|
Article Excerpt
The sexual health o f adolescents is a growing global public health issue. In developing countries, approximately 60% of new HIV infections occur among 15-24-year-olds, (1) and a similar proportion of pregnancies and births to adolescents are unintended. (2) In industrialized countries, the incidence of STDs among youth is increasing, (3) and adolescent pregnancy is associated with poor social outcomes. (4) These and other statistics have garnered adolescents attention as a group facing distinct issues.
Peer-led sexual health education is one means of addressing deficiencies in adolescent sexual health. Defined as the "teaching or sharing of information, values, and behaviors by members of similar age or status group," (5) peer-led sexual health education has been developed on the basis of two observations. First, the health beliefs and habits formed during childhood and adolescence are carried into adulthood; (6) second, teenagers influence each other's attitudes and behavior. (7) According to theory, peer educators may influence social behavior through their role as credible role models (8) or as innovators. (9) Moreover, peer-led education may be an approach by which young people, through partnerships, can define and tackle their own health needs. (9,10)
Although several systematic reviews of adolescent sexual health interventions have been conducted, (11,12) to our knowledge only one has focused on peer-delivered health promotion interventions. Harden and colleagues reviewed outcome and process evaluations of peer-led interventions (half of them involving sexual health) from randomized and quasi-randomized controlled trials published through September 1998. (13)
Harden and colleagues also appraised the methodology of the trials. In systematic reviews, methodological appraisals generally evaluate four areas of potential systematic bias: selection bias (differences in comparison groups), performance bias (differences in the care provided, apart from the intervention being evaluated), attrition bias (differences in withdrawals from trials) and detection bias (differences in outcome assessment). The rationale and content of criteria for the assessment of these types of bias are similar across reviews. (12-17)
While they were unable to reach robust conclusions regarding the effectiveness of peer-led interventions for young people, Harden and colleagues made a number of recommendations for the development and evaluation of such interventions. (13) Although other guidelines for the development and evaluation of complex sexual health interventions have been devised, (18) those of Harden and colleagues are, as far as we are aware, the only ones specifically developed to guide the development and evaluation of peer-led interventions for young people. Their criteria for intervention development were informed by the following perspectives: that young people should actively participate in meeting their own health needs, (19) that adolescents are not a homogenous group with uniform needs (7) and that peer-led health promotion is best delivered in the context of wider sociocultural and economic health promotion strategies. (20) In addition, the authors highlighted the importance of understanding the contribution that peer-led education can offer to wider health promotion strategies.
The recommendations developed by Harden and colleagues were supported by findings from their review. First, echoing other authors, (21) Harden and colleagues recommended that the health needs and views of the target group be assessed; they provided examples of how specific programs in their review used this information to tailor interventions to a particular context. Second, given the challenges that they identified within peer-led education interventions-including resource constraints, conflicting value systems and constraints on young people's autonomy (especially in schools)-they recommended that the specific boundaries of working partnerships with young people be established prior to project implementation, such that the roles of researchers and youth are clearly defined. Third, they noted that evidence suggests that the beneficiaries of peer-led sex education include the peer educators themselves; thus, they recommended the evaluation of the effects that peer education has on peer educators, and of reciprocal education, in which each member of a target population alternates between being an educator and a recipient. Fourth, they recommended that both quantitative and qualitative methods (and if possible, an integration of the two) be used to evaluate outcomes and processes.* Fifth, they concluded that the important characteristics of peer educators are unclear and recommended that to help elucidate the matter, authors describe how peer educators were recruited and selected. Finally, they recommended that young people's views regarding the intervention, including negative views, be fully reported.
We conducted a systematic review and methodological appraisal of randomized and quasi-randomized controlled trials of peer-led sex education interventions. We also evaluated the extent to which Harden's recommendations for the development and evaluation of peer-led interventions have been addressed in studies published since 1998.
METHODS
Eligibility Criteria and Methodological Appraisal
We examined all randomized and quasi-randomized controlled trials that evaluated interventions to promote adolescent sexual health using peer educators and that were published in 1998-2005. Any peer-led intervention intended to promote sexual health in any setting (e.g., health center, youth group, local extracurricular center, school) in high-, middle- or low-income countries was eligible. For inclusion in the review, studies had to have intervention and control groups, include adolescents aged 10-19 and be published in English.
In addition, studies were required to meet four methodological criteria: The studies had to include a control or comparison group whose social and demographic characteristics were similar to those of the intervention group, provide preintervention data for all groups, provide postintervention data for all groups and report all outcomes. Primary outcomes of interest were the occurrence of pregnancy or STDs, age at first sex, number and types of sexual partnerships, condom use and contraceptive use. Relevant secondary outcomes were measures of knowledge of sexual...
|
