Rapid Responses to:

RESEARCH: Meg Wiggins, Chris Bonell, Mary Sawtell, Helen Austerberry, Helen Burchett, Elizabeth Allen, and Vicki Strange Health outcomes of youth development programme in England: prospective matched comparison study BMJ 2009; 339: b2534 [Abstract] [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

No respite in sight at YDP site

Rajiv Mahajan, Kapil Gupta   (10 July 2009)

Authors' response to Mahajan

Chris P Bonell   (13 July 2009)

Evaluation of a youth development programme demonstrates the need for the randomised roll-out of community interventions

Lyndal Bond, Alastair Leyland, Sally Macintyre, and Danny Wight   (16 July 2009)

Self esteem core to battle

David G Samuel   (19 July 2009)

The case for Harm Reduction

Rudiger Pittrof, Punam Rubinstein   (23 July 2009)

No respite in sight at YDP site 10 July 2009
Rajiv Mahajan, Assistant Professor Adesh Institute of Medical Sciences & Research, Bathinda (India)-151109, Kapil Gupta Send response to journal: Re: No respite in sight at YDP site	The results of the study (1) are alarming. If youth development programs are not delivering in western and developed countries, (1, 2, 3) then their fate in developing countries is but obvious; where even sex education is under scanner. Inference of this study may give readymade material to the hardliners in developing countries that are already against the sex education in schools, to further boost their agenda and oppose sexual education. (4)As suggested by authors, results of this study should not be assumed to be generalised and should not influence government policies in other countries. The method of choosing study comparator also needs more deliberations. Comparative sites matched intervention sites in all aspects and service providers were chosen for comparator sites from among the youth service providers (might be NGOs) who bid for YPDP funds but could not receive it. (1) So, the only appreciable difference between intervention and comparative sites seems to be the ‘YPDP funds’, but the commitment of service providers at comparative sites even in the absence of YPDP funds can’t be questioned, as they might have other source of funds at their disposal. This may also lead to one confounding attribute- service providers at comparator sites might have worked hard in the anticipation of successful bids next times; by cashing on this opportunity. Suggestion of the authors for establishing separate provision for young men and women, to decrease peer group effect is also debatable. Are we accepting that these programs promote promiscuity? This way, we are going to label the whole program in bad taste. Are we going to label the interaction with opposite sex as ‘forbidden fruit’ once again? References 1.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 2.Philiber S, Kaye JW, Herrling S. The national evaluation of the Children’s Aid Society Carrera model program to prevent teen pregnancy. New York: Philiber Research Associations, 2001 3.Kirby DB, Rhodes T, Campe S. Implementation of multi-component youth programs to prevent teen pregnancy modelled after the Children’s AID Society-Carrera Program. Scotts Valley, CA: ETR Associates, 2005 4.Hirjikaka F. Debate over sex education in India. Buzzle.com 2008 April 24 (cited 2009 July 09) Available: http://www.buzzle.com/articles/debate-over-sex-education-in-india.html Competing interests: None declared
Authors' response to Mahajan 13 July 2009
Chris P Bonell, Senior Lecturer London School of Hygiene and Tropical Medicine, London WC1E 7HT Send response to journal: Re: Authors' response to Mahajan	In response to Rajiv Mahajan ( BMJ, 10 Jul 2009), we should stress that the Young People’s Development Programme (YPDP) was not a traditional sex education intervention and our evaluation should not be used to inform criticism of sex education. Previous studies consistently suggest sex education programmes do not increase early sexual activity nor teenage pregnancies. YPDP did include sex education but this was a relatively minor part of a much more substantial intervention. Youth-work sites in our comparison arm were not engaged in similar work to YPDP. YPDP differed from traditional youth work not only in receiving specific funding but also in that it was targeted at specific groups of young people, was very intensive (aiming to involved 6-10 hours per week for one year) and involved a wider range of activities (including, for example, mentoring, volunteering, arts and sports, and vocational and other education). Competing interests: None declared
Evaluation of a youth development programme demonstrates the need for the randomised roll-out of community interventions 16 July 2009
Lyndal Bond, Associate Director MRC Social and Public Health Sciences Unit, Alastair Leyland, Sally Macintyre, and Danny Wight Send response to journal: Re: Evaluation of a youth development programme demonstrates the need for the randomised roll-out of community interventions	The Department of Health is to be commended for allowing the publication of the evaluation of its youth development programme (1), which disclosed unexpectedly negative results, and was candid about the limitations of the research design. In an era of scepticism about government spin, it is very welcome that a government department authorises dissemination of an independent evaluation with uncomfortable findings. These findings are important given the widespread advocacy of this kind of intervention (including by ourselves), based on results from a previous trial in the USA. They also provide further confirmation that even RCT evidence cannot be generalised unproblematically from one country to another. The authors are admirably frank about the weaknesses of the evaluation design. It was unfortunate that a cluster RCT design was not considered feasible because of tendering process undertaken by the Department for agencies to be involved in the intervention. As with many other government policy initiatives/programmes (HAZ, Sure Start etc), it would appear that implementation and evaluation of the Young People’s Development Programme (YPDP) were considered as separate processes, thus compromising the evaluability of the programme. As the authors of this study are only too well aware, recruiting as controls agencies that had not been successful in the tendering process, compromises the evaluation. The very fact that these agencies were not selected in the tendering process by whatever criteria indicates they were different in some respects from the successful bidders: whether they were not ‘ready enough’, well-resourced enough and/or had a different clientele. We are not persuaded that an RCT was impractical and we are sure the evaluators would agree. Twice the number of agencies could have been recruited through competitive tendering and then randomised to deliver the intervention or be controls. As it stands we cannot know whether the negative results reported here are really due to an intervention which does harm or due to a non-comparable comparison group. It is excellent that the Department of Health is ready to contribute to the evidence base in this important area, even when the findings are awkward, but a disappointment that a more rigorous evaluation was not planned at the outset which could have resolved some of the unanswered questions at little extra cost. Acknowledging that the recommendations from the Health Inequalities, House of Commons Health Committee Health Inequalities report (2008) (2), were too late to inform DH evaluation strategies, the results of this evaluation reinforces the Report’s conclusion and recommendations: ‘Policy cannot be evidence-based if there is no evidence and evidence cannot be obtained without proper evaluation. The most damning criticisms of Government policies we have heard in this inquiry have not been of the policies themselves, but rather of the Government’s approach to designing and introducing new policies which make meaningful evaluation impossible’ (p115) (2) References 1. 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(jul07_2):b2534-. 2. House of Commons Health Committee. Health Inequalities Third Report of Session 2008–09 London: The Stationery Office Limited, 2008. Competing interests: None declared
Self esteem core to battle 19 July 2009
David G Samuel, F1 Paediatrics Prince Charles Hospital, Merthyr Tydfil CF47 9TD Send response to journal: Re: Self esteem core to battle	The study findings could be seen as a failure on the part of education schemes for adolescents. However, these programmes are targetting high risk teenagers who have probably already been engaging in risky behaviour, and their older peers certainly have already been having sex, drinking, smoking and in some cases taking other substances. coming from a poor socioeconomic area, with one of the highest rates of teenage preganancies in Europe, I was a rarity in even completing school. Most of my peers had a child by the time I was hitting clinical years at the AGE OF 20. Self esteem is the crucial component in altering behaviours. Many young people see having a child as an escape and a way of gaining greater support and financial gain. Addressing the esteem of individuals coupled with education will alter behabiours but this takes time. I am sure a longer follow up study will show reductions. In addition, many of the comparative studies have been undertaken in America - where the cultural and social norms are very different from inner city London. Competing interests: None declared
The case for Harm Reduction 23 July 2009
Rudiger Pittrof, Consultant in integrated sexual health and HIV EN1 1NJ, Punam Rubinstein Send response to journal: Re: The case for Harm Reduction	Promoting good sexual health among adolescents is difficult. For the UK we now know that neither peer led(1), teacher led(2) sex education nor targeted intensive holistic youth development programmes(3) reduce teenage pregnancy rates. While all these studies may have had their limitations they used state of the art interventions, were well funded and conducted and were as such more likely to assess efficacy than effectiveness of an intervention. They are also adequately powered to find clinically or politically meaningful benefit of the intervention. We believe that in developed countries it is likely that sex education and abstinence education(4) delivered to more than one person at a time has only little if any positive impact on adolescent sexual risk taking. We are not aware of any evidence that shows that one to one sexual health promotion for adolescents performs much better. If health promotion cannot stop harmful behaviour it should focus on harm reduction. For the prevention of teenage pregnancy we almost have the equivalent of a vaccine. We cannot prevent exposure but we can prevent the harmful consequence: subdermal and intrauterine(5) contraception can and should be promoted for teenagers at risk of pregnancy. This technology enables us to almost eliminate teenage pregnancy risks - one adolescent at a time. We know how to identify at risk adolescents. What we need is better marketing. This may have to include the current buzz word of health promotion “conditional cash transfer”. Incentives to use long acting reversible methods of contraception in adolescents are an ethical mine field and an open discussion about this should be conducted as soon as possible. 1 Stephenson J, Strange V, Allen E, Copas A, Johnson A, Bonell C, Babiker A, Oakley A; RIPPLE Study Team. The long-term effects of a peer- led sex education programme (RIPPLE): a cluster randomised trial in schools in England. PLoS Med. 2008 Nov 25;5(11): 2 Henderson M, Wight D, Raab GM, Abraham C, Parkes A, Scott S, Hart G. Impact of a theoretically based sex education programme (SHARE) delivered by teachers on NHS registered conceptions and terminations: final results of cluster randomised trial. BMJ. 2007 Jan 20;334(7585):133. Epub 2006 Nov 21. 3 Wiggins M, Bonell C, Sawtell M, Austerberry H, Burchett H, Allen E, Strange V. Health outcomes of youth development programme in England: prospective matched comparison study. BMJ. 2009 Jul 7;339:b2534 4 Trenholm C, Devaney B, Fortson K, Clark M, Bridgespan LQ, Wheeler J. Impacts of abstinence education on teen sexual activity, risk of pregnancy, and risk of sexually transmitted diseases. J Policy Anal Manage. 2008 Spring;27(2):255-76. 5 Deans EI, Grimes DA. Intrauterine devices for adolescents: a systematic review. Contraception. 2009 Jun;79(6):418-23 Competing interests: None declared