School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK.
Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, UK.
Public Health Res (Southampt). 2023 Sep;11(8):1-139. doi: 10.3310/YWXQ8757.
BACKGROUND: The need to engage boys in gender-transformative relationships and sexuality education (RSE) to reduce adolescent pregnancy is endorsed by the World Health Organization and the United Nations Educational, Scientific and Cultural Organization. OBJECTIVES: To evaluate the effects of on the avoidance of unprotected sex and other sexual health outcomes. DESIGN: A cluster randomised trial, incorporating health economics and process evaluations. SETTING: Sixty-six schools across the four nations of the UK. PARTICIPANTS: Students aged 13-14 years. INTERVENTION: A school-based, teacher-delivered, gender-transformative RSE intervention () versus standard RSE. MAIN OUTCOME MEASURES: Self-reported avoidance of unprotected sex (sexual abstinence or reliable contraceptive use at last sex) after 12-14 months. Secondary outcomes included knowledge, attitudes, skills, intentions and sexual behaviours. RESULTS: The analysis population comprised 6556 students: 86.6% of students in the intervention group avoided unprotected sex, compared with 86.4% in the control group {adjusted odds ratio 0.85 [95% confidence interval (CI) 0.58 to 1.26], = 0.42}. An exploratory post hoc analysis showed no difference for sexual abstinence [78.30% intervention group vs. 78.25% control group; adjusted odds ratio 0.85 (95% CI 0.58 to 1.24), = 0.39], but more intervention group students than control group students used reliable contraception at last sex [39.62% vs. 26.36%; adjusted odds ratio 0.52 (95% CI 0.29 to 0.920), = 0.025]. Students in schools allocated to receive the intervention had significantly higher scores on knowledge [adjusted mean difference 0.18 (95% CI 0.024 to 0.34), = 0.02], gender-equitable attitudes and intentions to avoid unintended pregnancy [adjusted mean difference 0.61 (95% CI 0.16 to 1.07), = 0.01] than students in schools allocated to receive the control. There were positive but non-significant differences in sexual self-efficacy and communication skills. The total mean incremental cost of the intervention compared with standard RSE was £2.83 (95% CI -£2.64 to £8.29) per student. Over a 20-year time horizon, the intervention is likely to be cost-effective owing to its impact on unprotected sex because it would result in 379 (95% CI 231 to 477) fewer unintended pregnancies, 680 (95% CI 189 to 1467) fewer sexually transmitted infections and a gain of 10 (95% CI 5 to 16) quality-adjusted life-years per 100,000 students for a cost saving of £9.89 (95% CI -£15.60 to -£3.83). LIMITATIONS: The trial is underpowered to detect some effects because four schools withdrew and the intraclass correlation coefficient (0.12) was larger than that in sample size calculation (0.01). CONCLUSIONS: We present, to our knowledge, the first evidence from a randomised trial that a school-based, male engagement gender-transformative RSE intervention, although not effective in increasing avoidance of unprotected sex (defined as sexual abstinence or use of reliable contraception at last sex) among all students, did increase the use of reliable contraception at last sex among students who were, or became, sexually active by 12-14 months after the intervention. The trial demonstrated that engaging all adolescents early through RSE is important so that, as they become sexually active, rates of unprotected sex are reduced, and that doing so is likely to be cost-effective. FUTURE WORK: Future studies should consider the longer-term effects of gender-transformative RSE as students become sexually active. Gender-transformative RSE could be adapted to address broader sexual health and other settings. TRIAL REGISTRATION: This trial is registered as ISRCTN10751359. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (PHR 15/181/01) and will be published in full in ; Vol. 11, No. 8. See the NIHR Journals Library website for further project information.
背景：世界卫生组织和联合国教科文组织都支持让男孩参与性别转变关系和性教育（RSE），以减少青少年怀孕。
目的：评估 对避免无保护性行为和其他性健康结果的影响。
设计：一项集群随机试验，纳入健康经济学和过程评估。
地点：英国四个国家的 66 所学校。
参与者：年龄在 13-14 岁的学生。
干预措施：基于学校的、教师主导的、性别转变的 RSE 干预（）与标准 RSE。
主要结局测量：12-14 个月后报告的避免无保护性行为（性禁欲或最后一次性行为时使用可靠的避孕措施）。次要结局包括知识、态度、技能、意图和性行为。
结果：分析人群包括 6556 名学生：干预组中 86.6%的学生避免了无保护性行为，而对照组中这一比例为 86.4%（调整后的优势比 0.85 [95%置信区间 0.58 至 1.26]，=0.42）。一项探索性事后分析显示，性禁欲方面没有差异[78.30%干预组与 78.25%对照组；调整后的优势比 0.85（95%置信区间 0.58 至 1.24），=0.39]，但干预组学生在最后一次性行为时使用可靠避孕措施的比例高于对照组[39.62%对 26.36%；调整后的优势比 0.52（95%置信区间 0.29 至 0.920），=0.025]。被分配接受干预的学校的学生在知识方面的得分显著高于对照组[调整后的平均差异 0.18（95%置信区间 0.024 至 0.34），=0.02]，性别平等态度和避免意外怀孕的意图也更高[调整后的平均差异 0.61（95%置信区间 0.16 至 1.07），=0.01]。与被分配接受标准 RSE 的学校相比，接受干预的学生在性自我效能感和沟通技能方面有积极但非显著的差异。与标准 RSE 相比，干预的总平均增量成本为每名学生 2.83 英镑（95%置信区间-2.64 至 8.29 英镑）。在 20 年的时间内，由于干预措施对无保护性行为的影响，该干预措施很可能具有成本效益，因为它将导致 379 例（95%置信区间 231 至 477 例）意外怀孕减少，680 例（95%置信区间 189 至 1467 例）性传播感染减少，10 例（95%置信区间 5 至 16 例）每 10 万学生增加 1 个质量调整生命年，节省成本 9.89 英镑（95%置信区间-15.60 至-3.83 英镑）。
局限性：由于四所学校退出，该试验的效力不足，无法检测到一些效果，而且组内相关系数（0.12）大于样本量计算中的系数（0.01）。
结论：我们首次提出了一项随机试验的证据，证明基于学校的、男性参与的性别转变 RSE 干预措施虽然不能有效增加所有学生避免无保护性行为的比例（定义为性禁欲或最后一次性行为时使用可靠避孕措施），但确实增加了在干预后 12-14 个月内有性行为的学生使用可靠避孕措施的比例。该试验表明，通过 RSE 尽早让所有青少年参与其中非常重要，这样，随着他们变得活跃，无保护性行为的比例就会降低，而且这样做很可能具有成本效益。
未来工作：未来的研究应该考虑性别转变 RSE 的更长期效果，因为学生开始有性行为。性别转变的 RSE 可以适应更广泛的性健康和其他环境。
试验注册：本研究已在 ISRCTN 注册，编号为 ISRCTN10751359。
资金：本项目由英国国家卫生与保健研究所（NIHR）公共卫生研究计划（PHR 15/181/01）资助，将在 杂志全文发表；第 11 卷，第 8 期。有关该项目的更多信息，请访问 NIHR 期刊库网站。
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