Using randomized designs to evaluate client-centered programs to prevent adolescent pregnancy

CONTEXT

Interventions to prevent adolescent pregnancy (primarily curriculum-based programs) have not produced convincing evidence as to their success. Moreover, many evaluation approaches have been inadequate to assess program effectiveness. Therefore, rigorous evaluation of different kinds of interventions may help identify potentially effective strategies to prevent adolescent pregnancy.

METHODS

An experimental design, in which clients were randomized to treatment and control groups, was used to evaluate the effects of a "client-centered" approach to reducing pregnancy among high-risk young people in seven communities in Washington State. Four projects served 1,042 youth (clients aged 9-13), and three served 690 teenagers (primarily clients aged 14-17). Projects offered a wide variety of services tailored to individual clients' needs, including counseling, mentoring and advocacy.

RESULTS

On average, clients in the treatment group at youth sites received 14 hours of service, and their teenage counterparts received 27 hours; controls received only 2-5 hours of service. At one youth site, clients were less likely to intend to have intercourse after the intervention than before; at another, they became less likely to intend to use substances. Clients at one teenage project reported reduced sexual behavior and improved contraceptive use after receiving services; teenagers at another site reported reduced sexual intentions and drug use, and a greater intention to use contraceptives. The programs showed no other effects on factors that place young people at risk of becoming pregnant, including their sexual values and educational aspirations, communication with their parents (measured at youth sites only), and sexual and contraceptive behavior (assessed for teenagers only).

CONCLUSIONS

High-risk clients likely need considerably more intervention time and more intensive services than programs normally provide. Rigorous evaluation designs allow continued assessment that can guide program modifications to maximize effects.

Long-term outcomes of an abstinence-based, small-group pregnancy prevention program in New York City schools

CONTEXT

Despite drops in U.S. teenage birthrates, questions continue to arise about how best to reduce the country's adolescent birthrate. School-based programs continue to be considered one of the best ways to reach adolescents at risk of early sexual activity.

METHODS

A total of 312 students completed a pretest, a posttest and a follow-up one year after the posttest: 125 who had participated in a 3-4-month-long abstinence-based small-group intervention led by trained social workers, and 187 in a comparison group that received no special services.

RESULTS

There were few significant differences between the intervention and comparison groups at posttest. At the one-year follow-up, however, intervention students had significantly better scores on locus of control, their relationship with their parents and (among males only) their attitudes about the appropriateness of teenage sex. Measures of depression, self-esteem, intentions to have sex, attitudes toward teenage pregnancy and various behaviors did not differ significantly between groups. By the time of the one-year follow-up, there was no difference between study groups among females in the initiation of sexual intercourse. Among the males, initiation of sexual intercourse appeared to be higher in the intervention group than in the comparison group, but the difference was not statistically significant. Positive outcomes were especially limited among students who were already sexually active at the start of the study, a finding that emphasizes the difficulties of reaching adolescents who are already at high risk for pregnancy

CONCLUSIONS

A small-group abstinence-based intervention focusing on mental health can have some impact on adolescents' attitudes and relationships (particularly with their parents). Long-term evaluations are important for determining the effects of an intervention, as it is difficult to change adolescent risk behavior.

Listening to youth: teen perspectives on pregnancy prevention

PURPOSE

To ascertain views of public high school students on preventing teen pregnancy. The authors hypothesized that students at varying risk for pregnancy (e.g., abstinent, consistent contraceptors, inconsistent contraceptors) would have differing views which would have implications for future pregnancy prevention programming.

METHODS

A 75-question anonymous survey designed for this study was administered in six Boston high schools. The sample consisted of 49% females and 51% males in 10th and 11th grades from diverse racial and ethnic backgrounds. One thousand surveys were received and analyzed using Chi-square tests to assess statistically significant differences in student responses.

RESULTS

Sixty-three percent of the students had had sexual intercourse: 72% of males and 54% of females. Of these, 35% were consistent contraceptors and 65% were inconsistent. Students believed that having more information on pregnancy and birth control (52%), education about relationships (33%), parental communication (32%), improved contraceptive access (31%), and education about parenting realities (30%) would prevent teen pregnancy. Abstinent teens were more likely (58%) to say that information on pregnancy and birth control was important (p<.05), whereas consistently contracepting teens were more likely (40%) to identify greater access to birth control (p <.01). Males were more likely than females to prefer their information on contraception from parents (23% vs. 18%) and health education classes (16% vs. 7.5%), whereas females were more likely than males to prefer the health arena (51% vs. 27%) (p<.001). Teens using contraception were also more likely to be having frequent conversations with parents (49%) (p<.001). When asked why they had not used contraception, inconsistent contraceptors were more likely than others to say that they never thought of it (15%) (p<.001).

CONCLUSIONS

Teens report that having more information from parents, school, and health arenas can prevent pregnancy. Abstinent, consistent contraceptors, and inconsistent contraceptors have different preferences regarding strategies. This information has important implications for educational content and policy discussions.

Teen pregnancy prevention: do any programs work?

This paper begins with a review of the problem of teen pregnancy in the United States. Domestic trends are compared with those of other developed countries. Antecedents of the problem are discussed. New developments in addressing the problem are then described, including the following: (a) a renewed emphasis on abstinence on the one hand; (b) a move toward a more positive view of teen sexuality on the other; (c) the development of new prevention initiatives such as STD/HIV/AIDS prevention programs, community-wide teen pregnancy prevention collaboratives, broad-based youth development programs, and state and local government initiatives; and (d) the lauching of the National Campaign to Prevent Teen Pregnancy. An analysis of the different ways in which the problem can be framed and the implications for solutions of the problem follow. Examples of promising teen pregnancy and STD/HIV/AIDS prevention programs are provided. The paper ends with a recommendation for an eclectic approach to framing the problem and possible solutions.

Effects of a replication of a multicomponent model for preventing adolescent pregnancy in three Kansas communities

CONTEXT

A significant amount of attention has been devoted to the complex issue of teenage pregnancy and to programs for reducing pregnancy among adolescents. Careful evaluations of such programs are needed to ascertain what strategies will be most effective at reducing teenage pregnancy.

METHODS

A pretest-posttest comparison group design was used to analyze the effects of a comprehensive multicomponent school and community intervention on estimated pregnancy rates and birthrates among young people in three Kansas communities: Geary County, Franklin County and selected neighborhoods of Wichita.

RESULTS

There were high levels of program activity in all three communities during the intervention period, including teacher training and sexuality education for students. Survey respondents rated highly such project interventions as the extension of school-linked clinic hours to accommodate student schedules and support groups established in middle schools. Between 1994 and 1997, the proportions of adolescents reporting that they had ever had sex decreased significantly among all ninth and 10th graders in Geary County, from 51% to 38% among females and from 63% to 43% among males. In Franklin County, more males in grades 11 and 12 reported using condoms in 1996 (55%) than had done so in 1994 (39%). Age at first intercourse remained relatively stable in Franklin and Geary counties during the intervention period. The estimated pregnancy rate among adolescents aged 14-17 decreased between 1994 and 1997 in Geary Country, while it increased in comparison areas. The estimated pregnancy rates among 14-17-year-olds decreased in both Franklin County and its comparison communities. The birthrate declined both in one target area of Wichita and in its comparison area from 1991-1993 to 1994-1996. Over the same time period, the birthrate increased in a second target area of Wichita, while it decreased in the comparison community.

CONCLUSIONS

This evaluation of a comprehensive multicomponent program for adolescent pregnancy prevention contributes to our understanding of this model and its replicability in diverse communities. Ongoing program evaluation is important for developing initiatives and for refining strategies so they respond to local conditions.

Short-term impact of safer choices: a multicomponent, school-based HIV, other STD, and pregnancy prevention program

This study evaluated the effectiveness of the first year of Safer Choices, a theoretically based, multicomponent HIV, STD, and pregnancy prevention program for high school youth. The study featured a randomized trial involving 20 schools in California and Texas, with a cohort of 3,869 ninth-grade students. Students who completed both the baseline and the first follow-up survey approximately seven months later were included in the analysis (n = 3,677). Safer Choices enhanced 9 of 13 psychosocial variables including knowledge, self efficacy for condom use, normative beliefs and attitudes regarding condom use, perceived barriers to condom use, risk perceptions, and parent-child communication. Safer Choices also reduced selected risk behaviors. Specifically, Safer Choices reduced the frequency of intercourse without a condom in the three months prior to the survey, increased use of condoms at last intercourse, and increased use of selected contraceptives at last intercourse.

Reflections on two decades of research on teen sexual behavior and pregnancy

During the past 20 years, both researchers and program developers made great progress in their efforts to reduce adolescent unprotected sex and prevent teen pregnancy. Research studies are now more likely to employ experimental designs with random assignments, to have large sample sizes with adequate statistical power, to measure actual sexual and contraceptive behaviors, to measure longer term effects, to employ proper statistical methods, and to report results in an unbiased manner. As a result of this body of research, large advances have occurred in our understanding of: 1) the incidence of teen pregnancy, and its consequences; 2) the effects of improving adolescent knowledge, increasing access to contraception, and improving parent/child communication; and 3) the characteristics of effective programs. The on-going evaluation of sex and HIV education programs coupled with creativity and perseverance on the part of program developers led to two groups of effective programs--sex and HIV education programs that reduce sexual risk-taking behavior, and youth development programs that reduce teen-age pregnancy and childbearing.

Preventing repeat adolescent pregnancies with early adoption of the contraceptive implant

CONTEXT

Even in intensive, adolescent-oriented programs, in which access to highly effective contraceptives is guaranteed, repeat adolescent pregnancies commonly occur.

METHODS

To assess whether adoption of the contraceptive implant would lower the rate of repeat pregnancy, contraceptive use and pregnancy outcomes were tracked among 309 adolescent mothers--171 "early" implant users who began use within six months of delivery and 138 who either adopted another method or had used no method. Participants were interviewed at delivery and at six-month intervals through the second year postpartum. Multivariate logistic regression analyses were conducted to ascertain the likelihood of a repeat pregnancy within the first and second year postpartum.

RESULTS

During the first year postpartum, although 7% of the early implant users had their implants removed, pregnancy rates were significantly (p < .0001) lower among early implant users (less than 1%) than among the other adolescent mothers in the sample (20%). By the end of the second year postpartum, 37% of early implant users had discontinued use. Nevertheless, their two-year pregnancy rate (12%) remained significantly lower (p < .0001) than that of the other adolescent mothers (46%). The multivariate analysis showed that early implant use was the only independent predictor of a repeat pregnancy within the first year postpartum, while early use, parity and number of risk factors for repeat pregnancy were independently associated with the likelihood of another pregnancy in the second year postpartum.

CONCLUSIONS

Although early implant insertion significantly decreased the rate of rapid, repeat adolescent pregnancies, the rates of removal and of pregnancy by the end of the second year postpartum were high. Thus, health care providers need to address the motivational components of adolescent pregnancy even among those who accept ostensibly long-term methods.

Peer counseling in a culturally specific adolescent pregnancy prevention program

This study evaluated the effects of peer counseling in a culturally specific adolescent pregnancy prevention program for African American females. A random pretest and multiple posttest experimental and comparison group design was used to obtain data on a sample of 63 female African American adolescents, ages 12 to 16, who lived in four public housing developments. Descriptive data and tests of significance revealed that none of the participants who received peer counseling became pregnant within three months of the intervention. Findings revealed a statistically significant increase in reproductive and other self-related knowledge topics among the experimental group when comparing pretest and eight-week posttest scores. Most participants had not had sexual intercourse; the average age of sexual onset was 12 years in the experimental group and 11 years in the controls. Designing and implementing culturally specific adolescent pregnancy prevention programs for adolescents younger than age 11 and/or before sexually active seems appropriate.

The Africentric Transtheoretical model in a school-based pregnancy prevention program

This article describes the use of a socio-culturally specific framework for a pregnancy prevention program for low income 10 to 12 year old African American middle school girls. The framework expands earlier (Johnson, 1995) conceptualizations by combining African and African American frames of reference with behavior change processes to influence sexual decision-making among young adolescents.

Focus on adolescent pregnancy and childbearing: a bit of history and implications for the 21st century

Early childbearing in the United States has roots in the past; is the focus of intense partisan debate at the present time; and will have demographic, social, and economic ramifications in the future. It is an extremely complex issue, for which its associated problems have no easy or simple answers. Early parenthood is viewed as a social problem that has defied public policy attempts to stem its growth. It has become the focus of concern primarily for three reasons: (1) sexual activity has increased sharply, most recently among the youngest teens; (2) out-of-wedlock childbearing has risen among all teenagers, regardless of age; and (3) the issue of welfare. A review of statistics highlights the problem and discussion focuses on means of mitigating the negative effects of early childbearing.

Gender differences in knowledge, intentions, and behaviors concerning pregnancy and sexually transmitted disease prevention among adolescents

Gender differences in knowledge, intentions, and behaviors regarding preventing pregnancies and sexually transmitted diseases were studied. Data for the study were collected from 1,033 students in 13 California high schools. Females in this sample were more likely than males to have discussed sexuality topics with parents, to have engaged in sexual intercourse more frequently, to have experienced a pregnancy scare, to have used oral contraceptives during their last sexual encounter, to perceive that a larger proportion of their peers were engaging in sex and using birth control, to obtain birth control from health facilities, and to report intentions to abstain or use protection in hypothetical situations placing them at risk for unprotected sex. In contrast, males reported that they were more likely to have always used birth control, to have used birth control during their first sexual encounter, and to have used a condom during their last sexual encounter. Furthermore, males were more likely to obtain birth control from a store or a friend. Finally, males knew more about using condoms correctly and their role in preventing sexually transmitted diseases. The efficacy of interventions designed to reduce unintended pregnancy and sexually transmitted diseases among adolescents may be increased by addressing these gender differences. Understanding gender differences may also facilitate an increased role for males in the overall prevention scheme. Further research is clearly needed to increase knowledge about these gender differences.

The long term benefits of a comprehensive teenage pregnancy program

A comprehensive program was founded in 1982 to provide adolescents with prenatal and family planning care. The program's impact through its first five years of operation on medical aspects of pregnancy course and fetal outcome will be the subject of a separate report. This study examines subsequent maternal and infant health of the patients attending the program compared to a control group. Four hundred ninety-eight adolescents and their newborns attending the program's mother-baby family planning clinic from 1982 to 1989 (subject group) were compared to ninety-one adolescents and their newborns receiving postpartum family planning and pediatrics clinics from 1980 through 1989 (control group). Seventy-five percent of the subject group regularly attended mother-baby clinic, compared to 18% of the control group attending family planning and pediatric clinics (P less than or equal to .0001). The subject group experienced less maternal and infant morbidity, greater school attendance, graduation, employment, and contraceptive use than the control group (P less than or equal to .0001). Many parameters improved with each program year indicating continued wide acceptance of our program by area adolescents.

Adolescent pregnancy in the United States: a review and recommendations for clinicians and research needs

Adolescent pregnancy, often unplanned and unwanted, has a negative impact on the physical, emotional, educational, and economic condition of the pregnant teenager. Forty percent of the one million adolescents who became pregnant in 1986 chose abortion, and, of the remainder, 61% were unmarried. Teenage mothers in greater numbers and at younger ages are opting to keep and raise their children. In 1987 over $19 billion in federal monies were expended on families begun when the mother was a teenager. The preferred approach to this problem is prevention of teenage pregnancy rather than abortion, with emphasis on sex education and access to family planning information and contraceptive devices for both females and males. Sex education in schools is presented in widely varying formats; in fact, prevention of pregnancy may not even be presented. Family planning clinics are subject to the whims and biases of the funding agencies. Clinicians have an important role in providing guidance for teenage patients and their parents, but can also influence school and community leadership to ensure that all teenagers receive sound sex education in school programs and that family planning agencies are permitted to counsel teenagers and provide contraceptive devices.

Tailoring family planning services to the special needs of adolescents

Experimental service protocols tailored to the needs of teenage family planning patients were developed that emphasized indepth counseling, education geared to an adolescent's level of development, and the provision of reassurance and social support. These protocols were tested against usual service delivery practices in a study involving 1,261 patients under 18 years of age at six nonmetropolitan family planning clinics. A comparison with teenagers obtaining services at control sites found that six months after their first clinic visit, patients at the experimental sites were more likely to be using a method, were less likely to experience difficulty in dealing with problems, were more likely to continue using their method despite problems and had learned more during the educational session. Teenage patients at the experimental clinics were also less likely to have become pregnant within one year than those who went to control clinics. Attrition during the year following the first study visit was similar among both groups; patient satisfaction was very high, and equivalent at experimental and control sites. The data show that the extra time and effort required to meet the special needs of teenagers is justified by their improved contraceptive use, greater knowledge and lower pregnancy rates.

Teaching refusal skills to sexually active adolescents

Refusal skills training was extended to sexually active handicapped female adolescents who lacked an effective refusal strategy. Role-plays for assessment and training were developed using the who, what, when and where of situations which resulted in unwanted intercourse. Refusal skills were trained following the format of rationale, modeling, rehearsal, feedback, and reinforcement. Baseline rates of most target behaviors were quite low. High frequencies of target behaviors were observed as each behavior became the focus of training. Generalization across staff and time was also observed. The skillfulness and effectiveness of the subjects' refusal skills were judged to be improved as a function of training. One-year follow-up showed decreased sexual activity for each girl.

Teenage mothers and their children: risks and problems: a review

Adolescent mothers and their offspring are a high risk group broth physically and emotionally. Poverty, malnutrition, complications of pregnancy, emotional problems such as depression, drug and alcohol use, are all risks for the mother. Children are also at greater risk for physical, cognitive and emotional problems. It is therefore important to identify factors which influence outcome on adolescent mothers and their children in order to suggest interventions which will more positively affect the physical and psychological health of this increasing population.

A research agenda on issues affecting poor and minority women: a model for understanding their health needs

Acquiring data on quality of life indicators such as health, mental health and family roles of poor and minority women remains a low research priority. This paper provides an assessment of current knowledge in this area and an overview of the context in which poor and racial/ethnic women utilize health care services. A model that encompasses the interactive effects of race, gender and class variables is proposed. Such a model is a necessity for understanding the health needs of poor and racial/ethnic women. Suggestions for future research and policy formulation are given.

Targeting the adolescent male

The National Urban League regards too early parenting among adolescents as an issue requiring high level, active attention from all segments of the Black community. Poverty, single parent households and adolescent pregnancies are not exclusively female problems. The role that males play has been missing from too many studies of these phenomena. In light of the fact that most sexual activity is male initiated, and most sexual behavior is male influenced, it becomes clear that there will be no resolution of the problem of teenage pregnancy without directing greater attention to the male. The issue of male responsibility is skirted too often due to parental pride on the part of mothers and fathers when their male children seek sexual relations with female partners. It is viewed as a sign that they are developing sexually within the norm. This is especially true, in many instances, in female headed households where the mother is concerned that she may not be providing her son with an adequate male role model. Sexual activity by female adolescents, however, is generally not condoned. This confusing double standard is further compounded by the disjointed fashion in which American society responds to adolescent sexuality on the whole. Although the home should be the focal point, many parents reluctantly admit an inability to communicate effectively about sex with their pre-adolescent children. Thus, the school, church, community and social agencies have all been enlisted in this task. The National Urban League's initiative in this area is expected to have significant impact on the course of adolescent sexuality and reproductive responsibility.(ABSTRACT TRUNCATED AT 250 WORDS)

The politics of adolescent pregnancy: a view of New York State

In 1965, the U.S. Supreme Court struck down the Connecticut statute outlawing the use of birth control by married couples. Since then, 26 related cases have been heard by the court. Many of these directly involved teenagers. Frequently, the determinations involved parental consent or a parental notice requirement. New York State does not have parental consent nor notice requirements for minors seeking contraceptive or abortion services. The physician makes the professional judgment of the maturity of the person seeking care. All efforts to institute any form of parental consent in New York State have failed. The New York State Bar Association has supported this posture. A statewide network of family planning clinics exists throughout New York State. Yet, in spite of their combined efforts, and the activities of many other agencies and organizations, the rate of pregnancy among 15 to 19 year olds increased 20 percent between 1972 and 1980. There is a need for bold public action. Informed community leaders, health professionals, and leaders in the educational community must form a coalition to support the special initiatives which New York State's governor and New York City's mayor support. Black physicians have an unusual opportunity and a special responsibility to the youth of this city to provide leadership in their communities, and in their profession, in providing information about the risks and complications of teen pregnancies and teen parenting.

Adolescent pregnancy: black and white

According to recent data from the Alan Guttmacher Institute, the United States leads nearly all other developed nations of the world in rates of teenage pregnancy, abortion and child-bearing even though it has comparable rates of sexual activity. Data show that this top-ranked status is not due to the high rates of pregnancy and parenthood among minority teens alone. Pregnancy rates for white teenagers are twice as high as those of Canada, France, and England. Moreover, the maximum difference in birth rates by race occurs among girls under 15, the most vulnerable teenagers. International data make it clear that the enormous costs of adolescent parenthood for teen parents, their children and society are not the inevitable outcomes of increased adolescent sexual activity. These costs represent inability as a society to deal in a preventive way with the implications of that increase, to provide adequate and comprehensive sex education, and to give sexually active teens easy access to family planning services and counseling. Many object to giving teenagers the capacity to delay parenthood while unsuccessfully imploring them to delay sexual activity. Withholding sex education and family planning services has not led to less teenage sexual activity in the U.S. Conversely, the provision of needed information and services in Europe and Canada has not resulted in increased sexual activity, but in heightened sexual responsibility. The costs of adolescent parenthood fall disproportionately on those least able to support them, teens from low-income/minority families and teens with poor basic skills and poor employment potential. They initiate sexual activity earlier than more advantaged teens and have poorer access to information and services.(ABSTRACT TRUNCATED AT 250 WORDS)