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      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.

          Related collections

          Most cited references123

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          Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial.

          Lack of education and an economic dependence on men are often suggested as important risk factors for HIV infection in women. We assessed the efficacy of a cash transfer programme to reduce the risk of sexually transmitted infections in young women. In this cluster randomised trial, never-married women aged 13-22 years were recruited from 176 enumeration areas in the Zomba district of Malawi and randomly assigned with computer-generated random numbers by enumeration area (1:1) to receive cash payments (intervention group) or nothing (control group). Intervention enumeration areas were further randomly assigned with computer-generated random numbers to conditional (school attendance required to receive payment) and unconditional (no requirements to receive payment) groups. Participants in both intervention groups were randomly assigned by a lottery to receive monthly payments ranging from US$1 to $5, while their parents were independently assigned with computer-generated random numbers to receive $4-10. Behavioural risk assessments were done at baseline and 12 months; serology was tested at 18 months. Participants were not masked to treatment status but counsellors doing the serologic testing were. The primary outcomes were prevalence of HIV and herpes simplex virus 2 (HSV-2) at 18 months and were assessed by intention-to-treat analyses. The trial is registered, number NCT01333826. 88 enumeration areas were assigned to receive the intervention and 88 as controls. For the 1289 individuals enrolled in school at baseline with complete interview and biomarker data, weighted HIV prevalence at 18 month follow-up was 1·2% (seven of 490 participants) in the combined intervention group versus 3·0% (17 of 799 participants) in the control group (adjusted odds ratio [OR] 0·36, 95% CI 0·14-0·91); weighted HSV-2 prevalence was 0·7% (five of 488 participants) versus 3·0% (27 of 796 participants; adjusted OR 0·24, 0·09-0·65). In the intervention group, we noted no difference between conditional versus unconditional intervention groups for weighted HIV prevalence (3/235 [1%] vs 4/255 [2%]) or weighted HSV-2 prevalence (4/233 [1%] vs 1/255 [<1%]). For individuals who had already dropped out of school at baseline, we detected no significant difference between intervention and control groups for weighted HIV prevalence (23/210 [10%] vs 17/207 [8%]) or weighted HSV-2 prevalence (17/211 [8%] vs 17/208 [8%]). Cash transfer programmes can reduce HIV and HSV-2 infections in adolescent schoolgirls in low-income settings. Structural interventions that do not directly target sexual behaviour change can be important components of HIV prevention strategies. Global Development Network, Bill & Melinda Gates Foundation, National Bureau of Economic Research Africa Project, World Bank's Research Support Budget, and several World Bank trust funds (Gender Action Plan, Knowledge for Change Program, and Spanish Impact Evaluation fund). Copyright © 2012 Elsevier Ltd. All rights reserved.
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            Unsafe abortion: the preventable pandemic.

            Ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative. As with other more visible global-health issues, this scourge threatens women throughout the developing world. Every year, about 19-20 million abortions are done by individuals without the requisite skills, or in environments below minimum medical standards, or both. Nearly all unsafe abortions (97%) are in developing countries. An estimated 68 000 women die as a result, and millions more have complications, many permanent. Important causes of death include haemorrhage, infection, and poisoning. Legalisation of abortion on request is a necessary but insufficient step toward improving women's health; in some countries, such as India, where abortion has been legal for decades, access to competent care remains restricted because of other barriers. Access to safe abortion improves women's health, and vice versa, as documented in Romania during the regime of President Nicolae Ceausescu. The availability of modern contraception can reduce but never eliminate the need for abortion. Direct costs of treating abortion complications burden impoverished health care systems, and indirect costs also drain struggling economies. The development of manual vacuum aspiration to empty the uterus, and the use of misoprostol, an oxytocic agent, have improved the care of women. Access to safe, legal abortion is a fundamental right of women, irrespective of where they live. The underlying causes of morbidity and mortality from unsafe abortion today are not blood loss and infection but, rather, apathy and disdain toward women.
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              Interventions using new digital media to improve adolescent sexual health: a systematic review.

              New digital media (e.g., the Internet, text messaging, and social networking sites [SNS]) have dramatically altered the communication landscape, especially for youth. These communication platforms present new tools for engaging youth in sexual health promotion and risk reduction. We searched eight public databases across multiple disciplines for all peer-reviewed studies published between January 2000 and May 2011 that empirically evaluated the impact of digital media-based interventions on the sexual health knowledge, attitudes, and/or behaviors of adolescents aged 13-24 years. Of 942 abstracts, 10 met inclusion criteria. Seven studies were conducted in the United States. Eight described Web-based interventions, one used mobile phones, and one was conducted on an SNS. Two studies significantly delayed initiation of sex, and one was successful in encouraging users of an SNS to remove sex references from their public profile. Seven interventions significantly influenced psychosocial outcomes such as condom self-efficacy and abstinence attitudes, but at times the results were in directions unexpected by the study authors. Six studies increased knowledge of HIV, sexually transmitted infections, or pregnancy. This area of research is emerging and rapidly changing. More data from controlled studies with longer (>1 year) follow-up and measurement of behavioral outcomes will provide a more robust evidence base from which to judge the effectiveness of new digital media in changing adolescent sexual behavior. Copyright © 2012 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.
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                Author and article information

                Journal
                Cochrane Database Syst Rev
                Cochrane Database Syst Rev
                cd
                The Cochrane Database of Systematic Reviews
                John Wiley & Sons, Ltd (Chichester, UK )
                1469-493X
                08 November 2016
                : 11
                : CD006417
                Affiliations
                [1 ]Department of Health Sciences, University of York York, UK
                [2 ]Department of Psychiatry and Mental Health, University of Cape Town Cape Town, South Africa
                [3 ]Interdisciplinary Health Sciences, University of Stellenbosch Cape Town, South Africa
                [4 ]Department of Clinical Sciences, Liverpool School of Tropical Medicine Liverpool, UK
                [5 ]Health Systems Research Unit, South African Medical Research Council Tygerberg, South Africa
                [6 ]School of Public Health and Family Medicine, University of Cape Town Cape Town, South Africa
                [7 ]Department of Psychology, Stellenbosch University Matieland, South Africa
                [8 ]Biostatistics Unit, South African Medical Research Council Cape Town, South Africa
                Author notes
                Department of Health Sciences, University of York , Seebohm Rowntree Building, Heslington, York, YO10 5DD, UK. amanda.mason-jones@ 123456york.ac.uk amandajmasonjones@ 123456gmail.com .
                Article
                10.1002/14651858.CD006417.pub3
                5461872
                27824221
                273c5987-cda5-41c9-b2ba-98a8279e99ce
                Copyright © 2016 The Authors. Cochrane Database of Systematic Reviews published by John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration.

                This is an open access article under the terms of the Creative Commons Attribution-Non-Commercial-No-Derivatives Licence, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

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