Published 9 July 2009, doi:10.1136/bmj.b2054
Cite this as: BMJ 2009;339:b2054

Editorials

Reducing pregnancy and health risk behaviours in teenagers

Intensive, multicomponent programmes are not always effective

Youth development programmes aimed at reducing pregnancy rates and health risk behaviour in teenagers have received strong support in many countries. Proponents of such programmes claim that they are holistic and can focus on the supports, opportunities, and services needed for success; they can tackle multiple risk behaviours, which are thought to be inter-related; and they can help build protective factors as well as reduce risk factors.

One of the most effective youth development programmes, the Children’s Aid Society (CAS) Carrera programme, reduced pregnancy by about a half over three years. Its results have been widely reported,¹ and this has led to the implementation of formally sanctioned CAS Carrera programmes, unsanctioned CAS Carrera-type programmes, and other types of youth development programmes.

In the linked matched comparison study (doi:10.1136/bmj.b2534), Wiggins and colleagues evaluated a programme based on the CAS Carrera programme and other youth development programmes.² This programme did not reduce the occurrence of pregnancy, however. Instead, pregnancy was significantly more common in the intervention group than in the matched comparison group (16% v 6%; adjusted odds ratio 3.55, 95% confidence interval 1.32 to 9.50). These results suggest that at best the programme had no effect, and at worst it had a negative effect.

One explanation for this effect lies in the methodological limitations of the study. For example, the lack of randomised assignment and slightly different criteria for selection into the programme group or comparison group may have led to the intervention group being at higher risk. Very low follow-up rates may also have affected results.

It is helpful to consider all four studies of the CAS Carrera or CAS Carrera-type programmes collectively. The first published study was a randomised controlled trial of 268 girls and 216 boys in six sites in New York City. In girls, the programme reduced current sexual activity, it increased the combined use of condoms and hormonal contraceptives, and it decreased the reported pregnancy rate (by half) over three years; in boys, the programme had no significant effect on sexual risk behaviour.³

That study included 12 sites, but only data from the six New York City sites were reported in the initial publication. The data from the other six sites were reported in a subsequent review of many studies.⁴ The other six sites, like the New York sites, participated in a randomised controlled trial. This trial included 457 girls and boys. The results indicate that the programme had no significant effect on current sexual activity or the risk of pregnancy (defined as abstinence or use of contraception) in girls or boys. One possible explanation is that the programme was not implemented as completely as in the New York sites.

The third randomised controlled trial included 372 girls and boys. It tried to replicate the CAS Carrera programme, but without training or sanction from the Children’s Aid Society. The programme provided no benefit on any measure of sexual behaviour; furthermore, at 13 months of follow-up, the pregnancy rate was lower in the control group, although this effect dissipated by the final 31 months of follow-up. The unexpected finding at 13 months was attributed to the unusually low rate of pregnancy in the control group during that period. The lack of benefit on any sexual behaviour was attributed to the fact that many members of the control group participated in other kinds of youth serving programmes when they were randomised to the control group and could not participate in the CAS Carrera-type programme. The main conclusion was not that these types of activities did not affect sexual behaviour, but that young people could receive them elsewhere, even in communities that presumably offered few programmes for young people.⁵

What can we learn from the pattern of the results across all four studies? One pattern is clear, consistent, and discouraging—none of the four studies found any positive effects on sexual behaviour in young men. This suggests that even intensive, comprehensive, and long term youth development programmes may have no effect on male sexual behaviour.

In girls, three of the four studies failed to find a significant benefit on current sexual activity or use of contraception and two reported significant increases in pregnancy rates. These results indicate that such programmes are not effective unless implemented fully and properly. Multicomponent programmes like the CAS Carrera programme are difficult to implement, and they may be particularly prone to implementation failure, which would dramatically reduce their effectiveness. Also, this programme requires extensive institutional knowledge and support and may not be as effective when implemented outside of New York City by organisations other than the Children’s Aid Society. It should be noted that in the first evaluation of the CAS Carrera programme, Michael Carrera—the charismatic programme founder—and his staff trained all the programme staff and visited them regularly.

As was seen in two of the studies, bringing together teenage girls at high risk of pregnancy might actually increase pregnancy rates, either as a result of being labelled as high risk or being exposed to peers who reinforce risk taking norms, as suggested by Wiggins and colleagues. However, more research is needed in this area.

Even though the CAS Carrera programme is intensive, comprehensive, and long lasting the combined results of the four studies were not encouraging. Studies have also shown that academic remediation and vocational education fail to reduce teenage pregnancy and childbearing.^{6 7 8}

But this does not mean that all youth development approaches are ineffective. For example, programmes may be more effective when implemented by charismatic staff, when they facilitate access to reproductive health services, when the staff connect with the teenage participants, or when the staff give a strong clear message about avoiding unprotected sex. Programmes may be less effective when one or more of these conditions are not met. In addition, different types of youth development programmes, such as service learning programmes, may be effective. Such programmes include intensive voluntary service in the community and organised small group discussions to prepare young people for the service and to debrief them afterwards. Notably, several studies have consistently shown that service learning programmes can have a positive effect on sexual risk behaviour and reported pregnancy rates.^{9 10 11 12}

Cite this as: BMJ 2009;339:b2054

¹ ETR Associates, Scotts Valley, CA 95066, USA

Research, doi:10.1136/bmj.b2534

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Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. Kirby DB. Emerging answers 2007. Research findings on programs to reduce teen pregnancy and sexually transmitted diseases. Washington, DC: National Campaign to Prevent Teen and Unwanted Pregnancy, 2007. www.thenationalcampaign.org/EA2007/.
2. Wiggins M, Bonell C, Sawtell M, Austerberry H, Burchett H, Allen E, et al. Health outcomes of youth development programme in England: prospective matched comparison study. BMJ 2009;339:b2534.[Abstract/Free Full Text]
3. Philliber S, Kaye JW, Herring S, West E. Preventing pregnancy and improving health care access among teenagers: an evaluation of the Children’s Aid Society—Carrera Program. Perspect Sex Reprod Health 2002;34:244-51.[CrossRef][Web of Science][Medline]
4. Scher LS, Maynard R. Interventions intended to reduce pregnancy-related outcomes among adolescents. Campbell Collaboration Social Welfare Group, 2006. www.campbellcollaboration.org/social_welfare/index.php.
5. Kirby DB, Rhodes T, Campe S. The implementation of multi-component youth programs to prevent teen pregnancy modeled after the Children’s Aid Society Carrera Program. Scotts Valley, CA: ETR Associates, 2005.
6. Cave G, Bos H, Doolittle F, Toussaint C. JOBSTART: final report on a program for school dropouts. New York: Manpower Demonstration Research Corporation, 1993. www.mdrc.org/publications/337/full.pdf.
7. Jastrzab J, Masker J, Blomquist J, Orr L. Youth corps: promising strategies for young people and their communities. Cambridge, MA: Abt Associates, 1997. www.abtassoc.com/reports/Youth-Corps.pdf.
8. Schochet PZ, Burghardt J, Glazerman S. National Job Corps Study: the short-term impacts of Job Corps on participants’ employment and related outcomes. Washington, DC: US Department of Labor, Employment and Training Administration, 2000. http://wdr.doleta.gov/opr/fulltext/00-jc_outcomes.pdf.
9. Allen JP, Philliber S, Herrling S, Kuperminc GP. Preventing teen pregnancy and academic failure: experimental evaluation of a developmentally-based approach. Child Dev 1997;64:729-42.[Medline]
10. Melchior A. National evaluation of learn and serve America school and community-based programs. Waltham, MA: Brandeis University, Center for Human Resources, 1998. www.eric.ed.gov/ERICDocs/data/ericdocs2sql/content_storage_01/0000019b/80/16/05/f8.pdf.
11. O’Donnell L, Doval AS, Duran R, Haber D, Atnafou R, Piessens P, et al. Reach for health: a school sponsored community youth service intervention for middle school students. Los Altos, CA: Sociometrics, 2003. www.socio.com/srch/summary/pasha/paspp10.htm.
12. Philliber S, Allen JP. Life options and community service: Teen Outreach Program. In: Miller BC, Card JJ, Paikoff RL, Peterson JL, eds. Preventing adolescent pregnancy. Newbury Park, CA: Sage Publications, 1992:139-55.

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