Exploring Alternative Outcome Measures to Improve Pregnancy Prevention Programming in Younger Adolescents

Promising Predictors of Adolescent Sexual Behavior Outcomes: A Systematic Review of Longitudinal Research

This review examined research to identify longitudinal predictors of adolescent sexual behavior outcomes. These predictors hold promise as potential outcomes for teen pregnancy prevention program evaluations when measuring sexual behavior outcomes is infeasible or theoretically, methodologically, or developmentally inappropriate. We conducted a systematic review using a prespecified search strategy and processes consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We examined 32 research studies published between 2008 and 2024. Four categories of predictors of sexual behavior during adolescence emerged across the reviewed studies. Variables within the caregiver control, self-regulation, sexting, and substance use categories each predict future sexual behavior outcomes, with findings consistent across 3 or more studies for each category. This systematic review documents the current evidence base for precursors of sexual behavior outcomes among adolescents and specifies which predictors have promising, potentially promising, mixed, and limited evidence. This review is the first step in gathering information that will eventually inform an avenue for teen pregnancy prevention program developers and researchers to highlight the promise of programs when evaluating impacts on sexual behavior outcomes is infeasible or inappropriate.

Implementation of a Booster Sexual Health Education Curriculum for Older Adolescents in Rural Communities

Ongoing education on sexual health and other health promotion topics is critical as young people transition into adulthood. A "booster" round of education may be an effective strategy to reinforce information previously taught and expand to additional topics relevant later in adolescence. In partnership with a Youth Advisory Council, we co-designed READY, Set, Go!, a booster curriculum for older adolescents with modules covering adult preparation skills, sexual identity, relationships, reproductive health, and mental health. From November 2021 to January 2023, we provided the curriculum to 21 cohorts of 12th grade students (N = 433) in rural communities of Fresno County, CA, and conducted an implementation evaluation to assess its feasibility in school settings, acceptability by participants, and changes in short-term outcomes. Health educators completed implementation logs to track program adaptations. Youth completed pretest/posttest surveys to assess changes in outcomes and participant satisfaction. We used descriptive statistics to examine program adaptations and satisfaction. We used multivariable regression models to examine changes in outcomes, adjusted for sociodemographic characteristics. Health educators completed most activities as planned, with adaptations occurring in response to youth needs and scheduling limitations. Sexual health knowledge, confidence in adult preparation skills, awareness of local sexual and mental health services, and willingness to seek health services all increased significantly from pretest to posttest. Youth feedback was strongly positive. We conclude that booster sexual health education is a promising strategy to address critical knowledge gaps and support health promotion, especially in rural and other under-resourced communities.

Addressing Evaluation Barriers with Early Innovation Development for Adolescent-Focused Sexual and Reproductive Health Interventions

Most evidence-based teen pregnancy prevention programs focus on individual-level sexual health outcomes (e.g., STIs, pregnancy, teen births). To expand program and intervention approaches within teen pregnancy prevention (TPP), the Department of Health and Human Services funded two grantees, Innovative Teen Pregnancy Prevention Programs (iTP3) and Innovation Next (IN) to support and enable early innovation to advance adolescent health and prevent teen pregnancy. The pipeline to support and enable innovation in adolescent health is complex, resulting in barriers and challenges to research and evaluation of novel programs. This paper presents some of the barriers encountered by the grantees. Data for this paper was collected from key personnel and secondary data sources. Focus group participants included seven representatives (n = 7) across the two organizations. Focus group questions assessed barriers related to innovative intervention development and evaluation. Key findings include four barriers to evaluation when fostering innovative adolescent-focused pregnancy prevention interventions. These included (a) funding constraints on evaluation activities, (b) innovation readiness for rigorous testing, (c) evaluation knowledge and expertise on innovation-development teams, and (d) challenges with evaluation requirements. Novel and promising system- and technology-focused interventions with the potential to impact TPP require alternative tools and approaches for evaluation. This would allow research to focus on how systems-level change mechanisms (i.e., policy, access to care) impact sexual risk behaviors and better understand ecological and social determinants of health for the priority population. The advancement of approaches to impact adolescent health identifies the need to expand the focus of evidence-based interventions beyond the adolescent themselves and understand approaches that impact external contexts and environments related to reducing sexual and reproductive health (SRH) risk-taking.

More comprehensive sex education reduced teen births: Quasi-experimental evidence

Sex education for youth in the United States has been the topic of considerable debate among researchers, policy makers, and the public at large. In this study, we focus attention on federal funding for more comprehensive sex education that was received by a mix of public and private organizations in 55 US counties. Our analyses provide population-level causal evidence that funding for more comprehensive sex education led to an overall reduction in the teen birth rate at the county level of more than 3%. This study thus contributes causal evidence relevant to ongoing debates on the potential role more comprehensive sex education may play in reducing teen births in the United States.

Women in the United States are much more likely to become mothers as teens than those in other rich countries. Teen births are particularly likely to be reported as unintended, leading to debate over whether better information on sex and contraception might lead to reductions in teen births. We contribute to this debate by providing causal evidence at the population level. Our causal identification strategy exploits county-level variation in the timing and receipt of federal funding for more comprehensive sex education and data on age-specific teen birth rates at the county level constructed from birth certificate natality data covering all births in the United States. Our results show that federal funding for more comprehensive sex education reduced county-level teen birth rates by more than 3%. Our findings thus complement the mixed evidence to date from randomized control trials on teen pregnancies and births by providing population-level causal evidence that federal funding for more comprehensive sex education led to reductions in teen births.

Teen Pregnancy Prevention Evaluation Technical Assistance: A Case Study

PURPOSE

This case study discusses Mathematica's experience providing large-scale evaluation technical assistance (ETA) to 65 grantees across two cohorts of Teen Pregnancy Prevention (TPP) Program grants. The grantees were required to conduct rigorous evaluations with specific evaluation benchmarks. This case study provides an overview of the TPP grant program, the evaluation requirements, the ETA provider, and other key stakeholders and the ETA provided to the grantees. Finally, it discusses the successes, challenges, and lessons learned from the effort.

CONCLUSION

One important lesson learned is that there are two related evaluation features, strong counterfactuals and insufficient target sample sizes, that funders should attend to prior to selecting awardees because they are not easy to change through ETA. In addition, if focused on particular outcomes (for TPP, the goal was to improve sexual behavior outcomes), the funder should prioritize studies with an opportunity to observe differences in these outcomes across conditions; several TPP grantees served young populations, and sexual behavior outcomes were not observed or were rare, limiting the opportunity to observe impacts. Unless funders are attentive to weaning out evaluations with critical limitations during the funding process, requiring grantees to conduct impact evaluations supported by ETA might unintentionally foster internally valid, yet underpowered studies that show nonsignificant program impacts. The TPP funder was able to overcome some of the limitations of the grantee evaluations by funding additional evidence-building activities, including federally led evaluations and a large meta-analysis of the effort, as part of a broader learning agenda.

Replication of It's Your Game…Keep It Real! in Southeast Texas

Despite the recent efforts of the Office of Adolescent Health to replicate programs with demonstrated efficacy, there are still few evidence-based HIV, sexually transmitted infection (STI), and teen pregnancy prevention programs that have been replicated in "real-world" settings. To test the effectiveness of It's Your Game…Keep It Real! (IYG), an evidence-based STI and pregnancy prevention program for middle schools, the curriculum was implemented by teachers in urban and suburban middle schools in Southeast Texas from 2012 to 2015. IYG was evaluated using a group-randomized wait-list controlled effectiveness trial design in which 20 middle schools in nine urban and suburban school districts in Southeast Texas were randomized equally, using a multi-attribute randomization protocol, to either the intervention condition (received IYG) (n = 10 schools comprising 1936 eligible seventh graders) or the comparison condition (received usual care) (n = 10 schools comprising 1825 eligible seventh graders). All students were blinded to condition prior to administering the baseline survey. The analytic sample comprised 1543 students (n = 804, intervention; n = 739, comparison) who were followed from baseline (seventh grade) to the 24-month follow-up (ninth grade). Multilevel regression analyses were conducted to assess behavioral and psychosocial outcomes at follow-up. There were no significant differences in initiation of vaginal or oral sex between study conditions at follow-up. However, at 12-month follow-up, compared with students in the comparison condition, students in the intervention condition reported increased knowledge, self-efficacy, and perceived favorable norms related to HIV/STIs, condoms, and/or abstinence; decreased intentions to have sex; and increased intentions to use birth control. Knowledge outcomes were statistically significant at 24-month follow-up. This IYG effectiveness trial did not replicate the behavioral effects of the original IYG efficacy trials. However, it adds to the growing literature on the replication of evidence-based programs, and underscores the need to better understand how variations in implementation, setting, and measurement affect the behavioral impact of such programs.Clinical trial registration clinicaltrials.gov (NCT03533192).

Moving the prevention timeline: A scoping review of the literature on precursors to sexual risk in early adolescence among youth of color

INTRODUCTION

Sexual health disparities are leading causes of morbidity among youth of color in the United States. We conducted a scoping review of the literature on precursors to sexual risk-taking among young adolescents of color (ages 10-14) to assess precedents of sexual experience and their utility as measurable proximal constructs and behaviors gauging sexual risk and sexual risk prevention efforts.

METHODS

This study was conducted using the PRISMA extension for scoping reviews (PRISMA-ScR) guidelines. We searched for quantitative studies that assessed the relationships between precursors and subsequent sexual behaviors, incorporated youth of color, and specified young adolescents as the study sample. All articles were in English, however we explored both U.S. and International databases.

RESULTS

The database search yielded 11 studies published between 2000 and 2017. Most literature focused on youth in urban settings, and on Black and Latinx youth, while only two addressed the special circumstances of American Indian and Alaska Native youth. Sex expectancies outcomes for youth of color were likely to predict sexual risk taking and self-efficacy about sex was related to abstinence.

CONCLUSIONS

Etiologic studies that seek to understand precursors to sexual risk taking among youth of color are limited and this paucity truncates the ability to develop sexual risk prevention programs for the age group in which prevention is most needed.

You-Me-Us: Results of a Cluster Randomized Trial of a Healthy Relationships Approach to Sexual Risk Reduction

By middle adolescence, most young people have been involved in at least one romantic relationship, a context in which many sexual interactions occur. Indeed, researchers have suggested the importance of attending to relationships in programs focused on sexual risk, yet few evidence-based programs have a strong relationships focus. Our study examined the impact of a healthy relationship program called You-Me-Us that included a classroom curriculum and a school-wide peer norms approach. We evaluated the intervention using a small group randomized trial that included nine participating urban middle schools (defined as schools that include grades 6-8) in three urban school districts. We invited all 7th grade students within the study schools to enroll. Students completed three surveys during 7th and 8th grades (baseline plus two follow up surveys at 6 and 18 months following baseline). A total of 911 youth with positive consent and assent were enrolled in the study. Follow up survey response rates among those taking the baseline were 92% at 6 months and 80% at 18 months. Multilevel regression models were used to adjust for the correlation among students within the same school, and the correlation of repeated measurements taken on the same student over time. The intervention reduced vaginal sexual initiation by about half at the 6-month follow-up, and this approached significance. Further, youth in the intervention condition were less likely to believe it is okay for people their age to have vaginal sex without using condoms if the girl is on birth control. None of the remaining variables differed significantly by intervention condition. This study provides insights on using a healthy relationship approach for younger urban adolescents. This approach produced a programmatically significant reduction in sexual initiation that did not reach standard levels of statistical significance, and warrants further exploration.

Examining the Effects of an Adolescent Pregnancy Prevention Program by Risk Profiles: A More Nuanced Approach to Program Evaluation

PURPOSE

The objective of the study was to examine whether latent class analysis (LCA) could (1) identify distinct subgroups of youth characterized by multiple risk and protective factors for early sexual initiation and (2) allow for a more nuanced assessment of the effects of a middle school program to prevent teen pregnancy/HIV/sexually transmitted infection.

METHODS

LCA was applied to data from the baseline (seventh grade) sample of 1,693 sexually inexperienced students participating in a randomized controlled trial of It's Your Game…Keep It Real in Harris County, Texas. Multilevel analysis was applied within subgroups defined by the latent classes to assess for potential differential program effects.

RESULTS

LCA identified 3 distinct profiles of youth: family disruption, other language household, and frequent religious attendance. Multilevel analyses found differential effects of the program across these profiles with a significant and substantial reduction (30%) in initiation of vaginal sex by ninth grade for students in the family disruption profile only.

CONCLUSIONS

Application of LCA may hold promise for conducting more nuanced evaluations and refinements of behavior change interventions for youth.

Effectiveness Evaluation of It's Your Game: Keep It Real, a Middle School HIV/Sexually Transmitted Infection/Pregnancy Prevention Program

PURPOSE

This study assessed the effectiveness of the HIV/sexually transmitted infection/pregnancy prevention program, It's Your Game: Keep It Real (IYG).

METHODS

IYG was implemented by classroom teachers in 24 urban middle schools from 2012 to 2015. Using a quasi-experimental design, each year we surveyed ninth-grade students in 10 high schools that were selected based on feeder patterns from project middle schools. We compared two groups of students (n = 4,562): (1) students whose middle school grade cohorts did not receive IYG ("No-IYG"), and (2) students whose middle school grade cohorts received IYG ("IYG"). Multilevel analyses examined differences between the two groups in the initiation of any type of sexual activity (oral, vaginal, or anal sex), presexual behaviors, and psychosocial mediators.

RESULTS

Students in the IYG group were less likely to report initiation of sexual activity by ninth grade compared to students in the No-IYG group (odds ratio .77; 95% confidence interval .66-.90). The IYG group was significantly less likely to have engaged in presexual behaviors, including having been on a date, had a boyfriend/girlfriend, and touched or been touched on private body parts. The IYG group had better outcomes on 11 of 19 psychosocial variables, including knowledge; beliefs about abstinence, sex, friends' beliefs, norms, and behaviors; reasons for not having sex; personal limits; exposure to risky situations; self-efficacy; and quality of dating relationships.

CONCLUSIONS

The results suggest that IYG, when implemented on a large scale by trained classroom teachers in urban public schools, had positive impacts on students' behaviors, beliefs, and knowledge.