Exploring the multi-level impacts of a youth-led comprehensive sexuality education model in Madagascar using Human-centered Design methods.

Comprehensive sexuality education (CSE) is recognized as a critical tool for addressing sexuality and reproductive health challenges among adolescents. However, little is known about the broader impacts of CSE on populations beyond adolescents, such as schools, families, and communities. This study explores multi-level impacts of an innovative CSE program in Madagascar, which employs young adult CSE educators to teach a three-year curriculum in government middle schools across the country. The two-phased study embraced a participatory approach and qualitative Human-centered Design (HCD) methods. In phase 1, 90 school principals and administrators representing 45 schools participated in HCD workshops, which were held in six regional cities. Phase 2 took place one year later, which included 50 principals from partner schools, and focused on expanding and validating findings from phase 1. From the perspective of school principals and administrators, the results indicate several areas in which CSE programming is having spill-over effects, beyond direct adolescent student sexuality knowledge and behaviors. In the case of this youth-led model in Madagascar, the program has impacted the lives of students (e.g., increased academic motivation and confidence), their parents (e.g., strengthened family relationships and increased parental involvement in schools), their schools (e.g., increased perceived value of schools and teacher effectiveness), their communities (e.g., increased community connections), and impacted broader structural issues (e.g., improved equity and access to resources such as menstrual pads). While not all impacts of the CSE program were perceived as positive, the findings uncovered opportunities for targeting investments and refining CSE programming to maximize positive impacts at family, school, and community levels.

Human immunodeficiency virus prevention outcomes associated with arts-based sexual health workshop participation among Northern and Indigenous adolescents in the Northwest Territories, Canada.

BACKGROUND: Contextually tailored, arts-based HIV prevention strategies hold potential to advance adolescent sexual health and wellbeing. We examined HIV prevention outcomes associated with arts-based sexual health workshop participation with Northern and Indigenous adolescents in the Northwest Territories (NWT), Canada. METHODS: An Indigenous community-based youth agency delivered arts-based workshops in school settings to adolescents aged 13-18 in 24 NWT communities. Pre and post-test surveys included socio-demographic characteristics, sexually infections (STI) knowledge, HIV/STI risk perception, sexual relationship equity, condom use self-efficacy, and safer sex efficacy (SSE). Latent change score models were conducted to assess pre-post differences and factors associated with these differences. RESULTS: Among participants (n = 344; mean age 14.3 years, SD: 1.3; Indigenous: 79%) most (66%) had previously attended this workshop. Latent change score models revealed a significant and large effect size for increased STI knowledge (ß = 2.10, SE = 0.48, p < .001) and significant and small effect sizes for increased HIV/STI risk perception (ß = 0.24, SE = 0.06, p < .001) and SSE (ß = 0.16, SE = 0.07, p = .02). The largest increases across several outcomes occurred with first time workshop participants; yet previous workshop participants continued to report increases in HIV/STI risk perception and SSE. CONCLUSION: Arts-based HIV prevention approaches show promise in advancing STI knowledge, risk perception, and SSE with Northern and Indigenous youth.

Effectiveness of a Comprehensive School-Based Sex Education Program for Young Adolescents in the Netherlands.

Most sexual education programs traditionally focused on providing sexual information regarding the risks of sex. However, current studies on sexual behavior in youth show a need for truly comprehensive sex education approaches with a sex-positive focus on sexuality, that effectively improve sexual competence. Therefore, in the current study the effectiveness of "Love is…", a four lesson school-based program based on the Sexual Interactional Competence model and Attitude-Social-Influence-Self-Efficacy-model was studied. A cluster-randomized controlled trial on the effectiveness of "Love is…" was conducted in 2018-2020. The sample consisted of 1160 adolescents in grades 8 and 9 from nine schools in the Netherlands. The sample was 48% female, 34% Dutch/Caucasian, 41% none-religious and 50% higher educated. They were randomized at class level into a program group [n = 32 classes; 567 students (Mage = 13.74 (SD = 0.74))] and a control group [n = 31 classes; 593 students (Mage = 13.86 (SD = 0.73))]. Results showed that "Love is…" increased sexual knowledge, that adolescents in the program group showed less cyber victim blaming attitudes and increased in communications skills after the program. In conclusion, the current study shows that "Love is…" was effective not only on the knowledge level, but also regarding sexual attitudes and competences. However, due to the developmental process of sexuality, there is a necessity to continue lessons in following grades through booster sessions by reinforcing competences as communicating comfortably about sexuality.On 12 November 2019 the study design and hypotheses were registered in the Dutch Trial Registration, number NL8150. ( https://onderzoekmetmensen.nl/nl/trial/26676 ).

Unconsummated marriage: a systematic review of etiological factors and clinical management.

BACKGROUND: Unconsummated marriage (UCM) is the inability of the heterosexual married couple to have penovaginal sexual intercourse. AIM: The study sought to systematically review current evidence regarding the etiological factors and clinical management of UCM. METHODS: A comprehensive bibliographic search on the MEDLINE, Scopus, Web of Science, and Cochrane Library databases was performed in June 2023. Studies were selected if they described married couples who never had sexual intercourse in case report or case series evaluating the related causes and/or management and reporting data with qualitative, quantitative, or mixed methods. The review was reported according to PRISMA (Preferred Reporting Items for Systematic Review and Meta-analyses) statement and registered in PROSPERO with ID CRD42023433040. RESULTS: A total of 27 studies including 1638 males and 1587 females were selected. Eight (29.6%) articles were case reports involving a single couple and 19 (70.4%) studies were case series. Mean Murad score was 4.1 (range, 1-8) showing low-intermediate overall study quality. All articles had a level of evidence of 4. Most of studies were conducted in Egypt (n = 5 [18.4%]), Israel (n = 4 [14.9%]), and the United States (n = 4 [14.9%]). The mean age of males and females varied between 24.2 and 37.6 years and from 21 to 27.4 years, respectively. The reasons for the medical visit that led to the diagnosis of UCM were inability to consummate in 23 (85.2%) studies, inability to conceive in 1 (3.7%) article, and mixed in 3 (11.1%) articles. The mean duration of UCM varied from 7 days to 3.5 years. Eight studies involving both men and women showed that vaginismus (8.4%-81%) and erectile dysfunction (10.5%-61%) were the most common causes of UCM. Three articles reported that 16.6% to 26% of all UCM cases were due to both male and female factors. Sildenafil, tadalafil, intracavernosal injection, penile plication, female genital reconstructive surgery, vaginal dilators, lubricants, psychosexual therapy, and sex education were the various treatment modalities in 27 studies to achieve consummation rate of 66.6% to 100%. STRENGTHS & LIMITATIONS: A strength is that this is the first systematic review covering the entire spectrum of UCM. Limitations comprised the low quality of most of the included articles and the large percentage of UCM cases probably not published. CONCLUSION: Erectile dysfunction and vaginismus are the most reported causes of UCM; however, a strong psychological component certainly underlies a significant number of cases. A multidisciplinary approach based on strategic integration of sex education, medical therapy, psychosexual support, and surgical treatment would seem the most suitable option to manage couples with UCM.

Addressing Evaluation Barriers with Early Innovation Development for Adolescent-Focused Sexual and Reproductive Health Interventions.

Most evidence-based teen pregnancy prevention programs focus on individual-level sexual health outcomes (e.g., STIs, pregnancy, teen births). To expand program and intervention approaches within teen pregnancy prevention (TPP), the Department of Health and Human Services funded two grantees, Innovative Teen Pregnancy Prevention Programs (iTP3) and Innovation Next (IN) to support and enable early innovation to advance adolescent health and prevent teen pregnancy. The pipeline to support and enable innovation in adolescent health is complex, resulting in barriers and challenges to research and evaluation of novel programs. This paper presents some of the barriers encountered by the grantees. Data for this paper was collected from key personnel and secondary data sources. Focus group participants included seven representatives (n = 7) across the two organizations. Focus group questions assessed barriers related to innovative intervention development and evaluation. Key findings include four barriers to evaluation when fostering innovative adolescent-focused pregnancy prevention interventions. These included (a) funding constraints on evaluation activities, (b) innovation readiness for rigorous testing, (c) evaluation knowledge and expertise on innovation-development teams, and (d) challenges with evaluation requirements. Novel and promising system- and technology-focused interventions with the potential to impact TPP require alternative tools and approaches for evaluation. This would allow research to focus on how systems-level change mechanisms (i.e., policy, access to care) impact sexual risk behaviors and better understand ecological and social determinants of health for the priority population. The advancement of approaches to impact adolescent health identifies the need to expand the focus of evidence-based interventions beyond the adolescent themselves and understand approaches that impact external contexts and environments related to reducing sexual and reproductive health (SRH) risk-taking.

Teaching comprehensive sexuality education using a praxis co-created with adolescents.

BACKGROUND:  Despite its reported positive deliverables, comprehensive sexuality education (CSE) in South African schools is unable to document an influence in reducing alarming statistics regarding adolescent sexual health. Prior research points to a gap that exists between what studies suggest and what is implemented in practice. AIM:  Drawing on Freire's theory of praxis, the aim of this study was to involve the voice of adolescents in reforming CSE - specifically, how the programme could be developed with the objective to co-construct a praxis in order to support sexuality educators in a delivery of CSE that is more responsive to the needs of adolescents. SETTING:  Ten participants were purposively selected from all five school quintiles in the Western Cape province of South Africa to take part in this study. METHODS:  A qualitative descriptive design with aspects of a phenomenological approach was utilised. Rich data were collected by means of semistructured interviews and were analysed thematically with ATLAS.ti. RESULTS:  The results illustrate the suggestions made by the participants towards the improvement of the CSE programme. They reported on approaches and strategies used to teach CSE that imply that it is often not delivered comprehensively - confirming the disjuncture between what the curriculum envisages and what is executed in practice. CONCLUSION:  The contribution might lead to change in disconcerting statistics and consequently an improvement in the sexual and reproductive health of adolescents.Contribution: The participants from this study assisted in co-constructing a praxis for CSE teachers to inform their practice.

Subgroup Analyses of Girl2Girl, a Text Messaging-Based Teen Pregnancy Prevention Program for Sexual Minority Girls: Results from a National RCT.

This study aims to investigate whether Girl2Girl, a text messaging-based pregnancy prevention program for cisgender LGB+ girls, had different effects on subgroups based on age, sexual identity, and experience with penile-vaginal sex. A total of 948 girls, 14-18 years old, were recruited nationally via social media and enrolled over the telephone. Once they completed the baseline, they were randomized to either Girl2Girl or an attention-matched control program that discussed "healthy lifestyle" topics (e.g., self-esteem). Both programs were 5 months long: Girls received daily messages for 8 weeks, and then went through a "latent" period of 3 months, and finished with a 1-week review. Outcome measures included condom-protected sex, uptake of other types of birth control, abstinence, and pregnancy. Measures were collected at baseline; 3-month, 6-month, 9-month, and 12-month post-intervention end, which was 17 months after enrollment. Effect modification was examined using longitudinal mixed effects models. Overall, results suggested significant moderating effects of age, (f2 = .12), sexual identity (f2 < .14), and sexual experience (f2 = .11) on rates of condom use and use of other contraception. Although there were no significant moderating effects on pregnancy, abstinence, or intentions to use condoms, use birth control, or be abstinent, (p's > .16), patterns of effects were in the same direction as for significant findings. For example, at 9-month post-intervention, among those who identified as bisexual, the incidence rate of protected sex events was 39% higher for intervention vs. control (IRR = 1.39, 95% CI: 1.06-2.70), adjusting for baseline rate of condom use and sexual experience. Similarly, at 12 months, among bisexual participants, intervention participants had a significantly higher IRR of condom-protected sexual events (IRR = 2.65, 95% CI: 1.31-5.34). There were also higher odds of uptake of birth control use other than condoms for intervention vs. control at 6- (OR = 1.10, 95% CI: 1.01-1.77), 9 m (OR = 1.11, 95% CI: 1.07-1.89), and 12-month (OR = 1.13, 95% CI: 1.07-1.78) follow-up. Girl2Girl appears to be particularly effective for older adolescents, bisexual girls, and those who have already had penile-vaginal sex. No one single approach is going to affect teen pregnancy. Instead, it is more likely that different intervention content and delivery methods will be more accessible and salient to some but not other youth. Understanding for whom the intervention works is just as important as understanding for whom the intervention does not, as this can inform opportunities for future intervention development.Clinical Trial Registration: ClinicalTrials.gov ID# NCT03029962.

"Not just the consequences, but also the pleasurable sex": a review of the content of comprehensive sexuality education for early adolescents in Rwanda.

BACKGROUND: Responding to adolescents' educational needs in sexual and reproductive health and rights (SRHR) is central to their sexual health and achieved through school-based comprehensive sexuality education (CSE). In 2016, Rwanda introduced CSE through the competence-based curriculum in schools to enhance learners' knowledge about sexuality, gender, and reproductive health issues, including HIV/AIDS. However, globally, the content of CSE is sometimes dissimilar, and little evidence surrounds its scope in many settings, including Rwanda. In addition, the extent to which CSE aligns with international guidelines has yet to be well known. This study assesses major areas of CSE for early adolescents in Rwanda, analyses how CSE correlates with international guidelines and makes recommendations accordingly. METHODS: We reviewed the Rwandan competence-based curriculum to map CSE competences for early adolescents and conducted semi-structured interviews with key informants (N = 16). Eleven of the 23 curriculum documents met the selection criteria and were included in the final review. We manually extracted data using a standard form in Microsoft Excel and analysed data using frequency tables and charts. Interviews were thematically analysed in NVivo 11 for Windows. FINDINGS: We found 58 CSE competences for early adolescents across various subjects, increasing with school grades. All recommended CSE areas were addressed but to a variable extent. Most competences fall under four recommended areas: sexual and reproductive health; human body and development; values, rights, and sexuality; and understanding gender. The least represented area is violence and staying safe. Of the 27 expected topics, there are two to six CSE competences for 13 topics, one CSE competence for each of the six others, and none for the eight remaining ones. Qualitative findings support these findings and suggest additional content on locally controversial but recommended areas of sexual pleasure, orientation, desire and modern contraceptive methods. CONCLUSION: This study explores the CSE content for early adolescents in Rwanda and how they align with sexuality education standards. Ensuring equal coverage of CSE areas and addressing missing topics may improve CSE content for this age group and foster their SRHR.

Who Benefits from School-Based Teen Pregnancy Prevention Programs? Examining Multidimensional Moderators of Program Effectiveness Across Four Studies.

Recent research has suggested the importance of understanding for whom programs are most effective (Supplee et al., 2013) and that multidimensional profiles of risk and protective factors may moderate the effectiveness of programs (Lanza & Rhoades, 2012). For school-based prevention programs, moderators of program effectiveness may occur at both the individual and school levels. However, due to the relatively small number of schools in most individual trials, integrative data analysis across multiple studies may be necessary to fully understand the multidimensional individual and school factors that may influence program effectiveness. In this study, we applied multilevel latent class analysis to integrated data across four studies of a middle school pregnancy prevention program to examine moderators of program effectiveness on initiation of vaginal sex. Findings suggest that the program may be particularly effective for schools with USA-born students who speak another language at home. In addition, findings suggest potential positive outcomes of the program for individuals who are lower risk and engaging in normative dating or individuals with family risk. Findings suggest potential mechanisms by which teen pregnancy prevention programs may be effective.

Evaluación de un curso online de educación sexual integral escolar de autoaprendizaje para público en general: curso MOOC / Evaluation of a comprehensive scholar sexual education course self-learning online to general population: MOOC course

Introducción: La educación sexual integral escolar es recomendada por la UNESCO, la OMS, la UNICEF y las NN.UU. Objetivo: Evaluación de un curso de educación sexual integral escolar on line de autoaprendizaje para público general, tipo MOOC (Massive Online Open Course), gratuito. Método: Constituido por 17 capítulos, 17 conferencias, 213 preguntas, 14 videos/talleres con 76 preguntas, curso en radio FM 102.5 UCH y 3 películas originales. Sin fecha de término. Resultados: Se inscribieron voluntariamente 230 estudiantes: el 88% provenientes de Chile, el 6% del extranjero y el 6% sin identificación. El 93% eran menores de 29 años, el 60% de sexo femenino y el 94% con educación media o universitaria. El tiempo de ejecución del curso fue menos de 50 días en el 6%, de 100 a 300 días en el 78,7%, y de 301 a 399 días en el 15%. De los 751 inscritos a diciembre de 2021, terminaron el primer módulo 230 (30,6%), el segundo 207 (28%), el tercero 199 (26%), el cuarto 184 (25%) y el quinto 177 (24%). De los 230 que iniciaron el primer módulo terminaron el curso 177 (77%). La evaluación final del cumplimiento de los objetivos de los cinco módulos del curso como bueno/excelente fue la siguiente: primero 89%, segundo 91%, tercero 92%, cuarto 93% y quinto 94%; para los cinco módulos fue 92% (intervalo de confianza del 95% [IC95%]: 90,9-92,7). La evaluación final de la calidad del desarrollo del curso como buena/excelente fue la siguiente: primero 92% (IC95%: 90,5-94,0) segundo 92% (IC95%: 90,1-93,9%), tercero 93% (IC95%: 91,2-94,9%), cuarto 94% (IC95%: 91,8-95,4%) y quinto 96% (IC95%: 92,0-98,4%); para los cinco módulos fue 93% (IC95%: 92,1-93,7%). Conclusiones: La evaluación de los participantes en el Cumplimiento de los Objetivos y en la Calidad del Desarrollo, en los 19 temas temas del curso alcanza un promedio de 92% y 93%, respectivamente.

Introduction: The comprehensive scholar sexual education is recommended by UNESCO, WHO, UNICEF and UN. Objective: Evaluation of comprehensive scholar sexual education course for general public, MOOC free. Method: On line course with 17 chapters, 17 conferences, 213 questions, 14 videos/workshops with 76 questions, course FM Radio 102.5 and 3 original films. Without date of term. Results: 230 free and voluntary student inscriptions: 88% were coming from Chile, 6% from other countries and 6% without identification. 93% were 29 years old or less, 60% were women and 94% with high school or university education. The periods of course execution were: 50 days or less in 6%, between 100 and 300 days in 78.7% and between 301 and 399 days in 15% on. From the 751 initial inscriptions at December/2021, 230 complete the first module (30,6%), 207 (28%) the second module, 199 (26%) the third module, 184 (25%) the fourth module and 177 (24%) the fifth module. From 230 initial of first module, finish 177 (77%). The final evaluation of the mastery of course objectives as good and excellent were: first module 89%, second module 91%, third module 92%, fourth module 93% and fifth module 94%; for the total course was 92% (95% confidence interval [95%CI]: 90.9-92.7). The course development quality were qualified as good and excellent in 92% (95%CI: 90.5-94.0) first module, 92% (95%CI: 90.1-93.9%) second module, 93% (95%CI: 91.2-94.9%) third module, 94% (95%CI:91.8-95.4%) fourth module and 96% (95%CI: 92.0-98.4%) fifth module; for the total course 93% (95%CI: 92.1-93.7%). Conclusions: The participants evaluation of the course, was 92% and 93% for the Mastery and Development Quality, respectively.

Meta-analysis of Federally Funded Adolescent Pregnancy Prevention Program Evaluations.

Beginning in 2010, the U.S. Department of Health and Human Services (HHS) sponsored numerous studies testing the effectiveness of Adolescent Pregnancy Prevention programs on youths' risky sexual behaviors. This article presents results from a meta-analysis of such studies completed between 2015 and 2019 and provided to us by HHS. Studies were eligible for inclusion if they used an experimental/quasi-experimental design, included a comparison condition, assigned at least 10 study participants to each condition, and measured and reported at least one outcome related to sexual behavior or consequences. Data were extracted using a standardized coding protocol and outcomes were coded as, or transformed to, log odds ratio effect sizes for analysis and then transformed to odds ratio effect sizes for presentation in the text. All outcomes were coded such that log odds ratios greater than zero (odds ratios greater than 1) indicate beneficial effects (e.g., reductions in risky sexual behavior). A total of 52 studies met the inclusion criteria. Across 7 outcome types, pooled effects were generally small, the direction of effects was mixed, and none achieved statistical significance: recent pregnancy (OR = 1.30, 95% CI [1.00, 1.68]), ever had sex (OR = 1.07, 95% CI [0.99, 1.15]), recent sexual activity (OR = 0.95, 95% CI [0.84, 1.09]), recent unprotected sexual activity (OR = 1.05, 95% CI [0.96, 1.16]), ever pregnant (OR = 1.21, 95% CI [0.51, 2.89]), number of sexual partners (OR = 1.08, 95% CI = [0.28, 4.22]), and proportion of recent sexual experiences that were unprotected (OR = 0.74, 95% CI = [0.43, 1.31]). Moderator analyses pooling across all 7 outcome types indicated minor differences in program effectiveness between program settings, with those delivered in classroom settings being the least effective (b = - 0.17, 95% CI [- 0.33, - 0.01]). These findings do not lend meaningful support for the overall effectiveness of this group of pregnancy prevention programs. However, because the meta-analysis sample only included programs recently funded by HHS, these findings may have limited generalizability to programs funded by other entities or implemented in other countries.

Effects of gender-transformative relationships and sexuality education to reduce adolescent pregnancy (the JACK trial): a cluster-randomised trial.

BACKGROUND: The need to engage boys in gender-transformative relationships and sexuality education (RSE) to reduce adolescent pregnancy is endorsed by WHO. We aimed to test an intervention which used a gender-transformative approach to engage adolescents in RSE to prevent unprotected sex. METHODS: This cluster-randomised trial with process and economic evaluations tested a school-based intervention entitled If I Were Jack versus standard RSE (control) for students (aged 14-15 years) in UK schools. Schools were randomly allocated (1:1) and masked to allocation at baseline. The primary outcome was self-reported avoidance of unprotected sex (sexual abstinence or use of reliable contraception at last sex) after 12-14-months. We analysed the data using intention-to-treat mixed effects regression models. FINDINGS: Of 803 schools assessed for eligibility, 263 schools were invited by letter, of which 66 schools agreed to be randomly assigned, of which 62 schools completed follow-up. The trial was done between Feb 1, 2018, and March 6, 2020. 8216 students participated at baseline in 2018; 6561 (79·85%) provided 12-14 months follow-up. There was no significant difference in the primary outcome of avoidance of unprotected sex: 2648 (86·62) of 3057 in the intervention group avoided unprotected sex versus 2768 (86·41%) of 3203 in the control group (adjusted odds ratio [aOR] 0·85 [95% CI 0·58-1·26], p=0·42). Exploratory post-hoc analysis of the two components of the primary outcome showed that significantly more intervention students used reliable contraception at last sex compared with control students and there was no significant difference between the groups for sexual abstinence. No adverse events were reported. INTERPRETATION: The intervention had a null effect on the primary outcome of preventing unprotected sex (increasing sexual abstinence or use of reliable contraception) in the whole student population. However, the results showed significant increases in use of reliable contraceptives for sexually active students. Engaging all young people early through RSE is important so that as they become sexually active, rates of unprotected sex are reduced. FUNDING: National Institute for Health Research.

Monitoring unplanned sexual health curricula adaptations: Using results to improve fidelity and support implementation.

Maintaining fidelity to an evidence-based curriculum is important, yet educators may need to adapt to unexpected situations or particular contexts. The purpose of this study is to identify the reasons for unplanned adaptations during implementation of an evidence-based sexual health education program in California. Evaluators reviewed fidelity checklists from the implementation of 571 cohorts for activities with reported unplanned adaptations. Reasons were qualitatively coded and compared across two phases of implementation and by setting. Educators reported 319 unplanned adaptations, affecting 21.5% of the 571 cohorts and 2.9% of 13,782 activities. The most common reasons for unplanned adaptations were due to time management issues, site logistic issues, and to increase participant engagement. Over time, health educators reported fewer unplanned adaptations, particularly those due to time management, resulting in a decrease in the cohorts and activities affected. Adaptations to evidence-based curricula are necessary and often occur during implementation to fit local conditions and populations. Ongoing review of adaptation data provides an opportunity to refine training and technical assistance efforts. Guidance about the types of permitted adaptations and how to anticipate and plan for adaptations for future implementation can ensure fidelity to the core curriculum components and responsiveness to youth participants.

Exposure to Sex Education and Its Effects on Adolescent Sexual Behavior in Nigeria.

Sexual behavior during adolescence fundamentally steers the future life of both girls and boys, and it should be guided with appropriate education, especially as it also represents a key factor to be considered in attainment of sustainable developmental goals. The study assessed the effect of exposure to sex education on adolescents' sexual behavior. The primary and cross-sectional survey data used for this study were analyzed using basic descriptive statistics and binary logistic regression analytical technique. The results, among others, highlighted that the most common sources of first sex education among the respondents are school (54.6%), family (21.6%), social media (9.5%), and others like television (7.6%) and books or magazines (4.9%). Frequency of discussion on sexual matters is positively associated with the use of protection such as condom (ß = 0.261; p ≤ 0.01). The study gave support to the increasing pursuit of sexuality education. However, since adolescents' needs could vary by demographics, streamlining sex education need by age and sex characteristics could enhance its effectiveness.

Evaluating the mechanisms and long-term effects of a web-based comprehensive sexual health and media literacy education program for young adults attending community college: study protocol for a three-arm randomized controlled trial.

BACKGROUND: Many community college students experience poor sexual and relationship health outcomes. Young adults consume a plethora of media content, much of which depicts unhealthy sexual and romantic relationships, and research has shown that media exposure can negatively impact health outcomes. Asynchronous, web-based media literacy education (MLE) programs have been shown to improve short-term sexual and relationship health outcomes. However, there is a dearth of research on the mechanisms by which MLE programs impact health outcomes and the long-term effects of MLE programs on sexual and relationship health outcomes among community college students. METHODS: This study will (1) evaluate the unique effects of MLE on primary and secondary sexual and relationship health outcomes; (2) compare the mechanisms underlying the effects of an asynchronous, web-based MLE sexual health program (Media Aware) to the mechanisms underlying the effects of an active control program on health outcomes; and (3) evaluate the long-term efficacy of Media Aware on media literacy skills and sexual and relationship health outcomes compared to active control and delayed intervention control groups. To address these aims, a three-arm randomized controlled trial with young adults attending community college will be conducted. It is expected that around 30 campuses will participate and approximately 67 students from each campus will be enrolled in the study (estimated n = 2010). Campuses will be randomized to either the (1) intervention group (Media Aware); (2) active control group (sexual health education from Media Aware without MLE content or methods); or (3) delayed intervention control group. Students will complete online questionnaires at pretest, posttest, 6-month, and 12-month follow-ups. DISCUSSION: This project has the potential to advance theory about the potential mechanisms through which MLE has an impact on sexual and relationship health outcomes by directly testing the impact of interventions using a randomized design. Additionally, this study is expected to establish strong evidence for the effectiveness of Media Aware for use with young adults and to help identify strategies to optimize the longer-term impact of the program on health. Students' satisfaction with programming will be discussed to inform future implementation efforts.

Parents' approaches to sexuality education of their adolescent boys: a qualitative study in Ahvaz, Iran.

BACKGROUND: Despite its important role in adolescent sexual health, sexuality education remains one of the most challenging responsibilities of families, especially those living in Muslim communities which experience the transition to modernity. There is little information about sexuality education of boys in Iran. This study aimed to explore parents' approaches to sexuality education of adolescent boys in Ahvaz, southwest of Iran. METHODS: This qualitative study was conducted in 2017 in Ahvaz, Iran. Participants were selected through purposeful sampling with maximum variation. Qualitative data were collected by conducting semi-structured in-depth interviews and focused group discussions with 27 parents from middle/high social class who had adolescent boys aged between 10 and 19. Data were analyzed using conventional qualitative content analysis. RESULTS: Parents' approaches to sexuality education of their boys emerged in six categories: Extreme monitoring and restricting; abstinence as the main content of sexuality education; struggling to establish peace and achieve tolerance; criticizing the cultural taboos; hoping for spontaneous learning; and uncertainty and confusion. The theme "Transition from tradition to modernity" emerged from these categories. CONCLUSION: Parents' approaches to sexuality education ranged from a restrictive traditional manner to approaches with some degree of modern attitudes. Parents are facing uncertainty and confusion regarding sexuality education. Abstinence is an underlying assumption in their sexuality education style. Educating parents through culturally-appropriate methods is a priority that is more acceptable at the policy level. Lack of understanding of the need for sexuality education of children in some parents can threaten the sexual health of children.

Children's sexuality education has an important role in adolescent sexual behaviors and health. However, it is one of the most challenging dimensions of education in families, especially in Muslim communities experiencing the transition to modernity. There is little information about sexuality education of adolescent boys in Iran. In this study we aimed to explore parents' experiences and perceptions of communicating sexuality education with their sons. Data were collected through individual interview with 11 parents and group discussion with 8 fathers and 8 mothers who had sons aged 10­19, living in Ahvaz, in south west of Iran. We summarized and categorized parents' approaches to sexuality education in categories including: Extreme monitoring and restricting; abstinence as the main content of sexuality education; struggling to establish peace and achieve tolerance; criticizing the cultural taboos; hoping for spontaneous learning; and uncertainty and confusion. Parents' approaches to sexuality education ranged from a restrictive traditional manner to some degree of modern conduct. Findings imply that parents are facing challenges regarding sexuality education: uncertainty about the necessity of it, and confusion between religious teachings and modernity. Abstinence is still a central assumption and pre-marital sex is off-limits in their sexuality education. They hoped that they could enhance the children's adherence to family's values regarding sexuality, by establishing a peaceful relationship with them. These findings provide evidence for culturally-appropriate educational programs for parents to improve their skills and knowledge about sexuality education. These findings highlighted the fact that Iranian parents are experiencing a "Transition from tradition to modernity".

Dose Matters in Evaluation of a School-Based Adolescent Sexual Health Education Program.

BACKGROUND: Research on the effects of intervention dose on outcomes within adolescent sexual health education programming is lacking. Existing research on dose typically utilizes the number of sessions as a variable. In a school setting, there are scheduling limitations, student absences, and other logistical barriers that have the potential to affect the number of sessions for an intervention and, in turn, impact the efficacy of programming. METHODS: This article evaluates the effectiveness of a school-based, peer-led adolescent comprehensive sexual health education program, with a focus on dose. A repeated measures MANOVA was used to evaluate the effects of individual difference variables and intervention variables on changes in participants' knowledge and attitudes across 2 time points. Additionally, paired t-tests were used to evaluate changes in specific behaviors. RESULTS: Results indicated that knowledge improved following the intervention, and specifically larger doses, measured in minutes, of the intervention were associated with larger improvements in knowledge. There were no significant effects related to attitudes or behavioral outcomes. CONCLUSIONS: This study adds to the knowledge base by including analysis of how the dose of intervention may impact youth outcomes. Implications for school health practices and research are discussed.

A Media Literacy Education Approach to High School Sexual Health Education: Immediate Effects of Media Aware on Adolescents' Media, Sexual Health, and Communication Outcomes.

Media may function as sex educators for adolescents; unfortunately, media messages often glamorize risky sexual behaviors and unhealthy relationships and neglect sexual health behaviors and communication. Media Aware is a web-based comprehensive sexual health program for high school students that uses a media literacy education approach. It is designed to improve adolescents' critical thinking about media messages and provide medically-accurate information and skills building related to sexual health and communication. A randomized controlled trial was conducted in 2019-2020 with students (grades 9 and 10; n = 590) from 17 high schools across the United States. The sample was 53% female, 58% white/Caucasian; and 13% Hispanic/Latinx. One high school teacher per school and all of their 9th and 10th grade students were randomly assigned to either the intervention or delayed-intervention (control) condition. The study assessed the immediate (posttest) and short-term (3-month) effects of Media Aware on adolescents' media, sexual health, and communication outcomes. For 9 of the 17 schools, students were home from school due to the beginning of the COVID-19 pandemic during the time of their 3-month data collection, which left the short-term analyses underpowered. However, several impacts of the program were found in the immediate posttest analyses. Media Aware was found to improve sexual health knowledge and redress inaccurate normative beliefs about the frequency of risky teen sex. Media Aware also improved critical thinking about media messages with demonstrated improvements in media message deconstruction skills and decreases in the perceived realism of media messages. Moderator analyses found some differential immediate effects of the program attributable to gender. Media Aware reduced girls' normative beliefs about teen sex, generally, and increased their sexual health communication with parents as well as reduced boys' acceptance of dating violence. Students gave positive feedback about Media Aware, especially related to the online format of the program. The results from this study provide evidence that Media Aware is an effective web-based program for positively enhancing high school students' media, sexual health, and sexual health communication outcomes.

A randomized controlled trial of the impact of the Teen Council peer education program on youth development.

This paper presents results of an impact evaluation of Teen Council, a program that trains youth as peer educators. Teen Council is designed to help peer educators make healthy sexual and reproductive decisions, increase their confidence and abilities to educate their peers and inspire them to advocate for just sexual policies. The program's impact on these educators was evaluated using a randomized controlled trial. Over 5 years, interested high school students in seven states were randomly assigned to a study condition. An intent-to-treat framework using ordinary least square (OLS) regression was employed to measure program effects. Relative to control, Teen Council youth showed enhanced comfort with their own sexuality, greater comfort with and more frequent communication with parents about sexuality and more positive sexual health behaviors, including accessing reproductive health care and adopting more effective means of contraception. Teen Council youth also reported greater confidence in talking with peers about sexuality and more confidence in their civic engagement skills.

Factors associated with unmet need for family planning in sub-Saharan Africa: A multilevel multinomial logistic regression analysis.

BACKGROUND: More than one out of every ten married women in the world, and one out of every five women in Africa, have unmet family planning needs. Despite this, studies concerning sub-Saharan Africa as well as the community-level factors that may influence the unmet need for family planning are scarce. OBJECTIVE: To assess factors associated with unmet need for family planning in sub-Saharan Africa. METHODS: This study used the nineteen demographic and health surveys (DHS) conducted between 2015 and 2020 in sub-Saharan Africa. A total weighted sample of 175, 820 women of reproductive age who were married during the survey was used for this study. To assess the factors associated with unmet need for family planning, I have employed a multilevel multinomial logistic regression model. After selecting variables using the bivariable analysis, a multivariable model was fitted. Finally, an adjusted relative risk ratio with its 95% Confidence Interval was reported and variables with a p-value less than 0.05 were declared to be significant predictors of unmet need for family planning. RESULT: The overall prevalence of unmet need for family planning in sub-Saharan Africa was 23.70%, of which unmet need for spacing and limiting was 15.81% and 7.90% respectively. In the multivariable multilevel multinomial model, women's age, women's education, age at cohabitation, heard about family planning through media, parity, number of under-five children, and knowledge about modern contraceptive methods were among the individual-level factors that were associated with both the unmet need for spacing and limiting. Place of residence, community level of women illiteracy, and region were among the community-level factors that were associated with both unmet needs for spacing and limiting. Household size and visiting the health facility in the last 12 months were associated with unmet need for spacing only and husband education was associated with unmet need for limiting only. CONCLUSION: Unmet need for family planning in sub-Saharan Africa was high. Both individual and community level factors were associated with both unmet need for spacing and limiting. Therefore, it is better to consider interventions at both individual and community levels.