The Impact of Making Proud Choices! on Youth's Sexual Health Attitudes, Knowledge, and Behaviors.

PURPOSE: To estimate the effect of the Making Proud Choices! (MPC) curriculum, one of the most popular evidence-based teen pregnancy prevention curricula being implemented nationwide. METHODS: A cluster randomized trial was used to assign high schools to receive the MPC program or to serve as a standard care comparison group. The study took place in 15 schools in four cities in the United States. A total of 31 clusters and over 2,800 youth (predominantly in grades 9 and 10) were assigned to condition between 2016 and 2019. Student surveys administered at baseline and approximately 9 months after baseline were used to estimate the effects of MPC on risk and protective factors (knowledge, attitudes, self-efficacy) as well as sexual behavior outcomes. RESULTS: The evaluation showed several large, statistically significant, and favorable impacts on nearly all of the risk and protective factors for risky sexual behavior. In addition, the study found a favorable effect of MPC on reducing the number of episodes of sex in the past 3 months. DISCUSSION: The evaluation showed that MPC, as it is commonly implemented today, has evidence of effectiveness on improving both risk and protective factors, and sexual behavior outcomes. Based on these findings, MPC will continue to be seen as an evidence-based teen pregnancy prevention program for implementation through federal grant programs.

Innovation to Impact: Introduction to the Special Issue on Evidence from the Teen Pregnancy Prevention Program Experiment with Innovation.

Congress has provided funding for the federal Teen Pregnancy Prevention (TPP) Program since 2009 for spending beginning in Fiscal Year 2010. Designated TPP programs develop, test, and evaluate innovations for reducing teen pregnancy, teen pregnancy disparities, and associated risk factors and for promoting positive youth development. Since its inception, the TPP Program has experimented with multiple uniquely structured cohorts of innovation and demonstration projects, producing critical insights into equitable and effective public health innovation while also serving as a highly productive contributor of evidence-based, TPP innovations for scale. This article briefly documents the innovation history of the TPP Program and its iterations in response to the shifting needs of the field. We then synthesize findings from the fifteen TPP innovators published in this special edition. We highlight emergent priorities of the TPP Program informed by this federal experiment in rigorous adolescent sexual health innovation development, testing, evaluation, and scaling and conclude by discussing how the TPP program adapted and refined its approach for fostering dynamic innovation-to-scale projects over time.

The impact of funding disruptions on large-scale teen pregnancy prevention research projects.

To advance the field of teen pregnancy prevention, new interventions must be developed and tested. The federal Teen Pregnancy Prevention program (TPP) funds the evaluation of promising interventions. We report on a funding disruption to 21 TPP Tier 2B research grantees across the US that was unusual for its ideological causation, sudden timing, severity, and ultimately court decisions compelling the agency to reverse the decision. We address the following question: How did challenges presented by the attempted funding termination impact grantees' ability to continue with their intended research? Results from grantee surveys in 2019 demonstrate the funding disruption negatively impacted participant recruitment, organizational collaboration, program delivery, research rigor, and compromised grantees' ability to complete high-quality evaluations. Results also show most projects could continue, with modified research goals, when funding was reinstated. We conclude administrations should avoid arbitrarily and prematurely terminating research projects. However, there is merit in reinstating funds to projects should a disruption occur. Results from this work are particularly relevant as we anticipate how health research projects may manage other disruptions to funding or timetables, such as those caused by COVID-19. Results are relevant to policy makers, researchers, government and private funders, grantees, and technical assistance teams.

Catalyzing Technology-Based Innovation in Teen Pregnancy Prevention: an Implementation Model and Findings from a Human-Centered Design Initiative.

From 2015 to 2021, the US Department of Health and Human Services' Teen Pregnancy Prevention (TPP) program funded Power to Decide, a national reproductive health nonprofit organization, to catalyze innovation in adolescent sexual and reproductive health through the development of technology-based interventions. Power to Decide's initiative, Innovation Next, supported twenty innovation teams in using human-centered design (HCD) to develop new products, services, and programs. We describe the Innovation Next implementation model, which can inform future efforts to develop innovative, technology-based TPP programs using HCD. To that end, we draw on quantitative and qualitative data collected for program improvement to summarize key implementation findings.

Comparing Virtual and In-Person Implementation of a School-Based Sexual Health Promotion Program in High Schools with Large Latino Populations.

Many sexual health programs transitioned to virtual implementation during the COVID-19 pandemic. Despite its devastation, the pandemic provided an opportunity to learn about virtual compared to in-person implementation of a sexual health promotion program-El Camino. This study assessed differences in program attendance, engagement, quality, and student ratings for virtual versus in-person implementation of El Camino as part of a rigorous evaluation in high schools with high Latino populations in Maryland. Drawing on positive youth development practices, El Camino helps participants identify personal goals and learn about sexual reproductive health and healthy relationships. This mixed-methods study incorporates data from performance measures, baseline and post-intervention participant surveys, observations, monthly implementation reports, and debriefs with facilitators to describe and compare virtual and in-person program implementation. At baseline, participants were an average of 16.2 years old; between 8 and 12th grade; 61% female; 79% Hispanic, Latino, or of Spanish origin; and 54% spoke mostly Spanish at home. Recruitment and retention of students outside of school classes were challenging for both forms of implementation. However, attendance was higher during in-person implementation and in schools where the organization implementing El Camino had a strong presence before the pandemic. Findings indicate high fidelity, excellent quality ratings, and positive student perceptions of the program and facilitators in both the virtual and in-person cohorts, which suggest that both forms of implementation were comparable and furthermore highlight the strength of the virtual adaptation of the El Camino program.

Implementation Fidelity and Theory-Informed Dose Effects of a Teen Pregnancy Prevention Program for Native American Youth.

In 2019, Native youth had the highest rate of teen pregnancy of all racial/ethnic groups. "Respecting the Circle of Life" (RCL) is one of the first evidence-based teen pregnancy prevention programs for Native teens and there is interest in replicating the program across tribal communities. To inform replication, it is important to consider process data including quality, fidelity, and dosage as these may all moderate impact of the program. Participants were Native youth aged 11-19 and a trusted adult. This study includes participants randomized to the RCL program only (N = 266). Data sources include independent observations, facilitator self-assessments, attendance logs, and self-report assessments completed by enrolled youth at baseline and 3 months post assessment. Data was compiled and summed by cohort. Dosage was number of minutes participating in activities separated by theoretical constructs. Linear regression models were utilized to assess moderation of the effects of the intervention dosage on outcomes of interest. Eighteen facilitators delivered RCL. One hundred eighteen independent observations and 320 facilitator self-assessments were collected and entered. Findings indicate RCL was implemented with high fidelity and quality (4.40 to 4.82 out of a 5-point Likert scale; 96.6% of planned activities completed). Dosage was high with an average completion of 7 out of 9 lessons. There was no association between theoretical construct dosage and outcomes of interest. Overall, this study indicates RCL was delivered with high fidelity, quality, and dosage in this trial. This paper informs future replication of RCL and provides support for hiring paraprofessionals from the local community as facilitators, delivering the RCL to peer groups of the same age and sex, delivering the RCL with short duration and high frequency, and encouraging youth to attend all RCL lessons, but continue to serve youth who have missed one or more lessons.

Crush: A Randomized Trial to Evaluate the Impact of a Mobile Health App on Adolescent Sexual Health.

PURPOSE: Mobile technology allows delivery of sexual and reproductive health (SRH) information directly to youth. We tested the efficacy of Crush, a mobile application aimed at improving sexual health by promoting the use of SRH services and contraception among female adolescents. METHODS: We recruited 1,210 women aged 14-18 years through social media advertising and randomized them into a Crush intervention group and a control group that received a wellness app. At 3 and 6 months post randomization, we compared changes from baseline in behaviors, attitudes, self-efficacy, perceived social norms, birth control knowledge, perceived control and use intentions, and SRH service utilization. Odds ratios were estimated with multivariable logistic regression and adjusted for baseline outcome, age, race/ethnicity, mother's education, and sexual experience. RESULTS: There was no difference in accessing SRH services according to study group. Three months post baseline, Crush users had higher odds (p < .05) than control participants of reporting confidence in accessing SRH services (adjusted odds ratio [aOR] = 1.6, 95% confidence interval [CI]: 1.1-2.3) and of believing that it is a good thing to use birth control consistently (aOR = 2.3, 95% CI: 1.4-3.8). Six months after baseline, Crush users had higher odds than control participants of reporting they can control whether birth control is used every time they have sex (aOR = 1.8, 95% CI: 1.2-2.6) and perceiving they would get pregnant if they did not use birth control (aOR: 1.5, 95% CI: 1.1-2.2). Impacts on other behavioral constructs were also found. DISCUSSION: Crush was associated with improvements in knowledge, attitudes, and self-efficacy related to key SRH behaviors and may be a strategy to deliver SRH education to adolescent women. Studies including larger numbers of sexually active adolescents are needed to demonstrate behavioral impacts.

Who Benefits from School-Based Teen Pregnancy Prevention Programs? Examining Multidimensional Moderators of Program Effectiveness Across Four Studies.

Recent research has suggested the importance of understanding for whom programs are most effective (Supplee et al., 2013) and that multidimensional profiles of risk and protective factors may moderate the effectiveness of programs (Lanza & Rhoades, 2012). For school-based prevention programs, moderators of program effectiveness may occur at both the individual and school levels. However, due to the relatively small number of schools in most individual trials, integrative data analysis across multiple studies may be necessary to fully understand the multidimensional individual and school factors that may influence program effectiveness. In this study, we applied multilevel latent class analysis to integrated data across four studies of a middle school pregnancy prevention program to examine moderators of program effectiveness on initiation of vaginal sex. Findings suggest that the program may be particularly effective for schools with USA-born students who speak another language at home. In addition, findings suggest potential positive outcomes of the program for individuals who are lower risk and engaging in normative dating or individuals with family risk. Findings suggest potential mechanisms by which teen pregnancy prevention programs may be effective.

Quality Improvement in Teen Pregnancy Prevention: Follow-Up to a "Focus on Fidelity".

BACKGROUND: In teen pregnancy prevention (TPP) evidence-based program replication, fidelity toolkits (FTKs) provide structure to ensure that essential curricular components are delivered as intended. OBJECTIVE: The purpose of this project was to extend quality improvement efforts (Flinders, 2017) through analysis of FTKs from four years of TPP implementation. METHODS: An evidence-based TPP program was delivered to females, 15-19 years of age (n = 1,658) from four suburban Ohio counties. Fidelity rates were calculated by agency staff and undergraduate nursing students. Grounded theory was used to identify themes from the narrative sections of the FTKs. Plan-Do-Study-Act methodology (Agency for Healthcare Research and Quality, 2008) guided this quality improvement work. RESULTS: Staff fidelity was reported as 98.38%. Student fidelity was reported at 99.05%. Key themes, identified as a result of the qualitative analysis, were categorized as participant factors, site factors, or presenter factors. CONCLUSIONS: Toolkits created an effective safeguard to ensure the replication of the evidence-based TPP program, with fidelity. IMPLICATIONS FOR NURSING: Undergraduate students are capable of implementing evidence-based programming, with fidelity, to meet the educational needs of their communities. Analysis of narrative comments from toolkits can influence FTK revisions to improve program delivery.

Meta-analysis of Federally Funded Adolescent Pregnancy Prevention Program Evaluations.

Beginning in 2010, the U.S. Department of Health and Human Services (HHS) sponsored numerous studies testing the effectiveness of Adolescent Pregnancy Prevention programs on youths' risky sexual behaviors. This article presents results from a meta-analysis of such studies completed between 2015 and 2019 and provided to us by HHS. Studies were eligible for inclusion if they used an experimental/quasi-experimental design, included a comparison condition, assigned at least 10 study participants to each condition, and measured and reported at least one outcome related to sexual behavior or consequences. Data were extracted using a standardized coding protocol and outcomes were coded as, or transformed to, log odds ratio effect sizes for analysis and then transformed to odds ratio effect sizes for presentation in the text. All outcomes were coded such that log odds ratios greater than zero (odds ratios greater than 1) indicate beneficial effects (e.g., reductions in risky sexual behavior). A total of 52 studies met the inclusion criteria. Across 7 outcome types, pooled effects were generally small, the direction of effects was mixed, and none achieved statistical significance: recent pregnancy (OR = 1.30, 95% CI [1.00, 1.68]), ever had sex (OR = 1.07, 95% CI [0.99, 1.15]), recent sexual activity (OR = 0.95, 95% CI [0.84, 1.09]), recent unprotected sexual activity (OR = 1.05, 95% CI [0.96, 1.16]), ever pregnant (OR = 1.21, 95% CI [0.51, 2.89]), number of sexual partners (OR = 1.08, 95% CI = [0.28, 4.22]), and proportion of recent sexual experiences that were unprotected (OR = 0.74, 95% CI = [0.43, 1.31]). Moderator analyses pooling across all 7 outcome types indicated minor differences in program effectiveness between program settings, with those delivered in classroom settings being the least effective (b = - 0.17, 95% CI [- 0.33, - 0.01]). These findings do not lend meaningful support for the overall effectiveness of this group of pregnancy prevention programs. However, because the meta-analysis sample only included programs recently funded by HHS, these findings may have limited generalizability to programs funded by other entities or implemented in other countries.

Teen Pregnancy Prevention Evaluation Technical Assistance: A Case Study.

PURPOSE: This case study discusses Mathematica's experience providing large-scale evaluation technical assistance (ETA) to 65 grantees across two cohorts of Teen Pregnancy Prevention (TPP) Program grants. The grantees were required to conduct rigorous evaluations with specific evaluation benchmarks. This case study provides an overview of the TPP grant program, the evaluation requirements, the ETA provider, and other key stakeholders and the ETA provided to the grantees. Finally, it discusses the successes, challenges, and lessons learned from the effort. CONCLUSION: One important lesson learned is that there are two related evaluation features, strong counterfactuals and insufficient target sample sizes, that funders should attend to prior to selecting awardees because they are not easy to change through ETA. In addition, if focused on particular outcomes (for TPP, the goal was to improve sexual behavior outcomes), the funder should prioritize studies with an opportunity to observe differences in these outcomes across conditions; several TPP grantees served young populations, and sexual behavior outcomes were not observed or were rare, limiting the opportunity to observe impacts. Unless funders are attentive to weaning out evaluations with critical limitations during the funding process, requiring grantees to conduct impact evaluations supported by ETA might unintentionally foster internally valid, yet underpowered studies that show nonsignificant program impacts. The TPP funder was able to overcome some of the limitations of the grantee evaluations by funding additional evidence-building activities, including federally led evaluations and a large meta-analysis of the effort, as part of a broader learning agenda.

Rigorous evaluation of a substance use and teen pregnancy prevention program for American Indian girls and their female caregivers: a study protocol for a randomized controlled trial.

BACKGROUND: Early sexual initiation is associated with higher risk for sexually transmitted infection, teen pregnancy, domestic violence and substance use in later adolescence and early adulthood. Native American adolescents are more likely to have early sexual initiation compared to other racial/ethnic groups. Few programs designed with and for Native adolescents to delay sexual initiation and substance use have been tested through rigorous evaluations. This is the protocol for the randomized controlled trial of the Asdzáán Be'eena' program, a teen pregnancy and substance use prevention program for young Native girls and their female caregivers. METHODS: N = 410 female adolescents ages 10-14 and their female caregivers will be enrolled in the study and randomized to the intervention or control arm. The intervention consists of the 11-session Asdzáán Be'eena' program. The control arm consists of mailed non-monetary incentives. All participants will complete evaluations at baseline and 3 follow-up timepoints (immediate, 6 and 12 months post intervention). Evaluations include measures to assess protective factors associated with delayed sexual initiation and substance use. DISCUSSION: This is one of the first rigorous evaluations of a gender-specific, culturally tailored teen pregnancy and substance use primary prevention program for Native girls and their female caregivers. If proven efficacious, Native communities will have a culturally appropriate program for promoting protective factors associated with delayed substance use and sexual risk taking. TRIAL REGISTRATION: NCT04863729 ; April 27, 2021.

The IN·clued Program: A Randomized Control Trial of an Effective Sex Education Program for Lesbian, Gay, Bisexual, Transgender, Queer, and Questioning Youths.

PURPOSE: The IN·clued: Inclusive Healthcare - Youth and Providers Empowered, program is an educational intervention designed to reduce unintended pregnancies and sexually transmitted diseases among lesbian, gay, bisexual, transgender, queer, and questioning youths. The goals are to increase sexual health knowledge, healthcare self-efficacy, and sexual healthcare use, and to reduce unprotected sexual behaviors. METHODS: Through funding from the federal Office of Adolescent Health Teen Pregnancy Prevention Initiative, IN·clued was evaluated using a cluster randomized control trial. The study took place in 16 states with 1,401 youths; 1,182 of whom (84.4%) completed surveys one year after the workshop. This analysis uses an intent-to-treat framework using ordinary least squares regressions to estimate the effects on each outcome. RESULTS: One year after the workshop, compared with the control youths, a significantly smaller proportion of IN·clued participants had vaginal sex without a condom in the past three months and did so significantly fewer times. Youths who received IN·clued demonstrated significantly higher knowledge and healthcare self-efficacy scores. A significantly greater proportion of the program youths had been to a doctor or clinic for and received contraception or birth control. A significantly greater proportion of the program youths reported feeling they could advocate for their own relevant sexual health care. CONCLUSIONS: IN·clued sought to change risky sexual behaviors, sexual health knowledge, receipt of sexual health care services, and self-efficacy regarding health care and achieved these goals. Findings were extremely positive with a population that has been neglected in sex education programs.

The Effectiveness of a Teen Outreach Pregnancy Prevention Program: Results From Youth After-School Clubs.

BACKGROUND: Teen pregnancy continues to burden families, communities, and society. Programs continue to educate and impower youth and young adults to make positive behavioral decisions. METHODS: We evaluated a program aimed at high-risk youth in after-school programs. The goal of the program was to instill a sense of community and empathy, as well as sexual health decision-making. The evaluation was a multiyear evaluation from external evaluators. RESULTS: There were statistically significant changes in empathy toward others in the community and a feeling of safety at school. Other positive changes noted were that students felt empowered to use condoms, other barriers, or birth control in the future when having sexual relations. The program noted a positive direction in students feeling they develop plans or goals and stick to them. CONCLUSIONS: These programs serve to instill a sense of empowerment, community, and responsibility in students. Evaluation data can serve as a metric of the merit of these programs and the impact on school health programs and communities.

Engaging Church Leaders in the Reduction of Teen Birth Rate in High-Risk Areas.

Involving faith-based organizations in community health promotion has gained widespread interest and has been a successful approach in addressing various health disparities in vulnerable communities. However, there is comparatively little evidence regarding sexual health promotion among faith-based organizations. Some agencies have responded to the challenge of reducing teen pregnancy with broad-based initiatives involving many different sectors of the community including faith-based organizations. Focus groups with key church leaders (n = 25) from zip codes with identified birth rates of 95 or higher were conducted to explore their perception of teen pregnancy among their communities. Purposive and snowball sampling were utilized. Recruitment was conducted through calls, email, and flyers. This study identified the barriers that church leaders encounter in their efforts to address teen pregnancy in their communities. Common themes that emerged include church education, parent support and communication, cultural barriers, availability of resources, awareness of services, and the need for comprehensive sexual education. Findings and recommendations to help those working in the faith community overcome identified barriers are addressed. Recent decreases in teen birth rates should not lead to complacency; rather they should inspire public health practitioners to do more, especially when some communities have not experienced the same success. Collaborating with faith-based organizations is one method to consider when considering community prevention efforts.

Cost analysis of a randomized trial of Getting to Outcomes implementation support for a teen pregnancy prevention program offered in Boys and Girls Clubs in Alabama and Georgia.

Implementation support can improve outcomes of evidence-based programs (EBP) for adolescents, but with a cost. To assist in determining whether this cost is worthwhile, this study estimated the cost of adding Getting To Outcomes© (GTO) implementation support to a teen pregnancy and sexually transmitted infection prevention EBP called Making Proud Choices (MPC) in 32 Boys and Girls Clubs (BGCs) in Alabama and Georgia. Enhancing Quality Interventions Promoting Healthy Sexuality (EQUIPS) was a 2-year, cluster-randomized controlled trial comparing MPC with MPC + GTO. We used micro-costing to estimate costs and captured MPC and GTO time from activity logs completed by GTO staff. Key resource use and cost components were compared between the randomized groups, years, and states (to capture different community site circumstances) using 2-sample t tests. There were no significant differences between randomized groups in attendees per site, resource use, or costs for either year. However, there were significant differences between states. Adding GTO to MPC increased the societal costs per attendee from $67 to $144 (2015 US dollars) in Georgia and from $106 to $314 in Alabama. The higher Alabama cost was due to longer travel distances and to more BGC staff time spent on GTO in that state. GTO also improved adherence, classroom delivery, and condom-use intentions more in Alabama youth. Thus, Alabama's GTO-related BGC staff time costs may be better estimates of effective GTO. If teen childbearing costs taxpayers approximately $20,000 per teen birth, adding GTO to MPC would be worthwhile to society if it prevented one more teen birth per 140 attendees than MPC alone.Trial registration. ClinicalTrials.gov , NCT01818791. Registered March 26, 2013, https://clinicaltrials.gov/ct2/show/NCT01818791?term=NCT01818791&draw=2&rank=1.

Tapping into Community Resiliency in Rural Adolescent Pregnancy Prevention: An Implementation Sciences Approach.

Although rural youth experience marked inequities in adolescent pregnancy, there is little guidance for implementing evidence-based programs (EBPs) in rural settings. When implementation occurs in rural communities, it frequently focuses on deficits, rather than strengths or capacity for growth. Using the consolidated framework for implementation research (CFIR), we describe a resiliency-focused implementation of two middle school EBPs in rural Midwestern communities, including the intervention, outer and inner settings, individuals, implementation processes and preliminary outcomes. Data included program staff interviews, feedback from local partners, community meetings notes, and participant surveys. Using the CFIR, we describe the engagement of rural communities themselves in a resilience-based implementation of adolescent pregnancy prevention EPBs. Communities self-described as rural, traditional and religious. They identified adolescent pregnancy, substance use, and academic success as priorities. To address infrastructure needs and build on local strengths, funds were used to hire local partners to implement the program. As small communities, stakeholders were closely networked and wanted to address local needs. Local partners selected the EBP based upon community values and priorities. Champions, including local partner organizations and schools were locally based and were well connected. Intensive training of local staff and piloting with adaptation assured fidelity and sustainability, while increasing community implementation skills and comfort. In Clinton County, enrollment was 1946 with students receiving the program in 6th, 7th, and/or 8th grades. In Southern Indiana, 7275 students received the program once in either 6th, 7th, or 8th. We conclude that the CFIR can facilitate the implementation of a community resilience-focused adolescent pregnancy prevention intervention in rural communities.

Longitudinal Patterns of School Disengagement before Conception among New York City Teen Mothers.

BACKGROUND: School-based pregnancy prevention programs should optimally be offered while students are still engaged in school since early disengagement is strongly associated with risk of a teen birth. METHODS: We used linked New York City birth and enrollment data (2005-2013), a sample of 6,809 teen mothers (mean age conception = 16.2 years). We measured preconception disengagement using monthly absences, age 12 until conception, and identified five attendance trajectories using group-based trajectory modeling. RESULTS: We identified five attendance trajectories that were heterogeneous with respect to age of onset and rate of increase of absenteeism. In two groups, 80% were chronically absent (CA) [2-<4 absences/month] or severely chronically absent (SCA) [4+ absences/month] at age 12, and over 90% by age 13, when they averaged 3.8-5.1 absences/month. Despite heterogeneity, 37% of teen mothers were CA or SCA at age 12, increasing to 56% by age 14. By early high school, age 15, 63% of teen mothers had absenteeism problems; 26% were CA and 37% SCA. CONCLUSIONS: Most teen mothers were disengaged before high school, years before conception. School-based pregnancy prevention programs should be offered in middle school or earlier when at-risk students are not missing significant amounts of school and may be more receptive to prevention messages.

Prospective Associations Among Youth Religiosity and Religious Denomination and Youth Contraception Use.

This study prospectively investigates associations among youth religiosity, religious denomination, and contraception use. Associations between youth religiosity and religious denomination, and type of contraceptive used and consistent contraceptive use among sexually active youth (N = 757) were analyzed using multinomial and binomial logistic regression. Identifying with a religious denomination was a predictor of dual contraceptive use relative to using no method of contraception (AOR = 2.17). There was no association between youth religiosity and type of contraceptive use or contraceptive consistency. Religious leaders and public health practitioners should collaborate to develop strategies to engage in conversations with sexually active youth about contraceptive use.