Systematic Review and Narrative Synthesis of the Effectiveness of Contraceptive Service Interventions for Young People, Delivered in Educational Settings

doi:10.1016/j.jpag.2010.03.007

Journal of Pediatric and Adolescent Gynecology

Volume 23, Issue 6, December 2010, Pages 341-351

https://doi.org/10.1016/j.jpag.2010.03.007 Get rights and content

Abstract

Study Objective

This review was undertaken to determine the effectiveness of contraception service interventions for young people that were delivered in educational settings.

Design

We conducted a systematic review and narrative synthesis.

Setting

Interventions were included where they were delivered in educational institutions, including schools, colleges, and pupil referral units.

Participants

Young people aged 19 and under. Studies of wider age groups were included if the majority of participants were aged under 19 years.

Interventions

We included interventions which consisted of contraceptive service provision, and also interventions to encourage young people to use existing contraceptive services.

Main Outcome Measures

The main outcome measures used in the studies were: rate of teenage pregnancy, rate of contraceptive use, and sexual behavior. Many outcome measures were self reported.

Results

Twenty-nine papers were included which reported on interventions to prevent adolescent pregnancy (and repeat pregnancy), school-based health centers, contraceptive use in college students, and multicomponent interventions. Intensive case management intervention conducted by a culturally matched school-based social worker (along with other components including peer education) were shown to be effective in preventing repeat adolescent pregnancy, at least for the duration of the intervention. Also, school-based health centers appear to be most effective when contraception provision is made available on site.

Conclusions

The evidence from these papers is limited, in terms of both quality and quantity, along with consistency of findings, but some recommendations in relation to effective interventions can be made.

Introduction

Teenage pregnancy and birth rates in the United States continue to present substantial problems for society, placing significant pressures on local authority social care, housing and education services. Teenage pregnancy rates in the U.S. remain one of the highest in the world despite a substantial decline of over 17% since the 1990s; around 60% of adolescent mothers live in poverty at the time of their child's birth.¹ This mirrors the rate of teenage pregnancy in England and Wales, which remains the highest in Western Europe despite the decline in rates of both under 18 and under 16 conceptions over the last 20 years, and teenage pregnancy is most prevalent in areas of social and material deprivation.²

Access to contraceptive services is most problematic for people in disadvantaged communities, and adolescents are among those least likely to have access to health care and have one of the lowest rates of primary care use of any age group.³ Under 18 conceptions can lead to socioeconomic deprivation, mental health difficulties, and lower levels of education. In addition, resulting children are at greater risk of low education attainment, emotional and behavioral problems, maltreatment or harm, and illness, accidents, and injury.⁴

There is a lack of strong evaluations of teenage pregnancy prevention programs overall, but some evidence exists which suggests that certain interventions, which provide services available to all in a school-based setting, can have an effect on primary outcome measures such as sexual behavior and pregnancy.⁵ Here we conduct a systematic review and narrative synthesis of literature which focuses specifically on interventions to provide contraception services for young people (or information to encourage young people to use established services), which were delivered in educational settings.

Section snippets

Methods

A full systematic search of key health and medical databases was undertaken. The search strategy included terms relating to young people, contraceptive services, family planning and pregnancy prevention. The search was limited by date (limited to 1995–2008), English language, and limited to humans. No restrictions were placed in terms of study type or place of publication. Additional methods to identify evidence were undertaken as follows: searching the reference lists of included papers;

Results

We identified 29 studies which met the inclusion criteria, all conducted in the U.S. The papers focused on preventing teenage pregnancy (7 studies) or repeat pregnancy (6 studies), multiple outcomes related to teenage pregnancy and sexual health (4 studies), the effectiveness of school-based sexual health care delivery (6 studies), and contraceptive provision in a college environment (2 studies) (Table 1). We also included curriculum interventions with additional elements relevant to this

Discussion

All the papers included in this review reported on studies conducted in the U.S., frequently in populations with a high proportion of minority ethnicities. We categorized the papers as those which aimed to address teenage pregnancy or repeat teenage pregnancy, studies to assess the effectiveness of school-based health centers, those with primary objectives to address both sexual health and teenage pregnancy, interventions which were part of educational interventions and those which addressed

Acknowledgments

This work was supported by the National Institute for Health and Clinical Excellence (NICE) for the purposes of informing public health guidance. The interpretation, analysis and views expressed are those of the authors and not necessarily those of NICE.

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This study examines whether comprehensive sexual health education that provides information on clinical services can change adolescents’ perceptions of barriers, facilitators, and intention to use services and whether changes in perceptions differ by participant characteristics.
Adolescent participants in a statewide sexual health education program in California were surveyed at baseline and at exit about their perceptions of barriers, facilitators, and intention to use clinical services. Linked baseline and exit surveys (n = 7,460) assessed change in perceptions after program completion. Logistic regression analyses that accounted for the clustered data structure assessed associations between participant characteristics and improvement in perceptions.
After the program, there were significant reductions in two perceived barriers (worry about cost and judgment by staff), but there were also small but significant increases in perceptions of two barriers (worry about confidentiality of services and test results). There were significant increases in all three perceived facilitators and intention to use sexual and reproductive health services, which rose from 90.6% at baseline to 96.2% at exit. Younger youth were more likely than older youth to show improvement in all perceived facilitators and intentions. Girls and Black youth were more likely than boys and Hispanic youth to show improvement in two facilitators (knowing what to expect and access). No sociodemographic characteristics were consistently associated with reductions in perceived barriers.
Comprehensive sexual health education that addresses adolescents’ questions and concerns regarding clinical services can help to reduce perceived barriers, increase facilitators, and increase intention to use services if needed.
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In the SBHC system, individual clinics can participate in the federal Family Planning program, Title X, if they meet program requirements including on-site contraceptive provision [14]. Previous work has examined the relationship between SBHCs and adolescent contraception [15,16]. However, studies often include small samples of SBHCs [17] or rely on clinic-level reporting or student-reported outcomes [18] rather than objective, individual-level data.
We describe provision of contraception to adolescents at Oregon school-based health centers (SBHCs). We examine trends over time, by race/ethnicity, and by Title X clinic status and test whether these factors are associated with provision of long-acting reversible contraception (LARC; intrauterine devices/IUDs and implants).
We conducted a retrospective cohort study of 33 SBHCs participating in a shared electronic health record 2012-2016. We identified 20,339 contraception provision visits to 5,934 adolescent females ages 14-19 using diagnosis and procedure codes. We used logistic regression to evaluate the association of clinic Title X status, race/ethnicity, and year with receipt of LARC, controlling for individual-, clinic-, and residence-level factors. We calculated adjusted probabilities.
Provision of IUDs and implants increased at Oregon SBHCs between 2012 and 2016. IUD provision increased almost 5-fold, (from 0.9% to 4.4% of contraception provision visits), and implants increased approximately 6.5-fold (from 1.1% to 7.2%). More adolescent contraception provision visits occurred at Title X SBHCs, which had greater than twice the adjusted probability of providing LARCs than non-Title X SBHCs (4.4% versus 1.7%). After adjusting for adolescent-, clinic-, and residence-level covariates, non-white adolescents had lower probabilities of receiving LARC methods than white adolescents.
SBHCs play an important role in providing access to contraceptive services to adolescents in Oregon. Access to IUDs and implants is increasing over time in SBHCs, particularly those that participate in the Title X program.
Adolescents have expanding access to IUDs and implants in SBHCs over time in Oregon. Participation in the Title X program can help further increase access to effective contraception in SBHCs.
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Disadvantaged groups were variously described as ‘low socioeconomic’,33 p.30 ‘areas of social disadvantage’,34 p.29 ‘children from low socioeconomic backgrounds’,35 p. 792 ‘children from schools in disadvantaged areas’36 p.e1362 (Table 2). Twenty-four reviews reported on the outcomes specifically for these disadvantaged groups.34,35,37–58 Formal quantitative measures of SES were reported in 18/140 SRs (Table 2).
Despite robust evidence on health inequalities in adulthood, less attention has been paid to inequalities in adolescence. The aim of this overview was to examine systematic review (SR) evidence on the equity impact of population-level interventions intended to improve health, happiness and wellbeing for adolescents.
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35,310 review titles were screened; 566 full texts were retrieved and 140 SRs met the predefined selection criteria. Differential intervention effects were considered in 42/140 (30%) SRs, 18/140 (13%) reported primary studies using an SES measure and 16/140 (11%) explicitly reported differential effects. 15/140 SRs (11%) explicitly focused on socioeconomic inequalities; of these 4/15 reported differential intervention effects in more detail, 7/15 concluded there was insufficient primary evidence to identify the impact of interventions on socioeconomic inequalities and 4/15 planned to examine differential effects by SES, but this was not reported further.
Our overview identifies that there is limited SR evidence on the equity impact of population-level interventions for adolescent health. Strengthening the evidence on whether interventions narrow or widen inequalities for adolescents must be a priority for public health research.
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In responding, health actions are needed at each level—from structural, through to community settings including schools, and health services (table 4, appendix table 4). The most effective programmes are typically multi-component and target one or more of these settings.239 The provision of accessible and quality health care (eg, provision of contraception, STI screening including HIV testing, treatment of STIs, provision of continuous care for HIV-positive adolescents), and high-quality, comprehensive sexuality education are likely to be effective, although much more so in conjunction with a broader suite of actions.
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The intervention was delivered by social workers involving: individual case-management and home visits; medical care for mothers and infants; peer support; and community outreach. Blank et al. [22] concluded such interventions can be effective in preventing repeat adolescent pregnancy. Results of these reviews should be treated cautiously.
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There is good evidence that various whole-school health interventions are effective in preventing teenage pregnancy, smoking, and bullying.

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Original StudySystematic Review and Narrative Synthesis of the Effectiveness of Contraceptive Service Interventions for Young People, Delivered in Educational Settings

Abstract

Study Objective

Design

Setting

Participants

Interventions

Main Outcome Measures

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Acknowledgments

J Subst Abuse Treat

J Adolesc Health

J Adolesc Health

J Adolesc Health

J Adolesc Health

J Adolesc Health

J Adolesc Health

J Adolesc Health

United States and the Russian Federation lead the world in teenage pregnancy rates

Adolescent Health, I: Summary and policy options

Families and Schools: Teenage parents: who cares? A guide to commissioning and delivering maternity services for young parents

Understanding the impact of effective teenage pregnancy prevention programmes

Fam Plann Perspect

National Institute for Health and Clinical Excellence: Methods for the development of NICE public health guidance

A brief decisional balance intervention increases motivation and behaviour regarding condom us in high-risk heterosexual college men

Arch Sex Behav

Evaluating the effectiveness of workshop interventions on contraceptive use among first year college students

J Psychol Human Sex

Efficacy of a secondary adolescent pregnancy prevention program: an ecological study before, during and after implementation of the second chance club

Int Q Community Health Educ

Original Study
Systematic Review and Narrative Synthesis of the Effectiveness of Contraceptive Service Interventions for Young People, Delivered in Educational Settings