Evaluating teen options for preventing pregnancy: Impacts and mechanisms.

This paper presents findings from an experimental evaluation of the Teen Options to Prevent Pregnancy (TOPP) program, an 18-month intervention that consists of a unique combination of personalized contraceptive counseling, facilitated access to contraceptive services, and referrals to social services. We find that TOPP led to large and statistically significant increases in the use of long-acting reversible contraceptives (LARCs), accompanied by substantial reductions in repeat and unintended pregnancy among adolescent mothers. We provide an exploratory analysis of the channels through which TOPP achieved its impacts on contraceptive behavior and pregnancy outcomes. A back-of-the-envelope decomposition implies that the increase in LARC use can explain at most one-third of the reduction in repeat pregnancy. We provide suggestive evidence that direct access to contraceptive services was important for increasing LARC use and reducing repeat pregnancy. We did not find any spillover effects on non-targeted outcomes, such as educational attainment and benefit receipt.

A Practical Guide to Cluster Randomized Trials in School Health Research.

BACKGROUND: When well-designed and implemented, cluster randomized trials can meet the high standards federal agencies and other funders increasingly require for evidence on the effectiveness of school health programs and services. However, designing and implementing these studies can present more challenges than at first appears. METHODS: I reviewed summaries of the methodological literature on cluster randomized trials. I then conducted a search to identify practical applications of these methods in school health research. RESULTS: The review identified 6 key issues or decisions school health researchers must address when designing, conducting, and analyzing data from a cluster randomized trial: (1) reasons to use a clustered design, (2) sample size calculation, (3) the use of matching or stratification, (4) definition of the school and student samples, (5) consent gathering, and (6) analysis methods. CONCLUSIONS: School health researchers can take several practical steps to ensure the availability of high-quality research evidence and meet the growing demands for evidence and accountability in education policy and programming. These steps include selecting the right research design for the intervention and evaluation setting, identifying appropriate sample definitions and analysis methods, and developing appropriate procedures for gathering parental permission and student assent.

Brief report: Assessing the risk of reporting bias in a RCT for adolescent mothers.

INTRODUCTION: Most adolescent sexual and reproductive health studies rely solely upon self-report surveys to assess key variables such as pregnancy and sexually transmitted infections (STIs). The current study investigated the risk of reporting bias that may result from using such surveys to measure outcomes in randomized controlled trials (RCTs). METHODS: As part of an RCT of a multicomponent intervention to delay repeat pregnancy among adolescent mothers, we compared survey data on repeat pregnancy with birth records from a state's vital statistics system. The survey assessed contraceptive use, pregnancy status, and future pregnancy intentions. The sample consisted of American adolescents ages 18 and 19 years who were at least 28 weeks pregnant or less than nine weeks postpartum. RESULTS: For 14 of 331 study participants (4 percent), we found a birth record in the vital statistics system for a mother who reported not having gotten pregnant on the survey. We found no evidence of underreporting for the other survey respondents. The rate of underreporting was similar for the intervention and control groups. CONCLUSIONS: A low rate of underreporting for repeat pregnancy in adolescent mothers was found in the present sample.

Impacts of a School-Wide, Peer-Led Approach to Sexuality Education: A Matched Comparison Group Design.

BACKGROUND: Teen Prevention Education Program (PEP) is a school-wide, peer-led comprehensive sexuality education program currently implemented in more than 50 schools across 2 states. Many teen pregnancy prevention researchers and practitioners view peer-led programs as a promising approach for reducing teen pregnancy and associated sexual risk behaviors. However, prior research on the effectiveness of these programs indicates mixed results. METHODS: We randomly assigned schools to implement Teen PEP immediately (intervention group) or on a delayed schedule (comparison group) and used propensity score matching to improve the comparability of the study groups. We surveyed students at baseline and about 6 months after the program ended. RESULTS: Teen PEP did not significantly impact rates of sexual activity or unprotected sex; however, the program led to improvements in exposure to information about sexual health topics and knowledge of preventing pregnancy and transmission of sexually transmitted infections. CONCLUSIONS: Teen PEP succeeded in accomplishing some of its most proximal goals, increasing students' access to information and knowledge. However, we found little evidence that the program affects sexual risk-taking within 6 months of its conclusion. Future research will examine the program's longer-term impacts on sexual risk behaviors.

A randomized trial of motivational interviewing and facilitated contraceptive access to prevent rapid repeat pregnancy among adolescent mothers.

BACKGROUND: Most interventions designed to reduce teen pregnancy rates have not focused on pregnant and/or parenting adolescents. Therefore, a large randomized controlled trial was conducted regarding a motivational interviewing program entitled Teen Options to Prevent Pregnancy in a low-income sample of adolescent mothers. This program recommended monthly sessions between a participant and a registered nurse over 18 months. This program also featured facilitated birth control access through transportation assistance and a part-time contraceptive clinic. OBJECTIVE: The impact of this program on rapid repeat pregnancies at 18 months after enrollment was evaluated. STUDY DESIGN: Five hundred ninety-eight adolescent females were enrolled from 7 obstetrics-gynecology clinics and 5 postpartum units of a large hospital system in a Midwestern city. Each participant was enrolled at least 28 weeks pregnant or less than 9 weeks postpartum. Each participant was randomized to either the Teen Options to Prevent Pregnancy intervention or a usual-care control condition. Intervention participants averaged 4.5 hours of assistance. Participants were contacted by blinded research staff at 6 and 18 months to complete self-report surveys. Differences in outcomes between the intervention and control groups were assessed using ordinary least-squares regression. RESULTS: There was an 18.1% absolute reduction in self-reported repeat pregnancy in the intervention group relative to the control group (20.5% vs 38.6%%; P < .001). There was a 13.7% absolute increase in self-reported long-acting reversible contraception use in the intervention group relative to the control group (40.2% vs 26.5%, P = .002). There was no evidence of harmful effects of the intervention on sexual risk behaviors, such as having sexual intercourse without a condom or greater number of partners. CONCLUSION: The Teen Options to Prevent Pregnancy program represents one of the few evidence-based interventions to reduce rapid repeat teen pregnancy. This relatively brief intervention may be a viable alternative to more time-intensive programs that adolescent mothers may be unable or unwilling to receive.

High-Stakes Systematic Reviews: A Case Study From the Field of Teen Pregnancy Prevention.

BACKGROUND: Systematic reviews help policy makers and practitioners make sense of research findings in a particular program, policy, or practice area by synthesizing evidence across multiple studies. However, the link between review findings and practical decision-making is rarely one-to-one. Policy makers and practitioners may use systematic review findings to help guide their decisions, but they may also rely on other information sources or personal judgment. OBJECTIVES: To describe a recent effort by the U.S. federal government to narrow the gap between review findings and practical decision-making. The Teen Pregnancy Prevention (TPP) Evidence Review was launched by the U.S. Department of Health and Human Services (HHS) in 2009 as a systematic review of the TPP literature. HHS has used the review findings to determine eligibility for federal funding for TPP programs, marking one of the first attempts to directly link systematic review findings with federal funding decisions. CONCLUSIONS: The high stakes attached to the review findings required special considerations in designing and conducting the review. To provide a sound basis for federal funding decisions, the review had to meet accepted methodological standards. However, the review team also had to account for practical constraints of the funding legislation and needs of the federal agencies responsible for administering the grant programs. The review team also had to develop a transparent process for both releasing the review findings and updating them over time. Prospective review authors and sponsors must recognize both the strengths and limitations of this approach before applying it in other areas.

Impacts of an Enhanced Family Health and Sexuality Module of the HealthTeacher Middle School Curriculum: A Cluster Randomized Trial.

OBJECTIVES: To evaluate the impacts of an enhanced version of the Family Life and Sexuality Module of the HealthTeacher middle school curriculum. METHODS: We conducted a cluster randomized trial of Chicago, Illinois, middle schools. We randomly assigned schools to a treatment group that received the intervention during the 2010-2011 school year or a control group that did not. The primary analysis sample included 595 students (7 schools) in the treatment group and 594 students (7 schools) in the control group. RESULTS: Students in the treatment schools reported greater exposure to information on reproductive health topics such as sexually transmitted infections (STIs; 78% vs 60%; P < .01), abstinence (64% vs 37%; P < .01), and birth control (45% vs 29%; P < .01). They also reported higher average scores on an index of knowledge of contraceptive methods and STI transmission (0.5 vs 0.3; P = .02). We found no statistically significant differences in rates of sexual intercourse (12% vs 12%; P = .99), oral sex (12% vs 9%; P = .18), or other intermediate outcomes. CONCLUSIONS: The program had modest effects when tested among Chicago middle school students.

Programs to reduce teen pregnancy, sexually transmitted infections, and associated sexual risk behaviors: a systematic review.

PURPOSE: This systematic review provides a comprehensive, updated assessment of programs with evidence of effectiveness in reducing teen pregnancy, sexually transmitted infections (STIs), or associated sexual risk behaviors. METHODS: The review was conducted in four steps. First, multiple literature search strategies were used to identify relevant studies released from 1989 through January 2011. Second, identified studies were screened against prespecified eligibility criteria. Third, studies were assessed by teams of two trained reviewers for the quality and execution of their research designs. Fourth, for studies that passed the quality assessment, the review team extracted and analyzed information on the research design, study sample, evaluation setting, and program impacts. RESULTS: A total of 88 studies met the review criteria for study quality and were included in the data extraction and analysis. The studies examined a range of programs delivered in diverse settings. Most studies had mixed-gender and predominately African-American research samples (70% and 51%, respectively). Randomized controlled trials accounted for the large majority (87%) of included studies. Most studies (76%) included multiple follow-ups, with sample sizes ranging from 62 to 5,244. Analysis of the study impact findings identified 31 programs with evidence of effectiveness. CONCLUSIONS: Research conducted since the late 1980s has identified more than two dozen teen pregnancy and STI prevention programs with evidence of effectiveness. Key strengths of this research are the large number of randomized controlled trials, the common use of multiple follow-up periods, and attention to a broad range of programs delivered in diverse settings. Two main gaps are a lack of replication studies and the need for more research on Latino youth and other high-risk populations. In addressing these gaps, researchers must overcome common limitations in study design, analysis, and reporting that have negatively affected prior research.

The effectiveness of mandatory-random student drug testing: a cluster randomized trial.

PURPOSE: This article presents findings from the largest experimental evaluation to date of school-based mandatory-random student drug testing (MRSDT). The study tested the effectiveness of MRSDT in reducing substance use among high school students. METHODS: Cluster randomized trial included 36 high schools and more than 4,700 9th through 12th grade students. After baseline data collection in spring 2007, about half the schools were randomly assigned to a treatment group that was permitted to implement MRSDT immediately, and the remaining half were assigned to a control group that delayed MRSDT until after follow-up data collection was completed 1 year later, in spring 2008. Data from self-administered student questionnaires were used to compare rates of substance use in treatment and control schools at follow-up. RESULTS: Students subject to MRSDT by their districts reported less substances use in past 30 days compared with students in schools without MRSDT. The program had no detectable spillover effects on the substance use of students not subject to testing. We found no evidence of unintentional negative effects on students' future intentions to use substances, the proportion of students who participated in activities subject to drug testing, or on students' attitudes toward school and perceived consequences of substance use. CONCLUSIONS: MRSDT shows promise in reducing illicit substance use among high school students. The impacts of this study were measured for a 1-year period and may not represent longer term effects.

Socioeconomic position and health: the differential effects of education versus income on the onset versus progression of health problems.

This article seeks to elucidate the relationship between socioeconomic position and health by showing how different facets of socioeconomic position (education and income) affect different stages (onset vs. progression) of health problems. The biomedical literature has generally treated socioeconomic position as a unitary construct. Likewise, the social science literature has tended to treat health as a unitary construct. To advance our understanding of the relationship between socioeconomic position and health, and ultimately to foster appropriate policies and practices to improve population health, a more nuanced approach is required--one that differentiates theoretically and empirically among dimensions of both socioeconomic position and health. Using data from the Americans' Changing Lives Study (1986 through 2001/2002), we show that education is more predictive than income of the onset of both functional limitations and chronic conditions, while income is more strongly associated than education with the progression of both.