Advancing Sexual and Reproductive Health and Rights
 
Family Planning Perspectives
Volume 33, Number 4, July/August 2001

States' Implementation of the Section 510 Abstinence Education Program, FY 1999

By Adam Sonfield and Rachel Benson Gold

Context: As part of its reworking of the nation's welfare system in 1996, Congress enacted a major new abstinence education initiative (Section 510 of Title V of the Social Security Act), projected to spend $87.5 million in federal, state and local funds per year for five years. The new program is designed to emphasize abstinence from sexual activity outside of marriage, at any age, rather than premarital abstinence for adolescents, which was typical of earlier efforts. The actual message and impact of the program, however, will depend on how it is implemented.

Methods: Program coordinators in all 50 states, the District of Columbia and Puerto Rico were surveyed concerning implementation of the Section 510 abstinence education program in FY 1999. The questionnaire asked about expenditures and activities performed, about policies established for a variety of specific situations and about how the term "sexual activity" is defined and what specific components of the federal definition of "abstinence education" are emphasized.

Results: Forty-five jurisdictions spent a total of $69 million through the Section 510 program in FY 1999. Of this total, $33 million was spent through public entities, $28 million was spent through private entities and $7 million (in 22 jurisdictions) was spent through faith-based entities. Almost all jurisdictions reported funding school-related activities, with 38 reporting in-school instruction and presentations. Twenty-eight jurisdictions prohibited organizations from providing information about contraception (aside from failure rates), even at a client's request, while only six jurisdictions prohibited information about sexually transmitted diseases. Few reported having a policy or rendering guidance about providing services addressing sexual abuse, sexual orientation or existing pregnancy and parenthood. Only six respondents said they defined "sexual activity" for purposes of the program, and 16 reported focusing on specific portions of the federal definition of "abstinence education."

Conclusions: More than one in 10 Section 510 dollars were spent through faith-based entities. Programs commonly conducted in-school activities, particularly instruction and presentations, not only through public entities, but also through private and faith-based entities. Most jurisdictions prohibited the provision of information about contraception, about providers of contraceptive services or about both topics, even in response to a direct question and when using other sources of funding. Most also left definitions of "abstinence" and "sexual activity" as local decisions, thus not clearly articulating what the program is designed to encourage clients to abstain from.

Family Planning Perspectives, 2001, 33(4):166-171

The federal government has had a long-standing interest in promoting abstinence as a means of preventing pregnancy and sexually transmitted diseases (STDs), particularly among adolescents, and has been involved in funding abstinence education programs for two decades. Congress's first foray into the issue was in 1981, with the passage of the Adolescent Family Life Act (AFLA).1 The program's goal was to prevent premarital adolescent pregnancy by promoting the values of chastity and self-discipline, as well as to promote adoption as the preferred option for pregnant adolescents and to provide support for pregnant and parenting adolescents.

Congress revisited the subject of abstinence when it overhauled the nation's welfare system in 1996. Many of this new law's provisions were focused on the idea that the traditional welfare system had become a disincentive to marriage and an incentive to nonmarital childbearing. As one effort to counter this trend, Congress included in the welfare law a major new abstinence education initiative. Administered by the federal Maternal and Child Health Bureau at the Department of Health and Human Services and codified under Title V, Section 510, of the Social Security Act, the abstinence education program guarantees $50 million annually per year from FY 1998 through FY 2002. States are required to match every four dollars in federal funds with three dollars in state or local funds (including in-kind contributions), bringing the expected annual total public expenditure to $87.5 million. In addition to providing direct educational activities with these funds, states are allowed to provide "where appropriate, mentoring, counseling, and adult supervision to promote abstinence from sexual activity."2

Funds under this program are allocated to states based on a federal formula related to the number of low-income children in each state. State agencies may directly administer abstinence education programs themselves, or they may provide grants to other public entities at the state or local level or to private, nonprofit agencies, including faith-based organizations. Faith-based entities are eligible to receive AFLA funds; however, under a court settlement arising from a challenge based on the First Amendment of the U.S. Constitution, they were prohibited from using government money to teach or promote religion. In guidelines issued in May 1997,3 the Maternal and Child Health Bureau recommended that states apply the same criteria to the Section 510 abstinence education program.

The Section 510 program marked a significant shift to a broader concept of promoting abstinence from sexual activity outside of marriage, at any age. Commenting on the intent of Congress in drafting the provision, Ron Haskins and Carol Statuto Bevan, congressional staff members who were key to the crafting of the abstinence education language, wrote that while some might consider the standard required by law to be outdated, it "was intended to align Congress with the social tradition...that sex should be confined to married couples."4

This departure from previous abstinence education initiatives was embodied in an eight-point definition of "abstinence education" that labels nonmarital sexual activity and childbearing as likely to be psychologically and physically harmful to individuals and society. It also states that faithful marriage is the expected standard of sexual activity.* The Maternal and Child Health Bureau's guidelines for the program state that "it is not necessary to place equal emphasis on each element of the definition."5 Although the guidelines go on to state that "a project may not be inconsistent with any aspect of the abstinence education definition," this language gives states and initiatives some flexibility in designing their abstinence education message.

Research regarding the structure, implementation and evaluation of the Section 510 program at the state level has been conducted by the Maternal and Child Health Bureau, in its annual summaries for the program. In addition, several outside organizations, such as the Association of Maternal and Child Health Programs, the Sexuality Information and Education Council of the United States and the State Policy Documentation Project (a joint project of the Center on Budget and Policy Priorities and the Center for Law and Social Policy) have examined some aspects of how the program has been implemented.6

Although these studies have looked at the types of organizations receiving funding and at the types of activities being conducted, they have not examined the extent to which funding goes to specific types of organizations, nor have they linked the types of activities being conducted to funding data. In addition, previous work has not examined the extent to which state abstinence efforts have chosen to emphasize specific components of the eight-point definition embodied in the federal legislation.

Moreover, none of these other studies have addressed a range of important issues on which both the law and the federal guidelines are vague, leaving key decisions to the states. First, while federal policy prohibits initiatives from promoting methods of pregnancy and STD prevention other than abstinence or from providing related services, federal rules are silent on how initiatives should or may handle direct questions from clients and requests for referrals. Similarly, there is no federal guidance on whether or how initiatives should address and provide support and referrals for groups for whom a strict message of abstinence outside of marriage does not easily apply—such as individuals who have been or who may have been sexually abused, who are or who may be homosexual, or who are pregnant or are already parenting.

Finally, the federal law and guidelines leave undefined the very term "sexual activity," even though a number of organizations, when commenting on the proposed guidelines issued by the Maternal and Child Health Bureau, specifically requested such a definition. Although these organizations were divided over how the term should be defined, they agreed that the term could be given a wide range of interpretations—from being synonymous with vaginal intercourse to including other types of sexual activity with significant risk of STD transmission (such as anal and oral intercourse) to including any expression of sexual feeling.

Health and abstinence educators also broadly disagree or are ambivalent about what constitutes "sex"—and, therefore, about what constitutes "abstinence." One recent report concludes that "abstinence proponents are wrestling with how to handle an evolving dilemma that pits those who stress the need to be as precise as possible in specifying the range of behaviors to be abstained from against others who insist that such specificity violates the core of abstinence-only education."7Consequently, it is important to determine how various states have dealt with these issues as they design and implement their Section 510 efforts.

METHODOLOGY

In April 2000, we sent questionnaires regarding implementation of the Section 510 abstinence education program during FY 1999 (October 1, 1998, through September 30, 1999) to the individuals listed by the Maternal and Child Health Bureau as program coordinators in 50 states, the District of Columbia and Puerto Rico. We obtained responses from 46 states, the District of Columbia and Puerto Rico; program coordinators in four states (Colorado, Louisiana, Mississippi and South Dakota) declined to complete the survey. Of the 48 respondents, two (California and New Hampshire) did not spend Section 510 funds during FY 1999 and therefore were not applicable to our survey. As a result, we compiled results from a total of 44 states, the District of Columbia and Puerto Rico.

Program officials were asked to report total expenditures during FY 1999 under the Section 510 program and to indicate how much of this total was in federal dollars and how much was in nonfederal dollars (including in-kind contributions). Officials also were asked to indicate how much of this total was spent through public entities, through private entities (excluding faith-based entities) and through faith-based entities, and to report what activities were performed under the Section 510 program through each of these types of entity.

In addition, we asked whether, under the Section 510 program, organizations were allowed to provide instruction promoting specific religious values or beliefs or to provide information about contraception, about STDs and about providers of related services when a client specifically asks for such information. Further, we asked officials whether they had policies on or provided guidance for the Section 510 program about services to clients with several types of special needs, as well as about defining the term "sexual activity." Finally, we asked officials to indicate which if any of the specific components of the definition of abstinence education they had chosen to emphasize.

Several methodological issues arose in the course of this study. For questions relating to funding, several respondents were unable to provide complete answers, and states were inconsistent in how they accounted for in-kind contributions; in fact, one reported such a massive in-kind contribution ($21 million above what was required) that we reduced the figure to the amount required by law, in order to avoid skewing the data. A few jurisdictions were unable to categorize a portion of their expenditures as spent through one of the three types of entities, even after consulting us for assistance. A number of responses indicated confusion over our distinction between adult counseling and mentoring and peer counseling and mentoring; for this analysis, we merged the two categories. Similarly, we merged the categories of classroom instruction and in-school presentations. Also, many respondents had difficulty answering a question about promoting specific religious values or beliefs; ultimately, we excluded this question from the analysis.

FINDINGS

Funding

Of the 46 jurisdictions that gave usable responses, all but one (Georgia) were able to provide funding data and to categorize their data into the three categories used here: public, private and faith-based.

Forty-three states, the District of Columbia and Puerto Rico reported having spent a total of $69 million through the Section 510 abstinence education program in FY 1999. Of that total, $34 million was in federal dollars and $35 million was in nonfederal dollars.

Thirty-nine states, the District of Columbia and Puerto Rico reported having spent $33 million through public entities, 48% of the total (Table 1). Thirty-six states spent $28 million (40% of the total) through private entities, and 22 states reported spending $7 million (11% of the total) through faith-based entities.

Nine jurisdictions spent all or nearly all of their funds through public entities, and another six spent more than half of their funds through such entities. Private entities were the only funding recipients in three states and received the majority of funds in 14 others. No jurisdiction spent a majority of their funds through faith-based entities, although five states spent at least one-quarter of program monies through such entities, and nine others spent at least 10%.

Activities Performed

Each of the 45 jurisdictions that answered the questions related to funding also reported what activities were performed through each type of entity in FY 1999 under the Section 510 program (Table 2). Among the 41 jurisdictions that spent money through public entities, the most commonly reported of the 12 activities about which we asked was program planning and evaluation. This activity was performed through public entities in 36 jurisdictions. In-school instruction and presentations and parent and family education (in 34 and 32 jurisdictions, respectively) also were common. The least frequently conducted activity, and the only one listed by fewer than half of the 41 jurisdictions, was sports, recreation and community service (in 17 jurisdictions).

Among the 36 jurisdictions that spent money through private entities, the activities most commonly conducted through these entities were media campaigns and public awareness efforts (in 27 jurisdictions), parent and family education (in 26) and in-school instruction and presentations (in 25). Again, sports, recreation and community service was listed least often (in 14 jurisdictions), and two others—curriculum development and implementation (in 17) and training for teachers and school officials (in 18)—were given by half of the 36 jurisdictions or fewer.

Twenty of the 22 jurisdictions that made expenditures through faith-based entities listed parent and family education among the activities performed by these entities. In-school instruction and presentations was reported by 18, while education programs outside of schools and counseling and mentoring were each given by 17. Training for teachers and school officials (in 10) and curriculum development and implementation (in 11) were mentioned least often.

Overall, 41 of the 45 jurisdictions reported that program planning and evaluation was performed under the Section 510 program in FY 1999, followed by parent and family education and in-school instruction and presentations (in 38 jurisdictions each). (Four jurisdictions— Connecticut, New Jersey, South Carolina and Washington—reported providing in-school instruction and presentations only through private or faith-based entities.) Four of the 45 jurisdictions—Maine, Massachusetts, Vermont and Wyoming—stood out from the rest in that they reported only activities without specific clients, including media campaigns and public awareness, program planning and evaluation, and administrative expenses (reported under an "other" category).

Information on Contraception and STDs

Nine jurisdictions reported that participating organizations, when specifically requested by a client, were allowed to provide information about contraception (aside from the failure rates of specific contraceptive methods). Three of these allowed such information to be provided using Section 510 funds, while the other six allowed it only when it was funded through sources other than the Section 510 program (Table 3). Twenty-eight jurisdictions prohibited such information entirely, while five provided no guidance on the issue.

Similarly, nine jurisdictions allowed organizations to provide information about available providers of contraceptive services, when asked by a client—four using Section 510 funds and five using other funds only. Twenty-three jurisdictions prohibited such information entirely, while 10 provided no guidance on the issue.

Six jurisdictions allowed organizations to answer questions both about contraception and about providers of contraceptive services (although not always with the same funding source). Three additional jurisdictions allowed organizations to provide referrals, upon request, for both types of information, and one was unable to answer our questions. Overall, 29 of the jurisdictions prohibited provision of information about one or both of these topics.

Thirty-two jurisdictions allowed participating organizations, when specifically requested by a client, to provide information about STDs, including HIV; all but four of these jurisdictions allowed organizations to use Section 510 funds to provide this information. Six jurisdictions prohibited such information entirely, while six provided no guidance on the issue. One additional jurisdiction allowed referrals for such information, while another jurisdiction allowed organizations to provide "general" information only.

Twenty-two jurisdictions allowed organizations, upon the client's request, to provide information about available providers of STD and HIV services, and 18 permitted this to be done with Section 510 funds. Ten jurisdictions prohibited the provision of such information entirely, while 11 provided no guidance on the issue. Three additional jurisdictions allowed referrals to such providers. All 22 jurisdictions that allowed organizations to answer questions about STD and HIV service providers also allowed answers about STDs and HIV as a topic.

Eighteen jurisdictions allowed organizations, upon the client's request, to provide information about STDs, including HIV, but prohibited similar information about contraception (aside from failure rates). Similarly, eight jurisdictions allowed organizations to provide information about available providers of STD and HIV services when they were asked by a client, but did not permit provision of information about pro- viders of contraceptive services. Several other jurisdictions prohibited one or both types of information related to contraception but provided no guidance on similar information related to STDs and HIV. The six jurisdictions that prohibited information about STDs and HIV also proscribed the provision of information about the other three categories.

Of the 29 jurisdictions that prohibited the provision of information upon request about contraception, about pro-viders of contraceptive services or about both, 25 spent Section 510 funds on in-school instruction and presentations (not shown). Twenty-one did so through public entities, 18 through private entities and 15 through faith-based entities. Among the 29 jurisdictions are the 10 that similarly prohibited information about providers of STD and HIV services (six of which also prohibited information about STDs and HIV as a topic). Six of these 10 spent funds on in-school instruction and presentations, including five through public entities, five through private entities and four through faith-based entities.

Specific Populations

Several states indicated that they had a policy or provided guidance to grantees about specific populations that might be served under the Section 510 abstinence education program. Sixteen jurisdictions responded that they had a policy or rendered guidance to grantees about providing services under Section 510 for clients who have or may have been sexually abused. Of these 16, five simply referenced or described their laws mandating that certain professionals, including teachers, report sexual abuse—laws that are universal in the United States. Most other jurisdictions reported that they required participating organizations to make referrals for services or counseling. Only a few answered that they provided or offered specific training on the subject.

Seven jurisdictions reported a policy or guidance about services for clients who are or may be homosexual. Two of these jurisdictions referenced portions of their sexuality education statutes—similar to those in many other states that did not reference them for this survey—that address what types of information about homosexuality may or must be discussed. Initiatives in Alabama must emphasize "in a factual manner and from a public health perspective, that homosexuality is not a lifestyle acceptable to the general public and that homosexual conduct is a criminal offense under the laws of the state." South Carolina's statute prohibits discussion of "alternate sexual lifestyles," except in the context of STDs. The other five jurisdictions briefly described less-specific, nonbinding guidance on counseling these clients.

Six jurisdictions answered that they have a policy or provide guidance about services for clients who are pregnant or already parenting. Two of these six (Arizona and Michigan) described an approach of encouraging "secondary virginity." The other four (Hawaii, Maryland, Minnesota and Puerto Rico) described some type of referral process for other services.

Definition of Sexual Activity

Only six respondents answered that they had a policy or provided guidance to grantees defining "sexual activity" for purposes of the Section 510 program. Three of these jurisdictions—Alabama, Hawaii and Virginia—described a definition that was limited to vaginal sexual intercourse, while Washington State's definition included vaginal, oral or anal sex. Maryland reported that it only asks about "intercourse" for its evaluation, but encourages initiatives to expand the definition in discussions. Finally, Oregon stated that while it does not have a specific definition, it does talk about "seven levels of physical affection" and lets "school values and comfort level" determine what is discussed.

Eight-Point Definition

Thirty of the 46 jurisdictions reported that they did not emphasize any specific components of the eight-point definition of "abstinence education" included in the statute that governs the Section 510 program (Table 4).§ The remaining 16 jurisdictions, about one-third of the total, reported that they took advantage of this option. Among these 16, most selected 3-4 components on which to focus.

Two components were most popular: how to reject sexual advances, including the role of alcohol and drugs (component G, emphasized by all 16 jurisdictions); and the importance of self-sufficiency before sexual activity (component H, emphasized by 15). Least popular were faithful marriage as the expected standard for sexual activity (component D, chosen by Hawaii only), and sexual activity outside marriage as likely to have harmful effects (component E, chosen by none).

DISCUSSION

The total amount spent through the Section 510 abstinence education program by the 45 jurisdictions that provided funding data for this survey—a total of $69 million in expenditures in FY 1999—is almost identical to the expected expenditures for those jurisdictions, $68 million, which includes the federal funds and the anticipated state match, based on the four-to-three matching requirement.**

More than one in 10 of these abstinence education dollars was spent through faith-based entities. Fourteen states spent at least 10% of their total allocations through faith-based entities, including five that spent at least one in four of their abstinence education dollars through such groups.

Jurisdictions commonly reported that Section 510 dollars went toward school-related activities, with 38 reporting that they funded actual in-school instruction and presentations. This confirms other research indicating that abstinence-only education in general has made substantial inroads in public schools over the past decade. A 1998 study of superintendents found that 35% of district-wide sexuality education policies teach abstinence as the only option outside of marriage,8 while a 1999 study of secondary school sexuality education teachers found that 23% taught that message, up from 2% in 1988.9

Significantly, however, we found that some in-school activities—particularly in-school instruction and presentations, although also, to a lesser extent, curriculum development and training for school personnel—were provided not only through public entities, but through private and faith-based entities as well. In fact, 25 of 36 jurisdictions that funded private entities conducted in-school instruction through such entities, along with 18 of 22 jurisdictions that funded faith-based entities. Moreover, four states conducted such instruction only through nonpublic entities.

With most states using Section 510 funds to provide instruction in a school context, where the population is not self-selected, it is vital that programs be able to address a wide variety of individuals, whose circumstances and needs may differ. Few jurisdictions, however, reported that they had a policy or had rendered guidance to ensure or encourage that initiatives address the needs of important populations for which an abstinence-only message may not necessarily apply (people who have or may have been sexually abused, who are or may be homosexual, or who are pregnant or already parenting). Among the few that did, most required or encouraged referrals to appropriate service providers. Providing referrals for necessary services beyond the scope of the initiative is an important component of any public health or education initiative, and states may wish to consider whether they need to require such referrals.

Further, most jurisdictions (29 of the 46 for which we had information) reported prohibiting the provision of information about contraception, about the providers of contraceptive services or about both, even in response to a direct question and even when an organization is using other sources of funding. Twenty-five of these 29 spent Section 510 funds on in-school instruction and presentations—a setting where students' questions are otherwise encouraged; moreover, 18 provided such instruction through private entities and 15 did so through faith-based entities.

Such policies are significant departures from what states generally require for sexuality and health education outside of the Section 510 program. While information on contraception may not be affirmatively included in the policies and curricula that some states already have in place for other forms of sexuality or health education, no state other than Utah goes so far as to restrict teachers in their responses to spontaneous student questions.10

A greater number of jurisdictions reported permitting programs to provide information about STDs or the providers of STD services, and even allowed Section 510 funds to be used for this purpose. Still, six jurisdictions prohibited programs from answering questions related to any of the four topics.

Nearly two-thirds of the jurisdictions opted not to take advantage of the Maternal and Child Health Bureau's invitation to emphasize particular components of the eight-point definition of abstinence.†† This decision nevertheless results in official state policy that appears to give tacit approval to the controversial components that focus on declared societal standards of abstinence outside of marriage and on the "likely" harmful consequences of nonmarital sex and childbearing, at least in that it puts them on an equal footing with the less controversial components. The 16 jurisdictions that emphasized particular components typically selected the less-controversial ones—those focusing on building skills and self-esteem and avoiding the concept of abstinence outside of marriage. Notably, five of the 16 are in New England, the region in which school districts are least likely to have an abstinence-only policy (14%, compared with 35% nationwide).11

Finally, by declining to formally define "sexual activity," most states appear to be putting themselves in the difficult position of not clearly articulating what it is that the abstinence education program is designed to encourage clients to abstain from. Unfortunately, the federal Maternal and Child Health Bureau also declined to provide a clear definition, and left the matter to the states. They now also appear to have opted not to decide. While this abdication of responsibility clearly poses a significant challenge for attempts to evaluate the program and assure accountability, it also makes it imperative that future research focus on the implementation of the program through local initiatives, where these and many other key decisions are unavoidable.

*Table 4 lists the eight components of the definition.

The eight-point definition has since been applied to AFLA and to a third federal abstinence program, part of the special projects of regional and national significance under Title V, Section 501(a)(2), of the Social Security Act.

Four states—Massachusetts, Nebraska, New Jersey and West Virginia—reported a total of $1 million (1% of the total) that they were unable to categorize as spent through one of the three types of entities.

§In these jurisdictions, individual participating organizations may still have been allowed to emphasize specific components. Wisconsin, in fact, reported that it required organizations to choose four components, one of which must be component B, D, E or F.

**This figure includes $39 million in federally allotted funds and $29 million in required matching funds. The remaining $11 million in federal funds slated for the program was allocated primarily for the one state that was unable to provide data for its expenditures ($1 million), the four states that did not respond to the survey ($3 million), and the two states that did not spend Section 510 money during FY 1999 ($6 million).

††Whether states have opted for a more indirect approach by, for example, using the grantee selection process to give preference to entities proposing to teach a specific type of message is beyond the scope of this research.

REFERENCES

1. Title XX of the Public Health Service Act.

2. U.S. Social Security Act 510(b)(1).

3. Maternal and Child Health Bureau (MCHB), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (DHHS), Abstinence Advisory #1, May 12, 1997.

4. Haskins R and Bevan CS, Abstinence education under welfare reform, Children and Youth Services Review, 1997, 19(5/6):465-484.

5. MCHB, HRSA, DHHS, Application Guidance for the Abstinence Education Provision of the 1996 Welfare Law, P.L. 104-193, New Section 510 of Title V of the Social Security Act, Rockville, MD: MCHB, May 1997, p. 9.

6. MCHB, 1999 Annual Summary for the Abstinence Education Provision of the 1996 Welfare Law, P.L. 104-193, Section 510 of Title V of the Social Security Act, Rockville, MD: MCHB, 2000; Pfau S, Abstinence Education in the States: Implementation of the 1996 Abstinence Education Law, Washington, DC: Association of Maternal and Child Health Programs, 1999; Daley D and Wong VC, Between the Lines: States' Implementation of the Federal Government's Section 510(b) Abstinence Education Program in Fiscal Year 1998, New York: Sexuality Information and Education Council of the United States, 1999; and State Policy Documentation Project, Abstinence Unless Married Education Program, 1999, <http://www.spdp.org/absteduc/ index.html>.

7. Remez L, Oral sex among adolescents: is it sex or is it abstinence? Family Planning Perspectives, 2000, 32(6): 298-304.

8. Landry DJ, Kaeser L and Richards CL, Abstinence promotion and the provision of information about contraception in public school district sexuality education policies, Family Planning Perspectives, 1999, 31(6):280-286.

9. Darroch JE, Landry DJ and Singh S, Changing emphases in sexuality education in U.S. public secondary schools, 1988-1999, Family Planning Perspectives, 2000, 32(5):204-211 & 265.

10. The Alan Guttmacher Institute, unpublished data on state sexuality education policies, Washington, DC, 2001.

11. Landry DJ, Kaeser L and Richards CL, 1999, op. cit. (see reference 8).

 

AUTHOR AFFILIATIONS

Adam Sonfield is public policy associate and Rachel Benson Gold is deputy director for policy analysis with The Alan Guttmacher Institute (AGI), Washington, DC. The research on which this article is based was supported in part by the General Service Foundation. The conclusions and opinions expressed in this article are those of the authors and AGI. The authors express their gratitude for the important contributions of Anjali Dalal in this effort. They also thank Daniel Daley, Christine Cralley Fogle, Lisa Kaeser, Shannon King and Vivian Wong for their guidance and comments on the survey instrument and Cory L. Richards for his advice and guidance throughout the project.