National Partnership for Women & Families

Monthly Women's Health Research Review

Research review examines effects of interventions aimed at improving adolescent sexual and reproductive health

Summary of "Improving adolescent sexual and reproductive health: A systematic review of potential interventions," Rehana A. Salam et al., Journal of Adolescent Health, October 2016.

"A significant number of adolescents around the globe are sexually active, and this proportion increases steadily from mid-to late adolescence," according to Rehana A. Salam of Aga Khan University's Division of Women and Child Health and colleagues.

Outlining the harmful effects of early pregnancy, poor reproductive health outcomes and female genital mutilation/cutting (FGM/C), the researchers wrote, "Adolescents have special sexual and reproductive health needs that remain unmet, mainly due to lack of knowledge, social stigma, laws and policies preventing provision of contraception and abortion to unmarried (or any) adolescents, and judgmental attitudes among service providers." According to the researchers, "To maintain sexual and reproductive health, adolescents need access to accurate information and to the safe, effective, affordable, and acceptable contraception method of their choice," as well as the information and tools they need to protect themselves from sexually transmitted infections (STIs).

In this study, part of a larger series aimed at assessing "the effectiveness of potential interventions for adolescent health and well-being," the researchers examine the effects "of interventions to improve sexual and reproductive health, prevent adolescent pregnancy; FGM/C; and intimate partner violence."

Methods

The researchers "reviewed all published literature up to December 2014 on interventions to improve sexual health in adolescent population focusing on sex education, preventing unintended adolescent pregnancy, intimate partner violence, and FGM/C." They "consolidate[d] the existing evidence through the following three methodologies in order to include all the recent evidence": an overview of systematic reviews, when recent reviews existed; updates for existing reviews if they "only included evidence prior to 2011"; and new reviews when no reviews were in place for a given intervention.

The researchers defined the adolescent population as ages 11 to 19. However, because many studies focused on young adults ages 15 through 24, "exceptions were made to include studies targeting adolescents and youth." According to the researchers, "The search was conducted till December 2014, and we did not apply any limitations on the start search date or geographical settings."

Findings

The researchers conducted "a [new] review for the effectiveness of sexual and reproductive health education and contraceptive availability" because the existing reviews were limited in scope. They also found a review on "interventions to prevent intimate partner violence," and they updated and broadened an older review focused on "interventions to prevent FGM/C."

Sexual and reproductive health interventions to prevent adolescent pregnancy

For the de novo review, the researchers found 48 studies that compared "any form of sexual and reproductive health education, counseling, and access to contraception ... delivered to adolescents compared to no intervention or general health education." Of those, 51 studies were randomized controlled trials, "29 were quasi-experimental design and four were pre-post studies." According to the researchers, "[F]ifty-four of the 84 studies focused on adolescent age group alone (11-19 years) while the rest had overlapping age groups." The researchers were able to conduct a meta-analysis for 48 of the studies, and of those, all but 10 were conducted in high-income countries (HICs).

The researchers found that "[i]nterventions mainly included (1) education and counseling through peer groups, parent education, community members, telephone calls, Web-based content, and home visitation; (2) youth-friendly health services; (3) improving access to contraceptives through pharmacy, clinic, and advance provision of contraceptives; (4) condom distribution; (5) abstinence-focused education; (6) emergency contraceptive promotion; (7) skills development; and (8) multicomponent interventions."

According the researchers, the "data suggest that sexual and reproductive health education, counseling, and contraceptive availability increased 'mean knowledge score about sexual health and contraception...,' 'mean condom use self-efficacy score...,' 'use of any contraception...,' and condom use." They found that sexuality education "did not significantly impact risk of having sex ... or STIs."

When the researchers pooled the eligible studies for analysis, they found "a 15 percent decrease ... in incidence of adolescent pregnancies and a 37 percent decrease ... in the rate of repeat adolescent pregnancies." The researchers also assessed the literature based on the type of intervention and found that:

  • "Peer-led counseling significantly improved mean knowledge score however did not significantly impact use of contraception";
  • "Parent-directed interventions were ... effective in improving sexual knowledge";
  • "Clinic-based interventions comprising counseling, skills building, and case management services improved mean knowledge";
  • Technology-based interventions on health behavior skills "and teen-led, media literacy curriculum focused on sexual portrayals in the media were effective in improving sexual knowledge but did not have any impact on contraceptive use"; and
  • "Schoolbased interventions including combined sex education with youth-friendly sexual health services, curriculum modules implemented by adult facilitators or peer cofacilitators ... and HIV prevention education were effective in improving contraceptive use but did not impact mean knowledge scores."

Intimate partner violence

For intimate partner violence, the researchers found a review of 38 studies "focusing on educational and skills-based interventions targeted at young people aged 12-25 years for preventing intimate partner violence." According to the researchers, 33 of the 38 studies were included in the meta-analysis and all of those studies were conducted in HICs.

According to the researchers, the review found "an increase in knowledge related to relationship violence in favor of the intervention," but the "evidence suggests no significant impact of such interventions on episodes of relationship violence..., behavior scores related to relationship violence..., and a skills score related to relationship violence (to communicate effectively)."

Discussion

"Our review suggests that sexual and reproductive health education, counseling, and contraceptive availability are effective in increasing adolescent knowledge related to sexual health, contraceptive use, and decreasing adolescent pregnancy," the researchers wrote. However, they noted that they "could not conduct subgroup analysis for the effectiveness of these interventions in HICs and [low- and medium-income countries (LMICs)] since there were limited studies from LMIC settings."

The researchers wrote that their "findings are in concordance with existing reviews evaluating the effectiveness of various interventions for improving adolescent sexual and reproductive health and also collate various interventions under a broader umbrella to evaluate the combined effectiveness of these interventions." Meanwhile, according to a recent report from the World Health Organization, evidence assessing the prevention of intimate partner and sexual violence "is still in its infancy."

The researchers outlined several limitations on the existing studies examining adolescent sexual reproductive health, including the failure of most studies "to utilize allocation concealment, blinding, and randomization to optimize their outcomes." As a result, "most of the outcomes were rated as low or moderate in methodological quality," the researchers wrote. Further, the researchers pointed to the "dearth of evidence on interventions for improving sexual health of adolescents living in LMICs where the majority of the adolescent population of the world resides," which could "lead to limited external validity for many of these interventions." In addition, the majority of studies failed to "segregat[e] by gender which is essential since males and females might respond differently to behavioral interventions."

The researchers concluded that while their "review suggests that a range of comprehensive interventions targeting sexual health education, counseling, consistent birth control methods promotion, and provision have the potential to prevent and control the adverse outcomes related to risky sexual behavior ... much more is needed to increase awareness and prevent ... intimate partner violence."