International Technical Guidance on Sexuality Education: An evidence-informed approach for schools, teachers and health educators: Volume I



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International Technical Guidance on Sexuality Education: An evidence-informed approach for schools, teachers and health educators: Volume I

  • International Technical Guidance on Sexuality Education: An evidence-informed approach for schools, teachers and health educators: Volume I

    • UNESCO 2009
    • http://unesdoc.unesco.org/images/0018/001832/183281e.pdf
  • Emerging Answers 2007: Research Findings on Programs to Reduce Teen Pregnancy and Sexually Transmitted Disease

    • Published by the National Campaign to Prevent Teen and Unplanned Pregnancy
    • http://www.thenationalcampaign.org/EA2007/EA2007_full.pdf


In many countries, there are:

  • In many countries, there are:

  • Increased gaps between puberty & marriage

  • High rates of unintended & premarital pregnancy

  • High rates of sexually transmitted infection (STI)

  • High rates of sexually transmitted HIV

  • Numerous other sex-related problems (e.g., gender-based pressure & violence)



Can be implemented in:

  • Can be implemented in:

    • Schools
      • Can reach many young people (most 5-13 year olds attend school)
      • Provide a structured setting designed to teach
      • Can reach young people before or during the time they initiate sex
    • Clinics
      • Can reach older and higher risk youth
      • Can reach them during “teachable moments”
    • Other community organizations and settings


Goals:

  • Goals:

  • Decrease unintended pregnancy

  • Decrease STIs including HIV/AIDS

  • Improve sexual health in other ways



Do comprehensive sex ed programs:

  • Do comprehensive sex ed programs:

  • Increase sexual behavior?

  • Delay sex or increase use of condoms or other forms of contraception?

  • Actually reduce unintended pregnancy and STI rates?



Programs had to:

  • Programs had to:

  • Be a curriculum- and group-based sex or STI/HIV education program

    • Not only spontaneous discussion, only one-on-one interaction, or only broad school, community, or media awareness activities
  • Focus primarily on sexual behaviour

    • As opposed to covering a variety of risk behaviours such as drug use, alcohol use, and violence in addition to sexual behaviour
  • Cover more than just abstinence until marriage

  • Focus on adolescents up through age 24 outside of the U.S. or up through age 18 in the U.S.

  • Be implemented anywhere in the world.



Research methods had to:

  • Research methods had to:

  • Include a reasonably strong experimental or quasi-experimental design with well-matched intervention and comparison groups and both pretest and posttest data.

  • Have a sample size of at least 100.

  • Measure programme impact on one or more of the following sexual behaviours for at least 3-6 months:

    • initiation of sex and frequency of sex,
    • number of sexual partners,
    • use of condoms and use of contraception more generally,
    • composite measures of sexual risk (e.g., frequency of unprotected sex.


Study had to:

  • Study had to:

  • Be completed in 1990 or thereafter

  • But did not have to be published in a peer-reviewed journal

    • Most were published in peer reviewed journals




Nearly all programs increased knowledge

  • Nearly all programs increased knowledge

    • Important for a “rights-based” approach
    • Important to educators
  • Some helped clarify values & attitudes, increased skills and improved intentions









Most studies underpowered

  • Most studies underpowered

  • Mema kwa Vijuana in Mwanza,Tanzania

    • Marginally powered
    • Had positive effects on behavior
    • No positive effects on either STI or pregnancy rates
  • Other studies had a few positive results on pregnancy and STI rates

    • Even with bio-markers


Draft: U.S. meta-analysis:

  • Draft: U.S. meta-analysis:

    • Pregnancy (N=11) Relative Risk = .89
      • Reduced pregnancy by 11%
    • STI (N=8) Relative Risk = .69
      • Reduced STI rate by 31%


Sex/HIV education programs

  • Sex/HIV education programs

    • Do not increase sexual activity
  • Some sex/HIV education programs:

    • Delay initiation of intercourse
    • Reduce number of sexual partners or
    • Increase use of condoms/contraception
    • Reduce unprotected sex
    • Reduce pregnancy and STI rates
  • Some do two or more

  • Some do none of these



Sex/HIV education programs that change behavior are different from those that do not change behavior.

  • Sex/HIV education programs that change behavior are different from those that do not change behavior.

  • 17+ Characteristics distinguish between them. E.g., Effective programs

    • Focus on sexual risk behavior
    • Give a clear message about that behavior
    • Address cognitive factors that affect behavior
    • Use interactive engaging activities to change these factors and thereby change behavior


Most effective programs incorporate these characteristics.

  • Most effective programs incorporate these characteristics.

  • Nearly all programs with these characteristics significantly change behavior





Programs are quite robust; they are effective with multiple groups:

  • Programs are quite robust; they are effective with multiple groups:

    • Males and females
    • Sexually experienced and inexperienced
    • Youth in advantaged and disadvantaged communities
    • Different countries and regions in the world




Sex and STI/HIV education programs:

  • Sex and STI/HIV education programs:

  • Are not a complete behavioral solution

  • Can be an effective component in a more comprehensive behavior change initiative





California schools: 16 sessions

  • California schools: 16 sessions

    • Delayed sex; increased contraceptive use
  • Arkansas schools: 16 sessions

  • Kentucky schools: 16 sessions

    • Delayed sex; no impact on condom use
  • Kentucky schools: 12 sessions

    • Delayed sex; no impact on condom use


Philadelphia: 5 hours on Saturdays

  • Philadelphia: 5 hours on Saturdays

    • Reduced sex & # partners; increased condom use
  • Philadelphia: 8 hours on Saturdays

    • Reduced freq of sex; increased condom use
  • 86 CBO in northeast: 8 hours on Saturdays

    • Increased condom use
  • Philadelphia: 8 hours on Saturdays

    • Reduced sex & # partners; increased condom use
  • Cleveland: 8 sessions in school

    • Deleted one condom activity
    • No significant effects on any behavior


Jackson, Miss health center: 12 90-minute sessions

  • Jackson, Miss health center: 12 90-minute sessions

    • Delayed sex; reduced frequency; increased condom use
  • Residential drug treatment: 12 90-minute sessions

    • Reduced sex & # partners; increased condom use
  • Juvenile reformatory: 6 1-hour sessions

    • No effects


Baltimore recreation center: 8 sessions

  • Baltimore recreation center: 8 sessions

    • Increased condom use
  • West Virginia rural areas: 8 90-minute sessions



Curricula can remain effective when implemented with fidelity by others!

  • Curricula can remain effective when implemented with fidelity by others!

    • Fidelity: All activities; similar structure
  • Substantially shortening programs may reduce behavioral impact

  • Deleting condom activities may reduce impact on condom use

  • Moving from voluntary after-school format to school classroom may reduce effectiveness



Include school-based programs

  • Include school-based programs

    • Can reach large numbers of young people before they have sex
    • Have the infrastructure to implement such programs (with appropriate training)
  • Include clinic-based programs

    • Attended by high risk youth
  • Include community-based programs

    • Can reach young people who have left school


Many studies with positive behavioral effects

  • Many studies with positive behavioral effects

  • Many randomized controlled trials

  • Rather consistent results

    • Especially for those that incorporate 17+ characteristics and are implemented with fidelity
  • Replications of results are consistently positive if programs are implemented with fidelity



Some studies have small sample sizes (hundreds)

  • Some studies have small sample sizes (hundreds)

  • Few studies measured impact on actual STI or pregnancy rates

  • Few studies measured impact after 3 years

  • Not all programs have positive impact on all groups of young people

  • Few or no studies of large scale roll out



Need more studies in developing countries

  • Need more studies in developing countries

  • Need more studies in Africa and other countries with generalized HIV epidemics

  • Need greater study of critical characteristics of effective programs

  • Need more studies on how to most effectively address gender





Little good data exist for most countries

  • Little good data exist for most countries

  • Anecdotal, observational and some survey data suggest:

    • Most youth do not participate in effective programs – China, India, Africa, Latin America, US
    • In some countries, youth do not participate in any sex education programs
    • Even in countries with many studies (e.g., U.S.), most youth do not participate in effective programs


Should adapt and implement “proven” programs with similar populations and cultures

  • Should adapt and implement “proven” programs with similar populations and cultures

    • U.S.
  • Or, should develop and implement programs that incorporate the characteristics of effective programs

  • Should conduct on-going rigorous research on impact and implementation in order to enhance the impact of programs





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