A Clustered Randomized Controlled Trial of the Positive Prevention PLUS Adolescent Pregnancy Prevention Program

摘要

Objectives. To determine the impact of Positive Prevention PLUS, a school-based adolescent pregnancy prevention program on delaying sexual intercourse, birth control use, and pregnancy. Methods. I randomly assigned a diverse sample of ninth grade students in 21 suburban public high schools in California into treatment (n?=?2483) and control (n?=?1784) groups that participated in a clustered randomized controlled trial. Between October 2013 and May 2014, participants completed baseline and 6-month follow-up surveys regarding sexual behavior and pregnancy. Participants in the treatment group were offered Positive Prevention PLUS, an 11-lesson adolescent pregnancy prevention program. Results. The program had statistically significant impacts on delaying sexual intercourse and increasing the use of birth control. However, I detected no program effect on pregnancy rates at 6-month follow-up. Conclusions. The Positive Prevention PLUS program demonstrated positive impacts on adolescent sexual behavior. This suggests that programs that focus on having students practice risk reduction skills may delay sexual activity and increase birth control use. The adolescent birth rate in the United States continues to decline and has dropped below 24.2 births for every 1000 adolescent females aged 15 to 19 years. 1 Although this reflects overall progress at achieving lower rates of adolescent pregnancy, progress is uneven. For example, in California, Hispanic adolescents continue to have the highest birth rate, at 34.9 per 1000. 2 National data reveal that more than 48% of all students in grades 9 to 12 have had sexual intercourse by the time they graduate, and only 41% of adolescents had used a condom the last time they had sexual intercourse, with Hispanic adolescents reporting slightly lower rates of condom use. 3 Because a significant number of adolescents engage in sexual risk behaviors, the need for effective adolescent pregnancy prevention program cannot be overstated. Although many adolescent pregnancy prevention programs can increase student knowledge about the consequences of becoming pregnant, only a few have demonstrated an impact on students’ behaviors. The US Department of Health and Human Services (HHS) sponsored a systematic review that examined the effectiveness of programs aimed to reduce adolescent pregnancies and the associated sexual risk behaviors. Of the approximately 2000 potentially relevant studies published between 1989 and January 2011, 200 met screening criteria for moderate or high-quality studies. Of these, only 31 provided credible evidence that demonstrated a statistically significant positive program impact on at least 1 sexual behavior or reproductive health outcome of interest (sexual activity, contraceptive use, or pregnancy). 4 The review concluded that there is a need for improved research quality and reporting to inform policy initiatives and programming decisions. In 2010, the Office of Adolescent Health (OAH) within HHS provided funding to rigorously evaluate new and innovative programs aimed at decreasing adolescent pregnancy and sexual risk behaviors. With funding from OAH, Positive Prevention PLUS, an 11-lesson, school-based adolescent pregnancy prevention program, was developed based on existing literature about effective school-based prevention programs. Many adolescent pregnancy prevention programs assume that youths participate in sexual risk-taking behaviors because they lack the knowledge regarding the consequences of unprotected sexual activity. 5,6 The existing literature supports prevention programs that use experiential, interactive activities to emphasize abstinence and risk reduction techniques rather than increasing student knowledge regarding reproductive anatomy or facts regarding the consequences of adolescent pregnancy. 5 Past research has suggested that the use of social cognitive theory in pregnancy and sexually transmitted disease (STD) prevention, particularly with adolescents, is far superior to other theoretical approaches or simply increasing student knowledge of reproductive anatomy or the consequences of unprotected sexual intercourse. 6 Social cognitive theory posits that behavior change occurs through several constructs, including observational learning, behavioral capability, outcome expectations, and self-efficacy. 6,7 For example, the adoption of strategies such as the ability to refuse offers to be sexually active or risk-reduction strategies like birth control use are more likely to occur if youths have learned and practiced these skills, and have developed the confidence to use these skills in their everyday life. 7 Positive Prevention PLUS aims to improve adolescents’ communication and negotiation skills to help them communicate assertively, abstain from sexual intercourse, and use birth control effectively. This study describes the methods and results of an external impact evaluation of the Positive Prevention PLUS adolescent pregnancy prevention