The effectiveness of the Reach for Health Community Youth Service learning program in reducing early and unprotected sex among urban middle school students

Use of contraceptives, empowerment and agency of adolescent girls and young women: a systematic review and meta-analysis

INTRODUCTION

The evidence on adolescent empowerment, which involves access to personal and material resources for reproductive autonomy and economic equity, is limited. This systematic review assesses the use of contraceptives in empowering and strengthening the agency and vice versa among adolescents and young women.

METHODS

We ran the searches in six electronic databases: Cochrane Database of Systematic Reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL), The Campbell Library, MEDLINE (PubMed), EMBASE, Cumulated Index to Nursing and Allied Health Literature (CINAHL) and Web of Science. The methodological quality of studies was assessed using ROBINS-I and ROB-II tools as appropriate. Meta-analysis was performed using Review Manager 5.4.

RESULTS

Forty studies that assessed the impact of empowerment on contraceptive use were included. Of these, 14 were non-randomised studies for intervention (NRSIs), and the remaining 26 were randomised controlled trials (RCTs). The results from RCTs show a significant effect of the sexual and reproductive health empowerment in increasing ever use of contraception (RR 1.22; 95% CI 1.02, 1.45; n=9; I²=77%; GRADE: Very Low), and insignificant effect on unprotected sex (RR 0.97; 95% CI 0.74, 1.26; n=5; I²=86%; GRADE: Very Low) and adolescent pregnancy (RR 1.07; 95% CI 0.61, 1.87; n=3; I²=36%; GRADE: Very Low). None of the studies assessed impact of contraceptive use on empowerment.

CONCLUSIONS

Empowerment of adolescents and young women certainly improves contraceptive use in the immediate or short-term period. However, more robust studies with low risk of bias, longer-term outcomes, and impact of contraceptive use on empowerment and agency-strengthening are required. To increase contraceptive use uptake, tailored policies and delivery platforms are necessary for youth in low- and middle-income countries.

Internet-Delivered Sexually Transmitted Infection and Teen Pregnancy Prevention Program: A Randomized Trial

BACKGROUND

Black older-teenaged women have disproportionately high rates of sexually transmitted infections (STI) and unintended pregnancy (UTP). Internet-based interventions can be delivered to large groups of people in a relatively inexpensive manner. In this randomized trial, we examine the efficacy of an evidence-based STI/UTP prevention intervention adapted for older teens and for Internet delivery.

METHODS

Black women aged 18-19 years who were not pregnant/seeking to become pregnant were enrolled (n = 637) and randomized to an 8-session intervention or attention control and were followed up at 6/12 months postintervention. The primary outcome was defined as uptake of reliable contraceptives. Other secondary outcomes were examined, including intention to use condoms, intention to use reliable contraception, and STI or pregnancy rates.

RESULTS

Overall, at baseline, reliable contraception was 54.8% and dual protection was 29.4%, and the prevalence of STI was 11.1%. Participants were similar by arm for most factors considered. Participation and follow-up rates were excellent (60.9% and 80.3%). There was no statistically significant difference in uptake of reliable contraception for intervention versus controls at 6 months (1.45 [0.99-2.12]) or 12 months (1.33 [0.92-1.91]). At 6 months, several secondary outcomes were improved/trended toward improvement in intervention compared with control, but this effect waned by 12 months, except for intention to use condoms which remained improved.

CONCLUSION AND RELEVANCE

The intervention was efficacious for increasing some self-reported UTP and STI prevention behaviors, which waned over time, and the intervention had minimal impact on STI or pregnancy rates suggesting that this type of online intervention may need additional components.

The Need for Earlier Implementation of Comprehensive Sexual Education Within a Formal Classroom Setting and Beyond Based on the Influences of Technology

Abstinence-only education taught predominately via formal classroom instruction has continuously been emphasized throughout history and in classrooms today. Although abstinence-only methods are often stressed, contraceptive education is occasionally but not consistently implemented in school curricula. A variety of other instructional delivery methods include student-peer education, education outside of the formal classroom setting, community youth service programs, education via telehealth, educational videos, self-study websites and social media. Providing comprehensive sexual education utilizing multiple instructional delivery methods could close the gap in sexual education for adolescents.

The age at which sexual education instruction is introduced has remained relatively unchanged throughout history. Adolescents are being formally educated within classrooms as early as grade five, although they are often exposed to informal and potentially misleading information regarding sexual education much earlier than this. In part, this is due to the relatively recent emergence and subsequent influence of technology such as social media. Thus, given the influence of technology such as social media in recent history we need to reevaluate the age of formal sexual education and increase comprehensive sexual education resources.

Additionally, it is important to note that sexual education instruction provided solely in formal classroom settings may not provide sufficient information for youth to make informed decisions. Thus, sexual education information including abstinence and contraceptive methods should be provided through additional means via utilizing differing instructional delivery methods in conjunction with formal classroom instruction. For example, comprehensive sexual education should also be provided in healthcare offices including pediatric and obstetrics and gynecology (OBGYN) offices. Sexual education could include discussing/providing external resources such as pamphlets that incorporate social media and other links to online resources that provide a more inclusive, accurate educational experience within a safe environment. This would allow healthcare professionals to provide a better targeted and engaging educational experience to adolescents as well as proactively allow for exposure of younger adolescents to helpful educational resources.

Service learning for improving academic success in students in grade K to 12: A systematic review

BACKGROUND

School-based service-learning is a teaching strategy that explicitly links community service to academic instruction. It is distinctive from traditional voluntarism or community service in that it intentionally connects service activities with curriculum concepts and includes structured time for reflection. Service learning, by connecting education to real world issues and allowing students to address problems they identify, may be particularly efficacious as it increases engagement and motivates students, in particular students who might not respond well to more traditional teaching methods.

OBJECTIVES

The main objective was to answer the following research question: What are the effects of service learning on academic success, neither employed, nor in education or training (NEET) status post compulsory school, personal and social skills, and risk behaviour of students in primary and secondary education (grades kindergarten to 12)? Further, we wanted to investigate study-level summaries of participant characteristics (e.g., gender, age or socioeconomic level) and quality of the service learning programme.

SEARCH METHODS

We identified relevant studies through electronic searches of bibliographic databases, governmental and grey literature repositories, hand search in specific targeted journals, citation tracking, and Internet search engines. The database searches were carried out in November 2019 and other resources were searched in October 2020. We searched to identify both published and unpublished literature, and reference lists of included studies and relevant reviews were searched.

SELECTION CRITERIA

The intervention was service learning which can be described as a curriculum-based community service that integrates classroom instruction (such as classroom discussions, presentations, or directed writing) with community service activities. We included children in primary and secondary education (grades kindergarten to 12) in general education. Our primary focus was on measures of academic success and NEET status. A secondary focus was on measures of personal and social skills, and risk behaviour (such as drug and alcohol use, violent behaviour, sexual risk taking). All study designs that used a well-defined control group were eligible for inclusion. Studies that utilised qualitative approaches were not included.

DATA COLLECTION AND ANALYSIS

The total number of potentially relevant studies constituted 13,719 hits. A total of 37 studies met the inclusion criteria. The 37 studies analysed 30 different populations. Only 10 studies (analysing nine different populations) could be used in the data synthesis. Eighteen studies could not be used in the data synthesis as they were judged to have critical risk of bias and, in accordance with the protocol, were excluded from the meta-analysis on the basis that they would be more likely to mislead than inform. Five studies did not provide enough information enabling us to calculate an effects size and standard error, and one study did not provide enough information to assess risk of bias. Finally, two clusters of studies used the same data sets, resulting in an additional three studies we did not use in the data synthesis. Meta-analysis of all outcomes were conducted on each conceptual outcome separately. All analyses were inverse variance weighted using random effects statistical models incorporating both the sampling variance and between study variance components into the study level weights. Random effects weighted mean effect sizes were calculated using 95% confidence intervals. We carried out a sensitivity analysis to examine the impact of correcting for clustered assignment of treatments.

MAIN RESULTS

The 10 studies (analysing nine different populations) used for meta analysis were all from the United States. The timespan in which included studies were carried out was 33 years, from 1980 to 2013; on average the intervention year was 2007. The average number of participants in the analysed service learning interventions was 937, ranging from 18 to 3556 and the average number of controls was 927, ranging from 20 to 3395. At most, the results from three studies could be pooled in any of the meta-analyses. All the meta-analyses showed a weighted average that favoured the intervention group except the pregnancy outcome. None of them was statistically significant except the weighted average of the two studies reporting math test results. The random effects weighted standardised mean difference was 0.09 [95% confidence interval (CI): -0.02 to 0.21] for students' general grade point average; 0.04 (95% CI: -0.08 to 0.16) for reading; 0.21 (95% CI: 0.09 to 0.33) for math; 0.03 (95% CI: -0.10 to 0.16) for days absent from school; 0.13 (95% CI: -0.14 to 0.40) for self-esteem; 0.07 (95% CI: -0.04 to 0.18) for locus of control. The random effects weighted odds ratio was 1.05 (95% CI: 0.63 to 1.74) for pregnancy and 0.96 (95% CI: 0.74 to 1.25) for sexual risk behaviour. In addition, a number of other outcomes were reported in a single study only. There were no appreciable changes in the results as indicated by the sensitivity analysis. We did not find any adverse effects.

AUTHORS' CONCLUSIONS

In this review, we aimed to find evidence of the effectiveness of service learning on students' academic success, personal and social skills, and risk behaviour. However, the evidence was inconclusive. We found only few randomised controlled trials and the risk of bias in the included non-randomised studies was very high. All available evidence used in the data synthesis was US-based. The majority of studies available for meta-analysis reported on a very limited number of outcomes; in particular few reported results on students' academic success even though the outcome was collected. Further, the majority of studies used in the meta-analyses reported implementation problems. These considerations point to the need for more rigorously conducted studies performed outside the United States, reporting a larger number of outcomes. It would be natural to consider conducting a series of randomised controlled trial with specific allocation to implementation of high-quality service learning as guided by the eight standards: (1) Meaningful service, (2) Link to curriculum, (3) Reflection, (4) Diversity, (5) Youth voice, (6) Community partnerships, (7) Progress monitoring and (8) Sufficient duration and intensity. Specific attention would also have to be paid to stringency in terms of conducting a well-designed randomised trial with low risk of bias and ensuring that the sample sizes are large enough to enable sufficient power.

Effects of preconception care and periconception interventions on maternal nutritional status and birth outcomes in low- and middle-income countries: A systematic review

Background

The preconception period is an ideal time to introduce interventions relating to nutrition and other lifestyle factors to ensure good pregnancy preparedness, and to promote health of mothers and babies. In adolescents, malnutrition and early pregnancy are the common challenges, particularly among those who live in low- and middle-income countries (LMIC) where 99% of all maternal and newborn deaths occur. These girls receive little or no attention until their first pregnancy and often the interventions after pregnancy are too late to revert any detrimental health risks that may have occurred due to malnutrition and early pregnancy.

Objectives

To synthesise the evidence of the effectiveness of preconception care interventions relating to delayed age at first pregnancy, optimising inter-pregnancy intervals, periconception folic acid, and periconception iron-folic acid supplementation on maternal, pregnancy, birth and child outcomes.

Search Methods

Numerous electronic databases (e.g., CINAHL, ERIC) and databases of selected development agencies or research firms were systematically searched for all available years up to July 2019. In addition, we searched the reference lists of relevant articles and reviews, and asked experts in the area about ongoing and unpublished studies.

Selection Criteria

Primary studies, including large-scale programme evaluations that assessed the effectiveness of interventions using randomised controlled trials (RCTs) or quasi-experimental designs (natural experiments, controlled before-after studies, regression discontinuity designs, interrupted time series [ITS]), that targeted women of reproductive age (i.e., 10-49 years) during the pre- and periconceptional period in LMICs were included. Interventions were compared against no intervention, standard of care or placebo.

Data Collection and Analysis

Two or more review authors independently reviewed searches, selected studies for inclusion or exclusion, extracted data and assessed risk of bias. We used random-effects model to conduct meta-analyses, given the diverse contexts, participants, and interventions, and separate meta-analyses for the same outcome was performed with different study designs (ITS, RCTs and controlled before after studies). For each comparison, the findings were descriptively summarised in text which included detailing the contextual factors (e.g., setting) to assess their impact on the implementation and effectiveness of each intervention.

Main Results

We included a total of 43 studies; two of these were included in both delaying pregnancy and optimising interpregnancy intervals resulting in 26 studies for delaying the age at first pregnancy (14 RCTs, 12 quasi-experimental), four for optimising interpregnancy intervals (one RCT, three quasi-experimental), five on periconceptional folic acid supplementation (two RCTs, three quasi-experimental), and 10 on periconceptional iron-folic acid supplementation (nine RCTs, one quasi-experimental). Geographically, studies were predominantly conducted across Africa and Asia, with few studies from North and Central America and took place in a combination of settings including community, schools and clinical. The education on sexual health and contraception interventions to delay the age at first pregnancy may make little or no difference on risk of unintended pregnancy (risk ratio [RR], 0.42; 95% confidence internal [CI], 0.07-3.26; two studies, =490; random-effect; χ ² p .009; I ² = 85%; low certainty of evidence using GRADE assessment), however, it significantly improved the use of condom (ever) (RR, 1.54; 95% CI, 1.08-2.20; six studies, n = 1604; random-effect, heterogeneity: χ ² p .004; I ² = 71%). Education on sexual health and and provision of contraceptive along with involvement of male partneron optimising interpregnancy intervals probably makes little or no difference on the risk of unintended pregnancies when compared to education on sexual health only (RR, 0.32; 95% CI, 0.01-7.45; one study, n = 45; moderate certainty of evidence using GRADE assessments). However, education on sexual health and contraception intervention alone or with provision of contraceptive showed a significant improvement in the uptake of contraceptive method. We are uncertain whether periconceptional folic acid supplementation reduces the incidence of neural tube defects (NTDs) (RR, 0.53; 95% CI, 0.41-0.77; two studies, n = 248,056; random-effect; heterogeneity: χ ² p .36; I ² = 0%; very low certainty of evidence using GRADE assessment). We are uncertain whether preconception iron-folic acid supplementation reduces anaemia (RR, 0.66; 95% CI, 0.53-0.81; six studies; n = 3430, random-effect; heterogeneity: χ ² p < .001; I ² = 88%; very low certainty of evidence using GRADE assessment) even when supplemented weekly (RR, 0.70; 95% CI, 0.55-0.88; six studies; n = 2661; random-effect; heterogeneity: χ ² p < .001; I ² = 88%; very low certainty of evidence using GRADE assessments),and in school set-ups (RR, 0.66; 95% CI, 0.51-0.86; four studies; n = 3005; random-effect; heterogeneity: χ ² p < .0001; I ² = 87%; very low certainty of evidence using GRADE assessment). Data on adverse effects were reported on in five studies for iron-folic acid, with the main complaint relating to gastrointestinal side effects. The quality of evidence across the interventions of interest was variable (ranging from very low to moderate) which may be attributed to the different study designs included in this review. Concerning risk of bias, the most common concerns were related to blinding of participants and personnel (performance bias) and whether there were similar baseline characteristic across intervention and comparison groups.

Authors' Conclusions

There is evidence that education on sexual health and contraception interventions can improve contraceptive use and knowledge related to sexual health, this review also provides further support for the use of folic acid in pregnancy to reduce NTDs, and notes that weekly regimes of IFA are most effective in reducing anaemia. However the certainty of the evidence was very low and therefore more robust trials and research is required, including ensuring consistency for reporting unplanned pregnancies, and further studies to determine which intervention settings (school, community, clinic) are most effective. Although this review demonstrates promising findings, more robust evidence from RCTs are required from LMICs to further support the evidence.

Attitudes, knowledge and sexual behavior among Finnish adolescents before and after an intervention

Adolescents are an important target group for sexual health promotion, and there are numerous programs and interventions carried out in this field. The aim of this study is to describe adolescents' attitudes, knowledge and sexual behavior before and after a sexual health promotion intervention. The intervention was developed in the study and consisted of three elements: (i) class-room session, (ii) information materials and (iii) free condom distribution. The study was carried out in eight randomly selected vocational schools in Finland. The participants were first year students aged 15-19 years. The data were collected using an electronic questionnaire before intervention (intervention baseline n = 500, control baseline n = 183) and two times after the intervention (intervention first follow-up n = 173/second follow-up n = 202, control first follow-up n = 115/second follow-up n = 46). There were significant differences before and after the intervention concerning better knowledge and more frequent testing for sexually transmitted infections (STIs). Schools are an important environment to reach adolescents during the phase where their sexual health is developing and there is an increased risk of STI transmission. More school-based interventions are therefore needed, and the results of this study can be utilized when developing sexual health promotion interventions among adolescents.

Volunteerism as adolescent health promotion asset: a scoping review

The Aim of this scoping review was to explore the available literature on volunteerism in adolescence and the benefits that this activity may report in their healthy development, from a salutogenic perspective. Searches were conducted in Pubmed, Cinahl, PsycINFO and Cochrane Library home databases; 15 articles were selected. Almost all of the studies were conducted in the United States between 1990 and 2000, primarily developed by psychologists and sociologists. The impact of volunteering was reflected in aspects that can be classified based on Lerner's dimensions of the PYD model. Volunteer activities promote an Improved academic, social, cognitive, and vocational competence in adolescents. An increase in conflict resolution capacity, leadership and personal agency, as well as improved pro-social attitudes and relationships with adults and peers, all of which contributed to their self-identification with the community. Moreover, increased positive development of adolescents reduces the rates of risky behaviors. Volunteerism may represent an opportunity for health promotion in adolescence. The concept of volunteering as an asset for health promotion during adolescence evokes the need to adopt and favor this view with regard to key areas of study associated with this stage such as education and health. Teams that work in community health, especially those in primary care, should recognize and value existing volunteer groups as an asset to promote the healthy development of adolescents. Friendlier health services should be encouraged that include comprehensive services from within educational institutions to community actions.

Experiential learning in oral health education

Experiential learning is an innovative learning method that knowledge is gained through experience. The aim of this paper was to review the application of experiential learning in health education and suggest an oral health education program using experiential learning. Experiential learning has been used in the past successfully in health education mostly in university curricula. In oral health education, its use is limited and without following a comprehensive structure. An experiential learning oral health education program, implemented in the classroom by a trained teacher, is proposed to be integrated in the school's curriculum. Initially, using brainstorming students express their opinions and feelings toward oral health. Then, students are allocated to working groups to develop oral health projects. The outcome of these projects is presented in the classroom to their peers through role playing, posters, songs, games, etc., Finally, a discussion is stimulated by the teacher to encourage children to express their feelings about oral health issues and thus experientially recognize the importance of oral health. Experiential learning has been effectively used in health education and can be a successful method for oral health education. For optimal results, a predetermined experiential method structure has to be followed.

NATIVE-It's Your Game: Adapting a Technology-Based Sexual Health Curriculum for American Indian and Alaska Native youth

Sexually transmitted infection (STI) and birth rates among American Indian/Alaska Native (AI/AN) youth indicate a need for effective middle school HIV/STI and pregnancy prevention curricula to delay, or mitigate, the consequences of early sexual activity. While effective curricula exist, there is a dearth of curricula with content salient to AI/AN youth. Further, there is a lack of sexual health curricula that take advantage of the motivational appeal, reach, and fidelity of communication technology for this population, who are sophisticated technology users. We describe the adaptation process used to develop Native It's Your Game, a stand-alone 13-lesson Internet-based sexual health life-skills curriculum adapted from an existing promising sexual health curriculum, It's Your Game-Tech (IYG-Tech). The adaptation included three phases: (1) pre-adaptation needs assessment and IYG-Tech usability testing; (2) adaptation, including design document development, prototype programming, and alpha testing; and (3) post-adaption usability testing. Laboratory- and school-based tests with AI/AN middle school youth demonstrated high ratings on usability parameters. Youth rated the Native IYG lessons favorably in meeting the needs of AI/AN youth (54-86 % agreement across lessons) and in comparison to other learning channels (57-100 %) and rated the lessons as helpful in making better health choices (73-100 %). Tribal stakeholders rated Native IYG favorably, and suggested it was culturally appropriate for AI/AN youth and suitable for implementation in tribal settings. Further efficacy testing is indicated for Native IYG, as a potential strategy to deliver HIV/STI and pregnancy prevention to traditionally underserved AI/AN middle school youth.

Effectiveness of Positive Youth Development Interventions: A Meta-Analysis of Randomized Controlled Trials

Positive youth development is thought to be essential to the prevention of adolescent risk behavior and the promotion of thriving. This meta-analysis examined the effects of positive youth development interventions in promoting positive outcomes and reducing risk behavior. Ten databases and grey literature were scanned using a predefined search strategy. We included studies that focused on young people aged 10-19 years, implemented a positive youth development intervention, were outside school hours, and utilized a randomized controlled design. Twenty-four studies, involving 23,258 participants, met the inclusion criteria and were included in the analysis. The impact of the interventions on outcomes including behavioral problems, sexual risk behavior, academic achievement, prosocial behavior and psychological adjustment were assessed. Positive youth development interventions had a small but significant effect on academic achievement and psychological adjustment. No significant effects were found for sexual risk behaviors, problem behavior or positive social behaviors. Intervention effects were independent of program characteristics and participant age. Low-risk young people derived more benefit from positive youth development interventions than high-risk youth. The studies examined had several methodological flaws, which weakened the ability to draw conclusions. Substantial progress has been made in the theoretical understanding of youth development in the past two decades. This progress needs to be matched in the intervention literature, through the use of high-quality evaluation research of positive youth development programs.

Teen Parents and Academic Success

The purpose of this study was to explore the personal life stories of women who became mothers while still in their teen years. The focus was on themes that evolved as important in the lives of these women, including family support, partner support, mentor support, economic opportunity, resiliency, optimism, and spirituality. Each of the 22 women in the study offered her formulas for success that are useful for consideration by school nurses. Factors the women perceived to contribute to their success in achieving a master’s or doctoral degree are explored. This study helps to identify the support and community efforts necessary to improve the outcome for teen mothers today. Their unique stories are exemplars of resiliency and achievement.

Effectiveness of Positive Youth Development Interventions: A Meta-Analysis of Randomized Controlled Trials

Positive youth development is thought to be essential to the prevention of adolescent risk behavior and the promotion of thriving. This meta-analysis examined the effects of positive youth development interventions in promoting positive outcomes and reducing risk behavior. Ten databases and grey literature were scanned using a predefined search strategy. We included studies that focused on young people aged 10-19 years, implemented a positive youth development intervention, were outside school hours, and utilized a randomized controlled design. Twenty-four studies, involving 23,258 participants, met the inclusion criteria and were included in the analysis. The impact of the interventions on outcomes including behavioral problems, sexual risk behavior, academic achievement, prosocial behavior and psychological adjustment were assessed. Positive youth development interventions had a small but significant effect on academic achievement and psychological adjustment. No significant effects were found for sexual risk behaviors, problem behavior or positive social behaviors. Intervention effects were independent of program characteristics and participant age. Low-risk young people derived more benefit from positive youth development interventions than high-risk youth. The studies examined had several methodological flaws, which weakened the ability to draw conclusions. Substantial progress has been made in the theoretical understanding of youth development in the past two decades. This progress needs to be matched in the intervention literature, through the use of high-quality evaluation research of positive youth development programs.

Interventions for preventing unintended pregnancies among adolescents

BACKGROUND

Unintended pregnancy among adolescents represents an important public health challenge in high-income countries, as well as middle- and low-income countries. Numerous prevention strategies such as health education, skills-building and improving accessibility to contraceptives have been employed by countries across the world, in an effort to address this problem. However, there is uncertainty regarding the effects of these interventions, hence the need to review the evidence-base.

OBJECTIVES

To assess the effects of primary prevention interventions (school-based, community/home-based, clinic-based, and faith-based) on unintended pregnancies among adolescents.

SEARCH METHODS

We searched all relevant studies regardless of language or publication status up to November 2015. We searched the Cochrane Fertility Regulation Group Specialised trial register, The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015 Issue 11), MEDLINE, EMBASE, LILACS, Social Science Citation Index and Science Citation Index, Dissertations Abstracts Online, The Gray Literature Network, HealthStar, PsycINFO, CINAHL and POPLINE and the reference lists of articles.

SELECTION CRITERIA

We included both individual and cluster randomised controlled trials (RCTs) evaluating any interventions that aimed to increase knowledge and attitudes relating to risk of unintended pregnancies, promote delay in the initiation of sexual intercourse and encourage consistent use of birth control methods to reduce unintended pregnancies in adolescents aged 10 years to 19 years.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and risk of bias, and extracted data. Where appropriate, binary outcomes were pooled using a random-effects model with a 95% confidence interval (Cl). Where appropriate, we combined data in meta-analyses and assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included 53 RCTs that enrolled 105,368 adolescents. Participants were ethnically diverse. Eighteen studies randomised individuals, 32 randomised clusters (schools (20), classrooms (6), and communities/neighbourhoods (6). Three studies were mixed (individually and cluster randomised). The length of follow up varied from three months to seven years with more than 12 months being the most common duration. Four trials were conducted in low- and middle- income countries, and all others were conducted in high-income countries. Multiple interventionsResults showed that multiple interventions (combination of educational and contraceptive-promoting interventions) lowered the risk of unintended pregnancy among adolescents significantly (RR 0.66, 95% CI 0.50 to 0.87; 4 individual RCTs, 1905 participants, moderate quality evidence. However, this reduction was not statistically significant from cluster RCTs. Evidence on the possible effects of interventions on secondary outcomes (initiation of sexual intercourse, use of birth control methods, abortion, childbirth, sexually transmitted diseases) was not conclusive.Methodological strengths included a relatively large sample size and statistical control for baseline differences, while limitations included lack of biological outcomes, possible self-report bias, analysis neglecting clustered randomisation and the use of different statistical tests in reporting outcomes. Educational interventionsEducational interventions were unlikely to significantly delay the initiation of sexual intercourse among adolescents compared to controls (RR 0.95, 95% CI 0.71 to 1.27; 2 studies, 672 participants, low quality evidence).Educational interventions significantly increased reported condom use at last sex in adolescents compared to controls who did not receive the intervention (RR 1.18, 95% CI 1.06 to 1.32; 2 studies, 1431 participants, moderate quality evidence).However, it is not clear if the educational interventions had any effect on unintended pregnancy as this was not reported by any of the included studies. Contraceptive-promoting interventionsFor adolescents who received contraceptive-promoting interventions, there was little or no difference in the risk of unintended first pregnancy compared to controls (RR 1.01, 95% CI 0.81 to 1.26; 2 studies, 3,440 participants, moderate quality evidence).The use of hormonal contraceptives was significantly higher in adolescents in the intervention group compared to those in the control group (RR 2.22, 95% CI 1.07 to 4.62; 2 studies, 3,091 participants, high quality evidence)

AUTHORS' CONCLUSIONS

A combination of educational and contraceptive-promoting interventions appears to reduce unintended pregnancy among adolescents.  Evidence for programme effects on biological measures is limited. The variability in study populations, interventions and outcomes of included trials, and the paucity of studies directly comparing different interventions preclude a definitive conclusion regarding which type of intervention is most effective.

It's Your Game…Keep It Real: can innovative public health prevention research thrive within a comparative effectiveness research framework?

The federal comparative effectiveness research (CER) initiative is designed to evaluate best practices in health care settings where they can be disseminated for immediate benefit to patients. The CER strategic framework comprises four categories (research, human and scientific capital, data infrastructure, and dissemination) with three crosscutting themes (conditions, patient populations, and types of intervention). The challenge for the field of public health has been accommodating the CER framework within prevention research. Applying a medicine-based, research-to-practice CER approach to public health prevention research has raised concerns regarding definitions of acceptable evidence (an evidence challenge), effective intervention dissemination within heterogeneous communities (a dissemination and implementation challenge), and rewards for best practice at the cost of other promising but high-risk approaches (an innovation challenge). Herein, a dynamic operationalization of the CER framework is described that is compatible with the development, evaluation, and dissemination of innovative public health prevention interventions. An effective HIV, STI, and pregnancy prevention program, It's Your Game…Keep It Real, provides a case study of this application, providing support that the CER framework can compatibly coexist with innovative, community-based public health prevention research.

Effects of an undergraduate HIV/AIDS course on students' HIV risk

This study utilizes a quasi-experimental pre- and post-test survey design to examine the effects of a course, called HIV/AIDS: Science, Behavior, and Society, on undergraduate students' HIV knowledge, attitudes and risky sexual behaviors. With the assistance of social work faculty the course incorporates experiential learning pedagogy and a transdisciplinary perspective. Although the course was not designed as a prevention program, the theory of health behavior suggests the incorporation of experiential learning will impact crucial HIV/AIDS attitudes and behaviors. When regression models were applied, relative to the comparison group (N = 111), the HIV/AIDS class students (N = 79) reported an increase in post-test HIV knowledge, perceived susceptibility to HIV among females, and a reduction of risky sexual attitudes among sexually active students.

The effectiveness of group-based comprehensive risk-reduction and abstinence education interventions to prevent or reduce the risk of adolescent pregnancy, human immunodeficiency virus, and sexually transmitted infections: two systematic reviews for the Guide to Community Preventive Services

CONTEXT

Adolescent pregnancy, HIV, and other sexually transmitted infections (STIs) are major public health problems in the U.S. Implementing group-based interventions that address the sexual behavior of adolescents may reduce the incidence of pregnancy, HIV, and other STIs in this group.

EVIDENCE ACQUISITION

Methods for conducting systematic reviews from the Guide to Community Preventive Services were used to synthesize scientific evidence on the effectiveness of two strategies for group-based behavioral interventions for adolescents: (1) comprehensive risk reduction and (2) abstinence education on preventing pregnancy, HIV, and other STIs. Effectiveness of these interventions was determined by reductions in sexual risk behaviors, pregnancy, HIV, and other STIs and increases in protective sexual behaviors. The literature search identified 6579 citations for comprehensive risk reduction and abstinence education. Of these, 66 studies of comprehensive risk reduction and 23 studies of abstinence education assessed the effects of group-based interventions that address the sexual behavior of adolescents, and were included in the respective reviews.

EVIDENCE SYNTHESIS

Meta-analyses were conducted for each strategy on the seven key outcomes identified by the coordination team-current sexual activity; frequency of sexual activity; number of sex partners; frequency of unprotected sexual activity; use of protection (condoms and/or hormonal contraception); pregnancy; and STIs. The results of these meta-analyses for comprehensive risk reduction showed favorable effects for all of the outcomes reviewed. For abstinence education, the meta-analysis showed a small number of studies, with inconsistent findings across studies that varied by study design and follow-up time, leading to considerable uncertainty around effect estimates.

CONCLUSIONS

Based on these findings, group-based comprehensive risk reduction was found to be an effective strategy to reduce adolescent pregnancy, HIV, and STIs. No conclusions could be drawn on the effectiveness of group-based abstinence education.

Interventions to reduce sexual risk for human immunodeficiency virus in adolescents: a meta-analysis of trials, 1985-2008

OBJECTIVE

To provide an updated review of the efficacy of behavioral interventions to reduce sexual risk of human immunodeficiency virus (HIV) among adolescents.

DESIGN

We searched electronic databases, leading public health journals, and the document depository held by the Synthesis of HIV/AIDS Risk Reduction Project. Studies that fulfilled the selection criteria and were available as of December 31, 2008, were included.

SETTING

Studies that investigated any behavioral intervention advocating sexual risk reduction for HIV prevention, sampled adolescents (age range, 11-19 years), measured a behavioral outcome relevant to sexual risk, and provided sufficient information to calculate effect sizes.

PARTICIPANTS

Data from 98 interventions (51,240 participants) were derived from 67 studies, dividing for qualitatively different interventions and gender when reports permitted it.

MAIN OUTCOME MEASURES

Condom use, sexual frequency, condom use skills, interpersonal communication skills, condom acquisition, and incident sexually transmitted infections (STIs).

RESULTS

Relative to controls, interventions succeeded at reducing incident STIs, increasing condom use, reducing or delaying penetrative sex, and increasing skills to negotiate safer sex and to acquire prophylactic protection. Initial risk reduction varied depending on sample and intervention characteristics but did not decay over time.

CONCLUSIONS

Comprehensive behavioral interventions reduce risky sexual behavior and prevent transmission of STIs. Interventions are most successful to the extent that they deliver intensive content.

Evaluation of a randomized intervention to delay sexual initiation among fifth-graders followed through the sixth grade

US adolescents initiate sex at increasingly younger ages, yet few pregnancy prevention interventions for children as young as 10-12 years old have been evaluated. Sixteen Washington, DC schools were randomly assigned to intervention versus control conditions. Beginning in 2001/02 with fifth-grade students and continuing during the sixth grade, students completed pre-intervention and post-intervention surveys each school year. Each year, the intervention included 10-13 classroom sessions related to delaying sexual initiation. Linear hierarchical models compared outcome changes between intervention and control groups by gender over time. Results show the intervention significantly decreased a rise over time in the anticipation of having sex in the next 12 months among intervention boys versus control boys, but it had no other outcome effects. Among girls, the intervention had no significant outcome effects. One exception is that for both genders, compared with control students, intervention students increased their pubertal knowledge. In conclusion, a school-based curriculum to delay sexual involvement among fifth-grade and sixth-grade high-risk youths had limited impact. Additional research is necessary to outline effective interventions, and more intensive, comprehensive interventions may be required to counteract adverse circumstances in students' lives and pervasive influences toward early sex.ClinicalTrials. gov identifier: NCT00341471.

Elements for successful collaboration between K-8 school, community agency, and university partners: the lead peace partnership

BACKGROUND

Researchers, schools, and community organizations are increasingly interested in forming partnerships to improve health and learning outcomes for adolescents. School-based service learning programs with young adolescents have been shown to improve students' health and educational outcomes. Quality school-based service learning practice requires partnerships that are collaborative, mutually beneficial, and address community needs. This article examines core elements of a community-school-university partnership engaged in implementing and evaluating Lead Peace, a service learning program for urban middle school youth.

METHODS

The partnership was assessed through (1) semistructured group interviews with program facilitators at each school at the end of the 2006 to 2007 and 2007 to 2008 school years; (2) key informant interviews with school administrators; and (3) participant observations of partnership meetings. Qualitative analysis was conducted to identify common and emerging themes that contribute to the success of the Lead Peace partnership.

RESULTS

Ten themes were identified as keys to the success of the Lead Peace partnership: (1) communication; (2) shared decision making; (3) shared resources; (4) expertise and credibility; (5) sufficient time to develop and maintain relationships; (6) champions and patron saints; (7) being present; (8) flexibility; (9) a shared youth development orientation; and (10) recognition of other partners' priorities.

CONCLUSIONS

Partnerships that are essential to quality service learning practice require deliberate planning and ongoing attention. Elements of the successful Lead Peace partnership may be useful for other collaborators to consider.

Standing in their shoes: student immersion in the community using service-learning with at-risk teens

The purpose of this study was to explicate students' perceptions of working with at-risk teens in a service-learning experience. In rural North Carolina, nursing students co-facilitated a wellness series for at-risk teens. A focus group explored students' perceptions. The focus group of ten students was recorded with participants' written consent and transcribed verbatim. Heideggerian hermeneutics guided thematic analysis. Five themes described students' perceptions: (a) Catching ourselves, (b) Learning how to drive home a concept, (c) Teaching is difficult, (d) Self as teacher/Self as learner, and (e) Seeing myself as a nurse. There was an overarching pattern of "Standing in their shoes."

A review of positive youth development programs that promote adolescent sexual and reproductive health

PURPOSE

Positive youth development (PYD) may be a promising strategy for promoting adolescent health. A systematic review of the published data was conducted to identify and describe PYD programs that improve adolescent sexual and reproductive health.

METHODS

Eight databases were searched for articles about PYD programs published between 1985 and 2007. Programs included met the following criteria: fostered at least one of 12 PYD goals in multiple socialization domains (i.e., family, school, community) or addressed two or more goals in at least one socialization domain; allocated at least half of the program activities to promoting general PYD outcomes (as compared with a focus on direct sexual health content); included youth younger than 20 years old; and used an experimental or quasi-experimental evaluation design.

RESULTS

Thirty programs met the inclusion criteria, 15 of which had evidence of improving at least one adolescent sexual and reproductive health outcome. Program effects were moderate and well-sustained. Program goals addressed by approximately 50% or more of the effective programs included promoting prosocial bonding, cognitive competence, social competence, emotional competence, belief in the future, and self-determination. Effective programs were significantly more likely than those that did not have an impact to strengthen the school context and to deliver activities in a supportive atmosphere. Effective programs were also more likely to build skills, enhance bonding, strengthen the family, engage youth in real roles and activities, empower youth, communicate expectations, and be stable and relatively long-lasting, although these differences between effective and ineffective programs were not statistically significant.

CONCLUSION

PYD programs can promote adolescent sexual and reproductive health, and tested, effective PYD programs should be part of a comprehensive approach to promoting adolescent health. However, more research is needed before a specific list of program characteristics can be viewed as a "recipe" for success.

Sexually transmitted infection among adolescents receiving special education services

BACKGROUND

To estimate the relative risk of sexually transmitted infections (STIs) among children identified as having learning disabilities through the special education system.

METHODS

This cross-sectional study used special education data and Medicaid data from Philadelphia, Pennsylvania, for calendar year 2002. The sample comprised 51,234 Medicaid-eligible children, aged 12-17 years, 8015 of whom were receiving special education services. Claims associated with diagnoses of STIs were abstracted, and logistic regression was used to estimate the odds of STI among children in different special education categories.

RESULTS

There were 3% of males and 5% of females who were treated for an STI through the Medicaid system in 2002. Among females, those in the mental retardation (MR) category were at greatest risk (6.9%) and those in the emotionally disturbed or "no special education" category at lowest risk (4.9% each). Among males, STIs were most prevalent among those classified as mentally gifted (6.7%) and lowest among those in the MR category (3.0%). In adjusted analyses, males with specific learning disabilities and females with MR or who were academically gifted were at excess risk for STIs.

CONCLUSIONS

The finding that children with learning disabilities are at similar or greater risk for contracting STIs as other youth suggests the need to further understand their risk behaviors and the potential need to develop prevention programs specific to their learning needs.

Psychosocial predictors of HIV-associated sexual behaviors and the efficacy of prevention interventions in adolescents at-risk for HIV infection: what works and what doesn't work?

The HIV epidemic among adolescents in the United States is inherently tied to individual, psychosocial, and cultural phenomena. Expanding intervention development and implementation to incorporate a broader spectrum of determinants of adolescents' sexual risk for sexually transmitted infections (STIs)/HIV acquisition may provide an opportunity to prevent disease transmission more effectively. To address the STI/HIV prevention needs of adolescents, we highlight research assessing adolescents' sexual risk behavior and place the findings in the context of the diverse array of psychosocial factors influencing adolescents. This synthesis provides an opportunity to examine why adolescents engage in risky sexual behavior and to review the effectiveness of theory-based prevention programs. Subsequently, we offer recommendations for improving future programs aimed at reducing the incidence of STI/HIV infection among adolescents.

Abstinence-plus programs for HIV infection prevention in high-income countries

BACKGROUND

Abstinence-plus interventions promote sexual abstinence as the best means of preventing acquisition of HIV, but also encourage safer-sex strategies (eg condom use) for sexually active participants.

OBJECTIVES

To assess the effects of abstinence-plus programs for HIV prevention in high-income countries.

SEARCH STRATEGY

We searched 30 electronic databases (eg CENTRAL, PubMed, EMBASE, AIDSLINE, PsycINFO) ending February 2007. Cross-referencing, hand-searching, and contacting experts yielded additional citations.

SELECTION CRITERIA

We included randomized and quasi-randomized controlled trials evaluating abstinence-plus interventions in high-income countries (as defined by the World Bank). Interventions were any efforts that encouraged sexual abstinence as the best means of HIV prevention, but also promoted safer sex. Results were self-reported biological outcomes, behavioral outcomes, and HIV knowledge.

DATA COLLECTION AND ANALYSIS

Three reviewers independently appraised 20070 citations and 325 full-text papers for inclusion and methodological quality; 39 evaluations were included. Due to heterogeneity and data unavailability, we presented the results of individual studies instead of a meta-analysis.

MAIN RESULTS

Studies enrolled 37724 North American youth; participants were ethnically diverse. Programs took place in schools (10), community facilities (24), both schools and community facilities (2), healthcare facilities (2), and family homes (1). Median final follow-up occurred 12 months after baseline. Results showed no evidence that abstinence-plus programs can affect self-reported sexually transmitted infection (STI) incidence, and limited evidence that programs can reduce self-reported pregnancy incidence. Results for behavioral outcomes were promising; 23 of 39 evaluations found a significantly protective intervention effect for at least one behavioral outcome. Consistently favorable program effects were found for HIV knowledge.No adverse effects were observed. Several evaluations found that one version of an abstinence-plus program was more effective than another, suggesting that more research into intervention mechanisms is warranted. Methodological strengths included large samples and statistical controls for baseline values. Weaknesses included under-utilization of relevant outcomes, self-report bias, and analyses neglecting attrition and clustered randomization.

AUTHORS' CONCLUSIONS

Many abstinence-plus programs appear to reduce short-term and long-term HIV risk behavior among youth in high-income countries. Evidence for program effects on biological measures is limited. Evaluations consistently show no adverse program effects for any outcomes, including the incidence and frequency of sexual activity. Trials comparing abstinence-only, abstinence-plus, and safer-sex interventions are needed.

Systematic review of abstinence-plus HIV prevention programs in high-income countries

BACKGROUND

Abstinence-plus (comprehensive) interventions promote sexual abstinence as the best means of preventing HIV, but also encourage condom use and other safer-sex practices. Some critics of abstinence-plus programs have suggested that promoting safer sex along with abstinence may undermine abstinence messages or confuse program participants; conversely, others have suggested that promoting abstinence might undermine safer-sex messages. We conducted a systematic review to investigate the effectiveness of abstinence-plus interventions for HIV prevention among any participants in high-income countries as defined by the World Bank.

METHODS AND FINDINGS

Cochrane Collaboration systematic review methods were used. We included randomized and quasi-randomized controlled trials of abstinence-plus programs for HIV prevention among any participants in any high-income country; trials were included if they reported behavioural or biological outcomes. We searched 30 electronic databases without linguistic or geographical restrictions to February 2007, in addition to contacting experts, hand-searching conference abstracts, and cross-referencing papers. After screening 20,070 abstracts and 325 full published and unpublished papers, we included 39 trials that included approximately 37,724 North American youth. Programs were based in schools (10), community facilities (24), both schools and community facilities (2), health care facilities (2), and family homes (1). Control groups varied. All outcomes were self-reported. Quantitative synthesis was not possible because of heterogeneity across trials in programs and evaluation designs. Results suggested that many abstinence-plus programs can reduce HIV risk as indicated by self-reported sexual behaviours. Of 39 trials, 23 found a protective program effect on at least one sexual behaviour, including abstinence, condom use, and unprotected sex (baseline n = 19,819). No trial found adverse program effects on any behavioural outcome, including incidence of sex, frequency of sex, sexual initiation, or condom use. This suggests that abstinence-plus approaches do not undermine program messages encouraging abstinence, nor do they undermine program messages encouraging safer sex. Findings consistently favoured abstinence-plus programs over controls for HIV knowledge outcomes, suggesting that abstinence-plus programs do not confuse participants. Results for biological outcomes were limited by floor effects. Three trials assessed self-reported diagnosis or treatment of sexually transmitted infection; none found significant effects. Limited evidence from seven evaluations suggested that some abstinence-plus programs can reduce pregnancy incidence. No trial observed an adverse biological program effect.

CONCLUSIONS

Many abstinence-plus programs appear to reduce short-term and long-term HIV risk behaviour among youth in high-income countries. Programs did not cause harm. Although generalisability may be somewhat limited to North American adolescents, these findings have critical implications for abstinence-based HIV prevention policies. Suggestions are provided for improving the conduct and reporting of trials of abstinence-plus and other behavioural interventions to prevent HIV.

Developing healthy kids in healthy communities: eight evidence‐based strategies for preventing high‐risk behaviour

Australian youth engage in behaviour that threatens their health and wellbeing. National surveys report that about a third of young Australians have tried an illicit drug. High rates of substance use and risky sexual behaviour among young Australians suggest that effective prevention efforts based on empirical evidence need to be expanded. Church-associated organisations are an untapped resource that could be used to improve the health and welfare of young people. We describe eight evidence-based elements to consider in designing strategies to prevent high-risk behaviour in young people.

Student and community outcomes in service-learning: part 1--student perceptions

Service-learning has a long and distinguished history of providing valuable experiences to students across all academic levels. Professional disciplines are well situated to provide students with opportunities related to service-learning while also providing needed health care services to communities. This article and Part 2 on pages 516-518 of this issue describe a service-learning initiative implemented in a bachelor of science in nursing program. Part 1 details students' perceptions of outcomes realized from the program, and Part 2 describes community outcomes. The purposes of the program were to enhance students' skills in history-taking, blood pressure and heart rate assessment skills, and beginning counseling skills, as well as provide the university community with blood pressure screening and counseling in a convenient and accessible location. Data on students' perceptions were collected for each semester of the program and for 1 year after students' participation in the program. Students perceived gains in blood pressure and heart rate skill performance, beginning counseling skills, their understanding of tailored client action plans, and their professional commitment to the health of the community.

A decade in review: building on the experiences of past adolescent STI/HIV interventions to optimise future prevention efforts

The major purpose of this article is to systematically review and synthesise empirical findings from selected adolescent STI/HIV interventions conducted in the United States between 1994 and 2004. Specifically, the most current adolescent STI risk reduction interventions conducted in diverse venues, such as in the community, schools, clinics, and specialised adolescent centres (that is, detention homes and drug programmes) were examined for reported efficacy, and were assessed for programmatic and methodological strengths and weaknesses. Next, a subset of programmatic characteristics was identified that were associated with the efficacy of STI risk reduction programmes both within a particular venue, as well as across all venues. Finally, we discuss the research and practice implications of these findings for optimising future evidence based STI risk reduction programmes for adolescents in the United States.

All4You! A randomized trial of an HIV, other STDs, and pregnancy prevention intervention for alternative school students

This study evaluated All4You!, a theoretically based curriculum designed to reduce sexual risk behaviors associated with HIV, other STDs, and unintended pregnancy among students in alternative schools. The study featured a randomized controlled trial involving 24 community day schools in northern California. A cohort of 988 students was assessed four times during an 18-month period using a self report questionnaire. At the 6-month follow-up, the intervention reduced the frequency of intercourse without a condom during the previous 3 months, the frequency of intercourse without a condom with steady partners, and the number of times students reported having intercourse in the previous 3 months. It also increased condom use at last intercourse. These behavioral effects were no longer statistically significant at the 12- and 18-month follow-ups. The All4You! intervention was effective in reducing selected sexual risk behaviors among students in alternative school settings; however, the effects were modest and short term.

Adult identity mentoring: reducing sexual risk for African-American seventh grade students

PURPOSE

This study was undertaken to determine whether the Adult Identity Mentoring (AIM) project successfully promotes abstinence, delays initiation of sex, and decreases intention to engage in sex.

METHODS

Twenty middle school classes of African-American seventh graders were randomly assigned to receive either the AIM intervention or a standard health education control curriculum. The AIM is a 10-session curriculum based on the theory of possible selves. Class exercises encourage students to articulate a possible future self-identity and to develop self-promotion skills. Surveys about sexual activity were conducted before the intervention, 19 weeks after baseline, and again at 1 year after the intervention.

RESULTS

Hierarchical logistic regression analyses showed significant effects for the intervention on sexual intentions, abstinence, and a trend toward fewer virgins initiating intercourse for the first time, 19 weeks after baseline. Specifically, students who received the intervention showed decreased intention to engage in sex and increased abstinence compared with students not receiving the intervention. Effects for 1-year follow-up, with smaller sample size, showed only that AIM male participants maintained the significant abstinence effect.

CONCLUSIONS

A new intervention, AIM was evaluated among African-American seventh graders. This program, by focusing students on positive future selves, effectively modified sexual risk without directly providing instruction on sexually explicit topics.

Integrating service learning into a curriculum to reduce health risks at alternative high schools

Service learning has been identified as a promising approach to reduce sexual risk behavior, among other outcomes. This study used qualitative data analysis to offer suggestions for optimally integrating service learning into a program to reduce sexual risks among alternative school students. Data were collected from student participants in the All4You! Project using classroom materials, focus groups, and individual interviews. Project educators and project staff also provided data through summary forms and field notes. Qualitative data analysis revealed 5 strategies for creating positive service experiences for alternative school students: (1) find appropriate service-learning sites, (2) create staff support, (3) maintain appropriate student participation and behavior; (4) enhance student reflection on service-learning experiences, and (5) address students' self-images.

Early alcohol initiation and subsequent sexual and alcohol risk behaviors among urban youths

OBJECTIVES

We examined relations between early alcohol use and subsequent alcohol and sexual risk behaviors among urban adolescents.

METHODS

A total of 1034 African American and Hispanic youths completed surveys assessing alcohol and sexual behaviors at 7th and 10th grade. After we controlled for early sexual initiation, we examined relations between early drinking and subsequent alcohol and sexual behaviors.

RESULTS

Early drinking was associated with alcohol and sexual risks through mid-adolescence. Early drinkers were more likely to report subsequent alcohol problems, unprotected sexual intercourse, multiple partners, being drunk or high during sexual intercourse, and pregnancy. Among females, early drinking was also related to sexual initiation and recent sexual intercourse.

CONCLUSIONS

Prevention programs should address combined risks of early alcohol use and sexual intercourse, especially where levels of HIV and other sexually transmitted infections are elevated.

School-based teenage pregnancy prevention programs: a systematic review of randomized controlled trials

We compared school-based abstinence-only programs with those including contraceptive information (abstinence-plus) to determine which has the greatest impact on teen pregnancy. The United States has one of the highest rates of teen pregnancy in the industrialized world. Programs aimed at reducing the rate of teen pregnancy include a myriad of approaches including encouraging abstinence, providing education about birth control, promoting community service activities, and teaching skills to cope with peer pressure. We systematically reviewed all published randomized controlled trials of secondary-school-based teen pregnancy prevention programs in the United States that used sexual behavior, contraceptive knowledge, contraceptive use, and pregnancy rates as outcomes.

Comparing the Cost-Effectiveness of HIV Prevention Interventions

OBJECTIVE

Communities need to identify cost-effective interventions for HIV prevention to optimize limited resources.

METHODS

The authors developed a spreadsheet tool using Bernoulli and proportionate change models to estimate the relative cost-effectiveness for 26 HIV prevention interventions including biomedical interventions, structural interventions, and interventions designed to change risk behaviors of individuals. They also conducted sensitivity analyses to assess patterns of the cost-effectiveness across different populations using various assumptions.

RESULTS

The 2 factors most strongly determining the cost-effectiveness of the different interventions were the HIV prevalence of the population at risk and the cost per person reached. In low-prevalence populations (eg, heterosexuals) the most cost-effective interventions were structural interventions (eg, mass media, condom distribution), whereas in high-prevalence populations (eg, men who have sex with men) individually focused interventions to change risk behavior were also relatively cost-effective. Among the most cost-effective interventions overall were showing videos in STD clinics and raising alcohol taxes. School-based HIV prevention programs appeared to be the least cost-effective. Needle exchange and needle deregulation programs were relatively cost-effective only when injection drug users have a high HIV prevalence.

CONCLUSIONS

Comparing estimates of the cost-effectiveness of HIV interventions provides insight that can help local communities maximize the impact of their HIV prevention resources.

Developmentally appropriate sexual risk reduction interventions for adolescents: rationale, review of interventions, and recommendations for research and practice

BACKGROUND

Despite awareness of the need to design developmentally appropriate sexual risk reduction interventions for adolescents, limited information exists to identify the aspects of intervention design or content that make an intervention developmentally appropriate.

PURPOSE

(a) To clarify the rationale for designing developmentally appropriate interventions, (b) to review randomized controlled trials (RCTs) of adolescent sexual risk reduction interventions, (c) to identify developmentally appropriate strategies, (d) to examine the relationship between developmental appropriateness and sexual risk outcomes, and (e) to provide recommendations for research.

METHODS

The authors examined studies (n = 24) published before 2003 that evaluated a risk reduction intervention, sampled adolescents, used an RCT study design, and evaluated sexual behavior outcomes.

RESULTS

Content analysis indicated that the interventions tested were often tailored to the cognitive level of adolescents, as indicated by the use of exercises on decision making, goal setting and planning, and concrete explanation of abstract concepts. Interventions also addressed the social influences of risky sex such as peer norms and provided communication skills training. Overall, the interventions tested in RCTs were more effective in delaying the onset of sexual activity than in promoting abstinence among sexually active youth. Interventions with booster sessions were effective in reducing sexual risk behavior. The use of process measures, linked with developmental constructs, was rare. However, improvements in sexual communication skills and perceived norms for safer sex were associated with reductions in sexual risk outcomes.

CONCLUSIONS

Developmental transitions during adolescence influence sexual behavior and should be considered when developing and evaluating risk reduction interventions for youth. Future research should assess process measures of key developmental constructs as well as risk behavior and biological outcomes.

Behavioral interventions to reduce incidence of HIV, STD, and pregnancy among adolescents: a decade in review

PURPOSE

To review adolescent sexual risk-reduction programs that were evaluated using quasi-experimental or experimental methods and published in the 1990s. We describe evaluated programs and identify program and evaluation issues for health educators and researchers.

METHODS

We systematically searched seven electronic databases and hand-searched journals to identify evaluations of behavioral interventions to reduce sexual risk behaviors among adolescents. Articles were included if they were published in the 1990s, provided a theoretical basis for the program, information about the interventions, clear aims, and quasi-experimental or experimental evaluation methods. We identified 101 articles, and 24 met our criteria for inclusion.

RESULTS

We reviewed these evaluations to assess their research and program characteristics. The majority of studies included randomized controlled designs and employed delayed follow-up measures. The most commonly measured outcomes were delay of initiation of sexual intercourse, condom use, contraceptive use, and frequency of sexual intercourse. Programs ranged from 1 to 80 sessions, most had adult facilitators, and commonly included skills-building activities about sexual communication, decision-making, and problem solving. The programs included a wide range of strategies for content delivery such as arts and crafts, school councils, and community service learning.

CONCLUSIONS

Analysis of these programs suggest four overall factors that may impact program effectiveness including the extent to which programs focus on specific skills for reducing sexual risk behaviors; program duration and intensity; what constitutes the content of a total evaluated program including researchers' assumptions of participants' exposure to prior and concurrent programs; and what kind of training is available for facilitators.

Long-term influence of sexual norms and attitudes on timing of sexual initiation among urban minority youth

This study assessed whether sexual norms and attitudes expressed during early adolescence by minority youth from economically disadvantaged urban areas produce a sustained influence on the timing of sexual initiation. African American and Latino youth attending three middle schools were enrolled in the Reach for Health study in seventh grade and followed from an average age of 12.2 to 16.1 years. Some 849 respondents answered the question, "Have you ever had sexual intercourse" at four time points: fall seventh, spring seventh, spring eighth, and spring 10th grade. Culturally tailored scales assessed sex norms and outcome expectancies, sexual responsibility, and refusal attitudes at fall seventh grade. Influence of these norms and attitudes in early adolescence on timing of first reported sexual intercourse was examined using ANOVA controlling for gender. At fall seventh grade, 30.7% of boys and 7.7% of girls reported sexual intercourse; by spring 10th grade, the figures were 74.8% and 56.4%, respectively. Those reporting greater peer involvement in sex and more positive sex outcome expectancies were more likely to have initiated sex by fall seventh grade. Through 10th grade, the higher the scores on peer norms (f = 41.08, p < .0001) and outcome expectancies (f = 5.87, p = .002) at entry into seventh grade, the earlier the timing of initiation. Higher scores on sex responsibility at baseline were associated with delayed sexual intercourse (f = 7.36, p < .001), as are refusal attitudes (f = 15.62, p < .0001). Despite significant gender differences in timing of initiation and mean scale scores, these relationships were similar for males and females. Findings suggest the importance of addressing sexual norms and attitudes of minority youth in interventions to delay early sexual initiation in urban environments where this risk is high. Given their sustained influence on timing of sexual initiation, such interventions must begin prior to middle school and continue through mid-adolescence, years when early sexual experience can lead to negative health and social outcomes.

Long-term reductions in sexual initiation and sexual activity among urban middle schoolers in the reach for health service learning program

PURPOSE

To evaluate the sustained effectiveness of a middle school service learning intervention on reducing sexual initiation and recent sex among urban African-American and Latino adolescents from 7th grade through the 10th grade.

METHODS

During the fall of seventh grade and again in eighth grade, students were randomly assigned by classroom to participate either in community youth service (CYS) or not (controls). Service learning is an educational strategy that couples meaningful service in the community with classroom instruction. Students in both intervention and control conditions received classroom health lessons. Surveys were conducted at seventh grade baseline and at the end of 10th grade, approximately 2 years after intervention. Self-reported sexual behaviors of youths who had participated in CYS were compared with those of controls receiving classroom curriculum alone (n = 195).

RESULTS

CYS participants were significantly less likely than controls to report sexual initiation (2 years CYS, odds ratio [OR] = 0.32; 1 year, OR = 0.49) as well as recent sex (2 years CYS, OR = 0.39; 1 year CYS, OR = 0.48). Among those who were virgins at seventh grade, 80% of males in the curriculum-only condition had initiated sex, compared with 61.5% who received 1 year of CYS, and 50% who received 2 years. Among females, the figures were 65.2%, 48.3%, and 39.6%, respectively.

CONCLUSION

A service learning intervention that combines community involvement with health instruction can have a long-term benefit by reducing sexual risk taking among urban adolescents.

Teen sexuality. Reaching out in the malls

BACKGROUND

Existing sexual health programs have not significantly reduced teen pregnancies or sexually transmitted diseases. A more creative approach is needed.

METHODS

An assessment of 539 teens in one Ontario city was conducted to identify knowledge about and use of birth control, comfort in discussing sexual health, and preferred sites, providers and methods of service delivery.

RESULTS

Knowledge of, and comfort discussing, birth control was not associated with frequency of use but was associated with grade. Adolescents were less comfortable discussing sexual health with teachers than health professionals. Over time, comfort increased with health professionals, but not teachers. Sexually active teens reported willingness to attend mall-based clinics.

CONCLUSIONS

Using birth control appears to be maturational given its association with grade. Since teens were consistently less comfortable with teachers, providing sexual health services in schools is likely ineffective. Teens may respond to clinics in creative settings such as malls.

Effective approaches to reducing adolescent unprotected sex, pregnancy, and childbearing

In the United States, there exist a multitude of different approaches to reducing adolescent sexual risk-taking, unintended pregnancy, childbearing, and sexually transmitted disease, including HIV. While many of these approaches have some positive effects upon some outcomes (such as greater knowledge), only some of these programs actually delay the initiation of sex, increase condom or contraceptive use, and reduce unprotected sex among youth. This article summarizes a review of 73 studies and their respective programs, and describes four groups of programs which have reasonably strong evidence that they delay sex, increase condom or contraceptive use, or reduce teen pregnancy or childbearing. These four groups of programs include (a) sex and HIV education curricula with specified characteristics, (b) one-on-one clinician-patient protocols in health settings with some common qualities, (c) service learning programs, and (d) a particular intensive youth development program with multiple components.

The impact of schools and school programs upon adolescent sexual behavior

Because most youth are enrolled in school for many years before they initiate sex and when they initiate sex, schools have the potential for reducing adolescent sexual risk-taking. This paper reviews studies which examine the impact upon sexual risk-taking of school involvement, school characteristics, specific programs in school that do not address sexual behavior, and specific programs that do address sexual risk-taking. Multiple studies support several conclusions. First, involvement in and attachment to school and plans to attend higher education are all related to less sexual risk-taking and lower pregnancy rates. Second, students in schools with manifestations of poverty and disorganization are more likely to become pregnant. Third, some school programs specifically designed to increase attachment to school or reduce school dropout effectively delayed sex or reduced pregnancy rate, even when they did not address sexuality. Fourth, sex and HIV education programs do not increase sexual behavior, and some programs decrease sexual activity and increase condom or contraceptive use. Fifth, school-based clinics and school condom-availability programs do not increase sexual activity, and either may or may not increase condom or contraceptive use. Other studies reveal that there is very broad support for comprehensive sex- and HIV-education programs, and accordingly, most youth receive some amount of sex or HIV education. However, important topics are not covered in many schools.