Shepherd and colleagues endeavored to assess the effectiveness and cost-effectiveness of schools-based skills-building behavioral interventions to encourage young people to adopt and maintain safer sexual behavior and to prevent them from acquiring sexually transmitted infections (STIs). Electronic bibliographic databases (e.g. MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, CINAHL, PsycINFO, CCRCT, NHS EED and DARE) were searched for the period 1985 to March 2008. Bibliographies of systematic reviews and related papers were screened and experts contacted to identify additional published and unpublished references. A systematic review of effectiveness and economic evaluation of cost-effectiveness was carried out. A descriptive map of studies that met inclusion criteria was produced, and keywords were developed and systematically applied to these studies to identify a policy-relevant subset of studies for the systematic review. Outcome data for variables including sexual behavior were extracted. An economic model was developed to compare the costs and consequences of the behavioral interventions. A Bernoulli statistical model was constructed to describe the probability of STI infection. There were few significant differences between the interventions and comparators in terms of changes in sexual behavior outcomes, although there were some significant differences for knowledge and some measures of self-efficacy. The studies included in this review conducted relatively short follow-up assessments at a time when many young people were becoming sexually active. It is therefore possible that favorable behavior change may have occurred, and become more cost-effective, with time, as sexual activity becomes more routine in young people's lives. The quality of the intervention provider influenced whether or not young people found the interventions to be acceptable and engaging; enthusiasm and considerable expertise were important for effective class management and delivery of skills-building activities, and a supportive school culture was also helpful. Recognition of young people's individual needs in relation to sexual health was another important factor. No conclusions could be drawn on the impact of the interventions on sexual health inequalities due to a lack of relevant data on socioeconomic status, gender, and ethnicity. The results of the economic evaluation were considered to be illustrative, mainly due to the uncertainty of the effect of intervention on behavioral outcomes. The results were most sensitive to changes in parameter values for the intervention effect, the transmission probability of STIs and the number of sexual partners. The costs of teacher-led and peer-led behavioral interventions, based on the resources estimated from the relevant randomized controlled trials in our systematic review, were 4 pounds 30 pence and 15 pounds per pupil, respectively. Teacher-led interventions were more cost-effective than peer-led interventions due to the less frequent need for training. The incremental cost-effectiveness of the teacher-led and peer-led interventions was 20,223 pounds and 80,782 pounds per quality-adjusted life-year gained, respectively. An analysis of individual parameters revealed that future research funding should focus on assessing the intervention effect for condom use from a school-based intervention.

WHAT THE STUDY MAY MEAN TO YOU AS A HEALTH CARE PROVIDER: School-based behavioral interventions for the prevention of STIs in young people can bring about improvements in knowledge and increased self-efficacy, but the interventions did not significantly influence sexual risk-taking behavior or infection rates. Future investigation should include long-term follow-up to assess the extent to which safer sexual behavior is adopted and maintained into adulthood, and prospective cohort studies are needed to look at the parameters that describe the transmission of STIs between partners. Funding should focus on the effectiveness of the interventions on influencing behavior.

WHAT THE STUDY MAY MEAN TO YOU AS AN ADOLESCENT OR PARENT: This is a very comprehensive review of school-based behavioral interventions for the prevention of sexually transmitted diseases in adolescents. The authors should be applauded for their efforts. At the same time, there is the need both to collect long-term follow-up data and to isolate what materials are particularly useful in teaching adolescents about sex. The fact that self-efficacy was important is a factor to also integrate in future studies of the self-management of sexual behavior.

J Shepherd et al. The effectiveness and cost-effectiveness of behavioral interventions for the prevention of sexually transmitted infections in young people aged 13-19: a systematic review and economic evaluation. Health Technology Assessment, 2010;14:1-230.