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

Mechanisms behind gender transformative approaches targeting adolescent pregnancy in low- and middle-income countries: a realist synthesis protocol

INTRODUCTION

Adolescent pregnancy is defined as pregnancy at the age of 19 or below. Pregnancy and childbirth complications are the most significant cause of death among 15-19-year-old girls. Several studies have indicated that inequitable gender norms can increase the vulnerability of adolescent girls, including violence exposure, early marriage, and adolescent pregnancy. To address these disparities, gender transformative approaches aim to challenge and transform restrictive gender norms, roles, and relations through targeted interventions, promoting progressive changes. This realist review aims to synthesise existing evidence from a broad range of data sources to understand how, why, for whom, and in what contexts gender transformative approaches succeed in reducing adolescent pregnancy in low- and middle-income countries.

METHOD AND ANALYSIS

We employ a five-step realist synthesis approach: (1) clarify the scope of review and assessment of published literature, (2) development of initial programme theories, (3) systematic search for evidence, (4) development of refined programme theories, and (5) expert feedback and dissemination of results. This protocol presents the results of the first three steps and provides details of the next steps. We extracted data from 18 studies and outlined eight initial programme theories on how gender transformative approaches targeting adolescent pregnancy work in the first three steps. These steps were guided by experts in the field of sexual and reproductive health, implementation science, and realist methodology. As a next step, we will systematically search evidence from electronic databases and grey literature to identify additional studies eligible to refine the initial programme theories. Finally, we will propose refined programme theories that explain how gender transformative approaches work, why, for whom, and under which circumstances.

ETHICS AND DISSEMINATION

Ethics approval is not required because the included studies are published articles and other policy and intervention reports. Key results will be shared with the broader audience via academic papers in open-access journals, conferences, and policy recommendations. The protocol for this realist review is registered in PROSPERO (CRD42023398293).

School-based comprehensive sexuality education for prevention of adolescent pregnancy: a scoping review

BACKGROUND

Adolescent pregnancy is a global public health problem. Numerous approaches for Comprehensive Sexuality Education (CSE) delivery in schools have been implemented around the world. Previous reviews on CSE did not follow the International Technical Guidance on Sexuality Education (ITGSE) because CSE is very diverse in terms of population, interventions, settings and outcomes. We conducted this scoping review to identify and map the evidence of school-based CSE for prevention of adolescent pregnancy with emphasis on adolescents' contraceptive use, unintended pregnancy and abortion.

METHODS

We searched PubMed, CENTRAL, Scopus, ISI Web of Science, CINAHL, and WHO ICTRP to identify potential eligible studies from their inception to 4th Nov 2023.We included randomized controlled trials (RCTs) and non-RCTs of CSE implemented in public or private schools for adolescents. CSE was defined as a multi-session intervention in school that covered topics including contraception, pregnancy, abortion, and HIV/STI. School-based interventions were the main intervention that may be either stand-alone or multicomponent. There was no limitation on study's geographical area, but only English-language studies were considered. Two reviewers selected and extracted data independently, discussed for consensus or consulted the third reviewer if there were discrepancies for final conclusion. Data were presented using figures, map and table.

RESULTS

Out of 5897 records, 79 studies (101 reports) were included in this review. Most studies were conducted in the United States and other high-income countries in secondary or high schools with cluster RCTs. All studies included participatory methods. Almost all studies included Sexual and Reproductive Health which is the eighth concept of CSE. Very few studies reported the prespecified primary outcomes of contraceptive use during last sex, unintended pregnancy and abortion and hence this highlighted the gaps of available evidence for these outcomes. The number of concepts, components, duration and providers of CSE varied across the included studies. However, none of the interventions identified in this scoping review adhered to the ITGSE recommended approach.

CONCLUSIONS

Our scoping review shows gaps in school-based CSE implementation in terms of completeness of concepts, components, providers, duration and outcomes recommended by ITGSE.

Exposure to comprehensive sexuality education in schools in South Africa: the implications on the uptake of HIV testing services among HIV positive adolescent girls

Comprehensive sexuality education (CSE) is seen as a key instrument through which to affect behaviour and improve sexual and reproductive health (SRH) outcomes amongst adolescents. However, few studies have to date evaluated key SRH outcomes following exposure to CSE within a school setting. This study estimates the association between CSE and HIV testing and HIV testing self-efficacy amongst HIV positive adolescent girls. Data were collected from a cross-sectional survey administered in four high HIV prevalence districts . Independent variables included exposure to CSE, with outcome variables measuring uptake of HIV testing in the 12 months preceding the survey, and HIV testing self-efficacy. The sample comprised 505 HIV positive adolescent girls aged 12-19. . Attending CSE was associated with both; being more confident to get an HIV test (AOR: 2.44, 95% CI: 1.47-4.06, p < 0.001) and having ever tested for HIV (AOR: 2.15, 95% CI: 1.39-3.33, p < 0.001) while controlling for numerous variables. Results suggest CSE can play an important role in not only affecting HIV-related behaviours themselves, but also critical factors that affect HIV behaviours, including self-efficacy.

Perceived knowledge gained from school-based sexuality education - results from a national population-based survey among young people in Sweden

BACKGROUND

School-based sexuality education is a core component of securing young people's right to attain health equity regarding sexual and reproductive health and rights. This paper aims to explore how perceived knowledge (sufficient or insufficient) of taking care of one's sexual health is associated with knowledge gained from school-based sexuality education and social determinants.

METHODS

The data material is drawn from a population-based survey conducted in Sweden in 2015. The survey had 7755 respondents and a response rate of 26%. To explore the aim descriptive statistics and logistic regression models were used.

RESULTS

Our results show that perceived insufficient knowledge from school-based sexuality education was associated with higher odds of reporting not being able to take care of one's sexual health. The highest significant excess risk for insufficient knowledge was found among young people from sexual minorities.

CONCLUSIONS

Young people in Sweden do not have equal abilities to receive knowledge needed to take care of their sexual health and thus attain sexual health literacy. There is an unequal distribution of perceived knowledge, and LGBTQI+ youth particularly face barriers in using school-based sexuality education as a resource for sexual health literacy.

Interventions to prevent unintended pregnancies among adolescents: a rapid overview of systematic reviews

Risks associated with unintended pregnancy include unsafe abortions, poor maternal health-seeking behaviour, poor mental health, and potentially, maternal and infant deaths. Adolescent girls with unintended pregnancies are particularly vulnerable as they are at higher risk of eclampsia, premature onset of labour, and increased neonatal morbidity and mortality. Unintended pregnancy, with the right combination of interventions, can be avoided. Evidence-based decision-making and the need for a robust appraisal of the evidence have resulted in many systematic reviews. This review of systematic reviews focuses on adolescent pregnancy prevention and will seek to facilitate evidence-based decision-making. Two review authors independently extracted data and assessed the methodological quality of each review according to the AMSTAR 2 criteria. We identified three systematic reviews from low- and middle-income countries and high-income counties and included all socioeconomic groups. We used vote counting and individual narrative review summaries to present the results. Overall, skill-building, peer-led and abstinence programmes were generally effective. Interventions focused on information only, counselling and interactive sessions provided mixed results.In contrast, exposure to parenting and delaying sexual debut interventions were generally ineffective. Adolescent pregnancy prevention interventions that deploy school-based primary prevention strategies, i.e. strategies that prevent unintended pregnancies in the first place, may effectively reduce teenage pregnancy rates, improve contraceptive use, attitudes and knowledge, and delay sexual debut. However, the included studies have methodological issues, and our ability to generalise the result is limited.

Investigating the pathways from preconception care to preventing maternal, perinatal and child mortality: A scoping review and causal loop diagram

In recent years, there has been a growing recognition that developing preconception care provides an opportunity to significantly reduce maternal and child mortality and morbidity. This involves targeting multiple risk factors through a large array of medical, behavioural and social interventions. In this study, we created a Causal Loop Diagram (CLD) to describe several pathways by which a set of preconception interventions may lead to women's improved health and better pregnancy outcomes. The CLD was informed by a scoping review of meta-analyses. It summarises evidence on the outcomes and interventions related to eight preconception risk factors. The authors reviewed literature from two databases (PubMed and Embase) and used the framework developed by Arksey and O'Malley. The CLD includes 29 constructs categorised into five different levels (mortality, causes of death, preconception risk factors, intermediate factors, interventions or policies). The model indicates interconnections between five sub-systems and highlights the role of preventing early and rapidly repeated pregnancies, as well as optimising women's nutritional status in the preconception period. It also shows the prevention of preterm birth as a privileged route for lowering child mortality and morbidity. The CLD demonstrates the potential benefits of strategies that address multiple preconception risk factors simultaneously and can be used as a tool to promote the integration of preconception care into efforts to prevent maternal and child mortality. With further improvements, this model could serve as a basis for future research on the costs and benefits of preconception care.

Perceptions, Experiences, and Needs of Adolescents About School-Based Sexual Health Education: Qualitative Systematic Review

Adolescents are particularly vulnerable to poor sexual health outcomes such as sexually transmitted diseases, sexually transmitted infections, human immunodeficiency virus, and unintended pregnancy. While school-based sexual health education (SBSHE) can address adolescents' needs, they are often insufficient. Hence, their perception of SBSHE should be explored to improve current education. This review aims to consolidate the available evidence on perceptions, experiences, and needs of adolescents about SBSHE. Six electronic databases were searched from their inception date till June 2022. The included studies were assessed using the method of the Critical Appraisal Skills Program tool, and findings were meta-synthesized using Sandelowski and Barroso (2007). This review was registered via the International Prospective Register of Systematic Reviews. Overall, 51 studies were included, and three themes were identified: (1) teachings of SBSHE and its impact, (2) adolescents' preferred approach to SBSHE, and (3) importance of engaging and safe SBSHE. In conclusion, adolescents had mixed reactions toward SBSHE. They expressed the need for inclusivity (gender identity and racial, ethnic, and cultural groups). Having a "safe space," well-trained educators, and interactive approaches were important and hence should also be considered. More qualitative studies from different geographical regions are needed. Diverse topics (e.g., mutual consent, sexual abuse, and violence) should also be discussed. The use of multiple educators (e.g., schoolteachers, specialist teachers, and peers) should also be deliberated in future SBSHE research. Findings from this review should be triangulated by evaluating the perceptions of various stakeholders (e.g., educators, adolescents, and SBSHE administrators).

Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs)

BACKGROUND

Adolescent girls and young women (AGYW), aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio-Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high-quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design.

OBJECTIVES

The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research.

METHODS

This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes-aimed at engaging AGYW in HIV prevention and research - that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass-media, community-based, interpersonal, and Information Communication and Technology (ICT)/Digital Media-based interventions. They were further sub-categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added.

SELECTION CRITERIA

To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15-24, as defined by UNAIDS. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention-related outcomes.

RESULTS

This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Despite increased digital penetration use of media and technology-driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school-based settings, and in many cases are part of sex-education curricula. Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics-related outcomes. Outcomes related to engagement in the research were least studied.

CONCLUSION

This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors-such as strengthening social and community norms, relationships, and household dynamics-that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass-media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.

Multidisciplinary peer-led sexual and reproductive health education programme in France, a prospective controlled-study

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 peer-led health prevention programme called the "Service Sanitaire" (SeSa), consisting of health education provided by healthcare students (peer educators) to teenagers. For the first time in France, the impact of the programme was prospectively evaluated during its first year 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 part of the SRH SeSa programme and those who were part of another programme. The same analysis of knowledge was performed with respect to teenagers who received SRH interventions as part of the SeSa compared to teenagers who did not participate in a specific SRH education programme. Risk perception and risky behaviour were studied before and after the programme among healthcare students and 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 participating in the SeSa interventions 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 impacts on sexuality.

Sexual and reproductive health and rights knowledge, perceptions, and experiences of adolescent learners from three South African townships: qualitative findings from the Girls Achieve Power (GAP Year) Trial

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 completing 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.

Influence of preventive sex education programmes in compulsory secondary education students: a descriptive observational study

BACKGROUND

Sex education programmes conducted by health professionals and educators are essential for young people to adopt healthy habits and attitudes towards their sexuality. The Forma Joven Program, promoted by the Andalusian Regional Government's Ministry of Health and Families and Education, is a good example of this. The aim of the study is to determine if different "degrees of intervention" in the informative consultancies of the Forma Joven Program imply differences in knowledge and attitudes towards sexuality.

METHODS

This descriptive observational study analysed 27 Compulsory Secondary Education high schools in Huelva. These were included in the Program and belonged to a Primary Care Health District. Out of the 17 institutes initially selected because they met the inclusion criteria (4.256 students), finally 14 (3.596 students) participated. During the 2018/2019 school year, students from 3rd, 4th year of Secondary Compulsory Education (ESO), 1st, and 2nd Baccalaureate of the selected centres were asked to fill in a questionnaire of knowledge and attitudes towards sexuality. It collected variables such as age, sex, school year, institute, educational level and employment status of the father or mother and profile of the professional who delivers the counselling.

RESULTS

A total of 1.237 students completed the questionnaire, which represents a participation rate of 34.4%. The average age was 15.59 years (SD 1.26) and 39.9% were girls. In some evaluated questions, we found statistically significant differences between the groups with different levels of exposure to counselling and the acquisition of knowledge and attitudes towards students' sexuality, although in most of them no such differences were found. The results of this study suggest the importance of the quality of counselling over quantity. Some classic myths persist in relation to sexuality and in some situations, they can be decisive when adopting preventive measures to avoid risks related to pregnancy and contagion of STIs.

CONCLUSIONS

A greater number of counselling sessions does not imply acquiring a higher level of knowledge or better attitudes towards sexuality. Perhaps the quality of the education is more important than the quantity of counselling sessions.

Young People Awareness of Sexually Transmitted Diseases and Contraception: A Portuguese Population-Based Cross-Sectional Study

Adolescents and young adults are an important target concerning reducing health-risk behavior adoption, including sexual health. Studying their knowledge concerning sexuality and their main counsellors, can be an important step in targeting an updated health promotion approach. This study characterized adolescents and young adults' knowledge and attitudes about sexually transmitted diseases (STDs), and contraception, prospecting for their main trusted counseling sources. We conducted a cross-sectional, population-based, self-report survey of 746 individuals aged between 14 and 24 years from Paredes, Portugal. The questionnaire included many dimensions, as demographic characteristics, youth behavior, currently sexually active status, main counselors concerning health topics, awareness, and knowledge about STDs and contraception. Mean age of the participants was 18.3 years, 50.5% of them had started their sexual activity. Males present themselves as more sexually active, starting earlier, and have more sexual partners than females. Participants reported an adequate knowledge perception about STDs and contraception methods, however we found different patterns on specific STDs and contraceptive methods, according to gender, age, and sexually active status. Our results help design specific interventions to reach youth, community, and healthcare providers, pointing out the value of bringing people to the center of health policies.

Which Structural Interventions for Adolescent Contraceptive Use Have Been Evaluated in Low- and Middle-Income Countries?

Reducing adolescent childbearing is a global priority, and enabling contraceptive use is one means of achieving this. Upstream factors, e.g., gender inequalities, fertility norms, poverty, empowerment and schooling, can be major factors affecting contraceptive use. We conducted a systematic map to understand which structural adolescent contraception interventions targeting these upstream factors have been evaluated in LMICs. We searched eight academic databases plus relevant websites and a 2016 evidence gap map and screened references based on set inclusion criteria. We screened 6993 references and included 40 unique intervention evaluations, reported in 138 papers. Seventeen evaluations were reported only in grey literature. Poverty reduction/economic empowerment interventions were the most common structural intervention, followed by interventions to increase schooling (e.g., through legislation or cash transfers) and those aiming to change social norms. Half of the evaluations were RCTs. There was variation in the timing of endline outcome data collection and the outcome measures used. A range of structural interventions have been evaluated for their effect on adolescent contraceptive use/pregnancy. These interventions, and their evaluations, are heterogenous in numerous ways. Improved understandings of how structural interventions work, as well as addressing evaluation challenges, are needed to facilitate progress in enabling adolescent contraceptive use in LMICs.

Adolescent and young adult preferences for financial incentives to support adherence to antiretroviral therapy in Kenya: a mixed methods study

INTRODUCTION

To develop a patient-centred financial incentive delivery strategy to improve antiretroviral treatment adherence in adolescents and young adults (AYA) living with HIV in Kisumu, Kenya, we conducted a mixed methods study exploring preferences.

METHODS

A discrete choice experiment (DCE) and focus group discussion (FGD) were conducted simultaneously to identify preferences for five incentive delivery strategy features: value, eligibility, recipient, format and disbursement frequency. We used consecutive sampling to recruit AYA (14-24 years) living with HIV attending three health facilities in Kisumu, Kenya. We calculated mean preferences, willingness to trade, latent class membership and predictors of latent class membership. The FGD explored preferred incentive features, and, after deductive and inductive coding, qualitative findings were triangulated with DCE results.

RESULTS

Two hundred and seven AYA living with HIV (46% 14-17 years, 54% 18-24 years; 33% male sex, 89% viral load <50 copies/ml) were recruited to the study (28 October-16 November 2020). Two distinct preference phenotypes emerged from the DCE analysis (N = 199), 44.8% of the population fell into an "immediate reward" group, who wanted higher value cash or mobile money distributed at each clinic visit, and 55.2% fell into a "moderate spender" group, who were willing to accept lower value incentives in the form of cash or shopping vouchers, and accrued payments. The immediate reward group were willing to trade up to 200 Kenyan Shillings (KSH)-approximately 2 US dollars (USD)-of their 500 KSH (∼5 USD) incentive to get monthly as opposed to accrued yearly payments. The strongest predictor of latent class membership was age (RR 1.45; 95% CI: 1.08-1.95; p = 0.006). Qualitative data highlighted the unique needs of those attending boarding school and confirmed an overwhelming preference for cash incentives which appeared to provide the greatest versatility for use.

CONCLUSIONS

Providing small financial incentives as cash was well-aligned with AYA preferences in this setting. AYA should additionally be offered a choice of other incentive delivery features (such as mobile money, recipient and disbursement frequency) to optimally align with the specific needs of their age group and life stage.

The impact of financial incentives on HIV incidence among adolescent girls and young women in Eswatini: Sitakhela Likusasa, a cluster randomised trial

INTRODUCTION

Incentives conditional on school attendance or on remaining free of sexually transmitted infections have produced mixed results in reducing HIV incidence.

METHODS

HIV-negative adolescent girls and young women aged 15-22%-50% of whom were out of school-were recruited from 293 clusters in Eswatini from urban (30%) and rural areas (70%).Financial incentives conditional on education attendance were randomly allocated at the cluster level. All participants were further individually randomised into eligibility for a raffle incentive conditional on random selection into the raffle, on negative tests for syphilis and Trichomonas vaginalis and on being a raffle winner, creating four subarms in a 2×2 factorial design: no-intervention, raffle incentive, education incentive and raffle & education incentive. Randomisation was unblinded to participants.Logistic regressions were used in intention-to-treat analysis of HIV incidence over 3 years to estimate the impact of incentives conditional on school attendance and raffle incentives conditional on remaining sexually transmitted infection free.

RESULTS

The study recruited 4389 HIV-negative participants, who were distributed into four subarms: no intervention (n=1068), raffle incentive (n=1162), education incentive (n=1088) and raffle and education incentive (n=1071).At endline, 272 participants from 3772 for whom endline data were collected, tested positive for HIV. HIV incidence among participants in education treatment arm was significantly lower than in the education control arm, 6.34% (119/1878) versus 8.08% (153/1894) (p=0.041); OR: 0.766 (0.598 to 0.981); adjusted OR (aOR): 0.754 (0.585 to 0.972). Compared with the no intervention subarm, HIV incidence in the raffle and education incentive subarm was significantly lower, 5.79% (54/878) versus 8.84% (80/905); OR: 0.634 (0.443 to 0.907); aOR: 0.622 (0.433 to 0.893), while it was not significantly lower in the raffle incentive subarm.

CONCLUSION

Financial incentives conditional on education participation significantly reduced HIV infection among adolescent girls and young women in Eswatini and appear to be a promising tool for prevention in high HIV prevalence settings.

TRIAL REGISTRATION NUMBER

Western Institutional Review Board-protocol number 20 141 630.Eswatini National Health Research Review Board-FWA00026661.Pan African Clinical Trials Registry-PACTR201811609257043.

“We Should Be Taught Self-Respect, Self-Confidence and Self-Love”: Youth Perspectives of Adult Influences on Their Sexuality and Relationships Among South African Adolescents Living With HIV

Introduction

Of the 1.75 million adolescents aged 10–19 years living with HIV globally, 84% reside in sub-Saharan Africa. This problem is most acute in South Africa, where there are 720,000 adolescents living with HIV (ALHIV). ALHIV navigate the same challenges as other adolescents—such as puberty and first relationships—as well as challenges specific to their HIV-status—including stigma, disclosure, and concerns about HIV transmission. This dual burden calls for tailored sexual and reproductive health (SRH) programs. Here, we qualitatively explore the reflections of South African ALHIV on SRH education, communication, and discussion provided by adults in schools, clinics, and the home related to their unique SRH needs.

Methods

This paper reports on qualitative data from a mixed-methods study to inform interventions that meet the SRH needs of ALHIV. In-depth interviews (N = 20) were conducted with ALHIV recruited from two clinics in Cape Town, South Africa. Nine males and 11 females aged 16–19 participated in semi-structured in-depth interviews to discuss their sexual health as ALHIV. The interview guide explored 1) perceived SRH needs; 2) healthy living with HIV; 3) future goals; 4) intimate relationships; 5) psychosocial challenges; and 6) preferred interventions. Data were thematically applied to an iteratively-developed codebook and analyzed by the cross-cultural research team using NVivo 12.

Results

These qualitative data reveal the pressing needs among ALHIV for open communication and accurate information about sexuality and HIV, given the risk to themselves and their partners as they enter intimate relationships. Three themes emerged from the data: 1) Intergenerational pressures coming from caregivers, clinicians, and teachers often stigmatize the sexual heath behaviors of ALHIV; 2) When present, open intergenerational communication can provide ALHIV with crucial information, resources, and social support that supports healthy decisions, and 3) ALHIV offer specific ideas about how adults can support their decision-making in the transition to adulthood.

Conclusions

Findings highlight adolescents' recommendations for programs involving open communication, stigma-reduction around sexuality, and support from both peer and adult mentors. This study lays the foundation for strategies to improve intergenerational communication about sexual health to promote positive approaches to sexuality for ALHIV.

"Your status cannot hinder you": the importance of resilience among adolescents engaged in HIV care in Kenya

BACKGROUND

Approximately 40% of the 110,000 adolescents living with HIV (ALHIV) in Kenya have not achieved viral suppression. Despite the increasing availability of adolescent-friendly services, adolescents face barriers that impact ART adherence. This study aimed to identify key stigma-related barriers to ART adherence and strategies used by adolescents in overcoming these barriers.

METHODS

Data were collected by LVCT Health, a Kenyan organization with a programmatic focus on HIV testing, prevention, and care. 122 participants were recruited from 3 clinical sites affiliated with LVCT Health in Nairobi, Kisumu, and Mombasa. In-depth interviews were conducted with ALHIV (n = 12). Focus group discussions were conducted with ALHIV (n = 5), peer leaders (n = 3), and adolescents receiving HIV services in community settings (AIC) irrespective of HIV status (n = 3). Interviews and focus groups were audio recorded, translated, and transcribed. Data were analyzed thematically, with a focus on stigma and resilience.

RESULTS

While AIC primarily focused on adherence barriers and stigma, ALHIV and, to some extent, peer leaders, also identified resilience factors that helped overcome stigma. Four major themes emerged: 1) knowledge and future-oriented goals can drive motivation for ALHIV to remain healthy; 2) disclosure to others strengthens support systems for ALHIV; 3) medication-taking strategies and strategic disclosure can overcome adherence challenges in school; and 4) a supportive clinic environment promotes continuous adolescent engagement in HIV care. These concepts were used to develop a conceptual stigma/resilience model depicting how resilience moderates negative effects of stigma among ALHIV.

CONCLUSIONS

This study demonstrates the positive effects of ALHIV resilience on ART adherence and illuminates how stigma impacts ALHIV differently depending on their resilience. Strengths-based interventions, focused on increasing resilience among ALHIV in Kenya, and more formal involvement of adolescent peers to bolster adolescent support, have the potential to improve ART adherence among ALHIV.

Psychometric Properties of the Sexual Self-Concept Inventory for Early Adolescent Girls

Objective: To establish the validity and dependability of the Sexual Self-Concept Inventory (SSCI) for early adolescent girls in Spanish among the Colombian population of Santander. Materials and methods: Methodological study with samples used for the theoretical construct validity of the study’s dimensions and internal consistency. The sample consisted of 308 adolescent girls aged between 10 and 14 from two schools in Girón, Santander, Colombia. Results: Inventory of 34 items with three dimensions; exploratory factor analysis confirmed the three factors with a total variance of 43.261 %. The instrument reported internal consistency of α = 0.89 for the following dimensions: sexual arousability (0.908), sexual agency (0.812), and negative sexual affect (0.572). Conclusions: The SSCI in Spanish is dependable enough to evaluate a person’s sexual behaviors or feelings and comprehend the sexual behavior of adolescent girls.

Sexual and reproductive health and rights knowledge, perceptions, and experiences of adolescent learners from three South African townships: qualitative findings from the Girls Achieve Power (GAP Year) Trial

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.

Feasibility and acceptability of a whole-school social-marketing intervention to prevent unintended teenage pregnancies and promote sexual health: evidence for progression from a pilot to a phase III randomised trial in English secondary schools

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.

Preventing Childhood Obesity in Primary Schools: A Realist Review from UK Perspective

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.

The role and effectiveness of School-based Extra-Curricular Interventions on children's health and HIV related behaviour: the case study of Soul Buddyz Clubs Programme in South Africa

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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12281-8.

Youth Internet Safety Education: Aligning Programs With the Evidence Base

BACKGROUND

This review critically examines the messages of youth internet safety education programs in the light of research about both the dynamics of internet dangers and the efficacy of youth prevention education.

METHODS

Using terms "internet safety education" and "digital citizenship," a Google search identified 12 multi-topic safety programs. Review articles were identified via Google Scholar for six forms of online harm to youth that have been targeted by many of these programs: cyberbullying (19 articles); online sexual exploitation (23 articles); sexting (19 articles); online fraud, hacking, and identity theft (6 articles); online suicide and self-harm promotion (18 articles); and internet overuse or addiction (15 articles).

FINDINGS

There appear to be mismatches between dynamics revealed in the research about internet harms and the messages emphasized in educational programs, particularly on the issues of sexual exploitation and sexting. Overall, the review literature also suggests major advantages to integrating internet safety into already well-established and evidence-based programs currently addressing related off-line harms, for example, programs focusing on general bullying, dating abuse, or sexual abuse prevention. The advantages stem from four factors: (1) the considerable overlap between online harms and similar off-line harms, (2) the apparent greater prevalence of off-line harms, (3) the evidence that the same risk factors lie behind both online and off-line harms, and most importantly, (4) the substantially superior evidence base for the longer standing programs developed originally around the off-line harms.

Primary Prevention of Neglect in Children through Health Education for Adolescent Girls in West Sumatra, Indonesia

BACKGROUND: High cases of stunting in toddlers require an effective and efficient primary prevention model. One of the efforts that can be done is to increase the knowledge of female adolescents to prevent anemia. AIM: The aim of the study was to produce a model that can be used as primary prevention of stunting in children. METHODS: Pre-test-Post-test Group Design. This research was conducted from March to November 2019 in Talamau District, West Pasaman Regency, involving 370 female adolescents as respondents. The intervention was carried out 3 times, followed by four separate evaluations. The intervention consists of engaging the respondents with various learning activities such as interactive lectures, group discussions, video screenings, messages through WhatsApp, and demonstrations. Data analysis was performed using GLM repeated measure. RESULTS: Health education interventions on anemia prevention can improve knowledge and attitudes among female adolescents; anemia prevention got a p-value of 0.00. CONCLUSION: The primary prevention model of stunting can increase knowledge and attitudes in female adolescents. It is recommended that parents, teachers, and health workers jointly provide health education regularly to prevent anemia so that stunting cases in toddlers no longer exist.

The Positive Choices trial: study protocol for a Phase-III RCT trial of a whole-school social marketing intervention to promote sexual health and reduce health inequalities

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.

A Systematic Review of Randomized Controlled Trials of School Based Interventions on Sexual Risk Behaviors and Sexually Transmitted Infections Among Young Adolescents in Sub-Saharan Africa

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.

Reviewing School Uniform through a Public Health Lens: Evidence about the Impacts of School Uniform on Education and Health

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.

Implementation and Evaluation of Life-planning Lecture to Enhance Perspective-Taking among High School Students: A School-based Nonrandomized Waitlist Intervention Study in Japan

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.

Effects of an Internet-Based and Teacher-Facilitated Sexuality Education Package: A Cluster-Randomized Trial

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.

[Unplanned pregnancy-now what? : Effectiveness and acceptance of medical teaching units for primary and secondary prevention in schools]

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.

AIMS

The accompanying evaluation study analyzes the effects of the teaching unit on the students' knowledge and their experience with self-efficacy concerning unplanned pregnancies.

METHODS

A two-armed cluster-randomized controlled study was conducted using a ten-page anonymous questionnaire with a closed answer format before and after the intervention.

RESULTS

In 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.

DISCUSSION

A 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.

Comparison of Health-Promoting Behaviors of Nursing Students From Different Racial/Ethnic Groups

BACKGROUND

Despite the known benefits of maintaining a healthy lifestyle in preventing many health-related issues, few nursing students practice health-promoting behaviors (HPB).

METHOD

This cross-sectional, descriptive, correlational study included 866 undergraduate nursing students who were members of the National Student Nurses' Association.

RESULTS

The difference in mean Health-Promoting Lifestyle Profile-II scores between White people and Asian Americans was statistically significant (F [4, 861]) = 2.95, p = .019). The difference in the mean self-efficacy scores between Black people and Asian Americans also was statistically significant (F [4, 861] = 4.41, p = .002). The regression model was significant (F [1, 862] = 6.683, p = .001, R2 =.235)], and self-efficacy (β = .457, t = 15.178, p = .001) significantly predicted nursing students' HPB.

CONCLUSION

The differences between racial/ethnic groups noted in this study indicate nursing faculty need to render culturally sensitive interventions to promote self-efficacy and HPB among undergraduate nursing students. [J Nurs Educ. 2021;60(9):500-508.].

Delaying sexual onset: outcome of a comprehensive sexuality education initiative for adolescents in public schools

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.

Are rhetorical commitments to adolescents reflected in planning documents? An exploratory content analysis of adolescent sexual and reproductive health in Global Financing Facility country plans

BACKGROUND

The Global Financing Facility (GFF) offers an opportunity to close the financing gap that holds back gains in women, children's and adolescent health. However, very little work exists examining GFF practice, particularly for adolescent health. As momentum builds for the GFF, we examine initial GFF planning documents to inform future national and multi-lateral efforts to advance adolescent sexual and reproductive health.

METHODS

We undertook a content analysis of the first 11 GFF Investment Cases and Project Appraisal Documents available on the GFF website. The countries involved include Bangladesh, Cameroon, Democratic Republic of Congo, Ethiopia, Guatemala, Kenya, Liberia, Mozambique, Nigeria, Tanzania and Uganda.

RESULTS

While several country documents signal understanding and investment in adolescents as a strategic area, this is not consistent across all countries, nor between Investment Cases and Project Appraisal Documents. In both types of documents commitments weaken as one moves from programming content to indicators to investment. Important contributions include how teenage pregnancy is a universal concern, how adolescent and youth friendly health services and school-based programs are supported in several country documents, how gender is noted as a key social determinant critical for mainstreaming across the health system, alongside the importance of multi-sectoral collaboration, and the acknowledgement of adolescent rights. Weaknesses include the lack of comprehensive analysis of adolescent health needs, inconsistent investments in adolescent friendly health services and school based programs, missed opportunities in not supporting multi-component and multi-level initiatives to change gender norms involving adolescent boys in addition to adolescent girls, and neglect of governance approaches to broker effective multi-sectoral collaboration, community engagement and adolescent involvement.

CONCLUSION

There are important examples of how the GFF supports adolescents and their sexual and reproductive health. However, more can be done. While building on service delivery approaches more consistently, it must also fund initiatives that address the main social and systems drivers of adolescent health. This requires capacity building for the technical aspects of adolescent health, but also engaging politically to ensure that the right actors are convened to prioritize adolescent health in country plans and to ensure accountability in the GFF process itself.

Nothing so practical as theory: a rapid review of the use of behaviour change theory in family planning interventions involving men and boys

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.

Effectiveness of school-based interventions in delaying sexual debut among adolescents in sub-Saharan Africa: a protocol for a systematic review and meta-analysis

INTRODUCTION

Early sexual debut is associated with poor sexual and reproductive health outcomes across the life course. A majority of interventions aimed at delaying sexual debut among adolescents in sub-Saharan Africa (SSA) have been implemented in schools with mixed findings on the effectiveness of such interventions. This systematic review will summarise and synthesise existing evidence on the effectiveness of school-based interventions in delaying sexual debut among adolescents aged 10-19 years.

METHODS AND ANALYSIS

We will conduct a comprehensive database search of peer-reviewed studies published in PubMed, Scopus, Science Direct, Web of Science, HINARI and EBSCO (PsycINFO, Global Health, CINAHL) and in Cochrane library, National Institute of Health and Turning Research into Practice databases for ongoing studies yet to be published. All studies conducted in SSA between January 2009 and December 2020, regardless of the study design, will be included. Two authors will independently screen all retrieved records and relevant data on sexual debut extracted.Data will be pooled using the random effects model. Dichotomous outcomes will be reported as risk ratios and continuous data as mean difference at 95% CI. Heterogeneity will be assessed using the I² statistic. Findings will be presented in tables and charts, while providing a description of all included studies, themes and concepts drawn from literature.

ETHICS AND DISSEMINATION

Ethical approval is not required. The findings will be disseminated through peer-reviewed publications, presentations at relevant conferences and other convening focusing on adolescent sexual and reproductive health.

Characterizing a sexual health and HIV risk stratification scale for sexually active adolescent girls and young women (AGYW) in Tanzania

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.

Sex Education in the Spotlight: What Is Working? Systematic Review

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.

Experiences of teachers and community health workers implementing sexuality and life skills education in youth clubs in Zambia

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.

Reducing HIV/STI Risk Among Adolescents Aged 12 to 14 Years: a Randomized Controlled Trial of Project Prepared

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.

Co-production of two whole-school sexual health interventions for English secondary schools: positive choices and project respect

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.

Assessment of Knowledge of HIV/AIDS and Association With Socioeconomic Disparities Among Young Women in Low- and Middle-Income Countries, 2003 to 2018

IMPORTANCE

Knowledge of HIV/AIDS among the younger population is crucial for long-term control. Little research has been done on which groups of young women (aged 15-24 years) in low- and middle-income countries (LMICs) have been left behind with respect to obtaining this knowledge.

OBJECTIVE

To provide an up-to-date assessment of the levels of and changes in knowledge of HIV/AIDS and its associations with socioeconomic disparity among young women in LMICs.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used nationally representative Demographic and Health Surveys with available data on HIV/AIDS knowledge in 51 LMICs between 2003 and 2018. The final data set contained 282 757 young women. For 40 LMICs with multiple surveys available, we examined changes in knowledge and socioeconomic disparities. Analyses of the survey data were conducted between December 1, 2019, and July 31, 2020.

MAIN OUTCOMES AND MEASURES

The percentage of young women who were able to (1) correctly identify the 2 major ways of preventing the sexual transmission of HIV, (2) reject the 2 most common local misconceptions about HIV transmission and (3) know that a healthy-looking person can transmit HIV. The level of and changes in young women's knowledge of HIV/AIDS as well as knowledge disparities by residential area, wealth status, and level of education on the aggregate and country levels were assessed.

RESULTS

Of a total of 282 757 young women from 51 LMICs, 29.3% (95% CI, 24.1% to 34.5%) reported having knowledge of HIV/AIDS in the latest years, ranging from 1.0% (95% CI, 0.7% to 1.3%) in Afghanistan in 2015 to 64.9% (95% CI, 63.3% to 66.5%) in Rwanda in 2014 to 2015. Those living in rural areas, living in households in the lowest income quintile, or with low levels of education reported less knowledge about HIV/AIDS than their counterparts (-12.8 [95% CI, -10.6 to -14.9] percentage points; -21.8 [95% CI, -18.3 to -25.3] percentage points; and -19.4 [95% CI, -16.6 to -22.2] percentage points, respectively). Among the 40 countries that had undertaken at least 2 surveys during the period, the surveys indicated that there was a significant increase in knowledge of HIV/AIDS among young women in 24 countries (60.0%), but a significant decrease in 10 countries (25.0%). Less than half of countries experienced significant reductions in disparities associated with residential area (8 countries [20.0%]), wealth (5 countries [12.5%]), or education (17 countries [42.5%]).

CONCLUSIONS AND RELEVANCE

This cross-sectional study of women in 51 LMICs found low levels and large gaps in knowledge of HIV/AIDS between groups, suggesting that future HIV-prevention campaigns should emphasize providing easily accessible information to socioeconomically disadvantaged groups.

A school-based social-marketing intervention to promote sexual health in English secondary schools: the Positive Choices pilot cluster RCT

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.

The Association Between Vaginal Microbiota Dysbiosis, Bacterial Vaginosis, and Aerobic Vaginitis, and Adverse Pregnancy Outcomes of Women Living in Sub-Saharan Africa: A Systematic Review

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.

The prevalence of pregnancy among adolescent girls and young women across the Southern African development community economic hub: A systematic review and meta-analysis

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.

A peer-led intervention to promote sexual health in secondary schools: the STASH feasibility study

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.

Impact evaluation of scripted lesson plans for HIV-related content in a life orientation curriculum: results from two provinces in South Africa

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.

Factors associated with the awareness of contraceptive methods, understanding the prevention of HIV/AIDS and the perception of HIV/AIDS risk among secondary school students in Dar es Salaam, Tanzania

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.

Effective educational interventions for the promotion of sexual and reproductive health and rights for school-age children in low- and middle-income countries: a systematic review protocol

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.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered at the International Prospective Register of Systematic Reviews (PROSPERO CRD42020173158).

Understanding further education as a context for public health intervention: qualitative findings from a study process evaluation

BACKGROUND

Over 1.2 million 16-18 year-olds are enrolled in further education (FE-advanced secondary education) in England. Life course transitions provide opportunities to change, establish or reinforce health behaviours. FE presents an opportunity for public health improvement, yet few interventions target this setting. Using a smoking prevention intervention, we explore how young people were viewed in FE and how this affected intervention acceptability.

METHODS

Eleven student and five staff focus groups were conducted in three intervention institutions (two colleges, one school sixth-form), as part of the process evaluation of a smoking prevention feasibility study. FE managers in intervention and control institutions were also interviewed (n = 5). Data were analysed using thematic analysis.

RESULTS

In both colleges and the sixth-form, students were viewed as emergent adults and treated differently from 'school-children', in practice if not in policy. Colleges permitted smoking in designated areas; in the school sixth-form smoking was unofficially tolerated but concealed from younger students. Using staff to deliver anti-smoking messages reintroduced an unwanted power dynamic which disrupted perceptions of students as young adults.

CONCLUSIONS

FE is an important setting for young people's health. Understanding the culture and context of FE is critical in designing acceptable and effective public health interventions.

Use of modern contraceptives among advanced-level secondary school girls in the Rukwa Region, Tanzania, 2018

OBJECTIVES

To determine contraceptive uptake, reasons for non-use and predictors of use.

METHODS

We conducted a cross-sectional study among girls in advanced-level secondary schools in the Rukwa region of Tanzania. Using probability proportional to size (PPS), we recruited a random sample of 660 girls out of 1447-targeted participants. A tool for data collection was a questionnaire. Data analyses included univariate analysis to describe study participants and Poisson regression analysis to assess the effect of independent factors to the dependent variable. A 5%-level of significance was used in multivariate analysis.

RESULTS

More than 40% of the girls report being sexually active and only 25% reported current use of modern contraceptives. The main reported main method being use of male condoms (93%). Barriers for non-use of contraceptives included fear of side effects, fear of being perceived or labeled as promiscuous, inadequate knowledge about contraceptives and for religious reasons. The predictor for using modern contraceptives was attending class sessions about modern contraceptives.

CONCLUSIONS

Although girls in advanced-level secondary schools are sexually active, the use of modern contraceptives is still low. Girls report several barriers frustrating their intention to use contraceptives, mainly based on misconceptions and lack of knowledge.