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School-based interventions to prevent HIV, STIs & adolescent pregnancy: What's the evidence?

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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

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.

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School-based interventions to prevent HIV, STIs & adolescent pregnancy: What's the evidence?

  1. 1. Welcome! School-based interventions to prevent HIV, STIs & adolescent pregnancy: What's the evidence? You will be placed on hold until the webinar begins. The webinar will begin shortly, please remain on the line.
  2. 2. Poll Questions: Consent • Participation in the webinar poll questions is voluntary • Names are not recorded and persons will not be identified in any way • Participation in the anonymous polling questions is accepted as an indication of your consent to participate Benefits: • Results inform improvement of the current and future webinars • Enable engagement; stimulate discussion. This session is intended for professional development. Some data may be used for program evaluation and research purposes (e.g., exploring opinion change) • Results may also be used to inform the production of systematic reviews and overviews Risks: None beyond day-to-day living
  3. 3. After Today • The PowerPoint presentation and audio recording will be made available • These resources are available at: – PowerPoint: http://www.slideshare.net/HealthEvidence – Audio Recording: https://www.youtube.com/user/healthevidence /videos 3
  4. 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
  5. 5. • Use CHAT to post comments / questions during the webinar – ‘Send’ questions to All (not privately to ‘Host’) • Connection issues – Recommend using a wired Internet connection (vs. wireless) • WebEx 24/7 help line – 1-866-229-3239 Participant Side Panel in WebEx Housekeeping
  6. 6. Housekeeping (cont’d) • Audio – Listen through your speakers – Go to ‘Communicate > Audio Broadcast’ • WebEx 24/7 help line – 1-866-229-3239
  7. 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
  8. 8. The Health Evidence™ Team Maureen Dobbins Scientific Director Heather Husson Manager Susannah Watson Project Coordinator Students: Emily Belita (PhD candidate) Jennifer Yost Assistant Professor Olivia Marquez Research Coordinator Emily Sully Research Assistant Liz Kamler Research Assistant Zhi (Vivian) Chen Research Assistant Research Assistants: Lina Sherazy Claire Howarth Rawan Farran
  9. 9. What is www.healthevidence.org? Evidence Decision Making inform
  10. 10. Why use www.healthevidence.org? 1. Saves you time 2. Relevant & current evidence 3. Transparent process 4. Supports for EIDM available 5. Easy to use
  11. 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. 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. 13. Poll Question #2 Have you heard of PICO(S) before? A. Yes B. No
  14. 14. Searchable Questions Think “PICOS” 1.Population (situation) 2.Intervention (exposure) 3.Comparison (other group) 4.Outcomes 5.Setting
  15. 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. 16. Dr. Amanda Mason-Jones Department of Health Sciences University of York
  17. 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. 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. 19. Altmetric
  20. 20. Media attention
  21. 21. Media attention
  22. 22. Media attention
  23. 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. 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. 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. 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. 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. 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. 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. 30. Results • 1183 unique references after duplicates were removed • 1112 excluded articles • 71 full-text articles screened • 8 cluster randomised trials included
  31. 31. 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
  32. 32. 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
  33. 33. Type of intervention • Educational • Incentive • Combined incentive plus education
  34. 34. 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
  35. 35. Logic model
  36. 36. 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
  37. 37. 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
  38. 38. Comparisons 1. Educational interventions versus no intervention 2. Incentive programmes versus no intervention 3. Educational intervention and incentive versus no intervention
  39. 39. Educational interventions- HSV2
  40. 40. Educational interventions- Pregnancy
  41. 41. Incentives- HSV2
  42. 42. Incentives- self reported debut
  43. 43. Incentives- pregnancy
  44. 44. Incentive plus education- HSV2
  45. 45. Risk of bias
  46. 46. Risk of bias- included studies
  47. 47. Risk of bias
  48. 48. Risk of bias • Random sequence generation • Recruitment bias • Baseline imbalance • Allocation concealment • Blinding • Incomplete outcome data • Selective reporting • Other potential sources of bias
  49. 49. 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.
  50. 50. Educational interventions
  51. 51. Incentives
  52. 52. Discussion • Completeness and applicability • Quality of the evidence • Potential biases in the review process • Agreements and disagreements with other studies or reviews
  53. 53. 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)
  54. 54. 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
  55. 55. 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]
  56. 56. Poll Question #4 The information presented today was helpful A. Strongly agree B. Agree C. Neutral D. Disagree E. Strongly disagree
  57. 57. What can I do now? Visit the website; a repository of over 5,000 quality-rated systematic reviews related to the effectiveness of public health interventions. Health Evidence™ is FREE to use. Register to receive monthly tailored registry updates AND monthly newsletter to keep you up to date on upcoming events and public health news. Tell your colleagues about Health Evidence™: helping you use best evidence to inform public health practice, program planning, and policy decisions! Follow us @HealthEvidence on Twitter and receive daily public health review- related Tweets, receive information about our monthly webinars, as well as announcements and events relevant to public health. Encourage your organization to use Health Evidence™ to search for and apply quality-rated review level evidence to inform program planning and policy decisions. Contact us to suggest topics or provide feedback. info@healthevidence.org
  58. 58. 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
  59. 59. Thank you! Contact us: info@healthevidence.org For a copy of the presentation please visit: http://www.healthevidence.org/webinars.aspx