The effectiveness of interventions targeting young men aimed at increasing condom-use
Systematic review
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Key message
The incidence of sexually transmitted infections (STIs) is rising. As young men with STIs are more likely to pass on the infection than women, it is conceivable that interventions encouraging young men to use condoms may reduce rates of STIs in both sexes.
We searched for systematic reviews and recent trials focusing on this area. We found one review that had looked at males of all ages and subsequently chose also to include a review of sexual health interventions aimed at young people of both sexes.
The only single sex studies that were included in these reviews were not directed at our chosen population – young men in general. Amongst the studies of interventions aimed at both sexes, there were two that reported results for young men separately. Both of these studies were of school based sex education programmes: one from Scotland (“the SHARE programme”) and another from the USA (“Safer Choices”). In addition, we identified a recent, small study of condom promotion videos among American college-students.
The Scottish study demonstrated no effect on condom use amongst boys. The American school-based study, on the other hand, showed positive (statistically significant) results for several different outcomes: boys who received the intervention had less unprotected sex with fewer partners, than boys receiving standard sex education. Condom use at last intercourse was also statistically significantly higher. The use of safer sex-promoting videos amongst college-students gave promising, but largely statistically non-significant, results.
We found two systematic reviews of qualitative studies. One of the reviews identified seven themes influencing young people’s sexual behaviour that were seen across studies from different countries and cultures. The other review identified common characteristics of successful STI/HIV prevention interventions carried out in the USA. The results of the review implied that tailor made interventions were more likely to yield positive results than a “one size fits all” approach.
There are no immediate conclusions to be drawn from the studies we have included. There is a need for high quality effect studies for new interventions in this area.
Summary
Background
The incidence of sexually transmitted infections (STIs) is increasing in Norway and elsewhere, and a disproportionate number of those infected are young adults and adolescents. Condoms have been shown to effectively reduce transmission of STIs, when used appropriately. Qualitative studies, from Norway and other western countries, suggest that young people may be more concerned with unplanned pregnancy than the risk of contracting an STI. Whilst the pill may be effective in prevent unwanted pregnancy, it does not protect against infection. Lack of condom use is of concern given the rising rates of diseases such as chlamydia amongst young women and men.
Given that infected males are often more likely to spread disease than females, interventions that encourage young men to use condoms may also be important in reducing the incidence of STIs in both sexes.
This report was commissioned by the Norwegian Health Directorate: it is an overview of systematic reviews that focuses on the effect of sexual health interventions targeted towards the general population of young males aged 15 to 20. The primary outcome measures are condom use by young men and rates of STIs.
Method
We searched systematically for systematic reviews in The Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE Cochrane), Centre for Reviews and Disseminations (CRD – DARE, HTA), The Campbell Collaboration database, Medline (Ovid), Embase (Ovid), PsycINFO (Ovid), Sociological Abstracts, ISI Web of Science. Two people screened the titles and abstracts identified from the searches for reviews using predetermined inclusion and exclusion criteria. We assessed the quality of relevant reviews using a validated checklist Those reviewers considered as being of high or moderate quality were included. In addition to quantitative reviews we identified relevant qualitative reviews based on the findings of our search. We summarised the findings in narrative form. Finally, we carried out a search for recently conducted trials.
Results
We found no systematic reviews that had looked at sexual health interventions solely directed towards the general population of young males. We found one review that had focused on males age 15 and over, but had published data from studies of both single sex and mixed interventions.
Whilst the review included studies of single sex interventions directed at young males from low and middle income countries, young offenders, intravenous drug-users and young gay men, there were no studies of single sex interventions directed at our target group. Of the studies where interventions were directed at mixed groups, we included one relevant randomised controlled trial of school based, sex education program from Scotland that presented separate data on condom use by boys (“SHARE-programme”). The intervention was a five day teacher training programme plus a 20 session pack.
The results of the study showed no statistically significant difference between control and intervention groups, for condom use at first intercourse (for the sexually inexperienced) or most recent intercourse. This was based on a questionnaire administered at six months after completion of the programme.
Given the lack of relevant single sex systematic reviews and primary studies, we chose to look at reviews of interventions directed at adolescents of both sexes – in the hope identifying additional studies providing data on young men. We found one such study of another school based intervention, carried out in the US. “Safer Choices” involved teachers, pupils, peer-educators and parents in a comprehensive educational programme, with many interactive elements. Both abstinence and condom use were promoted.
The study revealed some statistically significant differences favouring boys who received the Safer Choice programme rather than standard knowledge based sex education: the frequency of unprotected sex and the number of partners with whom they had unprotected sex with, were lower in the intervention group. The results of these outcomes were not presented in actual numbers for boys, but the authors stated that the results for boys were in fact better than for girls. Condom use at last intercourse was also statistically significantly higher amongst boys in the Safer Choices group (odds ratio 1.66; 95 % confidence interval 1.12 til 2.47).
In our search for more recent trials we identified a study where American college-students were randomised to either watching condom promoting videos, or not.
Both men and women took part, but results were reported separately for each sex. The study was small, and whilst the results were positive, the majority were not statistically significant.
We found two reviews of studies utilising qualitative methods. The authors of one review identified seven themes influencing sexual behaviour amongst adolescents (of both sexes) – five on general sexual behaviour and two on condom use. These themes could be found in studies carried out around the globe, in widely differing locations. The other review looked at features of successful sexual health interventions and suggested that those that were tailor-made for a specific group were more likely to succeed than a “one size fits all approach”.
Discussion
We did not find any reviews that focused on young men aged between 15 and 20. We based our findings on two reviews: one that had included studies of men of all ages and another that focused on adolescents, and one recently conducted trial.
We found no examples of experimental studies directed at the general population of young men. Our evidence is based on results of mixed interventions, aimed at teenagers of both sexes, where data on reported condom use were available for boys.
It is not easy to draw a single conclusion based on the three studies we have included. One school based study had no effect on male condom use, whilst the other had a positive effect, and the results from use of video where promising but not conclusive. In addition, there is uncertainly regarding the generalisability of sexual health interventions from one setting or target group, to another: Whether the results of mixed interventions can be generalised to single sex groups is also not well established.
Whilst this report set out to look at male-only interventions, we should not forget the relevance of interventions targeting young women which could also influence the use of condoms amongst their sexual partners.
Conclusion
The evidence base for interventions targeting the general population of young men -and aimed at increasing condom use in this group - is limited. Our report demonstrates a need for further experimental studies to address this topic.
Qualitative and non experimental studies have a significant role to play in the development of innovative sexual health interventions. The effectiveness of new
sexual health interventions should be evaluated e.g. via a cluster randomised trial, prior to large scale implementation.