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-

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]

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]

Poll Question #2

Have you heard of PICO(S) before?

A. Yes

B. No

Searchable Questions Think “PICOS”

1.Population (situation)

2.Intervention (exposure)

3.Comparison (other group)

4.Outcomes

5.Setting

How often do you use Systematic Reviews

to inform a program/services?

A. Always

B. Often

C. Sometimes

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E. I don’t know what a systematic review is

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

A. Strongly agree

B. Agree

C. Neutral

D. Disagree

E. Strongly disagree

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Poll Question #5

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