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Characteristics of Effective Interventions in Improving Young People's Sexual Health: A Review of Reviews

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Title: Characteristics of Effective Interventions in Improving Young People's Sexual Health: A Review of Reviews
Language: English
Authors: Poobalan, Amudha S., Pitchforth, Emma, Imamura, Mari
Source: Sex Education: Sexuality, Society and Learning. Aug 2009 9(3):319-336.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Physical Description: PDF
Page Count: 18
Publication Date: 2009
Document Type: Journal Articles
Reports - Evaluative
Descriptors: Sex Education, Bibliographic Databases, Preadolescents, Early Adolescents, Adolescents, Literature Reviews, Intervention, Sexuality, Health, Interpersonal Relationship, Barriers, Program Effectiveness, Program Evaluation, Physical Development, Values, Culturally Relevant Education, Developmentally Appropriate Practices, Acquired Immunodeficiency Syndrome (AIDS)
DOI: 10.1080/14681810903059185
ISSN: 1468-1811
Abstract: The purpose of this paper is to conduct a review of reviews to identify characteristics of effective sex and relationship education (SRE) interventions and/or programmes in young people to improve sexual health and identify barriers and facilitators for implementation. Six bibliographic databases were searched from 1986 to 2006 for systematic reviews that assessed SRE interventions or programmes in participants between 10 and 18 years old and their partners. All outcomes of improvement in sexual health were assessed and 30 systematic reviews were included. Effective interventions and/or programmes tended to be those targeting younger age groups before they become sexually active, focused interventions tailored to the physical and biological development stages, theory based, and abstinence education programmes that incorporate values of relationships and provide skills training and links to contraceptive services. Adequate training of personnel delivering the interventions and culturally sensitive programmes were identified as important facilitators of effectiveness. Future research should explore the appropriate age for initiating sex education and investigate targeting specific behaviour compared with multiple-outcome targeting. Research exploring the reasons for interventions focusing on specific populations (i.e. African and Hispanic origins), even if they were conducted in countries dominated by Caucasians, is warranted. (Contains 4 tables.)
Abstractor: As Provided
Number of References: 45
Entry Date: 2010
Accession Number: EJ865878
Database: ERIC
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  Value: <anid>AN0043641162;bf401aug.09;2019Mar28.12:57;v2.2.500</anid> <title id="AN0043641162-1">Characteristics of effective interventions in improving young people's sexual health: a review of reviews. </title> <sbt id="AN0043641162-2">Introduction</sbt> <p>The purpose of this paper is to conduct a review of reviews to identify characteristics of effective sex and relationship education (SRE) interventions and/or programmes in young people to improve sexual health and identify barriers and facilitators for implementation. Six bibliographic databases were searched from 1986 to 2006 for systematic reviews that assessed SRE interventions or programmes in participants between 10 and 18 years old and their partners. All outcomes of improvement in sexual health were assessed and 30 systematic reviews were included. Effective interventions and/or programmes tended to be those targeting younger age groups before they become sexually active, focused interventions tailored to the physical and biological development stages, theory based, and abstinence education programmes that incorporate values of relationships and provide skills training and links to contraceptive services. Adequate training of personnel delivering the interventions and culturally sensitive programmes were identified as important facilitators of effectiveness. Future research should explore the appropriate age for initiating sex education and investigate targeting specific behaviour compared with multiple-outcome targeting. Research exploring the reasons for interventions focusing on specific populations (i.e. African and Hispanic origins), even if they were conducted in countries dominated by Caucasians, is warranted.</p> <p>Rates of sexually transmitted infections such as chlamydia and HIV (human immunodeficiency virus) in the United Kingdom and the United States have increased in recent years, with the largest increases being among young people below the age of 25 years (Pedlow and Carey [<reflink idref="bib34" id="ref1">34</reflink>]; Health Protection Agency [<reflink idref="bib18" id="ref2">18</reflink>]; UK Collaborative Group for HIV and STI Surveillance [<reflink idref="bib43" id="ref3">43</reflink>]). Some industrialised countries also have persistently high teenage pregnancy rates, while rates are very low in other countries (93 in the USA, 63 in England and Wales and 43 in Canada per 1000 young women, compared with 8.1 per 1000 young women aged 15–19 years in the Netherlands) (DiCenso et al. [<reflink idref="bib10" id="ref4">10</reflink>]). Despite epidemiological evidence pointing to the need for effective prevention among young people, the Global AIDS Report in 2006 (UNAIDS [<reflink idref="bib44" id="ref5">44</reflink>]) highlighted that HIV-prevention efforts remain notably inadequate for young people, who account for over 40% of all new infections and that investing in prevention programmes for young people is critical.</p> <p>Several primary studies have been conducted in recent years to improve young people's knowledge and attitudes related to sexual health, reduce their risky sexual behaviour and thereby decrease the prevalence of sexually transmitted infections (STIs)/teenage pregnancies (Agha [<reflink idref="bib1" id="ref6">1</reflink>]; Coyle, Basen-Engquist, and Kirby [<reflink idref="bib7" id="ref7">7</reflink>]; Kinsman et al. [<reflink idref="bib23" id="ref8">23</reflink>]; Magnani, Gaffikin, and Leao de Aquino [<reflink idref="bib26" id="ref9">26</reflink>]). Systematic reviews have also been conducted to pool the best possible evidence of effectiveness of such interventions or programmes. However, each review has had a different focus and concentrated on one or two specific characteristics of interventions; for example, on age of participants or duration of interventions (Gallant and Maticka-Tyndale [<reflink idref="bib14" id="ref10">14</reflink>]; Grunseit et al. [<reflink idref="bib15" id="ref11">15</reflink>]; Kalichman, Carey, and Johnson [<reflink idref="bib21" id="ref12">21</reflink>]). Systematic review methodology often restricts reviews to considering isolated distinct features of interventions. In practice, interventions or programmes aimed at improving sexual health among young people are complex and it is important to draw all the essential elements of effective sex and relationship education (SRE) interventions or programmes together, to improve sexual health and identify barriers and facilitators for implementation. This study aimed to conduct a review of the existing systematic reviews of SRE interventions and/or programmes in both industrialised and non-industrialised countries. The objectives were to identify which interventions or programmes are effective in improving young people's sexual health and to explore what characteristics such interventions or programmes may have in common. This will help policy-makers and practitioners plan future interventions to improve young people's sexual health more effectively and efficiently.</p> <hd id="AN0043641162-3">Methodology</hd> <p>The methodology of the present review draws from systematic review methods developed by the Cochrane Collaboration as well as the NHS Centre for Reviews and Dissemination (Cochrane Collaboration [<reflink idref="bib6" id="ref13">6</reflink>]; Bruce and Mollison [<reflink idref="bib5" id="ref14">5</reflink>]; Centre for Reviews and Dissemination [<reflink idref="bib8" id="ref15">8</reflink>]).</p> <hd id="AN0043641162-4">Literature search</hd> <p>Six electronic bibliographic databases were searched systematically from 1986 to 2006; namely, MEDLINE, EMBASE, CINAHL, Cochrane Library (Cochrane DSR, DARE, CENTRAL and ACP Journal Club), ERIC and PsychINFO. MeSH terms and key words for 'sexual health', 'relationship', 'education', 'interventions' and 'youth' were combined with the Cochrane Collaboration strategy for identifying 'reviews'. The MEDLINE search strategy was adapted for searching other databases. Reference lists of all review articles were checked to identify other relevant reviews. The search was restricted to English-language reports.</p> <hd id="AN0043641162-5">Study selection</hd> <p>All systematic reviews assessing interventions and/or programmes that were part of SRE among young people were included. Table 1 summarises the inclusion and exclusion criteria.</p> <p>Table 1 Inclusion and exclusion criteria.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td /><td>Inclusion criteria</td><td>Exclusion criteria</td></tr></thead><tbody><tr><td>Population</td><td>Young people aged 10–18 years old and their partners</td><td>General population with few studies in young people; adults; children  < 10 years; reviews focused on specific groups (e.g. homeless youth; youth with learning disability; lesbian, gay, bi-sexual and trans-sexual youth; youths with chronic health conditions)</td></tr><tr><td>Setting</td><td>In both industrialised and non-industrialised countries. Both educational and community settings</td><td>Studies conducted in healthcare settings only, such as drug treatment centres</td></tr><tr><td>Intervention</td><td>Interventions involving sex and relationship education (e.g. formal and informal educational interventions; contraceptive services linked to schools)</td><td>All other interventions</td></tr><tr><td>Outcome measure</td><td>Prevalence of pregnancy; enhanced sexual health and well-being, including improved knowledge, attitudes, behavioural intentions and sexual behaviour</td><td>Other outcomes not related to sexual health; sexual abuse; only sexuality (knowledge of sexual development)</td></tr><tr><td>Study</td><td>All systematic reviews</td><td>Narrative reviews</td></tr></tbody></table> </ephtml> </p> <p>All identified abstracts were checked against the inclusion and exclusion criteria agreed <emph>a priori</emph> independently by two reviewers. Any queries about inclusion were discussed between reviewers or referred to a third reviewer if necessary. Full texts of all the potentially eligible reviews were obtained and critically appraised. A data extraction form was developed and piloted for the purposes of this review of reviews. Two reviewers independently extracted data from identified reviews, and discrepancies were resolved by consensus or arbitration. Data were recorded on year of publication and authors, number of databases searched, number of primary studies included, review methods, details of the population, characteristics of the intervention programmes, outcomes assessed with results as presented in the paper, follow-up, cost-effectiveness, barriers and facilitators of the implementation.</p> <hd id="AN0043641162-6">Quality assessment of the studies</hd> <p>The methodological quality of the identified reviews was assessed independently by two reviewers using the Effective Public Health Practice Project (Micucci and Thomas [<reflink idref="bib30" id="ref16">30</reflink>]) standard form. Quality was assessed on comprehensiveness of the search, search strategy for primary studies, relevance criteria for the primary studies, strength and weaknesses of primary studies assessed, quality assessment of primary studies assessed, integration of findings beyond the description of primary studies, and adequacy of reviewers' conclusion. Each of the above criteria was given a score of two for 'Yes', one for 'Unclear' and zero for 'No'. Reviews that had a total score of 11–14 were considered 'strong', a score of 7–10 was considered 'moderate' and a score of six or less as 'weak'. Reviewers were not blind to authors, institutions or journals.</p> <hd id="AN0043641162-7">Data analysis</hd> <p>After detailed data extraction, included reviews were analysed according to the characteristics and themes addressed within each review (Table 2). These were type of interventions; outcomes; theory basis for interventions/programmes; age and sex of participants; duration of interventions; delivery of interventions; training of instructors; settings; ethnicity and cultural sensitivity; and cost of interventions/programmes. Attempts were also made to identify any barriers and facilitators highlighted in the reviews.</p> <p>Table 2 Included reviews and themes addressed within each review.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Author, year, country of review </td><td>Focus<sup>a</sup></td><td>Theory basis</td><td>Age of participants</td><td>Sex of participants</td><td>Type of intervention<sup>b</sup></td><td>Duration of interventions</td><td>Delivery and training</td><td>Setting</td><td>Outcomes<sup>c</sup></td><td>Ethnicity; cultural sensitivity</td><td>Cost</td></tr></thead><tbody><tr><td>Applegate <xref ref-type="bibr" rid="bibr2">1998</xref>, USA</td><td>HIV/AIDS</td><td>√</td><td>√</td><td>√</td><td>√</td><td>√</td><td>√</td><td /><td /><td /><td>√</td></tr><tr><td>Bennett and Assefi, <xref ref-type="bibr" rid="bibr3">2005</xref>, USA</td><td>TP</td><td /><td /><td /><td>√</td><td /><td /><td /><td>√</td><td /><td /></tr><tr><td>Darbes, 2002 and updated in 2006, USA</td><td>HIV/AIDS</td><td>√</td><td /><td /><td>√</td><td>√</td><td>√</td><td /><td /><td>√</td><td /></tr><tr><td>Dickson et al., 1997, UK; and Fullerton, 1997, UK</td><td>TP</td><td /><td>√</td><td /><td>√</td><td /><td /><td /><td /><td /><td>√</td></tr><tr><td>DiCenso et al., <xref ref-type="bibr" rid="bibr10">2002</xref>, Canada</td><td>TP</td><td>√</td><td /><td /><td /><td /><td /><td /><td>√</td><td /><td /></tr><tr><td>Franklin et al., <xref ref-type="bibr" rid="bibr12">1997</xref>, USA</td><td>TP</td><td /><td>√</td><td /><td>√</td><td /><td /><td>√</td><td /><td /><td /></tr><tr><td>Frost and Forrest <xref ref-type="bibr" rid="bibr13">1995</xref>, USA</td><td>TP</td><td>√</td><td>√</td><td /><td>√</td><td /><td /><td /><td>√</td><td /><td /></tr><tr><td>Gallant and Maticka-Tyndale <xref ref-type="bibr" rid="bibr14">2004</xref>, Canada</td><td>HIV/AIDS</td><td /><td>√</td><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Grunseit et al., <xref ref-type="bibr" rid="bibr15">1997</xref>, UK</td><td>Combi</td><td>√</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Guyatt et al., <xref ref-type="bibr" rid="bibr16">2000</xref>, Canada</td><td>TP</td><td /><td /><td /><td /><td /><td /><td /><td>√</td><td /><td /></tr><tr><td>Jemmott and Jemmott <xref ref-type="bibr" rid="bibr19">2000</xref>, USA</td><td>HIV/AIDS</td><td>√</td><td /><td /><td /><td /><td /><td /><td>√</td><td>√</td><td /></tr><tr><td>Johnson et al., <xref ref-type="bibr" rid="bibr20">2003</xref>, USA</td><td>HIV/AIDS</td><td /><td /><td /><td>√</td><td /><td>√</td><td /><td /><td>√</td><td /></tr><tr><td>Kalichman et al., <xref ref-type="bibr" rid="bibr21">1996</xref>, USA</td><td>HIV/AIDS</td><td /><td /><td /><td /><td>√</td><td /><td /><td /><td /><td /></tr><tr><td>Kim et al., <xref ref-type="bibr" rid="bibr22">1997</xref>, USA</td><td>HIV/AIDS</td><td>√</td><td /><td /><td /><td>√</td><td /><td /><td /><td /><td /></tr><tr><td>Kirby et al., <xref ref-type="bibr" rid="bibr25">1994</xref>, USA</td><td>Combi</td><td /><td /><td /><td>√</td><td>√</td><td /><td /><td>√</td><td /><td /></tr><tr><td>Kirby, <xref ref-type="bibr" rid="bibr24">2002</xref>, USA</td><td>Combi</td><td /><td /><td>√</td><td>√</td><td /><td /><td /><td /><td>√</td><td /></tr><tr><td>Magnussen et al., <xref ref-type="bibr" rid="bibr27">2004</xref>, USA</td><td>HIV/AIDS</td><td /><td /><td /><td>√</td><td /><td>√</td><td /><td /><td /><td /></tr><tr><td>Meade and Ickovics, <xref ref-type="bibr" rid="bibr28">2005</xref>, USA</td><td>Combi</td><td /><td /><td /><td /><td>√</td><td /><td /><td /><td /><td /></tr><tr><td>Meschke et al., <xref ref-type="bibr" rid="bibr29">2002</xref>, USA</td><td>Combi</td><td /><td /><td /><td /><td /><td>√</td><td /><td /><td>√</td><td /></tr><tr><td>Morrison-Beedy and Nelson, <xref ref-type="bibr" rid="bibr32">2004</xref>, UK</td><td>HIV/AIDS</td><td>√</td><td>√</td><td /><td>√</td><td /><td /><td /><td /><td /><td /></tr><tr><td>Moos et al., <xref ref-type="bibr" rid="bibr31">2003</xref>, USA</td><td>TP</td><td /><td /><td /><td /><td /><td /><td /><td>√</td><td /><td /></tr><tr><td>Mullen et al., <xref ref-type="bibr" rid="bibr33">2002</xref>, USA</td><td>HIV/AIDS</td><td /><td /><td /><td /><td /><td /><td /><td /><td>√</td><td /></tr><tr><td>Pedlow and Carey, <xref ref-type="bibr" rid="bibr34">2003</xref>, USA</td><td>HIV/AIDS</td><td>√</td><td /><td /><td /><td>√</td><td /><td /><td>√</td><td /><td /></tr><tr><td>Pedlow and Carey, <xref ref-type="bibr" rid="bibr35">2004</xref>, USA; update of 2003 review</td><td>HIV/AIDS</td><td /><td>√</td><td /><td>√</td><td>√</td><td /><td /><td>√</td><td /><td /></tr><tr><td>Peersman et al., <xref ref-type="bibr" rid="bibr36">1996</xref>, UK</td><td>Combi</td><td /><td /><td /><td>√</td><td /><td>√</td><td>√</td><td /><td /><td>√</td></tr><tr><td>Robin et al., <xref ref-type="bibr" rid="bibr37">2004</xref>, Atlanta</td><td>Combi</td><td>√</td><td /><td /><td>√</td><td>√</td><td>√</td><td /><td /><td /><td /></tr><tr><td>Song et al., <xref ref-type="bibr" rid="bibr40">2000</xref>, USA</td><td>Combi</td><td>√</td><td /><td /><td>√</td><td /><td /><td /><td /><td /><td /></tr><tr><td>Speizer et al., <xref ref-type="bibr" rid="bibr41">2003</xref>, USA</td><td>Combi</td><td /><td /><td /><td>√</td><td /><td /><td /><td>√</td><td /><td /></tr><tr><td>Stout and Rivara, <xref ref-type="bibr" rid="bibr42">1989</xref>, USA</td><td>Combi</td><td /><td /><td /><td /><td /><td /><td /><td>√</td><td /><td /></tr><tr><td>Yamada et al., <xref ref-type="bibr" rid="bibr45">1999</xref>, USA</td><td>HIV/AIDS</td><td>√</td><td /><td /><td /><td /><td>√</td><td /><td>√</td><td /><td /></tr><tr><td>Notes: <sup>a</sup>TP, teenage pregnancy; Combi, general sexual health interventions of all sexual health outcomes. <sup>b</sup>Components of interventions. <sup>c</sup>Outcomes related to knowledge, attitudes or sexual behaviour.</td></tr></tbody></table> </ephtml> </p> <hd id="AN0043641162-8">Strengths and limitations of the review</hd> <p>This review of reviews aimed to compile comprehensive evidence from existing systematic reviews that focused on different aspects of effective interventions and/or programmes. However, specific details of components of effective interventions were not analysed in this review due to time constraints; due to not all reviews being focused on intervention components, but on other aspects such as theoretical basis or age; and due to this review of reviews being keen to identify all the key factors that could make an intervention or programme effective apart from intervention components, as many of them were multifaceted. This review of reviews also does not escape the common issue of the same primary studies being repeated in different reviews as one good study may influence the results of a review. Within the time constraints of review of reviews, it was not feasible to identify those individual studies. It is also important to recognise that the time lag between implementation, evaluation of interventions and measurement of the outcomes and inclusion in the reviews can be long, and that earlier reviews might have missed some more recent primary studies. Most interventions/programmes are concentrated in the USA and for populations of African origin. This makes it difficult to generalise the characteristics of effective interventions to other countries or ethnic populations where there are different sets of cultural beliefs and behaviours.</p> <hd id="AN0043641162-9">Methodological issues surrounding SRE interventions and/or programmes</hd> <p>Although many of the reviews have scored as 'strong' based on rigorous review methodology, the review results themselves are limited by the poor quality of included primary studies. The methodological weaknesses in primary studies were of the data collection (e.g. non-blinding of interviewers, self-reported sensitive data), very short follow-up time or no follow-up at all.</p> <p>Another issue in the SRE interventions and their assessments is the sensitivity of reporting these outcomes. Most of the primary studies rely on the self-reporting of outcome measures, which is prone to recall bias as well as inaccuracies, especially in socially proscribed behaviours, perhaps making the outcome data less valid and reliable. The intervention components and outcomes measures are varied, and sometimes definitions of outcome variables also differed. For example, the definition for use of contraceptives varied from 'consistently using contraceptives' to 'usage at last intercourse'.</p> <p>In pregnancy-prevention interventions, the majority of studies did not measure direct outcomes (i.e. pregnancy rates), but only measured changes in often self-reported contraceptive behaviours and sometimes only knowledge of contraception. It could be that the majority of interventions for reducing 'early' pregnancy are conducted in schools, and pregnant teenagers are either infrequent school attendees (in several developed settings) or likely to drop out of school and be lost to follow-up (in developing countries) for accurate measure of pregnancy rates. Self-reported measures with no access to reliable data, and short follow-up periods, also pose difficulty in measuring pregnancy rates.</p> <p>Moreover, most SRE interventions and/or programmes consisted of more than one component and it is difficult to examine the contribution of specific components, or whether all components are necessary. The duration of interventions and contact time act as confounders to identify effective programme components. Many reviews do not report effect sizes and studies rarely reported on cost-effectiveness of interventions/programmes, which is crucial for implementation as public health interventions.</p> <hd id="AN0043641162-10">Results</hd> <p>Our search identified 2333 titles and abstracts. Critical appraisal of the full texts of 245 potentially eligible articles identified 30 systematic reviews that met the final inclusion criteria. Thirteen reviews assessed interventions to prevent HIV/AIDS in young people (Applegate [<reflink idref="bib2" id="ref17">2</reflink>]; Darbes [<reflink idref="bib9" id="ref18">9</reflink>]; Gallant and Maticka-Tyndale [<reflink idref="bib14" id="ref19">14</reflink>]; Jemmott and Jemmott [<reflink idref="bib19" id="ref20">19</reflink>]; Johnson et al. [<reflink idref="bib20" id="ref21">20</reflink>]; Kalichman, Carey, and Johnson [<reflink idref="bib21" id="ref22">21</reflink>]; Kim et al. [<reflink idref="bib22" id="ref23">22</reflink>]; Magnussen et al. [<reflink idref="bib27" id="ref24">27</reflink>]; Morrison-Beedy and Nelson [<reflink idref="bib32" id="ref25">32</reflink>]; Mullen et al. [<reflink idref="bib33" id="ref26">33</reflink>]; Pedlow and Carey [<reflink idref="bib34" id="ref27">34</reflink>], [<reflink idref="bib35" id="ref28">35</reflink>]; Yamada et al. [<reflink idref="bib45" id="ref29">45</reflink>]), seven assessed interventions to prevent teenage pregnancies (Bennett and Asseffi [<reflink idref="bib3" id="ref30">3</reflink>]; Dickson et al. 1997; DiCenso et al. [<reflink idref="bib10" id="ref31">10</reflink>]; Franklin et al. [<reflink idref="bib12" id="ref32">12</reflink>]; Frost and Forrest [<reflink idref="bib13" id="ref33">13</reflink>]; Guyatt et al. [<reflink idref="bib16" id="ref34">16</reflink>]; Moos, Bartholomew, and Lohr [<reflink idref="bib31" id="ref35">31</reflink>]) and 10 assessed either general sexual health interventions in youth or reported combinations of sexual health outcomes (Grunseit et al. [<reflink idref="bib15" id="ref36">15</reflink>]; Kirby et al. [<reflink idref="bib25" id="ref37">25</reflink>]; Kirby [<reflink idref="bib24" id="ref38">24</reflink>]; Meade and Ickovics [<reflink idref="bib28" id="ref39">28</reflink>]; Meschke, Bartholomae, and Zentall [<reflink idref="bib29" id="ref40">29</reflink>]; Peersman et al. [<reflink idref="bib36" id="ref41">36</reflink>]; Robin et al. [<reflink idref="bib37" id="ref42">37</reflink>]; Song et al. [<reflink idref="bib40" id="ref43">40</reflink>]; Speizer, Magnani, and Colvin [<reflink idref="bib41" id="ref44">41</reflink>]; Stout and Rivara [<reflink idref="bib42" id="ref45">42</reflink>]). The basic characteristics of the included reviews are summarised in Table 3. Overall, the quality of the included reviews was moderate to strong. Most of the reviews were conducted in the USA. The majority of the interventions in SRE included in these reviews targeted young people of African origin, even though the interventions are conducted in multi-ethnic countries such as the USA or the United Kingdom. Each review derived the data from primary studies, ranging from only five studies in some reviews (Frost and Forrest [<reflink idref="bib13" id="ref46">13</reflink>]; Stout and Rivara [<reflink idref="bib42" id="ref47">42</reflink>]) up to 115 primary studies in some others (Song et al. [<reflink idref="bib40" id="ref48">40</reflink>]) (Table 3). The primary studies included randomised controlled trials, non-randomised controlled trials, cohorts and cross-sectional studies. Only seven reviews conducted meta-analysis on behavioural outcomes (Table 4). This review of reviews provides a narrative summary, as the same primary studies may be included in more than one review and also contribute to extreme variations in reported outcomes.</p> <p>Table 3 Details of the included reviews.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Author, year, country of review</td><td>Number of primary studies</td><td>Sample size</td><td>Types of studies</td><td>Quality of review</td><td>Method of analysis</td></tr></thead><tbody><tr><td>Applegate, <xref ref-type="bibr" rid="bibr2">1998</xref>, USA</td><td>42</td><td>Range: 43–2709</td><td>RCTs and non-RCTs</td><td>Strong</td><td>Narrative summary</td></tr><tr><td>Bennett and Assefi, <xref ref-type="bibr" rid="bibr3">2005</xref>, USA</td><td>16</td><td>Range: 36–10,600</td><td>Only RCTs</td><td>Strong</td><td>Narrative summary</td></tr><tr><td>Darbes, 2002 and updated in 2006, USA</td><td>174</td><td>2003: 60–1316; 2006: 522–3869</td><td>Only RCTs</td><td>Strong</td><td>Narrative summary</td></tr><tr><td>Dickson et al., 1997, UK; and Fullerton, 1997, UK</td><td>42</td><td>Range: 38–4800</td><td>RCTs and non-RCTs</td><td>Moderate</td><td>Narrative summary</td></tr><tr><td>DiCenso et al., <xref ref-type="bibr" rid="bibr10">2002</xref>, Canada</td><td>26</td><td>Range: 36–10,600</td><td>Only RCTs</td><td>Strong</td><td>Meta-analysis</td></tr><tr><td>Franklin et al., <xref ref-type="bibr" rid="bibr12">1997</xref>, USA</td><td>32</td><td>Not reported</td><td>RCTs and non-RCTs</td><td>Moderate</td><td>Meta-analysis</td></tr><tr><td>Frost and Forrest, <xref ref-type="bibr" rid="bibr13">1995</xref>, USA</td><td>5</td><td>Range: 178–722</td><td>RCTs and quasi-experimental studies</td><td>Moderate</td><td>Narrative summary</td></tr><tr><td>Gallant and Maticka-Tyndale, <xref ref-type="bibr" rid="bibr14">2004</xref>, Canada</td><td>11</td><td>Range: 72–2077</td><td>Longitudinal, repeated cross-sectional studies with pre and post tests</td><td>Strong</td><td>Narrative summary</td></tr><tr><td>Grunseit et al., <xref ref-type="bibr" rid="bibr15">1997</xref>, UK</td><td>67</td><td>Range: 41–18,876</td><td>RCTs, quasi-experimental studies, cross-sectional surveys, national and international comparisons</td><td>Moderate</td><td>Narrative summary</td></tr><tr><td>Guyatt et al., <xref ref-type="bibr" rid="bibr16">2000</xref>, Canada</td><td>30</td><td>Range: 51–3290</td><td>RCTs and observational studies</td><td>Strong</td><td>Meta-analysis</td></tr><tr><td>Jemmott and Jemmott, <xref ref-type="bibr" rid="bibr19">2000</xref>, USA</td><td>36</td><td>Range: 43–5905</td><td>RCTs and non-RCTs</td><td>Moderate</td><td>Meta-analysis</td></tr><tr><td>Johnson et al., <xref ref-type="bibr" rid="bibr20">2003</xref>, USA</td><td>45</td><td><italic>n</italic> = 35, 282</td><td>RCTs and quasi experimental studies</td><td>Strong</td><td>Meta-analysis</td></tr><tr><td>Kalichman et al., <xref ref-type="bibr" rid="bibr21">1996</xref>, USA</td><td>6</td><td>Range: 34–1201</td><td>RCTs and non-RCTs</td><td>Strong</td><td>Effect size for each study (0.31–0.91+)</td></tr><tr><td>Kim et al., <xref ref-type="bibr" rid="bibr22">1997</xref>, USA</td><td>40</td><td>Not reported</td><td>RCTs and non-RCTs</td><td>Strong</td><td>Meta analysis for one outcome –condom use (4 studies)</td></tr><tr><td>Kirby et al., <xref ref-type="bibr" rid="bibr25">1994</xref>, USA</td><td>23</td><td>Range: 36–6596</td><td>RCTs and quasi-experimental studies</td><td>Strong</td><td>Narrative summary</td></tr><tr><td>Kirby, <xref ref-type="bibr" rid="bibr24">2002</xref>, USA</td><td>73</td><td>All studies had at least 100 in each arm</td><td>RCTs and quasi-experimental studies</td><td>Moderate</td><td>Narrative summary</td></tr><tr><td>Magnussen et al., <xref ref-type="bibr" rid="bibr27">2004</xref>, USA</td><td>16</td><td>Range: 72–2026</td><td>RCTs and quasi-experimental studies</td><td>Strong</td><td>Narrative summary</td></tr><tr><td>Meade and Ickovics, <xref ref-type="bibr" rid="bibr28">2005</xref>, USA</td><td>9</td><td>Range: 88–789</td><td>Not clear but all had comparison groups</td><td>Strong</td><td>Narrative summary</td></tr><tr><td>Meschke et al., <xref ref-type="bibr" rid="bibr29">2002</xref>, USA</td><td>19</td><td>Not reported</td><td>Not clear</td><td>Weak</td><td>Narrative summary</td></tr><tr><td>Morrison-Beedy and Nelson, <xref ref-type="bibr" rid="bibr32">2004</xref>, UK</td><td>6</td><td><italic>n</italic> = 1043</td><td>Only RCTs</td><td>Strong</td><td>Narrative summary</td></tr><tr><td>Moos et al., <xref ref-type="bibr" rid="bibr31">2003</xref>, USA</td><td>13</td><td>Range: 79–1449</td><td>RCTs, non-RCTs, cohorts and cross-sectional studies</td><td>Strong</td><td>Narrative summary</td></tr><tr><td>Mullen et al., <xref ref-type="bibr" rid="bibr33">2002</xref>, USA</td><td>16</td><td>Not reported</td><td>RCTs and non-RCTs</td><td>Strong</td><td>Meta-analysis</td></tr><tr><td>Pedlow and Carey, <xref ref-type="bibr" rid="bibr34">2003</xref>, USA</td><td>22</td><td>Range: 34–3869</td><td>Only RCTs</td><td>Strong</td><td>Narrative summary</td></tr><tr><td>Pedlow and Carey, <xref ref-type="bibr" rid="bibr35">2004</xref>, USA; focus on developmental interventions</td><td>22</td><td>Range: 34–3869</td><td>Only RCTs</td><td>Strong</td><td>Narrative summary</td></tr><tr><td>Peersman et al., <xref ref-type="bibr" rid="bibr36">1996</xref>, UK</td><td>21</td><td>Not reported</td><td>RCTs and clinical trials</td><td>Strong</td><td>Narrative summary</td></tr><tr><td>Robin et al., <xref ref-type="bibr" rid="bibr37">2004</xref>, Atlanta</td><td>20</td><td>Range 90–10,600</td><td>RCTs and quasi-experimental studies</td><td>Strong</td><td>Narrative summary</td></tr><tr><td>Song et al., <xref ref-type="bibr" rid="bibr40">2000</xref>, USA</td><td>115 programs</td><td>Not reported</td><td>Not clear</td><td>Strong</td><td>Meta-analysis for one outcome-sexual knowledge (67 studies)</td></tr><tr><td>Speizer et al., <xref ref-type="bibr" rid="bibr41">2003</xref>, USA</td><td>41</td><td>Range: 226–4777</td><td>RCTs and quasi-experimental studies</td><td>Strong</td><td>Narrative summary</td></tr><tr><td>Stout and Rivara, <xref ref-type="bibr" rid="bibr42">1989</xref>, USA</td><td>5</td><td>Range: 469–12,069</td><td>Cross-sectional surveys, cohort and case–control studies</td><td>Weak</td><td>Narrative summary</td></tr><tr><td>Yamada et al., <xref ref-type="bibr" rid="bibr45">1999</xref>, USA</td><td>24</td><td>Range: 69–10,600</td><td>RCTs and non-RCTs</td><td>Strong</td><td>Narrative summary</td></tr><tr><td>Note: RCTs, randomised controlled trials.</td></tr></tbody></table> </ephtml> </p> <p>Table 4 Details of the meta-analysis on behavioural outcomes reported in reviews.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Author, year, country</td><td>Condom / contraceptive use</td><td>Unprotected sex</td><td>Abstinence / sexual initiation</td><td>Number of partners</td><td>Sexual frequency / activity</td><td>Sexually transmitted diseases / pregnancy</td></tr></thead><tbody><tr><td>DiCenso et al., <xref ref-type="bibr" rid="bibr10">2002</xref>, Canada<sup>b</sup></td><td>F: 8 studies, OR 0.95 (95% CI 0.69–1.30), NS; M: 3 studies, OR 0.90 (95% CI 0.70–1.16), NS</td><td>NR</td><td>SI F: 13 studies, OR 1.12 (95% CI 0.96–1.30), NS; M: 11 studies, OR 0.99 (95% CI 0.84 − 1.16), NS</td><td>NR</td><td>NR</td><td>Pregnancy rate, F: 12 studies, OR 1.04 (95% CI 0.78–1.40), NS</td></tr><tr><td>Franklin et al., <xref ref-type="bibr" rid="bibr12">1997</xref>, USA</td><td>16 studies, pooled ES 0.27, significant but low</td><td>NR</td><td>NR</td><td>NR</td><td>17 studies, pooled ES 0.110, NS</td><td>Pregnancy rate: 15 studies, ES–0.153, significant but small</td></tr><tr><td>Guyatt et al., <xref ref-type="bibr" rid="bibr16">2000</xref>, Canada<sup>a</sup></td><td>F: 14 studies, OR 1.21 (95% CI 0.98–1.50), NS; M: 5 studies, OR 0.94 (95% CI 0.68–1.29), NS</td><td>NR</td><td>SI (F: 18 studies, OR 0.78 (95% CI 0.62–0.99), significant; M: 10 studies, OR 0.77 (95% 0.53–1.13), NS</td><td>NR</td><td>NR</td><td>Pregnancy rate F: 20 studies, OR 0.86 (95% CI 0.71–1.03), NS; M: 7 studies, OR 0.88 (95% 0.74 − 1.04), NS</td></tr><tr><td>Jemmott III and Jemmott, 2000, USA</td><td>21 studies, mean ES 0.28, range − 0.12 to 0.79</td><td>8 studies, mean ES 0.19, range 0.00 − 0.60</td><td>A: 19 studies, mean ES 0.08, range − 0.05 to 0.40</td><td>14 studies, mean ES 0.10, range − 0.16 to 0.55</td><td>NR</td><td>NR</td></tr><tr><td>Johnson et al., <xref ref-type="bibr" rid="bibr20">2003</xref>, USA<sup>c</sup></td><td>42 studies, OR 1.13 (95% CI 1.06 − 1.21), significant</td><td>NR</td><td>NR</td><td>NR</td><td>38 studies, OR 1.10 (95% CI 1.04 − 1.17), significant</td><td>Sexually transmitted diseases: 5 studies, OR 1.06 (95% CI 0.93 − 1.22), NS</td></tr><tr><td>Kim et al., <xref ref-type="bibr" rid="bibr22">1997</xref>, USA</td><td>At 6 months (4 studies): I 80%, C 59%, <italic>p</italic> = 0.005; at 12 months: I 80%, C 62%, <italic>p</italic> = 0.01</td><td>NR</td><td>NR</td><td>NR</td><td>NR</td><td>NR</td></tr><tr><td>Mullen et al., <xref ref-type="bibr" rid="bibr33">2002</xref>, USA<sup>a</sup></td><td>NR</td><td>13 studies, OR 0.66 (95% CI 0.55 − 0.79), <italic>p</italic> < 0.001, significant</td><td>NR</td><td>8 studies, OR 0.89 (95% CI 0.76 − 1.05), <italic>p</italic> = 0.17, significant</td><td>NR</td><td>2 studies, OR 1.18 (95% CI 0.48 − 2.86), <italic>p</italic> = 0.72, NS</td></tr><tr><td>Notes: NR, not reported; ES, effect size; OR, pooled odds ratio; 95% CI, 95% confidence interval; I, intervention; C, controls; F, females; M, males; A, abstinence; SI, sexual initiation; NS, non-significant. <sup>a</sup>OR > 1 indicate undesirable effect of intervention and OR < 1 indicate desirable effect of intervention. <sup>b</sup>For intercourse and pregnancy outcomes, OR < 1 favour intervention; and for contraception outcomes, OR > 1 favour intervention. <sup>c</sup>OR > 1 indicate desirable effect of intervention.</td></tr></tbody></table> </ephtml> </p> <hd id="AN0043641162-11">Type of interventions</hd> <p>The interventions described varied widely. They were often complex, with exclusively educational components or in combination with psychosocial and behavioural components, delivered via a range of activities including lectures, audio-visual aids, role-plays and games. Interventions that were found to be effective included those that were appropriately matched to the adolescents' biological, cognitive and social developmental stage (Pedlow and Carey [<reflink idref="bib35" id="ref49">35</reflink>]), those that took account of social or media influences on sexual behaviour (Kirby [<reflink idref="bib24" id="ref50">24</reflink>]) and those that involved parents and peers (Pedlow and Carey [<reflink idref="bib35" id="ref51">35</reflink>]; Peersman et al. [<reflink idref="bib36" id="ref52">36</reflink>]). Interventions that encouraged participation and physical involvement of youth by conducting skills training workshops on decision-making, negotiation, condom use, and those that involved young people emotionally (for example, using a person with AIDS to deliver lectures and reinforcing specific values and norms) (Applegate [<reflink idref="bib2" id="ref53">2</reflink>]; Morrison-Beedy and Nelson [<reflink idref="bib32" id="ref54">32</reflink>]; Darbes [<reflink idref="bib9" id="ref55">9</reflink>]; Frost and Forrest [<reflink idref="bib13" id="ref56">13</reflink>]; Johnson et al. [<reflink idref="bib20" id="ref57">20</reflink>]; Kirby et al. [<reflink idref="bib25" id="ref58">25</reflink>]), were more likely to be effective in altering sexual behaviour than provision of information by films and videos alone. In spite of this, only 37% of interventions incorporated skills training and only 12% used peer educators (Song et al. [<reflink idref="bib40" id="ref59">40</reflink>]).</p> <p>As youngsters go through physical, social and psychological transition into adulthood over a period of time, 'education with a narrow focus' given in stages seems to be beneficial, which allows them time to understand the messages rather than to over load them with 'multiple messages at the same time'. Targeting single behaviours and being content specific at one point of time is identified as an important characteristic of effective intervention in reducing risky sexual behaviour (Kirby 1994). This concept was again identified and discussed in more recent reviews (Robin et al. [<reflink idref="bib37" id="ref60">37</reflink>]; Speizer, Magnani, and Colvin [<reflink idref="bib41" id="ref61">41</reflink>]). Similarly, promoting sexual abstinence only as a 'blunt message' does not seem to be effective in delaying sexual initiation, and it appears that it needs to be integrated with messages that include the values of stable relationships, encourage vocational development, include additional information on contraception and provide skills training (Bennett and Assefi [<reflink idref="bib3" id="ref62">3</reflink>]; Dickson et al. 1997; Franklin et al. [<reflink idref="bib12" id="ref63">12</reflink>]; Kirby et al. [<reflink idref="bib25" id="ref64">25</reflink>]; Kirby [<reflink idref="bib24" id="ref65">24</reflink>]), again delivered in stages taking their developmental progression into consideration.</p> <hd id="AN0043641162-12">Outcomes</hd> <p>Condom use and number of sexual partners are commonly measured outcomes in sex education interventions (Table 4), with fewer studies focusing on delayed sex and abstinence in those who were sexually inactive (Pedlow and Carey [<reflink idref="bib34" id="ref66">34</reflink>]). Overall, many reviews showed a positive impact on adolescent sexual knowledge and attitudes, but any effect (self-reported) on behaviour was less consistent (Jemmott and Jemmott [<reflink idref="bib19" id="ref67">19</reflink>]; Speizer, Magnani, and Colvin [<reflink idref="bib41" id="ref68">41</reflink>]). Nevertheless, a reduction in risky sexual behaviour (i.e. lower frequency of unprotected sex and increased condom use) was achieved more often than a reduction in sexual activity (i.e. frequency of sex or abstinence) (Jemmott and Jemmott [<reflink idref="bib19" id="ref69">19</reflink>]; Pedlow and Carey [<reflink idref="bib35" id="ref70">35</reflink>]; Yamada et al. [<reflink idref="bib45" id="ref71">45</reflink>]). It is noteworthy, however, that pregnancy prevention interventions generally did not report the gold standard outcome of reduced subsequent pregnancy rates, but rather resorted to surrogate measures such as use of contraception and frequency of sexual activity (Bennett and Assefi [<reflink idref="bib3" id="ref72">3</reflink>]).</p> <p>However, the literature seems to suggest that, although the positive effects of interventions on knowledge and attitudes are not on a par with the behavioural changes observed, they do seem to have some positive influence on behaviour. The review by Jemmott and Jemmott ([<reflink idref="bib19" id="ref73">19</reflink>]) extracted data on behavioural outcomes (e.g. condom use and number of sexual partners) and 'conceptual mediator' outcomes (e.g. knowledge, self efficacy and behavioural intention) separately and analysed whether there was any relationship between reported effect sizes of behavioural outcomes and the mediator outcomes. The analysis found that the effects of interventions on behaviour outcomes were greater if the interventions were also successful in improving the conceptual mediators, making the interventions targeting only the conceptual mediators worthwhile.</p> <hd id="AN0043641162-13">Themes identified in reviews</hd> <p></p> <hd id="AN0043641162-14">Theory basis</hd> <p>From the reviews, a theoretical basis for interventions is identified as an important element of successful interventions. Studies targeting HIV prevention (Applegate [<reflink idref="bib2" id="ref74">2</reflink>]; Darbes [<reflink idref="bib9" id="ref75">9</reflink>]; Jemmott and Jemmott [<reflink idref="bib19" id="ref76">19</reflink>]; Kim et al. [<reflink idref="bib22" id="ref77">22</reflink>]; Morrison-Beedy and Nelson [<reflink idref="bib32" id="ref78">32</reflink>]; Pedlow and Carey [<reflink idref="bib34" id="ref79">34</reflink>]; Yamada et al. [<reflink idref="bib45" id="ref80">45</reflink>]) and a combination of outcomes (prevention of teenage pregnancies and STIs) (Grunseit et al. [<reflink idref="bib15" id="ref81">15</reflink>]; Kirby et al. [<reflink idref="bib25" id="ref82">25</reflink>]; Robin et al. [<reflink idref="bib37" id="ref83">37</reflink>]; Song et al. [<reflink idref="bib40" id="ref84">40</reflink>]) had more emphasis on theoretical underpinning than those that focused on prevention of teenage pregnancy alone (DiCenso et al. [<reflink idref="bib10" id="ref85">10</reflink>]; Frost and Forrest [<reflink idref="bib13" id="ref86">13</reflink>]). Reasons for lack of use of theories or probably under-reporting of them in pregnancy-prevention interventions will be worth investigating to see whether there are any implications for program effectiveness.</p> <p>Activities based on Bandura's Social Learning Theory/Social Cognitive Theory were found to have a greater positive effect on attitudes and behaviour change compared with those based on the Theory of Reasoned Action and the Health Belief Model (Darbes [<reflink idref="bib9" id="ref87">9</reflink>]; Kim et al. [<reflink idref="bib22" id="ref88">22</reflink>]). The Theory of Reasoned Action significantly increased knowledge but no change was observed in behaviour (Applegate [<reflink idref="bib2" id="ref89">2</reflink>]). The review by Gruinseit et al. ([<reflink idref="bib15" id="ref90">15</reflink>]) highlighted the importance of Social Inoculation Theory to 'immunise' youth against social and peer pressure that encourages negative health behaviour. Although interventions were reportedly based on a theory, studies rarely describe the process of how the theories were used to design and implement interventions (Pedlow and Carey [<reflink idref="bib34" id="ref91">34</reflink>]).</p> <hd id="AN0043641162-15">Age of participants</hd> <p>Educational interventions targeting younger age groups seem to be more effective (Applegate [<reflink idref="bib2" id="ref92">2</reflink>]; Frost and Forrest [<reflink idref="bib13" id="ref93">13</reflink>]; Gallant and Maticka-Tyndale [<reflink idref="bib14" id="ref94">14</reflink>]; Pedlow and Carey [<reflink idref="bib35" id="ref95">35</reflink>]) compared with the interventions targeting those who are already sexually active at the commencement of interventions. Nevertheless, the majority of the interventions seems to target adolescents when they are already sexually active (Morrison-Beedy and Nelson [<reflink idref="bib32" id="ref96">32</reflink>]). Sexually active youth are less likely to change their sexual behaviour (Dickson et al. 1997) although older teenagers seem to respond better to programmes emphasising increased contraceptive use (Franklin et al. [<reflink idref="bib12" id="ref97">12</reflink>]).</p> <hd id="AN0043641162-16">Gender of the participants</hd> <p>Compared with young men, young women were more likely to demonstrate positive changes in sexual health knowledge, attitudes and behavioural intentions (Applegate [<reflink idref="bib2" id="ref98">2</reflink>]). Furthermore, females appeared to be more receptive to pregnancy-prevention interventions, whilst the males tended to be more receptive to HIV/AIDS-prevention interventions (Kirby [<reflink idref="bib24" id="ref99">24</reflink>]). This could be due to the major social and psychological implications of falling pregnant at a younger age for girls whilst the boys might see only HIV/AIDS as a greater threat for them. Boys may also not comprehend the responsibility of their partners falling pregnant. There appears to be an element of self-interest to this attitude between boys and girls.</p> <hd id="AN0043641162-17">Duration of interventions</hd> <p>Evidence on the optimum duration of intervention is inconsistent across all outcomes. Sustained interventions that included multiple booster sessions (Kim et al. [<reflink idref="bib22" id="ref100">22</reflink>]; Robin et al. [<reflink idref="bib37" id="ref101">37</reflink>]) were more effective than single sessions either of short or longer duration (Kalichman, Carey, and Johnson [<reflink idref="bib21" id="ref102">21</reflink>]; Pedlow and Carey [<reflink idref="bib35" id="ref103">35</reflink>]). The study by Rotheram-Borus et al. ([<reflink idref="bib38" id="ref104">38</reflink>]) mentioned in the review by Darbes ([<reflink idref="bib9" id="ref105">9</reflink>]) also highlighted that multiple sessions over long periods of time were more effective than long sessions over short period of time (e.g. seven sessions of 90 minutes is better than three sessions of 3.5 hours, although the total number of hours is the same). Yet, one review argued that duration <emph>per se</emph> was not important but duration of at least three hours may be effective if combined with the appropriate format of the intervention (Applegate [<reflink idref="bib2" id="ref106">2</reflink>]).</p> <hd id="AN0043641162-18">Delivery of interventions and training of instructors</hd> <p>School-based interventions were usually delivered by teachers and occasionally by peer leaders, health educators, nurses, medical students, charity workers, health personnel and research assistants. Community-based interventions were predominantly delivered by health personnel (nurses, health visitors). Training of these facilitators is identified as an important characteristic of effective intervention (Johnson et al. [<reflink idref="bib20" id="ref107">20</reflink>]; Robin et al. [<reflink idref="bib37" id="ref108">37</reflink>]; Yamada et al. [<reflink idref="bib45" id="ref109">45</reflink>]). More than one review also suggests that trained peer educators could be more effective than adult facilitators (Applegate [<reflink idref="bib2" id="ref110">2</reflink>]; Darbes [<reflink idref="bib9" id="ref111">9</reflink>]; Peersman et al. [<reflink idref="bib36" id="ref112">36</reflink>]).</p> <hd id="AN0043641162-19">Setting of interventions</hd> <p>Community-based studies seem to be more effective than school-based programmes but this may be due to the generally low percentage of distribution of contraceptives in school-based clinics compared with community-based clinics (Franklin et al. [<reflink idref="bib12" id="ref113">12</reflink>]). Another reason may be that schools are culturally very diverse and what SRE entails and how it is presented is influenced by the opinions of school teachers (Peersman et al. [<reflink idref="bib36" id="ref114">36</reflink>]).</p> <hd id="AN0043641162-20">Ethnicity and cultural sensitivity</hd> <p>Interventions that took place among a single ethnic group (five studies; odds ratio = 0.46 (95% CI 0.35–0.59)) instead of mixed ethnic groups (11 studies; odds ratio = 0.77 (95% CI 0.45–1.33)) in classrooms had more positive outcomes. This indicates the importance of cultural fit while approaching this sensitive topic (Mullen et al. [<reflink idref="bib33" id="ref115">33</reflink>]). Young people from different cultures seem to behave differently to reduce sexual risk. It was found that African Americans, for example, were more likely to reduce their number of unprotected sexual partners and Latino students tended to delay the initiation of sexual intercourse and increase contraceptive use (Darbes [<reflink idref="bib9" id="ref116">9</reflink>]), whereas white adolescents attempted to decrease their risk by using condoms (Kirby [<reflink idref="bib24" id="ref117">24</reflink>]). Although reviews highlight the importance of ethnic similarity of the participants and cultural sensitivity of the intervention programme (Darbes [<reflink idref="bib9" id="ref118">9</reflink>]; Jemmott and Jemmott [<reflink idref="bib19" id="ref119">19</reflink>]; Johnson et al. [<reflink idref="bib20" id="ref120">20</reflink>]; Mullen et al. [<reflink idref="bib33" id="ref121">33</reflink>]), the majority of intervention programmes were conducted in the USA among African-American and Hispanic populations as identified by other reviews (Simkhada et al. [<reflink idref="bib39" id="ref122">39</reflink>]). Paucity of these culturally specific interventions in Caucasian populations makes it difficult to generalise the effectiveness of the interventions in this group. It would be interesting to investigate why these interventions are focused in these specific populations even if they are conducted in countries dominated by Caucasians.</p> <hd id="AN0043641162-21">Cost of the interventions</hd> <p>Cost-effectiveness, which is crucial in implementation of sustainable interventions, is very rarely reported by primary programmes (Applegate [<reflink idref="bib2" id="ref123">2</reflink>]). One programme reported that it costs US$3 per student for health education (Peersman et al. [<reflink idref="bib36" id="ref124">36</reflink>]). Another review (Dickson et al. 1997) reported that provision of contraceptive services to a teenager saved UK£377, and general practitioner provision of oral contraception was estimated to save £466 per unwanted pregnancy avoided when compared with no service.</p> <hd id="AN0043641162-22">Barriers and facilitators identified</hd> <p>Resistance from school boards, refusal by teachers to deliver some behavioural aspects to students such as condom use, especially in primary schools and attitudes of the personnel delivering the interventions are among important barriers identified by a number of reviews (Applegate [<reflink idref="bib2" id="ref125">2</reflink>]; Gallant and Maticka-Tyndale [<reflink idref="bib14" id="ref126">14</reflink>]; Magnussen et al. [<reflink idref="bib27" id="ref127">27</reflink>]). However, there is some evidence to suggest that involvement and approval of the community and parents are key factors in improving behavioural intentions. Culturally sensitive programmes, which are matched for gender and ethnicity and use trained peers, facilitate the effectiveness of the interventions (Applegate [<reflink idref="bib2" id="ref128">2</reflink>]; Pedlow and Carey [<reflink idref="bib34" id="ref129">34</reflink>]).</p> <hd id="AN0043641162-23">Discussion</hd> <p>This review has tried to synthesise the evidence from various systematic reviews over the past two decades that assessed the effectiveness of the sex and relationship interventions. Age of sexual initiation is decreasing (Bozon and Kontula [<reflink idref="bib4" id="ref130">4</reflink>]) and risk-taking behaviour seems to be harder to change once young people become sexually active (Dickson et al. 1997). One of the key findings from this review is that whereas the majority of interventions targeted youth who were already sexually active, evidence suggests that starting SRE before young people become sexually active may postpone their sexual debut (Jemmott and Jemmott [<reflink idref="bib19" id="ref131">19</reflink>]; Meschke, Bartholomae, and Zentall [<reflink idref="bib29" id="ref132">29</reflink>]; Morrison-Beedy and Nelson [<reflink idref="bib32" id="ref133">32</reflink>]; Pedlow and Carey [<reflink idref="bib34" id="ref134">34</reflink>]). However, the ideal age for the initiation of SRE still needs to be explored paying attention to the issues of parental consent and sex terminology. Language and content in SRE should always be age-appropriate, taking account of young peoples' biological and psychological maturity (Pedlow and Carey [<reflink idref="bib35" id="ref135">35</reflink>]; Peersman et al. [<reflink idref="bib36" id="ref136">36</reflink>]). In spite of evidence in the literature that sex education does not increase sexual activity in young people (Dickson et al. 1997; Grunseit et al. [<reflink idref="bib15" id="ref137">15</reflink>]; Kirby [<reflink idref="bib24" id="ref138">24</reflink>]), parents might be concerned about possible harmful effects of SRE on younger children and stronger research evidence of any benefits or adverse effects of SRE in younger children is required to convince parents. Interventions should be interactive by involving young people physically and emotionally in learning various skills and the values of stable relationships.</p> <p>Evidence shows that modifying risky sexual behaviour is more difficult in spite of improvements achieved in knowledge and attitudes. The behavioural outcome that is most influenced by interventions seems to be condom use (Jemmott and Jemmott [<reflink idref="bib19" id="ref139">19</reflink>]; Kim et al. [<reflink idref="bib22" id="ref140">22</reflink>]; Yamada et al. [<reflink idref="bib45" id="ref141">45</reflink>]), so provision of condoms and teaching skills to use them should be encouraged further in those who are already sexually active. Condom usage also seems to be influenced by the perception of the risks by adolescents, as it is higher in HIV-focused programmes than general sexual and relationship education programmes (SREPs) that cover pregnancy and other STIs (Kirby [<reflink idref="bib24" id="ref142">24</reflink>]). More research is required on educational interventions to increase adolescent risk perception, which might then lead to change in their behaviour and also to identify barriers and facilitators. There also seems to be a gender difference in risk perception. Perhaps because the direct implications of risky sexual behaviour is greater for girls (pregnancy, STIs leading to infertility), they tend to be more receptive to SRE than males. Attention needs to be paid to recruit more males into SRE interventions/programmes and ensure the male partners are taught responsible sexual behaviour. As sexual behaviour often takes place in emotionally and sexually charged contexts, further research is required to develop risk reduction strategies tailored to such high arousal contexts (Johnson et al. [<reflink idref="bib20" id="ref143">20</reflink>]).</p> <p>Young people are a heterogeneous group in terms of development and social contexts in which they live. The idea of not bombarding young people with too many 'behavioural change' messages at the same time has been much discussed since the 1990s (Kirby et al. [<reflink idref="bib25" id="ref144">25</reflink>]; Robin et al. [<reflink idref="bib37" id="ref145">37</reflink>]; Speizer, Magnani, and Colvin [<reflink idref="bib41" id="ref146">41</reflink>]). Although the current drive is towards multifaceted and multi-targeted interventions, in a sensitive and complicated topic, such as sex education, interventions/programmes might need to take the developmental stage of young people into consideration and provide enough time to understand different aspects and practice the skills. Most of the interventions for young people seem to be conducted in schools, with either a one-off session or multiple sessions over a few days overloading them with many messages and targets. Multi-targeting might be efficient if carried out over a period of time in a planned, step-wise manner. For example: step 1, education on delaying sexual initiation in young teens who are still sexually inactive, incorporating and emphasising the values of relationships and good job prospects; step 2, awareness of consequences of irrational and risky sexual behaviour; step 3, to educate older youngsters on safe sex methods and contraceptives; and step 4, skills training to use contraception. However, different approaches and time periods might be necessary to deliver SRE effectively but the evidence for the ideal duration of intervention seems to be inconsistent in the literature. Taking developmental factors into consideration, multiple sessions of relevant age-specific interventions might be more effective than short-term interventions. However, these require more resources and commitment and may be subject to higher attrition rates.</p> <p>Although reviews suggest parental and peer group involvement to improve effectiveness, there is not enough evidence in the literature of the benefits of this. Assessment of effectiveness and appropriateness of peer-delivered health promotion interventions in young people for other health outcomes (Harden [<reflink idref="bib17" id="ref147">17</reflink>]) found unconvincing evidence in bringing positive changes in health behaviour. Parental involvement in SRE seems to increase communication between adolescents and parents (Meschke, Bartholomae, and Zentall [<reflink idref="bib29" id="ref148">29</reflink>]), but studies have not followed them long enough to assess changes in sexual behaviour of youth. Parental communication might also have potential negative effects on young people as the discussion could be biased by parents' beliefs and values, which also require investigation. Appropriate training to peers, parents and personnel involved in teaching sex education in schools is crucial to promoting unbiased messages.</p> <hd id="AN0043641162-24">Future research</hd> <p>One of the main findings from this review is that young people need to be taught sex education before they become sexually active, but the ideal age of initiating sexual education needs to be investigated further, primarily focusing on delaying the age of initiation of sex. Research that would shed some light on targeting specific behaviour rather than targeting multiple outcomes at any one point of time and the optimum duration for delivering these messages is urgently needed. Involvement of parents and peers in SREPs should be evaluated thoroughly before implementation. More primary studies specifically in Caucasian populations are needed to identify their risk perception, barriers and facilitators, as most of the studies tend to be conducted in African-American populations and the youngsters across different ethnic groups differ from each other in their beliefs and behaviour. Assessment of cost-effectiveness of interventions/programmes and long-term sustainability of the effectiveness is required. Qualitative studies looking into 'Why interventions work' would add to the understanding of 'What intervention works' in the field of SRE.</p> <hd id="AN0043641162-25">Acknowledgements</hd> <p>Thanks to NHS Health Scotland for funding this project. The views expressed in this paper are those of the authors, not the funders.</p> <ref id="AN0043641162-26"> <title> References </title> <blist> <bibl id="bib1" idref="ref6" type="bt">1</bibl> <bibtext> Agha, S.2002. 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Tucker; Kate Philip; Jenny Spratt; Lakshmi Mandava and Edwin van Teijlingen</p> <p>Reported by Author; Author; Author; Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib34" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib18" firstref="ref2"></nolink> <nolink nlid="nl3" bibid="bib43" firstref="ref3"></nolink> <nolink nlid="nl4" bibid="bib10" firstref="ref4"></nolink> <nolink nlid="nl5" bibid="bib44" firstref="ref5"></nolink> <nolink nlid="nl6" bibid="bib23" firstref="ref8"></nolink> <nolink nlid="nl7" bibid="bib26" firstref="ref9"></nolink> <nolink nlid="nl8" bibid="bib14" firstref="ref10"></nolink> <nolink nlid="nl9" bibid="bib15" firstref="ref11"></nolink> <nolink nlid="nl10" bibid="bib21" firstref="ref12"></nolink> <nolink nlid="nl11" bibid="bib30" firstref="ref16"></nolink> <nolink nlid="nl12" bibid="bib19" firstref="ref20"></nolink> <nolink nlid="nl13" bibid="bib20" firstref="ref21"></nolink> <nolink nlid="nl14" bibid="bib22" firstref="ref23"></nolink> <nolink nlid="nl15" bibid="bib27" firstref="ref24"></nolink> <nolink nlid="nl16" bibid="bib32" firstref="ref25"></nolink> <nolink nlid="nl17" bibid="bib33" firstref="ref26"></nolink> <nolink nlid="nl18" bibid="bib35" firstref="ref28"></nolink> <nolink nlid="nl19" bibid="bib45" firstref="ref29"></nolink> <nolink nlid="nl20" bibid="bib12" firstref="ref32"></nolink> <nolink nlid="nl21" bibid="bib13" firstref="ref33"></nolink> <nolink nlid="nl22" bibid="bib16" firstref="ref34"></nolink> <nolink nlid="nl23" bibid="bib31" firstref="ref35"></nolink> <nolink nlid="nl24" bibid="bib25" firstref="ref37"></nolink> <nolink nlid="nl25" bibid="bib24" firstref="ref38"></nolink> <nolink nlid="nl26" bibid="bib28" firstref="ref39"></nolink> <nolink nlid="nl27" bibid="bib29" firstref="ref40"></nolink> <nolink nlid="nl28" bibid="bib36" firstref="ref41"></nolink> <nolink nlid="nl29" bibid="bib37" firstref="ref42"></nolink> <nolink nlid="nl30" bibid="bib40" firstref="ref43"></nolink> <nolink nlid="nl31" bibid="bib41" firstref="ref44"></nolink> <nolink nlid="nl32" bibid="bib42" firstref="ref45"></nolink> <nolink nlid="nl33" bibid="bib38" firstref="ref104"></nolink> <nolink nlid="nl34" bibid="bib39" firstref="ref122"></nolink> <nolink nlid="nl35" bibid="bib17" firstref="ref147"></nolink>
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  Data: Characteristics of Effective Interventions in Improving Young People's Sexual Health: A Review of Reviews
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  Label: Abstract
  Group: Ab
  Data: The purpose of this paper is to conduct a review of reviews to identify characteristics of effective sex and relationship education (SRE) interventions and/or programmes in young people to improve sexual health and identify barriers and facilitators for implementation. Six bibliographic databases were searched from 1986 to 2006 for systematic reviews that assessed SRE interventions or programmes in participants between 10 and 18 years old and their partners. All outcomes of improvement in sexual health were assessed and 30 systematic reviews were included. Effective interventions and/or programmes tended to be those targeting younger age groups before they become sexually active, focused interventions tailored to the physical and biological development stages, theory based, and abstinence education programmes that incorporate values of relationships and provide skills training and links to contraceptive services. Adequate training of personnel delivering the interventions and culturally sensitive programmes were identified as important facilitators of effectiveness. Future research should explore the appropriate age for initiating sex education and investigate targeting specific behaviour compared with multiple-outcome targeting. Research exploring the reasons for interventions focusing on specific populations (i.e. African and Hispanic origins), even if they were conducted in countries dominated by Caucasians, is warranted. (Contains 4 tables.)
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: Ref
  Label: Number of References
  Group: RefInfo
  Data: 45
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2010
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ865878
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ865878
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1080/14681810903059185
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 18
        StartPage: 319
    Subjects:
      – SubjectFull: Sex Education
        Type: general
      – SubjectFull: Bibliographic Databases
        Type: general
      – SubjectFull: Preadolescents
        Type: general
      – SubjectFull: Early Adolescents
        Type: general
      – SubjectFull: Adolescents
        Type: general
      – SubjectFull: Literature Reviews
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Sexuality
        Type: general
      – SubjectFull: Health
        Type: general
      – SubjectFull: Interpersonal Relationship
        Type: general
      – SubjectFull: Barriers
        Type: general
      – SubjectFull: Program Effectiveness
        Type: general
      – SubjectFull: Program Evaluation
        Type: general
      – SubjectFull: Physical Development
        Type: general
      – SubjectFull: Values
        Type: general
      – SubjectFull: Culturally Relevant Education
        Type: general
      – SubjectFull: Developmentally Appropriate Practices
        Type: general
      – SubjectFull: Acquired Immunodeficiency Syndrome (AIDS)
        Type: general
    Titles:
      – TitleFull: Characteristics of Effective Interventions in Improving Young People's Sexual Health: A Review of Reviews
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Poobalan, Amudha S.
      – PersonEntity:
          Name:
            NameFull: Pitchforth, Emma
      – PersonEntity:
          Name:
            NameFull: Imamura, Mari
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 08
              Type: published
              Y: 2009
          Identifiers:
            – Type: issn-print
              Value: 1468-1811
          Numbering:
            – Type: volume
              Value: 9
            – Type: issue
              Value: 3
          Titles:
            – TitleFull: Sex Education: Sexuality, Society and Learning
              Type: main
ResultId 1