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A systematic review of school-based skills building behavioural interventions for preventing sexually transmitted infections A systematic review of school-based skills building behavioural interventions for preventing sexually transmitted infections in young people Dr Jonathan Shepherd Principal Research Fellow Southampton Health Technology Assessments Centre (SHTAC) University of Southampton

Project team Southampton Health Technology Assessments Centre (SHTAC) University of Southampton Jonathan Shepherd, Jo Project team Southampton Health Technology Assessments Centre (SHTAC) University of Southampton Jonathan Shepherd, Jo Picot, Jeremy Jones Keith Cooper, Debbie Hartwell, Alison Price, Geoff Frampton, Andy Clegg Evidence for Informed Policy and Practice Information and Co-ordinating Centre (EPPI-Centre), Social Science Research Unit, Institute of Education, University of London Josephine Kavanagh, Elaine Barnett-Page, Angela Harden

Rationale ► Rates of sexually transmitted infections (STIs) continue to increase, particularly amongst young Rationale ► Rates of sexually transmitted infections (STIs) continue to increase, particularly amongst young people ► Need for sound evidence to inform policy and practice ► Why a systematic review and why now? ► Topic advertised & commissioned by HTA programme

Objectives To conduct a systematic review and economic evaluation to assess the effectiveness of Objectives To conduct a systematic review and economic evaluation to assess the effectiveness of behavioural interventions for the prevention of STIs in young people aged 13 -19 years

Scoping and protocol Literature searching Inclusion / exclusion screening 1 Systematic review Descriptive mapping Scoping and protocol Literature searching Inclusion / exclusion screening 1 Systematic review Descriptive mapping methodology Further scoping Inclusion / exclusion screening 2 Narrative synthesis / meta-analysis Conclusions and recommendations

Inclusion criteria 1 Descriptive mapping exercise ► ► Participants: Young people aged 13 -19 Inclusion criteria 1 Descriptive mapping exercise ► ► Participants: Young people aged 13 -19 years Intervention: Behavioural interventions to prevent STIs Comparator: ‘Standard practice’ Outcomes: ► Sexual behaviour (e. g. ) ►Self-reported condom use ►Number of sexual partners ►Reported having had sex ► Additionally: STI rates; knowledge, beliefs, attitudes ► Study design: any type of outcome evaluation

Results: descriptive mapping exercise ► Total of 8037 references identified ► Total of 136 Results: descriptive mapping exercise ► Total of 8037 references identified ► Total of 136 studies included ► Design: 51% RCTs, 49% non-randomised studies ► Country: 60% USA; 18% Africa; <5% UK ► Topics: 60% HIV/AIDS; 47% STIs in general ► Intervention characteristics: ► Components: 90% Information; 60% skills training; 24% provision of resources ► Providers: 32% peer educators; 29% teachers; 17% health care professionals ► Location: 57% school/college; 27% community; 18% health-care

Scoping and protocol Literature searching Inclusion / exclusion screening 1 Systematic review Descriptive mapping Scoping and protocol Literature searching Inclusion / exclusion screening 1 Systematic review Descriptive mapping methodology Further scoping Inclusion / exclusion screening 2 Narrative synthesis / meta-analysis Conclusions and recommendations

Inclusion criteria 2 Systematic review of effectiveness ► Participants: Young people aged 13 -19 Inclusion criteria 2 Systematic review of effectiveness ► Participants: Young people aged 13 -19 years ► Intervention: School-based behavioural interventions to prevent STIs which teach safer sex skills as well as provide information ► Comparator: ‘Standard practice’ ► Outcomes: ► Sexual behaviour ► STI rates ► Knowledge, beliefs, attitudes ► Study design: Randomised Controlled Trials (RCTs) only

Results: systematic review ► Total of 15 studies included, of which 12 judged methodologically Results: systematic review ► Total of 15 studies included, of which 12 judged methodologically ‘sound’ ► Country n= 8 USA, n= 4 Europe, n= 3 Africa ► Types of skills: correct use of condoms; communication; negotiation ► Behavioural aims: increase protective behaviours; delay sex; reduce partners. ► Interventions of variable length / intensity ► Majority interventions theory-based ► Comparators: information only; or control groups ► Young people: ► Socio-demographic-economic profile mixed ► Between <10% to 80% sexually experienced

Examples of some of the interventions “Safer Choices” “Youth AIDS Prevention Project (YAPP)” (Chicago, Examples of some of the interventions “Safer Choices” “Youth AIDS Prevention Project (YAPP)” (Chicago, USA) (California + Texas, USA) “Focus on Kids” (West Virginia, USA) “All 4 You!” “RIPPLE study” (California, USA) (Central and Southern England) “Our times, our choices” (South Africa) “The SHARE study” (Scotland) “My future is my choice” (Namibia)

Narrative synthesis results ► Diverse range of sexual behavioural outcome measures ► Condom use Narrative synthesis results ► Diverse range of sexual behavioural outcome measures ► Condom use (first/last sex); frequency of condom use; consistency in condom use; whether had sex; frequency of sex; number of partners ► Few statistically significant differences between groups ► Self-efficacy: mixed findings ► Knowledge of STIs: significant differences favouring behavioural intervention ► Attitudes: mixed findings ► Intentions: mixed findings ► STI rates: no data

Meta-analysis: condom use “Safer Choices” (California + Texas) Individual study effects Pooled effect size Meta-analysis: condom use “Safer Choices” (California + Texas) Individual study effects Pooled effect size (Odds ratio 1. 07) Line of no effect

Results of process evaluations ► 9 of the 12 methodologically sound RCTs conducted a Results of process evaluations ► 9 of the 12 methodologically sound RCTs conducted a process evaluation. ► Synthesis of the process findings to explore reasons for the limited impact of the interventions revealed two sets of factors: ► (i) Interventions were not always implemented as intended ► Variations in school culture and administration ► Teachers not always able to facilitate skill development ► (ii) Not all young people found the interventions engaging or acceptable ► Gendered norms (mixed sex / single sex groups) ► Age appropriateness

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

Recommendations ► Evaluation of multi-component school-based interventions, including teachers / peers / whole school Recommendations ► Evaluation of multi-component school-based interventions, including teachers / peers / whole school approach / parents / specialist trainers ► Of suitable length – booster sessions as young people mature ► Long-term follow up ► Diversity in outcome measures: ► Quality of relationships ► Safety negotiations ► Use of STI testing / services ► Integral economic evaluation

www. hta. ac. uk www. hta. ac. uk

Contact Dr Jonathan Shepherd, Principal Research Fellow Southampton Health Technology Assessments Centre (SHTAC) Epsilon Contact Dr Jonathan Shepherd, Principal Research Fellow Southampton Health Technology Assessments Centre (SHTAC) Epsilon House, Enterprise Road Southampton Science Park, Chilworth University of Southampton, SO 16 7 NS Tel +44 (0) 2380 597055 Email: [email protected] ac. uk The views and opinions expressed are those of the authors and do not necessarily reflect those of the UK Department of Health.