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Table 1 Characteristics of Included Studies

From: School-based sexual health education interventions to prevent STI/HIV in sub-Saharan Africa: a systematic review and meta-analysis

STUDY (lead author surname and date) SETTING (LEVEL & COUNTRY) STUDY DESIGN PARTICIPANTS’ AGE (YEARS) & NUMBER INTERVENTION COMPARISON LENGTH (S) OF FOLLOW UP
Aderibigbe 2008 Secondary schools, Nigeria Quasi-experimental Age range: 10–19
Number: 521
Objectives: to reduce risky sexual behaviours.
Content: topics on HIV/AIDs, sexual behaviours including condom use and risks of exchange of sex for gifts were covered.
Activities: health education sessions consisting of lectures, film shows, and distribution of information, education and communication (IEC) materials.
Dose/frequency/duration: not reported (NR)
Theory used: NR
No intervention 3 months
Agha 2004 Secondary schools, Zambia Quasi-experimental Age range: 14–23
Number: 416
Objectives: to increase knowledge, normative belief and self-risk perception of contracting HIV.
Content: curriculum provided factual information on HIV, modes of transmissions, impact of the infection on immunity, high risk associated with anal sex and other non-sexual modes of transmission of HIV. It also contained information on abstinence, correct and consistent use of condom.
Activities: peer led discussions, drama skits and distribution of educational leaflets.
Dose/frequency/duration: one session of 1-h-and-45-min duration.
Theory used: NR
1-h-long, peer-led water purification intervention. 1 week and 6 months
Ajuwon 2007 Secondary schools, Nigeria Quasi-experimental Age range: 10–25
Number: 494
Objectives: to improve secondary school students’ sexual health knowledge, attitudes, perceived self-efficacy and sexual practices.
Content: information on aspects of reproductive health, STI/HIV/AIDS and condoms were covered.
Activities: teacher instructions, presentations, rotational talks, health quiz competitions, drama presentations, counselling of students and distribution of condoms with other educational materials.
Dose/frequency/duration: nine months (i.e., one academic session)
Theory used: NR
No intervention Immediate
Arnold 2012 Secondary schools, Nigeria Cluster Randomised Controlled Trial Age range: greater than 11 to less than 17
Number: 2589
Objectives: to reduce vulnerability of youths to HIV infection.
Content: the school curriculum included topics on human development, HIV infection, sexual behaviours, personal skills, relationships, and society and culture.
Activities: the participants received family life and HIV education programme in schools as well as community interventions from youths trained in working with youths and adults.
Dose/frequency/duration: the school curriculum was delivered over 3 years of junior secondary schools.
Theory used: Social Ecology Theory, Social Scripting Theory and AIDs Competent Community Model
No intervention while waiting for delayed intervention. 12 months and 18 months
Atwood 2012 Elementary or middle school, Liberia Randomised Controlled Trial Mean age: 16.3
Number: 812
Objectives: to promote attitudes and skills for safer sex.
Content: an eight-module programme designed to promote attitudes and skills for safer sex. These include positive attitudes towards condom use, skills to negotiate condom use, refuse sex and use condoms effectively.
Activities: NR
Dose/frequency/duration: one module per week over eight weeks.
Theory used: Social Cognitive Theory and Theory of Reasoned Action.
General health curriculum intervention which includes information on how to prevent malaria, Tuberculosis, worm infestation and HIV/STD knowledge that do not have behavioural theory underpinning and preventive skills. 3 months and 9 months
Brieger 2001 Secondary, post-secondary and out of school youths, Nigeria and Ghana Quasi-experimental Age: Adults below 25 years of age
Number: 1784
Objectives: to improve knowledge of reproductive health, and promote safe sex behaviours with contraceptive use among sexually active adolescent.
Content: information on sexuality and reproductive health, safer sex behaviours and contraceptives was provided.
Activities: peer counselling, youth involvement in information education and communication materials development, drama, and provision of contraceptives. Other activities include TV, radio, youth centre activities, nurse workshops, clinic visits, youth centre and street campaigns.
Dose/frequency/duration: 18 months.
Theory used: NR
No intervention 18 months
Burnett 2011 High schools, Swaziland Randomised Controlled Trial Mean age: 17.35
Number: 177
Objectives: an American HIV education programme adapted for Swaziland to improve HIV related knowledge, attitudes and safe sexual behaviours including HIV testing.
Content of curriculum: Topics including “understanding my body”, basics of HIV and STIs, HIV testing, prevention and treatment of HIV, stigma and discrimination for people living with HIV, relationships and assertive behaviours.
Activities: interactive techniques such as role play and group discussions.
Dose/frequency/duration: one hour per week for 13 weeks.
Theory used: Self-efficacy Theory.
No intervention Immediate
Cowan 2010 Secondary schools & community clinics, Zimbabwe Cluster Randomised Controlled Trial Age range: 18–22
Number: 6791
Objectives: a community-based multi-component HIV prevention intervention aiming to change adolescents’ social norms.
Content: Modified version of MkV curriculum (see Ross 2007 below). Also included sessions on self-awareness, communication, self-belief and gender issues.
Activities: peer educators led intervention; parents and community stakeholders programme to improve health knowledge, communication between parents and youths; and community support for adolescent reproductive health and provision of reproductive health services by nurses and staff working in rural clinics.
Dose/frequency/duration: NR
Theory used: Social Learning Theory and The Stages of Change Model.
No intervention 48 months
Cupp 2008 High schools, South Africa Cluster Randomised Controlled Trial Age range: 13–18
Number: 1095
Objectives: to reduce risky behaviours concerning alcohol and sex.
Content: 40 % focused on alcohol-related issues, while the other 60 % on reducing risky sexual activity to avoid HIV, other STIs and unwanted pregnancy.
Activities: role-plays, teachers and peers led group discussions and audio vignettes.
Dose/frequency/duration: 30–40 min per unit (15 units in total) over 8 weeks.
Theory used: Social Learning Theory, Theory of Planned Behaviour and Social Inoculation Theory.
Regular Life Orientation curriculum. 4-6 months and 14–18 months
Denison 2012 High schools, Zambia Quasi-experimental Age range: 11 to less than 19.
Number: 2476
Objectives: to increase knowledge, attitudes and protective behaviours related to HIV and reproductive health.
Content: curriculum addressed life skills and sexual behaviours including abstinence, being faithful and condom use.
Activities: provision of library materials and counselling from a youth resource centre; volunteer peer educators coordinated extracurricular activities; educational events to communities on specific topics; and workshops to teachers on specific topics as a way of capacity building.
Dose/frequency/duration: 40 min weekly over 7–9 months.
Theory used: NR
No intervention NR
Esere 2008 Secondary schools, Nigeria Quasi-experimental Age range: 13–19
Number: 24
Objectives: to reduce risky sexual behaviours and improve quality of sexual behaviours among school going adolescents.
Content: topics on puberty, reproduction, contraception, and negotiation in relationships, including training in assertiveness skills were covered.
Activities: active learning through small group discussions and games; skills development through role-play; and information dissemination through leaflets. Subjects on puberty, reproduction, contraception and negotiation/assertiveness skills were taught.
Dose/frequency/duration: one session per week over eight weeks.
Theory used: NR
No intervention Immediate
Fawole 1999 Secondary schools, Nigeria Randomised Controlled Trial Mean age: 17.6 (intervention group), 17.8 (control group).
Number: 450
Objectives: to improve knowledge, attitude and sexual risk behaviours of secondary school students.
Content: the course targeted knowledge, attitudes and sexual behaviours in relations to STIs including HIV.
Activities: film shows, lectures, stories, role-plays, songs, essays and debates as well as demonstration on how to use a condom.
Dose/frequency/duration: two hours per session, one session per week over six weeks.
Theory used: NR
No intervention 6 months
James 2005 Secondary schools, South Africa Randomised Controlled Trial Age range: 15 to less than 22
Number: 1168
Objectives: to improve knowledge, attitudes, communication and behavioural intentions concerning sexually transmitted infection.
Content: Laduma print provides the reader with information on sexually transmitted infections and clears any misconception on the issue. It also provides information that will bring about attitudinal change on the participants including safe sex behaviours, self-efficacy and adaptation skills for safe sex behaviour. Condom use for prevention of STI is clearly explained in Laduma.
Activities: Laduma print was given to participants to read.
Dose/duration/frequency: once and take averagely one hour to read the print.
Theory Used: NR
No intervention 3 weeks and 6 weeks
James 2006 Secondary schools, South Africa Randomised Controlled Trial Age range: 12-21years
Number: 1141
Objectives: to improve knowledge of HIV/AIDS and its prevention; safer sex practices and intentions to practice safer sex; and positive attitudes toward condom use and people living with AIDS.
Content: topics included information about HIV and AIDS, modes of transmission, the immune system, the progression of HIV to AIDS, and how to avoid HIV infection. Knowledge, attitude to condom use and people living with AIDS, gender norms, and perceptions about sexual behaviour were addressed.
Activities: programs were delivered through combination of different methods including didactic and interactive group work, teaching and role-play guided by a prescribed manual.
Dose/duration/frequency: one lesson per week over two school terms (20 weeks).
Theory used: NR
Students in the control group received odd lessons about aspects of HIV and AIDS education in a non-structured format and in some cases celebrated awareness days on the topic. 6 months and 10 months
Jemmott 2015 Primary schools, South Africa Cluster Randomised Controlled Trial Age range: 9–18
Number: 1057
Objectives: to increase knowledge on HIV risk reduction, sexuality, sexual maturation, sex role and rape myth beliefs, and skills/self-efficacy to negotiate sex.
Content: topics covered included HIV/STD risk-reduction knowledge; behavioural beliefs that support abstinence and condom use; skills and self-efficacy negotiating abstinence and condom use and to use condoms; and sex-specific modules that addressed sexuality, sexual maturation, appropriate sex roles, and rape myth belief.
Activities: games, role-playing, group discussions, brainstorming and comic workbooks using series of storylines and characters.
Dose/frequency/duration: 12 one hour modules (delivered 2 modules per day) over 6 days.
Theory used: Social Cognitive Theory and Theory of Planned Behaviour.
Health-promotion intervention designed to increase fruit and vegetable consumption and physical activity and decrease cigarette smoking and alcohol use. 3 months, 6 months, 12 months, 42 months and 54 months
Karnell 2006 Secondary schools, South Africa Quasi-experimental Median age: 16
Number: 661
Objectives: to give facts related to HIV and alcohol; consequence and alternatives to drinking alcohol and having unprotected sex; and techniques to resist drinking and having sex.
Content: half of the curriculum focused on alcohol related issues, while the remaining half on HIV-related issues.
Activities: the intervention was delivered as monologues role-play delivered by four fictional teenage characters that served the basis for class discussion and group assignments.
Dose/duration/frequency: 10 units, 30 min each over 8 weeks.
Theory used: Social Learning, Social Inoculation and Cognitive Behaviour Theory.
Regular Life Orientation curriculum. 5 months
Mason-Jones 2011 High schools, South Africa Quasi-experimental Age range: 15–16
Number: 3934
Objectives: to delay sexual debut and increase use of condoms.
Content: The intervention consisted of a mixture of taught weekly classroom sessions by peer educators following a standard curriculum covering issues on relationships, well-being and sexual health and confidence building.
Activities: It consists of weekly classroom taught sessions by peer educators trained on issues related to sexual health, confidence building, sexual health and wellbeing.
Dose/frequency/duration: NR
Theory used: NR
Comparison schools received their usual Life Orientation programme. 18 months
Mason-Jones 2013 High schools, South Africa Quasi-experimental Age range: 15–16
Number: 728
Objectives: a high school peer educators training programme to improve safe sexual behaviours and related psychosocial outcomes of the peer educators.
Content: training included information about sexual and reproductive health including HIV/AIDS and about community services available, learning about leadership, presentation skills, life skills lessons, communication skills, group work and community development. It also included the development of psychosocial skills believed to be protective in reducing risky sexual behaviours such as goal orientation, critical thinking, self-esteem and decision-making.
Activities: the intervention includes training peers that involves giving information on reproductive health including HIV/AIDs, availability of reproductive health services, life skills, presentation skills, communication skills, group work and community development.
Dose/frequency/duration: two training sessions (1 h each per month), 11 training sessions (over 3-day camp).
Theory used: NR
Students from comparison schools received no extra training. 18 months
Mathews 2012 High schools, South Africa and Primary Schools, Tanzania Cluster Randomised Controlled Trial Age range: 12–14
Number: 12139
Objectives: to reduce young adolescent risky sexual behaviours including delaying sexual debut and promoting condom use.
Content: topics included self-image and values clarification; personal, social and physical development, sexuality and reproduction; HIV, AIDS, STIs and substance use; condom use; gender roles; skills for protection and safety; intimate partner violence; contraception; sexual decision-making and sexual risk behaviour; sexual risk assessment; myths and misconceptions; healthy lifestyle; and reproductive health rights.
Activities: teacher led presentations, small group discussions, skills training, small group activities, role-play, condom demonstrations, quiz, drama, song composition and homework to involve parents.
Dose/frequency/duration: one school semester of approximately 5 months duration and 15–20 school hours.
Theory used: Attitude-Social Influence Efficacy (ASE) model.
No intervention 6 months and 12–15 months
Maticka-Tyndale 2007 Primary schools, Kenya Quasi-experimental Age range: 11–16
Number: 3452
Objectives: to provide information on transmission of HIV and skills building to withstand social, cultural or interpersonal pressure to involve in risky sexual behaviours as well as skills to reduce stigma to people living or affected by HIV.
Content: information on HIV transmission, prevention and progression. Program content addressed strategies and skills building for resisting the social, cultural and interpersonal pressures to engage in sexual intercourse, sessions to combat stigmatization of people living with or affected by HIV and care of people with AIDS.
Activities: teachers and peer supporters delivered classroom lessons, facilitate HIV and AIDS learning using anonymous question boxes, information corners, school health clubs and other school activities (assemblies and literary performance).
Dose/frequency/duration: once per week over usual school period.
Theory used: Social Learning Theory.
Control schools received the country’s ministry of education, science and technology guidelines for HIV/AIDS education, but had no PSABH trained teachers or Peer supporters in the schools. 18 months and 30 months
Mba 2007 Secondary schools, Nigeria Randomised Controlled Trial Age range: 10–20
Number: 360
Objectives: to improve knowledge of reproductive health and attitudes towards reproductive health issues.
Content: information on STIs including HIV and family planning were provided during a workshop.
Activities: a workshop on sexually transmitted diseases, HIV/AIDs, and family planning.
Dose/frequency/duration: three hours.
Theory used: NR
No intervention 6 weeks
Menna 2015 Secondary Schools, Ethiopia Quasi-experimental Age range: 15–18 (for about 80 % of the participants).
Number: 560
Objectives: to prevent and control HIV/AIDs epidemic by changing knowledge, attitudes and practices of school youths in urban Ethiopia.
Content: topics related to the structure and functions of human reproductive system, HIV/AIDS, prevention methods of HIV and risky sexual behaviours.
Activities: peer educators were trained to educate peers on structure and function of reproductive organs, HIV/AIDs, risky sexual behaviours and methods of prevention of HIV.
Dose/frequency/duration: at least 40 min, two sessions per week.
Theory used: NR
No intervention 3 months
Michielsen 2012 Secondary schools,
Rwanda
Non-randomised Controlled Trial Mean age: 18.41 (intervention group) and 17.60 (control group).
Number: 1950
Objectives: to reduce risky sexual behaviours and promotes sexual/productive health through anti-AIDs-clubs.
Content: training of peers consisted of provision of information on HIV/AIDS, sexually transmitted diseases, family planning and pregnancies, the role of the peer educator and teaching methods including message transmission and counselling.
Activities: peer educators teach students through group and individual counselling, songs, drama and other interactive activities to adopt positive and responsible behaviours.
Dose/frequency/duration: NR
Theory used: Theory of Reasoned Action, Social Learning Theory, Diffusion of Innovations Theory and Health Belief Model.
No intervention 6 months, 12 months
Okonofua 2003 Secondary schools, Nigeria Randomised Controlled Trial Mean age: 17.4 (intervention group) and 18.2 (control group).
Number: 1247
Objectives: an intervention to improve STI treatment-seeking behaviour and reduce STI prevalence among Nigerian youths.
Content: information on STIs and treatment were provided during health club activities.
Activities: (1) establishment of reproductive health clubs in schools that organises campaigns during which health professional provide factual information on STI and treatment. Other activities include: (1) distribution of IEC materials, organizing debates, symposia, drama, essay writing, film show on STI treatment and prevention; (2) training of peer educators to provide counselling to peers as well as distribute IEC material on STI and refer those who have symptoms of STIs to health care providers; and (3) training of health care providers (medical practitioners, patent medicine dealers and Pharmacist) with emphasis on treatment algorithms, condom promotion and partner tracing with treatment.
Dose/frequency/duration: 11 months.
Theory used: NR
No intervention 10 months
Rijsdijk 2011 Secondary schools, Uganda Quasi-experimental Mean age: 16.1
Number: 1986
Objectives: To build self-esteem, personal decision making, self-identity, sexual development, role of social environment, gender equity, sexual/reproductive right and sexuality.
Content: lessons focused on developing self-esteem, personal decision-making, gaining insights into a person’s identity and sexual development, the role of the social environment (e.g., peers, family, close friends, teachers, and media), gender equity, sexual and reproductive rights, sexuality issues, sexual health problems and the life skills necessary to know how to avoid or deal with them.
Activities: low-tech, computer-based interactive sex education. Participants also develop IT and creative skills, which improve their job prospects.
Dose/frequency/duration: 14 lessons over a period of six months.
Theory used: Theory of Planned Behaviour and Health Belief Model.
The comparison received nothing while waiting to receive intervention (waiting-list control group). Immediate
Ross 2007 Primary school and Health Centres, Tanzania Community Randomised Trial Age range: 14–≥ 18
Number: 13814
Objectives: to reduce the incidence of HIV, STI and unwanted pregnancy by providing knowledge and skills to enable youth reduce sexual risk, delay sexual debut and appropriate use of health services for sexual health issues.
Content: topics covered included what is reproductive health and why is it important?; leaving childhood: Puberty; what are HIV and AIDS?; the facts about AIDS; the facts about sexually transmitted diseases; girls and boys have equal abilities; misconceptions about sex; refusing temptations; saying ‘No’ to sex; sexually transmitted diseases: Going to the clinic; how HIV infection causes AIDS; how Sexually Transmitted Diseases are spread; the relationship between HIV and sexually transmitted diseases; the reproductive organs and their functions; pregnancy and menstruation; respecting other people’s decisions; recognising and avoiding temptations; protecting yourselves: What are condoms?; how to avoid HIV infection and AIDS; Sexually Transmitted Diseases and their consequences; making good decisions; practising saying ‘No’; being faithful; achieving your future expectations; planning for your future; and protecting yourself: Correct use of condoms & the truth about condoms.
Activities: (1) In–school interactive teacher led and peer led programme for primary school years 5–7. (2) Provision of youth friendly health services. (3) Distribution and promotion of condom use in the community. (4) Community mobilization activities including initial mobilization week and health weeks annually. Multiple activities were utilised across the four components of the intervention including question and answer, guided discussions, story reading, flip chart illustrations, role-plays and a scripted drama serial performed by class peer educators. it also includes: games; poems; comedy; video films; peer counselling; adult involvement; printed materials (pamphlets, brochures, manuals); awareness workshops for district council officials, religious leaders and ward development committee; condom distribution; and Youth Health Weeks held once a year, where interschool competitions take place
Dose/frequency/duration: 12, 40-min sessions per year over 3 years.
Theory used: Social Learning Theory.
No intervention 12 months, 36 months and 96 months (8 years)
Stanton 1998 Secondary schools, Namibia Randomised Controlled Trial Mean age: 17
Number: 515
Objectives: to improve basic knowledge on reproductive biology, HIV/AIDs, and risky behaviours.
Content: the curriculum focused on improving knowledge of reproductive biology, risky behaviours (alcohol, substance abuse, and partner violence), HIV/AIDs, communication skills and framework for decision-making.
Activities: variety of narratives, facts, games and exercises coupled with questions and discussions embedded in each session.
Dose/frequency/duration: two-hour length per session (14 sessions) over 7 weeks.
Theory used: Protective Motivational Theory.
Delay-control condition i.e., received intervention after the six month of follow up. Immediate, 6 months and 12 months
Taylor 2014 High schools, South Africa Randomised Controlled Trial Mean age: 14.25 (intervention group) and 14.22 (control group).
Number: 821
Objectives: to provide information that will improve attitudes and encourage intention to prevent teenage pregnancy.
Content: topics include knowing yourself, the choice is yours, relationships, making choices, body development, contraception, peer pressure, culture, parenthood, responsibility, and human rights and gender norms.
Activities: role-play, debates, small and large group discussion, and videos viewing to start up discussions with students.
Dose/frequency/duration: 12 weekly.
Theory used: I-change model.
School life skills programmes. 4 months and 8 months
Tibbits 2011 High schools, South Africa Randomised Controlled Trial Mean age: 14.0
Number: 4040 (second cohorts)
2383 (first cohorts)
Objectives: to increase knowledge, promote social, emotional and refusal skills on substance use and sexual behaviours as well as encouraging the use of healthy free time.
Content: topics include social-emotional skill programmes such as decision-making and self-awareness and positive use of time like beating boredom, and leisure motivations. Specific lessons on attitudes, knowledge, skills surrounding sexual risk and substance use were also included.
Activities: teachers delivered class lessons.
Dose/frequency/duration: 12 lessons and 6 booster lessons (each lesson 2–3 class periods).
Theory used: Self-Determination Theory, Selective Optimization with Compensation and Social Cognitive Theory.
Students in the comparison schools received the government mandated Life Orientation curriculum, which differ substantially between schools and overlap minimally with HealthWise content. 12 months, 18 months and 24 months
Van der Maas 2009 Secondary schools, Nigeria Quasi-experimental Age range: 10–30
Number: 250
Objectives: to increase HIV/AIDS awareness and HIV life skills.
Content: teaching included relevant topics on HIV and life skills.
Activities: sketches, songs, rallies, competitions and videos with scenarios from Africa translated into the local language. UNPFA/UNAIDS peer education toolkit and Family Health International peer-to-peer training guide manuals were used.
Dose/frequency/duration: NR
Theory Used: NR
The control group did not receive any peer education. 24 months
Ybarra 2013 Secondary schools, Uganda Randomised Controlled Trial Age range: 13–19
Number: 366
Objectives: to provide information about HIV, decision making and communication, motivations to be healthy, proper use of condom and healthy relationships.
Content: modules were on information about HIV including prevention; decision-making and communication; motivations to be healthy; how to use a condom to be healthy; and healthy relationships.
Activities: self-administered computer interactive sessions.
Dose/duration/frequency: One hour per module (six modules) over six weeks.
Theory used: Information-Motivation-Behaviour model.
The control arm was ‘treatment as usual’: Participants in the control arm received no programming or interaction beyond the
HIV programming that was currently being offered at their school as part of their usual schedule of extracurricular activities.
3 months and 6 months