Adolescent Sexual Health Interventions: Innovation, Efficacy, Cost, and the Urgent Need to Scale

African American and Latinx adolescents in the United States are at high risk for experiencing poor sexual health outcomes. Compared with their white peers, African American and Latina girls are nearly twice as likely to give birth before age 20.¹  Rates of HIV and other sexually transmitted infections are also higher for racial and/or ethnic minority adolescents.²  The persistence of these sexual health disparities, despite decades of intervention efforts, necessitates prevention approaches that are innovative, efficacious, cost-effective, and scalable.

In this issue of Pediatrics, Guilamo-Ramos et al³  provide rigorous evidence for a highly promising intervention, a triadic version of Families Talking Together (FTT). The triadic FTT intervention is innovative in that it involves African American and Latinx youth in early adolescence, their female caregivers, and their health care providers (HCPs). Of more than two dozen sexual health interventions for African American and/or Latinx adolescents that have been evaluated in randomized clinical trials,^4,5  FTT is the first of which we are aware that incorporates adolescents, parents, and HCPs in a single program. Incorporating both parents and HCPs into intervention efforts is wise for several reasons: HCPs can lend additional credibility to intervention messages, parents can promote such messages in daily life outside the clinic setting, and both HCPs and parents are important sources of sexual health information for adolescents.^6,7  FTT also leverages intervention activities both in a clinic setting and at home. Given recent declines in comprehensive school-based sex education in the United States,⁸  providing necessary sexual health information in other settings is increasingly important.

Regarding efficacy, Guilamo-Ramos et al³  rigorously tested FTT among 900 mother-adolescent-HCP triads in a randomized clinical trial. One year after the intervention was complete, just 5% of adolescents receiving FTT had engaged in vaginal intercourse compared with 18% in the control condition. Among youth who were sexually active, 74% receiving FTT used a condom the last time they had vaginal intercourse compared with 49% in the control condition. Not only did FTT improve safe-sex behavior, but it also improved mother–child communication, a factor that is known to be protective over time.⁹  These results were consistent for both boys and girls and African American and Latinx adolescents, demonstrating the program’s capacity to improve the sexual health of many young people. One important limitation is that only heterosexual youth were eligible to participate in the current study, so the efficacy of FTT among lesbian, gay, bisexual, and other sexual minority adolescents is still unknown and must remain a research priority.

Regarding cost-effectiveness, teenaged pregnancy has been linked to outcomes such as high school dropout and unemployment¹⁰  and costs the United States an estimated $21 billion dollars each year.¹¹  Furthermore, untreated sexually transmitted infections can result in severe outcomes, such as infertility, and cost the United States nearly $16 billion dollars each year.¹²  Given these personal and societal costs, how can we afford not to offer adolescents comprehensive sexual health interventions that could reduce sexual risk, such as the FTT intervention? As noted by Guilamo-Ramos et al,³  triadic interventions offer a relatively low-cost tool to strengthen partnerships between parents, adolescents, and providers and increase the potency of health messaging. The FTT program, in particular, lowers costs by incorporating “provider extenders” (eg medical assistants and social workers) as intervention delivery partners.

Given the promise of FTT, a logical next step is to ask how it can be scaled to reach more adolescents. Here, we briefly highlight 3 avenues to improve the scalability of FTT and other promising sexual health interventions to have the greatest impact. First, as Guilamo-Ramos et al³  have done, members of the target population (particularly adolescents) must be included throughout the research process, from intervention design to dissemination. When community members are involved from the moment of program conception, programs are more likely to be acceptable, feasible, and eventually adopted.¹³  Second, researchers can consider shifting from developing programs that rely exclusively or largely on in-person facilitators to online platforms (e-health and/or mobile health). These online platforms can help improve scalability by reducing the time and cost associated with training individual facilitators while also protecting the fidelity of program delivery, enhancing user privacy, and making it possible to tailor programming to specific populations.^14,15  Given that access to technology is nearly ubiquitous among adolescents in the United States (95% of adolescents have access to a smartphone, and nearly half report being online “almost constantly”¹⁶ ), online programs can also enhance the reach of sex education programs. A technology-adapted FTT intervention would be an exciting new tool to offer youth, families, and providers. Finally, when evaluating the effectiveness of interventions, researchers can consider newer research designs that allow for faster translation of science into practice and enhance public health impact. For example, Sequential Multiple Assignment Randomized Trials¹⁷  dynamically adapt intervention content over the course of a trial on the basis of individual variables (eg, risk factors and treatment response) to improve individual outcomes. Furthermore, effectiveness-implementation hybrid designs¹⁸  include a dual focus on evaluating intervention effectiveness and implementation protocols within the same study. Both approaches offer opportunities to move beyond traditional, static randomized trials and translate programs like FTT away from the research environment to clinical practice that will include a more diverse population of adolescents and a broader array of practices. Improving the scalability of interventions remains a critical and often unaddressed aspect of research regarding adolescent sexual health care delivery.

FTT

Families Talking Together

HCP

health care provider