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

Welcome!School-based interventions to

prevent HIV, STIs &

adolescent pregnancy: What's

the evidence?

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3

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),

CD006417http://www.healthevidence.org/view-

article.aspx?a=school-based-interventions-preventing-

hiv-sexually-transmitted-infections-29881

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A Model for Evidence-

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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]

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National Collaborating Centre for Methods and Tools. Evidence-Informed

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Searchable Questions Think “PICOS”

1.Population (situation)

2.Intervention (exposure)

3.Comparison (other group)

4.Outcomes

5.Setting

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Poll Question #3

Dr. Amanda Mason-Jones

Department of Health Sciences

University of York

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.

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

Altmetric

Media attention

Media attention

Media attention

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?

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

Search strategySearch 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)

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

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

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

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

Results

• 1183 unique references after duplicates

were removed

• 1112 excluded articles

• 71 full-text articles screened

• 8 cluster randomised trials included

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

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

Type of intervention

• Educational

• Incentive

• Combined incentive plus education

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

Logic model

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

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

Comparisons

1. Educational interventions versus no

intervention

2. Incentive programmes versus no

intervention

3. Educational intervention and incentive

versus no intervention

Educational interventions- HSV2

Educational interventions-

Pregnancy

Incentives- HSV2

Incentives- self reported

debut

Incentives- pregnancy

Incentive plus education-

HSV2

Risk of bias

Risk of bias- included studies

Risk of bias

Risk of bias

• Random sequence generation

• Recruitment bias

• Baseline imbalance

• Allocation concealment

• Blinding

• Incomplete outcome data

• Selective reporting

• Other potential sources of bias

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.

Educational interventions

Incentives

Discussion

• Completeness and applicability

• Quality of the evidence

• Potential biases in the review process

• Agreements and disagreements with

other studies or reviews

Ongoing studies

• 5 ongoing studies

• 4 Cluster RCT/1 Individually randomisedstudy

• South Africa (educational intervention)

• South Africa (incentive plus education)

• South Africa (incentive only)

• Botswana (educational intervention)

• India (educational intervention)

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

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]

Poll Question #4

The information presented today was

helpful

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C. Neutral

D. Disagree

E. Strongly disagree

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