The sexual and reproductive health of adolescents and young people is important both for them as they enter adult life and for the next generation. School-based interventions can help with this and an updated Cochrane Review from November 2016 brings together the evidence. Lead author, Amanda Mason-Jones from the University of York in the UK, tells us what she and her colleagues have found.
John: Hello, I'm John Hilton, editor of the Cochrane Editorial unit. The sexual and reproductive health of adolescents and young people is important both for them as they enter adult life and for the next generation. School-based interventions can help with this and an updated Cochrane Review from November 2016 brings together the evidence. Lead author, Amanda Mason-Jones from the University of York in the UK, tells us what she and her colleagues have found.
Amanda: The sexual and reproductive wellbeing of adolescents and young people has been largely neglected, despite the potential impact on public health. They continue to be at high risk of sexually transmitted infections including HIV, with over half of new HIV infections occurring in the 15-24 year age group and the African region continues to have 90% of the world’s HIV-related adolescent deaths. Similarly, although there has been a downward trend in adolescent pregnancies worldwide, inequalities exist both between and within countries. Most pregnancies to young women under the age of 18 are unwanted and many are terminated. Countries with restrictive abortion laws have high levels of maternal mortality from unsafe abortions, and unwanted pregnancies that continue are associated with adverse outcomes for both the mother and infant’s health. Poverty, family disruption, leaving school early and intimate partner violence have all been associated with poor sexual and reproductive health outcomes in young people, particularly girls.
The school environment has been considered to be an appropriate and accessible setting to promote adolescent sexual and reproductive health because it brings large numbers of young people together within an established infrastructure. It also plays a pivotal role in socialisation and the development of relationships that influence behaviour within and beyond school.
We investigated whether school-based programmes could reduce HIV, STIs and pregnancy outcomes in adolescents. We found eight, mostly well conducted, cluster randomised trials involving a total of more than 55,000 participants from Chile, England, Kenya, Malawi, Scotland, South Africa, Tanzania and Zimbabwe. The trials were from both rural and urban areas, and follow up ranged from 18 months to 7 years. The overall quality of the evidence was low to moderate, mainly because there were so few trials.
Combining the results, we found that keeping young people at school using incentives to address so called ‘upstream factors’ such as poverty, did reduce pregnancy and STIs. But there is insufficient evidence that educational programmes delivered at school reduced these outcomes.
Some trials also included self-reported measures of behaviour, which are generally the outcomes measured in adolescent sexual health research. We found that trials that included an incentive to stay at school delayed young people’s first sexual encounter whilst educational interventions did not. But, neither type of intervention increased self-reported condom use at first or last sex.
In summary, incentive-based interventions that focus on keeping young people in school have shown some promising, though conflicting, early results. Ongoing trials are investigating these types of interventions and when we update this review we will be able to clarify some of the current inconsistencies in the evidence. However, curriculum-based educational interventions did not change adolescent behaviour sufficiently to reduce adverse sexual health outcomes. It may be that they do not fully address the wider structural, cultural or gender norms that affect sexual health outcomes, so further work is needed to understand young people’s sexual health decision-making and the influences in their relationships that lead to adverse outcomes.
John: To read more about the evidence that Amanda and her colleagues have already been able to include in the review, and to watch for future updates as ongoing and new trials become available, you’ll find it at Cochrane Library dot com. It’s free to all and can be found with a search for ‘School-based interventions for preventing HIV’.