The Effectiveness of Population Based Risk Reduction Programs and Services in Reducing Risky Sexual Behavior among Young People in Developing Countries.

Abstract

Background Adolescence is the period between the ages of 10 and 19 years when young individuals grow into adulthood 28, 29. Increasing focus on the reproductive challenges of adolescence is a relatively recent phenomenon, more-so in the developing world 19. Some authors subdivide the period into early (10 -14 years) and late (15-19 years) adolescence 1, 7, whilst others refer to early (10-13 years), mid- (14 - 15 years) and late (16 - 19 years) adolescence 28. The youth are individuals in late adolescence and early adulthood (15-24 years). Adolescents (10-19 years) and the youth (15-24 years) together, form the larger grouping of young people (10-24 years) 26, 28. The World Bank (WB) groups countries according to their gross national income (GNI) per capita into four blocks, namely: low income ($995 or less), lower middle income ($996 to $3,945), upper middle income ($3,946 to $12,195) and high income ($12,196 or more) 24. This review focuses on countries within the low and middle income bracket, otherwise called the developing world. Risk taking is inherent in the lives of growing individuals as they learn their way into adulthood; the choices they make during this phase of life could enhance or diminish their future state of health 19, 28. Young people are increasingly being exposed to sexual risk taking due to changing social structure, migration patterns, disasters, globalization, developments in computerized communication media such as emails and instant messaging as well as the evolutions of social networking applications such as Facebook, unavailability or lack of accurate information and lack of care provision facilities, among others 26, 28. Factors contributing to sexual risk taking among young people are diverse; among them cultural such as gender roles 32, economic disparities, political decisions 5and social support or lack of it18, 32. Some risk taking of young people could be a reflection of situations in which there are inappropriate support structures; or of those situations that rather predispose adolescents to risk 20. HIV/AIDS is a leading cause of ill-health among persons aged 10-24 years worldwide 27, afflicting predominantly the developing world 21, 22, 29. Half of all new HIV infections occur among 15 to 24 year-olds 29, 75% of whom were residing in Sub-Saharan Africa as at December 2001 22. Young people of poor socioeconomic backgrounds in predominantly developing countries of sub-Saharan Africa and South Asia are at the center of the HIV/AIDS epidemic with a quarter of the 40 million infected individuals being between the ages of 15 and 24 22, 31. HIV prevalence trends of adolescents 15-19 years within Sub-Saharan Africa consistently show females with higher rates than males13. STIs rates have been high among young people 27, 30: those below 25 years accounting for a third of the estimated 333 million cases of curable STIs reported annually worldwide and 15-19 year olds coming second to 20-24 year olds. One out of twenty adolescents worldwide contracts STIs annually2. Teenage pregnancies are mostly a result of sexual risk taking, experimentation or poor risk perception; they are in themselves a “risk” perpetuating other adverse social outcomes on the “victims” 22. At the individual level, adolescent mothers have to contend with some levels of health as well as socioeconomic disadvantages during and after such pregnancies. In the course of pregnancies and labor, adolescents stand the risk of being anemic, having pre/-eclampsia, bleeding excessively, more prone to birth traumas in the form of perineal tears, defects leading to fistula and paralysis coupled with emotional trauma 22. Infants resulting from teenage pregnancies could have low birth weight and anemic, increasing their risk for morbidity and mortality. For every death during childbirth of an adolescent 15 to 30 others endure varying degrees of disability 22. Maternal deaths among females aged 15-19 years are twice as high as those above 20 years 16. Birth rates have been declining since the late 1980s among adolescents though not so dramatically across the globe with the developed contributing more than the developing countries 13. Some 14 million adolescents give birth each year as a result of unplanned sex, between a third and two-thirds of the resultant births are equally unplanned 29. Adolescents with children have curtailed potentials for maturation, self-development, thus increasing their chances of dropping out of school and living in poverty, thus creating a vicious cycle usually in impoverished or underserved communities. Infants born to teenage mothers tend to be unwanted and do not get the attention they duly deserve. An adolescent is not matured enough to withstand the pressures of child rearing, since they themselves are children entrusted with the unusual responsibility of taking care of another kid 22. Complications of unplanned pregnancies are abortions under unsafe conditions and higher risks of adverse outcomes for both the mother and the newborn: the maternal mortality ratio among adolescents is twice that of women in their twenties 29. Unwanted pregnancies are common among adolescents and they account for over a quarter of the estimated 20 million unsafe abortions performed globally each year22. Premature abortions among adolescents could aside physiological factors, be due to previously acquired STIs 30. The consequences of adolescent sexual risk taking temporarily could manifest in the short or long term 18; they could affect the individual, family/community and nations 22; they could be as traumatic and distressing on the individuals involved just as much as the family or society in which they reside 23; there could be of health, educational, social, economic and psychological costs to societies across the globe 22. These consequences though enormous are preventable. Increases in sexually transmitted infections (STI), teenage pregnancy and abortion rates coupled with the dire effects of the HIV/ AIDS pandemic have resulted in a renewed emphasis on moderating the sexual and reproductive risk taking behaviors of young people 19, 30. The serious challenges posed to global health by the increase in incidence and prevalence of HIV/ AIDS and STIs 30 led to the consensus in the 1990s by the WHO and its partner organizations to seriously pursue the Sexual Reproductive Health (SRH) needs of young people to avert a global disaster25. Working with the aim of enhancing the safety and wellbeing of young people, several public health (population based) interventions and programs have been developed and administered over the years to this population 3, 8, 9, 10. Most of these programs have components to build upon protective factors or reduce the influence of risk factors in the lives of young people and in so doing enhancing their ability to avoid risk taking with regards to their sexual and reproductive health 11, 14. Securing the health and wellbeing of young people is an investment in the individuals today and for society as a whole towards the future and the generations ahead 23. Healthy young people have a positive bearing on the health, social, economic and political facets of society 23. Intervening early in life to address sexual risk taking is far less expensive than managing the consequences in later life 6. Taking a proactive approach in managing sexual risk taking in adolescents therefore does not mitigate a reproductive health problem alone, but results in socioeconomic, political and cultural benefits to society as a whole 4, 12. Population based (public health) programs and interventions target populations and not individuals within communities 15. The aim of most sexual risk reduction programs targeting young people is to provide age and context appropriate interventions. For example, prevent early adolescents from initiating sex at an early stage and empowering those who have already began sexual activity to avoid risk taking and avoid the associated complications. Though outcomes of sexual risk taking are diverse, the focus of most assessments is on reduction of unintended pregnancies and sexually transmitted infections including HIV/AIDS 33. Some outcome measures of sexual risk taking in contemporary literature include educational achievement, number of sexual partners, frequency of sexual activity, knowledge about contraception, contraceptive (condom) use and self-efficacy, early or premarital sexual initiation, pregnancy rates, STI rates, substance/alcohol use and age mixing in sexual relationships 34, 35, 36, 37. In a search of published reviews from the Cochrane Library, the JBI Library of Systematic Reviews, and the Campbell Collaboration Library and via PUBMED, no reviews were found addressing the current topic under consideration. A review published in the Cochrane Library focused on population based clinical interventions aimed at reducing sexually transmitted infections and HIV in some developing countries 17, another by DiCenso, Guyatt, Willan & Griffith, 2002 3 discussed interventions aimed at reducing unintended pregnancies among adolescents in the developed world. The current review seeks generate the best available evidence about how risk reduction programs and services implemented in developing countries have addressed the purposes for which they were intended among young people. Improving child-health, maternal health and combating HIV/AIDS- the objectives of the millennium development goals 4, 5 and 6 respectively could be best achieved if sexual risk taking among adolescents is approached seriously and addressed appropriately. It is in the light of this that the current review seeks to generate the best available evidence on population based interventions that address sexual risk taking among adolescents. In the context of this systematic review, sexual and reproductive risk taking is defined as any unprotected sexual activity that exposes the adolescent to adverse health consequences such as sexually transmitted infections (STIs) including HIV/AIDS and Unwanted/ Unintended Pregnancies. Also, population based (public health) risk reduction programs and services (interventions) refer to those interventions that target groups of people and not individuals within communities. Review Questions/Objectives The objective of this review is to synthesise the best available evidence on the effectiveness of population based (public health) risk reduction programs and services (interventions) on sexual and reproductive health risk taking among young people (aged 10 to 24 years old) in developing countries (countries with low and middle gross national income (GNI) per capita as defined by World Bank). The specific review questions are: What is the effectiveness of population based (public health) risk reduction programs and services (interventions) on risky sexual behaviors among young people? What are the characteristics of population based interventions that are effective in reducing risky behaviors among young people? What specific outcome measures best assess the impact of interventions that effectively reduce sexual risk taking among adolescents in developing countries? Inclusion Criteria a. Types of Participants The review will consider individuals of ages 10 to 24 years residing in developing countries. b. Types of interventions The review will consider population based (public health) risk reduction programs and services that target young people in developing countries. c. Types of Studies The review will consider randomised controlled trials (RCTs). In the absence of RCTs, other research designs, such as quasi-experimental study designs and non-experimental study designs will be included in the review. d. Types of Outcomes Anticipated outcomes related to reduction in risky sexual behavior among young people include the following: Primary outcomes: Abstinence rates, rates of early/premarital sexual initiation, numbers of sexual partners, condom use at first sex, consistent and correct contraceptive (condom) use during sexual encounters among the study population, alcohol and/or substance use prior to or during sexual encounters (short term outcomes). Secondary outcomes: Pregnancies and their outcomes including rates of abortion, births (live and still), etc., STI rates, HIV/AIDS rates, maternal mortality and educational attainment levels of adolescents in the study population (Long term outcomes). Search Strategy The search strategy aims to find both published and unpublished studies in English language over the period of 1960 to 2010. The reason for the time period is that in spite of the fact that a greater focus was placed on the sexual and reproductive health needs of young people in the 1980s 25, there is the need to access other available and relevant works in the years prior to that spurt. Such an approach will help chart the progress or lack thereof of SRH interventions in the region. A three-step search strategy will be utilized in each component of this review. An initial limited search of MEDLINE/ PUBMED and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. The databases to be searched include: PUBMED/MEDLINE, CINAHL, QuEST, HINARI, PSYCNET (PSYCINFO, PSYCEXTRA, PSYCCRITIQUES, PSYCARTICLES, PSYCBOOKS), GOOGLE SCHOLAR, TRIP (Turning Research into Practice), Scirus.com The search for unpublished studies will include databases such as: WHOLIS (World Health Organization Library Database), LILACS (Latin American and Caribbean Health Sciences Literature) database, Networked Digital Library of Theses and Dissertations (PROQUEST), Popline, PAHO (Pan American Health Organization) Initial keywords to be used will be: young people, adolescents, youth, sexual risk taking, sexual and reproductive health, sexually transmitted infections, HIV/ AIDS, teenage pregnancies, abortions, public health interventions, and population based interventions Assessment of Methodological Quality Eligible papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data Collection/Extraction Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix II).The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data Synthesis Quantitative papers will, where possible be pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument Study findings will be pooled together with the help of the JBI-MAStARI analytical software. All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form. Conflicts of Interest None known thus far.