Contraceptive method at first sexual intercourse and subsequent pregnancy risk: findings from a secondary analysis of 16-year-old girls from the RIPPLE and SHARE studies

Associations Between Recent Contraceptive Use and First Sex Behaviors of Scottish Adolescents: A Brief Report

Objectives

We examined associations between recent contraceptive use and first-sex behaviors (early initiation, substance use, contraceptive use) among adolescents in Scotland.

Methods

We used data from the Health Behavior in School-aged Children study.

Results

Controlling for early initiation and substance use, girls and boys who used contraceptives at first sex were 7.5 and 12.3 times more likely to use contraceptives at most recent sexual intercourse than adolescents who did not (p < .001). We also present preliminary evidence on contraceptive use of Scottish adolescents in 2022.

Conclusions

Experiences during adolescents' first sex may have lasting implications for later sexual behavior.

Systematic review: risk sexual behavior, sexually transmitted infections, and adolescent pregnancy prevention interventions

In many countries, there is a high number of teenage pregnancies, Sexually Transmitted Infections (STIs), and unsafe sexual behavior, so there is a need for adolescent health intervention programs to change behavior. The effectiveness of comprehensive interventions in various contexts to reduce teenage pregnancy, STIs, and related sexual risk behaviors is reviewed in this systematic. This study aimed to identify risk sexual behavior, sexually transmitted infections, and adolescent pregnancy prevention interventions. Literature search strategy from January 2008 to December 2022 through electronic databases. Key words 'teenage prenancy' OR 'teen pregnancy' OR 'pregnancy adolescence', AND 'maternal education', AND 'randomised clinical trial', AND 'risk behavior'. Articles that were deemed worthy of following the PRISMA guidelines were 28 articles. Most studies looked at school-based, individual, community, clinic, and family-based care. Most studies were followed up after intervention at intervals from one month to seven years, and the majority of the population and sample were adolescents with ages ranging from 13 to 18 years. Implementation of research in urban, suburban, and rural areas. This program has proven successful in preventing pregnancy, contraceptive use, STI and HIV, sexual behavior, dropping out of school, knowledge about pregnancy, sexuality, attitudes towards sexuality, intention to change risky sexual behavior, self-efficacy, and increasing parent-children. This article describes some basic trends in adolescent pregnancy prevention interventions in several countries that can be used as a reference for health programs. Unproven effectiveness can be implemented in conjunction with other interventions that have a high-quality impact.

School-based relationship and sexuality education intervention engaging adolescent boys for the reductions of teenage pregnancy: the JACK cluster RCT

Background

The need to engage boys in gender-transformative relationships and sexuality education (RSE) to reduce adolescent pregnancy is endorsed by the World Health Organization and the United Nations Educational, Scientific and Cultural Organization.

Objectives

To evaluate the effects of If I Were Jack on the avoidance of unprotected sex and other sexual health outcomes.

Design

A cluster randomised trial, incorporating health economics and process evaluations.

Setting

Sixty-six schools across the four nations of the UK.

Participants

Students aged 13-14 years.

Intervention

A school-based, teacher-delivered, gender-transformative RSE intervention (If I Were Jack) versus standard RSE.

Main outcome measures

Self-reported avoidance of unprotected sex (sexual abstinence or reliable contraceptive use at last sex) after 12-14 months. Secondary outcomes included knowledge, attitudes, skills, intentions and sexual behaviours.

Results

The analysis population comprised 6556 students: 86.6% of students in the intervention group avoided unprotected sex, compared with 86.4% in the control group {adjusted odds ratio 0.85 [95% confidence interval (CI) 0.58 to 1.26], p = 0.42}. An exploratory post hoc analysis showed no difference for sexual abstinence [78.30% intervention group vs. 78.25% control group; adjusted odds ratio 0.85 (95% CI 0.58 to 1.24), p = 0.39], but more intervention group students than control group students used reliable contraception at last sex [39.62% vs. 26.36%; adjusted odds ratio 0.52 (95% CI 0.29 to 0.920), p = 0.025]. Students in schools allocated to receive the intervention had significantly higher scores on knowledge [adjusted mean difference 0.18 (95% CI 0.024 to 0.34), p = 0.02], gender-equitable attitudes and intentions to avoid unintended pregnancy [adjusted mean difference 0.61 (95% CI 0.16 to 1.07), p = 0.01] than students in schools allocated to receive the control. There were positive but non-significant differences in sexual self-efficacy and communication skills. The total mean incremental cost of the intervention compared with standard RSE was £2.83 (95% CI -£2.64 to £8.29) per student. Over a 20-year time horizon, the intervention is likely to be cost-effective owing to its impact on unprotected sex because it would result in 379 (95% CI 231 to 477) fewer unintended pregnancies, 680 (95% CI 189 to 1467) fewer sexually transmitted infections and a gain of 10 (95% CI 5 to 16) quality-adjusted life-years per 100,000 students for a cost saving of £9.89 (95% CI -£15.60 to -£3.83).

Limitations

The trial is underpowered to detect some effects because four schools withdrew and the intraclass correlation coefficient (0.12) was larger than that in sample size calculation (0.01).

Conclusions

We present, to our knowledge, the first evidence from a randomised trial that a school-based, male engagement gender-transformative RSE intervention, although not effective in increasing avoidance of unprotected sex (defined as sexual abstinence or use of reliable contraception at last sex) among all students, did increase the use of reliable contraception at last sex among students who were, or became, sexually active by 12-14 months after the intervention. The trial demonstrated that engaging all adolescents early through RSE is important so that, as they become sexually active, rates of unprotected sex are reduced, and that doing so is likely to be cost-effective.

Future work

Future studies should consider the longer-term effects of gender-transformative RSE as students become sexually active. Gender-transformative RSE could be adapted to address broader sexual health and other settings.

Trial registration

This trial is registered as ISRCTN10751359.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (PHR 15/181/01) and will be published in full in Public Health Research; Vol. 11, No. 8. See the NIHR Journals Library website for further project information.

Lower affective empathy in oral contraceptive users: a cross-sectional fMRI study

Evidence accumulates that oral contraceptive (OC) use modulates various socio-affective behaviors, including empathic abilities. Endogenous and synthetic sex hormones, such as estrogens and progestogens, bind to receptor sites in brain regions (i.e. frontal, limbic, and cerebellar) involved in socio-affective processing. Therefore, the aim of this study was to investigate the role of OC use in empathy. In a cross-sectional functional magnetic resonance imaging study, women in different hormonal states, including OC use (n = 46) or being naturally cycling in the early follicular (fNC: n = 37) or peri-ovulatory phase (oNC: n = 28), performed a visual, sentence-based empathy task. Behaviorally, OC users had lower empathy ratings than oNC women. Congruently, whole-brain analysis revealed significantly larger task-related activation of several brain regions, including the left dorsomedial prefrontal gyrus (dmPFG), left precentral gyrus, and left temporoparietal junction in oNC compared to OC women. In OC users, the activity of the left dmPFG and precentral gyrus was negatively associated with behavioral and self-reported affective empathy. Furthermore, empathy-related region-of-interest analysis indicated negative associations of brain activation with synthetic hormone levels in OC women. Overall, this multimodal, cross-sectional investigation of empathy suggests a role of OC intake in especially affective empathy and highlights the importance of including synthetic hormone levels in OC-related analyses.

Effects of an Oral Contraceptive on Dynamic Brain States and Network Modularity in a Serial Single-Subject Study

Hormonal contraceptive drugs are used by adolescent and adult women worldwide. Increasing evidence from human neuroimaging research indicates that oral contraceptives can alter regional functional brain connectivity and brain chemistry. However, questions remain regarding static whole-brain and dynamic network-wise functional connectivity changes. A healthy woman (23 years old) was scanned every day over 30 consecutive days during a naturally occurring menstrual cycle and again a year later while using a combined hormonal contraceptive. Here we calculated graph theory-derived, whole-brain, network-level measures (modularity and system segregation) and global brain connectivity (characteristic path length) as well as dynamic functional brain connectivity using Leading Eigenvector Dynamic Analysis and diametrical clustering. These metrics were calculated for each scan session during the serial sampling periods to compare metrics between the subject's natural and contraceptive cycles. Modularity, system segregation, and characteristic path length were statistically significantly higher across the natural compared to contraceptive cycle scans. We also observed a shift in the prevalence of two discrete brain states when using the contraceptive. Our results suggest a more network-structured brain connectivity architecture during the natural cycle, whereas oral contraceptive use is associated with a generally increased connectivity structure evidenced by lower characteristic path length. The results of this repeated, single-subject analysis allude to the possible effects of oral contraceptives on brain-wide connectivity, which should be evaluated in a cohort to resolve the extent to which these effects generalize across the population and the possible impact of a year-long period between conditions.

Risky Sexual Behavior Profiles in Youth: Associations With Borderline Personality Features

Adolescence and young adulthood are peak periods for risky sexual behaviors (RSB) and borderline personality disorder (BPD) features. RSB is a major public health concern and adolescents with BPD may be particularly vulnerable to RSB, but this is understudied. The aim of this study was to identify distinct RSB profiles in youth and determine whether a specific profile was associated with BPD features. Participants were 220 adolescents and young adults (age 14-21) recruited from the community. To identify groups of adolescents and young adults who engage in similar RSB, a latent profile analysis (LPA) was conducted on sexually active youth (57%). Next ANOVA was used to identify how profiles differed in terms RSB dimensions and BPD features. We identified three distinct RSB profiles: (1) a Low RSB profile that was manifested by the majority (77.7%) of youth; (2) an Unprotected Sex in Relationships profile (13.3%) and; (3) an Impulsive Sex Outside Relationships profile (12%) which was manifested by youth with significantly higher BPD features. The findings shed light on the difficulties youth with BPD manifest around integrating sexuality, intimacy, fidelity, and love. This contrasts with the majority of youth who are sexually active in the context of relationships and engage in little or no RSB. The findings have important clinical implications. Adolescent sexuality is frequently in the blind spot of clinicians. To address the elevated risk of RSB in adolescents with BPD, interventions are needed to help adolescents navigate this period and improve their understanding of the reasons for RSB while addressing difficulties in establishing sexual and attachment relationships.

The Positive Choices trial: study protocol for a Phase-III RCT trial of a whole-school social marketing intervention to promote sexual health and reduce health inequalities

Background

Positive Choices is a whole-school social marketing intervention to promote sexual health among secondary school students. Intervention comprises school health promotion council involving staff and students coordinating delivery; student survey to inform local tailoring; teacher-delivered classroom curriculum; student-run campaigns; parent information; and review of sexual/reproductive health services to inform improvements. This trial builds on an optimisation/pilot RCT study which met progression criteria, plus findings from another pilot RCT of the Project Respect school-based intervention to prevent dating and relationship violence which concluded such work should be integrated within Positive Choices. Young people carry a disproportionate burden of adverse sexual health; most do not report competence at first sex. Relationships and sex education in schools can contribute to promoting sexual health but effects are small, inconsistent and not sustained. Such work needs to be supplemented by ‘whole-school’ (e.g. student campaigns, sexual health services) and ‘social marketing’ (harnessing commercial marketing to social ends) approaches for which there is good review-level evidence but not from the UK.

Methods

We will conduct a cluster RCT across 50 schools (minimum 6440, maximum 8500 students) allocated 1:1 to intervention/control assessing outcomes at 33 months. Our primary outcome is non-competent first sex. Secondary outcomes are non-competent last sex, age at sexual debut, non-use of contraception at first and last sex among those reporting heterosexual intercourse, number of sexual partners, dating and relationship violence, sexually transmitted infections, and pregnancy and unintended pregnancy for girls and initiation of pregnancy for boys. We will recruit 50 school and undertake baseline surveys by March 2022; implement the intervention over the 2022–2024 school years and conduct the economic and process evaluations by July 2024; undertake follow-up surveys by December 2024; complete analyses, all patient and policy involvement and draft the study report by March 2025; and engage in knowledge exchange from December 2024.

Discussion

This trial is one of a growing number focused on whole-school approaches to public health in schools. The key scientific output will be evidence about the effectiveness, costs and potential scalability and transferability of Positive Choices.

Trial registration

ISRCTN No: ISRCTN16723909. Trial registration summary: Date:. Funded by: National Institute for Health Research Public Health Research Programme (NIHR131487). Sponsor: LSHTM. Public/scientific contact: Chris Bonell. Public title: Positive Choices trial. Scientific title: Phase-III RCT of Positive Choices: a whole-school social marketing intervention to promote sexual health and reduce health inequalities. Countries of recruitment: UK. Intervention: Positive Choices. Inclusion criteria: Students in year 8 (age 12–13 years) at baseline deemed competent by schools to participate in secondary schools excluding pupil referral units, schools for those with special educational needs and disabilities, and schools with ‘inadequate’ Ofsted inspections. Study type: interventional study with superiority phase III cluster RCT design. Enrollment: 1/9/21-31/3/22. Sample size: 50 schools and 6440–8500 students. Recruitment status: pending. Primary outcome: binary measure of non-competent first sex. Secondary outcomes: non-competent last sex; age at sexual debut; non-use of contraception at first and last sex; number of sexual partners; dating and relationship violence (DRV) victimisation; sexually transmitted infections; pregnancy and unintended pregnancy for girls and initiation of pregnancy for boys using adapted versions of the RIPPLE measures. Ethics review: LSHTM research ethics committee (reference 26411). Completion data: 1/3/25. Sharing statement: Data will be made available after the main trial analyses have been completed on reasonable request from researchers with ethics approval and a clear protocol. Amendments to the protocol will be communicated to the investigators, sponsor, funder, research ethics committee, trial registration and the journal publishing the protocol. Amendments affecting participants’ experience of the intervention or important amendments affecting the overall design and conduct of the trial will be communicated to participants.

LGB-Affirming School Climates and Sexual Health Outcomes Among U.S. High School Students 2015-2017: Differences by Sex and Sexual Identity

PURPOSE

Lesbian, gay, and bisexual (LGB) adolescents face disparities in sexual health outcomes compared to their heterosexual peers, which has implications for health outcomes and developmental trajectories. We examined whether adolescents living in jurisdictions with school climates that were more exclusionary toward LGB individuals engaged in higher risk sexual behaviors than those in jurisdictions with more inclusive school climates.

METHODS

Data on sexual identity, age at first sex, condom use at last sex and the number of lifetime partners came from the 2015 (20 jurisdictions) and 2017 (19 jurisdictions) Youth Risk Behavior Surveillance Surveys. Data on LGB climates in schools, aggregated to the state level, came from the School Health Profile Survey of the Centers for Disease Control and Prevention. Multilevel multivariable regressions examined the association between LGB school climate and sexual behaviors, including effect modification.

RESULTS

Overall, living in jurisdictions with more exclusionary LGB school climates was significantly associated with a lower age at first sex (β = -.04[-.07, -.02]) and a lower likelihood of condom use (OR = .94[.90, .98]), but not the number of lifetime partners. Associations differed by subgroup: sexual identity modified the relationship between school climate and age at first sex (β = -.09[-.15, -.03]) for bisexual adolescents, and school climate and condom use for bisexual (OR = .86[.76, .98]) and gay adolescents (OR = .66[.64, .68]).

CONCLUSIONS

Exclusionary LGB school climates are associated with a lower age at first sex and a lower likelihood of condom use for all adolescents, and particularly bisexual individuals. Additional research and practice should address school-level climates to support adolescents' healthy sexual development.

Can Teenage Men Be Targeted to Prevent Teenage Pregnancy? A Feasibility Cluster Randomised Controlled Intervention Trial in Schools

The World Health Organisation advocates a direct focus on adolescent men in reducing adolescent pregnancy; however, no trials have been conducted. This trial (ISRCTN11632300; NCT02092480) determines whether a novel Relationship and Sexuality Educational intervention, If I Were Jack, is acceptable and feasible to implement in mixed sex UK classrooms. The intervention is a teacher-delivered intervention that emphasises male alongside female  responsibility in preventing unintended pregnancies and is designed to prevent unprotected sex. The trial was a parallel-group cluster randomised controlled feasibility trial with embedded process and cost evaluation in eight secondary schools (unit of randomisation) among 831 pupils (mean age 14) in Northern Ireland, alongside a qualitative evaluation of transferability in ten schools in Scotland, Wales and England. The sampling strategy was a maximum variation quota sample designed to capture a range of school management types. Four schools were randomised to each arm and the control arm continued with usual practice. Study duration was 12 months (from November 2014), with follow-up 9 months post-baseline. Results demonstrated that the intervention was acceptable to schools, pupils and teachers, and could be feasibly implemented, cost-effectively, with minor enhancements. The between-group difference in incidence of unprotected sex (primary outcome at pupil level) of 1.3% (95% CI 0.5–2.2) by 9 months demonstrated a potential effect size consistent with those reported to have had meaningful impact on teenage pregnancy. The study responds to global health policy for a paradigm shift towards inclusion of men in the achievement of sexual and reproductive health goals in a practical way by demonstrating that a gender-sensitive as well as a gender transformative intervention targeting males to prevent teenage pregnancy is acceptable to adolescent men and women and implementable in formal education structures. If I Were Jack now merits further effectiveness testing.

Determinants of reproductive health services utilization among rural female adolescents in Asgede-Tsimbla district Northern Ethiopia: a community based cross-sectional study

BACKGROUND

Adolescents especially females in rural area are vulnerable to a wide range of reproductive health problems including sexually transmitted infections, unwanted pregnancies, and unsafe abortion. They have limited access to reproductive health services that focus on the special needs of female adolescents. This study was aimed to assess the determinants of reproductive health service utilization among rural female adolescents of Asgede-Tsimbla district.

METHODS

A community-based cross-sectional study was carried out from February to April 2018, in eight randomly selected sub-districts of Asgede-Tsimbla. A total of 844 female adolescents aged 15-19 were interviewed using a pre-tested structured questionnaire. Data were entered into Epi-info Version 3.5.3 and then exported to SPSS Version 21 for analysis. Bivariate and multivariate logistic regression analysis was carried out to assess the association. Statistical significance was declared by 95% confidence interval of the odds ratio.

RESULT

From 844 participants, 95.5% of female adolescents heard about reproductive services from different sources and 69.7% of them utilized the reproductive health services within the last 12 months. Factors like, age of 16-20 years (AOR = 1.85, 95%CI: 1.17-2.92), mother's educational status (being illiterate (AOR = .33, 95%CI:.14-.77)), discussion about reproductive health services with their family (AOR = 8.02, 9%CI:5.52-11.66), being Merchant (AOR = 2.7995%CI:1.11-6.96), unemployed (AOR = 2.90, 95%CI:1.19-7.06) or student (AOR:2.38, 95%CI:1.04-5.42) in occupation, high perceived severity (AOR = 4.05, 95%CI:2.68-6.11), high perceived barriers (AOR = .44, 95%CI:.30-64) were independent predictors of reproductive health services utilization among female adolescents the study area.

CONCLUSION

About 69.7% of the adolescent females were utilizing reproductive health services in the study area though it was very low as compared with the national plan. Introducing messages that increase the perceived threat and decreasing perceived barriers to utilize reproductive health services as well as increasing self-efficacy of adolescent females would help further increase reproductive health services utilization by adolescent females.

JACK trial protocol: a phase III multicentre cluster randomised controlled trial of a school-based relationship and sexuality education intervention focusing on young male perspectives

INTRODUCTION

Teenage pregnancy remains a worldwide health concern which is an outcome of, and contributor to, health inequalities. The need for gender-aware interventions with a focus on males in addressing teenage pregnancy has been highlighted as a global health need by WHO and identified in systematic reviews of (relationship and sexuality education (RSE)). This study aims to test the effectiveness of an interactive film-based RSE intervention, which draws explicit attention to the role of males in preventing an unintended pregnancy by reducing unprotected heterosexual teenage sex among males and females under age 16 years.

METHODS AND ANALYSIS

A phase III cluster randomised trial with embedded process and economic evaluations. If I Were Jack encompasses a culturally sensitive interactive film, classroom materials, a teacher-trainer session and parent animations and will be delivered to replace some of the usual RSE for the target age group in schools in the intervention group. Schools in the control group will not receive the intervention and will continue with usual RSE. Participants will not be blinded to allocation. Schools are the unit of randomisation stratified per country and socioeconomic status. We aim to recruit 66 UK schools (24 in Northern Ireland; 14 in each of England, Scotland and Wales), including approximately 7900 pupils. A questionnaire will be administered at baseline and at 12-14 months postintervention. The primary outcome is reported unprotected sex, a surrogate measure associated with unintended teenage pregnancy. Secondary outcomes include knowledge, attitudes, skills and intentions relating to avoiding teenage pregnancy in addition to frequency of engagement in sexual intercourse, contraception use and diagnosis of sexually transmitted infections.

ETHICS AND DISSEMINATION

Ethical approval was obtained from Queen's University Belfast. Results will be published in peer-reviewed journals and disseminated to stakeholders. Funding is from the National Institute for Health Research.

TRIAL REGISTRATION NUMBER

ISRCTN99459996.

Reproductive factors and risk of Parkinson's disease in women: A meta-analysis of observational studies

Evidence on the relationship between reproductive factors, use of oral contraceptives (OCs) and the incidence of Parkinson's disease (PD) remain inconclusive. The aim of this meta-analysis is to evaluate whether relevant reproductive factors including age at menarche, age at menopause, fertile lifespan, parity, type of menopause (surgical versus natural), and use of OCs are associated with risk of PD in women via random-effects model. PubMed and EMBASE database were used to search for case-control or cohort studies published before February17, 2017. 6 case-control and 5 cohort studies were included in the meta-analysis. The pooled relative risks (RRs) of PD risk were 1.00 (95% CI: 0.79-1.28) for use of OCs (ever versus never), 1.03 (95% CI: 0.84-1.26) for age at menarche, 0.98 (95% CI: 0.75-1.29) for age at menopause, 0.98(95% CI: 0.77-1.25) for fertile lifespan, 0.99(95% CI:0.0.79-1.25) for parity, 0.93 (95% CI:0.68-1.29) for type of menopause (surgical versus natural). In the subgroup analysis stratified by study design, age, caffeine intake and smoking, an inverse association was found between surgical menopause and risk of PD for those adjusting for caffeine intake (RR: 0.67, 95% CI: 0.45-0.99) and smoking (RR: 0.77, 95% CI: 0.63-0.94); while a positive association was found between surgical menopause and PD risk for those not adjusting for smoking (RR: 1.91, 95% CI: 1.29-2.83). In conclusion, our meta-analysis provided little epidemiological support for the role of reproductive factors in the incidence of PD. Whether surgical menopause is inversely associated with the risk of PD requires further explorations.

Increasing boys’ and girls’ intentions to avoid teenage pregnancy: a cluster randomised controlled feasibility trial of an interactive video drama-based intervention in post-primary schools in Northern Ireland

Background

Adolescent men have a vital yet neglected role in reducing unintended teenage pregnancy (UTP). There is a need for gender-sensitive educational interventions.

Objectives

To determine the value and feasibility of conducting an effectiveness trial of theIf I Were JackRelationship and Sexuality Education (RSE) intervention in a convenience quota sample of post-primary schools in Northern Ireland. Secondary objectives were to assess acceptability to schools, pupils (male/female, aged 14–15 years) and parents/guardians; to identify optimal delivery structures and systems; to establish participation rates and reach, including equality of engagement of different socioeconomic and religious types; to assess trial recruitment and retention rates; to assess variation in normal RSE practice; to refine survey instruments; to assess differences in outcomes for male and female pupils; to identify potential effect sizes that might be detected in an effectiveness trial and estimate appropriate sample size for that trial; and to identify costs of delivery and pilot methods for assessing cost-effectiveness.

Design

Cluster randomised Phase II feasibility trial with an embedded process and economic evaluation.

Intervention

A teacher-delivered classroom-based RSE resource – an interactive video drama (IVD) with classroom materials, teacher training and an information session for parents – to immerse young people in a hypothetical scenario of Jack, a teenager whose girlfriend is unintentionally pregnant. It addresses gender inequalities in RSE by focusing on young men and is designed to increase intentions to avoid UTP by encouraging young people to delay sexual intercourse and to use contraception consistently in sexual relationships.

Main outcome measures

Abstinence from sexual intercourse (delaying initiation of sex or returning to abstinence) or avoidance of unprotected sexual intercourse (consistent correct use of contraception). Secondary outcomes included Knowledge, Attitudes, Skills and Intentions.

Results

The intervention proved acceptable to schools, pupils and parents, as evidenced through positive process evaluation. One minor refinement to the parental component was required, namely the replacement of the teacher-led face-to-face information session for parents by online videos designed to deliver the intervention to parents/guardians into their home. School recruitment was successful (target 25%, achieved 38%). No school dropped out. Pupil retention was successful (target 85%, achieved 93%). The between-group difference in incidence of unprotected sex of 1.3% (95% confidence interval 0.55% to 2.2%) by 9 months demonstrated an effect size consistent with those reported to have had meaningful impact on UTP rates (resulting in an achievable sample size of 66 schools at Phase III). Survey instruments showed high acceptability and reliability of measures (Cronbach’s alpha: 0.5–0.7). Economic evaluation at Phase III is feasible because it was possible to (1) identify costs of deliveringIf I Were Jack(mean cost per pupil, including training of teachers, was calculated as £13.66); and (2) develop a framework for assessing cost-effectiveness.

Conclusion

Trial methods were appropriate, and recruitment and retention of schools and pupils was satisfactory, successfully demonstrating all criteria for progression to a main trial. The perceived value of culture- and gender-sensitive public health interventions has been highlighted.

Future work

Progression to a Phase III effectiveness trial.

Trial registration

Current Controlled Trials ISRCTN99459996.

Funding

This project was funded by the NIHR Public Health Research programme and will be published in full inPublic Health Research; Vol. 5, No. 1. See the NIHR Journals Library website for further project information.

Is "Sexual Competence" at First Heterosexual Intercourse Associated With Subsequent Sexual Health Status?

The timing of first sexual intercourse is often defined in terms of chronological age, with particular focus on "early" first sex. Arguments can be made for a more nuanced concept of readiness and appropriateness of timing of first intercourse. Using data from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), conducted in 2010-2012, this study examined whether a context-based measure of first intercourse-termed sexual competence-was associated with subsequent sexual health in a population-based sample of 17-to 24-year-olds residing in Britain (n = 2,784). Participants were classified as "sexually competent" at first intercourse if they reported the following four criteria: contraceptive protection, autonomy of decision (not due to external influences), that both partners were "equally willing," and that it happened at the "right time." A lack of sexual competence at first intercourse was independently associated with testing positive for human papillomavirus (HPV) at interview; low sexual function in the past year; and among women only, reported sexually transmitted infection (STI) diagnosis ever; unplanned pregnancy in the past year; and having ever experienced nonvolitional sex. These findings provide empirical support for defining the nature of first intercourse with reference to contextual aspects of the experience, as opposed to a sole focus on chronological age at occurrence.

Contribution of estradiol levels and hormonal contraceptives to sex differences within the fear network during fear conditioning and extinction

BACKGROUND

Findings about sex differences in the field of fear conditioning and fear extinction have been mixed. At the psychophysiological level, sex differences emerge only when taking estradiol levels of women into consideration. This suggests that this hormone may also influence sex differences with regards to activations of brain regions involved in fear conditioning and its extinction. Importantly, the neurobiological correlates associated with the use of hormonal oral contraceptives in women have not been fully contrasted against men and against naturally cycling women with different levels of estradiol. In this study, we begin to fill these scientific gaps.

METHODS

We recruited 37 healthy men and 48 healthy women. Of these women, 16 were using oral contraceptives (OC) and 32 were naturally cycling. For these naturally cycling women, a median split was performed on their serum estradiol levels to create a high estradiol (HE) group (n = 16) and a low estradiol (LE) group (n = 16). All participants underwent a 2-day fear conditioning and extinction paradigm in a 3 T MR scanner. Using the 4 groups (men, HE women, LE women, and OC users) and controlling for age and coil type, one-way ANCOVAs were performed to look at significant activations within the nodes of the fear circuit. Using post-hoc analyses, beta-weights were extracted in brain regions showing significant effects in order to unveil the differences based on hormonal status (men, HE, LE, OC).

RESULTS

Significant main effect of hormonal status group was found across the different phases of the experiment and in different sub-regions of the insular and cingulate cortices, amygdala, hippocampus, and hypothalamus. During conditioning, extinction and recall, most of the observed differences suggested higher activations among HE women relative to men. During the unconditioned response, however, a different pattern was observed with men showing significantly higher brain activations.

CONCLUSIONS

Our data further support the important contribution of estradiol levels in the activation of brain regions underlying fear learning and extinction. The results highlight the need to document gonadal hormonal levels, menstrual cycle phase as well as oral contraceptive use in women in order to avoid overlooking sex differences when investigating the neurobiology of emotional regulation.

Exploring Home-School Value Conflicts

U.S. colleges place a high value on the fulfillment of academic obligations by their students. The academic achievement of each individual student is the institutional priority; this is an individualistic frame of reference. However, many Latino first-generation college students have been raised to prioritize family obligations; their home socialization is collectivistic. Our exploratory study investigated how Latino first-generation college students experience home-school value conflict between family obligation and individual academic achievement during their transition to college. A group interview followed the prompt of a conflict scenario that each group member first responded to in writing. The written responses provide evidence of the prioritization of school or home and the conflict that can arise in making these decisions. The group discussions that followed identified multiple types of home-school conflict and provide insights into how these conflicts are experienced. Conflicts revealed by the data included attending family events or visiting parents versus doing academic work, family assistance versus focusing on academics, allocating money for travel to see family versus allocating money for educational expenses. In turn, these home-school value conflicts were experienced both as lasting over time and as playing a negative role in students’ academic achievement and sense of well-being.

50 years of hormonal contraception-time to find out, what it does to our brain

Hormonal contraceptives are on the market for more than 50 years and used by 100 million women worldwide. However, while endogenous steroids have been convincingly associated with change in brain structure, function and cognitive performance, the effects of synthetic steroids contained in hormonal contraceptives on brain and cognition have barely been investigated. In this article we summarize the sparse findings, describing brain structural, functional and behavioral findings from the literature and suggest that synthetic steroids may contribute to masculinizing as well as feminizing effects on brain and behavior. We try to identify methodological challenges, explain, how results on endogenous steroids may transfer into research on hormonal contraceptives and point out factors that need to be controlled in the study of hormonal contraceptive dependent effects. We conclude that there is a strong need for more systematic studies, especially on brain structural, functional and cognitive changes due to hormonal contraceptive use. The hormonal contraceptive pill is the major tool for population control. Hence, such behavioral changes could cause a shift in society dynamics and should not stay unattended.

Behavioral interventions for improving dual-method contraceptive use

BACKGROUND

Dual-method contraception refers to using condoms as well as another modern method of contraception. The latter (usually non-barrier) method is commonly hormonal (e.g., oral contraceptives) or a non-hormonal intrauterine device. Use of two methods can better prevent pregnancy and the transmission of HIV and other sexually transmitted infections (STIs) compared to single-method use. Unprotected sex increases risk for disease, disability, and mortality in many areas due to the prevalence and incidence of HIV/STI. Millions of women, especially in lower-resource areas, also have an unmet need for protection against unintended pregnancy.

OBJECTIVES

We examined comparative studies of behavioral interventions for improving use of dual methods of contraception. Dual-method use refers to using condoms as well as another modern contraceptive method. Our intent was to identify effective interventions for preventing pregnancy as well as HIV/STI transmission.

SEARCH METHODS

Through January 2014, we searched MEDLINE, CENTRAL, POPLINE, EMBASE, COPAC, and Open Grey. In addition, we searched ClinicalTrials.gov and ICTRP for current trials and trials with relevant data or reports. We examined reference lists of pertinent papers, including review articles, for additional reports.

SELECTION CRITERIA

Studies could be either randomized or non-randomized. They examined a behavioral intervention with an educational or counseling component to encourage or improve the use of dual methods, i.e., condoms and another modern contraceptive. The intervention had to address preventing pregnancy as well as the transmission of HIV/STI. The program or service could be targeted to individuals, couples, or communities. The comparison condition could be another behavioral intervention to improve contraceptive use, usual care, other health education, or no intervention.Studies had to report use of dual methods, i.e., condoms plus another modern contraceptive method. We focused on the investigator's assessment of consistent dual-method use or use at last sex. Outcomes had to be measured at least three months after the behavioral intervention began.

DATA COLLECTION AND ANALYSIS

Two authors evaluated abstracts for eligibility and extracted data from included studies. For the dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% CI was calculated using a fixed-effect model. Where studies used adjusted analysis, we presented the results as reported by the investigators. No meta-analysis was conducted due to differences in interventions and outcome measures.

MAIN RESULTS

We identified four studies that met the inclusion criteria: three randomized controlled trials and a pilot study for one of the included trials. The interventions differed markedly: computer-delivered, individually tailored sessions; phone counseling added to clinic counseling; and case management plus a peer-leadership program. The latter study, which addressed multiple risks, showed an effect on contraceptive use. Compared to the control group, the intervention group was more likely to report consistent dual-method use, i.e., oral contraceptives and condoms. The reported relative risk was 1.58 at 12 months (95% CI 1.03 to 2.43) and 1.36 at 24 months (95% CI 1.01 to 1.85). The related pilot study showed more reporting of consistent dual-method use for the intervention group compared to the control group (reported P value = 0.06); the investigators used a higher alpha (P < 0.10) for this pilot study. The other two trials did not show any significant difference between the study groups in reported dual-method use or in test results for pregnancy or STIs at 12 or 24 months.

AUTHORS' CONCLUSIONS

We found few behavioral interventions for improving dual-method contraceptive use and little evidence of effectiveness. A multifaceted program showed some effect but only had self-reported outcomes. Two trials were more applicable to clinical settings and had objective outcomes measures, but neither showed any effect. The included studies had adequate information on intervention fidelity and sufficient follow-up periods for change to occur. However, the overall quality of evidence was considered low. Two trials had design limitations and two had high losses to follow up, as often occurs in contraceptive trials. Good quality studies are still needed of carefully designed and implemented programs or services.

Factors related to contraceptive methods among female higher education students in Greece

STUDY OBJECTIVE

We aimed to determine the prevalence of contraceptive methods and identify factors associated with the use of contraception by Greek female higher education students.

DESIGN

Cross-sectional epidemiologic survey on the factors determining the use of contraception among higher educational students.

SUBJECT

3,624 female students between 18 and 26 years of age.

MAIN OUTCOME MEASURES

We used primary individualized data drawn from a survey carried among female college students in Greece. The dependent dichotomous variables were the responses "YES" or "NO" to the question: "During the last 12 months, what contraceptive method have you generally used in your sexual intercourses?" The methods were male condoms, oral contraceptive use (OCs) and emergency contraception (EC). The independent variables which were analysed in this survey were socio-demographic characteristics, variables related to lifestyle and variables associated with sexual habits.

RESULTS

Condom was the most widely used (53.87%). The variables associated independently and significantly with a greater likelihood of the use of condoms were condom use at first sexual intercourse, occupational status and higher educational level of parents. As for OCs, those who had relationship, had more than 2 sexual lifetime partners and had ever visited gynecologist (OR 6.40; 95%CI 2.80-9.40) was more likely to use. For the use of EC, those who were older, had relationship, were smokers and had more than 2 sexual lifetime partners (OR 2.15; 95%CI 1.75-2.64), was more likely to use this method.

CONCLUSIONS

Condom is the most used contraceptive method among female higher educational students in Greece, followed by EC. The variable most strongly associated with use of the OCs was a gynecologist visit. The factors associated with use of EC were having more than 2 sexual partners, smoking, and having a stable sexual partner.

Accessibility of sexual health services in teenage sexual health service users: local area geospatial analysis

BACKGROUND

Teenage pregnancy rates in the UK are the highest in Western Europe. Causes of teenage pregnancies are multifaceted with complex interplay of social, lifestyle and wider determinants influencing risk. Improving access to sexual health services through community services is an important factor in attempting to tackle this issue, but few studies have examined factors that influence this.

METHODS

Geospatial analysis was conducted on community sexual health service users and teenage conceptions from local sexual health services were recorded. Univariate and multinomial regression was performed to test associations between service type and socio-economic status.

RESULTS

No significant differences in accessibility of services between teenage girls who have conceived and those seeking sexual health services were found. Females aged 17 and under were more likely to use a young people's sexual health service than mainstream services (P < 0.001). However, a young person living in the most deprived quintiles was more likely to use a mainstream service if it was closer to their home address (adjusted odds ratios: 2.154, 95% confidence intervals: 1.533-3.027).

CONCLUSIONS

Service type and socio-economic status impact upon the choices young people make when accessing community sexual health services. The study supports policy for locating young person services within the most deprived areas of a community.

Predictors of contraceptive methods among adolescents and young women residing in Spain

INTRODUCTION

Preventing unwanted pregnancy is considered one of the main preventive measures of a developed health system.

AIMS

The aim of the study were to determine the prevalence of contraceptive methods and identify factors associated with the use of contraception by adolescents and young women residents in Spain.

METHODS

Descriptive cross-sectional epidemiologic study on the factors determining use of a contraceptive method among sexually active adolescents and young women aged 16-29 years, living in Spain. As the dependent variable, we took the answer to the questions "During the last 12 months, what contraceptive method have you generally used in your sexual relations?" Independent variables were socio-demographic factors, sexual habits, and variables associated with perception of sexual health. Using logistic multivariate regression models, we have estimated the independent effect of each of these variables on the contraceptive methods use.

MAIN OUTCOME MEASURES

We used secondary individualized data drawn from the first National Sexual Health Survey conducted in Spain.

RESULTS

The male condom seems to be the most widely used (56.7%). The likelihood of using a condom is greater to those who have more than two sexual partners (adjusted odds ratio [AOR]=3.11; 95% confidence interval [CI], 1.72-5.60). Predictors of use of oral contraceptives as the only method are age and having a positive view of one's sexual health (AOR=2.65; 95% CI, 1.28-5.45). Young women with two or more sexual partners were three times likelier to use the double method (AOR=3.83; 95% CI, 1.52-9.65).

CONCLUSIONS

The number of sexual partners, information on and importance of sexuality in one's life predicted the use of the condom as the only method. The factors associated with use of oral contraceptives were having a stable sexual partner and good perception of sexual health. The variable most strongly associated with use of the double method was number of sexual partners.

A prospective study of the sexual, emotional, and behavioral correlates associated with young women's first and usual coital events

CONTEXT

First coitus is considered a major transitional event imbued with cultural relevance. Research has focused on classifying women as virgins, with primary interest in pregnancy and sexually transmitted infection prevention and less on sexuality. This study prospectively explored young women's sexual interest and love at first and subsequent coitus.

METHODS

Daily diary data were collected during a longitudinal study of young women's sexual health (N = 387; 14-17 years at enrollment). Variables of interest included sexual interest, love, and contraceptive and disease prevention behaviors. Analysis of variance and multinomial logistic regression were utilized.

RESULTS

For first coital events, love and sexual interest were reported about "half of the day," with sexual interest significantly higher on the day of first coitus. Condom use was nine times more likely than no method at first compared to later coital events. For subsequent coitus, feeling of being in love was significantly higher compared to first coitus, with average sexual interest and love significantly higher with use of no contraceptive method over condoms. Condoms were associated with higher feelings of being in love, but lower sexual interest compared to hormonal contraception.

CONCLUSIONS

The results indicated that sexual interest and love are independent components of coital behavior. Yet the results also suggest that young women's first coitus does not fully capture the expected significance of "losing one's virginity." Thus, at first coitus, women can actively engage in protective behaviors and focus on pleasure.

Why do women experience untimed pregnancies? A review of contraceptive failure rates

Contraceptive failure contributes to a substantial proportion of unintended pregnancy, particularly in the developed world. A number of socio-demographic factors seem to impact on the risk of a woman experiencing contraceptive failure. Many of the issues exist across cultural boundaries and are complex to address. In discussing the failure rates for individual contraceptive methods, this article will highlight the advantage of improving uptake of long-acting reversible methods of contraception which have a high efficacy and are less user-dependent than many of the other available methods.

Global lessons on healthy adolescent sexual development

PURPOSE OF REVIEW

Examining global trends of adolescent sexual behavior is essential to inform clinical practice as well as for developing interventions and educational strategies to ensure healthy sexual development in young people.

RECENT FINDINGS

Most young people begin sexual activity in their teenage years. Extensive research has been conducted to elucidate risk and protective factors for sexual activity in adolescence and to evaluate the success of different sex education programs in influencing these factors. Some risk and protective factors were similar globally, whereas others differed by sex and community. Research findings suggest that comprehensive sex education, which includes skills-based interventions, is effective in changing youth behavior. In addition, research points towards the importance of addressing larger structural and contextual issues such as gender equality, poverty, and education in improving the sexual health of adolescents.

SUMMARY

Adolescents begin their sexual lives in their teen years; therefore, clinicians need to focus on positive ways to help teenagers develop healthy relationships while providing guidance around reducing risky sexual behaviors.