Efficacy of infant simulator programmes to prevent teenage pregnancy: a school-based cluster randomised controlled trial in Western Australia

BACKGROUND

Infant simulator-based programmes, which aim to prevent teenage pregnancy, are used in high-income as well as low-income and middle-income countries but, despite growing popularity, no published evidence exists of their long-term effect. The aim of this trial was to investigate the effect of such a programme, the Virtual Infant Parenting (VIP) programme, on pregnancy outcomes of birth and induced abortion in Australia.

METHODS

In this school-based pragmatic cluster randomised controlled trial, eligible schools in Perth, Western Australia, were enrolled and randomised 1:1 to the intervention and control groups. Randomisation using a table of random numbers without blocking, stratification, or matching was done by a researcher who was masked to the identity of the schools. Between 2003 and 2006, the VIP programme was administered to girls aged 13-15 years in the intervention schools, while girls of the same age in the control schools received the standard health education curriculum. Participants were followed until they reached 20 years of age via data linkage to hospital medical and abortion clinic records. The primary endpoint was the occurrence of pregnancy during the teenage years. Binomial and Cox proportional hazards regression was used to test for differences in pregnancy rates between study groups. This study is registered as an international randomised controlled trial, number ISRCTN24952438.

FINDINGS

57 (86%) of 66 eligible schools were enrolled into the trial and randomly assigned 1:1 to the intervention (28 schools) or the control group (29 schools). Then, between Feb 1, 2003, and May 31, 2006, 1267 girls in the intervention schools received the VIP programme while 1567 girls in the control schools received the standard health education curriculum. Compared with girls in the control group, a higher proportion of girls in the intervention group recorded at least one birth (97 [8%] of 1267 in the intervention group vs 67 [4%] of 1567 in the control group) or at least one abortion as the first pregnancy event (113 [9%] vs 101 [6%]). After adjustment for potential confounders, the intervention group had a higher overall pregnancy risk than the control group (relative risk 1·36 [95% CI 1·10-1·67], p=0·003). Similar results were obtained with the use of proportional hazard models (hazard ratio 1·35 [95% CI 1·10-1·67], p=0·016).

INTERPRETATION

The infant simulator-based VIP programme did not achieve its aim of reducing teenage pregnancy. Girls in the intervention group were more likely to experience a birth or an induced abortion than those in the control group before they reached 20 years of age.

FUNDING

Western Australian Health Promotion Foundation (Healthway), Lotteries WA, the Western Australian Department of Education and Training, and the Western Australian Department of Health.

Primary dysmenorrhea in young Western Australian women: prevalence, impact, and knowledge of treatment

PURPOSE

To explore the prevalence of dysmenorrhea among senior high school girls in Perth, Western Australia, its impact on school, sporting, and social activities, students' management strategies, and their knowledge of available treatment.

METHODS

A total of 388 female students in Grades 11 and 12 at three metropolitan secondary schools completed an anonymous questionnaire administered during class time. The following definition of dysmenorrhoea was used: any type of pain or discomfort associated with menstrual periods including cramps, nausea, and headaches.

RESULTS

The reported prevalence of dysmenorrhea among these girls was 80%; 53% of those girls with dysmenorrhea reported that it limited their activities. In particular, 37% said that dysmenorrhea affected their school activities. The most common medication used by those reporting dysmenorrhea was simple analgesics (53%), followed by nonsteroidal anti-inflammatory drugs (NSAIDs), used by 42%. More than a quarter of respondents (27%) were unaware that NSAIDs were a possible treatment option for dysmenorrhea.

CONCLUSION

The prevalence and impact of dysmenorrhea on Grade 11 and 12 girls is high, and they lack knowledge of and experience with effective treatment. Health education measures are needed in this area to prevent unnecessary suffering and interruption to school routine.

Pap smear screening at an urban aboriginal health service: report of a practice audit and an evaluation of recruitment strategies

A culturally appropriate women's health service was established at an Aboriginal community-controlled health service in Darwin in 1994. An initial file audit found that 48% of included women had ever been screened with a Pap smear and 37% of women were considered to have been adequately screened. The enhancement of opportunistic screening by file tagging had a modest effect on screening coverage over a 12-month period for women who attended the health service. The proportion of these women who were adequately screened increased from 43% to 48% and of those ever screened increased from 54% to 62%. A randomised trial of recruitment interventions including personal approach, letter and control groups was subsequently performed for women for whom Pap smears were overdue or not recorded. The impact of both interventions on the number of Pap smears performed was low, with 7% of women in the personal approach group, 2% of women in the letter group and no women in the control group having Pap smears during the three-month follow-up period. Low rates of abnormalities were observed for women having Pap smears over a two-year period. The minimal effect of a formal reminder system and letters at this urban Aboriginal health service has resulted in a re-orientation of activities towards strengthening opportunistic screening and the continued promotion of Pap smears in a range of clinic and community settings. It is important to place Pap smear screening in the context of other social, economic and health priorities for Aboriginal women and health workers.

Effects and sustainability of a cervical screening program in remote Aboriginal Australia

We assessed the effects of an organised cervical screening program, using a population-based cervical cytology register, for Aboriginal women in the Fitzroy Valley, a remote part of the Kimberley region of Western Australia. Comparison of age-specific screening rates in the area during 1987-88, 1990-92 and 1993-94 showed that establishing the program in late 1989 was accompanied by dramatic increases in cervical screening rates, ranging from two- to over fourfold, with the largest increases in women aged 50 years and over. Following the departure of the coordinator in early 1993, screening rates decreased to between 76 per cent and 29 per cent of their 1990-92 levels, with the largest decreases occurring in the 40-49 and 60-69 years age groups. Rates were still above 1987-88 levels for most age groups. Of 545 women screened during 1991-92, 65 per cent had undergone a second Pap smear within the follow-up period of two to four years. Among women recommended for a repeat smear in two years, the probability of having a second smear was negatively associated with age (log-rank statistic = 35.58, 4 df, P < 0.0001). Follow-up of smears recommended for repeat in 12 months or earlier was less adequate in 1993-94 (46 per cent) than in 1991-92 (75 per cent). The program was successful in recruiting a large proportion of eligible women within a relatively short time, but coverage, especially of older women, was not sustained after a decline in the functioning of the recall system owing to staffing and organisational changes.

Cost-effectiveness of interventions to promote cervical screening in general practice

A cost-effectiveness study of three different interventions to promote the uptake of screening for cervical cancer in general practice was carried out in Perth in 1991. Women eligible for a Pap smear were randomly allocated to one of four groups: one receiving letters with specific appointments to attend a screening clinic staffed by female doctors, one receiving letters informing them of the availability of the clinic and suggesting they make an appointment, one whose files were tagged to remind a doctor to offer a smear during a consultation, and a comparison control group that received opportunistic screening only. Variable and fixed costs for each group were itemised and summarised to give an average cost per smear taken. The cost and effectiveness of each intervention were then compared with those of the control group. Sensitivity analysis was performed on the major component of the costs, the doctor's time. Opportunistic screening cost $14.60 per smear and attained 16 per cent recruitment. Tagging files was the cheapest intervention ($14.75 per smear) although it was the least effective in recruiting women (20 per cent). This result held true for different scenarios of doctor's time allocated. Intervention by invitation letter with no appointment cost $45.35 per smear and attained 26 per cent recruitment, and intervention with a specific appointment cost $48.21 per smear and attained 30 per cent recruitment. Compared with the control group, the incremental cost-effectiveness for the tagged group was $15.40, for the letter-without-appointment group $97.75 and for the letter-with-appointment group $86.50.

Cervical cancer screening for hospital inpatients: report of an intervention study

A pilot study of a cervical cancer screening service was carried out at a major teaching hospital in Perth. The service, for women inpatients aged 20 to 69 years, was staffed by a women's health nurse. The effect of providing the service (service) was compared with giving a leaflet on Pap smears to eligible women (education) and with no intervention (control). Of 517 women in the service group, 184 (36 per cent) needed a Pap smear and were well enough to be offered screening; only 29 of 184 (16 per cent) refused and 132 of 184 (72 per cent) were screened. Of those screened, 29 per cent had never had a Pap smear. Information on women in the education and control groups was obtained by mailed questionnaire. Of the eligible women in the service group, 72 per cent accepted screening in hospital, but only 24 per cent of eligible women in the education group and 20 per cent in the control group reported having a Pap smear in the four months since leaving hospital. The service group showed a very large effect relative to the control group (odds ratio (OR) 17.71, 95 per cent confidence interval (CI) 10.05 to 31.22), but there was no significant difference between the education and control groups. Other significant variables in the logistic regression model were age, marital status, and sex of the woman's general practitioner. The effect of offering the service was greater for women over 50 (OR 51.51, CI 19.01 to 139.60) A hospital-based cervical screening service provides an important opportunity for screening women who are not being reached by other services.

Cervical screening in general practice

This study examined the effect of three interventions for encouraging women to have a Pap smear in a general practice: tagging the medical record to remind the doctor to offer a Pap smear, sending an invitation to make an appointment for a Pap smear, and sending an invitation with an appointment to attend for a Pap smear at a special screening clinic staffed by women. The study took place in a university general practice at Lockridge, near Perth. A computerised practice age-sex register provided 2139 women in the age range 36 to 69 inclusive. Of these, 757 were eligible for inclusion in the study and were allocated randomly to one of three intervention groups or a control group. In total, 177 women had a Pap smear during the study. Significantly more Pap smears were taken for the appointment-letter and letter-only groups than the control group (odds ratio (OR) 2.13, 95% confidence interval (CI) 1.34 to 3.57, and OR 1.67, CI 1.01 to 2.77 respectively), but there was no significant difference between the tagged-notes and the control groups. Women who attended the screening clinic rated the experience positively. Attendance, however, was inadequate for the clinic's viability in a private practice.

Cervical cancer screening in Western Australia in 1992: progress since 1983

OBJECTIVES

To estimate the rate of cervical cancer screening in Western Australia in 1992, and any variation by age, place of residence, and socio-economic status; and to determine the proportion of smears taken by different service providers.

DESIGN

Descriptive study; collection of data from Papanicolaou (Pap) smear request forms during one calendar month.

SETTING

All 13 cytology laboratories in Western Australia.

PARTICIPANTS

15,767 women in Western Australia aged 15 years and over having a cervical smear in March 1992.

MAIN OUTCOME MEASURES

Rates by age of cervical cancer screening per 1000 woman-years; age-standardised rate ratios for socioeconomic status and place of residence; proportion of smears taken by male and female service providers.

RESULTS

The estimated rate of Pap smears at ages 15 years and over was 303 smears per 1000 woman-years, an increase of 44% over a similar survey in 1983. The greatest increases were among women aged 50 years and over, but their rates were still well below that equivalent to three-yearly smears. Differences in the rate of screening by socioeconomic status (defined by residential postcode) were not statistically significant. The age-standardised rate ratio comparing country women with women in the Perth metropolitan area was 0.91 (95% confidence interval 0.87-0.94). General practitioners took 78% of the smears, and at least 46% of all smears were taken by female service providers. Almost all the increase in the screening rate since 1983 could be attributed to an increase in the rate of smears per 1000 woman-years taken by female general practitioners.

CONCLUSION

While there have been marked improvements in the rates of cervical screening in Western Australia over the past nine years, there are still major deficiencies in the screening coverage of women aged 50 years and over.

The Fitzroy Valley Pap Smear Register. Cervical screening in a population of Australian aboriginal women

OBJECTIVE

To describe the operation of the Fitzroy Valley Pap Smear Register, a population-based call and recall system for cervical screening for Aboriginal women, and the prevalence of cervical abnormalities in the women screened.

DESIGN

Descriptive study.

SETTING

An Aboriginal community in the far north-west of Western Australia.

PARTICIPANTS

Aboriginal women aged 15 to 69 years, living in the Fitzroy Valley, Kimberley region.

MAIN OUTCOME MEASURES

Proportion of eligible women on the Register; age distribution of women screened; prevalence of squamous cell abnormalities.

RESULTS

In December 1990, there were 507 Aboriginal women on the Register, being 86.9% of the Aboriginal women in the Fitzroy Valley aged 15-69 years. During 1990, 53.6% of the target population were screened; 369 Pap smears were taken from 312 Aboriginal women. Seventy-six (24.3%) had never previously been screened. Considering only the first smear for each woman in the study period, 10.6% showed minor abnormalities, and 1.6% (95% confidence interval [CI], 0.2%-3.0%) had cervical intraepithelial neoplasia (CIN I, II or III); 2.6% has smears showing definite evidence of human papillomavirus (HPV) infection. For 15-19 year olds the prevalence of CIN was 4.7% (95% CI, 1.0%-13.3%).

CONCLUSIONS

The study shows how an inexpensive call and recall system can ensure good coverage of cervical screening in a group of women who would otherwise be under-screened. The overall prevalence of CIN in Aboriginal women in the Fitzroy Valley was lower than the figure for all Victorian women (3.6%--data from the Victorian Cytology Service). Although the numbers are small, the relatively high prevalence of CIN in young women is of some concern, and emphasises the importance of regular screening in this group.

Genitourinary tract infections in pregnancy and low birth weight: case-control study in Australian aboriginal women

OBJECTIVE

To investigate the association between genital and urinary tract infections in pregnant Aboriginal women and low birth weight.

DESIGN

Retrospective case-control study controlling for potential confounding variables.

SETTING

Western Australia from 1985 to 1987.

SUBJECTS

All Aboriginal women (n = 269) who had given birth to singleton infants weighing 2250 g or less (cases), and 269 randomly selected Aboriginal women who had given birth to singleton infants weighing 3000 g or more (controls).

MAIN OUTCOME MEASURES

Proportions of women in case and control groups who had had genital and urinary tract infections; odds ratios for low birth weight when genitourinary tract infection was present; population attributable fraction of low birth weight to genitourinary tract infection.

RESULTS

At the time of delivery 51% of women in the case group (109/215) had genitourinary tract infections compared with 13% of controls (35/266). After controlling for potential confounding variables the odds ratio for giving birth to infants weighing 2250 g or less when genitourinary tract infection was present was 4.0 (95% confidence interval 2.3 to 7.0). The proportion of infants with low birth weight attributable to genitourinary tract infection in the whole population of Aboriginal women was 32% (95% confidence interval 17% to 49%).

CONCLUSIONS

There was a strong association between low birth weight and the presence of genitourinary tract infections in Aboriginal women both during pregnancy and at the time of delivery. A community intervention trial of screening and treatment of genitourinary infections in this population is recommended.

Are consumers provided with adequate information on the actions and uses of ipecacuanha syrup?

The results of a study to assess the level of consumer information about the action and uses of Ipecacuanha Syrup (Emetic) Australian Pharmaceutical Formulary (APF) are reported. Of 40 community pharmacies selected at random from the 321 pharmacies in the Perth metropolitan area, four were unable to supply the syrup. Dosage information provided on the labels of branded products was, for the most part, comprehensive and in line with APF recommendations. Syrup samples dispensed under pharmacy labels provided much less detailed dose information and no information on contraindications on the labels. Counselling by pharmacists was mostly adequate, but information provided by pharmacy assistants was much less detailed. The active alkaloid content of about 77% of the samples of ipecacuanha syrup was within +/- 12% of the target concentration; the remainder had only 56%-58% of the required alkaloid concentration, which indicates a need for more stringent quality control.

Circumcision and sexually transmissible disease

The relationship between circumcision and sexually transmissible disease was studied in 1350 men who attended the Public Health Department Special Treatment Clinic in Perth, Western Australia. Evidence of circumcision was obtained by examination. More than 98% of the men studied gave a verbal report of their circumcision status which was consistent with the examination findings. Eight hundred and forty-eight men had STD; 471 men, who presented to the clinic for diagnosis and treatment but who were found not to have STD, constituted the control group. The results of the study show significant associations between the state of being uncircumcised and four major sexually transmissible diseases--herpes genitalis, candidiasis, gonorrhoea and syphilis. Estimates of the relative risk suggest that uncircumcised men are twice as likely as circumcised men to develop herpes genitalis or gonorrhoea, and five times as likely to develop candidiasis or syphilis. However, the data for syphilis should be interpreted with caution because of the small number of cases. No significant increase in risk was found for any of the other sexually transmissible diseases diagnosed at the clinic.

Teenage pregnancies in Western Australia

Examination of fertility rates among teenagers in Western Australia from 1968 to 1978 revealed a steady decline n the birth rate among older teenagers (16-19); a similar decline did not occur among girls under 16. an increasing proportion of teenage births is occurring to these young teenagers. Information obtained from a linked file of birth and perinatal death registrations in Western Australia over the same period indicates that the infants of young teenage mothers have a substantially higher risk of low birthweight and perinatal death than infants of older mothers. The presence of this high-risk group of very young teenagers needs to be emphasized, as it is usually masked by presentation of data on all teenagers as a group. The authors recommended the involvement of special adolescent units in the prevention and management of teenage pregnancy.