|Interventions to prevent HIV/AIDS among adolescents in less developed countries: are they effective?
|Magnussen L, Ehiri J E, Ejere H O, Jolly P E
This review assessed interventions to prevent HIV and AIDS among adolescents in less developed countries. The authors concluded that the interventions showed only limited success and that higher quality research is required. It was difficult to assess the strength of evidence underpinning these conclusions because of limitations in the reporting of the results and study quality. However, the recommendation for further research appears appropriate.
To assess the effects of interventions to prevent human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) among adolescents in less developed countries.
Bibliomap, the Register of Review of Effectiveness in Health Promotion, LILACS, the Social Sciences Citation Index, the Science Citation Index, Source, PsycINFO, Dissertation Abstracts, OCLC, PubMED, EMBASE, ERIC, ELDIS, POPLINE, CINAHL, AIDSLINE and Google were searched for published studies; the search terms were reported. Thirteen named relevant journals were handsearched, while reports published by named non-governmental organisations were examined. The reference lists in retrieved studies were screened.
Study designs of evaluations included in the review
Studies with a control group were eligible for inclusion.
Specific interventions included in the review
Studies of health facility-, school- or community-based, direct or peer-led interventions to prevent HIV, AIDS or sexually transmitted diseases (STDs) were eligible for inclusion. The studies had to be set exclusively in less developed countries (defined as Latin America, the Caribbean, Africa, Asia and the Pacific, excluding developed market economies and economies in transition). The interventions could include one of more of the following: individualised information, education and communication, group education, lectures, poems, role-play, demonstrators and group discussions. Studies that did not specifically target adolescents were excluded, as were interventions aimed at preventing infected individuals passing on the virus. Most of the studies were set in Africa; others were set in Latin America. Most of the studies were school-based. The duration of the intervention duration ranged from one brief session to 2 years.
Participants included in the review
Studies of male and female in-school or out-of-school adolescents (aged 11 to 25 years) in rural or urban settings were eligible for inclusion.
Outcomes assessed in the review
Studies were eligible if they reported: pre- and post-intervention assessments of safe sex practices; knowledge about the transmission and prevention of HIV and AIDS; self-efficacy; uptake of voluntary counselling and testing; the perception of risks of HIV, AIDS and STDs; and the incidence of HIV or AIDS. Studies that only reported surveillance or risk perception without an intervention, or identified predictors of disease status, were excluded. Most of the included studies assessed knowledge and attitudes about sexually preventive behaviours.
How were decisions on the relevance of primary studies made?
The authors did not state how the papers were selected for the review, or how many reviewers performed the selection.
Assessment of study quality
The authors did not state that they formally assessed validity, but some aspects of validity were discussed in the paper.
The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction.
Methods of synthesis
How were the studies combined?
The studies were grouped by intervention setting (school or community) and outcome, and combined in a narrative.
How were differences between studies investigated?
Differences between the studies were discussed with respect to study characteristics and some aspects of quality.
Results of the review
Sixteen controlled studies (n=14,682) were included. Eight of these were described as randomised controlled trials (n=6,796).
General methodological limitations included the use of non-equivalent control groups, a lack of linking pre- and post-test samples in multiple cross-sectional surveys, assessment immediately post-intervention, unclear methods used for statistical comparisons, and inappropriate analysis of cluster trials.
Studies assessing knowledge or attitudes (12 studies): each study showed statistically significant improvements in overall summed knowledge scores. However, responses to individual questions were often unchanged and patterns of responses within studies showed incomplete knowledge.
Studies assessing behavioural intent (6 studies): 3 studies reported an improvement in behavioural intent with the intervention.
Studies assessing actual behaviour change (9 studies): 6 studies showed some improvements in behaviour change. Some of the positive studies had serious methodological flaws.
The studies generally showed only weak or modest improvements in knowledge about HIV and AIDS, altering attitudes, improving negotiation and communication skills or change in behaviour change (e.g. habitual use of condoms), abstinence, or decreasing the number of partners. Higher quality studies are required.
The review question was clear in terms of the study design, intervention, participants and outcomes. Many relevant sources were searched but the inclusion of only published studies raises the possibility of publication bias, as the authors acknowledged. It was unclear whether any language limitations were applied. The methods used to select studies and extract the data were not described, so it is not known whether any efforts were made to reduce errors and bias. Some aspects of study quality were discussed in the paper, but it was unclear whether validity had been formally assessed.
The narrative summary focused on describing study characteristics, including methodological issues, with only a very limited discussion of the results. Given the lack of a formal and structured assessment of the quality and results of the included studies, it is difficult to comment on the strength of the evidence underpinning the authors' conclusions regarding the effectiveness of the interventions. However, the authors' recommendation for further higher quality research appears appropriate in view of the general methodological limitations of current studies.
Implications of the review for practice and research
Practice: The authors stated that more intense, comprehensive interventions need to be integrated into programmes aimed at changing behaviour.
Research: The authors stated that higher quality studies are required to evaluate interventions. The authors recommended the use of randomised controlled trials or other rigorous study designs for assessing population-based behavioural interventions.
Magnussen L, Ehiri J E, Ejere H O, Jolly P E. Interventions to prevent HIV/AIDS among adolescents in less developed countries: are they effective? International Journal of Adolescent Medicine and Health 2004; 16(4): 303-323
Subject indexing assigned by NLM
Acquired Immunodeficiency Syndrome /prevention & control; Adolescent; Adolescent Health Services; Adolescent Medicine; Adult; Behavioral Research; Child; Controlled Clinical Trials as Topic; Developing Countries; Female; HIV Infections /prevention & control /psychology; Humans; Intervention Studies; Male; Program Evaluation
Date bibliographic record published
Date abstract record published
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.