Pregnancy and Parenthood in Young People Strategy

Appendix E: Executive Summary of Review Level Evidence

Executive Summary of Review Level Evidence^[i]

Evidence and/or evidence-informed recommendations informing the outcome framework was drawn primarily from six 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).

5. Key systematic reviews identified largely through the Cochrane Collaboration, the Evidence for Policy and Practice Information Co-ordinating Centre (EPPI-Centre) and the Campbell Collaboration

6. Reviews and reports commissioned by the Scottish Government, the UK Government and national organisations and collaborations.

We refer to this as 'highly-processed evidence'. Highly processed evidence was used as it provides a summary of high quality International evidence (including from Scotland and the rest of the UK where this is available) that has been quality assured and therefore less subject to bias.

As a consequence of the international nature of the research and more limited highly processed evidence based on UK studies, much of the evidence. 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. The research may not have been done or findings reported or reviewed alongside other similar studies. Similarly, lack of evidence should not always prevent us from acting or testing new approaches, however we may proceed with more caution than where there is good highly processed evidence.

The full evidences statement and references and the logic models can be found on the NHS Health Scotland website.

Strand 1: Strong leadership and accountability

• 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.
• NICE recommend that contraceptive service are informed by the views of young people and local data and are co-ordinated and comprehensive.
• NICE recommend the use of local data and the views of young people to tailor antenatal services and, partnership working to improve access to and continued contact with antenatal services.
• Staff training is key to delivery of reproductive health, antenatal and other service provision as well the delivery of RSHP programmes for young people and can increase access to services by young people.
• Young parents have varied preferences in relation to health, social and educational needs. More co-ordinated services may help them access appropriate information and advice to make choices appropriate to their needs and circumstances.

Strand 2: Giving young people more control

Positive outcomes and educational engagement

• Early childhood interventions 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 as well as educational and longer term social outcomes.
• 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 as well as academic outcomes. A UK adaptation of one approach reported negative impacts though these may be explained by the study design and poor implementation fidelity therefore transferability to the UK requires further research.
• There is promising evidence that universal youth work may contributed to improved educational attainment, employability and health and wellbeing however the highly processed evidence is limited. A number of characteristic of universal youth development programmes were identified as important for positive outcomes.
• A range of school, community and afterschool interventions in primary and secondary schools are effective in reducing school dropout and increasing school attendance and targeted school-, court- and community-based intervention have a modest impact on school attendance.

Supporting positive relationships and sexual wellbeing

• 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

• 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)

Relationships, sexual health and parenthood education

• Comprehensive sex and relationship (SRE) programmes are effective in contributing to positive sexual behaviour and there is no evidence that they increase risky sexual behaviour. Few studies have examined the impact on pregnancy however a small number of studies have found a positive impact. Comprehensive SRE 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.
• There is promising but mixed evidence about the effectiveness of peer-led SRE programmes. Poor implementation of programmes may explain the mixed results.
• 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 component are effective in reducing sexual risk behaviour. Promising evidence from one study suggests that whole school approach may have impact on sexual behaviour in the long term.
• 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.
• School, home and community based Sex and Relationship Education (SRE) programmes which involve parents can have a positive impact on young people's knowledge and attitudes and improve parent-child communication.
• There is limited highly-processed evidence about the effectiveness of SRE programmes including a parenting component in reducing risky sexual behaviour. Programmes that are intensive, focus on parental monitoring or regulation and help parents model the desired behaviour, are the most promising. There is reasonable evidence to suggest that intensive programmes have a positive impact on child-parent interactions.

Sexual and reproductive health services

• Young people experience a range of personal and service barriers to accessing service. Youth friendly services can increase access to services and, based on more limited evidence, may contribute to reduced sexual risk behaviour.
• 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.
• Targeted intensive community based interventions which include sexual health services can be effective in improving sexual behaviour and reducing pregnancy. A UK adaptation of one approach reported negative impacts though these may be explained by the study design and poor implementation fidelity therefore transferability to the UK requires further research. Targeted outreach programmes, some specifically targeting socially disadvantaged young people, can increase access to services. Little highly processed 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.
• 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.
• Adding outreach programmes to mainstream services can increase access and maintained contact with contraceptive service though the extent to which this impacts on sexual health behaviour and pregnancy is unclear. A small number of studies found comprehensive multicomponent programmes are effective in reducing repeat pregnancy however the provision of LARC is particularly important.
• Interventions that include discussion and demonstration of condoms are 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.

Strand 3: Pregnancy in young people

• 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 abortion 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 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.
• NICE PHG 51 includes guidance about the provision of advice and effective contraception in abortion services for young people and CMO (2015) 19 letter recommends targets for the provision of advice about effective contraceptive advice (including LARC), for women, particularly vulnerable women prior to discharge from abortion services in Scotland.

Strand 4: Parenthood in young people

Antenatal support and maternity services

• 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 abortion services, can result in reduced choices for young women.
• 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 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 up to 18 months by professionals (such as the Family-Nurse-Partnership) can reduce rapid repeat pregnancy and increase the spacing between first and second births. FNP (based on studies of the Nurse-Family Partnership model) can have a range of postiive short-, medium- and long-term beforits for mthers and their children, in particular conitive and language outcomes for children

Support to control reproductive health and pregnancy spacing

• NICE provide guidance about the provision of advice and effective contraception in maternity for young people. CMO (2015) 19 letter is a key driver for the provision of advice about effective contraceptive advice (including LARC), for women, particularly vulnerable women, prior to discharge from maternity services in Scotland.
• Enhanced home visiting beginning pre-natally and extending up to 18 months by professionals (such as the Family-Nurse-Partnership) can reduce rapid repeat pregnancy and increase the spacing between first and second births.
• The effectiveness of community based interventions in reducing repeat pregnancy is inconclusive. Some studies of home visitor programmes and peer support programmes showed a positive impact on reducing repeat pregnancy whilst others found no effect of repeat pregnancy. Single studies have found that sibling pregnancy prevention programmes and generic programmes may be effective in preventing repeat pregnancy and subsequent birth.
• Intensive care management, a school based programme, delivered by culturally matched social workers as part of a multicomponent intervention can have a positive impact on reducing repeated pregnancy.
• Curriculum interventions which include community outreach can be effective in reducing pregnancy rates and some evidence suggests that this may be particularly the case for teenagers who are already parents.

Education, training, childcare, housing and income maximisaiton

• Young parents experience a range of problems with housing, childcare, finances, educaton, training and employment. Common themes 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
• Educationand career development programmes, alongside 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 parents. Neither type of programme had a long-term impact 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 parents however, the effectiveness of these programmes in terms of improving participation in education, training or employment has not yet been established.
• Education and 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.
• Enhanced home visiting can be effective in increasing maternal employment as well as reducing use of welfare and arrest/convictions.
• 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 limited 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.