Condom promotion in women attending inner city general practices for cervical smears: a randomized controlled trial

Interventions for encouraging sexual behaviours intended to prevent cervical cancer

BACKGROUND

Human papillomavirus (HPV) is the key risk factor for cervical cancer. Continuing high rates of HPV and other sexually transmitted infections (STIs) in young people demonstrate the need for effective behavioural interventions.

OBJECTIVES

To assess the effectiveness of behavioural interventions for young women to encourage safer sexual behaviours to prevent transmission of STIs (including HPV) and cervical cancer.

SEARCH STRATEGY

Systematic literature searches were performed on the following databases: Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, 2009) Cochrane Gynaecological Cancer Review Group (CGCRG) Specialised Register, MEDLINE, EMBASE, CINAHL, PsychINFO, Social Science Citation Index and Trials Register of Promoting Health Interventions (TRoPHI) up to the end of 2009. All references were screened for inclusion against selection criteria.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of behavioural interventions for young women up to the age of 25 years that included, amongst other things, information provision about the transmission and prevention of STIs. Trials had to measure behavioural outcomes (e.g. condom use) and/or biological outcomes (e.g. incidence of STIs, cervical cancer).

DATA COLLECTION AND ANALYSIS

A narrative synthesis was conducted. Meta-analysis was not considered appropriate due to heterogeneity between the interventions and trial populations.

MAIN RESULTS

A total of 5271 references were screened and of these 23 RCTs met the inclusion criteria. Most were conducted in the USA and in health-care clinics (e.g. family planning).The majority of interventions provided information about STIs and taught safer sex skills (e.g. communication), occasionally supplemented with provision of resources (e.g. free sexual health services). They were heterogeneous in duration, contact time, provider, behavioural aims and outcomes. A variety of STIs were addressed including HIV and chlamydia. None of the trials explicitly mentioned HPV or cervical cancer prevention.Statistically significant effects for behavioural outcomes (e.g. increasing condom use) were common, though not universal and varied according to the type of outcome. There were no statistically significant effects of abstaining from or reducing sexual activity. There were few statistically significant effects on biological (STI) outcomes. Considerable uncertainty exists in the risk of bias due to incomplete or ambiguous reporting.

AUTHORS' CONCLUSIONS

Behavioural interventions for young women which aim to promote sexual behaviours protective of STI transmission can be effective, primarily at encouraging condom use. Future evaluations should include a greater focus on HPV and its link to cervical cancer, with long-term follow-up to assess impact on behaviour change, rates of HPV infection and progression to cervical cancer. Studies should use an RCT design where possible with integral process evaluation and cost-effectiveness analysis where appropriate. Given the predominance of USA studies in this systematic review evaluations conducted in other countries would be particularly useful.

Systematic review of interventions to prevent the spread of sexually transmitted infections, including HIV, among young people in Europe

AIM

To examine the effectiveness of interventions seeking to prevent the spread of sexually transmitted infections (STIs), including HIV, among young people in the European Union.

METHODS

For this systematic review, we examined interventions that aimed at STI risk reduction and health promotion conducted in schools, clinics, and in the community for reported effectiveness (in changing sexual behavior and/or knowledge) between 1995 and 2005. We also reviewed study design and intervention methodology to discover how these factors affected the results, and we compiled a list of characteristics associated with successful and unsuccessful programs. Studies were eligible if they employed a randomized control design or intervention-only design that examined change over time and measured behavioral, biologic, or certain psychosocial outcomes.

RESULTS

Of the 19 studies that satisfied our review criteria, 11 reported improvements in the sexual health knowledge and/or attitudes of young people. Ten of the 19 studies aimed to change sexual risk behavior and 3 studies reported a significant reduction in a specific aspect of sexual risk behavior. Two of the interventions that led to behavioral change were peer-led and the other was teacher-led. Only 1 of the 8 randomized controlled trials reported any statistically significant change in sexual behavior, and then only for young females.

CONCLUSION

The young people studied were more accepting of peer-led than teacher-led interventions. Peer-led interventions were also more successful in improving sexual knowledge, though there was no clear difference in their effectiveness in changing behavior. The improvement in sexual health knowledge does not necessarily lead to behavioral change. While knowledge may help improve health-seeking behavior, additional interventions are needed to reduce STIs among young people.

Recent use of condoms and emergency contraception by women who selected condoms as their contraceptive method

OBJECTIVE

This study was undertaken to determine how consistently indigent, predominantly Hispanic women who had previously selected male condoms as their contraceptive method had used condoms and emergency contraception (EC) during the 2 weeks before their family planning clinic visit and reasons for any nonuse.

STUDY DESIGN

Cross-sectional survey with no personal identifiers collected.

RESULTS

Two hundred forty-eight women were surveyed. Overall, 43.8% of sexually active women reported inconsistent condom use during the prior 14 days. Only 39% of women who had not used condoms consistently used EC at least once. The most common reason for nonuse of both condoms (44%) and EC (41%) was that the woman did not perceive that she was at risk.

CONCLUSION

Inconsistent use of condoms and low use of EC are very frequent, even in a short-time frame. Patients may be reluctant to volunteer to clinicians their real contraceptive choices. Risk taking occurs at high rates, even among couples provided ready and free access to male condoms and EC.

Gaps in the evidence for well-child care: a challenge to our profession

BACKGROUND

Up to one third of visits to pediatricians involve health supervision (well-child care), and recommendations for office-based preventive interventions have dramatically expanded. We reviewed the evidence for the effectiveness of these interventions.

METHODS

The well-child care recommendations of 7 major North American organizations were tabulated. Three types of health supervision interventions were recommended, ie, behavioral counseling, screening, and prophylaxis. For recommendations common to at least 2 of the 7 organizations, evidence of effectiveness was sought from systematic reviews and clinical trials. Immunizations were not considered for this review, because they have been reviewed elsewhere.

RESULTS

Forty-two preventive interventions were recommended by > or =2 of the organizations. Limited clinical trials show that counseling can change some health risk behaviors; repeated intensive counseling is most likely to be effective. Harmful effects were shown for a few behavioral counseling interventions. Trials have been conducted for only 2 of the recommended screening interventions; therefore, rigorous evidence supporting screening is very limited. Trials support the use of folate to prevent neural tube defects, trials of iron supplementation do not address developmental outcomes, and trials were not found for the other recommended prophylactic interventions.

CONCLUSIONS

Limited direct evidence was found to support the recommended interventions. Because a large number of interventions are routinely recommended and often mandated and because the implementation of any recommendation may cause harm (including the displacement of other beneficial activities), these recommendations should be based on the strongest possible evidence. When recommendations are made, supporting evidence should be clearly stated.