Author: McClung, Ashley A
Date published: March 1, 2012
The debate over sexual health education is currently making headlines due to the upcoming 2012 election combined with rising rates of adolescents who have sexually transmitted infections (STIs) or unwanted pregnancies. The debate has many of the elements it always has; for example, whether abstinence-only or comprehensive programs are the most effective in a school. It is evident that our society is impacted by sexual decisions, as 19 million STIs are reported every year, with half of these infections reported among adolescents and young adults (CDC, 2009; Kirby, 2007). Among all births in the United States, approximately 10% are to teenage mothers (Guttmacher, 2011a). Although the United States has witnessed a decline in adolescent pregnancies in the last decade, it still has the highest rate among industrialized nations (CDC, 2010; Guttmacher, 2011a). Pregnancy during the school years is particularly problematic because of its association with school
dropout (Kirby, 2007). These numbers are staggering, so few would argue against the need for sexual health education, but questions remain: Should it be administered in the schools and what should the content ofthat education entail? The National Association of School Psychologists' (NASP) official stand on sexual education is that it should be taught in schools to help young people make healthy decisions regarding sex throughout their lives. Accordingly, school psychologists have a responsibility to use their expertise to facilitate these programs. Without a comprehensive sexual education program facilitated by a professional who is educated in these issues, young adults will often base their decisions on misinformation from peers and unvetted Internet sources (NASP, 2003).
The purpose of this article is to inform readers about some of the issues associated with implementing and maintaining sexual health education programs in the schools. We will briefly describe the problems raised by the popular press, particularly in light of the ongoing political debate. Furthermore, we will discuss the variability in state requirements regarding school-based sexual health education. Then, we will provide an overview of the research related to the effectiveness of various programs. As part of this coverage, we will present two reviews of reviews (umbrella reviews) that critically evaluated different programs. Finally, this article will provide tips on how to create and implement an effective evidence-based curriculum, how to involve parents and the community, and most importantly, why school psychologists should be at the forefront of creating and implementing these programs.
POLITICAL AND RELIGIOUS DEBATE
The current debate revolves mostly around these issues: Should schools be involved at all in sexual education, and is abstinence the best message for adolescents? Many proponents of abstinence-only programs have strong religious affiliations and believe that teachingyoung adults about contraception will cause them to initiate sexual intercourse before marriage (Eisenberg, Bernāt, Bearinger, & Resnick, 2008; Mckay, Pietrusiak, & Holowaty, 1998). The problem is that many young people are initiating sexual intercourse without contraceptive knowledge, and thus, become at risk for STIs and unwanted pregnancies. In fact, research has found that abstinence-only programs are not generally effective, and comprehensive programs that include abstinence components show positive results (Kirby, 2007) . It is because of this research that the current federal administration provides funds for schools to teach comprehensive sexual health education programs (Sexuality Information and Education Council of the United States, 2010) . What maybe unknown is that a majority of parents believes that some sort of comprehensive sexual education program should be taught in the schools, ranging from 8996-95% approval; this support has been found across all demographic categories of parents (Eisenberg et al., 2008; Kirby, 2007; McKay et al., 1998). Many parents who support a comprehensive sexual education believe that most topics regarding sexual health should be first introduced either in the primary grades or during middle school (Eisenberg et al., 2008; McKay et al., 1998). Many parents may believe that the schools have the primary responsibility for educating their children about sexual health, and thus take a passive role. In addition, they may believe they lack knowledge or are not at ease discussing sexual health knowledge with their child (Byers, Sears, 8c Weaver, 2008) . They may also not know the best approach to having a dialogue about sexual health decisions.
Some have argued that open communication about sexual activity with children will initiate sexual activities at a younger age (Bersamin et al, 2008). However, research has shown that parental communication with the child, particularly between a mother and daughter, will not only delay sexual intercourse and create negative attitudes regarding pregnancy, but also decrease the likelihood of the youth having unprotected sex and decrease the number of sexual partners (Parsons, Butler, Kocik, Norman, 8c Nuss, 1998; Sunder, Ramos, Short, 8c Rosenthal, 2006). Thus, the content and quality of parent-child communication may have an effect on delaying or accelerating the time line for sexual initiation (Bersamin et al., 2008).
STATE VARIABILITY IN LEGAL MANDATES REGARDING SEXUAL HEALTH EDUCATION
At the state level, there is considerable variability in requirements as well as funding provided for programs. In 2011, changes occurred in many state legislatures regarding sexual health education within public schools, as many states added mandated sexual health education, whereas others mandated that if sexual education is taught, it should be medically accurate. Many of these new policies are still pending in some state legislatures (National Conference of State Legislatures, 2011). Furthermore, some states mandated that if sexual health education is provided, this education must stress abstinence only. Other states have promoted contraceptive use and the prevention of STIs, but also required abstinence discussions (Guttmacher Institute, 2011b). The reader is encouraged to consult the National Conference of State Legislatures' website (http:// www.ncsl.org) regarding state legislative activity pertaining to sex education.
Eventhoughmany states have laws about school-based sexual healtheducation, there is no doubt that districts themselves vary in how they design and implement these programs. Individual schools vary in curriculum content, teaching methods, and the nature of training of the instructor selected to teach sexual health education. These instructors typically have a variety of backgrounds, including health assistants, educators, and nurses (Landry, Darroch, Singh, 8c Higgens, 2003; Poobalan et al., 2009). The variability on all of these dimensions makes it difficult to evaluate which programs are effective and which are not.
KEY COMPONENTS OF EFFECTIVE INTERVENTIONS
There are two primary behavior changes that are the target outcomes for many programs: delay of sexual initiation and prevention of HIV, STIs, and unintended pregnancy. Kirby (2007) identified characteristics that were common among programs and found to be most successful in reducing STIs and HIV. The following components are adapted from Kirby unless otherwise noted:
* Set measurable health outcomes with specific behaviors attached.
* Discuss behaviors through a public health model of prevention and give accurate statements regarding effects of those behaviors (Meyers, Meyers, 8c Grogg, 2004).
* Give information regarding knowledge, risks, peer influence, and other factors associated with sexual health.
* Try to include service-learning components with voluntary/paid work in the community.
* Increase parental communication through a family systems model (Bersamin et al., 2008).
* Create an environment in which students feel comfortable discussing personal issues.
* Consider the characteristics of the target group when developing activities.
* Introduce activities and topics, in a sequential order, that focus on specific health behaviors identified and that have relevance to students in class.
* Make sure that teaching methods employed will not only catch the attention of the students, but will also help change their health behaviors.
Poobalan et al. (2009) also reviewed sexual health education programs that were implemented in both the schools and communities for youth 10 to 18 years old. The researchers noted that across 30 different review studies, successful sexual education programs considered the biological and cognitive aspects of the youth who were targeted for the program. Interventions that consisted of active involvement of participants, such as practicing negotiation skills, showed higher rates of success. Further, this review noted that programs that taught abstinence were effective only when also emphasizing other values as well as skills in contraception use.
Many studies do not have an underlying theory used to support a sexual education program; most use practical knowledge or common sense. The problem with understanding how theory is applied to sexual health education curricula is that publications often just mention the theory (if at all), and do not provide a description of how the theory was used to guide the development and implementation of the programs. Poobalan et al. (2009) noted that Bandura's social learning theory, which provides behavioral modeling skills to help the teen negotiate challenges of social and peer pressure, appears more successful in creating behavioral changes in contrast to the theory of reasoned action (Fisher, Fisher, 8c Rye, 1995) and the Health Belief Model (Glantz 8c Bishop, 2010).
Although it can be time consuming to maintain, service learning components have been shown to have long-term benefits when combined with sexual health instruction in delaying sexual initiation by youth (Kirby, 2007). Service learninginvolves students being placed in community organizations or businesses to gain practical experience. Students benefit not only from working at the site, but also from reflecting about the work they have performed. Further, programs should be altered based on the needs of the population that is to be targeted. For instance, students who are already sexually active should learn about contraceptives as well as positive behavioral skills regarding their sexual practices (Fisher, Fisher, Bryan, 8c Misovich, 2002; Kirby, 2007). Often, contraceptive knowledge and STI prevention programs show only short-term gains among those who are already sexually active (Coyle et al., 2006; Fisher et al., 2002). It is much more difficult to change sexual behaviors once they have begun than to delay the onset of those behaviors. Even so, it has been shown that older teens respond to the intervention by reporting increased condom usage for sex (Poobalan et al., 2009). In addition, there is little known about the moderating effect of culture and ethnicity on teens' response to these programs. This is an area of needed research vis-ą-vis program effectiveness.
CURRICULUM DEVELOPMENT AND IMPLEMENTATION
When creating a curriculum for a sexual education program, there should be experts who are knowledgeable about prevention science and theories behind effective evidence-based programs, and who also have knowledge regarding what sex education entails. Next, program developers should address areas on which to focus based on the needs, qualities, and age or developmental stage of the targeted group within the school district (Kirby, 2007; Walcott, Meyers, 8c Landau, 2007). There is a clear indication that the younger the age of those targeted by an intervention, the more successful the program. This is because with younger age groups, the program focus is more preventive; that is, having youth participate in a program before they become sexually active has been found to delay the onset of sexual activity (Poobalan et al., 2009).
Another consideration in developing a curriculum is to not only specify the health behaviors to be modified, but to also focus on behaviors/attitudes that impact these outcomes (Poobalan et al., 2009). Accordingly, the program must address risk and protective factors that affect those behaviors and reasons underlying the behaviors; this information should then be used to design activities that can change unhealthy sexual practices to desirable behaviors (Kirby, 2007). One recommendation is to try the proposed program out on a small scale before implementing it completely or locate an existing program with documented effectiveness (Kirby, 2007). The duration of sexual health programs studied has been inconsistent, so dose-response data or the optimal number of sessions has not been established (Poobalan et al., 2009).
Not surprisingly, the more support for the program, the better it is received. Those considering implementing a sexual education program should focus activities around ideals of the local population to facilitate support from administration, parents, and the community. Program educators should possess characteristics that allow them to connect with youth regarding uncomfortable topics, and should have appropriate training to enable the educator to effectively lead the program. Schools must determine whether the sexual education program is voluntary or if every student in a certain grade (with or without parental permission) will participate. In addition, consideration must be given to recruiting and retaining students to volunteer for participation. Alternative activities should be available for those who do not participate in programs that are voluntary. A critical step is to always implement the program with the utmost fidelity (Kirby, 2007).
PARENT AND COMMUNITY INVOLVEMENT
Parents. Many published studies (e.g., Poobalan et al., 2009) reported administrator and parent resistance to sexual health educationin the classroom, especially if those programs provided information about contraceptive options. One way to combat this resistance is to get approval from parents and community leaders before actually implementing the program. It is important to focus on community values where the program is to be implemented. If these values are not known, surveys can be sent home with the students. As noted previously, a majority of parents seems in favor of some type of sexual education program, especially if it will facilitate or supplement discussion at home. Specifically, when these programs addres s abstinence along with a sexual health education curriculum, parents seem to be more accepting and supportive of the curriculum. One should not assume that the opinions of parents are known. Many times, parents who are the most vocal in their opposition to school-based sexuality education hold the minority opinion, whereas those with a majority view remain silent on the issue (McKay et al., 1998). If there is parent opposition to sexual educationin the school, discuss concerns openly and provide evidence-based research and information to the parents (Walcott et al., 2007).
Community. Improving educational and career opportunities appear to be factors that are especially important in reducing pregnancy rates among female teens. In this regard, it has been found that becoming more involved in community service-learning can reduce sexual activity and pregnancy rates. Becoming more highly involved in the community can also facilitate what many comprehensive sexual education programs aim to accomplish. That is, these programs are often successful simply because community service involves afterschool activities instead of returning to an unsupervised home after school. Service learning programs can further increase community support by having adolescents positively contribute to their communities. As such, sexual education programs may not only get support from parents and community members by supplying sexuality knowledge via the program, but by also getting adolescents involved in afterschool community projects and goal-setting behaviors (Kirby, 2007).
THE ROLE OF THE SCHOOL PSYCHOLOGIST
There are three major considerations regarding the involvement of school psychologists in school-based sexual health education. First, what are their areas of expertise that make them suitable to address sexual health issues? Second, what framework supports the roles and functions of school psychologists to be involved in sexual health education of students? Third, within that framework, what is the best approach to become involved in sexual health education?
Regarding areas of expertise, school psychologists can provide important assistance for the learning and behavioral needs of students due to their knowledge and experience with evidence-based interventions, and data-based decision-making, andas consumers of research (NASP, 2005). They can provide this expertise using consultation through a public health model. School psychologists are trained in many of the theories espoused to make programs effective and can help through consultative efforts designed to ensure that programs are theory driven, developmentally appropriate, and culturally relevant (NASP, 2003). One example is that school psychologists are trained in family systems and can use this theoretical base to encourage parents to talk with their children about sexual health as a way to increase parental involvement. Given school psychologists' background in children's social-emotional well-being and knowledge of peer relationships, school psychologists can provide input when designing programs that incorporate information about how to cope with anxiety, peer pressure and rejection, and problems with assertiveness. Integrating psychological aspects of sexual health can help to strengthen programs that focus on facts and cognitive components of decision making. School psychologists who have knowledge of program evaluation can help guide educators in incorporating the appropriate outcome measures to monitor student progress and program effectiveness. Further, school psychologists can work with educators to tailor these programs for those with special learning needs.
Support for the role of the school psychologist in the matter of general health education fits within a public health perspective. A public health perspective uses prevention at the primary level by introducing early interventions or risk-reduction strategies on a school-wide basis. Furthermore, this perspective focuses on specific elements that affect the school atmosphere, allowing for prevention to be targeted at specific sexual health education needs (e.g., contraceptive use, STI prevention, communication skills; Meyers et al., 2004).
Among the competing roles and functions of school psychologists, perhaps the best way to make their involvement with sexual health education a reality is through consultation. Using consultation allows school psychologists to be indirectly involved in the school's sexual health education program by assisting other professionals in creating effective, evidence-based curricula that are developmentally appropriate. Furthermore, school psychologists can consult with those who are responsible for implementing the curriculum in the classroom. This strategy would reduce the time constraints placed on school psychologists who embrace the needfor sexual education to be implemented in their schools. This fits within a prevention science and public health model by considering students' health needs to be addressed on a school-wide basis and within the context of community values.*
National Conference of State Legislatures http://www.ncsl.org Summary of current state legislature pending on different issues
Teen Aid http://www.teen-aid.org Abstinence education information
Centers for Disease Control and Prevention http://www.cdc.gov/healthyyouth/sexual behaviors/index.htm Information regarding statistics on sexual health issues
Sexuality Information and Education Council of the United States http://www.siecus.org Contains many links regarding information on variety of issues: how to interpret state law, simplified definitions of sexual education terms, important publications, and guidelines of comprehensive sexual education K-12th grade
Guttmacher Institute http://www.guttmacher.org Contains many links on a variety of different topics in sexual and reproductive health; also provides research and state law analysis References
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ASHLEY A. MCCLUNG is a doctoral student in the school psychology program at the University of Arizona. MICHELLE M. PERFECT, PhD, is an assistant professor in the school psychology program at the University of Arizona