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J Nu s Sch. 2025;57:342–353.wileyonlinelib a y.com/jou nal/jnu
Recei ed: 12 Ap il 2024
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Re ised: 17 July 2024
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Accep ed: 29 July 2024
DOI: 10.1111/jnu.13015
WORLD HEALTH
E ec i eness o digi al in e en ions o educe school- age
adolescen sexual isks: A sys ema ic e iew
Ana Aguila - Quesada RN, MSN1 | Alba Sie a- Yagüe RN, MSN2 |
Ma ía González- Cano- Caballe o RN, MSN, PhD3 | José An onio Za a- Egea RN, MSN, PhD4 |
Ma a Lima- Se ano RN, MSN, PhD5,6
This is an open access a icle unde he e ms o he C ea i e Commons A ibu ion License, which pe mi s use, dis ibu ion and ep oduc ion in any medium,
p o ided he o iginal wo k is p ope ly ci ed.
© 2024 The Au ho (s). Jou nal o Nu sing Schola ship published by Wiley Pe iodicals LLC on behal o Sigma The a Tau In e na ional.
1Hospi al Uni e si a io San Cecilio,
G anada, Spain
2Ca alan Ins i u e o Heal h, Ba celona,
Spain
3Depa men o Nu sing, Facul y o Heal h
Sciences, Uni e si y o G anada, G anada,
Spain
4Depa men o Nu sing o he Facul y o
Heal h Sciences o UMan esa, Fundació
Uni e si à ia del Bages, Uni e si y o Vic,
Cen al Uni e si y o Ca alonia, Ba celona,
Spain
5Depa men o Nu sing, School o
Nu sing, Physio he apy, and Podia y,
Uni e si y o Se ille, Se ille, Spain
6Ins i u e o Biomedicine o Se ille (IBiS),
Se illa, Spain
Co espondence
Ma ía González- Cano- Caballe o,
Depa men o Nu sing, Facul y o Heal h
Sciences, Uni e si y o G anada, G anada,
Spain.
Email: ma iagcc@ug .es
Abs ac
In oduc ion: The inc ease in isky sexual beha io s among adolescen s uden s has
spa ked ala m and has become an a ea o esea ch in e es . As adolescen s p io -
i ize con iden iali y and accessibili y, digi al in e en ions a e becoming inc easingly
ele an in sex educa ion. We he e o e posed he ollowing esea ch ques ion: A e
digi al applica ion in e en ions e ec i e o p e en isky sexual beha io s in school
adolescen s?
Design: A sys ema ic pee e iew was conduc ed be ween Janua y and Decembe
2023 in i e da abases (PubMed, Web o Science, Scopus, EMBASE, and PsycINFO)
wi hou es ic ing o language o yea o publica ion.
Me hod: We included andomized con ol ials o quasi- expe imen al s udies ha
measu ed he e ec i eness o in e en ions a ge ing young people aged 10–19 yea s
o hei pa en s and de eloped in a school se ing. In e en ions aimed a young peo-
ple wi h in ellec ual disabili ies, lea ning di icul ies, o any disease equi ing a speci ic
in e en ion we e excluded.
Resul s: The sea ch ul ima ely yielded 27 s udies co e ing a o al o 18 digi al in e -
en ions ha demons a ed posi i e e ec s, no main ained o e ime, on knowledge,
a i udes, and beha io s, al hough he la e o a lesse ex en .
Discussion: We ha e ound e y in e es ing digi al in e en ions wi h e ec s, among
o he s, on knowledge, a i udes, and con acep i e use in adolescen s. In gene al,
digi al in e en ions ha e posi i e e ec s on knowledge and a i udes, bu i is mo e
di icul o modi y beha io s wi h s ic ly digi al in e en ions o combined wi h com-
plemen a y ace- o- ace sessions o g oup class ac i i ies.
Conclusion: We hus belie e ha digi al in e en ions a e adequa e o educe adoles-
cen sexual isk beha io s, and ou sys ema ic e iew acili a es he implemen a ion
o hese in e en ions by sha ing exis ing digi al in e en ions ha ha e had posi i e
e ec s, as well as he main cha ac e is ics a digi al in e en ion should possess o
educe sexually isky beha io s in adolescen s.
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EFFECTIVENESS OF DIGITAL INTERVENTIONS TO REDUCE SCHOOL- AGE ADOLESCENT SEXUAL
RISKS: A SYSTEMATIC REVIEW
INTRODUCTION
Adolescence is a pe iod o ansi ion ha in ol es g ea physical,
psychological, social, and emo ional changes, which a y based on
se e al ac o s such as he educa ion ecei ed, he en i onmen ,
con ex , and skills, among o he s (Simanjun ak e al., 2023), and can
a ec bo h sex educa ion and sexual beha io . Inc eases in isky
sexual beha io s among adolescen s uden s—such as ha ing sexual
in e cou se a younge ages o no using condoms in hei sexual
in e cou ses (Inchley e al., 2018)—ha e spa ked ala m and become
an a ea o in e es o global public heal h esea che s, who ha e
sough inno a i e app oaches o p omo e be e heal hy sexual ou -
comes (Ha una e al., 2018). Due o he inc ease in isky beha io s,
an inc ease in sexually ansmi ed in ec ions (STIs) has been ob-
se ed in his popula ion (Wo ld Heal h O ganiza ion [WHO], 2019).
O he es ima ed 39.0 million people li ing wi h HIV wo ldwide in
2022, 2.58 million we e child en aged 0–19. Human papilloma i us
(HPV) is he mos common STI, and he e we e abou 43 million
HPV in ec ions in 2018, many among people in hei la e eens and
ea ly 20s. Chlamydia, gonococcus, and HIV a e common STIs as well
(WHO, 2021a). In addi ion o sexually ansmi ed diseases, adoles-
cen gi ls ace he possibili y o unin ended p egnancies ha may
end in abo ions, eclampsia, pue pe al endome i is, and sys emic
in ec ions, which can be dange ous o he adolescen heal h (Sully
e al., 2019).
The Uni ed Na ions has p oclaimed sexual and ep oduc i e
heal h o be a uni e sal human igh (Panchaud, 2022). Acco ding o
WHO, sexual heal h is a s a e o physical, emo ional, men al, and so-
cial well- being in ela ion o sexuali y. Sexual heal h equi es a pos-
i i e and espec ul app oach o sexuali y and sexual ela ionships,
as well as he possibili y o ha ing pleasu able and sa e sexual expe-
iences, ee o coe cion, disc imina ion, and iolence (WHO, 2024).
So, he abo e da a show ha educa ion on sexuali y and ep oduc-
ion is necessa y o equip young people wi h he knowledge, skills,
a i udes, and alues hey need o de e mine and enjoy hei sex-
uali y, physically and emo ionally, indi idually and in ela ionships.
T adi ionally, he bes se ing o sex educa ion is he school, whe e
heal h p o essionals and eache s ha e easie access o young peo-
ple (Gold a b & Liebe man, 2021). Howe e , gi en ha adolescen s
p io i ize con iden iali y and accessibili y o e eliable heal h in o -
ma ion, digi al in e en ions ha e ecen ly become mo e ele an
o sex educa ion (B ayboy e al., 2018). Digi al in e en ions—also
called In e ne - based o web- based in e en ions—a e he use
o he In e ne o acili a e he dissemina ion o heal h- ela ed
in o ma ion and o connec pa ien s o suppo (Na ional Lib a y o
Medicine, 2023). This can include ex message in e en ions, sma -
phone applica ions, and websi es. The use o digi al in e en ions is
a p omising me hod o add ess sexual and ep oduc i e heal h dis-
pa i ies among di e en g oups o adolescen s. Such in e en ions
a e also mo e easily sp ead and implemen ed and ha e highe e -
icacy and g ea e engagemen compa ed o adi ional beha io al
in e en ions (B ayboy e al., 2018).
The WHO ecommends lis ening o young people o design sus-
ainable digi al solu ions, because hey a e expe s on hei heal h
needs, he echnologies hey use, and how hey access o in o -
ma ion (WHO, 2021b). Technologies a e pa o he ou ine o ad-
olescen s, who use hem o in o ma ion seeking, communica ion,
and leisu e. Mos (95%) o eens now epo ha ing a sma phone
o access o one (Robb e al., 2019). These mobile connec ions a e,
in u n, mo i a ing mo e pe sis en online ac i i ies: 45% o eens
now say hey a e online on a nea - cons an basis. Howe e , he e is
no clea consensus abou he e ec ha social ne wo ks and online
in e en ions ha e on he li es o young people oday. Mos eens
desc ibe ha e ec as mos ly posi i e (31%) o mos ly nega i e
(24%), bu nea ly hal (45%) say ha e ec is nei he posi i e no
nega i e (Robb e al., 2019). I is hus e y impo an o ensu e good
digi al li e acy and o each young people he necessa y esou ces
o use echnology o ma e s o sexual heal h. A digi al in e en-
ion in schools could hus be a p omising solu ion o he p omo ion
o sexual heal h and he p e en ion o isky sexual beha io among
adolescen s.
Se e al li e a u e e iews ha e been published on digi al in e -
en ions o p e en isky sexual beha io in adolescen s (B ayboy
e al., 2018; Gold a b & Liebe man, 2021; Nou imand e al., 2022),
bu he e has been no s anda diza ion o in e en ions and a clea
end owa d he use o echnologies (B ayboy e al., 2018) o he
use o he school as an in e en ion se ing. These e iews p o ide
ex ensi e suppo o a b oad and comp ehensi e ea men o sex
educa ion, as well as o he e ec i eness o digi al in e en ions
(B ayboy e al., 2018; Gold a b & Liebe man, 2021; Nou imand
e al., 2022). Howe e , hese e iews included a icles wi h di e en
designs, including andomized con ol ials (RCTs), c oss- sec ional
s udies, p o ocols, expe imen al and quasi- expe imen al s udies,
and coho s ha may ha e in luenced he indings (Nou imand
e al., 2022). Fo his eason, new e iews on his subjec a e ecom-
mended o o e come hese limi a ions.
The objec i e o his sys ema ic e iew is o summa ize and e alu-
a e exis ing esea ch on digi al in e en ions o imp o e adolescen s'
Clinical ele ance: Digi al in e en ions wi h adolescen s imp o e sexual beha io s
and can be a aluable esou ce in educa ion on his opic due o hei accessibili y and
con iden iali y, wo key poin s o young people.
KEYWORDS
adolescen , heal h educa ion, in e ne - based in e en ion, sexual beha io
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EFFECTIVENESS OF DIGITAL INTERVENTIONS TO REDUCE SCHOOL- AGE ADOLESCENT SEXUAL
RISKS: A SYSTEMATIC REVIEW
knowledge, a i udes, in en ion, and beha io s ela ed o sexual isk
and how such in e en ions ha e been implemen ed. Fo u u e e-
sea che s, i is in ended o be use ul o gene a e e ec i e online
in e en ions on sexuali y in schools. This e iew in es iga ed he
ollowing esea ch ques ion: A e digi al applica ion in e en ions e -
ec i e o p e en isky sexual beha io s in school- age adolescen s?
METHODS
To achie e he esea ch objec i es, a sys ema ic e iew was ca ied
ou be ween Janua y and Decembe 2023 in acco dance wi h he
PRISMA Decla a ion. This sys ema ic e iew has been egis e ed
wi h PROSPERO unde ID CRD42022306728. PROSPERO is an in-
e na ional da abase o p ospec i ely egis e ed sys ema ic e iews
in heal h and social ca e, wel a e, public heal h, educa ion, c ime,
jus ice, and in e na ional de elopmen and is unded by he Na ional
Ins i u e o Heal h Resea ch (NIHR). PROSPERO aims o p o ide
a comp ehensi e lis o sys ema ic e iews egis e ed a incep ion
o help a oid duplica ion and educe he oppo uni y o epo ing
bias by allowing compa ison o he comple ed e iew wi h wha was
planned in he p o ocol.
Eligibili y c i e ia
To be included, a icles should be RCTs o quasi- expe imen al
ials. The e we e no es ic ions on language and yea o
publica ion. A icles should include adolescen s (10–19 yea s
old) who ecei ed digi al applica ion in e en ions, in e en ions
de eloped in any school, and an e alua ion o he e ec i eness o
he digi al in e en ion. We decided ha he digi al in e en ions
would be de eloped a schools o uni y as much as possible he
cha ac e is ics and con ex o he popula ion and he de elopmen
and cha ac e is ics o he in e en ions. Ou sc eening eam
excluded an a icle i i was a case- con olled ial, coho s udy,
case epo , case se ies, non- o iginal esea ch, seconda y epo ,
commen a y, edi o ial, e iew, a s udy ha did no epo ou comes
ela ed o sexual p e en ion, a s udy weak me hodological quali y,
o a s udy ha included adolescen s wi h in ellec ual disabili y,
lea ning disabili ies, ano he disabili y, isk, o any illness ha
equi ed a speci ic in e en ion.
In o ma ion sou ces
The sea ch was conduc ed independen ly by wo esea che s in i e
elec onic da abases (PubMed, Web o Science, Scopus, EMBASE,
and PsycINFO). We also manually sea ched he e e ence lis o in-
cluded s udies o iden i y po en ially ele an s udies.
Resea ch s a egy
To selec he keywo ds, an ini ial sea ch was ca ied ou in di e en
e iew pape s wi h a simila subjec ma e o ob ain a be e o e iew
o he opic o be add essed and o ob ain all he essen ial in o ma ion
o his e iew. A specialized lib a ian was also consul ed. The sea ch
s a egy was elabo a ed ollowing he popula ion, in e en ion/expo-
su e, compa a o , ou come, ime, and s udy design (PICOTS) s uc u e
as isualized in Table 1 and he e iew ques ion was: “A e digi al ap-
plica ion in e en ions e ec i e o p e en isky sexual beha io s in
school- age adolescen s?” The ollowing sea ch s a egy was used:
(Adolescen OR s uden OR een OR school- age OR mino ) AND (ap-
plica ion OR so wa e OR de ice OR “mobile applica ion” OR “mobile
app” OR m- heal h OR e- heal h OR “in e ne based” OR “web based”
OR “Compu e - assis ed ins uc ion” OR “Educa ional echnology”
OR online) AND (“sexual beha io ” OR “sexual heal h” OR “STD” OR
“sexually ansmi ed diseases” OR “sexual and ep oduc i e heal h”
OR “HIV” OR “p egnancy, unwan ed” OR “sex o enses”) AND (in e -
en ion OR “sex educa ion” OR “heal h educa ion” OR p og am OR
p e en ion OR “heal h p omo ion”). The e we e no es ic ions on lan-
guage, yea o publica ion, o a icle ype. The sea ch s a egy adap ed
o he di e en da abases can be ound in Table S1.
Selec ion p ocess and da a collec ion
All sea ch esul s we e impo ed in o a Google sp eadshee o
sc een i le, au ho /s, and bibliog aphic e e ence. Two e iewe s
TABLE 1 Popula ion, in e en ion/exposu e, compa a o , ou come, ime, and s udy design (PICOTS) c i e ia.
PICOTS c i e ia
Popula ion Adolescen s (10–19- yea - olds) in school. Any social, economic, and cul u al class
In e en ion/Exposu e Digi al in e en ions o p e en isky sexual beha io s in adolescen s using web, applica ion mobile, online p og am,
e c.
Compa a o Habi ual me hodology educa ional in e en ion o p e en isky a ec i e- sexual beha io s in adolescen s o no
in e en ion
Ou come P e en ion o isky sexual beha io s in adolescen s and hei measu e o e ec s: condom use, numbe o pos coi al
con acep i es, numbe o unwan ed p egnancies, and numbe o induced abo ions and sexually ansmi ed diseases
Time No applicable
S udy design Randomized con olled ials (RCTs) o quasi- expe imen al ials
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EFFECTIVENESS OF DIGITAL INTERVENTIONS TO REDUCE SCHOOL- AGE ADOLESCENT SEXUAL
RISKS: A SYSTEMATIC REVIEW
selec ed s udies in wo di e en ounds. Fi s , bo h e iewe s
ead he i le and abs ac and so ed by inclusion o exclusion
c i e ia. Duplica e a icles we e emo ed manually. Second,
he included da a a icles ex ac ed independen ly by he wo
e iewe s we e impo ed in o an online Google sp eadshee in a
s anda dized o de . Bo h e iewe s ag eed on he e iew o he
a icles and all disc epancies and disag eemen s we e discussed
and esol ed by e iewing he inclusion o exclusion c i e ia and
eaching a consensus o asking o hi d e iewe . Finally, he whole
p ocess was alida ed by a senio esea ch membe . This sc eening
and da a ex ac ion p ocedu e is ep esen ed h ough he PRISMA
low diag am in Figu e 1.
Da a i ems and syn hesis me hods
Da a ex ac ed om he included a icles we e collec ed in h ee
s anda dized ables o eam consensus. These ables displayed he
in o ma ion by p ojec , because mo e han one pape o en e e ed
o he same p ojec . The i s able showed s udy cha ac e is ics,
design, coun y o s udy, popula ion, sample, and ollow- up, ou comes
included, and main e ec s o he in e en ion (only hose wi h
p < 0.05). When possible, Cohen's d was calcula ed; we conside ed
alues o 0.2 low, 0.5 mode a e, and 0.8 la ge e ec s. When o e ed,
we used he odds a io (1.50 low e ec , 3.50 mode a e, and 9.00
la ge e ec ). Howe e , gi en he he e ogenei y o he s udies wi h
espec o in e en ions, pa icipan s, and ou come measu es, we
did no calcula e pooled e ec sizes.
The second able summa ized he posi i e o nega i e e ec s
o he in e en ions on p ima y ou comes (sexual in e cou se and
con acep i e use) and seconda y ou comes (knowledge and a i-
udes) in a pe iod o less han 6 mon hs and in a pe iod longe han
6 mon hs. The hi d able cap u ed in e en ion ea u es such as se -
ing, heo y, objec i e, numbe , equency and du a ion o sessions,
acili a o s, esou ces, and implemen a ion. Any missing and unclea
in o ma ion was desc ibed as “no da a” in he ables.
Bias assessmen
Me hodological quali y was a ed using he Quali y Assessmen
Tool o Quan i a i e S udies de eloped by he E ec i e Public
Heal h P ac ice P ojec (EPHHP). The quali y assessmen i ems
we e selec ion bias, s udy design, con ounde s, blinding, da a
collec ion me hods, and wi hd awal/d opou (EPHHP, 2022). Bo h
e iewe s we e ained in he use o s udy- a ing ins umen s.
FIGURE 1 Flowcha o he selec ion o a icles o he sys ema ic e iew.
Reco ds iden i ied h ough da abase (n = 9060)
PubMed (n = 2579)
PsycINFO (n = 972)
Web o Science (n = 860)
EMBASE (n = 558)
Scopus (n = 4091)
Reco ds om g ay li e a u e (n = 0)
Reco ds om o wa d and backwa d e e ence
sc eening (n=1007)
Sc eening
Included Eligibili y Iden i ica ion
Reco ds a e duplica es emo ed
(n =6520)
Selec e e ences a e eading i le and
abs ac (n = 172)
Full- ex e e ences assessed o eligibili y
(n = 172)
Full- ex a icles excluded (n =145),
due o:
Me hodological quali y weak
No ela ed o in e en ion
No a RCT o quasi-
expe imen al
The e ec i eness o he
in e en ion no e alua ed
No adolescen s (10–19)
No in a school se ing
S udies included
(n=27)
Reco ds excluded
(n = 3547)
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EFFECTIVENESS OF DIGITAL INTERVENTIONS TO REDUCE SCHOOL- AGE ADOLESCENT SEXUAL
RISKS: A SYSTEMATIC REVIEW
We sco ed each i em wi h “s ong”, “mode a e” and “weak”
depending on he answe s o di e en ques ions ha desc ibes
Quali y Assessmen Tool o Quan i a i e S udies Dic iona y.
Finally, we classi ied a icles as “s ong”, “mode a e”, and “weak”.
A hi d e iewe econciled any disag eemen be ween he main
esea che s.
E ec measu es
The p incipal ou come was p e en ion o isky sexual beha io s in
adolescen s whose measu ed e ec s we e sexual in e cou se and
con acep i e use as p ima y ou comes and knowledge and a i-
udes as seconda y ou comes.
RESULTS
As can be seen in Figu e 1, he li e a u e sea ch in he a ious
da abases yielded 9060 eco ds (2579 PubMed, 972 PsycINFO,
860 Web o Science, 558 EMBASE, and 4091 Scopus) and 1007
eco ds om he bibliog aphies o he a icles included. We so ed
he iden i ied publica ions by i le and ound ha he e we e 3547
duplica es. A e he emo al o duplica es, he emaining e-
co ds we e il e ed in acco dance wi h he inclusion and exclusion
c i e ia by i le and abs ac . Examining he i les and abs ac s
esul ed in 172 eligible eco ds. The ull ex s o he emaining e-
co ds we e subsequen ly examined. S udies ha came om he
e e ence lis s o he included a icles we e examined. A o al o
27 publica ions we e ul ima ely conside ed eligible and e ained
o he e iew.
The da es o he publica ions o he 27 s udies included in
his sys ema ic e iew anged om 1987 o p esen ; howe e ,
mos we e published a e 2017. The p ojec s we e de eloped
mainly in he Uni ed S a es, wi h o he si es in Pue o Rico (Va as-
Díaz e al., 2019), Mexico (Cas illo- A cos e al., 2016; Doubo a
e al., 2017), B azil (Halpe n e al., 2008), China (Hu e al., 2023;
Jin e al., 2021), Malaysia (Nik Fa id e al., 2018), Ko ea (Jeong
e al., 2017), Uganda (Yba a e al., 2013, 2015), and Kenya (Halpe n
e al., 2008). Two o he p ojec s did no de ine he loca ion o he in-
e en ion (Fiellin e al., 2017; Robe o, Zimme man, Ca lyle, Abne ,
Cupp, e al., 2007).
Me hodological ea u es
The me hodological ea u es o he s udies a e shown in Table S2.
S udy design
Rega ding he s udy design, all we e clus e RCTs excep o i e
a icles, which we e quasi- expe imen al (Cas illo- A cos e al., 2016;
Halpe n e al., 2008; Jeong e al., 2017; Kann, 1987; Robe o,
Zimme man, Ca lyle, & Abne , 2007), and one ield ial (Doubo a
e al., 2017). Mos o he publica ions wo ked wi h a con ol g oup
and an in e en ion g oup, excep o h ee publica ions ha
used wo expe imen al g oups and one con ol g oup (Ma kham
e al., 2012; Mu y e al., 2018, 2019), one publica ion ha used an
expe imen al g oup and wo con ol g oups (Kann, 1987), and one
publica ion ha wo ked wi h wo expe imen al g oups and wo con-
ol g oups (Halpe n e al., 2008).
Finally, se en s udies used a p e es and pos es mea-
su e (Cas illo- A cos e al., 2016; Halpe n e al., 2008; Nik
Fa id e al., 2018; Robe o, Zimme man, Ca lyle, Abne , Cupp,
e al., 2007; Scull e al., 2018; To ole o e al., 2010; Widman
e al., 2020), one s udy used a p e es and 3- mon h- ollow- up
measu es (Raghupa hy e al., 2013), ano he s udy used a p e es
and 10- week- ollow- up measu e (Robe o, Zimme man, Ca lyle, &
Abne , 2007), wo s udies used a p e es and 6- mon h- ollow- up
(Mu y e al., 2018, 2019), and one s udy used a p e es and
12- mon h- ollow- up measu e (Peskin e al., 2015) wi hou an im-
media e pos es . The es o he s udies used mo e han wo mea-
su es o e ec s.
Quali y assessmen
O he 27 a icles included in he sys ema ic e iew, 13 we e classi-
ied as “s ong” in me hodological quali y and 14 as “mode a e”. Fou
publica ions (Chong e al., 2013; Ha una e al., 2019, 2021; Ligh oo
e al., 2007), ha we e o iginally included in he sys ema ic e iew
because hey me he inclusion c i e ia, we e emo ed om he e-
iew because hei me hodological quali y was “weak”, and he e-
sea ch eam decided o exclude i o ob ain highe quali y esul s.
Pa icipan s
Mos o he a icles included did no p o ide comple e in o ma ion
abou hei pa icipan s, which made i di icul o d aw a clea de-
mog aphic p o ile. In he 27 included a icles, he pa icipan s we e
adolescen s and in h ee o hem pa en s we e also included (Mu y
e al., 2018, 2019; Va as- Díaz e al., 2019).
The pa icipan s we e mos ly en olled in schools whe e digi al
in e en ions we e ca ied ou . O he se ings included an u ban
educa ional ins i u ion (Cas illo- A cos e al., 2016), a communi y o -
ganiza ion (Va as- Díaz e al., 2019), and u ban a e - school and sum-
me camp p og ams (Fiellin e al., 2017). The s udies whose sample
we e he pa en s o adolescen s we e also de eloped in schools
(Mu y e al., 2018, 2019; Va as- Díaz e al., 2019).
Rega ding gende , mos o he in e en ions we e aimed a bo h
boys and gi ls. Howe e , he e was a g ea e endency o gi ls o
pa icipa e. Howe e , we ound ou s udies in which he p opo ion
o boys in he s udy popula ion was highe (Fiellin e al., 2017; Nik
Fa id e al., 2018; Yba a e al., 2013, 2015) and wo s udies wi h an
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EFFECTIVENESS OF DIGITAL INTERVENTIONS TO REDUCE SCHOOL- AGE ADOLESCENT SEXUAL
RISKS: A SYSTEMATIC REVIEW
equal p opo ion o boys and gi ls (Jin e al., 2021; Scull e al., 2018).
Ano he s udy had wo s udy g oups in which one g oup (B azil) had
a highe p opo ion o gi ls and he o he g oup (Kenya) had a highe
p opo ion o boys (Halpe n e al., 2008). The e was one s udy ha
did no desc ibe he gende o i s pa icipan s (Po e e al., 2016).
Mos s udies calcula ed he mean age and s anda d de ia ion o
hei sample, luc ua ing be ween 12.09/0.79 (Jin e al., 2021) and
16.25/0.76 (Widman e al., 2020), excep o he s udy whose in e -
en ion was de eloped by pa en s whose mean age and s anda d
de ia ion was 42.5/8.25 (Va as- Díaz e al., 2019). Th ee s udies did
no make his calcula ion and included hei sample in age g oups,
om 12 yea s old (Kann, 1987; Nik Fa id e al., 2018) o 19 yea s old
(Kann, 1987). The e we e wo s udies ha did no p o ide his in o -
ma ion (Jeong e al., 2017; Po e e al., 2016).
When aken oge he , he size o he samples o he 27 s udies
anged om 88 (Jeong e al., 2017) o 3244 (Po e e al., 2016) pa -
icipan s, wi h a mean o 751.071 pa icipan s (SD = 786.979).
The e en ion a e o he in e en ions included in he sys ema ic
e iew was abo e 70%, excep in wo s udies (Robe o, Zimme man,
Ca lyle, & Abne , 2007; Robe o, Zimme man, Ca lyle, Abne , Cupp,
e al., 2007) whe e hese da a we e no desc ibed, ano he s udy
whe e he e en ion a e was 69.40% (To ole o e al., 2010), and an-
o he s udy which di ided i s sample in o wo g oups, one o which
achie ed a e en ion a e o 77% (B azil) and he o he 51% (Kenya)
(Halpe n e al., 2008).
In e en ion cha ac e is ics
In e en ion goal
Table S3 summa izes he cha ac e is ics o he in e en ions ob-
ained in he sys ema ic e iew. F om he 27 publica ions included,
18 digi al in e en ions we e ex ac ed. All digi al in e en ions in
ou sys ema ic e iew sough o imp o e adolescen sexual heal h.
Mos o hem achie ed his goal by inc easing sexual knowledge,
inc easing con acep i e use, and imp o ing adolescen sexual a -
i udes. Th ee in e en ions aimed o imp o e adolescen sexual
heal h by delaying sexual ini ia ion (Ma kham e al., 2012; Peskin
e al., 2015, 2019; Po e e al., 2016; To ole o e al., 2010), one
in e en ion aimed o imp o e media li e acy educa ion o im-
p o e adolescen sexual heal h (Scull e al., 2018, 2022), and wo
in e en ions aimed o imp o e adolescen communica ion wi h
pa en s (Mu y e al., 2018, 2019) o in e pe sonal communica ion
(Kann, 1987).
In e en ion acili a o s
All bu h ee in e en ions (Halpe n e al., 2008;Nik Fa id e al., 2018;
Widman e al., 2018, 2020) had acili a o s who de eloped he in e -
en ion and helped he adolescen s ca y i ou . These acili a o s
we e ei he school eache s wi h p io aining, membe s o he e-
sea ch eam, a membe o he heal h ca e eam, o echnology in e -
en ion assis an s o acili a o aine s speci ically chosen o he
in e en ion.
In e en ion s a egies
Mos o he in e en ions we e digi al, bu he e we e h ee s udies
ha used websi e and ace- o- ace sessions in he school (Cas illo-
A cos e al., 2016; Doubo a e al., 2017; Jeong e al., 2017), and
ou s udies used compu e - based ac i i ies and g oup- based class-
oom ac i i ies (Ma kham e al., 2012; Peskin e al., 2019; Po e
e al., 2016; To ole o e al., 2010).
The me hodologies used in he di e en in e en ions we e
mainly ideos (Hu e al., 2023; Jin e al., 2021; Nik Fa id e al., 2018;
Peskin e al., 2015; Raghupa hy e al., 2013; Va as- Díaz e al., 2019;
Widman e al., 2018, 2020; Yba a e al., 2013, 2015), i ual ole-
playing (Doubo a e al., 2017; Fiellin e al., 2017; Mu y e al., 2018,
2019; Peskin e al., 2015; Raghupa hy e al., 2013), games (Doubo a
e al., 2017; Fiellin e al., 2017; Widman e al., 2018, 2020), o quizzes
(Peskin e al., 2015; Raghupa hy e al., 2013; Widman e al., 2018,
2020). Fi e s udies did no p o ide de ails abou which me hodology
was used in hei in e en ions (Cas illo- A cos e al., 2016; Halpe n
e al., 2008; Kann, 1987; Mu y e al., 2018, 2019; Scull e al., 2018,
2022).
Theo ical amewo k
Mos in e en ions we e based on heo e ical models o beha io
change— ha is, social cogni i e heo y (Ma kham e al., 2012; Peskin
e al., 2019; Po e e al., 2016; To ole o e al., 2010; Va as- Díaz
e al., 2019), heo y o planned beha io (Scull e al., 2018, 2022;
Va as- Díaz e al., 2019), heo ies o easoned ac ion and planned
beha io (Scull e al., 2018, 2022; Va as- Díaz e al., 2019; Widman
e al., 2018, 2020), o he in o ma ion- mo i a ion- beha io al skills
model (Peskin e al., 2015; Yba a e al., 2013, 2015) among o he s.
Se en s udies did no desc ibe he heo e ical model o hei in e -
en ion heo e ical model (Fiellin e al., 2017; Halpe n e al., 2008;
Hu e al., 2023; Jin e al., 2021; Kann, 1987; Nik Fa id e al., 2018;
Raghupa hy e al., 2013).
In e en ion sessions
The e was a mean o 8.51 digi al sessions in he in e en ion
ac oss s udies (SD = 7.12) and a mode is six sessions (Cas illo-
A cos e al., 2016; Halpe n e al., 2008; Mu y e al., 2018, 2019;
Raghupa hy e al., 2013; Va as- Díaz e al., 2019; Yba a e al., 2013,
2015). The sho es in e en ions had 1 digi al session (Nik Fa id
e al., 2018; Widman e al., 2018, 2020) and he longes in e en-
ion has 24 digi al sessions (Ma kham e al., 2012; Peskin e al., 2019;
Po e e al., 2016; To ole o e al., 2010).
The du a ion o he sessions o he in e en ions anged be ween
15 and 90 min, wi h a mean o 49.21 (SD = 19.58). The e was one
s udy ha did no say how long he digi al sessions las ed, and his
was omi ed om he calcula ion o he mean (Halpe n e al., 2008).
In e en ion con en s
The con en s o he sessions o he di e en in e en ions a e
shown in Table S3. Main con en s o sessions we e knowledge abou
HIV/STI, p egnancy and con acep ion, sexual skills and s a egies o
imp o e communica ion.
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EFFECTIVENESS OF DIGITAL INTERVENTIONS TO REDUCE SCHOOL- AGE ADOLESCENT SEXUAL
RISKS: A SYSTEMATIC REVIEW
Main e ec s
Signi ican e ec s (p < 0.05) a e shown in Table 2 and Table S2. All
s udies showed some posi i e e ec on adolescen sexual heal h,
ei he in e ms o sexual knowledge, sexual a i ude, o sexual be-
ha io such as con acep i e use o heal hie sexual in e cou se
compa ed o ecei ing no sexual in e en ion o ecei ing he usual
sexual in e en ion om hei school. Mos in e en ions ha aimed
o imp o e sexual heal h educa ion in adolescen s ound low o
mode a e e ec s. The e we e ou publica ions ha ound la ge e -
ec s o seconda y ou comes, wi h d = 4.78 in HIV/sexually ans-
mi ed disease (STD) knowledge (Widman e al., 2018); d = 1.27 in
HIV/STD knowledge (Widman e al., 2020), d = 1.16 in sexual knowl-
edge (Hu e al., 2023), d = 1.38 in STI knowledge (Jeong e al., 2017);
and d = 0.90 in sexual knowledge (Robe o e al., 2008).
Focusing on he e alua ion ime amewo k, om s udies ha as-
sess p ima y sexual ou comes, eigh s udies showed posi i e e ec s
on sexual in e cou se (Ma kham e al., 2012; Peskin e al., 2019;
Raghupa hy e al., 2013; Robe o e al., 2008; Robe o, Zimme man,
Ca lyle, & Abne , 2007; Robe o, Zimme man, Ca lyle, Abne , Cupp,
e al., 2007; To ole o e al., 2010; Yba a e al., 2013), o which only
wo had such e ec s a 6 mon hs (Ma kham e al., 2012; To ole o
e al., 2010). These e ec s a sho ime we e low, anging om
d = 0.11 (Robe o, Zimme man, Ca lyle, & Abne , 2007) o d = 0.3
(Raghupa hy e al., 2013).
Rega ding concep i e use, 11 s udies (Jeong e al., 2017;
Ma kham e al., 2012; Peskin e al., 2015, 2019; Robe o e al., 2008;
Scull e al., 2018; To ole o e al., 2010; Widman e al., 2018, 2020;
Yba a e al., 2013, 2015) demons a ed low posi i e e ec s wi h
Cohen's d be ween d = 0.20 (Robe o e al., 2008) and d = 0.43
(Widman e al., 2018). Fi e s udies main ained hese e ec s o e
ime up o 6 mon hs (Jeong e al., 2017; Ma kham e al., 2012; Peskin
e al., 2015; Widman e al., 2018; Yba a e al., 2015). Addi ionally,
one s udy did no show signi ican da a be o e 6 mon hs bu showed
posi i e e ec s a 6 mon hs (Doubo a e al., 2017). Finally, and
one s udy showed nega i e e ec s on con acep i e use (Halpe n
e al., 2008).
Rega ding seconda y ou comes, 21 s udies ound ha sexual
knowledge was imp o ed by he digi al in e en ion (Cas illo- A cos
e al., 2016; Doubo a e al., 2017; Fiellin e al., 2017; Hu e al., 2023;
Jeong e al., 2017; Jin e al., 2021; Kann, 1987; Ma kham e al., 2012;
Nik Fa id e al., 2018; Peskin e al., 2015, 2019; Po e e al., 2016;
Raghupa hy e al., 2013; Robe o e al., 2008; Robe o, Zimme man,
Ca lyle, & Abne , 2007; Robe o, Zimme man, Ca lyle, Abne ,
Cupp, e al., 2007; Scull e al., 2022; To ole o e al., 2010; Widman
e al., 2018, 2020; Yba a e al., 2015), wi h 11 o hese s udies main-
aining he imp o emen o e ime (Doubo a e al., 2017; Fiellin
e al., 2017; Hu e al., 2023; Jeong e al., 2017; Ma kham e al., 2012;
Peskin e al., 2015, 2019; Po e e al., 2016; To ole o e al., 2010;
Widman e al., 2018; Yba a e al., 2015). A s udy showed ha he
le el o sexual knowledge d opped a 6 mon hs (Jin e al., 2021).
These posi i e e ec s we e di ided in o se en s udies ha had a
low e ec wi h Cohen's d be ween d = 0.13 (Robe o, Zimme man,
Ca lyle, Abne , Cupp, e al., 2007) and d = 0.39 (Cas illo- A cos
e al., 2016), one s udy wi h mode a e e ec s (d = 0.61; Robe o,
Zimme man, Ca lyle, & Abne , 2007) and i e s udies wi h la ge e -
ec s on knowledge whose Cohen's d was be ween d = 0.90 (Robe o
e al., 2008) and d = 4.78 (Widman e al., 2018). The emaining s ud-
ies did no gi e a Cohen's d.
Rega ding sexual a i udes, 7 ele en demons a ed posi i e e -
ec s (Doubo a e al., 2017; Fiellin e al., 2016; Hu e al., 2023; Jin
e al., 2021; Kann, 1987; Robe o e al., 2008; Robe o, Zimme man,
Ca lyle, & Abne , 2007; Robe o, Zimme man, Ca lyle, Abne , Cupp,
e al., 2007; Widman e al., 2018, 2020; Yba a e al., 2015). These
e ec s we e, in gene al, mode a e wi h Cohen's d be ween d = 0.55
(Widman e al., 2020) and d = 0.78 (Widman e al., 2018). They we e
main ained o e ime, excep o one a icle in which he posi i e
e ec s dec eased (Jin e al., 2021) and ano he in which long- e m
e ec s we e no desc ibed (Widman e al., 2020).
In e en ion s a egy
The in e en ions ha we e exclusi ely digi al showed a g ea e
inc ease in sexual knowledge (Hu e al., 2023; Jin e al., 2021;
Kann, 1987; Nik Fa id e al., 2018; Peskin e al., 2015; Raghupa hy
e al., 2013; Robe o, Zimme man, Ca lyle, & Abne , 2007; Robe o,
Zimme man, Ca lyle, Abne , Cupp, e al., 2007; Widman e al., 2018,
2020; Yba a e al., 2013, 2015), sexual a i ude (Halpe n e al., 2008;
Hu e al., 2023; Jin e al., 2021; Kann, 1987; Raghupa hy e al., 2013;
Robe o e al., 2008; Robe o, Zimme man, Ca lyle, & Abne , 2007;
Robe o, Zimme man, Ca lyle, Abne , Cupp, e al., 2007; Widman
e al., 2018, 2020; Yba a e al., 2013, 2015), sexual communica-
ion (Widman e al., 2018, 2020), and sel - e icacy/e icacy (Halpe n
e al., 2008; Peskin e al., 2015; Robe o e al., 2008; Robe o,
Zimme man, Ca lyle, & Abne , 2007; Robe o, Zimme man, Ca lyle,
Abne , Cupp, e al., 2007). Howe e , sexual beha io was no modi-
ied by he in e en ion, excep in one case (Kann, 1987). The a i-
cles ha measu ed esul s o e a pe iod o 6 mon hs showed hese
esul s we e no sus ained o e ime (Hu e al., 2023; Jin e al., 2021;
Raghupa hy e al., 2013; Widman e al., 2018, 2020).
Fi e in e en ions combined ace- o- ace sessions wi h dig-
i al sessions (Cas illo- A cos e al., 2016; Doubo a e al., 2017;
Jeong e al., 2017; Ma kham e al., 2012; Peskin e al., 2019; Po e
e al., 2016; To ole o e al., 2010) and hei e ec s we e gene ally
posi i e. In less han 6 mon hs, he e was an imp o emen in sex-
ual knowledge (Cas illo- A cos e al., 2016; Doubo a e al., 2017;
Jeong e al., 2017; Peskin e al., 2019; Po e e al., 2016; To ole o
e al., 2010), sel - e icacy (Jeong e al., 2017; Peskin e al., 2019;
Po e e al., 2016; To ole o e al., 2010), sexual a i ude (Doubo a
e al., 2017; Ma kham e al., 2012), and con acep i e use (Doubo a
e al., 2017; Jeong e al., 2017; Ma kham e al., 2012; Peskin
e al., 2019; Po e e al., 2016; To ole o e al., 2010), and in
mo e han 6 mon hs, he e we e posi i e e ec s in con acep i e
use (Jeong e al., 2017; Ma kham e al., 2012), sexual knowledge
(Jeong e al., 2017; Ma kham e al., 2012; Peskin e al., 2019; Po e
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EFFECTIVENESS OF DIGITAL INTERVENTIONS TO REDUCE SCHOOL- AGE ADOLESCENT SEXUAL
RISKS: A SYSTEMATIC REVIEW
TABLE 2 Ou comes e ec s.
In e en ion Au ho /s and yea
P ima y ou come Seconda y ou come
Sexual in e cou se Con acep i e use Knowledge A i udes
<6 mon hs ≥6 mon hs <6 mon hs ≥6 mon hs <6 mon hs ≥6 mon hs <6 mon hs ≥6 mon hs
“You and Me” Hu e al. (2023)NS NS NS NS + + + +
Jin e al. (2021)ND ND ND ND ++↓ +−
“Media Awa e” Scull e al. (2022)ND ND ND ND +ND ND ND
Scull e al. (2018)ND ND +ND ND ND ND ND
“HEART” Widman e al. (2020)ND ND +ND +ND +ND
Widman e al. (2018)ND ND + + + + + +
“Cuídalos” Va as- Díaz e al. (2019)ND ND ND ND ND ND ND ND
“Pa hways o A ican Ame ican Success”
(PAAS)
Mu y e al., 2019 ND ND ND ND ND ND ND ND
Mu y e al. (2018)ND ND ND ND ND ND ND ND
“Malaysian Ca e o Adolescen P ojec ”
(MyCAP)
Nik Fa id e al. (2018)ND ND ND ND +ND NS ND
“I 's You Game” (IYG) Peskin e al. (2019)+NS +NS + + NS NS
Po e e al. (2016)NS −NS NS + + NS NS
To ole o e al. (2010)+++NS + + ND ND
“IYG- Tech” Peskin e al. (2015)NS NS + + + + ND ND
Sma phone app Jeong e al. (2017)ND ND + + + + ND ND
In e ne - based educa ional in e en ion Doubo a e al. (2017)ND ND NS + + + + +
“PlayFo wa d” Fiellin e al. (2017)NS NS ND ND + + + +
“Connec ” Cas illo- A cos e al. (2016)ND ND ND ND +ND ND ND
“Cybe Senga” Yba a e al. (2015)ND ND + + + + + +
Yba a e al. (2013)+NS +NS ND ND ND ND
“Abs inence and Con acep ion Educa ion
S o ehouse”: ACES
Raghupa hy e al. (2013)+ND ND ND +ND ND ND
“Risk a oidance” (RA) and “Risk educ ion”
(RR)
Ma kham e al. (2012)+ + + + + + ND ND
“Teen Web” Halpe n e al. (2008)ND ND −ND −ND ND ND
Compu e - and In e ne - based in e en ion Robe o e al. (2008)+ND +ND +ND +ND
Robe o, Zimme man, Ca lyle,
and Abne (2007)
+ND NS ND +ND +ND
Robe o, Zimme man, Ca lyle,
and Abne (2007)
+ND NS ND +ND +ND
“CAI” Kann (1987)ND ND ND ND +ND +ND
Abb e i ions: ND, no da a; NS, no signi ican ; +, posi i e signi ican e ec s; −, nega i e signi ican e ec s.
15475069, 2025, 2, Downloaded om h ps://sigmapubs.onlinelib a y.wiley.com/doi/10.1111/jnu.13015 by Readcube (Lab i a Inc.), Wiley Online Lib a y on [10/04/2025]. See he Te ms and Condi ions (h ps://onlinelib a y.wiley.com/ e ms-and-condi ions) on Wiley Online Lib a y o ules o use; OA a icles a e go e ned by he applicable C ea i e Commons License
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EFFECTIVENESS OF DIGITAL INTERVENTIONS TO REDUCE SCHOOL- AGE ADOLESCENT SEXUAL
RISKS: A SYSTEMATIC REVIEW
e al., 2016), and sexual in e cou se (Ma kham e al., 2012; To ole o
e al., 2010). Be e esul s we e ob ained i he in e en ion was
comple ed (Doubo a e al., 2017).
Pa icipan s and exposu e
Digi al in e en ions ha ocused on adolescen s bu also on hei
pa en s (Mu y e al., 2018, 2019; Va as- Díaz e al., 2019) showed
imp o ed communica ion be ween hem and, he e o e, in he
sexual heal h o he adolescen s. The e we e also di e ences be-
ween hose adolescen s who ecei ed he ull digi al in e en ion
(“ ull exposu e”: 13 lessons) and hose who did no ecei e he ull
exposu e (“no exposu e”: 0 lessons, “low exposu e”: 1–4 lessons,
“mid- exposu e”: 5–8 lessons and “high exposu e”: 9–12 lessons),
wi h he inding ha “ ull exposu e” and “mid- exposu e” s uden s
we e less likely han “low exposu e” s uden s o ini ia e sex (Peskin
e al., 2015). Be e esul s we e also seen in hose in e en ions
ha included boos e sessions as opposed o hose in e en ions
ha only p o ided he main sessions (Robe o e al., 2008; Robe o,
Zimme man, Ca lyle, & Abne , 2007; Robe o, Zimme man, Ca lyle,
Abne , Cupp, e al., 2007; Yba a e al., 2013, 2015). One digi al
in e en ion ocused on imp o ing adolescen media li e acy suc-
ceeded in inc easing sexual knowledge and media and sexual heal h,
bu did no in luence communica ion (Scull e al., 2018, 2022).
Ano he digi al in e en ion was a ideo game ha imp o ed sexual
knowledge and a i udes, bu hese imp o emen s we e no sus-
ained o e ime, no did hey change pa icipan s' sexual beha io s
(Fiellin e al., 2017).
DISCUSSION
This sys ema ic e iew summa izes exis ing digi al in e en ions o
educe sexual isk beha io s and hus imp o e adolescen s' sexual
heal h. We ha e ound e y in e es ing digi al in e en ions wi h
e ec s, among o he s, on knowledge, a i udes, and con acep i e
use in adolescen s. In gene al, digi al in e en ions ha e posi i e
e ec s on knowledge and a i udes, bu i is mo e di icul o
modi y beha io s wi h s ic ly digi al in e en ions o combined
wi h complemen a y ace- o- ace sessions o g oup class ac i i ies
(Cas illo- A cos e al., 2016; Doubo a e al., 2017; Jeong e al., 2017;
Ma kham e al., 2012; Peskin e al., 2019; Po e e al., 2016; To ole o
e al., 2010). Fo example, dynamics such as g oup ac i i ies, ace-
o- ace ole- playing, and small g oup discussions ha e been shown
o imp o e he beha io al change ou comes o indi iduals (He be
& Loh mann, 2011). Howe e , he e is also e idence showing
posi i e e ec s on beha io s wi h all- digi al in e en ions (Downs
e al., 2004; Noa e al., 2009). The e o e, we can deduce ha one
o he mos impo an poin s o sexual educa ion is he dedica ion
o ime and esou ces o adolescen s and hei pa en s. These digi al
in e en ions can also wo k o imp o e he li e acy o adolescen s in
he media so ha hey can seek accu a e and app op ia e in o ma ion
on hei own (Scull e al., 2018, 2022). Ano he impo an inding o
ou e iew is he e ec s a e no main ained o e ime as much as
we would like (Hu e al., 2023; Jin e al., 2021), because hey begin
o diminish wi h he passage o mon hs. The bene icial e ec o
ein o cemen sessions is no ewo hy (Robe o e al., 2008; Robe o,
Zimme man, Ca lyle, & Abne , 2007; Robe o, Zimme man, Ca lyle,
Abne , Cupp, e al., 2007; Yba a e al., 2013, 2015).
Rega ding he a ge popula ion o he in e en ions, mos wo k
only wi h adolescen s, bu we ound wo in e en ions ha also in-
clude pa en s because hey we e based on he p o ec i e ac o o
amilies in adolescen heal h. Including pa en s in his ype o in-
e en ion means pa en s become mo e awa e o hei child en's
sexual p oblems and imp o e communica ion wi h hem. This im-
p o ed communica ion leads o g ea e knowledge abou STIs and
how o p e en hem, imp o ed sel - e icacy and inc eased in en ion
in heal h beha io s, bu o a lesse ex en (Mu y e al., 2018, 2019;
Va as- Díaz e al., 2019).
Mos in e en ions we e based on heo e ical models o beha -
io change, ecognizing ha he adop ion o his app oach p oduces
be e esul s (Jackson & Wa e s, 2005; Pe e s e al., 2009).
Adhe ence o he in e en ions was e alua ed wi h he e en ion
a e o he di e en s udies, which is gene ally high (abo e 70%); his
sugges s ha he digi al in e en ions we e well accep ed by adoles-
cen s as hey b eak he dynamics o lec u es and classes on sexual
heal h and make he in o ma ion mo e in e es ing o he s uden s.
I also gua an eed he con iden iali y and au onomy hey demanded
(B ayboy e al., 2018).
Rega ding applicabili y, al hough mos o he in e en ions we e
ca ied ou wi h a su icien sample, bu only one s udy de eloped
i s in e en ion in wo di e en coun ies wi h di e en con ex s
o ob ain di e en esul s, s a ing wi h adhe ence o he in e en-
ion by adolescen s, hus demons a ing ha he con ex in luences
he di e en in e en ions o pa icipan cha ac e is ics (Halpe n
e al., 2008).
The s eng h o his sys ema ic e iew is ha i wo ked wi h i e
da abases in addi ion o a p e ious and subsequen e e ence sea ch
o all he a icles o add new possible s udies o he e iew wi hou
language, publica ion da e, o o he es ic ions and wi h a ocus on
RCTs and quasi- expe imen al s udies o inc ease he quali y o he
esul s. Only in e en ions conduc ed wi hin schools we e consid-
e ed o inclusion. The me hodological quali y o he included s ud-
ies anged om high o mode a e. I is possible ha some ele an
s udies may ha e inad e en ly been omi ed, despi e ou ca e ul
selec ion o comp ehensi e keywo ds.
Howe e , he he e ogenei y in e ms o di e ences in in e en-
ions, s udy designs, me hodologies, and a iables used o ou come
measu es p e en s us om p o iding a comp ehensi e syn hesis o
he esul s, because we could no always calcula e he e ec size
o o he measu es ha would acili a e he objec i e compa ison o
one in e en ion wi h ano he . I was di icul o es ablish a speci ic
ime o he sho - and long- e m e ec s, because each in e en ion
had i s ollow- up es s a di e en imes (e.g., 1 mon h, 6 mon hs,
1 yea ), so we ha e desc ibed he esul s by di e en ia ing he
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