A systematic review of school-A systematic review of school-based skills building based skills building

behavioural interventions for behavioural interventions for preventing sexually transmitted preventing sexually transmitted

infections in young peopleinfections in young people

Dr Jonathan ShepherdPrincipal Research Fellow

Southampton Health Technology Assessments Centre (SHTAC)

University of Southampton

Project teamProject team

Southampton Health Technology Southampton Health Technology

Assessments Centre (SHTAC) University of SouthamptonAssessments Centre (SHTAC) University of Southampton

Jonathan Shepherd, Jo Picot, Jeremy Jones

Keith Cooper, Debbie Hartwell, Alison Price,

Geoff Frampton, Andy Clegg

Evidence for Informed Policy and Practice Evidence for Informed Policy and Practice

Information and Co-ordinating Centre (EPPI-Centre), Information and Co-ordinating Centre (EPPI-Centre),

Social Science Research Unit, Institute of Education, Social Science Research Unit, Institute of Education,

University of LondonUniversity of London

Josephine Kavanagh, Elaine Barnett-Page, Angela Harden

RationaleRationale

►Rates of sexually transmitted infections (STIs) continue to increase, particularly amongst young people

►Need for sound evidence to inform policy and practice

►Why a systematic review and why now?►Topic advertised & commissioned by HTA

programme

ObjectivesObjectives

To conduct a systematic review and economic evaluation to assess the

effectiveness of behavioural interventions for the prevention of STIs

in young people aged 13-19 years

Scoping and protocol

Literature searching

Inclusion / exclusion

screening 1

Descriptive

mapping

Further scoping

Inclusion / exclusion

screening 2Narrative

synthesis / meta-analysis

Conclusions and recommendations

Systematic

review

methodology

Inclusion criteria 1 - Inclusion criteria 1 - Descriptive mapping exerciseDescriptive mapping exercise

► Participants: Young people aged 13-19 years► Intervention: Behavioural interventions to prevent STIs► Comparator: ‘Standard practice’► Outcomes:

► Sexual behaviour (e.g.)►Self-reported condom use►Number of sexual partners►Reported having had sex

► Additionally: STI rates; knowledge, beliefs, attitudes

► Study design: any type of outcome evaluation

Results: descriptive mapping Results: descriptive mapping exerciseexercise

►Total of 8037 references identified►Total of 136 studies included►Design: 51% RCTs, 49% non-randomised studies►Country: 60% USA; 18% Africa; <5% UK►Topics: 60% HIV/AIDS; 47% STIs in general► Intervention characteristics:

► Components: 90% Information; 60% skills training; 24% provision of resources

► Providers: 32% peer educators; 29% teachers; 17% health care professionals

► Location: 57% school/college; 27% community; 18% health-care

Scoping and protocol

Literature searching

Inclusion / exclusion

screening 1

Descriptive

mapping

Further scoping

Inclusion / exclusion

screening 2Narrative

synthesis / meta-analysis

Conclusions and recommendations

Systematic

review

methodology

Inclusion criteria 2 - Inclusion criteria 2 - Systematic review of Systematic review of

effectivenesseffectiveness► Participants: Young people aged 13-19 years► Intervention: School-based behavioural interventions to

prevent STIs which teach safer sex skills as well as provide information

► Comparator: ‘Standard practice’► Outcomes:

► Sexual behaviour ► STI rates► Knowledge, beliefs, attitudes

► Study design: Randomised Controlled Trials (RCTs) only

► Total of 15 studies included, of which 12 judged methodologically ‘sound’

► Country n= 8 USA, n= 4 Europe, n= 3 Africa► Types of skills: correct use of condoms; communication;

negotiation► Behavioural aims: increase protective behaviours; delay

sex; reduce partners.► Interventions of variable length / intensity► Majority interventions theory-based► Comparators: information only; or control groups► Young people:

► Socio-demographic-economic profile mixed ► Between <10% to 80% sexually experienced

Results: systematic reviewResults: systematic review

Examples of some of the interventionsExamples of some of the interventions

“Safer Choices”(California + Texas, USA)

“RIPPLE study”(Central and Southern

England)

“The SHARE study”

(Scotland)

“All4You!”(California, USA)

“Youth AIDS Prevention Project (YAPP)”

(Chicago, USA) “Focus on Kids”(West Virginia,

USA)

“Our times, our choices”

(South Africa)

“My future is my choice”

(Namibia)

► Diverse range of sexual behavioural outcome measures► Condom use (first/last sex); frequency of condom use;

consistency in condom use; whether had sex; frequency of sex; number of partners

► Few statistically significant differences between groups

► Self-efficacy: mixed findings► Knowledge of STIs: significant differences favouring

behavioural intervention► Attitudes: mixed findings► Intentions: mixed findings► STI rates: no data

Narrative synthesis resultsNarrative synthesis results

Meta-analysis: condom use

Pooled effect

size

(Odds ratio 1.07)

Individual study

effects

Line of no effect

“Safer Choices”

(California + Texas)

► 9 of the 12 methodologically sound RCTs conducted a process evaluation.

► Synthesis of the process findings to explore reasons for the limited impact of the interventions revealed two sets of factors:

► (i) Interventions were not always implemented as intended► Variations in school culture and administration ► Teachers not always able to facilitate skill development

► (ii) Not all young people found the interventions engaging or acceptable► Gendered norms (mixed sex / single sex groups)► Age appropriateness

Results of process Results of process evaluationsevaluations

SummarySummary

► Map of the evidence base for behavioural interventions ► Our focus was on information and skills development► Improvements in knowledge ► Mixed effects for attitudes/ intentions / self-efficacy ► Limited / unclear effects on sexual behaviour► Number of factors influencing outcomes

► Implementation► Acceptability

RecommendationsRecommendations

► Evaluation of multi-component school-based interventions, including teachers / peers / whole school approach / parents / specialist trainers

► Of suitable length – booster sessions as young people mature

► Long-term follow up► Diversity in outcome measures:

► Quality of relationships► Safety negotiations► Use of STI testing / services

► Integral economic evaluation

www.hta.ac.uk

ContactContact

Dr Jonathan Shepherd, Principal Research FellowSouthampton Health Technology Assessments Centre (SHTAC)

Epsilon House, Enterprise RoadSouthampton Science Park, ChilworthUniversity of Southampton, SO16 7NS

Tel +44 (0) 2380 597055 Email: jps@soton.ac.uk

The views and opinions expressed are those of the authors and do not necessarily reflect those of the UK Department of Health.