Angela Harden

Teenage pregnancy and social disadvantage: systematic review integrating controlled trials and qualitative studies

Objectives To determine the impact on teenage pregnancy of interventions that address the social disadvantage associated with early parenthood and to assess the appropriateness of such interventions for young people in the United Kingdom. Design Systematic review, including a statistical meta-analysis of controlled trials on interventions for early parenthood and a thematic synthesis of qualitative studies that investigated the views on early parenthood of young people living in the UK. Data sources 12 electronic bibliographic databases, five key journals, reference lists of relevant studies, study authors, and experts in the field. Review methods Two independent reviewers assessed the methodological quality of studies and abstracted data. Results Ten controlled trials and five qualitative studies were included. Controlled trials evaluated either early childhood interventions or youth development programmes. The overall pooled effect size showed that teenage pregnancy rates were 39% lower among individuals receiving an intervention than in those receiving standard practice or no intervention (relative risk 0.61; 95% confidence interval 0.48 to 0.77). Three main themes associated with early parenthood emerged from the qualitative studies: dislike of school; poor material circumstances and unhappy childhood; and low expectations for the future. Comparison of these factors related to teenage pregnancy with the content of the programmes used in the controlled trials indicated that both early childhood interventions and youth development programmes are appropriate strategies for reducing unintended teenage pregnancies. The programmes aim to promote engagement with school through learning support, ameliorate unhappy childhood through guidance and social support, and raise aspirations through career development and work experience. However, none of these approaches directly tackles all the societal, community, and family level factors that influence young people’s routes to early parenthood. Conclusions A small but reliable evidence base supports the effectiveness and appropriateness of early childhood interventions and youth development programmes for reducing unintended teenage pregnancy. Combining the findings from both controlled trials and qualitative studies provides a strong evidence base for informing effective public policy.

Peer-delivered health promotion for young people: A systematic review of different study designs

Objective To examine the effectiveness and appropriateness of peer- delivered health promotion for young people. Design Systematic review of experimental studies assessing impact on health outcomes and qualitative studies evaluating intervention processes. Methods Studies were sought by searching electronic databases and hand searching. Those which met the reviews inclusion criteria were assessed for methodological quality. Outcome evaluations were reviewed for four methodological qualities. Process evaluations were mapped according to criteria commonly used to establish the reliability and validity of qualitative studies. Results Four hundred and thirty reports relevant to the topic area were identified. Two hundred and ten reported evaluations of peer-delivered interventions with 64 (49 outcome evaluations and 15 process evaluations) meeting the inclusion criteria. Only 12 (24 per cent) of the outcome evaluations were judged methodologically sound. Of these, seven found the method to be effective for at least one behavioural outcome. However, five sound studies directly compared the effectiveness of peers to other providers and found contradictory results. The majority of process evaluations examined the implementation (n=9, 60 per cent) and acceptability of the method (n=10, 67 per cent) and their findings provided insights into possible reasons for success or failure. Common methodological problems within studies included unclear details of sample and methodology suggesting that their conclusions may not be reliable. Conclusion The evidence for the effectiveness of peer-delivered health promotion for young people is not yet clear. Whilst the current evidence- base is able to suggest possible reasons for success or failure of this method, more systematic research into the conditions under which peer- delivered health promotion is effective in comparison to other methods of health promotion is needed. Integrating the evidence from experi mental studies and qualitative studies is complicated by the lack of standards for assessing reliability and validity in qualitative research.

The school environment and student health: a systematic review and meta-ethnography of qualitative research

BackgroundThere is increasing interest in promoting young people’s health by modifying the school environment. However, existing research offers little guidance on how the school context enables or constrains students’ health behaviours, or how students’ backgrounds relate to these processes. For these reasons, this paper reports on a meta-ethnography of qualitative studies examining: through what processes does the school environment (social and physical) influence young people’s health?MethodsSystematic review of qualitative studies. Sixteen databases were searched, eliciting 62, 329 references which were screened, with included studies quality assessed, data extracted and synthesized using an adaptation of Noblit and Hare’s meta-ethnographic approach.ResultsNineteen qualitative studies were synthesised to explore processes through which school-level influences on young people’s health might occur. Four over-arching meta-themes emerged across studies focused on a range of different health issues. First, aggressive behaviour and substance use are often a strong source of status and bonding at schools where students feel educationally marginalised or unsafe. Second, health-risk behaviours are concentrated in unsupervised ‘hotspots’ at the school. Third, positive relationships with teachers appear to be critical in promoting student wellbeing and limiting risk behaviour; however, certain aspects of schools’ organisation and education policies constrain this, increasing the likelihood that students look for a sense of identity and social support via health-risk behaviours. Fourth, unhappiness at school can cause students to seek sources of ‘escape’, either by leaving school at lunchtime or for longer unauthorized spells or through substance use. These meta-themes resonate with Markham and Aveyard’s theory of human functioning and school organisation, and we draw on these qualitative data to refine and extend this theory, in particular conceptualising more fully the role of young people’s agency and student-led ‘systems’ in constituting school environments and generating health risks.ConclusionInstitutional features which may shape student health behaviours such as lack of safety, poor student-staff relationships and lack of student voice are amenable to interventions and should be the subject of future investigation. Future qualitative research should focus on health behaviours which are under-theorised in this context such as physical activity, sexual and mental health.

Theories of how the school environment impacts on student health: systematic review and synthesis

Public-health interventions informed by theory can be more effective but complex interventions often use insufficiently complex theories. We systematically reviewed theories of how school environments influence health. We included 37 reports drawing on 24 theories. Narrative synthesis summarised and categorised theories. We then produced an integrated theory of school environment influences on student health. This integrated theory could inform complex interventions such as health promoting schools programmes. Using systematic reviews to develop theories of change might be useful for other types of complex public-health interventions addressing risks at the individual and community levels.

School-based cognitive-behavioural interventions: A systematic review of effects and inequalities

Abstract Little is known about the impact of preventive interventions on inequalities in young people’s mental health. We conducted a systematic review of mental health promotion interventions based on cognitive behavioural therapy (CBT) delivered in schools to young people aged 11–19. Meta-analysis of 17 high quality randomised controlled trials (RCTs) showed a reduction in symptoms of depression, which was generally short term. Interventions for people with clinical risk factors or existing symptoms were more effective, with benefits lasting up to six months. We also found that CBT may be more effective for young people from families with middle to high socioeconomic status (SES) than for those from low SES backgrounds. However, this finding was based on a metaregression with only six studies. A lack of long-term follow-up data and a failure to report subgroup analyses prevented further conclusions being drawn about the effect of these types of interventions on mental health inequalities.

Behavioural interventions for the prevention of sexually transmitted infections in young people aged 13-19 years: a systematic review

We systematically reviewed school-based skills building behavioural interventions for the prevention of sexually transmitted infections. References were sought from 15 electronic resources, bibliographies of systematic reviews/included studies and experts. Two authors independently extracted data and quality-assessed studies. Fifteen randomized controlled trials (RCTs), conducted in the United States, Africa or Europe, met the inclusion criteria. They were heterogeneous in terms of intervention length, content, intensity and providers. Data from 12 RCTs passed quality assessment criteria and provided evidence of positive changes in non-behavioural outcomes (e.g. knowledge and self-efficacy). Intervention effects on behavioural outcomes, such as condom use, were generally limited and did not demonstrate a negative impact (e.g. earlier sexual initiation). Beneficial effect on at least one, but never all behavioural outcomes assessed was reported by about half the studies, but this was sometimes limited to a participant subgroup. Sexual health education for young people is important as it increases knowledge upon which to make decisions about sexual behaviour. However, a number of factors may limit intervention impact on behavioural outcomes. Further research could draw on one of the more effective studies reviewed and could explore the effectiveness of booster sessions as young people move from adolescence to young adulthood.

Predictors of the timing of initiation of antenatal care in an ethnically diverse urban cohort in the UK.

BackgroundIn the UK, women are recommended to engage with maternity services and establish a plan of care prior to the 12th completed week of pregnancy. The aim of this study was to identify predictors for late initiation of antenatal care within an ethnically diverse cohort in East London.MethodsCross-sectional analysis of routinely collected electronic patient record data from Newham University Hospital NHS Trust (NUHT). All women who attended their antenatal booking appointment within NUHT between 1st January 2008 and 24th January 2011 were included in this study. The main outcome measure was late antenatal booking, defined as attendance at the antenatal booking appointment after 12u2009weeks (+6u2009days) gestation. Data were analysed using multivariable logistic regression with robust standard errors.ResultsLate initiation of antenatal care was independently associated with non-British (White) ethnicity, inability to speak English, and non-UK maternal birthplace in the multivariable model. However, among those women who both spoke English and were born in the UK, the only ethnic group at increased risk of late booking were women who identified as African/Caribbean (aOR: 1.40: 95% CI: 1.11, 1.76) relative to British (White). Other predictors identified include maternal age younger than 20u2009years (aOR: 1.32; 95% CI: 1.13-1.54), high parity (aOR: 2.09; 95% CI: 1.77-2.46) and living in temporary accommodation (aOR: 1.71; 95% CI: 1.35-2.16).ConclusionsSocio-cultural factors in addition to poor English ability or assimilation may play an important role in determining early initiation of antenatal care. Future research should focus on effective interventions to encourage and enable these minority groups to engage with the maternity services.

The effects on student health of interventions modifying the school environment: systematic review

Background Owing to the limited effectiveness of traditional health education curricula in schools, there is increasing interest in interventions aiming to promote young peoples health by modifying the school environment. Existing systematic reviews cannot determine whether environmental intervention is effective because they examine interventions combining environmental modifications and traditional health education. This gap is significant because school-environment interventions are complex to implement and may be sidelined in underfunded and attainment-focused school systems without evidence to support such an approach. This systematic review examined the effectiveness of school-environment interventions without health-education components on student health and inequalities. Methods This was a systematic review of experimental/quasi-experimental studies of school-environment interventions. Sixteen databases were searched, eliciting 62u2005329 references which were screened, with included studies quality assessed, data extracted and narratively synthesised. Results Sixteen reports of 10 studies were included, all from the USA and the UK. Five evaluations of interventions aiming to develop a stronger sense of community and/or improve relationships between staff and students suggested potential benefits particularly regarding violence and aggression. Two trials of interventions enabling students to advocate for changes in school catering and physical activity reported benefits for physical activity but not diet. Three evaluations of improvements to school playgrounds offered weak evidence of effects on physical activity. Conclusions School environment interventions show the potential to improve young peoples health particularly regarding violence, aggression and physical activity. Further trials are required to provide a stronger and more generalisable evidence base.

Protocol for a systematic review of the effects of schools and school-environment interventions on health: evidence mapping and syntheses

BackgroundSchools may have important effects on students and staffs health. Rather than treating schools merely as sites for health education, school-environment interventions treat schools as settings which influence health. Evidence concerning the effects of such interventions has not been recently synthesised.Methods/designSystematic review aiming to map and synthesise evidence on what theories and conceptual frameworks are most commonly used to inform school-environment interventions or explain school-level influences on health; what effects school-environment interventions have on health/health inequalities; how feasible and acceptable are school-environment interventions; what effects other school-level factors have on health; and through what processes school-level influences affect health.We will examine interventions aiming to promote health by modifying schools physical, social or cultural environment via actions focused on school policies and practices relating to education, pastoral care and other aspects of schools beyond merely providing health education. Participants are staff and students age 4-18 years.We will review published research unrestricted by language, year or source. Searching will involve electronic databases including Embase, ERIC, PubMed, PsycInfo and Social Science Citation Index using natural-language phrases plus reference/citation checking.Stage 1 will map studies descriptively by focus and methods. Stage 2 will involve additional inclusion criteria, quality assessment and data extraction undertaken by two reviewers in parallel. Evidence will be synthesised narratively and statistically where appropriate (undertaking subgroup analyses and meta-regression and where no significant heterogeneity of effect sizes is found, pooling these to calculate a final effect size).DiscussionWe anticipate: finding a large number of studies missed by previous reviews; that non-intervention studies of school effects examine a greater breadth of determinants than are addressed by intervention studies; and that intervention effect estimates are greater than for school-based health curriculum interventions without school-environment components.

Discrepancies in findings from effectiveness reviews: the case of health promotion for older people in accident and injury prevention

The present study introduces some of the key methodological issues in conducting and using effectiveness reviews, taking reviews of accident and injury prevention in older people as an example. A comparative analysis of six effectiveness reviews was undertaken. These reviews all related to the impact of exercise on falls in older people but offered apparently conflicting conclusions. The reviews were compared in terms of their scope, search strategies, methodological quality criteria, methods for data extraction and synthesising findings and review conclusions. The reviews were found to differ in terms of: whether they addressed a narrow or broad scope; the number of studies they included; and the quality criteria used to assess the included studies such that the same studies were treated differently in different reviews. Although the implications for research and practice from the reviews were found to conflict across different reviews, the authors of the reviews exercised caution when drawing final conclusions which served to minimise these conflicts. These results are discussed in terms of the implications for effectiveness reviews and their methodology within health promotion.