Biological and behavioural impact of an adolescent sexual health intervention in Tanzania: a community-randomized trial

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.

Community level youth-led interventions to improve maternal-neonatal outcomes in low- and middle-income countries: A systematic review of randomised trials

Background

Evidence on the effectiveness of youth-led interventions for improving maternal-neonatal health and well-being of women and gender diverse childbearing people in low-income and middle-income countries (LMICs) is incomplete. We aimed to summarise the evidence on whether community level youth-led interventions can improve maternal and neonatal outcomes in LMICs.

Methods

We included experimental studies of youth-led interventions versus no intervention, standard care, or another intervention. Participants were women and gender diverse childbearing people during antepartum, intrapartum, and postpartum periods. MEDLINE, Embase, CINAHL, Global Health, Web of Science, and Cochrane Library, and grey literature were searched to January 2023. All interventions addressing and targeting maternal-neonatal health and well-being that were youth-led and community level were included. Primary outcomes of interest were maternal death and neonatal death. We excluded based on population, intervention, comparison, and outcome (PICO) and design. Two reviewers independently extracted key information from each included study and assessed risk of bias. Random-effects meta-analysis was performed where there were sufficient data. The certainty of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE). A narrative synthesis was done for results that could not be pooled.

Results

Of the 8054 records retrieved, four trials (21 813 enrolled participants) met the inclusion criteria. The Cooperative for Assistance and Relieve Everywhere, Inc. (CARE) Community Score Card intervention compared to standard reproductive health services control did not significantly improve Antenatal Care coverage (difference-in-differences estimate β = 0.04; 95% confidence interval (CI) = -0.11, 0.18, P = 0.610; one study, low certainty of evidence). The multi-component social mobilisation interventions compared to standard of care had no effect on adolescent/youth pregnancy (adjusted odds ratio estimate = 1.08; 95% CI = 0.87, 1.33; three studies; low certainty of evidence).

Conclusions

Youth-led interventions in LMICs did not show a significant improvement in maternal outcomes. More studies are required to make more precise conclusions.

Registration

PROSPERO: CRD42021288798.

Interventions to prevent unintended pregnancies among adolescents: a rapid overview of systematic reviews

Risks associated with unintended pregnancy include unsafe abortions, poor maternal health-seeking behaviour, poor mental health, and potentially, maternal and infant deaths. Adolescent girls with unintended pregnancies are particularly vulnerable as they are at higher risk of eclampsia, premature onset of labour, and increased neonatal morbidity and mortality. Unintended pregnancy, with the right combination of interventions, can be avoided. Evidence-based decision-making and the need for a robust appraisal of the evidence have resulted in many systematic reviews. This review of systematic reviews focuses on adolescent pregnancy prevention and will seek to facilitate evidence-based decision-making. Two review authors independently extracted data and assessed the methodological quality of each review according to the AMSTAR 2 criteria. We identified three systematic reviews from low- and middle-income countries and high-income counties and included all socioeconomic groups. We used vote counting and individual narrative review summaries to present the results. Overall, skill-building, peer-led and abstinence programmes were generally effective. Interventions focused on information only, counselling and interactive sessions provided mixed results.In contrast, exposure to parenting and delaying sexual debut interventions were generally ineffective. Adolescent pregnancy prevention interventions that deploy school-based primary prevention strategies, i.e. strategies that prevent unintended pregnancies in the first place, may effectively reduce teenage pregnancy rates, improve contraceptive use, attitudes and knowledge, and delay sexual debut. However, the included studies have methodological issues, and our ability to generalise the result is limited.

Cluster randomized controlled trial analysis at the cluster level: The clan command

In this article, we introduce a new command, clan, that conducts a cluster-level analysis of cluster randomized trials. The command simplifies adjusting for individual- and cluster-level covariates and can also account for a stratified design. It can be used to analyze a continuous, binary, or rate outcome.

Involving men and boys in family planning: A systematic review of the effective components and characteristics of complex interventions in low- and middle-income countries

Background

Involving men and boys as both users and supporters of Family Planning (FP) is now considered essential for optimising maternal and child health outcomes. Evidence on how to engage men and boys to meet FP needs is therefore important.

Objectives

The main objective of this review was to assess the strength of evidence in the area and uncover the effective components and critical process- and system-level characteristics of successful interventions.

Search Methods

We searched nine electronic databases, seven grey literature databases, organisational websites, and the reference lists of systematic reviews relating to FP. To identify process evaluations and qualitative papers associated with the included experimental studies, we used Connected Papers and hand searches of reference lists.

Selection Criteria

Experimental and quasi-experimental studies of behavioural and service-level interventions involving males aged 10 years or over in low- and middle-income countries to increase uptake of FP methods were included in this review.

Data Collection and Analysis

Methodology was a causal chain analysis involving the development and testing of a logic model of intervention components based on stakeholder consultation and prior research. Qualitative and quantitative data relating to the evaluation studies and interventions were extracted based on the principles of 'effectiveness-plus' reviews. Quantitative analysis was undertaken using r with robust variance estimation (RVE), meta-analysis and meta-regression. Qualitative analysis involved 'best fit' framework synthesis.

Results

We identified 8885 potentially relevant records and included 127 in the review. Fifty-nine (46%) of these were randomised trials, the remainder were quasi-experimental studies with a comparison group. Fifty-four percent of the included studies were assessed as having a high risk of bias. A meta-analysis of 72 studies (k = 265) showed that the included group of interventions had statistically significantly higher odds of improving contraceptive use when compared to comparison groups (odds ratio = 1.38, confidence interval = 1.21 to 1.57, prediction interval = 0.36 to 5.31, p < 0.0001), but there were substantial variations in the effect sizes of the studies (Q = 40,647, df = 264, p < 0.0001; I 2 = 98%) and 73% was within cluster/study. Multi-variate meta-regression revealed several significant intervention delivery characteristics that moderate contraceptive use. These included community-based educational FP interventions, interventions delivered to women as well as men and interventions delivered by trained facilitators, professionals, or peers in community, home and community, or school settings. None of the eight identified intervention components or 33 combinations of components were significant moderators of effects on contraceptive use. Qualitative analysis highlighted some of the barriers and facilitators of effective models of FP that should be considered in future practice and research.

Authors' Conclusions

FP interventions that involve men and boys alongside women and girls are effective in improving uptake and use of contraceptives. The evidence suggests that policy should continue to promote the involvement of men and boys in FP in ways that also promote gender equality. Recommendations for research include the need for evaluations during conflict and disease outbreaks, and evaluation of gender transformative interventions which engage men and boys as contraceptive users and supporters in helping to achieve desired family size, fertility promotion, safe conception, as well as promoting equitable family planning decision-making for women and girls.

Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs)

Background

Adolescent girls and young women (AGYW), aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio-Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high-quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design.

Objectives

The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research.

Methods

This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes-aimed at engaging AGYW in HIV prevention and research - that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass-media, community-based, interpersonal, and Information Communication and Technology (ICT)/Digital Media-based interventions. They were further sub-categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added.

Selection Criteria

To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15-24, as defined by UNAIDS. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention-related outcomes.

Results

This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Despite increased digital penetration use of media and technology-driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school-based settings, and in many cases are part of sex-education curricula. Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics-related outcomes. Outcomes related to engagement in the research were least studied.

Conclusion

This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors-such as strengthening social and community norms, relationships, and household dynamics-that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass-media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.

Effects of the Waya Intervention on Marital Satisfaction and HIV Risk Behaviors in Western Kenya: A Pre-Post Study Design

Poor marital satisfaction is associated with high-risk sexual behavior and HIV transmission. We tested whether a counselor-led couple education and counseling intervention dubbed Waya (paternal aunt) would improve marital satisfaction and reduce HIV risk behavior among married couples in Kisumu County, western Kenya. In a pre-post design, we enrolled 60 heterosexual married couples at high risk for HIV to undergo five 1-h couple education and counseling sessions over 56 days. We collected self-reported data on marital satisfaction, the number of sex partners, and condom use with extramarital partners at pre- and post-intervention visits. We used Wilcoxon and McNemar tests to examine the association of our intervention with marital relationship satisfaction and reduction in HIV risk sexual behavior. The intervention was associated with marital relationship satisfaction score improvement from a median of 5 (interquartile range [IQR], 4-5) to 6 (IQR, 6-7) among men and 4 (IQR, 3-5) to 6 (IQR, 5-6) among women (p < .01). The intervention was also associated with reducing HIV risk sexual behaviors depicted by a reduction in the number of sex partners in the past one month and an increase in consistent extramarital condom use. The number of sex partners reduced from a median of 2 (IQR, 1-2) to 1 (IQR, 1-2) and consistent extramarital condom use increased from 4% at baseline to 56% among men. Our intervention was associated with improvements in marital relationship satisfaction and reductions in HIV high-risk behaviors necessary for achieving epidemic control in HIV hotspots such as fishing communities in western Kenya.

Health worker perceptions of stigma towards Zambian adolescent girls and young women: a qualitative study

Background

The high prevalence of HIV among adolescent girls and young women aged 15–24 in Eastern and Southern Africa indicates a substantial need for accessible HIV prevention and treatment services in this population. Amidst this need, Zambia has yet to meet global testing and treatment targets among adolescent girls and young women living with HIV. Increasing access to timely, high-quality HIV services in this population requires addressing the intensified anticipated and experienced stigma that adolescent girls and young women often face when seeking HIV care, particularly stigma in the health facility setting. To better understand the multi-level drivers and manifestations of health facility stigma, we explored health workers’ perceptions of clinic- and community-level stigma against adolescent girls and young women seeking sexual and reproductive health, including HIV, services in Lusaka, Zambia.

Methods

We conducted 18 in-depth interviews in August 2020 with clinical and non-clinical health workers across six health facilities in urban and peri-urban Lusaka. Data were coded in Dedoose and thematically analyzed.

Results

Health workers reported observing manifestations of stigma driven by attitudes, awareness, and institutional environment. Clinic-level stigma often mirrored community-level stigma. Health workers clearly described the negative impacts of stigma for adolescent girls and young women and seemed to generally express a desire to avoid stigmatization. Despite this lack of intent to stigmatize, results suggest that community influence perpetuates a lingering presence of stigma, although often unrecognized and unintended, in health workers and clinics.

Conclusions

These findings demonstrate the overlap in health workers’ clinic and community roles and suggest the need for multi-level stigma-reduction approaches that address the influence of community norms on health facility stigma. Stigma-reduction interventions should aim to move beyond fostering basic knowledge about stigma to encouraging critical thinking about internal beliefs and community influence and how these may manifest, often unconsciously, in service delivery to adolescent girls and young women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08636-5.

Association between sexual and reproductive health education in peer group and comprehensive knowledge of HIV among adolescent girls in rural eastern Ethiopia: a community-based cross-sectional study

OBJECTIVES

This study examined the association between sexual and reproductive health (SRH) education in peer-group discussion and comprehensive knowledge of HIV among young adolescent girls in rural eastern Ethiopia.

DESIGN

The study analysed data from a large quasi-experimental study involving 3290 young adolescent girls aged 13-17 years. The intervention targeted adolescent girls aged 10-14 years. Data were collected using a comprehensive HIV knowledge tool adopted from the demographic and health survey questionnaire. Multi-level mixed-effect logistic regression analysis was employed to examine associations using STATA/SE V.14 statistical software.

SETTING

West Hararghe, rural Ethiopia.

PARTICIPANTS

3290 adolescent girls.

RESULTS

Magnitude of comprehensive knowledge of HIV among those who received SRH education and those who did not receive SRH education was 16.78% (95% CI 14.41% to 19.45%) and 14.01% (95% CI 12.38% to 15.81%), respectively. Overall, 14.84% (95% CI 13.4.% to 16.39%) of the adolescent girls aged 13-17 years had comprehensive knowledge of HIV. The odds of having comprehensive HIV knowledge were higher (1.36 times) among adolescent girls who received SRH education compared with those who did not receive SRH education (adjusted OR 1.36, 95% CI 1.01 to 1.84) after controlling for selected potential confounders. Odds of having comprehensive HIV knowledge were also higher (1.73 times) among older adolescent girls (adjusted OR 1.733 95% CI 1.098 to 2.735) and (3.89 times) among those who attended secondary school (adjusted OR=3.889 95% CI 1.836 to 8.235) compared with young adolescent girls and the uneducated, respectively.

CONCLUSIONS

Comprehensive knowledge of HIV among young adolescent girls was very low. Providing SRH education for young adolescent girls improved their comprehensive knowledge of HIV in rural eastern Ethiopia. Initiating sexual education at an early age would benefit HIV prevention efforts.

Low condom use at the last sexual intercourse among university students in sub-Saharan Africa: Evidence from a systematic review and meta-analysis

BACKGROUND

There is inconsistent data about condom use at the last sexual intercourse (LSI) among university students in sub-Saharan Africa (SSA) and its association with sex, age, and condom negotiation efficacy. The primary objective of this study was to summarize the proportion of condom use at the LSI among university students in SSA. The secondary objective was to determine the association between condom use at the LSI with sex, age, and condom negotiation efficacy among university students in SSA.

METHODS

In this systematic review and meta-analysis, two reviewers independently searched electronic databases and grey literature for eligible studies published until July 30, 2020, extracted data, and assessed the risk of bias in the included studies. We used the Dersimonian-Liard random-effects model to pool the proportion of condom use at the LSI and the association between condom use at the LSI with sex, age, and condom negotiation efficacy, reported using risk ratio (RR). We assessed publication bias using funnel plot and Egger's test, and explored sources of heterogeneity using sub-group and meta-regression analyses.

RESULTS

We meta-analyzed 44 studies with a combined sample size of 27,948 participants.Of 14,778 sexually active participants, 8,744 (pooled proportion, 52.9%; 95% CI, 45.0-60.7; 95% prediction interval, 2.8-98.9; I-squared = 99.0%, p< 0.0001) reported condom use at the LSI and the proportion of condom use at the LSI remained stagnant between 2000 and 2019 (p = 0.512). Condom use at the LSI was not associated with being a female compared to a male (pooled RR, 1.08; 95% CI, 0.68-1.71), being of a younger age (≤24 years old) compared to older age (25 years and more) (pooled RR, 1.16; 95% CI, 0-85-1.57), and having a higher condom negotiation efficacy compared to a lower condom negotiation efficacy (pooled RR, 1.54; 95% CI, 0-81-2.94).

CONCLUSIONS

We found a low and heterogenous use of a condom at the LSI among university students in SSA which was not associated with sex, age, or condom negotiation efficacy. Accordingly, context-relevant interventions are needed to improve condom use at the LSI among university students in SSA.

The mediating role of partner communication on contraceptive use among adolescent girls and young women participating in a small-group intervention in Malawi: A longitudinal analysis

Though effective reproductive health interventions have been developed for adolescent girls and young women (AGYW) in sub-Saharan Africa, few have explored whether specific components of the interventions are responsible for observed changes in behaviour. Data for this longitudinal mediation analysis come from a quasi-experimental, sexual and reproductive health study conducted among AGYW (age 15-24) in Malawi. We assessed the extent to which the relationship between attending communication-specific small-group sessions and contraceptive use at one-year was mediated by contraceptive communication with partners at six months, using a bootstrapping procedure to estimate indirect effects. Of 358 participants, 44% attended communication-specific small-group sessions, 37% communicated with partners about contraception at six months, and 21% used non-barrier contraception at one-year. Participants who attended communication-specific small-group sessions had increased contraceptive communication with partners at six months (aOR = 1.48, 95% CI: 1.07-2.38) and increased non-barrier contraceptive use at one-year (aOR = 3.53, 95% CI: 1.86-6.69). The relationship between attending communication-specific small-group sessions and non-barrier contraceptive use at one-year was partially mediated by contraceptive communication with partners at six months (indirect effect = 0.04, 95% CI: 0.01-0.07). Our results suggest that contraceptive communication with partners is modifiable through interventions and important for AGYW non-barrier contraceptive uptake.

Effects of economic support, comprehensive sexuality education and community dialogue on sexual behaviour: Findings from a cluster-RCT among adolescent girls in rural Zambia

Adolescent girls in Sub-Saharan Africa are at high risk of poor sexual and reproductive health outcomes. We present findings from a cluster-randomised trial in rural Zambia on the effects of economic support, comprehensive sexuality education (CSE) and community dialogue on sexual activity, contraceptive use and beliefs among adolescent girls. We recruited 157 schools in 2016, and all girls in grade 7 were invited to participate. Schools were randomised to either economic support, combined economic support, CSE and community dialogue, or control. Economic support consisted of unconditional cash transfers to girls and their guardians, and payment of school fees for girls continuing to grades eight and nine. CSE and community dialogue meetings focused on practices around girls' fertility, marriage and education. The interventions lasted two years from 2016 to 2018, with follow-up for another two years. The effects on outcomes were measured in 2018 and 2019 and compared using generalised estimating equations. We found that economic support lowered sexual activity (risk ratio (RR) 0.70; 95% C.I. 0.54 to 0.91), with a small added benefit of CSE and community dialogue. Economic support and the additional CSE and community dialogue were effective in lowering unprotected sexual activity (RR 0.53 for combined support vs. control; 95% C.I. 0.37 to 0.75). There was no evidence of intervention effects on contraceptive use among those ever sexually active, but the addition of CSE and community dialogue improved contraceptive use among those recently sexually active (RR 1.26; 95% C.I. 1.06 to 1.50) and knowledge regarding contraceptives (RR 1.18; 95% C.I. 1.01 to 1.38) compared to economic support alone. Perceived community support regarding contraceptives was lower in both intervention arms compared to the control. These findings indicate that economic support in combination with CSE and community dialogue can improve the sexual and reproductive health of adolescent girls.

The role and effectiveness of School-based Extra-Curricular Interventions on children's health and HIV related behaviour: the case study of Soul Buddyz Clubs Programme in South Africa

Background

HIV education targeting children and adolescents is a key component of HIV prevention. This is especially important in the context of increasing HIV prevalence rates among adolescents and young people. The authors sought to examine the role and effectiveness of an extra-curricular school based programme, Soul Buddyz Clubs (SBC) on HIV knowledge, attitudes, behaviours and biomedical outcomes.

Methods

This paper employs a mixed methods approach drawing on data from independent qualitative and quantitative sources. Secondary data analysis was performed using survey data from a nationally representative sample that was restricted to 10-14 year-old males and females living in South Africa. Ten focus group discussions and ten in-depth interviews conducted with SBC members and facilitators from 5 provinces, as part of a process evaluation are used to triangulate the effectiveness of SBC intervention.

Results

The analysis of survey data from 2 198 children indicated that 12% of respondents were exposed to SBC with 4% reporting that they had ever belonged to a club. Children exposed to SBC were more likely to be medically circumcised (AOR 2.38; 95%CI 1.29 -4.40, p=0.006), had correct HIV knowledge (AOR 2.21; 95%CI 1.36 – 3.57, p<0.001) and had less HIV stigmatising attitudes (AOR 0.54; 95%CI 0.31-0.93, p=0.025), adjusting for age, sex, province and exposure to other media – in comparison to those not exposed. Propensity Score Matching findings were consistent with the regression findings. Qualitative findings also supported some of the quantitative results. SBC members reported having learnt about HIV prevention life skills, including condom use, positive attitudes towards people living with HIV, and alcohol abuse.

Conclusions

Participation in SBC is associated with accessing biomedical HIV prevention services, specifically MMC, correct HIV prevention knowledge and less HIV stigmatizing attitudes. This paper demonstrates the effectiveness of a school-based extracurricular intervention using a club approach targeting boys and girls ages 10-14 years on some of the key HIV prevention biomarkers as well as knowledge and attitudes. The article suggests that extra-curricular interventions can form an effective component of school-based comprehensive sexuality education in preventing HIV and promoting medical male circumcision.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12281-8.

Stakeholder acceptability of the risk reduction behavioural model [RRBM] as an alternative model for adolescent HIV risk reduction and sexual behavior change in Northern Malawi

We sought to assess stakeholder acceptability of a risk reduction behavioural model [RRBM] designed for adolescent HIV risk reduction and whose efficacy we tested in selected schools in Northern Malawi. We used qualitative procedures in sampling, data collection and data analysis. Our data collection instrument was the semi-structured interview and we applied thematic content analysis to establish stakeholder evaluations of the RRBM model. The study population included10 experts working within key organizations and teachers from two schools. The organizations were sampled as providers, implementers and designers of interventions while schools were sampled as providers and consumers of interventions. Individual study participants were recruited purposively through snowball sampling. Results showed consensus among participants on the acceptability, potential for scale up and likelihood of model sustainability if implemented. In essence areas to consider improving and modifying included: focus on the rural girl child and inclusion of an economic empowerment component to target the underlying root causes of HIV risk taking behavior. Stakeholders also recommended intervention extension to out of school adolescent groups as well as involvement of traditional leaders. Involvement of parents and religious leaders in intervention scale up was also highlighted. The study serves as a benchmark for stakeholder involvement in model and intervention evaluation and as a link between researchers and project implementers, designers as well as policy makers to bridge the research to policy and practice gap.

Where and how do young people like to get their sexual and reproductive health (SRH) information? Experiences from students in higher learning institutions in Mbeya, Tanzania: a cross-sectional study

Background

Sexual and reproductive health (SRH) among young adults in low- and middle-income countries (LMIC) is still a major public health challenge. Early school-based sexuality education programs and sexual health information sharing between teachers, parents and young people have been considered protective against the sexual health risks to which young people are exposed. There is, however, limited information on the preferred choices of “where”, “how” and “from whom” young people would like to receive SRH information. We aimed to describe the experience and preferences of young people regarding their SRH education and learning and in particular communication with their parents/guardians.

Methods

We conducted a cross-sectional study among randomly selected students aged 18-24y attending Higher Learning Institutions (HLIs) in Mbeya, Tanzania. We used a self-administered questionnaire to collect information on SRH education received, ability to discuss SRH matters with a parent/guardian and SRH information gaps encountered during their early sexual experience.

Results

We enrolled 504 students from 5 HLIs, of whom 446 (88.5%) reported to be sexually active, with mean age at sexual debut of 18.4y (SD 2.2). About 61% (307/504) of the participants found it difficult to discuss or did not discuss SRH matters with their parent/guardian while growing up. Learning about SRH matters was reported from peers (30.2%) and teacher-led school curriculum (22.7%). There was a strong gender-biased preference on SRH matters’ discussions, female and male participants preferred discussions with adults of their respective sex. Peers (18.2%), media (16.2%) and schools (14.2%) were described as the preferred sources of SRH information. On recalling their first sexual experience, sexually-initiated participants felt they needed to know more about sexual feelings, emotions and relationships (28.8%), safer sex (13.5%), how to be able to say ‘No’ (10.7%) and how to use a condom correctly (10.2%).

Conclusion

Young people have a gender preference when it comes to learning about SRH matters from their parents; however, such conversations seldom occur. Community health education should focus on building skills of parents on parent-child communication on SRH matters so as to empower them to confidently initiate and convey accurate SRH information. Comprehensive SRH education and skills building need to be strengthened in the current school SRH curriculum in order to meet the demand and needs of students and increase the competence of teachers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11728-2.

Implementation Strategies to Enhance Youth-Friendly Sexual and Reproductive Health Services in Sub-Saharan Africa: A Systematic Review

Introduction: Youth-friendly health service (YFHS) interventions are a promising, cost-effective approaches to delivering sexual and reproductive services that cater to the developmental needs of young people. Despite a growing evidence-base, implementation of such interventions into practice have proven to be challenging in sub-Saharan Africa (SSA). Thus, the purpose of this review is to synthesize existing evidence on YFHS implementation in SSA and understand which implementation strategies were used, in what context, how they were used, and leading to which implementation outcomes.

Methods: A comprehensive literature search in PubMed, Embase, Scopus, and CINAHL, was conducted to identify peer-reviewed research articles published from database inception up until August 2020. Eligible studies were required to include young people (ages 10–24 years) in sub-Saharan Africa. Studies that described implementation strategies, as conceptualized by the Expert Recommendations for Implementing Change (ERIC) project, used to enhance the implementation of YFHS were included. Implementation outcomes were extracted using Proctor and colleagues' 8 taxonomy of implementation outcomes.

Results: We identified 18 unique interventions (reported in 23 articles) from an initial search of 630 articles, including seven from East Africa, seven from South Africa, and four from West Africa. In most studies (n = 15), youth-friendly health services were delivered within the context of a health facility or clinic setting. The most frequently reported categories of implementation strategies were to train and educate stakeholders (n = 16) followed by infrastructure change (n = 10), to engage consumers (n = 9), the use of evaluative and iterative strategies (n = 8), support clinicians (n = 8), and providing interactive assistance (n = 6). The effectiveness of the strategies to enhance YFHS implementation was commonly measured using adoption (n = 15), fidelity (n = 7), acceptability (n = 5), and penetration (n = 5). Few studies reported on sustainability (n = 2), appropriateness (n = 1), implementation cost (n = 1) and feasibility (n = 0).

Conclusion: Results of the review emphasize the need for further research to evaluate and optimize implementation strategies for promoting the scale-up and sustainability of evidence-based, YFHS interventions in resource-constrained settings. This review also highlights the need to design robust studies to better understand which, in what combination, and in what context, can implementation strategies be used to effectively enhance the implementation of YFHS interventions.

A Rapid Review of Interventions to Prevent First Pregnancy among Adolescents and Its Applicability to Latin America

STUDY OBJECTIVE

To summarize recent literature on the effectiveness of interventions to prevent adolescent pregnancy and to explore the applicability of these interventions to Latin America (LA). Design, Setting, Participants, Interventions, and Main Outcome Measures: We carried out a rapid review of the literature (2005-2019). Studies were included if: they evaluated interventions targeting adolescents and prevention of pregnancy; they used a randomized controlled design; and pregnancy was measured as an outcome. Applicability of the interventions to LA was assessed using the following information: target population; intervention design and resources; type, skills, and training of providers; system arrangements; and acceptability and social context.

RESULTS

Nine studies were included, 5 described interventions in African countries, 2 in the United Kingdom, and 2 in the United States. Interventions were rated as highly applicable to LA in the context of target population, profile of the providers, and design; however, variations arose when assessing system arrangements and social context. Incentive-based interventions showed significant effects in the prevention of adolescent pregnancy and were rated as highly applicable.

CONCLUSION

This review provides professionals, policymakers, researchers, and educators potential criteria to consider when adapting successful evidence-based interventions to prevent adolescent pregnancy in LA.

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.

Indigenous Health Systems and Adolescent Sexual Health in Umguza and Mberengwa Districts of Zimbabwe: Community Key Stakeholders' Perspectives

Different stakeholders play varying roles in shaping up adolescent sexual behaviours that, in turn, influence their sexual experiences. In Zimbabwe, it has been reported that adolescents from cultural districts exhibit poor sexual health outcomes as compared to other districts. Therefore, this study sought to explore the role of different key community stakeholders in the indigenous health system and how it impacts on adolescent sexual health issues. The study further explored how the indigenous health system could be integrated into the modern health system. A qualitative cross-sectional survey was conducted on purposively and snowballed respondents in Umguza and Mberengwa districts. Interviews and focus group discussions were used to gather and record data from participants. The recorded data were transcribed verbatim, translated to English, coded and thematically analysed on MAXQDA Analytics Pro 2020. Four superordinate and 12 subordinate themes emerged from the data during analysis. Stakeholders play varied roles in adolescents’ upbringing and support though there are contradicting teachings from the indigenous health system and modern health system. It is possible to integrate these two systems though there were foreseen logistical challenges and clashes in the values and belief systems. Participants made suggestions on how these challenges could be overcome. There is a window of opportunity to pursue the suggested ways of integrating indigenous health systems and modern health systems for improved adolescent sexual health outcomes.

Assessing the Impact of an Intervention Project by the Young women's Christian Association of Malawi on Psychosocial Well-Being of Adolescent Mothers and Their Children in Malawi

Adolescent mothers in Malawi face psychosocial challenges such as low resilience level, low self-esteem, poor maternal-infant interaction, and exposure to intimate partner violence (IPV). Children of adolescent mothers often face numerous risks such as low birth-weight, stunted growth, infant death, low school enrolment, increased grade repetition, and dropouts that put them at greater risk of poor developmental outcomes and socio-emotional problems. This study assessed the impact of components of a community project conducted by the Young Women's Christian association of Malawi in providing psychosocial support to adolescent mothers and their children. The goals of the project were; (1) to improve early childhood development in babies born to adolescent mothers; and (2) to enhance the psychosocial well-being of adolescent mothers (self-esteem, resilience stress, and parenting skills). This descriptive mixed methods evaluation study comprised an intervention and control groups of adolescent mothers respectively. The project had 3 centers in southern region districts of Malawi. Target population was adolescent mothers 18 years of age and below. At baseline we enrolled 267 mothers and at the end of the project we had 211 mothers. The project involved monthly meetings with adolescent mothers imparting knowledge and skills and early childhood education activities. From July 2017 to June 2019, 58 sessions were conducted. In the first year the control group had no meetings, however they received the intervention in the second year. Overall results in the intervention group showed statistically significant increase in knowledge on parenting skills (p < 0.01), nutritional practice (p < 0.01), motor skills and cognitive functions in children (p < 0.01) as well as expressive language and socio-emotional capacities in children (p < 0.01), while the change in confidence and psychosocial well-being was not statistically significant (p = 0.8823). Community projects such as these enhance parenting skills and improve development of children born to adolescent mothers. Improving psychosocial support is complex and requires further research and a more holistic approach.

A Systematic Review of HIV Interventions for Young Women in Sub-Saharan Africa

Adolescent girls and young women (AGYW) ages (15-24 years old) in Southern and Eastern Africa account for nearly 30% of all new HIV infections. We conducted a systematic review of studies examining the effectiveness of behavioral, structural, and combined (behavioral + structural) interventions on HIV incidence and risky sexual behaviors among AGYW. Following PRISMA guidelines, we searched PubMed, CINAHL, Web of Science, and Global Health. Twenty-two studies met inclusion criteria conducted in Eastern and Southern Africa and comprised behavioral, structural, or combined (behavioral and structural) interventions. All findings are based on 22 studies. HIV incidence was significantly reduced by one structural intervention. All three types of interventions improved condom use among AGYW. Evidence suggests that structural interventions can reduce HIV incidence, while behavioral and combined interventions require further investigation.

Effective strategies to improve health worker performance in delivering adolescent-friendly sexual and reproductive health services

Background Despite recognition of the important role of health workers in providing adolescent-friendly sexual and reproductive health services (AFSRHS), evidence on strategies for improving performance is limited. This review sought to address: (1) which interventions are used to improve health worker performance in delivering AFSRHS? and (2) how effective are these interventions in improving AFSRHS health worker performance and client outcomes? Methods Building on a 2015 review, a search for literature on 18 previously identified programs was conducted to identify updated literature and data relevant to this review. Data was systematically extracted and analyzed. Results Due to the parent review's eligibility criteria, all programs included health worker training. Otherwise, supervision was the most frequently reported intervention used (n=10). Components and methods related to quality of trainings and supervision varied considerably in program reports. Nearly half of programs described employing processes to ensure availability of basic medicines and supplies (n=7). Other interventions (policies, standards, and job descriptions [n=5]; refresher trainings [n=5]; job aids or other reference material [n=3]) were less commonly reported to have been employed. No discernible patterns emerged in the relationship between interventions and outcomes of interest. Conclusions Multi-faceted complementary strategies are recommended to improve health worker performance to deliver AFSRHS; however, this was uncommonly reported in the programs that we reviewed. Effectiveness and cost-effectiveness evaluations of interventions and intervention packages are needed to guide efficient use of limited resources to enhance health worker capacity to deliver AFSRHS. In the interim, programs should be developed and implemented based on available existing evidence on improving health worker performance within and outside adolescent health. Implications and contribution This review is the first to examine the interventions commonly used to improve health worker performance in delivering AFSRHS. The findings indicate a need for additional effectiveness and cost-effectiveness evaluations of such interventions. In the meantime, existing evidence on improving health worker performance within and outside adolescent health must be integrated more thoughtfully into program planning and implementation.

Predictors of Responsiveness Among American Indian Adolescents to a Community-Based HIV-Risk Reduction Intervention Over 12 Months

This analysis explored predictors of responsiveness to the Respecting the Circle of Life (RCL) intervention, a sexual and reproductive health program for American Indian (AI) youth. Data were collected over 12-month follow-up with 267 AI youth aged 13-19. We used mixed effects regression models to examine: (1) whether trajectory patterns of HIV/AIDS knowledge, condom beliefs, condom use self-efficacy, condom use intention and partner negotiation skills differed by baseline levels categorized into low, medium, and high scorers, and (2) the characteristics of youth who made no improvement over the post-intervention period. Results indicate the RCL intervention had greater longitudinal impact among subgroups with low and medium initial scores. High initial scores in knowledge, beliefs, efficacy, intention and skills predicted unresponsiveness to the RCL intervention. Youth differences in age, gender and school truancy (skipping/suspension) did not predict responsiveness to RCL. Results have important prevention science implications: (1) AI youth at greater risk (i.e., those with low initial levels of knowledge, beliefs, self-efficacy, intention and skills) are likely to respond to RCL and should be the target of replication and dissemination efforts. (2) Responsiveness analyses can guide adaptation of RCL and other sexual and reproductive health programs for AI youth to improve efficacy among unresponsive subgroups (i.e., high initial scorers). (3) RCL is equally likely to impact AI youth across different ages, genders and school status, thus validating population-wide implementation strategies.

xtgeebcv: A command for bias-corrected sandwich variance estimation for GEE analyses of cluster randomized trials

Cluster randomized trials, where clusters (for example, schools or clinics) are randomized to comparison arms but measurements are taken on individuals, are commonly used to evaluate interventions in public health, education, and the social sciences. Analysis is often conducted on individual-level outcomes, and such analysis methods must consider that outcomes for members of the same cluster tend to be more similar than outcomes for members of other clusters. A popular individual-level analysis technique is generalized estimating equations (GEE). However, it is common to randomize a small number of clusters (for example, 30 or fewer), and in this case, the GEE standard errors obtained from the sandwich variance estimator will be biased, leading to inflated type I errors. Some bias-corrected standard errors have been proposed and studied to account for this finite-sample bias, but none has yet been implemented in Stata. In this article, we describe several popular bias corrections to the robust sandwich variance. We then introduce our newly created command, xtgeebcv, which will allow Stata users to easily apply finite-sample corrections to standard errors obtained from GEE models. We then provide examples to demonstrate the use of xtgeebcv. Finally, we discuss suggestions about which finite-sample corrections to use in which situations and consider areas of future research that may improve xtgeebcv.

A systematic review of sexual and reproductive health interventions for young people in humanitarian and lower-and-middle-income country settings

Background

Accessibility of sexual and reproductive health (SRH) services in many lower-and-middle-income countries (LMICs) and humanitarian settings remains limited, particularly for young people. Young people facing humanitarian crises are also at higher risk for mental health problems, which can further exacerbate poor SRH outcomes. This review aimed to explore, describe and evaluate SRH interventions for young people in LMIC and humanitarian settings to better understand both SRH and psychosocial components of interventions that demonstrate effectiveness for improving SRH outcomes.

Methods

We conducted a systematic review of studies examining interventions to improve SRH in young people in LMIC and humanitarian settings following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) standards for systematic reviews. Peer-reviewed journals and grey literature from January 1, 2000 to December 31, 2018 were included. Two authors performed title, abstract and full-text screening independently. Data was extracted and analyzed using a narrative synthesis approach and the practice-wise clinical coding system.

Results

The search yielded 813 results, of which 55 met inclusion criteria for full-text screening and thematic analysis. Primary SRH outcomes of effective interventions included: contraception and condom use skills, HIV/STI prevention/education, SRH knowledge/education, gender-based violence education and sexual self-efficacy. Common psychosocial intervention components included: assertiveness training, communication skills, and problem-solving.

Conclusions

Findings suggest that several evidence-based SRH interventions may be effective for young people in humanitarian and LMIC settings. Studies that use double blind designs, include fidelity monitoring, and focus on implementation and sustainability are needed to further contribute to this evidence-base.

Effects of Preconception Care and Periconception Interventions on Maternal Nutritional Status and Birth Outcomes in Low- and Middle-Income Countries: A Systematic Review

Pregnancy in adolescence and malnutrition are common challenges in low- and middle-income countries (LMICs), and are associated with many complications and comorbidities. The preconception period is an ideal period for intervention as a preventative tactic for teenage pregnancy, and to increase micronutrient supplementation prior to conception. Over twenty databases and websites were searched and 45 randomized controlled trials (RCTs) or quasi-experimental interventions with intent to delay the age at first pregnancy (n = 26), to optimize inter-pregnancy intervals (n = 4), and supplementation of folic acid (n = 5) or a combination of iron and folic acid (n = 10) during the periconception period were included. The review found that educational interventions to delay the age at first pregnancy and optimizing inter-pregnancy intervals significantly improved the uptake of contraception use (RR = 1.71, 95% CI = 1.42-2.05; two studies, n = 911; I2 = 0%) and (RR = 2.25, 95% CI = 1.29-3.93; one study, n = 338), respectively. For periconceptional folic acid supplementation, the incidence of neural tube defects were reduced (RR = 0.53; 95% CI = 0.41-0.77; two studies, n = 248,056; I2 = 0%), and iron-folic acid supplementation improved the rates of anemia (RR = 0.66, 95% CI = 0.53-0.81; six studies; n = 3430, I2 = 88%), particularly when supplemented weekly and in a school setting. Notwithstanding the findings, more robust RCTs are required from LMICs to further support the evidence.

Comparing Youth-Friendly Health Services to the Standard of Care Through "Girl Power-Malawi": A Quasi-Experimental Cohort Study

BACKGROUND

Adolescent girls and young women (AGYW) face challenges to seeking HIV and sexual and reproductive health services in sub-Saharan Africa. Integrated approaches designed for AGYW may facilitate service uptake, but rigorous evaluation is needed.

METHODS

Four comparable public-sector health centers were selected in Malawi and randomly assigned to a service delivery model. One offered "standard of care" (SOC), consisting of vertical HIV testing, family planning, and sexually transmitted infection management in adult-oriented spaces, by providers without extra training. Three offered youth-friendly health services (YFHS), consisting of the same SOC services in integrated youth-dedicated spaces and staffed by youth-friendly peers and providers. In each health center, AGYW aged 15-24 years were enrolled and followed over 12 months to determine use of HIV testing, condoms, and hormonal contraception. The SOC and YFHS models were compared using adjusted risk differences and incidence rate ratios.

FINDINGS

In 2016, 1000 AGYW enrolled (N = 250/health center). Median age was 19 years (interquartile range = 17-21 years). Compared with AGYW in the SOC, those in the YFHS models were 23% [confidence interval (CI): 16% to 29%)] more likely to receive HIV testing, 57% (CI: 51% to 63%) more likely to receive condoms, and 39% (CI: 34% to 45%) more likely to receive hormonal contraception. Compared with AGYW in the SOC, AGYW in the YFHS models accessed HIV testing 2.4 (CI: 1.9 to 2.9) times more, condoms 7.9 (CI: 6.0 to 10.5) times more, and hormonal contraception 6.0 (CI: 4.2 to 8.7) times more.

CONCLUSIONS

A YFHS model led to higher health service use. Implementation science is needed to guide scale-up.

Factors Influencing the Risk of Becoming Sexually Active Among HIV Infected Adolescents in Kampala and Kisumu, East Africa

About 2.1 million adolescents aged 10-19 years are living with HIV, 80% of them in sub-Saharan Africa. Early sexual activity remains an important risk factor for HIV transmission and potentially result in negative health consequences including onward transmission of sexually transmitted infections. Cross-sectional data of 580 adolescents living with HIV (ALHIV) aged 13-17 years (317 girls and 263 boys) from Kenya and Uganda were analyzed to assess factors associated with risk to become sexually active. Factors associated with risk of sexual intercourse were identified using Kaplan-Meier survival curves and Cox regression with gender-stratified bi-and multivariable models. Slightly more females (22%) than males (20%) reported they have had sex. Multivariable models showed that being aware of one's own HIV infection, and receiving antiretroviral treatment were negatively associated with risk of becoming sexually active, while subjective norms conducive to sexuality, and girls' poor health experience increased the risk. In the final multi-variable models, schooling was protective for girls, but not for boys. Being more popular with the opposite sex was negatively associated with the outcome variable only for girls, but not for boys. This study expands the knowledge base on factors associated with onset of sexual activity among ALHIV, potentially informing positive prevention interventions.

Improving communication about HIV prevention among people living with HIV and their at-risk social network members in Dar es Salaam, Tanzania

Although a number of HIV prevention programs have been implemented, such as mass media campaigns, high rates of unprotected and concurrent sexual partnerships, as well as low uptake HIV testing and limited HIV knowledge, persist in Tanzania. We examined the effect and predicting factors of HIV prevention communication among people living with HIV (PLH) exposed to NAMWEZA intervention, and their at-risk social network members (NMs) Quantitative data were collected from 326 participants at baseline and 24 months of follow-up. In-depth interviews with 20 PLH were conducted at follow-up. Results indicated specific communication about condom use and HIV testing increased; (mean increase of 0.28 (SD = 0.14) scores, P = 0.012 and 0.42 (SD = 0.11) scores, p < 0.001 respectively while general discussion about protecting other people from HIV did not change significantly; mean increase was 0.01 scores (SD = 0.005), p = 0.890. Positive predictors of communication included being single; OR = 1.10, p = 0.01, female; OR = 1.15, p = 0.03, aged 30 years or older; OR = 1.23, p < 0.01, HIV knowledge, dose of NAMWEZA participation; OR = 1.01, p < 0.001, and high self-efficacy for condom use; OR = 1.4, p < 0.001. Stigma demonstrated a significant but negative association with communication for condom use; OR = 1.01, p < 0.01.Qualitative data reflected perceived possession of more individual skills and ability to address some personal/cultural obstacles to communicating about HIV prevention including those observed in the quantitative data. NAMWEZA improved communication about HIV prevention among PLH with their at-risk-NMs. The approach is a promising complement to media campaigns in similar populations. Future research and program evaluation efforts should explore how communities perceive and communicate about protecting others from HIV.

A Systematic Global Review of Condom Availability Programs in High Schools

PURPOSE

High levels of HIV, sexually transmitted infections (STIs), and pregnancy among adolescents has motivated some countries to consider the implementation of condom availability programs (CAPs) in high schools. In this present study, we analyzed the impact of CAP on students' sexual behaviors and health outcomes.

METHODS

We conducted a systematic literature review of peer-reviewed articles published between 1990 and 2017.

RESULTS

Twenty-nine articles from seven countries were included in this review. We found that CAP does not increase sexual activity nor lead to a greater number of sexual partners. It also does not lower the age of sexual initiation. A majority of the studies reported an increase in condom uptake and use at last sex among students with CAP. All the studies that examined STI found a decrease of STI symptoms and rates for students with CAP compared with the control group. The data on HIV rates was inconclusive. There was no difference in pregnancy rates associated with participation in CAP programs.

CONCLUSION

This global literature review showed that the fears surrounding CAP and promiscuity are unfounded. Once CAP is in place, students utilize it, and condom use increases, which translates to improved sexual health outcomes.

Peer-facilitated community-based interventions for adolescent health in low- and middle-income countries: A systematic review

Background

Adolescents aged 10–19 represent one sixth of the world’s population and have a high burden of morbidity, particularly in low-resource settings. We know little about the potential of community-based peer facilitators to improve adolescent health in such contexts.

Methods

We did a systematic review of peer-facilitated community-based interventions for adolescent health in low- and middle-income countries (LMICs). We searched databases for randomised controlled trials of interventions featuring peer education, counselling, activism, and/or outreach facilitated by young people aged 10–24. We included trials with outcomes across key areas of adolescent health: infectious and vaccine preventable diseases, undernutrition, HIV/AIDS, sexual and reproductive health, unintentional injuries, violence, physical disorders, mental disorders and substance use. We summarised evidence from these trials narratively. PROSPERO registration: CRD42016039190.

Results

We found 20 studies (61,014 adolescents). Fourteen studies tested interventions linked to schools or colleges, and 12 had non-peer-facilitated components, e.g. health worker training. Four studies had HIV-related outcomes, but none reported reductions in HIV prevalence or incidence. Nine studies had clinical sexual and reproductive health outcomes, but only one reported a positive effect: a reduction in Herpes Simplex Virus-2 incidence. Three studies had violence-related outcomes, two of which reported reductions in physical violence by school staff and perpetration of physical violence by adolescents. Seven studies had mental health outcomes, four of which reported reductions in depressive symptoms. Finally, we found eight studies on substance use, four of which reported reductions in alcohol consumption and smoking or tobacco use. There were no studies on infectious and vaccine preventable diseases, undernutrition, or injuries.

Conclusions

There are few trials on the effects of peer-facilitated community-based interventions for adolescent health in LMICs. Existing trials have mixed results, with the most promising evidence supporting work with peer facilitators to improve adolescent mental health and reduce substance use and violence.

Extracurricular School-Based Social Change Communication Program Associated with Reduced HIV Infection Among Young Women in South Africa

BACKGROUND

Young women in South Africa are at high risk for HIV, particularly after they leave school. There are few studies examining the long-term impact of school-based public health interventions aimed at protecting young women from HIV. We undertook a long-term evaluation of an extracurricular, school-based HIV prevention program, that leveraged off a mass media television series in South Africa.

METHODS

We recruited 403 women aged 18-28 years. One hundred and seventy were members of Soul Buddyz Clubs (SBCs) between 2004 and 2008 and 233 were matched controls from the same communities as the ex-Buddyz. Face-to-face interviews were conducted and HIV testing undertaken. Analysis was restricted to 320 women who had ever had sex (136 ex-Buddyz and 184 controls). Multivariate analysis in Stata v14 was conducted.

FINDINGS

16.4% of women tested HIV positive. Ex-Buddyz were more likely to be HIV negative than controls (AOR 2.92, 95% CI 1.26-6.77, p = 0.013). Ex-Buddyz were more likely to have only had one sexual partner in the past year (AOR 2.14, 95% CI 1.17-3.89, p = 0.013) and 1.7 times more likely to have used a condom at first sex (95% CI 0.99-2.92, p = 0.053).

INTERPRETATION

Participation in an SBC is associated with a decrease in young women's HIV risk and suggests an impact on some key risky sexual behaviors. School-based prevention programs that leverage off of other media platforms demonstrate a positive outcome on health status.

Parents' reactions to testing for herpes simplex virus type 2 as a biomarker of sexual activity in Botswana junior secondary school students

Background Use of sexual activity biomarkers in HIV prevention trials has been widely supported to validate self-reported data. When such trials involve minors, researchers may face challenges in obtaining parental buy-in, especially if return of results procedures uphold the confidentiality and privacy rights of minors and preclude parental access to test results. In preparation for a randomised controlled trial (RCT) with junior secondary school (JSS) students in Botswana, a formative assessment was conducted to assess parents' opinions and concerns about testing for herpes simplex virus type 2 (HSV-2) (biomarker of sexual activity) as part of the RCT.

METHODS

Six focus groups were held with parents (n=32) of JSS students from urban, peri-urban and rural communities. Parents were asked their opinions of students being tested for HSV-2 and procedures for blood sample collection and return of results.

RESULTS

Overall, parents were supportive of HSV-2 testing, which they thought was a beneficial sexual health resource for adolescents and parents, and a motivation for parent-child communication about HSV-2, sexual activity and sexual abuse. Some parents supported the proposed plan to disclose HSV-2 test results to adolescents only, citing the importance of adolescent privacy and the possibility of HSV-2 positive adolescents being stigmatised by family members. Conversely, opposing parents requested parental access to results. These parents were concerned that adolescents may experience distress following a positive result and withhold this information thereby reducing parents' abilities to provide support. Parents were also concerned about support for victims of sexual abuse.

CONCLUSION

Although the present study demonstrates that parents can be accepting of sexual activity biomarker testing of adolescents, more research is needed to identify best approaches for returning test results.

[Trends in Research on Adolescent Sexuality Education, Fertility Awareness, and the Possibility of Life Planning Based on Reproductive Health Education]

In this paper, we describe the trends in research on adolescent sexuality education in Japan and other countries and on fertility awareness, as well as the possibility of life planning based on sex and reproductive health education. Mason-Jones AJ et al. reviewed the results of school-based intervention studies on the prevention of human immunodeficiency virus infection, sexually transmitted diseases, and pregnancy. There is little evidence supporting the idea that educational curriculum-based programs alone are effective in improving sex and reproductive health outcomes in adolescents. In another study, the effectiveness of school-based sexuality education for adolescents in Japan was evaluated. The Japan Medical Abstract Society was searched for articles published in the last 10 years. In many studies, the effects were compared before and after a single sexuality education lecture by professionals, such as doctors, midwives, and public health nurses. In Japan, effort has been directed toward sexuality education, but no systematic program based on behavior theory has been adopted. Therefore, sex education is insufficient. A third study clarified research on fertility awareness in adults and issues regarding improvements in related education and research. The Japan Medical Abstract Society and PubMed were searched for articles published in the last 10 years. The review suggested that awareness of female fertility is insufficient. Delaying childbearing based on inaccurate knowledge of the decline in female fertility could lead to unintended infertility. For males and females, sexual health education in schools and communities should include information on the age-related decline in female fertility. Although the determinants of the timing of childbearing are multifactorial, education on fertility issues is necessary to help adults make informed reproductive decisions based on accurate information. Finally, in this paper, we introduce examples of the pioneering efforts in sexual health education through collaboration between the governments of Oita and Okayama Prefectures and Oita and Okayama Universities.

Effectiveness of population based risk reduction programs for risky sexual behavior among young people in low- and middle-income countries: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to synthesize the best available evidence on the effectiveness of population based (public health) risk reduction interventions (programs and services) on sexual risk taking among young people (aged 10 to 24 years old) in low- and middle-income countries (LMICs).The specific review questions are.

Educating and Training the Future Adolescent Health Workforce

Unprecedented attention is now focused on adolescents with growing appreciation of their disease burden and of the opportunities of investing in adolescent health. New investments are required to build the technical capacity for policy, programming, research, and clinical care across the world, especially in resource-poor settings where most adolescents live. Strategies to educate and train the future workforce are needed. Competency-based education and training is the standard of education in preservice (undergraduate and postgraduate) health education and medical specialty training. Yet competency is difficult to quantify and standardize, as are the processes that underpin competency-based education and training. The primary objective of this review was to identify how quality education in adolescent health and medicine is determined. This information was used to inform the development of a conceptual framework for institutions teaching adolescent health, which can be used to assess the quality of teaching and learning and to monitor the implementation of these adolescent health competencies. Specific teaching modalities and assessment tools that have been used to teach adolescent health are described to exemplify how an educational program can be delivered and assessed. This framework is a step toward the development of a more adolescent-competent health workforce.

Methodology and Baseline Results From the Evaluation of a Sexuality Education Activity in Mpumalanga and KwaZulu-Natal, South Africa

In South Africa, adolescents and young adults (ages 15-24) are at risk of HIV, sexually transmitted infections, and unintended pregnancies. Recently, the Department of Basic Education has revised its sexuality education content and teaching strategies (using scripted lessons plans) as part of its life orientation curriculum. This paper presents the methodology and baseline results from the evaluation of the scripted lesson plans and supporting activities. A rigorous cluster-level randomized design with random assignment of schools as clusters is used for the evaluation. Baseline results from grade 8 female and male learners and grade 10 female learners demonstrate that learners are at risk of HIV and early and unintended pregnancies. Multivariable analyses demonstrate that household-level food insecurity and living with an HIV-positive person are associated with sexual experience and pregnancy experience. Implications are discussed for strengthening the current life orientation program for future scale-up by the government of South Africa.

Can family-centered programing mitigate HIV risk factors among orphaned and vulnerable adolescents? Results from a pilot study in South Africa

Let's Talk is a structured, family-centered adolescent HIV prevention program developed for use in South Africa using key components adapted from programs successfully implemented in the US and South Africa. It is designed to address individual HIV transmission risk factors common among orphaned and vulnerable adolescents, including elevated risk for poor psychological health and sexual risk behavior. These efforts are accentuated through parallel programing to support caregivers' mental health and parenting skills. Twelve Let's Talk groups, each serving approximately 10 families, were piloted by two local community-based organizations in Gauteng and Kwa-Zulu Natal provinces, South Africa. Face-to-face interviews were conducted among participating caregivers and adolescents at baseline and three months post-intervention to explore the potential effects of the program on intermediate outcomes that may support HIV preventive behavior. Specifically, generalized estimation equations were used to estimate average change on HIV prevention knowledge and self-efficacy, caregiver and adolescent mental health, and family dynamics. Among the 105 adolescents and their 95 caregivers who participated in Let's Talk and completed both surveys, statistically significant improvements were found for adolescents' HIV and condom use knowledge as well as condom negotiation self-efficacy, but not sexual refusal self-efficacy. Both caregivers and adolescents demonstrated significantly better mental health at post-test. Adolescent/caregiver connection and communication about healthy sexuality also improved. These preliminary results highlight the potential of HIV prevention interventions that engage caregivers alongside the vulnerable adolescents in their care to mitigate adolescent HIV risk factors. A more rigorous evaluation is warranted to substantiate these effects and identify their impact on adolescents' risk behavior and HIV incidence.

Exploring the socio-ecological levels for prevention of sexual risk behaviours of the youth in uMgungundlovu District Municipality, KwaZulu-Natal

BACKGROUND

Prevention of youth sexual risk behaviour among the youth in uMgungundlovu District Municipality continues to be a primary challenge for public health and health promotion. Current prevention interventions are targeted at an individual level, whilst youth behaviour is influenced by many social and environmental factors.

AIM

The aim of the study was to explore the factors influencing sexual risk behaviours of the youth at different socio-ecological levels in uMgungundlovu District Municipality.

METHODS

An explorative and descriptive qualitative study design was used, using in-depth interviews and focus group discussions for data collection. A framework analysis was used to develop themes derived from the socio-ecological theory.

RESULTS

Four themes were identified that influence youth to engage in sexual risk behaviours: (1) individual factors, related to role modelling behaviour, gender and negative stereotypes towards females; (2) the microsystem in which youth function including the influence of family and peers; (3) the exo-system comprising the disadvantaged socio-economic status of the communities where the youth live; and (4) the macrosystem where negative social norms were reported to influence youth health outcomes.

CONCLUSION

Sexual risk behaviour among youth in uMgungundlovu is influenced by many factors at multiple social levels. Interventions directed at these multiple levels are needed urgently.

Social determinants in the sexual health of adolescent Aboriginal Australians: a systematic review

While research indicates that Aboriginal and Torres Strait Islander adolescents may be at increased risk of some sexually transmitted infections, there is limited information about factors that may place these young people at more risk of adverse sexual health than their non-Indigenous counterparts. Current research has tended to focus on surveillance-type data, but there is an increasing need to understand social determinants of sexual health risk. This systematic review assessed the evidence of social determinants impacting on Aboriginal and Torres Strait Islander adolescents' sexual health in Australia. Published, English-language literature was searched across key databases from 2003 to 2015. Fourteen studies were included in the qualitative synthesis. Findings suggest that social determinants such as access to healthcare, poverty, substance use, educational disadvantage, sociocultural context, gender inequalities, status and identity, and social disadvantage impacted on Indigenous adolescents' sexual behaviours and sexual health risk. Evidence from the literature included in the review suggests that peer education may be an acceptable and appropriate approach for addressing such issues. There remains a need for programmes and services to be community-developed and community-led, thus ensuring cultural appropriateness and relevance. However, there is also a significant need for such programmes to be effectively and rigorously evaluated with data that goes beyond surveillance, and seeks to unpack how sexual norms are experienced by Indigenous adolescents, particularly outside of remote Australia - and how these experiences act as either risk or protective factors to good sexual health and positive social and emotional well-being.

Comparing four service delivery models for adolescent girls and young women through the 'Girl Power' study: protocol for a multisite quasi-experimental cohort study

INTRODUCTION

In sub-Saharan Africa, adolescent girls and young women (AGYW) face a range of sexual and reproductive health (SRH) challenges. Clinical, behavioural and structural interventions have each reduced these risks and improved health outcomes. However, combinations of these interventions have not been compared with each other or with no intervention at all. The 'Girl Power' study is designed to systematically make these comparisons.

METHODS AND ANALYSIS

Four comparable health facilities in Malawi and South Africa (n=8) were selected and assigned to one of the following models of care: (1) Standard of care: AGYW can receive family planning, HIV testing and counselling (HTC), and sexually transmitted infection (STI) syndromic management in three separate locations with three separate queues with the general population. No youth-friendly spaces, clinical modifications or trainings are offered, (2) Youth-Friendly Health Services (YFHS): AGYW are meant to receive integrated family planning, HTC and STI services in dedicated youth spaces with youth-friendly modifications and providers trained in YFHS, (3) YFHS+behavioural intervention (BI): In addition to YFHS, AGYW can attend 12 monthly theory-driven, facilitator-led, interactive sessions on health, finance and relationships, (4) YFHS+BI+conditional cash transfer (CCT): in addition to YFHS and BI, AGYW receive up to 12 CCTs conditional on monthly BI session attendance.At each clinic, 250 AGYW 15-24 years old (n=2000 total) will be consented, enrolled and followed for 1 year. Each participant will complete a behavioural survey at enrolment, 6 months and 12 months . All clinical, behavioural and CCT services will be captured. Outcomes of interest include uptake of each package element and reduction in HIV risk behaviours. A qualitative substudy will be conducted.

ETHICS/DISSEMINATION

This study has received ethical approval from the University of North Carolina Institutional Review Board, the University of Cape Town Human Research Ethics Committee and Malawi's National Health Sciences Research Committee. Study plans, processes and findings will be disseminated to stakeholders, in peer-reviewed journals and at conferences.

Structural Interventions in HIV Prevention: A Taxonomy and Descriptive Systematic Review

One of the four national HIV prevention goals is to incorporate combinations of effective, evidence-based approaches to prevent HIV infection. In fields of public health, techniques that alter environment and affect choice options are effective. Structural approaches may be effective in preventing HIV infection. Existing frameworks for structural interventions were lacking in breadth and/or depth. We conducted a systematic review and searched CDC's HIV/AIDS Prevention Research Synthesis Project's database for relevant interventions during 1988-2013. We used an iterative process to develop the taxonomy. We identified 213 structural interventions: Access (65%), Policy/Procedure (32%), Mass Media (29%), Physical Structure (27%), Capacity Building (24%), Community Mobilization (9%), and Social Determinants of Health (8%). Forty percent targeted high-risk populations (e.g., people who inject drugs [12%]). This paper describes a comprehensive, well-defined taxonomy of structural interventions with 7 categories and 20 subcategories. The taxonomy accommodated all interventions identified.

Planning community-based assessments of HIV educational intervention programs in sub-Saharan Africa

A key consideration in planning studies of community-based HIV education programs is identifying a sample size large enough to ensure a reasonable probability of detecting program effects if they exist. Sufficient sample sizes for community- or group-based designs are proportional to the correlation or similarity of individuals within communities. As a result, efficient and effective design requires reasonable a priori estimates of the correlational structure among individuals within communities. In this study, we investigate the degree of correlation among individuals within communities and regions using samples of sixth-grade adolescents from 609 local area district communities and 122 regions in 15 sub-Saharan African nations. We develop nation-specific and international summaries of these correlations using variance partitioning coefficients from multilevel models and subsequently assess the extent to which different types of background variables delineate key sources of these correlations. The results suggest persistent differences among communities and regions and that the degree of correlation among individuals within communities varied considerably by nation. The findings underscore the importance of empirically derived values of design parameters that are anchored in evidence specific to the outcome, nation and context of the planned study.

Interventions to strengthen the HIV prevention cascade: a systematic review of reviews

BACKGROUND

Much progress has been made in interventions to prevent HIV infection. However, development of evidence-informed prevention programmes that translate the efficacy of these strategies into population effect remain a challenge. In this systematic review, we map current evidence for HIV prevention against a new classification system, the HIV prevention cascade.

METHODS

We searched for systematic reviews on the effectiveness of HIV prevention interventions published in English from Jan 1, 1995, to July, 2015. From eligible reviews, we identified primary studies that assessed at least one of: HIV incidence, HIV prevalence, condom use, and uptake of HIV testing. We categorised interventions as those seeking to increase demand for HIV prevention, improve supply of HIV prevention methods, support adherence to prevention behaviours, or directly prevent HIV. For each specific intervention, we assigned a rating based on the number of randomised trials and the strength of evidence.

FINDINGS

From 88 eligible reviews, we identified 1964 primary studies, of which 292 were eligible for inclusion. Primary studies of direct prevention mechanisms showed strong evidence for the efficacy of pre-exposure prophylaxis (PrEP) and voluntary medical male circumcision. Evidence suggests that interventions to increase supply of prevention methods such as condoms or clean needles can be effective. Evidence arising from demand-side interventions and interventions to promote use of or adherence to prevention tools was less clear, with some strategies likely to be effective and others showing no effect. The quality of the evidence varied across categories.

INTERPRETATION

There is growing evidence to support a number of efficacious HIV prevention behaviours, products, and procedures. Translating this evidence into population impact will require interventions that strengthen demand for HIV prevention, supply of HIV prevention technologies, and use of and adherence to HIV prevention methods.

FUNDING

Bill & Melinda Gates Foundation.

The HIV prevention cascade: integrating theories of epidemiological, behavioural, and social science into programme design and monitoring

Theories of epidemiology, health behaviour, and social science have changed the understanding of HIV prevention in the past three decades. The HIV prevention cascade is emerging as a new approach to guide the design and monitoring of HIV prevention programmes in a way that integrates these multiple perspectives. This approach recognises that translating the efficacy of direct mechanisms that mediate HIV prevention (including prevention products, procedures, and risk-reduction behaviours) into population-level effects requires interventions that increase coverage. An HIV prevention cascade approach suggests that high coverage can be achieved by targeting three key components: demand-side interventions that improve risk perception and awareness and acceptability of prevention approaches; supply-side interventions that make prevention products and procedures more accessible and available; and adherence interventions that support ongoing adoption of prevention behaviours, including those that do and do not involve prevention products. Programmes need to develop delivery platforms that ensure these interventions reach target populations, to shape the policy environment so that it facilitates implementation at scale with high quality and intensity, and to monitor the programme with indicators along the cascade.

A qualitative study of sexual health education among Iranian engaged couples

BACKGROUND

Sexual health education for Iranian engaged couples is always ignored in the premarital education program.

OBJECTIVES

The aim of this study was to explore the necessity of sexual health education for Iranian engaged couples.

MATERIALS AND METHODS

This qualitative study was conducted in Rasht, Iran. The studied sample consisted of 38 engaged men and women; and also 9 health experts and policymakers. We used interview guides to collect data. The data was analyzed through content analysis method.

RESULTS

Analyzing participants' perspectives revealed six themes including: (1) socio-cultural changes, (2) emerging social pathologies, (3) inadequate sexual knowledge; (4) challenges in providing sexual health services, (5) individual consequences and (6) social consequences.

CONCLUSION

Most participants emphasized the necessity of sexual health education not only because of medical concerns, but also from the perspective of social issues. Providing these services should be considered a priority.

Gender-Specific Combination HIV Prevention for Youth in High-Burden Settings: The MP3 Youth Observational Pilot Study Protocol

Background

Nearly three decades into the epidemic, sub-Saharan Africa (SSA) remains the region most heavily affected by human immunodeficiency virus (HIV), with nearly 70% of the 34 million people living with HIV globally residing in the region. In SSA, female and male youth (15 to 24 years) are at a disproportionately high risk of HIV infection compared to adults. As such, there is a need to target HIV prevention strategies to youth and to tailor them to a gender-specific context. This protocol describes the process for the multi-staged approach in the design of the MP3 Youth pilot study, a gender-specific, combination, HIV prevention intervention for youth in Kenya.

Objective

The objective of this multi-method protocol is to outline a rigorous and replicable methodology for a gender-specific combination HIV prevention pilot study for youth in high-burden settings, illustrating the triangulated methods undertaken to ensure that age, sex, and context are integral in the design of the intervention.

Methods

The mixed-methods, cross-sectional, longitudinal cohort pilot study protocol was developed by first conducting a systematic review of the literature, which shaped focus group discussions around prevention package and delivery options, and that also informed age- and sex- stratified mathematical modeling. The review, qualitative data, and mathematical modeling created a triangulated evidence base of interventions to be included in the pilot study protocol. To design the pilot study protocol, we convened an expert panel to select HIV prevention interventions effective for youth in SSA, which will be offered in a mobile health setting. The goal of the pilot study implementation and evaluation is to apply lessons learned to more effective HIV prevention evidence and programming.

Results

The combination HIV prevention package in this protocol includes (1) offering HIV testing and counseling for all youth; (2) voluntary medical circumcision and condoms for males; (3) pre-exposure prophylaxis (PrEP), conditional cash transfer (CCT), and contraceptives for females; and (4) referrals for HIV care among those identified as HIV-positive. The combination package platform selected is mobile health teams in an integrated services delivery model. A cross-sectional analysis will be conducted to determine the uptake of the interventions. To determine long-term impact, the protocol outlines enrolling selected participants in mutually exclusive longitudinal cohorts (HIV-positive, PrEP, CCT, and HIV-negative) followed by using mobile phone text messages (short message service, SMS) and in-person surveys to prospectively assess prevention method uptake, adherence, and risk compensation behaviors. Cross-sectional and sub-cohort analyses will be conducted to determine intervention packages uptake.

Conclusions

The literature review, focus groups, and modeling indicate that offering age- and gender- specific combination HIV prevention interventions that include biomedical, behavioral, and structural interventions can have an impact on HIV risk reduction. Implementing this protocol will show the feasibility of delivering these services at scale. The MP3 Youth study is one of the few combination HIV prevention intervention protocols incorporating youth- and gender-specific interventions in one delivery setting. Lessons learned from the design of the protocol can be incorporated into the national guidance for combination HIV prevention for youth in Kenya and other high-burden SSA settings.

Trial Registration

ClinicalTrials.gov NCT01571128; http://clinicaltrials.gov/ct2/show/NCT01571128?term=MP3+youth&rank=1 (Archived by WebCite at http://www.webcitation.org/6nmioPd54)

Effectiveness of a girls' empowerment programme on early childbearing, marriage and school dropout among adolescent girls in rural Zambia: study protocol for a cluster randomized trial

Background

Adolescent pregnancies pose a risk to the young mothers and their babies. In Zambia, 35% of young girls in rural areas have given birth by the age of 18 years. Pregnancy rates are particularly high among out-of-school girls. Poverty, low enrolment in secondary school, myths and community norms all contribute to early childbearing. This protocol describes a trial aiming to measure the effect on early childbearing rates in a rural Zambian context of (1) economic support to girls and their families, and (2) combining economic support with a community intervention to enhance knowledge about sexual and reproductive health and supportive community norms.

Methods/design

This cluster randomized controlled trial (CRCT) will have three arms. The clusters are rural schools with surrounding communities. Approximately 4900 girls in grade 7 in 2016 will be recruited from 157 schools in 12 districts. In one intervention arm, participating girls and their guardians will be offered cash transfers and payment of school fees. In the second intervention arm, there will be both economic support and a community intervention. The interventions will be implemented for approximately 2 years. The final survey will be 4.5 years after recruitment. The primary outcomes will be “incidence of births within 8 months of the end of the intervention period”, “incidence of births before girls’ 18th birthday” and “proportion of girls who sit for the grade 9 exam”. Final survey interviewers will be unaware of the intervention status of respondents. Analysis will be by intention-to-treat and adjusted for cluster design and confounders. Qualitative process evaluation will be conducted.

Discussion

This is the first CRCT to measure the effect of combining economic support with a community intervention to prevent adolescent childbearing in a low- or middle-income country. We have designed a programme that will be sustainable and feasible to scale up. The findings will be relevant for programmes for adolescent reproductive health in Zambia and similar contexts.

Trial registration

ISRCTN registry: ISRCTN12727868, (4 March 2016).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1682-9) contains supplementary material, which is available to authorized users.

Theory-based interventions for contraception

BACKGROUND

The explicit use of theory in research helps expand the knowledge base. Theories and models have been used extensively in HIV-prevention research and in interventions for preventing sexually transmitted infections (STIs). The health behavior field uses many theories or models of change. However, many educational interventions addressing contraception have no explicit theoretical base.

OBJECTIVES

To review randomized controlled trials (RCTs) that tested a theoretical approach to inform contraceptive choice and encourage or improve contraceptive use.

SEARCH METHODS

To 1 November 2016, we searched for trials that tested a theory-based intervention for improving contraceptive use in PubMed, CENTRAL, POPLINE, Web of Science, ClinicalTrials.gov, and ICTRP. For the initial review, we wrote to investigators to find other trials.

SELECTION CRITERIA

Included trials tested a theory-based intervention for improving contraceptive use. Interventions addressed the use of one or more methods for contraception. The reports provided evidence that the intervention was based on a specific theory or model. The primary outcomes were pregnancy and contraceptive choice or use.

DATA COLLECTION AND ANALYSIS

We assessed titles and abstracts identified during the searches. One author extracted and entered the data into Review Manager; a second author verified accuracy. We examined studies for methodological quality.For unadjusted dichotomous outcomes, we calculated the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). Cluster randomized trials used various methods of accounting for the clustering, such as multilevel modeling. Most reports did not provide information to calculate the effective sample size. Therefore, we presented the results as reported by the investigators. We did not conduct meta-analysis due to varied interventions and outcome measures.

MAIN RESULTS

We included 10 new trials for a total of 25. Five were conducted outside the USA. Fifteen randomly assigned individuals and 10 randomized clusters. This section focuses on nine trials with high or moderate quality evidence and an intervention effect. Five based on social cognitive theory addressed preventing adolescent pregnancy and were one to two years long. The comparison was usual care or education. Adolescent mothers with a home-based curriculum had fewer second births in two years (OR 0.41, 95% CI 0.17 to 1.00). Twelve months after a school-based curriculum, the intervention group was more likely to report using an effective contraceptive method (adjusted OR 1.76 ± standard error (SE) 0.29) and using condoms during last intercourse (adjusted OR 1.68 ± SE 0.25). In alternative schools, after five months the intervention group reported more condom use during last intercourse (reported adjusted OR 2.12, 95% CI 1.24 to 3.56). After a school-based risk-reduction program, at three months the intervention group was less likely to report no condom use at last intercourse (adjusted OR 0.67, 95% CI 0.47 to 0.96). The risk avoidance group (abstinence-focused) was less likely to do so at 15 months (OR 0.61, 95% CI 0.45 to 0.85). At 24 months after a case management and peer-leadership program, the intervention group reported more consistent use of hormonal contraceptives (adjusted relative risk (RR) 1.30, 95% CI 1.06 to 1.58), condoms (RR 1.57, 95% CI 1.28 to 1.94), and dual methods (RR 1.36, 95% CI 1.01 to 1.85).Four of the nine trials used motivational interviewing (MI). In three studies, the comparison group received handouts. The MI group more often reported effective contraception use at nine months (OR 2.04, 95% CI 1.47 to 2.83). In two studies, the MI group was less likely to report using ineffective contraception at three months (OR 0.31, 95% CI 0.12 to 0.77) and four months (OR 0.56, 95% CI 0.31 to 0.98), respectively. In the fourth trial, the MI group was more likely than a group with non-standard counseling to initiate long-acting reversible contraception (LARC) by one month (OR 3.99, 95% CI 1.36 to 11.68) and to report using LARC at three months (OR 3.38, 95% CI 1.06 to 10.71).

AUTHORS' CONCLUSIONS

The overall quality of evidence was moderate. Trials based on social cognitive theory focused on adolescents and provided multiple sessions. Those using motivational interviewing had a wider age range but specific populations. Sites with low resources need effective interventions adapted for their settings and their typical clients. Reports could be clearer about how the theory was used to design and implement the intervention.

The Health Promoting Schools Framework: Known Unknowns and an Agenda for Future Research

The World Health Organization’s Health Promoting Schools (HPS) framework is a whole-school approach to promoting health that recognizes the intrinsic relationship between health and education. Our recent Cochrane systematic review found HPS interventions produced improvements in a number of student health outcomes. Here we reflect on what this review was not able to tell us: in other words, what evidence is missing with regard to the HPS approach. Few HPS interventions engage with schools’ “core business” by examining impacts on educational outcomes. Current evidence is dominated by obesity interventions, with most studies conducted with children rather than adolescents. Evidence is lacking for outcomes such as mental or sexual health, substance use, and violence. Activities to engage families and communities are currently weak and unlikely to prompt behavioral change. The HPS approach is largely absent in low-income settings, despite its potential in meeting children’s basic health needs. Intervention theories are insufficiently complex, often ignoring upstream determinants of health. Few studies provide evidence on intervention sustainability or cost-effectiveness, nor in-depth contextual or process data. We set out an agenda for future school health promotion research, considering implications for key stakeholders, namely, national governments, research funders, academics, and schools.