The effectiveness of using entertainment education narratives to promote safer sexual behaviors of youth: A meta-analysis, 1985-2017

Background: Risky sexual behaviors are associated with the transmission of sexually transmitted infections (STIs) and unwanted pregnancies, both major health concerns for youth worldwide. This review studies the effectiveness of narrated mass media programs in promoting safer sexual practices among youth in developed and developing countries. Methods: Electronic and manual searches were conducted to identify experimental and quasi-experimental studies with robust counterfactual designs published between 1985 and the first quarter of 2017. Effect sizes were meta-analyzed using mixed-effects models. Results: Eight experimental and two quasi-experimental studies met our inclusion criteria. The aggregated sample size was 23,476 participants, with a median of 902 participants per study. Entertainment education narratives had small but significant effects for three sexual behaviors. It reduced the number of sexual partners [standardized mean difference, (SMD) = 0.17, 95% confidence interval (CI) = 0.02-0.33, three effect sizes], reduced unprotected sex (SMD = 0.08, 95% CI = 0.03-0.12, nine effect sizes), and increased testing and management for STIs (SMD = 0.29, 95% CI = 0.11-0.46, two effect sizes). The interventions were not effective in reducing inter-generational sex, measured through the age-gap with sexual partners (SMD = 0.06, 95% CI = -0.06-0.19, four effect sizes). Entertainment education had medium-size effects on knowledge outcomes (SMD = 0.67, 95% CI = 0.32-1.02, seven effect sizes), where a time-decay relationship is observed. No effects were found on attitudes. Conclusion: Although mass media entertainment had small effects in promoting safer sexual practices, its economies of scales over face-to-face interventions suggest its potential to be a cost-effective tool above an audience threshold. The use of study participants from the general youth population and the use of mostly effectiveness trials mitigate concerns regarding its scalability. The overall paucity of high-quality studies affirms the need for strengthening the evidence base of entertainment education. Future research should be undertaken to understand the moderator effects for different subgroups and intervention characteristics.