The effect of the national demonstration project Healthy Respect on teenage sexual health behaviour

Interventions to Promote a Healthy Sexuality among School Adolescents: A Scoping Review

Schools are particularly suitable contexts for the implementation of interventions focused on adolescent sexual behavior. Sexual education and promotion have a multidisciplinary nature. Nurses' role and the spectrum of the carried-out interventions is not clear. We aimed to identify interventions that promote a healthy sexuality among school adolescents. Our review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews and was registered in the Open Science Framework. Published articles on sexuality in adolescents in school contexts were considered. The research limitations included primary studies; access in full text in English, Spanish, or Portuguese; and no data publication limitation. Research was carried out on the EBSCOhost, PubMed, SciELO, and Web of Science platforms; gray literature and the bibliographies of selected articles were also searched. A total of 56 studies were included in the sample. The studies used a broad range of research methods, and 10 types of interventions were identified. Multi-interventional programs and socio-emotional interventions showed a greater impact on long-term behavioral changes, and continuity seemed to be a key factor. Long-term studies are needed to reach a consensus on the effectiveness of interventions. Nurses' particular role on the multidisciplinary teams was found to be a gap in the research, and must be further explored.

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

Background

Young people report higher levels of unsafe sex and have higher rates of sexually transmitted infections than any other age group. Schools are well placed to facilitate early intervention, but more effective approaches are required. Peer-led approaches can augment school-based education, but often fail to capitalise on mechanisms of social influence. The potential of using social media in sexual health has not been tested in school settings.

Objectives

Finalise the design of the Sexually Transmitted infections And Sexual Health (STASH) intervention; assess the recruitment and retention of peer supporters, and acceptability to participants and stakeholders; assess the fidelity and reach, in addition to the barriers to and facilitators of, implementation; refine programme theory; understand the potential of social media; determine design parameters for a future randomised controlled trial, including economic evaluation; and establish whether or not progression criteria were met.

Design

This was a feasibility study comprising intervention development and refinement of the STASH pilot and non-randomised feasibility trial in six schools. Control data were provided by students in the year above the intervention group.

Setting

Secondary schools in Scotland.

Participants

Students aged 14–16 years, teachers and intervention delivery partners.

Interventions

The STASH intervention was adapted from A Stop Smoking In Schools Trial (ASSIST) (an effective peer-led smoking intervention). Based on diffusion of innovation theory, the STASH study involves peer nomination to identify the most influential students, with the aim of recruiting and training 15% of the year group as peer supporters. The peer supporters deliver sexual health messages to friends in their year group via conversations and use of Facebook (www.facebook.com; Facebook, Inc., Menlo Park, CA, USA) to share varied content from a curated set of web-based resources. Peer supporters are given support themselves via follow-up sessions and via trainer membership of Facebook groups.

Main outcome measures

The primary outcome was whether or not progression criteria were met in relation to intervention acceptability and feasibility. The study also piloted indicative primary outcomes for a full-scale evaluation.

Data sources

Peer supporter questionnaire; observations of activities; interviews with trainers, teachers, peer supporters and students; monitoring log of peer supporter activities (including on Facebook and meeting attendance); questionnaire to control year group (baseline characteristics, social networks, mediators and sexual health outcomes); baseline and follow-up questionnaire (approximately 6 months later) for intervention year group.

Results

A total of 104 students were trained as peer supporters (just over half of those nominated for the role by their peers). Role retention was very high (97%). Of 611 students completing the follow-up questionnaire, 58% reported exposure to STASH study activities. Intervention acceptability was high among students and stakeholders. Activities were delivered with good fidelity. The peer supporters were active, representative of their year group and well connected within their social network. Carefully managed social media use by peer supporters augmented conversations. A primary outcome of ‘always safer sex’ was identified, measured as no sex or always condom use for vaginal or anal sex in the last 6 months. The intervention cost £42 per student. Six progression criteria were met. A seventh criterion (regarding uptake of role by peer supporters) was not.

Limitations

Small feasibility study that cannot comment on effectiveness.

Conclusions

The STASH intervention is feasible and acceptable within the context of Scottish secondary schools. The results support continuation to a full-scale evaluation.

Future work

Small-scale improvements to the intervention, refinement to programme theory and funding sought for full-scale evaluation.

Trial registration

Current Controlled Trials ISRCTN97369178.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 15. See the NIHR Journals Library website for further project information.

Gendered discourses of youth sexualities--an exploration of PubMed articles on prevention of sexually transmissible infections

OBJECTIVE

To explore how gender is addressed in medical articles on the prevention of sexually transmissible infections (STI) among adolescents.

METHODS

Sixtyone articles were retrieved from a PubMed search and scrutinized by qualitative content analysis.

RESULTS

Most articles were affiliated with North American research institutions, but there were also reports from Europe, Africa, South America, and Asia. Gender turned up in the following four recurrent discourses: Gendered Receptiveness for Information, Stereotyped Heterosexual Expectations, Power Imbalance in Sexual Relations, and Gendered Prevention Approaches. Young women were described as knowledgeable, communicative, and responsible, but at risk because of feminine ideals and a lack of negotiating power. Men were described as less informed, more reluctant to discuss, and more risk taking due to masculine ideals and power dominance. Prevention approaches concerned how to postpone sex and/or tailor gender-sensitive programs for specific groups of young women and men.

CONCLUSION

Researchers' own gender expectations might have a substantial impact on how sex and sexual health is considered in prevention research. To avoid reconstruction of current inequalities and stereotypes regarding sexual practices of young women and men, the impact of gender, the power structures in intimate relations, and the cultural context should be considered. Medical research on STI prevention could benefit from including a wider array of gender perspectives.

Higher risk perception of HIV than of chlamydia and HPV among secondary school students in two German cities

Background

Chlamydia and genital human papillomavirus (HPV) are the two most common sexually transmitted infections (STIs) among teens and young adults in industrialised countries. The majority of adolescents, however, have limited or no knowledge of these infections. Within the context of a cross-sectional survey on awareness and knowledge of sexually transmitted infections, secondary school students attending the 8th grade and above in Bremen and Bremerhaven, two cities in northern Germany, were asked to rate the risk of peers to get infected with HIV, HPV or chlamydia.

Methods

Between October and December 2011, students aged 12–20 years completed an anonymous, self-administered questionnaire at their school. In addition to answering questions on awareness and knowledge of sexually transmitted infections, all students were also asked to rate the risk of peers to get infected with HIV, HPV or chlamydia. Furthermore, those reporting ever having sexual intercourse were asked to rate their own risk of getting infected with each of the three infections.

Results

1,148 students, 55% female, completed the questionnaire. 27% of the students reported having had sexual intercourse. 68% of all students rated the risk of same-aged students to get infected with HIV/AIDS as high/medium. The corresponding proportions for HPV and chlamydia were 19 and 25% respectively. Those reporting ever having sexual intercourse generally perceived their own risk of getting infected with HIV, chlamydia or HPV as lower than that of their peers.

Conclusion

Generally, the risk of getting infected with HIV was perceived as being higher than that of getting infected with HPV or chlamydia, most likely due to the fact that the students were more aware of HIV than of the other two infections. Efforts should be made to improve awareness and knowledge of HPV and chlamydia among school going adolescents, and to make them realize that these are common infections that are preventable.

Teenage sexual attitudes and behaviour in China: a literature review

China is the most populated of any country in the world. Social norms and values pertaining to love and marriage have changed considerably since the launch of its open-door policy and economic reforms of the 1980s. Attitudes to sex have become more open, while the negative consequences of early sexual intercourse have become issues of health and social concern. The aim of this study is to provide an overview of the teenage sexual attitudes and behaviour in contemporary China. A literature review was conducted between 2000 and 2010, using both English (Medline, CINAHL, PsycINFO, ASSIA) and Chinese language databases (China National Knowledge Infrastructure, Wanfang database). Thirty-six studies were included and reviewed. It was found that young people reported poor sexual knowledge, especially in relation to reproductive matters and sexually transmitted infections. The media, such as television, magazines and the Internet, were seen as their main sources of information on sex. Despite the frequently reported liberal attitudes to sexual behaviour, only a small number of young people had already lost their virginity or been involved in pregnancies. Young men were more likely than young women to report having had sex, while respondents at vocational high schools were less likely to remain virgins than those at common/key high schools. Although the prevalence of sexual intercourse among Chinese teenagers was still lower than that reported in studies conducted in most western countries, the findings do reflect some changes in sexual values and behaviour of young people within the country. They also suggest the need to develop more comprehensive sex education programmes in co-operation with young people, schools, health organisations, families and communities and to make sexual and reproductive health services accessible to teenagers and unmarried young people throughout China.

Collaboration between local health and local government agencies for health improvement

BACKGROUND

In many countries, national, regional and local inter- and intra-agency collaborations have been introduced to improve health outcomes. Evidence is needed on the effectiveness of locally developed partnerships which target changes in health outcomes and behaviours.

OBJECTIVES

To evaluate the effects of interagency collaboration between local health and local government agencies on health outcomes in any population or age group.

SEARCH METHODS

We searched the Cochrane Public Health Group Specialised Register, AMED, ASSIA, CENTRAL, CINAHL, DoPHER, EMBASE, ERIC, HMIC, IBSS, MEDLINE, MEDLINE In-Process, OpenGrey, PsycINFO, Rehabdata, Social Care Online, Social Services Abstracts, Sociological Abstracts, TRoPHI and Web of Science from 1966 through to January 2012. 'Snowballing' methods were used, including expert contact, citation tracking, website searching and reference list follow-up.

SELECTION CRITERIA

Randomized controlled trials (RCTs), controlled clinical trials (CCTs), controlled before-and-after studies (CBAs) and interrupted time series (ITS) where the study reported individual health outcomes arising from interagency collaboration between health and local government agencies compared to standard care. Studies were selected independently in duplicate, with no restriction on population subgroup or disease.

DATA COLLECTION AND ANALYSIS

Two authors independently conducted data extraction and assessed risk of bias for each study.

MAIN RESULTS

Sixteen studies were identified (28,212 participants). Only two were considered to be at low risk of bias. Eleven studies contributed data to the meta-analyses but a narrative synthesis was undertaken for all 16 studies. Six studies examined mental health initiatives, of which one showed health benefit, four showed modest improvement in one or more of the outcomes measured but no clear overall health gain, and one showed no evidence of health gain. Four studies considered lifestyle improvements, of which one showed some limited short-term improvements, two failed to show health gains for the intervention population, and one showed more unhealthy lifestyle behaviours persisting in the intervention population. Three studies considered chronic disease management and all failed to demonstrate health gains. Three studies considered environmental improvements and adjustments, of which two showed some health improvements and one did not.Meta-analysis of three studies exploring the effect of collaboration on mortality showed no effect (pooled relative risk of 1.04 in favour of control, 95% CI 0.92 to 1.17). Analysis of five studies (with high heterogeneity) looking at the effect of collaboration on mental health resulted in a standardised mean difference of -0.28, a small effect favouring the intervention (95% CI -0.51 to -0.06). From two studies, there was a statistically significant but clinically modest improvement in the global assessment of function symptoms score scale, with a pooled mean difference (on a scale of 1 to 100) of -2.63 favouring the intervention (95% CI -5.16 to -0.10).For physical health (6 studies) and quality of life (4 studies) the results were not statistically significant, the standardised mean differences were -0.01 (95% CI -0.10 to 0.07) and -0.08 (95% CI -0.44 to 0.27), respectively.

AUTHORS' CONCLUSIONS

Collaboration between local health and local government is commonly considered best practice. However, the review did not identify any reliable evidence that interagency collaboration, compared to standard services, necessarily leads to health improvement. A few studies identified component benefits but these were not reflected in overall outcome scores and could have resulted from the use of significant additional resources. Although agencies appear enthusiastic about collaboration, difficulties in the primary studies and incomplete implementation of initiatives have prevented the development of a strong evidence base. If these weaknesses are addressed in future studies (for example by providing greater detail on the implementation of programmes; using more robust designs, integrated process evaluations to show how well the partners of the collaboration worked together, and measurement of health outcomes) it could provide a better understanding of what might work and why. It is possible that local collaborative partnerships delivering environmental Interventions may result in health gain but the evidence base for this is very limited.Evaluations of interagency collaborative arrangements face many challenges. The results demonstrate that collaborative community partnerships can be established to deliver interventions but it is important to agree goals, methods of working, monitoring and evaluation before implementation to protect programme fidelity and increase the potential for effectiveness.

Awareness and knowledge of sexually transmitted diseases (STDs) among school-going adolescents in Europe: a systematic review of published literature

BACKGROUND

Sexually transmitted diseases (STDs) are a major health problem affecting mostly young people, not only in developing, but also in developed countries.We conducted this systematic review to determine awareness and knowledge of school-going male and female adolescents in Europe of STDs and if possible, how they perceive their own risk of contracting an STD. Results of this review can help point out areas where STD risk communication for adolescents needs to be improved.

METHODS

Using various combinations of the terms "STD", "HIV", "HPV", "Chlamydia", "Syphilis", "Gonorrhoea", "herpes", "hepatitis B", "knowledge", "awareness", and "adolescents", we searched for literature published in the PubMed database from 01.01.1990 up to 31.12.2010. Studies were selected if they reported on the awareness and/or knowledge of one or more STD among school-attending adolescents in a European country and were published in English or German. Reference lists of selected publications were screened for further publications of interest. Information from included studies was systematically extracted and evaluated.

RESULTS

A total of 15 studies were included in the review. All were cross-sectional surveys conducted among school-attending adolescents aged 13 to 20 years. Generally, awareness and knowledge varied among the adolescents depending on gender.Six STDs were focussed on in the studies included in the review, with awareness and knowledge being assessed in depth mainly for HIV/AIDS and HPV, and to some extent for chlamydia. For syphilis, gonorrhoea and herpes only awareness was assessed. Awareness was generally high for HIV/AIDS (above 90%) and low for HPV (range 5.4%-66%). Despite knowing that use of condoms helps protect against contracting an STD, some adolescents still regard condoms primarily as an interim method of contraception before using the pill.

CONCLUSION

In general, the studies reported low levels of awareness and knowledge of sexually transmitted diseases, with the exception of HIV/AIDS. Although, as shown by some of the findings on condom use, knowledge does not always translate into behaviour change, adolescents' sex education is important for STD prevention, and the school setting plays an important role. Beyond HIV/AIDS, attention should be paid to infections such as chlamydia, gonorrhoea and syphilis.

Collaboration between local health and local government agencies for health improvement

BACKGROUND

In many countries, national, regional and local inter- and intra-agency collaborations have been introduced in order to improve health outcomes. Evidence is needed on the effectiveness of locally-developed partnerships which target changes in individual health outcomes and behaviours.

OBJECTIVES

To evaluate the effects of interagency collaboration between local health and local government agencies on health outcomes.

SEARCH STRATEGY

Twenty-five databases were searched using a highly sensitive search strategy. 'Snowballing' methods were also used, including expert contact, website searching and reference list follow up.

SELECTION CRITERIA

Randomized controlled trials (RCTs), controlled clinical trials (CCTs), controlled before-and-after studies (CBAs) and interrupted time series (ITS) where the study reported on interagency collaboration between health and local government agencies. Studies were selected independently in duplicate by two of five authors.

DATA COLLECTION AND ANALYSIS

From the team of five review authors, two authors independently conducted data extraction and assessed risk of bias for each study.

MAIN RESULTS

Eleven studies were identified, presenting information on a total of 26,686 participants. Owing to the heterogeneity between studies a narrative synthesis was undertaken. The included studies covered a range of topics. Six studies examined mental health initiatives, of which one study showed health benefit; four showed modest improvement in one or more of the outcomes measured, but no clear overall health gain; and one study showed no evidence of health gain. Two studies were related to lifestyle improvements of which one failed to show health gains for the intervention population, while the other showed more unhealthy lifestyle behaviours persisting in the intervention population. Three studies were related to chronic disease management and all three failed to demonstrate health gains.

AUTHORS' CONCLUSIONS

Collaboration between local health and local government is commonly considered best practice. However, the review did not identify any reliable evidence that inter‑agency collaboration, compared to standard services, leads to health improvement. A few studies identified component benefits but these were not reflected in overall outcome scores and could have resulted from the use of significant additional resources. Although agencies appear enthusiastic about collaboration, methodological flaws in the primary studies and incomplete implementation of initiatives have prevented the development of a strong evidence base. If these flaws are addressed in future studies (for example by providing greater detail on the implementation of programs, using more robust designs, with integrated process evaluations and measurement of health outcomes) it could provide a better understanding of what might work and why.When updating this review, we will analyse any partnership or process evaluations of our included studies to try to identify markers of success in local collaborative partnerships that could inform policy developments in the future.

'The real deal': a feasibility study of peer-led sex education for early school leavers

OBJECTIVES

To explore female early school leaver's experience of sexual activity and sex education, and to assess the feasibility and potential impact of a peer-led sex education intervention.

METHODS

Forty five young female early school leavers and ten peer educators participated in the study. The ten peer educators, early school leavers who were teenage mothers, were trained to deliver the peer-led education intervention. Both quantitative (self-completed questionnaire) and qualitative (focus groups) research methods were used to evaluate the intervention.

RESULTS

The average age of participants was 17.5 years. The average age at leaving school was 15 years. Many participants were smokers and took alcohol on a regular basis. Over three quarters of the young women were sexually active. Although most used contraception in the past, over 30% had not the last time they had sex. While participants' knowledge around sexual issues showed some improvement following the pilot intervention, there was little change in attitudes to sexual behaviour.

CONCLUSIONS

This feasibility study was very well received by both peer educators and participants. To assess the effectiveness of the intervention we recommend that a larger randomised control trial be conducted.

Young people of Chinese origin in western countries: a systematic review of their sexual attitudes and behaviour

People of Chinese origin are a growing population group in western countries. The community is seen to be marginalised, under-researched and neglected, in fact the least understood ethnic minority. This paper reports on a systematic review of sexual attitudes and behaviour among ethnic Chinese young people (mainly aged 13-25 years) living in western countries. An extensive literature search was conducted to cover the period of 1989 and 2009 using Medline, CINAHL, PsycINFO and ScienceDirect databases. There has been a dearth of literature in this area. However, results from existing literature show that ethnic Chinese youth reported poorer sexual health knowledge than white young people in their host countries, while they were found to be more likely to disapprove of uncommitted sex, be virgins, lose their virginity at a later age and have fewer sexual partners. Factors associated with their sexual attitudes and behaviour have also been identified. Countries like the United Kingdom, United States and Canada have become multicultural societies with many diverse ethnic groups. Without doubt educators and sexual health professionals need to provide sex education and services which should be culturally appropriate to people from diverse ethnic backgrounds. An understanding of their sexual values, sexual behaviour and associated factors is the first step towards achieving this goal.

No change in adolescents' neglect on contraceptive use over two decades

PURPOSE

The sexual activity and contraceptive use is evaluated over 21 years amongst Danish adolescents in ninth grade.

METHODS

A repeated, cross-sectional questionnaire study in the municipality of Viborg, comparing the results of four consecutive surveys between 1986 and 2007.

RESULTS

In 2007, 40% of the pupils had sexual debut at an average age of 15.3 ± 1.5 years. At sexual debut condoms were used in 77% of the adolescents and the contraceptive pill in 15%. At their latest coitus 34% used any contraceptive pill as 27% of pupils changed from use of condom to the pill. Practical experience with condoms was found in 90% of both sexes at sexual debut. Fourteen percent of the adolescents used no contraception at all at debut in 2007, which is similar to 1986, 1993, and 2000. Eighteen percent of the pupils used no contraception at all at their last intercourse in 2007 and 2000.

CONCLUSION

Knowledge about and use of condoms is substantial amongst adolescents already at sexual debut. A shift is confirmed from condoms at first coitus to more frequent use of the pill later on. A considerable number of pupils (10-20%) are neither protected against sexually transmitted infections nor pregnancy at first or later intercourse.

Factors associated with self-reported first sexual intercourse in Scottish adolescents

Background

There is continuing concern about high pregnancy rates and increasing numbers of sexually transmitted infections being detected in Scottish adolescents. Consistent evidence about factors associated with risky sexual behaviours, including early first sexual intercourse, may help to identify adolescents at risk and help improve interventions. This study aimed to provide detailed analysis of the evidence of the associations between individual factors and early sexual intercourse using cross-sectional questionnaire data from 4,379 Scottish adolescents who participated in a sexual health intervention evaluation.

Findings

Multivariate secondary analysis showed that aspects of family and school life such as decreasing parental monitoring (OR 1.45, 95% CI 1.24–1.70) and decreasing enjoyment of school (OR 2.55, 95% CI 2.15–3.03) were associated with reporting previous sexual intercourse. Furthermore, females were more likely to report previous sexual intercourse than males (OR 1.48, 95% CI 1.14–1.91). Several factors commonly used to inform sexual health intervention design, such as socioeconomic status, self-esteem and religion, were not independently associated.

Conclusion

These results contribute to the evidence base for the association of several factors with early initiation of sexual activity. The findings suggest that interventions aiming to delay first intercourse may need to consider targeting aspects of individuals' connection to their school and family. Furthermore, the results do not support the need to consider socio-economic background, religion or self-esteem of the individuals in intervention design.