OBJECTIVE

Middle childhood is a critical period for physical, social, behavioral, and cognitive changes. A positive and healthy sexual and reproductive health and rights (SRHR) foundation can minimize SRHR risks, leading to better outcomes. Our objective is to identify effective educational interventions promoting or supporting the SRHR of school-age children in low and middle-income countries.

DATA SOURCES

Medline, Embase, CINAHL, APA PsycInfo, ERIC, Cochrane Central Register of Controlled Trials, Education Source, Web of Science, SciELO Citation Index, Global Health, and Sociological Abstract were searched from 2000 to December 2020.

STUDY SELECTION

Eligible articles had a sample mean age between 5 and 10 years, quantitatively tested the effects of educational interventions against a comparison group, and measured SRHR related outcomes.

DATA EXTRACTION

Data extracted from the 11 eligible articles were study methods, participant characteristics, interventions and comparisons, outcome measures, and results.

RESULTS

The review found evidence of significant intervention effects on protective knowledge, attitudes, behaviors, and skills for preventing sexual violence and HIV infection. The strongest evidence was for significant improvements in children’s knowledge of child sexual abuse prevention concepts and strategies.

LIMITATIONS

A meta-analysis could not be performed because most studies lacked randomization, included no information on the magnitude of effects, and had inadequate follow-up evaluations to truly assess retention. Only a few studies contributed to findings on protective attitudes, behaviors, and skills against child sexual abuse, gender-based violence, and human immunodeficiency virus infection, as well as physiologic outcome.

CONCLUSIONS

The educational interventions demonstrated significant improvements in primary school children’s protective capacities, especially in their protective knowledge against sexual abuse.

Middle childhood is a critical developmental period of vast physical, social, behavioral, and cognitive changes that can have a significant influence on one’s health status later in the life course.1  It is also a period when children develop curiosity about reproduction and anatomy, experience initial physical changes (puberty) related to sexual and reproductive development, develop foundational capacities to build social relationships with peers, and experience their first sexual and romantic attractions.2,3 

Middle-aged children learn about sexuality and reproduction and form perceptions, attitudes, and behaviors related to what they have absorbed.4  Their resulting perceptions, attitudes, and behaviors may contribute to healthy or unhealthy sexual and reproductive values, preferences, and decisions in subsequent life stages. Given that these decisions influence outcomes, including morbidity and poor quality of life, or death, in adolescence and adulthood, it is crucial to build a foundation for healthy and positive sexual and reproductive health outcomes in middle-aged children before they enter full sexual and reproductive maturity and activity.2 

In low and middle-income countries (LMICs), middle childhood aligns with school-age children, which generally range from 5 to 12 years.1,5,6  Although middle childhood is a critical period for the developmental changes and reproductive maturation of school-aged children, it is also a period in which children become increasingly vulnerable to sexual and reproductive health and rights (SRHR) violations and risks.1,7  SRHR risks are predictors of poor SRHR outcomes, such as gender-based violence and sexually transmitted infections.1,7,8  Gender-based violence targeting children is a rampant issue in LMICs.9  Victims of child sexual assault tend to be school-age children between the ages of 7 and 12 years. Given their incomplete cognitive, moral, and social development, school-age children do not have the foundational capacity to comprehend whether they are being sexually assaulted, nor can they provide informed consent.9 

Despite increasing global commitments and efforts to improve the SRHR of school-age children, there are still countless unmet SRHR challenges and needs for this population. Poor education and the corresponding lack of knowledge and awareness are 1 of the major unmet SRHR challenges and needs today.7,10,11  Many school-age children in LMICs start sexual activity and reproductive maturity with only limited access to timely and adequate SRHR education and information.7,10  A lack of education can create barriers to accessing and making informed decisions pertaining to SRHR, thereby increasing the likelihood of poor SRHR outcomes. Vast research evidence suggests that early educational attainment related to SRHR needs is a strong predictor of positive SRHR outcomes, including delays in sexual initiation, marriage, and pregnancy.3,12,13 

Developmental changes in the brain and behaviors of school-aged children, before their sexual initiation and reproductive maturation, present clear opportunities to introduce educational interventions that promote positive SRHR outcomes. There is existing systematic evidence on the effectiveness of SRHR interventions, including educational programs targeting adolescents and young adults between ages 10 and 25 in LMICs.11,1427  One paper has reviewed the evidence on the effectiveness of sexual abuse prevention programs for school-age children in developing countries.28  However, it did not adhere to a specific, structured method of synthesis. Therefore, there was a need for a comprehensive synthesis of the evidence on the effectiveness of existing educational interventions targeting positive SRHR outcomes among school-age children in LMICs. This systematic review aimed to identify educational interventions that have proven to be effective in promoting or supporting the SRHR of school-age children in LMICs. Identifying evidence-based, developmentally appropriate, and proven educational interventions on SRHR outcomes will help to address the neglected and unmet educational needs of school-age children in LMICs. While these children transition through the subsequent developmental stages, having the information and knowledge needed to make informed sexual and reproductive decisions will increase their likelihood of positive SRHR outcomes in adolescence and adulthood. Ultimately, the review findings will inform global efforts aiming to ensure access to effective SRHR information and services and aiming to reduce future risks of morbidity and mortality of school-age children.

This systematic review was reported in accordance with the reporting guidance provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.29  The review protocol has been registered within the International Prospective Register of Systematic Reviews (#CRD42020173158) and published in BMC Systematic Reviews.30 

The eligibility criteria were reported using the population, intervention, comparison, outcomes and study (PICOS) design framework (Table 1).30 

TABLE 1

Eligibility Criteria

CategoryEligibility Criteria
Population The review included studies that assessed educational interventions on school-age children in LMICs. Given the evidence gap, the focus of this review was on the 5 to 10 y age range. In accordance, studies that solely focused on early adolescents and older (≥11 y) and have not included children ≤10 y were ineligible. The eligible studies must have had a disaggregated age range for 5 to 10 y olds or a mean age of participants that falls between 5 and 10 y. 
Intervention Any educational intervention aiming to improve knowledge, awareness, attitudes, sexual behaviors, or reproductive behaviors that are relevant to the review objectives were eligible. The review considered studies that quantitatively evaluated the effects of educational interventions aiming to promote or support the SRHR of school-aged children in LMICs. Studies with comprehensive, composite interventions that aggregate educational interventions and noneducational interventions were ineligible if the educational intervention and its effects on an SRHR outcome were not clearly disaggregated. 
Comparison The review included studies that compared the target educational intervention group(s) to no intervention groups, other intervention groups, or pre and post intervention of the same group. 
Outcomes Eligible primary outcomes included knowledge, awareness, and attitudes about SRHR topics regarding HIV infection and gender-based violence (female genital cutting, rape, assault). Eligible secondary outcomes included, but were not limited to, sexual initiation, number of sexual partners, prevalence or timing of adolescent pregnancy, unintended or unplanned pregnancies, child marriages, contraceptive use or safe-sex practices, gender-based violence, and sexually-transmitted infections.a The rationale for including knowledge, attitudes, and behaviors as the primary outcomes was based on the desired age range of the cohort (5–10 y old) for whom the primary goal of an intervention is to educate and promote positive SRHR attitudes and decisions in subsequent years when sexual and reproductive maturation amplifies.b 
Study Design Experimental and quasi-experimental studies that evaluated the effects of educational programs designed to promote or support the SRHR of school-aged children were eligible. This included randomized control trials, nonrandomized controlled trials, quasi-randomized controlled trials, pre and post studies, and interrupted time-series trials. Studies without a comparison group were ineligible, unless they were observational studies. Observational studies (crosssectional and cohort) that examined the effectiveness of educational interventions targeting improvements in knowledge, awareness, or attitudes related to an SRHR outcome were eligible. Articles that merely indicated the prevalence of an SRHR outcome or investigated factors that influenced an SRHR outcome, without implementing and testing intervention effect, were ineligible. Only studies conducted in LMICs and published in peer-reviewed journals were eligible for inclusion. In terms of language, only studies conducted in English and French were eligible for inclusion. 
CategoryEligibility Criteria
Population The review included studies that assessed educational interventions on school-age children in LMICs. Given the evidence gap, the focus of this review was on the 5 to 10 y age range. In accordance, studies that solely focused on early adolescents and older (≥11 y) and have not included children ≤10 y were ineligible. The eligible studies must have had a disaggregated age range for 5 to 10 y olds or a mean age of participants that falls between 5 and 10 y. 
Intervention Any educational intervention aiming to improve knowledge, awareness, attitudes, sexual behaviors, or reproductive behaviors that are relevant to the review objectives were eligible. The review considered studies that quantitatively evaluated the effects of educational interventions aiming to promote or support the SRHR of school-aged children in LMICs. Studies with comprehensive, composite interventions that aggregate educational interventions and noneducational interventions were ineligible if the educational intervention and its effects on an SRHR outcome were not clearly disaggregated. 
Comparison The review included studies that compared the target educational intervention group(s) to no intervention groups, other intervention groups, or pre and post intervention of the same group. 
Outcomes Eligible primary outcomes included knowledge, awareness, and attitudes about SRHR topics regarding HIV infection and gender-based violence (female genital cutting, rape, assault). Eligible secondary outcomes included, but were not limited to, sexual initiation, number of sexual partners, prevalence or timing of adolescent pregnancy, unintended or unplanned pregnancies, child marriages, contraceptive use or safe-sex practices, gender-based violence, and sexually-transmitted infections.a The rationale for including knowledge, attitudes, and behaviors as the primary outcomes was based on the desired age range of the cohort (5–10 y old) for whom the primary goal of an intervention is to educate and promote positive SRHR attitudes and decisions in subsequent years when sexual and reproductive maturation amplifies.b 
Study Design Experimental and quasi-experimental studies that evaluated the effects of educational programs designed to promote or support the SRHR of school-aged children were eligible. This included randomized control trials, nonrandomized controlled trials, quasi-randomized controlled trials, pre and post studies, and interrupted time-series trials. Studies without a comparison group were ineligible, unless they were observational studies. Observational studies (crosssectional and cohort) that examined the effectiveness of educational interventions targeting improvements in knowledge, awareness, or attitudes related to an SRHR outcome were eligible. Articles that merely indicated the prevalence of an SRHR outcome or investigated factors that influenced an SRHR outcome, without implementing and testing intervention effect, were ineligible. Only studies conducted in LMICs and published in peer-reviewed journals were eligible for inclusion. In terms of language, only studies conducted in English and French were eligible for inclusion. 
a

The review considered studies that measured the mentioned SRHR primary and secondary outcomes, which were informed by select previous reviews on the topics.1419,2628 

b

The rationale for selecting the primary and secondary outcomes were based on the target age range and the literature on the types of intervention content for various life stages.3,12,13 

Electronic searches were performed by an information specialist (K.F.) in the following databases: Medline(R), ALL (Ovid), Embase (Ovid), CINAHL (EBSCOHost), APA PsycInfo (Ovid), ERIC (Ovid), Cochrane Central Register of Controlled Trials (Ovid), Education Source (EBSCOHost), Web of Science (Clarivate Analytics), SciELO Citation Index (Clarivate Analytics), Global Health (Ovid), Sociological Abstract (Proquest). Studies were identified using a combination of each of the databases’ unique subject headings and keywords (when applicable). Concepts pertaining to age (eg, children), sexual health and rights, educational programs, and LMICs were developed for each database (see Supplemental Information for Medline’s search strategy). The Cochrane LMICs filter31  was modified to reflect the current list of LMICs identified by the World Bank.32  The search filters for randomized controlled trials and observational studies developed by the Scottish Intercollegiate Guidelines Network were used and modified to include quasi-experimental designs as well.33  All peer-reviewed publications from January 2000 onwards were retrieved. This period accounts for a new wave and focus of studies on primary level education following the release of the Millennium Development Goals at the turn of the century.34 

All the database results were imported into Covidence (Veritas Health Innovation Ltd.), where duplicate records were automatically removed. The articles were then sent to the title and abstract screening phase. One reviewer independently screened all titles and abstracts, while 2 other reviewers independently screened a split of the titles and abstracts. This method ensured that each article was screened by 2 reviewers within a reasonable time frame. A.W.B. resolved conflicts between A.W.F. and D.I.W., whereas D.I.W. resolved conflicts between A.W.F. and A.W.B. The same procedure was repeated in screening the full-texts that were retained after the title and abstract screening phase. Following full-text screening, 1 reviewer manually searched the journals Prevention Science and Child Abuse and Neglect for additional relevant articles. In addition, the reference lists of included studies were manually perused to identify additional relevant articles. Finally, articles that cited the included full-text articles were searched using the database Scopus to ensure the identification of additional relevant articles that may not have been discovered through the database searching.

Two reviewers independently assessed the methodological quality of retained studies following full-text screening. The assessments were done using Joanna Briggs Institute (JBI) critical appraisal tools (checklists) for randomized controlled trials and quasi-experimental studies.35,36  The overall quality of the studies was reported as “low” (<70%), “moderate” (70% to 85%), or “high quality” (>85%) based on the percentage of criteria met. Any disagreements between the 2 reviewers were settled through discussion, or a third reviewer when required. Studies were not excluded or weighted based on the quality of the reporting assessment.

Two reviewers independently extracted data from all included studies to minimize potential biases. Disagreements were resolved through discussion, or a third reviewer when required. Extraction was conducted by adapting a standardized data extraction tool, the JBI Meta-Analysis of Statistics Assessment and Review Instrument.36  The extracted data included specific details about the study characteristics, study methods, participant characteristics, interventions, outcome measures, and study results related to the review question and objectives. In the event of any missing or ambiguous data from a study, the corresponding authors of the study were contacted through e-mail to retrieve missing or additional data. There were 3 ostensibly relevant articles that were excluded because of no response from authors, thereby leaving uncertainties about the mean age of the target populations.3739 

We did not conduct a meta-analysis because of the differing assessments and reporting of outcomes across studies, making it unfeasible to pool data and generate a single effect estimate. In addition, following considerations of time, resources, and appropriateness for addressing the aim of this review, a narrative summary of the effects of interventions across different studies was deemed most appropriate. We used Popay’s guidance on the conduct of a narrative synthesis to conduct a narrative synthesis of the interventions targeting improvements in SRHR outcomes.40  The review also used the synthesis without meta-analysis reporting guideline to help guide the reporting of the narrative synthesis.41  The guideline has been developed to guide reviews of interventions that conduct a narrative synthesis of intervention effects.

The reviewers synthesized the evidence on the quantitatively determined effects of the various types of educational interventions using textual summaries and tabulation. The studies were grouped by outcome domains, constituting similar outcomes. The groupings considered broader outcomes and terminology reported in related reviews for harmonization of synthesis findings;16,17,26  this provides more manageable and applicable synthesis findings for use by policymakers and program designers. Structured textual summaries were developed for each of the individual studies reporting the same information in a consistent manner.40  The summaries contextualized the extracted data and included key information about the educational interventions and key findings. Where needed, the summaries are accompanied by tabulated findings for each outcome. Additional information on study characteristics and findings are provided in Supplemental Table 9. Investigations of heterogeneity were not prespecified. Vote counting based on direction of effect was used to synthesize results because of inconsistency in the effect measures and data reported across the studies.42  The effect was categorized as beneficial (using binary metric 1), harmful (binary metric 0) or not significant (not included in the synthesis of vote counting based on direction of effects).

Reviewers examined the variability in findings between settings, study populations, and intervention implementation strategies. The subgroup synthesis enabled the reviewers to identify variabilities within and between studies and their results. For relationships within studies, patterns identified by authors of included studies were first compiled.40  Reviewers then looked across extracted data to explore and compare relationships between studies. They looked for patterns that may have uncovered factors to possibly explain any differences in the effects of interventions across the individual studies.40 

The review assessed the confidence and certainty of the review evidence for each outcome using the Grading of Recommendations Assessment, Development and Evaluations (GRADE) approach.43  The overall GRADE certainty of evidence score for each outcome was classified as “high,” “moderate,” “low,” or “very low.” The overall scores were based on judgements of 5 key GRADE domains: methodological limitations, indirectness, imprecision, inconsistency, and the likelihood of publication bias.44  Two reviewers independently rated the certainty of evidence for the outcomes, and discrepancies were resolved by consensus or with input from a third reviewer. The review findings are discussed in the context of evidence certainty, strengths, and limitations of findings, along with their implications for policy initiatives, programmatic actions, and future research.

A total of 19 941 potential articles were identified for this review. Following the removal of duplicates and title and abstract screening, 221 articles were left for full-text screening. Following full-text screening, 11 papers were found to have met our inclusion criteria (Fig 1). Of the 11 included studies, many of them (10) were quasi-experimental studies and 1 was a randomized controlled trial (Table 2). Three of the studies were conducted in Latin America,4547  4 in Asia,4851  3 in Africa,5254  and 1 in Europe.55  The participants in 9 of the studies were both female and male children, whereas in 2 studies, only female children participated.51,53  In total, there were 4754 children between ages 5 and 14, with a mean age of 9.3 across the included studies; 9 studies focused on child sexual abuse (CSA) prevention4552,55  and 2 focused on HIV prevention.53,54  The CSA prevention interventions covered numerous concepts, such as knowledge of private parts, disclosure of secrets, and appropriate and inappropriate touching. The HIV prevention interventions covered concepts such as intentions to postpone sexual activity and removing oneself from compromising situations. The effects of interventions were compared with comparison groups that either received no intervention,47,51,52,54,55  a conventional intervention,4850  or intervention at a different point in time.45,46  In 1 study, the intervention group was assessed as the comparison group in a before and after comparison.53  Refer to Supplemental Tables 9 and 10 for a detailed description of the included studies.

FIGURE 1

PRISMA flowchart of the selection process.

FIGURE 1

PRISMA flowchart of the selection process.

Close modal
TABLE 2

Summary Characteristics of Included Studies

First Author, YearSettingStudy DesignParticipantsInterventionComparisonOutcomes
Bustamante, 201945  6 public primary schools, Ecuador Cluster-randomized trial 496 primary school children (mean age = 9.3 y) 407 children (group 1) received the “I Have the Right to Feel Safe” self-protection program through workshops 89 children (group 2) received the program after the intervention group Identifying what constitutes abuse 
      Distinguishing between potential abusers and people they can trust 
      Knowing that not all secrets must be kept 
      Recognizing that children have rights 
Cecen-Erogul, 201355  1 primary school, Turkey Quasi-experiment 36 children in grade 4 with a mean age of 9.6 y 18 children received the “Preventing Child Sexual Abuse” psycho-educational training program through workshops 18 children did not receive any intervention Differentiation between good and sexually abusive touches 
Dunn, 201152  20 primary schools, South Africa Quasi-experiment 1697 children in grade 4 with a mean age of 9.61 y (intervention group) and 9.68 y (comparison group) 407 children received the “Hands Off Our Children – Your Child is My Child campaign” through a board game 1290 children did not receive any intervention Knowledge of appropriate touching 
      Knowledge of inappropriate touching 
Enah, 201053  1 primary school, Cameroon Quasi-experiment 60 primary school children (all girls) with a mean age of 10.5 y The 60 girls received the “Responsible Behaviour: Delaying Sex Curriculum” and “Be Proud! Be Responsible!” intervention through a workshop The 60 girls before they received the intervention Intentions to postpone sexual activity 
      Sexual abstinence behavior skills 
Fitriana, 201849  2 primary schools, Indonesia Quasi-experiment 84 children in grades 4 and 5 with a mean age of 10.95 y (intervention group) and 10.86 y (control group) 42 children received the peer education program 42 children received a general intervention provided by the Public Health Service Knowledge of preventing sexual violence 
      Self-efficacy in preventing sexual violence 
Holden, 201954  Primary school and parish compound, Tanzania Quasi-experiment 177 primary school children with HIV with a mean age of 10 y 177 children with HIV received the “Stepping Stone with Children” training program through workshops 91 children with HIV did not receive any intervention Adherence to ARV medication 
      Change in CD4 cell count 
Hurtado, 201446  Children’s museum, El Salvador Quasi-experiment 247 primary school children (originally 248, but 1 excluded from study for being 17 y old) with a mean age of 9.38 y 59 children who completed the questionnaire after receiving the “My Body Belongs to Me” educational exhibit 189 children who completed the questionnaire before entering the museum Knowledge of body ownership 
      Saying NO and getting away 
      Knowledge to avoid self-blame and of the right to ask for help 
      Knowledge of private parts 
Khoori, 202051  Iran Quasi-experiment 56 preschool girls with a mean age of 6.3 y 28 children in the intervention group received the body safety training program 28 children in the control group did not receive any training Saying and responding 
      Doing 
      Reporting and telling 
      Identifying and responding to appropriate and inappropriate touching 
Neherta, 201750  Multiple primary schools in Indonesia Quasi-experiment 1112 primary school children with a mean age of 9.5 y 747 children in 2 intervention groups received a visual auditory kinesthetic education program, but with different instructors. Group 1 included children in nurse taught group (n = 362), whereas group 2 included children in teacher taught group (n = 385) 365 children received a conventional program taught by teachers Knowledge on sexual abuse prevention 
Segura, 202047  1 primary school, Colombia Quasi-experiment 344 children in grades 2 and 3 with a mean age of 7.8 y 200 children in second and third grade received a gender-based intimate partner violence prevention program through classroom lessons 144 children second and third grade did not receive any intervention Assertive behavior 
      Attitudes toward gender-based violence against women 
      Attitudes about gender stereotypes and gender roles 
      Empathy 
      Self-esteem 
      Emotional intelligence 
Weatherley, 201248  5 primary schools, Malaysia Quasi-experiment 445 primary school children with a mean age of 9 y 261 children who received “The Keeping Me Safe” curriculum program 184 children received a conventional curriculum Response to adult stranger situation 
      Telling about unsafe situations 
      Secrets 
      Saying no to inappropriate touch 
      Knowledge about private parts 
First Author, YearSettingStudy DesignParticipantsInterventionComparisonOutcomes
Bustamante, 201945  6 public primary schools, Ecuador Cluster-randomized trial 496 primary school children (mean age = 9.3 y) 407 children (group 1) received the “I Have the Right to Feel Safe” self-protection program through workshops 89 children (group 2) received the program after the intervention group Identifying what constitutes abuse 
      Distinguishing between potential abusers and people they can trust 
      Knowing that not all secrets must be kept 
      Recognizing that children have rights 
Cecen-Erogul, 201355  1 primary school, Turkey Quasi-experiment 36 children in grade 4 with a mean age of 9.6 y 18 children received the “Preventing Child Sexual Abuse” psycho-educational training program through workshops 18 children did not receive any intervention Differentiation between good and sexually abusive touches 
Dunn, 201152  20 primary schools, South Africa Quasi-experiment 1697 children in grade 4 with a mean age of 9.61 y (intervention group) and 9.68 y (comparison group) 407 children received the “Hands Off Our Children – Your Child is My Child campaign” through a board game 1290 children did not receive any intervention Knowledge of appropriate touching 
      Knowledge of inappropriate touching 
Enah, 201053  1 primary school, Cameroon Quasi-experiment 60 primary school children (all girls) with a mean age of 10.5 y The 60 girls received the “Responsible Behaviour: Delaying Sex Curriculum” and “Be Proud! Be Responsible!” intervention through a workshop The 60 girls before they received the intervention Intentions to postpone sexual activity 
      Sexual abstinence behavior skills 
Fitriana, 201849  2 primary schools, Indonesia Quasi-experiment 84 children in grades 4 and 5 with a mean age of 10.95 y (intervention group) and 10.86 y (control group) 42 children received the peer education program 42 children received a general intervention provided by the Public Health Service Knowledge of preventing sexual violence 
      Self-efficacy in preventing sexual violence 
Holden, 201954  Primary school and parish compound, Tanzania Quasi-experiment 177 primary school children with HIV with a mean age of 10 y 177 children with HIV received the “Stepping Stone with Children” training program through workshops 91 children with HIV did not receive any intervention Adherence to ARV medication 
      Change in CD4 cell count 
Hurtado, 201446  Children’s museum, El Salvador Quasi-experiment 247 primary school children (originally 248, but 1 excluded from study for being 17 y old) with a mean age of 9.38 y 59 children who completed the questionnaire after receiving the “My Body Belongs to Me” educational exhibit 189 children who completed the questionnaire before entering the museum Knowledge of body ownership 
      Saying NO and getting away 
      Knowledge to avoid self-blame and of the right to ask for help 
      Knowledge of private parts 
Khoori, 202051  Iran Quasi-experiment 56 preschool girls with a mean age of 6.3 y 28 children in the intervention group received the body safety training program 28 children in the control group did not receive any training Saying and responding 
      Doing 
      Reporting and telling 
      Identifying and responding to appropriate and inappropriate touching 
Neherta, 201750  Multiple primary schools in Indonesia Quasi-experiment 1112 primary school children with a mean age of 9.5 y 747 children in 2 intervention groups received a visual auditory kinesthetic education program, but with different instructors. Group 1 included children in nurse taught group (n = 362), whereas group 2 included children in teacher taught group (n = 385) 365 children received a conventional program taught by teachers Knowledge on sexual abuse prevention 
Segura, 202047  1 primary school, Colombia Quasi-experiment 344 children in grades 2 and 3 with a mean age of 7.8 y 200 children in second and third grade received a gender-based intimate partner violence prevention program through classroom lessons 144 children second and third grade did not receive any intervention Assertive behavior 
      Attitudes toward gender-based violence against women 
      Attitudes about gender stereotypes and gender roles 
      Empathy 
      Self-esteem 
      Emotional intelligence 
Weatherley, 201248  5 primary schools, Malaysia Quasi-experiment 445 primary school children with a mean age of 9 y 261 children who received “The Keeping Me Safe” curriculum program 184 children received a conventional curriculum Response to adult stranger situation 
      Telling about unsafe situations 
      Secrets 
      Saying no to inappropriate touch 
      Knowledge about private parts 

⊕⊕⊕⊕, high certainty; ⊕⊕⊕O, moderate certainty; ⊕⊕OO, low certainty, ⊕OOO, very low certainty.

Overall, 8 of the studies had a high methodological quality, whereas 3 had a moderate methodological quality (Tables 3 and 4). Studies with a moderate quality did not adequately explain the conditions of the experimental and comparison groups, did not adequately explain differences in follow-up, and did not adequately measure outcomes reliably. Four studies were unclear about whether there were differences between the experimental and comparison groups in terms of the intervention received.47,49,50,55  As a result, it was not clear whether the reported effects could be attributed to their interventions. Five studies with follow-up assessments did not adequately explain loss to follow-up, presenting a threat to internal validity.45,49,52,55  The lack of clarity about the reliability of outcome measurements, such as intrarater reliability, in 6 studies suggested weak inferences about the relationship between the intervention and effects.46,47,49,51,52,55  Refer to Supplemental Tables 11 and 12 for the full quality assessment tables.

TABLE 3

JBI Critical Appraisal Results for Quasi-Experimental Studies

StudyQ1Q2Q3Q4Q5Q6Q7Q8Q9Total %
Cecen-Erogul55  0.5 0.5 0.5 83.3 
Dunn52  0.5 83.3 
Enah53  88.9 
Fitriana49  0.5 0.5 77.8 
Holden54  100 
Hurtado46  0.5 N/A 0.5 87.5a 
Khoori51  0.5 0.5 88.9 
Neherta50  0.5 N/A 93.8a 
Segura47  0.5 N/A 0.5 87.5a 
Weatherley48  0.5 94.4 
StudyQ1Q2Q3Q4Q5Q6Q7Q8Q9Total %
Cecen-Erogul55  0.5 0.5 0.5 83.3 
Dunn52  0.5 83.3 
Enah53  88.9 
Fitriana49  0.5 0.5 77.8 
Holden54  100 
Hurtado46  0.5 N/A 0.5 87.5a 
Khoori51  0.5 0.5 88.9 
Neherta50  0.5 N/A 93.8a 
Segura47  0.5 N/A 0.5 87.5a 
Weatherley48  0.5 94.4 

1, Yes; 0, No; 0.5, Unclear; N/A, not applicable.

a

Score is out of 8 because of an inapplicable item.

TABLE 4

JBI Critical Appraisal Results for Randomized Controlled Trial Study

StudyQ1Q2Q3Q4Q5Q6Q7Q8Q9Q10Total
Bustamante45  0.5 0.5 0.5 85.0% 
StudyQ1Q2Q3Q4Q5Q6Q7Q8Q9Q10Total
Bustamante45  0.5 0.5 0.5 85.0% 

The CSA prevention concepts can be categorized into the following outcome domains: protective knowledge against CSA, protective characteristics against CSA and gender-based violence (GBV), protective characteristics against HIV, and physiologic outcome. See Table 5 for the effects of interventions on the outcomes and their domains. The positive effects indicate statistically significant improvement, whereas the null effects indicate nonsignificant changes.

TABLE 5

Effects of Interventions on Outcomes

InterventionOutcome DomainOutcomesEffect of Intervention
CSA Prevention    
 “I Have the Right to Feel Safe” self-protection program45  Protective knowledge against CSA Identifying what constitutes abuse 
Distinguishing abusers from safety nets 
Knowing that not all secrets must be kept 
Recognizing that children have rights 
 “Preventing Child Sexual Abuse” psycho-educational training program55  Distinguish good and sexually abusive touches 
 “Hands Off Our Children – Your Child is My Child” campaign52  Knowledge of appropriate touching 
Knowledge of inappropriate touching 
 “Body Safety Training” Program51  Say Null 
 Do 
 Tell 
 Respond 
 Identifying appropriate touching 
 Identifying inappropriate touching Null 
 “My Body Belongs to Me” program46  Knowledge of body ownership 
Saying NO and getting away 
Knowledge to avoid self-blame 
Knowledge of the right to ask for help 
Knowledge of girls’ private parts 
Knowledge of boys’ private parts Null 
 “Keeping me Safe” curriculum program48  Response to stranger situations 
Telling about being unsafe situations 
Not keeping secrets Null 
Children’s learning about telling secrets 
Saying no to inappropriate touch from known adult 
Saying no to inappropriate touch from stranger adult Null 
Saying no to friends’ inappropriate touch and requests Null 
Knowledge about private parts 
 Peer education program49  Knowledge of preventing sexual violence 
Self-efficacy in preventing sexual violencea 
 Visual auditory kinesthetic education program50  Knowledge of sexual abuse prevention 
Protective characteristics against CSA and GBV Assertiveness behavior 
 Gender-based intimate partner violence prevention program47  Attitudes toward gender-based violence 
Attitudes about gender stereotypes and roles 
Empathy 
Self-esteem Null 
Emotional intelligence Null 
HIV Prevention    
 “Stepping Stones with Children” training program54  Protective characteristics against HIV Intentions to postpone sexual activity 
Sexual abstinence behavior skills 
 “Responsible Behavior: Delaying Sex Curriculum and ‘Be Proud!’ Be Responsible!” program53  Adherence to ARV medication 
Physiologic outcome Change in CD4 cell count 
InterventionOutcome DomainOutcomesEffect of Intervention
CSA Prevention    
 “I Have the Right to Feel Safe” self-protection program45  Protective knowledge against CSA Identifying what constitutes abuse 
Distinguishing abusers from safety nets 
Knowing that not all secrets must be kept 
Recognizing that children have rights 
 “Preventing Child Sexual Abuse” psycho-educational training program55  Distinguish good and sexually abusive touches 
 “Hands Off Our Children – Your Child is My Child” campaign52  Knowledge of appropriate touching 
Knowledge of inappropriate touching 
 “Body Safety Training” Program51  Say Null 
 Do 
 Tell 
 Respond 
 Identifying appropriate touching 
 Identifying inappropriate touching Null 
 “My Body Belongs to Me” program46  Knowledge of body ownership 
Saying NO and getting away 
Knowledge to avoid self-blame 
Knowledge of the right to ask for help 
Knowledge of girls’ private parts 
Knowledge of boys’ private parts Null 
 “Keeping me Safe” curriculum program48  Response to stranger situations 
Telling about being unsafe situations 
Not keeping secrets Null 
Children’s learning about telling secrets 
Saying no to inappropriate touch from known adult 
Saying no to inappropriate touch from stranger adult Null 
Saying no to friends’ inappropriate touch and requests Null 
Knowledge about private parts 
 Peer education program49  Knowledge of preventing sexual violence 
Self-efficacy in preventing sexual violencea 
 Visual auditory kinesthetic education program50  Knowledge of sexual abuse prevention 
Protective characteristics against CSA and GBV Assertiveness behavior 
 Gender-based intimate partner violence prevention program47  Attitudes toward gender-based violence 
Attitudes about gender stereotypes and roles 
Empathy 
Self-esteem Null 
Emotional intelligence Null 
HIV Prevention    
 “Stepping Stones with Children” training program54  Protective characteristics against HIV Intentions to postpone sexual activity 
Sexual abstinence behavior skills 
 “Responsible Behavior: Delaying Sex Curriculum and ‘Be Proud!’ Be Responsible!” program53  Adherence to ARV medication 
Physiologic outcome Change in CD4 cell count 
a

The self-efficacy outcome measure is part of the ‘Protective characteristics against CSA and GBV’ outcome domain.

Protective Knowledge Against CSA

Protective knowledge refers to children’s knowledge of CSA prevention concepts and strategies, such as distinguishing appropriate and inappropriate touch and knowledge of private parts. In Ecuador, the “I Have the Right to Feel Safe” self-protection program was initially provided to 407 children.45  Through workshop sessions, children reviewed themes from a workbook, an interactive activity, and discussions of lessons from the activity. The intervention had a significant effect in increasing medium-term knowledge gains of self-protection strategies, such as distinguishing abusers from safety nets, with signs of knowledge retention 6 months later. In Turkey, the “Preventing Child Sexual Abuse” was provided to 18 children.55  Through workshop sessions, the children received passive teaching, such as video and lecture, and engaged in active teaching, such as role-playing and modeling. The intervention was significantly effective in improving children’s knowledge of sexual abuse prevention strategies, with signs of knowledge retention 8 weeks later. In South Africa, the “Hands Off Our Children – Your Child is My Child campaign” was provided to 407 children.52  The intervention was delivered through a board game that included information statements, questions, and “remember blocks,” which featured prevention concepts against CSA and color-coded body parts for appropriate and inappropriate touch. The intervention was significantly effective in improving children’s knowledge of body awareness, such as inappropriate and appropriate touch, compared with the control group 6 weeks later. In El Salvador, the “My Body Belongs to Me” intervention was provided to 59 children in the Tin Marin Children’s Museum in El Salvador.46  Through a museum exhibit, children partook in playing along, watching a video, and discussing the video with a museum guide. The intervention was significantly effective in increasing children’s knowledge of child sexual abuse prevention concepts, such as saying NO and getting away. In Malaysia, the “Keeping me Safe” curriculum intervention was provided to 261 children.48  Through a curriculum, children took part in interactive activities featuring games and role-playing. The intervention had both significant and nonsignificant effects on knowledge about child sexual abuse prevention concepts. In Indonesia, a peer education program was provided to 42 children, with knowledge of preventing sexual violence being the first outcome measure.49  The children engaged in discussions with peers, played games, drew, and watched prevention videos. The intervention was significantly effective in increasing children’s knowledge of abuse scores. In Indonesia, a visual auditory kinesthetic education program was provided to 747 children, with knowledge of sexual abuse prevention being the first outcome measure.50  Through classroom media, children role-played and watched and listened to movies, pictorial sketch stories, songs, and presentations. The intervention models were significantly effective in increasing children’s knowledge on sexual abuse prevention. In Iran, the “Body Safety Training (BST) program” was provided to 56 preschool girls.51  The intervention was delivered through a personal safety training class that included training for mothers, followed by the provision of education about body safety from the mothers to their daughters. The intervention had some significant effects in improving children’s knowledge about body safety concepts and strategies.

Protective Characteristics Against CSA and GBV

Protective characteristics refer to protective attitudes, abilities, and behaviors, such as assertiveness, to prevent CSA and GBV. The second outcome measurement in the peer education program was self-efficacy.49  The intervention was significantly effective in increasing self-efficacy of children in preventing sexual violence. Likewise, the second outcome measurement in the visual auditory kinesthetic education program was assertiveness.50  The nurse-led and teacher-led program models were both significantly effective in increasing children’s scores on assertiveness. In Colombia, a gender-based intimate partner violence prevention program was provided to 200 children.47  Children received classroom lessons about gender construction, gender-based partner violence, and socioemotional competence. The lessons were accompanied with experiential learning, skills training, socioemotional learning, and the promotion of cognitive, emotional, and behavioral change. The intervention had some significant and nonsignificant effects in improving attitudes toward and skills for, CSA and GBV (Table 5).

Protective Characteristic Against HIV Infection

Protective characteristics against HIV infection refers to protective attitudes, abilities, and behaviors, such as sexual abstinence, to protect against HIV. In Cameroon, the “Responsible Behavior: Delaying Sex Curriculum and ‘Be Proud!’ Be Responsible!” program was provided to 60 girls.53  Through a workshop, the children received lessons and participated in interactive activities (eg, role plays) and group discussions about bodily changes during puberty, HIV, values clarification, and skills. The intervention was significantly effective in increasing protective characteristics, including intention to postpone sexual activity and to employ learned sexual abstinence behavioral skills. In Tanzania, the “Stepping Stones with Children” training program was provided to 86 children with HIV.54  Through workshops, children reviewed information from previous workshop sessions and participated in discussions. The intervention was significantly effective in improving adherence to antiretrovial medication in children with HIV.

Physiologic Outcome

The “Stepping Stones with Children” training program also assessed the effect of the intervention on CD4 cell count54 ; the intervention was found to significantly improve the robustness of the immune system (CD4 cell count).

Vote Counting Based on the Direction of Effect

Of the 11 studies, 1 was excluded in the vote counting synthesis because direction of effect was not available (ie, not significant). There was evidence that the selected interventions had an effect on improved outcomes of SRHR of children with 10 out of 10 studies favoring the interventions (P = .002); 7 interventions were judged high for methodological quality, 3 were rated moderate, and none were rated low. The available effect estimates are presented in Table 6.

TABLE 6

Vote Counting Based on Direction of Effect

StudyOverall Methodological QualityAvailable Data2-Sided PStandard Metric
Bustamante45  High Intervention: 69 Favors intervention group  
  Comparison: 58 P = .074 NS 
Cecun_Erogul55  Moderate Intervention: 8.66(1.28) Favors intervention group  
  Comparison:6.16(1.42) P < .001 
Dunn52  Moderate Intervention: 5.61(2.044); 14.06 (4.148) Favors intervention group  
  Comparison: 4.97(2.132);12.94(4.236) P = .01 
Enah53  High Pre: 5.70 (4.00); 10.28(4.18)a Favors intervention group  
  Post: 4.55(3.05); 8.74 (3.98)a P = .001 
   P < .001  
Fritriana49  Moderate Intervention (posttest): 36 (knowledge); 33(self-efficacy) Favors Intervention group  
  Comparison: 24 (knowledge); 17 (self-efficacy) P = .008 (knowledge)  
   P < .001 (self-efficacy) 
Holden54  High Intervention:847.12 (CD4); 80 (adherence) Favors Intervention group  
  Comparison: 690.30 (CD4); 60 (adherence) P = .01 (CD4)  
   P = .001 (adherence) 
Hurtado46  High Pre and Post intervention results on 5 questions; 4 of 5 statistically significant improvement (at least P < .05) Favors the intervention group  
   4 of 5 statistically significant improvement (at least P < .05) 
Khoori51  High Interventions 28/56; Control 28/56; Gains in knowledge by intervention group on 6 of 8 key variables compared with comparison group Favors intervention group  
   Multiple P values (P < .05 - P < .001) 
Neherta50  High Mean Difference in Knowledge & Assertiveness: Nurses versus Comparison; Teachers versus Comparison and Teachers versus Nurses; nurses best outcomes, followed by teachers then comparison group Favors the 2 intervention groups  
   P < .001 
Segura47  High Before and after significantly different for intervention versus comparison on 3 of 5 variables; better outcomes after for intervention group Favors intervention group  
   Multiple P values (P < .05 - P < .001) 
Weatherley48  High Gains in knowledge by intervention group on about two-thirds of items tested compared with comparison group Favors intervention group  
   Multiple P values (P < .05 - P < .001) 
Binomial probability test 
  Vote counting based on direction of effect (P value)** P = .002  
StudyOverall Methodological QualityAvailable Data2-Sided PStandard Metric
Bustamante45  High Intervention: 69 Favors intervention group  
  Comparison: 58 P = .074 NS 
Cecun_Erogul55  Moderate Intervention: 8.66(1.28) Favors intervention group  
  Comparison:6.16(1.42) P < .001 
Dunn52  Moderate Intervention: 5.61(2.044); 14.06 (4.148) Favors intervention group  
  Comparison: 4.97(2.132);12.94(4.236) P = .01 
Enah53  High Pre: 5.70 (4.00); 10.28(4.18)a Favors intervention group  
  Post: 4.55(3.05); 8.74 (3.98)a P = .001 
   P < .001  
Fritriana49  Moderate Intervention (posttest): 36 (knowledge); 33(self-efficacy) Favors Intervention group  
  Comparison: 24 (knowledge); 17 (self-efficacy) P = .008 (knowledge)  
   P < .001 (self-efficacy) 
Holden54  High Intervention:847.12 (CD4); 80 (adherence) Favors Intervention group  
  Comparison: 690.30 (CD4); 60 (adherence) P = .01 (CD4)  
   P = .001 (adherence) 
Hurtado46  High Pre and Post intervention results on 5 questions; 4 of 5 statistically significant improvement (at least P < .05) Favors the intervention group  
   4 of 5 statistically significant improvement (at least P < .05) 
Khoori51  High Interventions 28/56; Control 28/56; Gains in knowledge by intervention group on 6 of 8 key variables compared with comparison group Favors intervention group  
   Multiple P values (P < .05 - P < .001) 
Neherta50  High Mean Difference in Knowledge & Assertiveness: Nurses versus Comparison; Teachers versus Comparison and Teachers versus Nurses; nurses best outcomes, followed by teachers then comparison group Favors the 2 intervention groups  
   P < .001 
Segura47  High Before and after significantly different for intervention versus comparison on 3 of 5 variables; better outcomes after for intervention group Favors intervention group  
   Multiple P values (P < .05 - P < .001) 
Weatherley48  High Gains in knowledge by intervention group on about two-thirds of items tested compared with comparison group Favors intervention group  
   Multiple P values (P < .05 - P < .001) 
Binomial probability test 
  Vote counting based on direction of effect (P value)** P = .002  

NS, findings not statistically significant (ie, no information on direction).

a

lower scores indicate greater confidence.

**

Binomial probability test: Microsoft Excel calculation42  = 2*BINOM.DIST(0,10,0.05, TRUE) = 0.00195.

Confidence in the Evidence

There is a high certainty of the evidence of intervention effects belonging to the ‘protective knowledge against CSA’ outcome domain (Table 7). The “protective characteristics against CSA and GBV” outcome domain has a low certainty of evidence, whereas the “protective characteristics against HIV infection” and “physiologic outcome” groups have a very low certainty of evidence. Refer to Supplemental Table 13 for the detailed rating of each GRADE domain.

TABLE 7

Certainty of Evidence

Outcome DomainsContributing StudiesOverall EffectGRADE (Certainty of Evidence)
Protective knowledge against CSA Bustamente,45  Dunn,52  Hurtado, 46  Cecen-Erogul,55  Fitriana,49  Khoori,51  Neherta,50  Weatherley48  Majority of the studies found statistically significant improvements in protective knowledge against child sexual abuse High certainty - ⊕⊕⊕⊕ (minor concerns about publication bias) 
Protective characteristics against CSA and GBV Fitriana,49  Neherta,50  Segura47  Most of the results were statistically significant for improvements in attitudes, behaviors, and abilities to prevent CSA and GBV Low certainty - ⊕⊕OO (serious concerns with inconsistency and minor concerns with imprecision) 
Protective characteristics against HIV infection Enah,53  Holden54  The results were statistically significant for improvements in attitudes, behaviors, and abilities to prevent HIV infection Very low - ⊕OOO (because of a lack of studies and borderline indirectness, as well as serious concerns with imprecision and publication bias) 
Physiologic outcome Holden54  One study found that there was a statistically significant improvement in the robustness of the immune system against HIV infection Very low - ⊕OOO (because of a lack of studies, and serious concerns with indirectness and imprecision) 
Outcome DomainsContributing StudiesOverall EffectGRADE (Certainty of Evidence)
Protective knowledge against CSA Bustamente,45  Dunn,52  Hurtado, 46  Cecen-Erogul,55  Fitriana,49  Khoori,51  Neherta,50  Weatherley48  Majority of the studies found statistically significant improvements in protective knowledge against child sexual abuse High certainty - ⊕⊕⊕⊕ (minor concerns about publication bias) 
Protective characteristics against CSA and GBV Fitriana,49  Neherta,50  Segura47  Most of the results were statistically significant for improvements in attitudes, behaviors, and abilities to prevent CSA and GBV Low certainty - ⊕⊕OO (serious concerns with inconsistency and minor concerns with imprecision) 
Protective characteristics against HIV infection Enah,53  Holden54  The results were statistically significant for improvements in attitudes, behaviors, and abilities to prevent HIV infection Very low - ⊕OOO (because of a lack of studies and borderline indirectness, as well as serious concerns with imprecision and publication bias) 
Physiologic outcome Holden54  One study found that there was a statistically significant improvement in the robustness of the immune system against HIV infection Very low - ⊕OOO (because of a lack of studies, and serious concerns with indirectness and imprecision) 

⊕⊕⊕⊕, high certainty; ⊕⊕⊕O, moderate certainty; ⊕⊕OO, low certainty, ⊕OOO, very low certainty.

One key pattern found across the studies belonging to the “protective knowledge” outcome domain (high certainty of evidence) was related to the intervention activities. Interventions that solely employed active and interactive activities as a learning tool or together with passive activities were consistently effective in improving knowledge of CSA prevention concepts and strategies.45,46,4850,52,55  Funded studies in the protective knowledge outcome domain received nongovernment, government, or industry funding, which may have contributed to the research capacity building in regions with limited resources. In terms of patterns within the studies, girls scored higher than boys for improvements in knowledge of CSA prevention concepts and strategies.45,48  One study45  found greater improvement of postintervention knowledge scores of CSA prevention concepts among older children. In contrast, another study46  found that younger children had greater improvement in their postintervention knowledge scores of CSA prevention concepts.

This review identified educational interventions designed to prevent CSA and HIV among children. The review found evidence of significant improvements in protective knowledge, attitudes, behaviors, and skills among children exposed to various types of interventions and intervention activities. Given the certainty of evidence ratings, the review found strong evidence of significant improvements in children’s knowledge of CSA prevention concepts and strategies, including body awareness, identifying private parts, recognizing body ownership rights, saying NO, and avoiding self-blame. The review found low and very low certainty evidence of some significant improvements in children’s protective attitudes, behaviors, and skills against CSA, GBV, and HIV infection.

Most interventions in studies included in this review were primary prevention programs that were found to have significant effects in preventing CSA, GBV, and HIV in children. This is similar to the results of a study which reported that primary prevention programs that teach children sexual abuse protection concepts, improve their knowledge and abilities to protect themselves against CSA.56  The literature also supports the significant effects of primary prevention programs on children’s protective capacity against GBV57  and HIV.58 

The review provided evidence that education is an effective vehicle for developing children’s protective knowledge and skills, as well as creating attitudinal and behavioral changes to prevent CSA and HIV. This is consistent with findings from other studies.16,5961  In addition, studies with follow-up tests found that children can retain protective knowledge weeks to months after receiving education. However, the literature suggests that retention of knowledge should be measured beyond 3 to 12 months,60  which was only accomplished by 1 study in this review.45  The majority of studies in this review were conducted in school settings, which are crucial and far-reaching platforms for promoting positive SRHR messages.62  Vast literature evidence indicate that schools have a crucial influence in providing children with the protective knowledge, understanding, attitudes, behaviors, and skills needed to make and act on positive SRHR related decisions.6266  United Nations’ reports also support this fact, stating that HIV and AIDS education is a predictor of reduced HIV risk.11,63 

Concerning effective intervention activities to promote SRHRs, the literature reveals that programs featuring multiple activities, including interactive activities, are effective in keeping children engaged and absorbent to SRHR information.11,15,67  However, the review did not find any strong evidence to support sole passive learning through didactic teaching as an effective learning and teaching tool. Interestingly, the peer education program showed some significant improvements in protective knowledge and characteristics scores among children.49  This is supported by other reports stating that children are more comfortable discussing sensitive SRHR topics with their peers.63,65 

Looking at the coverage of sex and gender in SRHR school curricula, a 10-country review in sub-Saharan Africa found that the curricula covered sexual abuse focusing mainly on girls.68  In this review however, all but 2 studies51,53  included both boys and girls, highlighting the fact that protection against sexual abuse and HIV infection should be the responsibility of both sexes. Finally, with regards to protective knowledge, characteristics, and sociocultural barriers, although review findings display improved protective knowledge and characteristics among boys and girls, sociocultural stigma surrounding disclosure of sexual abuse in some regions can still hinder children from openly disclosing their experiences.69  The widespread, nonevidence based belief that sexual and reproductive health education will encourage children to initiate sex earlier is another major sociocultural and religious barrier to children’s learning of SRHR concepts.11,70  In some regions, teacher discomfort and resistance, regardless of institutional policies, can lead to ineffective teaching and diluted content.11  Educational programs with diluted messages significantly reduce the effect of an intervention, which may have been the case for the nonsignificant effects reported in this review.48 

This review had some limitations. Although our rationale for completing a narrative synthesis was sound, given the high levels of heterogeneity, a meta-analysis across the primary and secondary outcomes was not completed. Only 1 study was a truly randomized trial; studies with no randomization limit the ability to conclude a causal association between the intervention and effects of the measured outcomes. Narrative synthesis reviews of public health interventions tend to lack transparency in data presentation and elicited conclusions, thereby threatening the validity of the evidence. However, the reviewers used Popay's guidance for narrative synthesis reviews and the synthesis without meta-analysis guideline to reduce issues of transparency and increase utility of this systematic review. We used vote counting based on direction of effect to help with the synthesis; however, this provides no information on the magnitude of effects, does not account for differences in relative sizes of the studies, and is less powerful than methods used to combine p -values.42,71  Thus, confounding variables were not statistically considered in the overall analysis of the review. Only 1 study assessed retention of knowledge beyond 3 months whereas the 3 other studies that did look at follow-up ranged between 6 and 8 weeks; therefore, the review did not include adequate follow-up evaluation to assess retention. Considering the low number of studies contributing to 3 of the outcome domains, there was not enough evidence to discuss the true effect seen in the findings. There were 10 studies that were excluded for being reported in languages other than English or French (language bias), which may have led to the exclusion of potentially relevant articles. Additionally, this review addresses a highly sensitive subject among a vulnerable population (children) from which consent is difficult to attain; we anticipate that there are reports and unpublished studies, which were not considered in this review. This presents publication bias toward peer-reviewed and published studies.

This review has both macro level policy and micro level intervention implementation implications. Table 8 provides an overview of implications regarding policy changes, highlights key implications for future intervention implementation, as well as flags opportunities for research in SRHR programs directed at improving knowledge, attitudes, and behaviors of primary school children.

TABLE 8

Implications for Policy, Intervention Programs, and Future Research

ImplicationsDescription
Implications for policy Collaboration between educational institutions, governments, (ie, Ministry of Education) and relevant grassroots or community organizations is vital for the provision of culturally appropriate SRHR interventions to primary school-age children. 
 Leadership and financial support, particularly from the government, are critical to support the implementation of SRHR curriculums. 
 Many children may be captured in school, however, 63 million children at the primary school age level (6–11 y) are out of school, mainly in LMICs.a It is important for governments and organizations to develop SRHR programs targeting out of school children who are at high risk of negative SRHR outcomes. 
Implications for intervention programs targeting primary school-aged children’s SRHR knowledge, attitude, and behaviors Engagement and necessary training of skilled facilitators, teachers, trainers, parents, and peers delivering the curriculum and knowledge is key for the provision of high-quality education to the children. 
 Communities, particularly the parents and families of the children participating, have a role in supporting the implementation of interventions. Targeted interventions should be informed by formative research that unpacks the contextual needs of the target population; some educational programs may not be suited for children if designed irrespective of local barriers, such as restrictive cultural and religious beliefs. 
 Given the evidence supporting interactive activities and active engagement, enabling children to inform the development of educational activities could help program designers and implementers in tailoring and increasing the appeal of SRHR education plans. 
 Age-appropriate knowledge regarding SRHR should be integrated into the curriculum long term (from early primary to high school) to ensure it is maintained, increasing the likelihood for protective behaviors, attitudes, and abilities later on when threats to SRHR increase. 
Implications for future research There is a paucity of research on the protective attitudes, behaviors, and abilities of children (5–10 y) against sexual abuse and sexually transmitted diseases. The majority of work with this age group focuses on knowledge to protect; however, how that translates to behavior, attitude, and abilities is unknown, particularly in LMICs. More interventions directed at improving attitude, behaviors, and abilities are necessary in this region. 
 Studies with longer follow-up evaluations help to demonstrate retention of knowledge. As such, longitudinal interventions designed to deliver and retain knowledge are important to assess how this improves protective characteristics. This will help in terms of application of the lessons learned at an early age, and later in childhood when the chances of abuse and violence increase. 
 Randomized studies of interventions addressing both protective knowledge and characteristics (ie, attitudes, behaviors, and abilities) of children against CSA, GBV, and HIV will further contribute to the current evidence to show the characteristics of effective interventions. Most of the studies in this review did not control for confounding factors. 
 The school setting has proven to be an effective setting for improving SRHR knowledge; it is also cost-efficient (ie, integrated appropriately into curriculum) and scalable (ie, reaching large numbers), and thus an ideal venue to deliver interventions. Future studies should thereby explore other interventions which have shown promise in terms of successful delivery and positive effect measures: skilled trainer and facilitator of the education (ie, peer, trainer, teacher, nurse) and experiential and active learning. 
ImplicationsDescription
Implications for policy Collaboration between educational institutions, governments, (ie, Ministry of Education) and relevant grassroots or community organizations is vital for the provision of culturally appropriate SRHR interventions to primary school-age children. 
 Leadership and financial support, particularly from the government, are critical to support the implementation of SRHR curriculums. 
 Many children may be captured in school, however, 63 million children at the primary school age level (6–11 y) are out of school, mainly in LMICs.a It is important for governments and organizations to develop SRHR programs targeting out of school children who are at high risk of negative SRHR outcomes. 
Implications for intervention programs targeting primary school-aged children’s SRHR knowledge, attitude, and behaviors Engagement and necessary training of skilled facilitators, teachers, trainers, parents, and peers delivering the curriculum and knowledge is key for the provision of high-quality education to the children. 
 Communities, particularly the parents and families of the children participating, have a role in supporting the implementation of interventions. Targeted interventions should be informed by formative research that unpacks the contextual needs of the target population; some educational programs may not be suited for children if designed irrespective of local barriers, such as restrictive cultural and religious beliefs. 
 Given the evidence supporting interactive activities and active engagement, enabling children to inform the development of educational activities could help program designers and implementers in tailoring and increasing the appeal of SRHR education plans. 
 Age-appropriate knowledge regarding SRHR should be integrated into the curriculum long term (from early primary to high school) to ensure it is maintained, increasing the likelihood for protective behaviors, attitudes, and abilities later on when threats to SRHR increase. 
Implications for future research There is a paucity of research on the protective attitudes, behaviors, and abilities of children (5–10 y) against sexual abuse and sexually transmitted diseases. The majority of work with this age group focuses on knowledge to protect; however, how that translates to behavior, attitude, and abilities is unknown, particularly in LMICs. More interventions directed at improving attitude, behaviors, and abilities are necessary in this region. 
 Studies with longer follow-up evaluations help to demonstrate retention of knowledge. As such, longitudinal interventions designed to deliver and retain knowledge are important to assess how this improves protective characteristics. This will help in terms of application of the lessons learned at an early age, and later in childhood when the chances of abuse and violence increase. 
 Randomized studies of interventions addressing both protective knowledge and characteristics (ie, attitudes, behaviors, and abilities) of children against CSA, GBV, and HIV will further contribute to the current evidence to show the characteristics of effective interventions. Most of the studies in this review did not control for confounding factors. 
 The school setting has proven to be an effective setting for improving SRHR knowledge; it is also cost-efficient (ie, integrated appropriately into curriculum) and scalable (ie, reaching large numbers), and thus an ideal venue to deliver interventions. Future studies should thereby explore other interventions which have shown promise in terms of successful delivery and positive effect measures: skilled trainer and facilitator of the education (ie, peer, trainer, teacher, nurse) and experiential and active learning. 
a

Based on a UNESCO report.72 

This review identified effective educational interventions that developed primary school children’s protective capacities for sexual abuse, GBV, and HIV prevention. Statistical analysis based on the directions of effect in 9 of the studies indicated significant improvements in the protective knowledge against CSA domain. The evidence of significant intervention effects on the other outcome domains was weak and requires further research. There was sufficient evidence regarding effectiveness of educational interventions that had interactive components alongside passive learning. Government, education, and community organizations in LMICs must collaborate to provide culturally appropriate interventions for primary-school aged children both in and out of school.

Mr Fantaye, Mr Buh, and Mrs Wheeler conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript; Ms Fournier developed the search strategies, drafted portions of the initial manuscript, and reviewed the manuscript; Dr Yaya conceptualized and designed the study, coordinated and supervised the review, and critically reviewed the manuscript for its intellectual property content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work

FUNDING: This work was supported by a grant from the International Development Research Centre (#109010-001). The funder did not participate in the work.

CONFLICT OF INTEREST DISCLOSURES: The authors have no conflicts of interest relevant to this article to disclose

     
  • CSA

    child sexual abuse

  •  
  • HIV

    human immunodeficiency virus

  •  
  • GBV

    gender-based violence

  •  
  • GRADE

    Grading of Recommendations, Assessment, Development and Evaluations

  •  
  • JBI

    Joanna Briggs Institute

  •  
  • LMICs

    low and middle-income countries

  •  
  • SRHR

    sexual and reproductive health and rights

  •  
  • PICOS

    population, intervention, comparison, outcomes, and study designs

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