In Reply We appreciate the thoughtful critique made by Yuan and Niuregarding our meta-analysis1 on parent-based sexual health interventions. They call attention to 3 types of heterogeneity (clinical, methodologic, and statistical), and they suggest we focused exclusively on statistical heterogeneity. Clinical heterogeneity refers to variability in clinical characteristics (eg, participant characteristics, types of interventions, and outcomes); methodologic heterogeneity refers to variability in trial design or quality; and statistical heterogeneity refers to variability in observed treatment effects.2 We agree these forms of heterogeneity are important to consider, and we have in fact considered all 3 throughout the planning and evaluation of our study. We first considered clinical and methodologic heterogeneity in determining the scope of our meta-analysis and study selection criteria. We limited the scope to peer-reviewed randomized clinical trials of parent-based sexual health interventions that reported behavioral outcomes among US adolescents. Yet even within this sample restriction, we recognized there remained important clinical and methodologic heterogeneity and therefore reported study-level data on adolescent characteristics, parent characteristics, intervention design, and study settings in the study characteristics table (Table 1).1 We also comment on issues related to heterogeneity (particularly in the assessment of outcomes) in the Discussion section. In analyses, we considered the importance of clinical heterogeneity in participant and intervention characteristics and found adolescent age, sex, and race/ethnicity, as well as intervention design and parent involvement, moderated the effects of interventions on condom use. It is true that we did not run statistical comparisons of potential moderators on outcomes where there was not statistical heterogeneity. There is not a clear consensus regarding the best approach to handling clinical/methodologic heterogeneity in the absence of significant statistical heterogeneity.2 As Gagnier et al2 recommend, we determined our approach to reporting and examining moderators a priori, and we agree with their assertion that there remains “a need to develop a comprehensive set of recommendations for how to perform valid, applicable, and appropriate investigations of clinical covariates.”2(p12)
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Widman L, Evans R, Choukas-Bradley S. More Meta-analytical Explorations on Adolescent Sexual Health Interventions Are Needed—Reply. JAMA Pediatr. Published online February 03, 2020. doi:10.1001/jamapediatrics.2019.5894
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