Division of Population, Health Sciences and Education, St George s, University of London, London, UK 2

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1 Deveoping and pioting a peer mentoring intervention to reduce teenage pregnancy in ooked-after chidren and care eavers: an exporatory randomised controed tria Giian Mezey, 1* Deborah Meyer, 1 Fiona Robinson, 1 Chris Bone, 2 Rona Campbe, 3 Steve Giard, 1 Peter Jordan, 4 Nadia Mantovani, 1 Kaye Weings 5 and Sarah White 1 1 Division of Popuation, Heath Sciences and Education, St George s, University of London, London, UK 2 Socia Science Research Unit, Facuty of Chidren and Learning, Institute of Education, London, UK 3 Schoo of Socia and Community Medicine, University of Bristo, Bristo, UK 4 Peter Jordan Associates, London, UK 5 Department of Heath Services Research and Poicy, Facuty of Pubic Heath and Poicy, London Schoo of Hygiene and Tropica Medicine, London, UK *Corresponding author Decared competing interests of authors: Rona Campbe receives persona fees from the Wecome Trust for work as a member of an Expert Review Group. She is aso Director of DECIPHer Impact Limited, a not-for-profit company that is whoy owned by the University of Bristo and Cardiff University. Pubished October 2015 DOI: /hta19850 Scientific summary Reduce teenage pregnancy in LAC and care eavers Heath Technoogy Assessment 2015; Vo. 19: No. 85 DOI: /hta19850 NIHR Journas Library

2 SCIENTIFIC SUMMARY: REDUCE TEENAGE PREGNANCY IN LAC AND CARE LEAVERS Scientific summary Background Teenage pregnancy is associated with a range of adverse heath and socia outcomes and is recognised as a major pubic heath issue. Looked-after chidren (LAC) who have been in care have the highest rates of teenage pregnancy (for ease of reference, throughout the text we use the term ooked-after chidren or LAC to refer to both chidren and young women who are, or who have been, in care). Interventions that have been introduced in the past decade to combat this probem, such as improved sex and reationships education in schoos, have resuted in a fa in the rate of teenage pregnancy in the UK popuation generay but this fa has not been mirrored amongst LAC. Girs and young women within the care system have often experienced a range of adverse eary ife experiences that brought them into care and, for some of them, becoming a mother represents an opportunity to fee a sense of achievement and to combat feeings of worthessness and ow sef-esteem. Having access to a mentor may hep young women to deveop a sense of emotiona security, sef-esteem and confidence, as we as providing an opportunity to deiver important messages around sexuaity, reationships and eary pregnancy. There is some evidence of mentoring programmes enabing young peope to make positive decisions and choices in their ives, particuary around their education and persona deveopment. Young peope often report the need to tak to someone of a simiar age and background, athough there have been few evauations of the effectiveness of peer mentoring interventions in young peope and none that target pregnancy or sexua reationships using an experimenta design in LAC. Intervention A peer mentoring intervention for chidren and young peope who have been in care was deveoped and pioted (Phase I) foowed by an exporatory randomised controed tria (RCT) (Phase II), based on the Medica Research Counci s origina framework for evauating compex interventions. The components of the peer mentoring intervention were informed by a scoping exercise and targeted iterature review to identify existing exampes of, and evidence for, the effectiveness of peer mentoring and other interventions to reduce teenage pregnancy and mentoring and peer mentoring in LAC and non-lac, both to reduce pregnancy and in reation to other areas such as education. A behaviour determinants intervention (BDI) ogic mode was designed to describe and expain the intended causa mechanism of the intervention. Study aim, objectives and research questions The aim of the study was to deveop a peer mentoring intervention to reduce teenage pregnancy in LAC and to undertake an exporatory RCT. This tria did not aim to (and therefore was not powered to) study intervention effects. The objectives were to: deveop a compex intervention to reduce teenage pregnancy in girs and young women who are ooked after conduct an exporatory RCT of the intervention in three oca authorities (LAs) in Engand assess the feasibiity of a Phase III tria based on the foowing criteria: avaiabiity of eigibe participants; recruitment and retention of mentors and mentees; acceptabiity of consent and randomisation; evidence of harm to participants; appropriateness of proposed outcome measures; costs for a future fu-scae Phase III tria; and abiity to manuaise the intervention ii NIHR Journas Library

3 HEALTH TECHNOLOGY ASSESSMENT 2015 VOL. 19 NO. 85 (SCIENTIFIC SUMMARY) determine the costs of the intervention and deveop a mode of the running costs suitabe for estimating the costs of a arger tria embed a process evauation within the exporatory tria to assess the acceptabiity and feasibiity of the intervention and the tria procedures to LAC and those working as mentors. Methods The piot (Phase I) was conducted in one LA with four mentor mentee dyads. Phase II consisted of an exporatory RCT of the intervention in three LA areas. The target was to recruit 48 LAC mentees (young women aged years) and 24 care eaver mentors (young women aged years). The LAC mentees were individuay randomised in the exporatory tria, stratified by LA, using bocking, with haf receiving the peer mentor intervention and haf receiving usua support. A mentor training package was deveoped. Adjustments were made to recruitment methods and the training for the exporatory tria foowing feedback received from participants, trainers and LA professionas. Data were obtained from the foowing sources: observation of the training programme; semistructured individua interviews with a mentors and mentees and the usua support group at baseine and 1 year; anaysis of seected measures of psychoogica heath and hep seeking; information regarding sexua activity, pregnancy and reationships; interviews with mentors post training; interviews with project co-ordinators (PCs); focus groups with LA staff and socia care professionas; and nationa surveys of young peope in care, directors of chidren s services and socia workers regarding the acceptabiity of the intervention and the feasibiity of a Phase III tria. Project co-ordinators were asked to record the time that they spent managing the intervention and any costs incurred. Mentors were aso asked to record the time spent on activities with their mentee and retain records of a expenses. The process evauation was informed by semistructured interviews with mentors, mentees and PCs and mentor diary data, focus groups, survey data and interviews with other professionas. Resuts The peer mentoring intervention for LAC was unsuccessfu, argey because of the inappropriateness of this intervention within a LA context. Difficuties were encountered in meeting the recruitment target for both the piot and the exporatory tria, with ony 54% (26 LAC) of target recruitment reached for the exporatory tria. Thirteen out of 20 mentors (65%) and 19 out of 30 participants aged years (63%) (recruited during Phases I and II) were retained for the research. The training programme for mentors was acceptabe to mentors and coud be manuaised and repicated. Difficuties in recruiting the target number of mentors and mentees deayed the start of the intervention. LAs acked the infrastructure or resources to be abe to manage the intervention effectivey, the PCs found it difficut to prioritise the demands of the research without additiona resources and support from senior management and socia workers tended to act as informa gatekeepers, which imited access to potentia participants. Queen s Printer and Controer of HMSO This work was produced by Mezey et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. iii

4 SCIENTIFIC SUMMARY: REDUCE TEENAGE PREGNANCY IN LAC AND CARE LEAVERS Randomisation was acceptabe to the young peope and mentees appeared to vaue the intervention. However, weeky meetings were not feasibe and ony one in four of the reationships continued for the fu year. Mentees were irreguar in their attendance at meetings. Mentors aso found it difficut to set up meetings or to compy with a of the requirements of the roe, incuding competion of contact diaries, keeping a record of expenses and ensuring that a contacts were safe and communicated to members of their professiona network. Mentors and socia workers considered that more individua and group support woud need to be provided in any future tria. There was no evidence of harm to any of the participants. The study did not aim to detect intervention effects and acked both statistica power and intervention duration to be abe to do so. However, anaysis of quaitative data was indicative of improved sef-esteem and decision-making in the intervention group, especiay around socia networks and education, as had been anticipated in the BDI ogic mode. Mentors aso reported increased confidence and sef-efficacy. There was a sufficient poo of potentia participants for a peer mentoring intervention in a future Phase III tria. However, various changes woud be required for such a tria: peer mentoring shoud be deivered in an individua and a group format, with sex and reationship education best deivered within a group setting; the project woud need to be managed internay by LAs athough deivered in coaboration with an externa agency such as a charity or the third sector; and LAs woud need to receive research support costs to be abe to ensure dedicated PC time to support recruitment and retention of mentees and mentors. In future, mentees shoud be recruited at a younger age, from around 12 years (instead of 14 years), based on the fact that many of them were aready sexuay active by the age of 14 years, and mentors woud need to be oder (21 28 years), based on the reative vunerabiity and immaturity of this group. Formaised structures for recruiting and seecting mentors and ensuring that they have the capacity, as we as the wiingness, to deiver the mentoring in a consistent and responsibe way shoud be introduced. The data do not aow us to be abe to address whether a peer mentoring programme is effective in reducing rates of teenage pregnancy. The measures used were acceptabe and appropriate athough, given the size of the sampe, we are unabe to comment on the impact of the intervention on hep seeking, attachment or other psychoogica measures reated to genera anxiety, sef-esteem and ocus of contro. Young peope were happy to answer questions reated to sexuaity and reationships. Concusions and recommendations The intervention as it was impemented in this study was not appropriate in this setting and was unsuccessfu. A Phase III tria of peer mentoring in the future woud require more resources for participating LAs, better structure, both within the mentoring programme and the management of the project, and more individua and group support for mentors. A new deveopment phase to adapt the intervention manua in ine with the findings from this study foowed by a sma-scae exporatory intervention, incorporating the changes recommended by participants and based on our findings, woud be necessary before proceeding to a Phase III tria. Funding Funding for this study was provided by the Heath Technoogy Assessment programme of the Nationa Institute for Heath Research. iv NIHR Journas Library

5 Heath Technoogy Assessment HTA/HTA TAR ISSN (Print) ISSN (Onine) Impact factor: Heath Technoogy Assessment is indexed in MEDLINE, CINAHL, EMBASE, The Cochrane Library and the ISI Science Citation Index. This journa is a member of and subscribes to the principes of the Committee on Pubication Ethics (COPE) ( Editoria contact: nihredit@southampton.ac.uk The fu HTA archive is freey avaiabe to view onine at Print-on-demand copies can be purchased from the report pages of the NIHR Journas Library website: Criteria for incusion in the Heath Technoogy Assessment journa Reports are pubished in Heath Technoogy Assessment (HTA) if (1) they have resuted from work for the HTA programme, and (2) they are of a sufficienty high scientific quaity as assessed by the reviewers and editors. Reviews in Heath Technoogy Assessment are termed systematic when the account of the search appraisa and synthesis methods (to minimise biases and random errors) woud, in theory, permit the repication of the review by others. HTA programme The HTA programme, part of the Nationa Institute for Heath Research (NIHR), was set up in It produces high-quaity research information on the effectiveness, costs and broader impact of heath technoogies for those who use, manage and provide care in the NHS. Heath technoogies are broady defined as a interventions used to promote heath, prevent and treat disease, and improve rehabiitation and ong-term care. The journa is indexed in NHS Evidence via its abstracts incuded in MEDLINE and its Technoogy Assessment Reports inform Nationa Institute for Heath and Care Exceence (NICE) guidance. HTA research is aso an important source of evidence for Nationa Screening Committee (NSC) poicy decisions. For more information about the HTA programme pease visit the website: This report The research reported in this issue of the journa was funded by the HTA programme as project number 08/20/03. The contractua start date was in March The draft report began editoria review in January 2014 and was accepted for pubication in August The authors have been whoy responsibe for a data coection, anaysis and interpretation, and for writing up their work. The HTA editors and pubisher have tried to ensure the accuracy of the authors report and woud ike to thank the reviewers for their constructive comments on the draft document. However, they do not accept iabiity for damages or osses arising from materia pubished in this report. This report presents independent research funded by the Nationa Institute for Heath Research (NIHR). The views and opinions expressed by authors in this pubication are those of the authors and do not necessariy refect those of the NHS, the NIHR, NETSCC, the HTA programme or the Department of Heath. If there are verbatim quotations incuded in this pubication the views and opinions expressed by the interviewees are those of the interviewees and do not necessariy refect those of the authors, those of the NHS, the NIHR, NETSCC, the HTA programme or the Department of Heath. Queen s Printer and Controer of HMSO This work was produced by Mezey et a. under the terms of a commissioning contract issued by the Secretary of State for Heath. This issue may be freey reproduced for the purposes of private research and study and extracts (or indeed, the fu report) may be incuded in professiona journas provided that suitabe acknowedgement is made and the reproduction is not associated with any form of advertising. Appications for commercia reproduction shoud be addressed to: NIHR Journas Library, Nationa Institute for Heath Research, Evauation, Trias and Studies Coordinating Centre, Apha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Pubished by the NIHR Journas Library ( produced by Prepress Projects Ltd, Perth, Scotand (

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