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This article has been cited by other articles in PMC. Abstract Background Peer-led sex education is widely believed to be an effective approach to reducing unsafe sex among young people, but reliable evidence from long-term studies is lacking. To assess the effectiveness of one form of school-based peer-led sex education in reducing unintended teenage pregnancy, we did a cluster school randomised trial with 7 y of follow-up. Methods and Findings Twenty-seven representative schools in England, with over 9, pupils aged 13—14 y at baseline, took part in the trial.
Schools were randomised to either peer-led sex education intervention or to continue their usual teacher-led sex education control. Peer educators, aged 16—17 y, were trained to deliver three 1-h classroom sessions of sex education to to y-old pupils from the same schools. The sessions used participatory learning methods designed to improve the younger pupils' skills in sexual communication and condom use and their knowledge about pregnancy, sexually transmitted infections STIs , contraception, and local sexual health services.
Main outcome measures were abortion and live births by age 20 y, determined by anonymised linkage of girls to routine statutory data. Assessment of these outcomes was blind to sex education allocation. The proportion of girls who had one or more abortions before age 20 y was the same in each arm intervention, 5. The odds ratio OR adjusted for randomisation strata was 1. The proportion of girls with one or more live births by Fewer girls in the peer-led arm self-reported a pregnancy by age 18 y 7.
There were no significant differences for girls or boys in self-reported unprotected first sex, regretted or pressured sex, quality of current sexual relationship, diagnosed sexually transmitted diseases, or ability to identify local sexual health services. Conclusion Compared with conventional school sex education at age 13—14 y, this form of peer-led sex education was not associated with change in teenage abortions, but may have led to fewer teenage births and was popular with pupils.
It merits consideration within broader teenage pregnancy prevention strategies. Teenage pregnancies are fraught with problems. Children born to teenage mothers are often underweight, which can affect their long-term health; young mothers have a high risk of poor mental health after the birth; and teenage parents and their children are at increased risk of living in poverty. Little wonder, then, that faced with one of the highest teenage pregnancy rates in Western Europe, the Department of Health in England launched a national Teenage Pregnancy Strategy in to reduce teenage pregnancies.
The main goal of the strategy is to halve the under pregnancy rate—there were Approaches recommended in the strategy to achieve this goal include the provision of effective sexual health advice services for young people, active engagement of health, social, youth support, and other services in the reduction of teenage pregnancies, and the improvement of sex and relationships education SRE.
Why Was This Study Done? Although the annual under pregnancy rate in England is falling, it is still very high, and it is extremely unlikely that the main goal of the Teenage Pregnancy Strategy will be achieved.
Experts are, therefore, looking for better ways to reduce both teenage pregnancy rates and the high rates of sexual transmitted diseases among teenagers.
Many believe that peer-led SRE—the teaching sharing of sexual health information, values, and behaviours by people of a similar age or status group—might be a good approach to try.
Peers, they suggest, might convey information about sexual health and relationships better than teachers. However, little is known about the long-term effectiveness of peer-led SRE. In this randomized cluster trial, the researchers compare the effects of a peer-led SRE program and teacher-led sex education given to to y-old pupils on abortion and live birth numbers among young women up to age 20 y. What Did the Researchers Do and Find? Each school was randomly assigned to peer-led SRE the intervention arm or to existing teacher-led SRE the control arm.
For peer-led SRE, trained to y-old peer educators gave three 1-h SRE sessions to the younger pupils in their schools. These sessions included practice with condoms, role play to improve sexual negotiating skills, and exercises to improve knowledge about sexual health. The researchers then used routine data on abortions and live births to find out how many female study participants had had an unintended pregnancy before the age of 20 y.
One in 20 girls in both study arms had had one or more abortions. Slightly more girls in the control arm than in the intervention arm had had live births, but the difference was small and might have occurred by chance. However, significantly more girls in the intervention arm There were no differences between the two arms for girls or boys in any other aspect of sexual health, including sexually transmitted diseases.
What Do These Findings Mean? These findings indicate that the peer-led SRE program used in this trial had no effect on the number of teenage abortions but may have led to slightly fewer live births among the young women in the study. This particular peer-led SRE program was very short so a more extended program might have had a more marked effect on teenage pregnancy rates; this possibility needs to be tested, particularly since the pupils preferred peer-led SRE to teacher-led SRE.
Even though peer-led SRE requires more resources than teacher-led SRE, this form of SRE should probably still be considered as part of a broad teenage prevention strategy, suggest the researchers. Please access these Web sites via the online version of this summary at http: This study is further discussed in a PLoS Medicine Perspective by David Ross Directgov, an official government Web site for UK citizens, provides advice for parents on talking to children about sex and teenage pregnancy and advice for young people on sexual health and preventing pregnancy Teachernet, a UK source of online publications for schools, also provides information for parents about sex and relationships education and the UK government's current guidance on SRE in schools Avert, an international AIDS charity, also provides a fact sheet on sex education The Sex Education Forum in the UK is the national authority on Sex and Relationships Education Introduction The sexual health of young people in the United Kingdom has been declared a crisis [ 1 ].
UK teenage pregnancy rates remain the highest in Western Europe and sexually transmitted infections STIs continue to rise [ 2 ].
In , the Department of Health in England launched a national strategy to halve teenage under 18 y pregnancy rates by [ 3 ]. Improving sex and relationships education SRE at school is a key theme of the strategy, and peer-led SRE has been highlighted as a promising approach [ 4 ]. The egalitarian interaction between young people may allow more open and culturally relevant communication about sexual health issues, with peers conveying information in a more credible and appealing way than teachers.
Several theories are used to support this view, based on the importance of social networks and the values and beliefs of peers in influencing people's behaviour [ 6 ]. However, systematic reviews have shown a lack of reliable evidence for the benefits of peer interventions [ 7 , 8 ]. A meta-analysis of randomised trials of a range of school, clinic, and community-based interventions to reduce teenage pregnancy concluded that such interventions do not delay sex, improve contraceptive use, or reduce pregnancy [ 9 ].
But none of the school-based trials involved long-term follow-up, and all relied on self-report measures. The programme had been used sporadically in schools in England before the trial; it was designed along pragmatic rather than explicitly theoretical lines, with emphasis on generalisability.
Planned interim analyses showed that peer-led SRE was more popular than teacher-led SRE and associated with significantly fewer girls reporting sexual intercourse by age 16 y [ 10 ]. Here we present the final follow-up to age 20 y, with anonymised linkage of all girls in the trial to routine statutory reports of abortions and live births, to assess the effectiveness of peer-led SRE in reducing unintended teenage pregnancy.
Methods Design and Purpose of Trial Schools were randomised to peer-led SRE intervention or to continue their usual teacher-led SRE control when pupils were aged 13—14 y in and , with follow-up to age 20 y.
The trial was designed to compare the effectiveness of the two approaches to reducing abortion, unprotected sexual intercourse, and improving the quality of sexual relationships. The trial design Text S1 and S2 is described in detail elsewhere [ 11 ]. Participating Schools and Pupils Eligible schools in central and southern England were comprehensive, from rural and urban areas, with intake of girls and boys to age 18 y.
All pupils in Year 9 8th grade, aged 13—14 y were eligible to take part unless their parents opted to withdraw them, following written information to parents [ 11 ]. The pupils were given oral and written information about the study and the voluntary nature of participation was stressed when they were invited to complete questionnaires. In intervention schools, all pupils in Year 12 11th grade, aged 16—17 y were eligible to be peer educators; those wishing to participate did not have to meet any selection criteria.
Peer educators gave signed consent to participate. The trial was approved by the committee on the ethics of human research at University College London. Intervention and Implementation The intervention was designed by an external team of health promotion practitioners with experience in delivering peer-led sexual health programmes in schools.
It was based on a programme that had been used in a variety of schools in England, and was not designed around any particularly theoretical framework. It was piloted to ensure that it could be implemented in a standardised way across different types of schools [ 12 ]. The peer educators were trained to prepare classroom sessions aimed at improving the younger pupils' skills in sexual communication and condom use, and their knowledge about pregnancy, STIs, contraception, and local sexual health services.
They delivered three 1 h sessions of SRE to Year 9 pupils, using participatory learning methods and activities focusing on relationships, STIs, and contraception Box 1. Teachers were not present in the classroom. Outcomes The primary outcome, chosen as a clear indicator of an unintended pregnancy, was abortion before age 20 from routine statutory data collected until 31 December Since the abortion rate by itself cannot reflect all unintended pregnancies, we also obtained routine data on live births collected until 10 June and age Following list-cleaning of the trial register through the National Health Service NHS central register, girls were matched to routine data on live births from two sources: We sent the trial register to the Office for National Statistics for matching to birth registrations, and to Northgate Information Solutions for matching to maternity registrations.
Girls were matched to routine data derived from statutory abortion notification forms using date of birth and postcode, with confirmation of matches using name held on paper records only. We sent the trial register to the Department of Health for abortion matching. For both live births and abortions, matching was done by staff who were blind to allocation, and individually matched data were aggregated and returned to us as a simple count per school, so that no participant with an abortion or live birth could be identified.
Further secondary outcomes based on questionnaire data included self-reported pregnancy and unintended pregnancy; sexual intercourse and use of contraception at first and last sex ; regretted or pressured sex at first and last sex , quality of relationship with current partner enjoyment of time together and ease of communication ; self-reported STD diagnosed by a doctor or nurse and attendance at a clinic for advice about sex, knowledge of the emergency contraceptive pill, and ability to identify local sexual health services.
Data Collection Questionnaires were completed in the classroom at baseline and at approximately 6 and 18 mo after intervention. The third follow-up questionnaire was completed in the classroom by participants still attending school at approximately 54 mo after baseline; participants who had left school were provided with questionnaires by post, by home visit from an interviewer, or failing that, via their general practitioner GP.
The mean standard deviation age of students at third questionnaire follow-up was Process data were gathered from the questionnaires and from extensive observation of peer educator training, sessions of peer-led and teacher-led SRE, focus groups with pupils, and interviews with key staff [ 13 , 14 ]. Taking the cluster design into account, and assuming the coefficient of variation for the primary outcome to be 0.
To achieve at least girls aged 13—14 y per school, we recruited two successive cohorts of Year 9 pupils in autumn and autumn respectively. Randomisation Before randomisation, schools were divided into high-, medium-, and low-risk strata according to seven risk variables [ 11 ]: From this information, the schools were ranked and divided into three risk strata of approximately equal size.
Randomisation of schools occurred within strata, using a computer-generated sequence of allocation of block size ten for each. This process resulted in 15 experimental schools and 14 control schools. Statistical Methods Primary analysis was by intention-to-treat. All female pupils were included in analysis of abortions primary outcome and live births ascertained from routine data through anonymised linkage.
These abortions were included in analysis by age 20, but not by age Analysis was based on the method of generalised estimating equations GEE [ 15 ], incorporating the correlation of data within schools, and based on the robust variance estimator. For outcomes obtained from the third follow-up questionnaire, we present the prevalence of each outcome and ORs with and without weighting. Where the outcome referred to time until present, questionnaires returned via GP were excluded because this occurred substantially later than other responses.
In summary, the weights were designed to deal with the missing data for those pupils who did not complete a third follow-up questionnaire, and are based on how the completion rates are seen to vary by factors collected previously, i. Such weighting is a standard approach to dealing with missing data, particularly in surveys.
For example suppose pupils reporting having had sex in an earlier questionnaire are seen to be less likely to complete the third follow-up. In this case those pupils reporting sex earlier who do complete a third follow-up questionnaire will be given more weight in analysis so as to represent themselves and also other similar pupils who did not complete the third follow-up.