Pregnancy has been seen to be the cause of death for many young women aged 15-19 years old around the world (WHO, 2008). 15 million adolescent girls give birth each year; this is roughly 11% of all births worldwide. Furthermore, the UK has the highest teenage pregnancy rate in Europe (WHO, 2007). Although the Office for National Statistics (ONS, 2010) has shown that the under 18 pregnancy rate for the UK has dropped significantly between 1998 and 2008; it is still a concern as numbers are nevertheless high and a large percentage of these pregnancies result in abortion. Moreover, according to the Health Protection Agency (2005) the diagnosis of STIs such as Chlamydia, Genital Warts, Gonorrhoea, Genital Herpes and Syphilis has significantly increased between 1995 and 2004 in the UK. This implies that there is a need to emphasize the importance of condom use in order to reduce the risk of STIs. This in turn can further reduce the rate of teenage pregnancies.
There is some evidence that certain groups of teenagers are particularly vulnerable to becoming teenage parents. As well as those who come from a low socio economic background (Botting et al, 1998), it has been found that adolescents who display below average achievement are at a significantly higher risk of becoming teenage parents (Kiernan, 1995) along with those involved in crime (Botting et al, 1998) and homeless young people (JRF, 1995). Young people in care have also shown a higher risk of teenage pregnancy (Biehal, 1995). Children that were born to teenage parents are more likely to become teen parents themselves (Ermisch and Pevalin, 2003) as well as some ethnic minority groups (Berthoud, 2001). However, becoming a teenage parent is the norm in some cultures and it is not seen as a negative thing.
Teenage pregnancy can have adverse effects on both the parents and baby. Studies have shown that newborn death rates are 60% higher in adolescent mothers (Berthoud, 2001). Other studies have found a link between early pregnancy and negative effects on newborn health (Conde-Agudelo et al, 2005).
As stated by the World Health Organisation (2007) teenage pregnancy and early parenthood have been associated with poor academic achievement, poor physical and mental health, poverty, and social isolation. Socio-economic disadvantage can be both a cause and an effect of adolescent parenthood. A report published by the Social Exclusion Unit (1999) stated that young mothers not only have problems at school before pregnancy, but are less likely to complete their education, are more likely to have no qualifications and be in receipt of low incomes or benefits. It is also evident that teenage mothers and their children are more likely to have lone parent families, have an increased risk of poverty and poor housing (Botting et al, 1998).
Research implies that becoming a teenage parent has many short term and long term negative effects on both the parents and the child. However, it is important to recognise that not all unintended pregnancies results in abortion. Also not all teenage pregnancies are unintended; some teenagers choose to become young parents and see it positively (NICE, 2007). Several researchers state that the emphasis on negative aspects of teenage pregnancy contributes towards negative stereotypes and judgemental attitudes towards teenage parents. They also emphasize that teenage parenthood can sometimes improve their lives and make them more responsible, motivated individuals (YWCA, 2004; Alexander et al, 2010).
Protection Motivation Theory
Roger’s (1975) Protection Motivation Theory (PMT) is based upon the idea of effective fear arousing communication. It argues that the level of fear induced in messages influences cognitive responses which result in the adoption of adaptive behaviours to avoid a certain negative outcome. It is based upon both threat appraisal and coping appraisal; in that the health threat and the coping responses result in the intention to perform adaptive responses or protection motivation. Protection motivation is the result of perceived severity and perceived vulnerability, as well as response efficacy and self-efficacy. Various studies have shown that PMT can be used successfully for the prediction of intentions to adopt preventive health behaviours (Boer and Seydel, 1996). Other studies have demonstrated the effectiveness of PMT in the prevention of sexually transmitted diseases (Van der Velde and Van der Pligt, 1991). Greening et al (2001) found that PMT was a predictor of condom use in sexually active adolescents. Other studies have also found that the PMT predicts STI risk reducing behaviour such as condom use (Bengal et al, 1996; Eppright et al, 1994). However some studies do not support findings that all of the constructs of the PMT are equally important in determining behavioural intentions as findings have differed from study to study (Eagly and Chaiken, 1993).
Social Cognitive Theory
The Social Cognitive Theory (SCT) (Bandura, 1988) identifies human behaviour as an interaction of personal factors, environmental factors and behaviours. Personal factors are cognitions, experiences and beliefs about situations which influence behaviour. Conversely, environmental factors are the social and physical environment surrounding a person which influences their behaviours. The main factors involved in the SCT which can be utilised in the present health intervention are: Environment and situation in which the individual is educated about the problem situation; expectations and expectancies in which individuals are aware of the benefits of a certain behaviour; vicarious learning in which individuals acquire knowledge through the observation of others; reproduction and reinforcement in which the individuals put their learned knowledge intro practice and are rewarded; self efficacy in which individuals are confident in their ability to carry out a particular behaviour; emotional coping in which individuals are taught ways to cope effectively in certain situations and reciprocal determinism in which individuals are able to carry out the behaviour when faced with the situation. Coyle et al (2001) used the SCT as a framework for their intervention for the reduction of STIs; their findings reported the intervention group to result in more protective behaviours against STIs and more knowledge of STIs than the control group.
Self efficacy was developed by Bandura (1977) and derives from his Social Learning Theory. Self efficacy can be used to facilitate positive behavioural change. Bandura defined self efficacy as; “A judgement of one’s capability to accomplish a certain level of performance.” (1986). It is suggested that a person with a high level of perceived self efficacy is more likely to master a particular behaviour than a person with a lower level of perceived self efficacy. Bandura outlined 4 main sources of self efficacy, these are; performance accomplishment, vicarious experiences, verbal persuasion and physiological arousal. These could be targeted in interventions by providing participants with opportunities to practice the behaviour such as condom use. Secondly, participants can observe others carry out the behaviour, persuasive messages can be conveyed and finally, physiological state can be the physical feedback from the participant throughout the task. Increasing individual’s self efficacy can be a useful tool for the reduction of STIs and teenage pregnancies.
Aims and Objectives
The aim of the intervention is to reduce teenage pregnancy rate in the UK by providing an incentive for teenagers to change their cognitions towards teenage pregnancy and their protective behaviours against pregnancy and STIs. It aims to educate them about the reality of teenage pregnancy and parenthood and increase their self efficacy in maintaining good sexual health and protecting themselves from STIs and unwanted pregnancies.
The justification for this intervention is the high number of teenage pregnancies in the UK and the high percentage of them that result in abortion, health problems and even fatality. The increasing diagnosis of STIs has also been highlighted as an important motivation for this intervention.
It is hypothesised that the intervention will change the cognitions of the students about vulnerability to STIs and teenage parenthood, increase their self efficacy and induce more protective behaviours such as condom use.
The study will utilise a longitudinal between subjects experiment. It will employ a randomized control trial (RCT) with school 1 as the experimental group receiving the intervention and school 2 the control group receiving no intervention. The independent variable will be the intervention received and the dependent variable will be change in cognitions and behaviours. The baseline measurement will take place at the start of the intervention and measured again after each session. An overall post intervention measurement will be taken at the end of the study and a follow up post intervention measurement will be repeated after a year.
Participants would be approximately 200 year 10 secondary school students aged between 14 and 15 years. This will involve 100 participants each for both the experimental and control groups. Participants will be of a low socio economic region and will be obtained from the target population through cluster sampling. There will be both male and female participants and it is supposed that their ethnic backgrounds will be diverse.
An information sheet and consent form for parents/carers of the students.
Consent form for the students.
A questionnaire will be given to each student at the beginning of the intervention and then after each session including in the follow up session a year post intervention. The questionnaire will include questions relating to demographic details and the sexual behaviours of the students as well as the following scales: Teen Attitudes Pregnancy Scale (TAPS) (Somers et al, 2002 which looks at teenagers’ future orientation, realism about child rearing, personal intentions, and sexual self-efficacy. Attitudes towards Condom Scale (ATC) (Brown, 1984), this is a 40 item measure on a Likert type scale developed to determine specific attitudes toward condoms. Condom Use Self Efficacy Scale (CUSES) (Brafford and Beck, 1991) which assesses efficacy to purchase condoms apply and remove them and negotiate their use with partners and the Risk Behaviour Diagnosis Scale (RBD) (Witte et al, 1996).
5 large images showing physical symptoms of STIs (Chlamydia, Genital Warts, Gonorrhoea, Genital Herpes and Syphilis).
2 types of contraception (Condoms, Contraceptive Pills).
Video of peer pressure role plays. These will show young teenagers being coerced into sex with their partners through peer pressure; the videos will also display pressure to engage in unprotected sex from partners and will teach the students how to avoid and tackle these situations.
Pregnancy bump simulators. The Bump weighs about 12 – 12.5 kilos which is the weight of a healthy average sized pregnant woman. It is designed to give the wearer a better understanding of the weight gain experienced during pregnancy.
Video of child birth. This shows the whole process of giving birth in a graphic real life video to show the student the extent of the pain and difficulty associated with giving birth.
Real life simulation baby dolls. These are just as demanding as real babies, and provide students with a realistic parenting simulation. They need feeding, burping, rocking, nappy changing and require their heads to be gently supported, and the carer has to determine the care needed. A wireless ID is worn on the wrist of the student, and allows the Baby to communicate with them. The Baby monitors the quality of care it receives, and reports on the numbers of times each type of care was provided as well as the number of failed requests for care and frequency of wrong position, rough handling and shaking.
Information leaflets about protection from STIs and unwanted pregnancies, contraception and where to access it confidentially and free of charge, peer pressure and ways to tackle it, teenage pregnancy facts and negative effects.
The intervention for school 1 will involve 6, 1 hour long, interactive sessions which will run once a month in the place of the year group’s PHSE lesson. This will cover an academic term. The control group at school 2 will receive no intervention but will part take in the school’s standard PHSE lessons. There will be a follow up session after a year to test the long term effectiveness of the intervention. This will take place when the students are in year 11 of secondary school.
Session 1. The first session will involve a brief introduction of the programme followed by a questionnaire for each participant to fill in. The experimenter will then explain to the participants the importance of good sexual health and will talk in detail about the risks of underage and unprotected sex. STIs and teenage pregnancies will be explored and students will be told the short term and long term negative effects of these. The next stage will be an interactive group card game in which the students will be required to match large pictures of 5 common STIs with their symptoms. These will be; Chlamydia, Genital Warts, Gonorrhoea, Genital Herpes and Syphilis. Furthermore, the experimenter will talk about ways to avoid STIs and teen pregnancy and how to be sexually safe and healthy. Contraception, hygiene routines and screening programmes will be discussed. 2 types of contraceptives will be explored and passed around for the students to see. These will be condoms and contraceptive pills as they are the most suitable for young teens. Particular emphasis will be put on condom use and the experimenter will demonstrate how to use a condom and will enable each student to practice so that they are confident in their ability to use it and understand fully that they should always use a condom in conjunction with other methods to be 100% safe from STIs and unwanted pregnancies. The students will also be given information about how to access them confidentially and free of charge. Finally, the experimenter will hand out the questionnaire again for each student to fill in; this will be the close of the session.
Session 2. For the second session, the experimenter will talk in detail about underage sex and the pressures young people face to have sex at an early age. The importance of making the right decision and sticking to it will be discussed and students will be empowered to stay strong and not be influenced by others. The group will then be shown a series of videos displaying peer pressure to engage in sexual activity and different ways of tackling this. The group will then be divided into smaller groups who will then take part in role plays to enact peer pressure and different ways on how to avoid giving in. Those groups willing to will then act these out for the whole group and each role play will be discussed in detail. Further information will be provided and contact details will be given in case any student wishes to use additional support services. Finally, the experimenter will hand out a questionnaire for each student to fill in.
Session 3. The next session will involve a discussion about teenage pregnancies and factors which lead towards them. There will also be information about the negative effects of teenage pregnancy on the parents and baby. A young teenage mother will be present to share her experiences of becoming a teenage parent and the difficulties she may have faced. The students will have the opportunity to ask her questions about her experience. The teenage mother will then give the students helpful advice and tips to keep safe and healthy. She will then provide the students with a leaflet containing further information as well as facts about teenage pregnancy. At the end of the session, the students will again fill in the same questionnaire.
Session 4. The fourth session will involve the experimenter talk in detail about pregnancy and the difficulties throughout the process. The students will then be divided into pairs of opposite sexes. For the next hour, the girls will be required to wear a pregnancy bump simulator to replicate the weight gain and change in shape that women experience during pregnancy. The boys will be required to assist the girls and support them throughout the hour. The end of the session will be with each student repeating the same questionnaire.
Session 5. In this session, the experimenter will talk in detail about giving birth and the difficulties during the process. The students will then watch a video of child birth following which they can ask the experimenter questions and will discuss their feelings towards the process of giving birth. The session will end with the students filling out the questionnaire.
Session 6. The Final session of the intervention will involve information about being a teenage parent and the trials that accompany it. The group will then be divided into pairs and given a real life simulation baby doll to care for over the hour. The students will be required to change, feed, rock and put the babies to sleep on demand as well as support the head gently. This task will give the students an idea of the responsibility involved in being a young parent and will enable them to understand the difficulty to carry on life as normal after becoming a parent. At the end of the session, the students will be given the questionnaire to fill in.
Follow up Session: The follow up session will involve all participants that took part in the intervention the previous year to repeat the questionnaire.
Ethical approval will first be obtained from the British Psychological Society and the Local Education Authority. Consent will then be received from both secondary schools willing to participate in the study. Staff at both institutions will be informed of the study and what it entails. Parents of all year 10 students in school 1 will be sent information about the intervention with a consent form and agreement. Those students granted parental consent will be asked for their assent to taking part in the intervention.
Throughout the intervention, the experimenter will adhere to the BPS ethical guidelines and code of conduct (2009) ensuring the students are aware of their ethical rights of withdrawal, confidentiality and being impartially treated. The experimenter will be available to provide help and support throughout the sessions and will be open to any questions or queries from the students; students will also have the opportunity to speak to the experimenter on a one to one basis at any time. The experimenter will provide students with information leaflets at the end of each session with contact details of relevant organisations that can help them with any issues or problems regarding anything covered in the sessions.
It is supposed that the intervention group will show a change in cognitions about teenage pregnancy and STIs and their vulnerability and susceptibility. The intervention group is also expected to show an increase in self efficacy and intentions to perform protective behaviours such as condom use. Previous studies have found that perceptions of vulnerability to STIs and self efficacy to engage in safe sex practices had a significant effect on safe sex intentions (Tanner et al, 1989; Yzer et al, 1998).
The proposed intervention has many advantages. The RCT will enable the experimenter to evaluate the effectiveness of the intervention and to measure the difference between the two groups. However RCTs have been seen to be expensive (Sanson-Fisher et al, 2007). The post session measurement will enable the experimenter to see which session has had the most impact on the attitudes and behaviours of the students. However, a possible problem with this is the inability to determine whether any other factors have contributed towards a change in their attitudes and behaviours. Also, follow up after a year can also have this problem as the individuals may be exposed to many events that may influence their sex behaviours and attitudes in that period of time.
Swan and colleagues (2003) found evidence to suggest that interventions such as school-based sex education may effectively prevent or reduce teenage pregnancies in the UK. The intervention will be implemented on a mixed sex group. This can be seen as an advantage as past studies have found that communication about contraception and STI risk is a powerful predictor of future contraception and STI protection (Catiana et al, 1994; Sheeran et al, 1999). The mixed sex session will enable the students to be at ease with discussing contraception with the opposite sex and enhance their self efficacy in relation to this.
Providing the students with the opportunity to talk about contraception and to handle and practice how to use the condoms will enable them to develop a more positive attitude towards using them and reduce the embarrassment associated with them. It will also facilitate them to increase their self efficacy in their ability to use condoms. Many studies have found these methods to be significantly correlated with future condom use (Mahoney et al, 1995; Bryan et al, 1996).
The sessions which portray negative aspects of unprotected sex and teenage pregnancy will be based upon fear appeals. Although the messages provoke negative feelings in the students, there will be information provided on how to avoid the negative effects of unprotected sex and teenage pregnancy. This is supported by previous studies which have found that fear appeals are most likely to influence behaviour when accompanied by instructions on how to act and how to avoid certain behaviours (Leventhal, 1970).
Another positive factor was the idea of the intervention including a teenage mother, as the students were able to relate to her. This would encourage them to understand the message she was conveying and enable the students to take on board her advice and learn from her mistakes. Previous studies have found that peer led sex education is more popular with teenagers and the interaction between them is more effective. Results of the RIPPLE trial showed that the group which received peer led sex education reported lower unintended pregnancies (Stevenson et al, 2004). This is also relevant in relation to the Social Cognitive Theory as the students will be influenced by their social environment.
Research has also supported the idea of giving teenagers infant simulation dolls. Baby Think It Over (BTIO) is a programme aimed at modifying teenager’s attitudes towards unprotected sex and teen pregnancy and parenting (Jurmain, 1994). A qualitative study by Out and Lafreniere (2001) found that after 3 days’ experience with the dolls, teenagers in the intervention group reported a change in their attitudes towards teenage pregnancy and acknowledged their risk of teenage pregnancy due to unprotected sex more realistically. Other studies also found the programme effective in educating teenagers about the reality of teenage parenthood and the importance of preventing it (Strachan and Gorey, 1997).
In addition, Saltz, Perry, and Cabral (1994) support the idea of role play such as pressure role play to encourage students to change their attitudes towards teenage pregnancy. Observing others’ actions may change the student’s beliefs and enhance their self efficacy through social modelling and persuasion (Bandura, 1986). It may also prompt protective intention formation (Ajzen and Madden, 1986). Consistent with these findings, Wessberg et al (1979) found that observing and part taking in role play of condom use is a good methodology to increase condom use self efficacy. However, (Wight and Abraham, 2000) concluded that face to face role play is not effective in sex education interventions due to the lack of seriousness on the students’ part. They suggested videos depicting scenarios of sexual relationships and reported these to be more effective. Nevertheless, the proposed intervention includes both of these methods to cater for the different learning styles of the students.
A possible analysis for the experiment is a multiple regression to examine associations between demographic details, attitudes towards teenage pregnancy, self efficacy, perceived vulnerability, perceived susceptibility, and sexual behaviours. This is suitable as there are many elements of the intervention that can contribute towards the possible change in cognitions and behaviours.
Possible limitations of the intervention may be the reliance on self report for the questionnaires. Students may display socially desirable responses or may not take the questionnaires seriously, giving invalid responses. Further limitations may be the lack of parental consent for their children taking part in the intervention. Moreover parents of students in the intervention group may be expecting definite positive results and may not understand the idea of the research programme. Another negative aspect may be that the follow up session being after a year may result in a loss of participants. Giving the students the opportunity to deal with real life simulation babies may increase their desire of having a baby as they may not fully reflect the responsibility involved in caring for a baby. Finally, the child birth video and images of the physical symptoms of STIs may be deemed as inappropriate for the age of the students.