Exploring Explanations for Local Reductions in Teenage Pregnancy Rates in England: An Approach Using Qualitative Comparative Analysis

How effective was England's teenage pregnancy strategy? A comparative analysis of high-income countries

Teenage pregnancy is associated with numerous health risks, both to mothers and infants, and may contribute to entrenched social inequalities. In countries with high rates of teenage pregnancy there is disagreement on effective action to reduce rates. England's Teenage Pregnancy Strategy, which cost £280 million over its ten year implementation period, has been highlighted as an effective way of reducing pregnancies after rates fell by more than 50% from 1998 to 2014 and widely advocated as a replicable model for other countries. However, it is not clear whether the fall is attributable to the strategy or to background trends and other events. We aimed to evaluate the impact of the Teenage Pregnancy Strategy on pregnancy and birth rates using comparators. We compared under-18 pregnancy rates in England with Scotland and Wales using interrupted time series methods. We compared under-18 birth rates and under-20 pregnancy rates in England with European and English-speaking high-income countries using synthetic control methods. In the controlled interrupted time series analyses, trends in rates of teenage pregnancy in England closely followed those in Scotland (0.08 fewer pregnancies per 1000 women per year in England; -0.74 to 0.59) and Wales (0.14 more pregnancies per 1000 women per year in England; -0.48 to 0.76). In synthetic control analyses, under-18 birth rates were very similar in England and the synthetic control. Under-20 pregnancy rates were marginally higher in England than control. Although teenage pregnancies and births in England fell following implementation of the Teenage Pregnancy Strategy, comparisons with other countries suggest the strategy had little, if any, effect on pregnancy rates. This raises doubts about whether the strategy should be used as a model for future public health interventions in countries aiming to reduce teenage pregnancy.

Understanding the decline in under-18 conception rates throughout England's local authorities between 1998 and 2017

We consider England's two-decade teenage conception decline in the context of societal changes: rising educational aspirations; growing second- and third-generation teenage ethnic minority populations; increased deprivation associated with economic recession and post-2008 Government austerity; and changing housing availability. Using England's Local Authority Districts (LAD) 1998-2017, we explore the role of area characteristics in explaining spatial differences in under-18 conception rates and how changing characteristics may explain temporal changes. Urban/rural distinctions in teenage conceptions are largely minimised after considering LAD characteristics. Area characteristics continue to partly explain teenage conception rates but are better at explaining area differences than variation over time.

The impact of sex education mandates on teenage pregnancy: International evidence

To date most studies of the impact of school-based sex education have focused either on specific, local interventions or experiences at a national level. In this paper, we use a new cross-country dataset to explore the extent to which laws on sex education affect teenage pregnancy rates in developed countries. We find some evidence that laws mandating sex education in schools are associated with higher rates of teenage fertility. Parental opt out laws may minimise adverse effects of sex education mandates for younger teens. The estimated effects of mandatory sex education are robust to some but not all of our specifications designed to tease out causality. Taken together, changes in national laws relating to sexual health are unable to explain the significant declines in teenage pregnancy rates, which have been observed in many developed countries in recent years.

Reconceptualising precision public health

As currently conceived, precision public health is at risk of becoming precision medicine at a population level. This paper outlines a framework for precision public health that, in contrast to its current operationalisation, is consistent with public health principles because it integrates factors at all levels, while illuminating social position as a fundamental determinant of health and health inequities. We review conceptual foundations of public health, outline a proposed framework for precision public health and describe its operationalisation within research and practice. Social position shapes individuals' unequal experiences of the social determinants of health. Thus, in our formulation, precision public health investigates how multiple dimensions of social position interact to confer health risk differently for precisely defined population subgroups according to the social contexts in which they are embedded, while considering relevant biological and behavioural factors. It leverages this information to uncover the precise and intersecting social structures that pattern health outcomes, and to identify actionable interventions within the social contexts of affected groups. We contend that studies informed by this framework offer greater potential to improve health than current conceptualisations of precision public health that do not address root causes. Moreover, expanding beyond master categories of social position and operationalising these categories in more precise ways across time and place can enrich public health research through greater attention to the heterogeneity of social positions, their causes and health effects, leading to the identification of points of intervention that are specific enough to be useful in reducing health inequities. Failure to attend to this level of particularity may mask the true nature of health risk, the causal mechanisms at play and appropriate interventions. Conceptualised thus, precision public health is a research endeavour with much to offer by way of understanding and intervening on the causes of poor health and health inequities.As currently conceived, precision public health is at risk of becoming precision medicine at a population level. This paper outlines a framework for precision public health that, in contrast to its current operationalization, is consistent with public health principles because it integrates factors at all levels, while illuminating social position as a fundamental determinant of health and health inequities. We review conceptual foundations of public health, outline a proposed framework for precision public health and describe its operationalization within research and practice. Social position shapes individuals' unequal experiences of the social determinants of health. Thus, in our formulation, precision public health investigates how multiple dimensions of social position interact to confer health risk differently for precisely defined population subgroups according to the social contexts in which they are embedded, while considering relevant biological and behavioural factors. It leverages this information to uncover the precise and intersecting social structures that pattern health outcomes, and to identify actionable interventions within the social contexts of affected groups. We contend that studies informed by this framework offer greater potential to improve health than current conceptualizations of precision public health that do not address root causes. Moreover, expanding beyond master categories of social position and operationalizing these categories in more precise ways across time and place can enrich public health research through greater attention to the heterogeneity of social positions, their causes and health effects, leading to identification of points of intervention that are specific enough to be useful in reducing health inequities. Failure to attend to this level of particularity may mask the true nature of health risk, the causal mechanisms at play and appropriate interventions. Conceptualized thus, precision public health is a research endeavour with much to offer by way of understanding and intervening on the causes of poor health and health inequities.

The effect of spending cuts on teen pregnancy

In recent years, English local authorities have been forced to make significant cuts to devolved expenditure. In this paper, we examine the impact of reductions in local expenditure on one particular public health target: reducing rates of teen pregnancy. Contrary to predictions made at the time of the cuts, panel data estimates provide no evidence that areas which reduced expenditure the most have experienced relative increases in teenage pregnancy rates. Rather, expenditure cuts are associated with small reductions in teen pregnancy rates, a result which is robust to a number of alternative specifications and tests for causality. Underlying socio-economic factors such as education outcomes and alcohol consumption are found to be significant predictors of teen pregnancy.

Causal conditions for loneliness: a set-theoretic analysis on an adult sample in the UK

While age has been identified as a risk factor for loneliness, whether it is a necessary or sufficient condition for loneliness has never been examined. This is the first study that applies fuzzy-set QCA, a special type of set-theoretic method, to discover the necessary and sufficient causal conditions for loneliness, respectively, among adults in the UK, analysing the data collected from the UK sample of Round 6 of the European Social Survey (ESS, 2012, n = 2163). It firstly examines the configurations of five conditions: being female, old age, not living with spouse/partner, bad health, and not being frequently social with others. Gender was found neither a necessary nor a sufficient condition for loneliness, and old age was close to being a necessary condition and became necessary when united with any of the other conditions; the configuration of not living with spouse/partner and not healthy and not frequently social with others is a sufficient condition. Robustness of results was tested with two different conditions (a limiting illness and a confidante), and a separate analysis on the absence of loneliness was conducted. The effect of the unbalanced distribution of cases across different values of the outcome was highlighted as a source of uncertainty, and the results on the absence of loneliness are different from those on its presence.

Is education the best contraception: the case of teenage pregnancy in England?

This paper examines potential explanations for recent declines in teenage pregnancy in England. We estimate panel data models of teenage conception, birth and abortion rates from regions in England. Although point estimates are consistent with the promotion of long acting reversible contraception (LARC) having a negative impact on teenage pregnancy rates, the effects are generally small and statistically insignificant. In contrast, improvements in educational achievement and, to a lesser extent, increases in the non-white proportion of the population are associated with large and statistically significant reductions in teenage pregnancy.