1. A systematic review of school-based skills building behavioural interventions for preventing sexually transmitted infections in young people Dr Jonathan Shepherd Principal Research Fellow Southampton Health Technology Assessments Centre (SHTAC) University of Southampton

2. Project team Southampton Health Technology Assessments Centre (SHTAC) University of Southampton Jonathan Shepherd, Jo Picot, Jeremy Jones Keith Cooper, Debbie Hartwell, Alison Price, Geoff Frampton, Andy Clegg Evidence for Informed Policy and Practice Information and Co-ordinating Centre (EPPI-Centre), Social Science Research Unit, Institute of Education, University of London Josephine Kavanagh, Elaine Barnett-Page, Angela Harden

3. Rationale Rates of sexually transmitted infections (STIs) continue to increase, particularly amongst young people Need for sound evidence to inform policy and practice Why a systematic review and why now? Topic advertised & commissioned by HTA programme

4. Objectives To conduct a systematic review and economic evaluation to assess the effectiveness of behavioural interventions for the prevention of STIs in young people aged 13-19 years

5. Scoping and protocol Literature searching Inclusion / exclusion screening 1 Descriptive mapping Further scoping Inclusion / exclusion screening 2 Narrative synthesis / meta-analysis Conclusions and recommendations Systematic review methodology

6. Inclusion criteria 1 - Descriptive mapping exercise Participants: Young people aged 13-19 years Intervention: Behavioural interventions to prevent STIs Comparator: Standard practice Outcomes: Sexual behaviour (e.g.) Self-reported condom use Number of sexual partners Reported having had sex Additionally: STI rates; knowledge, beliefs, attitudes Study design: any type of outcome evaluation

7. Results: descriptive mapping exercise Total of 8037 references identified Total of 136 studies included Design: 51% RCTs, 49% non-randomised studies Country: 60% USA; 18% Africa; <5% UK Topics: 60% HIV/AIDS; 47% STIs in general Intervention characteristics: Components: 90% Information; 60% skills training; 24% provision of resources Providers: 32% peer educators; 29% teachers; 17% health care professionals Location: 57% school/college; 27% community; 18% health-care

8. Scoping and protocol Literature searching Inclusion / exclusion screening 1 Descriptive mapping Further scoping Inclusion / exclusion screening 2 Narrative synthesis / meta-analysis Conclusions and recommendations Systematic review methodology

9. Inclusion criteria 2 - Systematic review of effectiveness Participants: Young people aged 13-19 years Intervention: School-based behavioural interventions to prevent STIs which teach safer sex skills as well as provide information Comparator: Standard practice Outcomes: Sexual behaviour STI rates Knowledge, beliefs, attitudes Study design: Randomised Controlled Trials (RCTs) only

10. Total of 15 studies included, of which 12 judged methodologically sound Country n= 8 USA, n= 4 Europe, n= 3 Africa Types of skills: correct use of condoms; communication; negotiation Behavioural aims: increase protective behaviours; delay sex; reduce partners. Interventions of variable length / intensity Majority interventions theory-based Comparators: information only; or control groups Young people: Socio-demographic-economic profile mixed Between <10% to 80% sexually experienced Results: systematic review

11. Examples of some of the interventions Safer Choices (California + Texas, USA) RIPPLE study (Central and Southern England) The SHARE study (Scotland) All4You! (California, USA) Youth AIDS Prevention Project (YAPP) (Chicago, USA) Focus on Kids (West Virginia, USA) Our times, our choices (South Africa) My future is my choice (Namibia)

12. Diverse range of sexual behavioural outcome measures Condom use (first/last sex); frequency of condom use; consistency in condom use; whether had sex; frequency of sex; number of partners Few statistically significant differences between groups Self-efficacy: mixed findings Knowledge of STIs: significant differences favouring behavioural intervention Attitudes: mixed findings Intentions: mixed findings STI rates: no data Narrative synthesis results

13. Meta-analysis: condom use Pooled effect size (Odds ratio 1.07) Individual study effects Line of no effect Safer Choices ( California + Texas)

14. 9 of the 12 methodologically sound RCTs conducted a process evaluation. Synthesis of the process findings to explore reasons for the limited impact of the interventions revealed two sets of factors: (i) Interventions were not always implemented as intended Variations in school culture and administration Teachers not always able to facilitate skill development (ii) Not all young people found the interventions engaging or acceptable Gendered norms (mixed sex / single sex groups) Age appropriateness Results of process evaluations

15. Summary Map of the evidence base for behavioural interventions Our focus was on information and skills development Improvements in knowledge Mixed effects for attitudes/ intentions / self-efficacy Limited / unclear effects on sexual behaviour Number of factors influencing outcomes Implementation Acceptability

16. Recommendations Evaluation of multi-component school-based interventions, including teachers / peers / whole school approach / parents / specialist trainers Of suitable length – booster sessions as young people mature Long-term follow up Diversity in outcome measures: Quality of relationships Safety negotiations Use of STI testing / services Integral economic evaluation

17. www.hta.ac.uk

18. Contact Dr Jonathan Shepherd, Principal Research Fellow Southampton Health Technology Assessments Centre (SHTAC) Epsilon House, Enterprise Road Southampton Science Park, Chilworth University of Southampton, SO16 7NS Tel +44 (0) 2380 597055 Email: jps@soton.ac.ukjps@soton.ac.uk The views and opinions expressed are those of the authors and do not necessarily reflect those of the UK Department of Health.