Health Evidence hosted a 60 minute webinar examining the effectiveness of school-based interventions for preventing HIV, sexually transmitted infections and pregnancy in adolescents. Click here for access to the audio recording for this webinar: https://youtu.be/yCeIEQ4OTCc Amanda Mason-Jones, Senior Lecturer in Global Public Health, Faculty of Science, University of York led the session and presented findings from her recent Cochrane review: Mason-Jones A, Sinclair D, Mathews C, Kagee A, Hillman A, & Lombard C. (2016). School-based interventions for preventing HIV, sexually transmitted infections, and pregnancy in adolescents.Cochrane Database of Systematic Reviews, 2016(11), CD006417 http://healthevidence.org/view-article.aspx?a=school-based-interventions-preventing-hiv-sexually-transmitted-infections-29881 Sexually active adolescents are at risk of contracting HIV and STIs. Unintended pregnancy can have detrimental impact on young people’s lives. This review examines the impact of school sexual education programs on number of young people that contract STIs and number of adolescent pregnancies. Eight cluster randomized control trials, including 55,157 participants are included in this review. Findings suggest there is little evidence that school programs alone are effective in improving sexual and reproductive health outcomes for adolescents. This webinar examined the effectiveness and components of interventions that prevent HIV, STIs and adolescent pregnancy.

1. Welcome!
School-based interventions to
prevent HIV, STIs &
adolescent pregnancy: What's
the evidence?
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3

4. What’s the evidence?
Mason-Jones A, Sinclair D, Mathews C, Kagee
A, Hillman A, & Lombard C. (2016). School-
based interventions for preventing HIV,
sexually transmitted infections, and
pregnancy in adolescents. Cochrane
Database of Systematic Reviews, 2016(11),
CD006417
http://www.healthevidence.org/view-
article.aspx?a=school-based-interventions-preventing-
hiv-sexually-transmitted-infections-29881

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7. Poll Question #1
How many people are watching
today’s session with you?
A. Just me
B. 2-3
C. 4-5
D. 6-10
E. >10

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10. Why use www.healthevidence.org?
1. Saves you time
2. Relevant & current evidence
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4. Supports for EIDM available
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11. A Model for Evidence-
Informed Decision Making
National Collaborating Centre for Methods and Tools. (revised 2012). A
Model for Evidence-Informed Decision-Making in Public Health (Fact
Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

12. Stages in the process of
Evidence-Informed Public Health
National Collaborating Centre for Methods and Tools. Evidence-Informed
Public Health. [http://www.nccmt.ca/eiph/index-eng.html]

13. Poll Question #2
Have you heard of PICO(S) before?
A. Yes
B. No

14. Searchable Questions Think “PICOS”
1.Population (situation)
2.Intervention (exposure)
3.Comparison (other
group)
4.Outcomes
5.Setting

15. How often do you use Systematic Reviews
to inform a program/services?
A. Always
B. Often
C. Sometimes
D. Never
E. I don’t know what a systematic review is
Poll Question #3

16. Dr. Amanda Mason-Jones
Department of Health Sciences
University of York

17. The team
• David Sinclair, Liverpool School of Tropical
Medicine, England.
• Cathy Mathews, Health Systems Research Unit,
South African Medical Research Council (MRC).
• Ashraf Kagee, Department of Psychology,
Stellenbosch University, South Africa.
• Alex Hillman, Department of Health Sciences,
University of York, England.
• Carl Lombard, Biostatistics Unit, South African
MRC.

18. Acknowledgements
• Joy Oliver, South African Cochrane Centre
• Paul Garner & Ann-Marie Stephani, Cochrane
Infectious Diseases Group, Liverpool School of
Tropical Medicine
• Hasci Horvath, HIV/AIDS Collaborative review
group, University of California, San Francisco
• Alan Flisher & Wanjiru Mukoma, University of
Cape Town
• Jimmy Volmink- Stellenbosch University

19. Altmetric

20. Media attention

21. Media attention

22. Media attention

23. Research question
• Can school-based sexual and reproductive
health programmes reduce sexually
transmitted infections (such as HIV,
herpes simplex virus, and syphilis), and
pregnancy among adolescents?

24. Inclusion criteria
• Population- adolescents 10-19 attending
school
• Intervention- any that aimed to reduce risk
of HIV, STIs and pregnancy
• Comparison- usual practice/other
intervention
• Outcome- ‘Biological’ outcomes, HIV, STIs,
and pregnancy objectively measured
• Study design-Randomised controlled trials

25. Search strategy
Search dates: 1 Jan 1990-7 April 2016
• MEDLINE
• Embase
• CENTRAL
• WHO International Clinical Trials Registry
Platform
• ClinicalTrials.gov
• Conference databases (AIDS, AEGIS)
• NLM GATEWAY)
• Other resources (CDC, CRD, WHO, reference
lists, other researchers)

26. Data collection
• Two reviewers independently reviewed all
studies (titles and abstracts)
• Full text articles were obtained for all
identified as potentially relevant
• Second screening for inclusion/exclusion
• New/ongoing studies were also identified

27. Data extraction and
management
• Data were extracted for all included studies
independently by two authors (location,
context, theoretical framework,
participants, interventions, quality and
results).
• Any discrepancies or disagreements were
resolved by looking at the
original/supporting papers or contacting the
authors
• Trials with multiple publications were
managed as one study

28. Analysis
• Relative risk of the outcome was used
and we reported risk ratios (RR) with 95%
confidence intervals (CIs)
• If odds ratios and CIs were reported this
was used to estimate the design effect
and intraclass correlation coefficient
• Multiple interventions in one trial were
analysed separately

29. Quality and risk of bias
• The GRADE approach was used to assess
the quality of evidence
• The Cochrane risk of bias assessment tool
for cluster RCTs was used

30. Results
• 1183 unique references after duplicates
were removed
• 1112 excluded articles
• 71 full-text articles screened
• 8 cluster randomised trials included

32. Excluded studies
• Reasons for exclusion
– 26 with no biological outcomes
– 10 not school-based
– 12 were not randomised controlled trials
– 11 systematic reviews
– 4 protocol/early reports

33. Included studies
• Eight cluster randomised trials
• Countries- Chile, England, Kenya, Malawi,
Scotland, South Africa, Tanzania,
Zimbabwe
• 281 clusters
• Cluster size ranged from 18-461
• 55,157 participants
• Follow up from 18 months to 7 years

34. Type of intervention
• Educational
• Incentive
• Combined incentive plus education

35. Educational interventions
• Theoretical frameworks focused on
changing knowledge, attitudes,
behaviours and social norms
• From three one-hour sessions over one
year to 36 sessions of 40 minutes over
three years
• Used peer educators or teachers/adult
facilitators to deliver programmes
• Drama, games, role play, gender roles

36. Logic model

37. Incentive-based interventions
• Theoretical framework based on ‘upstream
factors’ that influence sexual health
outcomes such as poverty, inequality and
school attendance
• Incentives given such as cash (USD1-5 for
participant and USD 4-10 for family) or other
material transfer (two school uniforms)
which were either:
– Conditional (e.g. on school attendance)
– Unconditional

38. Outcome measurement
• HIV, HSV2 and other STIs measured by:
– Dried blood spots
– Blood sera
– Urine tests
• Pregnancy (current) measured by:
– Urine tests
• Pregnancy at follow up measured by:
– Linkage to health service records
– School reports

39. Comparisons
1. Educational interventions versus no
intervention
2. Incentive programmes versus no
intervention
3. Educational intervention and incentive
versus no intervention

40. Educational interventions- HSV2

41. Educational interventions-
Pregnancy

42. Incentives- HSV2

43. Incentives- self reported
debut

44. Incentives- pregnancy

45. Incentive plus education-
HSV2

46. Risk of bias

47. Risk of bias- included studies

48. Risk of bias

49. Risk of bias
• Random sequence generation
• Recruitment bias
• Baseline imbalance
• Allocation concealment
• Blinding
• Incomplete outcome data
• Selective reporting
• Other potential sources of bias

50. Grade approach
• High certainty: further research is very unlikely to
change our confidence in the estimate of effect.
• Moderate certainty: further research is likely to have
an important impact on our confidence in the
estimate of effect and may change the estimate.
• Low certainty: further research is very likely to have
an important impact on our confidence in the
estimate of effect and is likely to change the
estimate.
• Very low certainty: we are very uncertain about the
estimate.

51. Educational interventions

52. Incentives

53. Discussion
• Completeness and applicability
• Quality of the evidence
• Potential biases in the review process
• Agreements and disagreements with
other studies or reviews

54. Ongoing studies
• 5 ongoing studies
• 4 Cluster RCT/1 Individually randomised
study
• South Africa (educational intervention)
• South Africa (incentive plus education)
• South Africa (incentive only)
• Botswana (educational intervention)
• India (educational intervention)

55. Conclusions
• Implications for practice
– Sexual and relationship health provision
• Implications for research
– Logic model
– Theoretical approaches
– Length of intervention
– Length of follow up
– Outcome measures

57. A Model for Evidence-
Informed Decision Making
National Collaborating Centre for Methods and Tools. (revised 2012). A
Model for Evidence-Informed Decision-Making in Public Health (Fact
Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

58. Poll Question #4
The information presented today was
helpful
A. Strongly agree
B. Agree
C. Neutral
D. Disagree
E. Strongly disagree

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60. Poll Question #5
What are your next steps? [Check all
that apply]
A. Access the full text systematic review
B. Access the quality assessment for the
review on www.healthevidence.org
C. Consider using the evidence
D. Tell a colleague about the evidence

61. Thank you!
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