Impact of Two Adolescent Pregnancy Prevention Interventions on Risky Sexual Behavior Interview with:

Anita P. Barbee, MSSW, Ph.D. Professor and Distinguished University Scholar President-Elect, International Association for Relationship Research Kent School of Social Work University of Louisville Louisville, KY 40292

Dr. Anita P. Barbee

Anita P. Barbee, MSSW, Ph.D.
Professor and Distinguished University Scholar
President-Elect, International Association for Relationship Research
Kent School of Social Work
University of Louisville
Louisville, KY 40292 What is the background for this study?

Response: In 2010, our team at the University of Louisville with colleagues from Spalding University, were awarded a Tier 2 grant from the Office of Adolescent Health to study innovative teen pregnancy prevention interventions. We assembled a fantastic team of staff, students, community members and twenty three community based organizations to work together collaboratively to recruit and retain close to 1450 youth from the most distressed areas of our metropolitan area in order to conduct a randomized controlled trial.

We tested the efficacy of two interventions compared to a control condition. Our reason for this was to see how a new type of teen pregnancy intervention would perform compared to a more typical comprehensive sex education program, Reducing the Risk, which was already on the OAH list of evidence based interventions as well as to a control condition, which focused on community building but had no content on personal self esteem building, healthy relationships, dating violence or sexuality. The new program that was tested was Love Notes. Love Notes is a healthy relationship curriculum that addresses the context of sexual exploration as well as key points in preventing problematic outcomes of sexual activity such as the spread of disease, pregnancy and emotional heartache. The groups of youth that continue to have high rates of pregnancy tend to be disconnected from society through poverty and discrimination (minority and poor youth) or from family as a result of leaving home countries (refugees and immigrants), being removed from their homes due to child abuse or neglect (foster youth) or being rejected from families due to their LGBTQ orientations.

Love Notes seeks to empower youth to envision their futures- both in terms of future work and relationships. As youth set a vision for their lives, they are given research based information on the role of family and other relationship history on decision making, how to frame past experiences in terms of what to carry forward and what to leave behind in their relationships with others, how to choose romantic partners who are a good match and who will treat the youth with respect and the role of the success sequence on the chance of completing education and training to enhance self sufficiency. This theme of partner selection is carried through the curriculum with a heavy emphasis on detection of controlling and potentially abusive, coercive and violent partners through examination of red flags and warning signs. Youth are taught about setting expectations and respect in relationships and how to guard their hearts as well as their bodies from violence or unwanted sexual advances.

On the bright side, youth are also taught how to form and maintain healthy relationships and given information about love and various types of ways to get close to others. There is content on building communication skills and conflict resolution skills as well as how to extract oneself safely from a controlling or violent relationship. As youth are given these tools of setting goals and negotiating their relationships, they are given information about how love and attraction affect the brain chemicals (neurotransmitters and hormones), judgment and decision making and how alcohol and drugs further complicate those higher order functions. Youth are shown a video about reproductive anatomy, given medically accurate information about sexually transmitted infections, including HIV/AIDS, the risk of pregnancy, and other facts about sexual behaviors and their impact. Youth learn about the facts about condoms and other forms of birth control but are also given the facts about abstinence and how to manage sexual situations if they choose abstinence. Youth also have the opportunity to think about boundary setting with regards to their bodies and sexuality and the risks of sliding into sexual relationships. The curriculum is highly interactive, utilizing polling, games, art, music videos, films by youth for youth, role playing exercises, discussion and reflection in a journal as they move through each of the 13 modules. Youth are encouraged to find a trusted adult connection and are given questions to ask them about the content of the curriculum in-between sessions. Finally, youth are given space to think about future children they may have and the impact of partner choice and unwanted or unplanned pregnancy through the eyes of a child.

We thought that youth who are disconnected are often seeking connection through sexual expression in hopes of closeness with a romantic partner and possibly through formation of their own family. In Kentucky, a third of youth report wanting to have a baby as a teen. Thus, we hypothesized that youth would benefit from a healthy relationship based curriculum that contextualized sexuality in the ways described above. What are the main findings?

Response: We found that Reducing the Risk, with the addition of some adaptations (6 videos that explore in more depth anatomy, abstinence, STIs, birth control and sexual decision making and revision of some exercises) continues to be an effective curriculum in reducing risky sexual behaviors of sexual initiation, and enhancing the use of condoms and birth control. The program was moved to a stronger position on the list of evidence based programs by OAH. We also found that Love Notes reduced risky sexual behaviors of sexual initiation, enhanced the use of condoms and birth control in those who were sexually active and reduced the number of sexual partners up to 6 months post intervention. In addition, across the first year after the intervention, youth in Love Notes were 46% less likely to become pregnant or impregnate a partner than those in the control condition. There was no difference between Reducing the Risk and the control condition on pregnancy. What should readers take away from your report?

Response: Like all human beings, youth desire connection and meaning in their lives. There are strong messages in the media and among their peers to explore their sexuality early and often. But, most sex education programs do not go into depth about partner selection, love, signs of trouble or abuse, and how to navigate the emotions that accompany sex. Youth want to understand how to form relationships that will be healthy and affirming and respectful, as well as fun and romantic. Programs like Love Notes give youth tools and information to make well informed decisions about who they want to spend their time with, how to detect and escape from people who are controlling and violent, and how to engage in sexual relationships in a way that avoids negative physical and emotional outcomes. Previous research found that Love Notes reduces verbal aggression and changes attitudes about dating violence. The most recent RCT demonstrates that Love Notes also reduces risky sexual behavior and pregnancy.

Love Notes tackles multiple issues facing youth- teen pregnancy, dating violence, and sexual assault. In times when resources for prevention are shrinking, programs that address multiple areas that could impact youth development negatively are more efficient both financially and in terms of time. What recommendations do you have for future research as a result of this study?

Response: We will continue to analyze this data set to examine the impact of the two interventions on other outcomes such as attitudes, transmission of STIs, and dating violence.

Future research needs to continue to test the efficacy of the Love Notes intervention in different settings and across different spans of time. We covered the curricula in this study across two consecutive Saturdays. We believe the outcomes would have lasted even longer if the coverage of the material was spread out across a longer period of time. But, this is an empirical question.

We also believe that if some modules were expanded, the program could also potentially reduce drug and alcohol use, depression and suicide and vulnerability to sex trafficking. Again, there is a need for robust programming to help youth navigate all of the landmines of growing up. Since Love Notes already addresses several issues, it could form a base for more problem management.

Reducing the Risk has been rigorously evaluated several times now. While the program is very effective in helping youth delay the onset of sexual behavior and in reducing risky sexual behaviors regarding use of condoms and birth control, it has not shown an impact on pregnancy itself. The question is why not? A qualitative study asking youth what they took away from Reducing the Risk is in order to see what information could be added to make the curriculum even more effective. Similarly, asking youth who participate in Love Notes what they took away may also give insights into the active ingredients that made it successful in preventing pregnancy. Is there anything else you would like to add?

Response: Ten current OAH grantee sites are currently utilizing Love Notes in their jurisdictions as they scale up teen pregnancy prevention interventions. We eagerly await the results of this next round of work.

We are grateful to OAH for their support of this important work. Over 500,000 youth were served and thousands of facilitators were given training in dozens of TPP programs in the first half of the decade. Teen pregnancy and birth rates continue to drop and hopefully innovations like the ones we tested will help to move the needle on this important issue even further. Thank you for your contribution to the community.


Am J Public Health. 2016 September; 106(Suppl 1): S85–S90.
Published online 2016 September. doi: 10.2105/AJPH.2016.303429
PMCID: PMC5049476
Impact of Two Adolescent Pregnancy Prevention Interventions on Risky Sexual Behavior: A Three-Arm Cluster Randomized Control Trial
Anita P. Barbee, MSSW, PhD, Michael R. Cunningham, PhD, Michiel A. van Zyl, PhD, Becky F. Antle, MSSW, PhD, and Cheri N. Langley, PhD, MPH

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on October 14, 2016 by Marie Benz MD FAAD