Process evaluation of comprehensive sexuality education programme in Zambia: a focus on contextual factors, mechanisms of impact, quality of development and implementation process.

BACKGROUND: Comprehensive sexuality education (CSE) is critical in addressing negative sexual and reproductive health (SRH) outcomes among adolescents. Yet in many low- and middle-income countries (LMICs) including Zambia, little is known about the impact, realities of CSE implementation, the quality of teaching and the comprehensiveness of the content covered. METHODS: Our approach was informed by a process evaluation incorporating recommendations by the European Expert Group guidance on evaluating sexuality education programmes and the Medical Research Council (MRC) guidelines on process evaluation. The development process and quality of CSE implementation were assessed using eight and six quality criteria respectively. In-depth interviews (IDIs), focus group discussions (FGDs), document analysis and classroom observation were employed to assess contextual factors, implementation process and mechanisms of impact of CSE. In-depth interviews (50) and focus group discussions (2) with seven pupils in each group were conducted among 64 purposefully selected participants. The sample comprised pupils (35), parents (4) and teachers (17) from nine secondary schools (four peri-urban, four urban and one rural), policymakers (4), and religious leaders (4). We employed deductive content analysis to analyse the data. RESULTS: Contextual factors that influenced the implementation of CSE included: (1) piecemeal funding for the CSE programme; (2) lack of monitoring programmes in schools; (3) lack of community engagement; (4) religious and socio-cultural barriers; (5) lack of skills and competency to teach CSE; and (6) insufficient time allocation for CSE. The assessment of the quality of the development of CSE revealed: (1) a lack of sexual diversity; (2) no meaningful participation of pupils in programme implementation; (3) a lack of stakeholder engagement during programme implementation; (4)  lack of gender sensitivity; and (5) lack of human rights approach. Assessment of the quality of the implementation of CSE revealed: (1) no evidence of skill-based CSE teaching; (2) no linkage between CSE and SRH services in the communities; and (3) a lack of incorporation of multiple delivery methods during CSE teaching. The mechanisms of impact of CSE were related to the acceptability and positive changes in pupils' SRH practices. CONCLUSION: The complex influences of contextual factors during CSE implementation highlight the need for contextual analysis during the interventional design. Co-creation of the CSE programme through stakeholder participation could reduce social opposition and enable a culturally sensitive CSE. Comprehensive teacher training, a guiding curriculum as well as setting of appropriate monitoring tools and indicators are likely to enhance the quality of CSE implementation.

Sexual Knowledge, Sexual Attitudes, and the Need for Sex Education Among Adolescent Defectors From North Korea.

INTRODUCTION: Adolescent North Korean defectors are vulnerable due to harmful environments during defection, limited access to sex education in North Korea, and exposure to different sexual norms in South Korea. The purpose of this study was to investigate the sexual knowledge, attitudes, and sex education needs of North Korean refugee adolescents. METHODS: A cross-sectional, descriptive survey was administered to 102 North Korean refugee adolescents. RESULTS: The correct answer rate for questions on genital anatomy, physiology, masturbation, and contraception was less than 20%. The participants exhibited conservative attitudes toward female contraception, masturbation, and having friends of the opposite sex. A significant positive correlation was found between knowledge and the need for sex education. DISCUSSION: These results highlight the importance of tailored sex education in providing accurate information, improving sexual knowledge, fostering positive attitudes, and enabling healthy behaviors among adolescent North Korean defectors.

Assessing quality of family planning counseling and its determinants in Kenya: Analysis of health facility exit interviews.

BACKGROUND: Available evidence suggests that provision of quality of care in family planning services is crucial to increasing uptake and continuation of use of contraception. Kenya achieved a modern contraceptive prevalence rate of 60% in 2018, surpassing its 2020 target of 58%. With the high prevalence, focus is geared towards improved quality of family planning services. The objective of this study is to examine the quality of family planning counseling and its associated factors in health facilities in Kenya. METHODS: We conducted a secondary analysis of the 2019 Kenya Performance Monitoring and Action, client exit data of women who had received family planning services. Quality of counseling was assessed using the Method Information Index Plus. We conducted a multivariable ordinal logistic regression analysis of data from 3,731 women to establish determinants of receiving quality family planning services. RESULTS: The Method Information Index Plus score for higher-quality counseling was 56.7%, lower-quality counseling 32.4%, and no counseling 10.9%. Women aged 15-24 years (aOR = 0.69, 95% CI = 0.56-0.86, p = 0.001) had lower odds of receiving better counseling compared to women aged 35 years and above. Those with no education (aOR = 0.52, 95% CI = 0.33-0.82, p = 0.005), primary (aOR = 0.56, 95% CI = 0.44-0.71, p<0.001) and secondary (aOR = 0.79, 95% CI = 0.65-0.98, p = 0.028) were less likely to receive better counseling compared to those with tertiary education. Women who received long acting and reversible contraception methods (aOR = 1.75, 95% CI = 1.42-2.17, p<0.001), and those who were method switchers (aOR = 1.24, 95% CI = 1.03-1.50, p = 0.027), had a higher likelihood of receiving better quality of counseling as compared to those on short-term methods and those who were continuers, respectively. CONCLUSION: The quality of family planning counseling in Kenya is still sub-optimal considering that some women receive no form of counseling at service delivery point. There is need to review the existing FP guidelines and training packages to increase focus on the quality of counseling services offered by health providers. Social accountability strategies that empower women to demand quality services should be included in community-level family planning interventions.

The effect of sexual health education on sexual activity, sexual quality of life, and sexual violence in pregnancy: a prospective randomized controlled trial.

BACKGROUND: Some women avoid sexual intercourse during pregnancy due to the physiological changes they undergo during this period as well as their fear of causing harm to the fetus and to themselves, which can lead to problems in sexual health. The aim of the present study was to investigate the effects of a sexual health education package on the dimensions of sexual health in pregnant women. METHODS: This randomized, longitudinal, clinical trial was carried out in 2018-2019 on 154 pregnant women in early to late pregnancy who presented to comprehensive health centers in Rasht, Iran, and were divided into three groups: Group A or the training group (50 participants), Group B or the self-training group (53 participants), and Group C or the control group (51 participants). The study tools included the Pregnancy Sexual Response Inventory (PSRI), the Sexual Quality of Life-Female (SQOL-F) and the Sexual Violence Questionnaire. The dimensions of sexual health were examined before beginning each intervention in each trimester of pregnancy and then at the end of pregnancy using these questionnaires. The collected data were analyzed using statistical tests, namely the Chi-square test, one-way ANOVA, Cochrane's test, and the repeated measures ANOVA at a significance level of P < 0.05. RESULTS: There was no statistically significant difference in the mean total scores of SQOL-F and PSRI in the three groups at baseline. As for the intergroup results, there was a statistically significant difference in the mean score of SQOL-F and PSRI at the end of pregnancy. The mean scores of PSRI and SQOL-F in the training group (Group A) increased from the beginning to the end of pregnancy compared to the control and self-training groups. As for the intergroup comparisons, there was no statistically significant difference in the mean total scores of sexual violence among the pregnant women in the different groups in the third trimester of pregnancy and at the end of the third trimester. Although sexual violence was not statistically significant, the number of sexually-violated women in the training group decreased during the training period compared to the self-training and control groups. CONCLUSION: The results obtained in the intervention group compared to the control group revealed the effectiveness of the sexual health education package in terms of improvement in the dimensions of sexual health. According to the results, in order to maintain and promote the sexual health of pregnant women, health care providers are recommended to offer sexual health training during pregnancy along with other health care services. TRIAL REGISTRATION: IRCT20190427043398N1 ; the trial was registered on June 2, 2019. (retrospective registration).

Effectiveness of Sex Education Interventions in Adolescents: An Overview.

The objective of this overview was to identify and evaluate the effectiveness of sex education interventions aimed at reducing sexual risk behaviors in adolescents. A search was conducted of systematic reviews in English, Spanish and Portuguese from 1946 until July 2018 in the following databases: MEDLINE (Ovid), EMBASE, Scopus, PsyArticles, Cochrane Central Register of Controlled Trials, LILACS and additional resources. The extraction and analysis of data was synthesized in a narrative mode describing intervention, population, and key outcomes such as decreased risky sexual behavior, decreases in sexually transmitted infections, and adolescent pregnancy. There were 2289 potentially relevant studies, of which 31 systematic reviews related to adolescent interventions were included. It was demonstrated that interventions involve parents and the community as participants, are based on audiovisual media and school workshops, and their emphasis is on information and training in school. Different reviews framed in methods of psychosocial intervention based on community groups and the home as a fundamental axis were reported. Finally, a large amount of scientific evidence related to the subject was identified. New directions are presented for interventions in sexual education for adolescents based on the combination of actions and techniques, the implementation of digital technology, and socio-cultural and contextual adaptations.

Evaluating the implementation of the Reproductive Life Plan in disadvantaged communities: A mixed-methods study using the i-PARIHS framework.

INTRODUCTION: The Reproductive Life Plan (RLP) is a clinical tool to help clients find strategies to achieve their reproductive goals. Despite much research on the RLP from high-income countries, it has never been studied in low- or middle income countries. Together with health workers called Mentor Mothers (MMs), we used a context-adapted RLP in disadvantaged areas in Eswatini. Our aim was to evaluate the implementation of the RLP in this setting. METHODOLOGY: MMs participated in focus group discussions (FGDs, n = 3 MMs n = 29) in January 2018 and at follow-up in May 2018 (n = 4, MMs n = 24). FGDs covered challenges in using the RLP, how to adapt it, and later experiences from using it. We used a deductive qualitative thematic analysis with the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, creating themes guided by its four constructs: facilitation, innovation, recipients and context. The MMs also answered a questionnaire to assess the implementation process inspired by normalization process theory. RESULTS: The RLP intervention was feasible and acceptable among MMs and fit well with existing practices. The RLP questions were perceived as advantageous since they opened up discussions with clients and enabled reflection. All except one MM (n = 23) agreed or strongly agreed that they valued the effect the RLP has had on their work. Using the RLP, the MMs observed progress in pregnancy planning among their clients and thought it improved the quality of contraceptive counselling. The clients' ability to form and achieve their reproductive goals was hampered by contextual factors such as intimate partner violence and women's limited reproductive health and rights. DISCUSSION: The RLP was easily implemented in these disadvantaged communities and the MMs were key persons in this intervention. The RLP should be further evaluated among clients and suitable approaches to include partners are required.

Reproductive health needs of adolescent and young adult women with pediatric rheumatic diseases.

BACKGROUND: The purpose of this study was to identify reproductive health knowledge gaps and topics that concern adolescent and young adult (AYA) women with pediatric rheumatic diseases and their parents. METHODS: Data collection occurred in two cohorts. In the first cohort, young women (15-20 years old) with pediatric-onset rheumatic conditions and their parents were recruited from a single, academic pediatric rheumatology center. In the second cohort, young women (18-25 years old) with pediatric-onset rheumatic conditions were recruited from a national conference for families with pediatric rheumatic diseases. This resulted in 20 adolescents and young adults (18.3 ± 2.4 years old), and 7 parent focus group participants. Focus group leaders facilitated discussions centered on reproductive health topics that participants identified as important, their sources of knowledge, and preferences for patient education and ongoing follow-up. Data were summarized independently by 4 researchers to reduce potential bias and subsequently analyzed using rapid qualitative analysis. RESULTS: All participants, regardless of diagnosis, medication, current sexual activity, or current intention to have children, expressed concern about the effect of their rheumatic condition and medications on fertility, risks to mother and child during and after pregnancy, and obtaining safe and effective contraception. Additionally, some participants discussed the burden of disease and its potential impact on motherhood. Finally, participants raised concern around the effect of disease and medication on routine reproductive health care, such as menstrual cycles, feminine self-care, and preventive exams. Three themes emerged: 1) participants had been advised to avoid unplanned pregnancy, however reported receiving inadequate explanation to support this instruction, 2) participants conceptualized reproductive health as tied to rheumatic disease management and thus suggested ways to include family members in discussion, and 3) rheumatology practitioners were not considered a resource of reproductive health information. CONCLUSIONS: Young women and their parents reported dissatisfaction with the availability, quantity, and quality of reproductive health information they received, particularly when related to their pediatric-onset rheumatic disease. These findings provide an initial step in understanding the patient perspective of reproductive health in rheumatology, and how to address these concerns in the care of young women with rheumatic diseases.

Facilitators and barriers for nurses in providing sexual education to myocardial-infarction patients: A qualitative systematic review.

BACKGROUND: Myocardial infarction (MI) greatly impacts an individual's sexual health. It is reported that almost 40 to 80% population with MI are not able to resume their sexual routine after the illness due to organic or psychological sexual dysfunction. To reduce the prevalence of sexual dysfunction after MI, cardiac nurses are required to provide sexual counselling to their stable patients. However, this responsibility is seldom fulfilled by nurses due to several barriers. These barriers are not explicitly explored from the nurses' perspective, which is necessary to understand in order to promote sexual counselling in cardiac health care settings. OBJECTIVE: To explore the facilitators and barriers of cardiac nurses in providing sexual education to post-MI patients. DESIGN AND METHOD: A qualitative systematic review was undertaken by performing a systematic search from six databases along with search from reference lists of related studies. FINDINGS: Four studies revealed 49 findings, which formed 10 categories and yielded four synthesised findings. These are: (1) Institutional Barriers such as lack of education, guidelines and material resources can prevent nurses from providing sexual education to MI patients; (2) Personal barriers such as uncertainty about the nurse's role in sexual education, giving least priority to sexual counselling and lack of comfort with discussing sexuality can affect how nurses provide sexual education to MI patients; (3) Socio-cultural and religious barriers such as contradictory beliefs and gender differences can challenge nurses when providing sexual education to MI patients and (4) Nurses consider different strategies for addressing sexual education with MI patients, in individual or group settings. CONCLUSION: To promote sexual counselling, strategies are proposed by nurses, which can help in limiting barriers and facilitate in conducting counselling sessions. These strategies need to be validated from extensive research before implementing them into nursing practice.

Characterisation of induced abortion and consequences to women's health at Hospital Central do Huambo - Angola.

To characterise patients with abortion in Huambo, Angola, we have undertaken a descriptive, longitudinal, prospective survey. A structured questionnaire was applied to 715 patients. The study variables were grouped in socio-demographic and clinical-epidemiological variables. There were 29.8% women were aged 20-24, 45.6% had primary education, 41.1% were single and 26.9% worked as a non-formal salesperson. Menarche occurred at 16-18 years (55.5%), first sexual intercourse at 13-15 years (40.3%) and 74.8% did not use contraceptive methods. Abortion was of indeterminate type in 84.3% and 79.3% had had a previous abortion. Serious complications occurred in 8.0% with six maternal deaths (0.8%). Age of menarche and age at onset of sexual activity are interdependent variables (p ≤ .001), the earlier menarche appears, the earlier sexual activity begins. When there was a history of abortion, new abortions occurred earlier (p ≤ .001) and were of indeterminate type (89%). Indeterminate induced abortion is influenced by socioeconomic, educational and political conditions and continues to be a frequent cause of morbidity and mortality.Impact statementWhat is already known on this subject? Unsafe abortion contributes greatly to maternal morbidity and mortality, principally in countries with restrictive abortion laws. The relationship between socio-educational level and unwanted pregnancies is consensual.What the results of this study add? Early initiation of sexual activity combined with non-contraception contributes to unwanted pregnancy and consequent unsafe abortion. Most of the women had previously had an abortion.What the implications are of these findings for clinical practice and/or further research? It is necessary to develop access to adequate information and family planning to combat unwanted pregnancies. It is also important to evaluate long-term consequences of unsafe abortion.

Sexuality Education During Adolescence and Use of Modern Contraception at First Sexual Intercourse Among Mexican Women.

PURPOSE: Mexico has implemented comprehensive sexuality education. We hypothesized that young women who received sexuality education as adolescents would be more likely to report modern contraceptive use at first sexual intercourse. METHODS: We used a nationally representative survey of Mexican women aged 20-24 years who were asked about experiences during adolescence. We defined our treatment variable in three mutually exclusive groups: comprehensive sexuality education (receipt of education in nine topics); incomplete sexuality education (receipt of at least one topic in each of three themes); or no sexuality education. Our outcome was use of modern contraception at first sexual intercourse. We included individual- and household-level sociodemographic factors. All presented data used survey weights. We used multivariable logistic regression and predicted probabilities to estimate the association between sexuality education and using modern contraception at first intercourse. RESULTS: In our sample (n = 2,725; population N = 4,008,722), 60.6% of participants reported receipt of comprehensive, 15.6% of incomplete, and 23.9% of no sexuality education; 62.5% reported utilizing a modern method of contraception at first intercourse. Women who reported receiving comprehensive (adjusted odds ratio: 2.3, 95% confidence interval [CI]: 1.7, 3.2) or incomplete (adjusted odds ratio: 2.4, 95% CI: 1.3, 4.2) sexuality education had higher odds of using contraception at first intercourse compared with no sexuality education. The absolute multivariable probabilities of using modern contraception at first intercourse were 57.5% (95% CI: 55.2%-59.8%), 60.4% (95% CI: 56.0%-64.9%), and 37.6% (95% CI: 33.9%-41.3%) among comprehensive, incomplete, and no sexuality education, respectively. CONCLUSIONS: Sexuality education is associated with contraception use at first intercourse among young women in Mexico.

[Ivory-Coast: Textbooks Misinform on HIV]. / Côte d'Ivoire : la désinformation des manuels scolaires sur l'infection à VIH.

Schools are considered as one of the most effective vectors for education on sexually transmitted diseases among young people. We report here the results of a study of HIV infection as presented in school textbooks in Ivory Coast, conducted in June 2018 as part of the development of a communication strategy to increase demand for HIV infection testing, especially among young people. Surprisingly, even though the textbooks studied were published between 2007 and 2017, almost all of them stated that HIV infection leads to death, with no mention of the existence of treatments that make it possible to live in good health. Some textbooks even stated that no treatment is available. These findings highlight one cause - perhaps major - for the reluctance of young people to get tested. The misrepresentation of HIV infection, reinforced by education, hampers incentive campaigns for HIV testing, for which the best argument is that awareness of a positive HIV status makes it possible to benefit from treatment. The present study included textbooks from the French educational program, used throughout French-speaking Africa, and from the Ivory Coast program. It would be interesting to conduct a similar study in other French-speaking and English-speaking African countries. Adapting the presentation of HIV in school textbooks to reflect the current situation in the fight against HIV infection should be a priority.

L'éducation scolaire est connue comme l'un des vecteurs les plus efficaces d'éducation sur les maladies sexuellement transmissibles chez les jeunes. Nous rapportons ici les résultats d'une étude de la présentation de l'infection à VIH dans les manuels scolaires en Côte d'Ivoire. De façon surprenante, bien qu'ils aient été imprimés entre 2007 et 2017, ces manuels affirment dans leur quasi-totalité que le VIH conduit à la mort, sans mentionner l'existence de traitements qui permettent de vivre en bonne santé, voire pour certains en affirmant qu'il n'existe pas de traitement. Ceci met en lumière une cause, peut-être majeure, de la réticence des jeunes à se faire dépister. La représentation erronée de l'infection à VIH renforcée par l'enseignement entrave les campagnes d'incitation au passage du test de dépistage, le meilleur argument pour celui-ci étant que connaître son statut positif permet de bénéficier des traitements. Certains des livres étudiés sont utilisés dans toute l'Afrique francophone. Il serait intéressant de mener une étude similaire dans d'autres pays d'Afrique francophone et anglophone. Vérifier le contenu scientifique et adapter le discours des manuels scolaires sur le VIH à la situation actuelle de la lutte contre l'infection devraient être une urgence.

Process evaluation of a comprehensive sexuality education intervention in primary schools in South Western Uganda.

BACKGROUND: We present findings of a process evaluation of a Comprehensive Sexuality Education (CSE) program for young adolescents in 15 schools in South-Western Uganda. METHODS: Using the Medical Research Council (UK) framework for process evaluation and the European Expert Group guidance on evaluation of sexuality education programs, we conducted a mixed methods study comprised of a review of relevant implementation documents, qualitative interviews(16), and focus group discussions(4) distributed among 50 participants including pupils, teachers, student educators and parents. RESULTS: Delivery of the anticipated 11 CSE lessons occurred in all target schools with moderate to high pupil attendance, however the duration of sessions was often shorter than planned. Facilitating factors for implementation included establishment of a community advisory board, use of multiple interactive delivery methods and high acceptance of the program by key stakeholders. Socio-cultural norms, geographical access, time constraints and school related factors were barriers. CONCLUSIONS: It was feasible to implement a contextually adapted CSE program for young adolescents in schools successfully with overall high acceptance by key stakeholders. Proper coordination of school activities with the program, ensuring linkages of the school based CSE program with community support systems for adolescent SRH and addressing socio-cultural impedances could be beneficial.

Addressing broader reproductive health needs of female sex workers through integrated family planning/ HIV prevention services: A non-randomized trial of a health-services intervention designed to improve uptake of family planning services in Kenya.

BACKGROUND: Despite considerable efforts to prevent HIV and other sexually transmitted infections (STI) among female sex workers (FSW), other sexual and reproductive health (SRH) needs, such preventing unintended pregnancies, among FSW have received far less attention. Programs targeting FSW with comprehensive, accessible services are needed to address their broader SRH needs. This study tested the effectiveness of an intervention to increase dual contraceptive method use to prevent STIs, HIV and unintended pregnancy among FSW attending services in drop-in centers (DIC) in two cities in Kenya. The intervention included enhanced peer education, and routine screening for family planning (FP) needs plus expanded non-condom FP method availability in the DIC. METHODS: We conducted a two-group, pre-/posttest, quasi-experimental study with 719 FSW (360 intervention group, 359 comparison group). Participants were interviewed at baseline and 6 months later to examine changes in condom and non-condom FP method use. RESULTS: The intervention had a significant positive effect on non-condom, FP method use (OR = 1.38, 95%CI (1.04, 1.83)), but no effect on dual method use. Consistent condom use was reported to be high; however, many women also reported negotiating condom use with both paying and non-paying partners as difficult or very difficult. The strongest predictor of consistent condom use was partner type (paying versus non-paying/emotional); FSW reported both paying and non-paying partners also influence non-condom contraceptive use. Substantial numbers of FSW also reported experiencing sexual violence by both paying and non-paying partners. CONCLUSIONS: Self-reported difficulties with consistent condom use and the sometimes dangerous conditions under which they work leave FSW vulnerable to unintended pregnancy STIs/HIV. Adding non-barrier FP methods to condoms is crucial to curb unintended pregnancies and their potential adverse health, social and economic consequences. Findings also highlight the need for additional strategies beyond condoms to reduce HIV and STI risk among FSW. TRIAL REGISTRATION: Clinicaltrials.gov NCT01957813.

Sexual health experiences, knowledge and understanding in low SES female teenagers: A diary approach.

INTRODUCTION: Understanding how teenagers think about sexual health and assessing the ways in which they engage with sexual health information are important issues in the development of appropriate sexual health education programmes. Sexual health education programs in the UK are inconsistent and is not possible to assume that teenagers' information needs are being met by such programs. Teenagers often feel uncomfortable discussing sexual health making it difficult to assess teenagers' understanding and engagement with the topic. METHODS: we used qualitative diaries to explore how thoughts about and exposure to sexual health information features in teenagers' day-to-day lives. Thirty-three low SES female teenagers aged 13 and 14 from schools in the UK kept a daily note of any sexual health related thoughts and feelings, and any sexual health information they encountered. RESULTS & CONCLUSIONS: Thematic analysis indicated three themes (1) Knowledge gaps and a desire for factual information (2) The social and emotional context of sexual health and (3) limited access to reliable information. Teenagers showed poor understanding of the biological aspects of sexual health and were concerned about the social and emotional context of sexual health. The teenagers' did not actively seek out sexual health information and access to information resources was limited. Although teenagers showed gaps in their knowledge they were curious about sexual health and were open to receiving sexual health information. Being aware of the ways that low SES female teenagers are thinking about sexual health is useful in developing education programs and other resources that will help fill gaps in knowledge and understanding.

EBCOG position statement - Public health role of sexual health and relationships education.

Sexual and relationship education should be part of educational curriculum in early teenage years. The young people should be provided with evidence based education to reduce the risks of untimed pregnancies and sexually transmitted infections.