Which Structural Interventions for Adolescent Contraceptive Use Have Been Evaluated in Low- and Middle-Income Countries?

Reducing adolescent childbearing is a global priority, and enabling contraceptive use is one means of achieving this. Upstream factors, e.g., gender inequalities, fertility norms, poverty, empowerment and schooling, can be major factors affecting contraceptive use. We conducted a systematic map to understand which structural adolescent contraception interventions targeting these upstream factors have been evaluated in LMICs. We searched eight academic databases plus relevant websites and a 2016 evidence gap map and screened references based on set inclusion criteria. We screened 6993 references and included 40 unique intervention evaluations, reported in 138 papers. Seventeen evaluations were reported only in grey literature. Poverty reduction/economic empowerment interventions were the most common structural intervention, followed by interventions to increase schooling (e.g., through legislation or cash transfers) and those aiming to change social norms. Half of the evaluations were RCTs. There was variation in the timing of endline outcome data collection and the outcome measures used. A range of structural interventions have been evaluated for their effect on adolescent contraceptive use/pregnancy. These interventions, and their evaluations, are heterogenous in numerous ways. Improved understandings of how structural interventions work, as well as addressing evaluation challenges, are needed to facilitate progress in enabling adolescent contraceptive use in LMICs.

Can text messages increase safer sex behaviours in young people? Intervention development and pilot randomised controlled trial.

BACKGROUND: Younger people bear the heaviest burden of sexually transmitted infections (STIs). Partner notification, condom use and STI testing can reduce infection but many young people lack the knowledge, skills and confidence needed to carry out these behaviours. Text messages can provide effective behavioural support. The acceptability and feasibility of a randomised controlled trial of safer sex support delivered by text message are not known. OBJECTIVES: To assess the acceptability and feasibility of a randomised controlled trial of a safer sex intervention delivered by text message for young people aged 16-24 years. DESIGN: (1) Intervention development; (2) follow-up procedure development; (3) a pilot, parallel-arm randomised controlled trial with allocation via remote automated randomisation (ratio of 1 : 1) (participants were unmasked, whereas researchers analysing samples and data were masked); and (4) qualitative interviews. SETTING: Participants were recruited from sexual health services in the UK. PARTICIPANTS: Young people aged 16-24 years diagnosed with chlamydia or reporting unprotected sex with more than one partner in the last year. INTERVENTIONS: A theory- and evidence-based safer sex intervention designed, with young people's input, to reduce the incidence of STIs by increasing the correct treatment of STIs, partner notification, condom use and STI testing before unprotected sex with a new partner. The intervention was delivered via automated mobile phone messaging over 12 months. The comparator was a monthly text message checking contact details. MAIN OUTCOME MEASURES: (1) Development of the intervention based on theory, evidence and expert and user views; (2) follow-up procedures; (3) pilot trial primary outcomes: full recruitment within 3 months and follow-up rate for the proposed primary outcomes for the main trial; and (4) participants' views and experiences regarding the acceptability of the intervention. RESULTS: In total, 200 participants were randomised in the pilot trial, of whom 99 were allocated to the intervention and 101 were allocated to the control. We fully recruited early and achieved an 81% follow-up rate for our proposed primary outcome of the cumulative incidence of chlamydia at 12 months. There was no differential follow-up between groups. In total, 97% of messages sent were successfully delivered to participants' mobile phones. Recipients reported that the tone, language, content and frequency of messages were appropriate. Messages reportedly increased knowledge of and confidence in how to use condoms and negotiate condom use and reduced stigma about STIs, enabling participants to tell a partner about a STI. CONCLUSIONS: Our research shows that the intervention is acceptable and feasible to deliver. Our pilot trial demonstrated that a main trial is feasible. It remains unclear which behaviour change techniques and elements of the intervention or follow-up procedures are associated with effectiveness. A further limitation is that in the trial one person entering data and the participants were unmasked. A randomised controlled trial to establish the effects of the intervention on STIs at 12 months is needed. TRIAL REGISTRATION: Current Controlled Trials ISRCTN02304709. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 57. See the NIHR Journals Library website for further project information.

The development of a multi-criteria decision analysis aid to help with contraceptive choices: My Contraception Tool.

My Contraception Tool (MCT) applies the principles of multi-criteria decision analysis to the choice of contraceptive method. Its purpose is to make the decision-making process transparent to the user and to suggest a method to them based on their own preferences. The contraceptive option that emerges as optimal from the analysis takes account of the probability of a range of outcomes and the relative weight ascribed to them by the user. The development of MCT was a collaborative project between London School of Hygiene & Tropical Medicine, Brook, FPA and Maldaba Ltd. MCT is available online via the Brook and FPA websites. In this article we describe MCT's development and how it works. Further work is needed to assess the impact it has on decision quality and contraceptive behaviour.

Addressing sexual health needs: a comparison of a one-stop shop with separate genitourinary medicine and family planning services.

BACKGROUND AND METHODOLOGY: Little evidence is available on the extent to which one-stop shops address users' sexual health needs and the extent to which they identify additional needs users may not have identified. As part of the One-Stop Shop Evaluation, a questionnaire was designed to compare the reasons for users' visits and the reported outcomes of visits at a one-stop shop with the experiences of users in separate genitourinary medicine (GUM) and contraceptive clinics. RESULTS: The difference in the proportions of those attending the one-stop shop and those attending the control sites services for a sexually transmitted infection (STI)-related reason who were diagnosed with an STI was minimal, but those attending for an STI-related reason in the one-stop shop were more likely to receive an additional contraceptive outcome. Women attending for a contraceptive-related reason at the one-stop shop were more likely to have an STI screen than those attending the control sites for the same reason, but there was little difference in the proportions amongst this group receiving an STI diagnosis or receiving treatment. When focusing on women attending for a pregnancy-related reason, one-stop shop users were more likely to have received contraceptive advice or supplies. DISCUSSION AND CONCLUSIONS: It was not possible in our evaluation to determine the relative effectiveness of the one-stop shop in comparison to the traditional GUM and contraceptive clinics in improving sexual health status, however the one-stop shop was more likely to address additional sexual health needs that service users may not have previously identified.

'Always between two cultures': young British Bangladeshis and their mothers' views on sex and relationships.

This paper presents data on the sexual health perspectives of young British Bangladeshis and their mothers. It discusses the implications of these data for the development of appropriate sexual health education. Between April and September 2006, 36 young people and 25 mothers of Bangladeshi young people were interviewed through seven focus group discussions. Groups were gender and age specific (16-18 years, 19-20 years and mothers). Recruitment took place in community-based organisations in an inner city London borough. Mothers expressed concern about pre-marital sex but felt unable to control out-of-home activity. Feelings of isolation, lack of control and communication difficulties were key issues for them. Young people had varied perspectives on pre-marital sex. Some experienced emotional conflict between what was expected of them in terms of their faith and their engagement in intimate relationships. Both the young people and mothers highlighted the need for sex and relationship education to take account of cultural perspectives and the involvement of parents and the wider community. However, parents and community representatives require information and communication support to enable this involvement. Sex and relationships education content needs to be inclusive, have both secular and faith perspectives and engage where relevant with local communities.

What impact has England's Teenage Pregnancy Strategy had on young people's knowledge of and access to contraceptive services?

PURPOSE: To describe young people's knowledge and use of contraceptive services over initial stages of England's Teenage Pregnancy Strategy, and to investigate factors associated with use of different services. METHODS: A random location sample of young people aged 13-21 years (n = 8879) was interviewed in 12 waves over 2000-2004. Individual data were analysed to investigate factors associated with knowledge and use of contraceptive services and to observe trends over time. Area-level data were analyzed to explore differences in key variables. RESULTS: In all, 77% of young women and 65% of young men surveyed knew a service they could use to obtain information about sex. Amongst those who had had vaginal sexual intercourse, the most common source of contraceptive supplies was general practice for young women (54%) and commercial venues for young men (54%). Young women's use of school-based services to obtain supplies increased significantly from 15.4% in Year 1 to 24.4% in Year 4, p < .001. Young men's use of the commercial sector declined significantly over the same time period (60.3% to 50.6%, p = .002), while their use of general practice and family planning clinics increased (from 8.9% to 12.4%, p = .008, and 21.2% to 29.1%, p = .054, respectively). Use of family planning clinics and designated young people's clinics was associated with first vaginal intercourse before the 16th birthday and living in a deprived area. CONCLUSIONS: Young people's patterns of contraceptive service use have changed since implementation of the Strategy; although no increase in overall service use was observed. The contribution of school-based services needs further exploration.

The experience of young people with contraceptive consultations and health care workers.

In the United Kingdom, services for contraceptive consultation and family planning were first opened in the 1960s. Early and relevant information to adolescents is of importance. The aim of this paper was to examine young people's attitudes towards and experiences of consultations with health care providers about contraception, taking account of the context of their contraceptive use. Young people aged 16-21 years were recruited to the study from health services (young people's contraceptive and sexual health clinics and a termination of pregnancy clinic), secondary schools and community projects (a youth club, a young mothers' support group, a community education project and a young women offenders unit). As part of the needs' assessment, in-depth interviews and focus groups were conducted. Thirty-two young male and females were interviewed. Knowledge about contraception, sexually transmitted infections and the risk of pregnancy was often high. Many respondents noted that in a five to ten minute consultation there was not the time to discuss personal factors that may affect contraceptive decision making and effective use of methods. Many described a feeling of being rushed through the service and did not feel they had the opportunity to ask questions. What young people said they wanted from consultations with health care workers and their experiences of the consultation process often conflicted. They wanted the time and opportunity to discuss their options. Often the young men, who were accessing services, described how initially they had gone in to collect condoms, but once they knew the clinic and staff would consider making an appointment. It is concluded that young people want to be given choices and information regarding contraception that fit their lifestyles. Improving the structures of contraceptive and sexual health services for young people will help to remove some of the barriers that prevent some young people from accessing them. However, it is just as important that barriers in the service delivery are tackled to ensure young people receive effective contraceptive advice.