Improving Adolescent Sexual and Reproductive Health: A Systematic Review of Potential Interventions

Adolescents have special sexual and reproductive health needs (whether or not they are sexually active or married). This review assesses the impact of interventions to improve adolescent sexual and reproductive health (including the interventions to prevent female genital mutilation/cutting [FGM/C]) and to prevent intimate violence. Our review findings suggest that sexual and reproductive health education, counseling, and contraceptive provision are effective in increasing sexual knowledge, contraceptive use, and decreasing adolescent pregnancy. Among interventions to prevent FGM/C, community mobilization and female empowerment strategies have the potential to raise awareness of the adverse health consequences of FGM/C and reduce its prevalence; however, there is a need to conduct methodologically rigorous intervention evaluations. There was limited and inconclusive evidence for the effectiveness of interventions to prevent intimate partner violence. Further studies with rigorous designs, longer term follow-up, and standardized and validated measurement instruments are required to maximize comparability of results. Future efforts should be directed toward scaling-up evidence-based interventions to improve adolescent sexual and reproductive health in low- and middle-income countries, sustain the impacts over time, and ensure equitable outcomes.

of whom, 95% are from low-and middle-income countries (LMICs) [4]. Almost half of the women aged 20e24 years in Asia and Africa are married by age 18 years, putting them at a higher risk for early pregnancy, repeated pregnancies, maternal disability, and death [3,5]. Adolescent birth rate in LMICs is more than double that of high-income countries (HICs) and often within a formal marital relationship, especially in Asia, Middle East, and North African regions [6]. Although rates of births among adolescent girls have declined in all regions since 1990, they are still high in Africa, Asia, Latin America, and Caribbean. Among females aged 15e19 years, pregnancy-related death is the second leading cause of death after self-harm [7]. Younger mothers are at an increased risk of obstetric fistula, anemia, eclampsia, postpartum hemorrhage, and puerperal endometritis [7e9]. Girls younger than 19 years have a 50% increased risk of stillbirths and neonatal deaths, as well as an increased risk for preterm birth, low birth weight, and asphyxia [8]. In addition to affecting the health of the mother, early marriage and/or childbearing also often prevent girls from attending school and perpetuate the cycle of poverty [9e11]. In LMICs, adolescent pregnancy is a severe impediment to development and can lead to a number of challenges including abandonment by their partners, school dropout, and lost productivity, which ultimately limits their future social and economic opportunities leading to intergenerational transmission of poverty [12,13].
Female genital mutilation/cutting (FGM/C) is a hazardous traditional practice on prepubescent girls that involves partial or total removal of the external female genitalia or other injury to the female genital organs for nonmedical reasons [14]. It is practiced in about 28 countries of Africa, and recent figures suggest a prevalence of more than 70% in Burkina Faso, Djibouti, Egypt, Eritrea, Ethiopia, Guinea, Mali, Mauritania, Northern Sudan, Sierra Leone, and Somalia [15,16]. It is also practiced by immigrant communities in a number of other countries, including Australia, Canada, France, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the U.S. [17]. However, there is considerable variation in prevalence between and within countries, reflecting ethnicity and tradition. Girls exposed to FGM/C are at risk of immediate physical consequences, such as severe pain, bleeding, shock, difficulty in passing urine and feces, and infections. Long-term consequences can include chronic pain, sexual/orgasmic dysfunction, infections, and mental trauma [18,19].
In 2011, the World Health Organization (WHO) issued guidelines on preventing early pregnancy and poor reproductive outcomes in adolescents from LMICs focusing on four major pregnancy prevention outcomes: (1) increasing access to and use of contraception; (2) preventing marriage before 18 years; (3) increasing knowledge and understanding of the importance of early pregnancy prevention; and (4) preventing coerced sex [20].
Adolescents have special sexual and reproductive health needs that remain unmet, mainly due to lack of knowledge, social stigma, laws and policies preventing provision of contraception and abortion to unmarried (or any) adolescents, and judgmental attitudes among service providers [21]. To maintain sexual and reproductive health, adolescents need access to accurate information and to the safe, effective, affordable, and acceptable contraception method of their choice. They must be informed and empowered to protect themselves from STIs. All sexually active adolescents, regardless of marital status, deserve to have their contraceptive needs acknowledged and responded to. This article is part of a series of reviews conducted to evaluate the effectiveness of potential interventions for adolescent health and well-being. A detailed framework, methodology, and other potential interventions have been discussed in separate articles [22e28]. This article aims to assess the impact of interventions to improve sexual and reproductive health, prevent adolescent pregnancy; FGM/C; and intimate partner violence.

Methods
We systematically reviewed all published literature up to December 2014 on interventions to improve sexual health in adolescent population focusing on sex education, preventing unintended adolescent pregnancy, intimate partner violence, and FGM/C. We took a systematic approach to consolidate the existing evidence through the following three methodologies in order to include all the recent evidence: 1. Overview of systematic reviews: We conducted an overview of systematic reviews for interventions where recent systematic reviews existed; 2. Updating existing reviews: We updated the existing systematic reviews if the existing review only included evidence prior to 2011; and 3. De novo review: For interventions where no reviews existed, we conducted a de novo review.
For the purpose of this review, the adolescent population was defined as aged 11e19 years; however, since many studies targeted youth (aged 15e24 years) along with adolescents, exceptions were made to include studies targeting adolescents and youth. Studies were excluded if they targeted age groups other than adolescents and youth or did not report segregated data for the age group of interest. The search was conducted till December 2014, and we did not apply any limitations on the start search date or geographical settings and have attempted to carry out subgroup analysis for various interventions and settings, where data permitted.

Methodology for de novo review
For de novo reviews, our priority was to select existing randomized, quasi-randomized, and before/after studies, in which the intervention was directed toward adolescents and related to sexual and reproductive health outcomes. A separate search strategy was developed for each aspect using appropriate keywords, medical subject heading, and free text terms. The following principal sources of electronic reference libraries were searched to access the available data: The Cochrane Library, Medline, PubMed, Popline, LILACS, CINAHL, EMBASE, World Bank's JOLIS search engine, CAB Abstracts, British Library for Development Studies BLDS at Institute of Development Studies, the WHO regional databases, Google, and Google Scholar. The titles and abstracts of all studies identified were screened independently by two reviewers for relevance and matched. Any disagreements on selection of studies between these two primary abstractors were resolved by the third reviewer. After retrieval of the full texts of all the studies that met the inclusion/ exclusion criteria, data from each review or study were abstracted independently and in duplicate into a standardized form. Quality assessment of the included randomized controlled trials (RCTs) was done according to the Cochrane risk of bias assessment tool. We conducted a meta-analysis for individual studies using the software Review Manager, version 5.3 (Cochrane Collaboration, London, United Kingdom). Pooled statistics were reported as the relative risk (RR) for categorical variables and standard mean difference (SMD) for continuous variables between the experimental and control groups with 95% confidence intervals (CIs). A grade of "high," "moderate," "low," and "very low" was used for grading the overall evidence indicating the strength of an effect on specific health outcome according to the Grading of Recommendations Assessment, Development and Evaluation criteria [29].

Methodology for existing systematic review
We considered all available published systematic reviews on the interventions to improve adolescent sexual health. Our priority was to select existing Cochrane and non-Cochrane systematic reviews of randomized or non-RCTs, which fully or partly addressed the interventions. A broad search strategy was used that included a combination of appropriate keywords, medical subject heading, and free text terms, and search was conducted in The Cochrane Library, Medline, and PubMed. The abstracts (and the full sources where abstracts are not available) were screened by two abstractors to identify systematic reviews adhering to our objectives. Any disagreements on selection of reviews between these two primary abstractors were resolved by the third reviewer. After retrieval of the full texts of all the reviews that met the inclusion/exclusion criteria, data from each review were abstracted independently and in duplicate into a standardized form. Information was extracted on (1) the characteristics of included studies; (2) description of methods, participants, interventions, and outcomes; (3) measurement of treatment effects; (4) methodological issues; and (5) risk of bias tool. We extracted pooled effect size for the outcomes of interest with 95% CIs. We assessed and reported the quality of included reviews using the 11-point assessment of the methodological quality of systematic reviews (AMSTAR) criteria [30].

Methodology for updated review
We updated the existing systematic reviews only if the most recent review on a specific intervention was conducted before December 2011. For updating the existing reviews, we adopted the same methodology and search strategy mentioned in the existing review to update the search and find all the relevant studies after the last search date of the existing review. After retrieval of the full texts of all the articles that met the inclusion/ exclusion criteria, data from each study were abstracted independently and in duplicate into a standardized form. Information was extracted on study design, geographical setting, intervention type and description, mode of delivery, and outcomes assessed. We then updated the estimates of reported outcomes by pooling the evidence from the new studies identified in the updated search and reported new effect size for the outcomes of interest with 95% CIs. We then assessed and reported the quality of included reviews using the 11-point AMSTAR criteria [30].

Results
We found existing systematic reviews on interventions for improving adolescent sexual and reproductive health; however, they were limited in their scope to a particular strategy such as school-based interventions [31,32], peer-led interventions [33], mass media [34,35], and youth centers [36]; geographic settings [37,38]; or limited to trial data only [13,39]. Hence, we conducted a de novo review for the effectiveness of sexual and reproductive health education and contraceptive availability. We found a recent existing Cochrane review by Fellmeth et al. [40] on interventions to prevent intimate partner violence and reported the relevant findings. For interventions to prevent FGM/C, we updated the review by Berg and Denison [14] and also broadened its scope to include studies outside of Africa. Figure 1 depicts the search flow diagrams while Table 1 describes in detail the characteristics of the included studies for the de novo review.

Sexual and reproductive health interventions to prevent adolescent pregnancy
Studies were included if any form of sexual and reproductive health education, counseling, and access to contraception was delivered to adolescents compared to no intervention or general health education. We identified 1,123 titles from the search conducted in all databases. After screening the titles and abstracts, 84 studies were identified that met the inclusion criteria [41e83] [84e109] [110e124]; 51 studies were RCTs while 29 were quasi-experimental design and four were preepost studies. Fifty four of 84 studies focused on adolescent age group alone (11e19 years) while the rest had overlapping age groups. Metaanalysis could be conducted for 48 studies as other studies did not report data that could be pooled. Most of these studies were conducted in HICs in North America and Europe except 10 studies that were conducted in LMICs including Zambia, Zimbabwe, Cameroon, Tanzania, Gambia, Kenya, China, and Peru. Interventions mainly included (1) education and counseling through peer groups, parent education, community members, telephone calls, Web-based content, and home visitation; (2) youth-friendly health services; (3) improving access to contraceptives through pharmacy, clinic, and advance provision of contraceptives; (4) condom distribution; (5) abstinence-focused education; (6) emergency contraceptive promotion; (7) skills development; and (8) multicomponent interventions.
Subgroup analysis according to the type of interventions suggests that peer-led counseling significantly improved mean knowledge score however did not significantly impact use of contraception. Peer-led counseling comprised peer educators providing information and counseling through one-on-one sessions, group talks and presentations, and distribution of print materials. Number of group sessions varied from study to study, ranging from three sessions to nine sessions. The intervention mainly emphasized male and female anatomyephysiology of the reproductive system, preventive precautions against sexually transmitted diseases and HIV/AIDS, family planning methods, communication skills, ethnic and gender pride, condom use skills, and healthy relationships. Parent-directed interventions were also effective in improving sexual knowledge, and the interventions included a 20-minute video filmed, which addressed decision-making regarding future planning for the parent and child, parentechild communication about sexual decisionmaking, followed by role-playing and a condom demonstration. The video was followed by a structured discussion among the participants. Clinic-based interventions comprising counseling, skills building, and case management services improved mean knowledge. These findings are limited to a single study only. Clinic-based face-to-face behavioral counseling and education followed by monthly phone calls for 6 months and reproductive health intervention combining a highly explicit half-hour slide-tape program with a personal health consultation did not have any impact on contraceptive use. Technology-based interventions including custom-computerized intervention in which content and delivery were based on the Informatione MotivationeBehavioral Skills model of health behavior change and teen-led, media literacy curriculum focused on sexual portrayals in the media were effective in improving sexual knowledge but did not have any impact on contraceptive use. Schoolbased interventions including combined sex education with youth-friendly sexual health services, curriculum modules implemented by adult facilitators or peer cofacilitators (including abstinence education, delaying sexual intercourse or reducing its frequency, safer sex intervention, condom use), and HIV prevention education were effective in improving contraceptive use but did not impact mean knowledge scores. Subgroup analysis for HICs and LMICs could not be conducted due to limited number of studies in LMIC settings (Table 2). Data quality was rated to be "moderate" since the study designs were not robust (included RCTs, quasi and preepost studies), substantial statistical heterogeneity, and limited generalizability.
Search strategy same as used by Berg         Female genital mutilation  and converting circumcisers; (5) alternative rites; (6) positive deviance; and (7) comprehensive social development including outreach and advocacy. Findings from low-quality evidence suggest that interventions to prevent FGM/C did not have any significant impact on belief that FGM/C compromises human rights of women, though there was significant statistical heterogeneity in the two included studies (RR: 1.30; 95% CI: .47e3.64). However, these interventions significantly reduced the prevalence of FGM/C (RR: .86; 95% CI: .75e.99) and improved knowledge of harmful consequences of FGM/C (RR: 1.53; 95% CI: 1.08e2.16; Figures 4 and 5), though there was significant heterogeneity in the interventions (Table 3). Subgroup analysis suggests that these interventions significantly improved knowledge of harmful consequences in both men and women. These studies suggest that the factors related to the continuance and discontinuance of FGM/C varied across contexts, but the main factors that supported FGM/C were tradition, religion, and reduction of women's sexual desire.

Intimate partner violence
We report the findings from a Cochrane review by Fellmeth et al. [40] focusing on educational and skills-based interventions targeted at young people aged 12e25 years for preventing intimate partner violence with an AMSTAR rating of 11 . A total of 38 studies were included, 33 of which were included in the metaanalysis. All the included studies were conducted in HICs. There was an increase in knowledge related to relationship violence in favor of the intervention (SMD: .44; 95% CI: .28e.60). However, moderate-quality evidence suggests no significant impact of such interventions on episodes of relationship violence (RR: .77; 95% CI: .53e1.13), behavior scores related to relationship violence (SMD: À.07; 95% CI: À.31 to . 16), and a skills score related to relationship violence (to communicate effectively; SMD: .03; 95% CI: À.11 to .17). Subgroup analyses showed no statistically significant differences by intervention setting or type of participants.

Discussion
Our review suggests that sexual and reproductive health education, counseling, and contraceptive availability are effective in increasing adolescent knowledge related to sexual health, contraceptive use, and decreasing adolescent pregnancy. We could not conduct subgroup analysis for the effectiveness of these interventions in HICs and LMICs since there were limited studies from LMIC settings. Among interventions to prevent FGM/C, community mobilization and female empowerment have the potential to raise awareness of the adverse health consequences of FGM/C and decrease its prevalence; however, there is a need to conduct methodologically rigorous intervention evaluations. Overall, there was limited and inconclusive evidence for the effectiveness of interventions to prevent intimate partner violence.
Our findings are in concordance with existing reviews evaluating the effectiveness of various interventions for improving adolescent sexual and reproductive health and also collate various interventions under a broader umbrella to evaluate the combined effectiveness of these interventions. An existing Cochrane review on primary prevention interventions (school based, community or home based, clinic based, and faith based) on unintended pregnancies among adolescents also suggests that combination of educational and contraceptive interventions can lower the rate of unintended pregnancy among adolescents with nonconclusive evidence on secondary outcomes, including initiation of sexual intercourse, use of birth control methods, abortion, childbirth, and STIs [13]. Group-based comprehensive risk reduction has been reported as an effective strategy to reduce adolescent pregnancy, HIV, and STIs while effectiveness of group-based abstinence education was inconclusive [136]. Another review on adolescent fertility in LMICs suggests improved knowledge-based indicators in the intervention groups of almost all interventions evaluated; however, it is not clear that such interventions necessarily lead to short-or longterm behavior change [137,138].
The United Nations Fund for Population Activities (UNFPA) and United Nations International Children's Emergency Fund (UNICEF) joint program, developed in 2007 to protect girls and women by accelerating abandonment of FGM/C and providing care for its consequences, has accelerated existing changes toward FGM/C abandonment by legal frameworks, coordination mechanisms, and access to services at both community and national level. But, further efforts are needed, especially at the national and community levels, to bring changes in behaviors and practices [139]. A recent report by WHO on preventing  intimate partner and sexual violence suggests that evidence is still in its infancy and much remains to be accomplished [140].
This existing evidence on adolescent sexual reproductive health has several limitations. Most trials failed to utilize allocation concealment, blinding, and randomization to optimize their outcomes. Hence, most of the outcomes were rated as low or moderate in methodological quality. There was a lack of rigorous study design for the interventions to prevent FGM/C with most studies utilizing before and after designs without comparable controls, although individual or cluster RCTs to address FGM/C would pose huge ethical challenges. Nevertheless, many of the trials focused on nonstandardized and selfreported outcomes with short follow-up periods that might have been insufficient to detect any meaningful behavioral changes to establish or to wash out the effect of intervention. Most studies on intimate partner violence analyzed outcomes such as attitude and knowledge rather than episodes of violence and behavioral change. Furthermore, we found a dearth of evidence on interventions for improving sexual health of adolescents living in LMICs where the majority of the adolescent population of the world resides. This might lead to limited external validity for many of these interventions. Most of the studies did not report data segregated by gender which is essential since males and females might respond differently to behavioral interventions. The wide variability in study constructs, nonuniformity in subgroup population, lack of subgroup analysis of gender, socioeconomic status, and nonstandardized outcomes all preclude the external validity and effectiveness of the present interventions in LMICs.
Our review suggests that a range of comprehensive interventions targeting sexual health education, counseling, consistent birth control methods promotion, and provision have the potential to prevent and control the adverse outcomes related to risky sexual behavior. However, much more is needed to increase awareness and prevent FGM and intimate partner violence.