Decline in Adolescent Pregnancy in the United States: A Success Not Shared by All

Although the steady decreases in adolescent pregnancy that the United States has been experiencing are noteworthy and warrant celebration, not all adolescents have shared equally in this success. Hispanic, African American, and American Indian/Alaska Native adolescents, for example, still have the highest adolescent birth rates in the country.¹ Rates for other vulnerable groups, such as runaway and homeless adolescents, adolescents in foster care, and adolescents living in rural areas, are higher than those of the general adolescent population. Furthermore, we know that risky sexual behaviors leading to increased risks of pregnancy and sexually transmitted infections are also often correlated with increased risks for other unhealthy activities. This is consistent with Jessor’s problem behavior theory,² which suggests that an adolescent with one risk factor, such as tobacco use, is likely to be at higher risk for other factors, such as using alcohol and other drugs and engaging in risky sex and violent acts. Consequently, these multiple risk factors may intertwine to produce serious, long-term, adverse life consequences for the affected adolescents.

REACHING VULNERABLE ADOLESCENTS

A first step toward reducing disparities stemming from these sexual and other risks is to assess the strategies we use and the barriers we face in effectively reaching these vulnerable adolescents. For a risk reduction strategy to be effective, at a minimum, adolescents must be exposed to the intervention, receptive to the messages being delivered, and view the messages as personally relevant and meaningful. Popular strategies that work well for the general adolescent population may fall short of meeting these criteria for vulnerable, higher-risk populations.

Schools are a common setting for adolescent pregnancy prevention interventions. School-based programs provide an efficient way to reach large numbers of adolescents, but they may be less effective for gaining access to some groups of adolescents who are at higher risk, as Campa et al. discuss in this issue (p. S32). Research suggests that adolescents engaging in risky sexual behaviors are more likely to have experienced trauma than peers who are not sexually active.³ For adolescents who have been victims of trauma, reproductive health messages could be trauma triggers—particularly in school-based settings, if the school has not successfully incorporated trauma-informed approaches for reproductive health interventions. The resulting stress and anxiety could impede the trauma-affected adolescent’s ability to process sexual risk reduction messages.³

CULTURAL RELEVANCE ALIGNMENT

From the perspective of “hearing the intervention’s message,” adolescents are less responsive to interventions that lack cultural relevance and fail to align with their worldview. In this issue, Mongro-Wilson and Fifield (p. S15) support the common-sense assumption that interventions effective for one group may not be equally appropriate or effective for another group. For example, Bowes et al. (p. S32) suggest that in tribal communities it is critical to adapt and implement interventions that incorporate the broader community and cultural context. Intervention messages also need to be appropriately vetted and tested to ensure they are not perceived as reinforcing stereotypes or being otherwise offensive.

PRECISION-FOCUSED INTERVENTIONS

These potential gaps, among others, highlight the need for more precision-focused interventions that incorporate strategies specifically designed to reach and engage underserved, vulnerable adolescents. Implementing a precision-focused intervention approach will require reaching adolescents in less traditional settings, such as shelters for homeless adolescents, adolescent incarceration facilities, and community-based settings in which the priority populations live and interact. Adaptations for other settings, such as using more inclusive and trauma-informed approaches in school-based settings, could make interventions more responsive to adolescents’ needs and preferences. Also, messages need to be tailored to and tested with the various priority groups that will be served.

A major challenge to using a precision-focused approach is the additional testing required. Evidence-based curricula and approaches are commonly evaluated with a general population and within a specific setting that can more readily provide the sample sizes and associated statistical power needed to detect whether an intervention is effective. Modifications to the content, target populations, or settings for these interventions may affect the overall efficacy for these evidence-based approaches—that is, at some point the intervention may become sufficiently different from the tested model that it can no longer be considered evidence based. Thus, additional research would be needed to test modified, precision-focused interventions for vulnerable adolescents—and that research is difficult and expensive. Methodological challenges such as small sample sizes for the priority groups, lack of ready comparison groups in the settings in which the interventions are being implemented, and a high number of iterations required to provide precision-focused approaches across populations and settings are some of the common challenges.

LEARNING FROM GOOD SCIENCE

Despite these challenges, precision-focused approaches need to be rigorously evaluated. Both policymakers and researchers will benefit from recognizing and finding solutions to the challenges of achieving high levels of methodological rigor. It should be noted, though, that even a precision-focused intervention might sometimes fall short of reaching and serving groups at high risk. Nonetheless, the knowledge gained through the process makes for good science and helps to inform best practices.

A second step toward closing the gaps in risky sexual behaviors and pregnancy rates for higher-risk groups is to draw upon strategies designed to address multiple risk factors simultaneously. For example, interventions designed to help parents and other caregivers better monitor their adolescents’ behavior can produce benefits for a variety of adolescent risk behaviors, including tobacco and alcohol use, risky sexual behaviors, violent behaviors, and unsafe driving.⁴ Similarly, approaches that focus on broad holistic and health-promoting strategies designed to build adolescents’ self-confidence, provide adulthood preparation opportunities, increase educational and skills development opportunities, and improve physical and emotional health and well-being may also help adolescents avoid sexual and other types of risk behaviors.

Ultimately, the longer-term fix for closing the disparity gaps and improving the health of adolescents at greatest risk for health disparities may be a combination of precision-focused interventions and strategies that address multiple risk factors. Rigorous evaluation will be needed to provide evidence on the effectiveness for different strategies. This combined approach offers promise for reducing sexual and other correlated risks while promoting a broader approach to optimal health for traditionally underserved adolescents at high risk. We hope the research, experiences, and lessons learned included in this supplement will be useful for advancing the knowledge base, improving strategies, and identifying next steps for narrowing the disparities gap for vulnerable, higher-risk adolescents.