Evidence-Based Sexual Education Programs on Teen Pregnancy

Abstract

The project deals with the issue of the effectiveness of sexual health education programs on teen pregnancy rates reduction. Namely, the paper investigates the outcomes of abstinence-only education compared to comprehensive sexual education approaches associated with teen pregnancy reduction. It has been found that contemporary researchers consider the effectiveness of the comprehensive approach to be obvious. Therefore, instead of comparing the effectiveness of both types of programs, they examine additional ways to enhance the effectiveness of comprehensive education. Taking it into account, the project focuses on the effectiveness of comprehensive sexual education with family involvement in reducing the teen pregnancy rate in a Hispanic community. Under the culture care framework, the randomized controlled trial would be conducted to measure the correlation between family involvement and teen pregnancy rate and compare it to the outcomes of the comparison group. Though no relevant difference between the outcomes of the two groups is expected, the appropriateness of a culture-based approach to sexual education will be tested.

Introduction

Practice Issue

According to the Centers for Disease Control and Prevention (CDC) (2017), although in 2015 teen birth rate dropped by 8%, the U.S. teen pregnancy and abortion rates remain one of the highest in the developed countries. Namely, birth rates fell by 7% for women aged 18-19 years and by 9% for 15-17-year-old women. Though the reasons for such a decline remain unclear, CDC contributes it to increased teen abstinence from sex as well as birth control measures adopted by sexually active teens (Centers for Disease Control and Prevention, 2017). It has been found that teen pregnancy and childbirth cost U.S. taxpayers around $9.4 billion annually due to increased healthcare spending, higher incarceration rates among teen parents’ children as well as lost tax revenue caused by lower-income and education level among teen mothers (Centers for Disease Control and Prevention, 2017). These factors demonstrate the need for prevention practices, among which comprehensive sexual education is one of the most effective ones.

The attempts to handle this problem involve national and local initiatives, including the National Campaign to Prevent Teen and Unplanned Pregnancy as well as the State Health Education Standards for sexual health education. To manage teen pregnancy issues, several types of sexual education have been developed. First, abstinence-only-until-marriage, or sexual risk avoidance programs consider abstinence as the only morally appropriate option of sexual expression for adolescents. To prevent sexually transmitted diseases and unintended pregnancy, information about contraception is censored. Second, abstinence-centered, or assistance-only education focuses on abstinence as the only way to prevent unintended pregnancy. Third, the curricula of abstinence-plus education programs contain information about contraception but have a strong emphasis on abstinence. Finally, comprehensive sex education though views abstinence as the most effective method teaches about contraception to avoid unintended pregnancy and infection transmission, including HIV. Each of these programs has been deployed in the U.S., and their effectiveness has been reflected in CDC’s reports.

Though the need for sexual education has been recognized by officials since the end of the 19th century, an agreement on the content of the curriculum has not been reached. The analysis of the history of sexual education in the U.S. allows establishing the effectiveness of a particular curriculum. After the years of discussions on appropriate sexual education, birth control was officially recognized by the American Medical Association as an essential component of health education in 1937. At this stage, the urgent need for sexual education has been recognized, which intensified the preparation and implementation of the sexual health education program.

As soon as FDA approved the sale of oral contraceptives in 1960, a wave of organized opposition to sexual education has begun. However, it did not result in a decline of sexual education. Thus, in 1976, sexual education and prevention services were expanded to teenagers. In 1981, the Adolescent Family Life Act that promoted sexual abstinence before marriage was signed. At this period, the abstinence-only discourse has taken place. Surgeon General sent a report to millions of households in 1988, claiming that HIV/AIDS is not a moral but public health issue. Furthermore, abstinence-only education was included in the Welfare Reform Act by the Congress and received $250 million of funding. Despite obvious ineffectiveness of abstinence-only programs, in 2003 federal government increased their funding by $15 million. Though Bush administration provided $170 million for abstinence-only education, in 2004 claims about the flawed curricula were made at the official level. As a result, in 2008, twenty-five states rejected federal funding of these programs, as they did not influence teens’ sexual behavior. In 2010, the Personal Responsibility Education Program was funded by Congress. It provides $75 million annually to prevent sexually transmitted diseases and teen pregnancy via evidence-based and medically appropriate health education with consideration of consumer’s age and includes both abstinence and contraception issues (Caldwell, 2015). Since that period, the public discourse has shifted to comprehensive sex education programs including abstinence and contraception, but the proponents of abstinence remain active.

Practice Issue (Summary)

The recent years were marked with a number of researches that demonstrate advantages of comprehensive sexual health education compared to previous programs. In 2010, the Office of Adolescent Health (OAH) was established to pursue evidence-based approach to sex education (Kappeler et al., 2014, p. 3). Though most of researchers agree that comprehensive sexual education is more effective than abstinence-only programs, the main ‘tools’ to solve teen pregnancy issues are still a matter of a debate. The situation becomes more complicated due to politicization of the issue. Thus, while the Democratic Party supports age-appropriate and evidence-based approaches to sexual education, the Republican Party pursues abstinence-only programs. The loss of the Democratic Party and prevalence of Republican approaches to sex-related issues may contribute to promotion of abstinence-only programs. These circumstances emphasize the need for appropriate sexual health education for adolescents to decrease teen pregnancy rates.

The Aims of the Project

Taking into account the need for evidence-based sexual health education as a prevention of teen pregnancy, this project is aimed to compare the effectiveness of abstinence-only and comprehensive sexual health education, which includes information about both abstinence and contraception in adolescents aged 13-19 years. In particular, the project pursues the following aims:

1. To review studies that examine the effects of abstinence-only education.

2. To examine studies on the influence of comprehensive sexual education on teen pregnancy.

3. To consider sociological indexes regarding teen pregnancy, including examination of factors that contribute to teen pregnancy.

4. Based on information about teen pregnancy antecedents, to identify the most effective strategies of teen pregnancy prevention in accordance with a particular situation.

5. To formulate a comprehensive and conceptualized conclusion on the most effective methods of teen pregnancy prevention within sexual education curricula for the Hispanic ethnic minority.

6. To test the effectiveness of culture-based approach in terms of comprehensive sexual education.

7. To investigate the benefits of sexual education with family involvement.

Overall, the project is aimed to increase evidence-based practice, in this case evidence-based sexual education, which would enhance a decline of teen pregnancy rates. This project would fill the gap between the theory and research by implementing an evidence-based approach in daily medical practice. In addition, apart from studying effects of comprehensive sexual education on teen pregnancy, the research emphasizes approach that would help adolescents become more conscious of their health and sexual behaviors.

PICOT Question

In adolescents aged 13-19 (P), how does comprehensive sexual health education (I) compared with abstinence-only education (C) reduce the rate of teenage pregnancy (O)?

Significance

After a particular sexual education program is considered effective, the issue of its cost-effectiveness in particular political and economic conditions is raised. The international experience of school-based sexual education demonstrates that efficiency and, in turn, the cost-effectiveness of sexual education programs depend on the context (the particular culture) and content (abstinence-only or comprehensive approach). In countries where sexual health and rights are not a sensitive issue, sexual education programs are more effective than in countries where there is no open discussion of the issue (UNESCO, 2015). The UNESCO (2015) report also confirmed that comprehensive sexual education programs would be most effective when delivered mandatory (p. 25). However, it is impossible to determine the cost-effectiveness of comprehensive sexual education programs compared to abstinence-only education because no dedicated federal funding is provided for comprehensive sexual education. Instead, there is a belief that abstinence-only education is cheaper than comprehensive education, which has not been confirmed. It is worth recognizing that debate on cost-effectiveness of the two approaches is impacted by republican and liberal ideologies, whereas the health care position should be prioritized. Comprehensive sexual health education in the U.S. has not been supported by federal funding, while abstinence-only programs have been promoted despite their low cost-effectiveness.

The comprehensive approach may be threatened by the proponents of abstinence-only programs, such as AOUM (abstinence-only-until-marriage) and SRA (Sexual Risk Avoidance) (Hall, Sales, Komro, & Santelli, 2016, p. 597). While the effectiveness of AOUM programs is widely recognized, the SRA program was included in the working Bill of the House of Representatives in 2015 (Schalet et al., 2014). Nevertheless, although ample evidence suggests existence of a variety of potential strengths to the comprehensive approach, it is expected to lead to further teen pregnancy rate decline.

Evidence Review and Synthesis

Databases Used

To find the recent and relevant studies for this project PubMed, CINAHL, EBSCO, ProQuest, and Medline databases were used.

Summary of the Studies

In the study “Linking changes in contraceptive use to declines in teen pregnancy rates,” Manlove, Karpilow, Welti, and Thomas (2015) distinguish factors that contributed to teen pregnancy rates decline. The authors used the Teen FamilyScape model, which was designed to imitate real-world fertility-related behaviors, on the one hand, and changes in the contraceptives market, on the other hand. To ensure that the model is reliable, the results of the study were compared to official statistics on birth and pregnancies. The research revealed a correlation between behavioral patterns and contraceptives use development. The decline of teen pregnancy rates was associated with teens’ transition from less effective contraception methods (condoms) to more effective ones (hormonal or injectable contraception) (Manlove et al., 2015, p. 7-8). In addition, the number of teens who do not use any birth control has decreased. This study belongs to level VII, which means that it is a descriptive research that relies on simulation. The results of the research are determined by variables that have been considered reliable. Additional factors which might have contributed to the decline in the teen pregnancy rate, such as abstinence, were not considered. It means that contraception is a significant, yet not a single factor that contributed to teen pregnancy rate decline. Nevertheless, this research is useful because it demonstrates the significance of contraception use in teen pregnancy rates decline, which means that contraception should be an irreplaceable component of sexual health education. Additionally, the recommendations provided in this study are worth considering. To promote a further decline in teen pregnancy rates, the authors suggest developing programs that target sexually active teens who do not use contraception and increasing the effectiveness of contraception (such as evidence-based contraceptive counseling). Taking into account the aims of the project, this study will help to develop programs on contraception, including education and counseling about the appropriate circumstances and use of contraceptives.

The study “Reducing sexual risk behavior in adolescent girls: Results from a randomized controlled trial” by Morrison-Beedy et al. (2013) focuses on the effectiveness of behavioral interventions in reducing the high risk of contracting STDs, HIV, and becoming pregnant. Via a randomized controlled trial, the authors assessed the effectiveness of sexual behavioral interventions on urban sexually active girls with 3, 6, and 12-month postintervention. The participants of sexual risk-reduction interventions were more likely to be sexually abstinent. In those patients who remained sexually active, the episodes of unprotected vaginal sex at 3- and 12-months intervention, as well as the total sex partners number at 6-months intervention, have decreased (Morrison-Beedy et al., 2013). Secondary abstinence was another consequence of this intervention. However, interventions on contraceptives use and positive health promotion were the primary purpose of the intervention. It is worth noting that this study provides level II high-quality evidence because it allows developing more effective methods of teen pregnancy reduction. It goes beyond the topic (comparison of abstinence-only and comprehensive sex education) and demonstrates that risky populations require behavioral interventions and that the dichotomy of abstinence-only vs. comprehensive education must not be extrapolated to all groups.

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Lindberg and Maddow-Zimet (2012) researched the impact of sex education on the behavior of teens. In the study “Consequences of sex education on teen and young adult sexual behaviors and outcome” the results of a particular sex education program were investigated. The results demonstrated that sex education leads to delay in first sex independently from the education type. The respondents who received instructions on both abstinence and contraception were likely to use contraceptives during first sex. Results for those individuals who received abstinence instructions were not statistically distinguishable from those who received instructions of both types (abstinence and birth control) or no instruction. Nevertheless, the participants who received education of both types were more likely to use contraception than those who received instructions on abstinence only. This study is useful because it demonstrates that the probability of teen pregnancy is decreased in case teens receive instructions on both abstinence and contraceptives use, although any type of education leads to first sex delay. The limitations of the study include unclear instructions that result in inability to statistically distinguish abstinence-only and abstinence and contraception instruction. Nevertheless, due to considering a variety of analytical tools and sociodemographic factors, this study belongs to level III evidence, and its reliability is high.

Another position on teen pregnancy reduction within abstinence-only vs. comprehensive education programs dichotomy was provided by Francis and DePalma (2014). The authors studied the condition of sex education in South Africa and presented the issue from the teacher’s point of view. This study demonstrates that abstinence-only education cannot provide a solution to high rates of teen pregnancy and sexually transmitted diseases. Furthermore, the authors conclude that this approach can lead to higher pregnancy rate among teenagers. Therefore, they proposed to combine both approaches to provide comprehensive sexuality education. Though this is a level VII study, it is useful because it demonstrates the significance of the context-based approach to sex education. For this project, the insights from this study allow creating more complex approaches to sexual education, whereas ineffectiveness of abstinence-only education is another major finding.

Synthesis of the Body of Evidence

The effectiveness of comprehensive sexual education has been confirmed in the studies prior to 2010. As the studies demonstrate, although abstinence-only education received additional funding, its ineffectiveness was obvious due to high teen pregnancy rates in the 1980s – 1990s. The recent researches accept advantages of comprehensive sex education as common knowledge and work on its implementation. Namely, there are studies against abstinence-only education (Caldwell, 2015; Glass-Dixton, 2016; Gresl?-Favier, 2013), and studies that explore different modes of the comprehensive approach, including behavioral interventions (Morrison-Beedy et al., 2013; Grossman, Tracy, Charmaraman, Ceder, & Erkut, 2014). Overall, abstinence-only programs have been criticized for popularization of the myth about human sexuality as well as for violation of the human right to receive to accurate information. Numerous pieces of evidence from experimental studies and systematic reviews demonstrate that the decline of teen pregnancy rate is connected with enhanced contraception use (Caldwell, 2015; Hamilton & Mathews, 2016), which necessitates including medically-accurate information in educational curricula. Another reason for criticism of abstinence-only education is its focus on moralization, which is both ineffective and harmful for teens and young adults. The studies also demonstrate that providing instructions and recipes is much more effective than moralization within abstinence-only programs. Considering the conditions of the most vulnerable population groups, instructions on proper use of contraception as well as behavioral interventions lead to a decline of episodes of unprotected sex, abstinence from first sex as well as secondary abstinence. Whereas two decades ago, studies compared the effectiveness of abstinence-only programs to comprehensive education, recently studies focus on undeniable effectiveness of comprehensive education, as it views sexual health comprehensively. Thus, comprehensive sex education includes not only instructions on pregnancy prevention but also focuses on formation of healthy relationships and maintenance of sexual health. That is why the recent orientation of the government on abstinence-only education provoked intense discussion in social media and periodicals.

Purpose of the Project

Clinical Issue

Initially, the project was aimed at investigating the effectiveness of abstinence-only compared to comprehensive sex education programs on teen pregnancy rates decline. As a result, it has been found that the advantages of comprehensive education are obvious to contemporary researchers. To elaborate and extend this data, the proposed intervention focuses on sex education for populations at risk, particularly 13- 15-year-old boys and girls from low-income ethnic/racial minorities (Hispanic) families. The intervention provides a school-based comprehensive sexual education involving families, which is aimed to reduce teens and young adults’ risky behaviors. Based on the findings of Grossman et al. (2014) on the effectiveness of parent involvement, the given project would fill the gap in evidence and represent usefulness of family and community involvement to meet the challenges of poverty, discrimination, and illiteracy.

Theoretical Framework

As the project extends evidence on the consequences of comprehensive family counseling in high-risk population, in particular, in an ethnic minority, it is based on Madeleine Leininger’s theory of culture care. Considering the importance of family in Hispanic culture, this framework will allow adapting the advantages of comprehensive sexual education to the sample population effectively. It is worth underlying the significance of diversity and universality concepts for the given project. Thus, the project allows taking into account the physical, psychological, and cultural features of Hispanic population and removing stigmatization and discrimination. Furthermore, this project emphasizes the significance of cultural context when designing sexual health education, especially in providing programs for ethnic/racial minorities.

Clinical Questions

The project aims to answer the following clinical questions:

1. Is comprehensive education with family involvement more useful than without that family involvement?

2. How can comprehensive education programs be accommodated to culturally diverse populations?

3. How can a comprehensive approach to sexuality be pursued in a culture with distinct values in a non-judgmental and non-discriminative way?

Methods

Study Design

The intervention will be conducted via the randomized controlled trial design, which allows using the benefits of random selection to make the results more valid. In addition, it is a widely accepted tool of measuring the intervention and its outcomes and addressing the issues of correlation and causation. It would help to ensure the accuracy of experiment and calculations and thus make the results relevant and valid.

Setting/Sample

The participants are two groups of eighth-grade children (n=200) living in Hispanic communities with a high rate of teen pregnancy. The selected participants will have similar characteristics that may be statistically significant (Hispanic origin, 8th grade, from low-income families, without a record of mental illnesses). The participants (both girls and boys) will be randomly assigned to two groups: the intervention group and the comparison group. Family members of the intervention group participants will also visit comprehensive sexual education program classes for 2 months. The intervention will take place in the school’s classrooms twice a week.

Confidentiality

The researchers keep committed to participants’ right to privacy of individually identifiable health information. The participants are free to decide to whom and when their health information, as well as the conditions of the experiment, can be disclosed. The protection of private information will be maintained within the intervention setting and during all stages of the research.

Procedure/Intervention

The parents of the children will sign an agreement for their children’s participation in the project. Prior to the introduction of the sexual education program, the participants will fill in an anonymous questionnaire on family history details and awareness of contraception methods. The same questionnaire will be administered in the last lesson. The participants will be asked to attend each lesson of sexual education classes during the experiment. Family members of participants assigned to the intervention group will also attend classes on the same conditions. Two groups will study in separate classrooms, where male and female educators with expertise in medicine and psychology will provide information about sexual health in an interactive lecture format. The classes will cover bodily changes during puberty and the resulting psychological and social transformations, the issues of healthy relationships and sex, proper use of contraceptives, instructions on maintaining abstinence, and, finally, positive sexual health promotion by encouraging conscious and responsible choice of sexual partners.

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Aligning Stakeholders

The key stakeholders may be divided into the following groups: non-governmental organizations (advocacy groups for sex education, the Office of Adolescent Health, UNESCO, etc.); governmental organizations (Centers for Disease Control and Prevention, the Food and Drugs Administration); industry representatives (medical contraceptive devises companies, contraceptives manufacturing companies); health care providers (sexual health education specialists, health educators, psychologists); other individuals (family members, school staff, law enforcement representatives, media). As sexual education is a topical social issue that leads to individuals’ emotional engagement, providing access of these stakeholders to information about the project will allow ensuring trust of the society to the program and sexual education overall. The representatives of governmental and non-governmental organizations, law enforcement representatives, and other health care providers will contribute to openness and accessibility of the project. Media representatives and health care representatives will help to spread the results and contribute to improvement of sexual education-related policies. The involvement of representatives of organizations that oppose sexual education and proponents of abstinence-only education is significant because it will allow demonstrating the usefulness of the proposed approach in practice. The former group may pose challenges to the project by taking protest and attempts to sabotage the experiment. Nevertheless, it may be prevented by providing them with clear and accurate information and articulating the project’s vision and mission to avoid misunderstanding. The representatives of contraception producers may try to influence the experiment because its result would affect the sales of particular types of contraception. To avoid it, the preparation of contraception for demonstration on the lessons and free distribution should be conducted using governmental support. The interests of the stakeholders will be balanced by providing a common vision of the experiment, its values, and its goals. They will be informed about the experiment’s outcomes in the same way.

Instrument/Scales and Measurement of Outcomes

The primary measure of the project outcomes will be teen pregnancy within 3 years after the experiment has begun. Therefore, a mixed design of instruments (both quantitative and qualitative) will be applied. The scales for pregnancy rates identification would be becoming pregnant for female students and getting someone pregnant for male students. The results for female and male participants will be measured separately. To measure the results of 20 multiple-choice item survey, marginal testing using Fisher’s Exact Test, standard Chi-square coefficient test (to analyze group differences) as well as Cramer’s V test will be employed.

Data Collection

This will be a longitudinal study using multiple-group logistic regression to assess the delay of first sex as well as prevention of other risky behaviors in intervention and comparison groups. The participants are two groups of eighth-grade children living in a Hispanic community with a high rate of teen pregnancy. The measurement will be taken 6 months, 12 months, and 3 years after the study is conducted to identify short-term and long-term outcomes of comprehensive sexual education in both intervention and comparison groups. The sociodemographic variables for the questionnaire will include ethnicity/race and four-point ordinary scale to measure the participants’ intentions to have sex and to use birth control methods.

To evaluate outcomes of the proposed intervention propensity score matching will be used. It will be stratified in accordance with gender and estimated intervention propensity, including sociodemographic variables mentioned above (ethnicity/race, baseline sexual activity, family information, and baseline intentions to engage in sex in the following year). To analyze teen pregnancy rates, a discrete time-to-event analysis will be used. Multiple-group logistic regression analysis will be employed to consider a delay in sex as well as teen pregnancy rates in the two groups. Post-hoc power analysis will be conducted to determine approximate sample size to attain statistical significance.

Data Analysis

Outcomes to Be Analyzed

The measured outcomes are first sex delay, episodes of unprotected vaginal sex during a year after sex education course, and pregnancy within three years of the course. The participants will be interviewed each three months during the first year to indicate the episodes of vaginal sex, sex delay outcomes, contraceptives used, sexually transmitted diseases, and pregnancy. During the following two years, the participants will be interviewed twice a year about pregnancy.

Expected Outcomes

It is hypothesized that both groups will demonstrate delay in first sex or secondary abstinence. The difference between the two groups will not be statistically significant, though the participants of the intervention group will report fewer sex partners and enhanced use of contraceptives.