Effects of Interventions Addressing School Environments or Educational Assets on Adolescent Sexual Health: Systematic Review and Meta-analysis

Contents, Methods, and Outcomes of Adolescent Sexual Health Promotion in School Environments: A Scoping Review. THE JOURNAL OF SCHOOL HEALTH 2024;94:184-199. [PMID: 37723616 DOI: 10.1111/josh.13393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

Schools play a significant role in adolescent sexual health (SH) promotion. Although adolescents' SH has improved, growing challenges still exist in some areas. Previous studies have noted a lack of knowledge about SH promotion implementation in school environments. The purpose of this review is to describe the contents, methods, and outcomes of adolescent SH promotion in school environments.

METHODS

Three databases (Cinahl, ERIC, Medline) were searched for peer-reviewed articles published in 2011 to 2022, to identify SH promotion in school environments for adolescents aged 12 to 19 years old. After critical appraisal, inductive content analysis was conducted.

RESULTS

After screening, 25 studies from 8 countries were included. Sexually transmitted diseases and contraception were emphasized in the contents of the methods. Five SH promotion methods were identified: traditional, virtual, interactive, practical skills supporting, and creative. The outcomes were advancement in SH abilities, changes in sexual behavior, and the strengthening of sexual identity.

CONCLUSIONS

The contents mostly considered negative consequences of sexual behavior, whereas positive aspects were less discussed. Traditional methods were emphasized, yet positive outcomes were identified regardless of the method. SH promotion should aim to better support adolescents' sexual identity reinforcement.

Dosage in Implementation of an Effective School-Based Health Program Impacts Youth Health Risk Behaviors and Experiences

PURPOSE

This study is part of a larger evaluation of a multilevel, multistrategy federal program to reduce high school students' risk for HIV/sexually transmitted infection and unintended pregnancy. Local education agencies supported schools in implementing three strategies: delivering exemplary sexual health education, increasing student access to quality sexual health services, and enhancing safe and supportive school environments (SSE). We examined how levels of school implementation of these strategies moderated program effects on targeted student outcomes.

METHODS

The Youth Risk Behavior Survey was implemented in participating local education agencies in 2015 and 2017 to assess student behaviors and experiences, whereas the School Health Profiles surveys assessed school policies and practices in 2014 and 2016. We used these surveys to measure student-level outcomes and school-level program delivery, respectively, which were analyzed using multilevel modeling in a difference-in-differences framework.

RESULTS

Levels of SSE implementation significantly moderated program effects on multiple student outcomes, including ever having sex, having four or more lifetime sexual partners, being sexually active, using hormonal birth control, dual use of a condom and hormonal birth control, ever being forced to have sex, missing school because of safety concerns, and lifetime and current marijuana use. However, we found few moderating effects of exemplary sexual health education and sexual health services dosage.

DISCUSSION

We found a significant relationship between incremental increases in implementation of activities to increase the safety and supportiveness of school environments and enhanced program effects in improving multiple student health outcomes. These findings suggest that school implementation of SSE activities contributed to intended program effects.

A Survey on Knowledge, Prevention, and Occurrence of Sexually Transmitted Infections among Freshmen from Four Italian Universities

Background. The peak of sexually transmitted infections (STI) among adolescents/young adults suggests a low level of prevention. In order to assess whether the level of sexual health education (SHE), received by several channels, was effective at improving sexual behaviors, we conducted a survey among freshmen from four Italian universities. Methods. This observational cross-sectional study was carried out with an anonymous self-reported paper questionnaire, administered during teaching lectures to university freshmen of the northern (Padua, Bergamo, and Milan campuses) and southern (Palermo campus) parts of the country. Knowledge of STI (a linear numerical score), knowledge of STI prevention (dichotomous variable: yes vs. no) and previous STI occurrence (polytomous variable: "no"; "don't know"; "yes") were the outcomes in the statistical analysis. Results. The final number of freshmen surveyed was 4552 (97.9% response rate). The mean age of respondents was 21.4 ± 2.2 years and most of them (70.3%) were females. A total of 60% of students were in a stable romantic relationship. Only 28% respondents knew the most effective methods to prevent STI (i.e., condom and sexual abstinence), with a slightly higher prevalence of correct answers among females (31.3%) than males (25.8%). Students with history of STIs were 5.1%; they reported referring mostly to their general practitioner (GP) (38.1%) rather than discussing the problem with their partner (13.1%). At multivariable analysis, a significantly higher level of STI knowledge was observed in older students (25+ years of age), biomedical students, and those from a non-nuclear family; lower levels were found among students of the University of Palermo, and those who completed a vocational secondary school education. Those who had less knowledge about the most effective tools to prevent STIs included males, students from the University of Palermo, students registered with educational sciences, economics/political sciences, those of foreign nationality, and those whose fathers had lower educational levels. The risk of contracting a STI was significantly lower only in students not in a stable relationship (relative risk ratio, RRR = 0.67; 95% confidence interval, 95%CI = 0.48; 0.94), whereas such risk was significantly higher in students with higher STI knowledge (RRR = 1.15; 95%CI = 1.08; 1.22). Discussion and Conclusions. University freshmen investigated in this study had poor knowledge of STIs and their prevention. Unexpectedly, those with higher levels of knowledge had an increased risk of STIs. There have been no educational interventions-with good quality and long-term follow-ups-that increased the confidence that such SHE programs could have population level effects. A new high-quality study is therefore recommended to assess the effectiveness of an intervention generating behavioral changes; increasing only STI knowledge may not be sufficient.

High HIV Prevalence and Low HIV-Service Engagement Among Young Women Who Sell Sex: A Pooled Analysis Across 9 Sub-Saharan African Countries

BACKGROUND

Epidemiological data are needed to characterize the age-specific HIV burden and engagement in HIV services among young, marginalized women in sub-Saharan Africa.

SETTING

Women aged ≥18 years who reported selling sex were recruited across 9 countries in Southern, Central, and West Africa through respondent driven sampling (N = 6592).

METHODS

Individual-level data were pooled and age-specific HIV prevalence and antiretroviral therapy (ART) coverage were estimated for each region using generalized linear mixed models. HIV-service engagement outcomes (prior HIV testing, HIV status awareness, and ART use) were compared among women living with HIV across age strata (18-19, 20-24, and ≥25 years) using generalized estimating equations.

RESULTS

By age 18%-19%, 45.4% [95% confidence interval (CI): 37.9 to 53.0], 5.8% (95% CI: 4.3 to 7.8), and 4.0% (95% CI: 2.9 to 5.4) of young women who sell sex were living with HIV in Southern, Central, and West Africa respectively. Prevalence sharply increased during early adulthood in all regions, but ART coverage was suboptimal across age groups. Compared with adult women ≥25, young women aged 18-19 were less likely to have previously tested for HIV [prevalence ratio (PR) 0.76; 95% CI: 0.72 to 0.80], less likely to already be aware of their HIV status (PR 0.48; 95% CI: 0.35 to 0.64), and less likely to be taking ART (PR 0.67; 95% CI: 0.59 to 0.75).

CONCLUSIONS

HIV prevalence was already high by age 18-19 in this pooled analysis, demonstrating the need for prevention efforts that reach women who sell sex early in their adolescence. ART coverage remained low, with women in the youngest age group the least engaged in HIV-related services. Addressing barriers to HIV service delivery among young women who sell sex is central to a comprehensive HIV response.

Sex Education in the Spotlight: What Is Working? Systematic Review

Adolescence, a period of physical, social, cognitive and emotional development, represents a target population for sexual health promotion and education when it comes to achieving the 2030 Agenda goals for sustainable and equitable societies. The aim of this study is to provide an overview of what is known about the dissemination and effectiveness of sex education programs and thereby to inform better public policy making in this area. Methodology: We carried out a systematic review based on international scientific literature, in which only peer-reviewed papers were included. To identify reviews, we carried out an electronic search of the Cochrane Database Reviews, ERIC, Web of Science, PubMed, Medline, Scopus and PsycINFO. This paper provides a narrative review of reviews of the literature from 2015 to 2020. Results: 20 reviews met the inclusion criteria (10 in school settings, 9 using digital platforms and 1 blended learning program): they focused mainly on reducing risk behaviors (e.g., VIH/STIs and unwanted pregnancies), whilst obviating themes such as desire and pleasure, which were not included in outcome evaluations. The reviews with the lowest risk of bias are those carried out in school settings and are the ones that most question the effectiveness of sex education programs. Whilst the reviews of digital platforms and blended learning show greater effectiveness in terms of promoting sexual and reproductive health in adolescents (ASRH), they nevertheless also include greater risks of bias. Conclusion: A more rigorous assessment of the effectiveness of sexual education programs is necessary, especially regarding the opportunities offered by new technologies, which may lead to more cost-effective interventions than with in-person programs. Moreover, blended learning programs offer a promising way forward, as they combine the best of face-to-face and digital interventions, and may provide an excellent tool in the new context of the COVID-19 pandemic.

Effects of the school environment on early sexual risk behavior: A longitudinal analysis of students in English secondary schools

INTRODUCTION

The theory of human functioning and school organization proposes that schools promote health by strengthening students' educational engagement. Previous studies have relied on proxy measures of engagement and not examined sexual health. This paper addresses these gaps.

METHODS

Longitudinal data came from the control arm of a randomized trial involving female and male students ages 12-14 in English secondary-schools (n = 3337 students). Exposures measured at baseline included a proxy measure of school-level engagement (value-added education, VAE: the difference between observed absence and attainment rates and those predicted based on student characteristics) and direct measures of school- and student-level engagement (commitment, belonging, relationships and participation). Sexual behavior was measured at 24- and 36-months, including sexual debut and contraception use at first sex.

RESULTS

Higher school-level VAE was associated with an increased risk of early sexual debut at 24-months. Students attending schools with higher overall levels of commitment and belonging were less likely to report sexual debut at 36 months. Students reporting stronger personal commitment to learning and teacher relationships at baseline were less likely to report sexual debut at both follow-up points. Associations involving participation and contraception use were largely nonsignificant.

CONCLUSIONS

Direct measures of the school environment are more strongly associated with reduced sexual risk behavior in early adolescence than the proxy measure, VAE. Results provide some support for the theory and suggest that personal disposition towards school as well as attending a school with high levels of student commitment and belonging are important for subsequent sexual decision making.