April, 2017 - SUPPORT Summary of a systematic review | print this article |

Do out-of-facility HIV and reproductive health services increase the use of these services by youth?

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.

Key messages

  • Few studies that included data comparing out-of-facility services with facility-based services were conducted in low- and middle-income countries
  • Improved access to self-test kits probably leads to more youth being screened for chlamydia, compared to clinic-based testing.
  • Access to emergency contraception through pharmacies without a doctor’s prescription (‘over the counter’ access) 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.
  • The distribution of condoms and health education messages by street outreach workers may increase condom use.
  • It is uncertain whether street and youth centre-based outreach improves follow through on HIV referral for homeless or street-based youth.
  • It is uncertain whether the use of community youth programme promoters and integrated youth centres increase the use of contraceptives.
  • It is uncertain whether members of the poorest households are more likely to use home-based counselling and testing for HIV, compared to those living in wealthier households.

 

Background

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).

 



About the systematic review underlying this summary

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.

Summary of findings

Twenty studies were included in the review. The findings of the 10 studies that included comparative data are summarised in the table below.

 

  • Improved access to self-test kits probably leads to more youth being screened for chlamydia, compared to clinic-based testing. The certainty of this evidence is moderate.
  • Access to emergency contraception 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. The certainty of this evidence is low.
  • The distribution of condoms and health education messages by street outreach workers may increase condom use. The certainty of this evidence is low.
  • It is uncertain whether street and youth centre-based outreach improves follow through on HIV referral for homeless or street-based youth as the certainty of this evidence is very low.
  • It is uncertain whether the use of community youth programme promoters and integrated youth centres increase the use of contraceptives as the certainty of this evidence is very low.
  • It is uncertain whether 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 this evidence is very low.

 

Out-of-facility vs facility-based health services to increase the use of health services by youth*

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

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

* 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

Relevance of the review for low-income countries

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:
www.supportsummaries.org/methods



 

Additional information

Related literature

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.

 

This summary was prepared by

Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Anna Brittain and Airton T Stein. We did not receive

any comments from the review authors.

 

This review should be cited as

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.

 

The summary should be cited as

Ciapponi A, Do out-of-facility HIV and reproductive health services increase the use of these services by youth? A SUPPORT Summary of a systematic review. April 2017. www.supportsummaries.org

 

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.



Comments