Artigos

Conteúdo (article):

Interventions to prevent sexual abuse of children and adolescents in school environments: scientific evidence

Jessica De Lucca Da Silva (1)
(jessicalucca27@gmail.com; https://orcid.org/0000-0002-8822-5639)
Emanuelly Camargo Tafarello (1)
(manu.tafarello@gmail.com; https://orcid.org/0000-0003-4171-2664)
Letícia Aparecida Lopes Bezerra da Silva (1)
(leehloplopes@gmail.com; https://orcid.org/0000-0001-8913-2699
Tereza Setsuko Toma (1)
(ttoma.ats@gmail.com; https://orcid.org/0000-0001-9531-9951)
Fernando Meirinho Domene (1)
(fernando.domene@alumni.usp.br; https://orcid.org/0000-0003-2806-7875)
Rosana Evangelista Poderoso (2)
(rosanae@unicamp.br; https://orcid.org/0000-0001-8661-1168
Jorge Otávio Maia Barreto (3)
(jorgeomaia@hotmail.com; https://orcid.org/0000-0002-7648-0472)
¹ Núcleo de Evidências do Instituto de Saúde (NEv-IS), SP, Brasil
2 Biblioteca da Faculdade de Ciências Médicas da Unicamp, Campinas, SP
3 Fundação Oswaldo Cruz, Brasília, DF, Brasil

Abstract
Children and adolescents account for the majority of victims of sexual violence in Brazil, meaning that it is necessary to step up investment in prevention measures to promote healthy development. In 2022, Brazil was ranked 25th among 60 countries for prevention of child sexual exploitation and abuse. This article presents evidence on the effects of interventions to prevent child and adolescent sexual abuse in school environments. We conducted a rapid review based on searches of six scientific literature databases, resulting in the identification of 14 systematic reviews. The results show that a wide range of school-based interventions were implemented. The interventions were effective for the following outcomes: knowledge, skills, attitudes, behaviors, perpetration and victimization. Most of the primary studies cited in the systematic reviews were conducted in high-income countries. No Brazilian studies were found.
Keywords: Child Sexual, Abuse; Child Advocacy; Sex Offenses; Schools; Review

INTRODUCTION
The World Health Organization (WHO) defines sexual violence or abuse as "actual or threatened physical intrusion of a sexual nature, whether by force or under unequal or coercive conditions"1.
According to data from the National Human Rights Ombudsman, children and adolescents account for the majority of victims of sexual violence2. In the first five months of 2022, 5,881 incidents of rape of children and adolescents were reported via the human rights violations hotline Dial 100, accounting for 79% of all reports during the period. This figure represented a 76% increase in reports involving abuse of children and adolescents compared to the same period in 20212.
According to data from the country’s notifiable diseases information system, the most frequent place of occurrence of sexual abuse of children and adolescents is at home (approximately 71.7% of cases)3. Against this background, many studies have investigated prevalence rates, risk and protection factors and prevention strategies aimed at addressing child and adolescent abuse in institutional settings4.
Child sexual abuse is a public health priority. Schools can play a key role in tackling this problem by promoting educational activities that provide children and adolescents the opportunity to discuss the issue, acquire prevention skills and report abuse. Data from a study conducted by the São Paulo State Public Security Department showed that around 75% of rapes committed in the state were of children and adolescents aged 0 to 17 years. Based on the findings, it is estimated that more than 600 boys and 3,000 girls attending public schools in the state of São Paulo are victims of rape each year5.
In August 2022, Law 14432 was passed creating the "Orange May" campaign, aimed at promoting actions to combat the sexual abuse and exploitation of children and adolescents6. The law emphasizes that educational campaigns, prevention and mobilization are fundamental to guaranteeing the healthy development of children and adolescents7.
Globally, in 2023 the WHO launched its zero tolerance policy towards sexual misconduct and inaction against sexual misconduct, and any form of retaliation against those who report, or participate in an investigation of, allegations of sexual misconduct8.
Victim-centered sexual violence prevention approaches can be relationship-based and/or behavior-based. The latter encompasses the development of active and self-protective modes of behavior and strategies, which can be classified into primary, secondary or tertiary prevention. Primary prevention involves measures to reduce sexual violence from the outset at an individual, social and community level. Secondary prevention includes measures used in high-risk situations to put a stop to emerging or ongoing abuse. Tertiary prevention concentrates on preventing further harm to a person who has already been subjected to sexual abuse9.
Although information and knowledge about child sexual abuse is widespread in society, there is a need for further research and action, especially when it comes to prevention9.
This review is relevant because it presents scientific evidence on interventions for the prevention of sexual violence and abuse against children and adolescents in the school environment identified using a systematic and transparent method.
METHODS
Study design
This rapid review of systematic reviews (SRs) used a validated method10 to answer the research question in a timely manner. Rapid reviews (RRs) help inform health policy and system decision-making by compiling relevant evidence in a timely manner. RRs often stem directly from requests by end-users, contributing to their usability to strengthen local health systems and respond to pressing political decisions11.
The review protocol was drawn up beforehand and registered with the Open Science Framework (OSF)12. The report followed the guidelines set out in the PRISMA 2020 expanded checklist13.
The research question was as follows: "What interventions/programs are effective in preventing the sexual abuse of children and adolescents in institutionalized and similar environments?". The question was formulated based on the PICOS framework: Population - children and adolescents in institutionalized and similar environments; Intervention - strategies to prevent sexual abuse; Comparator - no intervention or other interventions; Outcome - reduction or prevention of sexual abuse; and Study design - systematic reviews including meta-analysis or not.
Inclusion and exclusion criteria
We included SRs published in English, Spanish and Portuguese analyzing the effectiveness of interventions or programs to prevent the sexual abuse of children and adolescents in institutionalized and similar settings. Publications that did not meet these criteria were excluded (study designs, age groups, settings and languages that did not match the research question). No restrictions were applied for date of publication and/or methodological quality.
Databases and search strategies
Searches were undertaken of the following databases between 4 and 7 May 2023: Medline (via PubMed); Latin American and Caribbean Center on Health Sciences Information (LILACS), via the Virtual Health Library (VHL); Embase, Health Systems Evidence; PsycINFO; and ERIC - Educational Resources Information Centre. The search strategies were designed using a combination of the following health sciences descriptors (DeCS) "Sexual Offences"; "Childhood Sexual Abuse"; "Rape"; and the free term "Prevention". The searches and initial exclusion of duplicates were performed by a librarian and are detailed in Box 1 of the supplementary material14.
Data selection, extraction and analysis
The SRs were selected independently in duplicate by two reviewers using the Rayyan QCRI15 reference manager. Any disagreements were resolved by consensus or by another reviewer.
The following data were extracted to an online Excel spreadsheet: author(s), year, study objective, conflicts of interest and funding and study information (research design, location, participant characteristics, strategies analyzed, results, and conclusions). The data were extracted independently in duplicate by two reviewers.
Methodological quality was assessed by one reviewer and checked by another using AMSTAR 216.
The results are summarized in boxes synthesizing the focus of the interventions and context of the participants and outcomes analyzed by the included SRs.
RESULTS
The searches retrieved 524 records. Twenty-six articles were considered eligible for full text screening after title/abstract screening. Twelve of these were excluded because they did not meet the inclusion criteria (Box 2, supplementary material)14, resulting in a final sample of fourteen articles17-30 (Box 3, supplementary material)14 (Figure 1).
Figure 1

Methodological quality of systematic reviews
Figure 2 shows the results of the methodological quality assessment of the included reviews. Overall reliability of the results was high in 1 review19, moderate in 1 review23, low in 2 reviews22,30 and critically low in 10 reviews17,18,20,21,24-29. The results of the analysis of the critical methodological weaknesses using the criteria established by AMSTAR 2 revealed that more than half of the reviews did not report the existence of a research protocol (57.14%). Furthermore, most of the reviews had search strategy flaws (71.42%) and did not provide a list of excluded studies with justifications (78.57%). Most of the reviews used adequate techniques to assess risk of bias in the included primary studies and these risks were taken into account when interpreting and discussing the results (78.57%). Publication bias was adequately investigated by the seven reviews that conducted a meta-analysis.
Figure 2

General characteristics of the systematic reviews
The fourteen SRs17-30 analyzed sexual abuse prevention strategies conducted in school/educational contexts and one26 also explored strategies in an educational context within a rehabilitation centre for young people with disabilities.
The reviews included only children20,26-30 or adolescents18,21,22,24,25 or both groups17,19,23. The primary studies addressed various sexual violence prevention strategies, which were generally analyzed together in the reviews. Box 1 summarizes the focus/area of the interventions and context of the participants. Further details on the interventions and general characteristics can be found in boxes 4 and 5 of the supplementary material14.
Box 1

The primary studies included in the reviews were conducted in high-income countries in North America (n=103)17-19,21,24,25,27-30, middle- and high-income European countries (n=22)17,20,21,25,26,28-30 and high-income countries in Oceania (n=1)29. Studies were also conducted in Asia (n=18)17,20,26,30, Africa (n=17)20,23,24,26 and South America and the Caribbean17,20 (there were no Brazilian studies). One review did not report the countries where the primary studies were conducted22.
The authors declared that there were no conflicts of interest in ten reviews17,19,20,22-25,27,28,30. The remaining four18,21,26,29 did not mention conflicts of interest. Twelve reviews reported having received funding17-26,28,30, one reported that funding had not been received27 and one did not mention funding29.
Synthesis of results by analyzed outcomes
Table 2 summarizes the results by the outcomes analyzed by the reviews: knowledge, skills, attitudes, behaviors, perpetration and victimization.
Box 2

Below we present the results by outcome with emphasis on the evidence from the meta-analyses, using the following effect estimates: standardized mean difference (SMD), confidence interval (CI), heterogeneity index (I²), effect size (θ), statistical significance (p); odds ratio (OR) and Hedges\' g. Further details are available in Da Silva et al. (2024)14.
Knowledge about childhood sexual abuse and intimate partner violence
Seven reviews analyzed the effects of interventions on knowledge about child sexual abuse17,20,26,28-30 and dating violence among adolescents19.
Che Yusof et al. (2022)17 investigated gains in knowledge of child sexual abuse in school-based intervention programs from pre-intervention to post-intervention and between the intervention and control groups. The findings showed that intervention programs increased knowledge levels in schoolchildren compared to pre-intervention (SMD= -1.06; 95%CI= -1.29 to -0.84; I²= 97%; 24 studies; 20,022 participants). In the studies with control groups, there was an increase in knowledge in the intervention group (SMD= 0.9; 95%CI= 0.63 to 1.18; I²= 97%; 20 studies; 8,740 participants; high quality evidence). In the subgroup analyses, the effect size was large for primary school students (SMD= 0.85; 95%CI= 0.51 to 1.18; I²= 97%; 15 studies; 7,090 participants; high quality evidence). However, no differences were found between preschool (SMD= 3.08; 95%CI= -0.72 to 6.89; I²= 98%; 2 studies; 208 participants; high quality evidence) and secondary school students (SMD= 0.28; 95%CI= -0.4 to 0.95; I²= 33%; 2 studies; 912 participants; high quality evidence). Considerable heterogeneity was found for all groups except the secondary school students.
Walsh et al. (2015)30 assessed the effectiveness of interventions in improving knowledge in studies with controls using questionnaires and verbal, picture and video vignettes. In the studies using questionnaires, the results of the meta-analysis showed increased sexual abuse knowledge and prevention in the intervention group (SMD = 0.61; 95%CI = 0.45 to 0.78; I² = 84%; 18 studies; 4,657 participants; moderate quality evidence). In the studies using vignettes, the findings showed a positive effect on applied knowledge among children receiving the interventions (SMD = 0.45; 95%CI = 0.24 to 0.65; I² = 71%; 11 studies; 1,688 participants). In the studies using questionnaires, the findings show a decrease in retention of knowledge at one to three months follow-up (SMD = 0.69; 95%CI = 0.51 to 0.87; I² = 25%) compared to immediately after the intervention (SMD = 0.78; 95%CI = 0.38 to 1.17; I² = 84%). Heterogeneity ranged from moderate to high, except in the follow-up period.
In a review of studies with control groups, De La Rue et al. (2014)19 reported that students in the intervention group showed greater knowledge of dating violence immediately after the intervention (θ= 0.22; 95%CI= 0.05 to 0.39; 13 studies), and that this knowledge was retained at follow-up.
Narrative systematic reviews reported improved knowledge of child sexual abuse28 and prevention20,29, and that interventions using active and interactive approaches were more effective20. Several studies showed that the positive effects of interventions on knowledge of self-protection were maintained over time29. Significant improvements in knowledge about appropriate/inappropriate touching and sexual abuse were observed among participants, including children with mild intellectual disabilities. In addition, both teachers and nurses were able to improve knowledge and assertiveness26.
Child sexual abuse and intimate partner violence protective skills
Six of the reviews assessed child sexual abuse protective skills17,26,27,29, conflict tactics19 and gender-based violence prevention skills23.
Che Yusof et al. (2022)17 assessed the effects of school-based child sexual abuse intervention programs based on pre-post intervention studies and studies with control groups. The results of the meta-analysis showed increased skill levels among schoolchildren in post-intervention compared to pre-intervention with large effect size (SMD= -0.91; 95%CI= -1.2 to -0.61; I²= 93%; 12 studies; 4,632 participants; high quality evidence). This positive effect was maintained in schoolchildren without disabilities in the subgroup analysis (SMD= -0.76; 95%CI= -1.04 to -0.49; I²= 93%; 10 studies; 4,510 participants; high quality evidence), but no difference was found for schoolchildren with disabilities (SMD= -4.27; 95%CI= -10.69 to 2.15; I²= 98%; 2 studies; 156 participants; high quality evidence). A meta-analysis of studies with control groups showed increased skills in the intervention group with a medium effect size (SMD= 0.39; 95%CI= 0.07 to 0.71; I²= 95%; 13 studies; 4,638 participants; high quality evidence). Although the evidence was high quality, considerable heterogeneity was observed in the meta-analyses.
De La Rue et al. (2014)19 reported an increased level of conflict tactics skills in dating situations among students in the intervention group (θ= 0.18; 95%CI= 0.12 to 0.23; 8 studies). Levels remained significant at follow-up.
Narrative systematic reviews reported an increase in self-protection skills26,29 and recognizing appropriate and inappropriate touching26. Results regarding risk perception were mixed and inconclusive29. Skill gains were maintained or decreased slightly at 2 to 3 month follow-up29. There was a reduction in exposure to gender-based violence among adolescents and young people vulnerable to HIV living in low- and middle-income countries due to self-defense strategies for girls and interventions to improve safety in schools. Sexual health and social empowerment interventions did not reduce exposure to intimate partner violence23.
A review assessing the effectiveness of school-based programs to prevent child sexual abuse found that the most effective programs were those with the following characteristics: those of a longer duration (four sessions or more), those involving repetition of important ideas and concepts, those that demand active participation from children with multiple occasions to practice new skills and abilities, and those based on concrete concepts rather than abstract notions27.
Attitudes towards child sexual abuse and intimate partner violence
Four reviews addressed attitudinal outcomes relative to child sexual abuse17,30, dating violence19, sexual violence and coerced sex23.
Che Yusof et al. (2022)17 found improved attitudes after intervention. However, this result was not statistically significant (SMD= -0.51; 95%CI= -3.61 to 0.58; I²= 97%; 2 studies; 158 participants; high quality evidence). The results of the meta-analysis of studies with a control group showed statistically significant improved attitudes in the intervention group (SMD= 1.76; 95%CI= 0.46 to 3.07; I²= 96%; 3 studies; 342 participants; high quality evidence). However, considerable heterogeneity was observed in the meta-analysis.
Walsh et al. (2015)30 showed that the odds of disclosure of sexual abuse were higher among children in the intervention group (OR= 3.56; 95%CI= 1.13 to 11.24; I²= 0%; 3 studies; 1,788 participants; moderate quality evidence).
De La Rue et al. (2014)19 observed improved attitudes towards violence among intervention participants (θ= 0.14; 95%CI= 0.09 to 0.19; 11 studies). This pattern was maintained at follow-up.
A systematic narrative review with adolescents and young people vulnerable to HIV in low- and middle-income countries reported improved attitudes towards gendered-based sexual violence following school safety programs. However, sexual health and social empowerment interventions did not improve attitudes towards coerced sex23.
Child sexual abuse and intimate partner violence protective behaviors
Five reviews assessed the effects of interventions on child sexual abuse protective behaviors30, acceptance of rape myths19, bystander involvement in the prevention of sexual abuse22, peer violence23 and emotional gains29.
In a meta-analysis of two studies with 102 participants, Walsh et al. (2015)30 found that protective behaviors were greatly enhanced in intervention groups immediately after the intervention (OR= 5.71; 95%CI 1.98 to 16.51; I²= 27%; moderate quality evidence).
In a meta-analysis of four studies, De La Rue et al. (2014)19 reported that intervention participants were less likely to defend rape myths (θ= -0.47; 95%CI= -0.69 to -0.26).
In a study of secondary school students using mixed-effects meta-regression models, Kettrey et al. (2019)22 found that there was no statistically significant association between bystander intervention behavior and prevention of sexual assault (Hedges\' g = -0.16; 95%CI = -0.38 to 0.05).
A systematic narrative review revealed emotional gains among intervention participants. The children were more positive towards safe scenes, less socially anxious, and reported a greater sense of efficacy in using self-protective skills. In addition, parents reported that their children were more self-confident29.
Perpetration and sexual victimization among adolescents
Six reviews addressed the perpetration of sexual violence24,25, dating violence19 or intimate partner violence18,21,23, gender-based violence23, perpetration and/or experience of sexual violence24, sexual violence survivorship 25, and violence victimization18,19,21.
Piolanti and Foran (2022)25 found reduced perpetration of sexual violence in the intervention group; however, this result was not statistically significant (OR= 0.88; 95%CI= 0.76 to 1.02; I²= 0.7%; 6 randomized trials). Another review24 found that the OR was in favor of the intervention group (OR= 0.83; 95%CI= 0.73 to 0.95; I2= 28.4%; 12 studies). The same result was found for perpetration and/or experience of sexual violence (OR= 0.87; 95%CI= 0.78 to 0.97; I2= 39.4%; 20 studies)24 and experience of sexual violence (OR= 0.87; 95%CI= 0.78 to 0.98; I2=45.1%; 16 studies). The OR for sexual violence survivorship was in favor of the intervention group; however, this result was not statistically significant (OR= 0.88; 95%CI= 0.71 to 1.08; I²= 45.3%; 4 studies)24.
De La Rue et al. (2014)19 found no differences in levels of perpetration of dating violence between intervention and control students (θ= -0.01; 95%CI = -0.04 to 0.05; 3 studies); however, there was a decrease in this difference at follow-up (θ= -0.11; 95%CI = -0.21 to -0.01). The same review found that intervention participants were less likely to experience dating violence victimization; however, the effect was not statistically significant (θ= -0.21; 95%CI= -0.41 to 0.02; 5 studies).
A narrative systematic review18 assessing perpetration of intimate partner violence among adolescents from 70 rural secondary schools found that fewer males in the intervention group reported perpetrating violence at follow-up. Positive effects were also reported by a systematic review with secondary school youth. The findings show that a program that started with middle-school students and followed them through to high school was effective in reducing perpetration and victimization at three-year follow-up21. In contrast, a systematic review23 reported that there was no reduction in perpetration of sexual violence among adolescents and young people vulnerable to HIV living in low- and middle-income countries. Furthermore, a study of perpetration of gender-based violence after safer school programs showed mixed results23. A narrative systematic review18 assessing sexual intimate partner violence among adolescents in rural schools showed no significant differences between the intervention and control groups over the first four follow-ups. However, four years after the intervention, participants in the intervention group were significantly less likely to report sexual victimization. Prevalence of victimization declined by 50% after six months compared to the control group.
Adverse events related to interventions
Three reviews presented results on adverse events related to the interventions analysed23,29,30.
Walsh et al. (2015)30 found that there was no increase or decrease in anxiety or fear in child sexual abuse intervention participants, including both children and parents (SMD= -0.08; 95%CI= -0.22 to 0.07; I²= 0%; 3 studies; 795 participants; moderate quality evidence).
Topping and Barron (2009)29 found that over half the primary studies reported negative effects on participants. These effects were rarely measured in a consistent or standardized way and tended to be based on parental or teacher observations. The effects were reported as small in number, mostly mild in nature and of short duration: anxiety and dependence, fear of strangers, aggression, embarrassment to upset, wariness of touch, extent of injury and risk of perception.
A narrative review of interventions with adolescents and young people vulnerable to HIV living in low- and middle-income countries reported an increase in peer sexual violence after safer school interventions23.
DISCUSSION
This rapid review included 14 SRs that assessed interventions and programs to prevent sexual abuse of children and adolescents conducted in educational settings - schools and a rehabilitation center. Such interventions help prepare children and adolescents to deal with abuse, regardless of the environment in which it may occur.
Although sensitive searches were performed of six literature databases, we did not identify SRs on child and adolescent abuse prevention interventions in other types of institutions. Difficulty finding studies of interventions in other institutional settings was also pointed out by a previous review31.
The current review presents important existing evidence for outcomes evaluated across various strategies and programs (Box 4, supplementary material)14 that can contribute to tackling this serious global public health problem. Most of the results indicate that the interventions were effective in enhancing knowledge, skills, attitudes and behaviors related to preventing child sexual abuse and reducing perpetration of sexual violence and victimization among adolescents.
As mentioned above, seven reviews17,19,20,26,28-30 reported positive results from school-based interventions related to gains in knowledge about different aspects of sexual abuse prevention. Other studies31,32 corroborate the knowledge gains of school-based programs, suggesting that interventions appear to be more effective with children who are 8 years and older than in younger children32. This knowledge can enable children to recognize abuse or unsafety, both in their own situation and that of their peers, helping to increase individual and collective self-protection skills33.
Five of the SRs reported positive results for sexual abuse prevention skills among both children and adolescents17,19,23,26,29. It is worth highlighting that the most effective programs are those of a longer duration involving repetition of important ideas and concepts, demanding active participation from children with multiple occasions to practice new skills and abilities, and based on concrete concepts27. While acquiring knowledge is an important step, further research is needed on the acquisition of individual skills for dealing with abuse.
A gender-specific approach is also essential. While both sexes are subjected to sexual abuse, girls aged 7-14 account for the majority of abused children. According to estimates, almost one in four Brazilian girls under the age of 18 experience sexual abuse7. Considering the heightened vulnerability of girls and women to violence and abuse, in 2019 the WHO and UN Women: The United Nations Entity for Gender Equality and the Empowerment of Women created the RESPECT framework, consisting of the following seven strategies: Relationships skills strengthened; Empowerment of women; Services ensured; Poverty reduced; Environments made safe; Child and adolescent abuse prevented; and Transformed attitudes, beliefs, and norms34.
Relationships skills strengthened includes Program H, created in Brazil in 2002. The program was implemented first in schools in two Brazilian states with school children aged 14-25 living in low-income urban communities and later extended to adult men and older adult men. The program addressed sexual and reproductive health issues, co-responsibility of care, couple relationships and sexual diversity, gender-based violence and non-violent interaction with gender equality. The evaluation of the program showed that there was an increase in support for gender-equitable attitudes, a decrease in self-reported symptoms of sexually transmitted diseases, increased condom use, changes in attitudes towards violence against women, a reduction in intimate partner violence and increased male participation in domestic tasks34.
This rapid review also showed that school-based interventions resulted in improvements in attitudes19,23,30 and a reduction in reporting of perpetration of sexual violence by adolescents18,21,23.
The SRs included in this review mainly investigated interventions or programs carried out in high-income countries. No Brazilian studies were cited. According to the Out of the Shadows Index (OOSI) 2022 report, Brazil ranked 11th overall, obtaining the highest score for support services and recovery (3rd place) and lowest score for prevention (25th place)35. Based on information from 60 countries, the OOSI is the first global assessment of how countries are addressing child sexual exploitation and abuse.
Considering the difficulties in dealing with such a sensitive issue, lack of training of educators can be a major bottleneck for the effective implementation of strategies. From a child care perspective, for example, educators emphasize the challenge of working with children from backgrounds involving violence and abandonment36. Sexual abuse can have negative emotional and psychological consequences, underscoring the importance of psychosocial programs for early identification, the provision of emotional support, strengthening protective factors and promoting safe environments for children and adolescents.
Finally, it is important to consider some of the limitations inherent to the rapid review method. Despite performing systematic searches and studies selection in duplicate, shortcuts used in this type of review may have limited the number of reviews retrieved. The absence of citations of Brazilian studies may be partially explained by the language restriction applied by the included systematic review, meaning that articles written only in Portuguese were not captured by them. It would therefore be interesting to explore primary studies on this topic undertaken in Brazil.
FINAL CONSIDERATIONS
This rapid review identified systematic reviews that assessed interventions and programs to prevent sexual violence and abuse against children and adolescents in school settings. The effects were generally positive and reported across a variety of interventions and outcomes.
Before replicating the interventions that were shown to be effective, it is important to bear in mind that in most of the SRs methodological quality was low or critically low. It is also worth highlighting that most of the primary studies included in the SRs were undertaken in high-income countries in North America.
Collaborators
FM Domene, JL Da Silva and TS Toma drafted the review protocol, contributed to planning and data selection and extraction and assessed the methodological quality of the studies. All authors contributed to data analysis and interpretation, the description of results and writing the text. RE Poderoso planned and designed the search strategy. JOM Barreto coordinated the project and supervised all the stages of the review. All authors reviewed and approved the final version of the manuscript.
Conflicts of interest
The authors declare that there are no conflicts of interest.
Funding
This rapid review was commissioned by and received funding from Letter of Agreement SCON2022-00396 between the Oswaldo Cruz Foundation (Fiocruz) and Pan American Health Organization (PAHO Brazil), at the request of the Ministry of Health’s Primary Health Care Secretariat’s Department of Disease Prevention and Health Promotion. The authors declare that the review and presentation of the results was not influenced by a secondary interest.
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