Sexual health interventions for young people in state care: a systematic review

Abstract

Objectives: To describe evaluated sexual health interventions for young people in state care and provide an assessment of the quality of and evidence for these interventions. Methods: A systematic review of sexual health interventions for young people in state care was conducted. Randomised controlled trials and quasi-experimental designs were eligible, 2051 records were screened, 412 full-text studies retrieved, and 12 publications with low-to-moderate risk of bias included. Results: Due to substantial heterogeneity in study populations, settings, intervention approaches, outcomes and measures, standard summary measures for intervention outcomes was not used. Instead, data were synthesised across studies and presented narratively. Conclusion: Without making recommendations, the result suggests that group-based educational interventions in general increase knowledge, attitudes and behaviour compared with standard care. However, these findings need to be further investigated, with a special emphasis on cultural context and the involvement of young people.

Keywords

Adolescents incarceration intervention secure settings sexual and reproductive health and rights (SRHR)

Background

Sexual and reproductive health and rights, as part of human rights, are important global public health goals [1]. This concerns young people to a large extent, and they are repeatedly the targets of sexual health interventions aiming at avoiding unwanted pregnancies, HIV and other sexually transmitted infections (STIs). Depending on cultural context, these interventions range from abstinence-only programs to comprehensive sex education. Young people in state care, within juvenile justice systems or under the care of social authorities, have an impaired general health [2 –5]. This also applies to sexual health, manifested as a higher prevalence of STIs, higher rates of unintended pregnancies and experiences of unwanted sex [6 –10]. Interventions that strengthen sexual health among young people in state care are thus called for. As the World Health Organization (WHO) [1] states: ‘young people have the right to comprehensive sexual and reproductive health services, including knowledge through education and a right to sexual privacy’. The exposed position of people in prison or other detention facilities is especially acknowledged by the WHO, as they are reliant upon the incarcerating authority to access sexual health services [1]. Young people in state care are in similar exposed positions.

In 2010, a review of HIV prevention interventions for adolescents in juvenile justice settings was conducted [11]. Not only were the interventions found very few in number (n = 16), they were also lacking in cultural sensitivity, and the authors concluded that future interventions need to include the impact of family, mental health and substance use, in order to be more relevant to youth in these particular settings. To better inform the use of existing interventions, or the development of future sexual-health-promoting interventions, this paper presents the findings from a systematic literature review on sexual health interventions among young people in state care. The main objectives were to describe evaluated sexual health interventions for young people in state care and provide an assessment of the quality of, and evidence, for these interventions.

Methods

A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was conducted [12].

Study eligibility

Based on the assumption that the number of studies eligible for review would be low, the following six inclusion and exclusion criteria were used:

Publication. Peer-reviewed studies written in English or any of the Scandinavian languages, published from 1 January 1999 to 1 December 2014 were included.

Study design. Randomised controlled trials (RCT) and quasi-experimental designs including a control group and at least a pre-test, post-tests and an additional follow-up were included. No limitation was made on number of subjects in the treatment or the comparison group or the length of the follow-up period.

Participants. Young people (0–20 years of age) in state care, temporarily or during a longer period residing outside the home (including juvenile offenders) were included. Mixed populations of young adults and adults, e.g. 18–65 years of age, were excluded.

Intervention. Interventions of interest were those designed to promote sexual and/or reproductive health or intervention to prevent adverse health effects related to sexual and/or reproductive health. The intervention could be medical (such as vaccination), behavioural (such as education or social support) or multidimensional. Treatment studies (e.g. programs targeting sexual offenders) were excluded.

Control condition. Comparison group receiving standard care, information only, or a control intervention were included. Studies with irrelevant or obviously biased comparison groups, e.g. intervention dropouts, were excluded.

Outcomes. Changes in sexual or reproductive health (STI prevalence, pregnancies etc.) or in knowledge, attitudes and behaviours related to sexual or reproductive health (e.g. correct condom use) were included.

Search strategy

RCTs and quasi-experimental controlled trials were identified through searches of PubMed (NLM/NCBI), PsycInfo (ProQuest), sociological abstracts (ProQuest), social services abstracts (ProQuest), SweMed+ (Karolinska Institute), Cinahl (EBSCO), Academic Search Elite (EBSCO), ERIC (EBSCO) and the Cochrane Library, up to 1 December 2014. An information specialist located at a university library was used. Table I presents the Core database search strategy later adapted for subsequent databases. Additionally, reference lists were screened, and key researchers contacted to identify further studies.

Table I.

Core database search strategy.

Search #	Search terms
	Population: age group
#1	[mh “Child”] OR [mh “Adolescent”] OR [mh “Young adult”] :ti,ab,kw (Word variations have been searched)
	Population: placement
#2	[mh “Juvenile Delinquency”] or [mh “Residential Facilities”] or [mh “Foster Home Care”] or [mh “Adolescent, Institutionalized”] or [mh “Child, Institutionalized”] or [mh Prisoners]:ti,ab,kw (Word variations have been searched)
	Intervention: Sexual and reproductive health
#3	[mh Sexuality] or [mh “Sexual Behavior”] or [mh “Reproductive Health”] or [mh “Reproductive Rights”] or [mh Reproduction] or [mh “Sexual Partners”] or [mh “Sex Workers”] or [mh “Sex Offenses”] or [mh “Sexually Transmitted Diseases”] or [mh Contraception] or [mh “Gender Identity”] or [mh “Transgendered Persons”] or [mh “Abortion, Induced”]:ti,ab,kw (Word variations have been searched)
	Combined sets and Limiters
#4	#1 AND #2 AND #3 Limiters - Published Date: 19990101-20141201; Language: English, Swedish, Norwegian, Danish; Scholarly (Peer Reviewed) Journals

mh: searches MeSH heading, with term explosion.

In all, 2051 records were screened for abstracts/title (Figure 1). In the first level of review, a master level public health development manager (SH, first author) reviewed the 2051 records, eliminating articles obviously off topic and duplicates. The remaining 412 records were deemed potentially eligible. Using standard eligibility criteria tailored for this study, the first author and KS (MD and specialist in infectious diseases, second author) and ML (PhD, last author) reviewed these 412 abstracts for inclusion. Two reviewers from the pool of three mentioned above, independently read each of the 412 abstracts. If either reviewer considered a study potentially eligible from information in the abstract only, the full text was obtained and read by two reviewers. Across all 412 studies examined, pairwise agreements were 95%; consensus was achieved for the remaining articles.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram of search and data extraction.

Based on this initial review, 394 studies were considered ineligible due to not being an intervention study, e.g. reviews or cross-sectional studies (n = 313), having no control group (n = 30), having no sexual health outcome (n = 25), having an irrelevant population, e.g. not residing outside home, or adults (n = 22), or describing individual treatment or therapy (n = 4). A total of 18 studies remained.

Determination of bias and data synthesis

The 18 eligible studies advanced to the next level of review, assessment of bias, conducted by all three researchers who worked independently at first, and achieved consensus for ratings of bias based on a discussion among all three reviewers. This level of review involved calculation of estimated bias by using a protocol for assessment of randomised studies based on the GRADE approach [13]. Bias assessment was made using a protocol for assessment of randomised studies used in standard practice at The Swedish Council on Health Technology Assessment and Assessment of Social Services (SBU), similar to the principles of Higgins and colleagues [14]. Selection bias, performance bias, detection bias, attrition bias, reporting bias and conflict of interest in each publication was assessed. In this last stage, six studies were excluded due to an overall high risk of bias in all the different areas, mainly selection bias, performance bias and reporting bias (see Table II). Finally, 12 studies with low or moderate risk of bias were considered in the final synthesis (Table III).

Table II.

Risk of bias assessment of studies excluded due to high risk of bias.

First Author (year)	Selectionbias	Performance bias	Detectionbias	Attrition bias	Reporting bias	Conflict of interest	Overall assessment of risk of bias
Godin(2003)	H	H	H	H	H	H	High risk of bias: Quasi-experimental controlled trial without randomisation. No blinding reported. High drop-out/attrition (34%). Differences between drop-outs and those who completed the study. No reference to study protocol. Intervention developed by author.
Hurd(2010)	M	M	H	H	H	L	High risk of bias: Quasi-experimental controlled trial without randomisation. No follow-up. Compares original eight-session HIVEd program to adapted four-session HIVEd program. HIVEd program is a modified version of the evidence based BART intervention. No blinding reported. No reference to study protocol. Per-protocol analysis (only adolescents who completed post-test and at least 75% of program sessions are included in the analysis), no information on those who were excluded by this method.
Kelly(2004)	H	H	M	H	H	M	High risk of bias: Quasi-experimental controlled trial without randomisation. No blinding reported. No information on drop-out. No information on compliance. No reference to study protocol. Significant differences in intervention and control groups in terms of girls’ risk backgrounds, being higher in the intervention group.
Mouttapa (2009)	H	H	L	H	H	M	High risk of bias: Quasi-experimental non randomised pre-post comparison group design. No follow-up. Small sample. No reference to study protocol. No info on sample size at baseline. Participants received a $10 coupon as a compensation for their participation, which was presented to them upon their release.
Mouttapa (2010)	H	H	M	H	H	L	High risk of bias: Quasi-experimental non randomised pre-post comparison group design. No follow-up. Small sample. Incomplete info on sample sizes, dropout and compliance. Analytic sample are those with compliance >20% and who completed posttest. No reference to study protocol. All participants received 2 $10 IRB-approved food coupons as compensation for their participation.
Slonim-Nevo (2001)	H	H	L	L	H	H	High risk of bias: Quasi-experimental controlled trial without randomisation. Small sample. No blinding reported. No information on compliance. Low attrition. Selection bias, as 95% of participants in the experimental intervention were Jewish and 57% in the control intervention were Arab. Group differences at baseline (ethnicity, age, gender, birthplace) are partially controlled for. No reference to study protocol. Intervention developed by author.

L: Low risk of bias (plausible bias unlikely to alter the results); M: moderate risk of bias (plausible bias that raises some doubt about the results); H: high risk of bias (plausible bias that seriously weakens confidence in the results).

Table III.

Risk of bias assessment for studies included in the review.

First Author (year)	Selectionbias	Performance bias	Detectionbias	Attrition biasbias	Reporting bias	Conflict of interest	Overall assessment of risk of bias
RCTs
Bryan(2009)	L	M	L	M	H	H	Moderate risk of bias: Randomisation of condition to groups not individuals, Participants blind to intervention condition, Short intervention, High attrition, Author developed intervention, Study protocol published in retrospect, Participants received up to $125
Di Clemente(2014)	L	L	L	M	H	H	Moderate to low risk of bias: allocation concealment at randomisation, non-blinded study personnel doing assessment, blinding of participants not stated, low attrition and high compliance, short follow-up, no reference to study protocol, program recommended by Centers for Disease Control, author developed intervention, participants received up to $150
Freudenberg(2010)	L	H	L	M	H	H	Moderate risk of bias: standard random assignment, no blinding stated for staff or participants, contracted evaluators at follow-up were blinded, high attrition, both jail and community based, 12 months follow-up period, low compliance, no reference to study protocol, authors developed intervention, participants received up to $130
Goldberg(2009)	L	L	L	M	H	H	Moderate to low risk of bias: randomisation using random numbers table, analyst was blind to group assignment, no other bindings, no info on compliance, possible contamination, high attrition, no reference to study protocol, author developed intervention
Kerr (2009) &Leve (2013)	L	M	L	L	H	H	Moderate to low risk of bias: randomised (coin flip) to condition or control, not to trial 1 or trial 2, compares treatment foster care to group care, high compliance and low attrition, assessment staff blind to group assignment and not involved in intervention delivery, no reference to study protocol, one author is owner/partner in the organisation that disseminates intervention
Kim(2013)	L	L	M	M	H	H	Moderate risk of bias: randomised, type not described, small sample size, blinded assessments but not participants, low attrition in total but attrition rate per condition is not reported, no reference to study protocol, both girls and caregivers were compensated, coauthors are developers of intervention
St. Lawrence(1999)	L	M	L	L	H	H	Moderate risk of bias: no information on type of randomisation or blinding, high compliance, low attrition, no information on group differences, 69 participants were lost before randomisation due to facility overcrowding, no reference to study protocol, author developed intervention, program recommended by Centers for Disease Control
St Lawrence(2002)	M	M	L	L	H	H	Moderate risk of bias: neither type of randomisation nor compliance stated, blinded assessment, no info on assessed participants of each condition, no reference to study protocol, 1/3 of eligible participants did not complete detoxification and excluded from participation, author developed intervention, program recommended by Centers for Disease Control, participants received up to $60
Quasi-experimental controlled trials
Lauby(2010)	M	L	M	L	H	H	Moderate risk of bias: not randomised, dose effect on knowledge, medium attrition, compliance rate acceptable, no reference to study protocol, author developed intervention, program recommended by Centers for Disease Control, participants received up to $ 40
Robertson(2011)	M	M	L	L	H	H	Moderate risk of bias: not randomised, only role-play assessments blind, high compliance, medium attrition, no reference to study protocol, author developed intervention, program recommended by Centers for Disease Control
Rotheram-Borus(2003)	M	H	L	M	H	H	Moderate risk of bias: randomisation only by shelter not by individuals, long follow-up, no reference to study protocol, program recommended by Centers for Disease Control, author developed intervention, participants received food at randomly selected sessions and $1 for carrying a condom and arriving at the program on time

No test for heterogeneity was performed, due to substantial differences in study populations, settings, specific intervention approaches, outcomes and measures, so standard summary measures for intervention outcomes was deemed not applicable. Instead, data were synthesised across studies and are presented narratively [15]. With a deductive approach, we examined the extent to which each intervention had effects in six domains (D1–D6) relevant to sexual health and public health, defined by Hogben and colleagues [16]. The domains are The intrapersonal: Knowledge (D1), Attitudes, norms, intentions, and self-efficacy (D2); The interpersonal: Negotiation and communication (D3), Health care use (D4), Sexual behaviour (D5) and Health outcomes: Adverse outcomes (D6).

Results

A summary of the final 12 publications (one intervention resulted in two publications) meeting the inclusion criteria is presented in Table IV. The table presents first author, publication year, setting, name of intervention, population, intervention and control condition, intervention duration, follow-up, measures and significant outcomes in the above-mentioned domains D1–D6 (knowledge, attitudes, norms, intentions, self-efficacy, negotiation and, communication, health care use, sexual behaviour and adverse health outcomes). For a more detailed description of the interventions, see Table V.

Table IV.

Summary of sexual health interventions aimed at young people in state care and significant outcomes in Hogben domain.

First author(year)	SettingName of interventionPopulation at baseline	InterventionControl condition	DurationFollow-upMeasured Hogben^a domain	Significant outcome in Hogben domain
Bryan(2009)	Juvenile detentionGroup based psychosocial sexual risk reduction intervention + group based motivational enhancement therapy484 (17% females & 83% males)	Group-based psychosocial education + skills-trainingGroup-based psychosocial education + skills-training + group based motivational enhancement therapyHealth information	4 h3, 6, 9, 12 monthsD5	None
Di Clemente(2014)	Juvenile detentionThe Imara intervention (based on HORIZONS)188 females	Individual counselling + Skills-training + Role-playStandard care + Health information	6 h,3 ,6 monthsD1, D2, D5, D6	D1, D2, D5
Freudenberg(2010)	Juvenile detention + communityREAL MEN552 males	Group-based psychosocial education + Community-based organisationDischarge planning session	30 h12 monthsD5	D5
Goldberg(2009)	Secure custody + communityUnnamed educational intervention391 (26% females & 74% males)	Group-based education + Skills-trainingGroup-based education + Skills-training + boosterStandard care	6 + 1 h1, 3, 6 monthsD1, D2, D5	D1, D2, D5
Kerr (2009)Leve (2013)^b	Foster care, Group careMultidimensional Treatment Foster Care166 females	Caregiver training + Individual counselling + Group-based education + Role-playStandard care + Community-based group care	9–12 months6,12,18, 24 + 7 yearsD6	D6
Kim(2013)	Foster careMiddle School Success100 females	Caregiver training + Skills-training + Group-based education + Individual counsellingStandard care	6+6+2 h/week for 12 months6, 12, 24, 36 monthsD5	D5
Lauby(2010)	Juvenile justice facilityPALMS289 males	Group-based education + Role-playStandard care	3 sessions6 monthsD1, D2, D5	D1, D2, D5
Robertson(2011)	Correctional facilityThe Healthy Teen Girls project333 females	Group-based education + Individual counselling + Skills trainingGroup-based education + Individual counselling	18 h9 monthsD1, D2, D3, D5, D6	D1, D3
Rotheram-Borus (2003)	ShelterStreet Smart187 (49% females, 61% males)	Group-based education + Skills training + Individual counselling + Health care visitStandard care	10 sessions3, 6, 12, 18, 24 monthsD5	D5
St. Lawrence (1999)	State reformatorySexual risk reduction skills-training = abbreviated version of BART361 males	Group-based education + Skills-training + Role-playAnger management training	9 h6 monthsD1, D2, D5	D1, D2
St Lawrence(2002)	Residential drug treatment facilityInformation + skills-based safer sex training + a risk-sensitisation manipulation161 (32% females & 68% males)	Group-based education + Skills trainingHealth education	18 hours6, 12 monthsD1, D2, D5	D1, D2, D5

Sexual health intervention domains by Hogben et al. [16]: D1: Knowledge; D2: Attitudes, norms, intention and self-efficacy; D3: Negotiation and communication; D4: Health care use; D5: Sexual behaviour; D6: Adverse health outcomes. ^bOne study resulted in two publications (Kerr, 2009 and Leve, 2013).

Table V.

Detailed description of studies included in the review of sexual health interventions aimed at young people in state care.

First author, yearcountry	Population	Study design	Experimental intervention	Control condition	Outcome measures	Main results
Bryan, 2009, USA	Inclusion criteria: 14-17years, English-speaking, current residents at one of three detention facilities, fully informed consent from parent or legal guardian, and themselves.Exclusion criteria: no infoSetting: 3 juvenile detention facilities, Denver.No at base line: 484Mean age: 15.8 (SD 1.1)Gender: 82.7% malesStudy period: 2004–2006	RCTRandom assignment by session to three different conditions, using a random numbers table blocked on gender.Assessment: Audio-computer assisted self-interview.Follow-up: 3, 6, 9 and 12-months	►Group based psychosocial sexual risk reduction intervention (GPI)Sessions: 3h x 1Content: Same info as control but through skills training and active participation and strong focus on attitudinal and normative change to promote safer sex.Theoretical base: Theory of planned behaviour & Social cognitive theoryNumber of participants:Randomised: 157Assessed: no infoCompliance: 96.5%►GIP + group based motivational enhancement therapy (GPI + GMET)Sessions: 3-4h x 1Condition included alcohol risk reduction (MET). Feedback on alcohol consumption compared with average adolescents.Number of participants:Randomised: 165Assessed: no infoCompliance: 96.5%Interventions delivered in same-sex groups of 1–10 participants by masters-level intervention leaders.	Information only (GINFO)Sessions: 2h x 1Content: Basic STI and HIV information, modes of transmission, effectiveness of condom use. Resources for testing and other sexual health services.Delivered by masters-level intervention leaders.Number of participantsRandomised: 162Assessed: no infoCompliance: 96.5%	Sexual behaviour past 3 months:Condom-use behaviourFrequency of intercourse while drinkingAlcohol-related problems (past year).	Condom use: significant decreased condom use over time in the GINFO but non-significant change over time in the 2 theory-based interventions.Frequency of intercourse while drinking: decreased over time in all 3 conditions, no significant differences dependent on condition observed.Alcohol Problems: Decreased over time in GPI and GPI+MET.The interaction between time and condition approached significance (F2,807 = 2.75; p = .06), providing some evidence that the significant changes over time were dependent on condition.Attrition: 27–42% depending on follow-up and condition
Di Clemente, 2014, USA	Inclusion criteria: African American, 13–17 years of age, and reporting ever willingly had vaginal intercourse with a male.Exclusion criteria: married, pregnant, Wards of the state of Georgia, or would be placed in a restricted location upon release (i.e., group home) were excluded from the study.Setting: Juvenile detentionNo at base line: 188Mean age: 15.3 (SD 1.06)Gender: 100% femaleStudy period: 2011–2012	RCTAllocation concealmentThe Imara intervention is based on HORIZONS.Assessment: audio computer-assisted self-interview, a urine pregnancy screen, condom skills assessment, and self-collected vaginal swab to detect chlamydia and gonorrhoea.Follow-up: 3 and 6 months post-randomisation	►The Imara interventionA multi-faceted intervention consisting of individual counselling in the detention facility and in girls’ homes following release.Theoretical base: Social cognitive theory and theory of gender and power.Sessions: 3 x 1.5 h individually with health educator & 4 x 20-min phone sessions; partner therapy offered to STI-positive adolescents.Content: combination of approaches, including skills training, HIV/STI risk assessment, sexual health goal setting, role-play and interactive computer activities to address multiple aspects of sexual behaviour. Emphasis on key issues specific to detained youth including emotion regulation, trauma, and relationship betweensubstance use and risky behaviour.Number of participantsRandomised: 95Assessed: 88 (93%)Compliance: 100%, 93%, 91% received the first, second and third session respectively.	►Standard care (SD)SD provided by the detention centre, which included weekly, 1 hr, group-based HIV/STI information sessions provided to all youth, STI testing, treatment, and counselling.Number of participantsRandomised: 93Assessed: 83 (89%)	Sexual behaviourpast 3 months:Knowledge of HIV/STI preventionCondom use skillsCondom use self-efficacyPartner communicationself-efficacyCondom-protectedsex actsConsistent condom useNumber of sex partnersConfirmed chlamydia or gonorrhoea	Higher condom use self-efficacy, mean difference for intervention condition relative to the controls was 4.43 (95% CI: 2.26, 6.60).- Higher HIV/STI knowledge, mean difference for intervention condition relative to the controls was 1.33 (95% CI: 0.78, 1.88),- Better condom use skills (p < 0.001) compared with control participants.No significant differences between trial conditions in incident Chlamydia or gonorrhoea infections, condom use, or number of vaginal sex partners.Attrition: 9% at 6-month assessment
Freudenberg 2010, USA	Inclusion criteria: Males 16–18 years old, individuals determined to be eligible for release within 12 months of intake, and planning to return to the Bronx, Brooklyn, or Manhattan.Exclusion criteria: Individuals with psychiatric conditions that would preclude participationin group intervention.Setting: 2 detention centers and in the community/New YorkNo at base line: 552Mean age: 17.99 (SD 0.71)Gender: 100% malesStudy period: 2003–2007	RCTparticipants were randomly assigned to receive a single jail-based discharge planning session or a psychosocial educational intervention that began in jail and continued in the community after release.To investigate the effect of additional voluntary participation in a community basedorganisation (CBO)Assessment: interviewFollow-up: 12 months after release from jail.	►REAL MEN (Returning Educated African-American and Latino Men to Enriched Neighbourhoods) A 30-h psychosocial educational group–based intervention recognising the role of life circumstances and social services in helping people succeed after leaving jail.5 sessions in jail: Getting ready for going home; staying healthy to stay free; being a REAL MAN in today’s world, sex in the risk zone; my people, my pride.3 sessions after release: drugs in your life, getting the information you need to stay free and healthy, and staying free and healthy for life.CBO): Family meetings, open groups, activities such as trips, opportunity to participate in community partner’s activities.Number of participants Randomised: 277Assessed: 196 (71%)Compliance: 64% in ⩾4 sessions, 45% made ⩾ 1 visit to the CBO, and 40% participated in ⩾4 sessions and made a visit to the CBO.	►A single jail-based discharge planning session.Number of participants Randomised: 275Assessed: 201 (73%)17% made at least one visitto the CBO	Sexual behaviour past 3 months:Number of sex partnersCondom use with long-term partnerCondom use with casual partnerSex under the influence of substanceSubstance dependenceCriminal justice involvement (past year)School/work involvement (past year)	While neither REAL MEN alone nor CBO alone reduced risky sexual behaviour, the combined effect of these services did (OR=0.334, p= ⩽ .05).Assignment to REAL MEN and, independently, use of CBO services, significantly reduced the odds of substance dependence (OR = .52, p = .05; OR = .41, p = .05, respectively) 1 year after release.Those assigned to the intervention spent 29 fewer days in jail compared with the comparison group (p = .05). Compared with non- visitors, those who visited the CBO were more likely to have attended school or found work in the year after release (OR = 2.02, p = .01).Attrition: 28%
Goldberg, 2009,Canada	Inclusion criteria: residence in facility during time of the program; age 12–18; no current enrollment in other in-depth HIV-education program; ability to provide informed consent.Exclusion criteria: unmanaged psychiatric conditions and estimated discharge date <3 weeks or >5 weeks from recruitment.Setting: Two young offender secure custody facilities and in the community.No at base line: 391Mean age: 16.0 (SD 1.1)Gender: 26% female and 74% maleStudy period: 2000–2003	RCTParticipants randomly assigned, using a random numberstable, to one of three conditions: (a) education intervention; (b) education intervention with booster; or (c) no intervention.Assessment: Structured interviews conducted by trained project staff.Follow-up: 1, 3, and 6 months post intervention.Analyses were stratified by gender.	►Education intervention (E)Sessions: 6 x 1 h over a 3-week period. An interactive curriculum incorporating a strong attitudinal and skills-building component.Topics: Putting a Face to HIV/AIDS, Sexual Anatomy, Condom Demonstrations, and Communicating about Condoms/Barriers, Needles and Levels of Risk, Communication and SOS (Smarts on Sex).Theoretical base: Social learning theory►Education intervention + booster (E+B)Educational sessions and booster session 3 months post intervention, administered either in person or by telephone.Interventionists: Two trained educators. Intervention was delivered to male and female participants separately.Number of participants Randomised: 130/conditionAssessed: 53%(E), 58%(E+B)Compliance: 85%, 70% of E+B participants received booster	►Standard care(Controls received a condensed education at the study completion)Number of participants Randomised: 131Assessed: 67%	Sexual behaviour past 3 months:Risk behaviour knowledgeSelf efficacy ratingSelf-assessment of riskPrevention attitudeCondom attitudeCondom use	At 6 months, males in the education and booster groups’ sustained increased knowledge scores (p < 0.001). Females sustained increased condom attitude scores (p = 0.004).Males in booster group sustained increased prevention attitude scores (p = 0.017).Females in booster group reported more consistent condom use (OR = 4.20; 95% CI = 1.81, 9.77). Age, gender, drug use, and psychological profiles were predictive of outcome.Over time, the knowledge levels of controls improved.Attrition: 28.4% at 3 months and 40.4% at 6 months.
Kerr, 2009, USA	Inclusion criteria: 13–17 years of age, at least one criminal referral in the prior 12 months, not currently pregnant, and placed in out-of-home care within 12 months following referral.Exclusion criteria: no infoSetting: Foster care, OregonNo at base line: 166Mean age: 15.31 (SD = 1.17)Gender: 100% femaleStudy period: 1997–2006	RCT, 2 consecutively run trials. Random assignment (coin flip) of girls to either intervention or control. In trial 2 girls assigned intervention received an additional component targeting sexual risk behaviours. Girls were not randomly assigned to Trial 1 or 2, participation in these consecutively run trials was based on when girls were enrolled.Assessment: Girl and caregiver interview.Follow-up: 6,12,18 & 24 months	►Multidimensional Treatment Foster Care (MTFC)Trial 1: girls were individually placed in 1 of 22 highly trained and supervised homes with certified foster parents. Interventions were individualised but included all basic MTFC components and lasted 9–12 months.Trial 2: the MTFC condition also included an additional intervention component that targeted drug abuse and HIV risk behaviours. The girls were provided with information on dating and sexual behaviour norms and on HIV risk behaviours and were taught strategies for being sexually responsible, including decision making and refusal skills. Role-play exercises.Number of participants Randomised: 81Assessed: 78 (96%)Compliance: 100% treatment services were received by all youths, though treatment length varied.	►Standard careGirls were placed in 1 of 35 community-based group care (GC) programs; across the two trials, each site served 1–12 study participants. GC programs represented typical services for girls being referred to out-of-home care by the juvenile justice system.Number of participants Randomised: 85Assessed: 81 (95%)Compliance: 100% some treatment services were received by all youths, though treatment length varied.	Sexual behaviour past 6 months:Number of pregnancies	Fewer post baseline pregnancies were reported for MTFC girls (26.9%) than for GC girls (46.9%), (OR = 0.42, 95% CI = 0.23– 0.75). The effect remained significant after controlling for baseline criminal referrals, pregnancy history, and sexual activity.Baseline number of criminal referrals (OR = 1.05, 95% CI = 1.01–1.08, p = .010), sexual activity (OR = 3.70, 95% CI = 1.17–11.67, p = .025), and history of a prior pregnancy (OR = 3.12, 95% CI = 1.47– 6.64, p = .003) each predicted follow-up pregnancy.Trial, or the Group x Trial interaction did not predict follow-up pregnancy.Attrition: 4.2%
Kim, 2013, USA	Inclusion criteria: In relative or nonrelative foster care in one of two counties containing major metropolitan areas inthe Pacific Northwest and in their final year of elementary school (11 years), referred through the child welfare system.Setting: Foster care in two counties containing major metropolitan areas in the Pacific Northwest.No at base line: 100Mean age: 11.54 (SD 0.48)Gender: 100% femaleStudy period: No info, before 2006.	RCTExamined the effects of the Middle School Success (MSS), a program to promote healthy adjustment in foster girls, on their health-risking sexual behaviour.Assessment: Structured interview and questionnaires for each girl and her caregiver, an interview with the girl’s caseworkers, and collection of child welfare records.Trained interviewers, blinded to condition assignment.Follow-up: 6, 12 and 24 months, plus at 36-months for girls.	► MSSComponents: (1) six sessions of group-based caregiver management training for foster parents and (2) six sessions of group-based skill-building sessions for girls. Seven participants/group met twice a week for 3 weeks; 2–3 facilitators per session. Additional ongoing training and support to caregivers and girls in the intervention group 1/week for 2 h during the first year of middle school.Topics for girls: pro-social skills; cooperating with peers; peer norms for abstinence from substance use, sexual activity, and violence; meeting new people, feelings of exclusion, and talking to friends and teachers about life in foster care.Number of participants Randomised: 48Assessed: no infoCompliance: On average, participants completed 5.62/6 sessions (SD = .99) and caregivers attended 20 weekly follow-up sessions (SD = 10.4).	►Standard careServices provided by the child welfare system, such as referrals to individual or family therapy, parenting classes for biological parents, and case monitoring.Number of participants Randomised: 52Assessed: no info	Sexual behaviour past 12 months:Health-risking sexual behaviour (Touching a boy’s body above or below the waist, sexual intercourse, sex with someone who they just met, sex under the influence of substance)Tobacco andmarijuana use past yearPlacement changes	Girls in the intervention condition showed significantly lower levels of health-risking sexual behaviour than did girls in the control condition at 36 months post-baseline (average of 0.89 acts (SD 1.17) vs. 1.69 acts (SD 2.04) The group difference was significant (t (88) = 2.28, p = 0.03, Cohen’s d = 0.48).Path analysis indicated that this intervention effect on health-risking sexual behaviour was fully mediated through its effects on girls’ tobacco and marijuana use (β = −.12, p = .04), and not through increased placement stability, even though placement disruptions were significantly related to girls’ tobacco and marijuana use in the path model.4.4% of the girls in the MSS condition, as opposed to 17.8% of the girls in the control condition, reported sexual intercourse in the past year (x² = 4.05, df = 1, p = 0.04).Attrition: 2–10%
Lauby, 2010, USA	Inclusion criteria: 12-18 years of age, resident in the facility, could read and speak English, and had not previously received the PALMS intervention.Exclusion criteria: no informationSetting: Two juvenile justice facilities in PhiladelphiaNo at base line: 289 youthMean age: 15.1 years (SD 1.5)Gender: 100% male.Study period: 2005–2006	Quasi-experimental, concurrent comparison group design.Evaluates the efficacy of Preventing AIDS through Live Movement and Sound (PALMS) in comparison to standard care.Assessment: In-person or telephone interview.Follow-up: 6months after completion of the intervention	►Preventing AIDS through Live Movement and Sound (PALMS)An HIV risk-reduction intervention that uses theatrical performances and role-play.Sessions: 3, in one week.Components: Groups of 8–20 adolescents, led by a trained health educator and a co-facilitator. Trained actors aged 20–35, selected to reflect the ethnic composition of participants, delivered much of the intervention. They portrayed dramatic performances of real-life situations often faced by adolescents.Topics: benefits and barriers to HIV testing, HIV stigma, condom use, and postponing sexual activities.Theoretical base: Health belief model, social cognitive theory.Number of participants Randomised: 146Assessed: 120 (82%)Compliance: 85% completed at least 2 of 3 PALMS sessions, and 67% completed all 3 sessions.	►Standard careBoth the intervention and comparison group received information on health,substance use, and sexual behaviour provided to all adolescents in Philadelphia’s juvenile justice facilities.Number of participants Randomised: 143Assessed: 113 (79%)	Sexual behaviour past 6 months:Knowledge of HIVCorrect condom useAttitudes toward HIV testingAttitudes toward people living with HIVNumber of sex partnersCondom at last sexCondom with non-main partner	At 6-month follow-up, PALMS participants demonstrated greater increases in HIV and condom use knowledge and improved attitudes toward HIV testing and toward persons living with HIV/AIDS than did those in the comparison condition. PALMS participants were also significantly more likely to use a condom during their last sexual contact with a non-main female partner than comparison participants (adjusted OR = 5.50, 95% CI = 1.05, 28.85).Significant dose effect on HIV and condom use knowledge (p = .002 and .001, respectively)No significant intervention effects on changes in the reported number of sex partners, condom use at last sex.Attrition: 19% at 6 months
Leve, 2013, USA	(For more information see the original article, Kerr et al., 2009, above.)	7 years follow-up of a previously published RCTAssessment: interview primarily completed through telephone, 20% occurring in person.Follow-up: 7 years post intervention	(For more information see the original article, Kerr et al., 2009, above)	(For more information see the original article, Kerr et al., 2009, above)	(For more information see the original article, Kerr et al., 2009, above)	Intervention condition was not predictive of any of the young adult outcomes examined in the study. Becoming pregnant during the 2-year follow-up was related to certain outcomes 7 years post baseline: illicit drug use (Wald = 4.62, p = .032, OR = 1.84, 95% CI = 1.06–3.36); miscarriage from a new pregnancy (Wald = 10.34, p = .001, OR = 3.86, 95% CI = 1.70–8.80); and child welfare involvement regarding their parenting (Wald = 3.97, p = .046, OR = 2.76, 95% CI = 1.01–3.24). Baseline marijuana use predicted marijuana use at 7 years post-baseline (Wald = 4.24, p = .039, OR = 2.76, 95% CI = 1.05–7.23).Attrition (7 years): 4–15%
Robertson, 2011, USA	Inclusion criteria: aged 12–17 and not assigned to the maximum security unit.Setting: State correctional facilityNo at base line: 333Mean age: 15.1 (SD 1.3)Gender: 100% femaleStudy period: 2004–2007	Quasi-experimental design.Cohorts randomly assigned to the experimental conditions in blocks separated by a washout period, a STD risk reductionintervention (SRR) based on Becoming A Responsible Teen (BART), or health education (HE).Assessment: Audio computer-assisted self-interviewFollow-up: 9 months after release.	►The Healthy Teen Girls project: STD risk reduction (SRR)Sessions: 18 x 1 h group sessions and one individual goal-setting session provided by interventionists specifically trained to deliver the program.Content: Same health education as controls (information on reproductive health, effects of alcohol, tobacco and other drugs on health, STD and contraceptive methods). Intervention group also received skills training, practice on condom application, partner negotiation and refusal skills.Theoretical base: Social cognitive theory and information, motivation, behavioural skills model (IMB).Number of participants Randomised: 166Assessed: 113 (80%)Compliance: no info (in total 23 administratively withdraw and 5 voluntarily withdraw during intervention).	►Health education (HE)Sessions: 18 x 1 h group sessions and one individual goal-setting session provided by interventionists specifically trained to deliver program.Content: Information on reproductive health, effects of alcohol, tobacco and other drugs on health, STD and contraceptive methods.Number of participants Randomised: 167Assessed: 133 (79%)	Sexual behaviour past 3 months:Health knowledgeCondom application skillCondom attitudeCommunication skillsCondom useNumber of sex partnersUnprotected sex actsSex under the influence of substanceSafer sexConfirmedchlamydia or gonorrhoea	Post intervention, girls in intervention group demonstrated acquisition of risk-reduction behavioural skills and improved condom application skills. At follow-up assessment 9 months after release, girls in both conditions reported fewer unprotected sexual intercourse occasions (F (1, 215) = 14.35, p < .001) and less sex while under the influence of alcohol or other drugs [F(1, 238) = 9.77, p = .002].Neither condition (AOR = 0.51, p = .07) nor having an STI at baseline (AOR = 1.90, p = .12) was associated with STI infection at follow-up.Attrition: 19.3%
Rotheram-Borus, 2003, USA	Inclusion criteria: 11–18 years, residing at shelter, informed consent obtainedExclusion criteria: No information.Setting: 4 shelters in New YorkNo at base line: 311, 187 in the propensity-score matched analytic sample.Mean age: 15.8 (SD 1.47)Gender: 49% female, 61% maleStudy period: No information, before 2003	Quasi-experimental design. Randomisation occurred by shelter,not by youth. The efficacy of an HIV prevention program was evaluated over 2 years among 2 groups of runaways: (1) those at 2 shelters who received Street Smart, and (2) youth at 2 control shelters.Assessment: interview by trained staff.Follow-up: 3, 6, 12, 18, and 24 months post intervention	►Street Smart (SS), an intensive HIV intervention program.Sessions: 10 over 3 weeks.Content: A skill-focused prevention program including; general and personal knowledge of HIV, social skills and individual barriers to safer sex. Delivered in small groups & one private counselling. SS provided weekly visit to a health care agency including a free meal, a tour, a planned group activity and free condoms.Theoretical base: Social learning theory.All staff initially attended 10 days of training in Street Smart. Sessions were co-led by a research and a shelter staff member.Number of participants Randomised: 101Assessed: no infoCompliance: mean number of sessions 9.1 (SD 6.13, range 1–28 sessions).	►Standard careYouth in control shelters received the “currentpractice in the field.” Staff received HIV educationtraining. However, there was no systematic introductionof HIV prevention information or education for youth.Number of participants Randomised: 86Assessed: no infoCompliance: no info	Sexual behaviour past 3 months:Number of sex partnersNumber of unprotected vaginal or anal sexual actsAbstinence from vaginal or anal sexual actsSubstance use past 3 months	Females in intervention condition compared with those in control group at 24 months post intervention:Lower average number of recent sexual partners (OR = 0.68, p = 0.084), lower number of unprotected sexual acts (OR = 0.29, p = 0.055), higher rates of abstinence (OR = 2.41, p = 0.088). Less marijuana use at the 6-month follow-up (OR = 0.31, p = 0.033) and the 12-month follow-up (OR = 0.19, p = 0.005).Males in the intervention condition showed significant reductions in marijuana use over 6 months compared with control youth but no significant differences in the number of sexual partners or in the number of unprotected sexual acts.Attrition: 30–50% at different assessments.74% had at least three data points.
St. Lawrence, 1999, USA	Inclusion criteria: Informed consent by guardian and adolescent and no obvious physical or mental impairment that would preclude participation.Exclusion criteria: no infoSetting: A southern state reformatoryNo at base line: 428, (361 randomised)Mean age: 15.8 (SD 0.7)Gender: 100% maleStudy period: No information, before 1999.	RCTRandomised assessment of a behavioural STD/HIV risk reduction intervention and a violence prevention intervention.Assessment: anonymous questionnaires presented orally by staff.Follow-up: 6-months	►Sexual risk reduction skills-training (ST) an abbreviated version of Becoming a Responsible Teen (BART) program.Sessions: 6 x 1.5 h, in groups of 10-12 participants.Content: information on STD/HIV and training in 5 skill components, condom application, refusal of unwanted sexual initiations, negotiation for condom use, information provision for peers and self-reinforcement for adaptive behaviour. Participants observed group leaders and peer role models on videos practice the skills, and then practiced the skills in dyads.Theoretical base: Information, motivation, behaviour (IMB) model, Social learning theoryNumber of participants Randomised: 180Assessed: no infoCompliance: no info, 97% in all the conditions combined	►Anger management (AM) based on Positive Adolescent Choices Training (PACT).Sessions: 6 x 1.5 h, in groups of 10–12 participants.Delivered by experienced PACT project member.Content: training in 5 skill components, giving positive/negative feed-back, accepting criticism, resisting peer pressure, solving problems, and conflict resolution. Participants observed group leaders and peer role models on videos and then practiced the skills.Number of participants Randomised: 181Assessed: no infoCompliance: no info, 97% in all the conditions combined.	Sexual behaviour, past 3 months:AIDS knowledge Condom skillsSelf-efficacyPerception of HIV-riskCondom attitude Frequency of unprotected intercourseFrequency of condom-protected intercourseNumber of sex partnersNumber of casual encountersUnwanted sex Trading sex for drugs	Post intervention youth in the ST intervention evidenced higher scores on AIDS knowledge, more favourable attitudes toward condom use, and enhanced self-efficacy than youth in AM intervention. The ST group also significantly improved all 6 condom application skills, whereas the AM group was unchanged.For all sexual behaviour outcomes youth reported lower frequencies at follow-up, regardless of condition. No effect of condition was seen at follow-up. Possibly explained by spill-over effect through informal peer-teaching.Attrition: 11% at the 6-month follow-up.
St Lawrence, 2002, USA	Inclusion criteria: Adolescents admitted to facilities were drawn from a statewide catchment area and diagnosed by an interdisciplinarytreatment team as being substance dependent.Exclusion criteria: Not completing detoxification.Setting: 2 residential drug treatment programs in Mississippi.No at base line: 161Mean age: 16.0 (SD 1.3)Gender: 68% male and 32% femaleStudy period: 1995–1998	RCTAssessment of 3 interventions designed to increase safer sex behaviours of substance-dependent adolescents. Random assignment to either:a) Health information intervention (I only)b) Information plus skills-based safer sex training (IB)c) experimental condition (IB) + a risk-sensitisation manipulation (IMB)Assessment: Project staff administered questionnaire and presented questions orally. Simulated role-play assessments. Raters were blinded.Follow-up: 6 and 12 months after discharge.	Sessions: 12 x 1.5 h over 4 weeks.Sessions co-led by 1 male and 1 female facilitator with degrees in psychology who received extensive training and supervision. Theoretical base: Information, motivation, behavioural skills model (IMB), Extended parallel process model, Social– cognitive theory.Number of participants Randomised: no infoAssessed: no infoCompliance: no info►Information + skills-based safer sex training (IB)2 sessions about STI and HIV as in the I only condition, the remaining were based on Becoming a Responsible Teen (BART), including training and practice regarding correct condom use, partner negotiation, refusal of unwanted sexual invitations, and peer information provision. Anger management skills on the basis of the Positive Adolescent Choices Training (PACT) program.►IB + a risk-sensitisation manipulation (IMB)A photograph of each participant was taken at baseline. The image was then electronically transformed to visually depict how the adolescent might appear in end-stage AIDS. Participants discussed how the transformed image might affect their willingness to engage in risky and safer sexual behaviours.	►Health information intervention (I only)Sessions: 12 x 1.5 h over 4 weeks.Total hours: 18A student-centred format with educational games and group discussions.Topics: STI, HIV, birth control, drinking & driving, drug education, peer pressure, smoking & health, gangs & weapons and handling stress.Number of participants Randomised: no infoAssessed: no info	Sexual behaviour, past 3 months:AIDS KnowledgeSocial skills in sexual encountersAttitudes towardcondom Attitudes toward preventionPerceived riskSelf-efficacyFrequency of unprotected intercourseCondom-protected intercourse Number of sex partnersSubstance useAnger management skills	All three conditions increased their scores on the AIDS Knowledge Test. The IB and IMB conditions, as compared with the I only condition, (a) produced more favourable attitudes toward condoms; (b) reduced the frequency of unprotected vaginal sex; and (c) increased behavioural skill performance, frequency of condom-protected sex, percentage of intercourse occasions that were condom protected, and number of adolescents who abstained from sex.IMB was more resistant to decay.3 (group) x 4 (time) repeated measures MANOVA assessed changes in the frequency of adolescents’ sexual practices and indicated significant main effects for group, Wilks’ λ = .87, dfs = 6, 258, p = .05, and time, Wilks’ λ = .89, dfs = 6, 125, p = .05, and for their interaction, Wilks’ λ = .86, dfs = 12, 682, p = .05.Attrition: 3% at the 6-month follow-up and 11% at the 12-month follow-up

Populations

All studies originated from the USA, except one (Goldberg et al., 2009) from Canada. Sample sizes varied between 100 (Kim et al., 2013) and 552 (Freudenberg et al., 2010), median 311. Sample sizes were spread across a range of four studies with n < 200 (Di Clemente et al., 2014; Kerr et al., 2009; Leve et al., 2013; St Lawrence et al., 2002) and two with n > 400 (Bryan et al., 2009; Freudenberg et al., 2010). Genders were mixed in four studies (Bryan et al., 2009; Goldberg et al., 2009; Rotheram-Borus et al., 2003; St Lawrence et al., 2002). Three studies included only males (Freudenberg et al., 2010; Lauby et al.; 2010; St Lawrence, 1999) and five studies only females (Di Clemente et al., 2014; Kerr et al., 2009: Leve et al., 2013; Kim et al., 2013; Robertson et al., 2011). Participant age varied between 11 and 18 years, in most studies (n = 9) with a mean age of 15–16 years. One study targeted 11-year-old girls (Kim et al., 2013) and one young men with an average age of 18 years (Freudenberg et al., 2010).

Settings

The most common setting was a youth detention centre, correctional centre or equivalent (n = 7), i.e. a restricted environment were young people are placed, alleged or convicted of crime, including status offences. Three studies described interventions delivered within the foster care system (Kerr et al., 2009; Leve et al., 2013; Kim et al., 2013), one was delivered at a shelter for run-away youth (Rotheram-Borus et al., 2003) and one at a residential drug treatment facility (St Lawrence et al., 2002).

Study designs

Of the 12 studies, 9 were based on experimental methods, principally RCTs, with behavioural outcomes. Three were quasi-experimental studies based on pre/post designs with matched comparison groups and at least one follow-up (Lauby et al., 2010; Robertson et al., 2011; Rotheram-Borus et al., 2003). The follow-up periods ranged from 3–36 months post intervention, the majority had more than one follow-up and all studies had followed their subjects for 6 months or longer. The attrition rate was relatively high in most studies, ranging between 3% and 50% for each assessment. High attrition was commonly explained by difficulties locating participants after release from detention centre or change of residence. Both compliance and how compliance data are reported varies between studies, while three studies (Robertson et al., 2011; St Lawrence et al., 1999, 2002) reported no compliance data. The lowest rate reported was 64% taking part in at least half of the sessions (Freudenberg et al., 2010), but compliance rates above 90% were found in four studies (Bryan et al., 2009; Di Clemente et al., 2014; Kerr et al., 2009; Leve et al., 2013). Most interventions (n = 9) refer to theoretical bases, including The health belief model and social cognitive theories among others. Three studies (Freudenberg et al., 2010; Kerr et al., 2009; Leve et al., 2013) do not state any theoretical base. All interventions had components of skills training.

Control condition

Nine studies had comparison groups receiving standard care, or a short health information session of 1 h. In the remaining three studies, controls received another intervention: two control groups received an 18-h health education (Robertson et al., 2011; St Lawrence et al., 2002), and one, a 9-h anger management training (St Lawrence et al., 1999).

Intervention types

Three broad intervention types were identified: group-based education, treatment foster care and individual counselling. The most common was group-based educational interventions (n = 9), using a combination of techniques including skills training, role-play, visits to health clinic, interactive computer activities, etc., sometimes accompanied with individual counselling or activities arranged by community-based organisations. The number of sessions in each intervention varied between studies (1–18 sessions, mean 8) as well as the total hours of education delivered (3–30 h, mean 8). All group-based interventions were delivered within 4 weeks.

Two interventions were treatment foster care (Kerr et al., 2009; Leve et al., 2013), including training of foster parents, group-based and individual sessions with the young person, home-based visits and regular family counselling by trained professionals. The duration of these interventions was family-specific but lasted 9–12 months in general. Sexual and reproductive health and rights issues appear to have been a minor part of these interventions.

One intervention (Di Clemente et al., 2014) constituted solely of individual counselling, both in detention and over telephone after release. Various approaches were used during these sessions which amounted to a total of 6 h of counselling.

Outcomes by intervention type and domains

In all, 10 studies reported at least one positive finding that could be attributed to the intervention, but all studies also reported findings of no differences among groups on some outcome (i.e. null findings). None reported harms.

Group-based education (n = 9)

Overall trends for interventions based on group-based education was measuring the domains knowledge (D1), attitudes (D2) and sexual behaviours (D5). Consistent increases were found in knowledge, and less conclusive results for pro-sexual health attitudes and behaviours. All studies (Goldberg et al., 2009; Lauby et al., 2010; Robertson et al., 2011; St Lawrence et al., 1999, 2002) measuring increases in knowledge (D1) found positive effects. Pro-sexual health attitudes (D2) increased in four out of five studies (Goldberg et al., 2009; Lauby et al., 2010; St Lawrence et al., 1999, 2002) measuring this dimension. All nine interventions using group-based education measured at least one sexual behaviour (D5), and six studies (Freudenberg et al., 2010; Goldberg et al., 2009; Kim et al., 2013; Lauby et al., 2010; Rotherham-Borus et al., 2003; St Lawrence et al., 2002) found positive effects. The most common behavioural measures were condom use and number of sexual partners. One study (Kim et al., 2013) report significant intervention effects, but only presents a summary measure called “health-risking sexual behaviour” including several measures, such as touching a boy’s body above/below the waist, sexual intercourse, sex with someone who they just met, and sex under the influence of a substance.

Amongst the three studies with null findings for behaviours (Bryan et al., 2009; Robertson et al., 2011; St Lawrence et al., 1999) were two interventions with active control (Bryan et al., 2009; Robertson et al., 2011), i.e. the control group received an alternate intervention, which might have limited differences between groups. The principal sources of null findings in the group-based education interventions were in the realm of adverse health outcomes (D6). The study (Robertson et al., 2011) measuring STI (confirmed chlamydia or gonorrhoea) or unwanted sex, reported no change.

Treatment foster care (n = 2)

The two treatment foster care publications, based on the same intervention, measured adverse health outcomes (D6). The study (Kerr et al., 2009), measuring pregnancy, found significant intervention effects on the 3-year follow-up, but without stating whether these pregnancies were unintended or planned. At the 7-year follow-up (Leve et al., 2013) the differences between groups were no longer significant.

Individual counselling (n = 1)

The individual counselling intervention (Di Clemente et al., 2014) measured eight different outcomes: two in knowledge (D1), two in pro-sexual health attitudes (D2) three in behaviour (D5) and one in adverse health outcomes (D6). Positive effects were found only in knowledge and attitudes: increased knowledge of HIV/STI prevention and in condom use skills and self-efficacy. No outcome effects were found in behaviour or adverse health outcomes: no increase in actual or consistent condom use, no reduction in number of sex partners or reduction in confirmed chlamydia or gonorrhoea.

Discussion

The aim of this study was to describe evaluated sexual health interventions for young people in state care, and to provide an assessment of the quality of, and evidence for, these interventions. Due to the wide range of interventions, settings and measured outcomes, the overall quality of evidence and specific recommendations cannot be provided. However, without making recommendations, the results suggest that group-based educational interventions in general can improve sexual health in terms of knowledge, attitudes and behaviour, compared with standard care. But, when statistically significant effects were found, effect sizes were small, and several studies showed no effects.

The results show a lack of use of evidence-based sexual health interventions. Only two studies used interventions (Street smart and PALMS), recommended as evidence-based HIV prevention programs in the US, by the Centers for Disease Control and Prevention [17]. This does not automatically improve study quality since it can be argued that modular programs such as these are inadequate in meeting the needs of young people. As Bay-Cheng explains, a “standardised, linear expert-novice model may ease the measurement of a program’s effectiveness in meeting discreet objectives, but it leaves little opportunity for teachers or students to pursue more complex, less quantifiable forms of inquiry and understanding” [18, p. 351]. In addition, HIV prevention programs may have a narrower scope than programs addressing sexual and reproductive health and rights.

It is unexpected that only one study measured outcomes in domain 3 (Communication and negotiation). Communication skills have been found to be vital in connection to sexual health, regarding, for instance, condom use [19]. Furthermore, it is surprising that no study measured outcomes in domain 4 (Healthcare use) as this domain offers measures that are more proximal to the actual health of the youth, and less biased compared with measures of knowledge, attitudes and sexual behaviour. This finding is in accordance with reviews on interventions directed to adult populations [16].

Of the few studies measuring health outcomes in domain 6 (Adverse health outcomes), only one demonstrated results of significantly lower number of pregnancies in the intervention group. Although this is a dimension of value in sexual health interventions, interventions and programs cannot be expected to have direct effects on this level without moving through effects in domain 1–5 (Knowledge, Attitudes, norms, intentions and self-efficacy, Negotiation and communication, Sexual behaviour and Health care use) – areas not explicitly addressed in the intervention. Moreover, it is remarkable, given the vulnerable population in focus of this review, that only one study measured sexual violence outcomes.

Of interest, some interventions also had positive impact on outcomes such as placement disruption, criminal justice involvement, school/work involvement, as well as alcohol and drug use. This suggests that addressing a mixture of sexual health and other health, and social determinants in interventions aimed at young people in state care may be beneficial and is in line with findings both in the review on HIV prevention interventions for adolescents in juvenile justice settings [11], and the review of sexual health interventions for adult populations [16]. Moreover, the link between variables such as stable housing and less risky lifestyles is well documented in the literature [20, 21]. The incorporation of other health determinants, including social health determinants, into sexual health promotion among young people in state care appears vital and needs to be further investigated.

It can be questioned whether the findings are relevant in a Scandinavian context. For instance, outcome variables found in some of the studies, e.g. “touching a boy’s body above/below the waist” or “sexual intercourse” do not come across as health-risking sexual behaviour. This could be connected to the origin of the studies – all but one study had been conducted in the USA. Compared with the US and other Western countries, the Scandinavian countries have a history of acceptance towards adolescent sexuality [22,23]. Importing interventions from the US to a Scandinavian context is therefore not warranted. Another difference between the US and Scandinavia is the organisation of young people in state care, and youth prisons for those under the age of 18. The latter do not exist in Scandinavia. The restricted environments in which the reviewed interventions were conducted are, however, similar to many Scandinavian settings. For instance, in Sweden, young people are forcibly placed, sometimes due to criminality, in secure homes run by the National Board of Institutional Care [24]. Although the search strategy explicitly aimed for Scandinavian studies, none were found. This identifies an important gap: interventions, and especially evaluations of interventions promoting sexual health and acknowledging sexual rights for young people in state care in Scandinavia, are needed. When developing context-specific interventions, we suggest a rights-based, youth-centred perspective, i.e. interventions that have their departing point in the wishes and needs of young people. Development of sex education curricula in cooperation with young people in state care, in institutional settings, is possible and has been made both in the US, and in Sweden [25,26]. Moreover, global policy documents on how to be youth-centred when implementing young people’s sexual rights do exist [27], and should inform both current and future interventions and evaluations.

Study limitations

The study has limitations. Although using a thorough search strategy, we were invariably constrained by search terms and may have overlooked some studies. As the focus was on peer-reviewed outcome or impact evaluations of rigorous design, grey literature was not assessed. The same applies for studies in other languages than English or any of the Scandinavian languages. Moreover, only information that was available in the reviewed publications were assessed. In addition, a more updated search is lacking.

Conclusion

Given the well-known risk for impaired sexual health among young people in state care, the lack of evidence-based interventions that can safeguard and promote sexual and reproductive health and rights in this group is surprising, and worrisome. The result could therefore be of major interest to policy makers, care givers and juvenile justice organisations. The findings suggest that group based educational interventions in general can improve sexual health in terms of knowledge, attitudes and behaviour, compared with standard care. Further research is however needed, taking cultural context into consideration. With a rights perspective, it is paramount to involve young people in state care in future sexual health promotion concerning them.

Footnotes

Declaration of Conflicting Interests

All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Funding

This research was supported by The Public Health Agency of Sweden, Grant Nr. 557/2013 awarded to SH. The funder had no influence on the process or conclusions of the present work. The views expressed are those of the authors and not necessarily those of the founder.

ORCID iDs

Sofia Hammarström

Malin Lindroth

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