Background

Risk taking is inherent in young people as they reach adulthood; the choices they make during this phase of life could enhance or diminish their future health and wellbeing.1,2 Young people are increasingly exposed to sexual risk taking due to changing social structures, migration patterns, disasters, lack of care provision facilities and globalization. Developments in computerized communication media (e.g. emails and instant messaging) and social networking applications (e.g. Facebook, Twitter, Whatsapp, etc.), unavailability or lack of accurate information, among others, contribute to risk taking.1,3

Young people are those aged between 10 and 24 years.1,3

The increasing global focus on the sexual and reproductive challenges of young people is a relatively recent phenomenon, more so in the developing world.2 Sexual risk taking includes behaviors such as early sexual initiation, poor self-efficacy at negotiating safer sex or condom use, having multiple sexual partners, non-use of contraceptives (particularly condoms) during sexual activities, and engaging in sexual activities under the influence of alcohol and other substances.4-7 Factors contributing to sexual risk taking among young people are diverse, among them, cultural factors such as gender roles,8 economic disparities, political decisions9 and social support or lack of it.8,9 Some sexual risk taking of young people could be a reflection of situations in which there are inappropriate support structures or those that rather predispose them to risks.10 Sexual risk taking could place young people at risk of adverse health outcomes such as sexually transmitted infections (STIs) including human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and unintended pregnancies, among others.2 Sexually transmitted infection rates have been high among young people,11,12 with 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.13 One out of 20 adolescents worldwide contracts STIs annually.13 The human immunodeficiency virus/acquired immune deficiency syndrome is a leading cause of ill health among persons aged 10-24 years worldwide,11 afflicting predominantly the developing world.14-16 Half of all new HIV infections occur among 15 to 24 year-olds,14 75% of whom were residing in sub-Saharan Africa (SSA) as at December 2001.16 Young people of poor socioeconomic backgrounds in predominantly developing countries of SSA and South Asia are at the center of the HIV/AIDS epidemic with a quarter of the 40 million infected individuals aged 15 to 24 years.16,17 The HIV prevalence trends of adolescents 15-19 years within Sub-Saharan Africa consistently show females with higher rates than males.18 Adolescence is the period between 10 and 19 years when young individuals enter adulthood.1,14

Adolescent 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".16 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 face the risk of being anemic, having pre/-eclampsia, bleeding excessively, being more prone to birth traumas in the form of perineal tears, and having defects leading to fistula and paralysis, coupled with emotional trauma.16 Infants resulting from adolescent pregnancies could have low birth weight and anemia, increasing their morbidity and mortality risks. For every death during childbirth of an adolescent, 15 to 30 others endure varying degrees of disability.16 Maternal deaths among females aged 15-19 years are twice as high as those over 20 years.19

Birth rates have been declining since the late 1980s among adolescents, although not as dramatically across the globe, with developed countries contributing more than developing countries.18 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.14 Adolescents with children have curtailed potential for maturation, self-development, 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 adolescent mothers tend to be unwanted and do not get the attention they duly deserve. An adolescent is not mature enough to withstand the pressures of bringing up a child, because they themselves are children with the added responsibility of taking care of another child.16 Complications of unplanned pregnancies are abortions under unsafe conditions and higher risks of adverse outcomes for both the mother and the newborn.14 Unwanted pregnancies are common among adolescents and they account for over a quarter of the estimated 20 million unsafe abortions performed globally each year.16 Aside physiological factors, premature abortions among adolescents could be due, to previously acquired STIs.12

The consequences of adolescent sexual risk taking could temporarily manifest in the short or long term;9 they could affect the individual, family/community and nations;16 they could be just as traumatic and distressing on the individuals involved as they are on the family or society in which they reside;20 they could incur health, educational, social, economic and psychological costs to societies across the globe.16 These consequences though enormous are preventable.

Increases in STIs, 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.2,12 Serious challenges posed to global health by the increased incidence and prevalence of HIV/AIDS and STIs12 have led to the WHO and its partner organizations deciding in the 1990s to pursue the sexual and reproductive health (SRH) needs of young people to avoid a global disaster.3

Working with the aim of enhancing the safety and wellbeing of young people, several population based interventions and programs have been developed and administered over the years to this population.21-25 Most of these programs have components that build upon protective factors or reduce the influence of risk factors in the lives of young people and in so doing enhance their ability to avoid risk taking with regards to their SRH.26,27 Ensuring the health and wellbeing of young people is an investment in individuals today and society as a whole towards the future and the generations ahead.20 Healthy young people have a positive bearing on the health, social, economic and political aspects of society.20 Intervening early in life to address sexual risk taking is far less expensive than managing the consequences in later life.28 A proactive approach in managing sexual risk taking in young people therefore not only mitigates a reproductive health problem but results in socioeconomic, political and cultural benefits for society as a whole.29,30

Public health programs and interventions target populations and not individuals within communities.31 The aim of most sexual risk reduction programs targeting young people is to provide age and context appropriate interventions. For example, whilst some programs aim at preventing early sexual initiation, others empower those already sexually active to avoid unintended pregnancies, STIs and their associated complications to improve sexual health.32,33 Sexual risk reduction public health programs utilize structured curricula with defined activities involving groups and not individuals to address sexual behavior of young people.32,33 Such programs have yielded positive outcomes on some sexual risk measures after being implemented in communities, schools and health care settings.24,25,33-36

Though outcomes of sexual risk taking are diverse, the focus of most assessments is on reduction of unintended pregnancies and STIs including HIV/AIDS.32 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.36-39

In a search of published reviews from the Cochrane Library, the JBI Database of Systematic Reviews and Implementation Reports (JBISRIR) and the Campbell Collaboration Library and via PUBMED, recent reviews comprehensively addressing the current topic under consideration were not identified. A review on population-based clinical interventions aimed at reducing STIs and HIV in some developing countries improved STI prevention, but did not reduce HIV incidence.40 The review by DiCenso and colleagues in 2002 concluded that abstinence only programs resulted in increased pregnancies among adolescents in comparison to their comprehensive counterparts.21 Other reviews of population-based comprehensive risk reduction programs in the developing world resulted in enhanced condom use, reduced sexual partners and initiation,41 improved HIV knowledge, reduced high-risk sexual behavior,42 and reductions in HIV and STIs43 among adolescents. Furthermore, some reviews of effective interventions included studies up to the year 2008,44 or were focused on only school- or community-based interventions.45-47 The current review seeks to generate the best available evidence on the effectiveness of population based risk reduction programs and services on SRH risk taking among young people in low and middle income countries (LMICs). The World Bank in 2016 grouped countries according to their gross national income per capita, into four blocks, namely: low income (US$1,025 or less), lower middle income (US$1,026 to US$4,035), upper middle income (US$4,036 to US$12,475) and high income (US$12,476 or more).48 Therefore low, lower middle and upper middle income countries constitute LMICs.

Improving maternal and child health, and combating HIV/AIDS could be best achieved if sexual risk taking among young people is approached seriously and addressed appropriately. In the context of this systematic review, sexual risk taking is defined as any unprotected sexual activity that exposes the individual to adverse health consequences such as STIs including HIV/AIDS and unwanted/unintended pregnancies. Also, population based (public health) risk reduction programs and services refer to those interventions that target groups of people and not individuals within communities.

Inclusion criteria

Types of participants

This review will consider studies that include persons aged 10 to 24 years residing in LMICs.

Types of intervention(s)

This review will consider studies that evaluate or report on population based risk reduction programs and services that target young people in LMICs.

Types of comparators

The comparator studies to be considered in this review will be those undertaken at the population level. They could be existing risk reduction programs or nothing at all.

Outcomes

This review will consider studies that include the following outcome measures related to reduction in risky sexual behavior among young people: time to sexual initiation, number of sexual partners, condom use at first sex, consistent and correct contraceptive (condom) use during sexual encounters [condom use skills], self-efficacy in negotiating safer sex and condom use. These outcomes would have been assessed six or more months after the introduction of the interventions.

Types of studies

The review will consider randomized controlled trials (RCTs), particularly cluster RCTs. In the absence of RCTs, quasi-experimental study designs will be included in the review. These would be studies carried out within the community, school or health facility, e.g. Youth Friendly Services. Interventions carried out at the individual level will not be included in the review.

Search strategy

The search strategy aims to find both published and unpublished studies starting from 1980. The reason for this timeline stems from the fact that, although adolescent SRH attracted significant global public health attention in the 1990s,3 literature searches point to interventions dating back to the early 1980s.49-51 A three-step search strategy will be utilized in this review. An initial limited search of PubMed and POPLINE will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe identified articles. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference lists of all identified reports and articles will be searched for additional studies. Studies published in English but not other language/s will be considered for inclusion in this review. This could result in a limitation where some important non-English language studies would not be included in the review.

The databases to be searched include: PubMed, POPLINE, PsycINFO and Web of Science. The search for gray literature will include: WHOLIS (World Health Organization Library Database), Networked Digital Library of Theses and Dissertations (ProQuest), United Nations Population Fund, Advocates for Youth, Pathfinder International, the National Academy Press of the National Academy of Science.

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 maternal mortality, public health interventions, and population based interventions, developing countries.

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 standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).52 If required, authors of original papers will be contacted for clarification on issues relevant to their papers. Appraisal will be piloted on a sample of five publications and notes compared to ensure congruity between the reviewers' assessments. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Data extraction

Quantitative data will be extracted from papers included in the review by two independent reviewers using the standardized data extraction tool from JBI-MAStARI.53 The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Reviewers will pilot the data extraction tools on a sample of five publications, compare notes to ensure the requisite details are accessed. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Data synthesis

Quantitative data will, where possible be pooled in statistical meta-analysis using JBI-SUMARI and where necessary, metan, a meta-analysis package in the Stata data analysis and statistical software. Effect sizes expressed as odds or risk ratios (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard I² and Chi-square and also explored using subgroup analyses based on the different study designs, intervention types and outcome measures included in this review. Results of randomized studies will be pooled based on similarity in randomization design (completely randomized, stratified randomized, matched-pair randomized), and randomization unit (community, school, household, health facility, etc.) and time after implementation of intervention. Based on cluster sizes and number of clusters for selected studies, the appropriate method (adjusted Mantel-Haenszel test, Woolf procedures, ratio estimator procedure or generalized estimation equations [GEE])54 will be used to pool the results. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.

Acknowledgements

We acknowledge Associate Professor Edoardo Aromataris for his commentary and feedback during the development of this protocol.

References