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

      Abstract

      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.

      Keywords

      A significant number of adolescents around the globe are sexually active, and this proportion increases steadily from mid- to late adolescence [
      • Chandra-Mouli V.
      • McCarraher D.R.
      • Phillips S.J.
      • Williamson N.E.
      • Hainsworth G.
      Contraception for adolescents in low and middle income countries: Needs, barriers, and access.
      ]. Sexual activity of adolescents varies markedly by gender and region; more girls compared with boys are sexually active in sub-Saharan Africa, Asia, and central Asia while in Latin America and Caribbean, more boys are sexually active than girls [
      • Chandra-Mouli V.
      • McCarraher D.R.
      • Phillips S.J.
      • Williamson N.E.
      • Hainsworth G.
      Contraception for adolescents in low and middle income countries: Needs, barriers, and access.
      ]. About 3 in 10 unmarried adolescent women in sub-Saharan Africa and nearly one in four in South America have ever had sex [
      ]. Early sexual debut increases the risk of sexually transmitted infections (STIs), including HIV, and can result in unintended pregnancy and early childbearing. Adolescents have limited and, in some places, no access to sexual and reproductive health education and contraception, making adolescent girls more prone to early and unintended pregnancies [
      • Williamson N.
      State of world population 2013. Motherhood in childhood.
      ].
      Nearly a quarter of girls aged 15–19 years are married with an estimated 16 million adolescents giving birth each year globally, of whom, 95% are from low- and middle-income countries (LMICs) [

      United Nations: We can end poverty: Millennium development goals and beyond 2015. Available at: http://www.un.org/millenniumgoals/childhealth.shtml. Accessed November 16, 2015.

      ]. Almost half of the women aged 20–24 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 [
      • Williamson N.
      State of world population 2013. Motherhood in childhood.
      ,
      World Health Organization
      Adolescent pregnancy.
      ]. 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 [
      United Nations Fund for Population Activities
      Adolescent and youth demographics: A brief overview.
      ]. 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 15–19 years, pregnancy-related death is the second leading cause of death after self-harm [

      World Health Organization: Health for the world's adolescents: A second chance in the second decade. Available at: http://public.tableausoftware.com/profile/digitalteam#!/vizhome/shared/3JW3RBSZ3. Accessed November 16, 2015.

      ]. Younger mothers are at an increased risk of obstetric fistula, anemia, eclampsia, postpartum hemorrhage, and puerperal endometritis [

      World Health Organization: Health for the world's adolescents: A second chance in the second decade. Available at: http://public.tableausoftware.com/profile/digitalteam#!/vizhome/shared/3JW3RBSZ3. Accessed November 16, 2015.

      ,
      • Haldre K.
      • Rahu K.
      • Karro H.
      • Rahu M.
      Is a poor pregnancy outcome related to young maternal age? A study of teenagers in Estonia during the period of major socio-economic changes (from 1992 to 2002).
      ,
      • Michaud P.A.
      • Ambresin A.E.
      The health of adolescents around a world in transition.
      ]. 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 [
      • Haldre K.
      • Rahu K.
      • Karro H.
      • Rahu M.
      Is a poor pregnancy outcome related to young maternal age? A study of teenagers in Estonia during the period of major socio-economic changes (from 1992 to 2002).
      ]. 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 [
      • Michaud P.A.
      • Ambresin A.E.
      The health of adolescents around a world in transition.
      ,
      United Nations International Children's Emergency Fund (UNICEF)
      Progress for children: A report card on adolescents. (No. 10).
      ,
      United Nations Population Fund
      Motherhood in childhood: Facing the challenge of adolescent pregnancy.
      ]. 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 [
      World Health Organization (WHO)
      Adolescent pregnancy—unmet needs and undone deeds: A review of the literature and programmes.
      ,
      • Oringanje C.
      • Meremikwu M.M.
      • Eko H.
      • et al.
      Interventions for preventing unintended pregnancies among adolescents.
      ].
      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 [
      • Berg R.C.
      • Denison E.
      Interventions to reduce the prevalence of female genital mutilation/cutting in African countries.
      ]. 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 [
      • Yoder S.
      • Abderrahim N.
      • Zhuzhuni A.
      Female genital cutting in the demographic and health surveys: A critical and comparative analysis. DHS comparative reports no. 7.
      ,
      • Yoder S.
      • Kahn S.
      Numbers of women circumcised in Africa: The production of a total. DHS working papers.
      ]. 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. [
      HRP (the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction). Progress in sexual and reproductive health, Newsletter 72.
      ]. 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 [
      • Berg R.C.
      • Denison E.
      Does female genital mutilation/cutting (FGM/C) affect women's sexual functioning? A systematic review of the sexual consequences of FGM/C.
      ,
      • Banks E.
      • Meirik O.
      • et al.
      WHO study group on female genital mutilation and obstetric outcome
      Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries.
      ].
      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 [
      World Health Organization
      WHO guidelines on preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries.
      ].
      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 [
      United Nations Fund for Population Activities
      Adding it up: The cost and benefit of investing in sexual and reproductive health.
      ]. 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 [
      • Salam R.A.
      • Das J.K.
      • Lassi Z.S.
      • Bhutta Z.A.
      Adolescent health and well-being: Background and methodology for review of potential interventions.
      ,
      • Salam R.A.
      • Hooda M.
      • Das J.K.
      • et al.
      Interventions to improve adolescent nutrition: A systematic review and meta-analysis.
      ,
      • Das J.K.
      • Salam R.A.
      • Arshad A.
      • et al.
      Systematic review and meta-analysis of interventions to improve access and coverage of adolescent immunizations.
      ,
      • Das J.K.
      • Salam R.A.
      • Arshad A.
      • et al.
      Interventions for adolescent substance abuse: An overview of systematic reviews.
      ,
      • Das J.K.
      • Salam R.A.
      • Lassi Z.S.
      • et al.
      Interventions for adolescent mental health: an overview of systematic reviews.
      ,
      • Salam R.A.
      • Arshad A.
      • Das J.K.
      • et al.
      Interventions to prevent unintentional injuries among adolescents: A systematic review and meta-analysis.
      ,
      • Salam R.A.
      • Das J.K.
      • Lassi Z.S.
      • Bhutta Z.A.
      Adolescent health interventions: Conclusions, evidence gaps, and research priorities.
      ]. 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 11–19 years; however, since many studies targeted youth (aged 15–24 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 [
      • Walker N.
      • Fischer-Walker C.
      • Bryce J.
      • et al.
      Standards for CHERG reviews of intervention effects on child survival.
      ].

       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 [
      • Shea B.J.
      • Grimshaw J.M.
      • Wells G.A.
      • et al.
      Development of AMSTAR: A measurement tool to assess the methodological quality of systematic reviews.
      ].

       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 [
      • Shea B.J.
      • Grimshaw J.M.
      • Wells G.A.
      • et al.
      Development of AMSTAR: A measurement tool to assess the methodological quality of systematic reviews.
      ].

      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 [
      • Mason-Jones A.J.
      • Crisp C.
      • Momberg M.
      • et al.
      A systematic review of the role of school-based healthcare in adolescent sexual, reproductive, and mental health.
      ,
      • Bennett S.E.
      • Assefi N.P.
      School-based teenage pregnancy prevention programs: A systematic review of randomized controlled trials.
      ], peer-led interventions [
      • Kim C.R.
      • Free C.
      Recent evaluations of the peer-led approach in adolescent sexual health education: A systematic review.
      ], mass media [
      • Guse K.
      • Levine D.
      • Martins S.
      • et al.
      Interventions using new digital media to improve adolescent sexual health: A systematic review.
      ,
      • Jones K.
      • Eathington P.
      • Baldwin K.
      • Sipsma H.
      The impact of health education transmitted via social media or text messaging on adolescent and young adult risky sexual behavior: A systematic review of the literature.
      ], and youth centers [
      • Zuurmond M.A.
      • Geary R.S.
      • Ross D.A.
      The effectiveness of youth centers in increasing use of sexual and reproductive health services: A systematic review.
      ]; geographic settings [
      • Wamoyi J.
      • Mshana G.
      • Mongi A.
      • et al.
      A review of interventions addressing structural drivers of adolescents' sexual and reproductive health vulnerability in sub-Saharan Africa: Implications for sexual health programming.
      ,
      • Speizer I.S.
      • Magnani R.J.
      • Colvin C.E.
      The effectiveness of adolescent reproductive health interventions in developing countries: A review of the evidence.
      ]; or limited to trial data only [
      • Oringanje C.
      • Meremikwu M.M.
      • Eko H.
      • et al.
      Interventions for preventing unintended pregnancies among adolescents.
      ,
      • DiCenso A.
      • Guyatt G.
      • Willan A.
      • Griffith L.
      Interventions to reduce unintended pregnancies among adolescents: Systematic review of randomised controlled trials.
      ]. 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. [
      • Fellmeth G.L.
      • Heffernan C.
      • Nurse J.
      • et al.
      Educational and skills-based interventions for preventing relationship and dating violence in adolescents and young adults.
      ] 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 [
      • Berg R.C.
      • Denison E.
      Interventions to reduce the prevalence of female genital mutilation/cutting in African countries.
      ] 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.
      Figure thumbnail gr1
      Figure 1(A) Search flow for interventions to improve sexual and reproductive health and prevent adolescent pregnancy (de novo review). (B) Search flow for interventions to prevent FGM/C (update).
      Table 1Characteristics of included studies for sexual health education
      Author, yearDesignCountrySettingInterventionTarget populationOutcomes
      Aarons et al., 2000
      • Aarons S.J.
      • Jenkins R.R.
      • Raine T.R.
      • et al.
      Postponing sexual intercourse among urban junior high school students-a randomized controlled evaluation.
      RCTU.S.A.School basedReproductive health classes, the Postponing Sexual Involvement curriculum, health risk screening, and “booster” educational activities during the following (eighth grade) school year.Eighth-grade studentsUse of contraception
      Agha and Van Rossem, 2004
      • Agha S.
      • Van Rossem R.
      Impact of a school-based peer sexual health intervention on normative beliefs, risk perceptions, and sexual behavior of Zambian adolescents.
      QuasiZambiaCommunity basedPeer-led education projects focusing on promoting abstinence and condom use among male and female school children. Peer educators consisted of people aged 18–22 years who were trained by a professional peer education trainer to convey their messages through a mixture of techniques.Males and females aged 14–23 yearsAbstinence, multiple sexual partners, condom use
      Baptiste et al., 2006
      • Baptiste D.R.
      • Bhana A.
      • Petersen I.
      • et al.
      Community collaborative youth-focused HIV/AIDS prevention in South Africa and Trinidad: Preliminary findings.
      RCTSouth Africa and Trinidad and TobagoCommunity basedCommunity participatory research framework to adapt and deliver family-based prevention.YouthCommunication, HIV knowledge and prevalence
      Barnet et al., 2007
      • Barnet B.
      • Liu J.
      • DeVoe M.
      • et al.
      Home visiting for adolescent mothers: Effects on parenting, maternal life course, and primary care linkage.
      RCTU.S.A.Home basedHome visiting or routine care. They delivered a parenting curriculum, encouraged contraceptive use, connected the teen with primary care, and promoted school continuation.Pregnant females aged 12–18 yearsBirth control after index child, repeat pregnancy
      Berenson and Rahman, 2012
      • Berenson A.B.
      • Rahman M.
      A randomized controlled study of two educational interventions on adherence with oral contraceptives and condoms.
      RCTU.S.A.ClinicFace-to-face behavioral counseling and education at their baseline clinic visit or this same intervention followed by monthly phone calls for 6 months or standard care.Females aged 16–24 yearsConsistent contraceptive use, hormonal contraceptive use, condom use, dual usage, no contraception
      Morrison-Beedy et al., 2012
      • Morrison-Beedy D.
      • Jones S.H.
      • Xia Y.
      • et al.
      Reducing sexual risk behavior in adolescent girls: Results from a randomized controlled trial.
      RCTU.S.A.Community basedPeer education groups. Theory-based sexual risk reduction intervention or a structurally equivalent health promotion control group.Females aged 15–19 yearsMultiple sexual partners, intercourse
      Black et al., 2006
      • Black M.M.
      • Bentley M.E.
      • Papas M.A.
      • et al.
      Delaying second births among adolescent mothers: A randomized, controlled trial of a home-based mentoring program.
      RCTU.S.A.Home basedHome visiting or routine care. Home-based intervention curriculum was based on social cognitive theory and focused on interpersonal negotiation skills, adolescent development, and parenting.Postpartum females 13.5–17.9 yearsRepeat pregnancy
      Blake et al., 2003
      • Blake S.M.
      • Ledsky R.
      • Goodenow C.
      • et al.
      Condom availability programs in Massachusetts high schools: Relationships with condom use and sexual behavior.
      QuasiU.S.A.School basedCondom availability in high schoolHigh-school adolescentsCondom use
      Bonell et al., 2013
      • Bonell C.
      • Maisey R.
      • Speight S.
      • et al.
      Randomized controlled trial of 'teens and toddlers': A teenage pregnancy prevention intervention combining youth development and voluntary service in a nursery.
      RCTEnglandCommunity based“Teens and toddlers” intervention: 18–20 weekly sessions in preschool nurseriesTeensContraception use
      Brieger et al., 2001
      • Brieger W.R.
      • Delano G.E.
      • Lane C.G.
      • et al.
      West African youth initiative: Outcome of a reproductive health education program.
      QuasiWest Africa: Nigeria and GambiaCommunity basedPeer education groups. Peer educators provided information and counseling through one-on-one sessions, group talks and presentations, and distribution of print materials.Male and female adolescentsKnowledge
      Bull et al., 2012
      • Bull S.S.
      • Levine D.K.
      • Black S.R.
      • et al.
      Social media delivered sexual health intervention: A cluster randomized controlled trial.
      RCTU.S.A.Community social mediaExposure to Just/Us, a Facebook page developed with youth input, or to control content on 18–24 News, a Facebook page with current events for 2 months.YouthCondom use
      Chen et al., 2010
      • Chen X.
      • Stanton B.
      • Gomez P.
      • et al.
      Effects on condom use of an HIV prevention programme 36 months postintervention: A cluster randomized controlled trial among Bahamian youth.
      RCTU.S.A.Community and school based“Focus on Youth in the Caribbean” (FOYC) is based on the Protection Motivation Theory (PMT), consists of 10 primary sessions (delivered weekly after a baseline survey) and two annual boosters (delivered after 12 and 24 months postintervention assessment). The sessions are designed to augment decision-making skills, including the development of a lifelong perspective in decision-making, communication and listening skills, and protective knowledge and skills regarding safer sexual behavior. GFI and CImPACT are parenting interventions. GFI includes a 20-minute video filmed in the USA, which addresses decision-making regarding future planning for the parent and child; the video is followed by a structured discussion among the participants. CImPACT includes a 20-minute video filmed in the Bahamas addressing parent–child communication about sexual decision-making, followed by role-playing and a condom demonstration.Males and females aged 10–12 yearsKnowledge, condom use
      Clark et al., 2005
      • Clark L.F.
      • Miller K.S.
      • Nagy S.S.
      • et al.
      Adult identity mentoring: Reducing sexual risk for African-American seventh grade students.
      RCTU.S.A.School basedThe AIM is a 10-session curriculum based on the theory of possible selves. Class exercises encourage students to articulate a possible future self-identity and to develop self-promotion skills.Seventh-grade African-AmericansAbstinence, sex initiation
      Cornelius et al., 2013
      • Cornelius J.B.
      • Dmochowski J.
      • Boyer C.
      • et al.
      Text-messaging-enhanced HIV intervention for African American adolescents: A feasibility study.
      Pre–postU.S.A.Community social mediaBecoming a Responsible Teen (BART) is a community-based HIV prevention curriculum, which consists of interactive group discussions and role plays that allow participants to practice behavioral skills for safer sex. BART was followed by the delivery of daily multimedia messages for 3 monthsAfrican-American adolescentsKnowledge, condom use, HIV prevention scores
      Coyle et al., 2001
      • Coyle K.
      • Basen-Engquist K.
      • Kirby D.
      • et al.
      Safer choices: Reducing teen pregnancy, HIV, and STDs.
      RCTU.S.A.School basedSafer Choices, a theory-based, multicomponent educational program designed to reduce sexual risk behaviors and increase protective behaviors in preventing HIV, other STDs, and pregnancy among high-school students.Ninth-grade studentsCondom use
      Coyle et al., 2004
      • Coyle K.K.
      • Kirby D.B.
      • MarÃn B.V.
      • et al.
      Draw the line/respect the line: A randomized trial of a middle school intervention to reduce sexual risk behaviors.
      RCTU.S.A.School basedDraw the Line/Respect the Line, a theoretically based curriculum designed to reduce sexual risk behaviors among middle-school adolescents.Sixth gradersSex initiation, knowledge
      Coyle et al., 2013
      • Coyle K.K.
      • Glassman J.R.
      • Franks H.M.
      • et al.
      Interventions to reduce sexual risk behaviors among youth in alternative schools: A randomized controlled trial.
      RCTU.S.A.School based(1) HIV/STI/pregnancy prevention curriculum only; (2) service learning only; (3) HIV/STI/pregnancy prevention curriculum plus service learning; or (4) an attention control curriculumHigh-school adolescentsMean sexual intercourse, mean use of condom
      Daniel 2008
      • Daniel E.E.
      • Masilamani R.
      • Rahman M.
      The effect of community-based reproductive health communication interventions on contraceptive use among young married couples in Bihar, India.
      QuasiIndiaCommunity basedOrientation and training of reproductive health teams of community leaders and influential residents, and through group meetings with young couples' parents and in-laws; messages were disseminated through street theater performances and wall paintings, and formal and informal rural health service providers were trained on reproductive health issues and contraception.Young couples aged <25 yearsContraceptive use, knowledge and attitude
      Danielson et al., 1990
      • Danielson R.
      • Marcy S.
      • Plunkett A.
      • et al.
      Reproductive health counseling for young men: What does it do?.
      RCTU.S.A.ClinicA reproductive health intervention combining a highly explicit half-hour slide-tape program with a personal health consultation was provided.Males aged 15–18 yearsConsistent contraceptive use, hormonal contraceptive use, condom use, dual usage, no contraception
      DiClemente et al., 2004
      • DiClemente R.J.
      • Wingood G.M.
      • Harrington K.F.
      • et al.
      Efficacy of an HIV prevention intervention for African American adolescent girls: A randomized controlled trial.
      RCTU.S.A.Community basedPeer education groups. All participants received four 4-hour group sessions. The intervention emphasized ethnic and gender pride, HIV knowledge, communication, condom use skills, and healthy relationships. The comparison condition emphasized exercise and nutrition.Females aged 14–18 yearsCondom use
      DiClemente et al., 2009
      • DiClemente R.J.
      • Wingood G.M.
      • Rose E.S.
      • et al.
      Efficacy of sexually transmitted disease/human immunodeficiency virus sexual risk-reduction intervention for African American adolescent females seeking sexual health services: A randomized controlled trial.
      RCTU.S.A.ClinicIntervention participants received two 4-hour group sessions and four telephone contacts over a 12-month period, targeting personal, relational, sociocultural, and structural factors associated with adolescents' STD/HIV risk and were given vouchers facilitating male partners' STD testing/treatment.Females aged 15–21 yearCondom use
      Dilorio et al., 2007
      • DiIorio C.
      • McCarty F.
      • Resnicow K.
      • et al.
      Real men: A group-randomized trial of an HIV prevention intervention for adolescent boys.
      RCTU.S.A.Community basedHIV education, communication skills, take-home activities for fathers and adolescents.Males aged 11–14 yearsCondom use
      Downs et al., 2004
      • Downs J.S.
      • Murray P.J.
      • Bruine de Bruin Wn
      • et al.
      Interactive video behavioral intervention to reduce adolescent females' STD risk: A randomized controlled trial.
      RCTU.S.A.Community basedVideo-based sessions versus book-based informationUrban adolescent girlsAbstinence, condom use, STI
      Elliott et al., 2012
      • Elliott L.
      • Henderson M.
      • Nixon C.
      • Wight D.
      Has untargeted sexual health promotion for young people reached its limit? A quasi-experimental study.
      QuasiScotlandSchool basedHealthy Respect 2 (HR2) combined sex education with youth-friendly sexual health services, media campaigns and branding, and encouraged joint working between health services, local government and the voluntary sector.15- to 16-year-old adolescentsKnowledge, condom acceptability, having sex, condom use
      Erulkar et al., 2004
      • Erulkar A.S.
      • Ettyang L.I.
      • Onoka C.
      • et al.
      Behavior change evaluation of a culturally consistent reproductive health program for young Kenyans.
      QuasiKenyaCommunity basedThe Nyeri Youth Health Project, a community-based project for young people. Adult counselors worked in their own communities to educate both adolescents and parents on reproductive health and to encourage dialogue between them. The counselors were trained for 1 month and used a life skills curriculum entitled “Life Planning Skills for Adolescents in Kenya,” which includes sessions on community, family and individual values, adolescent development, sexuality, gender roles, relationships, pregnancy, STIs, HIV/AIDS, harmful traditional practices, substance abuse, planning for the future, children's rights, and advocacy.10–24 years of ageSexual initiation, secondary abstinence, condom use, sex partners, communication with parents
      Ferguson, 1998
      • Ferguson S.L.
      Peer counseling in a culturally specific adolescent pregnancy prevention program.
      RCTU.S.A.Community basedPeer education groups. Peer counseling in a culturally specific adolescent pregnancy prevention program.Females aged 12–16 yearsCondom use
      Forehand et al., 2007
      • Forehand R.
      • Armistead L.
      • Long N.
      • et al.
      Efficacy of a parent-based sexual-risk prevention program for African American preadolescents: A randomized controlled trial.
      RCTU.S.A.CommunityEnhanced communication intervention (five sessions), single-session communication intervention(one session)African-American parent–preadolescent dyads (child, aged 9–12 years)Mean change in knowledge
      Garcia et al., 2012
      • Garcia P.J.
      • Holmes K.K.
      • Carcamo C.P.
      • et al.
      Prevention of sexually transmitted infections in urban communities (Peru PREVEN): A multicomponent community-randomised controlled trial.
      RCTPeruCommunity basedThe intervention comprised four modalities: strengthened STI syndromic management by pharmacy workers and clinicians; mobile-team outreach for STI screening and pathogen-specific treatment; periodic presumptive treatment of FSWs for trichomoniasis; and condom promotion.Urban young men (aged 18–29 years) and female sex workersSexual intercourse, STI prevalence
      Gold et al., 2004
      • Gold M.A.
      • Wolford J.E.
      • Smith K.A.
      • Parker A.M.
      The effects of advance provision of emergency contraception on adolescent women's sexual and contraceptive behaviors.
      RCTU.S.A.Clinic basedThe intervention group received information about EC and was told how to access EC and in addition received one complete course of EC for future use. Participants in the AEC group were informed that they could obtain up to two additional courses of advance EC during the 6 months of the study and were told that they could obtain these subsequent courses from the study office whenever they requested them. Participants in the control group received written and verbal information about EC and were told how to access EC on request from the adolescent clinic.Urban adolescent females aged 15–20 yearsEC use
      Hall et al., 2012
      • Hall K.S.
      • Westhoff C.L.
      • Castano P.M.
      The impact of an educational text message intervention on young urban women's knowledge of oral contraception.
      RCTU.S.A.Community text messagingThe intervention group received 180 daily text messages, including 47 individual messages (which were repeated up to four times over the study).Young women aged 13–25 yearsOC knowledge
      Harper et al., 2009
      • Harper G.W.
      • Bangi A.K.
      • Sanchez B.
      • et al.
      A quasi-experimental evaluation of a community-based HIV prevention intervention for Mexican American female adolescents: The SHERO's program.
      QuasiU.S.A.Community basedPeer education groups. Nine-session SHERO's (a female-gendered version of the word hero) intervention or a single-session information-only HIV prevention intervention.Females aged 12–21 yearsIntercourse, knowledge
      Herceg-Baron et al., 1986
      • Herceg-Baron R.
      • Furstenberg Jr., F.F.
      • Shea J.
      • Harris K.M.
      Supporting teenagers' use of contraceptives: A comparison of clinic services.
      QuasiU.S.A.ClinicIncrease family + teenager or teenager + clinic staff contactAdolescent aged 12–17 yearsContraceptive use, unintended pregnancy
      Howard and McCabe, 1990
      • Howard M.
      • McCabe J.B.
      Helping teenagers postpone sexual involvement.
      QuasiU.S.A.Community basedPeer education. The program is led by older teenagers and focuses on helping students resist peer and social pressures to initiate sexual activity.Males and females aged 14–16 yearsIntercourse
      Hughes et al., 1995
      • Hughes M.E.
      • Furstenberg Jr., F.F.
      • Teitler J.O.
      The impact of an increase in family planning services on the teenage population of Philadelphia.
      RCTU.S.A.ClinicIncrease in family planning clinic for education counseling and access compared with no clinic.Females aged 14–18 yearsUnintended pregnancy, intercourse
      Jemmott III et al., 1998
      • Jemmott III, J.B.
      • Jemmott L.S.
      • Fong G.T.
      Abstinence and safer sex HIV risk-reduction interventions for African American adolescents: A randomized controlled trial.
      RCTU.S.A.School basedHIV and abstinence education: intervention involved eight 1-hour modules implemented by adult facilitators or peer cofacilitators. Abstinence education enforced delaying sexual intercourse or reducing its frequency; safer sex intervention stressed condom use; control intervention concerned health issues unrelated to sexual behaviors.African-American adolescentsHaving sex, condom use, knowledge, self-efficacy
      Jemmott et al., 2005
      • Jemmott J.B.
      • Jemmott L.S.
      • Braverman P.K.
      • Fong G.T.
      HIV/STD risk reduction interventions for African American and Latino adolescent girls at an adolescent medicine clinic: A randomized controlled trial.
      RCTU.S.A.ClinicCounseling, skills building, and case management servicesFemales aged 12–19 yearsKnowledge, number of sex partners, unprotected intercourse
      Jemmott et al., 2010
      • Jemmott J.B.
      • Jemmott L.S.
      • O'Leary A
      • et al.
      School-based randomized controlled trial of an HIV/STD risk-reduction intervention for South African adolescents.
      RCTSouth AfricaSchool basedTwo 6-session interventions based on behavior-change theories and qualitative research. The HIV/STD risk-reduction intervention targeted sexual risk behaviors; the attention-matched health promotion control intervention targeted health issues unrelated to sexual behavior.Sixth-grade studentsHaving sex, multiple sex partners, condom use
      Mason-Jones et al., 2011
      • Mason-Jones A.J.
      • Mathews C.
      • Flisher A.J.
      Can peer education make a difference? Evaluation of a South African adolescent peer education program to promote sexual and reproductive health.
      QuasiU.S.A.Community basedPeer-led education sessions. Peer educators were recruited and trained to provide information and support to their fellow students.Males and females aged 15–16 yearsAbstinence, condom use
      Key et al., 2008
      • Key J.D.
      • Gebregziabher M.G.
      • Marsh L.D.
      • O'Rourke K.M.
      Effectiveness of an intensive, school-based intervention for teen mothers.
      QuasiU.S.A.School basedSchool-based social work services coordinated with comprehensive health care.Teen mothersContraception, pregnancy
      Kiene and Barta, 2006
      • Kiene S.M.
      • Barta W.D.
      A brief individualized computer-delivered sexual risk reduction intervention increases HIV/AIDS preventive behavior.
      RCTU.S.A.Community computer basedCustom computerized intervention. Content and delivery were based on the Information–Motivation–Behavioral Skills model of health behavior change and used Motivational Interviewing techniques.College studentsKnowledge, condom availability and use, sexual risk behavior
      Kim et al., 2001
      • Kim Y.M.
      • Kols A.
      • Nyakauru R.
      • et al.
      Promoting sexual responsibility among young people in Zimbabwe.
      QuasiZimbabweCommunity-based mass mediaMultimedia campaign promoted sexual responsibility among young people in Zimbabwe, while strengthening their access to reproductive health services by training providers.10–24 years of ageContraceptive knowledge, contraceptive use
      Kinsler et al., 2004
      • Kinsler J.
      • Sneed C.D.
      • Morisky D.E.
      • Ang A.
      Evaluation of a school-based intervention for HIV/AIDS prevention among Belizean adolescents.
      QuasiU.S.A.School basedHIV prevention education: Project Light uses a cognitive-behavioral approach to motivate the program participants to change their risk behaviors and adopt safer behaviors.Primary and secondary school studentsKnowledge, efficacy, communication
      Kirby et al., 2004
      • Kirby D.B.
      • Baumler E.
      • Coyle K.K.
      • et al.
      The “safer choices” intervention: Its impact on the sexual behaviors of different subgroups of high school students.
      RCTU.S.A.School basedSafer Choices was designed to reduce unprotected sex by delaying initiation of sex, reducing its frequency, or increasing condom use. Its five components included: school organization, an intensive curriculum with staff development, peer resources and school environment, parent education, and school-community linkages.Ninth-grade adolescentsSexual risk-taking
      Kirby et al., 2010
      • Kirby D.
      • Raine T.
      • Thrush G.
      • et al.
      Impact of an intervention to improve contraceptive use through follow-up phone calls to female adolescent clinic patients.
      RCTU.S.A.Clinic- and telephone-based follow-upsRegular clinic services or regular clinic services plus nine follow-up phone calls over 12 months to improve sexual risk behaviors.Females aged 14–18 yearsUse of contraception
      Kisker et al., 1996
      • Kisker E.E.
      • Brown R.S.
      Do school-based health centers improve adolescents' access to health care, health status, and risk-taking behavior?.
      QuasiU.S.A.School basedSchool-Based Adolescent Health Care Program, which provided comprehensive health-related services.YouthHealth care access, knowledge, sexual risk behaviors
      Klepp et al., 1997
      • Klepp K.-I.
      • Ndeki S.S.
      • Leshabari M.T.
      • et al.
      AIDS education in Tanzania: Promoting risk reduction among primary school children.
      RCTTanzaniaSchool basedSexual and HIV risk reduction and awarenessSixth gradersKnowledge, sexual initiation
      Kogan et al., 2012
      • Kogan S.M.
      • Yu T.
      • Brody G.H.
      • et al.
      Integrating condom skills into family-centered prevention: Efficacy of the strong African American families' teen program.
      RCTU.S.A.Community basedThe Strong African American Families–Teen (SAAF–T) program, a family-centered preventive intervention that included an optional condom skills unit.16-year-old African-American and their caregiversUnprotected intercourse and condom use efficacy
      Koo et al., 2011
      • Koo H.P.
      • Rose A.
      • El-Khorazaty M.N.
      • et al.
      Evaluation of a randomized intervention to delay sexual initiation among fifth-graders followed through the sixth grade.
      RCTU.S.A.School based10–13 classroom sessions related to delaying sexual initiationFifth-grade studentsKnowledge, communication, having sex, abstinence
      Larkey et al., 2010
      • Larke N.
      • Cleophas-Mazige B.
      • Plummer M.L.
      • et al.
      Impact of the MEMA kwa Vijana adolescent sexual and reproductive health interventions on use of health services by young people in rural Mwanza, Tanzania: Results of a cluster randomized trial.
      RCTTanzaniaCommunity and school basedProvision of youth-friendly health services, as part of a package of interventions including reproductive health education in primary school; the provision of youth-friendly sexual and reproductive health services; community-based condom promotion and distribution; and community-wide activities.Adolescents 15 years onward and community peoplePrevalence of STI, clinic visit and condom distribution
      Lewis et al., 2010
      • Lewis L.N.
      • Doherty D.A.
      • Hickey M.
      • Skinner S.R.
      Implanon as a contraceptive choice for teenage mothers: A comparison of contraceptive choices, acceptability and repeat pregnancy.
      QuasiAustraliaClinicContraceptive education and use of Implanon or depot medroxyprogesterone acetate (DMPA) or nothingPostpartum females (12–18 years old)Unintended pregnancy
      Lim et al., 2012
      • Lim M.S.C.
      • Hocking J.S.
      • Aitken C.K.
      • et al.
      Impact of text and email messaging on the sexual health of young people: A randomised controlled trial.
      QuasiAustralia, New ZealandCommunity text messagingThe 12-month intervention included SMS (catchy sexually transmissible infections prevention slogans) and e-mails.Youth aged 16–29 yearsHaving sex, condom use, STI test
      Lou et al., 2004
      • Lou C.H.
      • Wang B.
      • Shen Y.
      • Gao E.S.
      Effects of a community-based sex education and reproductive health service program on contraceptive use of unmarried youths in Shanghai.
      QuasiChinaCommunity basedThe intervention intended to build awareness and offer counseling and services related to sexuality and reproduction among unmarried youths, in addition to the routine program activities, which were exclusively provided in the control site.15–24 years of ageContraceptive use, condom use
      Marcell et al., 2013
      • Marcell A.V.
      • Allan E.
      • Clay E.A.
      • et al.
      Effectiveness of a brief curriculum to promote condom and health care use among out-of-school young adult males.
      QuasiU.S.A.Community basedPeer education. Participants received three 1-hour curriculum sessions on consecutive days.Males aged 16–24 yearsMultiple sexual partners, intercourse, condom use, knowledge
      Markham et al., 2012
      • Markham C.M.
      • Tortolero S.R.
      • Peskin M.F.
      • et al.
      Sexual risk avoidance and sexual risk reduction interventions for middle school youth: A randomized controlled trial.
      RCTU.S.A.School basedGroup and individualized computer-based activities addressing psychosocial variables. The risk avoidance (RA) program met federal abstinence education guidelines; the risk reduction (RR) program emphasized abstinence and included computer-based condom skills training.African-American and Hispanic seventh- to ninth-grade studentsHaving sex, unprotected sex, sexual initiation, number of sex partners
      McBride et al., 2007
      • McBride C.K.
      • Baptiste D.
      • Traube D.
      • et al.
      Family-based HIV preventive intervention: Child level results from the CHAMP family program.
      QuasiU.S.A.Community basedThe Collaborative HIV/AIDS Adolescent Mental Health Project (CHAMP): the program involves having youth participate with parents and/or other adult caregivers who can steer them through pubertal changes, increases in romantic thoughts and feelings, and social pressure to engage in risky behavior, which may involve sexual activity.Males and females aged 9–11 yearsParent–adolescent communication
      Meekers, 2000
      • Meekers D.
      The effectiveness of targeted social marketing to promote adolescent reproductive health: The case of Soweto, South Africa.
      QuasiSouth AfricaCommunity basedTargeted social marketing program on reproductive health beliefs and behaviorYoung femalesKnowledge and awareness
      Meekers et al., 2005
      • Meekers D.
      • Agha S.
      • Klein M.
      The impact on condom use of the “100% Jeune” social marketing program in Cameroon.
      Pre–postCameroonCommunity based“100% Jeune” social marketing campaignYouth 15–24 years oldPerceived condom attributes and access, self-efficacy, and perceived social support
      Merakou and Kourea-Kremastinou, 2006
      • Merakou K.
      • Kourea-Kremastinou J.
      Peer education in HIV prevention: An evaluation in schools.
      QuasiU.S.A.School basedPeer education. Recruitment and training of the peer educators, implementation of HIV prevention activities in schools on behalf of the peer educators and evaluation.13- to 17-year-old adolescentsSexual encounter, condom use
      Munodawafa et al., 1995
      • Munodawafa D.
      • Marty P.J.
      • Gwede C.
      Effectiveness of health instruction provided by student nurses in rural secondary schools of Zimbabwe: A feasibility study.
      QuasiZimbabweSchool basedStudent nurses to provide health instruction among rural school-age populations.School-based adolescentsKnowledge
      O-Donnell et al., 2005
      • O-Donnell L.
      • Stueve A.
      • O'Donnell C.
      • et al.
      Long-term reductions in sexual initiation and sexual activity among urban middle schoolers in the reach for health service learning program.
      RCTU.S.A.Community based“Saving sex for later”—a parent and youth education programFemales and males aged 10–11 yearsCommunication
      Ozcebe et al., 2004
      • Ozcebe H.
      • Akin L.
      • Aslan D.
      A peer education example on HIV/AIDS at a high school in Ankara.
      Pre–postTurkeyCommunity basedPeer education groups. An education program was scheduled every week and included the following discussion subjects: male and female anatomy–physiology of the reproductive system; types of STIs; etiopathology, progress and treatment of HIV/AIDS; preventive precautions against sexually transmitted diseases and HIV/AIDS; family planning methods; and communication skills.Male and female adolescentsKnowledge
      Pearlman et al., 2002
      • Pearlman D.N.
      • Camberg L.
      • Wallace L.J.
      • et al.
      Tapping youth as agents for change: Evaluation of a peer leadership HIV/AIDS intervention.
      QuasiU.S.A.Community basedPeer education program. Short course and ongoing group work to plan HIV/AIDS outreach activities supervised by an adult.YouthKnowledge, perception, risk raking behaviors
      Peltzer et al., 2011
      • Peltzer K.
      • Simbayi L.
      • Banyini M.
      • Kekana Q.
      HIV risk reduction intervention among traditionally circumcised young men in South Africa: A cluster randomized control trial.
      RCTU.S.A.ClinicCounseling, skills building: 18-minute information–education segment used a tabletop flip chart and visual materials to illustrate key concepts and interactive activities to dispute HIV myths, stigmas, and misinformation. The information component focused on HIV destigmatization as well as providing accurate risk information including risks related to male circumcision.Males aged 18–35 yearsKnowledge, number of sex partner, unprotected intercourse
      Petersen et al., 2007
      • Petersen R.
      • Albright J.B.
      • Garrett J.M.
      • Curtis K.M.
      Acceptance and use of emergency contraception with standardized counseling intervention: Results of a randomized controlled trial.
      RCTU.S.A.PHCContraceptive counseling with optional advance EC prescriptionWomen aged 16–44 yearsEC acceptance (only for 16- to 25-year age group)
      Pinkleton et al., 2008
      • Pinkleton B.E.
      • Austin E.W.
      • Cohen M.
      • et al.
      Effects of a peer-led media literacy curriculum on adolescents' knowledge and attitudes toward sexual behavior and media portrayals of sex.
      QuasiU.S.A.Community and schoolTeen-led, media literacy curriculum focused on sexual portrayals in the media.Primary- to middle-school studentsKnowledge, efficacy, abstinence
      Prado et al., 2012
      • Prado G.
      • Pantin H.
      • Huang S.
      • et al.
      Effects of a family intervention in reducing HIV risk behaviors among high-risk Hispanic adolescents: A randomized controlled trial.
      RCTU.S.A.Community basedFamily-specific interventions designed to reduce HIV risk behaviorsHispanic males and females aged 12–17 yearsParent–adolescent communication, intercourse
      Raymond et al., 2006
      • Raymond E.G.
      • Stewart F.
      • Weaver M.
      • et al.
      Impact of increased access to emergency contraceptive pills: A randomized controlled trial.
      RCTU.S.A.Clinic basedTwo methods of access to emergency contraceptive pills: increased access (two packages of pills dispensed in advance with unlimited resupply at no charge) or standard access (pills dispensed when needed at usual charges)Females aged 14–24 yearsPregnancy, having sex, use of contraception, STI
      Rickert et al., 2006
      • Rickert V.I.
      • Tiezzi L.
      • Lipshutz J.
      • et al.
      Depo Now: Preventing unintended pregnancies among adolescents and young adults.
      RCTU.S.A.ClinicContraceptive education and Depo Now compared to initiating with a bridge method (pills, transdermal patch, or vaginal ring)Female aged 14–26 yearsConsistent contraceptive use, hormonal contraceptive use, condom use, dual usage, no contraception, unintended pregnancy
      Rocca et al., 2007
      • Rocca C.H.
      • Schwarz E.B.
      • Stewart F.H.
      • et al.
      Beyond access: Acceptability, use and nonuse of emergency contraception among young women.
      RCTU.S.A.Clinic basedAccess to EC through advance provision, pharmacies, or clinicsFemales aged 15–24 yearsEC use
      Rosenbaum, 2009
      • Rosenbaum J.E.
      Patient teenagers? A comparison of the sexual behavior of virginity pledgers and matched nonpledgers.
      QuasiU.S.A.Community basedVirginity pledgers>15 years of age virginity pledgersPremarital sex, sexually transmitted diseases, and anal and oral sex variables
      Ross et al., 2007
      • Ross D.A.
      • Changalucha J.
      • Obasi A.I.N.
      • et al.
      Biological and behavioural impact of an adolescent sexual health intervention in Tanzania: A community-randomized trial.
      RCTTanzaniaCommunity basedCommunity activities; teacher-led, peer-assisted sexual health education in Years 5–7 of primary school; training and supervision of health workers to provide “youth-friendly” sexual health services; and peer condom social marketing.AdolescentsKnowledge, attitude, HIV, HSV
      Rotheram-borus et al., 1998
      • Rotheram-Borus M.J.
      • Gwadz M.
      • Fernandez M.I.
      • Srinivasan S.
      Timing of HIV interventions on reductions in sexual risk among adolescents.
      RCTU.S.A.Community based(1) Seven sessions of 1.5 hours each (10.5 hours); (2) three sessions of 3.5 hours each (10.5 hours); or (3) a no-intervention condition.Adolescent aged 13–24 yearsSelf-efficacy, condom use.
      Schreiber et al., 2010
      • Schreiber C.A.
      • Ratcliffe S.J.
      • Barnhart K.T.
      A randomized controlled trial of the effect of advanced supply of emergency contraception in postpartum teens: A feasibility study.
      RCTU.S.A.Clinic basedRoutine postpartum contraceptive care and advanced supply of one pack of EC pills with unlimited supply thereafter upon request.Postpartum teenage femalesSexual encounter, any contraception, condom use, EC use, pregnancy
      Shrier et al., 2001
      • Shrier L.A.
      • Ancheta R.
      • Goodman E.
      • et al.
      Randomized controlled trial of a safer sex intervention for high-risk adolescent girls.
      RCTU.S.A.Clinic basedCounseling and education. Standard STD education or to watch a videotape and have an individualized intervention session.Female adolescents diagnosed with STICondom use, knowledge
      Sieving et al., 2012
      • Sieving R.E.
      • Bernat D.H.
      • Resnick M.D.
      • et al.
      A clinic-based youth development program to reduce sexual risk behaviors among adolescent girls prime time pilot study.
      RCTU.S.A.ClinicCounseling, skills building, and case management services.Females aged 13–17 yearsNumber of sex partner
      Suffoletto et al., 2013
      • Suffoletto B.
      • Akers A.
      • McGinnis K.A.
      • et al.
      A sex risk reduction text-message program for young adult females discharged from the emergency department.
      RCTU.S.A.Community text messagingIntervention participants received a sequence of text messages that assessed risky encounters over the past week, were provided personalized feedback on risk behavior, and were prompted collaborative goal setting to not have a risky encounter for the coming week.Females aged 18–25 yearsCondom use
      Tocce et al., 2012
      • Tocce K.M.
      • Sheeder J.L.
      • Teal S.B.
      Rapid repeat pregnancy in adolescents: Do immediate postpartum contraceptive implants make a difference?.
      QuasiU.S.A.ClinicContraceptive education and etonogestrel implant (IPI)Females aged 13–23 yearsConsistent contraceptive use, hormonal contraceptive use, condom use, no contraception, unintended pregnancy
      Villarruel et al., 2006
      • Villarruel A.M.
      • Jemmott J.B.
      • Jemmott L.S.
      A randomized controlled trial testing an HIV prevention intervention for Latino youth.
      RCTU.S.A.School basedThe HIV and health-promotion control interventions consisted of six 50-minute modules delivered by adult facilitators to small, mixed-gender groups in English or Spanish.Latino adolescents aged 13–18 yearsSelf-reported sexual behavior
      Villarruel et al., 2008
      • Villarruel A.M.
      • Cherry C.L.
      • Cabriales E.G.
      • et al.
      A parent-adolescent intervention to increase sexual risk communication: Results of a randomized controlled trial.
      RCTMexicoCommunityParent education for adolescent sexual risk reductionParents of adolescentsCommunication
      Walker et al., 2004
      • Walker D.
      • Gutierrez J.P.
      • Torres P.
      • Bertozzi S.M.
      HIV prevention in Mexican schools: Prospective randomised evaluation of intervention.
      RCTMexicoSchool basedAn HIV prevention course that promoted condom use, the same course with emergency contraception as backup, or the existing sex education course.High-school studentsKnowledge, condom use
      Weed et al., 2008
      • Weed S.E.
      • Ericksen I.H.
      • Lewis A.
      • et al.
      An abstinence program's impact on cognitive mediators and sexual initiation.
      QuasiU.S.A.School basedAbstinence education program; the core of the program was a nine-unit abstinence curriculum taught consecutively over 20 class periods, called Reasonable Reasons to Wait: Keys to Character.Seventh-grade adolescentsSexual initiation
      Wiggins et al., 2009
      • Wiggins M.
      • Bonell C.
      • Sawtell M.
      • et al.
      Health outcomes of youth development programme in England: Prospective matched comparison study.
      QuasiEnglandCommunity basedIntensive, multicomponent youth development program including sex and drugs education (Young People's Development Program) versus standard youth provision.13- to 15-year-old adolescentsPregnancy, weekly cannabis use, and monthly drunkenness
      Winter and Breckenmaker, 1990
      • Winter L.
      • Breckenmaker L.C.
      Tailoring family planning services to the special needs of adolescents.
      QuasiU.S.A.ClinicIn-depth counseling and education in an adolescent friendly environmentTeenagersContraceptive use, pregnancy
      Zimmer-Gembeck, 2001
      • Zimmer-Gembeck M.J.
      • Doyle L.S.
      • Daniels J.A.
      Contraceptive dispensing and selection in school-based health centers.
      Pre–postU.S.A.School basedFamily planning care visits and contraceptive availabilityFemale adolescentsUse of contraception
      AEC = advance emergency contraceptive; AIM = Adult Identity Mentoring; CImpact = Caribbean Informed Parents and Children Together; EC = emergency contraceptive; FSW = female sex workers; GFI = goal for information technology; HSV = herpes simplex virus; IPI = immediate postpartum transplant; OC = oral contraceptive; PHC = primary health care; RCT = randomized controlled trial; SMS = short messaging service; STD = sexually transmitted disease; STI = sexually transmitted infection.

       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 [
      • Aarons S.J.
      • Jenkins R.R.
      • Raine T.R.
      • et al.
      Postponing sexual intercourse among urban junior high school students-a randomized controlled evaluation.
      ,
      • Agha S.
      • Van Rossem R.
      Impact of a school-based peer sexual health intervention on normative beliefs, risk perceptions, and sexual behavior of Zambian adolescents.
      ,
      • Baptiste D.R.
      • Bhana A.
      • Petersen I.
      • et al.
      Community collaborative youth-focused HIV/AIDS prevention in South Africa and Trinidad: Preliminary findings.
      ,
      • Barnet B.
      • Liu J.
      • DeVoe M.
      • et al.
      Home visiting for adolescent mothers: Effects on parenting, maternal life course, and primary care linkage.
      ,
      • Berenson A.B.
      • Rahman M.
      A randomized controlled study of two educational interventions on adherence with oral contraceptives and condoms.
      ,
      • Black M.M.
      • Bentley M.E.
      • Papas M.A.
      • et al.
      Delaying second births among adolescent mothers: A randomized, controlled trial of a home-based mentoring program.
      ,
      • Blake S.M.
      • Ledsky R.
      • Goodenow C.
      • et al.
      Condom availability programs in Massachusetts high schools: Relationships with condom use and sexual behavior.
      ,
      • Bonell C.
      • Maisey R.
      • Speight S.
      • et al.
      Randomized controlled trial of 'teens and toddlers': A teenage pregnancy prevention intervention combining youth development and voluntary service in a nursery.
      ,
      • Brieger W.R.
      • Delano G.E.
      • Lane C.G.
      • et al.
      West African youth initiative: Outcome of a reproductive health education program.
      ,
      • Bull S.S.
      • Levine D.K.
      • Black S.R.
      • et al.
      Social media delivered sexual health intervention: A cluster randomized controlled trial.
      ,
      • Chen X.
      • Stanton B.
      • Gomez P.
      • et al.
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      ]; 51 studies were RCTs while 29 were quasi-experimental design and four were pre–post studies. Fifty four of 84 studies focused on adolescent age group alone (11–19 years) while the rest had overlapping age groups. Meta-analysis 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.
      Moderate quality data suggest that sexual and reproductive health education, counseling, and contraceptive availability increased “mean knowledge score about sexual health and contraception” (SMD: 2.04; 95% CI: 1.31–2.78), “mean condom use self-efficacy score” (SMD: .76; 95% CI: .22–1.30), use of any contraception (RR: 1.07; 95% CI: 1.00–1.14), and condom use (RR: 1.11; 95% CI: 1.04–1.20; Figures 2 and 3). Sexual health education did not significantly impact risk of having sex (RR: 1.00; 95% CI: .93–1.07) or STIs (RR: 1.08; 95% CI: .79–1.46). Pooled analysis from moderate quality evidence showed a 15% decrease (RR: .85; 95% CI: .74–.98) in incidence of adolescent pregnancies and a 37% decrease (RR: .63; 95% CI: .49–.82) in the rate of repeat adolescent pregnancies.
      Figure thumbnail gr2
      Figure 2Impact of sexual health education/counseling on mean knowledge score. CI = confidence interval; FOYC = Focus on Youth in the Caribbean; GIT = Goal for IT; IV = inverse variance; SD = standard deviation.
      Figure thumbnail gr3
      Figure 3Impact of sexual health education/counseling on use of any contraception. CI = confidence interval; IV = inverse variance; SE = standard error.
      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 anatomy–physiology 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, parent–child communication about sexual decision-making, 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 Information–Motivation–Behavioral 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. School-based 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 pre–post studies), substantial statistical heterogeneity, and limited generalizability.
      Table 2Summary of findings for the effect of sexual and reproductive health interventions
      Quality assessmentSummary of findings
      Number of studiesDesignLimitationsConsistencyDirectnessNumber of participantsRR/SMD (95% CI)
      Generalizability to population of interestGeneralizability to intervention of interestInterventionControl
      Mean knowledge score: moderate outcome-specific quality of evidence
       13RCT and pre–postStudy design is not robustTwelve studies suggest benefit Substantial heterogeneity, I2 = 100%All studies targeted adolescentsMulticomponent interventions6,2066,2932.04 (1.31–2.78)
      Mean efficacy score: moderate outcome-specific quality of evidence
       5RCT and pre–postStudy design is not robustFour studies suggest benefit Substantial heterogeneity, I2 = 99%All studies targeted adolescentsMulticomponent intervention2,6992,508.76 (.22–1.30)
      Use of any contraception: moderate outcome-specific quality of evidence
       16RCT and pre–postStudy design is not robustFive studies suggest benefit Substantial heterogeneity, I2 = 89%All studies targeted adolescentsMulticomponent intervention9,2699,3641.07 (1.00–1.14)
      Condom use: moderate outcome-specific quality of evidence
       23RCT and pre–postStudy design is not robustSeven studies suggest benefit Considerable heterogeneity, I2 = 72%All studies targeted adolescentsMulticomponent intervention9,6599,8421.11 (1.04–1.20)
      Sexual encounter: moderate outcome-specific quality of evidence
       23RCT and pre–postStudy design is not robustOnly two studies suggest reduced sex Substantial heterogeneity, I2 = 88%All studies targeted adolescentsMulticomponent intervention16,84516,7461.00 (.93–1.07)
      Adolescent pregnancies: moderate outcome-specific quality of evidence
       18RCTFour studies showed significant improvement Some heterogeneity, I2 = 54%All studies targeted adolescentsComprehensive interventions addressing communities, sexual and reproductive health services, contraceptive provision and school-based education, and youth development1,5721,868.85 (.74–.98)
      Repeat adolescent pregnancies: moderate outcome-specific quality of evidence
       16RCTSix studies showed significant improvement Considerable heterogeneity, I2 = 74%All studies targeted adolescentsParental skills training and encouraging young mothers to finish school, as well as comprehensive medical care1,5721,868.63 (.49–.82) [I2: 74%]
      STI: moderate outcome-specific quality of evidence
       SixRCT and pre–postStudy design is not robustOnly one study suggests reduced sex Considerable heterogeneity, I2 = 78%All studies targeted adolescentsMulticomponent intervention2983671.8 (.79–1.46) [I2: 78%]
      CI = confidence interval; RCT = randomized controlled trial; RR = relative risk; SMD = standard mean difference; STI = sexually transmitted infection.

       Female genital mutilation

      A search was conducted for literature published after March 2011 following the same methodology as Berg et al. A total of 11 studies [
      • Diop N.
      • Sangaré M.
      • Tandia F.
      • Touré K.
      Study of the effectiveness of training Malian social and health agents in female genital cutting issues and in educating their clients.
      ,
      • Diop N.J.
      • Faye M.M.
      • Moreau A.
      • et al.
      The TOSTAN program: Evaluation of a community based education program in Senegal.
      ,
      • Mounir G.M.
      • Mahdy N.H.
      • Fatohy I.M.
      Impact of health education program about reproductive health on knowledge and attitude of female Alexandria University students.
      ,
      • Babalola S.
      • Brasington A.
      • Agbasimalo A.
      • et al.
      Impact of a communication programme on female genital cutting in eastern Nigeria.
      ,
      • Chege J.
      • Askew I.
      • Igras S.
      • Mutesh J.K.
      Testing the effectiveness of integrating community-based approaches for encouraging abandonment of female genital cutting into CARE's reproductive health programs in Ethiopia and Kenya.
      ,
      • Easton P.
      • Miles R.
      • Monkman K.
      Final report on the evaluation of the Tostan/IEP village empowerment program pilot project in the Republic of Mali.
      ,
      • Ouoba D.
      • Congo Z.
      • Diop N.J.
      • et al.
      Experience from a community based education program in Burkina Faso the Tostan Program.
      ,
      • Monkman K.
      • Miles R.
      • Easton P.
      The transformatory potential of a village empowerment program: The Tostan replication in Mali.
      ,
      • Asekun-Olarinmoye E.O.
      • Amusan O.A.
      The impact of health education on attitudes towards female genital mutilation (FGM) in a rural Nigerian community.
      ,
      • Ekwueme O.C.
      • Ezegwui H.U.
      • Ezeoke U.
      Dispelling the myths and beliefs toward female genital cutting of woman assessing general outpatient services at a tertiary health institution in Enugu State, Nigeria.
      ,
      • Hassanin I.M.
      • Shaaban O.M.
      Impact of the complete ban on female genital cutting on the attitude of educated women from Upper Egypt toward the practice.
      ] (eight included in existing review + three new studies) were included, mostly from Africa. All studies were pre–post studies. For female genital mutilation prevention, studies focused on interventions, including: (1) legislation against FGM/C; (2) education about health risks associated with FGM/C; (3) training health workers as change agents; (4) training 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: .47–3.64). However, these interventions significantly reduced the prevalence of FGM/C (RR: .86; 95% CI: .75–.99) and improved knowledge of harmful consequences of FGM/C (RR: 1.53; 95% CI: 1.08–2.16; 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.
      Figure thumbnail gr4
      Figure 4Impact of interventions to prevent FGM on FGM prevalence. CI = confidence interval; FGM = female genital mutilation; IV = inverse variance; SE = standard error.
      Figure thumbnail gr5
      Figure 5Impact of interventions to prevent FGM on knowledge of harmful consequences. CI = confidence interval; FGM = female genital mutilation; IV = inverse variance; SE = standard error.
      Table 3Summary of findings for the effect of interventions to prevent female genital mutilation
      Quality assessmentSummary of findings
      Number of studiesDesignLimitationsConsistencyDirectnessNumber of participantsSMD/RR (95% CI)
      Generalizability to population of interestGeneralizability to intervention of interestInterventionControl
      Belief that FGM/C compromise human rights of women: low outcome-specific quality of evidence
       OnePre–postStudy design is not robustOnly one studyAll studies targeted adolescentsMulticomponent intervention1,1201,1201.30 (.47–3.64)
      Prevalence of FGM/C: low outcome-specific quality of evidence
       ThreePre–postStudy design is not robustTwo studies showed reduced prevalence. Low heterogeneity, I2 = 38%All studies targeted adolescentsMulticomponent intervention1,377916.63 (.49–.82)
      Knowledge of harmful consequences of FGM/C: low outcome-specific quality of evidence
       ThreePre–postStudy design is not robustTwo studies showed benefit Substantial heterogeneity, I2 = 98%All studies targeted adolescentsMulticomponent intervention2,3681,9871.53 (1.08–2.16)
      CI = confidence interval; FGM/C = Female Genital Mutilation/Cutting; RR = relative risk; SMD = standard mean difference.

       Intimate partner violence

      We report the findings from a Cochrane review by Fellmeth et al. [
      • Fellmeth G.L.
      • Heffernan C.
      • Nurse J.
      • et al.
      Educational and skills-based interventions for preventing relationship and dating violence in adolescents and young adults.
      ] focusing on educational and skills-based interventions targeted at young people aged 12–25 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 meta-analysis. 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: .28–.60). However, moderate-quality evidence suggests no significant impact of such interventions on episodes of relationship violence (RR: .77; 95% CI: .53–1.13), behavior scores related to relationship violence (SMD: −.07; 95% CI: −.31 to .16), and a skills score related to relationship violence (to communicate effectively; SMD: .03; 95% CI: −.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 [
      • Oringanje C.
      • Meremikwu M.M.
      • Eko H.
      • et al.
      Interventions for preventing unintended pregnancies among adolescents.
      ]. 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 [
      • Chin H.B.
      • Sipe T.A.
      • Elder R.
      • et al.
      The effectiveness of group-based comprehensive risk-reduction and abstinence education interventions to prevent or reduce the risk of adolescent pregnancy, human immunodeficiency virus, and sexually transmitted infections: Two systematic reviews for the guide to community preventive services.
      ]. 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 long-term behavior change [
      • McQueston K.
      • Silverman R.
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      ,
      • Widman L.
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      • et al.
      Parent-adolescent sexual communication and adolescent safer sex behavior: A meta-analysis.
      ].
      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 [
      United Nations Fund for Population ActivitiesUnited Nations International Children's Emergency Fund
      UNFPA-UNICEF joint programme on female genital mutilation cutting: Accelerating change.
      ]. 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 [
      World Health Organization/London School of Hygiene and Tropical Medicine
      Preventing intimate partner and sexual violence against women: Taking action and generating evidence.
      ].
      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 self-reported 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.

      Acknowledgments

      All authors contributed to finalizing the manuscript.

      Funding Sources

      The preparation and publication of these papers was made possible through an unrestricted grant from the Bill & Melinda Gates Foundation (BMGF).

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