Norman A. Constantine

Use of physical and neurologic observations in assessment of gestational age in low birth weight infants

The relative validities of three clinical assessment methods for estimating gestational age in newborn low birth weight infants were evaluated with reference to estimates based on the date of the mothers last menstrual period. For 1246 infants in eight diverse institutions, estimates based on physical criteria correlated more strongly with dates estimates, yielded estimates more similar on average to dates estimates, and yielded higher proportions of correct classifications of prematurity and small for gestational age than did estimates based on neurologic criteria or neurologic and physical criteria combined. These results support the use of physical criteria rather than neurologic or combined criteria for the clinical assessment of gestational age in low birth weight infants. In a subsample of 511 black and white infants, there were no ethnic differences in mean error of estimate for any of the three methods.

Recruitment and retention in a clinical trial for low birth weight, premature infants

We report on recruiting and retaining a sample of low birth weight, premature infants for a clinical trial as well as results of tests evaluating sampling and retention biases. A total of 4551 infants were screened, and 1302 were found eligible. Consent was obtained for 1028 infants. After randomization and the presentation of group assignment, the number of infants enrolled was 985 (75.7% of those eligible). Of these, 92.7% completed the 3-year study. Tests to evaluate recruitment bias revealed significant relationships between nonenrollment and site, maternal race, and infant birth weight. Tests to evaluate retention bias revealed a significant relationship between dropout and maternal education. Additionally, infant birth weight and maternal age interacted with treatment in predicting dropout. Despite these statistically significant recruitment and retention biases, there was no evidence of problems with sample representativeness to the population of interest or of treatment group differences on study-relevant background variables. J Dev Behav Pediatr 14:1–7, 1993. Index terms: bias, infant, recruitment, retention, sample.

Implementing early intervention : from research to effective practice

Preface Evolution of the Early Intervention Philosophy, Richmond, Ayoub. Conceptualizing Eligibility for Early Intervention Services, Benn. Enhancing Screening Procedures for Infants and Toddlers: The Application of Knowledge to Public Policy and Program Initiatives, Kochanek. Definitional Issues: Prevalence, Participation, and Service Utilization, Foster, Foster. Creating Family-Centered Programs and Policies, Duwa, Wells, Lalinde. Traditions in Family Assessment: Toward and Inquiry-Oriented, Reflective Model, Bailey, Henderson. Sensible Strategies for Assessment in Early Intervention, Bagnato, Neisworth. Instruments for the Screening, Evaluation, and Assessment of Infants and Toddlers, Taylor. Models of Service Delivery, Bryant, Graham. Strategies for Creating Incisive Early Childhood Settings, Hanline, Galant. Characteristics of Quality-Effective Service Delivery Systems for Children with Special Needs, Graham, Bryant. Contemporary Therapies for Infants and Toddlers: Preferred Approaches, Vergara, Adams, Masin, Beckman. Predicting the Costs of Early Intervention, Hall, Stone, Walsh, Wager. Systems of Financing Early Intervention, Clifford, Bernier. Policy Designed for Diversity: New Initiatives for Children with Disabilities, Gallagher. Index.

Converging Evidence Leaves Policy Behind: Sex Education in the United States

A c fi v r e o e s a p c n d s ( T o d s s d o t w e s School-based sex education has the potential to prevent exually transmitted infections and unwanted pregnancies nd to promote healthy sexuality. Yet local, state, and naional sex education policies in the United States comprise bewildering patchwork of mandates, funding restrictions, missions, and compromises, often at odds from one level o the next. As a result, the sex education received by most tudents is fragmented, incomplete, and frequently based on neffective approaches and curricula [1–3]—an unacceptble state of affairs in a time of increasing teen birth rates nd epidemics of sexually transmitted infections among merican youth [4,5]. Much of this policy chaos arises out of politically fueled nd morally motivated debates over the appropriateness of omprehensive sex education (CSE) versus abstinence-only AO) education [6–8]. Although often rancorous and emoionally charged, these debates typically invoke researchased evidence [9]. Three domains of evidence are most elevant—evidence on effectiveness of AO programs, evience on effectiveness of CSE programs, and evidence of arental (and public) support for one type of program versus he other. At this point in time, rigorous and compelling vidence has been amassed in two of these three domains— O programs are not effective, and parents do overwhelmngly support CSE. For the third question—the effectiveess of CSE—the evidence is building. Two articles in this month’s issue add to the growing onvergence of evidence in each of these three areas. Kohler nd colleagues [10] present persuasive new findings on the ffectiveness of CSE compared with AO or no sex educaion, and the article by Dr. Eisenberg and colleagues [11] resents results of a statewide survey of Minnesota parents hat add to the generalizabilty of previous state and national urveys demonstrating ubiquitous public and parent support or CSE. Kohler and colleagues employed data from the 2002 ational Survey of Family Growth (NSFG) to evaluate the ffectiveness of both types of sex education programs at the

Promoting Prenatal and Early Childhood Health: Evaluation of a Statewide Materials-Based Intervention for Parents

OBJECTIVES There is a critical need for effective, large-scale health communication programs to support parents of children aged 0-5 years. We evaluated the effectiveness of the Kit for New Parents, a multimedia health and parenting resource now distributed annually to 500000 parents in California. METHODS In this quasi-experimental study, 462 mothers in the intervention group and 1011 mothers in the comparison group, recruited from prenatal and postnatal programs, completed a baseline interview about health-relevant parenting knowledge, and mothers in the intervention group received the kit. Both groups were reinterviewed 2 months later. At 14-months postbaseline, 350 mothers in the intervention group and a sample of 414 mothers who had equivalent demographic characteristics (comparison group) were interviewed about parenting knowledge and practices. RESULTS Of the mothers in the intervention group, 87% reported using the kit within 2 months after receiving it, and 53% had shared it with their partner. At both follow-ups, mothers in the intervention group showed greater gains in knowledge and reported better practices at 14 months than did mothers in the comparison group. Gains were greater for prenatal recipients and for Spanish speakers. Providers considered the kit a valuable resource for their parenting programs. CONCLUSIONS The kit is an effective, low-cost, statewide health intervention for parents.

Parent–Adolescent Sexual Communication and Its Association With Adolescent Sexual Behaviors: A Nationally Representative Analysis in the Netherlands

Sexual communication is a principal means of transmitting sexual values, beliefs, expectations, and knowledge from parents to children. Although this area has received considerable research attention, more studies with representative samples are needed to assure that findings are reflective of populations of interest. A nationally representative sample of parent–adolescent dyads (N = 2,965; mean adolescent age = 13.8 years) in the Netherlands was employed to examine the frequency of parent–adolescent sexual communication and its association with adolescent sexual behaviors (defined as sexual initiation, condom use, and contraceptive pill use). Nine communication topics in the areas of anatomy, relationships and rights, and protection and contraception were examined. In all, 75%of parents reported having discussed at least one topic multiple times with their adolescents. Romantic relationships were discussed most frequently. Hierarchical logistic regression analyses indicated that parent–adolescent sexual communication on protection and contraception was positively associated with adolescent sexual initiation and contraceptive pill use but not condom use. This may reflect that adolescents, when they become sexually active, are more likely to discuss sexuality with their parents. Findings are interpreted within the context of Dutch culture, which is generally accepting of adolescent sexuality and characterized by open sexual communication.

Sexuality Education Websites for Adolescents: A Framework-Based Content Analysis

The web has unique potential for adolescents seeking comprehensive sexual health information. As such, it is important to understand the nature, scope, and readability of the content and messaging provided by sexuality educational websites. We conducted a content analysis of 14 sexuality education websites for adolescents, based on the 7 essential components (sexual and reproductive health and HIV, relationships, sexual rights and sexual citizenship, pleasure, violence, diversity, and gender) of the International Planned Parenthood Framework for Comprehensive Sexuality Education. A majority of content across all sites focused on sexual and reproductive health and HIV, particularly pregnancy and STI prevention, and other information about STIs and HIV. No other topic comprised more than 10% of content coverage across a majority of sites. The authors found little discussion of gender issues, sexual rights, sexual diversity, or sexual violence. Most sites provided brief references to sexual pleasure, generally moderated with cautionary words. Language used implied a heterosexual female audience. Reading levels for most sites were above the 9th-grade level, with several at the college level. These findings have implications for enhancing online sexuality education and broadening the coverage of essential topics.

Short-term effects of a rights-based sexuality education curriculum for high-school students: a cluster-randomized trial

BackgroundAn emerging model for sexuality education is the rights-based approach, which unifies discussions of sexuality, gender norms, and sexual rights to promote the healthy sexual development of adolescents. A rigorous evaluation of a rights-based intervention for a broad population of adolescents in the U.S. has not previously been published. This paper evaluates the immediate effects of the Sexuality Education Initiative (SEI) on hypothesized psychosocial determinants of sexual behavior.MethodsA cluster-randomized trial was conducted with ninth-grade students at 10 high schools in Los Angeles. Classrooms at each school were randomized to receive either a rights-based curriculum or basic sex education (control) curriculum. Surveys were completed by 1,750 students (N = 934 intervention, N = 816 control) at pretest and immediate posttest. Multilevel regression models examined the short-term effects of the intervention on nine psychosocial outcomes, which were hypothesized to be mediators of students’ sexual behaviors.ResultsCompared with students who received the control curriculum, students receiving the rights-based curriculum demonstrated significantly greater knowledge about sexual health and sexual health services, more positive attitudes about sexual relationship rights, greater communication about sex and relationships with parents, and greater self-efficacy to manage risky situations at immediate posttest. There were no significant differences between the two groups for two outcomes, communication with sexual partners and intentions to use condoms.ConclusionsParticipation in the rights-based classroom curriculum resulted in positive, statistically significant effects on seven of nine psychosocial outcomes, relative to a basic sex education curriculum. Longer-term effects on students’ sexual behaviors will be tested in subsequent analyses.Trial registrationClinicalTrials.gov NCT02009046.

Intervention Effectiveness Research in Adolescent Health Psychology: Methodological Issues and Strategies

Interventions to promote adolescent health have been widely implemented with a variety of goals, settings, populations, and approaches. Research evidence regarding effectiveness has been accumulating for some intervention approaches, yet the validity and integrity of this evidence and the way in which it is used require careful scrutiny. This chapter examines the scientific foundations for intervention effectiveness research and its use. The fundamental strategy of identifying and addressing plausible alternative explanations for research findings is emphasized, together with the importance of qualitative reasoning and well-justified argument. The essential roles of theory and demonstrated mechanisms of change, converging evidence, and research critique are discussed. Common threats to validity are reviewed, as are threats to research integrity potentially fueled by largely unintentional conflicts of interest and motivated reasoning. A case example critiquing research syntheses on the effectiveness of interventions to reduce adolescent sexual risk behaviors is used to illustrate frequently encountered issues and challenges.

Regression Analysis and Causal Inference: Cause for Concern?

Norman A. Constantine is senior scientist and director, Center for Research on Adolescent Health and Development, Public Health Institute, Oakland, CA, and clinical professor of community health and human development, School of Public Health, University of California, Berkeley. Regular readers of Perspectives on Sexual and Reproductive Health may have noticed a preference among published authors for regression analysis as their primary methodology. In fact, last year, a substantial majority of this journal’s articles employed some form of regression analysis, predominantly logistic regression. Such methodological dominance—which is by no means unique to this journal—supports the need for a critical review of the common uses and misuses of these types of analyses, and a careful examination of the validity threats and issues associated with the claims, conclusions and recommendations that typically result. When used appropriately, regression analysis can be a powerful tool: It allows one to statistically model the relationship between a dependent (outcome) variable and a set of independent (predictor) variables. Linear regression is used with continuous dependent variables, such as number of sex partners or infant birth weight, while logistic regression is used with dichotomous dependent variables, such as a history of pregnancy or STD infection. Both forms of regression allow for the assessment of whether an independent variable (such as age, attitudes, protective behaviors or services received) is associated with an outcome variable while controlling for (statistically removing) the outcome’s overlapping associations with other variables. These types of analyses are generally applied to correlational data, such as survey, census or administrative data, in so-called observational studies. Of course, regression analysis is not needed in every study employing quantitative data. For example, results of abortion surveillance over time and across locations can be usefully presented employing just percentage or rate distributions. The potential power and added complexity of regression analysis are best reserved for either predicting outcomes or explaining relationships. The prediction of outcomes on the basis of current characteristics is possible without regard to the causal relationships among variables. For instance, regression analyses have shown that Asian and college-educated parents are the least likely among all social and demographic subgroups to support human papillomavirus vaccination for their daughters; these fi ndings can be used to identify the need for educational campaigns for these two subgroups even without understanding why they are the least supportive of vaccination. However, to develop effective educational campaigns, it is also necessary to understand the factors that infl uence parents’ support for having their daughters vaccinated. When the goal is to understand (i.e., explain) the causal infl uences on a population outcome—a prerequisite for the design and development of any sexual health intervention—regression analysis can be a powerful tool, but it has some fundamental limitations. Its appropriate use requires substantial care and skill, as well as suffi cient inferential humility.