Interventions Promoting Child Sexual and Reproductive Health and Rights in LMICs: A Systematic Review

This systematic review was reported in accordance with the reporting guidance provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.²⁹  The review protocol has been registered within the International Prospective Register of Systematic Reviews (#CRD42020173158) and published in BMC Systematic Reviews.³⁰ 

The eligibility criteria were reported using the population, intervention, comparison, outcomes and study (PICOS) design framework (Table 1).³⁰ 

Electronic searches were performed by an information specialist (K.F.) in the following databases: Medline(R), ALL (Ovid), Embase (Ovid), CINAHL (EBSCOHost), APA PsycInfo (Ovid), ERIC (Ovid), Cochrane Central Register of Controlled Trials (Ovid), Education Source (EBSCOHost), Web of Science (Clarivate Analytics), SciELO Citation Index (Clarivate Analytics), Global Health (Ovid), Sociological Abstract (Proquest). Studies were identified using a combination of each of the databases’ unique subject headings and keywords (when applicable). Concepts pertaining to age (eg, children), sexual health and rights, educational programs, and LMICs were developed for each database (see Supplemental Information for Medline’s search strategy). The Cochrane LMICs filter³¹  was modified to reflect the current list of LMICs identified by the World Bank.³²  The search filters for randomized controlled trials and observational studies developed by the Scottish Intercollegiate Guidelines Network were used and modified to include quasi-experimental designs as well.³³  All peer-reviewed publications from January 2000 onwards were retrieved. This period accounts for a new wave and focus of studies on primary level education following the release of the Millennium Development Goals at the turn of the century.³⁴ 

All the database results were imported into Covidence (Veritas Health Innovation Ltd.), where duplicate records were automatically removed. The articles were then sent to the title and abstract screening phase. One reviewer independently screened all titles and abstracts, while 2 other reviewers independently screened a split of the titles and abstracts. This method ensured that each article was screened by 2 reviewers within a reasonable time frame. A.W.B. resolved conflicts between A.W.F. and D.I.W., whereas D.I.W. resolved conflicts between A.W.F. and A.W.B. The same procedure was repeated in screening the full-texts that were retained after the title and abstract screening phase. Following full-text screening, 1 reviewer manually searched the journals Prevention Science and Child Abuse and Neglect for additional relevant articles. In addition, the reference lists of included studies were manually perused to identify additional relevant articles. Finally, articles that cited the included full-text articles were searched using the database Scopus to ensure the identification of additional relevant articles that may not have been discovered through the database searching.

Two reviewers independently assessed the methodological quality of retained studies following full-text screening. The assessments were done using Joanna Briggs Institute (JBI) critical appraisal tools (checklists) for randomized controlled trials and quasi-experimental studies.^35,36  The overall quality of the studies was reported as “low” (<70%), “moderate” (70% to 85%), or “high quality” (>85%) based on the percentage of criteria met. Any disagreements between the 2 reviewers were settled through discussion, or a third reviewer when required. Studies were not excluded or weighted based on the quality of the reporting assessment.

Two reviewers independently extracted data from all included studies to minimize potential biases. Disagreements were resolved through discussion, or a third reviewer when required. Extraction was conducted by adapting a standardized data extraction tool, the JBI Meta-Analysis of Statistics Assessment and Review Instrument.³⁶  The extracted data included specific details about the study characteristics, study methods, participant characteristics, interventions, outcome measures, and study results related to the review question and objectives. In the event of any missing or ambiguous data from a study, the corresponding authors of the study were contacted through e-mail to retrieve missing or additional data. There were 3 ostensibly relevant articles that were excluded because of no response from authors, thereby leaving uncertainties about the mean age of the target populations.^37–39 

We did not conduct a meta-analysis because of the differing assessments and reporting of outcomes across studies, making it unfeasible to pool data and generate a single effect estimate. In addition, following considerations of time, resources, and appropriateness for addressing the aim of this review, a narrative summary of the effects of interventions across different studies was deemed most appropriate. We used Popay’s guidance on the conduct of a narrative synthesis to conduct a narrative synthesis of the interventions targeting improvements in SRHR outcomes.⁴⁰  The review also used the synthesis without meta-analysis reporting guideline to help guide the reporting of the narrative synthesis.⁴¹  The guideline has been developed to guide reviews of interventions that conduct a narrative synthesis of intervention effects.

The reviewers synthesized the evidence on the quantitatively determined effects of the various types of educational interventions using textual summaries and tabulation. The studies were grouped by outcome domains, constituting similar outcomes. The groupings considered broader outcomes and terminology reported in related reviews for harmonization of synthesis findings;^16,17,26  this provides more manageable and applicable synthesis findings for use by policymakers and program designers. Structured textual summaries were developed for each of the individual studies reporting the same information in a consistent manner.⁴⁰  The summaries contextualized the extracted data and included key information about the educational interventions and key findings. Where needed, the summaries are accompanied by tabulated findings for each outcome. Additional information on study characteristics and findings are provided in Supplemental Table 9. Investigations of heterogeneity were not prespecified. Vote counting based on direction of effect was used to synthesize results because of inconsistency in the effect measures and data reported across the studies.⁴²  The effect was categorized as beneficial (using binary metric 1), harmful (binary metric 0) or not significant (not included in the synthesis of vote counting based on direction of effects).

Reviewers examined the variability in findings between settings, study populations, and intervention implementation strategies. The subgroup synthesis enabled the reviewers to identify variabilities within and between studies and their results. For relationships within studies, patterns identified by authors of included studies were first compiled.⁴⁰  Reviewers then looked across extracted data to explore and compare relationships between studies. They looked for patterns that may have uncovered factors to possibly explain any differences in the effects of interventions across the individual studies.⁴⁰ 

The review assessed the confidence and certainty of the review evidence for each outcome using the Grading of Recommendations Assessment, Development and Evaluations (GRADE) approach.⁴³  The overall GRADE certainty of evidence score for each outcome was classified as “high,” “moderate,” “low,” or “very low.” The overall scores were based on judgements of 5 key GRADE domains: methodological limitations, indirectness, imprecision, inconsistency, and the likelihood of publication bias.⁴⁴  Two reviewers independently rated the certainty of evidence for the outcomes, and discrepancies were resolved by consensus or with input from a third reviewer. The review findings are discussed in the context of evidence certainty, strengths, and limitations of findings, along with their implications for policy initiatives, programmatic actions, and future research.

A total of 19 941 potential articles were identified for this review. Following the removal of duplicates and title and abstract screening, 221 articles were left for full-text screening. Following full-text screening, 11 papers were found to have met our inclusion criteria (Fig 1). Of the 11 included studies, many of them (10) were quasi-experimental studies and 1 was a randomized controlled trial (Table 2). Three of the studies were conducted in Latin America,^45–47  4 in Asia,^48–51  3 in Africa,^52–54  and 1 in Europe.⁵⁵  The participants in 9 of the studies were both female and male children, whereas in 2 studies, only female children participated.^51,53  In total, there were 4754 children between ages 5 and 14, with a mean age of 9.3 across the included studies; 9 studies focused on child sexual abuse (CSA) prevention^45–52,55  and 2 focused on HIV prevention.^53,54  The CSA prevention interventions covered numerous concepts, such as knowledge of private parts, disclosure of secrets, and appropriate and inappropriate touching. The HIV prevention interventions covered concepts such as intentions to postpone sexual activity and removing oneself from compromising situations. The effects of interventions were compared with comparison groups that either received no intervention,^{47,51,52,54,55}  a conventional intervention,^48–50  or intervention at a different point in time.^45,46  In 1 study, the intervention group was assessed as the comparison group in a before and after comparison.⁵³  Refer to Supplemental Tables 9 and 10 for a detailed description of the included studies.

Overall, 8 of the studies had a high methodological quality, whereas 3 had a moderate methodological quality (Tables 3 and 4). Studies with a moderate quality did not adequately explain the conditions of the experimental and comparison groups, did not adequately explain differences in follow-up, and did not adequately measure outcomes reliably. Four studies were unclear about whether there were differences between the experimental and comparison groups in terms of the intervention received.^47,49,50,55  As a result, it was not clear whether the reported effects could be attributed to their interventions. Five studies with follow-up assessments did not adequately explain loss to follow-up, presenting a threat to internal validity.^45,49,52,55  The lack of clarity about the reliability of outcome measurements, such as intrarater reliability, in 6 studies suggested weak inferences about the relationship between the intervention and effects.^{46,47,49,51,52,55}  Refer to Supplemental Tables 11 and 12 for the full quality assessment tables.

The CSA prevention concepts can be categorized into the following outcome domains: protective knowledge against CSA, protective characteristics against CSA and gender-based violence (GBV), protective characteristics against HIV, and physiologic outcome. See Table 5 for the effects of interventions on the outcomes and their domains. The positive effects indicate statistically significant improvement, whereas the null effects indicate nonsignificant changes.

Protective knowledge refers to children’s knowledge of CSA prevention concepts and strategies, such as distinguishing appropriate and inappropriate touch and knowledge of private parts. In Ecuador, the “I Have the Right to Feel Safe” self-protection program was initially provided to 407 children.⁴⁵  Through workshop sessions, children reviewed themes from a workbook, an interactive activity, and discussions of lessons from the activity. The intervention had a significant effect in increasing medium-term knowledge gains of self-protection strategies, such as distinguishing abusers from safety nets, with signs of knowledge retention 6 months later. In Turkey, the “Preventing Child Sexual Abuse” was provided to 18 children.⁵⁵  Through workshop sessions, the children received passive teaching, such as video and lecture, and engaged in active teaching, such as role-playing and modeling. The intervention was significantly effective in improving children’s knowledge of sexual abuse prevention strategies, with signs of knowledge retention 8 weeks later. In South Africa, the “Hands Off Our Children – Your Child is My Child campaign” was provided to 407 children.⁵²  The intervention was delivered through a board game that included information statements, questions, and “remember blocks,” which featured prevention concepts against CSA and color-coded body parts for appropriate and inappropriate touch. The intervention was significantly effective in improving children’s knowledge of body awareness, such as inappropriate and appropriate touch, compared with the control group 6 weeks later. In El Salvador, the “My Body Belongs to Me” intervention was provided to 59 children in the Tin Marin Children’s Museum in El Salvador.⁴⁶  Through a museum exhibit, children partook in playing along, watching a video, and discussing the video with a museum guide. The intervention was significantly effective in increasing children’s knowledge of child sexual abuse prevention concepts, such as saying NO and getting away. In Malaysia, the “Keeping me Safe” curriculum intervention was provided to 261 children.⁴⁸  Through a curriculum, children took part in interactive activities featuring games and role-playing. The intervention had both significant and nonsignificant effects on knowledge about child sexual abuse prevention concepts. In Indonesia, a peer education program was provided to 42 children, with knowledge of preventing sexual violence being the first outcome measure.⁴⁹  The children engaged in discussions with peers, played games, drew, and watched prevention videos. The intervention was significantly effective in increasing children’s knowledge of abuse scores. In Indonesia, a visual auditory kinesthetic education program was provided to 747 children, with knowledge of sexual abuse prevention being the first outcome measure.⁵⁰  Through classroom media, children role-played and watched and listened to movies, pictorial sketch stories, songs, and presentations. The intervention models were significantly effective in increasing children’s knowledge on sexual abuse prevention. In Iran, the “Body Safety Training (BST) program” was provided to 56 preschool girls.⁵¹  The intervention was delivered through a personal safety training class that included training for mothers, followed by the provision of education about body safety from the mothers to their daughters. The intervention had some significant effects in improving children’s knowledge about body safety concepts and strategies.

Protective characteristics refer to protective attitudes, abilities, and behaviors, such as assertiveness, to prevent CSA and GBV. The second outcome measurement in the peer education program was self-efficacy.⁴⁹  The intervention was significantly effective in increasing self-efficacy of children in preventing sexual violence. Likewise, the second outcome measurement in the visual auditory kinesthetic education program was assertiveness.⁵⁰  The nurse-led and teacher-led program models were both significantly effective in increasing children’s scores on assertiveness. In Colombia, a gender-based intimate partner violence prevention program was provided to 200 children.⁴⁷  Children received classroom lessons about gender construction, gender-based partner violence, and socioemotional competence. The lessons were accompanied with experiential learning, skills training, socioemotional learning, and the promotion of cognitive, emotional, and behavioral change. The intervention had some significant and nonsignificant effects in improving attitudes toward and skills for, CSA and GBV (Table 5).

Protective characteristics against HIV infection refers to protective attitudes, abilities, and behaviors, such as sexual abstinence, to protect against HIV. In Cameroon, the “Responsible Behavior: Delaying Sex Curriculum and ‘Be Proud!’ Be Responsible!” program was provided to 60 girls.⁵³  Through a workshop, the children received lessons and participated in interactive activities (eg, role plays) and group discussions about bodily changes during puberty, HIV, values clarification, and skills. The intervention was significantly effective in increasing protective characteristics, including intention to postpone sexual activity and to employ learned sexual abstinence behavioral skills. In Tanzania, the “Stepping Stones with Children” training program was provided to 86 children with HIV.⁵⁴  Through workshops, children reviewed information from previous workshop sessions and participated in discussions. The intervention was significantly effective in improving adherence to antiretrovial medication in children with HIV.

The “Stepping Stones with Children” training program also assessed the effect of the intervention on CD4 cell count⁵⁴ ; the intervention was found to significantly improve the robustness of the immune system (CD4 cell count).

Of the 11 studies, 1 was excluded in the vote counting synthesis because direction of effect was not available (ie, not significant). There was evidence that the selected interventions had an effect on improved outcomes of SRHR of children with 10 out of 10 studies favoring the interventions (P = .002); 7 interventions were judged high for methodological quality, 3 were rated moderate, and none were rated low. The available effect estimates are presented in Table 6.

There is a high certainty of the evidence of intervention effects belonging to the ‘protective knowledge against CSA’ outcome domain (Table 7). The “protective characteristics against CSA and GBV” outcome domain has a low certainty of evidence, whereas the “protective characteristics against HIV infection” and “physiologic outcome” groups have a very low certainty of evidence. Refer to Supplemental Table 13 for the detailed rating of each GRADE domain.

One key pattern found across the studies belonging to the “protective knowledge” outcome domain (high certainty of evidence) was related to the intervention activities. Interventions that solely employed active and interactive activities as a learning tool or together with passive activities were consistently effective in improving knowledge of CSA prevention concepts and strategies.^{45,46,48–50,52,55}  Funded studies in the protective knowledge outcome domain received nongovernment, government, or industry funding, which may have contributed to the research capacity building in regions with limited resources. In terms of patterns within the studies, girls scored higher than boys for improvements in knowledge of CSA prevention concepts and strategies.^45,48  One study⁴⁵  found greater improvement of postintervention knowledge scores of CSA prevention concepts among older children. In contrast, another study⁴⁶  found that younger children had greater improvement in their postintervention knowledge scores of CSA prevention concepts.

This review identified educational interventions designed to prevent CSA and HIV among children. The review found evidence of significant improvements in protective knowledge, attitudes, behaviors, and skills among children exposed to various types of interventions and intervention activities. Given the certainty of evidence ratings, the review found strong evidence of significant improvements in children’s knowledge of CSA prevention concepts and strategies, including body awareness, identifying private parts, recognizing body ownership rights, saying NO, and avoiding self-blame. The review found low and very low certainty evidence of some significant improvements in children’s protective attitudes, behaviors, and skills against CSA, GBV, and HIV infection.

Most interventions in studies included in this review were primary prevention programs that were found to have significant effects in preventing CSA, GBV, and HIV in children. This is similar to the results of a study which reported that primary prevention programs that teach children sexual abuse protection concepts, improve their knowledge and abilities to protect themselves against CSA.⁵⁶  The literature also supports the significant effects of primary prevention programs on children’s protective capacity against GBV⁵⁷  and HIV.⁵⁸ 

The review provided evidence that education is an effective vehicle for developing children’s protective knowledge and skills, as well as creating attitudinal and behavioral changes to prevent CSA and HIV. This is consistent with findings from other studies.^16,59–61  In addition, studies with follow-up tests found that children can retain protective knowledge weeks to months after receiving education. However, the literature suggests that retention of knowledge should be measured beyond 3 to 12 months,⁶⁰  which was only accomplished by 1 study in this review.⁴⁵  The majority of studies in this review were conducted in school settings, which are crucial and far-reaching platforms for promoting positive SRHR messages.⁶²  Vast literature evidence indicate that schools have a crucial influence in providing children with the protective knowledge, understanding, attitudes, behaviors, and skills needed to make and act on positive SRHR related decisions.^62–66  United Nations’ reports also support this fact, stating that HIV and AIDS education is a predictor of reduced HIV risk.^11,63 

Concerning effective intervention activities to promote SRHRs, the literature reveals that programs featuring multiple activities, including interactive activities, are effective in keeping children engaged and absorbent to SRHR information.^11,15,67  However, the review did not find any strong evidence to support sole passive learning through didactic teaching as an effective learning and teaching tool. Interestingly, the peer education program showed some significant improvements in protective knowledge and characteristics scores among children.⁴⁹  This is supported by other reports stating that children are more comfortable discussing sensitive SRHR topics with their peers.^63,65 

Looking at the coverage of sex and gender in SRHR school curricula, a 10-country review in sub-Saharan Africa found that the curricula covered sexual abuse focusing mainly on girls.⁶⁸  In this review however, all but 2 studies^51,53  included both boys and girls, highlighting the fact that protection against sexual abuse and HIV infection should be the responsibility of both sexes. Finally, with regards to protective knowledge, characteristics, and sociocultural barriers, although review findings display improved protective knowledge and characteristics among boys and girls, sociocultural stigma surrounding disclosure of sexual abuse in some regions can still hinder children from openly disclosing their experiences.⁶⁹  The widespread, nonevidence based belief that sexual and reproductive health education will encourage children to initiate sex earlier is another major sociocultural and religious barrier to children’s learning of SRHR concepts.^11,70  In some regions, teacher discomfort and resistance, regardless of institutional policies, can lead to ineffective teaching and diluted content.¹¹  Educational programs with diluted messages significantly reduce the effect of an intervention, which may have been the case for the nonsignificant effects reported in this review.⁴⁸ 

This review had some limitations. Although our rationale for completing a narrative synthesis was sound, given the high levels of heterogeneity, a meta-analysis across the primary and secondary outcomes was not completed. Only 1 study was a truly randomized trial; studies with no randomization limit the ability to conclude a causal association between the intervention and effects of the measured outcomes. Narrative synthesis reviews of public health interventions tend to lack transparency in data presentation and elicited conclusions, thereby threatening the validity of the evidence. However, the reviewers used Popay's guidance for narrative synthesis reviews and the synthesis without meta-analysis guideline to reduce issues of transparency and increase utility of this systematic review. We used vote counting based on direction of effect to help with the synthesis; however, this provides no information on the magnitude of effects, does not account for differences in relative sizes of the studies, and is less powerful than methods used to combine p -values.^42,71  Thus, confounding variables were not statistically considered in the overall analysis of the review. Only 1 study assessed retention of knowledge beyond 3 months whereas the 3 other studies that did look at follow-up ranged between 6 and 8 weeks; therefore, the review did not include adequate follow-up evaluation to assess retention. Considering the low number of studies contributing to 3 of the outcome domains, there was not enough evidence to discuss the true effect seen in the findings. There were 10 studies that were excluded for being reported in languages other than English or French (language bias), which may have led to the exclusion of potentially relevant articles. Additionally, this review addresses a highly sensitive subject among a vulnerable population (children) from which consent is difficult to attain; we anticipate that there are reports and unpublished studies, which were not considered in this review. This presents publication bias toward peer-reviewed and published studies.

This review has both macro level policy and micro level intervention implementation implications. Table 8 provides an overview of implications regarding policy changes, highlights key implications for future intervention implementation, as well as flags opportunities for research in SRHR programs directed at improving knowledge, attitudes, and behaviors of primary school children.

This review identified effective educational interventions that developed primary school children’s protective capacities for sexual abuse, GBV, and HIV prevention. Statistical analysis based on the directions of effect in 9 of the studies indicated significant improvements in the protective knowledge against CSA domain. The evidence of significant intervention effects on the other outcome domains was weak and requires further research. There was sufficient evidence regarding effectiveness of educational interventions that had interactive components alongside passive learning. Government, education, and community organizations in LMICs must collaborate to provide culturally appropriate interventions for primary-school aged children both in and out of school.

CSA

child sexual abuse

HIV

human immunodeficiency virus

GBV

gender-based violence

GRADE

Grading of Recommendations, Assessment, Development and Evaluations

JBI

Joanna Briggs Institute

LMICs

low and middle-income countries

SRHR

sexual and reproductive health and rights

PICOS

population, intervention, comparison, outcomes, and study designs