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Enhancing Sexual Wellbeing In Scotland: A Sexual Health Relationship Strategy

SEXUAL HEALTH AND RELATIONSHIPS EDUCATION FOR YOUNG PEOPLE

1. Introduction

1.1 In supporting the proposed Sexual Health and Relationships Strategy, this paper provides an overview of the issues influencing learning about sex and sexual health among young people and summarises the research findings in terms of levels and sources of young people's knowledge about sexual health.

1.2 It details the background to effective sex education and then highlights the key influencers on young people's learning about sex and sexual health. A detailed commentary is provided on early childhood programmes, the role of parents and carers and school based sex and relationships education and sex education outside school settings.

2. Background

2.1 For some time, issues relating to the sexual health of young people have featured in health and education policy in Scotland. The two major issues that have dominated public health policy and research are HIV/STIs and teenage pregnancy. More recently, work has begun to explore other aspects of poor sexual outcomes such as coercion and regret in relationships.

2.2 Why focus on young people? Research indicates that early sexual behaviour can put young people at increased risk of poor sexual outcomes such as sexually transmitted infections and unintended pregnancies in teenage years. These can have long-term health, social and economic consequences (as highlighted in Supporting Paper 2 on the wider social and cultural factors which influence sexual health and wellbeing).

2.3 Reviews of international and national evidence indicate that the number of unintended pregnancies and sexually transmitted infections can be reduced through:

2.3.1 A good general education or vocational programme leading to:

• Increased aspirations and expectations

• Motivation to avoid risk behaviour

2.3.2 The provision of sex education which aims to:

• Provide skills and confidence to maintain respectful relationships

• Provide information and skills to delay the timing of first sexual activity

• Provide information and skills to encourage individuals to protect themselves against unwanted pregnancy and sexually transmitted infections

• Increase knowledge of contraceptive use and availability of contraceptive services

• Increase awareness and understanding of post coital contraception.

2.3.3 The provision of contraceptive services and counselling which seek to:

• increase contraceptive use and compliance

• increase the use of post coital contraception following unprotected sex or contraceptive failure

2.4 Many factors are associated with early sexual initiation, contraceptive use and teenage pregnancy and have been identified in other supporting papers. A summary of these factors is shown in the table below:

Table 1: Factors associated with early initiation, contraceptive use and teenage pregnancy (NHSCRD, 1997)

3. Influences on Learning About Sex

3.1 Learning opportunities are important to improving sexual health but learning about sex does not occur in a vacuum. It is a lifelong process that commences in childhood through adolescence and into adulthood. From an early age, children and young people are exposed to a range of influences such as parents, siblings, friends, community and schools. References to sexuality abound in Scottish culture, especially in the media. The social context in which people live has a great impact on how young people view sexual health. Providing young people with the confidence and skills to interpret the sometimes mixed messages from all these sources is key to sex education.

3.2 There is much evidence about learning about sex based on school based sex education and whilst important, it is important to recognise the other influences as identified in Table 1. Parents, peers, the media and the community at large have a vital role helping young people gain the confidence and self esteem to be able to make informed choices about their sexual behaviour and influence their sexual wellbeing.

Early Childhood Programmes

3.3 A number of studies have evaluated early childhood programmes (the Seattle Social Development Programm and the Abecedarian project). Follow-up of the children at age 18 and 21 found that participants in both programmes were less likely to report a pregnancy than those in the comparison group (Hawkins et al, 1999). They also achieved higher intellectual and academic levels (Campbell 1999).

3.4 These findings have been reinforced by the results from a systematic review of the long term effects of day-care which highlight the benefits of long term strategies beginning in early years in preventing teenage pregnancy (Zoritch et al 2000). Further research is needed to identify the essential elements of early years prevention programmes.

Parents and Carers

3.5 From an early age, parents and carers are key to the development of sexual values and skills of their children as well as influencing their sexual behaviour because:

• parents and carers provide role models for inter-personal relationships

• parents and carers teach about the roles of males and females in both family and wider contexts

• the family provides a moral and values framework which influences sexual behaviour

• good parent to child communication about sexuality and sexual health can increase knowledge and may help more responsible decision making.

3.6 The role of the family is discussed further in Supporting Paper 2. In terms of learning, the key aspects of family dynamics include the amount of time spent in family activities, parenting style and monitoring and parental support (Wight et al 2002, Aggleton 1998, Ingham and van Zesson 1998). Seamark and Gray (1997) and MacDowell (2002) showed that family discussion about sexual matters can result in lower incidence of sexual risk taking behaviour and increased knowledge whilst Wellings (2001) and Currie et al (1999) reported that males who talked to their parents about sex tended to use contraception more often when compared to those who did not talk to their parents about such matters.

What do parents currently do?

3.7 There is some evidence which indicates that parents do have some discussion with their children about a range of sexual health issues. However, what is discussed between parents and young men and women varies greatly ranging from very little to detailed discussion of personal relationships. Currie et al (1999) showed that parents were more likely to discuss sex and sexual health with their daughters on at least one occasion compared to their communication with their sons. This is supported by the findings of the Scottish sample of the Natsal survey (MacDowell 2002) which also found that young people want to discuss such matters with their parents.

3.8 Ingham explored the extent of sexual health discussion from a parental perspective and found significant differences between what parents felt they should talk to their children about and what they actually did talk about in terms of contraception, abortion, saying "no", the role of emotions and abuse and rape. (Ingham 2002)

Who does the talking?

3.9 There are differences between mother/father and son/daughter discussions about sex. Feldman and Rosenthal (2000) showed that this is influenced by the general parenting styles adopted.

3.10 Numerous studies have shown that mothers tend to be the main educators in the household (Walker et al 2001, Feldman and Rosenthal 2000 and Miller et al 2001) and this is no less the case in respect of sexual health matters. Moreover, young people see it being more important for mothers than fathers to communicate about sex (Feldman and Rosenthal, 2000). This is likely because they view mothers as being less judgemental than fathers. In addition, Walker et al (2001) found that mothers can relate to their own daughters by drawing on their own experience. This does point to the need to influence informal sex education for boys within the family environment. This is particularly pertinent as young men are expected to know about sex without ever having been taught and then adopt the "macho" predatory sexual male attitude (Wight 1994, Holland et al 1998)

How can parents be helped to talk to their children about sexual health?

3.11 Walker et al (2001) and Ingham (2002) identified a number of barriers which prevented parents talking about sexual health:

• Lack of awareness of the need for sex education

• Embarrassment

• Uncertainty about what they should do or knowledge of what is going on in schools

• Lack of accurate knowledge

• Absence of skills to communicate about sexual health

3.12 Enhancing factors to help parents in their role as sex "educators" identified by Walker et al (2001) and Feldman and Rosenthal (2000) include:

• Stimuli which trigger opportunities for discussion, for example TV

• Rejecting notion that sexual health matters in the family are taboo

• Open communication and better general communication

• Introducing and responding to ideas in line with child's development

• Better communication between parents and the school

• Access to information and resources

3.13 The proposed Sexual Health and Relationships strategy suggests a range of initiatives to enhance the role of parents and carers:

• Mass media initiatives focussing on general communication between parents and their children

• Provision of better resources and information for parents

• Involving parents more actively in school based sex education programmes and school based services

• Community based initiatives supporting improved parenting skills

3.14 This builds on the existing activities within Scotland that are supporting parents and carers, for example:

• Healthy Respect: booklets to support parents in role as sex educators and information on confidentiality issues

• Highland Health Board: research with parents of children under 10

• HEBS/Healthy Respect: booklet for parents with teenage children

School Based Sex & Relationships Education

3.15 Whilst it is acknowledged that parents have a key role in sex education, it is also recognised that many parents have opted out of this role with the result that schools have had to fill the void and be actively engaged in sex education. (MacDowell 2002, Ingham and van Zesson 1998) This is not a new phenomenon and was recognised as early as 1943 by the Board of Education. Improvements have continued to be made to school based sex education (particularly more recently by Curriculum Paper 14 (1974) and the Report of the Working Group on Sex Education, McCabe Report (Scottish Executive 2000)). Both of these recognised the complementary role of schools and parents in sex education.

3.16 The objective of school based sex and relationships education (SRE) is to help and support pupils through their physical, emotional, moral and spiritual development regardless of whether this is in denominational or non-denominational schools ¹. SRE should link with other parts of the school curriculum such as moral and religious education and be firmly rooted in good Personal, Social and Health Education (PHSE) as laid out in the guidance from the Scottish Executive Education Department ( see appendix, also found on website www.scotland.gov.uk/library3/education/nat.advice.pdf) Effective SRE helps young people make responsible and well informed decisions about their lives by enabling them to develop considered attitudes, values and skills which influence the way they behave. As early as 1985 the World Health Organisation recommended that sex education should be "an integral part of education in every school system, to be implemented before puberty and enforced by legislation". (WHO 1984)

3.17 The Report from the Working Group on Sex Education in Scottish Schools (Scottish Executive 2000) goes some way to meeting this recommendation (although is not enforced by legislation). Key principles for sex education were identified by the McCabe Report as:

• Sex education should be viewed as one element of health education, set within the wider context of health promotion and the health promoting ethos of the school

• Sex education should contribute to the physical, emotional, moral and spiritual development of all young people within the context of today's society

• Education about sexuality should reflect cultural, ethnic and religious influences within the home, school and community

• Sex education starts informally at an early stage with parents and carers and continues through adulthood both within the home and at all stages of school life.

3.18 Guidelines for school based sex education have been set out by the Scottish Executive Education Department and supported by Learning and Teaching Scotland (appended is a summary of the range of guidance currently in force). Her Majesty's Inspectorate of Education (HMIE) is reviewing its implementation: the report on secondary schools is due in 2003 and will be followed by 5-14 curriculum review the following year. Healthy Respect and its partners are developing guidelines on confidentiality and an educational curriculum framework to support sex and relationships education across primary and secondary schools. These will be piloted in Lothian as part of the next phase of Healthy Respect.

Approaches to school based SRE

3.19 A range of providers may deliver SRE programmes: teachers, peers and external professionals. Collins et al (2002) categorised such programmes into two types: abstinence only and comprehensive sex education/abstinence plus programmes.

Box 1: Key Features of Abstinence Plus Education and Abstinence Only Education programmes

3.20 Abstinence only programmes:

When compared to comprehensive (abstinence plus) sex education programmes, abstinence only programmes have not been found to have any additional effect on either delaying sexual activity or reducing pregnancy (Christopher and Roosa, 1990; Jorgensen 1991. Kirby (1997) found no measurable impact on the initiation of sex, frequency of sex or the number of partners in a 12 month follow up study of the Postponing Sexual Involvement programme and in a subsequent study of abstinence programmes (Kirby 2002). Dicenso (2002) found that there was a rise in the number of pregnancies among those participating in abstinence only programmes.

3.21 Abstinence Plus programmes (also known as comprehensive sex education programmes):

Some abstinence plus sex education programmes are associated with delay in first intercourse and increased condom and other contraception at first and subsequent intercourse (NHSCRD 1997). There is no evidence to suggest that the provision of these programmes leads to increased sexual activity or higher rates of pregnancy (NHSCRD 1997, Wellings et al 1996, Wight et al 2002). Jemmott (1998) identified that abstinence plus programmes had longer-term effects on the use of birth control than abstinence only interventions. In other European countries, particularly Scandinavia and the Netherlands, indicates that good sex education is associated with fewer teenage pregnancies, particularly when linked with access to services (Hosie 2002).

3.22 In Scotland, the SHARE (Sexual Health and Relationships: Safe Happy and Responsible) programme has been piloted in two areas: Lothian and Tayside. This is a teacher delivered abstinence plus programme aimed at 13-15 year olds. Interim findings from the pilot are mixed (Wight et al, 2002, Buston et al 2002, Wight and Buston (in press)). The pilots confirmed that sex education does not encourage earlier sexual activity, pupils and teachers evaluated SHARE more highly than other sex education programmes, and it led to increased sexual health knowledge and reduced regret of first sex with most recent partner. There was however no reported difference in levels of sexual activity or in the use of condoms or contraceptives. Buston et al (2002) found that for the minority of some young women, who start sex at an early age, the programme had been delivered "too late" for themselves or their sexually active peers and that the programme tended to be seen as supplementary to other sources, such as friends, magazines and mothers. In addition, SHARE does not explicitly cover same sex relationships and issues relevant to people with learning disabilities. The timing and content of SRE programmes and training of deliverers are important factors in influencing the effectiveness of the programme (Buston et al 2002). Further information on the MRC research from SHARE can be found on www.msoc-mrc.gla.ac.uk/Reports/Pages/share_MAIN.html.

Variations on models

3.23 School based education with parental involvement: some programmes have had limited success in reducing risk behaviours. These used parent newsletters with information on the programme, HIV/AIDS, STIs and pregnancy together with tips on talking with teenagers and student/parent homework activities to facilitate communication (Safer Choices, Managing the Pressures before Marriage and Growing Together programmes (Blake 2001, Nicholson and Postrado 1991 and 1992). Healthy Respect is developing activities to encourage parental involvement which will build on the work being taken by schools to consult with parents (as recommended by the McCabe Report (Scottish Executive 2000)).

3.24 Links to contraceptive services through schools may face a number of barriers which restrict their establishment as reported by Santelli (2003). However, such programmes have shown success in reducing pregnancy rates and STIs:

• Zabin (1986) found that school based sex education combined with an on site sexual health advice and contraceptive service resulted in a delay in sexual activity among young women, increase in contraceptive use among men and women already sexually active and significant decrease in pregnancy rates. When the programme discontinued, pregnancy rates increased. Similar results were found by Hosie (2002) in examining a reduction in school based health support in Finland.

• Vincent and Dod (1989) found that at 2 year follow up teenage pregnancy rates dropped as a result of a multifaceted community programme involving sexuality education training for school staff, classroom training and decision making skills for students, school nurse dispensing condoms and transport to contraceptive services. Following prohibition of contraceptive provision, Koo et al (1994) discovered rising pregnancy rates.

• Kirby (2001) demonstrated that schools with health clinics and schools with condom availability have consistently shown that the provision of condoms or other contraceptives through schools does not increase sexual activity.

Supporting Paper 5B on Clinical Services sets out more detail on links between schools and services.

3.25 The findings from programmes involving one to one education through counselling in health care settings have had mixed success in reaching "harder to reach" groups including black and minority ethnic populations (St Lawrence, Jefferson et al 1994, Jemmott 1993)

3.26 Although the majority of sex education programmes are school-based, a number of innovative out of schools programmes have been developed (Olsen and Farkas 1991, Allen and Philliber 1997, Philliber et al 2002). For example, community based programmes that aim to address the education needs of young people within and outside the school setting. Such programmes link school programmes with young people's home setting or community settings (i.e. youth clubs).

3.27 The links between educational attainment and aspiration andpositive sexual health outcomes are highlighted in Supporting Paper 2 on the wider determinants of sexual health. Evidence suggests that educational and job related interventions could be successful in reducing teenage pregnancy rates. Kirby and Coyle (1997) suggest that their success is due to ongoing relationships between participants and mentors, supervision and alternative activities reduced opportunities for problem behaviour and volunteering improved self esteem. Philliber (2002) found similar results from the CAS-Carrera after school youth development programme which combined sexuality education with academic and vocational advice and access to health services.

3.28 Community education programmes, which are designed to foster ownership, empowerment and involvement for young people, have shown promising results in reducing behaviour associated with HIV transmission, which in turn will impact on STIs. (NAM, 2001) Studies have highlighted the need for an understanding of the social and sexual networks of the target population and identification and involvement of appropriate peers to lead such programmes.

4. Features associated with successful education programmes

4.1 Despite the variety of the different approaches used in the delivery of sex education programmes, some general lessons emerge. For example, there is consistent evidence that providing comprehensive sex and relationships education in school settings does not lead to an increase in sexual activity or incidence of pregnancy. Indeed, the provision of clear information about contraceptive methods and how and when to access contraceptive services appears to be important to the success of educational programmes.

4.2 Kirby (2001) identified 10 characteristics of effective sex and HIV education programmes which are reinforced in this review of the evidence:

• Deliver and consistently reinforce clear prevention messages about abstinence, condom use and other forms of contraception

• Provide basic, accurate information about the risks of sexual activity and about ways to avoid intercourse or methods of protection against HIV/STI and pregnancy

• Include activities that address social pressures related to sexual behaviour

• Provide examples of and rehearse with communication, negotiation, and refusal skills (for example, role plays)

• Focus on reducing one or more sexual behaviour that lead to unintended pregnancy or HIV/STI infection

• Use teaching methods that involve students and have them personalise the information

• Incorporate behavioural goals, teaching methods and curricula that are appropriate to the age, sexual experience, and cultural of students

• Last a sufficient length of time

• Employ theoretical models

• Select teachers or peer leader who support the programme and provide them with adequate training.

Box 2 sets out the general features and key learning objectives of school based SRE programmes promoted by the proposed Sexual Health and Relationships Strategy.

Box 2 : General features and key learning objectives of school based SRE programmes

General Features

• Educational and employment opportunities that encourage future aspirations and build self-esteem.

• A range of formal and informal learning opportunities delivered in an open and pragmatic way to help develop and maintain respectful relationships, whatever one's sexual orientation, and make informed choices about sex.

• The provision of appropriate and accurate knowledge and skills to help young people become "sexually competent" ², ideally delivered at an age and ability appropriate to the individual.

• Be supported by easily accessible, confidential clinical services including contraception.

Delivery of Programmes

4.3 Peer Led Sex Education - Peers

The delivery of educational messages ranges from the traditional didactic approach to more innovative participatory approaches such as peer education. Peers are an important influence on young people's health behaviours, and are considered credible role models and disseminators of social information and have been used to deliver a number of health promotion activities (Fennell 1993). The Social Exclusion Unit in England has recommended peer led approaches for delivering sex education in schools (Social Exclusion Unit, 1999). These approaches are popular with young peer educators and professionals (Mellanby et al 2001, Strange et al 2002a and 200b, Forrest 1997).

4.4 Robust evidence of effectiveness of peer led programmes has been limited to date (Harden et al. 2001) but may be addressed through the findings of a MRC funded school based peer delivered programme (RIPPLE). Initial results point to benefits for peer educators (Strange et al. 2002a; Strange et al. 2002b).

Peers V Adults

4.5 Few studies have compared the effectiveness of different forms of programme delivery of the same programme. Jemmott and Mellanby attempted to compare peer v adult led sex education (Jemmott et al. 1998; Mellanby et al. 2001). They concluded that both adult and peer led education have an important place in effective sex and relationships education: peer leaders are more effective at establishing conservative norms and attitudes to sexual behaviour than adults whilst less effective at imparting factual information and involving students in classroom activities. This confirms the view that the methods used should fit the aims of the SRE programme.

Timing of Programmes

4.6 The timing of educational programmes is important. It is likely that young people who are already sexually active at the commencement of an intervention, for example, are less likely to change their sexual and contraceptive behaviour. This is borne out by the recent SHARE study which found that the greatest effects were with those already sexually active at the start of the programme (Wight et al 2002). However, skills based programmes have to be currently relevant to their target group. One of the limitations of delivery timetabled across the whole year group and for whole classes is that individuals are unlikely to develop sexual negotiation skills at the time most salient to them.

4.7 Young people are not all same and have different needs at different times. It is important that programmes should be tailored to the needs and experiences of the group, at an age relevant to their needs and delivered by those with an interest and training in delivering sex and relationships education. This can include a mix of inputs from teachers, to peers, to outside experts. The proposed Sexual Health and Relationships Strategy promotes an integrated model, which combines teacher skills with those of available non school professionals and who are all trained in the delivery of sex and relationships education.

4.8 A targeted approach complementing existing sex and relationships education might be appropriate so that young men and women who are considered more likely to engage in early sex are provided with an opportunity to develop relevant skills. Work in Fife and West Lothian has incorporated SRE into wider health promotion activities.

Cost Effectiveness

4.9 Few studies have included a cost effectiveness evaluation of prevention programmes. In Wang's evaluation (Wang et al 2000), the US Safer Choices programme was estimated to cost $105,243. At one year follow-up, it achieved a 15% increase in condom use and an 11% increase in contraceptive use among 345 students. This was estimated to prevent 0.12 cases of HIV, 24 cases of chlamydia, 2.8 cases of gonorrhoea, 5.8 cases of pelvic inflammatory disease, and 18.5 pregnancies. Furthermore, it was estimated that for every dollar invested in the programme $2.65 in medical and social costs was saved.

5. Summary of Sex Education Programmes

5.1 This review of sex education programmes aimed to reduce teenage pregnancy and/or improved sexual health among children and young people confirms findings from a number of studies that the provision of comprehensive school based sex and relationships education does not lead to early sexual behaviour.

5.2 Those studies that have demonstrated a reduction of teenage pregnancy and/or promotion of positive sexual health adopted a multi faceted approach linking sex education programmes with youth development projects and/or to sexual health services, including contraceptive services.

5.3 However, the lack of evidence of effectiveness of other approaches may reflect the poor evaluation design - lack of appropriate control group, small sample sizes or short follow-up. Such design flaws may account for the absence of significant effect rather than ineffectiveness of the programme.

5.4 Most of the evaluated programmes described in this paper address a number of individual factors associated with teenage pregnancy and sexually transmitted infections, and have shown some success. Some provide an analysis of the range of social, economic and educational factors associated with an increased risk of early sexual initiation and teenage pregnancy. However, only a small number attempt to tackle the underlying social, economic and educational factors associated with increased risk of pregnancy or risky sexual behaviour: those that do have shown some encouraging findings (Social Exclusion Unit 1999, see also update reports from Teenage Pregnancy Unit www.doh.tpu.gov.uk). Further research is needed in this area.

5.5 Programmes that focus on both sexual and non-sexual antecedents, which are "comprehensive" and long term in duration, have shown reductions in the number of sexually transmitted infections and unwanted pregnancies among participating young people. (Swann et al 2003, Philliber et al 2002, Philliber and Allen 1992). It is evident that adopting a simplistic approach to a highly complex area of social behaviour will not succeed in changing adolescent sexual behaviour or reducing teenage pregnancy. With this in mind, the proposed Sexual Health and Relationships Strategy advocates a multi faceted approach, of which sex and relationships education is just one part of the agenda to address sexual health and wellbeing in Scotland.

Additional Issues for school based sex and relationships education

Gender inequity: Educational research suggests that boys and girls may be treated very differently within the classroom (Innes 2002, Holland et al 1992 and 1998, Nayak and Kehily 1996). Boys are often viewed as irresponsible and less open to discussion and learning than girls. As a result, teaching, including sex and relationships education is aimed more at girls. This is problematic for two reasons. First, responsibility is imposed upon females when they often lack control. Second, around a third of boys cite school as their main source of information about sex and relationships (MacDowell 2002). If they are being excluded, deliberately or not, this means that a large proportion of boys are ill-prepared when it comes to making informed decisions about their sexuality.

Heterosexism and homophobia: some people argue that schools force young people to strive for normality as a survival mechanism. Proving normality involves identification of "other". Lesbian, gay and bisexual young people are an invisible minority and arguably one of the most "at risk" group of adolescents (Big Step review, Coia et al 2002, Sharpe 2002). Schools do not do well in protecting young people from homophobic bullying and can actively contribute to it through teachers' own homophobia. SHARE research indicates that teachers were sometimes complicit in homophobia (Buston and Hart 2001). Of course, teachers are not all homophobic but there is a heterosexist assumption underpinning sex education which perpetuates the invisibility of gay and lesbian sexuality.

Epstein (1997) highlights the difficulty in teaching for LGB teachers and coming "out" as a teacher and the dilemmas faced by gay and lesbian teachers having to hide their identity. Homophobia is also directed at children of gay men and lesbians (Redman 2000).

The proposed Sexual Health and Relationships Strategy promotes the inclusion of LGB aspects among sex and relationships education programme, sitting alongside aims for the heterosexual population.

September 2003

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