Consultation on the Pregnancy and Parenthood in Young People Strategy

Appendix 4

Executive Summary of Review Level Evidence

Evidence and/or evidence-informed recommendations and suggested have been drawn primarily from four key health related sources:

1. National Institute for Health and Care Excellence (NICE) public health guidance (and relevant NHS Health Scotland Commentaries/Scottish Perspectives)

2. National Institute for Health and Care Excellence (NICE) clinical guidance

3. NICE and Health Development Agency (HDA) public health briefings.

4. Publications from the World Health Organization (WHO).

We have called this information 'highly-processed evidence'. Additional sources of evidence and theory have been drawn from relevant key systematic reviews identified largely through the Cochrane Collaboration, the Evidence for Policy and Practice and Co-coordinating Centre (EPPI) and the Campbell Collaboration, reviews and reports commissioned by the The Scottish Government, the UK Government and national organisations and collaborators. Highly processed evidence, including systematic reviews, is used as it provides a summary of high quality evidence that has been quality assured and therefore less subject to bias.

Much of the evidence is drawn from evaluations of studies in North America and other countries where the health, social care and education systems are different to those in Scotland, Where the evidence is largely from outside Scotland the applicability of the evidence to the Scottish context should be considered carefully as results may not replicate in a different context.

For a variety of reasons, we do not always have 'good evidence'. This lack of evidence, however, does not necessarily mean there is no link between two components in a logic model nor that evidence of effectiveness does not exist, it just has not been reported or evaluated. Similarly, lack of evidence should not always prevent us from acting or testing new approaches.

Strand 1: Strong leadership and workforce

• Young people face both personal and service related barriers that influence their access to services. These include embarrassment about discussing sex and using services, perceptions of trust and legitimacy of services; accessibility of services in terms of location/opening hours and the attitudes of staff, in particular the importance of respectful and non-judgemental staff.
• Staff training is associated with improved access to services by young people.
• More co-ordinated services to access appropriate information and advice helps young people to make choices appropriate to their needs and circumstances.

Strand 2: Supportive and youth friendly services

• Young people experience a range of personal and service barriers to accessing service. Youth friendly services increase access to services and may contribute to reduced sexual risk behaviour. The evidence is based on relatively poor quality research.
• Targeted intensive community based interventions which include sexual health services are effective in improving sexual behaviour and reducing pregnancy however transferability to the UK is questionable. Targeted outreach programmes, some specifically targeting socially disadvantaged young people, can increase access to services. No high level evidence was identified about the effectiveness of tailored and targeted services for young people who are in looked after accommodation, are homeless or from Black and Ethnic Minority communities.
• Young people have gaps in their knowledge about sexual activity, contraception, including emergency contraception (EC), and where to access contraception. They may also have negative views about EC and the trustworthiness of services. Advanced provision of emergency contraception increases use and speed of use of EC and does not generally impact on other contraceptive use or increase sexual risk behaviour.
• Long Acting Reversible Contraception (LARC) is the most effective and cost-effective form of contraception. NICE guidance outlines a range of recommendations for the provision of LARC.
• Outreach services may increase access and maintained contact with generic service though the extent to which this impacts on sexual health behaviour and pregnancy is unclear. A small number of studies have evaluated comprehensive multicomponent programmes and these are effective in reducing pregnancy however the provision of LARC is particularly important.
• Interventions that include discussion and demonstration of condoms is effective in engaging young people in services and increasing use of condoms. There is evidence that some interventions that use additional services to increase contraceptive use may be effective.
• School Based and School Linked Health Centres are not associated with increased sexual activity and may contribute to reduced levels of sexual activity and delay sexual initiation. On-site dispensing of condoms is associated with greater provision/uptake of condoms though impact on use has not been fully evaluated.
• A range of personal and service based factors influence access and use of services by young people. Based on the available evidence key characteristics have been proposed to inform service development and evaluations.
• Carrera, an intensive community based youth development programme may be effective in reducing pregnancy and improving sexual behaviour. A UK adaptation of this model reported negative impacts though these may be explained by the study design and poor implementation fidelity.
• Pregnant young women are less likely to access services early in pregnancy. Late engagement with services is associated poorer health outcomes for mothers and their offspring and in relation to termination services can result in reduced choices for young women.
• No highly processed evidence was identified about effective ways of supporting young people to make early informed choices following conception.
• Young women experience a large number of personal and service barriers to accessing antenatal care. There is promising evidence that specialist service which emphasise early initiation of care and multifaceted community based service, including home visits by trained lay advocates increased early booking.

Strand 3: Education and Positive Destinations

• Comprehensive sex and relationship (SRE) programmes are effective in contributing to positive sexual behaviour and no evidence that they increase risky sexual behaviour. Few studies have examined the impact of pregnancy and a small number of studies have found a positive impact. Comprehensive programmes are more likely to be successful if they include a theoretical basis, are delivered by trained professionals and provide specific content focusing on sexual risk reduction. The available evidence points to a number of common characteristics that are associated with the effectiveness of interventions in terms of the development, content and delivery of SRE programmes.
• Programmes that are multimodal and incorporate education, skills building and condom promotion may reduce pregnancy and sexual activity.
• The effectiveness of abstinence based programmes is inconclusive and is based on a smaller number of high quality evidence. Better quality studies suggest these programmes are not effective in reducing sexual activity or pregnancy.
• A small number of studies indicate that general health education programmes which involve a community components are effective in reducing sexual risk behaviour. Weak evidence from one study suggests that whole school approach may have impact on sexual behaviour in the long term.
• There is limited evidence about the effectiveness programmes including a parenting component in reducing risky sexual behaviour. Programmes that are intensive and focus on parental monitoring or regulation are the most promising. There is reasonable evidence to suggest that intensive programmes have a positive impact on child-parent interactions.
• A range of interventions to address the social and emotional wellbeing of children and young people in schools can be found in the mental health improvement outcomes framework (MHIOF)
• No highly processed evidence was identified for the effectiveness of parenthood programmes on improving knowledge around parenting, delaying pregnancy and improving health and social outcomes for parents and children in the long term.
• Limited highly processed evidence was identified for the effectiveness of programmes to address gender based inequalities and violence. Whilst some primary prevention approaches are promising, there is not currently sufficient evidence to recommend any particular adolescent dating violence prevention programme over another
• Early childhood intervention and social development projects in primary school targeted at those who experience social disadvantage can have a positive impact on pregnancy and/or birth rates, reduced sexual activity or increase safe sexual behaviour and contribute to reducing unintended teenage pregnancy.
• Youth development programmes addressing non-sexual risk factors for unintended teenage pregnancy as well as those incorporating services to address sexual risk factors can have a positive impact on unintended teenage pregnancy.
• A range of school, community and afterschool interventions in primary and secondary schools are effective in reducing school dropout and increasing school attendance and that targeted school-, court- and community-based intervention have a modest impact on school attendance.

Strand 4: Supporting young parents

• Young women experience a large number of personal and service barriers to accessing antenatal care. Specialist services which emphasise early initiation of care and multifaceted community based service, including home visits by trained lay advocates increase early booking.
• Antenatal classes designed for young people, home visiting and assistance with transport costs, specialist antenatal services and continuity of care for young women help young people maintain contact with services. There is conflicting evidence about the most appropriate additional services and limited evidence about what additional information is need to support young women.
• Enhanced home visiting beginning pre-natally and extending upto 18 months by professionals (such as the Family-Nurse-Partnership) can reduce repeat pregnancy and increase the spacing of pregnancy. It can positively impact upon the social and emotional development of young mothers and their children (see below).
• Young people experience a range of problems with housing, childcare, financies, educaton, training and employment. Common themese include diverse needs and lack of choice; stereotypes of teenage mothers; reliance on family; consideration of the cost and benefits of education and employment; continuation of social problems prior to pregnancy. Actions to meet these needs may contribute to improved life courses for teenage pareents
• Education/career development programmes and welfare sanctions and bonus programmes are effective in improving in education and training though the former are more effective and may be more appropriate to the needs of young people. Neither type of programme had a long term impacts on employment rates. Education alone is unlikely to improve employment prospects. A focus on employment and provision of jobs and higher earning for teenage mothers is associated with improved long-term self-sufficiency. Holistic programmes address many of the needs identified by young people however, the effectiveness of these programmes in terms of improving participation in education, training or employment has not yet been established.
• Education/career development interventions and holistic programmes had a positive but non-significant effect on emotional wellbeing and had a non-significant impact on reducing further pregnancy.
• A number of recommendations for social inclusion have been proposed on the basis of the available qualitative and quantitative evidence
• Enhanced home visiting is effective in increasing maternal employment as well as reducing use of welfare, arrest/convictions and domestic violence
• Day care for young children is associated with improved prospects of education, training and employment for mothers, including teenage mothers. The Abecedarian project, an early childhood intervention targetted at teenage parents was assocated with improvements in high school completion, participation in training and employment as well as a reduction in repeat pregancy.
• There is imited highly processed evidence about the experiences of young fathers and how to effectively and appropriately engage them in services to improve outcomes for themselves, their partners and their children. There is promising evidence from evaluations of FNP and Sure Start Plus which begin to address this area.