STI Health Disparities: A Systematic Review and Meta-Analysis of the Effectiveness of Preventive Interventions in Educational Settings

A systematic review of interventions to improve male knowledge of fertility and fertility-related risk factors

Male infertility is a global health concern. The effectiveness of interventions developed to improve males' knowledge of fertility regulation and fertility-related risk factors remains unclear. This systematic review aimed to synthesize and evaluate the evidence for these interventions. Four databases were searched from inception to June 2023. Eligible studies examined interventions to increase fertility knowledge among presumed fertile males aged ≥16 years of age. Conference abstracts, protocols and studies without sex-disaggregated results for males were excluded. A narrative synthesis without meta-analysis was performed. A total of 4884 records were identified. Five studies (reported in six publications), all conducted in high-income countries, were included. Two were randomized control trials, and three were experimental studies. Interventions were delivered in person by a health professional (n = 3), online and via a mobile app. All studies showed a significant improvement in knowledge of fertility or fertility-related risk factors from baseline to follow-up. The largest improvement was observed for secondary and vocational students. A moderate, long-term retainment of knowledge was observed at two-year follow-up in one study. Available evidence suggests interventions to improve males' fertility knowledge are effective, particularly for younger, less educated males.

The Epidemic of Congenital Syphilis in the Indigenous and Rural Populations of South Dakota

From 2020 to 2023, South Dakota witnessed a substantial increase in cases of congenital syphilis (CS), with the highest rates identified in rural and Native American (NA) communities. Here, we discuss 3 severe cases of CS in premature infants born to NA individuals and communities in South Dakota with poor access to prenatal care. The infants in these 3 cases presented with varying clinical conditions, including respiratory failure, persistent pulmonary hypertension of the newborn, severe direct hyperbilirubinemia, feeding intolerance, and necrotizing enterocolitis. Lack of prenatal care and other systemic health disparities likely contributed to the increased disease burden. For NA communities, rurality, limited resources, systemic racism, historical trauma, and lack of trust in medical institutions likely contribute to inadequate prenatal care. All 3 of these cases also occurred in pregnant people with a present or history of substance use disorders, which may have led to further hesitancy to seek care because of fear of prosecution. To combat the rising number of syphilis and CS cases, we advocate for new and continued outreach that provides education about and testing for sexually transmitted diseases to NA and rural populations, increased care coordination, the integration of point-of-care testing and treatment strategies in lower resource centers, and legislative allocation of additional resources to engage pregnant people with or at risk for substance use disorders.

Predicting sexually transmitted infections among men who have sex with men in Zimbabwe using deep learning and ensemble machine learning models

There is a substantial increase in sexually transmitted infections (STIs) among men who have sex with men (MSM) globally. Unprotected sexual practices, multiple sex partners, criminalization, stigmatisation, fear of discrimination, substance use, poor access to care, and lack of early STI screening tools are among the contributing factors. Therefore, this study applied multilayer perceptron (MLP), extremely randomized trees (ExtraTrees) and XGBoost machine learning models to predict STIs among MSM using bio-behavioural survey (BBS) data in Zimbabwe. Data were collected from 1538 MSM in Zimbabwe. The dataset was split into training and testing sets using the ratio of 80% and 20%, respectively. The synthetic minority oversampling technique (SMOTE) was applied to address class imbalance. Using a stepwise logistic regression model, the study revealed several predictors of STIs among MSM such as age, cohabitation with sex partners, education status and employment status. The results show that MLP performed better than STI predictive models (XGBoost and ExtraTrees) and achieved accuracy of 87.54%, recall of 97.29%, precision of 89.64%, F1-Score of 93.31% and AUC of 66.78%. XGBoost also achieved an accuracy of 86.51%, recall of 96.51%, precision of 89.25%, F1-Score of 92.74% and AUC of 54.83%. ExtraTrees recorded an accuracy of 85.47%, recall of 95.35%, precision of 89.13%, F1-Score of 92.13% and AUC of 60.21%. These models can be effectively used to identify highly at-risk MSM, for STI surveillance and to further develop STI infection screening tools to improve health outcomes of MSM.

Effectiveness of a Comprehensive School-Based Sex Education Program for Young Adolescents in the Netherlands

Most sexual education programs traditionally focused on providing sexual information regarding the risks of sex. However, current studies on sexual behavior in youth show a need for truly comprehensive sex education approaches with a sex-positive focus on sexuality, that effectively improve sexual competence. Therefore, in the current study the effectiveness of "Love is…", a four lesson school-based program based on the Sexual Interactional Competence model and Attitude-Social-Influence-Self-Efficacy-model was studied. A cluster-randomized controlled trial on the effectiveness of "Love is…" was conducted in 2018-2020. The sample consisted of 1160 adolescents in grades 8 and 9 from nine schools in the Netherlands. The sample was 48% female, 34% Dutch/Caucasian, 41% none-religious and 50% higher educated. They were randomized at class level into a program group [n = 32 classes; 567 students (Mage = 13.74 (SD = 0.74))] and a control group [n = 31 classes; 593 students (Mage = 13.86 (SD = 0.73))]. Results showed that "Love is…" increased sexual knowledge, that adolescents in the program group showed less cyber victim blaming attitudes and increased in communications skills after the program. In conclusion, the current study shows that "Love is…" was effective not only on the knowledge level, but also regarding sexual attitudes and competences. However, due to the developmental process of sexuality, there is a necessity to continue lessons in following grades through booster sessions by reinforcing competences as communicating comfortably about sexuality.On 12 November 2019 the study design and hypotheses were registered in the Dutch Trial Registration, number NL8150. ( https://onderzoekmetmensen.nl/nl/trial/26676 ).

Prevent2Protect Project: Regulatory Focus Differences in Sexual Health Knowledge and Practices

The way people perceive risks and make decisions about their health is regulated by two motivational systems-prevention of harm or promotion of pleasure. People more focused on prevention strive to avoid negative outcomes and enact more health-protective behaviors. In contrast, people more focused on promotion strive to attain positive outcomes and take more risks with their health. Building upon recent evidence extending this framework to sexual behaviors and health, we conducted a pre-registered online survey ( OSF ) with Portuguese and Spanish adults (N = 742; M_age = 31.42, SD = 9.16) to examine whether self-reported STI knowledge and sexual health practices differ based on predominant regulatory focus. This study was part of the Prevent2Protect project ( OSF ). Results showed that prevention-focused participants had heard about more STIs and retrieved more of their knowledge from scientific sources but had been tested for fewer STIs in the past. In contrast, promotion-focused participants indicated they had specific knowledge about more STIs, retrieved more of their knowledge from medical and peer sources, and had been tested for more STIs in the past. They also reported more frequent STI testing, using free testing facilities or asking their family practice doctor to get tested, more routine sexual health check-ups, and more use of other contraceptive methods, such as birth control pills. These results remained unchanged after controlling for demographic differences. Overall, our findings showed that different motives in sexuality shape sexual health knowledge and sexual health practices.

Increasing access to family planning services among women receiving medications for opioid use disorder: A pilot randomized trial examining a peer-led navigation intervention

OBJECTIVE

High rates of unintended pregnancy occur among women with opioid use disorder (OUD). OUD treatment settings may provide an ideal opportunity to address the family planning needs of patients. However, few studies have rigorously evaluated interventions designed to address family planning needs in the OUD treatment setting. This study assessed the feasibility, acceptability, and preliminary efficacy of a peer-led navigation intervention designed to educate and link women receiving medications for OUD to family planning services.

METHODS

The study recruited women from four OUD treatment programs in Denver, Colorado, to participate in a pilot randomized controlled trial from March 2018 to February 2019. Eligible participants were English-speaking adult females who were neither pregnant nor desiring a pregnancy and who were not using a long-acting reversible contraceptive (LARC) method. Participants completed a baseline survey, and the study randomized them to receive a two-session, peer-led family planning navigation intervention or usual care. The study assessed feasibility by participant engagement in the intervention. The study used follow-up self-report surveys and electronic health record data to assess intervention acceptability and intervention efficacy for the primary outcomes of a family planning visit and use of a LARC method.

RESULTS

The study enrolled 119 women who were randomized to the Sexual Health Initiative for Navigation and Empowerment (SHINE) peer-led navigation intervention (n = 56) or usual care (n = 63). The average age was 32 (SD = 6.4); 76% were receiving methadone, 24% were receiving buprenorphine and 19% reported a treatment provider had ever discussed family planning with them. Most had a previous pregnancy (82%) and of these, 93% reported an unplanned pregnancy. Among intervention participants, 93% completed the first navigation session, 90% felt that intervention topics were important, 76% indicated that the information was new, and 82% found working with a peer helpful. At six months postbaseline, significantly more (p = 0.01) intervention participants (36%) received a family planning visit compared to control participants (14%). There was no between-group difference on use of LARC methods.

CONCLUSIONS

A peer-led family planning navigation intervention was feasible to implement, acceptable to participants, and showed evidence of preliminary efficacy. This model may be an effective and potentially sustainable approach to support the family planning needs of women in treatment for OUD.

Evidence map on serious games in preventing sexually transmitted infections among adolescents: Systematic review about outcome categories investigated in primary studies (Preprint)

Background

Sexually transmitted infections (STIs) represent a global health risk. Adolescents are at increased risk of infection for several reasons such as lack of knowledge, risky sexual behaviors, and lack of behavioral sills (eg, to negotiate safer sex). Given the fact that adolescents often use digital media and that serious games are considered to have the potential to change knowledge, attitudes and behavior, serious games represent an opportunity for the prevention of STIs.

Objective

The aim of this systematic review was to identify and systematically summarize the dimensions that have been investigated in primary studies on serious games targeting STI prevention among adolescents.

Methods

A systematic review was conducted in PubMed and Web of Science. Studies published from 2009 to 2021 were included that assessed the effectiveness of serious games on adolescent sexual health. A total of 18 studies met the inclusion criteria and were categorized according to dimensions of effectiveness and user experience.

Results

Various dimensions of effectiveness and aspects of user experience were investigated in the primary studies. In total, 9 dimensions of effectiveness were observed: sexual behavior, behavioral intentions, knowledge, attitudes and beliefs, self-efficacy and personal limitations, character traits and future orientation, environmental and individual risk factors, risk perception and risk assessment, as well as normative beliefs and (social) norms. Furthermore, several dimensions related to user experience were investigated in primary studies, that is, motivation, acceptability, trustworthiness, comprehensibility, handling and control, perceived effectiveness, as well as satisfaction.

Conclusions

This review provides an overview of serious games interventions that are vastly different in approach, content, and even platform. In previous studies, knowledge has already been comprehensively assessed, and a positive influence of serious games on knowledge about sexual topics is evident. The results clearly show that adolescents’ sexual knowledge has been increased by the serious games interventions. However, methodological and content differences in the surveys make it difficult to draw conclusions about the effectiveness related to changes in attitudes and behavior.

Structural equation modeling test of the pre-intentional phase of the health action process approach (HAPA) model on condom use intention among senior high school students in Tianjin, China

Based on the Theory of Health Action Process Approach (HAPA) Model, this study aimed to investigate factors associated with condom use intention in Chinese adolescents.In 2017, we conducted a cross-sectional study using stratified cluster, convenience sampling method to assess condom use intention among senior high school students in Tianjin, China. One thousand eighty two senior high school students were anonymously surveyed through self-administered questionnaires. Structural equation modelling was used to assess the pre-intentional phase of HAPA model.Among the participants, 41.5% (449/1082) were male, 54.1% (585/1082) were female, 4.4% (48/1082) were gender-deficient. The average age was 16.7 years. The final pre-intentional phase of HAPA model was acceptable (CFI = 0.95; GFI = 0.94; RMSEA = 0.06). Action self-efficacy (r = 0.60) had a strong direct effect on condom use intention.The pre-intentional phase of HAPA model is valid to assess condom use intention among Chinese senior high school students. The pre-intention phase of the HAPA model could be applied to guide AIDS health educations of students, and further research is needed to evaluate the effect.

Test@Work Texts: Mobile Phone Messaging to Increase Awareness of HIV and HIV Testing in UK Construction Employees during the COVID-19 Pandemic

Background: HIV poses a threat to global health. With effective treatment options available, education and testing strategies are essential in preventing transmission. Text messaging is an effective tool for health promotion and can be used to target higher risk populations. This study reports on the design, delivery and testing of a mobile text messaging SMS intervention for HIV prevention and awareness, aimed at adults in the construction industry and delivered during the COVID-19 pandemic. Method: Participants were recruited at Test@Work workplace health promotion events (21 sites, n = 464 employees), including health checks with HIV testing. Message development was based on a participatory design and included a focus group (n = 9) and message fidelity testing (n = 291) with assessment of intervention uptake, reach, acceptability, and engagement. Barriers to HIV testing were identified and mapped to the COM-B behavioural model. 23 one-way push SMS messages (19 included short web links) were generated and fidelity tested, then sent via automated SMS to two employee cohorts over a 10-week period during the COVID-19 pandemic. Engagement metrics measured were: opt-outs, SMS delivered/read, number of clicks per web link, four two-way pull messages exploring repeat HIV testing, learning new information, perceived usefulness and behaviour change. Results: 291 people participated (68.3% of eligible attendees). A total of 7726 messages were sent between March and June 2020, with 91.6% successfully delivered (100% read). 12.4% of participants opted out over 10 weeks. Of delivered messages, links were clicked an average of 14.4% times, max 24.1% for HIV related links. The number of clicks on web links declined over time (r = -6.24, p = 0.01). Response rate for two-way pull messages was 13.7% of participants. Since the workplace HIV test offer at recruitment, 21.6% reported having taken a further HIV test. Qualitative replies indicated behavioural influence of messaging on exercise, lifestyle behaviours and intention to HIV test. Conclusions: SMS messaging for HIV prevention and awareness is acceptable to adults in the construction industry, has high uptake, low attrition and good engagement with message content, when delivered during a global pandemic. Data collection methods may need refinement for audience, and effect of COVID-19 on results is yet to be understood.

The needs of LGBTI+ people within student nurse education programmes: A new conceptualisation

There is a growing body of international research evidence highlighting concerns around social exclusion and discrimination, significant health inequalities and health needs, and barriers to accessing effective healthcare for LGBTI + people. However, ways in which the healthcare needs of LGBTI + people can be addressed in student nurse education programmes have yet to be fully explored. The aim of this discussion paper is to present the evidence to support the inclusion of LGBTI + health throughout the nursing curriculum. A new conceptualisation of the full and effective integration of LGBTI + health content across and within the nursing curriculum is proposed. This can be achieved by further developing theory, skills simulation and practice learning opportunities. There is a need to ensure that nursing students are positioned and adequately prepared to effectively address concerns of social justice, reducing health inequalities, and providing responsive person-centred care for LGBTI + health service users.

Sexual Health Programs for Latinx Adolescents: A Meta-analysis

CONTEXT

Latinx adolescents are at risk for negative sexual health outcomes, and many interventions have been developed to reduce this risk.

OBJECTIVE

In this meta-analysis, we synthesized the literature on sexual health interventions for Latinx adolescents and examined intervention effects on 3 behavioral outcomes (abstinence, condom use, number of sex partners) and 3 psychological outcomes (safer sex knowledge, intentions, self-efficacy). Moderators of intervention success were explored.

DATA SOURCES

A systematic search of studies published through January 2019 was conducted by using PubMed, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature databases.

STUDY SELECTION

All studies included a US-based sample of Latinx adolescents, evaluated sexual health intervention by using an experimental or quasiexperimental design, included a behavioral outcome, and were in English.

DATA EXTRACTION

Standardized mean difference (d) and 95% confidence intervals (CIs) were meta-analyzed by using random-effects models.

RESULTS

Effect sizes from 12 studies, sampling 4673 adolescents, were synthesized. Sexual health interventions improved abstinence (d = 0.15, 95% CI: 0.02 to 0.28), condom use (d = 0.44, 95% CI: 0.18 to 0.70), number of sex partners (d = -0.19, 95% CI: -0.37 to -0.001), and sexual health knowledge (d = 0.40, 95% CI: 0.10 to 0.70), compared with control conditions. Effects were consistent across a number of demographic and clinical characteristics, although culturally tailored interventions produced greater change in condom use than nontailored interventions.

LIMITATIONS

There was variation across studies in measures of sexual behavior, and some elements of individual study quality were unclear.

CONCLUSIONS

Sexual health interventions have a small but significant impact on improving safer sexual behavior among Latinx adolescents. Health educators should consider the importance of cultural tailoring to program success.

Association of Sexual Health Interventions With Sexual Health Outcomes in Black Adolescents: A Systematic Review and Meta-analysis

IMPORTANCE

Black adolescents are at increased risk of contracting HIV and other sexually transmitted infections (STIs) and experiencing unplanned pregnancy. Although sexual health interventions aimed at decreasing these risks exist, evidence of the association between sexual health interventions and the sexual behavior of black adolescents has not been synthesized to our knowledge.

OBJECTIVE

To examine the associations between sexual health interventions and behavioral, biological, and psychological outcomes.

DATA SOURCES

For this systematic review and meta-analysis, a systematic search was conducted of studies published through January 31, 2019, using the PubMed, PsycINFO, and CINAHL databases and relevant review articles. The following key words were used: youth, adolesc* or teen*; sexual health or safe* sex or sexually transmitted disease or sexually transmitted infection or STD or STI or HIV or AIDS or pregnancy or reproductive health or condom* or contracept* or unprotected sex or abstinence; intervention or program or education or prevention or promotion or trial; latino* or latina* or latinx* or minorit* or ethnic* or hispanic or african american* or black* or race or racial or biracial.

STUDY SELECTION

Studies were included if they included a US-based sample of black adolescents, evaluated a sexual health intervention using experimental or quasi-experimental designs, included a behavioral outcome, and were published in English.

DATA EXTRACTION AND SYNTHESIS

Standardized mean differences and 95% CIs were extracted and meta-analyzed using random-effects models.

MAIN OUTCOMES AND MEASURES

Behavioral outcomes were abstinence, condom use, and number of sex partners. Biological outcomes were pregnancy and STI contraction. Psychological outcomes were sexual health intentions, knowledge, and self-efficacy.

RESULTS

Across 29 studies including 11 918 black adolescents (weighted mean age, 12.43 years), there was a significant weighted mean association of sexual health interventions with improvements in abstinence (Cohen d = 0.14; 95% CI, 0.05-0.24) and condom use (Cohen d = 0.25; 95% CI, 0.11-0.39). No significant mean association of these interventions with number of sex partners, pregnancy, or STI contraction was found. Sexual health interventions were significantly associated with improvements in psychological outcomes: sexual health intentions (Cohen d = 0.17; 95% CI, 0.05-0.30), knowledge (Cohen d = 0.46; 95% CI, 0.30-0.63), and self-efficacy (Cohen d = 0.19; 95% CI, 0.09-0.28). Intervention effect sizes were consistent across factors, such as participant sex and age and intervention dose.

CONCLUSIONS AND RELEVANCE

The findings suggest that sexual health interventions are associated with improvements in sexual well-being among black adolescents. There appears to be a need for wide-scale dissemination of these programs to address racial disparities in sexual health across the US.

Youth perspectives on sexual health education: Voices from the YEP study in Toronto

The Youth Engagement Project (YEP) is a community-based pilot study in Toronto, Canada that we developed to better understand perspectives about and experiences of sexual health education among socioeconomically marginalized, racialized, and LGBTQ youth. We investigated: 1) what sex-related messages these young people received as they grew up, 2) how those messages affected their perspectives and sexual behaviour, and 3) their recommendations for sexual health education that meets their needs. Engaging youth whose voices are often overlooked due to their low socioeconomic status and their racial, sexual, and religious identities, and using a place-based method, we recruited a total of 47 young people, aged 16–24, and divided them into six groups based on gender and residential neighbourhood. The data was collected through a demographic and sexual practice survey, followed by a series of two focus groups. We conducted thematic analysis, guided by a socio-ecological approach and paying particular attention to participants’ intrapersonal, interpersonal and environmental factors. Our results indicate that participants received inadequate and contradictory sexuality related information from multiple sources. These mixed messages contributed to confusion, misconceptions, distress, and sexual vulnerabilities. Youth expressed their need for more inclusive and relevant sexual health education starting from an early age, more support for parents and teachers to help them talk with children and youth about sexuality, and more youth-driven integrated health promotion programs to allow them to make informed choices. Their voices and perspectives are useful in informing inclusive and youth-centred sexual health education at home, in school and in the community.

Intervention and Public Policy Pathways to Achieve Health Care Equity

Health care equity reflects an equal opportunity to utilize public health and health care resources in order to maximize one's health potential. Achieving health care equity necessitates the consideration of both quantity and quality of care, as well as vertical (greater health care use by those with greater needs) and horizontal (equal health care use by those with equal needs) equity. In this paper, we summarize the approaches introduced by authors contributing to this Special Issue and how their work is captured by the National Institute of Minority Health and Health Disparities (NIMHD) framework. The paper concludes by pointing out intervention and public policy opportunities for future investigation in order to achieve health care equity.