A systematic review of school-based
skills building behavioural
interventions for preventing sexually
transmitted infections in young people
Dr Jonathan Shepherd
Principal Research Fellow
Southampton Health Technology Assessments Centre (SHTAC)
University of Southampton
Project team
Southampton Health Technology
Assessments 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
Information and Co-ordinating Centre (EPPI-Centre),
Social Science Research Unit, Institute of Education,
University of London
Josephine Kavanagh, Elaine Barnett-Page, Angela Harden
Rationale
► 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
Objectives
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
Systematic review
Descriptive mapping
methodology
Further scoping
Inclusion / exclusion
screening 2
Narrative synthesis /
meta-analysis
Conclusions and
recommendations
Inclusion criteria 1 Descriptive 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 exercise
► 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
Systematic review
Descriptive mapping
methodology
Further scoping
Inclusion / exclusion
screening 2
Narrative synthesis /
meta-analysis
Conclusions and
recommendations
Inclusion criteria 2 Systematic review of effectiveness
► 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
Results: systematic review
► 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
Examples of some of the interventions
“Safer Choices”
“Youth AIDS
Prevention Project (YAPP)”
(Chicago, USA)
(California + Texas, USA)
“Focus on Kids”
(West Virginia,
USA)
“All4You!”
“RIPPLE study”
(California, USA)
(Central and Southern
England)
“Our times,
our choices”
(South Africa)
“The SHARE
study”
(Scotland)
“My future
is my choice”
(Namibia)
Narrative synthesis results
► 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
Meta-analysis: condom use
“Safer Choices”
(California + Texas)
Individual
study
effects
Pooled effect
size
(Odds ratio 1.07)
Line of no effect
Results of process evaluations
► 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
Summary
►
►
►
►
►
►
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
Recommendations
► 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
Contact
Dr Jonathan Shepherd, Principal Research Fellow
Southampton Health Technology Assessments Centre (SHTAC)
Epsilon House, Enterprise Road
Southampton Science Park, Chilworth
University of Southampton, SO16 7NS
Tel +44 (0) 2380 597055
Email: [email protected]
The views and opinions expressed are those of the authors and do
not necessarily reflect those of the UK Department of Health.