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Causal effects of education on sexual and reproductive health in low and middle-income countries: A systematic review and meta-analysis.

ABSTRACT: Background:Despite strong theoretical grounding, important gaps in knowledge remain regarding the degree to which there is a causal relationship between education and sexual and reproductive health, as many claims have been made based on associations alone. Understanding the extent to which these relationships are causal is important both to inform investments in education and health, as well as to understand the mechanisms underlying these relationships. Methods:We conducted a systematic review of the evidence for a causal link between education and sexual and reproductive health (SRH) in low and middle-income countries. Education indicators included exposure to formal schooling and learning. SRH outcomes included: age at first sex, age at first marriage, age at first pregnancy/birth, contraceptive use, fertility, and HIV status and other sexually transmitted infections. When possible, we also conducted meta-analyses to estimate mean effects by outcome, and to understand sources of variation between studies. Results:We identified 35 papers that met our inclusion criteria. Although many of the studies report evidence of a causal relationship between education and one or more SRH outcomes, estimated effects are often small in magnitude. Our meta-analyses reveal mostly null mean effects, with the exception of small effects of increased grade attainment on lower fertility and HIV positive status. We also found inconsistent evidence supporting mechanisms linking education and SRH. Conclusions:This review demonstrates that, although investments in schooling may have positive ripple effects for sexual and reproductive health in some circumstances, those effects may not be as large or consistent as expected. Further, our understanding of the circumstances in which schooling is most likely to improve SRH remains somewhat limited. An accurate picture of whether and when improvements in education lead to better health outcomes is essential for the achievement of global development goals.

SUBMITTER: Psaki SR

PROVIDER: S-EPMC6582211 | biostudies-literature | 2019 Aug

REPOSITORIES: biostudies-literature

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Causal effects of education on sexual and reproductive health in low and middle-income countries: A systematic review and meta-analysis.

Psaki Stephanie R SR Chuang Erica K EK Melnikas Andrea J AJ Wilson David B DB Mensch Barbara S BS

SSM - population health 20190520

<h4>Background</h4>Despite strong theoretical grounding, important gaps in knowledge remain regarding the degree to which there is a causal relationship between education and sexual and reproductive health, as many claims have been made based on associations alone. Understanding the extent to which these relationships are causal is important both to inform investments in education and health, as well as to understand the mechanisms underlying these relationships.<h4>Methods</h4>We conducted a sy ...[more]

PMID: 31245525

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Project description:INTRODUCTION:Health education programmes (HEPs) have been associated with a number of benefits. These include providing individuals with information on matters related to their mental, social, physical as well as emotional health. HEPs also play a major role in preventing diseases and reducing the level of engagement of individuals in risky behaviours. While this is the case, there are barriers to the effective implementation of HEPs, especially in low-income and middle-income countries (LMICs) where resources are scarce. Available evidence has revealed socioeconomic challenges ranging from literacy issues, discomfort about issues of sexuality, and cultural barriers to financial constraints as key barriers to the implementation of sexual and reproductive health HEPs in LMICs. We will focus on HEPs related to sexual and reproductive health; all age groups will be considered with no restrictions on geographical setting nor model of HEP delivery. This review will map literature on the barriers to the effective implementation of HEPs in LMICs to guide future implementation research. METHODS:Arksey and O'Malley's 2005 scoping methodological framework will act as the guide for this review. We will search the following electronic databases: EBSCOhost (Academic search complete, PsycINFO, Health Sources, CINAHL and MEDLINE with full text), Google Scholar, PubMed, SCOPUS, Science Direct and Web of Science. Grey literature from Mount Kenya University theses and dissertations, governments' as well as international organisations' reports, such as WHO, and reference lists of included studies will be searched for eligible studies. We will limit our search to publications from 1 January 2000 to 30 September 2019. Using thematic content analysis, we will employ NVivo V.12 to extract the relevant outcomes from the included articles. We will conduct a quality appraisal of the included articles using the mixed methods appraisal tool (MMAT) version 2018. ETHICS AND DISSEMINATION:No ethical approval is needed for the study as it will not include animal nor human participants. The results of the proposed scoping review will be disseminated electronically, in print and through conference presentation as well as at key stakeholder meetings.

Project description:IntroductionThe Sustainable Development Goals, which are grounded in human rights, involve empowering women and girls and ensuring that everyone can access sexual and reproductive health and rights (Goal 5). This is the first systematic review reporting interventions involving rights-based approaches for sexual and reproductive health issues including gender-based violence, maternity, HIV and sexually transmitted infections in low and middle-income countries.AimsTo describe the evidence on rights-based approaches to sexual and reproductive health in low and middle-income countries.MethodsEMBASE, MEDLINE and Web of Science were searched until 9/1/2020. Inclusion criteria were: Study design: any interventional study.Population: females aged over 15 living in low and middle-income countries.Intervention: a "rights-based approach" (defined by the author) and/or interventions that the author explicitly stated related to "rights".Comparator: clusters in which no intervention or fewer components of an intervention were in place, or individuals not exposed to interventions, or exposed to fewer intervention components.Outcome: Sexual and reproductive health related outcomes. A narrative synthesis of included studies was undertaken, and outcomes mapped to identify evidence gaps. The systematic review protocol was registered on PROSPERO (CRD42019158950).ResultsDatabase searching identified 17,212 records, and 13,404 studies remained after de-duplication. Twenty-four studies were included after title and abstract, full-text and reference-list screening by two authors independently. Rights-based interventions were effective for some included outcomes, but evidence was of poor quality. Testing uptake for HIV and/or other sexually transmitted infections, condom use, and awareness of rights improved with intervention, but all relevant studies were at high, critical or serious risk of bias. No study included gender-based violence outcomes.ConclusionConsiderable risk of bias in all studies means results must be interpreted with caution. High-quality controlled studies are needed urgently in this area.

Project description:BackgroundAdolescent girls aged 15-19 bear a disproportionate burden of negative sexual and reproductive health outcomes in low- and middle-income countries. Research from several high-income countries suggests that early age at menarche is an important determinant of sexual and reproductive health. We conducted this systematic review to better understand whether and how early menarche is associated with various negative sexual and reproductive health outcomes in low- and middle-income countries and the implications of such associations.MethodsWe systematically searched eight health and social sciences databases for peer-reviewed literature on menarche and sexual and reproductive health in low- and middle-income countries. Two reviewers independently assessed all studies for inclusion, overall quality and risk of bias, and performed data extraction on all included studies.ResultsTwenty-four articles met all inclusion criteria-nine of moderate quality and fifteen with several methodological weaknesses. Our review of the minimal existing literature showed that early menarche is associated with early sexual initiation, early pregnancy and some sexually transmitted infections in low- and middle-income countries, similar to what has been observed in high-income countries. Early menarche is also associated with early marriage-an association that may have particularly important implications for countries with high child marriage rates.ConclusionsEarly age at menarche may be an important factor affecting the sexual and reproductive health of adolescent girls and young women in low- and middle-income countries. More research is needed to confirm the existence of the identified associations across different settings and to better understand the process through which early menarche and other markers of early pubertal development may contribute to the increased vulnerability of girls to negative sexual and reproductive health outcomes in low- and middle-income countries. Given the association of early menarche with early marriage, ongoing efforts to reduce child marriage may benefit from targeting efforts to early maturing girls.

Project description:ObjectivesTo synthesise evidence on the effectiveness, cost-effectiveness and barriers to responding to violence against women (VAW) in sexual and reproductive health (SRH) services in low/middle-income countries (LMICs).DesignMixed-methods systematic review.Data sourcesMedline, Embase, Psycinfo, Cochrane, Cinahl, IMEMR, Web of Science, Popline, Lilacs, WHO RHL, ClinicalTrials.gov, Google, Google Scholar, websites of key organisations through December 2019.Eligibility criteriaStudies of any design that evaluated VAW interventions in SRH services in LMICs.Data extraction and synthesisConcurrent narrative quantitative and thematic qualitative syntheses, integration through line of argument and mapping onto a logic model. Two reviewers extracted data and appraised quality.Results26 studies of varied interventions using heterogeneous outcomes. Of ten interventions that strengthened health systems capacity to respond to VAW during routine SRH consultation, three reported no harm and reduction in some types of violence. Of nine interventions that strengthened health systems and communities' capacity to respond to VAW, three reported conflicting effects on re-exposure to some types of VAW and mixed effect on SRH. The interventions increased identification of VAW but had no effect on the provision (75%-100%) and uptake (0.6%-53%) of referrals to VAW services. Of seven psychosocial interventions in addition to SRH consultation that strengthened women's readiness to address VAW, four reduced re-exposure to some types of VAW and improved health. Factors that disrupted the pathway to better outcomes included accepting attitudes towards VAW, fear of consequences and limited readiness of the society, health systems and individuals. No study evaluated cost-effectiveness.ConclusionsSome VAW interventions in SRH services reduced re-exposure to some types of VAW and improved some health outcomes in single studies. Future interventions should strengthen capacity to address VAW across health systems, communities and individual women. First-line support should be better tailored to women's needs and expectations.Prospero registration numberCRD42019137167.

Project description:ObjectivesWe synthesise evidence on sexual harassment from studies in low-income and middle-income countries (LMICs) to estimate its prevalence and conduct a meta-analysis of the association between sexual harassment and depressive symptoms.MethodsWe searched eight databases. We included peer-reviewed studies published in English from 1990 until April 2020 if they measured sexual harassment prevalence in LMICs, included female or male participants aged 14 and over and conceptualised sexual harassment as an independent or dependant variable. We appraised the quality of evidence, used a narrative syntheses approach to synthesise data and conducted a random effects meta-analysis.ResultsFrom 49 included studies, 38 focused on workplaces and educational institutions and 11 on public places. Many studies used an unclear definition of sexual harassment and did not deploy a validated measurement tool. Studies either used a direct question or a series of behavioural questions to elicit information on acts considered offensive or defined as sexual harassment. Prevalence was higher in educational institutions than in workplaces although there was high heterogeneity in prevalence estimates across studies with no international comparability. This posed a challenge for calculating an overall estimate or measuring a range. Our meta-analysis showed some evidence of an association between sexual harassment and depressive symptoms (OR: 1.75; 95% CI: 1.11 to 2.76; p=0.016) although there were only three studies with a high risk of bias.ConclusionTo our knowledge, this is the first systematic review to assess measurement approaches and estimate the prevalence of sexual harassment across settings in LMICs. We also contribute a pooled estimate of the association between sexual harassment and depressive symptoms in LMICs. There is limited definitional clarity, and rigorously designed prevalence studies that use validated measures for sexual harassment in LMICs. Improved measurement will enable us to obtain more accurate prevalence estimates across different settings to design effective interventions and policies.

Project description:ObjectivesSchool-based sex education is a cornerstone of HIV prevention for adolescents who continue to bear a disproportionally high HIV burden globally. We systematically reviewed and meta-analyzed the existing evidence for school-based sex education interventions in low- and middle-income countries to determine the efficacy of these interventions in changing HIV-related knowledge and risk behaviors.MethodsWe searched five electronic databases, PubMed, Embase, PsycInfo, CINAHL, and Sociological Abstracts, for eligible articles. We also conducted hand-searching of key journals and secondary reference searching of included articles to identify potential studies. Intervention effects were synthesized through random effects meta-analysis for five outcomes: HIV knowledge, self-efficacy, sexual debut, condom use, and number of sexual partners.ResultsOf 6191 unique citations initially identified, 64 studies in 63 articles were included in the review. Nine interventions either focused exclusively on abstinence (abstinence-only) or emphasized abstinence (abstinence-plus), whereas the remaining 55 interventions provided comprehensive sex education. Thirty-three studies were able to be meta-analyzed across five HIV-related outcomes. Results from meta-analysis demonstrate that school-based sex education is an effective strategy for reducing HIV-related risk. Students who received school-based sex education interventions had significantly greater HIV knowledge (Hedges g?=?0.63, 95% Confidence Interval (CI): 0.49-0.78, p<0.001), self-efficacy related to refusing sex or condom use (Hedges g?=?0.25, 95% CI: 0.14-0.36, p<0.001), condom use (OR?=?1.34, 95% CI: 1.18-1.52, p<0.001), fewer sexual partners (OR?=?0.75, 95% CI:0.67-0.84, p<0.001) and less initiation of first sex during follow-up (OR?=?0.66, 95% CI: 0.54-0.83, p<0.001).ConclusionsThe paucity of abstinence-only or abstinence-plus interventions identified during the review made comparisons between the predominant comprehensive and less common abstinence-focused programs difficult. Comprehensive school-based sex education interventions adapted from effective programs and those involving a range of school-based and community-based components had the largest impact on changing HIV-related behaviors.

Project description:In low- and middle-income countries (LMICs), e-learning for medical education may alleviate the burden of severe health worker shortages and deliver affordable access to high quality medical education. However, diverse challenges in infrastructure and adoption are encountered when implementing e-learning within medical education in particular. Understanding what constitutes successful e-learning is an important first step for determining its effectiveness. The objective of this study was to systematically review e-learning interventions for medical education in LMICs, focusing on their evaluation and assessment methods. Nine databases were searched for publications from January 2007 to June 2017. We included 52 studies with a total of 12,294 participants. Most e-learning interventions were pilot studies (73%), which mainly employed summative assessments of study participants (83%) and evaluated the e-learning intervention with questionnaires (45%). Study designs, evaluation and assessment methods showed considerable variation, as did the study quality, evaluation periods, outcome and effectiveness measures. Included studies mainly utilized subjective measures and custom-built evaluation frameworks, which resulted in both low comparability and poor validity. The majority of studies self-concluded that they had had an effective e-learning intervention, thus indicating potential benefits of e-learning for LMICs. However, MERSQI and NOS ratings revealed the low quality of the studies' evidence for comparability, evaluation instrument validity, study outcomes and participant blinding. Many e-learning interventions were small-scale and conducted as short-termed pilots. More rigorous evaluation methods for e-learning implementations in LMICs are needed to understand the strengths and shortcomings of e-learning for medical education in low-resource contexts. Valid and reliable evaluations are the foundation to guide and improve e-learning interventions, increase their sustainability, alleviate shortages in health care workers and improve the quality of medical care in LMICs.

Dataset Information

Causal effects of education on sexual and reproductive health in low and middle-income countries: A systematic review and meta-analysis.

Publications

Causal effects of education on sexual and reproductive health in low and middle-income countries: A systematic review and meta-analysis.

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