SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
April, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
Many young people, particularly those who are at risk for HIV and reproductive health-related problems, do not seek traditional facility-based health services. Out-of-facility services for this group are therefore being implemented in many different settings. Such services aim to reach young people where they are, for example in schools, workplaces, youth centres and on the street.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Risk-taking behaviours such as unprotected sex and injection drug use can have important impacts on youth health. Health services and health education could prevent unnecessary morbidity and mortality related to pregnancies, especially unintended pregnancies, and sexually transmitted infections (STIs), including HIV. However, many young people do not utilise traditional facility-based health services. Out-of-facility interventions may be important ways to reach youth. These interventions include promoting HIV or reproductive health services (including STI, HIV, or pregnancy testing) and making commodities available (including condoms, contraceptives, or emergency contraception; clean needles and syringes or exchanges).
| Review objectives: To estimate the effectiveness of out-of-facility HIV and reproductive health services in increasing HIV and reproductive health service use by youth. | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials, non-randomised trials, controlled observational studies, interrupted time series and studies examining the percentage of a target population reached with outreach-based services. | Twenty studies met the inclusion criteria, including 10 containing comparative data (1 randomised trial, 2 non-randomised trials, 2 interrupted time series studies, 2 controlled and 1 uncontrolled before-after studies and 2 cross sectional studies). Five of the twenty studies investigated the delivery of emergency contraception through community-based pharmacies. Other interventions were community youth program promoters, integrated youth centres, mail-based interventions or distributing commodities. Many studies included some health education component. |
| Participants | Adolescents and/or young adults. |
Most patients were between 10 and 24 years old. |
| Settings | Out-of-health facility locations, including pharmacies, detention centers, on the street, in parks, and in community centers. School-based outreach was excluded from the review |
USA (8), UK (3), The Netherlands (3), Canada (1), Denmark (1), France (1), Malawi (1), Mexico (1), Zambia (1) |
| Outcomes |
Use of HIV or reproductive health services or receipt/use of related commodities |
Proportion screened for chlamydia (4 studies); proportion following through on HIV-related referral (1); counselling and testing (1); emergency contraception use (5); number of contraceptive users over time (1); condom use at last sexual encounter (1). |
| Date of most recent search: March 2010 | ||
| Limitations: This is a well-conducted systematic review with only minor limitations. | ||
Denno DM, Chandra-Mouli V, Osman M. Reaching youth with out-of-facility HIV and reproductive health services: a systematic review. The Journal of adolescent health: official publication of the Society for Adolescent Medicine. 2012;51(2):106-21.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
Twenty studies were included in the review. The findings of the 10 studies that included comparative data are summarised in the table below.
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Out-of-facility vs facility-based health services to increase the use of health services by youth* |
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People Adolescents and/or young adults (10 – 24 years) Settings Outside of health facilities, including in pharmacies, in jails and detention centres, on the street or in community centres Intervention Out-of-facility HIV and reproductive health services, including policies promoting or mandating HIV or reproductive health services or commodities, or programmes or projects providing these services Comparison Traditional facility-based health services, or usual mode of access to care |
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|
Outcomes |
Impact |
Number of studies |
Certainty of the evidence (GRADE) |
|
|
Screened for chlamydia |
Mailed test kits probably lead to more youth being screened for chlamydia, compared to clinic-based testing (RR females = 4.1 (95% CI: 3.8 to 4.4); RR males = 19.1 (95% CI: 16.0 to 22.8)) Mailed cards that could be returned to request a test kit probably lead to more youth being screened for chlamydia, compared to clinic-based testing (RR females = 3.5 (95% CI: 3.2 to 3.8); RR males = 11.8 (95% CI: 9.8 to 14.2)) |
1 |
Moderate |
|
|
Follow through on HIV-related referrals |
It is uncertain whether street and youth centre-based outreach improve follow through on HIV referral for homeless or street-based youth as the certainty of the evidence is very low |
1 |
Very low |
|
|
Emergency contraception use |
Policies that allow emergency contraception access through pharmacies without a doctor’s prescription may increase non-prescription emergency contraception use, but may have mixed effects on overall use of emergency contraception with increases in some settings but not others |
5 |
Low |
|
|
Number of contraceptive users |
It is uncertain whether the use of community youth programme promoters and integrated youth centres increase the use of contraceptives as the certainty of the evidence is very low |
1 |
Very low |
|
|
Condom use at last sexual encounter |
The distribution of condoms and health education messages by street outreach workers may increase condom use at the last sexual encounter (OR 1.4, 95% CI 1.2 to 1.6) |
1 |
Low |
|
|
Home-based counselling and testing for HIV |
It is uncertain if members of the poorest households are more likely to use home-based counselling and testing for HIV, compared to those living in wealthier households, as the certainty of the evidence is very low |
1 |
Very low |
|
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* Based on the findings of the 10 studies from the review that included comparative data CI: Confidence interval GRADE: GRADE Working Group grades of evidence (see above and last page) OR: Odds Ratio RR: Relative Risk |
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| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| Only 3 out of 20 studies included in the systematic review were conducted in low-income countries. In addition, one study was conducted in a middle-income country |
Although a minority of studies were conducted in low-income countries, the outreach-based programmes primarily aimed to reach marginalized youth from low-income settings. The findings may therefore be applicable to marginalised groups in other settings When assessing the applicability of these findings to low-income countries, resource availability, the acceptability and feasibility of the interventions, and cost should be considered Some out-of-facility HIV and reproductive health services may require changes to national policies, for example to allow emergency contraception to be bought at pharmacies without a prescription from a doctor |
| EQUITY | |
| There was no information in the included studies regarding the differential effects of the interventions on resource-disadvantaged populations |
The resources needed to implement out-of-facility HIV and reproductive health services may be less available in poorer settings Out-of-facility interventions may increase inequities if they are not made available to, or adapted to, disadvantaged populations and settings |
| ECONOMIC CONSIDERATIONS | |
| The systematic review did not address economic considerations |
Scaling up many of the interventions will require significant resources, including human resources and changes to supply chains Implementation, including in low-income countries, should therefore be accompanied by economic evaluation |
| MONITORING & EVALUATION | |
| Most of the evidence on the effectiveness of out-of-facility strategies to increase access to HIV and reproductive health services for youth is of low or very low certainty |
More rigorous studies are required to determine the effects and the cost-effectiveness of these strategies, particularly in disadvantaged populations in low-income countries Implementation at scale of out-of-facility HIV and reproductive health services for youth should be accompanied by monitoring and evaluation |
|
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgments were made see: |
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Brickley DB, Almers L, Kennedy CE, Spaulding AB, Mirjahangir J, Kennedy GE, et al. Sexual and reproductive health services for people living with HIV: a systematic review. AIDS care. 2011;23(3):303-14.
Howe EC, Buck DS, Withers J. Delivering health care on the streets: Challenges and opportunities for quality management. Qual Manag Health Care 2009;18:239-46.
Jones K, Eathington P, Baldwin K, Sipsma H. The impact of health education transmitted via social media or text messaging on adolescent and young adult risky sexual behavior: a systematic review of the literature. Sexually Transmitted Diseases. 2014;41(7):413-9.
Kesterton AJ, Cabral de Mello M. Generating demand and community support for sexual and reproductive health services for young people: A review of the literature and programmes. Geneva, Switzerland: WHO, 2009.
Shah NM, Brieger WR, Peters DH. Can interventions improve health services from informal private providers in low and middle-income countries? A comprehensive review of the literature. Health Policy Plan 2011;33:275-87.
Zuurmond MA, Geary RS, Ross DA. The effectiveness of youth centers in increasing use of sexual and reproductive health services: a systematic review. Studies in family planning. 2012;43(4):239-54.
Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Anna Brittain and Airton T Stein. We did not receive
any comments from the review authors.
Denno DM, Chandra-Mouli V, Osman M. Reaching youth with out-of-facility HIV and reproductive health services: a systematic review. The Journal of adolescent health: official publication of the Society for Adolescent Medicine. 2012;51(2):106-21.
Keywords
evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care.
Health services; Outreach; Out-of-facility health service delivery; Community-based delivery; HIV and reproductive health services; Sexually transmitted infections; Marginalized youth; Homeless youth.
