Study Design:
The Mediterranean Perinatology Network led this multicentric observational prospective controlled study from November 2018 to June 2019 in Aix-Marseille and Nice Sophia-Antipolis Universities. Two populations were studied: the first population included healthcare students (peer-educators) participating in the SRH part of the SeSa programme (SRH peer-educators) who were compared to healthcare students participating in other modules (nutrition, addiction, and dental hygiene) (other peer-educators), and the second population included secondary school students (teenagers) benefiting from the SeSa SRH programme (SeSa-intervention teenagers) who were compared to secondary school students receiving the classic national education programme (no-intervention teenagers). Although the ages would not be the same, both populations are students and can be considered peers given the small age difference between the groups and their shared student status. Levels of knowledge, risk perception and risky behaviour were studied before and after the SeSa programme among those populations (Figure 1).
The programme for healthcare students included 20 hours of global health prevention courses, 31 hours of specific prevention (addiction, dental hygiene, nutrition and sexual education) and one to four field interventions during which the healthcare students communicated their knowledge to the teenagers. Gynaecologists, SRH education experts, and governmental and nongovernmental organizations specializing in reproductive health and health education led the SRH-specific programme during the 31 hours and covered RTIs and HIV/AIDS information and prevention, contraception, abortion procedures, rights and laws, sexual and gender minority awareness and legal aspects as well as matters of respect and consent. Five healthcare students per group, one from each health branch (dentist, medical doctor, midwife, pharmacist and physiotherapist), led the field interventions. The logistical aspects and duration of the interventions were decided and organized by the schools participating in the SeSa programme. Interventions lasted for one to four hours for one class on one day.
The classic French national secondary school curriculum includes reproductive health during the penultimate year, and school attendance is mandatory until 16 years of age. These two grades represented the most relevant groups of students to study.
Procedure:
We recruited all students of all healthcare branches participating in the SeSa programme as planned by law at Aix-Marseille and Nice Sophia Antipolis Universities as follows: the first year of studies for the dental care and midwifery schools, the second year for pharmacy and physiotherapy schools and the third year for the school of medicine. Healthcare students were randomly assigned to one module of the programme, except for midwives in Nice who were assigned to the SRH module as an organizational matter. Each healthcare student participating in the SeSa programme was invited to answer a questionnaire in November 2018 before participating in any course. At the end of the entire programme, in May 2019, the same questionnaire was again provided. Information on age, gender and type of study (dentistry, medicine, midwifery, physiotherapy, and pharmacy) was collected.
For teenagers, we recruited voluntary secondary schools in Marseille and selected the penultimate and last year of secondary school (13-15 years old). Teenagers were invited to complete a questionnaire before the interventions in February 2019. The same questionnaire was given three months after the end of the programme. Schools not participating in the SeSa programme received the first questionnaire in February or March 2019 and the postintervention questionnaires in May or June 2019 to respect a 3-month delay between the administration of the two. Information on age, class, school and gender were collected.
For reasons related to participation, organization and anonymity, the data collected in this study were not paired. Anonymity numbers, first planned in the study, were not possible given the number of participants and the lack of adherence expected if total anonymity was not ensured to both teenagers and healthcare students. Since students were part of a specific programme, we assumed that they would not change. The investigators distributed the questionnaires. Neither the schoolteachers nor the university professors had access to the documents.
Participants:
To participate in the study, peer educators (SRH and others) had to be on 2018 promotion (which meant part of the SeSa programme), speak French and be over eighteen years old. For teenagers, inclusion was possible if parents or legal guardians had consented to the study, and access to the postintervention questionnaire was not possible if the pretest questionnaire had not been completed (absent and/or no legal authorization). The distribution of participant variables is presented in Figure 1.
Outcome Measures:
The primary outcome, knowledge acquisition, was measured with 30 “true or false” questions (TFs) for healthcare students (also called peer educators) and teenagers as well as 30 additional multiple-choice questions (MCQs) for health students. The number of participants required was 1000 participants and was determined to have 80% statistical power and a bilateral significance of 5%, assuming a difference of 12% between the two groups in the postintervention score. The questions assessed knowledge of contraception use, reproductive Tract Infections (RTIs), French SRH laws (access to abortion, free contraception, laws against homophobia, and access to pornography) and reproductive biology.
For the secondary outcome, risk perception was measured using a Likert scale(23) from 0 to 5. Participants had to decide about the level of risk of a situation, between not risky (0) and very risky (5). Eleven situations assessed the perception of pregnancy and the transmission risk of RTIs at first intercourse, with or without a barrier protection method (condom). Information on behaviour was collected using an adapted version of the Centers for Disease Control and Prevention’s Youth Risk Behavior Survey (24). Participants were asked to record their age at first intercourse, lifetime number of partners and the number of partners in the last three months, the contraceptive method used, if needed, and the use of alcohol or drugs, and condoms during last intercourse. The participants were also asked whether they had “risky intercourse” (unprotected sex without knowing the RTI status of the partner) during the last two months.
Analysis:
The quantitative data are reported as the mean ± standard deviation or as the median [minimum-maximum] and were compared using Student’s t-test or the Mann-Whitney tests. The categorical data are reported as the absolute count (percentage) and were compared using the χ² test. Spearman’s rank correlation coefficient (ρ) was used to study the relationship between continuous and/or ordinal variables. The p for interaction between the timing of the questionnaire (pre- or postintervention) and the intervention (exposure or not to the SRH SeSa programme) was computed in a linear regression model to test the differential changes in quantitative outcomes among healthcare students and teenagers (p[between group]). All tests were two-sided. Differences were considered significant when the p value was less than 0.05. Statistical analyses were performed using IBM SPSS Statistics 20.0 (IBM Corp., Armonk, NY, USA).
Ethical considerations:
Healthcare students, secondary school students and their legal guardians gave their consent to participate in the study. The study received the approval of the French National Committee for Person’s Protection (CPP) (national number: 2018-A03066-49) and the National Committee for Data Protection and Liberties (national number: 2212148v0).