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JUNE 2014 ISSUE OF
PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH
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1. A Rights-Based Approach to Sexuality Education: Conceptualization, Clarification and Challenges
2. Dual Method Use Among a Sample of First-Year College Women
3. Attitudes Toward Over-the-Counter Access to Oral Contraceptives Among a Sample of Abortion Clients in the United States
4. Prime Time: Long-Term Sexual Health Outcomes of a Clinic-Linked Intervention
5. Access to and Experience of Later Abortion: Accounts from Women in Scotland
6. Social Inequalities in Teenage Fertility Outcomes: Childbearing and Abortion Trends of Three Birth Cohorts in Finland
7. Digests (summaries of other important research in the field)
Despite growing discussion of a rights-based approach to sex education in recent years, consensus on what that means is lacking. In interviews conducted among 21 U.S. and international sexuality education experts, four elements were consistently identified as components of a “rights-based” approach. According to “A Rights-Based Approach to Sexuality Education: Conceptualization, Clarification and Challenges,” by Nancy F. Berglas of the Public Health Institute et al., these were an underlying principle that youth have sexual rights; program goals expanded beyond preventing unintended pregnancy and STDs; broadened curricula content that includes issues likes gender norms, sexual orientation, violence, and individual rights and responsibilities in relationships; and a teaching strategy that engages youth in participatory learning and critical thinking about their sexuality and sexual choices.
The study, which took place in 2012, found no disagreement among participants about the core elements to be included in the definition, but some disagreement about the feasibility of implementing a rights-based approach in the United States. Concerns about feasibility were voiced more frequently and consistently by experts who work in teen pregnancy prevention policy than by those involved in advocacy or program development. The researchers note that this highlights the important differences in the contexts in which the respondents work.
They emphasize that without a clear definition of a rights-based approach, it will be difficult to develop and evaluate programs, as well as to compare this model of sexuality education with others and to advocate for or against its expansion. They recommend having open dialogue on the definition of a rights-based approach, developing ways to measure and evaluate elements of the approach and incorporating findings from rights-based approaches into existing lists of evidence-based interventions.
College women participating in a yearlong study reported using hormonal contraceptives during 53% of intercourse events and condoms during 63% of events. Yet dual method use was reported only 28% of the time, and only 14% of participants were consistent dual method users, according to “Dual Method Use Among a Sample of First-Year College Women,” by Jennifer L. Walsh, of the Miriam Hospital, et al. A dual method approach is recommended by experts—particularly among high-risk populations—because condom use is the most effective method for STD prevention, while hormonal methods are the most effective for preventing pregnancy. Yet prior research suggests that uptake of the practice remains low.
To assess the prevalence of dual method use and the characteristics associated with that use, the authors conducted 12 consecutive monthly surveys of 296 first-year female college students, who provided data relating to 1,843 vaginal intercourse events. This study is the first ever to take an event-level approach to this issue.
The study found that the likelihood of dual method use was elevated when sex partners were friends rather than romantic or former romantic partners. By contrast, dual method use was less likely among women who had used a less reliable contraceptive method or who reported more months of hormonal method use, those who were older and those who had had a greater number of partners prior to college.
Given high rates of STDs and unplanned pregnancies among college-age women, the authors suggest that increasing dual method use among this population could help prevent negative outcomes. They suggest that a better understanding of the characteristics related to dual method use could help in the creation of effective interventions.
Eighty-one percent of women seeking abortion services at a sample of urban clinics in the United States stated support for access to birth control pills without a prescription, according to “Attitudes Toward Over-the-Counter Access to Oral Contraceptives Among a Sample of Abortion Clients in the United States,” by Kate Grindlay, of Ibis Reproductive Health, et al. The study found that women aged 20 or older, uninsured women, those who had previously used oral contraceptives and those who had had difficulty refilling a prescription for hormonal contraceptives had an increased likelihood of reporting that they would use over-the-counter pills.
The study’s findings stem from a May–July 2011 survey of women who were seeking an abortion or having a follow-up appointment at one of six large urban clinics that were selected because of their geographic and demographic diversity.
While 42% of women planned on using the pill—which is currently accessible only by prescription—as their contraceptive method after their abortion, 61% said they would probably use it if it were available without a prescription. Additionally, 33% of women who planned to use no contraceptive method and 38% of women who planned to use condoms after their abortion reported that they would use an over-the-counter pill. According to the researchers, making the pill accessible over the counter could help increase first-time and continued pill use among abortion patients, a group at increased risk for unintended pregnancy.
High-risk teens who participated in Prime Time, an 18-month intervention program, reported more months of consistent condom and dual method use in the past seven months than did those in a control group receiving standard clinic services, according to “Prime Time: Long-Term Sexual Health Outcomes of a Clinic-Linked Intervention,” by Renee E. Sieving, of the University of Minnesota, et al. Additionally 15% of intervention participants, compared with 6% of controls, reported having abstained from sex in the past six months. The study relied on a randomized trial in which 253 sexually active teens at high risk of pregnancy were assigned either to Prime Time or to a control group that received usual clinic services. Outcomes were measured one year after completion of the intervention program.
Intervention participants who reported higher levels of family or school connectedness reported better outcomes on some measures than those with lower levels of connectedness. The authors suggest that young people are less likely to engage in healthy behaviors when they lack supportive family or school attachments.
In addition to experiencing better sexual health outcomes, participants in the intervention group showed better outcomes in education. Among youth who had completed high school by the time of the final follow-up, seven in 10 Prime Time participants, but only four in 10 members of the control group, were attending college or technical school, suggesting to the researchers that the program had a positive impact on teens' transition to early adulthood, too.
The authors recommend prevention programs that take a long-term approach and incorporate a range of both social and behavioral issues as the best way to reduce teen pregnancy among high-risk teens. They suggest that cost-effectiveness and cost-benefit studies assess whether the up-front costs of this type of intervention can result in long-term benefits to society.
Although the legal limit for abortion in Great Britain is 24 weeks’ gestation, abortion for nonmedical reasons is not generally available after 18–20 weeks in Scotland, according to “Access to and Experience of Later Abortion: Accounts from Women in Scotland,” by Carrie Purcell, of the University of Edinburgh, et al. Those women who are unable to access later abortion services locally have to travel to England for the procedure, a step that adds to the financial and logistical barriers and to the stigma around the procedure.
Purcell and her coauthors conducted in-depth interviews with 23 women presenting for abortion services at 16 or more weeks’ gestation at participating National Health Service clinics in Scotland. The study participants were asked about their reasons for seeking later abortion services and the consequences of doing so, as well as their experiences with the procedure.
Common reasons reported for later presentation for abortion included that women did not recognize that they were pregnant; that their life circumstances had changed since they became pregnant; or that they experienced conflicting emotions about whether to continue the pregnancy or seek abortion. Among women with children, the key reason for seeking abortion was concern for the well-being of their family.
Women seeking later services reported that their perceptions of the resources required to travel to England were potential barriers to access. Those who did travel to England had to take time off from work and raise significant funds to cover the high travel costs, accommodations booked at short notice and the out-of-pocket cost of the procedure, for which many were unable to claim reimbursement. For these women, the need to travel to England exacerbated an already stressful experience, and some reported feeling stigmatized as a result.
The authors report that the burden of traveling to England is one of the most significant barriers to later abortion in Scotland. They recommend that future efforts to improve access to health services include a focus on reducing barriers and expanding local access to later abortion services.
Although teenagers in Finland have a relatively low pregnancy rate, those who come from backgrounds of low socioeconomic status are consistently more likely than those from better-off backgrounds to become pregnant and to give birth, according to “Social Inequalities in Teenage Fertility Outcomes: Childbearing and Abortion Trends of Three Birth Cohorts in Finland,” by Heini Väisänen and Michael Murphy, of the London School of Economics and Political Science. Among teenagers born in 1965–1969 or in 1975–1979, those whose parents were upper-level employees—the highest socioeconomic standing—had a 63–69% lower risk of giving birth than those whose parents were manual laborers. Among teenagers born in 1955–1959, children of upper-level employees had a 53% lower risk of childbirth than children of manual laborers.
The study analyzed nationally representative, longitudinal data from 259,242 Finnish women in three birth cohorts. It found that upper-level employees’ children had a 45% lower risk of experiencing an abortion than manual laborer’s children in the earliest and latest cohorts, and a 53% lower risk in the 1960s cohort. However, in every cohort, pregnant teenagers from upper-level backgrounds were the most likely to choose to have an abortion: They had three times the odds of manual workers’ children in the 1950s cohort and more than twice the odds of that group in the later cohorts.
The researchers observe that socioeconomic status remains strongly linked to teenage fertility behavior even though Finland has a free education system, access to a wide range of contraceptives and good welfare policies. They recommend an assessment of available information on reproductive health, as well as of whether all teenagers benefit equally from sex education and know how to access reproductive health care and abortion services. They also note that these persistent disparities could result from some teenagers’ wishing to become parents, and recommend more research on women’s’ decision making about fertility.
The Digests section of this issue contains summaries by Perspectives editors of recent research on a range of topics: fertility among teenagers with major mental illness, the impact of a street-based outreach program for HIV testing, correlates of condom use among patients at an STD clinic and more. Click here to access these valuable resources.