Kristien Michielsen

Effectiveness of HIV prevention for youth in sub-Saharan Africa: systematic review and meta-analysis of randomized and nonrandomized trials

Objective:Systematically assess the effectiveness of HIV-prevention interventions in changing sexual behaviour of young people (10–25 years) in sub-Saharan Africa. Methods:Three online databases were searched using prespecified terms. Additional articles were identified on websites of international organizations and by searching bibliographies. Randomized and nonrandomized trials of interventions aiming to reduce risk behaviour were included as well as single-arm studies reporting effects of differential exposure to an intervention. Data were extracted independently in duplicate using predefined data fields. Results:Thirty-one studies on 28 interventions met the inclusion criteria, including 11 randomized trials. Difficulties with implementing planned activities were reportedly common and differential exposure to intervention was high. Two hundred and seventeen outcome measures were extracted: 88 early (within 1 year of intervention) and 129 late outcomes (more than 1 year after the end of the intervention). Sex education and condom promotion among youth did not increase sexual behaviour as well as risky sexual behaviour. No positive effects on sexual behaviour were detected either and condom use at last sex only increased among males [relative risk = 1.46; 95% confidence interval = 1.31–1.64]. One study reported a reduction of herpes simplex virus-2, but not HIV incidence. Conclusion:There remains a stark mismatch between the HIV burden in youth and the number of attempts to design and test prevention interventions – only two trials report biological outcomes. More effective interventions targeting youth are needed. Attention should go to studying implementation difficulties, sex differences in responses to interventions, determinants of exposure to interventions and perhaps inclusion of other factors apart from HIV/AIDS which influence sexual behaviour.

Impact of selection strategies on representation of underserved populations and intention to practise: international findings

Socially accountable medical schools aim to reduce health inequalities by training workforces responsive to the priority health needs of underserved communities. One key strategy involves recruiting students from underserved and unequally represented communities on the basis that they may be more likely to return and address local health priorities. This study describes the impacts of different selection strategies of medical schools that aspire to social accountability on the presence of students from underserved communities in their medical education programmes and on student practice intentions.

Nothing as Practical as a Good Theory? The Theoretical Basis of HIV Prevention Interventions for Young People in Sub-Saharan Africa: A Systematic Review

This paper assesses the extent to which HIV prevention interventions for young people in sub-Saharan Africa are grounded in theory and if theory-based interventions are more effective. Three databases were searched for evaluation studies of HIV prevention interventions for youth. Additional articles were identified on websites of international organisations and through searching references. 34 interventions were included; 25 mentioned the use of theory. Social Cognitive Theory was most prominent (n = 13), followed by Health Belief Model (n = 7), and Theory of Reasoned Action/Planned Behaviour (n = 6). These cognitive behavioural theories assume that cognitions drive sexual behaviour. Reporting on choice and use of theory was low. Only three articles provided information about why a particular theory was selected. Interventions used theory to inform content (n = 13), for evaluation purposes (n = 4) or both (n = 7). No patterns of differential effectiveness could be detected between studies using and not using theory, or according to whether a theory informed content, and/or evaluation. We discuss characteristics of the theories that might account for the limited effectiveness observed, including overreliance on cognitions that likely vary according to type of sexual behaviour and other personal factors, inadequately address interpersonal factors, and failure to account for contextual factors.

Effectiveness of a peer-led HIV prevention intervention in secondary schools in Rwanda: results from a non-randomized controlled trial

BackgroundWhile the HIV epidemic is levelling off in sub-Saharan Africa, it remains at an unacceptably high level. Young people aged 15-24 years remain particularly vulnerable, resulting in a regional HIV prevalence of 1.4% in young men and 3.3% in young women. This study assesses the effectiveness of a peer-led HIV prevention intervention in secondary schools in Rwanda on young people’s sexual behavior, HIV knowledge and attitudes.MethodsIn a non-randomized longitudinal controlled trial, fourteen schools were selected in two neighboring districts in Rwanda Bugesera (intervention) and Rwamagana (control). Students (n = 1950) in eight intervention and six control schools participated in three surveys (baseline, six and twelve months in the intervention). Analysis was done using linear and logistic regression using generalized estimation equations adjusted for propensity score.ResultsThe overall retention rate was 72%. Time trends in sexual risk behavior (being sexually active, sex in last six months, condom use at last sex) were not significantly different in students from intervention and control schools, nor was the intervention associated with increased knowledge, perceived severity or perceived susceptibility. It did significantly reduce reported stigma.ConclusionsAnalyzing this and other interventions, we identified several reasons for the observed limited effectiveness of peer education: 1) intervention activities (spreading information) are not tuned to objectives (changing behavior); 2) young people prefer receiving HIV information from other sources than peers; 3) outcome indicators are not adequate and the context of the relationship in which sex occurs and the context in which sex occurs is ignored. Effectiveness of peer education may increase through integration in holistic interventions and redefining peer educators’ role as focal points for sensitization and referral to experts and services. Finally, we argue that a narrow focus on sexual risks will never significantly turn the tide.

HIV among out-of-school youth in Eastern and Southern Africa: a review

The overall decline of the HIV epidemic in Sub-Saharan Africa conceals how the HIV burden has shifted to fall on areas that have been more difficult to reach. This review considers out-of-school youth, a category typically eluding interventions that are school-based. Our review of descriptive studies concentrates on the most affected region, Southern and Eastern Africa, and spans the period between 2000 and 2010. Among the relatively small but increasing number of studies, out-of-school youth was significantly associated with risky sexual behavior (RSB), more precisely with early sexual debut, high levels of partner concurrency, transactional sex, age-mixing, low sexually transmitted infection (STI)/HIV risk perception, a high lifetime number of partners, and inconsistent condom use. Being-in-school not only raises health literacy. The in-school (e.g., age-near) sexual network may also be protective, an effect which the better-studied (and regionally less significant) variable of educational attainment cannot measure. To verify such double effect of being-in-school we need to complement the behavioral research of the past decade with longitudinal cohort analyses that map sexual networks, in various regions.

Sexuality education: what is it?

Abstract This policy brief developed by the European Expert Group on Sexuality Education provides an overview of key issues in sexuality education. It focuses primarily on sexuality education in Europe and Central Asia but is also relevant to countries outside of these regions.

Determinants of Acceptance and Subsequent Uptake of the HPV Vaccine in a Cohort in Eldoret, Kenya

The development of Human Papillomavirus (HPV) vaccines provides new opportunities in the fight against cervical cancer. Many acceptability studies have revealed high interest in these vaccines, but acceptance is only a precursor of behavior, and many factors, at personal, community and provider level, may inhibit the translation of willingness to vaccinate into actual uptake. Through a longitudinal study in Eldoret, Kenya, HPV vaccine acceptability was measured before a vaccination program (n = 287) and vaccine uptake, as reported by mothers, once the program was finished (n = 256). In between baseline and follow-up, a pilot HPV vaccination program was implemented via the GARDASIL Access Program, in which parents could have their daughter vaccinated for free at the referral hospital. The program was promoted at schools: Health staff informed teachers who were then asked to inform students and parents. Even though baseline acceptance was very high (88.1%), only 31.1% of the women reported at follow-up that their daughter had been vaccinated. The vaccine was declined by 17.7%, while another 51.2% had wanted the vaccination but were obstructed by practical barriers. Being well-informed about the program and baseline awareness of cervical cancer were independently associated with vaccine uptake, while baseline acceptance was correlated in bivariate analysis. Side effects were of great concern, even among those whose daughter was vaccinated. Possible partner disapproval lowered acceptance at baseline, and women indeed reported at follow-up that they had encountered his opposition. In Kenya, women prove to be very willing to have their daughter vaccinated against cervical cancer. However, in this study, uptake was more determined by program awareness than by HPV vaccine acceptance. School-based vaccination might improve coverage since it reduces operational problems for parents. In addition, future HPV vaccination campaigns should address concerns about side effects, targeting men and women, given both their involvement in HPV vaccination decision-making.

A cross-sectional study on attitudes toward gender equality, sexual behavior, positive sexual experiences, and communication about sex among sexually active and non-sexually active adolescents in Bolivia and Ecuador.

Background It is widely agreed upon that gender is a key aspect of sexuality however, questions remain on how gender exactly influences adolescents’ sexual health. Objective The aim of this research was to study correlations between gender equality attitudes and sexual behavior, sexual experiences and communication about sex among sexually active and non-sexually active adolescents in 2 Latin American countries. Design In 2011, a cross-sectional study was carried out among 5,913 adolescents aged 14–18 in 20 secondary schools in Cochabamba (Bolivia) and 6 secondary schools in Cuenca (Ecuador). Models were built using logistic regressions to assess the predictive value of attitudes toward gender equality on adolescents’ sexual behavior, on experiences and on communication. Results The analysis shows that sexually active adolescents who consider gender equality as important report higher current use of contraceptives within the couple. They are more likely to describe their last sexual intercourse as a positive experience and consider it easier to talk with their partner about sexuality than sexually experienced adolescents who are less positively inclined toward gender equality. These correlations remained consistent whether the respondent was a boy or a girl. Non-sexually active adolescents, who consider gender equality to be important, are more likely to think that sexual intercourse is a positive experience. They consider it less necessary to have sexual intercourse to maintain a relationship and find it easier to communicate with their girlfriend or boyfriend than sexually non-active adolescents who consider gender equality to be less important. Comparable results were found for boys and girls. Conclusions Our results suggest that gender equality attitudes have a positive impact on adolescents’ sexual and reproductive health (SRH) and wellbeing. Further research is necessary to better understand the relationship between gender attitudes and specific SRH outcomes such as unwanted teenage pregnancies and sexual pleasure among adolescents worldwide.

Improving adolescent sexual and reproductive health in Latin America: reflections from an International Congress

In February 2014, an international congress on Promoting Adolescent Sexual and Reproductive Health (ASRH) took place in Cuenca, Ecuador. Its objective was to share evidence on effective ASRH intervention projects and programs in Latin America, and to link this evidence to ASRH policy and program development. Over 800 people participated in the three-day event and sixty-six presentations were presented.This paper summarizes the key points of the Congress and of the Community Embedded Reproductive Health Care for Adolescents (CERCA) project. It aims at guiding future ASRH research and policy in Latin America.1. Context matters. Individual behaviors are strongly influenced by the social context in which they occur, through determinants at the individual, relational, family, community and societal levels. Gender norms/attitudes and ease of communication are two key determinants.2. Innovative action. There is limited and patchy evidence of effective approaches to reach adolescents with the health interventions they need at scale. Yet, there exist several promising and innovative examples of providing comprehensive sexuality education through conventional approaches and using new media, improving access to health services, and reaching adolescents as well as families and community members using community-based interventions were presented at the Congress.3. Better measurement. Evaluation designs and indicators chosen to measure the effect and impact of interventions are not always sensitive to subtle and incremental changes. This can create a gap between measured effectiveness and the impact perceived by the targeted populations.Thus, one conclusion is that we need more evidence to better determine the factors impeding progress in ASRH in Latin American, to innovate and respond flexibly to changing social dynamics and cultural practices, and to better measure the impact of existing intervention strategies. Yet, this Congress offered a starting point from which to build a multi-agency and multi-country effort to generate specific evidence on ASRH with the aim of guiding policy and program decision-making. In a region that contains substantial barriers of access to ASRH education and services, and some of the highest adolescent pregnancy rates in the world, the participants agreed that there is no time to lose.ResumenEn febrero de 2014, un congreso internacional sobre la promoción de la Salud Sexual y Reproductiva de los adolescentes (SSRA) tuvo lugar en Cuenca, Ecuador. Su objetivo era compartir evidencia sobre proyectos y programas de intervención eficaz en SSRA en América Latina, y vincular esta evidencia a la política de SSRA y al desarrollo de programas. Más de 800 personas participaron en un evento de tres días con sesenta y seis presentaciones.Este documento resume los puntos clave del congreso y del proyecto CERCA (Cuidado de la Salud sexual y Reproductiva para Adolescentes enmarcada en la comunidad). Su objetivo es orientar la investigación futura y la política de SSRA en América Latina.1. El contexto es importante. Los comportamientos individuales están fuertemente influenciados por el contexto social en el que se producen a través de factores determinantes a nivel individual, relacional, familiar, comunitario y social. Las normas de género, actitudes y facilidad de comunicación son dos factores determinantes.2. Acción innovadora. Hay evidencia limitada e irregular de los enfoques eficaces para llegar a los adolescentes con intervenciones que necesitan llevarse a escala. Sin embargo, existen varios ejemplos que fueron presentados en el congreso y que se ven prometedores e innovadores porque proporcionan una educación integral de la sexualidad a través de los métodos convencionales y el uso de nuevos medios de comunicación, la mejora del acceso a servicios de salud, y uso de intervenciones comunitarias para llegar a los adolescentes, familias y su comunidad.3. Mejor medición. Los diseños de evaluación y los indicadores elegidos para medir el efecto e impacto de las intervenciones no siempre son sensibles a los cambios sutiles y graduales. Esto puede crear una brecha entre la eficacia de medidas y el impacto percibido por las poblaciones beneficiarias.Por lo tanto, una conclusión es que necesitamos más pruebas para determinar mejor los factores que obstaculizan el progreso en la SSRA de América Latina, para innovar y responder con flexibilidad a los cambios en la dinámica social y las prácticas culturales, y para medir mejor el impacto de las estrategias de intervención existentes. No obstante, este congreso proporcionó un punto de partida para construir un esfuerzo común entre las multi-agencias y multi-país que genere evidencia específica sobre SSRA con el objetivo de orientar la toma de decisiones políticas y programas. En una región que aún tiene barreras de acceso a la educación y los servicios de SSRA y se encuentran las tasas de embarazo adolescente más altas del mundo, los participantes coincidieron en que no hay tiempo que perder.

Evaluation of holistic sexuality education: A European expert group consensus agreement

Objectives Holistic sexuality education (HSE) is a new concept in sexuality education (SE). Since it differs from other types of SE in a number of important respects, strategies developed for the evaluation of the latter are not necessarily applicable to HSE. In this paper the authors provide a basis for discussion on how to evaluate HSE. Methods First, the international literature on evaluation of SE in general was reviewed in terms of its applicability to HSE. Second, the European Expert Group on Sexuality Education extensively discussed the requirements of its evaluation and suggested appropriate indicators and methods for evaluating HSE. Results The European experience in SE is scarcely represented in the general evaluation literature. The majority of the literature focuses on impact and neglects programme and implementation evaluations. Furthermore, the current literature demonstrates that evaluation criteria predominantly focus on the public health impact, while there is not yet a consensus on sexual well-being criteria and aspects of positive sexuality, which are crucial parts of HSE. Finally, experimental designs are still considered the gold standard, yet several of the conditions for their use are not fulfilled in HSE. Realising that a new evaluation framework for HSE is needed, the European expert group initiated its development and agreed upon a number of indicators that provide a starting point for further discussion. Conclusions Aside from the health impact, the quality of SE programmes and their implementation also deserve attention and should be evaluated. To be applicable to HSE, the evaluation criteria need to cover more than the typical public health aspects. Since they do not register long-term and multi-component characteristics, evaluation methods such as randomised controlled trials are not sufficiently suitable for HSE. The evaluation design should rely on a number of different information sources from mixed methods that are complemented and triangulated to build a plausible case for the effectiveness of SE in general and HSE in particular. 摘要 目的 整体型性教育（HSE）是性教育中一种新的理念，由于整体型性教育在很多重要方面和其他类型性教育不同，所以为后者的评价而发展的策略不一定适用于HSE。在这篇文章中作者为如何评价HSE的讨论提供了依据。 方法 首先，复习关于性教育评价的国内外文献，评估其对于HSE的适用性。第二，欧洲性教育专家组广泛讨论整体型性教育评价的要求并且提出评价HSE的适宜的指标和方法。 结果 欧洲在性教育方面的经验几乎可以说是总的关于评价文献的代表。大多数文献关注性教育活动的影响而忽略了对于计划和执行情况的评价。另外，目前的文献资料表明，性教育评价标准主要集中在对公众健康的影响，而关于性满意的标准和性生活积极的方面目前尚没有共识，而这正是HSE至关重要的部分。最后，实验研究设计仍然被看作评价性教育的金标准，但是实验研究设计的一些条件在HSE中不能满足。 意识到需要一个新的针对HSE的评价体系，欧洲专家组开始着手评价体系的发展并且通过一系列的指标，这为进一步的讨论提供了一个起点。 结论 除了对健康的影响以外，性教育方案的质量和方案的实施也值得关注并且应该加以评价。为了适用于HSE，评价标准需要涵盖比传统的公共健康更多的范畴。由于像随机对照实验这样的研究方法不注重长期性和多因素等特征，所以并不是很适合HSE。评价的设计应该依靠很多来自各种方法的不同的信息资源，这些方法互相补充，呈三角形，一起构建一个合理的关于性教育尤其是HSE有效性评价的实例。