The United States has a higher teenage pregnancy rate than most other industrialized countries.¹ The national Hispanic teenage birthrate is twice that of non-Hispanic whites,² and in California, Hispanic adolescents are four times more likely than whites to become parents.*³ In addition, the Hispanic population in California is growing rapidly because of immigration and high fertility rates.⁴ Such growth will put pressure on the educational and health care systems' ability to address the needs of Hispanics, most of which are fundamentally shaped by the cultural differences and economic disadvantages that often characterize Hispanics living in the United States. There is a clear necessity for teenage pregnancy prevention and intervention efforts that are grounded in the unique needs and experiences of Hispanic youth.⁵

Numerous prevention and intervention programs and curricula target teenage pregnancy. Although several program guides include information for tailoring programs for ethnic and cultural groups,⁶ few prevention programs have been developed specifically for Hispanic populations. In light of the high Hispanic population growth and teenage pregnancy rates, many researchers, policymakers and health advocates have urged teenage pregnancy prevention programs to develop culturally sensitive practices.⁷ Over the last decade, there has been growing attention to Hispanic cultural sensitivity and its application in prevention settings.⁸ However, most research and recommendations for pregnancy prevention practice have been based on studies of Hispanic teenagers;⁹ the experiences of professional teenage pregnancy prevention practitioners have been largely overlooked. The study described in this article was designed to investigate cultural sensitivity in Hispanic teenage pregnancy prevention programs—its meanings and practices—from the perspective of practitioners who work with Hispanic youth in California.

HISPANIC CULTURE AND PREVENTION OF TEENAGE PREGNANCY

Research on Hispanic cultural values, attitudes and behaviors that influence sexual and contraceptive behavior has shown that sexuality is often a taboo subject and that parental communication regarding sexuality is often lacking in Hispanic homes.¹⁰ At the same time, Hispanic culture supports early and high fertility, as well as the belief that early motherhood and continued education are incompatible.¹¹ These cultural values may explain why Hispanic women desire marriage and children at a younger age than do blacks, Southeast Asians and whites.¹² In addition, Mexican Americans are more likely than whites to believe that marriage affirms one's womanhood.¹³ Although Hispanics have more conservative attitudes toward sexuality than whites or blacks,¹⁴ they are more likely to enter sexual relationships at a young age, perhaps as a result of their desire to marry early. Also, the average age difference within Hispanic couples is often large, particularly between teenage women and their male partners.¹⁵

Attitudes toward sexuality, marriage and motherhood are central to the strong gender roles of traditional Hispanic culture. Male sexual behavior may be encouraged, whereas similar behavior in women is socially unacceptable.¹⁶ Within the family, men are expected to have more power and status because of their primary role as provider.¹⁷ Attitudes regarding sexuality and gender roles are supported by the value of familialism: strong feelings of loyalty to and solidarity with extended family.¹⁸ These values may be stronger than predominant U.S. values of individual success through educational and occupational achievements. Thus, for Hispanic families with traditional cultural values, support for continued education in the face of early motherhood may be low.¹⁹ Finally, the experiences and expressions of these dimensions of traditional Hispanic culture vary significantly according to country of origin, economic status, immigrant status and acculturation;²⁰ traditional Hispanic values are strongest among those who are least acculturated in the United States.²¹

Hispanic culture thus plays an important role in understanding Hispanic teenage pregnancy, yet information about effective pregnancy prevention programs that are aligned with the cultural experiences and values of Hispanic youth is lacking. As a result, the National Council of La Raza, the largest national constituency-based Hispanic organization in the United States, has recommended strategies for effective Hispanic teenage pregnancy prevention.²² The recommendations call for programs to have culturally sensitive, nonjudgmental staff; emphasize education and support high aspirations; be responsive to Hispanic subgroup differences; involve parents, families and male partners; and recognize cultural values regarding gender roles.

A preliminary study conducted in 1998 in the San Francisco Bay area found that many programs have the goal of employing strategies consistent with the La Raza recommendations; however, practitioners face multiple challenges to putting the recommendations into action, and little attention has been given to practitioners' experiences and perspectives. We set out to learn from practitioners the relevance of the recommendations for contemporary Hispanic teenage pregnancy prevention programs, the challenges associated with implementation and strategies for success. Our purpose was not to define the recommendations for practitioners, but rather to hear in their own words their understanding of the recommendations.

METHODS

Between February and June of 2001, we interviewed 58 practitioners who were employed in pregnancy prevention programs in the San Francisco Bay area and in California's southern Central Valley, a less urban region. The practitioners were identified from the authors' professional networks for voluntary participation. Purposeful sampling was used to select participants who provide a broad range of pregnancy prevention and parenting services to Hispanic teenagers, their families and their partners. Teenagers reached through their programs are predominantly Mexican American and, as in most pregnancy prevention programs, predominantly female.²³

Twenty-four of the practitioners worked in the San Francisco Bay area, and 34 in the Central Valley. Twenty-six were Hispanic, and 26 were male. Ten practitioners were 20-29 years old, 21 were 30-39, 17 were 40-49 and 10 were 50-59. The sample was diverse in educational level (high school to medical degree) and type of program (schools, health or social services agencies, and nonprofit organizations).

All practitioners were interviewed individually at the program site, except two, who were interviewed as a pair. The interviews were conversational, following an interview guide that addressed each summary recommendation. We asked practitioners to describe what each recommendation meant, whether it has been put into practice in their program, and possible barriers to and successful strategies for implementation. Each interview took approximately 45 minutes, and we compensated participants with a Best Practices in Teenage Pregnancy Prevention Handbook.²⁴

Each interview was audiotaped, transcribed and analyzed using qualitative methods.²⁵ Working in pairs, the research team read all of the transcripts and categorized and coded excerpts using qualitative data coding software. The La Raza recommendations were used as an initial coding list to organize and analyze data.²⁶ Themes were developed regarding the relevance of each recommendation, strategies to operationalize it, as well as impediments; all excerpts pertaining to these themes were placed with similar quotes into categories. The research team met regularly to review the coding process and discuss emerging themes. We highlighted frequently mentioned ideas as well as those that we felt were particularly innovative or unique. The quotes in this article were selected to represent a general theme in the participants' responses or for their richness and range.

RESULTS

Culturally Sensitive, Nonjudgmental Staff

The first issue discussed was the recommendation that programs have culturally sensitive, nonjudgmental staff. Our analysis reveals two diverging streams of thought: Some practitioners defined cultural sensitivity in terms of discrete practices, or as a professional "skill set," whereas others discussed complex ideas about the interplay between personal experience, program goals and youths' cultural backgrounds.

For at least a subgroup of these professionals, cultural sensitivity is viewed almost as a credential—a qualification that can be obtained by taking the proper classes and workshops. Others interpreted it as having staff who understand and speak Spanish, or are Hispanic. At least some non- Hispanic practitioners gave the impression that they hire Hispanic or Spanish-speaking staff to be responsible for communication with Hispanic teenagers and their families—in essence, to be "culture experts," whose presence relieves them when they are faced with intercultural challenges.

Other practitioners mentioned similar intercultural skills and experiences, but linked them to how teenagers and their families experience the program or to the program's effectiveness. They suggested that when programs include Spanish-speaking practitioners, parents of teenage participants are more likely to listen and respond to advice. For some practitioners, "speaking the language" means language of origin (i.e., Spanish or English), but may also take into account dialect, slang, social class and immigrant generation. A Hispanic, Spanish-speaking doctor in his 30s summarized the importance of language as follows:

"It would be important to have an ability to use the language around sexuality and pregnancy prevention because depending on the level of English language ability and acculturation, people might be accustomed to hearing it in one language or the other. I think most important is to speak the language that the client is most comfortable in. It might be in one for the young person, and it might be in a different language for the parent."

Still other practitioners provided rich definitions and perspectives on cultural sensitivity and being nonjudgmental. They pointed out that although sharing a cultural background is a benefit for understanding Hispanic teenagers, it does not guarantee cultural sensitivity. Several practitioners suggested that staff members' skills, experiences and commitment to helping teenagers are more important than their language ability or cultural heritage. Important skills or experiences mentioned include the abilities to connect with and care for young people, to be an appropriate role model for teenagers, and to relate to and communicate with teenagers' families, as well as being from the same economic background or having been a teenage parent. Although being Hispanic is not imperative to these practitioners, some knowledge and awareness of Hispanic culture is viewed as essential.

The practitioners described many strategies that they use to achieve a culturally sensitive, nonjudgmental program atmosphere. Many pointed out the success of having teams of staff with diverse backgrounds and perspectives, so that they can learn from one another's experiences. Another strategy mentioned, involving parents in program efforts, is often recommended as a program strategy in general pregnancy prevention efforts and is, in fact, one of the La Raza program recommendations.²⁷ A non-Hispanic male caseworker said:

"I really like to be sensitive to what [teenagers have] been raised up with so that they don't think we're disrespecting them. And then, too, I find that I have a lot more progress, not only with my client, but with the family, because a lot of times the family support makes a difference."

Finally, several practitioners brought up the conflicting messages that pregnant and parenting teenagers often get from traditional Hispanic culture on the one hand, and from contemporary U.S. culture on the other. According to a non-Hispanic, government-sponsored health program administrator with many years of experience, the job of program staff is to balance competing cultural demands, some of which are at times at odds with the goal of teenage pregnancy prevention:

"They're having children at a younger age, and it's more acceptable to stay at home with the kids rather than finish school....If you're aware of those types of things, it's going to help you understand. It's going to help you communicate with the teenager better....You don't want to completely tell them, 'Okay, you don't have to go to school because this is how it is in your country.'...At the same time, you want to teach them that school is important. And then you try to find a balance."

Emphasize Education and Support High Aspirations

In general, practitioners interpret an emphasis on education to mean encouraging teenagers to complete high school or GED requirements. Others interpret education in terms of key program elements: health and sex education or life skills such as managing personal finances. High aspirations might include personal goal-setting for vocational education or college attendance. Overall, practitioners agree that support for education and aspirations are important but challenging program components. They often described transportation challenges and lack of knowledge of the advanced educational system as factors inhibiting teenagers from attending college. Youth have difficulty filling out the forms, believe that they will not be able to afford college or think that there will be limited or no child-care services available. A non-Hispanic female family therapist intern noted:

"Sometimes that is all it takes—somebody to just walk them through the process. Sometimes they are so afraid. They [can't] get on the telephone and start asking questions."

Barriers to supporting education and aspirations were described in the context of working with Hispanic teenagers who are already parents—typically teenage mothers. Practitioners noted that if a teenage mother's parents did not complete high school, they often expect her to stay at home to raise her child. In situations where parents or older siblings have "made it" without a high school education, families may have similar expectations for their teenage children. Other respondents suggested that boyfriends often do not want their girlfriends to go to school; as a non-Hispanic male program director noted, "they see it as a threat to their connectiveness."

Many efforts to promote education and high aspirations respond to the particular needs of Hispanic youth and their partners. Strategies include fostering Hispanic teenagers' self-esteem, showcasing career opportunities and coaching youth through the college application process. In California, there are programs that provide teenage parents with financial incentives for college. A non-Hispanic male case manager noted:

"I tell them, 'There's money if you maintain C averages or better and graduate. You can get a down payment on your first car.'"

Some practitioners invite Hispanic guest speakers to discuss career options with youth; others secure adult or peer mentors. To foster youths' self-esteem and willingness to continue their education, some practitioners offer personal support. Several interviewees dedicate time outside of work to support youth. For example, the director of a school-based program in the Central Valley mentioned that case managers have driven girls to school on their way to work, "because the case manager was the only thing in that [teenager's] life that they could count on that was stable." For these practitioners, emphasizing education and supporting high aspirations is more than a professional program practice—it is a personal commitment.

These stories speak to the many barriers to education that Hispanic teenagers may face. Blocked expectations may lead some teenagers to value early parenthood as one of the few meaningful adult roles that they can achieve.²⁸ Many adolescents view higher education, stable employment and a marriage defined by economic security as unattainable. Hispanic teenagers may also face a low cultural value on women's education because of the emphasis on motherhood and family roles.²⁹ For these teenagers, program practitioners may play a particularly important role in instilling and reinforcing values and motivations for attaining education. Consistent with the now classic observations of resilience among disadvantaged youth,³⁰ these practitioners help many teenagers overcome what would otherwise feel like insurmountable obstacles in their lives.

Responsiveness to Subgroup Differences

Although we did not specifically ask practitioners to discuss acculturation, much of their discussion of Hispanic subgroup differences centered on the degree to which teenagers and their families were acculturated to U.S. society. Most practitioners acknowledged subgroup differences with respect to country of origin, parental educational attainment and immigrant generation. Several mentioned that Hispanic parents who are less educated or who are recent immigrants are less likely than others to reinforce the goals put forth by the program. Generally, parents with higher levels of education have values and goals that are more congruent with pregnancy prevention programs. For example, practitioners suggested that parents' education is associated with teenagers' knowledge about sexuality and how to prevent pregnancy. A Hispanic male doctor suggested:

"There's more awareness of sexuality and pregnancy prevention if the parents of the teenagers have more education. So the more educated the parents are, the more likely that their children will be aware of pregnancy prevention, contraception."

Teenagers whose parents are less educated are less familiar and comfortable with educational institutions, and tend to be intimidated by school officials and bureaucracy. They tend to be shyer and less confident of their ability to learn. Additionally, their parents may have substantial work demands, including multiple jobs, long hours or overtime work. These obligations may explain why some practitioners feel that less educated parents care less about their children's education and are less involved in their children's lives than are more educated parents.

Some practitioners noted that educated parents from urban areas have different goals for their daughters than do parents who have little education or are from rural backgrounds. Educated parents are more likely to want their daughters to become educated themselves and to postpone pregnancy so that motherhood does not interfere with their education. A Hispanic female community worker observed:

"In the rural areas, it's more common to see a younger woman getting pregnant or getting married as early as 13 years old....But if it's a person who is coming from the city areas and they have more education, then they don't expect their daughters to become pregnant or [want] to get married at 13 or 14; they want them to finish their education."

Most practitioners agreed that there are important differences by whether youth were born outside or inside the United States. Immigrant teenagers and their families experience greater cultural and language barriers than those born in the United States, and their values and views are more likely to be different from those of the pregnancy prevention program. New immigrants may feel wary when interacting with government employees and people in positions of authority, which makes it difficult to connect with appropriate services and programs. Often, practitioners must first address clients' issues of confidentiality and assure that they do not report to the Immigration and Naturalization Service. Overall, the practitioners recognized the importance of being sensitive and responsive to differences among subgroups of the Hispanic youth whom they serve.

Involvement of Parents, Families and Male Partners

Given the importance of family in Hispanic cultures, it is not surprising that most practitioners viewed the involvement of parents and extended family members as very important. As a non-Hispanic male program director stated:

"Nobody is an isolated individual. You need contacts and framework with which to address that person, and usually it's within a family."

However, the family can either help or hinder prospects for teenage parents and their children. Most practitioners acknowledged that when parents understand and share the goals of the program, fewer conflicts arise between the program and the family. A non-Hispanic counselor described his approach:

"When you have the support of the family...then change is allowed to occur. Again, the goal is to remove barriers. It could be that young people are exposed to options, alternatives, or are able to explore things, but they go back into a family system that discourages them making those fundamental changes."

Most practitioners agreed that it is difficult to involve parents in their programs, citing language barriers, parents' lack of time and energy because of work schedules, and more serious causes, such as parental abuse of teenagers. For some teenagers, parents can be a negative influence if they are not present or responsive to their teenagers' needs. However, even when parents are willing to participate in the programs, practitioners face challenges overcoming cultural ideas or practices that are inconsistent with program goals or accepted practices in the United States. Furthermore, some families want to keep family problems private. A non-Hispanic female program director suggested:

"I think there is some cultural carryover...to keep the problems in the family. They just don't want other people knowing their family business."

To develop a solid relationship with parents, practitioners need to establish trust and demonstrate respect for parents' role. Practitioners described communication as a key to gaining parents' trust—both in the practitioner and in the program. A non-Hispanic female nurse explained:

"You want to establish some trust. You want them to respect what you're telling them."

Communication, however, is not always easy to achieve, and takes a great deal of time and investment. A non-Hispanic female caseworker noted:

"It's just finding their comfort zones and what's acceptable to them and what's not comfortable."

Practitioners described employing strategies to involve parents in their programs, such as visiting parents, starting mentoring programs, teaching better communication skills and offering parenting groups with trained counselors. Some provide monthly mother-daughter events, family nights, open houses or back-to-school nights. Overall, practitioners want to communicate with parents to facilitate their understanding and awareness of the program and its goals. A non-Hispanic program director described his approach:

"It's not just the teenager that we're serving, but the whole family unit. We want to make sure that the teenager is well supported....So anyone in the household could potentially be someone that we needed to connect with and link to the services."

Practitioners mentioned challenges related to involving young men in any reproductive health program,³¹ noting that the physical spaces (i.e., images on the walls, waiting and examining room reading materials) are typically geared to women, most of the clients are women and programs are typically staffed by women. In regard to men and the clinic, a female Hispanic clinic worker said:

"They didn't feel comfortable in having to go in there."

Additionally, young Hispanic women often have adult partners³² and may know about statutory rape laws. Therefore, they may be reluctant to give information about their partner for fear that he will be arrested. Practitioners shared their observation that although the father might be active in the lives of the teenager and her child, often he is socially invisible to avoid legal repercussions. Practitioners work to involve men by providing job training and placement, by offering all-male support groups and by conducting intensive case management that include personal contacts and home visits.

Recognize Cultural Values Regarding Gender Roles

Gender roles are viewed primarily in terms of their influence on young women's education, work status and potential to become self-sufficient. Several practitioners noted that some Hispanic men do not want external influences, such as friends, school, work or social agencies, in contact with their partners and families. A non-Hispanic female caseworker commented:

"The last thing [men] want is some social worker coming in and changing all their family dynamics. And some of the senior dads, because of their background, don't believe that community resources should even come into their home, because it's a private thing."

Hispanic teenage women whose partners have these attitudes may become socially isolated and more dependent on their partners. In some programs, practitioners emphasize the U.S. value of equality between men and women; however, in doing so, they have difficulty countering traditional attitudes that are often held by both young men and women.

Practitioners noted that some parents of pregnant or parenting teenagers believe in the traditional gender roles and see practical advantages of young women's marrying older men. A non-Hispanic male public health nurse observed:

"[For] some of the parents, back where they came from, their parents always liked [daughters] to marry someone much older who's more stable. If you don't take that into account...you look at them and just say, 'What bad parents. They're allowing their daughter to be with this man.'"

To encourage young women to remain engaged in education, practitioners explain to them that it is the norm in the United States for women to be educated and to work. These practitioners tell teenagers that it is acceptable to follow other paths than those taken by their mothers and grandmothers. Many of the practitioners point out to teenage mothers that continuing their education (including learning English) will create opportunities for the future and stress that in doing so, they will serve as positive role models for their children. In addition, they often provide teenagers with information about educational opportunities and financial aid or plan presentations by well-educated Hispanics to serve as role models.

According to practitioners, young mothers often assume that the father will support them and their children, and that they need not worry about getting an education or becoming employable. Thus, encouraging teenage mothers to be economically self-sufficient is another important issue for many pregnancy prevention programs. Several practitioners noted that the concept of self-sufficiency has a different meaning and value within the Mexican culture. This is particularly true as it pertains to female roles within and outside the family, which confer upon women a status that may be equivalent to the status of self-sufficiency so valued in the United States. A Spanish-speaking doctor in the San Francisco Bay area commented:

"I think the whole concept of self-sufficiency might be an adopted value from [U.S.] culture."

This practitioner went on to articulate a unique dilemma that Hispanic women face in the United States. In Mexico, women with traditional roles are interdependent with their families. The dilemma for Hispanic women in the United States is that not only is a traditional Hispanic role devalued, but family interdependence is undermined by patronizing or harsh attitudes toward "homemakers" (particularly those who are low-income) and by notions of self-sufficiency that are rigidly defined in economic terms.³³ Therefore, the U.S. concept of self-sufficiency may simply be inappropriate in the context of Hispanic cultures, which value family interdependence more highly than individual economic self-sufficiency.

DISCUSSION

Our conversations with 58 pregnancy prevention practitioners in California have helped us better understand the realities of and challenges for integrating cultural sensitivity into ongoing pregnancy prevention efforts. However, before discussing the results, it is important that we acknowledge the limitations and perspectives that have defined our study. First, our focus was on California, and although we interviewed practitioners from two regions in the state, most worked in programs that served primarily Mexican American adolescents. Thus, the perspectives discussed here may not represent practitioners who work in other areas of the United States or primarily reach other Hispanic subgroups. In addition, we did not attempt to examine differences in these perspectives based on practitioners' characteristics (e.g., region, gender, ethnicity, education or age). This is an important area for further exploration, and one that we will take up in future research.

It is also important to acknowledge our own values and perspectives. We hold that although pregnancy and parenthood among Hispanic teenagers are not in themselves bad, early parenthood limits the options for young parents and their children in the United States. The study described in this article reflects our multicultural perspectives, yet we acknowledge that this work is shaped by our biases—both those that we are conscious of and those that we have not recognized but that the reader may infer. Finally, we acknowledge the difficulties in fully capturing the meanings of the interactions—those not reflected in the written words—that took place during the interviews.³⁴

Practitioners' Perspectives and Professional Realities

Other researchers have argued that interventions need to move from being "expert-led" to being "community-led."³⁵ Our study is grounded in conversations with pregnancy prevention practitioners, who are typically positioned somewhere between the community and the role of the expert. Their professional lives consist of their translating expert knowledge into practice within a community. It is ironic that only rarely are the perspectives of practitioners taken as a source of information on prevention or intervention programs.

Much of what the practitioners told us points out the conflicts inherent in their role—conflicts that crossed personal, professional and structural realities of teenage pregnancy prevention programs. For many practitioners, the professional role is secondary to a personal commitment to the teenagers in their programs; they described commitments and activities that extended far beyond "professional" duties to the teenagers for and with whom they worked. Erickson argues that a basic problem of U.S. teenage pregnancy prevention programs is their inability to address fundamental social, economic and cultural challenges at the root of teenage pregnancy.³⁶ The practitioners' descriptions of the realities of their daily work hint at the larger societal issues of social class, poverty and ethnicity that define U.S. teenage pregnancy—its contexts, causes and consequences.³⁷

The extension of the practitioner's role to fulfilling so many basic needs for teenagers highlights both the fundamentally limited opportunities that characterize these teenagers' lives and some fundamental mismatches between the goals of teenage pregnancy prevention programs and clients' needs. Practitioners acknowledged significant challenges to involving families and male partners in program activities; several described the program settings as being fundamentally designed by and for women, a fact that unintentionally discourages male involvement in pregnancy prevention efforts.

Finally, despite differences in their understandings of cultural sensitivity for prevention programs, all of the practitioners we interviewed value cultural sensitivity. Generally, they told us that staff characteristics such as sharing a Hispanic cultural background or Spanish-language ability does not guarantee that staff will be culturally sensitive and effective in working with Hispanic teenagers and their families. Practitioners spoke of culturally sensitive staff as understanding youth culture and language, sharing experiences, being a role model and having an awareness of Hispanic cultures and acculturation. It is noteworthy that they viewed personal commitment to clients as a very important staff characteristic—more important than cultural sensitivity per se. This is consistent with findings from other studies of community-based programs serving youth.³⁸ Finally, the ability to work in teams with diverse skills and perspectives was described as critical for serving teenagers and their families.

The Clash Between Hispanic and Program Cultures

We are struck by what we interpret to be a clash between U.S.-based values that guide teenage pregnancy prevention programs and the values of traditional Hispanic cultures. These value differences remained implicit in our conversations with practitioners, but were evident in the tensions that they described in talking about their work across these cultures. The culture of teenage pregnancy prevention in the United States places the highest value on postponing pregnancy and parenthood until individuals are economically self-sufficient. Economic self-sufficiency is often linked to marriage and education, which are most typically achieved well after the teenage years. Thus, although both teenage pregnancy prevention culture and Hispanic culture value marriage, the fundamental dimensions of teenage pregnancy prevention culture directly contradict Hispanic cultural traditions that place the highest value on family and motherhood roles for women. In essence, these prevention programs may challenge the familialism that is a fundamental source of strength for many Hispanics.

In the United States, Hispanic teenage pregnancy prevention programs are almost by definition invested in acculturating their clients to the values of individual economic self-sufficiency and gender equality. These values hinge on a shift in thinking about what it means to be Hispanic—a shift from an interdependent and family-based identity to one based on economic and individual independence from both family and intimate partners. Practitioners emphasized issues of Hispanic women's education and employment when they discussed the program recommendation to recognize and address cultural values regarding gender roles. Some talked about how women's economic independence could be threatening to Hispanic men, whereas others described ambivalence or resistance to U.S. values for women's education and work. One practitioner expressed the double bind that Hispanic women in the United States face in attempts to integrate the competing values placed on family roles with pressures to be economically independent.

Conflicts between teenage pregnancy prevention programs and Hispanic cultures were also evident in discussions about the challenges and strategies for involving families and men in pregnancy prevention programs. Practitioners were almost unanimous in their view that involving families and men is an important strategy for working with Hispanic teenage populations on pregnancy prevention. At the same time, the notion of "involvement" is problematic for practitioners. Some families or male partners are active in the lives of Hispanic teenage parents, but may not participate in teenage pregnancy prevention programs because they do not share the values and perspectives those programs promote. Practitioners described efforts to balance the potentially competing values of families, partners and programs. For others, family and male involvement is a "culturally appropriate" program strategy, with the underlying assumption that this involvement should not challenge program goals.

Ultimately, the purpose of all prevention and intervention efforts is to promote good health and well-being among participants; a secondary and perhaps only indirectly acknowledged goal for many programs is to teach and reinforce predominant U.S. cultural values. Such efforts may conflict with cultures of origin, and yet we found variability in the degree to which practitioners acknowledged this conflict of cultures. We hope that our research may prompt dialogue about the purposes of prevention programs. Regardless of whether acculturation to U.S. values is universally valued, we suggest that the ability of young people to make the best choices for themselves and their futures should be.