Behavioral Interventions: Comprehensive Sexuality Education

This systematic review of 63 studies on the impact of sex and sexually transmitted infection education on young people’s sexual behavior found that most of the interventions increase young people’s knowledge. Approximately a third delayed sexual debut, frequency of sexual intercourse, and number of partners, while approximately 40 percent of the interventions increased the use of condoms and other contraceptives. The reduction in risky sexual practices was not dramatic, but was sufficient to reduce rates of pregnancy and sexually transmitted infections, the author notes. Although the studies covered a wide geographical area, their findings may not have worldwide applicability, and none of the studies looked at same-sex sexual behavior or population-level changes due to large-scale roll-out.

This review examines which factors have the greatest bearing on adolescent health in a developing country setting, both in terms of risk and protection. Sixty-one papers were analyzed, and the review looked at factors associated with premarital sex, condom use, and pregnancy. It revealed that factors outside the individual, such as peer, partner, family, and school level, had little impact on sexual risk behaviors, while the strongest associations were related to adolescents themselves, such as gender, education, and non-sexual risk behaviors. The authors note the lack of rigorous research in this area and call for a broader research base. However, the review already identifies several important factors, for example, communication with partners, concurrently targeting different risk factors such as substance abuse and sexual behavior, and harnessing the powerful role of parents in influencing their adolescent children.

This review summarizes research into sexual risk behavior and its consequences among young people in the United States. It is the largest, most in-depth systematic review of multiple kinds of programs. There is information about the prevalence of risky sexual behavior, and the resultant rates of teen pregnancy and sexually transmitted infections (STIs). There are detailed chapters on the case for prevention; factors affecting teenagers’ sexual behavior; a description of the review methodology; and the findings, divided into curriculum-based sex and HIV/STI prevention interventions and other types of programs. The report concludes with a chapter on application of research to communities, highlighting those that have strong evidence of efficacy in reducing teen pregnancy and rates of STIs.

This review presents in a table format more than 500 risk and protective factors that can affect the rate of teen pregnancy and sexually transmitted infections (STIs), and assesses the extent to which interventions aimed at reducing teen pregnancy and STI rates can change them. The findings are based on over 400 studies. The review gives each intervention a star rating (one star denoting a factor that is the most difficult to change directly by pregnancy and STI programs, up to three stars denoting those factors most amenable to change by pregnancy and STI programs). The factors fall into four broad categories: individual biological factors; disadvantage and dysfunction in the teenager’s lives and environments; the sexual values and modeled behavior of teenagers as well as their parents, peers, and partners; and connections that discourage early sexual activity and teen pregnancy, such as attachment to influential adults in schools and via religious organizations.

This randomized controlled trial tested the effectiveness of a HIV prevention intervention in a cohort of 550 Latino adolescents. The participants underwent six 50-minute modules delivered in English or Spanish by adult facilitators either on HIV or health promotion. They were then followed up for a year and self-reported their sexual behavior. Sexual intercourse, multiple partners, and unprotected sex were reported less by the adolescents in the HIV group. At follow-up, adolescents in the HIV group who were sexually inexperienced at baseline reported less incidences of unprotected sex in the previous three months compared to the adolescents in the health promotion group. The study was the first to demonstrate that such an intervention can be effective among Spanish-speaking young people, and the activities may have applicability in Latin American and other Spanish-speaking countries, although more research is needed to test the generalizability of the findings, the authors note.

This randomized control trial tested the Relative Risks Information Campaign, which was implemented among 2,500 Grade 8 students in 71 schools in Kenya, comparing them with the cohort a year ahead or below as the control group. The information campaign informed the teenagers of the higher prevalence of HIV among adult men and their partners relative to teenage boys. The intervention led to a 65 percent reduction in teenage pregnancies to adult male partners, suggestive of a significant reduction in cross-generational unprotected sex. It also led to an increase in self-reported condom use among teenage couples. This suggests a substitution effect, but it did not lead to an increase in pregnancies where both partners were teenagers. The author argues that educating teens about HIV risks without specifying the risk distribution may be missing out on an important opportunity for risk reduction.

A group of international youth HIV and reproductive health researchers, program implementers, curriculum development experts, educators, and others met to discuss the Kirby 2005 review of characteristics of effective curricula. This expert consultation provided the crucial perspective of those implementing curriculum-based health education programs in developing countries. Based on their program implementation experiences, each of the characteristics Kirby identified as a hallmark of successful programs was carefully reviewed and discussed. This resulted in the group developing 24 standards of high-quality health program features that can assess the quality of a curriculum—existing or proposed—and its implementation. The standards are divided into three sections: (1) curriculum development and adaptation, (2) curriculum content and approach, and (3) curriculum implementation. The implementation section has multiple examples and lessons learned from implementation experiences worldwide.

This systematic review of 83 program evaluations had two main aims: to ascertain the effects of curriculum-based sex and HIV education on sexual risk behaviors, and to discover the shared characteristics of those programs that were effective. The studies covered composite risk-taking measures as well as individual risk factors such as timing of sexual debut, frequency of sex, number of sexual partners, and use of condoms and other contraceptives. The programs had an overall positive impact on one or more sexual risk behaviors, and outcomes were similar in developed and developing country settings. Factors that successful interventions had in common include curricula developed by diverse teams working toward clearly defined goals, a safe environment for young people that gave them ownership of the information, and implementation by trained educators with minimal support from authorities. The report offers recommendations, both for program designers and for further research.

This detailed report presents an evaluation of the Primary School Action for Better Health project, implemented in Nyanza and Rift Valley in Kenya. The project had numerous positive outcomes. First, it shifted pupils’ primary reported source of information about HIV away from the mass media and toward teachers and school texts, although this did not undermine female relatives as the preferred source of information for both sexes. Second, the project corrected misinformation among pupils and improved their critical thinking about HIV. Abstinence was presented as the only fully effective means of HIV prevention, and the project incorporated strategies to encourage it. However, information about condom use was often negative and at times even factually incorrect, reflecting teachers’ ambivalence about discussing condoms with pupils. Overall though, teachers responded well to the project, and HIV education is more prominent on the school curriculum as a result of the project, the study found.

To respond to the intractable HIV epidemic among youth, the United Nations Educational, Scientific and Cultural Organization and partners undertook a systematic review of sexuality education programs. Their conclusions were informed by studies that evaluated 85 worldwide youth sexuality education programs through 2009. Volume 1 presents the evidence for developing comprehensive sexuality education programs, the characteristics of effective programs, and recommendations based on good practices in schools. It is intended to help people develop and implement comprehensive sexuality education in schools.

This comprehensive package of resources takes as its starting point gender inequality as a key driver of the HIV pandemic. It is a practical curriculum that focuses on gender, sexuality, and HIV, and has seven key features: it is evidence based, comprehensive, takes a human rights-based approach, is gender sensitive, promotes critical thinking, encourages engagement, and is culturally sensitive. It comprises of guidelines and activities. The guidelines are for curriculum developers and educators as well as health and education policymakers and school administrators. There is also a book of 54 activities for young people to foster critical thinking skills. It is available in English, Spanish, and French.

This practical tool enables users to deploy intervention mapping to plan school-based sexual and reproductive health and rights education programs. In this way, they can determine to what extent the curriculum incorporates interventions that are based on evidence of efficacy in changing behavior. The primary target users are project workers from government and nongovernment organizations working on sexual and reproductive health and rights projects in developing countries, although it is also useful for researchers and curriculum consultants. There is a detailed description of intervention mapping and a step-by-step guide to using it to evaluate curricula.

This randomized controlled trial evaluated a HIV prevention curriculum delivered to 500 sexually experienced African American teenage girls. The curriculum comprised four group sessions of four hours each. Intervention group sessions covered HIV knowledge and condom use skills, as well as ethnic and gender pride, healthy relationships, and communication. The control group received sessions on exercise and nutrition. Six and twelve months after the intervention, the participants were interviewed, self-completed a questionnaire, provided samples to test for sexually transmitted infections, and also showed their condom use skills. Among the intervention group, condom use was more consistent. The girls in this group also demonstrated better condom application skills, fewer new partners, and fewer acts of unprotected sex. Chlamydia infections and self-reported pregnancy outcomes were also positive. It was the first trial to demonstrate that it is possible to effect behavior change among sexually experienced African American adolescent girls, the authors note.