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Homework answers / question archive / HSCI 270 An mHealth Intervention for Pregnancy Prevention for LGB Teens: An RCT BACKGROUND: Although lesbian, gay, bisexual and other sexual minority (LGB1) girls are more abstract likely than heterosexual girls to be pregnant during adolescence, relevant pregnancy prevention programming is lacking
HSCI 270 An mHealth Intervention for Pregnancy
Prevention for LGB Teens: An RCT
BACKGROUND: Although lesbian, gay, bisexual and other sexual minority (LGB1) girls are more abstract likely than heterosexual girls to be pregnant during adolescence, relevant pregnancy
prevention programming is lacking.
METHODS: A national randomized controlled trial was conducted with 948 14- to 18-year-old cisgender LGB1 girls assigned to either Girl2Girl or an attention-matched control group.
Participants were recruited on social media between January 2017 and January 2018 and enrolled over the telephone. Between 5 and 10 text messages were sent daily for 7 weeks.
Both experimental arms ended with a 1-week booster delivered 12 weeks subsequently.
RESULTS: A total of 799 (84%) participants completed the intervention end survey. Participants were, on average, 16.1 years of age (SD: 1.2 years). Forty-three percent were minority race;
24% were Hispanic ethnicity. Fifteen percent lived in a rural area and 29% came from a lowincome household. Girl2Girl was associated with significantly higher rates of condomprotected sex (adjusted odds ratio [aOR] = 1.48, P , .001), current use of birth control other than condoms (aOR = 1.60, P = .02), and intentions to use birth control among those not
currently on birth control (aOR = 1.93, P = .001). Differences in pregnancy were clinically but
not statistically significant (aOR = 0.43, P = .23). Abstinence (aOR = 0.82, P = .34), intentions to
be abstinent (aOR = 0.95, P = .77), and intentions to use condoms (aOR = 1.09, P = .59) were
similar by study arm.
CONCLUSIONS: Girl2Girl appears to be associated with increases in pregnancy preventive
behaviors for LGB1 girls, at least in the short-term. Comprehensive text messaging–based
interventions could be used more widely to promote adolescent sexual health behaviors
across the United States.
WHAT’S KNOWN ON THIS SUBJECT: Although sexual
minority girls are more likely than heterosexual girls
to be pregnant as a teenagers, pregnancy prevention
programs tailored to the lived experiences of these
girls are lacking.
WHAT THIS STUDY ADDS: Girl2Girl positively impacts
condom use and uptake of other types of
contraception for sexual minority girls, at least in the
short-term. Findings further suggest that intensive
programming delivered over a long period is
acceptable to sexual minority girls.
To cite: Ybarra M, Goodenow C, Rosario M, et al. An
mHealth Intervention for Pregnancy Prevention for LGB
Teens: An RCT. Pediatrics. 2021;147(3):e2020013607
a
Center for Innovative Public Health Research, San Clemente, California; b
Independent Consultant, Northborough,
Massachusetts; c
City College and Graduate Center, The City University of New York, New York, New York; and d
School of Nursing, University of British Columbia, Vancouver, Canada
Dr Ybarra made substantial contribution to conception and design, acquisition of data, and analysis
and interpretation of data and drafted the article; Ms Prescott made substantial contribution to the
acquisition of data and revised the manuscript critically for important intellectual content; Drs
Saewyc, Rosario, and Goodenow made substantial contribution to analysis and interpretation of
data, provided consultation on the study design, and revised the manuscript critically for important
intellectual content; and all authors approved the final manuscript as submitted and agree to be
accountable for all aspects of the work.
This trial has been registered at www.clinicaltrials.gov (identifier NCT03029962).
Deidentified individual participant data will not be made available.
DOI: https://doi.org/10.1542/peds.2020-013607
Accepted for publication Nov 13, 2020
PEDIATRICS Volume 147, number 3, March 2021:e2020013607 ARTICLE Downloaded from www.aappublications.org/news at Queens Univ on September 8, 2021
Although adolescent pregnancy rates
in the United States have decreased
over the past 40 years, just under
200 000 girls, 15 to 19 years old,
became pregnant in 2017.1 Cisgender
sexual minority girls, who comprise
an estimated 10% to 15% of female
youth,2 face differential risk: It may
seem counterintuitive given
assumptions that cisgender lesbian,
gay, bisexual, and other sexual
minority (LGB1) girls are only having
sex with other girls, but researchers
consistently find that they are
significantly more likely to get
pregnant than heterosexual girls.3–5
Cisgender LGB1 girls also are more
likely than their heterosexual female
peers to have sex at a younger
age,2,4,6,7 report more lifetime and
recent numbers of female or male
sexual partners,2,4,6,8 and are less
likely to use barrier methods to
prevent sexually transmitted
infections or pregnancy.2,7,9
Access to school-based sex education
varies widely across the United
States10: 19 states require an
abstinence-only perspective and 39
require that abstinence is presented
as an option; only 20 states require
contraception to be included in the
sexual education curriculum. Despite
the heightened risks of pregnancy
and sexually transmitted infections
that cisgender LGB1 girls face, sex
education that addresses these
disparities is often scarce or
inadequate.11,12 Indeed, although 11
states and the District of Columbia
require LGBT1 inclusive sex
education, an additional 7 require
that homosexuality be presented
negatively and/or that
heterosexuality be presented as the
only acceptable sexual identity.
To address the lack of sexual health
programming for many sexual
minority adolescents, we developed
and tested Girl2Girl, a text messagingbased pregnancy prevention program
tailored to the unique needs of
sexually experienced and
inexperienced cisgender LGB1
adolescent girls. In this study, we
report the preliminary outcomes of
the randomized controlled trial (RCT)
at intervention end, 5 months after
program enrollment. Information
about the iterative, user-centered
intervention development, which
included 269 cisgender LGB1 girls
from across the country, is available
elsewhere.13 Findings from the
current investigation will contribute
to the growing literature examining
behavioral outcomes associated with
text messaging-delivered behavior
change content, particularly that
which targets complex behaviors,
such as pregnancy prevention.
METHODS
Girls were recruited and enrolled
between January 23, 2017, and
January 12, 2018. After completing
the baseline survey, they were
randomized and began the 5-month
program. Most participants completed
the intervention or control program
and their survey by May 31, 2018.
Advarra Institutional Review Board,
an Office of Human Research
Protections–approved institutional
review board, reviewed and approved
the research protocol. We were
granted a waiver of parental
permission so that girls would not
have to put themselves in
a potentially unsafe situation by
disclosing their sexual identity to
their parents to obtain permission to
participate in the study. The waiver
also prevented sampling bias that
would have occurred by including
only girls who were out to their
parents.
Participants
Girls were recruited across the United
States. To be eligible for the study,
participants were (1) aged 14 to 18
years, (2) cisgender female (ie,
assigned female sex at birth and
endorsed a female gender identity),
(3) sexual minority (eg, lesbian,
bisexual), (4) in high school or the
equivalent (including those who did
not finish or dropped out), (5) English
speaking, (6) exclusive users of a cell
phone (ie, they do not share the
phone with someone else) with an
unlimited text messaging plan, (7)
users of text messaging for at least 6
months, (8) intending to have the
same cell number for the next year,
and (9) able to provide informed
assent for those ,18 years of age and
consent for those 18 years of age,
including an acceptable score on the
“capacity to consent” and self-safety
assessment.14 Exclusion criteria
included knowing another girl
enrolled in the RCT and having
participated in a previous
intervention development activity.
Description of the Intervention and
Control Group Content
Girl2Girl is a 20-week, text
messaging–based teenage pregnancy
prevention program. For the first 7
weeks, participants are sent between
4 and 12 messages per day. They then
enter a 12 week “latency” period
when they receive ∼1 to 2 messages
per week. Finally, participants receive
4 to 12 messages daily for a review
week. This “booster” delivers
messages that reiterate the main
concepts discussed in the first 7
weeks of the program.
Intervention content is guided by the
information, motivation, behavioral
skills model15,16 and focuses on
pregnancy prevention information
(eg, how one gets pregnant),
motivations (eg, reasons to initiate
birth control), and behavioral skills
(eg, how to use barriers). Additional
content describes topics and
scenarios that are relevant to sexual
decision-making for sexual minority
girls (eg, aspects of a healthy
relationships).17,18 Content is tailored
on the basis of participants’ selfreported sexual experience (ever
versus never had sex) and sexual
identity (lesbian or gay versus all
others, except for girls who identified
as queer; in this case, their sexual
attractions determined which content
2 YBARRA et al
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they received). Content was not
further tailored to the individual.
As described elsewhere,13 most
program messages are
unidirectional (see Table 1).
Bidirectional, interactive
components included (1) links to
brief online videos in the messages
that aimed to reinforce behavioral
skills; (2) G2Genie, an on-demand
advice text line that provided
information about sex, relationships,
and the LGBT1 community19,20; (3)
“leveling up” by answering a text
message question correctly about
the week’s content; and (4) being
awarded “badges,” which was a gif
sent over text, for achieving
behavioral skills they were
presented in the program (eg,
getting barriers; talking to a health
provider about contraception).
Girl2Girl participants also were paired
with another participant, their “text
buddy.”
19,20 As part of the program
content, buddies received messages
that encouraged them to provide
social support to one other and
practice skills taught in the program.
Intervention participants accepted
a Buddy Code of Conduct, which
outlined acceptable and unacceptable
behavior. Buddy messages were
TABLE 1 Example Girl2Girl Program Messages That are Unidirectional and Bidirectional
Example Intervention Test Message
Unidirectional messages by domain
Teenage pregnancy prevention
information
I get that you’re into girls, not guys. Here’s the thing: LGB1 girls are 2–4 times MORE likely to get pregnant than hetero
girls. Totally unexpected, huh?a
About 1 in 20 teen girls are on an intrauterine device (IUD) or an implant. They can be great: They last 3–10 years so
you get it put in and forget about it.
Being on your period doesn’t protect you because sperm can live in your vagina for up to 5 days. So your period can
be over, but sperm are still swimming around.
Teenage pregnancy prevention
motivation
There are a lot of reasons why LGB1 girls are more likely to get pregnant. Some assume they’re never going to have
sex that involved a penis so they don’t have condoms.
Maybe surprisingly, women in committed relationships with women can have high STD rates. In fact, 13% to 30% of
women having sex with women have HPV (source: bit.ly/1SMlxH6)
A girl told me: “Most people won’t look bad at you for buying condoms or going to a gyno to get birth control. No
shame. It’s only natural.” Too right!
Some women say the female condom has more sensation than a male condom. And it rubs against your clitoris during
sex - bonus!
Dental dams/condoms prevent STDs and pregnancy but a backup never hurts - like having a car charger in case your
phone goes dead. And that’s birth control!
Teenage pregnancy prevention
behavioral skills
It’s fast and simple: Unroll the male condom. Cut off the tip of the condom. Cut down the length of the tube. Unfold to
a square. Done!
Unsure how to ask about birth control? Tell the provider you have questions about it and they’ll take it from there.
Don’t worry - they talk to teens every day.
No need to wait for a crisis. Go online to see where the nearest store is. Too far to get to? Buy the morning after pill
online so you have it if you need it.
Socio-cultural factors Dating violence can also happen. 2 in 5 LGB1 girls have been victims. 1 in 3 were violent themselves. It’s not ok to use
hurtful words or physical force.
If you or someone you know is assaulted, *please* get help. RAINN is amazing - they have an online chat (ohl.rainn.org/
online) and a hotline: 800-656-4673.
It’s common for us to question our sexual attractions and identity. Or for these to change over time. It’s OK to take time
to explore and discover who you are.
Bidirectional messages by domain
Level-up Initial message: I’m not sure where the last 2 weeks went, but here we are! This is for Level 2. True or False: You need
your parents’ permission for the morning after pill.
Correct response from participant: Yessss! You are absolutely right. You can get emergency contraception at many
drug stores or online and you don’t need your parent’s ok. Hellllooo Level 2!
Incorrect response form participant: Good news! You can get emergency contraception at many drug stores or online
and you don’t need your parent’s ok.
G2Genie Texting the keyword “condom” to G2Genie: If condoms (aka cut up to be dental dams) are too expensive, go to a clinic
and get them for free. The icondom app can help you find free stuff too. The Internet is magical!
Badges Initial message: Great! So, what’s your dental dam/condom status at the moment? Do you have one in your possession
(like in your bedroom, school bag, etc)? Let me know (yes/no).
Participant says yes: Nice! You earned your Go Getter Girl Badge!
Participant says no: It might seem really hard to get dental dams/condoms: they’re expensive, they can be
embarrassing to buy, and maybe you don’t know where to get them. What stops you: Parents, Cost, IDK where to go,
Embarrassed, Not having sex, Not having sex w/a guy, Waiting to have sex, In a relationship, No transport, Other.
“No” participant responds she is not having sex with a guy: I totally get that you’re not having sex with a guy but
practicing now to buy condoms now just makes it easier to them if you need them later on.
a This message is written specifically for lesbian or same-sex attracted girls.
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routed through the study server so
that participants’ phone numbers
were not disclosed to buddies. Buddy
conversations were monitored by
research staff from 6 AM to 10 PM PST
to ensure harmful messages were not
being sent.
The control arm received a similar
intensity and duration of messaging as
the intervention. Content addressed
topics relevant to adolescents,
including diet, exercise, and how to
deal with bullying. To help blind this
arm, 2 days of pregnancy prevention
content readily available online were
included. Interactive components (eg,
Text Buddy) were not available to this
group.
Recruitment and Retention
Procedures
Participants were recruited through
online advertisements on Facebook
and Instagram. The ads were targeted
to users who indicated on their
profile that they were female,
between 14 and 18 years of age, and
“interested in females” or “interested
in males and females.” Youth who
clicked on the advertisement were
directed to the online screener form.
Potentially eligible youth were
contacted in order of receipt of
screeners while also considering
preset demographic targets to ensure
sample diversity. For example, once
the targeted number of non-Hispanic
white girls was enrolled, additional
demographically similar candidates
were not contacted. Enrollment
occurred over the phone with
research staff. Once eligibility was
confirmed and informed assent and
consent were obtained, participants
were emailed a unique link to the
baseline survey. Girls were
randomized to a study arm after they
completed the survey.
Randomization
Participants were randomly assigned
to the Girl2Girl intervention (n = 473)
or the attention-matched control
group (n = 475) at a 1-to-1
randomization allocation ratio. The
random allocation was stratified by
(1) sexual experience and (2) sexual
identity.21 Participants, but not
researchers, were blind to arm
allocation.
Power
Effect size estimates for samples that
include both sexually experienced
and inexperienced LGB1 youth are
ill-defined because, as noted above,
pregnancy programs for LGB1
adolescent women are lacking. To
inform our power estimates about
sexual abstinence, we used data from
the authors’ Girl2Girl “recruitment
pilot” study. Among the 257 14- to
18-year-old sexual minority girls
surveyed, 22% had never had penilevaginal sex (M.Y., unpublished data).
A power estimate for condom use was
based on data from the authors’ Teen
Health and Technology survey.22
Eleven percent of LGB1 girls 14 to 18
years old reported having penilevaginal or penile-anal sex without
a condom in the past 3 months (M.Y.,
unpublished data). On the basis of
these prevalence estimates and
assuming 80% power and statistical
significance set at P = .05, the
minimum detectable odds ratio we
could detect with a sample size of 420
girls in each experimental group (n =
840) were 0.49 for condomless sex
and 1.66 for abstinence.23–27
Recruitment was more successful
than anticipated, with 948
participants recruited and
randomized.
Incentive
Participants received between $5 and
$35 for completing the survey at
intervention end; incentives varied on
the basis of the mode and length of
the survey they completed (see Data
Collection below). Youth were not
incentivized to complete the baseline
survey.
Data Collection
Baseline surveys were collected
online. We initially intended to collect
intervention end data via text
messaging. When funding
uncertainties arose, we shifted to an
online data collection format. As such,
299 participants completed the
intervention end survey via text
message and 500 completed it online.
Survey mode was balanced by
experimental arm: 62% of control
and 63% of intervention participants
completed the survey online (P = .71).
Program participation length varied
for intervention participants on the
basis of their responsiveness to
programmatic activities. For example,
those who did not respond to a levelup question or badge message were
sent multiple reminders before the
program content resumed. Thus,
some had an intervention experience
that was longer than 20 weeks.
Measures
Main outcomes included (1) condomprotected penile-vaginal sex in the
past 3 months, (2) current use of
contraception other than condoms,
(3) abstinence from penile-vaginal
sex in the past 3 months, and (4)
pregnancy since program enrollment.
Secondary outcomes included
behavioral intentions in the next year
to (5) use condoms and (6) other
forms of contraception and (7) be
abstinent. Outcome measures were
adapted from those recommended by
the Office of Adolescent Health.28
Because of the 160-character
limitation in text messages, questions
in the text messaging–based
intervention end survey varied from
the online version. Wording of
outcome measures is shown in Table
2.
Statistical Analyses
Participants who did not complete the
intervention end survey were
excluded from the analyses. Missing
data also occurred within the
intervention end survey when
participants declined to answer an
outcome measure. Intentions to use
condoms (5%), intentions to have
4 YBARRA et al
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penile-vaginal sex (4%), and
intentions to use birth control (4%)
had the highest rates of decline to
answer. To analyze a consistent
sample across outcome measures,
decline to answer was treated as
outcome failure (eg, no condomprotected sex; no intention to use
condoms). As a sensitivity analyses,
models also were estimated with these
youth eliminated from the analyses.
Analyses were intention to treat;
gender identity was assessed during
the enrollment call. A small number
of youth (n = 10) self-reported
a cisgender identity over the
telephone and a noncisgender
identity in the baseline survey.
Because these answers were not
again assessed for eligibility, these
TABLE 2 Girl2Girl2 RCT Outcome Measures
Measure Online Survey Text (Baseline and Intervention
End)
Text Messaging Survey Text (Intervention
End)
Outcomes Computation
Abstinence in the past
3 mo
In the past 3 months, how many times have
you had sex when a human penis went into
your vagina?
Since the beginning of the G2G program
on [date], how many times have you
had sex when a human penis (not
a toy) went in your vagina?
Those who answered 0 were coded as being
abstinent. Those who reported 1 or more
times at baseline were coded as being
recently sexually active.
No. condom-protected
sex acts in the past
3 mo
You said you had sex when a human penis
(not a toy) went into your vagina [insert
number] in the past 3 months. How many
times did you use a female or male
condom?
And of the [3] times you had sex when
a human penis went in your vagina
since G2G started, how many times did
you use female or male condoms?
Responses were treated as a count.
Currently using birth
control
Youth were asked 6 separate questions about
whether they were currently using any
types of the following methods of birth
control: (1) birth control pills, (2) the shot
(like Depo-Provera), (3) the patch (like
Xulane), (4) the ring (like NuvaRing), (5)
IUD (like Skyla, Mirena, or Paragard), and
implants (like Implanon or Nexplanon).
Response options were no, yes, I don’t
know what this is, and do not want to
answer. Those who initially said they did
not know about the type of birth control
were directed to a pictorial representation
and a more detailed description.
Are you on birth control? I mean the pill,
shot (Depo-Provera), ring (NuvaRing),
patch (Xulane), an IUD (like Paragard),
or implant (like Implanon).
Current use of birth control was indicated if
online survey respondents answered yes
to any of the 6 types of birth control
queried, or text message survey
respondents answered yes to the single
item.
Pregnancy since RCT
enrollment
As far as you know, have you been pregnant,
even if no child was born, ever/since
Girl2Girl started on [insert start date]?
As far as you know, since Girl2Girl started
on [date] have you been pregnant even
if no child was born?
Those who said yes were coded as having
been pregnant.
Intentions to use
condoms in the
futurea
“If I have sex where a human penis (not a toy)
goes into my vagina in the next year, I plan
to use or have my partner use a female or
male condom.” Response options were on
a 5-point Likert scale ranging from very
untrue to very true.
In the next 3 months, if you have sex when
a human penis goes into your vagina,
do you plan to use female or male
condoms? Def not, Prob not, Prob, Def,
or IDK.
Those who said “somewhat true” or very
true” online or “Prob” or “Def’ via text
were coded as having intentions to use
condoms.
Intentions to use birth
control other than
condoms in the
futureb
“In the next year, do you plan to use these
methods of birth control?” The 6 types of
birth control described above. Response
options were on a 4-point Liker scale
ranging from no, definitely not to yes,
definitely.
“In the next 3 months, do you plan to use
birth control (the pill, shot, ring, patch,
IUD, implant)? Def not, Prob not, Prob,
Def, IDK, or not sure what this is.”
Those who said “Yes, probably” or “Yes,
definitely” to the online survey or “Prob”
or “Def” via text messaging, and said
they were not currently on birth control,
were coded as having intentions to use
birth control.
Intentions to be
abstinent in the
future
“In the next year, do you think you might have
the following types of sex with a guy, or
someone with a penis regardless of their
gender presentation?” The specific item
was: “Sex with a human penis (not a toy)
that goes into your vagina.” Response
options were on a 4-point Likert scale
ranging from “no, definitely not” to “yes,
definitely.”
“And in the next 3 months, do you think
you might have sex when a human
penis (not a toy) goes into your vagina?
Def not, Prob not, Prob, Def, IDK.”
Those who responded “Yes, probably” or
Yes, definitely” online, of “Prob” or “Def”
via text were coded as having an
intention to be abstinent.
Two hundred and ninety-nine participants completed the intervention end survey via text message and 500, online. Online survey questions were based on those recommended by the
Office of Adolescent Health. Messages were adapted by the authors for text messaging. IDK, I don’t know.
a In the text messaging–based survey, this question was asked of everyone except those who said “definitely not” to the question about intentions to have penile-vaginal sex. It was asked
of everyone in the online survey.
b In the text messaging survey, this question was asked only of those who were not currently on birth control. In the online survey, it was asked of everyone.
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youth were included in the study
sample. One of these participants’
baseline surveys was deleted. Eight
completed both the baseline and
follow-up surveys and are included in
analyses.
Logistic regression was used to
quantify the relative odds of
dichotomous measures:
contraception, abstinence, and
behavioral intentions. Poisson
regression was used to quantify the
relative count of condom-protected
sex acts.
Differences in behaviors at baseline
were likely equally distributed
between treatment and control
groups because arm assignment was
random. Because statistically
significant differences in these
characteristics might occur by chance,
any baseline characteristics on which
the experimental arms were
imbalanced were included in
multivariate models. Multivariate
models also adjusted for the baseline
indicator of the outcome in question
(eg, condom-protected sex) and the
survey mode through which the
intervention end survey was
completed (ie, online versus text
messaging).
Analyses were performed twice: once
with all youth and once for youth who
reported penile-vaginal sex in the 90
days before baseline, hereafter
referred to as “sexually active girls.”
Girls who had sex for the first time
during the observation period were
not included in the latter group. The
former provided an estimate of the
intervention effect in the target
population as a whole, and the latter
provided an estimate among those at
greater risk for pregnancy. We also
examined behavioral intentions among
youth who had not had penile-vaginal
sex in the past 3 months at baseline
(ie, were “not sexually active”).
RESULTS
As shown in Fig 1, 59 of 948
participants either actively
terminated their involvement in the
RCT or were lost to follow-up. The
remaining 94% received all program
messages, thereby completing the
program. Seven hundred and ninetynine (84%) completed the
intervention end survey and are
included in the current analyses. No
unintended harms were reported.
Intervention and control participants
were equivalent on their baseline
characteristics except for age, which
was borderline statistically
significantly different (P = .051; see
Table 3).
Behavioral Outcomes
At RCT end, 5 months
postenrollment, 22% of intervention
and 19% of control participants
reported penile-vaginal sex in the
past 3 months; 17% and 13%
reported at least 1 condom-protected
sex act; and 10% and 12% reported
at least 1 condomless protected sex
act, respectively. The number of
condom-protected sex acts ranged
between 0 and 70 for intervention
and 0 to 60 for control participants.
Among those who reported penilevaginal sex in the past 3 months at
baseline (ie, sexually active girls),
46% of intervention and 43% of
control participants reported at least
1 condom-protected sex act in the
past 3 months at intervention end;
32% and 49%, respectively, reported
at least 1 condomless protected sex
act over the same time period.
As shown in Table 4, the rate of
condom-protected sex acts in the past
3 months was significantly higher at
intervention end for those in the
intervention versus control group
(adjusted odds ratio [aOR] = 1.48, P ,
.001) after adjusting for survey mode,
age, and number of condomprotected sex acts at baseline. The
magnitude of association was similar
when examined among sexually
active girls (aOR = 1.64, P , .001).
The intervention also was associated
with significantly lower rates of
condomless sex acts generally (aOR =
FIGURE 1
CONSORT Diagram for Girl2Girl RCT.
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TABLE 3 Comparison of Baseline Characteristics of Girl2Girl RCT Participants Among Those Who Completed the Intervention End Survey (n = 799)
Youth Characteristics Control (n
= 410)
Intervention
(n = 389)
P
Age, mean (SD) 15.97 (1.2) 16.14 (1.2) .051
Hispanic ethnicity, n (%) .25
No 300 (73.2) 302 (77.6)
Yes 109 (26.6) 85 (21.9)
Decline to answer 1 (0.2) 2 (0.5)
Race, n (%) .47
White 226 (55.1) 232 (59.6)
Black or African American 61 (14.9) 57 (14.7)
Asian American 16 (3.9) 14 (3.6)
Native Hawaiian or Other Pacific Islander 3 (0.7) 2 (0.5)
American Indian or Alaska native 9 (2.2) 3 (0.8)
Multiracial 58 (14.2) 54 (13.9)
Some other race 26 (6.3) 23 (5.9)
Do not want to answer 11 (2.7) 4 (1.0)
Rural,a n (%) 70 (17.1) 51 (13.1) .12
Income,b n (%) .86
Lower than the average 122 (29.8) 110 (28.3)
Similar to the average 213 (52.0) 200 (51.4)
Higher than the average 61 (14.9) 62 (15.9)
Do not want to answer 14 (3.4) 17 (4.4)
Sexual identity,c n (%)
Gay 83 (20.2) 78 (20.1) .95
Lesbian 178 (43.4) 169 (43.4) .99
Bisexual 172 (42.0) 170 (43.7) .62
Pansexual 106 (25.9) 121 (31.1) .10
Heterosexual 3 (0.7) 2 (0.5) .70
Queer 89 (21.7) 77 (19.8) .51
Asexual 9 (2.2) 8 (2.1) .89
Questioning 50 (12.2) 43 (11.1) .62
Unsure 7 (1.7) 8 (2.1) .72
Do not want to answer 0 (0) (0) 0 —
Gender identity, n (%) .55
Cisgender female 406 (99.0) 385 (99.0)
Male to female transgenderd 1 (0.2) 0 (0.0)
Male to female transgenderd 0 (0.0) 1 (0.3)
Genderqueer or pangenderd 0 (0.0) 1 (0.3)
I am unsured 2 (0.5) 2 (0.5)
Other 1 (0.2) 0 (0.0)
Do not want to answer 0 (0) 0 (0)
Ever penile-vaginal sex, n (%) .99
No 279 (68.1) 263 (67.6)
Yes 130 (31.7) 125 (32.1)
Do not want to answer 1 (0.2) 1 (0.3)
Penile-vaginal sex in the past 3 mo, n (%) .75
No 342 (83.4) 319 (82.0)
Yes 67 (16.3) 68 (17.5)
Do not want to answer 1 (0.2) 2 (0.5)
No. condom-protected vaginal sex acts in the past 3 mo, mean (SD) 0.8 (5.7) 1.1 (4.9) .42
Do not want to answer 0 (0) 0 (0)
Currently on birth control, n (%) .45
Yes, to any 101 (24.6) 87 (22.4)
Birth control pills .82
No 339 (82.7) 324 (83.3)
Yes 71 (17.3) 65 (16.7)
I don’t know what this is 0 (0) 0 (0)
Do not want to answer 0 (0) 0 (0)
The shot .69
No 401 (97.8) 382 (98.2)
Yes 9 (2.2) 7 (1.8)
I don’t know what this is 0 (0) 0 (0)
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0.79, P = .007) and among sexually
active girls specifically (aOR = 0.65, P
, .001).
The relative odds of current use of
birth control other than condoms was
60% higher in the intervention versus
control group (aOR = 1.60, P = .02).
Differences were not significant
among sexually active girls, however
(aOR = 0.98, P = .97).
The relative odds of abstaining from
penile-vaginal sex in the past 3
months at intervention end were
statistically similar for intervention
and control participants generally
(aOR = 0.82, P = .34) and sexually
active girls specifically (aOR = 1.20, P
= .63).
The magnitude of the relative odds of
pregnancy between intervention and
control participants was clinically
meaningful but not statistically
significant in general (aOR = 0.43, P =
.23) or among sexually active girls
(aOR = 0.39, P = .21).
Behavioral Intentions
As shown in Table 4, the relative odds
of intending to use birth control
among girls who were not currently
on birth control were significantly
higher for those in the intervention
versus control group at intervention
end (aOR = 1.93, P = .001). This also
was true among sexually active girls
(aOR = 3.25, P = .052) and abstinent
girls (aOR = 1.87, P = .003). When
girls who intended to use birth
control were combined with girls
currently on birth control, the relative
odds of being in the intervention
group were significantly higher
among all girls (aOR = 2.08, P ,
.001), as well as among sexually
active (aOR = 3.02, 0.04) and
abstinent (aOR = 2.10, P , .001) girls
specifically (data not shown).
Intentions to use condoms (aOR =
1.09, P = .59) and intentions to be
abstinent did not differ by study arm
(aOR = 0.95, P = .77).
Sensitivity Analysis
Results were similar when youth who
declined to answer an outcome
question were dropped rather than
coded as failure. Data are available on
request.
DISCUSSION
To our knowledge, Girl2Girl is the
first pregnancy prevention program
developed for and tested among
sexual minority girls across the
United States and the first
comprehensive, technology-based
teenage pregnancy prevention
program for any group of youth. In
TABLE 3 Continued
Youth Characteristics Control (n
= 410)
Intervention
(n = 389)
P
Do not want to answer 0 (0) 0 (0)
The patch .62
No 405 (98.8) 385 (99.0)
Yes 4 (1.0) 2 (0.5)
I don’t know what this is 1 (0.2) 2 (0.5)
Do not want to answer 0 (0) 0 (0)
The ring .82
No 406 (99.0) 384 (98.7)
Yes 3 (0.7) 3 (0.8)
I don’t know what this is 1 (0.2) 2 (0.5)
Do not want to answer 0 (0) 0 (0)
IUD .15
No 400 (97.6) 384 (98.7)
Yes 7 (1.7) 1 (0.3)
I don’t know what this is 3 (0.7) 3 (0.8)
Do not want to answer 0 (0.0) 1 (0.3)
Implants .44
No 393 (95.9) 379 (97.4)
Yes 16 (3.9) 9 (2.3)
I don’t know what this is 1 (0.2) 1 (0.3)
Do not want to answer 0 (0) 0 (0)
Ever pregnant, n (%) .50
No 388 (94.6) 369 (94.9)
Yes 15 (3.7) 13 (3.3)
I don’t know 5 (1.2) 7 (1.8)
Do not want to answer 0.5% (2) 0.0% (0)
—, not applicable.
a Based on the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties.29
b Self-appraised.
c Multiple response.
d Gender identity was assessed during the enrollment call. A small number of youth self-reported a noncisgender identity in the baseline survey. Because these answers were not again
assessed for eligibility, they were included in the sample.
8 YBARRA et al
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this large-scale RCT, outcomes at
intervention end suggest that
Girl2Girl is associated with increased
rates of condom use and increased
odds of using other types of
contraception. The intervention also
appears to be associated with
increased intentions to use birth
control among girls not on birth
control. Although few pregnancies
were reported over the 5 months, the
intervention group had half the odds
of pregnancy versus the control
group; given this rare event, the effect
size was not statistically significant.
Taken together, these findings suggest
that Girl2Girl may be associated with
multiple pregnancy preventive
behaviors, at least in the short-term.
Girl2Girl does not appear to be
effective in promoting sexual
abstinence or a return to abstinence
among recently sexually active girls.
This may be in part because the
health promotion messages were
intentionally sex positive and focused
on healthy relationships and use of
barriers and testing, rather than
solely emphasizing abstinence. Also,
other researchers have documented
that abstinence-focused interventions
appear to have no effect on sexually
active girls.30,31 Future research
about sex-positive programs that
includes sexually experienced and
inexperienced youth might consider
adding an outcome that reflects selfefficacy to consent to sex when it is
wanted and demur to sex when it is
not.
Limitations
Given the nature of the intervention,
findings may not be generalizable to
girls who do not use social media or
have cell phones with a limited
messaging plan. Moreover, social
media advertising was targeted to
girls whose profiles indicated they
were “interested in” other girls.
Therefore, girls who saw the ads were
TABLE 4 Pregnancy Preventive Behavior and Intentions Outcomes at Girl2Girl RCT Intervention End (n = 799)
Pregnancy Preventive Behaviors and Intentions Control
(n = 410)
Intervention
(n = 389)
IRR/
OR
95% CI P IRR/
aOR
95% CI P
No. condom-protected sex acts in the past 3 mo
All youth (n = 799) mean (SD) 1.2 (6.0) 1.4 (5.9) 1.21 1.07–1.37 .002 1.48 1.30–1.68 ,.001
Youth who have had vaginal sex in the past 3 mo at baseline (n = 135)
mean (SD)
4.7 (11.9) 5.3 (11.6) 1.13 0.97–1.31 .13 1.64 1.40–1.93 ,.001
No. condomless sex acts in the past 3 moa
All youth (n = 799) mean (SD) 0.7 (2.3) 0.6 (2.1) 0.83 0.70–0.99 .04 0.79 0.66–0.94 .007
Youth who have had vaginal sex in the past 3 mo at baseline (n = 135)
mean (SD)
3.5 (4.4) 2.3 (3.8) 0.64 0.52–0.79 ,.001 0.65 0.53–0.80 ,.001
Currently using birth control, n (%)
All youth (n = 799) 110
(26.8)
121 (31.1) 1.23 0.91–1.67 .18 1.60 1.08–2.37 .02
Youth who have had vaginal sex in the past 3 mo at baseline (n = 135) 37 (55.2) 33 (48.5) 0.76 0.39–1.50 .44 0.98 0.41–2.34 .97
Abstaining from penile-vaginal sex in the past 3 mo, n (%)
All youth (n = 799) 330
(80.5)
301 (77.4) 0.83 0.59–1.17 .28 0.82 0.55–1.23 .34
Youth who have had vaginal sex in the past 3 mo at baseline (n = 135) 22 (32.8) 26 (38.2) 1.27 0.62–2.57 .51 1.20 0.57–2.55 .63
Pregnancy since program enrollment, n (%)
All youth (n = 799) 8 (2.0) 3 (0.8) 0.39 0.10–1.48 .17 0.43 0.11–1.70 .23
Youth who have had vaginal sex in the past 3 mo at baseline (n = 135) 7 (10.5) 3 (4.4) 0.40 0.10–1.60 .19 0.39 0.09–1.73 .21
Intentions to use condoms in the next year, n (%)
All youth (n = 799) 265
(64.6)
261 (67.1) 1.12 0.83–1.50 .46 1.09 0.79–1.52 .59
Youth who have had vaginal sex in the past 3 mo at baseline (n = 135) 41 (61.2) 48 (70.6) 1.52 0.74–3.12 .25 1.54 0.72–3.30 .26
Youth who have not had sex (n = 661) 223
(65.2)
213 (66.8) 1.07 0.78–1.48 .67 1.04 0.72–1.51 .84
Intentions to use birth control in the next year,b n (%)
All youth (n = 568) 99 (33.0) 128 (47.8) 1.86 1.32–2.61 ,.001 1.93 1.31–2.84 .001
Youth who have had vaginal sex in the past 3 mo at baseline (n = 65) 15 (50.0) 27 (77.1) 3.37 1.16–9.79 .03 3.25 0.99–10.70 .052
Youth who have not had sex (n = 500) 83 (30.9) 101 (43.7) 1.74 1.21–2.51 .003 1.87 1.24–2.84 .003
Intentions to be abstinent in the next year, n (%)
All youth (n = 799) 178
(43.4)
157 (40.4) 0.88 0.67–1.17 .38 0.95 0.67–1.35 .77
Youth who have had vaginal sex in the past 3 mo at baseline (n = 135) 9 (13.4) 7 (10.3) 0.74 0.26–2.12 .57 0.75 0.23–2.42 .63
Youth who have not had sex (n = 661) 169
(49.4)
150 (47.0) 0.91 0.67–1.23 .54 0.95 0.65–1.38 .79
Sample size for intentions does not equal 799 because 3 people who declined to answer about recent vaginal sex are not included in either category. Models adjusted for survey mode,
age, and baseline indicator of outcome of interest (eg, condom use). aIRR, adjusted incident rate ratio; aOR, adjusted odds ratio; IRR, incident rate ratio; OR, odds ratio.
a Because of outliers (range: 0–663, SD = 24.2), censored at 101 acts.
b Among those not currently on birth control.
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“out” at least on their social media
profile. Findings may not be
generalizable to those who are not
out to others. Additionally, it is
impossible to determine if
a particular program message was
read. This is not unlike school-based
programs in which it is unknown
whether students are listening to the
intervention facilitator. Finally,
because of funding uncertainty,
surveys at intervention end were
collected either via text messaging or
online. Aside from potential mode
differences, questions were worded
slightly differently and, in some cases,
referred to different time frames (eg,
next 12 months versus next 3
months). To mitigate the potential
impact of this, we adjusted for survey
mode in multivariate models.
Balancing these limitations, it should
be noted that the national sample was
diverse in terms of race and ethnicity,
sexual identity, rural and urban
setting, and age. The intervention also
was novel in its intervention target
(ie, sexual minority girls), delivery
mechanism (ie, comprehensive text
messages), and scope (ie, across the
United States).
Implications
Reviews suggest that text
messaging–based interventions can
affect and sustain complex health
behavior changes across a variety of
behaviors, including HIV testing,
medication adherence, physical
activity, and smoking cessation.32–42
Results here provide reason for
optimism that this approach can be
effective with adolescent pregnancy
prevention as well.
The high program completion rate
suggests that sexual minority
adolescent girls are willing to receive
voluminous amounts of sexual healthrelated text messages over
a relatively long period of time (ie, 5
months). Given the relative cost
efficiency and wide reach of text
messaging as a delivery mechanism
compared with more traditional
models such as facilitator-based
education,43 researchers may
consider using this modality to
address other adolescent behavior
change efforts as well.
Opportunities for future research are
noted. First, it is unknown whether
some or all components of the
intervention (eg, Text Buddy,
G2Genie, level-up questions)
meaningfully contributed to behavior
change. Understanding the relative
contributions of these features could
inform the future development of
technology-based interventions that
seek to include game-like program
components. Second, girls of various
sexual minority identities were
analyzed together. Subsequent
research may wish to examine
outcomes for lesbian and bisexual
girls separately given they differ in
their sexual behaviors with girls and
boys.17,44 Additionally, it would be
useful to explore the optimal length of
interventions such as this, as well as
the timing of the booster delivery.
Other important questions include
whether the behavioral changes are
sustained over time and if behavioral
changes are noted in an effectiveness
trial.
CONCLUSIONS
Sexual minority girls are
significantly more likely to be
pregnant during their teenage years
compared to heterosexual girls and
yet, limited teenage pregnancy
prevention programming is available
that is tailored to their needs.
Findings suggest that Girl2Girl is
associated with changes in teenage
pregnancy preventive behaviors and
behavioral intentions with both
sexual minority girls who are having
penile-vaginal sex and those who are
not, at least in the short-term. The
latter are key to a comprehensive
public health approach that gives all
girls the tools they need to make
healthy decisions if, and when, they
choose to have sex that could lead to
pregnancy.
ACKNOWLEDGMENTS
We thank the study participants and
research team, particularly Katrina
Nardo, Dr Myeshia Price-Feeney, and
Desiree Fehmie for their
contributions to the study.
