HSCI 270 An mHealth Intervention for Pregnancy Prevention

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

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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

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

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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

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

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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)

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)

PEDIATRICS Volume 147, number 3, March 2021 7

Downloaded from www.aappublications.org/news at Queens Univ on September 8, 2021

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)

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

Downloaded from www.aappublications.org/news at Queens Univ on September 8, 2021

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,

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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

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