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Adolescent Indicators

Teen pregnancy rate

Background

Nationally, teenage mothers account for 4.8% of all births (Jordan, Bayly and Sawyer, undated).  Victoria has the lowest proportion of teenage births of all Australian states, at 3.1%, although this varies across the state and is as high as 6% in some rural areas and up to 22% among Indigenous women (Jordan et al., undated).

The fertility rate of Australian teenagers is relatively high: this country ranked 11th among 28 OECD countries on Unicef’s teenage birth ‘league table’ in 2001.  With a birth rate of 18.1 per 1000 women aged 15 to 19, Australia was similar to Ireland, Poland and Canada, but considerably lower than the United States (which has the highest teen birth rate in the developed world, at 52.1/1000), the United Kingdom and New Zealand (Unicef, 2001).

It is difficult to estimate teenage pregnancy rates in Australia as there is no requirement for mandatory reporting of abortion nationally or in any state, with the exception of South Australia.  In 2006, 892 South Australian teenagers gave birth, and a further 998 had abortions (Chan, Scott, Nguyen and Sage, 2007).  These data indicate that teen pregnancy rates could be at least twice birth rates.  This is supported by estimates derived from Australian Bureau of Statistics and Australian Institute of Health and Welfare data, which suggest that Australia’s rate of teenage pregnancy is around 38.9/1000 women aged 15-19 years (Shine SA, 2008). 

A series of national surveys of secondary students in Australia show that adolescents are becoming sexually active earlier, and there are high rates of risky behaviour (Smith, Agius, Dyson, Mitchell and Pitts, 2003; Agius, Dyson, Pitts, Mitchell and Smith, 2006).  In 2002, a quarter of Year 10 students and more than half of the Year 12 students surveyed had had sex.  Of these sexually active adolescents, only 65.8% of Year 10s reported that they always used a condom, and this fell to 51.8% in Year 12, although the older group may be using the contraceptive pill at higher rates.  Six percent of the sample reported having been pregnant (Smith et al., 2003).

Early motherhood is associated with considerable disadvantage, both for the young woman and her child, increasing her risk of poverty, poor physical and mental health, exposure to domestic violence, crime and substance abuse, low educational attainment and social exclusion (Jordan et al., undated).  Children of teenage mothers are more likely to grow up without fathers, to be the victims of abuse or neglect, and eventually to become teenage parents themselves (Unicef, 2001). 

Reducing teenage births offers an opportunity to reduce the likelihood of poverty, and of its perpetuation from one generation to the next (Unicef, 2001, p. 2).

The evidence base

Policy approaches to reducing teenage pregnancy vary widely, depending on the prevailing value system (Unicef, 2001).  Much prevention and evaluation research in this area has been conducted in the United States, where policy is dominated by a religious viewpoint that sex and childbearing before marriage are primarily moral issues.  This means that many of the school-based programs developed in that country emphasise abstinence from premarital sex rather than providing comprehensive information about sexuality and sexual health.  Recent reviews have concluded that ‘abstinence-only’ interventions are, on the whole, ineffective (Santelli et al., 2006; Trenholm et al., 2008; US Government Accountability Office, 2008; but see also Manlove, Franzetta, McKinney, Romano Papillo and Terry-Humen, 2004).  In any case, such interventions are inconsistent with Australian social policy which approaches the problem from the perspective of improving health and reducing disadvantage.  In Victoria, the purpose of universal school-based sexuality education is to:

build on knowledge, skills, and behaviours, thus enabling young people to make responsible and safe choices (DEECD, 2007).

In one large national study in the US, adolescents who received comprehensive sex education in school were significantly less likely to report teen pregnancy and marginally less likely to have had sex than those who had received no formal sex education, while abstinence-only education had no effect on either measure (Kohler, Manhart and Lafferty, 2008).  Overall, however, the evidence for sex education in schools is mixed: some reviewers have concluded it has no effect on age of initiating sexual intercourse, teen pregnancy or use of birth control (DiCenso, Guyatt and Griffith, 2002; Sabia, 2006).  Other reviewers (McKay, Fisher, Maticka-Tyndale and Barrett, 2001; Kirby, 2002a, 2002b; Manlove et al., 2004; Bennett and Assefi, 2005) have identified effective programs, some of which are described below.

School-based programs that provide knowledge and seek to change attitudes and behaviour are, however, only part of the solution (Jordan et al., undated).  Teen pregnancy rates are strongly linked to inequality in society and those most at risk are adolescents who dislike school, underachieve and have low life expectations (Fergusson and Woodward, 2000; Bonnell et al., 2003; Harden et al., 2006; Fletcher, Harden, Brunton, Oakley and Bonnell, 2008).  Broad-based, multi-component youth development programs are designed to address these social determinants of teenage pregnancy along with a host of common risk and protective factors for other problem behaviours and outcomes among young people.  Such programs are well supported by evidence (Kirby, 2002b; Harden et al., 2006) but can be expensive and difficult to replicate (e.g., Wiggins et al., 2008).

The influence of parents on adolescents’ behaviour has been acknowledged in the design of another group of interventions (Meschke, Bartholomae and Zentall, 2002).  These approaches focus on improving communication and strengthening family relationships.  Some promising strategies are emerging, but many of these studies do not include measures of safe sex behaviour, contraceptive use or pregnancy outcomes.

Another approach that would appear to be relevant and potentially cost-effective is individual counselling in a primary health care setting (e.g., see Danielson DATE, below).  There is, however, a lack of studies providing high-quality evidence in this area (Moos, Bartholomew and Lohr, 2003).

Selection of interventions

There is an abundance of school-based sex education programs that aim to prevent teenage pregnancy.  An expert review panel for the Program Archive on Sexuality, Health and Adolescence identified 56 programs they classified as ‘effective’ (Card, Lessard and Benner, 2007).  Our review narrowed the field by focusing on studies with strong research designs and reported, longer-term outcomes for teenage pregnancy or contraceptive use.

Safer Choices is a well-documented school-based sex education program that incorporates information on AIDS/STD prevention information, parent involvement and links with community health services.  Although it is an American program, it takes a harm minimisation approach.  The program is taught in 20, 45-minute lessons delivered in two blocks or levels: 10 in the first year, and 10 in the following year, starting in 9th grade (US).  Staff training events are held in preparation.  A randomised, controlled trial demonstrated that the program had statistically and clinically significant effects on students’ contraceptive use and safe sex practices 31 months after baseline (Basen-Engquist et al 2001; Coyle et al 2001, 2006).

The SHARE program was piloted with more than 14,000 adolescents aged 11-15 years in 15 secondary schools in South Australia over three years from 2003.  Like Safer Choices, SHARE has broader aims beyond teenage pregnancy prevention, namely promoting the sexual health, safety and wellbeing of young people.  This ‘whole-school’ program supports positive changes to the school ethos and involves parents and the community.  The curriculum involves 15 one-hour lessons delivered to students in years 8, 9 and 10 (ages 11-15) by teachers who receive specific training (Shine SA, circa 2006).  It was developed by Shine SA, based on extensive consultation, research and a review of the literature on effective comprehensive sex education in schools (Dyson et al., 2003).

The pilot program was independently evaluated (Dyson and Fox, 2006), although this did not include behavioural outcome measures.  A qualitative evaluation examined course content and implementation and concluded that the SHARE program was

an exemplary model of a comprehensive sexual health and relationships program.  It is a thoroughly researched, theoretically rigorous, comprehensive and 'usable' set of materials and guides (Johnson, 2006, p. 33)

This program has been included in the catalogue as a promising strategy that is particularly relevant to the Australian context.  In order for it to be disseminated and used more widely, further evaluation (preferably measuring outcomes such as contraceptive use) is strongly recommended.

The Teen Outreach Program uses a ‘service learning’ approach to enhance teenagers’ social development and connections with school and the community.  This school-based program incorporates a minimum of 20 hours’ community service activities annually, supervised by trained staff.  Weekly classroom discussions are wide-ranging, and sexuality education forms only a small part of the curriculum.  Instead, classroom sessions are designed to maximise the learning opportunities from the volunteer experiences and address participants’ social and personal development needs.  This intervention significantly reduced pregnancy rates among participants (4.2%) compared with a control group (9.8%), after controlling for demographic factors and other existing differences between the groups.  The program also had large positive impacts on school failure and suspension (Allen, Philliber, Herrling and Kuperminc, 1997). 

Another ‘service learning’ program that has also been well evaluated is Reach For Health (O’Donnell et al., 2002).  Two years after the program, participants were less likely than controls to report sexual initiation and recent sex.  Contraceptive use and pregnancy outcomes were not reported.  Other service learning and youth development programs recommended by reviewers include the Seattle Social Development Project and Quantum Opportunities Program (see Harden et al., 2006, for a summary). 

The strategy with the strongest evidence in terms of demonstrated reductions in teen pregnancy rates is the Children’s Aid Society (CAS) Carrera Program (Philliber, Kaye and Herrling, 2001; Philliber, Williams-Kaye, Herrling and West, 2002).  CAS-Carrera is an intensive and sustained intervention for at-risk youth aged 13-15 years.  It runs 5-6 times per week over three years as an after-school program and incorporates seven activities, one of which is family life and sex education.  The goal is to develop genuine, long-term relationships with program staff, treat participants as if they have potential and provide tailored, integrated health, educational and social services to them and their families.  A randomised, controlled trial at 12 sites in seven American cities found that after three years in the program, female participants had less than half the risk of teenage pregnancy than girls in the control group (Philliber et al., 2001).  They were more than twice as likely as controls to have used a condom and a hormonal contraceptive method at last intercourse (Philliber et al., 2002).

A recent replication of this model in the United Kingdom did not achieve positive results, however.  The Young People's Development Programme was holistic and intensive, and included education (literacy, numeracy, IT and vocational skills), training and employment opportunities, life skills, mentoring, volunteering, health education, arts, sports and advice on access to services.  Young women who took part had poorer outcomes than controls relating to teen pregnancy, truancy and school exclusion, expectation of teen parenthood and sexual activity (Wiggins et al., 2008).  The evaluators recommended that youth development programs may be better offered separately to females and males. Also, it is important to ensure that the program does not bring participants into contact with 'a more risky group of friends' (Wiggins et al., 2008, p. vi). They offered suggestions on how this could be avoided: work with different age groups, or with broad groups defined by general social disadvantage (as CAS-Carrera does) rather than defined by specific risks, or work with pre-existing friendship groups.

A very different, yet effective, approach was taken in an innovative study of reproductive health counselling for young men (Danielson, Marcy, Plunkett, Wiest and Greenlick, 1990).  This strategy was designed to increase knowledge, provide personalised, directive advice, reduce coercive behaviours (which have been shown to influence early initiation of intercourse and unprotected sex) and make participants more comfortable in discussing sexual and contraceptive topics with their partners.

The counselling intervention was provided individually to almost 1200 adolescent males aged 15-18 years, during a one-hour medical appointment at the participant's usual medical clinic.  Each participant sat alone in a private room to view a half-hour audiovisual presentation, which included explicit photographs and information on reproductive anatomy, fertility, hernia, testicular self-examination, STDs, contraception, couple communication and access to health services. This was followed by a consultation focusing on contraception and guided by the participant's own interests and questions.  Those who received the consultation were more likely than controls to report that their last sexual intercourse was protected by the pill and that their main method of contraception in the previous year was the pill.  Effects were strongest among those not sexually active at the time of the baseline survey (Danielson et al., 1990).  A similarly personalised, primary care-based approach for teenage girls at ‘high risk’ of pregnancy succeeded in persuading many participants to use contraception and postpone motherhood for six months or more (Cowley, Farley and Beamis, 2002).

Discussion

A ‘whole-school approach’ to sexuality education has been advocated by recent Australian reviewers (Dyson, Mitchell, Dalton and Hillier, 2003; Jordan et al., undated; Dyson et al., 2008).  This is defined (Mitchell et al., 2000, cited in Dyson et al., 2008) as going beyond a formal curriculum to include consultation and interaction with parents and the school community, access to community resources, student involvement and changes to school policy and guidelines.  There is evidence that this approach has been implemented internationally, although there appear to be no formal evaluations (Dyson et al., 2008).

Nevertheless, a whole-school approach harmonises with recommendations by reviewers who have identified elements of successful prevention programs (e.g., Gourlay, 1996 and Ollis, 1996, both cited in Dyson et al., 2003; Kirby, 2001, cited in Manlove et al., 2004).  Below is a summary of the key factors (for a full list, see Dyson et al., 2003):

  • Acknowledging young people as sexual beings
  • Addressing and catering for diversity
  • Using developmentally based curricula that are appropriate and inclusive
  • Identifying and addressing educators’ training needs
  • Involving parents and communities

In their review of sexual risk-reduction interventions for adolescents, Robin and colleagues (2004) noted that successful programs focused on building specific skills that reduced particular risk behaviours.  Broad, multi-component youth development strategies also have much to offer, however.  In particular, programs that build life expectations and connection with school have the potential to reach those most at risk of teenage parenthood (Fletcher et al., 2008).

Many studies have demonstrated that sex education in schools does not, as feared by some conservative elements in society, lead to increased sexual behaviour among high school students (Kirby, 2002b).  However, these attitudes represent a potential barrier to successful implementation of evidence-based programs (see Johnson, 2006, for an Australian example).

References

Agius PA, Dyson S, Pitts MK, Mitchell A and Smith AM (2006) Two steps forward and one step back? Australian secondary students' sexual health knowledge and behaviors 1992-2002. Journal of Adolescent Health. Vol. 38, No. 3, pp. 247-252.

Allen JP, Philliber S, Herrling S and Kuperminc GP (1997) Preventing teen pregnancy and academic failure: Experimental evaluation of a developmentally based approach. Child Development. Vol. 68, No. 4, pp. 729-742.

Basen-Engquist K, Coyle KK, Parcel GS, Kirby D, Banspach SW, Carvajal SC and Baumler E (2001) Schoolwide effects of a multicomponent HIV, STD, and pregnancy prevention program for high school students. Health Education and Behavior. Vol. 28, No. 2, pp. 166-185.

Bennett SE and Assefi NP (2005) School-based teenage pregnancy prevention programs: a systematic review of randomized controlled trials. Journal of Adolescent Health. Vol. 36, No. 1, pp. 72-81.

Bonell CP, Strange VJ, Stephenson JM, Oakley AR, Copas AJ, Forrest SP, Johnson AM and Black S (2003) Effect of social exclusion on the risk o teenage pregnancy: development of hypotheses using baseline data from a randomised trial of sex education. Journal of Epidemiology and Community Health. Vol. 57, pp. 871-876.

Card JJ, Lessard L and Benner T (2007) PASHA: facilitating the replication and use of effective adolescent pregnancy and STI/HIV prevention programs. Journal of Adolescent Health. Vol. 40, No. 3, pp. 275.e1-14.

Chan A, Scott J, Nguyen AM and Sage L (2007) Pregnancy outcome in South Australia 2006. Adelaide, South Australia: Pregnancy Outcome Unit, Epidemiology Branch, Department of Health.

Cowley CB, Farley T and Beamis K (2002) "Well, maybe I'll try the pill for just a few months...." Brief motivational and narrative-based interventions to encourage contraceptive use among adolescents at high risk for early childbearing. Families, Systems and Health. Vol. 20, No. 2, pp. 183-204.

Coyle K, Basen-Engquist K, Kirby D, Parcel G, Banspach S, Collins J, Baumler E, Carvajal S and Harrist R (2001) Safer choices: reducing teen pregnancy, HIV, and STDs. Public Health Reports. Vol. 116, Suppl 1, pp. 82-93.

Coyle K, Kirby D, Robin L, Banspach S, Baumler E and Glassman J (2006) All4You! A randomized trial of an HIV, other STD, and pregnancy prevention intervention for alternative school students. AIDS Education and Prevention. Vol. 18, No. 3, pp. 187-203.

Danielson R, Marcy S, Plunkett A, Wiest W and Greenlick MR (1990) Reproductive health counseling for young men: what does it do? Family Planning Perspectives. Vol. 22, No. 3, pp. 115-121.

DEECD (2007) Sexuality Education. In Victorian Government Schools Reference Guide. Melbourne: Victorian Government Department of Education and Early Childhood Development, accessed 18 Sept 2008.

DiCenso A, Guyatt G, Willan A and Griffith L (2002) Interventions to reduce unintended pregnancies among adolescents: systematic review of randomised controlled trials. British Medical Journal. Vol. 324, No. 7351, pp. 1426-1430.

Dyson S and Fox C (2006) An evaluation of the Sexual Health and Relationships Education (Share) project 2003 - 2005. Shine SA: Australian Research Centre in Sex, Health and Society.

Dyson S et al. (2008) Catching on Everywhere: Sexuality education program development for Victorian schools. Part 1, Program planning: concepts and policy. Melbourne: Student Learning Programs Division Office for Government School Education, Department of Education and Early Childhood Development.

Dyson S, Mitchell A, Dalton D and Hillier L (2003) Factors for success in conducting effective sexual health and relationships education with young people in schools: A literature review. Melbourne: Australian Research Centre in Sex, Health and Society, La Trobe University.

Fergusson DM and Woodward LJ (2000) Teenage pregnancy and female educational underachievement: A prospective study of a New Zealand birth cohort. Journal of Marriage and the Family. Vol. 62, No. 1, pp. 147-161.

Fletcher A, Harden A, Brunton G, Oakley A and Bonnell C (2008) Interventions addressing the social determinants of teenage pregnancy. Health Education. Vol. 108, No. 1, pp. 29-39.

Harden A, Brunton G, Fletcher A, Oakley A, Burchett H and Backhans M (2006) Young people, pregnancy and social exclusion: A systematic synthesis of research evidence to identify effective, appropriate and promising approaches for prevention and support. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London.

Johnson B (2006) An evaluation of the trial implementation of the Sexual Health and Relationships Education (Share) program 2003 – 2005. Shine SA: University of South Australia.

Jordan L, Bayly C and Sawyer SM (2005) The Sexual and Reproductive Health of Young Victorians. Melbourne: Family Planning Victoria, Royal Women’s Hospital and Centre for Adolescent Health.

Kirby D (2002a) The impact of schools and school programs upon adolescent sexual behaviour. The Journal of Sex Research. Vol. 39, No. 1, pp. 27-33.

Kirby D (2002b) Effective approaches to reducing adolescent unprotected sex, pregnancy, and childbearing. The Journal of Sex Research. Vol. 39, No. 1, pp. 51-57.

Kirby DB, Baumler E, Coyle KK, Basen-Engquist K, Parcel GS, Harrist R and Banspach SW (2004) The "Safer Choices" intervention: its impact on the sexual behaviors of different subgroups of high school students. Journal of Adolescent Health. Vol. 35, No. 6, pp. 442-452.

Kohler PK, Manhart LE and Lafferty WE (2008) Abstinence-only and comprehensive sex education and the initiation of sexual activity and teen pregnancy. Journal of Adolescent Health. Vol. 42, No. 4, pp. 344-351.

McKay A, Fisher W, Maticka-Tyndale E and Barrett M (2001) Commentary: Adolescent Sexual Health Education. Does it Work? Can it Work Better? An Analysis of Recent Research and Media Reports. The Canadian Journal of Human Sexuality. Vol. 10, No. 3 and 4, pp. 127-135.

Manlove J, Franzetta K, McKinney K, Papillo AR and Terry-Humen E (2004) No time to waste: programs to reduce teen pregnancy among middle school-aged youth. Washington DC: National Campaign to Prevent Teen Pregnancy.

Meschke LL, Bartholomae S and Zentall SR (2002) Adolescent Sexuality and Parent-Adolescent Processes: Promoting Healthy Teen Choices. Journal of Adolescent Health. Vol. 31, No. 6 (Suppl), pp. 264-279. 

Moos MK, Bartholomew NE and Lohr KN (2003) Counseling in the clinical setting to prevent unintended pregnancy: an evidence-based research agenda. Contraception. Vol. 67, No. 2, pp. 115-132.

O'Donnell L, Stueve A, O'Donnell C, Duran R, Doval AS, Wilson RF, Haber D, Perry E and Pleck JH (2002) Long-term reductions in sexual initiation and sexual activity among urban middle schoolers in the reach for health service learning program. Journal of Adolescent Health. Vol. 31, No. 1, pp. 93-100.

Philliber S, Kaye J and Herrling S (2001) The National Evaluation of the Children’s Aid Society Carrera–Model Program to Prevent Teen Pregnancy. New York: Philliber Research Associates.

Philliber S, Kaye JW, Herrling S and West E (2002) Preventing Pregnancy and Improving Health Care Access Among Teenagers: An Evaluation Of the Children's Aid Society - Carrera Program. Perspectives on Sexual and Reproductive Health. Vol. 34, No. 5, pp. 244-251.

Robin L, Dittus P, Whitaker D, Crosby R, Ethier K, Mezoff J, Miller K and Pappas-Deluca K (2004) Behavioral interventions to reduce incidence of HIV, STD, and pregnancy among adolescents: a decade in review. Journal of Adolescent Health. Vol. 34, No. 1, pp. 3-26.

Sabia JJ (2006) Does sex education affect adolescent sexual behaviors and health? Journal of Policy Analysis and Management. Vol. 25, No. 4, pp. 783-802.

Santelli J, Ott MA, Lyon M, Rogers J, Summers D and Schleifer R (2006) Abstinence and abstinence-only education: a review of U.S. policies and programs. Journal of Adolescent Health. Vol. 38, No. 1, pp. 72-81.

Shine SA (2008) Sexual health statistics. South Australia: Sexual Health information, networking and education.

Shine SA (2006) Health, respect, life: the final report on the Sexual Health and Relationships Education (Share) project, 2003-2005. Kensington, South Australia: Shine SA. Available from http://www.publications.health.sa.gov.au/hprom/2/ 

Smith A, Agius P, Dyson S, Mitchell A and Pitts M (2003) Secondary students and sexual health 2002: Report of the findings from the 3rd National Survey of Australian Secondary Students, HIV/AIDS and Sexual Health. Melbourne: Monograph series No. 47, Australian Research Centre in Sex, Health and Society, La Trobe University.

Trenholm C, Devaney B, Fortson K, Clark M, Bridgespan LQ and Wheeler J (2008) Impacts of abstinence education on teen sexual activity, risk of pregnancy, and risk of sexually transmitted diseases. Journal of Policy Analysis and Management. Vol. 27, No. 2, pp. 255-276.

UNICEF (2001) A league table of teenage births in rich nations. Innocenti Report Card No. 3. Florence, Italy: UNICEF Innocenti Research Centre.

United States Government Accountability Office (2008) Abstinence Education: Assessing the accuracy and effectiveness of Federally Funded Programs. Washington DC: GAO-08-664T.

Wang LY, Davis M, Robin L, Collins J, Coyle K and Baumler E (2000) Economic evaluation of Safer Choices: A school-based human immunodeficiency virus, other sexually transmitted diseases, and pregnancy prevention program. Archives of Pediatrics and Adolescent Medicine. Vol. 154, No. 10, pp. 1017-1024.

Wiggins M, Bonell C, Burchett H, Sawtell M, Austerberry H, Allen E and Strange V (2008) Young People’s Development Programme Evaluation: Final Report. London: Social Science Research Unit, Institute of Education, University of London.

Key

Supporting evidence

  1. Well-supported practice – evaluated with a prospective randomised controlled trial
  2. Supported practice – evaluated with a comparison group and reported in a peer-reviewed publication
  3. Promising practice – evaluated with a comparison group
  4. Acceptable practice – evaluated with an independent assessment of outcomes, but no comparison group (such as pre- and post-testing, post-testing only or qualitative methods) or historical comparison group (such as normative data)
  5. Emerging practice – evaluated without an independent assessment of outcomes (such as formative evaluation, service evaluation conducted by host organisation)

Replication

Has the intervention been implemented and independently evaluated at more than one site? (yes or no)

Documentation

Are the content and methods of the intervention well documented (such as provider training courses and user manuals) and standardised to control quality of service delivery? (yes or no)

Theoretical basis

Is the intervention based on a well-accepted theory or developed from a continuing body of work in its field? (yes or no)

Cost Effectiveness

Are cost-effectiveness studies available? (yes or no)

Cultural reach

Has the program been trialed with people in disadvantaged communities, Indigenous people or people from culturally and linguistically diverse backgrounds? (LOW SES/INDIGENOUS/CALD). Universal if no specific target group identified.

Table 1 Teenage pregnancy rates – recommended strategies

  Supporting evidence Replication Documentation Theoretical
basis
Cost
effectiveness
Cultural
reach
(20.1)  Reproductive health counselling for young men 1 N N Y N Universal
(20.2) Teen Outreach Program (TOP) 1 Y Y Y Y Universal
(20.3) Children’s Aid Society Carrera Program (CAS-Carrera) 1 Y Y Y Y Low SES CALD
(20.4) Sexual Health and Relationships Education (SHARE) 4 N Y Y N Universal
(20.5) Safer Choices 1 Y Y Y Y Universal

Recommended strategy 1 - Reproductive health counselling for young men

Name of intervention

Reproductive health counselling for young men.

Organisation

Kaiser Permanente Center for Health Research, Oregon.

Brief literature review

Interviewing/counselling was delivered individually in a health setting, combining a personal health consultation with a half-hour audiovisual presentation.  Adolescent males aged 15-18 years were recruited through a Health Maintenance Organisation, with parental permission.  The intervention took place during a one-hour medical appointment at the participant's usual medical clinic.  The practitioner provided a brief introduction, then left the participant alone in a private room to view the half-hour audiovisual presentation, which included explicit photographs and information on reproductive anatomy, fertility, hernia, testicular self-examination, STDs, contraception, couple communication and access to health services. This was followed by a consultation focusing on contraception and guided by the participant's own interests and questions, with the goal of increasing the participant's comfort level regarding discussion of sexual and contraceptive topics.

How and why does this intervention work?

The evaluation used a randomised, controlled design with 12-month follow-up. The intervention reduced 'sexual impatience' among participants (this was a composite measure of dissatisfaction with being a virgin, which was found to be strongly related to intentions to have unprotected sex). Those who received the consultation were more likely than controls to report that their last sexual intercourse was protected by the pill and that their main method of contraception in the previous year was the pill.  Participants also had better knowledge of fertility and prevention of STDs and were more likely to practise testicular self-examination.

On what population does this intervention work best?

This was a universal intervention targeting male adolescents aged 15-18 years.  The trial population consisted of 1195 young men in three US states. The intervention worked best with those who were not sexually active at the time of the baseline survey.

Where will this intervention work best?

Primary health care setting such as a community health centre.

What is required to implement this intervention?

The intervention was delivered by nurse practitioners, nurses or physicians' assistants who had received specific training.  It requires a culturally appropriate audiovisual presentation (this intervention adapted materials from two programs made by the University of Minnesota, “Young Men’s Reproductive Health” and “Young Men’s Sexual Responsibility”) and computer or DVD on which to play it in a private setting.

Resources and contact information

Contact details provided in the journal article are no longer current (see http://www.kpchr.org/public/default.aspx). However, the methods are described in full in the article referenced below.

References

Danielson et al., 1990.

Recommended strategy 2 - Teen Outreach Program (TOP)

Name of intervention

Teen Outreach Program (TOP).

Organisation

The Wyman Center, Missouri.

Brief literature review

TOP is a school-based service learning program incorporating community service and classroom instruction, which does not focus specifically on sexuality education but addresses more general developmental needs of participants.  The program is designed to involve adolescents in volunteer activities supervised by trained staff and often working with staff and volunteers of local community organisations such as hospitals or nursing homes.  Activities may include working as a nursing aide or peer tutoring.  A minimum of 20 hours' volunteer experience is provided over a year, although participants in the trial actually received 45 hours on average.  Weekly classroom discussions also take place, with the aim of maximising the learning opportunities from the volunteer experiences.  Material specifically about sexuality forms only a small part of the curriculum. Instead, the program aims to give adolescents a forum in which thoughts and feelings can be safely discussed and they can understand and evaluate their future life options.  The structured community service provides an opportunity to establish skills and autonomy and to be viewed in a positive role.

How and why does this intervention work?

Evaluation design was a randomised controlled trial with outcomes measured after 12 months.  Rates of pregnancy were significantly lower in the intervention group (4.2%) than the control group (9.8%) at follow-up, after controlling for demographic factors and other existing differences between the groups.  The program also had large positive impacts on school failure and suspension. Costs of the program were estimated (in 1997) at US$500-US$700 per student when delivered to classes of 18-25 students, including costs for a facilitator and site co-ordinator.

On what population does this intervention work best?

TOP can be run as a universal youth development strategy or as a more targeted intervention (see below).  It is designed for young people aged 12-17 years.  The trial population consisted of 695 high school students (342 intervention and 353 control group) at 25 randomly chosen sites in the US.

Where will this intervention work best?

The program is designed for high schools and can be implemented in various ways: during class time, either as an elective or integrated with core subjects; as an after-school voluntary program; or as a component of enrichment programs such as social clubs, recreation, mentoring and tutoring initiatives, or other after-school activities.

What is required to implement this intervention?

In the US, facilitators attend a 2 ½ day training course before delivering TOP. Curriculum materials are available commercially and include a guide to evaluating TOP.  The program’s publisher offers technical support in setting up and running the program.

Resources and contact information

Claire Wyneken, The Wyman Center (http://www.wymancenter.org/wyman_top.htm)
600 Kiwanis Drive, Eureka, Missouri 63025, USA. clairew@wymancenter.org

References

Allen et al., 1997.

Recommended strategy 3 - Children’s Aid Society Carrera Program (CAS-Carrera)

Name of intervention

Children’s Aid Society Carrera Program (CAS-Carrera).

Organisation

Children’s Aid Society, United States.

Brief literature review

This is a long-term intensive holistic program incorporating: family life and sex education; individual academic assessment and tutoring; a work-related intervention; artistic and sporting activities; mental health care; comprehensive health care. Young people join the program in early teens (13-15 years). CAS-Carrera is run as an after-school program five days a week during the school year and there are occasional meetings, trips and help with employment during holidays. Services are tailored and integrated. Program staff  build relationships with the participating youth and their families.

How and why does this intervention work?

A randomised, controlled trial at 12 sites in seven American cities found that after three years in the program, female participants had less than half the risk of teenage pregnancy than girls in the control group (Philliber et al., 2001).  They were more than twice as likely as controls to have used a condom and a hormonal contraceptive method at last intercourse (Philliber et al., 2002). In addition, young people in the program were more likely to have work experience and to receive medical care. There were no significant program impacts on males’ sexual behaviour outcomes and young men most at risk – those who had initiated sexual intercourse before enrolment – were least likely to attend regularly.

On what population does this intervention work best?

CAS-Carrera targets adolescents at risk of teenage pregnancy and other poor health and social outcomes (although organisers refer to them as ‘at promise’). The trial population was about 600 adolescents attending six agencies in New York City, plus 100 young people at each of six other sites in different US cities. Most were from minority ethnic groups and all were socially disadvantaged, with about half from single-parent homes and high rates of substance use, illness, parental incarceration and domestic violence in their families. About half lived in families with no working adult and/or reliant on public assistance.

Where will this intervention work best?

The original program was run through youth agencies, boys and girls clubs and multi-service agencies. Participants were recruited through schools, letterbox fliers, contacting families already on agency lists and recruiting teens involved in youth activities at the participating agencies.

What is required to implement this intervention?

Part-time staff are required to run the program activities, with a full-time coordinator and a full-time community organiser who handles logistics and maintains continuous contact with participants and their families. This person needs to have good rapport with community members. The program requires coordination with health and mental health services.

Resources and contact information

Children’s Aid Society (http://www.childrensaidsociety.org/)

References

Philliber et al., 2001, 2002.

Recommended strategy 4: Sexual Health and Relationships Education (SHARE)

Name of intervention

Sexual Health and Relationships Education (SHARE).

Organisation

SHine SA.

Brief literature review

SHARE is not specifically a teen pregnancy prevention program but has broader aims for high school students, their parents and families, teachers and the school environment or ethos.  ts goal was to improve the sexual health, safety and wellbeing of young people. The curriculum involved 15 one-hour lessons delivered to students in years 8, 9 and 10 (ages 11-15). Parent information evenings were held in schools, and student health and wellbeing teams set up including representatives from parents, teachers, students and local community agencies.

How and why does this intervention work?

The SHARE model was based on extensive consultation, research and review of the literature on effective comprehensive sex education in schools. Two independent evaluations were conducted of the pilot program (2003-2005).  Dyson and Fox (2006) surveyed students in three SHARE and three control schools in 2003 and 2005.  Due to very small numbers of completed surveys from control schools, these data were not used.  Instead the evaluators compared student responses in 2003, before the SHARE program, to responses from a (different) group of students who had received two or three years' SHARE training. After the program, students had improved understanding of safe sex behaviours but there was no change in their confidence about talking to prospective partners about using condoms or obtaining condoms (these were at high levels before and after).  Impacts on safe-sex behaviours were not measured. A qualitative evaluation by Johnson (2006) examined course content and implementation but not behavioural outcomes for young people.  This study concluded that the SHARE program was "an exemplary model of a comprehensive sexual health and relationships program.  It is a thoroughly researched, theoretically rigorous, comprehensive and 'usable' set of materials and guides ..." (p. 33).

On what population does this intervention work best?

This is a universal program for high school students. It is particularly relevant to the Australian context. The trial population consisted of more than 14,000 adolescents aged 11-15 years in 15 metropolitan and regional secondary schools in South Australia.

Where will this intervention work best?

High schools.

What is required to implement this intervention?

Teachers who delivered the SHARE curriculum received 15 hours of training. Program coordinators from SHine SA provided support to participating schools. Materials include a teacher activity manual, and parent and student booklets.

Resources and contact information

Mel Cameron, Phone (08) 8300 5300.

References

Dyson and Fox 2006; Johnson 2006; Shine SA circa 2006.

Recommended strategy 5 - Safer Choices

Name of intervention

Safer Choices.

Organisation

ETR Associates, California.

Brief literature review

Safer Choices consists of school-based sex education with AIDS/STD prevention information plus parent involvement and community health links.  Although American in origin, this is not an abstinence-only program. It is taught in 20, 45-minute lessons delivered in two blocks or levels: 10 in the first year, and 10 in the following year, starting in 9th grade (US).   Other components of the program are a School Health Promotion Council involving teachers, parents, students, administrators and community representatives; a peer team that hosts school-wide activities; parent education via newsletters, homework and parent events; and links between schools and community services.

How and why does this intervention work?

A randomised controlled trial was conducted with 31-month follow-up (79% retention rate). Sexually experienced students in intervention schools reported less intercourse without condoms in the past three months than those in control schools (ratio of 0.63) and fewer partners with whom they had unprotected sex (ratio 0.73). Intervention group students were 1.68 times more likely than comparison students to use condoms, and 1.76 times more likely to use an effective pregnancy prevention method such as the pill, pill plus condoms, or condoms alone. An economic evaluation found a return of US$2.65 in medical and social cost savings for every dollar spent on the program (Wang et al., 2000).

On what population does this intervention work best?

This is a universal program for younger adolescents. The trial population was 3869 students attending 20 high schools in California and Texas.

Where will this intervention work best?

High schools.

What is required to implement this intervention?

In the US, training events are held for teachers who will deliver Safer Choices. Program materials include curricula, workbooks, Peer Leader Training Guide, implementation manual and activity kit. They are available commercially (2008 cost is US$179 for the whole program).

Resources and contact information

ETR Associates - Program Services Division (http://programservices.etr.org/index.cfm?fuseaction=Projects.summary&ProjectID=13)

Dr Karin Coyle, ETR Associates, PO Box 1830, Santa Cruz CA 95061-1830, karinc@etr.org

References

Wang et al 2000; Basen-Engquist et al 2001; Coyle et al 2001, 2006.