 
development and distribution of educational materials. CDC is also 
sponsoring research on the effectiveness of an abstinence-until- 
marriage education program. 

ASPE: 

ASPE advises the Secretary of HHS in several areas, including policy 
development in health, human services, data, and science. ASPE is 
responsible for the development of policy analyses and it conducts 
research and evaluation studies in several areas, including the health 
of children and adolescents. ASPE is currently sponsoring research on 
the effectiveness of abstinence-until-marriage education programs. 

NIH: 

NIH is the primary federal agency that conducts and supports medical 
and behavioral research among various populations, including children 
and adolescents. NIH is currently sponsoring research on the 
effectiveness of abstinence-until-marriage education programs. 

Federal and State Efforts to Assess the Scientific Accuracy of 
Materials Used in Abstinence-until-Marriage Education Programs Have 
Been Limited: 

Efforts by HHS and states to assess the scientific accuracy of 
materials used in abstinence-until-marriage education programs have 
been limited. ACF--which awards grants to two programs that account for 
the largest portion of federal spending on abstinence-until-marriage 
education--does not review its grantees' education materials for 
scientific accuracy and does not require grantees of either program to 
review their own materials for scientific accuracy. In addition, not 
all states funded through the State Program have chosen to review their 
program materials for scientific accuracy. In contrast to ACF, OPA has 
reviewed the scientific accuracy of grantees' proposed educational 
materials and corrected inaccuracies in these materials. 

ACF Does Not Review Program Materials for Scientific Accuracy and Does 
Not Require Grantees to Do So, though Some State Grantees Have 
Conducted Such Reviews: 

There have been limited efforts to review the scientific accuracy of 
educational materials used in ACF's State and Community-Based Programs-
-the two programs that account for the largest portion of federal 
spending on abstinence education. ACF does not review materials for 
scientific accuracy in either reviewing grant applications[Footnote 17] 
or in overseeing grantees' performance. Prior to fiscal year 2006, 
State Program and Community-Based Program applicants were not required 
to submit copies of their proposed educational materials with their 
applications. While ACF required grantees of the Community-Based 
Program--but not the State Program--to submit their educational 
materials with their fiscal year 2006 applications, ACF officials told 
us that grantee applications and materials are only reviewed to ensure 
that they address all aspects of the scope of the Community-Based 
Program, such as the A-H definition of abstinence education.[Footnote 
18] Further, documents provided to us by ACF indicate that the agency 
does not review grantees' educational materials for scientific accuracy 
as a routine part of its oversight activities. In addition, ACF also 
does not require its grantees to review their own materials for 
scientific accuracy. Similarly, when HRSA was responsible for the State 
and Community-Based Programs, the agency did not review materials used 
by grantees for scientific accuracy or require grantees to review their 
own materials. 

Not all grantees of the State Program have chosen to review the 
scientific accuracy of their educational materials. Officials from 5 of 
the 10 states in our review reported that their states have chosen to 
conduct such reviews.[Footnote 19],[Footnote 20] Officials in these 
states identified a variety of reasons why their states reviewed 
abstinence-until-marriage educational materials, including program 
requirements, state education laws and guidelines, and past lawsuits, 
to ensure that materials used in abstinence-until-marriage programs 
were accurate. For example, Michigan's Revised School Code states that 
materials and instruction in the sex education curricula, including 
information on abstinence, "shall not be medically 
inaccurate,"[Footnote 21] and Ohio's fiscal year 2007 abstinence-until- 
marriage education program guidance states that abstinence-until- 
marriage educational materials "should be medically accurate in all 
assertions."[Footnote 22] 

The five states we contacted that review abstinence-until-marriage 
educational materials for scientific accuracy have used a variety of 
approaches in their reviews. Some states contracted with medical 
professionals--such as nurses, gynecologists, and pediatricians--to 
serve as medical advisors who review program materials and use their 
expertise to determine what is and is not scientifically accurate. Some 
states have created checklists or worksheets to guide their staff 
conducting the review and document findings of inaccuracy or 
verification of a statement. All five states use medical professionals 
in conducting these reviews. One of the states requires that all 
statistics or scientific statements cited in a program's materials are 
sourced to CDC or a peer-reviewed medical journal. Officials from this 
state told us that if statements in these materials cannot be 
attributed to these sources, the statements are required to be removed 
until citations are provided and materials are approved. Officials from 
this state told us they have also supplemented their review of program 
materials with on-site classroom observations to assess the scientific 
accuracy of the information presented to students. 

Officials from two of the five states reported that they have found 
inaccuracies as a result of their reviews. For example, one state 
official stated that because information is constantly evolving, state 
officials have had to correct out-of-date scientific information. In 
addition, this official cited an instance where materials incorrectly 
suggested that HIV can pass through condoms because the latex used in 
condoms is porous. In addition, this official provided documentation 
that the state has had to correct a statement indicating that when a 
person is infected with the human papillomavirus,[Footnote 23] the 
virus is "present for life" because, in almost all cases, this is not 
true. State officials who have identified inaccuracies told us that 
they informed their grantees of inaccuracies so that they could make 
corrections in their individual programs. One state official added that 
she contacted the authors of the materials to report an inaccuracy. 

Some of the educational materials that states have reviewed are 
materials that are commonly used in the Community-Based Program. 
Officials from four of the five states that review materials for 
scientific accuracy told us that they have each reviewed at least one 
of the five curricula most commonly used in the Community-Based Program 
because programs in their state were using them: Choosing the Best, 
WAIT Training, Sex Can Wait, A.C. Green's Game Plan Abstinence Program, 
and Worth the Wait. Based on ACF documents, we found that there were 58 
different curricula used by grantees of the Community-Based Program in 
fiscal year 2005. However, more than half of the grantees of the 
Community-Based Program reported using at least one of these five 
curricula.[Footnote 24] 

While there has been limited review of materials used in the State and 
Community-Based Programs, grantees of these programs have received some 
technical assistance designed to improve the scientific accuracy of 
their materials. For example, ACF officials reported that the agency 
provided a conference for grantees of the Community-Based Program in 
February 2006 that included a presentation focused on medical accuracy, 
including a discussion of state legislative proposals that would 
require medical accuracy in abstinence-until-marriage education, and 
how to identify reliable data. In addition, in 2002, HRSA awarded a 
contract to the National Abstinence Clearinghouse requiring, among 
other things, that the contractor develop and implement a program to 
provide medically accurate information and training to grantees of the 
State and Community-Based Programs.[Footnote 25] (See app. I for a 
description of HRSA's process for awarding this contract). The portion 
of the contract that focused on providing medically accurate 
information to grantees was subcontracted to the Medical Institute for 
Sexual Health (Medical Institute),[Footnote 26] which has conducted 
presentations at regional educational conferences to provide grantees 
with medical and scientific information, such as updated information on 
condoms and STD transmission. The Medical Institute has also provided 
consultative services to grantees by responding to medical and 
scientific questions. 

OPA Reviews Materials Used by AFL Program Grantees for Scientific 
Accuracy: 

In contrast to ACF, OPA reviews for scientific accuracy the educational 
materials used by AFL Program grantees. Specifically, OPA reviews its 
grantees' proposed educational materials for scientific accuracy before 
they are used. Agency officials stated that they began to review these 
materials while litigation concerning the AFL Program was ongoing. OPA 
continued to review these materials as part of a 1993 settlement to 
this lawsuit.[Footnote 27] The settlement agreement expired in 1998, 
though the agency has continued to review grantees' proposed 
educational materials for accuracy as a matter of policy. OPA officials 
told us that grant applicants submit summaries of materials they 
propose to use, though the materials are not reviewed for scientific 
accuracy until after grantees have been selected. OPA officials said 
that after grants are awarded, a medical education specialist (in 
consultation with several part-time medical experts) reviews the 
grantees' printed materials and other educational media, such as 
videos. OPA officials explained that the medical education specialist 
must approve all materials before they are used. On many occasions, OPA 
grantees have proposed using--and therefore OPA has reviewed--materials 
commonly used in the Community-Based Program. For example, an OPA 
official told us that the agency had reviewed three of the Community- 
Based Program's commonly used curricula--Choosing the Best, Sex Can 
Wait, and A.C. Green's Game Plan Abstinence Program--and is also 
currently reviewing another curriculum commonly used by Community-Based 
Program grantees, WAIT Training.[Footnote 28] 

OPA officials stated that the medical education specialist has 
occasionally found and addressed inaccuracies in grantees' proposed 
educational materials. OPA officials stated that these inaccuracies are 
often the result of information being out of date because, for example, 
medical and statistical information on STDs changes frequently. OPA has 
addressed these inaccuracies by either not approving the materials in 
which they appeared or correcting the materials through discussions 
with the grantees and, in some cases, the authors of the materials. In 
fiscal year 2005, OPA disapproved of a grantee using a specific 
pamphlet about STDs because the pamphlet contained statements about STD 
prevention and HIV transmission that were considered incomplete or 
inaccurate. For example, the pamphlet stated that there was no cure for 
hepatitis B, but the medical education specialist required the grantee 
to add that there was a preventive vaccine for hepatitis B. In 
addition, OPA required that a grantee correct several statements in a 
true/false quiz--including statements about STDs and condom use--in 
order for the quiz to be approved for use. For example, the medical 
education specialist changed a sentence from "The only 100% effective 
way of avoiding STDs or unwanted pregnancies is to not have sexual 
intercourse." to "The only 100% effective way of avoiding STDs or 
unwanted pregnancies is to not have sexual intercourse and engage in 
other risky behaviors." 

While OPA and some states have reviewed their grantees' abstinence- 
until-marriage education materials for scientific accuracy,[Footnote 
29] these types of reviews have the potential to affect abstinence- 
until-marriage education providers more broadly. Such efforts may 
create an incentive for authors of abstinence-until-marriage education 
materials to ensure they are accurate. Thus, some authors of abstinence-
until-marriage education materials have recently updated materials in 
their curricula following reports that questioned their accuracy. For 
example, one of the most widely used curricula used by grantees of the 
Community-Based Program--WAIT Training--has been recently updated and 
provides the updated information on its Web site. A representative from 
WAIT Training stated that the company recently revised its curriculum, 
in part, in response to a congressional review that found inaccuracies 
in its abstinence-until-marriage education materials. 

A Variety of Efforts Have Been Made to Assess the Effectiveness of 
Abstinence-until-Marriage Education Programs, but a Number of Factors 
Limit the Conclusions That Can Be Drawn: 

HHS, states, and researchers have made a variety of efforts to assess 
the effectiveness of abstinence-until-marriage education programs; 
however, a number of factors limit the conclusions that can be drawn 
about the effectiveness of these programs. ACF and OPA have required 
their grantees to report on various outcomes used to measure the 
effectiveness of grantees' abstinence-until-marriage education 
programs,[Footnote 30] though the reporting requirements for each of 
the three abstinence-until-marriage programs differ. In addition, to 
assess the effectiveness of the State and Community-Based Programs, ACF 
has analyzed national data on adolescent birth rates and the proportion 
of adolescents who report having had sexual intercourse. Other 
organizational units within HHS--ASPE, CDC, and NIH--are funding 
studies designed to assess the effectiveness of abstinence-until- 
marriage education programs in delaying sexual initiation, reducing 
pregnancy and STD rates, and reducing the frequency of sexual activity. 
Despite these efforts, several factors limit the conclusions that can 
be drawn about the effectiveness of abstinence-until-marriage education 
programs. Most of the efforts to evaluate the effectiveness of 
abstinence-until-marriage education programs that we describe in our 
review have not met certain minimum criteria that experts have 
concluded are necessary in order for assessments of program 
effectiveness to be scientifically valid, in part because such designs 
can be expensive and time-consuming to carry out. In addition, the 
results of some efforts that meet the criteria of a scientifically 
valid assessment have varied, and two key studies that meet these 
criteria have not yet been completed. 

HHS, States, and Researchers Have Made a Variety of Efforts to Assess 
the Effectiveness of Abstinence-until-Marriage Education Programs: 

Efforts of HHS, states, and researchers to assess the effectiveness of 
abstinence-until-marriage education programs have included ACF and OPA 
requiring grantees to report data on outcomes of their abstinence- 
until-marriage education programs; ACF analyzing national data on 
adolescent behavior and birth rates; and other HHS agencies, states, 
and researchers funding or conducting studies to assess the 
effectiveness of abstinence-until-marriage education programs. 

ACF and OPA Have Required Grantee Reporting of Data on Outcomes: 

ACF has made efforts to assess the effectiveness of abstinence-until- 
marriage education programs funded by the State Program and the 
Community-Based Program. One of ACF's efforts has been to require 
grantees of both programs to report data on outcomes, though the two 
programs have different requirements for the outcomes grantees must 
report. For the State Program, as of fiscal year 2006, grantees must 
report annually on four measures of the prevalence of adolescent sexual 
behavior in their states, such as the rate of pregnancy among 
adolescents aged 15 to 17 years, and compare these data to program 
targets over 5 years. To report on these four measures, states may 
choose the data sources they will use.[Footnote 31] States must also 
develop and report on two additional performance measures that are 
related to the goals of their programs.[Footnote 32] (See table 3 for a 
list of ACF's fiscal year 2006 reporting requirements for the State 
Program.) 

Table 3: ACF's Reporting Requirements for the State Program and the 
Community-Based Program, Fiscal Year 2006: 

State Program: 
* Report on four performance measures: (1) rate of pregnancy among 
female teenagers aged 15 to 17, (2) proportion of adolescents who have 
engaged in sexual intercourse, (3) incidence of youths 15 to 19 years 
old who have contracted selected STDs, and (4) rate of births among 
female teenagers aged 15 to 17; 
Community-Based Program: 
* Report on program goals that are developed by grantees with a third-
party evaluator. Such outcomes could include changes in knowledge about 
abstinence or declared behavior among participants of abstinence-until-
marriage programs. 

State Program: 
* Develop and report on two additional performance measures that are 
related to individual program goals. Past examples of these additional 
measures have included the percentage of high school students who 
reported using drugs or alcohol before intercourse and the percentage 
of high school students who had sexual intercourse for the first time 
before age 13; 
Community-Based Program: 
* Report on program "outputs" the number of youth served, the hours of 
service provided to each youth, and the number of youths who complete 
the program. Grantees choose additional outputs that allow for 
effective monitoring and management of the project. The additional 
outputs may include tracking the number of staff trained to provide 
services, the number of events hosted, number of marketing materials 
distributed, and so forth. 

Sources: State and Community-Based Programs' announcements, fiscal year 
2006. 

[End of table] 

As of fiscal year 2006, ACF requires Community-Based Program grantees 
to develop and report on outcome measures designed to demonstrate the 
extent to which grantees' community-based abstinence education programs 
are accomplishing their program goals.[Footnote 33] ACF requires 
grantees of the Community-Based Program to contract with third-party 
evaluators, who are responsible for both helping grantees develop the 
outcome measures and monitoring grantee performance against the 
measures,[Footnote 34] but because this is a new requirement 
established for fiscal year 2006 grantees, ACF has not yet received the 
results of these evaluations. In addition to outcome reporting, ACF 
requires grantees of the Community-Based Program to report on program 
"outputs," which measure the quantity of program activities and other 
deliverables, such as the number of participants who are served by the 
abstinence-until-marriage education programs. According to ACF 
officials, the agency requires grantees of both the State Program and 
the Community-Based Program to report on program outcomes in order to 
monitor grantees' performance, target training, and technical 
assistance, and help grantees improve service delivery. (See table 3 
for a list of ACF's fiscal year 2006 reporting requirements for the 
Community-Based Program.) 

ACF's fiscal year 2006 reporting requirements for grantees of the State 
Program are the same as HRSA's when it administered the State Program. 
In contrast, ACF's fiscal year 2006 reporting requirements for the 
Community-Based Program differ from HRSA's reporting requirements for 
the program. For example, for Community-Based Program grants awarded in 
fiscal year 2001, HRSA required[Footnote 35] grantees to report on the 
effectiveness of their programs, as measured by program participation 
as well as behavioral and biological outcomes.[Footnote 36] These 
performance measures were modified for fiscal year 2002, in part HHS 
officials explained, because of concerns expressed by members of the 
abstinence-education community that the original performance measures 
did not accurately reflect the efforts of the grantees of the Community-
Based Program. For grants awarded from fiscal years 2002 through 2004, 
HRSA required grantees of the Community-Based Program to report on a 
combination of program outputs, such as the proportion of adolescents 
who completed an abstinence-until-marriage education program, and 
measures of adolescent intentions, such as the proportion of 
adolescents who committed to abstaining from sexual activity until 
marriage.[Footnote 37] For grants awarded in fiscal year 2005, when ACF 
assumed responsibility for the Community-Based Program from HRSA, 
grantees were not required to report on any specific performance 
measures. 

OPA has also made efforts to assess the effectiveness of the AFL 
Program. Specifically, OPA requires grantees of the AFL Program to 
develop and report on outcome measures that are used to help 
demonstrate the extent to which grantees' programs are having an effect 
on program participants.[Footnote 38],[Footnote 39] According to OPA 
officials, the agency recommends that grantees report on outcome 
measures, such as participants' knowledge of the benefits of abstinence 
and their reported intentions to abstain from sexually activity, 
reported beliefs in their ability to remain abstinent, and reported 
parental involvement in their lives. To collect data on these outcome 
measures and any others, OPA requires all grantees funded in fiscal 
year 2004 and beyond to administer, at a minimum, a standardized 
questionnaire--developed by OPA--to their program participants, both 
when participants begin an abstinence-only education program and after 
the program's completion.[Footnote 40] The standardized questionnaire 
includes questions intended to obtain information on participants' 
reported involvement in extracurricular activities, behaviors linked to 
health risks, attitudes and intentions about abstinence, and opinions 
about the consequences of premarital sexual activity. Like ACF, OPA 
requires its grantees to contract with independent evaluators, such as 
colleges or universities, which are responsible for evaluating the 
effectiveness of grantees' individual abstinence-until-marriage 
education programs.[Footnote 41] In addition to evaluating the extent 
to which grantees are meeting their goals, OPA officials stated that 
the independent evaluators may also provide input to grantees of the 
AFL Program on other aspects of the program to improve their service 
delivery. Unlike ACF, OPA requires that the third-party evaluations 
incorporate specific methodological characteristics, such as control 
groups or comparison groups[Footnote 42] and sufficient sample 
sizes.[Footnote 43] In addition, OPA requires that the evaluations for 
grantees funded in fiscal year 2004 and beyond account for baseline and 
follow-up data obtained from the standardized questionnaires. 

OPA's requirement that grantees use a standardized set of 
questionnaires, with data from these questionnaires used in 
evaluations, differs from OPA's previous requirements. Previously, 
grantees of the AFL Program were not required to use a standardized 
method for collecting data that could be used to assess the 
effectiveness of their programs; instead, grantees chose their own data 
collection instruments. As a result, an OPA official explained, the 
collected data varied from one project to another. OPA officials said 
that the agency developed the standardized questionnaire to ensure 
uniformity in the data collected and allow the agency to more 
effectively aggregate the data reported in evaluations of individual 
abstinence-until-marriage education programs. 

OPA officials told us that they plan to aggregate information from 
certain questions in the standardized set of questionnaires in order to 
report on certain performance measures as part of the agency's annual 
performance reports.[Footnote 44] The measures include the extent of 
parental involvement in adolescents' lives and the extent to which 
adolescents understand the benefits of abstinence. An agency official 
stated that the agency expects to begin receiving data from grantees 
that are using these questionnaires in January 2007. OPA did not 
previously have long-term measures of the performance of the AFL 
Program. Its current measures were developed in collaboration with the 
Office of Management and Budget (OMB) in response to an OMB review in 
2004 that found that the AFL Program did not have any annual 
performance measures for measuring progress toward long-term goals. 

In addition to requiring their grantees to report on outcomes used to 
assess program effectiveness, both ACF and OPA have provided technical 
assistance and training to their grantees in order to support grantees' 
own program evaluation efforts. For example, in November 2005 the two 
agencies sponsored an evaluation conference for abstinence-until- 
marriage grantees that included presentations about evaluations and 
their methodology. Similarly, ACF's Office of Planning, Research, and 
Evaluation sponsors annual evaluation conferences, and an ACF official 
told us that a recent conference placed "a significant emphasis" on the 
evaluation of abstinence-until-marriage education programs. In 
addition, HHS officials told us that ACF, along with ASPE, is funding a 
multiyear project that is designed to identify gaps in abstinence 
education evaluation and technical assistance needs, develop materials 
on abstinence education evaluation, deliver technical assistance and 
capacity-building activities related to program evaluation, and develop 
research reports related to abstinence education. OPA officials also 
told us that they attempt to help ensure grantees' progress and 
effectiveness by offering various technical assistance workshops and 
conferences. For example, in May 2006 OPA provided a 2-day training 
conference to its grantees on the importance of program evaluations and 
administering evaluation instruments. In addition, OPA officials stated 
that the agency contracts with evaluation consultants, who review 
grantees' evaluation tools and activities. OPA officials explained that 
these consultants provide in-depth technical assistance to grantees on 
how to improve grantees' evaluations. 

ACF Uses National Data on Adolescent Behavior as a Measure of the 
Overall Effectiveness of Its Two Programs: 

Requiring outcome reporting from state and community-based grantees is 
not ACF's only effort to assess the effectiveness of its two programs. 
ACF also analyzes trends in adolescent behavior, as reflected in 
national data on birth rates among teens and the proportion of surveyed 
high school students reporting that they have had sexual 
intercourse.[Footnote 45] ACF uses these national data as a measure of 
the overall effectiveness of its State and Community-Based Programs, 
comparing the national data to program targets. In its annual 
performance reports, the agency summarizes the progress being made 
toward lowering the rate of births to unmarried teenage girls and the 
proportion of students (grades 9-12) who report having ever had sexual 
intercourse. 

ACF's use of national data to assess the effectiveness of the State and 
Community-Based Programs represents a change from how HRSA assessed the 
overall effectiveness of these programs. Whereas ACF compares national 
data on adolescent behavior to program targets, HRSA aggregated data 
from its state and community-based grantees. HRSA's state grantees were 
allowed to select the data sources used to gauge their progress against 
certain performance measures. For example, in its annual performance 
reports on the State Program, HRSA reported information on the 
percentage of its state grantees meeting target rates for reducing the 
proportion of adolescents who have engaged in sexual intercourse, the 
incidence of youths aged 15 to 19 who have contracted selected STDs, 
and the rate of births among youths aged 15 to 17. To determine their 
progress in meeting their target rates, some state grantees, for 
example, reported national data from the Youth Risk Behavior 
Surveillance System, while other grantees reported state-collected 
data. After ACF assumed responsibility for the State and Community- 
Based Programs from HRSA, ACF began using national data on adolescent 
behavior as a measure of the programs' effectiveness. According to ACF 
officials, the agency changed how it assessed its programs out of 
concern over the quality of the data state grantees were using in their 
performance reporting and because the agency wanted to use parallel 
measures of effectiveness for both programs. For example, according to 
state performance reports for fiscal year 2001 that we reviewed, two 
reports did not include adolescent pregnancy rates that year because 
the states did not collect data on abortions among this 
population.[Footnote 46] In addition, ACF officials told us that they 
decided not to use national data on STDs as a measure of program 
effectiveness because the goal of reducing STD rates is not as central 
to the State and Community-Based Programs as reducing sexual activity 
and birth rates among teens. However, one official stated that reducing 
STDs is an important "by-product" of the programs. 

Some States Have Made Additional Efforts to Assess the Effectiveness of 
Abstinence-until-Marriage Education Programs: 

Some states have made additional efforts to assess the effectiveness of 
abstinence-until-marriage education programs, although they are not 
required by ACF.[Footnote 47] Specifically, we found that 6 of the 10 
states in our review that receive funding through ACF's State Program 
have made efforts to conduct evaluations of selected abstinence-until- 
marriage programs in their state. All 6 of the states worked with third-
party evaluators, such as university researchers or private research 
firms, to perform the evaluations, which in general measure self-
reported changes in program participants' behavior and attitudes 
related to sex and abstinence as indicators of program effectiveness. 
To obtain this information, the third-party evaluators have typically 
relied on surveys administered to program participants at the start of 
a program, its conclusion, and during a follow-up period anywhere from 
3 months to almost 3 years after the conclusion. The third-party 
evaluations for 4 of the 6 states in our review have been completed as 
of February 2006, and the results of these studies have 
varied.[Footnote 48] 

Among the 4 states that have completed third-party evaluations, 3 
states require the abstinence programs in their state to measure 
reported changes in participants' behavior as an indicator of program 
effectiveness--both at the start of the program and after its 
completion. The 3 states require their programs to track participants' 
reported incidence of sexual intercourse. In addition, 2 states require 
their programs to track biological outcomes, such as pregnancies, 
births, or STDs. In addition, 6 of the 10 states in our review require 
their programs to track participants' attitudes about abstinence and 
sex, such as the number of participants who make pledges to remain 
abstinent. 

Some states also provide technical assistance to the abstinence-until- 
marriage programs they support in their state. This assistance is 
designed to help programs evaluate and improve their effectiveness. 
Officials from 5 of the 10 states in our review either told us or 
provided documentation that they provide technical assistance on 
evaluations to abstinence programs in their state. One state official 
said that the abstinence-until-marriage programs supported by the state 
were found to be ill-prepared to conduct evaluations themselves, and 
that she now requires these programs to dedicate a portion of their 
grants to contract with a third-party or state evaluator to assist them 
in program-level evaluations. Officials from another state told us that 
they contract with a private organization of public health 
professionals in order to provide evaluation consultation and technical 
assistance for the abstinence-until-marriage programs the state 
supports. 

ASPE, CDC, and NIH Are Funding Studies Designed to Assess the 
Effectiveness of Abstinence-until-Marriage Education Programs: 

In addition to ACF and OPA, other organizational units within HHS have 
made efforts to assess the effectiveness of abstinence-until-marriage 
education programs. ASPE is currently sponsoring a study of the 
Community-Based Program and a study of the State Program.[Footnote 49] 
For the former program, ASPE has contracted with Abt Associates to help 
design the study, and an ASPE official told us that once the agency 
selects an appropriate design, it will competitively award a contract 
to conduct the study.[Footnote 50] For the latter program, ASPE has 
contracted with Mathematica Policy Research, Inc. (Mathematica), which 
is in the process of examining the impact of five programs funded 
through the State Program on participants' attitudes and behaviors 
related to abstinence and sex.[Footnote 51] As of August 2006, 
Mathematica has published two reports on findings from its study--an 
interim report documenting the experiences of schools and communities 
that receive abstinence-until-marriage education funding, and a report 
on the first-year impacts of selected state abstinence-until-marriage 
education programs.[Footnote 52],[Footnote 53] Mathematica's final 
report, which has not been completed, will examine the impact of the 
State Program on behavioral outcomes, including abstinence, sexual 
activity, risk of STDs, risk of pregnancy, and drug and alcohol 
use.[Footnote 54] An ASPE official told us that the agency expects a 
final report to be published in 2007. 

Like ASPE, CDC has made its own effort to assess the effectiveness of 
abstinence-until-marriage education. CDC is sponsoring a study to 
evaluate the effectiveness of two middle school curricula--one that 
complies with abstinence education program requirements and one that 
teaches a combination of abstinence and contraceptive information and 
skills.[Footnote 55] In CDC's study, five middle schools chosen at 
random will receive a program consisting of abstinence-until-marriage 
education exclusively; five schools will receive comprehensive sex 
education, which also includes information on contraception; and five 
schools will be assigned to a control group. The study will examine the 
relative effectiveness of the programs on behavioral outcomes such as 
reported sexual risk behaviors and changes in attitudes related to 
abstinence and sex. CDC plans to recruit approximately 1,500 seventh 
grade students into its study and will follow them over a 2-year 
period. The agency expects to complete the study in 2009. 

NIH has funded studies comparing the effectiveness of education 
programs that focus only on abstinence with the effectiveness of sex 
education programs that teach both abstinence and information about 
contraception. As of August 2006, NIH is funding five studies, which in 
general are comparing the effects of these two types of programs on the 
sexual behavior and related attitudes among groups of either middle 
school or high school students. For example, in one NIH study, 
researchers are using groups of seventh and eighth grade adolescents to 
assess the impact of a variety of programs on, among other issues, 
adolescents' reported sexual activities, knowledge, and beliefs. For 
this study, researchers are comparing these outcomes among students who 
received abstinence-until-marriage education; students who received a 
combination of abstinence and contraceptive education; and students who 
participated in a general health class, who serve as a comparison 
group. NIH expects both this study and its other four studies to be 
competed in 2006. 

Other Researchers Have Also Made Efforts to Assess the Effectiveness of 
Abstinence-until-Marriage Education Programs: 

In addition to the efforts of researchers working on behalf of HHS and 
states, other researchers--such as those affiliated with universities 
and various advocacy groups--have made efforts to study the 
effectiveness of abstinence-until-marriage education programs. This 
work includes studies of the outcomes of individual programs and 
reviews of other studies on the effectiveness of individual abstinence- 
until-marriage education programs. In general, research studies on the 
effectiveness of individual abstinence-until-marriage education 
programs have examined the extent to which they changed participants' 
demonstrated knowledge, declared intentions, and reported behavior 
related to sexual activity and abstinence. For example, some studies 
examined the impact of abstinence-until-marriage education programs on 
participants' knowledge of concepts taught in the programs, as well as 
participants' declared attitudes about abstinence and teen sex. Some 
studies examined the impact of these programs on such outcomes as 
participants' declared commitment to abstain from sex until marriage, 
participants' understanding of the potential consequences of having 
intercourse, and participants' reported ability to resist pressures to 
engage in sexual activity. Some of the studies we reviewed examined the 
impact of abstinence-until-marriage programs on participants' sexual 
behavior, as measured, for example, by the proportion of participants 
who reported having had sexual intercourse and the frequency of sexual 
intercourse reported by participants. In general, the efforts to study 
and build a body of research on the effectiveness of most abstinence 
education programs have been under way for only a few years, in part 
because grants under the two programs that account for the largest 
portion of federal spending on abstinence education--the State Program 
and the Community-Based Program--were not awarded until 1998 and 2001, 
respectively. 

Several Factors Limit the Conclusions That Can Be Drawn about the 
Effectiveness of Abstinence-until-Marriage Education Programs: 

Most of the efforts of HHS, states, and other researchers to evaluate 
the effectiveness of abstinence-until-marriage education programs 
included in our review have not met certain minimum criteria that 
experts have concluded are necessary in order for assessments of 
program effectiveness to be scientifically valid. For example, most of 
the efforts included in our review did not include experimental or 
quasi-experimental designs, nor did they measure behavioral or 
biological outcomes. In addition, the results of some assessment 
efforts that meet the criteria of a scientifically valid assessment 
have varied, and two key studies that meet these criteria have not yet 
been completed. 

Experts Have Developed Criteria to Evaluate Efforts to Assess 
Abstinence-until-Marriage Education Programs: 

In an effort to better assess the merits of the studies that have been 
conducted on the effectiveness of sexual health programs--including 
abstinence-until-marriage education programs--scientific experts have 
developed criteria that can be used to gauge the scientific rigor of 
these evaluations. For example, in 2001, the National Campaign to 
Prevent Teen Pregnancy--an organization focused on reducing teen 
pregnancy--published a report by a panel of scientific experts that 
assessed the evidence reported on abstinence-until-marriage education 
programs in peer-reviewed journals and other literature.[Footnote 56] 
The panel developed criteria that an evaluation of a program's 
effectiveness must meet in order for the program's results to be 
considered scientifically valid. In addition, in 2004, former U.S. 
Surgeon General David Satcher convened a panel of experts to discuss, 
among other things, best practices for evaluating the effectiveness of 
sexual health education programs--including abstinence-until-marriage 
education programs.[Footnote 57] This panel published a report in 2006 
that describes similar scientific criteria that assessments of program 
effectiveness need to meet in order for their results to be 
scientifically valid. Further, experts we interviewed agreed that these 
criteria are important for ensuring that the results of a study support 
valid conclusions. In general, these panels, as well as the experts we 
interviewed, agreed that scientifically valid studies of a program's 
effectiveness should include the following characteristics: 

* An experimental design that randomly assigns individuals or schools 
to either an intervention group or control group, or a quasi- 
experimental design that uses nonrandomly assigned but well-matched 
comparison groups. According to the panel of scientific experts 
convened by the National Campaign to Prevent Teen Pregnancy, 
experimental designs or quasi-experimental designs with well-matched 
comparison groups have at least three important strengths that are 
typically not found in other studies, such as those that use aggregated 
data: they evaluate specific programs with known characteristics, they 
can clearly distinguish between participants who did and did not 
receive an intervention, and they control for other factors that may 
affect study outcomes. Therefore, experimental and quasi-experimental 
study designs have a greater ability to assess the causal impact of 
specific programs than other types of studies.[Footnote 58] According 
to scientific experts, studies that include experimental or quasi- 
experimental designs should also collect follow-up data for a minimum 
number of months after subjects receive an intervention.[Footnote 59] 
Experts reported that follow-up periods are important in order to 
identify the effects of a program that are not immediately apparent or 
to determine whether these effects diminish over time. In addition, 
experts have reported that studies should have a sample size of at 
least 100 individuals for study results to be considered scientifically 
valid.[Footnote 60] 

* Studies should assess or measure changes in biological outcomes or 
reported behaviors instead of attitudes or intentions. According to 
scientific experts, biological outcomes--such as pregnancy rates, birth 
rates, and STD rates--and reported behaviors--such as reported 
initiation and frequency of sexual activity--are better measures of the 
effectiveness of abstinence-until-marriage programs, because adolescent 
attitudes and intentions may or may not be indicative of actual 
behavior. For example, adolescents may report that they intend to 
abstain from sexual intercourse but may not actually do so. 

Most Efforts to Assess the Effectiveness of Abstinence-until-Marriage 
Education Programs Have Not Used an Experimental or Quasi-Experimental 
Design: 

Many of the efforts by HHS, states, and other researchers that we 
identified in our review lack at least one of the characteristics of a 
scientifically valid study of program effectiveness. That is, most of 
the efforts to assess the effectiveness of these programs have not used 
experimental or quasi-experimental designs with sufficient follow-up 
periods and sample sizes to make their conclusions scientifically 
valid. For example, ACF--and before it, HRSA--used, according to ACF 
officials, grantee reporting on outcomes in order to monitor grantees' 
performance, target training and technical assistance, and help 
grantees improve service delivery. However, because the outcomes 
reported by grantees have not been produced through experimentally or 
quasi-experimentally designed studies, such information cannot be 
causally attributed to any particular abstinence-until-marriage 
education program. While ACF requires its fiscal year 2006 grantees of 
the Community-Based Program to contract with third-party evaluators to 
select and monitor outcomes for their programs, ACF is not specifically 
requiring these grantees to use experimental or quasi-experimental 
designs. Therefore, it is not clear whether these evaluations will 
include such designs. Similarly, ACF's use of national data on 
adolescent behavior and birth rates to assess its State and Community- 
Based Programs is of limited value because these data do not 
distinguish between those who participated in abstinence-until- 
marriage education programs and those who did not. Consequently, these 
national data sets, which represent state-reported vital statistics and 
a nationwide survey of high school students, cannot be used to causally 
link declines in birth rates and adolescent sexual activity to the 
effects of specific abstinence-until-marriage education 
programs.[Footnote 61] 

Similarly, the efforts we identified by states and researchers to 
assess the effectiveness of abstinence-until-marriage education 
programs often did not include experimental or quasi-experimental 
designs. None of the state evaluations we reviewed that have been 
completed included randomly assigned control groups. For instance, one 
state evaluation that we reviewed only included students who 
volunteered to participate in the study. This evaluation report stated 
that the absence of a randomly assigned control group in the evaluation 
did not allow the evaluators to determine whether observed changes in 
participants' reported sexual behavior--as indicated through surveys 
administered at the beginning and end of a program--could be attributed 
to the abstinence-until-marriage education program.[Footnote 62] 
Similarly, some of the journal articles that we reviewed described 
studies to assess the effectiveness of abstinence-until-marriage 
programs that did not include experimental or quasi-experimental 
designs needed to support scientifically valid conclusions about the 
programs' effectiveness. In these studies, researchers administered 
questionnaires to study participants before and after they completed an 
abstinence-until-marriage education program and assessed the extent to 
which the responses of participants changed.[Footnote 63] These studies 
did not compare the responses of study participants with a group that 
did not participate in an abstinence-until-marriage education program. 
In addition, some of the studies used insufficient follow-up periods, 
thereby limiting the conclusions that can be drawn about the 
effectiveness of the abstinence-until-marriage education programs being 
studied. For example, two journal articles that we reviewed described 
studies that measured the effectiveness of abstinence-until- marriage 
programs in delaying the initiation of sexual activity from 1 to 2 
months after completion of the program.[Footnote 64] Scientific experts 
consider this follow-up period too short to assess whether the programs 
had a valid effect. 

According to scientific experts, HHS, states, and other researchers 
face a number of challenges in designing experimental or quasi- 
experimental studies of program effectiveness. According to these 
experts, experimental or quasi-experimental studies can be expensive 
and time-consuming to carry out, and many grantees of abstinence-until- 
marriage education programs have insufficient time and funding to 
support these types of studies. Moreover, it can be difficult for 
researchers assessing abstinence-until-marriage education programs to 
convince school districts to participate in randomized intervention and 
control groups, in part because of sensitivities to surveying 
attitudes, intentions, and behaviors related to abstinence and sex. For 
example, in a third-party evaluation of its program, one grantee of the 
State Program originally planned to administer follow-up surveys 1 year 
after participants finished their abstinence education program, but the 
evaluators decided not to conduct this follow-up because of 
confidentiality concerns and the difficulty of locating students. In 
addition, the contractors hired to design ASPE's study of the 
effectiveness of the Community-Based Program have reported difficulties 
finding school districts that are willing to participate in randomly 
assigned intervention and control groups receiving either abstinence- 
until-marriage education or comprehensive sex education. An ASPE 
official told us that although a "randomized approach" is the best 
design for assessing the effectiveness of a program, the approach is 
also the most difficult to conduct. 

Most Efforts to Assess the Effectiveness of Abstinence-until-Marriage 
Education Programs Have Not Measured Behavioral or Biological Outcomes: 

Another factor that limits the conclusions that can be drawn about the 
effectiveness of abstinence-until-marriage education programs is the 
fact that most efforts in our review to study the effectiveness of 
these programs did not measure changes in behavioral or biological 
outcomes among participants. Instead, most of the efforts we identify 
in our review used reported intentions and attitudes in order to assess 
the effectiveness of abstinence-until-marriage programs. For example, 
neither ACF's community-based grantees nor OPA's AFL grantees are 
required to report on behavioral or biological outcomes, such as rates 
of intercourse or pregnancy. Similarly, the journal articles we 
reviewed were more likely to use reported attitudes and intentions-- 
such as study participants' reported attitudes about premarital sexual 
activity or their reported intentions to remain abstinent until 
marriage--rather than their reported behaviors or biological outcomes 
to assess the effectiveness of abstinence-until-marriage programs. For 
example, in one journal article we reviewed, participants were asked to 
rate the likelihood that they would have sexual intercourse as 
unmarried teenagers; another journal article described a study in which 
participants rated the likelihood that they would have sexual 
intercourse in the next year, before finishing high school, and before 
marriage.[Footnote 65] 

Experts, as well as state and HHS officials, have reported that it can 
be difficult to obtain scientifically valid information on biological 
outcomes and sexual behaviors. Specifically, experts have reported that 
when measuring an abstinence-until-marriage education program's affect 
on biological outcomes--such as reducing pregnancy or birth rates--it 
is necessary to have large sample sizes in order to determine whether a 
small change in biological outcomes is the result of the abstinence- 
until-marriage education program. In addition, state and federal 
officials told us that they have experienced difficulties obtaining 
information on sexual behaviors because of the sensitive nature of the 
information they were trying to collect. For example, one state 
official told us that her state's effort to evaluate abstinence-until- 
marriage education programs was only able to measure changes in 
participants' reported attitudes, instead of behaviors, because the 
evaluators needed to obtain consent from the parents of the program 
participants in order to ask them about their sexual behavior. The 
state official explained that the requirement to obtain consent from 
parents raised issues of self-selection, and therefore state officials 
decided to ultimately halt the study and only report on the attitudes 
that they had measured. In another example, ACF's fiscal year 2006 
budget justification reports that ACF has had some difficulty in 
obtaining reliable data from state grantees, in part because questions 
about teenage sexual behavior are sensitive. OPA officials also 
acknowledged that many communities will not allow grantees to ask 
program participants questions about their sexual behavior because the 
communities believe such questions are too intrusive. One OPA official 
said that such restrictions affect the agency's ability to measure 
behavioral outcomes, explaining that OPA cannot measure what it cannot 
ask about. 

Results of Some Scientifically Valid Assessment Efforts Have Varied, 
and Other Key Studies Have Not Been Completed: 

Among the assessment efforts we identified are some studies that meet 
the criteria of a scientifically valid effectiveness study. However, 
results of these studies have varied, and this limits the conclusions 
that can be drawn about the effectiveness of abstinence-until-marriage 
education programs. Some researchers have reported that abstinence- 
until-marriage education programs have resulted in adolescents 
reporting having less frequent sexual intercourse or fewer sexual 
partners.[Footnote 66] For example, in one study of middle school 
students, participants in an abstinence-until-marriage education 
program who had sexual intercourse during the follow-up period were 50 
percent less likely to report having two or more sexual partners when 
compared with their nonparticipant peers.[Footnote 67] In contrast, 
other studies have reported that abstinence-until-marriage education 
programs did not affect the reported frequency of sexual intercourse or 
number of sexual partners.[Footnote 68] For example, one study of 
middle school students found that participants of an abstinence-until- 
marriage program were not less likely than nonparticipants at the 1 
year follow-up to report less frequent sexual intercourse or fewer 
sexual partners.[Footnote 69] In addition to these varied findings, one 
study found that an abstinence-until-marriage program was effective in 
delaying the initiation of sexual intercourse in the short term but not 
long term.[Footnote 70] Experts with whom we spoke emphasized that 
there are still too few scientifically valid studies completed to date 
that can be used to determine conclusively which, if any, abstinence- 
until-marriage programs are effective. 

Additionally, among the assessment efforts we identified are some 
studies that experts anticipate will meet the criteria of a 
scientifically valid effectiveness study but are not yet completed. One 
of these key studies is the final Mathematica report, contracted by 
ASPE, on the State Program.[Footnote 71] The final report was 
originally slated for publication in 2005, but an ASPE official stated 
that the final report has been delayed until 2007 so that researchers 
can extend the follow-up period to improve their response rate and the 
reliability of the information they collect. Another key study is CDC's 
research on middle school programs, which is not expected to be 
completed until 2009. 

Experts and federal officials we interviewed stated that they expect 
the results of these two federally funded studies to add substantively 
to the body of research on the effectiveness of abstinence-until- 
marriage education programs. One expert with whom we spoke said that 
she expects the final Mathematica report on participants' behaviors to 
provide the groundwork for the field. Another expert we interviewed 
stated that the CDC study was very well-designed and she expects the 
results to contribute to the development of effective abstinence-until- 
marriage education curricula. 

Conclusions: 

There have been various efforts--by HHS, states, and others--to assess 
the scientific accuracy of educational materials used in abstinence- 
until-marriage education programs and the effectiveness of these 
programs. However, efforts to evaluate both the accuracy and 
effectiveness of abstinence-until-marriage education programs have 
been, in various ways, limited. ACF, which administers the two programs 
that account for the largest portion of federal spending on abstinence- 
until-marriage education, does not review or require its grantees to 
review program materials for scientific accuracy. In addition, not all 
grantees of the State Program have chosen to review their materials. 
Because of these limitations, ACF cannot be assured that the materials 
used in its State and Community-Based Programs are accurate. Moreover, 
OPA, which reviews all grantees' proposed abstinence-until-marriage 
educational materials, and states that review educational materials 
have found inaccuracies in some educational materials used by 
abstinence-until-marriage programs. 

Similarly, most of the efforts described in our review to assess the 
effectiveness of abstinence-until-marriage programs have not met 
minimum scientific criteria needed to draw valid conclusions about 
their effectiveness. Specifically, most efforts by agencies, states, 
and other researchers have not included experimental or quasi- 
experimental designs that can establish whether changes in behaviors or 
biological outcomes can be causally linked to specific abstinence- 
until-marriage education programs. While these types of studies are 
time-consuming and expensive, experts said that they are the only 
definitive way to draw valid conclusions about the effectiveness of 
these programs. In addition, among the assessment efforts we identified 
are some studies funded by HHS that experts anticipate will meet the 
criteria of a scientifically valid effectiveness study but are not yet 
completed. When completed, these HHS-funded studies may add 
substantively to the body of research on the effectiveness of 
abstinence-until-marriage education programs. 

Recommendation for Executive Action: 

To address concerns about the scientific accuracy of materials used in 
abstinence-until-marriage education programs, we recommend that the 
Secretary of HHS develop procedures to help assure the accuracy of such 
materials used in the State and Community-Based Programs. To help 
provide such assurances, the Secretary could consider alternatives such 
as (1) extending the approach currently used by OPA to review the 
scientific accuracy of the factual statements included in abstinence- 
until-marriage education to materials used by grantees of ACF's 
Community-Based Program and requiring grantees of ACF's State Program 
to conduct such reviews or (2) requiring grantees of both programs to 
sign written assurances in their grant applications that the materials 
they propose using are accurate. 

Agency Comments and Our Evaluation: 

HHS provided written comments on a draft of this report. (See app. 
III.) 

In its written comments, HHS stated that it will consider requiring 
grantees of both ACF programs to sign written assurances in grant 
applications that the materials they use are accurate. Regarding 
accuracy, HHS's written comments also noted that all applicants for 
federal assistance attest on the application form--Standard Form 424-- 
that all data in their applications are "true and correct," and that in 
the view of HHS, this applies to information presented in curricula 
funded by federal grants. However, as we stated in the draft report, 
grantees of the State Program are not required to submit curricula as a 
part of their applications; therefore, the attestation in Standard Form 
424 would not apply to curricula used by those grantees. In addition, 
as stated in the draft report, some states have reviewed materials used 
in abstinence-until-marriage education programs, but these reviews 
occurred after they received funding from ACF. Further, while grantees 
of the Community-Based Program were required to submit copies of their 
curricula and a Standard Form 424 in fiscal year 2006 as part of their 
applications, none of the materials specifically require an assurance 
of scientific accuracy. Further, OPA and states have found inaccuracies 
in educational materials used by abstinence-until-marriage programs. 

HHS's written comments also stated that ACF requires that curricula 
conform to HHS's standards grounded in scientific literature. HHS's 
comments refer to the curriculum standards for this program that detail 
what types of information must be included in abstinence-until-marriage 
curricula, and the comments stated that the curricula must provide 
supporting references for this information. Further, HHS's comments 
stated that ACF staff review the curricula to ensure compliance with 
these standards. The draft report stated this. However, a requirement 
that curricula include certain types of information does not 
necessarily ensure the accuracy of the scientific facts included in the 
abstinence-until-marriage materials. For example, while education 
materials may include information on failure rates associated with 
contraceptives or STD infections, this information may be outdated or 
otherwise inaccurate or incomplete. HHS's written comments also stated 
that if it finds inaccurate statements during the review process or at 
any time during the grant period, ACF works with grantees to take 
corrective action. To ensure completeness, we have added this statement 
to the report. Further, HHS stated that 2 inaccuracies cited in the 
draft report had been corrected before our work began. We believe HHS 
is referring to inaccuracies identified by OPA during its review of 
materials for scientific accuracy and this reinforces the need for 
review of materials used by ACF's grantees. 

As HHS noted in its written comments, we did not define the term 
scientific accuracy. HHS stated that it disagreed with certain findings 
of the report because it was difficult to precisely determine the 
criteria we employed in making the recommendation as to scientific 
accuracy. As we stated in the scope and methodology section of the 
draft report, the objective of our work was to focus on efforts by HHS 
and states to review the accuracy of scientific facts included in 
abstinence-until-marriage education materials. Performing an 
independent assessment of the criteria used by these entities to 
determine the scientific accuracy of education materials or the quality 
of the reviews was beyond the scope of the work. 

Regarding effectiveness, HHS's written comments also described a number 
of actions it is taking to determine program effectiveness and improve 
the quality of programs and research. Specifically, HHS's comments 
described (1) studies undertaken or funded by ASPE, CDC, and NIH; (2) 
technical assistance provided by OPA and ACF; (3) grantee evaluation 
requirements; and (4) ACF and OPA requirements for the amount of grant 
funds to be spent on evaluations. All of this information was included 
in our draft report. HHS's comments also described a new effort funded 
by ACF and ASPE that is designed to build capacity for quality research 
in the field of abstinence education. We added information on this 
effort to the report. HHS's written comments also describe evaluations 
that resulted from an Abstinence Education Evaluation Conference 
sponsored by ACF and OPA. While this conference was described in the 
draft report, we added more detail regarding the content of the 
conference. HHS's written comments also describe OPA's efforts to 
assess the effectiveness of the AFL Program. We had included this 
information in the draft report. 

HHS's written comments stated that it may be too soon to draw 
conclusions about the effectiveness of ACF's and OPA's programs, in 
part, because key studies have not been completed. We agree and 
discussed this in the draft report. As we noted in the draft report, 
key studies funded by HHS that experts anticipate will meet the 
criteria of a scientifically valid effectiveness study are not yet 
completed, but when completed these HHS funded studies may add 
substantively to the body of research on the effectiveness of 
abstinence-until-marriage education programs. 

In addition, the comments stated that having an inadequate amount of 
scientifically valid and conclusive evaluation studies is not unique to 
abstinence-until-marriage education programs, and a recent ASPE review 
of comprehensive sex education programs found mixed results on their 
effectiveness. However, the scope of our report was focused on 
abstinence-until-marriage education programs, and we did not review 
comprehensive sex education programs or make any comparisons between 
the two types of programs. 

HHS also provided technical comments, which we incorporated into the 
report as appropriate. 

As agreed with your office, unless you publicly announce its contents 
earlier, we plan no further distribution of this report until 30 days 
after its date. We will then send copies of this report to the 
Secretary of HHS and to other interested parties. In addition, this 
report is available at no charge on GAO's Web site at [Hyperlink, 
http://www.gao.gov]. We will also make copies available to others upon 
request. 

If you or your staff have any questions about this report, please call 
me at (202) 512-3407 or crossem@gao.gov. Contact points for our Offices 
of Congressional Relations and Public Affairs may be found on the last 
page of this report. GAO staff who made major contributions to this 
report are listed in appendix IV. 

Signed by: 

Marcia Crosse: 
Director, Health Care: 

List of Requesters: 

The Honorable Henry A. Waxman: 
Ranking Minority Member: 
Committee on Government Reform: 
House of Representatives: 

The Honorable Pete Stark: 
Ranking Minority Member: 
Subcommittee on Health: 
Committee on Ways and Means: 
House of Representatives: 

The Honorable Sherrod Brown: 
Ranking Minority Member: 
Subcommittee on Health: 
Committee on Energy and Commerce: 
House of Representatives: 

The Honorable Barbara Boxer: 
The Honorable Maria Cantwell: 
The Honorable Richard J. Durbin: 
The Honorable Russell D. Feingold: 
The Honorable Dianne Feinstein: 
The Honorable Tom Harkin: 
The Honorable James M. Jeffords: 
The Honorable Edward M. Kennedy: 
The Honorable Frank R. Lautenberg: 
The Honorable Patrick Leahy: 
The Honorable Patty Murray: 
United States Senate: 

The Honorable Howard L. Berman: 
The Honorable Lois Capps: 
The Honorable Jay Inslee: 
The Honorable Barbara Lee: 
The Honorable Nita M. Lowey: 
The Honorable Betty McCollum: 
House of Representatives: 

[End of section] 

Appendix I: HRSA's Technical Assistance Contract for Abstinence 
Education: 

The Health Resources and Services Administration (HRSA) awarded a 
contract to the National Abstinence Clearinghouse (NAC) in 2002 to 
provide assistance with its Community-Based Abstinence Education 
Program (Community-Based Program) and Abstinence Education Program 
(State Program).[Footnote 72] NAC is a nonprofit educational 
organization whose mission is to promote the appreciation for and 
practice of sexual abstinence until marriage through the distribution 
of age appropriate, factual, and medically referenced materials. The 
purpose of the contract was (1) to develop national criteria for the 
review of abstinence-until-marriage educational materials and to create 
a directory of approved materials; (2) to provide medical accuracy 
training to grantees; and (3) to provide technical support to grantees, 
such as assistance with program evaluation.[Footnote 73] 

We are reporting on the steps that HRSA took to award the contract to 
NAC in response to concerns that have been raised by a congressional 
requester. In general, these concerns centered on the extent to which 
the selection process was competitive and whether HRSA identified the 
potential for an organizational conflict of interest. 

HRSA awarded the contract to address three concerns it had with the 
Community-Based Program during 2001, the first year of its 
implementation. First, HRSA officials needed guidance to determine 
whether abstinence-until-marriage education materials conformed to the 
definitional requirements of the Social Security Act.[Footnote 74] 
Second, many grantees lacked the medical background and training to 
ensure that they would provide medically accurate, science-based 
information in their programs. Third, grantees also lacked experience 
with the technical management of federal grants, including how to 
conduct evaluations of their programs. 

HRSA Used Full and Open Competition Procedures to Award the Contract to 
NAC: 

HRSA used full and open competition procedures to award the contract to 
NAC. In doing so, HRSA (1) publicly solicited proposals from potential 
contractors; (2) conducted technical evaluations of both the original 
proposals and the revised proposals for those considered to be in the 
competitive range; and (3) determined that NAC's proposal represented 
the best overall value to the government. This process, which took 
place from May 2002 through September 2002, resulted in HRSA awarding 
NAC the contract with a potential value of nearly $2.7 million. 

HRSA issued a notice on May 20, 2002, on the FedBizOpps Web site, the 
government point of entry for notifying potential contractors of 
federal contract opportunities, indicating its intent to publicly 
request proposals from prospective contractors in June 2002.[Footnote 
75] On June 20, 2002, HRSA posted the solicitation on the FedBizOpps 
Web site indicating that the abstinence contract would be awarded using 
full and open competition procedures, that is, all responsible 
prospective contractors would be provided the opportunity to 
compete.[Footnote 76] The solicitation, which was a Request for 
Proposals (RFP), described the contract objectives, which included (1) 
the development of national criteria for the review of abstinence- 
until-marriage educational materials and the development of a directory 
of approved materials; (2) the provision of medical accuracy training 
to grantees; and (3) the provision of technical support to grantees, 
such as assistance with program evaluation. The RFP stated that HRSA 
intended to award a cost-reimbursement contract with fixed fee for a 1- 
year base period and 2 option years.[Footnote 77] This was a best value 
procurement; that is, HRSA reserved the right in the RFP to select for 
award the proposal that HRSA determined offered the best value to the 
government, even if it did not offer the lowest cost. Further, the RFP 
stated that the technical evaluation of the prospective contractors' 
proposals would receive paramount consideration in the selection of the 
contractor. According to the RFP, this evaluation would include an 
assessment of the prospective contractor's technical approach, the 
organizational experience and expertise of the prospective contractor, 
the plans for personnel and management of the work, and the prospective 
contractor's statement and understanding of the project purpose. Other 
factors, such as the estimated cost, past performance under other 
contracts for similar services, and the subcontracting plan would also 
be considered in the selection process. Five prospective contractors 
submitted proposals to HRSA by July 31, 2002, when proposals were due. 

HRSA established a review committee to conduct the technical evaluation 
of the five proposals. This committee included three voting members and 
a nonvoting chairperson. The Director of HRSA's Community-Based and 
State Programs and two analysts from other programs within the 
Department of Health and Human Services (HHS) served as the voting 
members, and the chairperson of the review committee was a project 
officer of HRSA's Community-Based Program. The committee members 
conducted the technical evaluation of the proposals, according to the 
criteria in the RFP, as described above. Three proposals with the 
highest technical scores were determined to be in the competitive 
range,[Footnote 78] with NAC's proposal receiving the highest technical 
score. HRSA requested in writing that the competitive range offerors 
address certain technical and cost issues and submit revised proposals 
to HRSA by September 17, 2002.[Footnote 79] For example, HRSA requested 
that one of the prospective contractors other than NAC clearly describe 
its proposed management of day-to-day tasks of the contract and provide 
justification for several labor and travel expenditures. HRSA did not 
have oral discussions with the competitive range offerors. HRSA's 
review committee evaluated the revised proposals and again gave NAC's 
revised proposal the highest technical score. 

Although NAC's estimated cost was not the lowest among the proposals in 
the competitive range, HRSA determined that NAC had proposed a 
realistic cost estimate for the contract. Accordingly, and in light of 
the NAC proposal's high technical rating and the RFP's evaluation 
criteria giving paramount consideration to the technical evaluation, 
HRSA determined that NAC's proposal represented the best value to the 
government. HRSA awarded a contract to NAC on September 27, 2002. The 
contract had a 1-year base period of performance with an estimated 
value of $854,681, and included 2 option years for a total potential 
value of $2,673,784. According to a HRSA official, this cost- 
reimbursement contract did not include a fee. All of the prospective 
contractors were made aware that a debriefing to explain the selection 
decision and contract award would be provided at their request. One 
prospective contractor requested and received a debriefing from HRSA. 
No protests were filed with the agency challenging the award of the 
contract to NAC. There were no bid protests filed with GAO.[Footnote 
80] 

HRSA Identified No Actual or Potential Organizational Conflicts of 
Interest: 

HRSA officials told us that they did not identify any actual or 
potential organizational conflicts of interest during the acquisition 
process. As defined in the Federal Acquisition Regulation (FAR), an 
organizational conflict of interest arises where: 

* because of other activities or relationships, a person is unable or 
potentially unable to provide impartial assistance or advice to the 
government; or: 

* the person's objectivity in performing the contract work is or might 
be otherwise impaired; or: 

* a person has an unfair competitive advantage.[Footnote 81] 

An organizational conflict of interest may result when factors create 
an actual or potential conflict of interest during performance of a 
contract, or when the nature of the work to be performed under one 
contract creates an actual or potential conflict of interest involving 
a future acquisition.[Footnote 82] Under the FAR, contracting officers 
are required to analyze planned acquisitions to identify and evaluate 
potential organizational conflicts of interest as early in the 
acquisition process as possible, and to take steps to avoid, 
neutralize, or mitigate significant potential conflicts of interest 
before a contract is awarded.[Footnote 83] 

According to HRSA's contracting officer, HRSA did not identify any 
actual or potential organizational conflicts of interest. In reaching 
this conclusion, the contracting officer told us that he reviewed the 
statement of work, including the background and objectives of the 
proposed contract, the stated purpose of the contact, the criteria 
established to evaluate the proposals, the past performance of the 
competitors, and NAC's proposal. HRSA's contracting officer also told 
us that he did not formally document his assessment of organizational 
conflict of interest.[Footnote 84] 

[End of section] 

Appendix II: Methodology for Identifying and Reviewing Research 
Studies: 

To identify research studies that examine the effectiveness of 
abstinence-until-marriage education programs among adolescents and 
young adults, we searched two reference database systems, PubMed and 
ProQuest. We used the following keywords to search for research studies 
that were published from January 1, 1998, through May 22, 2006: 
"virginity," "abstinence education," "abstinence and curriculum," 
"abstinence only," "teen pregnancy and prevention," and "abstinence 
until marriage."[Footnote 85] We reviewed the research article titles 
that were generated from the PubMed and ProQuest searches and 
identified articles that appeared to focus on the evaluation of the 
effectiveness of abstinence-until-marriage education programs. In cases 
where we could not determine, based on the title, whether a study 
appeared to focus on an abstinence-until-marriage education program 
evaluation, we reviewed a summary of the article to obtain more 
information about the research study. We also examined previous 
summaries of the literature to identify additional research studies. 

We then selected research studies for inclusion in our literature 
review if they met three criteria. First, the study evaluated a group- 
based, abstinence-until-marriage education program. We did not select 
studies that evaluated one-on-one interactions, such as education 
programs focused exclusively on parent-child interactions, or that 
evaluated media campaigns. We reviewed the description of each 
education program and curriculum, as described in the study, to 
determine whether an abstinence-until-marriage education program was 
being evaluated. Education programs that were described as including 
detailed contraceptive information in their curricula, for example, 
were not classified as abstinence-until-marriage programs. Second, the 
study targeted adolescents and young adults in the United States, for 
example, by indicating that participants in the evaluation were high 
school or middle school students. Third, the study was a quantitative 
rather than a qualitative evaluation of an abstinence-until-marriage 
education program. We selected 13 research studies for inclusion in our 
literature review. 

We reviewed the selected research studies to obtain detailed 
information about their methodologies and outcome variables. For 
example, we determined whether each study used an experimental or quasi-
experimental design and whether the outcome measures included 
attitudes, behavioral intentions, behaviors such as initiation of 
sexual intercourse, or a combination of these. 

[End of section] 

Appendix III: Comments from the Department of Health and Human 
Services: 

Office Of The Assistant Secretary For Legislation: 
Department Of Health & Human Services: 
Washington, D.C. 20201: 

SEP 22 2006: 

Ms. Marcia Crosse: 
Director, Health Care: 
U.S. Government Accountability Office: 
Washington, DC 20548: 

Dear Ms. Crosse: 

Enclosed are the Department's comments on the U.S. Government 
Accountability Office's (GAO) draft report entitled, "Abstinence 
Education: Efforts to Assets the Accuracy and Effectiveness of 
Federally Funded Programs" (GAO-06-984), before its publication. 

The Department provided several technical comments directly to your 
staff. 

These comments represent the tentative position of the Department and 
are subject to reevaluation when the final version of this report is 
received. 

Sincerely, 

Signed by: 

Vincent J. Ventimiglia: 
Assistant Secretary for Legislation: 

Comments Of The Department Of Health And Human Services On The 
Government Accountability Office's Draft Report Entitled "Abstinence 
Education: Efforts To Assess The Accuracy And Effectiveness Of 
Federally Funded Programs" (GAO-06-984): 

GAO Recommendations: 

GAO recommends that to address concerns about the scientific accuracy 
of materials used in abstinence-until-marriage education programs, the 
Secretary of HHS develop procedures to help assure the accuracy of such 
materials used in the State and Community-based Programs. GAO further 
recommends that to help provide such assurances, the Secretary could 
consider alternatives such as (1) extending the approach currently used 
by OPA to review the scientific accuracy of the factual statements 
included in abstinence-until-marriage education materials used by 
grantees of ACF's Community-based Programs and requiring grantees of 
ACF's State Program to conduct such reviews, or (2) requiring grantees 
of both programs to sign written assurances in their grant applications 
that the materials they propose using are accurate. 

HHS Comments: 

HHS will consider requiring grantees of both ACF programs to sign 
written assurances in grant applications that the materials they use 
are accurate. However, as described 'below, ACF already requires 
applicants to submit curricula that conform to standards grounded in 
scientific data with their applications; and applicants for Federal 
grant assistance already assure the government that all data in their 
application, which includes data in curricula funded by a Federal 
grant, are true and correct. 

The report is divided into two main categories - scientific accuracy 
and effectiveness of abstinence-until-marriage programs. Comments are 
provided in that format. 

Scientific Accuracy: 

Although GAO was requested to "assess the scientific accuracy of 
materials used in abstinence-until-marriage programs." (page 3), GAO 
never defines the term "scientific accuracy" in the report. In fact, 
the report specifically recognizes (page 3) that it does not attempt to 
define or clarify the term. As such, it is difficult to precisely 
determine the criteria employed by GAO in making the recommendations as 
to scientific accuracy. 

In part due to the lack of precision in the report's use of the term 
"scientific accuracy," but also due to the report's incomplete 
depiction of how such materials are developed and reviewed, HHS does 
not agree with key claims of the report. One of the main claims of the 
report, for example, involves the often-repeated claim "ACF. does not 
review its grantees education materials for scientific accuracy, and 
does not require grantees . to review their own materials for 
scientific accuracy." (pages 5, 14, 39). HHS disagrees for the 
following reasons: 

First, all applicants for Federal assistance attest in their 
applications that "all data in their applications are true and correct" 
(Standard Form 424, [Hyperlink, 
http://www.acf.hhs.gov/programs/ofs/forms.htm]). In the view of HHS, 
this applies to information presented in curricula funded by Federal 
grant funds. 

Second, ACF requires its abstinence-education grantees to submit 
educational curricula that conform to, and are thoroughly grounded in, 
scientific literature. Indeed, the Fiscal Year 2006 Program 
Announcement for the Community-Based Abstinence Education Program, the 
largest of the three Federally funded abstinence programs, required 
that successful applicants' curricula conform to very specific, 
detailed curriculum standards (pages 5 through 13 of the program 
announcement, [Hyperlink, http://www.acf.hhs.gov/grants/open/HHS-2006-
ACF-ACYF-AE-0099.html]). Each of these standards has robust backing in 
scientific literature. Additionally, at least two of these standards 
discussed specific requirements by which successful applicants' 
curricula would adhere to scientific accuracy. Namely, the guidance 
specifies that the curricula teach "the published failure rates 
associated with contraceptives relative to pregnancy Prevention, 
including ,real use' versus trial or `laboratory use,' human error, 
product defect, teen use and possible side effects of contraceptives" 
(Theme CI). Furthermore, the guidance for successful applicants' 
curricula required that applicants' curricula teach "the epidemiology 
of sexually transmitted diseases (STDs) in the U.S., e.g., infection 
rates, modes of transmission, existence of incurable and potentially 
fatal STDs" (Theme C2). Curricula must provide supporting references 
for this information. Upon submission, ACF staff reviews the 
application, including the curricula, to ensure compliance with these 
scientifically valid standards. Should we find inaccurate statements 
during the review process, or at any time during the grant project 
period, ACF works with the grantees to take corrective action, as they 
would do with any other ACF grantee. 

Increased grantee awareness of the scientific and medical facts 
relative to their delivery of abstinence education has been, and 
continues to be, an important area of focus for ACF. For this reason, 
ACF offers numerous training and technical assistance (T/TA) 
opportunities to all of its grantees on a number of program-related 
areas. In addition, as is the case with ACF's grantees in other program 
areas, when ACF finds inaccuracies in a grantee's information or when 
an inaccuracy is brought to the attention of ACF, whether during the 
review process or at any time during the project period, ACF requires 
and works with the grantee to have tie inaccuracy corrected as soon as 
possible. In the few cases of which ACF is aware of inaccuracies found 
to exist in abstinence materials, corrections were made once the 
grantee became aware of those inaccuracies. For example, the two 
inaccuracies cited in the GAO report were corrected before GAO even 
began working on the report. 

The GAO report presents an adequate assessment of OPA's review of 
materials used in Adolescent Family Life (AFL) Abstinence Education 
Programs. There are, However, a few points about this review process 
that should be both clarified and highlighted. First, when OPA does 
find inaccuracies in education materials proposed for use in an AFL 
demonstration project, the grantee is notified and must make the 
specified correction(s) before OPA approves their use. Similarly, OPA 
grants include the condition, in each Notice of Grant Award issued for 
AFL demonstration projects, that all educational materials must be 
submitted to OPA for review and approval before they can be used in AFL 
projects. 

Aspects of the CDC review of materials for accuracy also warrant 
additional clarification. Specifically, all materials developed and/or 
used by national, State and local grantees are reviewed and approved by 
the grantees' materials review panel. The review panel is a requirement 
of the CDC cooperative agreement. 

Effectiveness: 

HHS is taking extensive action to determine program effectiveness and 
improve the quality of programs and research. Work is being done 
through the program offices, research agencies and through 
Congressionally mandated studies. These efforts include the following: 

* ASPE is overseeing a Congressionally mandated experimental evaluation 
of abstinence education programs that will examine behavioral outcomes 
over an extended period of time, and is in the process of designing 
another large-scale longitudinal study that will also include an 
experimental design and measure behavioral outcomes. 

* A new effort that is not included in the report is the development if 
a Center for Research and Evaluation on Abstinence Education. This is a 
multi-year project funded by ACF and ASPE in FY 2006. It is designed to 
build capacity for quality research in the field of abstinence 
education. The main activities include a) conducting a needs assessment 
to identify gaps in abstinence-education evaluation and technical 
assistance needs; b) developing materials on abstinence-education 
evaluation; c) delivering technical assistance and capacity- building 
activities related to program evaluation; and d) developing several 
research reports related to abstinence education. The goal is to 
stimulate greater collaboration and quality implementation and outcome-
evaluation research of abstinence education programs. 

* CDC is undertaking a study to evaluate the effectiveness of two 
middle school curricula. The study will examine the relative 
effectiveness of programs on behavioral outcomes. 

* NIH is currently funding several studies related to the effectiveness 
of abstinence education, which are underway. 

* The two program offices (OPA and ACF) provide technical assistance 
and fund research activities related to evaluation. In addition, two of 
the grant programs (the AFL program and the Community-based Program) 
currently have evaluation requirements of grantees - OPA allows up to 
25 percent of grant funds awarded to be spent on evaluation and ACF is 
now requiring that a minimum of 15 percent of funds awarded to be spent 
on evaluation. 

Although GAO does acknowledge that "ACF has made efforts to assess the 
effectiveness of abstinence-until-marriage education programs." (page 
20), GAO fails to mention two key elements of these efforts. First, 
while GAO mentions the new evaluation requirement on Community- Based 
Abstinence Education (CBAE) grantees, there is no mention in the report 
that grantees are now required to spend at least 15 percent of their 
Federal funding on evaluation activities. Depending on the amount of 
the project, this amount could be up to $450,000 over five years for 
each grant awarded. Never before have CBAE grantees been required to 
comply with such a significant commitment to evaluation and research 
activity. HHS believes that this requirement will dramatically improve 
its grantees' ability to determine the effectiveness of the programs. 
The improvements made to this year's guidance caused one peer-reviewed 
scientific medical journal to claim that "...a rigorous evaluation of 
project impact may now be possible."[Footnote 86] Second, the report 
omits any mention of the abstinence-education evaluation; from the 
first Abstinence Education Evaluation Conference sponsored by ACF and 
OPA.[Footnote 87] The evaluations contained in this publication were 
peer-reviewed for presentation at the conference and conform to many of 
the standards published in the report (pages 31 through 33). ACF 
recommends that GAO insert language in the report reflecting these 
significant commitments to assessing program effectiveness. 

While GAO also generally acknowledges that "OPA has also made efforts 
assess the effectiveness of the AFL Program" it would be helpful to 
specify what those efforts are since they, too, already conform to many 
of the standards published in the report. [n particular, OPA has 
developed performance measures and requires projects to develop outcome 
objectives, conduct independent evaluations and use core evaluation 
instruments. 

Further, in response to the Office of Management and Budget's (OMB) 
Program Assessment Review Tool (PART), OPA has developed performance 
measures for their AFL program. Two of these performance measures apply 
to AFL prevention demonstrations. AIL Prevention Core Evaluation 
Instrument data, aggregated across prevention projects, will be used to 
track them (Only the AFL projects, funded in fiscal year 2004 and 
later, are required to use the core instruments, and thus, it will 
require a few more funding cycles before tracking data are available 
for all projects.) 

Each AFL prevention-demonstration project is expected to develop 
specific and measurable outcome objectives, two of which should address 
the performance measures developed by OPA for prevention projects. 
While these objectives are intended more as a way to focus the 
individual project than as away to evaluate it, projects are expected 
to tie their independent evaluations to their outcome objectives. 

All AFL demonstration projects are required, by statute, to conduct an 
independent evaluation of their project. The GAO report covers the many 
difficulties these evaluation; face and OPA has taken steps, in the 
past few years, to improve the quality of its AFL evaluations. The 
limit of five percent of project funds for evaluation has been waived, 
pursuant to statutory authority, and beginning in fiscal year 2004, new 
projects can request up to 25 percent of project funds for evaluation. 
Proposals considered for funding are held to commensurately more 
rigorous criteria with respect to their evaluation plan. Core 
evaluation instruments have been developed; all demonstration projects 
are encouraged to use them and, beginning in fiscal year 2004, all new 
demonstration projects funded by AFL were required to use them. The AFL 
program also provides, through expert consultants, evaluation technical 
assistance to all projects that require it. 

OPA has developed two sets of core evaluation instruments for the AFL 
program baseline and follow-up for both prevention and care 
demonstrations to ensure that data, reflecting AFL legislative 
requirements, are captured in the independent evaluations. The 
instruments are intended as core only and additional instrumentation, 
addressing specific and unique components of AFL demonstrations, can 
also be used in the individual independent evaluations. 

We note that because evaluation is a new requirement for ACF's 
Abstinence Education Program and only recently intensified for OPA's 
Abstinence Education Program, it may be too soon to be drawing 
conclusions about their effectiveness. It would also be important to 
note that because youth are typically 9-14 years of age in OPA's 
Abstinence Education Program and 12-18 years of age in ACF's Abstinence 
Education Program, following youth in both programs takes time. That 
these large evaluations of the State and Community-based Programs are 
still underway suggests that the conclusions drawn in the GAO report 
may be premature or Speculative and may change significantly as new 
information becomes available. 

We agree with the report when it states that there are still too few 
scientifically valid studies which have been completed, to date, and 
which have been able to be used to determine conclusively which, if 
any, abstinence-until-marriage programs have been effective We would 
point out, however, that having an inadequate amount of scientifically 
valid and conclusive evaluation studies as of yet is not unique to 
abstinence until marriage education programs. A recent ASPE review of 
comprehensive sex education programs show that while some have a 
positive impact on some outcome measures, some have no impact and some 
have a negative impact. 

We believe that the answer to this challenge is not only a greater 
emphasis on evaluation among grantees, but also the conducting of a 
greater number of experimental programs generally. HHS would appreciate 
greater mention of both of these efforts. 

As HHS funds numerous abstinence demonstration projects across the 
country, and as we do so with an emphasis on evaluation, we believe 
that the field will mature to show the level of effectiveness and 
impact of these programs. Furthermore, HHS eagerly awaits the results 
of the first experimental trial referred to in the report, which will 
undoubtedly strengthen service delivery within the abstinence- 
education field, and benefit the youth who are choosing to remain 
abstinent in ever-increasing numbers. 

[End of section] 

Appendix IV: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Marcia Crosse, (202) 512-7119 or crossem@gao.gov: 

Acknowledgments: 

In addition to the contact named above, Kristi Peterson, Assistant 
Director; Kelly DeMots; Pam Dooley; Krister Friday; Julian Klazkin; and 
Amy Shefrin made key contributions to this report. 

FOOTNOTES 

[1] Abstinence-until-marriage education programs also support HHS's 
objective to promote family formation and healthy marriages. 

[2] See K. L. Wilson et al., "A Review of 21 Curricula for Abstinence- 
Only-Until-Marriage Programs," The Journal of School Health, vol. 75, 
no. 3 (2005), and The Content of Federally Funded Abstinence-Only 
Education Programs, United States House of Representatives, Committee 
on Government Reform-Minority Staff, Special Investigations Division 
(2004). 

[3] See, for example, E. A. Borawski et al., "Effectiveness of 
Abstinence-only Intervention in Middle School Teens," American Journal 
of Health Behavior, vol. 29, no. 5 (2005), and J. B. Jemmott III, L. S. 
Jemmott, and G. T. Fong, "Abstinence and Safer Sex HIV Risk-Reduction 
Interventions for African American Adolescents: A Randomized Controlled 
Trial," Journal of the American Medical Association, vol. 279, no. 19 
(1998). 

[4] The 10 states that received the largest share of funding in fiscal 
year 2005 through the State Program were Arizona, Florida, Georgia, 
Illinois, Louisiana, Michigan, New York, North Carolina, Ohio, and 
Texas. 

[5] See Douglas Kirby, Emerging Answers: Research Findings on Programs 
to Reduce Teen Pregnancy (Washington, D.C.: National Campaign to 
Prevent Teen Pregnancy, 2001). The experts identifying the design 
characteristics of a scientifically valid study for the National 
Campaign to Prevent Teen Pregnancy were drawn from institutions that 
include the National Institutes of Health, the Medical Institute for 
Sexual Health, the Alan Guttmacher Institute, the Institute for 
Research and Evaluation, and various universities. See David Satcher, 
The National Consensus Process on Sexual Health and Responsible Sexual 
Behavior: Interim Report (Atlanta: Morehouse School of Medicine, 2006). 
The panel convened by David Satcher included experts from a variety of 
organizations, including the Medical Institute for Sexual Health, the 
Alan Guttmacher Institute, and the American Academy of Pediatrics. In 
addition, characteristics of a scientifically valid study have been 
identified by other experts in the field of evaluation research. For 
example, see Carol H. Weiss, Evaluation (Upper Saddle River: Prentice 
Hall, 1998). 

[6] HHS's Family Planning Program, for example, also supports the 
objective to reduce the incidence of STDs and unintended pregnancies by 
providing access to contraceptive supplies and family planning 
information, especially for low-income persons, at community health 
clinics. This program is authorized under Title X of the Public Health 
Service Act. 

[7] There are other federal sources of funding that are used for 
abstinence education, such as the Temporary Assistance for Needy 
Families (TANF) Program that is administered by ACF. Some states have 
allocated some of their TANF funding for abstinence education programs. 
For example, Florida has used TANF funds to provide community-based and 
faith-based organizations with contracts to carry out abstinence 
education. Other sources of funding that are used for abstinence 
education include ACF's Compassion Capital Fund and CDC's Division of 
Adolescent and School Health grants. 

[8] 42 U.S.C. § 710(b)(2). This definition is also referred to as the A-
H definition. This statutory provision defines abstinence education for 
purposes of the State Program. Annual appropriations acts and program 
announcements have extended this definition to the Community- Based and 
AFL Programs. See, e.g , Departments of Labor, Health and Human 
Services, and Education, and Related Agencies Appropriations Act, 
2006,Pub. L. No. 109-149,119 Stat. 2833, 2855-56. 

[9] Through the State Program funds are also provided to insular areas 
and the District of Columbia. 

[10] Pub. L. No. 104-193, § 912; 110 Stat. 2353-54 (codified at 42 
U.S.C. § 710). 

[11] In this report, we refer to U.S. territories and commonwealths as 
"insular areas." 

[12] Some states and insular areas have not applied for funding under 
the State Program. California, Maine, and Pennsylvania did not apply 
for funding under the State Program in fiscal year 2005. In this 
report, when we refer to "states," we are referring to all grantees of 
the State Program--including states, insular areas, and the District of 
Columbia. 

[13] The Community-Based Program is conducted under section 1110 of the 
Social Security Act. See 42 U.S.C. § 1310. 

[14] In addition to the 63 grants awarded in fiscal year 2005, ACF is 
also responsible for other grants that the agency awarded before 2005. 

[15] See 42 U.S.C. § 300z et seq. The AFL Program also supports other 
projects for pregnant and parenting adolescents, their infants, male 
partners, and family members. The purpose of these projects is to 
improve the outcomes of early childbearing for teen parents, their 
infants, and their families. However, in this report, when we use the 
term "AFL Program," we are referring only to the abstinence-until- 
marriage component of the AFL Program. 

[16] ACF awards formula grants under the State Program each year, and 
states have 2 years to spend the funds they are awarded. In the 
Community-Based Program and AFL Program, grantees develop multiyear 
projects--up to 5 years--for which the first year of funding is 
provided through competitive grants; for subsequent years, grantees may 
obtain funding through noncompetitive continuation grants. 

[17] In reviewing grantees applications, ACF does examine several 
issues, including applicants' stated program goals and need for 
assistance, their compliance with the A-H definition of abstinence 
education, their intended approach in carrying out their objectives, 
and their budget plan. 

[18] HHS officials told us that if ACF finds inaccurate statements 
during this more general review process or if inaccuracies are brought 
to their attention at any time during the grant period, ACF officials 
work with the grantees to take corrective action. 

[19] In addition to reviewing materials for accuracy, one state 
requires abstinence-until-marriage providers to sign a written 
assurance that their materials are scientifically accurate. Officials 
from this state also reported providing abstinence-until-marriage 
education programs with public health consultants to provide technical 
assistance and training to help ensure the accuracy of their 
educational materials. 

[20] In addition, some state officials we interviewed told us that 
review committees for local school districts may review the scientific 
accuracy of educational materials that include information about HIV 
and other STDs, including abstinence-until-marriage education 
materials. 

[21] Mich. Comp. Laws Ann. § 380.1507b(2)(West 2004). 

[22] See Ohio Department of Health, "Abstinence Education Program 
Request for Proposals for Fiscal Year 2007," (program announcement, 
2005). 

[23] The human papillomavirus (HPV) causes an STD called genital HPV 
infection. 

[24] Some grantees of the Community-Based Program reported using more 
than one of these curricula in fiscal year 2005. 

[25] The administration of this contract was transferred to ACF in May 
2005. 

[26] The Medical Institute is a nonprofit organization that provides 
educational resources, conferences, and seminars to educators, health 
professionals, pregnancy care centers, and faith-based groups about 
behaviors to decrease STDs and out-of-wedlock pregnancies, including 
abstinence. 

[27] See generally Bowen v. Kendrick, 487 U.S. 589 (1988), 657 F. Supp 
1547 (D.D.C. 1987). 

[28] In addition, a CDC official told us that some of its grantees are 
producing educational materials with CDC funds to be used by abstinence-
until-marriage education programs, which are likely to include State 
and Community-Based Program grantees. These materials are required to 
be reviewed for scientific accuracy. CDC officials told us that they 
have made corrections to some of these materials. Materials used in 
school-based HIV prevention education programs that are supported with 
CDC funds are also reviewed for scientific accuracy. A CDC official 
told us that some of these programs are abstinence-until- marriage 
education programs. 

[29] In addition to OPA and some states, others have also reviewed the 
scientific accuracy of abstinence-until-marriage education materials. 
See, for example, Wilson et al. 

[30] This reporting is a part of ACF's efforts to collect evaluative 
information about these programs. These efforts include both 
performance measurement--the ongoing monitoring and reporting of 
program accomplishments toward preestablished goals--and program 
evaluation--individual systematic studies to assess how well a program 
is working. Both types of assessments aim to support decisions to 
improve service delivery and program effectiveness. See GAO, 
Performance Measurement and Evaluation: Definitions and Relationships, 
GAO-05-739SP (Washington, D.C.: May 2005), for more information on 
types of assessments. 

[31] Previously, to report on the four measures, states have relied on 
either state or national data sources, such as CDC's Youth Risk 
Behavior Surveillance System. 

[32] For example, in fiscal year 2002, state grantees developed such 
measures as the percentage of teens surveyed who show an increase in 
participating in structured activities after school hours; the 
percentage of live births to women younger than 18, fathered by men age 
20 and older; the percentage of program participants proficient in 
refusal skills; the percentage of high school students who reported 
using drugs or alcohol before intercourse; and the percentage of high 
school students who had sexual intercourse for the first time before 
age 13. 

[33] The fiscal year 2006 program announcement for the Community-Based 
Program provides examples of outcome measures that grantees could use, 
including increased knowledge of the benefits of abstinence, the number 
of youths who commit to abstaining from premarital sexual activity, and 
increased knowledge of how to avoid high-risk situations and risk 
behaviors. 

[34] Fiscal year 2006 Community-Based Program grantees are required to 
devote a minimum of 15 percent of their requested budgets to 
performance monitoring by third-party contractors. 

[35] Some grantees of the Community-Based Program may have to meet 
reporting requirements established by HRSA. Grants under this program 
are awarded for projects that may extend over a period of several 
years. Grantees that were awarded grants when HRSA administered the 
program and have since received noncompetitive continuation grants for 
these projects are required to meet the reporting requirements in place 
at the time they first received the competitively awarded grants. 

[36] In fiscal year 2001, HRSA required grantees of the Community-Based 
Program to report on the following four performance measures: the 
proportion of program participants who successfully complete or remain 
enrolled in an abstinence-only education program; the proportion of 
program participants who have engaged in sexual intercourse; the 
proportion of program participants who report a reduction in risk 
behaviors, such as tobacco, alcohol, and drug use; and the rate of 
births to female program participants. 

[37] Specifically, HRSA required grantees of the Community-Based 
Program to report annually on the following six performance measures: 
the proportion of program participants who successfully completed or 
remained enrolled in an abstinence-only education program; the 
proportion of adolescents who understood that abstinence from sexual 
activity is the only certain way to avoid out-of-wedlock pregnancy and 
STDs; the proportion of adolescents who indicated an understanding of 
the social, psychological, and health gains to be realized by 
abstaining from premarital sexual activity; the proportion of 
participants who reported that they had the skills necessary to resist 
sexual urges and advances; the proportion of youth who committed to 
abstaining from sexual activity until marriage; and the proportion of 
participants who intended to avoid situations and risk behaviors, such 
as drug use and alcohol consumption, which make them more vulnerable to 
sexual advances and urges. 

[38] In addition to these outcomes, grantees of the AFL Program are 
required to report on program outputs, such as the number of program 
participants, the average number of participants per session, and the 
average number of sessions attended by participants. Agency officials 
stated that OPA has implemented a new format for its grantees' reports, 
which is intended to standardize their reporting on these outputs. 

[39] OPA's grantees are required to perform evaluations of their 
programs that are directly tied to their program objectives. For these 
evaluations, OPA requires grantees to develop research hypotheses that 
reflect the outcomes the grantees intend to achieve. This type of 
evaluation is generally considered to be an outcome evaluation--which 
assesses the extent to which a program achieves its outcome-oriented 
objectives. These evaluations focus on outputs and outcomes to judge 
program effectiveness but may also assess program process to understand 
how outcomes are produced. In addition, grantees of the AFL Program are 
required to perform implementation evaluations. 

[40] OPA officials stated that grantees may also supplement the 
standardized questionnaire with additional data collection instruments 
to obtain information on the effectiveness of their abstinence-until- 
marriage education programs. 

[41] OPA has required that its grantees perform independent evaluations 
of their programs since the program first awarded grants in 1982, and 
requires that grantees devote from 1 percent to 5 percent of grant 
funds to the evaluation of their programs. In cases where a more 
rigorous or comprehensive evaluation is proposed, OPA may allow these 
grantees to use up to 25 percent of their grant funds. 

[42] A control group is a group of individuals or communities in a 
study that is compared to an intervention group--a group in a study 
that is receiving or participating in the program being studied. A 
control group is a randomly assigned group that does not receive the 
program. A comparison group is not randomly assigned like a control 
group. However, individuals or communities in well-matched comparison 
groups should have similar characteristics. 

[43] Specifically, OPA requires that third-party evaluations of 
grantees of the AFL Program compare, when possible, randomized control 
or matched comparison groups with groups receiving abstinence-until- 
marriage education. In addition, OPA requires that these evaluations 
include a sufficient sample size to ensure that any observed 
differences between the groups are statistically valid and that the 
evaluations include a follow-up assessment of program participants at 
least 6 months after the abstinence-until-marriage intervention has 
been tested. 

[44] OPA prepares annual performance reports as a part of HHS's 
responsibilities under the Government Performance and Results Act, 
which include program performance measures to help link funding 
decisions with performance and review of related outcome measures. 

[45] Data on teen birth rates and adolescents' reported sexual behavior 
are contained in the National Vital Statistics System and the Youth 
Risk Behavior Surveillance System, respectively. The former is a 
national data set of public health statistics reported by states to 
CDC, and the latter is a national data set based on nationwide surveys 
administered to high school students by CDC. 

[46] In order to estimate pregnancy rates among adolescents, states use 
data on both birth rates and abortions among adolescents. 

[47] ACF does require grantees of the State Program to describe, in 
their grant applications, their plans for "tracking activities and 
measuring achievement" of their program goals and objectives. 

[48] See, for example, LeCroy & Milligan Associates, Inc., Abstinence 
Only Education Program: Fifth Year Evaluation Report, a report prepared 
for the Arizona Department of Health Services, 2003; Patricia Goodson 
et al., Abstinence Education Evaluation: Phase 6, a report prepared for 
the Texas Department of State Health Services, 2005; MGT of America, 
Evaluation of Georgia Abstinence Education Programs Funded Under Title 
V, Section 510, a report prepared for the Georgia Department of Human 
Resources, 2005; Thomas E. Smith, It's Great to Wait: An Interim 
Evaluation, a report prepared for the Florida Department of Health, 
2001. 

[49] According to the House Appropriations Committee report 
accompanying the fiscal year 2005 appropriation act for Labor, HHS, 
Education, and related agencies, the effectiveness of abstinence 
education programs should be determined by measures that include the 
prevention and reduction of adolescent pregnancies and STD infections, 
age at first sexual activity and intercourse, frequency of sexual 
activity and intercourse, and numbers who postpone sexual activity or 
intercourse through adolescence. See H.R. Rep. No. 108-636, at 139-140 
(2004). 

[50] According to ASPE officials, one factor that has contributed to 
delays in the initiation of this study is the difficulty in recruiting 
schools to participate. 

[51] The five abstinence-until-marriage education programs being 
studied are My Choice, My Future! in Powhatan, Virginia; ReCapturing 
the Vision in Miami, Florida; Teens in Control in Clarksdale, 
Mississippi; Families United to Prevent Teen Pregnancy in Milwaukee, 
Wisconsin; and Heritage Keepers in Edgefield, South Carolina. 

[52] See B. Devaney et al., The Evaluation of Abstinence Education 
Programs Funded Under Title V Section 510: Interim Report, a report 
prepared for ASPE, 2002. 

[53] See R. Maynard et al., First-Year Impacts of Four Title V, Section 
510 Abstinence Education Programs, a report prepared for ASPE, 2005. 
Mathematica's report on the first-year impacts of selected state 
abstinence-until-marriage education programs focused on intermediate 
outcomes, including attitudes about abstinence, teen sex, and marriage; 
perceived consequences of teen and nonmarital sex; and expectations to 
abstain from sexual intercourse. 

[54] An impact evaluation assesses the net effect of a program by 
comparing program outcomes with an estimate of what would have happened 
in the absence of the program. This form of evaluation is employed when 
external factors are known to influence the program's outcomes, in 
order to isolate the program's contribution to achievement of its 
objectives. 

[55] HHS officials told us that the two curricula being tested are 
intended to be comparable in length, intensity, and other 
characteristics. 

[56] See Kirby. This panel included experts from NIH, the Medical 
Institute for Sexual Health, the Alan Guttmacher Institute, the 
Institute for Research and Evaluation, and various universities. 

[57] See Satcher. This panel included experts from a variety of 
organizations, including the Medical Institute for Sexual Health, the 
Alan Guttmacher Institute, and the American Academy of Pediatrics. 

[58] For example, experts have reported that the use of randomly 
assigned intervention and control groups is particularly important when 
assessing the effectiveness of abstinence-until-marriage programs 
because adolescents who voluntarily participate in such programs may be 
self-selecting--that is, they may be more willing to accept the 
principles of--and be influenced by--such programs when compared with 
other adolescents. Mathematica's interim report on the evaluation of 
the State Program noted that selection bias can "seriously undermine 
the credibility" of study results. 

[59] For example, one expert reported that studies assessing program 
effectiveness should obtain information on participants for at least 3 
months after the conclusion of a program when they are measuring 
behaviors that can change quickly, such as frequency of sex. For 
behaviors or outcomes that change less quickly, such as initiation of 
sex or pregnancy rates, information on participants should be collected 
for at least 6 months after the conclusion of a program. 

[60] The panel of experts convened by the National Campaign to Prevent 
Teen Pregnancy agreed that large sample sizes are necessary to 
determine the magnitude of any discernable program effect and to ensure 
that results of any study of effectiveness are statistically valid. 

[61] In addition, according to ACF and CDC officials, it is difficult 
to draw conclusions from national data sets about the effectiveness of 
abstinence-until-marriage education programs because the national 
survey questions used to produce these data often do not identify the 
specific type of program or intervention survey respondents may have 
participated in or received. 

[62] See Goodson et al. 

[63] See, for example, S. M. Fitzgerald et al., "Effectiveness of the 
Responsible Social Values Program for 6th Grade Students in One Rural 
School District," Psychological Reports, vol. 91 (2002), and J. E. 
Barnett and C. S. Hurst, "Abstinence Education for Rural Youth: An 
Evaluation of the Life's Walk Program, " The Journal of School Health, 
vol. 73, no. 7 (2003). 

[64] See, for example, D. A. Zanis, "Use of a Sexual Abstinence Only 
Curriculum with Sexually Active Youths," Children & Schools, vol. 27, 
no. 1 (2005), and G. Denny et al., "An Evaluation of An Abstinence 
Education Curriculum Series: Sex Can Wait," American Journal of Health 
Behavior, vol. 26, no. 5 (2002). 

[65] See, for example, L. Sather and K. Zinn, "Effects of Abstinence- 
Only Education on Adolescent Attitudes and Values Concerning Premarital 
Sexual Intercourse, " Family and Community Health, vol. 25, no. 2 
(2002), and G. Denny, M. Young, and C. E. Spear, "An Evaluation of the 
Sex Can Wait Abstinence Education Curriculum Series," American Journal 
of Health Behavior, vol. 23, no. 2 (1999). 

[66] See Borawski et al. See also T. L. St. Pierre et al., "A 27-Month 
Evaluation of a Sexual Activity Prevention Program in Boys & Girls 
Clubs Across the Nation," Family Relations, vol. 44, no. 1 (1995). 

[67] See Borawski et al. 

[68] See N.G. Harrington et al., "Evaluation of the All Stars Character 
Education and Problem Behavior Prevention Program: Effects on Mediator 
and Outcome Variables for Middle School Students," Health Education & 
Behavior, vol. 28, no. 5 (2001). See also Jemmott, Jemmott, and Fong. 

[69] See Harrington et al. 

[70] See Jemmott, Jemmott, and Fong and J. B. Jemmott III, L. S. 
Jemmott, and G. T. Fong, reply to letter to editor, Journal of the 
American Medical Association, vol. 281, no. 16 (1999), 1487. This study 
found that an abstinence-until-marriage program delayed the initiation 
of sexual intercourse at the 3-month follow-up period but not at 6 and 
12 months. 

[71] According to several scientific experts, Mathematica's study is an 
important one, in part because of its sound design: the study randomly 
assigns and compares control groups with groups receiving abstinence- 
until-marriage education and uses surveys to follow up with program 
participants for several months after their completion of a program. 

[72] The administration of this contract was transferred from HRSA to 
the Administration of Children and Families (ACF) in May 2005. 

[73] The contract resulted in the development of criteria for reviewing 
abstinence-until-marriage educational materials, and ACF included these 
criteria in the fiscal year 2006 program announcement for the Community-
Based Program. According to the announcement, ACF will evaluate grant 
applicants' proposed educational materials to ensure compliance with 
the criteria. Medical accuracy training and technical support were 
provided to grantees as a result of the contract. According to an ACF 
official, a directory of approved abstinence-until- marriage 
educational materials was not completed. 

[74] Section 510(b)(2) of the Social Security Act defines abstinence 
education as an educational or motivational program that: A. has as its 
exclusive purpose, teaching the social, psychological, and health gains 
to be realized by abstaining from sexual activity; B. teaches 
abstinence from sexual activity outside marriage as the expected 
standard for all school age children; C. teaches that abstinence from 
sexual activity is the only certain way to avoid out-of-wedlock 
pregnancy, sexually transmitted diseases, and other associated health 
problems; D. teaches that a mutually faithful monogamous relationship 
in context of marriage is the expected standard of human sexual 
activity; E. teaches that sexual activity outside of the context of 
marriage is likely to have harmful psychological and physical effects; 
F. teaches that bearing children out-of-wedlock is likely to have 
harmful consequences for the child, the child's parents, and society; 
G. teaches young people how to reject sexual advances and how alcohol 
and drug use increases vulnerability to sexual advances; and H. teaches 
the importance of attaining self-sufficiency before engaging in sexual 
activity. 

[75] The current FedBizOpps Web site address is [Hyperlink, 
http://www.fbo.gov/. Prior to October 1, 2005, the Web site address was 
http://www.eps.gov/. The solicitation number was 240-MCHB-012(02)-abg. 

[76] The Federal Acquisition Regulation (FAR) requires the contracting 
officer to ensure that prospective contractors are responsible. FAR § 
9.103. A responsible source refers to a prospective contractor that 
has, among other things, adequate financial resources, the necessary 
experience and technical skills to perform the work of the contract, a 
satisfactory performance record, and the ability to meet the delivery 
schedule. FAR § 9.104-1. 

[77] Cost-reimbursement contracts are used only when uncertainties 
involved in contract performance do not permit costs to be estimated 
with sufficient accuracy to use any type of fixed-price contract. FAR § 
16.301-2. 

[78] Based on the ratings of each proposal against all evaluation 
criteria, the contracting officer establishes a competitive range 
consisting of all of the most highly rated proposals. FAR § 
15.306(c)(1). 

[79] HRSA officials, including an auditor, reviewed the cost proposals 
in the competitive range. 

[80] GAO's Office of General Counsel resolves disputes concerning 
awards of federal contracts, which are known as bid protests. 

[81] FAR § 2.101. 

[82] FAR § 9.502(c). 

[83] The FAR requires contracting officers to exercise common sense, 
good judgment, and sound discretion in determining whether a 
significant potential conflict of interest exists. FAR § 9.505. 

[84] The FAR requires HRSA's contracting officers to formally document 
their assessment only when a substantive issue concerning a potential 
organizational conflict of interest exists. FAR § 9.504(d). HHS 
acquisition regulations do not explicitly address the assessment of 
organizational conflict of interest. Therefore, FAR subpart 9.5 is the 
controlling regulation when HHS encounters an issue related to an 
organizational conflict of interest. 

[85] ACF first awarded grants under the State Program in fiscal year 
1998. 

[86] Michael Young & Tina Penhollow, "The Impact of Abstinence 
Education: What Does the Research Say?" Journal of Health Education 37, 
no. 4 (July 1, 2006). 

[87] Evaluating Abstinence Education Programs: Improving Implementation 
and Assessing In pact. Compiled manuscripts from "Strengthening 
Abstinence Education Programs through Scientific Evaluation," November 
3-4, 2005. 

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