Article

School-based interventions for preventing HIV, sexually transmitted infections, and pregnancy in adolescents

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Abstract

Background School-based sexual and reproductive health programmes are widely accepted as an approach to reducing high-risk sexual behaviour among adolescents. Many studies and systematic reviews have concentrated on measuring effects on knowledge or self-reported behaviour rather than biological outcomes, such as pregnancy or prevalence of sexually transmitted infections (STIs). Objectives To evaluate the effects of school-based sexual and reproductive health programmes on sexually transmitted infections (such as HIV, herpes simplex virus, and syphilis), and pregnancy among adolescents. Search methods We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) for published peer-reviewed journal articles; and ClinicalTrials.gov and the World Health Organization's (WHO) International Clinical Trials Registry Platform for prospective trials; AIDS Educaton and Global Information System (AEGIS) and National Library of Medicine (NLM) gateway for conference presentations; and the Centers for Disease Control and Prevention (CDC), UNAIDS, the WHO and the National Health Service (NHS) centre for Reviews and Dissemination (CRD) websites from 1990 to 7 April 2016. We handsearched the reference lists of all relevant papers. Selection criteria We included randomized controlled trials (RCTs), both individually randomized and cluster-randomized, that evaluated school-based programmes aimed at improving the sexual and reproductive health of adolescents. Data collection and analysis Two review authors independently assessed trials for inclusion, evaluated risk of bias, and extracted data. When appropriate, we obtained summary measures of treatment effect through a random-effects meta-analysis and we reported them using risk ratios (RR) with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE approach. Main results We included eight cluster-RCTs that enrolled 55,157 participants. Five trials were conducted in sub-Saharan Africa (Malawi, South Africa, Tanzania, Zimbabwe, and Kenya), one in Latin America (Chile), and two in Europe (England and Scotland). Sexual and reproductive health educational programmes Six trials evaluated school-based educational interventions. In these trials, the educational programmes evaluated had no demonstrable effect on the prevalence of HIV (RR 1.03, 95% CI 0.80 to 1.32, three trials; 14,163 participants; low certainty evidence), or other STIs (herpes simplex virus prevalence: RR 1.04, 95% CI 0.94 to 1.15; three trials, 17,445 participants; moderate certainty evidence; syphilis prevalence: RR 0.81, 95% CI 0.47 to 1.39; one trial, 6977 participants; low certainty evidence). There was also no apparent effect on the number of young women who were pregnant at the end of the trial (RR 0.99, 95% CI 0.84 to 1.16; three trials, 8280 participants; moderate certainty evidence). Material or monetary incentive-based programmes to promote school attendance Two trials evaluated incentive-based programmes to promote school attendance. In these two trials, the incentives used had no demonstrable effect on HIV prevalence (RR 1.23, 95% CI 0.51 to 2.96; two trials, 3805 participants; low certainty evidence). Compared to controls, the prevalence of herpes simplex virus infection was lower in young women receiving a monthly cash incentive to stay in school (RR 0.30, 95% CI 0.11 to 0.85), but not in young people given free school uniforms (Data not pooled, two trials, 7229 participants; very low certainty evidence). One trial evaluated the effects on syphilis and the prevalence was too low to detect or exclude effects confidently (RR 0.41, 95% CI 0.05 to 3.27; one trial, 1291 participants; very low certainty evidence). However, the number of young women who were pregnant at the end of the trial was lower among those who received incentives (RR 0.76, 95% CI 0.58 to 0.99; two trials, 4200 participants; low certainty evidence). Combined educational and incentive-based programmes The single trial that evaluated free school uniforms also included a trial arm in which participants received both uniforms and a programme of sexual and reproductive education. In this trial arm herpes simplex virus infection was reduced (RR 0.82, 95% CI 0.68 to 0.99; one trial, 5899 participants; low certainty evidence), predominantly in young women, but no effect was detected for HIV or pregnancy (low certainty evidence). Authors' conclusions There is a continued need to provide health services to adolescents that include contraceptive choices and condoms and that involve them in the design of services. Schools may be a good place in which to provide these services. There is little evidence that educational curriculum-based programmes alone are effective in improving sexual and reproductive health outcomes for adolescents. Incentive-based interventions that focus on keeping young people in secondary school may reduce adolescent pregnancy but further trials are needed to confirm this. School-based interventions for preventing HIV, sexually transmitted infections, and pregnancy in adolescents Cochrane researchers conducted a review of the effects of school-based interventions for reducing HIV, sexually transmitted infections (STIs), and pregnancy in adolescents. After searching for relevant trials up to 7 April 2016, they included eight trials that had enrolled 55,157 adolescents. Why is this important and how might school-based programmes work? Sexually active adolescents, particularly young women, are at high risk in many countries of contracting HIV and other STIs. Early unintended pregnancy can also have a detrimental impact on young people's lives. The school environment plays an important role in the development of children and young people, and curriculum-based sexuality education programmes have become popular in many regions of the world. While there is some evidence that these programmes improve knowledge and reduce self-reported risk taking, this review evaluated whether they have any impact on the number of young people that contracted STIs or on the number of adolescent pregnancies. What the research says Sexual and reproductive health education programmes As they are currently configured, educational programmes alone probably have no effect on the number of young people infected with HIV during adolescence (low certainty evidence). They also probably have no effect on the number of young people infected with other STIs (herpes simplex virus: moderate certainty evidence; syphilis: low certainty evidence), or the number of adolescent pregnancies (moderate certainty evidence). Material or monetary incentive-based programmes to promote school attendance Giving monthly cash, or free school uniforms, to encourage students to stay in school may have no effect on the number of young people infected with HIV during adolescence (low certainty evidence). We do not currently know whether monthly cash or free school uniforms will reduce the number of young people infected with other STIs (very low certainty evidence). However, incentives to promote school attendance may reduce the number of adolescent pregnancies (low certainty evidence). Combined educational and incentive-based programmes Based on a single included trial, giving an incentive such as a free school uniform combined with a programme of sexual and reproductive health education may reduce STIs (herpes simplex virus; low certainty evidence) in young women, but no effect was detected for HIV or pregnancy (low certainty evidence). Authors' conclusions There is currently little evidence that educational programmes alone are effective at reducing STIs or adolescent pregnancy. Incentive-based interventions that focus on keeping young people, especially girls, in secondary school may reduce adolescent pregnancy but further high quality trials are needed to confirm this.

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... De La Rue et al and Fellmeth et al examined dating violence, 51,52 Walsh et al examined sexual abuse, 53 and the remaining 7 reviews examined sexually risky behavior (including interventions to prevent unintended pregnancies, encourage the use of contraceptives, and prevent sexually transmitted diseases). 10,[54][55][56][57][58][59] To address dating violence, educational programs containing an additional component, such as self-defense and communication skills, were provided. 51,52 To address sexual abuse, educational programs focusing on sexual-abuse awareness and prevention concepts, as well as self-defense skills, were provided. ...
... 53 Regarding interventions for preventing sexually risky behavior, sex education that emphasized abstinence and contraception, 54,55,58,59 cognitive and behavioral training with lessons on emergency contraception, 56 and monetary incentive programs for promoting school attendance were reported. 57,58 Most participants in these studies were teenagers, and providers included teachers, school psychologists, counselors, social workers, school nurses, police officers, researchers, and graduate/medical students. ...
... low certainty evidence). 57 Multiple risk behavior interventions may not be effective for preventing engagement in sexually risky behaviors. 10 Substance use/abuse. ...
Article
BACKGROUND Universal prevention approaches that target the general population can be effective for promoting children's health. This overview aims to summarize evidence presented in existing reviews of school‐based interventions. METHODS We present an overview of evidence sourced from Campbell and Cochrane systematic reviews. These reviews examined randomized controlled trials concerning school‐based health‐promotion programs for children (mostly aged 4‐18 years) in the general population. RESULTS We identified 56 high‐quality reviews. The reviews focused on emotional and behavioral outcomes, infectious diseases, injury reduction, mental health, nutrition intake, oral health, physical and developmental changes, sense‐organ diseases, sexual‐health outcomes, and substance use/abuse. Positive evidence—such as vision screening plus provision of free spectacles for spectacle wear increase and a combination of social competence and social‐influence approaches for preventing illicit drug use—were considered high certainty. CONCLUSIONS Of the various interventions implemented in school settings that involved people from various occupations, some positive effects were found. In most cases, evidence certainty was negatively affected by a high risk of bias within studies, inconsistencies within the estimates, and insufficient sample sizes. Further primary studies in these areas would be helpful for accumulating evidence to promote stronger cooperation between health and education stakeholders.
... The national epidemic is largely heterogeneous, influenced by sexual networks, multiple deprivation, migration and poor access to SRHR services [6][7][8][9]. Adolescent girls and young women (AGYW) aged [15][16][17][18][19][20][21][22][23][24] years are at the greatest risk of acquiring new HIV infections, with an estimated 1300 new infections every week [9]. The KwaZulu-Natal (KZN) province has the highest HIV prevalence amongst pregnant women attending state clinics (44.4%), with 18% of these being teenagers [10]. ...
... School-based SRHR programmes have the capacity to reach the underserviced in a holistic manner [22]. There is, however, mixed evidence on the effectiveness of SRHR school-based programmes and a paucity of data in sub-Saharan Africa [22][23][24]. Programmes have largely focussed on single interventions; either on behavioural change through comprehensive education or improving service delivery-and few uses a combination approach [15,19,22]. A meta-analysis on the effectiveness of school-based SRHR programmes suggests that educational programmes alone have limited impact on the SRHR outcomes of adolescents [24]. ...
... Programmes have largely focussed on single interventions; either on behavioural change through comprehensive education or improving service delivery-and few uses a combination approach [15,19,22]. A meta-analysis on the effectiveness of school-based SRHR programmes suggests that educational programmes alone have limited impact on the SRHR outcomes of adolescents [24]. ...
Article
Southern Africa remains the epicentre of the human immunodeficiency virus (HIV) epidemic with AIDS the leading cause of death amongst adolescents. Poor policy translation, inadequate programme implementation and fragmentation of services contribute to adolescents’ poor access to sexual and reproductive health and rights (SRHR) services. This study assessed an integrated, school-based SRHR and HIV programme, modelled on the South African Integrated School Health Policy in a rural, high HIV-prevalence district. A retrospective cohort study of 1260 high-school learners was undertaken to assess programme uptake, change in HIV knowledge and behaviour and the determinants of barrier-methods use at last sexual intercourse. Programme uptake increased (2%–89%; P�<�0.001) over a 16-month period, teenage-pregnancy rates declined (14%–3%; P�<�0.050) and accurate knowledge about HIV transmission through infected blood improved (78.3%–93.8%; P�<�0.050), a year later. Post-intervention, attending a clinic perceived as adolescent-friendly increased the odds of barrier-methods use during the last sexual encounter (aOR=1.85; 95% CI: 1.31–2.60), whilst being female (aOR=0.69; 95% CI: 0.48–0.99), <15 years (aOR=0.44; 95% CI: 0.24–0.80), or having >5 sexual partners in the last year (aOR=0.59; 95% CI: 0.38–0.91) reduced the odds. This study shows that the unmet SRHR needs of under-served adolescents can be addressed through integrated, school-based SRHR programmes.
... According to the AMSTAR II quality assessment tool's developers [42] scores may range from 1 to 16: in this case only 2 reviews scored 16 out of 16: 1 in a school setting [45], and 1 on a digital platform [46]. 6 of the 20 systematic reviews were of high quality: 5 in school settings [45,[47][48][49][50], and 1 in digital platforms [46]; there was one study of medium quality in a school setting [51]. ...
... According to the AMSTAR II quality assessment tool's developers [42] scores may range from 1 to 16: in this case only 2 reviews scored 16 out of 16: 1 in a school setting [45], and 1 on a digital platform [46]. 6 of the 20 systematic reviews were of high quality: 5 in school settings [45,[47][48][49][50], and 1 in digital platforms [46]; there was one study of medium quality in a school setting [51]. The remaining studies were of low or very low quality (N = 13). ...
... Ten studies (50%) dealt with school-based interventions [45,[47][48][49][50][51][52][53][54][55], 9 (45%) referred to online interventions [46,[56][57][58][59][60][61][62][63] and 1 (5%) was a review of blended learning programs [64]. In total 491 studies were included in the 20 reviews covered by the present RoR. ...
Article
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Adolescence, a period of physical, social, cognitive and emotional development, represents a target population for sexual health promotion and education when it comes to achieving the 2030 Agenda goals for sustainable and equitable societies. The aim of this study is to provide an overview of what is known about the dissemination and effectiveness of sex education programs and thereby to inform better public policy making in this area. Methodology: We carried out a systematic review based on international scientific literature, in which only peer-reviewed papers were included. To identify reviews, we carried out an electronic search of the Cochrane Database Reviews, ERIC, Web of Science, PubMed, Medline, Scopus and PsycINFO. This paper provides a narrative review of reviews of the literature from 2015 to 2020. Results: 20 reviews met the inclusion criteria (10 in school settings, 9 using digital platforms and 1 blended learning program): they focused mainly on reducing risk behaviors (e.g., VIH/STIs and unwanted pregnancies), whilst obviating themes such as desire and pleasure, which were not included in outcome evaluations. The reviews with the lowest risk of bias are those carried out in school settings and are the ones that most question the effectiveness of sex education programs. Whilst the reviews of digital platforms and blended learning show greater effectiveness in terms of promoting sexual and reproductive health in adolescents (ASRH), they nevertheless also include greater risks of bias. Conclusion: A more rigorous assessment of the effectiveness of sexual education programs is necessary, especially regarding the opportunities offered by new technologies, which may lead to more cost-effective interventions than with in-person programs. Moreover, blended learning programs offer a promising way forward, as they combine the best of face-to-face and digital interventions, and may provide an excellent tool in the new context of the COVID-19 pandemic.
... School-based programming focused on youth ages 17 years and below can be an effective vehicle to provide SRH education and promote positive behaviors given that many young people in this age group are in school or are required to be in school and spend a considerable amount of their time at school. Recent meta-analyses of school-based HIV and SRH prevention programs have demonstrated mixed results of their effect on prevention of adolescent pregnancy, sexually transmitted infections, and HIV in the United States [13,14], in low-and middle-income countries (LMIC) [15], and in global reviews [16]. Based on these reviews, it is not possible to recommend specific approaches that work for future pregnancy, STI, and HIV prevention programming for young people. ...
... The approaches used for the evaluations of pregnancy, STI, and HIV prevention programming use different outcomes and study methods. For example, one of the systematic reviews focused on LMIC included self-reported SRH outcomes (e.g., knowledge, attitudes, sexual initiation, condom use, and number of partners) [14], and another global review that identified eight eligible studies focused on health status outcomes such as incidence and prevalence of HIV, STIs, or pregnancy [16]. Furthermore, while most of the meta-analyses included randomized controlled trials (RCTs) and other study designs that were able to attribute impact to a program, many studies within the meta-analyses were ranked as having low to moderate levels of evidence [13][14][15][16]. ...
... For example, one of the systematic reviews focused on LMIC included self-reported SRH outcomes (e.g., knowledge, attitudes, sexual initiation, condom use, and number of partners) [14], and another global review that identified eight eligible studies focused on health status outcomes such as incidence and prevalence of HIV, STIs, or pregnancy [16]. Furthermore, while most of the meta-analyses included randomized controlled trials (RCTs) and other study designs that were able to attribute impact to a program, many studies within the meta-analyses were ranked as having low to moderate levels of evidence [13][14][15][16]. Finally, the studies from LMIC that examined self-reported outcomes generally showed that the school-based programs increased knowledge, selfefficacy, and condom use; however, these evaluations had weaker study designs [15] than the small number of studies that used RCTs and measured health status outcomes [16]. ...
Article
Full-text available
Background Young people under age 25 years are a key population at risk of unintended pregnancies, HIV and other sexually transmitted infections. School-based programming, focusing on youth under 17 years is strategic given that many in this age group are in school or are required to be in school and spend a considerable amount of their time at school. Prior evaluations of school-based HIV prevention programs for young people often employed weak study designs or lacked biomarkers (e.g., HIV or STI testing) to inform outcomes. Methods This study used longitudinal data collected in 2016 from a cohort of grade-8 girls from Mpumalanga and KwaZulu-Natal Provinces in South Africa. We followed them for 2 years to examine the impact of the South African Department of Basic Education’s revised scripted lesson plans for the HIV and sexual content of a “life orientation” curriculum on knowledge, attitudes, condom use behaviors, pregnancy incidence, and genital herpes incidence. Schools were randomized to intervention and control arms. Multivariable analyses were undertaken using hazard modeling for incidence-based outcomes (genital herpes and pregnancy) and generalized linear latent and mixed modeling for outcomes measured at each time period (knowledge, attitudes, and condom use). Results At end line, 105 schools were included from the two provinces (44 from Mpumalanga and 61 from KwaZulu-Natal). Fifty-five were intervention and fifty were control schools. A total of 2802 girls were surveyed at both time periods (1477 intervention and 1325 control). At baseline, participating girls were about 13.6 years; by end line, they were about 2 years older. Longitudinal data demonstrated few differences between intervention and control groups on knowledge, attitudes, condom use, genital herpes, and pregnancy experience. Monitoring data demonstrated that the program was not implemented as intended. Our results demonstrated 7% incidence of genital herpes in the two-year follow-up period indicating sexual risk-taking among our cohort. Conclusions We did not find significant effects of the revised life orientation curriculum on key outcomes; however, this may reflect poor implementation. Future HIV prevention programs for young people need to be implemented with fidelity to ensure they meet the crucial needs of the next generation. Trial Registration: This study has been registered at ClinicalTrials.gov . The trial registration number is: NCT04205721 . The trial was retrospectively registered on December 18, 2019.
... There is good evidence that RSE delivered in school classrooms can contribute to promoting sexual health, and preventing unintended pregnancies and STIs [22][23][24][25][26][27]. Features associated with effective RSE interventions include the following: addressing individual knowledge, attitudes, self-efficacy and skills; addressing gender and other social norms; and use of interactive, culturally appropriate methods and materials [22][23][24][25][26][27][28][29]. ...
... There is good evidence that RSE delivered in school classrooms can contribute to promoting sexual health, and preventing unintended pregnancies and STIs [22][23][24][25][26][27]. Features associated with effective RSE interventions include the following: addressing individual knowledge, attitudes, self-efficacy and skills; addressing gender and other social norms; and use of interactive, culturally appropriate methods and materials [22][23][24][25][26][27][28][29]. Informed by this evidence, Positive Choices is informed by an explicit theory of change to ensure it systematically addresses knowledge, attitudes, self-efficacy, skills and social norms; and uses interactive, culturally relevant methods. ...
... The above evidence indicates that Positive Choices meets a clear, evidenced, long-term need in terms of high prevalence of non-competence at first sex, STIs, unintended pregnancies, non-volitional sex, sexual violence and DRV, all of which are associated with major social and economic costs. Positive Choices is informed by previous systematic reviews [22][23][24][25][26][27] and by wholeschool and social marketing interventions with strong evidence of effectiveness [36-38, 40, 44, 45, 47] and has been successfully piloted. The phase III RCT will be informed by learning from the pilot RCTs of the Positive Choices and Project Respect interventions, and be the first UK RCT of a whole-school social marketing intervention. ...
Article
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Background Positive Choices is a whole-school social marketing intervention to promote sexual health among secondary school students. Intervention comprises school health promotion council involving staff and students coordinating delivery; student survey to inform local tailoring; teacher-delivered classroom curriculum; student-run campaigns; parent information; and review of sexual/reproductive health services to inform improvements. This trial builds on an optimisation/pilot RCT study which met progression criteria, plus findings from another pilot RCT of the Project Respect school-based intervention to prevent dating and relationship violence which concluded such work should be integrated within Positive Choices. Young people carry a disproportionate burden of adverse sexual health; most do not report competence at first sex. Relationships and sex education in schools can contribute to promoting sexual health but effects are small, inconsistent and not sustained. Such work needs to be supplemented by ‘whole-school’ (e.g. student campaigns, sexual health services) and ‘social marketing’ (harnessing commercial marketing to social ends) approaches for which there is good review-level evidence but not from the UK. Methods We will conduct a cluster RCT across 50 schools (minimum 6440, maximum 8500 students) allocated 1:1 to intervention/control assessing outcomes at 33 months. Our primary outcome is non-competent first sex. Secondary outcomes are non-competent last sex, age at sexual debut, non-use of contraception at first and last sex among those reporting heterosexual intercourse, number of sexual partners, dating and relationship violence, sexually transmitted infections, and pregnancy and unintended pregnancy for girls and initiation of pregnancy for boys. We will recruit 50 school and undertake baseline surveys by March 2022; implement the intervention over the 2022–2024 school years and conduct the economic and process evaluations by July 2024; undertake follow-up surveys by December 2024; complete analyses, all patient and policy involvement and draft the study report by March 2025; and engage in knowledge exchange from December 2024. Discussion This trial is one of a growing number focused on whole-school approaches to public health in schools. The key scientific output will be evidence about the effectiveness, costs and potential scalability and transferability of Positive Choices. Trial registration ISRCTN No: ISRCTN16723909. Trial registration summary: Date:. Funded by: National Institute for Health Research Public Health Research Programme (NIHR131487). Sponsor: LSHTM. Public/scientific contact: Chris Bonell. Public title: Positive Choices trial. Scientific title: Phase-III RCT of Positive Choices: a whole-school social marketing intervention to promote sexual health and reduce health inequalities. Countries of recruitment: UK. Intervention: Positive Choices. Inclusion criteria: Students in year 8 (age 12–13 years) at baseline deemed competent by schools to participate in secondary schools excluding pupil referral units, schools for those with special educational needs and disabilities, and schools with ‘inadequate’ Ofsted inspections. Study type: interventional study with superiority phase III cluster RCT design. Enrollment: 1/9/21-31/3/22. Sample size: 50 schools and 6440–8500 students. Recruitment status: pending. Primary outcome: binary measure of non-competent first sex. Secondary outcomes: non-competent last sex; age at sexual debut; non-use of contraception at first and last sex; number of sexual partners; dating and relationship violence (DRV) victimisation; sexually transmitted infections; pregnancy and unintended pregnancy for girls and initiation of pregnancy for boys using adapted versions of the RIPPLE measures. Ethics review: LSHTM research ethics committee (reference 26411). Completion data: 1/3/25. Sharing statement: Data will be made available after the main trial analyses have been completed on reasonable request from researchers with ethics approval and a clear protocol. Amendments to the protocol will be communicated to the investigators, sponsor, funder, research ethics committee, trial registration and the journal publishing the protocol. Amendments affecting participants’ experience of the intervention or important amendments affecting the overall design and conduct of the trial will be communicated to participants.
... hormone-based medication). [26][27][28][29] Evidence from older systematic reviews suggests that school-based sex education has an effect on sexual health knowledge and attitudes, but only some programmes delay sexual behaviour and increase condom use. 3 Shepherd et al. 25 are cautious about the impact of such programmes in bringing about behavioural change, acknowledging that significant changes in sexual health knowledge and self-efficacy (e.g. knowing how to use a condom) are more common. ...
... Studies rarely show an impact on biological markers, such as human immunodeficiency virus, herpes and syphilis, partly because these are relatively rare outcomes and require extremely large samples to detect an effect. 29 A number of contextual factors affect these outcomes. A review of process data from trials 30 suggests two key influences: (1) fidelity, influenced by the extent to which the school has a supportive culture, a flexible administration, and enthusiasm and expertise among those delivering the sexual health content; and (2) acceptability and engagement, influenced by enthusiasm, credibility and expertise of intervention providers, and relevance and enjoyment to young people. ...
Article
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Background Young people report higher levels of unsafe sex and have higher rates of sexually transmitted infections than any other age group. Schools are well placed to facilitate early intervention, but more effective approaches are required. Peer-led approaches can augment school-based education, but often fail to capitalise on mechanisms of social influence. The potential of using social media in sexual health has not been tested in school settings. Objectives Finalise the design of the Sexually Transmitted infections And Sexual Health (STASH) intervention; assess the recruitment and retention of peer supporters, and acceptability to participants and stakeholders; assess the fidelity and reach, in addition to the barriers to and facilitators of, implementation; refine programme theory; understand the potential of social media; determine design parameters for a future randomised controlled trial, including economic evaluation; and establish whether or not progression criteria were met. Design This was a feasibility study comprising intervention development and refinement of the STASH pilot and non-randomised feasibility trial in six schools. Control data were provided by students in the year above the intervention group. Setting Secondary schools in Scotland. Participants Students aged 14–16 years, teachers and intervention delivery partners. Interventions The STASH intervention was adapted from A Stop Smoking In Schools Trial (ASSIST) (an effective peer-led smoking intervention). Based on diffusion of innovation theory, the STASH study involves peer nomination to identify the most influential students, with the aim of recruiting and training 15% of the year group as peer supporters. The peer supporters deliver sexual health messages to friends in their year group via conversations and use of Facebook ( www.facebook.com ; Facebook, Inc., Menlo Park, CA, USA) to share varied content from a curated set of web-based resources. Peer supporters are given support themselves via follow-up sessions and via trainer membership of Facebook groups. Main outcome measures The primary outcome was whether or not progression criteria were met in relation to intervention acceptability and feasibility. The study also piloted indicative primary outcomes for a full-scale evaluation. Data sources Peer supporter questionnaire; observations of activities; interviews with trainers, teachers, peer supporters and students; monitoring log of peer supporter activities (including on Facebook and meeting attendance); questionnaire to control year group (baseline characteristics, social networks, mediators and sexual health outcomes); baseline and follow-up questionnaire (approximately 6 months later) for intervention year group. Results A total of 104 students were trained as peer supporters (just over half of those nominated for the role by their peers). Role retention was very high (97%). Of 611 students completing the follow-up questionnaire, 58% reported exposure to STASH study activities. Intervention acceptability was high among students and stakeholders. Activities were delivered with good fidelity. The peer supporters were active, representative of their year group and well connected within their social network. Carefully managed social media use by peer supporters augmented conversations. A primary outcome of ‘always safer sex’ was identified, measured as no sex or always condom use for vaginal or anal sex in the last 6 months. The intervention cost £42 per student. Six progression criteria were met. A seventh criterion (regarding uptake of role by peer supporters) was not. Limitations Small feasibility study that cannot comment on effectiveness. Conclusions The STASH intervention is feasible and acceptable within the context of Scottish secondary schools. The results support continuation to a full-scale evaluation. Future work Small-scale improvements to the intervention, refinement to programme theory and funding sought for full-scale evaluation. Trial registration Current Controlled Trials ISRCTN97369178. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research ; Vol. 8, No. 15. See the NIHR Journals Library website for further project information.
... The Theory of Planned Behavior extends the Theory of Reasoned Action by adding degree of perceived personal control over it (Ajzen, 1991). Sexual risk reduction programs based only on these cognitive theories have small, short-term effects, prompting researchers to apply socioecological perspectives (Bronfenbrenner, 1977;Miller et al., 2000;Kotchick et al., 2001;Coates et al., 2008;Protogerou and Johnson, 2014;Atkiss et al 2011;Mason-Jones et al., 2016) that emphasize positive youth development, gender norms, relationship status, and developmental stage. Ecodevelopmental Theory (Perrino et al., 2000;Pantin et al., 2004) adds a developmental perspective-the person and context change over time (Pantin et al., 2004). ...
... Interventions for 12-14 year olds demonstrate mixed results (Coyle et al., 2004;Mason-Jones et al., 2016;Nelson et al., 2016). "For Keeps" (Borawski et al., 2005) increased HIVrelated knowledge and decreased intentions to have intercourse but did not influence sexual initiation or condom use. ...
Article
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Despite calls for evidence-based HIV/STI prevention programs for youth aged 12 to 14 transitioning to adolescence, few effective programs exist. In a two-group intent-to-treat randomized trial in the Bronx, NY, 397 participants were randomly assigned to Project Prepared or an attention control, TEEN. Participants completed surveys at baseline, 6 months, and 12 months. Prepared had two components, an 11-session program and a 3-week internship. Content covered sexual risk behavior, social cognitions, gender norms, relationships, and resilience. TEEN built communication skills and had the same intensity and structure as Prepared but no sexual content. In both, boys and girls were trained together in mixed groups of ~ 11 teens. Primary outcomes were HIV knowledge, self-efficacy, condom outcome expectancy, and behavioral intentions. Secondary outcomes were relationship expectations and endorsement of risky gender norms. Generalized estimating equation analyses showed youth randomized to Prepared had significant improvements compared to TEEN at T2 in HIV knowledge, sexual self-efficacy, and outcome expectancy for condom use. At T3, there were significant differences favoring Prepared in outcome expectancy for condom use, sexual self-efficacy, and intention for partner communication about HIV/AIDS or STIs. Analyses by gender showed program effects in both boys (intention to talk to a partner about condom use, abstinence self-efficacy, sexual self-efficacy, and condom outcome expectancy) and girls (gender norms, and abstinence outcome expectancy). Prepared effectively reduced risk in young adolescents. ClinicalTrials.gov ID: NCT01880450, Protocol ID: 2008-551
... 4 University plays an important role in the development of peer relationships that may influence individual and group behaviors beyond other local communities. 5 A large proportion of U.S. young people have entered college with sexual experience. 6 The recent research indicated that the mean age of first sexual intercourse is around 17 years old. ...
... Few studies among Chinese population were included in the previous systematic review about intervention to promote safer sex practices. 5,77 This may be because fewer studies among Chinese population would be published in English. After we searched the Chinese dataset, some studies in Chinese population indeed were included in our systematic review. ...
Article
Objective This study aims to critically review the characteristics and effectiveness of university-based intervention to promote safer sex practice. Participants and Methods The published studies were selected from 5 databases with the publication year restricted between 1974 and 2018. The data were then pooled using a random-effect meta-analysis. Results A total of 41 studies with 10,144 participants were included from 5,253 potentially relevant citations. Compared with minimal intervention, those people who participated in the intervention reported a statistically significant increase in the frequency of condom use (SMD 0.61; 95%CI 0.46–0.77, I² = 9%). There was an insignificant change after the intervention (SMD 0.34; 95%CI −0.04–0.72, I² = 72%) in communication with sexual partners and the heterogeneity existed in diversity of sessions of the intervention. Conclusion Behavioral interventions can significantly increase in the frequency of condom use but not in communication with sexual partners. A standardized measurement is a necessary consideration for future studies.
... It is also necessary to realize that structural health determinants, such as the provision of continuing secondary education, are important aspects to be addressed to improve adolescents' sexual and reproductive results, especially in less favored regions 41 . Ideally starting with the family, but in conjunction with the school and health services 41,42 . ...
... It is also necessary to realize that structural health determinants, such as the provision of continuing secondary education, are important aspects to be addressed to improve adolescents' sexual and reproductive results, especially in less favored regions 41 . Ideally starting with the family, but in conjunction with the school and health services 41,42 . ...
Article
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Backgroung: Attitudes Towards Sexuality in Adolescents (ATSA) are built according to the experiences and different social contexts. Objectives: to analyze attitudes towards sexuality itself, according to socioeconomic factors in adolescents aged. Methods: Cross-sectional school-based study was carried out with 2,292 adolescents enrolled in high school, in 54 schools, through interviews using the Attitudes Toward Sexuality in Adolescents (AFSA) instrument that has four dimensions, and measures the Permissiveness, Communion, Instrumentality and Sexual Practices. Then, the attitude of each adolescent was classified as: unfavorable, indifferent and favorable. Pearson’s Chi-square test and Multinomial Logistic Regression were used in statistical analyses. Results: It was verified that the majority of the adolescents presented unfavorable AFSA, being these behaviors directly associated to: age of 15/16 and 17 years (OR=0.59; OR=0.47); lower secondary education (OR=2.03); adolescent’s head of family having low education (OR=2.00); to live with the partner (OR=2.77); race / color black (OR=2.04) and brown (OR=1.88); and lower family income (OR=2.50). Conclusion: Adolescents with lower socioeconomic status are more likely to have unfavorable attitudes towards their own sexuality. Keywords: sexuality, adolescent health, sex education, unprotected sex.
... There is good evidence that school-based relationships and sex education (RSE) is a key element in preventing unintended pregnancy and promoting sexual health [10][11][12][13][14]. Interventions involving wholeschool in addition to classroom elements represent particularly promising approaches over basic curriculum only programmes, which systematic reviews suggest often have limited and inconsistent and impact on behavioural outcomes [11,13,[15][16][17][18]. Whole-school action can include: changes to school policies and practice to support promotion of sexual-health; student participation in planning and delivering activities; school-wide health promotion campaigns; parent engagement; and improving student access to contraceptive, sexual health and other relevant support services. ...
... Eight staff and nine students ( ve girls, four boys) from year 8 (age 12-13) participated in the Positive Choices consultations. Fourteen staff and 66 students (34 girls, 32 boys) from years 9-10 (age [13][14][15] participated in the Project Respect consultations ( Table 2). ...
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Background: Whole-school interventions represent promising approaches to promoting adolescent sexual health, but have not been rigorously trialled in the UK. The importance of involving intended beneficiaries, implementers and other key stakeholders in the co-production of such complex interventions prior to costly implementation and evaluation studies is widely recognised. However, practical accounts of such processes remain scarce. We report on co-production with specialist providers, students, school staff and other practice and policy professionals of two new whole-school sexual heath interventions for implementation in English secondary schools. Methods: Formative qualitative inquiry involving 75 students aged 13–15 and 22 school staff. A group of young people trained to advise on public health research were consulted on three occasions. Twenty-three practitioners and policy makers shared their views at a stakeholder event. Detailed written summaries of workshops and events were prepared and key themes identified to inform the design of each intervention. Results: Data confirmed acceptability of addressing unintended teenage pregnancy, sexual health and dating and relationships violence via multi-component whole-school interventions and of curriculum delivery by teachers (providing appropriate teacher selection). The need to enable flexibility for the timetabling of lessons and mode of parent communication; ensure content reflected the reality of young people’s lives; and develop prescriptive teaching materials and robust school engagement strategies to reflect shrinking capacity for schools to implement public-health interventions were also highlighted and informed intervention refinements. Our research further points to some of the challenges and tensions involved in co-production where stakeholder capacity may be limited and their input may conflict with best practice or what is practicable within the constraints of a trial. Conclusions: Multi-component, whole-school approaches to addressing sexual health with teacher delivered curriculum may be feasible for implementation in English secondary schools. They must be adaptable to individual school settings; limit additional burden on staff; and accurately reflect the realities of young people’s lives. Co-production can reduce research waste and may be particularly useful for developing complex interventions that must be adaptable to varying institutional contexts and address needs that change rapidly. When co-producing, potential limitations in relation to the representativeness of participants, the ‘depth’ of engagement necessary as well as the burden on participants and how they will be recompensed must be carefully considered. Having well-defined, transparent procedures incorporating stakeholder input from the outset are also essential. Formal feasibility testing of both co-produced interventions in English secondary schools via cluster RCT is warranted.
... Moreover, local epidemics of STI and burden of adverse pregnancy outcomes might also explain population differences in VMB composition across sub-Saharan Africa (10, 55,[123][124][125][126][127]. Studies across Europe, Latin America, and sub-Saharan Africa have suggested that school attendance and school-based sexual and reproductive health programs promote acceptance of care during pregnancy and avoidance of early high-risk sexual activities that might lead to increase susceptibility to BV or other genital infections (128,129). Nonetheless, school attendance in certain parts of sub-Saharan Africa is lower than in other world regions due to social (for instance, gender inequality), economical, and infrastructural reasons (129)(130)(131); therefore, access to sexual education remains a problem for these populations, particularly girls (129). Even if school education is provided in certain urban communities in sub-Sahara Africa, as in other low-and middle-income countries, misconceptions and stigma about sexual and reproductive-health-related issues persist (132). ...
Article
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Background: Previous studies have described the association between dysbiosis of the vaginal microbiota (VMB) and related dysbiotic conditions, such as bacterial vaginosis (BV) and aerobic vaginitis (AV), and various adverse pregnancy outcomes. There is limited overview of this association from countries in sub-Saharan Africa (SSA), which bear a disproportionally high burden of both vaginal dysbiotic conditions and adverse pregnancy outcomes. This systematic review assesses the evidence on the association between VMB dysbiosis, BV, and AV, and late adverse pregnancy outcomes in women living in SSA. Methods: The Preferred Reporting Items for Systematic Review and Meta-Analysis Statement (PRISMA) guidelines were followed. Three databases [PubMed, Embase (Ovid), and Cochrane] were used to retrieve observational and intervention studies conducted in SSA that associated VMB dysbiosis, BV, or AV and preterm birth/labor/delivery, preterm rupture of membranes (PROM), low birthweight, small for gestational age, intrauterine growth restriction, intrauterine infection, intrauterine (fetal) death, stillbirth, perinatal death, or perinatal mortality. Results: Twelve studies out of 693 search records from five SSA countries were included. One study identified a positive association between VMB dysbiosis and low birthweight. Despite considerable differences in study design and outcome reporting, studies reported an association between BV and preterm birth (7/9), low birthweight (2/6), PROM (2/4), intrauterine infections (1/1), and small for gestational age (1/1). None of the retrieved studies found an association between BV and pregnancy loss (5/5) or intrauterine growth retardation (1/1). At least two studies support the association between BV and PROM, low birthweight, and preterm birth in Nigerian pregnant women. No reports were identified investigating the association between AV and late adverse pregnancy outcomes in SSA. Conclusion: Two of the included studies from SSA support the association between BV and PROM. The remaining studies show discrepancies in supporting an association between BV and preterm birth or low birthweight. None of the studies found an association between BV and pregnancy loss. As for the role of VMB dysbiosis, BV, and AV during pregnancy among SSA women, additional research is needed. These results provide useful evidence for prevention efforts to decrease vaginal dysbiosis and its contribution to adverse pregnancy outcomes in SSA.
... A study from Tanzania also reported that most female undergraduate students had knowledge of contraception, however the prevalence of the actual use of contraception was not high among sexually active students 17) . It is clear that the promotion of contraceptive methods and the prevention of HIV infection among AYA should be continued 18) , although knowledge cannot be the only factor to motivate individuals to use contraception and methods for HIV prevention. Despite the low evidence of effective educational program curricula and provision methods, school-based approaches are recommended for AYA 19) . ...
Article
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Objective: To assess the awareness of contraceptive methods, understanding of HIV/AIDS prevention and the perception of HIV/AIDS risks among secondary school students in Tanzania. Methods: An anonymous self-administered questionnaire survey was conducted among secondary school students in Tanzania. The questionnaire included sociodemographic characteristics, awareness of contraceptive methods, an understanding of HIV/AIDS prevention, and the perception of HIV/AIDS risks. Three secondary schools were selected by considering the gender balance and location, which included the urban and surrounding areas. The research objectives, methods, and ethical considerations were explained, and the students voluntarily completed the questionnaire. Results: A total of 233 responses were collected, and 204 responses were considered valid for the analysis. The mean and standard deviation of age were 18.5 ± 1.0. Regardless of the gender, age, religion, and major course of study, the maternal educational status (adjusted odds ratio [AOR]: 3.129; 95% confidence interval [CI]: 1.324, 7.398; P=0.009) and the number of information sources (AOR: 7.023, 95% CI: 3.166, 15.579, P<0.001) demonstrated associations with the awareness of contraceptive methods. Respondents who lived outside a dormitory (AOR: 3.782; 95% CI: 1.650, 8.671; P=0.002) and who currently had a partner (AOR: 3.616; 95% CI: 1.486, 8.800; P=0.005) were associated with a high level of understanding of HIV/AIDS prevention regardless of gender, age, religion, and major course of study. Respondents with few information sources were associated with a high level of perception of HIV/AIDS risks (AOR: 0.293; 95% CI: 0.115, 0.747; P=0.010), regardless of gender, age, religion, and major course of study. Conclusion: Factors associated with the awareness of contraceptive methods, the understanding of HIV/AIDS prevention, and perception of HIV/AIDS risks were not consistent. To ensure the improvement of these factors among secondary school students, sexual health education should be integrated into educational programs and provided holistically.
... There is existing systematic evidence on the effectiveness of SRHR interventions, including educational programs targeting adolescents and young adults between ages 10 and 25 in LMICs. 11,[14][15][16][17][18][19][20][21][22][23][24][25][26][27] One paper has reviewed the evidence on the effectiveness of sexual abuse prevention programs for school-age children in developing countries. 28 However, it did not adhere to a specific, structured method of synthesis. ...
Article
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OBJECTIVE Middle childhood is a critical period for physical, social, behavioral, and cognitive changes. A positive and healthy sexual and reproductive health and rights (SRHR) foundation can minimize SRHR risks, leading to better outcomes. Our objective is to identify effective educational interventions promoting or supporting the SRHR of school-age children in low and middle-income countries. DATA SOURCES Medline, Embase, CINAHL, APA PsycInfo, ERIC, Cochrane Central Register of Controlled Trials, Education Source, Web of Science, SciELO Citation Index, Global Health, and Sociological Abstract were searched from 2000 to December 2020. STUDY SELECTION Eligible articles had a sample mean age between 5 and 10 years, quantitatively tested the effects of educational interventions against a comparison group, and measured SRHR related outcomes. DATA EXTRACTION Data extracted from the 11 eligible articles were study methods, participant characteristics, interventions and comparisons, outcome measures, and results. RESULTS The review found evidence of significant intervention effects on protective knowledge, attitudes, behaviors, and skills for preventing sexual violence and HIV infection. The strongest evidence was for significant improvements in children’s knowledge of child sexual abuse prevention concepts and strategies. LIMITATIONS A meta-analysis could not be performed because most studies lacked randomization, included no information on the magnitude of effects, and had inadequate follow-up evaluations to truly assess retention. Only a few studies contributed to findings on protective attitudes, behaviors, and skills against child sexual abuse, gender-based violence, and human immunodeficiency virus infection, as well as physiologic outcome. CONCLUSIONS The educational interventions demonstrated significant improvements in primary school children’s protective capacities, especially in their protective knowledge against sexual abuse.
... There is good evidence that school-based relationships and sex education (RSE) is a key element in preventing unintended pregnancy and promoting sexual health [10][11][12][13][14]. Interventions involving whole-school in addition to classroom elements represent particularly promising approaches over basic curriculum only programmes, which systematic reviews suggest often have limited and inconsistent impact on behavioural outcomes [11,13,[15][16][17][18]. Whole-school action can include changes to school policies and practice to support promotion of sexual health; student participation in planning and delivering activities; school-wide health promotion campaigns; parent engagement; and improving student access to contraceptive, sexual health and other relevant support services. ...
Article
Full-text available
Background Whole-school interventions represent promising approaches to promoting adolescent sexual health, but they have not been rigorously trialled in the UK and it is unclear if such interventions are feasible for delivery in English secondary schools. The importance of involving intended beneficiaries, implementers and other key stakeholders in the co-production of such complex interventions prior to costly implementation and evaluation studies is widely recognised. However, practical accounts of such processes remain scarce. We report on co-production with specialist providers, students, school staff, and other practice and policy professionals of two new whole-school sexual heath interventions for implementation in English secondary schools. Methods Formative qualitative inquiry involving 75 students aged 13–15 and 23 school staff. A group of young people trained to advise on public health research were consulted on three occasions. Twenty-three practitioners and policy-makers shared their views at a stakeholder event. Detailed written summaries of workshops and events were prepared and key themes identified to inform the design of each intervention. Results Data confirmed acceptability of addressing unintended teenage pregnancy, sexual health and dating and relationships violence via multi-component whole-school interventions and of curriculum delivery by teachers (providing appropriate teacher selection). The need to enable flexibility for the timetabling of lessons and mode of parent communication; ensure content reflected the reality of young people’s lives; and develop prescriptive teaching materials and robust school engagement strategies to reflect shrinking capacity for schools to implement public-health interventions were also highlighted and informed intervention refinements. Our research further points to some of the challenges and tensions involved in co-production where stakeholder capacity may be limited or their input may conflict with the logic of interventions or what is practicable within the constraints of a trial. Conclusions Multi-component, whole-school approaches to addressing sexual health that involve teacher delivered curriculum may be feasible for implementation in English secondary schools. They must be adaptable to individual school settings; involve careful teacher selection; limit additional burden on staff; and accurately reflect the realities of young people’s lives. Co-production can reduce research waste and may be particularly useful for developing complex interventions, like whole-school sexual health interventions, that must be adaptable to varying institutional contexts and address needs that change rapidly. When co-producing, potential limitations in relation to the representativeness of participants, the ‘depth’ of engagement necessary as well as the burden on participants and how they will be recompensed must be carefully considered. Having well-defined, transparent procedures for incorporating stakeholder input from the outset are also essential. Formal feasibility testing of both co-produced interventions in English secondary schools via cluster RCT is warranted. Trial registration Project Respect: ISRCTN12524938. Positive Choices: ISRCTN65324176
... 20,21 Compared to other social public health challenges (HIV, SGBV, and youth unemployment), AGYW pregnancy interventions, awareness and information efforts are still limited. 6,[22][23][24] Pregnancy education and awareness varies geographically, due to differences in socio-economics, socio-cultural, and social norms. 13 Although country specific statistics may be available, included clear criteria for probing the literature, the search techniques/ search wordings and language, appraisal and retrieval of evidence data. ...
Article
Full-text available
Background: Despite the high rate of HIV infections, there is still high rate of early unprotected sex, unintended pregnancy, and unsafe abortions especially among unmarried adolescent girls and young women (AGYW) 10-24 years of age in sub Saharan Africa. AGYW face challenges in accessing health care, contraception needs, and power to negotiate safer sex. This study aimed to estimate the rate of pregnancy among AGYW aged 10-24, 10-19 and 15-19 years in the Southern African Development Community (SADC) economic region. Methods: A systematic review and meta-analysis was used to describe the prevalence of pregnancy among AGYW in 15 SADC member countries between January 2007 and December2017. The articles were extracted from PubMed/MEDLINE, African Index Medicus, and other reports. They were screened and reviewed according to PRISMA methodology to fulfil study eligibility criteria. Results: The overall regional weighted pregnancy prevalence among AGYW 10-24 years of age was 25% (95% CI: 21% to 29%). Furthermore, sub-population 10-19 years was 22% (95% CI:19% to 26%) while 15-19 years was 24% (18% to 30%). There was a significant heterogeneity detected between the studies (I=99.78%, P < 0.001), even within individual countries. Conclusion: The findings revealed a high pregnancy rate among AGYW in the SADC region. This prompts the need to explore innovative research and programs expanding and improving sexual and reproductive health communication to reduce risk and exposure of adolescents to early planned, unplanned and unwanted pregnancies, SRHR challenges, access to care, HIV/STIs, as well as other risk strategies. Keywords: Pregnancy, Adolescents, Prevalence, Systematic review, Southern Africa
... Providing comprehensive SRH education can play a key role in preventing and responding to teenage pregnancies (Amaugo et al., 2014;Boonstra, 2015;Goicolea et al., 2019;Mason-Jones et al., 2016). However, promotion of sexual abstinence is the most common form of SRH education despite studies showing that abstinence education has no or very limited effect on sexual risk behaviour and pregnancy risks (Denford et al., 2015;Ott & Santelli, 2007;Santelli et al., 2017). ...
Article
Full-text available
Zambia, like other low- and middle-income countries, faces numerous adolescent sexual and reproductive health challenges such as teenage pregnancies. This study aimed at understanding teachers' and community health workers' (CHWs) implementation of comprehensive sexuality education (CSE) as part of a comprehensive support package for adolescent girls to prevent early childbearing. Data collected using in-depth interviews [n = 28] with teachers [n = 15] and community health workers [n = 13] were analysed using thematic analysis. The teachers and CHWs reported that the use of participatory approaches and collaboration between them in implementing CSE enabled them to increase girls' and boys' participation youth clubs. However, some teachers and CHWs experienced practical challenges with the manuals because some concepts were difficult to understand and translate into local language. The participants perceived that the youth club increased knowledge on CSE, assertiveness and self-esteem among the learners. Training and providing a detailed teaching manual with participatory approaches for delivering CSE, and collaborative teaching enabled teachers and CHWs to easily communicate sensitive SRH topics to the learners. However, for the adoption of CSE to be even more successful, piloting of the curriculum with local facilitators and translating the manuals into the local languages before they are implemented, is recommended.
... Developmental changes in the brain and behaviors of school-aged children, before their sexual initiation and reproductive maturation, present clear opportunities to introduce educational interventions promoting healthy and positive SHRH outcomes. There is existing systematic evidence on the effectiveness of SRHR interventions, including educational programs, targeting adolescents and young adults between ages 10 and 25 in LMICs [17,[23][24][25][26][27][28][29][30][31][32][33][34][35][36]. One manuscript in particular has reviewed the evidence on the effectiveness of sexual abuse prevention programs for school-aged children in developing countries [37]. ...
Article
Full-text available
Background Biological changes underlying the sexual and reproductive maturation of school-age children are linked with various sexual and reproductive health and rights risks. SRHR risks are predictors of poor SRHR outcomes, such as poor knowledge of sexually transmitted diseases and early sexual initiation occurring predominantly among school-age children. The aim of this proposed review, therefore, is to identify educational interventions that have proven to be effective in promoting or supporting the sexual and reproductive health and rights of school-aged children in low- and middle-income countries. Methods A systematic review of studies on the strategies promoting the SRHR of school-aged children shall be conducted. Electronic searches will be conducted from January 2000 onwards on the following databases: MEDLINE(R) ALL (Ovid), Embase (Ovid), CINAHL (EBSCOHost), APA PsycInfo (Ovid), ERIC (Ovid), Cochrane Central Register of Controlled Trials (Ovid), Education Source (EBSCOHost), Web of Science (Clarivate Analytics), SciELO Citation Index (Clarivate Analytics), Global Health (Ovid), and Sociological Abstract (Proquest). Studies eligible for inclusion will be randomized control trials (RCTs), non-randomized trials, quasi-experimental studies (e.g., pre-post tests), and observational studies (cross-sectional and cohort studies). Peer-reviewed studies published in English and/or French and involving school-aged children 5–10 years old will be included. The primary outcomes of interest will include knowledge, awareness, or attitudes about SRHR topics. The secondary outcomes of interest will include sexual and reproductive behaviors. Two reviewers will independently screen all citations, abstract data, and full-text articles, and the methodological quality of each study will be appraised using JBI critical appraisal tools. A narrative synthesis of extracted data will be conducted. Discussion The systematic review will synthesize the evidence on existing educational interventions targeting SRHR outcomes of school-aged children in low- and middle-income countries. It will identify which interventions have proven to be effective, and which interventions have not proven to be effective in promoting or supporting their SRHR. Review findings will provide a useful reference for policy-makers, program developers, global health leaders, and decision makers who wish to support the SRHR of school-age children.
... Isso inclui as diversas instituições de educação frequentadas nos diferentes momentos de formação e desenvolvimento humano (Innstrand & Christensen, 2018). Neste sentido, a educação em saúde nas salas de aula das escolas pode ser eficaz na promoção da saúde sexual e na prevenção da gravidez na adolescência, bem como na redução de comportamentos sexuais de alto risco, uma vez que comportamentos de saúde moldados no início da vida persistem na idade adulta (Zukowsky-Tavares et al., 2017;Mason-Jones et al., 2016). ...
Article
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Apesar de diversas iniciativas, gravidez na adolescência, doenças sexualmente transmissíveis e aborto ainda são comuns entre adolescentes em idade escolar, com relato de substanciais lacunas no conhecimento sobre saúde reprodutiva e sexual entre adolescentes escolares, sendo assim essencial revisar os recursos de ensino e aprendizagem disponíveis. Logo, o objetivo deste estudo foi identificar contribuições em educação sexual para prevenção da gravidez na adolescência no contexto da saúde escolar disponíveis na literatura científica. Trata-se de uma revisão integrativa da literatura. A busca das produções científicas foi realizada nas bases PubMed® e Educational Resources Information Center. Foram selecionados artigos publicados entre janeiro de 2016 e dezembro de 2020, com texto completo, resumo disponível e em português ou inglês. A busca foi mediada pelas palavras-chave em inglês: "Sex Education" AND "School Health" AND "Teenage Pregnancy". Foram prevalentes ensaios clínicos randomizados e estudos de avaliação de programas de intervenção aplicados ou baseados na escola, que, em geral, apresentaram resultados positivos significantes em relação aos mecanismos de comparação (controle ou pré-intervenção), para os diferentes desfechos relacionados à prevenção da gravidez na adolescência, com exceção do programa baseado em simulador de bebês, em que não houve redução significante em relação aos controles para o desfecho gravidez antes dos vinte anos. Concluí-se que prevalentemente os programas de educação em saúde sexual no contexto escolar tem se alinhado a medidas de atraso da iniciação sexual e ou proteção sexual. Esses programas têm se tornado uma ferramenta eficaz para a promoção da saúde, pois por meio das ações educativas os escolares têm oportunidade de estar exposto a repertorio que favorece a atenuação de fatores de risco a saúde e melhorar sua qualidade de vida.
... The associations between early sex debut, multiple sexual partners, transactional sex and increased risk of HIV and other STIs are well-documented in the literature [45,46,47]. These risk factors pertaining to individuals' sexual network and behaviors are particularly threatening to out-of-school girls as they typically lack access to resources and interventions from school-based health programs [48,49]. It highlights the importance of targeted, communitybased SRH education and services to mitigate their risks early on. ...
Article
Full-text available
Adolescent girls and young women (AGYW) aged 15 to 24 years face disproportionately high risks of acquiring HIV and other sexually transmitted infections (STIs). A sexual health risk stratification tool can support the development and implementation of tailored HIV and STI prevention services for sub-groups of at-risk AGYW. Data were collected among sexually active AGYW aged 15 to 24 years in Tanzania between April 2015 and March 2017. Exploratory and confirmatory factor analyses were conducted to construct and assess the latent structure of a ten-item scale for rapid assessment of sexual health risks. Items with high factor loadings and minimal cross loadings were retained in the final scale. Scale performance was appraised against condomless sex (defined as unprotected vaginal or anal intercourse) reported by AGYW for construct validity. A three-factor structure of vulnerability to HIV among AGYW was supported with subscales for socioeconomic vulnerability; lack of adult support; and sexual behavioral risks. The chi-square goodness-of-fit test, root mean square error of approximation, comparative fit index, and Tucker-Lewis index indicated a strong goodness-of-fit of the three-factor scale. Cronbach alphas (0.55 for socioeconomic vulnerability, 0.55 for lack of support, and 0.48 for sexual risk) indicated sub-optimal internal consistency for all sub-scales. The factor-item and factor-factor correlations identified in these analyses were consistent with the conceptual framework of vulnerability of HIV infection in AGYW, suggesting good construct validity. The scale also demonstrated a statistically significant association with condomless sex and could be potentially used for sexual health risk stratification (OR = 1.17, 95% CI: 1.12, 1.23). The sexual health and HIV risk stratification scale demonstrated potential in identifying sexually active AGYW at high risk for HIV and other STIs. Ultimately, all AGYW in Tanzania are not at equal risk for HIV and this scale may support directing resources towards those at highest risk of HIV.
... There is scientific evidence examining educational strategies to improve the use of contraceptive methods and prevent STIs [18,19]. However, there are no studies on interventions that meet the WHO-defined criteria for correct comprehensive sexuality education [11]. ...
Article
Full-text available
Adolescence is the time during which the personal and sexual identity develops. The specific characteristics of adolescents and the lack of maturity facilitates the acquisition of sexual risk behaviors such as relaxation in the use of barrier contraceptives or the use of toxic substances, alcohol or drugs during sexual relations, increasing of sexually transmitted infections (STIs) and unwanted pregnancies. Health education in sexuality is one of the best ways to prevent risk behaviors and to promote healthy and responsible sexuality. While there have been different works in sex education in adolescents, there is still a lack of a comprehensive systematic literature review that including randomized and non-randomized clinical trials and quasi-experimental pre-post studies addressing education programs that provide information on healthy and responsible sexuality. Further, it is noted that a protocol drafted in consideration of the existing approaches is needed to present a basis for a systematic literature review in this area. This article, therefore, proposes a review protocol that will evaluate the impact of comprehensive sex education programs in the level of knowledge about STIs, behavioral level concerning the frequency of use of effective contraceptive methods and level of knowledge about sexual identity, diversity and/or responsible sexuality, after the intervention.
... Evidence has shown that the school is a good place for providing health services to adolescents but provided little or no proof that educational curriculum-based programmes alone are effective in improving the sexual and reproductive health outcomes for adolescents. [10] Healthcare providers, especially family and primary care physicians as well as public health physicians, play an important role in the development of school health programmes to provide school health services including sexual and reproductive health services to adolescents. [11,12] Comprehensive sexual health services can be provided in school community using a four-pronged approach which includes promotive sexual health services (including rights-based sexuality education and gender-focused as well as family life and life-skills education), preventive sexual health services (including screening for high-risk behaviours, STIs, and sexual abuse as well as provision for vaccinations), treatment services (including treatment of STIs), and counseling services (including counseling regarding STIs and sexuality-related issues). ...
Article
Full-text available
Introduction: Sexual interaction between students may be different in coeducational (CE) and non-coeducational (NC) schools. The objective was to compare sexual behaviour and knowledge of prevention of sexually transmitted infections (STIs) among senior secondary school students in CE and NC institutions in Ibadan, Nigeria. Method: A comparative cross-sectional study was carried out using a multistage sampling technique. A total of 510 respondents (250 from CE schools and 260 from NC schools) completed semi-structured self-administered questionnaires which included a 30-point STI knowledge scale with scores classified as good and poor. Chi-square statistics were significant at P ≤ 0.05. Results: The mean age of respondents was 15.9 ± 1.5 years, 47.5% were girls. There were no significant differences in sexual behaviour and knowledge of STIs between the students in the two types of schools. However, there were gender differences, as a significantly higher proportion of girls in CE than NC schools had ever had sexual intercourse with the opposite sex (25.6%-CE, 12.4%-NC) and had multiple sexual partners (29.0%-CE, 0%-NC). Girls in NC schools had better knowledge of causes and prevention of STIs than those in CE schools (28.8%-CE, 45.5%-NC). There were no significant differences in the sexual practices and knowledge of STIs among boys in the two types of schools. Conclusion: More girls in CE schools have had sexual intercourse compared to NC schools whereas girls in NC schools had better knowledge of the prevention of STIs. There is a need for strategies to increase reproductive health education in schools, particularly in CE schools.
... The programs also have the ability to reach large numbers of young adolescents simultaneously [30] and has the potential to transform country-level HIV epidemics [31]. Numerous school and community-based adolescent focused life-skills programs have been initiated to empower young people in communities to lead positive and healthy lives, pursue successful futures and stay HIV free [11,[32][33][34][35]. Several systematic reviews have also assessed and evaluated the effectiveness of interventions for adolescents to improve adolescent health, reduce the risk of curable STIs, HSV-2, HIV and unintended pregnancies [30,[36][37][38][39][40][41][42]. However, these reviews included studies of different study designs, were of varying quality and implemented both within schools and the broader community environments which could potentially bias the results [43]. ...
Article
Full-text available
Young adolescents in Sub-Saharan Africa (SSA) are at high risk of involvement in sexual risk behaviors; and curable sexually transmitted infections (STI), herpes simplex virus type 2 (HSV-2), human immunodeficiency virus (HIV) and unintended pregnancies remain persistently high in this population. Evidence based strategies are urgently needed to improve these outcomes. The aim of this systematic review was to synthesize the evidence from randomized controlled trials (RCT) to determine whether school-based interventions promote safe sex behaviors, reduce sexual risk behaviors and risk of curable STIs, HSV-2, HIV and unintended pregnancies among young adolescents aged 9–19 years in SSA. Electronic databases were searched for published studies and manual searches were conducted through reviewing of references of cited literature in the English language up to December 2019. Two independent reviewers screened and abstracted the data. We identified 428 articles and data from nine RCTs (N = 14,426 secondary school students) that fulfilled the selection criteria were analysed. Two studies measured pregnancy as an outcome and showed significant declines in unintended pregnancies. Of the five studies that measured HIV/AIDS related-knowledge, condom-use outcomes (normative beliefs, knowledge, and self-efficacy) and attitudes to HIV testing, four showed significant improvements. Of the six studies that measured sexual debut, four reported moderate but non-significant declines and in two studies sexual debut information was either incomplete or unreliable. One study measured curable STIs and found no significant declines; whilst the second study that measured HSV-2 and HIV, no significant declines were observed. This review highlights the need to undertake well-designed research studies to provide evidence on the impact of interventions on curable STIs, HSV-2 and HIV, critical to improving the health of young adolescents.
... Early adolescence is seen as an ideal time to conduct education with a focus on gender and rights, before harmful gender norms become entrenched, enabling improved SRH and non-violent outcomes 48 . School and curriculum based educational interventions have been implemented globally, seeking to improve adolescent SRH outcomes 49 . This has largely been informed by a rigorous evidence review of over 77 randomised controlled trials and systematic reviews conducted by UNESCO 50 , evaluating the impact of Comprehensive Sexuality Education (CSE). ...
Article
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Background: Adolescence is a time of psycho-social and physiological changes, with increased associated health risks including vulnerability to pregnancy, HIV, sexually transmitted infections, and gender-based violence. Adolescent learners, from three townships in South Africa, participated in a 44 session, after-school asset-building intervention (GAP Year), over 2 years providing sexual and reproductive health (SRH) education. This paper explores adolescent learners’ SRH, sexual risk and rights knowledge; perceptions about transactional sex; and contraceptive method preferences and decision-making practices. Methods: The intervention was conducted in 13 secondary schools across Khayelitsha, Thembisa, and Soweto, South Africa. A baseline survey collected socio-demographic data prior to the intervention. Overall, 26 focus group discussions (FGDs): 13 male and 13 female learner groups, purposively selected from schools, after the intervention (2 years after baseline data collection). Descriptive analyses were conducted on baseline data. Qualitative data were thematically coded, and NVivo was used for data analysis. Results: In total, 194 learners participated in the FGDs. Mean age at baseline was 13.7 years (standard deviation 0.91). Participants acquired SRH and rights knowledge during the GAP Year intervention. Although transactional sex was viewed as risky, some relationships were deemed beneficial and necessary for material gain. Negative healthcare provider attitudes were the main barrier to healthcare service utilisation. There was awareness about the benefits of contraceptives, but some myths about method use. The injectable was the preferred contraceptive method, followed by the implant, with equal preference for condoms and oral pill. Conclusions : An afterschool intervention at school is a viable model for the provision of SRH and rights education to learners. Recommendations include the need for risk reduction strategies in the curriculum, dealing with misconceptions, and the promotion of informed decision making. Endeavours to ensure health services are youth friendly is a priority to limit barriers to accessing these services.
... Numerous systematic reviews have been carried out looking at the delivery and effectiveness of sex education programmes (See for example : Cushman et al. 2014;Mason-Jones et al. 2016;Poobalan et al. 2009); the programmes reviewed primarily have an aim to delay sexual initiation, reduce STIs, unintended pregnancy or domestic violence. Studies have found that programmes which use interactive, participatory learning and skills-building strategies to promote 'rights-based content, positive, youthcentred messages are effective in empowering adolescents with knowledge and tools required for healthy sexual decision-making and behaviours' (Hall et al. 2016). ...
Article
This paper reviews published research and gray literature on education programmes which aim to teach young people aged between 11 and 18 skills to develop and maintain healthy intimate relationships. Programmes focussing solely on sexual (risky) behaviour, HIV prevention or partner violence were not the focus of this review and thus excluded. Systematic searches were conducted and 76 English language programmes were reviewed, with 17 identified as meeting the inclusion criteria. Characteristics of the included programmes (aims, target audience, content and delivery method) are described. Most programmes were designed to be delivered in school by a teacher covering a broad age range (5 years or more) and focused on the intrapersonal and interpersonal dimensions of relationships reflecting adult therapeutic relationship educational models. Future research should focus on further developing and evaluating the content and delivery of relationship skills education programmes grounded in young people’s social and cultural context within a framework of human rights.
... IST na escola teve efeito protetor para a prática de relação sexual segura. Assim, reitera-se a necessidade dos serviços de saúde promoverem o empoderamento dos adolescentes na tomada de decisões relacionadas à saúde, sendo imprescindível que atendam às necessidades dos adolescentes, contemplando orientações sobre saúde sexual e reprodutiva, inclusive sobre as opções de preservativos e contraceptivos.16 Para tanto, sugere-se que os profissionais de diferentes áreas utilizem estratégias atrativas e de diferentes modalidades a fim de facilitar a adesão dos jovens as ações de conscientização, como por exemplo, o desenvolvimento de grupos em redes sociais, realização de dinâmicas, entre outros.Contudo, apenas a execução e existência dos programas de saúde na escola não são suficientes para interferir no comportamento sexual dos adolescentes. ...
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Objetivo: identificar a prevalência de relação sexual em adolescentes escolares de uma capital no sul do Brasil e sua associação com fatores sociodemográficos e comportamentais. Métodos: estudo transversal que utilizou dados da Pesquisa Nacional de Saúde do Escolar de 2015. A amostra foi composta por escolares matriculados no 9º ano do ensino fundamental de Curitiba (n= 1.770). Realizou-se estatística descritiva e inferencial. Resultados: a prevalência de relação sexual alguma vez foi de 22,9%, sendo mais frequente em adolescentes do sexo masculino, com 15 anos ou mais, de cor preta, sem acesso à internet e que recebeu orientações na escola sobre educação sexual, utilizavam drogas lícitas e ilícitas, e se envolviam em brigas. Conclusão: a prevalência da relação sexual alguma vez nos adolescentes escolares foi elevada e está associada a fatores sociodemográficos, comportamentos de risco e convivência com situações de violência.
... There is good evidence that school-based relationships and sex education (RSE) is a key element in preventing unintended pregnancy and promoting sexual health [11][12][13][14][15][16]. However, existing systematic reviews suggest that curriculum interventions alone may be insufficient to produce consistent, sizeable and sustained changes in the behaviours underlying unintended teenage pregnancy and poor sexual health, and therefore populationlevel improvements in these outcomes [11-13, 15, 17]. ...
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Background Reducing unintended teenage pregnancy and promoting adolescent sexual health remains a priority in England. Both whole-school and social-marketing interventions are promising approaches to addressing these aims. However, such interventions have not been rigorously trialled in the UK and it is unclear if they are appropriate for delivery in English secondary schools. We developed and pilot trialled Positive Choices, a new whole-school social marketing intervention to address unintended teenage pregnancy and promote sexual health. Our aim was to assess the feasibility and acceptability of the intervention and trial methods in English secondary schools against pre-defined progression criteria (relating to randomisation, survey follow-up, intervention fidelity and acceptability and linkage to birth/abortion records) prior to carrying out a phase III trial of effectiveness and cost-effectiveness. Methods Pilot RCT with integral process evaluation involving four intervention and two control schools in south-east England. The intervention comprised a student needs survey; a student/staff-led school health promotion council; a classroom curriculum for year-9 students (aged 13–14); whole-school student-led social-marketing activities; parent information; and a review of local and school-based sexual health services. Baseline surveys were conducted with year 8 (aged 12–13) in June 2018. Follow-up surveys were completed 12 months later. Process evaluation data included audio recording of staff training, surveys of trained staff, staff log books and researcher observations of intervention activities. Survey data from female students were linked to records of births and abortions to assess the feasibility of these constituting a phase III primary outcome. Results All six schools were successfully randomised and retained in the trial. Response rates to the survey were above 80% in both arms at both baseline and follow-up. With the exception of the parent materials, the fidelity target for implementation of essential elements in three out of four schools was achieved. Student surveys indicated 80% acceptability among those who reported awareness of the programme and interviews with staff suggested strong acceptability. Linkage to birth/abortion records was feasible although none occurred among participants. Conclusions The criteria for progression to a phase III trial were met. Our data suggest that a whole-school social-marketing approach may be appropriate for topics that are clearly prioritised by schools. A phase III trial of this intervention is now warranted to establish effectiveness and cost-effectiveness. Births and terminations are not an appropriate primary outcome measure for such a trial. Trial registration ISRCTN65324176.
... These factors were encompassed in some way by the aforementioned most popular theories of behaviour change. This was also further exemplified by reviews that presented a conceptual theory of change applied to studying several interventions [37][38][39][40][41][42][43]. These reviews also typically drew on existing behaviour change theories, synthesising a general proposed theory of change and applying this to the context and content investigated. ...
Article
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Background: There is growing recognition of the need for interventions that effectively involve men and boys to promote family planning behaviours. Evidence suggests that the most effective behavioural interventions in this field are founded on theoretical principles of behaviour change and gender equality. However, there are few evidence syntheses on how theoretical approaches are applied in this context that might guide best practice in intervention development. This review addresses this gap by examining the application and reporting of theories of behaviour change used by family planning interventions involving men and boys. Methods: We adopted a systematic rapid review approach, scoping findings of a previously reported evidence and gap map of intervention reviews (covering 2007-2018) and supplementing this with searches of academic databases and grey literature for reviews and additional studies published between 2007 and 2020. Studies were eligible for inclusion if their title, abstract or keywords referred to a psychosocial or behavioural intervention targeting family planning behaviours, involved males in delivery, and detailed their use of an intervention theory of change. Results: From 941 non-duplicate records identified, 63 were eligible for inclusion. Most records referenced interventions taking place in low- and middle-income countries (65%). There was a range of intervention theories of change reported, typically targeting individual-level behaviours and sometimes comprising several behaviour change theories and strategies. The most commonly identified theories were Social Cognitive Theory, Social Learning Theory, the Theory of Planned Behaviour, and the Information-Motivation-Behaviour Skills (IMB) Model. A minority of records explicitly detailed gender-informed elements within their theory of change. Conclusion: Our findings highlight the range of prevailing theories of change used for family planning interventions involving men and boys, and the considerable variability in their reporting. Programmers and policy makers would be best served by unified reporting and testing of intervention theories of change. There remains a need for consistent reporting of these to better understand how complex interventions that seek to involve men and boys in family planning may lead to behaviour change.
... These results could be attributed to the use of a reflective methodology and the teacher's recovery of tacit knowledge, which they could have applied to the subject [34]. It is also important to highlight that young people identify different actors to meet their reproductive health needs; from parents as confidants in courtship issues, to doctors for sexuality problems (sexual impotence and pregnancy), and to teachers as counselors in sexuality issues [35]. ...
Article
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Background A common risk behavior in adolescence is the early initiation of unprotected sex that exposes adolescents to an unplanned pregnancy or sexually transmitted infections. Schools are an ideal place to strengthen adolescents’ sexual knowledge and modify their behavior, guiding them to exercise responsible sexuality. The purpose of this article was to evaluate the knowledge of public secondary school teachers who received training in comprehensive education in sexuality (CES) and estimate the counseling’s effect on students’ sexual behavior. Methods Seventy-five public school teachers were trained in participatory and innovative techniques for CES. The change in teacher knowledge (n = 75) was assessed before and after the training using t-tests, Wilcoxon ranks tests and a Generalized Estimate Equation model. The students’ sexual and reproductive behavior was evaluated in intervention (n = 650) and comparison schools (n = 555). We fit a logistic regression model using the students’ sexual debut as a dependent variable. Results Teachers increased their knowledge of sexuality after training from 5.3 to 6.1 (p < 0.01). 83.3% of students in the intervention school reported using a contraceptive method in their last sexual relation, while 58.3% did so in the comparison schools. The students in comparison schools were 4.7 (p < 0.01) times more likely to start sexual initiation than students in the intervention schools. Conclusion Training in CES improved teachers’ knowledge about sexual and reproductive health. Students who received counseling from teachers who were trained in participatory and innovative techniques for CES used more contraceptive protection and delayed sexual debut.
... Investment in child health has resulted in impressive reductions in childhood morbidity and mortality [6,7]. In high-income countries, routine adolescent preventive health interventions, largely school-based, have been shown to have some efficacy for sexual and reproductive health [8], preventing unhealthy behaviors such as smoking [9] and alcohol abuse [10], and for mental health [11]. WHO provides guidance for countries to develop tailored adolescent health programs [12], but does not provide specific guidance on whether routine health checkups for adolescents should be conducted, and, if so, their content and method of delivery. ...
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Purpose The absence of routine health check-ups during adolescence in low- and middle-income countries is a missed opportunity for prevention, early identification, and treatment of health issues, and health promotion. We aimed to codesign the content and delivery for routine adolescent health checkups in Zimbabwe, with adolescents and key adults in their lives. Methods We held participatory workshops with adolescents (16 workshops; 96 adolescents) and parents (8 workshops; 95 parents), and in-depth interviews with key informants including policymakers, programmers, and healthcare workers (n = 25). Analysis was iterative and the design of the checkups was refined based on participant preferences, document review of burden of disease data, and feasibility considerations. Results Participants overwhelmingly supported the introduction of routine health checkups. Reported facilitators to attendance included free cost and desire to know one’s health status. Barriers included tendencies for health service seeking only when ill, fear of diagnosis and judgment, and religious beliefs. Delivery preferences were by nonjudgmental medical professionals, in a youth friendly environment, and accompanied by youth engagement activities. Preferred location was schools for younger adolescents (10–14 years), and community settings for older adolescents (15–19 years). Prioritized content included sexual health, oral health, mental health, hearing, eyesight, growth and nutrition, anemia, immunization, and deworming, based on health burden and participant preferences. Discussion This study resulted in an outline design of two routine health checkups with stakeholders in Zimbabwe, in schools for young adolescents, and in community settings for older adolescents. Evidence of feasibility, effectiveness, and cost-effectiveness of such checkups is required.
... Interventions using education as the sole mechanism appeared to have a limited impact on behaviour or BMIz. This aligns with the broader evidence base, which suggests educational interventions are unlikely to elicit effective changes for children [53,54], and for the general population [55]. Relying on individual agency is unlikely to translate into substantial or sustained behavioural change, and consequently obesity prevention [56]. ...
Article
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Childhood obesity is a global public health concern. While evidence from a recent comprehensive Cochrane review indicates school-based interventions can prevent obesity, we still do not know how or for whom these work best. We aimed to identify the contextual and mechanistic factors associated with obesity prevention interventions implementable in primary schools. A realist synthesis following the Realist And Meta-narrative Evidence Syntheses–Evolving Standards (RAMESES) guidance was with eligible studies from the 2019 Cochrane review on interventions in primary schools. The initial programme theory was developed through expert consensus and stakeholder input and refined with data from included studies to produce a final programme theory including all of the context-mechanism-outcome configurations. We included 24 studies (71 documents) in our synthesis. We found that baseline standardised body mass index (BMIz) affects intervention mechanisms variably as a contextual factor. Girls, older children and those with higher parental education consistently benefitted more from school-based interventions. The key mechanisms associated with beneficial effect were sufficient intervention dose, environmental modification and the intervention components working together as a whole. Education alone was not associated with favourable outcomes. Future interventions should go beyond education and incorporate a sufficient dose to trigger change in BMIz. Contextual factors deserve consideration when commissioning interventions to avoid widening health inequalities.
... Likewise, Simmons-Zuilkowski [105] found that in South Africa enrollment rates among the very poor are lower because of cost of uniforms. In Kenya, Mutengi [106] found a statistically significant link between uniform cost and education access, and Green et al. [107], Sitieni and Pillay [108] and Cho et al. [109] describe free uniform as part of support and incentive packages for at-risk children to attend school [110]. In Ghana, Alagbela [111] and Akaguri [112] show that uniform cost creates a barrier to education for the very poor. ...
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This study uses a public health lens to review evidence about the impacts of wearing a school uniform on students’ health and educational outcomes. It also reviews the underlying rationales for school uniform use, exploring historical reasons for uniform use, as well as how questions of equity, human rights, and the status of children as a vulnerable group are played out in debates over school uniforms. The literature identified indicates that uniforms have no direct impact on academic performance, yet directly impact physical and psychological health. Girls, ethnic and religious minorities, gender-diverse students and poorer students suffer harm disproportionately from poorly designed uniform policies and garments that do not suit their physical and socio-cultural needs. Paradoxically, for some students, uniform creates a barrier to education that it was originally instituted to remedy. The article shows that public health offers a new perspective on and contribution to debates and rationales for school uniform use. This review lays out the research landscape on school uniform and highlights areas for further research.
... The value of engaging community leadership and participatory intervention development is well-known in promoting HIV and sexual health services, and Girl Champ illustrated the critical role such leadership can play in disseminating health communication campaigns to adolescents [58][59][60]. In particular, schools play an important role in youth lives and sexual and reproductive health, as a venue for accessing services, information, and support [61][62][63][64][65][66][67][68]. ...
Article
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Efforts to engage adolescent girls and young women (AGYW) in HIV services have struggled, in part, due to limited awareness of services and stigma. Strategic marketing is a promising approach, but the impact on youth behavior change is unclear. We report findings from a mixed methods evaluation of the Girl Champ campaign, designed to generate demand for sexual and reproductive services among AGYW, and piloted in three clinics in the Manzini region of eSwatini. We analyzed and integrated data from longitudinal, clinic-level databases on health service utilization among AGYW before and after the pilot, qualitative interviews with stakeholders responsible for the implementation of the pilot, and participant feedback surveys from attendees of Girl Champ events. Girl Champ was well received by most stakeholders based on event attendance and participant feedback, and associated with longitudinal improvements in demand for HIV services. Findings can inform future HIV demand creation interventions for youth.
... Contrary to fears expressed by parents, school-based sexuality education programs do not lead to early sexual debut or increased sexual activity [23][24][25][26]. A review by Mason-Jones et al. revealed that combined (sexual and reproductive) educational and incentivebased programmes had a positive effect on sexually transmitted infections (STIs) (herpes simplex virus infection) [27]. Ross et al. indicated that incentive-based interventions are likely to reduce adolescent pregnancy [22]. ...
Article
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Background: HIV education targeting children and adolescents is a key component of HIV prevention. This is especially important in the context of increasing HIV prevalence rates among adolescents and young people. The authors sought to examine the role and effectiveness of an extra-curricular school based programme, Soul Buddyz Clubs (SBC) on HIV knowledge, attitudes, behaviours and biomedical outcomes. Methods: This paper employs a mixed methods approach drawing on data from independent qualitative and quantitative sources. Secondary data analysis was performed using survey data from a nationally representative sample that was restricted to 10-14 year-old males and females living in South Africa. Ten focus group discussions and ten in-depth interviews conducted with SBC members and facilitators from 5 provinces, as part of a process evaluation are used to triangulate the effectiveness of SBC intervention. Results: The analysis of survey data from 2 198 children indicated that 12% of respondents were exposed to SBC with 4% reporting that they had ever belonged to a club. Children exposed to SBC were more likely to be medically circumcised (AOR 2.38; 95%CI 1.29 -4.40, p=0.006), had correct HIV knowledge (AOR 2.21; 95%CI 1.36 - 3.57, p<0.001) and had less HIV stigmatising attitudes (AOR 0.54; 95%CI 0.31-0.93, p=0.025), adjusting for age, sex, province and exposure to other media - in comparison to those not exposed. Propensity Score Matching findings were consistent with the regression findings. Qualitative findings also supported some of the quantitative results. SBC members reported having learnt about HIV prevention life skills, including condom use, positive attitudes towards people living with HIV, and alcohol abuse. Conclusions: Participation in SBC is associated with accessing biomedical HIV prevention services, specifically MMC, correct HIV prevention knowledge and less HIV stigmatizing attitudes. This paper demonstrates the effectiveness of a school-based extracurricular intervention using a club approach targeting boys and girls ages 10-14 years on some of the key HIV prevention biomarkers as well as knowledge and attitudes. The article suggests that extra-curricular interventions can form an effective component of school-based comprehensive sexuality education in preventing HIV and promoting medical male circumcision.
... As per the Cochrane systematic review in 2016, evidence that sex education interventions for adolescents reduce sexually transmitted infections and pregnancy was lacking (9) . An Australian study reported a program (referred to as "empathy sessions" below) that encouraged husbands to have a better understanding and more empathy during pregnancy, which was found to suppress postpartum depression in mothers (10) . ...
Article
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Introduction: The Australian "empathy session," which is a parenting program aimed at alleviating postpartum depression by increasing empathy among expecting couples, was adapted to a life-planning education program for Japanese high school students. In this present study, we aimed to assess changes in high school students' empathy levels. Methods: A nonrandomized, controlled, waitlist intervention was performed in 210 first-year students. They were divided into intervention and waitlist control groups. The life-planning lecture consisted of two parts: (1) reproductive health and (2) empathy and communication skills. The main outcome indicator was the Perspective-Taking subscale of an empathy index. Logistic regression was used to examine the association between the intervention and change in the Perspective-Taking scale score controlling for background factors. Results: As per our findings, a significant difference was noted in the scale scores of Perspective-Taking before and after the program within the intervention group (3.76 ± 0.61 before the lecture and 3.86 ± 0.64 after the lecture; P = 0.01). In the between-group analysis, the likelihood of an increase in the scale score of Perspective-Taking was significantly higher in the intervention group (OR = 2.29, 95 % confidence interval = 1.23-4.26). Conclusions: Japanese high school students' Perspective-Taking improved through learning reproductive life-planning and communication skills.
... Esta realidad limita la posibilidad de ofrecer a los jóvenes educación, o remitir a los servicios de salud para que obtengan asesoría en SSR (29) . La evidencia muestra que en los países que han optado por hablar desde edades tempranas con los jóvenes acerca de la sexualidad y reconocer su vivencia en la etapa juvenil, son los que tienen las tasas más bajas de embarazos no planeados en jóvenes y adolescentes (30,31) . ...
Article
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El condón es un método de prevención de las Infecciones de Transmisión Sexual (ITS) y del embarazo, sin embargo, su uso en jóvenes colombianos es bajo. Objetivo: Identificar las barreras y limitaciones individuales, culturales e institucionales, en el uso del condón en jóvenes universitarios. Materiales y métodos: Investigación cualitativa, con 4 grupos focales mixtos con jóvenes de 17 a 24 años. Se realizó codificación con el software ATLAS.TI y un análisis temático. Resultados: A nivel individual se evidencia baja intención de uso, la confianza en la pareja aleja el temor de una ITS y el embarazo es la principal preocupación que desplaza su uso por otro método anticonceptivo. A nivel cultural las relaciones de género refuerzan que la mujer es responsable de los anticonceptivos y el hombre del condón. A nivel institucional, las políticas y los servicios de salud limitan su acceso. La lógica mercantilista y el enfoque de riesgo limitan la distribución gratuita y masiva. Conclusiones: El reconocimiento de factores individuales y sociales que limitan el uso del condón, permite la promoción del cuidado de sí y del otro; además la orientación de estrategias para promover una adecuada atención en los servicios de Salud Sexual y Reproductiva.
... Comprehensive sexuality education plays an important role in preventing adverse sexual and reproductive health outcomes [9][10][11]. Comprehensive sexuality education is beyond teaching adolescents about the anatomy and physiology of sexual reproduction. ...
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Background: This study aimed to evaluate the effects of an internet-based and teacher-facilitated sexuality education package on the sexual knowledge and attitudes of Chinese adolescents. Methods: Six middle schools where no sexuality education had been performed with a total of 501 adolescent students (245 males and 256 females) were included in the trial. In total, 14 classes were randomly assigned to the intervention (internet-based sexuality education package) or the control group (classes were conducted as per normal). Students' sexual knowledge and attitudes were assessed at the baseline, at the end of the intervention, and 12 months after the intervention. Generalized linear models were employed to assess the effects of the intervention. Results: Positive effects of the intervention were observed on sexual knowledge (β = 4.65, 95% CI: 4.12-5.17) and attitudes (β = 1.25, 95% CI: 1.00-1.50) at the end of the intervention. After 12 months, the effects sustained but the magnitude declined for sexual knowledge (β = 2.39, 95% CI: 1.85-2.93) and attitudes (β = 0.49, 95% CI: 0.23-0.75). There were no significant differences between male and female students. Conclusions: Although further modifications are required, the sexuality education package can increase the accessibility of comprehensive sexuality education to adolescents in rural areas in China.
Article
This study evaluated The Grassroot Project, a middle school sexual health promotion program in Washington, DC that uses university-level athlete role models and sports-based games. Seven schools were allocated to immediate (n = 160) or delayed intervention (n = 166). Students were tested before and immediately after the intervention on attitudes and self-efficacy to avoid sexual risk, intentions to avoid or engage in sexual intercourse, HIV stigma, and endorsement of violent behaviors. There was no evidence of differences between groups; however, the intervention has promise in respect of key outcome domains. This research justifies future longitudinal evaluation to assess behavioral and biomedical outcomes.
Article
Background The German Medical Society for Health Promotion (ÄGGF) has developed a school-based teaching unit for students in grade 8 and higher that aims at primary and secondary prevention of unplanned pregnancies.AimsThe accompanying evaluation study analyzes the effects of the teaching unit on the students’ knowledge and their experience with self-efficacy concerning unplanned pregnancies.MethodsA two-armed cluster-randomized controlled study was conducted using a ten-page anonymous questionnaire with a closed answer format before and after the intervention.ResultsIn the first survey, 1855 students participated; 1523 students participated in the second. Participants in the intervention group showed a greater increase in knowledge over time. Compared to the control group, they showed an increased intention to use the pill and condoms as well as a marked increase in self-efficacy in the case of an unplanned pregnancy. Furthermore, they significantly corrected their perception of the age at which same-aged boys start having sexual intercourse. All effects remained stable when covariates were controlled. The teaching units were highly accepted: more than 90% of the participants stated that they would recommend them to other students.DiscussionA school-based medical teaching unit about the prevention of unplanned teenage pregnancies was able to contribute to the improvement of students’ knowledge and competency. The intervention itself was highly accepted within the target group.
Article
Background To improve teen contraceptive use, the SpeakOut intervention combines structured counseling, online resources, and text reminders to encourage teens to share their experiences using intrauterine contraception (IUC) or an implant with peers. Methods To evaluate the effectiveness of remote delivery of the SpeakOut intervention in increasing teen contraceptive use, we conducted a cluster randomized trial involving female adolescents who were recruited online. Primary participants (n=520) were randomly assigned to receive SpeakOut or an attention control; each primary participant recruited a cluster of up to five female peers as secondary participants (n=581). We assessed contraceptive communication, knowledge, and use, at baseline, three and nine months after participants enrolled. We examined differences between study groups, controlling for clustering by primary participant and baseline characteristics. Results The trial's primary outcome, contraceptive use by secondary participants, was similar between groups at both three and nine months post-intervention. Compared to controls, primary participants receiving SpeakOut tended to be less likely to discontinue contraception within nine months (4.8% vs 7.8%, p=0.11 for IUC; 7.8% vs 9.8%, p=0.45 for implants), but this did not reach statistical significance. SpeakOut failed to increase contraceptive communication; regardless of study group, most secondary participants reported peer communication about contraception (86% vs 88%, p=0.57). Most secondary participants were aware of the hormonal IUC (91.4% vs 90.4%, p=0.72), copper IUC (92.9% vs 88.6%, p=0.13), and implant (96.5% vs 96.1%, p=0.83) three months after enrolling, regardless of the intervention their primary participant received. However, contraceptive knowledge remained incomplete in all study groups. Conclusion Remote delivery of the SpeakOut Intervention did not improve contraceptive communication, knowledge or use among participating teens or their peers. Implications Efforts to support teen-to-teen contraceptive communication and ensure that teens have accurate information about the full range of contraceptive methods, including highly effective reversible contraceptives, require refinement.
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Background: Sexual education is an international priority to promote sexual and reproductive health (SRH) and to reduce risky sexual behaviour. Experts recommend holistic and comprehensive SRH peer-led education. In 2018, the French government launched a new public health peer-led prevention programme called “Service Sanitaire” (SeSa), consisting of health education provided by healthcare students (peer educators) to teenagers. During the first year of the programme and for the first time in France, the impact of the programme was prospectively evaluated to examine whether the programme improved the SRH knowledge of healthcare students and teenagers. Risk perception and risky sexual behaviour among these populations were also evaluated. Method: A prospective multicentre controlled study was conducted from November 2018 to May 2019. SRH knowledge was compared before and after the SeSa programme, and the evolution of this knowledge was compared, with linear regression, between healthcare students benefiting from the SRH SeSa programme and those who were part of another programme. The same analyses of knowledge were performed for teenagers who received the SeSa SRH interventions compared to teenagers who had no specific SRH education programme. Risk perception and risky behaviour were studied before and after the programme among healthcare students and among teenagers. Results: More than 70% of the targeted population participated in the study, with 747 healthcare students and 292 teenagers. SRH peer educators increased their knowledge score significantly more than other peer educators (a difference of 2.1 points/30 [95% CI 1.4 – 2.9] (p[between group] < 0.001)). Teenagers receiving the SeSa intervention also had a greater increase in their knowledge score than the other teenagers (+5.2/30 [95% CI 3.2 – 7.4] p[between group] <0.001). There was no evidence of change in sexual risk behaviours for the healthcare student population. Conclusion: The “Service Sanitaire” programme significantly improved the sexual and reproductive health knowledge of peer-educator healthcare students and teenagers compared to a classic education programme. Longer and/or qualitative studies are needed to evaluate changes in sexual behaviour as well as positive aspects of sexuality.
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Background The UK still has the highest rate of teenage births in western Europe. Teenagers are also the age group most likely to experience unplanned pregnancy, with around half of conceptions in those aged < 18 years ending in abortion. After controlling for prior disadvantage, teenage parenthood is associated with adverse medical and social outcomes for mothers and children, and increases health inequalities. This study evaluates Positive Choices (a new intervention for secondary schools in England) and study methods to assess the value of a Phase III trial. Objectives To optimise and feasibility-test Positive Choices and then conduct a pilot trial in the south of England assessing whether or not progression to Phase III would be justified in terms of prespecified criteria. Design Intervention optimisation and feasibility testing; pilot randomised controlled trial. Setting The south of England: optimisation and feasibility-testing in one secondary school; pilot cluster trial in six other secondary schools (four intervention, two control) varying by local deprivation and educational attainment. Participants School students in year 8 at baseline, and school staff. Interventions Schools were randomised (1 : 2) to control or intervention. The intervention comprised staff training, needs survey, school health promotion council, year 9 curriculum, student-led social marketing, parent information and review of school/local sexual health services. Main outcome measures The prespecified criteria for progression to Phase III concerned intervention fidelity of delivery and acceptability; successful randomisation and school retention; survey response rates; and feasible linkage to routine administrative data on pregnancies. The primary health outcome of births was assessed using routine data on births and abortions, and various self-reported secondary sexual health outcomes. Data sources The data sources were routine data on births and abortions, baseline and follow-up student surveys, interviews, audio-recordings, observations and logbooks. Results The intervention was optimised and feasible in the first secondary school, meeting the fidelity targets other than those for curriculum delivery and criteria for progress to the pilot trial. In the pilot trial, randomisation and school retention were successful. Student response rates in the intervention group and control group were 868 (89.4%) and 298 (84.2%), respectively, at baseline, and 863 (89.0%) and 296 (82.0%), respectively, at follow-up. The target of achieving ≥ 70% fidelity of implementation of essential elements in three schools was achieved. Coverage of relationships and sex education topics was much higher in intervention schools than in control schools. The intervention was acceptable to 80% of students. Interviews with staff indicated strong acceptability. Data linkage was feasible, but there were no exact matches for births or abortions in our cohort. Measures performed well. Poor test–retest reliability on some sexual behaviour measures reflected that this was a cohort of developing adolescents. Qualitative research confirmed the appropriateness of the intervention and theory of change, but suggested some refinements. Limitations The optimisation school underwent repeated changes in leadership, which undermined its participation. Moderator analyses were not conducted as these would be very underpowered. Conclusion Our findings suggest that this intervention has met prespecified criteria for progression to a Phase III trial. Future work Declining prevalence of teenage pregnancy suggests that the primary outcome in a full trial could be replaced by a more comprehensive measure of sexual health. Any future Phase III trial should have a longer lead-in from randomisation to intervention commencement. Trial registration Current Controlled Trials ISRCTN12524938. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research ; Vol. 9, No. 1. See the NIHR Journals Library website for further project information.
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Der Beitrag gibt einen Überblick über die sozialen und wirtschaftlichen Lebensbedingungen von Kindern und Jugendlichen in Mittel- und Südamerika und beleuchtet insbesondere die Bereiche Gesundheit, Fertilität und Sexualität sowie Bildung und Erziehung aus der Perspektive der aktuellen Kindheits- und Jugendforschung in Lateinamerika. Wird die Lebenslage junger Menschen ausschließlich auf Grundlage aggregierter Länderindikatoren beurteilt, erscheint diese im globalen Vergleich überdurchschnittlich. Ein fokussierter Blick auf konkrete Forschungsergebnisse zeigt jedoch, dass die Region von großer sozialer Ungleichheit zwischen einzelnen Ländern wie auch innerhalb dieser geprägt ist. Viele der positiven Entwicklungen der letzten Jahre erreichen oft nur die sozioökonomisch bessergestellte urbane Bevölkerung. Zugleich treten – nicht zuletzt verstärkt durch die Globalisierung – neue Problemlagen wie Bildungsprivatisierung und Übergewicht zutage. Der Beitrag kommt zu dem Schluss, dass von der insgesamt positiven Entwicklung der Lebenssituation von Kindern und Jugendlichen in Lateinamerika nicht alle Kinder und Jugendlichen im gleichen Maße profitieren: Marginalisierte (soziale) Gruppen werden im Zuge der aktuellen Entwicklungen weiterhin benachteiligt.
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Background School health services (SHS) can be defined as health services provided to enrol pupils by health professionals and/or allied professions. The aim of this study was to explore the current state of the governance, organization and workforce of SHS and their provision of preventive activities in European countries. Methods Observational study. Data were collected as part of the Horizon 2020-funded project ‘Models of Child Health Appraised’. Only 1 expert from each of the 30 included European countries answered a closed-items questionnaire during the years 2017 and 2018. Results All countries (except Spain and the Czech Republic, which do not have formal SHS) provided school-based individual screening and health-enhancing measures. The majority performed height, weight, vision and hearing checks; some integrated other assessments of limited evidence-based effectiveness. Most countries also delivered health education and promotion activities in areas, such as sexual health, substance use and healthy nutrition. Almost all countries seemed to suffer from a shortage of school health professionals; moreover, many of these professionals had no specific training in the area of school health and prevention. Conclusions Many EU countries need better administrative and legal support. They should promote evidence-based screening procedures and should hire and train more school health professionals. Overall, they need to adapt to the evolving health priorities of pupils, adopt a more holistic paradigm and extend their activities beyond traditional screening or vaccination procedures.
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Purpose: Teenage pregnancy is an issue of inequality affecting the health, wellbeing and life chances of young women, young men and their children. Consequently, high levels of teenage pregnancy are of concern to an increasing number of developing and developed countries. The UK Labour Government’s Teenage Pregnancy Strategy for England was one of the very few examples of a nationally led, locally implemented evidence based Strategy, resourced over a long duration, with an associated reduction of 48% in the under-18 conception rate. This paper seeks to identify the lessons applicable to other countries. Methods: The paper focuses on the prevention programme. Drawing on the detailed documentation of the ten-year Strategy it analyses the factors that helped and hindered implementation against the WHO ExpandNet Framework. The Framework strives to improve the planning and management of the process of scaling-up of successful pilot programmes with a focus on sexual and reproductive health, making it particularly suited for an analysis of England’s teenage pregnancy Strategy. Results: The development and implementation of the Strategy matches the Framework’s key attributes for successful planning and scaling up of sexual and reproductive health programmes. It also matched the attributes identified by the Centre for Global Development for scaled up approaches to complex public health issues. Conclusion: Although the Strategy was implemented in a high-income country, analysis against the WHO-ExpandNet Framework identifies many lessons which are transferable to low and medium income countries seeking to address high teenage pregnancy rates.
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Introduction: Human Immunodeficiency Virus (HIV) and Sexually Transmitted Infections (STIs) among youths represent an important public health challenge in developing countries. The incidence of HIV peaked in the 1990's and saw a decline from 2005. What was done to prompt the decline? To answer this question selecting studies between 1990 and 2005 was appropriate to assess whether the drop in HIV incidence in developing countries was as a result of education interventions. School based interventions are widely used to change young people's attitudes towards early sexual activity and to prevent the transmission of HIV/STIs, and have been implemented by countries across the world. Methods: Electronic databases were searched to identify studies in HIV/STI education interventions conducted in schools in developing countries published from 1990 to 2005. Studies from 1990 effectively gave a clearer explanation of whether education interventions contributed to the genesis of the decline. In addition to assessing HIV incidence, the reviewer also included studies performed on sexually transmitted infections (STIs) as knowledge on STI prevention could lead to preventing HIV transmission. Studies were eligible if they had an appropriate comparison group; published in English and full text retrieved. Twenty-eight full text articles were assessed for eligibility, 17 articles met the inclusion criteria and 11 articles were rejected due to, not addressing HIV or sex education programmes in schools or were abstracts only. The Cochrane Effective Practice and Organization of Care tool for randomized controlled trials (RCTs), non-randomized controlled trials (NRCTs) and controlled before and after (CBA) studies was used to critically appraise studies. Results: All 17 studies reviewed established positive effects on knowledge. Programmes have similar characteristics and were more effective if they were conducted by adults. Conclusions: The overall conclusion of evidence gathered was that curriculum based programmes on HIV and sex education could be effective in changing the behavior of young people in developing countries if conducted properly. They were also effective in increasing knowledge on problems associated with risky sexual activity among young people. Further research is needed to assess the long-term positive effects of such programmes in schools in developing countries.
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Young women in South Africa are at high risk for HIV infection. Cash transfers offer promise to reduce HIV risk. We present the design and baseline results from HPTN 068, a phase III, individually randomized trial to assess the effect of a conditional cash transfer on HIV acquisition among South African young women. A total of 2533 young women were randomized to receive a monthly cash transfer conditional on school attendance or to a control group. A number of individual-, partner-, household- and school-level factors were associated with HIV and HSV-2 infection. After adjusting for age, all levels were associated with an increased odds of HIV infection with partner-level factors conveying the strongest association (aOR 3.05 95 % CI 1.84-5.06). Interventions like cash transfers that address structural factors such as schooling and poverty have the potential to reduce HIV risk in young women in South Africa.
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Objective: To evaluate the effectiveness of a complex intervention implementing best practice guidelines recommending clinicians screen and counsel young people across multiple psychosocial risk factors, on clinicians' detection of health risks and patients' risk taking behaviour, compared to a didactic seminar on young people's health. Design: Pragmatic cluster randomised trial where volunteer general practices were stratified by postcode advantage or disadvantage score and billing type (private, free national health, community health centre), then randomised into either intervention or comparison arms using a computer generated random sequence. Three months post-intervention, patients were recruited from all practices post-consultation for a Computer Assisted Telephone Interview and followed up three and 12 months later. Researchers recruiting, consenting and interviewing patients and patients themselves were masked to allocation status; clinicians were not. Setting: General practices in metropolitan and rural Victoria, Australia. Participants: General practices with at least one interested clinician (general practitioner or nurse) and their 14-24 year old patients. Intervention: This complex intervention was designed using evidence based practice in learning and change in clinician behaviour and general practice systems, and included best practice approaches to motivating change in adolescent risk taking behaviours. The intervention involved training clinicians (nine hours) in health risk screening, use of a screening tool and motivational interviewing; training all practice staff (receptionists and clinicians) in engaging youth; provision of feedback to clinicians of patients' risk data; and two practice visits to support new screening and referral resources. Comparison clinicians received one didactic educational seminar (three hours) on engaging youth and health risk screening. Outcome measures: Primary outcomes were patient report of (1) clinician detection of at least one of six health risk behaviours (tobacco, alcohol and illicit drug use, risks for sexually transmitted infection, STI, unplanned pregnancy, and road risks); and (2) change in one or more of the six health risk behaviours, at three months or at 12 months. Secondary outcomes were likelihood of future visits, trust in the clinician after exit interview, clinician detection of emotional distress and fear and abuse in relationships, and emotional distress at three and 12 months. Patient acceptability of the screening tool was also described for the intervention arm. Analyses were adjusted for practice location and billing type, patients' sex, age, and recruitment method, and past health risks, where appropriate. An intention to treat analysis approach was used, which included multilevel multiple imputation for missing outcome data. Results: 42 practices were randomly allocated to intervention or comparison arms. Two intervention practices withdrew post allocation, prior to training, leaving 19 intervention (53 clinicians, 377 patients) and 21 comparison (79 clinicians, 524 patients) practices. 69% of patients in both intervention (260) and comparison (360) arms completed the 12 month follow-up. Intervention clinicians discussed more health risks per patient (59.7%) than comparison clinicians (52.7%) and thus were more likely to detect a higher proportion of young people with at least one of the six health risk behaviours (38.4% vs 26.7%, risk difference [RD] 11.6%, Confidence Interval [CI] 2.93% to 20.3%; adjusted odds ratio [OR] 1.7, CI 1.1 to 2.5). Patients reported less illicit drug use (RD -6.0, CI -11 to -1.2; OR 0·52, CI 0·28 to 0·96), and less risk for STI (RD -5.4, CI -11 to 0.2; OR 0·66, CI 0·46 to 0·96) at three months in the intervention relative to the comparison arm, and for unplanned pregnancy at 12 months (RD -4.4; CI -8.7 to -0.1; OR 0·40, CI 0·20 to 0·80). No differences were detected between arms on other health risks. There were no differences on secondary outcomes, apart from a greater detection of abuse (OR 13.8, CI 1.71 to 111). There were no reports of harmful events and intervention arm youth had high acceptance of the screening tool. Conclusions: A complex intervention, compared to a simple educational seminar for practices, improved detection of health risk behaviours in young people. Impact on health outcomes was inconclusive. Technology enabling more efficient, systematic health-risk screening may allow providers to target counselling toward higher risk individuals. Further trials require more power to confirm health benefits. Trial registration: ISRCTN.com ISRCTN16059206.
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Youth centers, peer education, and one-off public meetings have generally been ineffective in facilitating young people’s access to sexual and reproductive health (SRH) services, changing their behaviors, or influencing social norms around adolescent SRH. Approaches that have been found to be effective when well implemented, such as comprehensive sexuality education and youth-friendly services, have tended to flounder as they have considerable implementation requirements that are seldom met. For adolescent SRH programs to be effective, we need substantial effort through coordinated and complementary approaches. Unproductive approaches should be abandoned, proven approaches should be implemented with adequate fidelity to those factors that ensure effectiveness, and new approaches should be explored, to include greater attention to prevention science, engagement of the private sector, and expanding access to a wider range of contraceptive methods that respond to adolescents’ needs.
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Background: Young people who engage in substance use are at risk for becoming infected with HIV and diseases with similar transmission dynamics. Effective disease prevention programs delivered by prevention specialists exist but are rarely provided in systems of care due to staffing/resource constraints and operational barriers-and are thus of limited reach. Web-based prevention interventions could possibly offer an effective alternative to prevention specialist-delivered interventions and may enable widespread, cost-effective access to evidence-based prevention programming. Previous research has shown the HIV/disease prevention program within the Web-based therapeutic education system (TES) to be an effective adjunct to a prevention specialist-delivered intervention. The present study was the first randomized, clinical trial to evaluate the comparative effectiveness of this Web-based intervention as a standalone intervention relative to a traditional, prevention specialist-delivered intervention. Methods: Adolescents entering outpatient treatment for substance use participated in this multi-site trial. Participants were randomly assigned to either a traditional intervention delivered by a prevention specialist (n=72) or the Web-delivered TES intervention (n=69). Intervention effectiveness was assessed by evaluating changes in participants' knowledge about HIV, hepatitis, and sexually transmitted infections, intentions to engage in safer sex, sex-related risk behavior, self-efficacy to use condoms, and condom use skills. Findings: Participants in the TES intervention achieved significant and comparable increases in HIV/disease-related knowledge, condom use self-efficacy, and condom use skills and comparable decreases in HIV risk behavior relative to participants who received the intervention delivered by a prevention specialist. Participants rated TES as easier to understand. Conclusion: This study indicates that TES is as effective as HIV/disease prevention delivered by a prevention specialist. Because technology-based interventions such as TES have high fidelity, are inexpensive and scalable, and can be implemented in a wide variety of settings, they have the potential to greatly increase access to effective prevention programming.
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Reproductive coercion (RC) involves indirect and direct partner behaviors that interfere with effective contraceptive use. RC has been identified as a correlate of intimate partner violence (IPV) among ethnically diverse women sampled from urban health clinics or shelters. Research is needed to determine whether RC is experienced more generally by young women and, if so, whether RC is associated with IPV, multiple indicators of sexual health, or both. In the present study, sexually active undergraduate women (N = 223, 80% Caucasian/White) provided self-report data on their sexual health and behaviorally specific lifetime experiences of both RC and partner physical violence. About 30% reported experiencing RC from a male sexual partner. Most commonly, RC involved condom manipulation or refusal within an adolescent dating relationship. Experiences of RC and partner violence were not independent; half of the women who reported RC also reported experiencing partner physical violence. Women with a history of RC reported a significantly reduced rate of contraceptive use during last vaginal sex and lower contraceptive and sexual self-efficacy. Additional research on the sociocultural and relational contexts of RC is needed. © The Author(s) 2015.
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This secondary data analysis sought to determine what mediated reductions in self-reported sexual initiation over the 24-month postintervention period in early adolescents who received "Promoting Health among Teens," a theory-based, abstinence-only intervention (Jemmott, Jemmott, & Fong, 2010). African American Grade 6 and 7 students at inner-city public middle schools were randomized to 1 of 5 interventions grounded in social-cognitive theory and the theory of reasoned action: 8-hr abstinence-only targeting reduced sexual intercourse; 8-hr safer-sex-only targeting increased condom use; 8-hr and 12-hr comprehensive interventions targeting sexual intercourse and condom use; 8-hr control intervention targeting physical activity and diet. Primary outcome was self-report of vaginal intercourse by 24 months postintervention. Potential mediators, assessed immediately postintervention, were theory-of-reasoned-action variables, including behavioral beliefs about positive consequences of abstinence and negative consequences of sex, intention to have sex, normative beliefs about sex, and HIV and sexually transmitted infection (STI) knowledge. We tested single and serial mediation models using the product-of-coefficients approach. Of 509 students reporting never having vaginal intercourse at baseline (324 girls and 185 boys; mean age = 11.8 years, SD = 0.8), 500 or 98.2% were included in serial mediation analyses. Consistent with the theory of reasoned action, the abstinence-only intervention increased positive behavioral beliefs about abstinence, which reduced intention to have sex, which in turn reduced sexual initiation. Negative behavioral beliefs about sex, normative beliefs about sex, and HIV/STI knowledge were not mediators. Abstinence-only interventions should stress the gains to be realized from abstinence rather than the deleterious consequences of sexual involvement. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
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Adolescents need access to effective sexual and reproductive health (SRH) interventions, but face barriers accessing them through traditional health systems. School-based approaches might provide accessible, complementary strategies. We investigated whether a 21-session after-school SRH education programme and school health service attracted adolescents most at risk for adverse SRH outcomes and explored motivators for and barriers to attendance. Grade 8 adolescents (average age 13 years) from 20 schools in the intervention arm of an HIV prevention cluster randomised controlled trial in the Western Cape Province of South Africa, were invited to participate in an after-school SRH program and to attend school health services. Using a longitudinal design, we surveyed participants at baseline, measured their attendance at weekly after-school sessions for 6 months and surveyed them post-intervention. We examined factors associated with attendance using bivariate and multiple logistic and Poisson regression analyses, and through thematic analysis of qualitative data. The intervention was fully implemented in 18 schools with 1576 trial participants. The mean attendance of the 21-session SRH programme was 8.8 sessions (S.D. 7.5) among girls and 6.9 (S.D. 7.2) among boys. School health services were visited by 17.3 % (14.9 % of boys and 18.7 % of girls). Adolescents who had their sexual debut before baseline had a lower rate of session attendance compared with those who had not (6.3 vs 8.5, p < .001). Those who had been victims of sexual violence or intimate partner violence (IPV), and who had perpetrated IPV also had lower rates of attendance. Participants were motivated by a wish to receive new knowledge, life coaching and positive attitudes towards the intervention. The unavailability of safe transport and domestic responsibilities were the most common barriers to attendance. Only two participants cited negative attitudes about the intervention as the reason they did not attend. Reducing structural barriers to attendance, after-school interventions are likely to reach adolescents with proven-effective SRH interventions. However, special attention is required to reach vulnerable adolescents, through offering different delivery modalities, improving the school climate, and providing support for adolescents with mental health problems and neurodevelopmental academic problems. Current Controlled Trials ISRCTN56270821 ; Registered 13 February 2013.
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Background: While many Ghanaian adolescents encounter sexual and reproductive health problems, their usage of services remains low. A social learning intervention, incorporating environment, motivation, education, and self-efficacy to change behaviour, was implemented in a low-income district of northern Ghana to increase adolescent services usage. This study aimed to assess the impact of this intervention on usage of sexual and reproductive health services by young people. Methods: Twenty-six communities were randomly allocated to (i) an intervention consisting of school-based curriculum, out-of-school outreach, community mobilisation, and health-worker training in youth-friendly health services, or (ii) comparison consisting of community mobilisation and youth-friendly health services training only. Outcome measures were usage of sexually-transmitted infections (STIs) management, HIV counselling and testing, antenatal care or perinatal services in the past year and reported service satisfaction. Data was collected, at baseline and three years after, from a cohort of 2,664 adolescents aged 15-17 at baseline. Results: Exposure was associated with over twice the odds of using STI services (AOR 2.47; 95%CI 1.78-3.42), 89% greater odds of using perinatal services (AOR 1.89; 95%CI 1.37-2.60) and 56% greater odds of using antenatal services (AOR 1.56; 95%CI 1.10-2.20) among participants in intervention versus comparison communities, after adjustment for baseline differences. Conclusions: The addition of targeted school-based and outreach activities increased service usage by young people more than community mobilisation and training providers in youth-friendly services provision alone.
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Competencies for adolescents with a healthy sexuality (COMPAS) is the only school-based sexual health promotion program in Spain that has been found to be as effective as an evidence-based intervention (¡Cuídate!) in the short term. This study's aim was to compare data from a 12-month follow-up evaluation on the effects of COMPAS on adolescents' sexual risks (knowledge, attitudes, perceived norms, sexual risk perception and intentions) and sexual behaviours (age of the first sex, consistent condom use and multiple partners) with an evidence-based intervention (¡Cuídate!) and a control group. Eighteen schools from five provinces of Spain were randomly assigned to one of three conditions: COMPAS, ¡Cuídate! and a control group. The adolescents (N = 1563; 34% attrition) were evaluated 1 week before and after the program, and 1 year post-program implementation. We found that the COMPAS program was as effective as ¡Cuídate!, the evidence-based program, in increasing the adolescents' knowledge about sexually transmitted infections and in fostering favourable attitudes about condom use and people living with HIV/AIDS. COMPAS was more effective than ¡Cuídate! in increasing the adolescents' perceptions of their peer's consistent condom use and the age delay of their first vaginal intercourse. However, it was less effective in maintaining the adolescents' intentions to use condoms and in delaying the age of their first oral sex experience. COMPAS was as effective as ¡Cuídate! in reducing sexual risk among adolescents. © The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
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Controlled trials of HIV prevention and care interventions are susceptible to contamination. In a randomized controlled trial of a social network peer education intervention among people who inject drugs and their risk partners in Philadelphia, PA and Chiang Mai, Thailand, we tested a contamination measure based on recall of intervention terms. We assessed the recall of test, negative and positive control terms among intervention and control arm participants and compared the relative odds of recall of test versus negative control terms between study arms. The contamination measures showed good discriminant ability among participants in Chiang Mai. In Philadelphia there was no evidence of contamination and little evidence of diffusion. In Chiang Mai there was strong evidence of diffusion and contamination. Network structure and peer education in Chiang Mai likely led to contamination. Recall of intervention materials can be a useful method to detect contamination in experimental interventions.
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Background: Child sexual abuse is a significant global problem in both magnitude and sequelae. The most widely used primary prevention strategy has been the provision of school-based education programmes. Although programmes have been taught in schools since the 1980s, their effectiveness requires ongoing scrutiny. Objectives: To systematically assess evidence of the effectiveness of school-based education programmes for the prevention of child sexual abuse. Specifically, to assess whether: programmes are effective in improving students' protective behaviours and knowledge about sexual abuse prevention; behaviours and skills are retained over time; and participation results in disclosures of sexual abuse, produces harms, or both. Search methods: In September 2014, we searched CENTRAL, Ovid MEDLINE, EMBASE and 11 other databases. We also searched two trials registers and screened the reference lists of previous reviews for additional trials. Selection criteria: We selected randomised controlled trials (RCTs), cluster-RCTs, and quasi-RCTs of school-based education interventions for the prevention of child sexual abuse compared with another intervention or no intervention. Data collection and analysis: Two review authors independently assessed the eligibility of trials for inclusion, extracted data, and assessed risk of bias. We summarised data for six outcomes: protective behaviours; knowledge of sexual abuse or sexual abuse prevention concepts; retention of protective behaviours over time; retention of knowledge over time; harm; and disclosures of sexual abuse. Main results: This is an update of a Cochrane Review that included 15 trials (up to August 2006). We identified 10 additional trials for the period to September 2014. We excluded one trial from the original review. Therefore, this update includes a total of 24 trials (5802 participants). We conducted several meta-analyses. More than half of the trials in each meta-analysis contained unit of analysis errors.1. Meta-analysis of two trials (n = 102) evaluating protective behaviours favoured intervention (odds ratio (OR) 5.71, 95% confidence interval (CI) 1.98 to 16.51), with borderline low to moderate heterogeneity (Chi² = 1.37, df = 1, P value = 0.24, I² = 27%, Tau² = 0.16). The results did not change when we made adjustments using intraclass correlation coefficients (ICCs) to correct errors made in studies where data were analysed without accounting for the clustering of students in classes or schools.2. Meta-analysis of 18 trials (n = 4657) evaluating questionnaire-based knowledge favoured intervention (standardised mean difference (SMD) 0.61, 95% CI 0.45 to 0.78), but there was substantial heterogeneity (Chi² = 104.76, df = 17, P value < 0.00001, I² = 84%, Tau² = 0.10). The results did not change when adjusted for clustering (ICC: 0.1 SMD 0.66, 95% CI 0.51 to 0.81; ICC: 0.2 SMD 0.63, 95% CI 0.50 to 0.77).3. Meta-analysis of 11 trials (n =1688) evaluating vignette-based knowledge favoured intervention (SMD 0.45, 95% CI 0.24 to 0.65), but there was substantial heterogeneity (Chi² = 34.25, df = 10, P value < 0.0002, I² = 71%, Tau² = 0.08). The results did not change when adjusted for clustering (ICC: 0.1 SMD 0.53, 95% CI 0.32 to 0.74; ICC: 0.2 SMD 0.60, 95% CI 0.31 to 0.89).4. We included four trials in the meta-analysis for retention of knowledge over time. The effect of intervention seemed to persist beyond the immediate assessment (SMD 0.78, 95% CI 0.38 to 1.17; I² = 84%, Tau² = 0.13, P value = 0.0003; n = 956) to six months (SMD 0.69, 95% CI 0.51 to 0.87; I² = 25%; Tau² = 0.01, P value = 0.26; n = 929). The results did not change when adjustments were made using ICCs.5. We included three studies in the meta-analysis for adverse effects (harm) manifesting as child anxiety or fear. The results showed no increase or decrease in anxiety or fear in intervention participants (SMD -0.08, 95% CI -0.22 to 0.07; n = 795) and there was no heterogeneity (I² = 0%, P value = 0.79; n=795). The results did not change when adjustments were made using ICCs.6. We included three studies (n = 1788) in the meta-analysis for disclosure of previous or current sexual abuse. The results favoured intervention (OR 3.56, 95% CI 1.13 to 11.24), with no heterogeneity (I² = 0%, P value = 0.84). However, adjusting for the effect of clustering had the effect of widening the confidence intervals around the OR (ICC: 0.1 OR 3.04, 95% CI 0.75 to 12.33; ICC: 0.2 OR 2.95, 95% CI 0.69 to 12.61).Insufficient information was provided in the included studies to conduct planned subgroup analyses and there were insufficient studies to conduct meaningful analyses.The quality of evidence for all outcomes included in the meta-analyses was moderate owing to unclear risk of selection bias across most studies, high or unclear risk of detection bias across over half of included studies, and high or unclear risk of attrition bias across most studies. The results should be interpreted cautiously. Authors' conclusions: The studies included in this review show evidence of improvements in protective behaviours and knowledge among children exposed to school-based programmes, regardless of the type of programme. The results might have differed had the true ICCs or cluster-adjusted results been available. There is evidence that children's knowledge does not deteriorate over time, although this requires further research with longer-term follow-up. Programme participation does not generate increased or decreased child anxiety or fear, however there is a need for ongoing monitoring of both positive and negative short- and long-term effects. The results show that programme participation may increase the odds of disclosure, however there is a need for more programme evaluations to routinely collect such data. Further investigation of the moderators of programme effects is required along with longitudinal or data linkage studies that can assess actual prevention of child sexual abuse.
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