school-based interventions to prevent hiv, stis & adolescent pregnancy: what's the...
TRANSCRIPT
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]
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?
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Poll Question #3
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
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
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
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
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.
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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