Effective comprehensive sexuality education: What is known and what is needed?

This article is one of three linked discussions of Comprehensive Sexuality Education (CSE) produced as part of the scoping work of the ACCESS consortium by the Open University team. The other articles focus on CSE for out-of-school refugee youth and Online CSE.

The literature review employed structured searches of the Cumulative Index of Nursing and Allied Healthcare Literature (CINHAL), limiting results to those published 2010-2020 in English. Initial searches focused on CSE in Sub-Saharan Africa. Further searching widened the geographical scope. We supplemented this with Google searches for global overviews of CSE effectiveness published in English. The full review of 47 papers is available [here], as a companion piece to this paper.

Barriers

A review of 10 years of implementing a CSE programme in Global Southern settings found three main types of barriers:

1. societal factors such as socio-cultural norms around what is acceptable, and power differences between young people, and between young people and educators,
2. organisational or school level barriers such as access to resources and perceived value within the curriculum,
3. teacher-level barriers around attitudes, training and skills, and barriers at the level of the individual learner through problems such as feeling unsafe, and having competing tasks (1).

A further barrier is that it is clear that education is being delivered under the badge of CSE that is not comprehensive – e.g. abstinence only and medically/biologically focused curricula (2). It is also clear that adapting CSE content to exclude contentious topics, such as abortion and masturbation, is a common pragmatic strategy to enable acceptance of at least some sexuality education (3). Where contentious topics are taught, they may be contextualised by the trainer in a way that undermines the intention of the materials’ creators, for example, treating LGBT people as pitiful (4). Everyday experiences of e.g. sexual harassment and gender hierarchies, inside or outside the classroom/learning group, may undermine even well-taught content (3, 5).

The pervasiveness of cascade training models means that educators at the bottom of the cascade often receive only a few hours of training to deliver education on complex and contested topics (2, 3). 

©  Jonathan Brodsky  CC BY

Enablers

There is some evidence that participatory design improves the acceptability and effectiveness of CSE, although young people are less likely to be involved in co-design than older stakeholders (2, 6). There is also some evidence that discursive and skills-based teaching methods are more effective than didactic ones (7). There are also reports, though, that CSE that uses more participatory teaching styles may not be well received in educational cultures that favour didactic methods (2). Interventions that combine CSE with other topics or resources sometimes increase acceptability e.g. IT skills or access to free beauty services (2).

Effectiveness

Measuring the effectiveness and impact of CSE programmes is challenging because so many factors influence effectiveness. Most studies that attempt to evaluate the effectiveness of CSE conceptualise SRHR narrowly and focus on measurable individual outcomes rather than processes and system-wide changes, which are much more challenging to evaluate.

Identifying which topics are covered in a particular curriculum and whether it is delivered as intended is an important first step in identifying how effective a programme is. Tools such as UNESCO’s SERAT  and IPPF’s ‘Inside and Out’ enable this kind of analysis and have demonstrated the persistence of the barriers identified above. However, on their own, these kinds of evaluations do not show whether, when the curriculum is delivered as intended, the interventions have the effects that the curriculum’s designers intended.

Evaluations that measure specific desired outcomes, such as national/regional reductions in teenage pregnancy or HIV infection rates, usually show small improvements or no effect at all (8). Many studies find reported increases in knowledge, self-efficacy, condom use and delayed onset of sexual activity (9). However, these studies usually rely on self-report which, while providing important evidence of changed attitudes and capacities, do not necessarily prove changed behaviours. Changed behaviours also require access to resources (such as contraception) and sufficient power within sexual relationships to act on new knowledge and intentions. Since sexual health behaviours occur in complex and ever-changing environments, simple outcome measures are unlikely to ever capture the wider benefits of CSE (10, 11).

There is, however, quite strong evidence that CSE combined with contraceptive availability reduces unintended teenage pregnancy (10), and that CSE that includes discussion of gender and power inequalities is more effective that CSE that does not (11).

© Jonathan McIntosh CC BY-NC

Co-design and participatory approaches

Participatory approaches to developing CSE curricula are widely recommended in the sector and there is some evidence that these approaches are more effective than more ‘top-down’ approaches to CSE (12). However, evidence for this is still limited, especially as involving end users in the very early stages of curriculum design is less common than consulting them once curricula have begun to be developed. It is even less common for the impetus for new resources to come from young people or educators, rather than NGOs and charities.

There is clear evidence that acceptability to parents, educators and young people themselves is a major barrier to implementation, and this suggests that co-design may help, and should include fundamental decisions about topic, focus and the form of any intervention. While there may sometimes be tensions between local acceptability and global standards and aspirations for truly comprehensive sexuality education, co-design offers the opportunity for negotiation and making informed choices as to what is optimal for each specific setting.

Our review of the literature, summarised above, leads us to the following recommendations: 

Recommendations for future participatory work on CSE

There are many excellent, inclusive CSE curricula and resources already available – it is important not to ‘reinvent the wheel’. However, a commitment to co-design and participatory approaches means starting from the needs and priorities of stakeholders, especially the most marginalised, and this is more difficult to do if the starting point of a project is existing curricula and resources. Once context-specific needs and priorities have been identified, existing resources should be reviewed and the most promising discussed to see whether they can be adapted or reused in ways that make them more effective. An early activity for a co-creation group could be to specify how to review and critically appraise existing outputs in a structured way, focusing especially on usability and acceptability.

Co-design needs to include discussion of pedagogic issues as well as content – discursive and experiential approaches will only be more effective if teachers and trainers are supported to feel comfortable employing them, and if local educational cultures can value non-didactic learning.

Explicit discussion of gender and power inequalities should be integrated into CSE materials whenever possible.

In order to be most effective, CSE needs to be supported by other interventions, such as accessible, high-quality health services. CSE providers should therefore conceptualise CSE as part of a package of resources, not as a stand-alone intervention.

There is a clear need to improve support and training for teachers and trainers of CSE. Creating online and distance resources has the potential to enable organisations to move away from cascade models of training, thereby improve the quality of training received. Ongoing support for trainers, such as facilitating communities of practice, is also an important priority. Support for teachers and trainers may be a particularly good candidate for scaling and recontextualization for new contexts.

When scaling up resources developed in one setting for use more widely, discussion of acceptability, sustainability and implementation in the new context must be an explicit part of the scaling-up process.

It is clear that the context of use is at least as important as the CSE materials themselves. CSE providers therefore need to explore barriers and enablers to delivery of existing curricula and identify ways in which these can be improved. It is also vital to work with relevant authorities to increase inclusion in official curricula wherever possible.

Measures of effectiveness should be holistic and nuanced, and consider the whole system. Identifying appropriate strategies for evaluation should be an early part of the work of any co-creation group. 

Checklist of questions for proposed CSE work

• What do (diverse) stakeholders think is needed?
• Do stakeholder representatives include young people and other marginalised groups?
• Are there any points of tension between local acceptability and global standards? What scope is there for negotiation around these?
• How can explicit discussion of gender and power differences be integrated?
• What pedagogies and educational approaches are appropriate for this topic and context?
• Does something similar to the planned resource already exist? Could existing resources be versioned for this new context?
• How will this curriculum be supported by other related services and interventions?
• How will teachers/trainers be supported to deliver these resources?
• What are the main barriers and enablers to delivery and acceptability? How can barriers be reduced and enabling factors increased?
• How will we be able to evaluate whether this intervention is effective?

References

1. Vanwesenbeeck I, Westeneng J, de Boer T, Reinders J, van Zorge R. Lessons learned from a decade implementing Comprehensive Sexuality Education in resource poor settings: The World Starts With Me. Sex Education. 2016;16(5):471-86.
2. Wekesah FM, Nyakangi V, Onguss M, Njagi J, Bangha M. Comprehensive Sexuality Education in Sub-Saharan Africa. Nairobi, Kenya: 2019.
3. Population Council. Sexuality education: A ten-country review of school curricula in East and Southern Africa. New York: 2012.
4. Francis DA. What does the teaching and learning of sexuality education in South African schools reveal about counter-normative sexualities? Sex Education. 2019;19(4):406-21.
5. Ngabaza S, Shefer T, Macleod Catriona I. “Girls need to behave like girls you know”: The complexities of applying a gender justice goal within sexuality education in South African schools. Reproductive Health Matters. 2016;24(48):71-8.
6. Keogh SC, Stillman M, Awusabo-Asare K, Sidze E, Monzón AS, Motta A, et al. Challenges to implementing national comprehensive sexuality education curricula in low- and middle-income countries: Case studies of Ghana, Kenya, Peru and Guatemala. PloS one. 2018;13(7):e0200513.
7. Jearey-Graham N, Macleod Catriona I. Gender, dialogue and discursive psychology: A pilot sexuality intervention with South African High-School learners. Sex Education. 2017;17(5):555-70.
8. Picot J, Shepherd J, Kavanagh J, Cooper K, Harden A, Barnett-Page E, et al. Behavioural interventions for the prevention of sexually transmitted infections in young people aged 13–19 years: a systematic review. Health Education Research. 2012;27(3):495-512.
9. WHO. Preventing HIV/AIDS in young people: A systematic review of the evidence from developing countries. Geneva: World Health Organisation, 2006.
10. Oringanje C, Meremikwu MM, Eko H, Esu E, Meremikwu A, Ehiri JE. Interventions for preventing unintended pregnancies among adolescents. The Cochrane database of systematic reviews. 2009(4):Cd005215.
11. Haberland NA. The case for addressing gender and power in sexuality and HIV education: A comprehensive review of evaluation studies. International Perspectives on Sexual and Reproductive Health. 2015;41(1):31-42.
12. Cobbett M, McLaughlin C, Kiragu S. Creating ‘participatory spaces’: Involving children in planning sex education lessons in Kenya, Ghana and Swaziland. Sex Education. 2013;13(sup1):S70-S83.