Chapter 1: Introduction to the Study
Introduction
Sexual health education is the foundation on which sexually transmitted diseases
(STD) and human immunodeficiency virus/acquired immunodeficiency syndrome
(HIV/AIDS) prevention programs were built (Francis, 2009; Galson, 2008). Access to
effective comprehensive sexual health education supports the development of
wellrounded, balanced, and sexually healthy youth (Sex Information and Education
Council of Canada [SIECCAN], 2009). Most states have policies requiring HIV
education as a complement to a broader comprehensive sexual health education program
(Guttmacher, 2016). According to the Future of Sex Education (FoSE) Initiative (2012),
there are clear guidelines and standards to assist states that do not have specific policies
on sexual health education with the development and/or evaluation of programs to ensure
that schools
“design and develop sexual health education that is planned, sequential, and part of a
comprehensive school health education approach” (p. 6).
Educators initially implemented sexual health education to counter
misinformation that was circulated throughout society, but it has now evolved into a field
of study that focuses on improving youths’ quality of life. Sexual health education is a
shared responsibility of state and local government, parents, teachers, the community, and
school administrators, and it requires the attention of all entities to support the
development of sexually healthy youth (Corngold, 2010; SIECCAN, 2009). Sex
education provides young people with necessary information to make informed choices
regarding their sexual health (Sexuality Information and Education Council of the United
States. [SIECUS], 2012; FoSE, 2012). Literature related to sexual health education is
overwhelmingly abundant, and literature regarding school administrators’ perceived
barriers to implementing sexual health education is available in abundance. However, the
degree to which the consistent implementation of comprehensive sexual health education
influences sexual risk behaviors among high school youth in grades 9–12 in comparison
to the enactment of sexual health education policy is limited.
The outcomes from this study were directly associated with the implications for
social change, and indicate the need for legislators and school district leaders to increase
support for the enactment of comprehensive sexual health education policy that will help
mitigate the sexual risk behaviors of high school youth through the implementation of
standardized comprehensive sexual health education. Additionally, this study contributed
to the existing literature by showing how: (a) the inequities experienced by youth
contribute to the sexual risk behaviors they engage in, and (b) sexual risk behaviors can
be addressed as part of a comprehensive, standardized health education program. In this
study, I sought to explore the statistical relationship between the consistent
implementation of comprehensive sexual health education before and after the enactment
of the Chicago Public School’s (CPS) sexual health education policy, and the sexual risk
behaviors of Chicago high school youth in grades 9–12. Comprehensive sexual health
education helps delay onset of sexual activity, reduce high-risk sexual behaviors, and
lower the STD/HIV incidence rates among high school youth (CDC, 2012c; Kirby, 2008).
In Chapter 1, I offer an introduction to comprehensive sexual health education and
to the rationale for this research. More specifically, I offer a guided narrative on the
relevance of the research to the future of adolescent health, organized by the following
topic areas: (a) the background of comprehensive sexual health education, (b) the
problem associated with the inconsistent implementation of comprehensive sexual health
education, (c) the purpose of this study, (d) the research questions and hypotheses, (e) the
theoretical frameworks used as the foundation for the study, (f) the study design, (g) key
definitions, (h) the assumptions associated with the study, (i) the scope of the study,
including the delimitations and limitations, (j) the significance of the study, and (k) a brief
summary of the information discussed throughout the chapter.
Background
Legislation at the federal level, H.R. 332, the Real Education for Healthy Youth
Act, was introduced in 2011. This legislation mandated that federally funded
comprehensive sexual health education programs must seek to promote healthy and safe
relationships and include the most current and accurate scientific information available
(SIECUS, 2012).
A large-scale study of sex education laws and policies with regard to preventing
teen pregnancy in all U.S. states showed that abstinence-only education did not reduce,
and likely increased, teen pregnancy rates (Stanger-Hall & Hall, 2011). Stanger-Hall and
Hall (2011) also reported that comprehensive sex and/or STD education that includes
abstinence as a desired behavior was associated with the lowest teen pregnancy rates
across states. My study’s discussion on the U.S. government’s funding of abstinence only
and teen pregnancy prevention (abstinence plus) programs is limited to the effectiveness
of abstinence-only state policies as compared to state policies that support the consistent
implementation of sexual health education via mandates for comprehensive sexual health
education only if sexual health education is taught.
Support for sexual health education continues to increase (Boonstra, 2014). Sex
Education in America (Kaiser Family Foundation, 2004) is a survey of national
significance and one of the most comprehensive studies conducted to assess the views of
students, teachers, parents, and principals on sex education in the classroom. This study, a
follow up to the Sex Education in America national survey conducted in 2000, was based
on two nationwide telephone surveys, a survey of the general public, and of principals.
The survey of the general public was conducted among a random nationally
representative sample of 1,759 respondents 18 years of age or older, including an
oversample of parents of children in 7th through 12th grades (Kaiser Family Foundation,
2004). This survey showed that only 7% of Americans said that sexual health education
should not be taught in schools. Further, the study showed that 15% of Americans
believed that schools should teach only about abstinence from sexual intercourse and
should not provide information on how to obtain and use condoms and other
contraception (Kaiser Family Foundation, 2004). Forty-six percent of the respondents
believed that abstinence-plus or comprehensive sexual health education should be taught
even though abstinence is the only guarantee of unintended outcomes. However, this
study did not address how the inconsistent implementation of sexual health education
within state or local governments affects the sexual health and sexual risk behaviors of
youth.
Support for comprehensive sexual health education among parents has been well
studied. A telephone survey of parents of school age children in Minnesota conducted
from September 2006 to March 2007 indicated that the majority of parents favored
comprehensive sexual health education and supported the inclusion of specific topics that
may be viewed as controversial (Eisenberg, Bernat, Bearinger, & Resnick, 2008). The
researchers also determined that there was a mismatch between parents’ expressed
opinions and preferences, and the actual sexual health education content as it was
currently being taught in the majority of public schools in Minnesota. Although the study
showed parental support for sexual health education, it also showed that the views of the
parents did not necessarily translate to the development of policy to support the consistent
implementation of comprehensive sexual health education.
Prior to the passing of Illinois’ Sexual Health Education Bill in 2013, the Illinois
Campaign for Responsible Sex Education (2007) conducted a study among Illinois sex
education teachers to ascertain their practices, beliefs, and influences. This study showed
that 93% of sex education teachers who participated in the study offered some component
of sex education; however, two-thirds of these teachers omitted critical elements of
comprehensive sexual health education. Ninety-two percent of the teachers surveyed said
the curriculum greatly influenced the topics they covered. This study also showed that the
inconsistent implementation of comprehensive sexual health education was directly
related to the lack of state or local standards, policies, and funding.
The Kaiser Family Foundation (2004) has noted, “Principals report that the most
influential players in sex education are their local governments and school districts” (p.
50). The lack of standardized state sexual health education policy leaves the
implementation of sexual health education to the discretion of local and district
administrators (Corngold, 2010; Fornby, Hirst, Owen, Hayter, & Stapleton, 2010).
Additionally, both the Guttmacher Institute (2016) and Fornby, Hirst, Owen, Hayter, and
Stapleton (2010) have discussed the implementation of policies governing sexual health
education in schools at the local level. They found that varying mandates for sex
education at the local and district levels, regardless of the type of sexual health education
taught, have potentially encouraged a decentralization of sexual health education. This
has resulted in the inconsistent implementation of sexual health education.
On the contrary, Atkins and Bradford (2013) conducted a study to evaluate how
state-level sex education policies affect the youth population. More specifically, Atkins
and Bradford found that states that require sexual health education and information on the
use of contraceptives, or states that mandate education but allow local districts to
determine the content or curriculum to be used, have higher rates of contraception use
when teens are sexually active. Further, Atkins and Bradford found that sexually active
teens are less likely to use contraception in states that require sexual health education and
the inclusion of abstinence content. The research shows that the variance in sexual health
education curriculums used at the local level does not negatively affect the sexual health
of youth. However, Adkins and Bradford did not evaluate the states with policies that
mandate comprehensive sexual health education only if a local government elects to
deliver it.
Support for comprehensive sexual health education is apparent and exists across a
variety of stakeholders invested in the development of sexually healthy youth. Alton,
Valois, Oldendick, and Drane (2009) conducted telephone interviews with 547 registered
voters in South Carolina to ascertain their opinions on the use of abstinence-only versus
comprehensive sexual health education. Approximately 52% of the individuals the
researchers contacted agreed to participate in the study, 25% declined to participate, 20%
were unable to participate for various reasons, and less than 2% were unable to
participate due to language barriers. Overall, 81% of registered voters who participated in
the survey supported comprehensive sex education. Only 4% of the respondents did not
support a single sex education topic. Findings from this poll showed that the majority of
registered voters in a highly conservative state supported comprehensive sex education
(Alton, Valois, Oldendick, & Drane, 2009).
Mufune (2008) conducted 18 focus group discussions and eight key informant
interviews to determine to what extent stakeholders (i.e., teachers, parents, and health
professionals) supported sex education in Namibia. Mufune (2008) believed that
understanding the stakeholders’ perspectives was necessary to implement new and
enhance existing sexual health education programs. The study showed broad support for
sexual health education. More specifically, stakeholders indicated that sex education
programs should be taught by teachers and health workers, and should be specifically
targeted to youth.
Researchers have studied students’ ability to access accurate information related to
their sexual health and have found that students desire information to live a sexually
healthy adolescent life. For instance, Benzaken, Ashutosh, Palep, and Gill (2011)
conducted a study to determine students’ exposure to sexual health education, and to
identify the students’ perceptions of their access to information regarding their sexual
health and their preferences on the implementation of sexual health education. The
researchers found that of the 427 students who completed the survey, 90% felt sexual
health education was an important part of the school curriculum, but only 60% were
exposed to sexual health education in school. Forty-five percent of the students surveyed
felt they received good advice about contraception and sexual health. Benzaken,
Ashutosh, Palep, and Gill (2011), however, did not assess the type of sex education the
students received. The findings from my study will further reduce the gaps in the
literature related to the relationship between the consistent implementation of sexual
health education and the sexual risk behaviors of youth.
Constantine, Jerman, and Huang (2007) conducted a study of parents in California
and found that, consistent with previous national and state-level studies, the majority of
California parents preferred approaches to sexual health education that included
instruction on how to prevent teen pregnancy and the spread of STDs and HIV among
students who decide to have sex.
Adolescents have the right to sexual knowledge, and the skills and abilities to
make rationale and well-informed decisions. The ultimate purpose of comprehensive
health education, by virtue of default sexual health education, is to equip adolescents with
the tools needed to evaluate different ways of life and choose intelligently among the
options in front of them (FoSE, 2012; Corngold, 2011).
I found that scholarly literature was replete with studies documenting the
effectiveness of school-based sexual health education in helping youth reduce their risk
for pregnancy, HIV, and STDs. My study contributed to the body of literature by
examining the consistent implementation of sexual health education in relation to the
sexual-risk behaviors of youth in grades 9–12. Prior to my research, there was limited
literature in which researchers explored the statistical relationship between the consistent
implementation of comprehensive sexual health education before and after enactment of
sexual health education policy.
Problem Statement
High school youth in grades 9–12 who are in public schools without
comprehensive sexual health education are more likely to engage in high-risk sexual
behaviors and have higher rates of HIV and STDs than their peers in schools with
comprehensive sexual health education. Nearly half (46%) of female and over half (60%)
of male high school students in Chicago reported that they have had sexual intercourse
(CDC, 2011). There are many possible factors contributing to this problem, including
socio-economic and cultural factors, knowledge, and peer pressure (Benzaken, Palep, &
Gill, 2011).
CPS, the third largest public school system in the United States, currently
mandates comprehensive school-based sexual health education; CPS adopted a new
comprehensive school-based sexual health education policy in 2013 that will be fully
implemented in 2016 (CDPH, 2013; SIECUS, 2013). CPS implemented comprehensive
school-based sexual education in 2008, but the state of Illinois has limited the mandate
for the teaching of comprehensive sexual health education to schools that choose to do so.
This inconsistency in sexual health policies is a problem that impacts the overall public
health of youth in Illinois. According to the CDC (2015a) young people aged 1324
accounted for an estimated 22% of all new HIV diagnoses in the United States in 2014.
Half of the nearly 20 million new STDs reported each year were among young people
between the ages of 15–24 (CDC, 2015b). Furthermore, in 2014, approximately 250,000
babies were born to teen girls aged 15–19 years in 2014 (CDC, 2015c). According to the
CDC’s, Office of Adolescent Health, as of 2014, Illinois ranked 26th in the number of
pregnancies to females aged 15-19, and had the 24th highest teen birth rate among females
aged 15–19. In 2014, Chicago adolescents and young adults between 13 and 24 years old
accounted for 65% and 70% of gonorrhea and chlamydia cases, respectively (CDPH,
2014). Moreover, the teen birth rate in Chicago was one and a half times higher than the
national average (CDPH, 2013). The ultimate goal of comprehensive sexual health
education is to provide a foundation of support for youth to mature into sexually healthy
adults (SIECUS, 2011b).
Purpose of the Study
The purpose of this correlational study was to explore the statistical relationship
between the consistent implementation of comprehensive sexual health education, before
and after the enactment of CPS’ sexual health education policy in 2008, and the sexual
risk behaviors of Chicago high school youth in grades 9–12. In this study, I analyzed
sexual risk behavior data obtained by the CPS’ Youth Risk Behavior Survey (YRBS)
between the years of 2007 and 2013.
For the purposes of this study, comprehensive sexual health education was the
independent variable, and sexual risk behaviors were the dependent variables. Sexual risk
behaviors, as defined by the Youth Risk Behavior Surveillance System (YRBSS), are
sexual risk behaviors that contribute to unintended pregnancy and STDs, including HIV
infections (CDC, 2013a). The YRBSS includes the national and district-school-based
YRBS, conducted by CDC and state and large urban school districts, respectively.
Research Questions and Hypotheses
Research Questions
In this study, I designed and worked to answer the following research questions:
1. How does the implementation of comprehensive sexual health education
influence (increase or decrease) the following sexual behaviors of Chicago high
school youth in grades 9–12:
• Ever had sexual intercourse.
• Sexual intercourse before the age of 13 years (for the first time).
• Sexual intercourse with four or more persons during their life.
• Currently sexually active (sexual intercourse with at least one person
during the 3 months before the survey).
• Did not use a condom (during last sexual intercourse among students who
were currently sexually active).
• Did not use birth control pills (before last sexual intercourse to prevent
pregnancy among students who were currently sexually active).
• Did not use any method to prevent pregnancy (during last sexual
intercourse among students who were currently sexually active).
• Drank alcohol or used drugs before last sexual intercourse (among
students who were currently sexually active).
• Were never taught about AIDS or HIV in school.
2. How does the implementation of comprehensive sexual health education
influence (increase or decrease) sexual behaviors of Chicago high school youth in
grades 9–12 , by race/ethnicity (covariate)?
3. How does the implementation of comprehensive sexual health education
influence (increase or decrease) sexual behaviors of Chicago high school youth in
grades 9–12, by gender (covariate)?
Hypotheses
Null Hypothesis (H01): The consistent implementation of comprehensive sexual
health education is not significantly related to the sexual risk behaviors among Chicago
high school youth in grades 9–12.
Research Hypothesis (H1): The consistent implementation of comprehensive
sexual health education is significantly related to the sexual risk behaviors among
Chicago high school youth in grades 9–12.
Null Hypotheses (H02): The consistent implementation of comprehensive sexual
health education does not significantly influence (increase or decrease) the sexual risk
behaviors among Chicago high school youth in grades 9–12.
Research Hypothesis (H2): The consistent implementation comprehensive sexual
health education does significantly influence (increase or decrease) the sexual risk
behaviors among Chicago high school youth in grades 9–12.
Theoretical Framework
Comprehensive sexual health education is rooted in research and reflects the core
elements associated with many theoretical frameworks. For this study, the salutogneic
model/theoretical framework served as the foundation for my exploration of the statistical
relationship between the consistent implementation of comprehensive sexual health
education, before and after the enactment of sexual health education policy, and the
sexual risk behaviors of Chicago high school youth in grades 9–12. The salutogenic
model explores the origin of health while focusing on creating health instead of disease
(Lindstrom & Eriksson, 2009). Researchers use the salutogenic model to study the
strengths and weaknesses of disease prevention, health promotion, and the development
of practices and healthy public policies (Antonovsky, 1996). The implementation of
comprehensive sexual health education in schools is anchored by the foundational
construct of the salutogenic model. The correlation between positive health outcomes at
the individual (high school youth), organizational (schools), and population (state and
local policy) levels emphasizes the importance of a structured environment and people
are encouraged to identify and use the resources available to them to promote the health
of the individual, community, and the nation (Mittlemark & Bull, 2013; Lindstrom &
Eriksson, 2009). Youth are a product of, and deeply influenced by, their environments
(Stranger-Hall & Hall, 2011). The salutogenic model takes the concept of health
promotion, as the foundation, and intertwines the sense of coherence, and the availability
of internal and external resources (generalized resistance resources) to help individuals,
organizations, and society move toward optimal well-being (Mittlemark & Bull, 2013;
Becker, Glascoff, & Felts, 2010). Chapter 2 includes a more detailed discussion of the
theoretical framework for this study.
Nature of the Study
In this study, I employed a correlational research model to examine the
relationship between the consistent implementation of comprehensive sexual health
education (the independent variable) and sexual risk behaviors (the dependent variables)
of Chicago youth via the analysis of secondary data collected via CPS’ YRBS for the for
the years 2007 - 2013. These data allowed for a comparison of the sexual risk behaviors
as reported by high school youth in grades 9–12, stratified by gender and race/ethnicity,
the covariates. In the study, I determined the influences of comprehensive sexual health
education policy on Chicago high school youths’ sexual risk behaviors.
Definitions
Abstinence-only curriculum: Abstinence-only curriculum is a sexual health
curriculum in which abstinence only until marriage is taught as the only option within
sexuality education programs (Illinois Consortium on Adolescent Pregnancy Prevention,
2002).
Abstinence-plus curriculum (comprehensive sex education): Abstinence-plus
curriculum is a sexual health curriculum in which abstinence and methods of
contraception are taught within a sexuality education program (Illinois Consortium on
Adolescent Pregnancy Prevention, 2002).
Comprehensive sexual health education (comprehensive sexuality education):
Comprehensive sexual health education are programs that start in kindergarten and
continue through 12th grade. These programs include age-appropriate, medically accurate
information on a broad set of topics related to sexuality, including human development,
relationships, decision-making, abstinence, contraception, and disease prevention.
Sexuality education programs provide students with opportunities for developing skills,
as well as learning information (FoSE 2012; SIECUS, 2008).
Human immunodeficiency virus (HIV): HIV is the virus that can lead to acquired
immunodeficiency syndrome, or AIDS (CDC, 2013b).
Sexual risk behaviors: Sexual risk behaviors are sexual behaviors that contribute
to unintended pregnancy and sexually transmitted diseases, including HIV infections
(CDC, 2013b).
Sexually transmitted disease (STD): Sexually transmitted disease is a disease that
is spread primarily through sexual activity or contact (CDC, 2013b).
Socioeconomic status: Socioeconomic status is the social standing or class of an
individual or group. It is often measured as a combination of education, income and
occupation (American Psychological Association [APA], 2014)
Assumptions
In this study I assumed that: (a) socioeconomic factors associated with large
metropolitan areas are representative of health disparities that directly impact the data I
analyzed, (b) the consistent implementation of comprehensive sexual health education is
positively influenced by the enactment of sexual health education policy, (c) the
consistent implementation of comprehensive sexual health education influences (i.e.,
decreases the rate) the sexual risk behaviors among high school youth, and (d) the
consistent implementation of comprehensive sexual health education is consistently
significant in relation to the race/ethnicity and gender of high school youth.
Scope and Delimitations
In this study, I sought to determine if there was a correlation between the
consistent implementation of comprehensive sexual health education and sexual risk
behaviors among Chicago high school youth in grades 9–12 before and after enactment of
CPS’ sexual health education policy. It is important to focus on the implementation of
sexual health education rather than the curriculum used because the use of specific
curriculums is not standardized and therefore cannot be included as an outcome of this
study, though it may be directly related to the overall problem.
I limited the study sample to the high school students in grades 9–12 at the time the
YRBSs were conducted for CPS. The age of students participating in the YRBS was not
captured and therefore did not allow me to generalize the findings to a specific age range,
but rather only to students in grades 9-12.
According to the Guidelines of Comprehensive Sexuality Education:
Kindergarten through 12th Grade, sexual health education should only be taught by
specially-trained teachers (FoSE, 2012; SIECUS, 2004). However, I did not seek to
examine the relationship between the implementation of comprehensive sexual health
education and the qualifications of the individuals responsible for teaching the approved
curricula.
Limitations
This study was limited by the following factors.
• A secondary data source was used; therefore, there was no control over the
development of the instrument used to collect data and the data collection
processes.
• The data collected were limited to students who were in attendance at school
during the timeframe in which the survey was administered and, therefore, not
representative of all persons in the high school age group.
• The data collected were representative of all CPS high schools and did not allow
for the comparison of prevalence rates by school or geographic location within
CPS. Thus, the differences in curriculums utilized for the instruction of sexual
health education may have inadvertently influenced the relationship between the
implementation of sexual health education programs and the sexual risk behaviors
of high school youth in grades 9–12.
• The sexual health education policy was enacted in 2008; however, it does not take
into account the availability of professional development to provide guidance on
how to teach comprehensive sexual health education.
• The lack of a specified mandated sexual health education curriculum may have
inadvertently influenced the relationship between implementation of sexual health
education programs and the sexual risk behaviors of youth in grades 9–12.
• The policy may have been subject to the interpretation of the school administrator
(e.g., principal) responsible for approving the curricula.
Significance
This study, contributed to the body of knowledge related to the influence of
comprehensive school-based sexual health education on the sexual risk behaviors of
Chicago high school youth in grades 9–12. Further, this study allowed for a comparison
of the sexual risk behaviors before and after the 2008 enactment of CPS’ comprehensive
sexual health education policy, using data from the YRBS. My analyses of these data
were intended to further inform future sexual health education policy initiatives at the
state and local levels. Additionally, I intend for the findings from this study to be used to
inform CPS’ expansion of its sexual health education policy, effective in 2016, and to
assist lawmakers with crafting public policy to support the standardization of
comprehensive sexual health education.
Summary
In this chapter, I provided a brief introduction to comprehensive sexual health
education and focused on the purpose and intent of this study. A complete understanding
of comprehensive sexual health education is needed to better ascertain the relevance and
importance behind this study. In Chapter 2, I discuss the vast amounts of research and
literature associated with the evolution of comprehensive sexual health education in the
United States, the state of Illinois, and the city of Chicago.
Chapter 2: Literature Review
Introduction
High school youth in grades 9–12 who are in public schools without
comprehensive sexual health education are more likely to engage in high-risk sexual
behaviors and have higher rates of HIV and STDs than their peers in schools with
comprehensive sexual health education. The purpose of this correlational study was to
explore the statistical relationship between the consistent implementation of
comprehensive sexual health education, before and after the enactment of CPS’ sexual
health education policy, and the sexual risk behaviors of Chicago high school youth in
grades 9–12. I analyzed sexual risk behavior data obtained from CPS’ YRBS
administered between 2007 and 2013.
In my review of the literature, I found vast amounts of literature that indicate
comprehensive sexual health education: (a) helps students postpone sexual intercourse,
(b) reduces their number of sexual partners, and (c) helps students who are sexually
active choose protection more consistently. The literature shows that these outcomes are
especially evident when sexual health education is delivered by trained professionals,
age-appropriate, and inclusive of accurate information on HIV and STDs, teen pregnancy,
and establishing strong relationships (FoSE, 2012; CDC, 2012d; Boonstra, 2010b, Kirby,
2007). I also reviewed literature on abstinence-only sexual health education. I found that
most of the abstinence-only sexual health education programs were devoid of sexual and
reproductive health information, particularly regarding birth control and safer sex
alternatives (Ochiogu, Miettole, Ilika, & Vaskilampi, 2011;
Jemmott, Jemmott, & Fong, 2010). While the bulk of literature for abstinence only
programs supported the federal government’s definition of abstinence-only education, a
study conducted by Jemmott, Jemmott, and Fong (2010) was unique, in that, the focus
was on the efficacy of theory-based interventions, and did not discuss sex in a negative
light, emphasized the morality of engaging in sex before marriage, and did not discourage
the use of condoms. Access to comprehensive sexual health education that addresses the
socio-cultural, biological, psychological, and spiritual dimensions of sexuality by
providing information; exploring feelings, values, and attitudes; and developing
communication, decision-making, and critical-thinking skills is perceived to be a right of
all people, including adolescents at various ages (SIECUS, 2012).
Sexual health education is the foundation on which instruction on STDs and HIV
prevention programs were built (Francis, 2009). Access to effective comprehensive sex
education supports the development of well-rounded, balanced, and sexually healthy
youth (SIECCAN, 2009). Most states have a policy requiring HIV education as a
complement to a broader comprehensive sexual health education program (Guttmacher,
2016). However, according to FoSE (2012), for the states without sexual health education
policies, there are clear guidelines and standards to assist schools, in the design and
development of sexual health education programs as a part of a comprehensive school
health education approach.
Sexual health education was initially implemented to counter misinformation that
was circulated throughout society, but has evolved into a field of necessity and a shared
responsibility of state and local government, parents, teachers, the community, and school
administrators (Corngold, 2010; SIECCAN, 2009). Sex education provides young people
with necessary information to make informed choices regarding their sexual health
(SIECUS, 2012; FoSE, 2012). Sexual health education evokes emotional responses that
are representative of what sexual health education means to people with differing
philosophical, cultural, political, and religious views and beliefs (Bleakley, Hennessy, &
Fishbein, 2010; SIECCAN, 2009). Literature related to sexual health education was
overwhelmingly abundant, and literature regarding school administrators’ perceived
barriers to implementing sexual health education was available in abundance. However,
the degree to which the consistent implementation of sexual health education programs
influence sexual risk behaviors of youth, more specifically Chicago youth, in grades 9–
12, before and after the enactment of sexual health education policy, was limited.
I have organized this review of research relevant to comprehensive sexual health
education and the associated national and state policies into following topic areas: (a) a
description of the literature search strategy employed, (b) the theoretical foundation of the
study, (c) a review of literature related to key variables and concepts, and (d) a summary
and conclusion of the literature I discuss in this chapter. Looking at sexual health
education programs and the associated national and state policies from a broader context,
and then moving to a specific focus on the city of Chicago and mandates for sexual health
education in public schools or the lack thereof, allowed me a greater appreciation and
understanding of the evolution of sexual health education and the critical need for
standardized statewide policy that supports the development and implementation of such
programs.
Literature Search Strategy
I obtained literature relevant to sex education and associated national and state
policies from the CDC’s online publication journal databases, Walden University’s online
library publication journal databases, and hard copy journals (e.g., American Journal of
Public Health, Eta Sigma Gamman). More specifically, I used the following library
databases and search engines: Political Science Complete, ProQuest Central,
Academic Search Complete, Google Scholar, EBSCO, PubMed, Science Direct, Sage
Journals, CINAHL, PsychInfo, Social Science Research Network, and PLOS ONE. For
the searches, I used the following keywords and terms to identify relevant literature:
sexual health education in schools, sex education in schools, comprehensive sex
education, Illinois and sex education, school administrators and sex education, sex
education policy, perspectives on sex education, stakeholders’ perspectives on sex
education; abstinence-only education; abstinence-plus education, Illinois school health
policy, healthy public policy, Illinois sex education legislation, youth and sex education,
sex education surveys, sex education in the U.S., theory based sex education, sex
education programs that work, evaluation of sex education, support of sex education,
Sexual Information and Education Council of the United States. (SIECUS),
comprehensive school health education, teen pregnancy rates, opinions on sex education,
school health policy, salutogenic model, salutogenesis, health promotion theory, and
healthy public policy.
In its current status as a well-rounded discipline, sexual health education has
evolved from a rich history of educational and health policy research. Therefore, I limited
my initial literature search to materials published in 2000 or after, the majority of which
referenced research conducted by Dr. Doug Kirby in 2007 and the Kaiser Family
Foundation, in collaboration with National Public Radio, in 2000 and 2004. However, I
focused my primary literature search on publications from 2009-2016. Peer reviewed,
scholarly journals were the primary sources I used as literature to support this study.
Sexual health education has garnered mention by national organizations and philanthropic
organizations that develop and publish standardized policies, guidelines, and
recommendations related to sexual health policy, and that track, analyze, and summarize
sexual health education policies and programs. Therefore, I also accessed data and
literature from these organizations to further diversify the literature review. Examples of
these organizations include the United States Congress reports, the CDC, Kaiser
Family Foundation, SIECUS, SIECCAN, FoSE, and the Guttmacher Institute.
Theoretical Foundation
Comprehensive sexual health education is rooted in research, and is associated
with the core elements of several theoretical frameworks. For this study, the salutogenic
model/theoretical framework served as the foundation for my exploration of the statistical
relationship between the consistent implementation of comprehensive sexual health
education, before and after the enactment of sexual health education policy, and the
sexual risk behaviors of Chicago high school youth in grades 9–12. The salutogenic
model, based on the premise of salutogenesis, was introduced in 1979 by Aaron
Antonovsky. Salutogenesis is the study of health development in general, and more
specifically is focused on creating, enhancing, and improving physical, mental, and social
well-being (Becker, Glascoff, & Felts, 2010).
The salutogenic model was introduced as an alternative to the pathogenic model, a
model that widely dominated the field of public health (Anderson, Moore, Hayden, &
Becker, 2014; Garcia-Maya, Rivera, Moreno, Lindstrom, & Jiminez-Igelsias, 2012).
Pathogenesis is the study of disease development, and more precisely the avoidance,
management, and/or elimination of disease, whereas researchers use the salutogenic
model to explore the origin of health while focusing on creating health instead of disease
(Lindstrom & Eriksson, 2009). Researchers use the salutogenic model to study the
strengths and weaknesses of disease prevention, health promotion, and the development
of practices and healthy public policies, as described in the Ottawa Charter of 1986
(Nutbeam, 2008; Antonovsky, 1996).
Comprehensive sexual health education is rooted in the foundational construct of
the salutogenic model. The correlation between positive health outcomes at the individual
(high school youth), organizational (schools), and population (state and local policy)
levels emphasizes the importance of a structured environment and people are encouraged
to identify and use the resources available to them to promote the health of the individual,
community, and the nation (Mittlemark & Bull, 2013; Lindstrom & Eriksson, 2009).
Youth are a product of, and deeply influenced by, their environments (Stranger-Hall &
Hall, 2011). The salutogenic model takes the concept of health promotion as the
foundation, and intertwines the sense of coherence and the availability of internal and
external resources (generalized resistance resources) to help individuals, organizations,
and society move toward optimal well-being (Mittlemark & Bull, 2013; Becker, Glascoff,
& Felts, 2010), the overall goal of comprehensive sexual health education (SIECUS,
2012).
Lindstrom and Eriksson (2009) have noted that “public health has taken on the
challenge to establish co-operation between different sectors in society” to make health
an issue for society as a whole (p. 17). Comprehensive sexual health education is a shared
responsibility of government, parents, communities, school administrators, and teachers
that requires the attention of all entities to support the development of sexually healthy
youth (Corngold, 2010; SIECCAN, 2009). The salutogenic model can be used as a
foundation for healthy public policy that merges together the spectrum of risk factors,
protective factors, and promotion factors into a holistic model focused on proactivity
versus reactivity (Lindstrom & Eriksson, 2009). The emphasis is on health promotion,
which ignites control of personal health and the determinants of health, thereby
contributing to overall quality of life (Bengt & Eriksson, 2009).
The salutogenic model has been used as the framework for several policies and
health studies. The Ottawa Charter of 1986, drafted at a World Health Organization
meeting, is based on the premise of creating healthy public policy, environments that
support health and strengthen community actions, the development of personal skills, and
the reorientation of health challenges (Nutbeam, 2008). Creation of healthy public policy
is based on two frameworks: the salutogenic model and a contextual quality of life model.
Hence, the salutogenic model has been the basis of research in promotion of positive
health (Anderson, Moore, Hayden, & Becker, 2013). Researchers have used the
Salutogenic Wellness Promotion Scale (SWPS) to examine the interpersonal beliefs and
behaviors that contribute to positive health based on physical, social, emotional,
intellectual, vocational, spiritual, and environmental factors (Anderson, Moore, Hayden,
& Becker, 2013). Similarly, Durlak, Weissberg, Dymnicki, Taylor, and Schellinger (2011)
have shown that there is an overlap in the factors that influence the support and
implementation of comprehensive sexual health education. Anderson, Moore, Hayden,
and Becker (2013) found that SWPS was a reliable measure for positive health, and
showed how the salutogenic model can be used as foundation for a healthy public policy
that drives the development of health promotion programs designed to promote positive
health, growth, and development--the basis for comprehensive sexual health education.
Literature Review Related to Key Variables and/or Concepts
Statistics on Adolescent Sexual Behavior in the United States
According to the CDC (2015a), at the end of 2012, an estimated 1.2 million
persons aged 13 years and older were living with HIV infection, 14% had undiagnosed
HIV infection. Over the past decade, the number of people living with HIV has increased,
while the number of new HIV infections remained relatively stable, with approximately
50,000 new infections, annually. However, the number of new HIV infections continues
to increase among certain groups, such as African-Americans, Latinos/Hispanics, and
youth. According to the CDC (2014a), youth aged 13–24 made up 17% of the U.S.
population, but accounted for an estimated 26% of all new HIV infections in the United
States in 2010; approximately 60% of youth with HIV in the United States did not know
they are infected.
In 2012, CDC estimated that young people aged 15–24 years represented only
25% of the sexually experienced population; however, they accounted for nearly half of
all new STDs. Sexually active adolescents aged 15–19 years and young adults aged 20–
24 years are at higher risk of acquiring STDs for a combination of behavioral, biological,
and cultural reasons when compared to older adults. Teenage pregnancy and STDs,
including HIV, are major problems in the United States (CDC, 2012b; CDC, 2012d).
Comprehensive sexual health education and access to contraception are important
to the overall health of youth throughout the United States (U.S. Congress, 2011;
Corngold, 2010). According to Advocates for Youth (2014), the majority of adolescents
become sexually active during their teenage years. According to data obtained from the
CDC’s national YRBS data (2016), among U.S. high school students surveyed in 2015,
41% of the students indicated they had sexual intercourse at least once in their life and
30% had sexual intercourse during the previous three months. Of the high school students
who had sex during the previous three months, 43% did not use a condom the last time
they had sex; 14 % did not use any method to prevent pregnancy; and 21% drank alcohol
or used drugs before their last sexual intercourse. Comprehensive sexual health education
reflective of a balanced approach is a critical tool necessary to support healthy sexuality
throughout the lives of adolescents (Fonner, Armstrong, Kennedy, O’Reilly, and Sweat,
2014; and Stranger-Hall and Hall, 2011).
Effective communication and the implementation of comprehensive sexual health
education programs result in youth being more likely to practice contraception without
interruption over the course of a year and are more likely to practice sporadic use of
contraception (Guttmacher, 2016).
The first efforts to standardize comprehensive sexual health education in schools
were initiated in 1990. A group of leading educators, health professionals, and
representatives from national organizations who focused on adolescent development,
education, and sexuality were brought together to convene the first National Guidelines
Task Force. To further define and guide the development of sexual health education
programs, the Task Force developed the Guidelines of Comprehensive Sexuality
Education: Kindergarten through 12th Grade. These Guidelines were first published in
1991 and subsequently revised in in 1995 and 2004.
The Guidelines provided a framework for the development of new comprehensive
sexual health education programs and evaluation of existing curricula for teachers,
politicians, and administrators implementing new or restructuring existing sexual health
education programs. The Guidelines are based on the premise that: (a) sexual health
education should be offered as a part of an overall comprehensive health education
program; (b) sexual health education should only be taught by specially trained teachers;
(c) the community must be involved in the development and implementation of the
program; (d) all children and youth, regardless of gender, ethnicity, community and
disability will benefit from comprehensive sexual health education; and (e) the three
learning domains, cognitive, affective, and behavioral, should be addressed in all sexual
health education programs (FoSE, 2012; SIECUS, 2004).
Subsequently, the FoSE Initiative, a partnership between key proponent groups for
comprehensive sexual health education was launched to promote the institutionalization
of comprehensive sex education in public schools (FoSE, 2012). The manner in which
sexual health education was implemented varied dependent on the interpretation of state
or local laws governing sexual health education, personal perspectives of school
administrators, etc. (Fornby et al., 2010). FoSE developed the National Sexual Health
Education Standards: Core Content and Skills, K-12 as a complement to the Guidelines of
Comprehensive Sexual health education. The National Sexual Health Education
Standards provided clear and consistent guidance on the minimum core content that
should be included in schools throughout the United States. The seven topics identified as
the minimum, essential content and skills for grades K-12 sexual health education
included: (a) anatomy and physiology, (b) puberty and adolescent development, (c)
identity, (d) pregnancy and reproduction, (e) sexually transmitted diseases and HIV, (f)
healthy relationships, and (g) personal safety (FoSE, 2012).
My research focused on the correlation between the consistent implementation of
comprehensive sexual health education in Chicago and the sexual risk behaviors of high
school youth in grades 9 – 12. As discussed throughout this section, there were an
abundance of frameworks and guidance available to support the implementation of
comprehensive sexual health education programs. However, the availability of such
resources and the inconsistency in which comprehensive sexual health education is
delivered points to a larger issue, the perceived barriers to the implementation of
comprehensive sexual health education programs.
The History and Evolution of Sex Education in the United States
Sexual health education has evolved from prohibiting any form of sexual
expression; the Comstock Laws prohibited the mailing of information or advertisements
about sexuality, including information on contraception or abortion (McCracken, 2010).
However, sexual health education has been and continues to be shrouded with
controversy.
Before the twentieth century, sexual health education was comprised of personal
observations and informal discussions. There were few resources that discussed or
provided basic information about sexual activity. The modern movement to place sexual
health education in public schools grew out of a broader Progressive Era in opposition to
prostitution and venereal diseases, but supportive of the viewpoint that the purpose of sex
was procreation. This movement was called the social-hygiene movement (Carter, 2001;
APHA, 1913).
Two questions remained at the forefront of the social hygiene movement: (a)
should sex hygiene be taught in the public schools and (b) what could be done to
suppress prostitution, the initial basis for initiating the teaching of sex hygiene. In
response, the American Social Hygiene Association (ASHA) initiated the push for
sexual health education (APHA, 1913). ASHA argued that sexual health education was
essential to dispel ignorance about sex, disease, and the immorality that made
prostitution and other misbehaviors possible (APHA, 1913); likely resulting in
abstinence-only education. While this approach led to the delivery of sex education, the
argument weakened the potential for future approaches.
In 1924 the United States Public Health Service (USPHS) produced The Science
of Life, which consisted of two sexual health education films for adolescents, Personal
Hygiene for Boys and Personal Hygiene for Girls (Lord, 2004). Although, the USPHS
was not able to require school districts to show these films, the films were shown in
many classrooms until the 1930s. A shift in the focus of sexual health education
occurred in the 1940s as a result of Surgeon General Thomas Parran’s view that “most of
us are now agreed that some kind of sexual health education is necessary” (Parran,
1940); this shift encouraged healthy sexuality for family life.
In 1964 SIECUS was founded; created to challenge the dominating influence of
the American Social Hygiene Association on the development of sex-education curricula.
More importantly, SIECUS sought to actively promote sexuality as a natural and healthy
part of life (SIECUS, 2012). SIECUS leaders supported teaching sexuality in a
valueneutral manner that allowed students to reach their own conclusion about sexual
behavior and sexual morality (SIECUS, 2004).
The 1980s were characterized by the AIDS epidemic and the height of sexual
freedom and expression. In response to the AIDS epidemic in the United States, Surgeon
General C. Everett Koop issued a report calling for comprehensive AIDS and sexual
health education in public schools, starting as early as the third grade (Galson, 2008).
When conservative opponents in the United States realized that sexual health education
was going to be taught, they initiated a movement to replace sexual health education with
abstinence education (National Library of Medicine, n.d.). Religious conservatives
worked to add provisions for abstinence education to the 1996 Welfare Reform Act.
Hence, the federal government began allocating millions of dollars to support abstinence
education programs (Jones, 2011). This time period resulted in a retreat from the
comprehensive approach to sexual health education and was replaced with emphasis on
abstinence education, an authoritative approach that emphasized conservative views on
abstaining from sex until marriage (Jones, 2011).
Effective programs are determined by the key components of the program which
serve as a blueprint for the implementation. Kirby (2007; 2002) conducted two separate
evaluation studies to determine the characteristics shared by effective sexual health
education programs. The findings resulted in the development of criteria for assessing the
effectiveness of sexual health education programs. The findings also indicated that
effective sexual health education programs should: (a) focus on reducing one or more
sexual risk behaviors that lead to unintended pregnancy or HIV/STD infection, (b)
provide a basis on theoretical approaches to modifying social behavior, (c) provide a clear
message by reinforcing a clear stance on certain behaviors, (d) provide basic and accurate
information about the risk of unprotected intercourse and methods of avoiding
unprotected intercourse, (e) address social pressures on sexual behavior, (f) model and
practice communication, negotiation, and refusal skills, (g) employ a variety of teaching
methods, (h) incorporate goals, teaching methods, and materials appropriate to the
students, (i) last a sufficient length of time, and (j) provide training for teachers and peer
educators.
Abstinence-only programs promote abstinence from all sexual activity as the
preferred choice for adolescents and those that are not married. Whereas, comprehensive
sexual health education programs teach abstinence as the first choice, but also provide
information on ways to prevent pregnancy such as the use of contraceptives (FoSE,
2012). According to Corngold (2011) proponents of abstinence-only education support
the focus on “chastity as the correct way of life for all unmarried persons” (p. 79).
Whereas, advocates of comprehensive sexual health education agreed that abstinence
should be stressed as a smart and healthy choice; this messaging should be complimented
with medically accurate, age appropriate, and complete information about contraception,
reproduction, STDs and HIV (SIECUS, 2012; Boonstra, 2012; Corngold, 2011; Kirby,
2008).
Despite the availability of research and evidenced based findings on the most
effective form of sexual health education, the debate regarding school based sexual health
education at the national, state, and local government level has continued (Corngold,
2012; Corngold, 2010; Jemmott, Jemmott, & Fong, 2010). Scientific consensus has not
been reached in relation to the implementation of comprehensive sexual health education
versus abstinence-only education. More specifically, although state policies and
regulations vary greatly with regard to whether sexual health education should be
provided and the content that should be included, research on the impact of state policies
on sexual health outcomes for youth is scarce (Atkins and Bradford, 2014; Sabia, 2006).
Thus, my research discusses several research studies focused on the relationship between
sexual health education and youth sexual risk behaviors and the science in support of and
opposition to comprehensive sexual health education. There was minimal research
available that studied the correlation between state level sexual health education policies
and the sexual risk behaviors of youth.
As previously discussed, very few studies linking state policies and sexual health
outcomes have been conducted. However, three studies attempted to evaluate the
correlation between state policies and the sexual health outcomes of youth. A study
conducted by Atkins and Bradford (2013) utilized YRBS data for 39 states to estimate the
impact of state level sex education policies. Demographic data of the students was used to
examine the relationship between sexual health education and sexual risk behaviors of
youth. This study showed that states that required sexual health education and
contraceptive content or states that mandated sexual health education but left the content
to the discretion of the local school districts had higher rates of contraception use among
teens that were sexually active. The aforementioned study provides a foundation for my
research described in Chapter 3.
Hogben, Chesson, and Aral (2010) linked the impact of abstinence only program
requirements mandated by state policy to STD rates in the United States. Specifically,
utilizing gonorrhea and chlamydia data, the researchers found that states with mandated
abstinence only education had higher rates of STDs than states without an abstinence
only education mandate. Cavazos-Rehg et al. (2012) conducted a study to examine the
relationship between state level teen birth rates and 13 measures of average state
classroom coverage of sexual health education topics. The researchers found minimal
consistent evidence of the average educational effects on teen fertility. Conversely,
researchers relied on a bi-annual survey of school health educators to determine whether
students received lessons on specific topics that did not characterize the state policies
versus analyzing the actual state policies.
The beginning of the 20th century marked the birth of the sexual health education
debate throughout the United States, focusing on two main issues. The first issue being
debated was whether school based sexual health education should be taught. The second
was the type of school based sexual health education that should be taught,
abstinenceonly or abstinence-plus also known as comprehensive sexual health education.
A study conducted by Stranger-Hall and Hall (2011) showed that increased emphasis on
abstinence education was positively correlated with teenage pregnancy and birth rates.
Furthermore, this study utilized state data on youth sexual risk behaviors and sexual
activity (i.e., teenage pregnancy rates, abortion rates, and birth data) in conjunction with
information on each state’s sex education policy to quantify evidence related to the
effectiveness of abstinence-only sexual health education. The researchers conducted a
multivariate analyses of the dependent variables; the independent variable being
abstinence only education. Findings from this study indicated that the more state laws and
policies emphasized abstinence only education, the higher the average teenage pregnancy
and birth rate were. Whereas, states that taught comprehensive sex and/or HIV education
tended to have the lowest teen pregnancy rates.
The argument surrounding abstinence-only versus abstinence-plus education is
rooted in politics and is a health topic at the mercy of the current political environment
(Corngold 2010). A study originally conducted by Durlak and DuPre (2008) and later
discussed by Durlak, Weissberg, Dymnicki, Taylor and Schellinger (2011) sought to
assess the impact of implementation on program outcomes and identify factors that affect
the implementation process. The study showed that there are various factors that
influence implementation, the researchers divided these factors into five categories: (a)
characteristics of innovations, (b) individuals, (c) communities, (d) features associated
with prevention delivery, and (e) features associated with support systems. The sexual
health education debate is driven by perceptions, beliefs, and expertise of individuals and
communities of people (e.g., educators, administrators, politicians, etc.). The
effectiveness of sexual health education is dependent upon the mode of implementation
and the system in place to support the implementation. Thus, the shared responsibility of
decision-making by parents, teachers, administrators, and politicians enhances the
implementation of sexual health education and helps resolve potential challenges
(Benzaken, Palep, and Gill, 2011). However, this shared responsibility has not resulted in
a democratic decision making process focused on the health needs of youth, but rather the
ideals of what is believed to be most appropriate by those with decision making authority
(Marples, 2014).
Abstinence-only Sexual Health Education
The decrease in support for sex education in schools fueled the shift to what
became known as abstinence-only sex education (Boonstra, 2009). Authentic abstinence
programs are described as utilizing a more holistic approach to human sexuality and
being concerned with the social and psychological aspects of sex (Bailey, 2014). Bailey
(2014) believed that authentic abstinence curricula place a major emphasis on love,
intimacy, and commitment. These curricula teach youth that personal happiness, love, and
intimacy are most likely to occur within the commitment of a faithful marriage and that
abstinence is a solution to the problems of pregnancy, STDs and emotional harm.
Abstinence-only education generally emphasizes abstinence from sex to the
exclusion of all other types of sexual and reproductive health education, particularly
regarding birth control and safe sex (Boonstra 2014; Kirby, 2008). This type of sexual
health education promotes sexual abstinence until marriage and either has completely
avoided any discussion about the use of contraceptives or has focused on the failure rates
associated with use of contraception (Guttmacher Institute, 2016; FoSE, 2012: Oster
2008; Kirby 2008). Furthermore, advocates for abstinence only programs have argued
that controversial topics associated with sex education, such as contraception, sexual
orientation, etc. send mixed messages, thereby creating questions regarding expectations
of students (Jones, 2011; Oster; 2008).
Abstinence-plus Sexual Health Education (Comprehensive Sexual Health
Education)
Abstinence-plus sexual health education (also known as comprehensive sexual
health education) teaches about abstinence as the best method for avoiding STDs and
unintended pregnancy, while also including instruction about condoms and
contraception to reduce the risk of unintended pregnancy and contracting of STDs
and/or HIV (Helmich, 2009; Advocates for Youth, 2008b). Furthermore, comprehensive
sexual health education also teaches interpersonal and communication skills and helps
young people explore their own values, goals, and options.
The argument in support of and in opposition to comprehensive sexual health is
ongoing and is interpreted by some as sending mixed messaged to students. This is an
argument that has been seemingly supported by the actions of the United States federal
government. According to Stranger-Hall and Stranger (2011), the federal government’s
support of two different types of sexual health education programs has allowed state
legislators to choose the type of sex education that will be implemented in their states.
The federal government has provided funding for abstinence-only sexual programs
since 1981 despite the lack of research showing the effectiveness of such programs.
(Boonstra, 2010a) There were three federal programs, of significance, that supported
abstinence-only programs, the Adolescent Family Life Act (AFLA),
Community Based Abstinence Education, originally known as Special Projects of
Regional and National Significance – Community-Based Abstinence Education
(SPRANS-CBAE), and Title V – Welfare Reform Act.
Adolescent Family Life Act (AFLA). In 1981, the Adolescent Family Life Act
(AFLA) also known as the “Chastity Act” was signed into law as Title X of the Public
Health Service Act. The enactment of AFLA represented the first time the federal
government invested in teen pregnancy prevention programs that specifically focused on
self-discipline and chastity, while denying funding for abortion (Jones, 2011; Oster,
2008). The AFLA provided funding for two basic types of demonstration projects: (a)
prevention demonstration projects to develop, test, and use curricula that provided
education and activities designed to encourage adolescents to postpone sexual activity
until marriage; and (b) care demonstration projects to develop interventions with pregnant
and parenting teens, their infants, male partners, and family members in an effort to
reduce the effects of too-early-childbearing for teen parents, their babies, and their
families (Jones, 2011; Oster, 2008).
Title V – Social Security Act (Welfare Reform Legislation). The Temporary
Assistance for Needy Families Act (TANF), was signed into law in 1996 (Social Security
Act, 42 U.S.C. § 710. Pub. L. No. 104-193 (1996). This added Title V, Section 510(b) of
the Social Security Act to the list of funding for abstinence-only sexual health education.
The Title V abstinence-only program allocated money to the state Mother and Child
Health Bureaus to support the implementation of abstinence only until marriage
programs. The abstinence-only provision in Title V allowed funding of schools that
implemented abstinence-only sex education programs in direct alignment with the eight
point federal definition of abstinence education. Abstinence education was defined as an
educational or motivational program that:
• Has as its exclusive purpose teaching the social, psychological, and health
gains to be realized by abstaining from sexual activity.
• Teaches abstinence from sexual activity outside marriage as the expected
standard for all school-age children.
• Teaches that abstinence from sexual activity is the only certain way to avoid
out of wedlock pregnancy, sexually transmitted diseases, and other associated
health problems.
• Teaches that a mutually faithful, monogamous relationship in the context of
marriage is the expected standard of sexual activity.
• Teaches that sexual activity outside the context of marriage is likely to have
harmful psychological and physical effects.
• Teaches that bearing children out-of-wedlock is likely to have harmful
consequences for the child, the child’s parents, and society.
• Teaches young people how to reject sexual advances and how alcohol and
drug use increases vulnerability to sexual advances.
• Teaches the importance of attaining self-sufficiency before engaging in sexual
activity (Canders, 2012; SIECUS, 2010; Advocates for Youth, 2008a).
On June 30, 2009, the Title V abstinence-only until marriage program, as
originally written, was allowed to expire. By the time the program expired,
nearly half of the states were no longer participating in this program
(Boonstra, 2012; SIECUS, 2010; Jones, 2011; Oster, 2008). Title V was
amended to allow states to decide where to place emphasis on each of the
eight points associated with abstinence education (Boonstra, 2010a). Of the
states that refused the money, 80% did so based on research that showed
abstinence-only-until-marriage programs were ineffective (Boonstra, 2010a;
Oster, 2008;
SIECUS, 2008).
The Special Projects of Regional and National Significance. The Special
Projects of Regional and National Significance—Community-Based Abstinence
Education (SPRANS-CBAE) were created in October 2000 as the third iteration of
abstinence-only funding approved by Congress. Under this funding, awards were granted
directly to community based organizations implementing abstinence-based education
programs (Canders, 2012) that adhered to the eight-point definition. These funds were
more restrictive than Title V, in that the funding required recipients of the funds to: (a)
implement programs that targeted adolescents between ages 12 through 18; (b) be
responsive to each of the eight points, rather than determining which points to place
relative emphasis; and (c) not provide adolescents with positive information about
contraception or safer-sex practices, regardless of the parameters associated with other
funding sources (Canders, 2012).
Teen Pregnancy Prevention Initiative. In December 2009, legislation approved by
Congress and signed into law by President Obama provided funding to support the Teen
Pregnancy Prevention Initiative. This initiative allocated $114.5 million to support the
development and implementation of evidence-based programs and innovative models to
prevent teen pregnancy and STDs, including HIV (Stranger-Hall & Hall, 2011; Boonstra,
2010b). The enactment of this initiative galvanized many organizations and advocacy
groups to continue the fight to include comprehensive sexual health education in public
schools.
In an attempt to advance the science associated with sexual health education,
several studies have been conducted to analyze the effectiveness and efficacy of
abstinence only and comprehensive sexual health education programs. Kirby (2007)
conducted what has been considered to be one of the most significant and comprehensive
studies in the field of sexual health. In his review of 115 sexual health education
programs, Kirby (2007) suggested that sex education programs do not hasten the onset of
sex, increase the frequency of sex, or increase the number of sex partners. In fact, results
from the review showed the opposite. Findings from the review scientifically supported
research findings and evidenced a delay in the initiation of sex, the number of sexual
partners, and increases the use of condoms during sexual intercourse (Advocates for
Youth, 2012; FoSE, 2012; CDC, 2009; Kirby, 2007).
Comparatively, according to Rector (2002), ten effective abstinence programs
were scientifically evaluated and found to reduce sexual activity among young people.
These programs were evaluated as “real abstinence programs” that did not provide
contraceptives or encourage the use of contraceptives. Findings from the evaluation of
these programs showed reductions in sexual activity, although the statistical significance
was slightly below the 95% confidence level; five of the evaluations were never
published in scholarly journals (Young & Penhallow, 2006). When implemented in
conjunction with other programs, these programs offered evidence reinforcing the case
for overall effectiveness of abstinence education, as reported by the researcher. While
this study was used as a benchmark for the evaluation of abstinence only programs, the
findings indicated that abstinence only programs are not effective, on their own, in
promoting abstinence.
The above study was subsequently followed by a second study conducted by
Kim and Rector (2008) focused on confirming the authenticity of the type of sex
education program rather than the effectiveness of the program. The researchers
reviewed 21 abstinence education programs Findings from the review presented 15 of
the programs as authentic abstinence programs; 11 of them reported positive findings.
The other six studies analyzed virginity pledges; five out of the six reported positive
findings. The researchers noted positive results, such as, delayed sexual initiation and
reduced levels of early sexual activity.
A study for Mathematica conducted by Trenholm, Devaney, Fortson, Clark, Quay
and Wheeler (2008), examined the impact of four abstinence-only education programs
on adolescent sexual activity. The impact analysis used survey data previously collected
from more than 2,000 teens who were randomly assigned to a program group. The
findings from this study showed no significant impact on teen sexual activity or
differences in rates of unprotected sex. The findings also showed some impact on the
teens’ knowledge of STDs and perceived effectiveness of condoms and birth control
pills. Trenholm et al (2008) found that youth in the program group were no more likely
than those in the control group to have abstained from sex. Findings from the study also
indicated that youth in the program group who had engaged in sex, had similar numbers
of sexual partners as those in the control group. Additionally, youth in the program
group were no more likely to have unprotected sex than youth in the control group
(Kirby; 2008; Trenholm, et al, 2008; Trenholm et al, 2007).
In response to the Mathematica study (2008), Kim and Rector (2008) stated that
surveying students four to six years after initial program enrollment was too long a span
of time to evaluate the programs. The researchers suggested that follow-up intervals
usually range from 12 to 48 months after the program for long term impact studies. Kim
and Rector (2008) quoted the Mathematica researchers as saying “given the smaller
sample sizes available for estimate impact as the site level…the study cannot rule out
modest site-specific impacts on these outcomes” (Trenholm et al., 2008).
The belief that sexual health education increases sexual risk behaviors has been
studied and reported otherwise (SIECUS, 2012; Boonstra, 2012; Corngold, 2011; Kirby,
2008; Trenholm et al, 2008; Kirby, 2007). Evaluations of sexual health education
programs have strongly supported the conclusion that sexual health education curricula
do not increase sexual intercourse by hastening the onset of intercourse, increasing the
frequency, or increasing the number of sexual partners (FoSE, 2012; Boonstra, 2010).
Kohler, Manhart, and Lafferty (2008) studied the national Survey of Family Growth
to determine the impact of sexual health education on youth sexual risk-taking for
adolescents ages 15-19. The researchers performed a comparative analysis of the sexual
health risks of youth that received abstinence-only versus those that received abstinence-
plus education or no formal sexual health education was conducted. The researchers
found that the teens that received abstinence-plus education were 50% less likely to
become pregnant than those who received abstinence-only education or no sexual health
education. The findings from this research support existing literature, indicating
abstinence-only programs have a minimal effect on reducing, sexual risk behavior
(Advocates for Youth, 2012; CDC, 2009; Goldman, 2010; Hemlich, 2009).
CDC’s Community Preventive Services Task Force is an independent, nonfederal
body comprised of public health and prevention experts appointed by the Director of the
CDC to oversee the prioritization processes for systematic reviews; participate in the
development and refinement of review methods; serve as members of review teams; and
consider findings of all reviews and issue recommendations and findings to help inform
decision making regarding policy, practice, research, and research funding (CDC, 2012a).
A review of 62 Comprehensive Risk Reduction (CRR) reduction interventions conducted
by the Task Force (2009) showed that the most effective programs to promote behaviors
that reduce risk of becoming pregnant and preventing STDs and HIV are comprehensive
programs that include a focus on delaying sexual behavior and provide information on
how sexually active adolescents can protect themselves. Based on the systematic review
of available CRR interventions implemented in schools or community settings with
groups of adolescents aged 10-19, the Task Force recommended the implementation of
group-based CCR interventions for adolescents to promote healthy and safer sexual risk
behaviors. The CCR interventions were found to have sufficient evidence in reducing a
number of self-reported risk behaviors, including: (a) engagement in any sexual activity,
(b) frequency of sexual activity, (c) number of partners, (d) frequency of unprotected
sexual activity, (e) increase in self-reported use of protection against pregnancy and
STDs, and (f) reduction in the incidence of self-reported or clinically-documented STDs.
While the above studies are dated, the findings are consistent with other studies
that evaluated abstinence only sexual health education programs. Specifically, the
research for the abstinence plus programs seemed to be more conclusive in the reports of
effectiveness. In recent years, researchers have focused on analyzing state sex education
policies in direct correlation with sexual risk behaviors of youth by conducting
metaanalyses of abstinence only and abstinence plus programs, and assessing the
perceptions of students.
Moreover and as previously discussed, Stranger-Hall and Hall, (2011) in an
attempt to respond to the controversy surrounding sexual health education programs,
analyzed national data from all U.S. states with information on sex education laws or
policies. The assumption was that the effectiveness of abstinence-only programs would
directly correlate to the sexual risk behaviors of the youth in the states. However, the
data showed that the incidence of teenage pregnancies and births were positively
correlated with the degree of abstinence education. The findings of this study identified a
direct correlation between states with abstinence based programs and the incidence of
teenage pregnancies and births. However, there were underlying factors, as recognized
by the researchers, which may have also influenced the findings, such as household
income, race demographics of the community, etc.
A study on the efficacy of theory based abstinence only interventions by
Jemmott, Jemmott, and Fong (2010) showed that these interventions may have a role in
preventing adolescent sexual activity. A strength of this study was that few randomized
control trials tested the efficacy of abstinence interventions; thereby, enhancing the
contributions to the literature. However, the interventions included in the study did not
adhere to the federal governments definition of an abstinence only program, thereby
interjecting questions regarding the evaluation of these programs as abstinence-based
versus abstinence plus.
In summary, Young and Penhollow (2006) recommended researchers: (a)
examine the efficacy of existing programs in helping youth avoid sexual risk behaviors,
(b) develop new theory-based interventions and test them using rigorous evaluation
design, and (c) use clear measures of behavior that go beyond traditional sexual
intercourse and elicit information regarding participation in other potentially risky
sexual risk behaviors. Minimal evidence was found to support the claim that
abstinenceonly programs were effective in delaying sexual intercourse and protecting
youth from unintended pregnancy, STDs, and HIV. On the contrary, comprehensive
sexual health education programs have been shown to be quite effective in delaying
sexual intercourse, decreasing the number of sex partners, and increasing condom use.
The type of sexual health education provided is an ongoing debate at the various levels
of the government (Corngold, 2011). The time has come to shift the debate about sexual
health education instruction from whether and how to teach about abstinence to whether
and how condoms and other methods of contraception are taught consistently in sexual
health education classes (Helmich, 2009).
Comprehensive Sexual Health Education in the United States - The Present
The signing of the Affordable Care Act (ACA) into law established key processes
to support comprehensive health insurance reform (U.S. Department of Health and
Human Services, 2010). Comprehensive health care reform was intended to: (a) improve
access to quality healthcare for all Americans; (b) increase focus on prevention,
preventive care, and access to health education; and (c) increase the responsibility of
individuals to manage their healthcare (U.S. Department of Health and Human Services,
2010). Subsequently, standardization and implementation of comprehensive health
education, including comprehensive sexual health education as a form of prevention
complements the expansion of health care; thereby, realizing future reductions in health
care cost (Milstein, Horner, & Hirsch, 2010).
As a means to encourage public schools to take responsibility for the health of their
students, the CDC developed the coordinated school health program (CSHP) initiative, a
strategy used to improve the health of students in public schools by providing funding to
states to help schools implement broader coordinated school health (CDC, 2011). The
School Health Policies and Practices Study (SHPPS) is a national survey conducted every
6 years to assess coordinated school health programs across the United States (CDC,
2012e). SHPPS was the first study that measured policies and programs at the state,
district, school, and classroom levels across multiple components of CSHP. SHPPS was
conducted at all levels in 1994, 2000, and 2006. The 2012 study collected data at the state
and district levels only, and the 2014 study collected data at the school and classroom
levels only (CDC, 2014b).
Perceived Barriers to Consistent Implementation of Comprehensive Sexual
Health Education. Sexual health education has been surrounded by controversy and
ongoing debate since the early 1900s (Jones, 2011). Much of controversy stemmed from
the type of sexual health education, abstinence-only or comprehensive sexual health
education (abstinence-plus), that was being implemented or being considered for
implementation in public schools. However, with the ongoing debates and controversy
taken into consideration, the barriers to the implementation of comprehensive sexual
health education have remained the same. The barriers identified in Scales (1989) were
listed as future barriers; although there has been significant progress in the
implementation of comprehensive sexual health education (Boonstra, 2010), the barriers
listed below continue to exist in today’s debate of comprehensive sexual health education
(Jones, 2011; Goldman, 2010; Oster, 2008; Kirby, 2007). Barriers to the implementation
of comprehensive sexual health education, include: (a) teachers’ lack of knowledge of
content area, (b) teachers’ lack of professional development, (c) community opposition to
sexual health education, (d) parents’/guardians’ opposition to sexual health education, (e)
teachers’ comfort level with teaching sexual health education (f) involvement of politics,
(g) perceptions of parents’ support of sexual health education, (h) responsibility of the
school, (i) responsibility of the parents’ to deliver sexual health education, (j)
misconceptions of what sexual health education encompasses, (k) belief that coverage of
reproductive systems in biology class is adequate for sexual health education, and (l)
belief that sexual health education will increase sexual risk behaviors, remain, albeit with
varying degrees of impact in today’s society.
Despite, an abundance of research in support of the benefits of comprehensive
sexual health education, politics continue to play a key role in the discussion of
comprehensive sexual health education in public schools, whether in support of or in
opposition to sexual health education (Jones; 2011; Boonstra, 2010). At various times in
United States history, federal and state governments have allocated significant funding to
support abstinence-only and abstinence-plus programs, although fewer in number.
However, currently, minimal direction beyond stressing abstinence in conjunction with
providing age appropriate and medically accurate information is provided. According to
Corngold (2010) is his analysis of Gutmann’s Democratic Education, education authority
is shared among state, parents, and education professionals, but argues against Gutmann’s
assertion that local communities should have the freedom to decide whether or not
comprehensive sexual health education is offered in their community. Thus, resulting in
the inconsistent implementation of comprehensive sexual health education.
The degree of support from community stakeholders has often been dependent on
the political and ideological environment in which a school resides (Brandon, Smith,
Trenholm, and Devaney, 2010). Politicians have traditionally made decisions based on
two ideologies: (a) their personal and moral beliefs, regardless of the availability of
scientific evidence; and (b) to accommodate their political base to help them attain future
political goals (Oster, 2008, p. 130). Oster (2008), explained considerations given to the
decision making process of politicians as “political paradoxes caused by two primary
goals of politicians, political goals and policy goals” (p. 133). Comprehensive sexual
health education has been on both sides of the fence, dependent on the political climate.
The CPS’ Family Life and Comprehensive Sexual Health Education policy was
recognized as having a comprehensive approach to sexual health education (SIECUS,
2011a). Reducing teen pregnancy and STD rates among Chicago adolescents was a cry
heard, by local Chicago politicians, hence the fulfillment of their policy and political
goals.
The lack of knowledge and the lack of professional development among teachers
responsible for providing sexual health education programs has been a concern in the
field of sexual health education (Goldman, 2010). Sexual health education should be
taught by teachers with specialized training in the area of sexual health education and
include the key components of a sexual health education program, as outlined previously
(FoSE 2012; SIECANN, 2009,). Often times, physical education teachers or coaches of
athletic teams, with no formal training, have been given the responsibility of teaching
sexual health education. These teachers too often do not have the skills, training, or
inclination to teach sexual health education (Goldman, 2010). Relying on professionals
who are not trained to teach adolescents this aspect of health education is detrimental to
an adolescent evolving into a balanced sexually healthy adult. The sexually healthy
adolescent must feel comfortable expressing their thoughts and feelings regarding their
sexuality and seeking information related to human sexuality, without thoughts of shame
due to their sexual feelings (Francis, 2009). Comprehensive education taught by
appropriately trained educators requires a standardized theoretical approach to support the
curriculum development; this approach emphasizes clear goals, objectives, learning
processes, and outcomes (Goldman, 2010).
State Policies on Sexual Health Education
The federal government’s role in state level sexual health education policy is
limited; policies governing sexual health education in schools are made at the state and
local level (Guttmacher, 2016). However, in the1980s, schools began reevaluating their
sexual health education polices due to the tremendous impact of the AIDS epidemic; most
states began requiring public schools to teach some form of sex or STD/HIV education
(Guttmacher, 2016). The ongoing debate of abstinence only versus comprehensive sexual
health education significantly influenced the degree of variance in the ways in which
states have approached the development of sexual health education policies (Corngold,
2011). Some states however, have placed requirements on how abstinence or
contraception must be taught within the school district’s curriculum.
(Guttmacher Institute, 2016).
The Guttmacher Institute (2016) summarized the following highlights of state sex
and HIV education policies.
General Requirements for Sex Education and HIV Education:
• 24 states and the District of Columbia mandate that public schools teach
sexual health education.
• 33 states and the District of Columbia mandate HIV education; of these states,
13 mandate only HIV.
• 27 states and the District of Columbia mandate that, when provided, sex and
HIV education programs meet certain general requirements.
• 38 states and the District of Columbia require school districts to involve
parents in sex education, HIV education, or both.
Content requirements when sex education is taught:
• 18 states and District of Columbia require that information on contraception
be provided.
• 37 require that information be provided; 26 states require that abstinence be
stressed.
• 19 states require that instruction on the importance of engaging in sexual
activity only with marriage be provided.
• 13 states require discussion of sexual orientation.
• 13 states require the inclusion of information on the negative outcomes of teen
sex and pregnancy.
• 28 states and District of Columbia require the provision of information about
skills for healthy sexuality, healthy decision making and family
communication skills.
The inconsistent implementation of comprehensive sexual health education is not unique
to a state, but rather spans across the United States.
Sexual Health Education in Illinois
The Guttmacher Institute (2016) noted, "concerns over AIDS and teen pregnancy
galvanized widespread public support for sexual health education in schools”. However,
the state of Illinois does not mandate sex education or HIV education; if sex education is
taught in Illinois, it must stress abstinence and be age appropriate. According to CDC
(2015d), Illinois ranked 8th among the 50 states in the number of HIV diagnoses; an
estimated 2,077 adults and adolescents were diagnosed with HIV in 2013. Additionally, in
2013, Illinois ranked 12th in chlamydial infections and 13th in gonorrheal infections
among the 50 states. The primary goal of comprehensive sex education has been to help
young people mature into sexually healthy adults void of shame about their sexual
feelings and to promote the maturation into becoming a sexually healthy adult. Therefore,
appropriate mechansims must be in place to support the provision of comprehensive
sexual health education (SIECUS, 2011b; Francis, 2010).
Today, most states have a policy requiring HIV education, as a complement to a
broader sexual health education program. Unlike the mandate for the provision of HIV
education in Illinois, sexual health education, of any kind, is not mandated in Illinois
(Guttmacher Institute, 2016). Furthermore, if sexual health education is provided in
Illinois, abstinence must be stressed with specific emphasis on the importance of sex only
with marriage; negative outcomes of teen sex; and avoiding coercion. In fact, Illinois was
the only state that required HIV-positive high school students to notify the school
principal of their HIV status; allowing the principal to share the information with other
school personnel as deemed appropriate (Advocates for Youth, 2014). This law further
supports the need for the implementation of comprehensive sexual health education
throughout the state of Illinois.
Researchers from the University of Chicago Medical Center (2008) conducted a
study to examine the content, quality, and influences on sex education to determine the
predictors of a comprehensive sex education curriculum. The study found that 93% of
Illinois public schools offered sex education, either by their own teachers and/or with the
help of outside agencies. Approximately 24% of the teachers who responded to the survey
indicated that they taught an abstinence-only curriculum in combination with, or
supplemented by, materials from other curriculums. Nearly one-third of the sex education
teachers indicated that they had not received sex education training and about half
reported seven or fewer years of experience. When asked why certain topics were
omitted, school or district policy was most commonly cited (Lindau, Tetteh, Kasza,
Gilliam, 2008). Sexual health education is a component of the overall health education
policy discussion. However, as a result of the decentralized management structure of
education systems within the states, the sexual health education curricula used are often
established or influenced at the district or local level (Fornby et al, 2010).
The current sexual health education policy for the state of Illinois, the Critical
Health Problems - Comprehensive Health Education Act, requires the following topics be
addressed in all elementary schools and secondary schools: (a) human ecology; (b)
human growth and development; (c) emotional, psychological, hygienic, and social
responsibilities of family life, including sexual abstinence until marriage; (d) prevention
and control of disease; and (e) the transmission and spread of AIDS (SIECUS, 2011a;
Comprehensive Health Education Act, 110, 2011). More specifically, this policy requires
all schools, that elect to implement sexual health education, to emphasize abstinence as
the expected norm and as the only method that provides 100% protection from unwanted
teenage pregnancy, STDs, and HIV/AIDS (Comprehensive Health Education Act, 110,
2011; SIECUS, 2011a). Sexual health education, in any form, is not delivered
consistently in Illinois, even when the requirements of the Comprehensive Health
Education Act are implemented as written. The inconsistency in which sexual health
education is delivered has the potential to influence the sexual risk behaviors of high
school youth.
The Illinois Personal Responsibility Education Program Act (Senate Bill 1619)
was introduced in February of 2011. This legislation proposed to amend the state law to
require sexual health education be offered in public schools to include, instruction on
contraception. The Act proposed to eliminate language requiring instruction on abstinence
until marriage. Senate Bill 1610 did not pass the vote of the full Senate. Subsequently,
House Bill 3027, reintroduced the Illinois Personal Responsibility
Education Program Act as an amendment, referred to as the Sexual Health Education
Bill. Although not a mandate to provide comprehensive sexual health education, when
implemented, the contents of this legislation required school districts to offer sexual
health education in grades six thru 12. The enactment of this policy reflected the lack of
standardized policy throughout the state and supported researchers’ assertions that sexual
health education policy is often influenced at the district or local level.
While state legislation regarding comprehensive sexual health education was
pending, CPS adopted the Family Life and Comprehensive Sexual Health Education
Policy in 2008 (SIECUS, 2011a). This policy required all schools to provide
comprehensive, age-appropriate, and medically accurate family life and sexual health
education. Furthermore, comprehensive sexual health education must be incorporated
into every school’s program of study. In 2013, CPS adopted a new policy that mandated
comprehensive sexual health education for grades K through 12. This policy also
mandated that the curriculum be aligned with the National Sexuality Education
Standards, be age appropriate for each grade level, and include instruction about gender
identity, gender expression, and sexual orientation. The expanded requirements were
scheduled to be fully implemented in 2016 (CDPH, 2013). A critical step in reducing
sexual risk behaviors of youth is the consistent implementation of sexual health education
(Fonner, Armstrong, Kennedy, O’Reilly, and Sweat, 2014). Requiring comprehensive
sexual health education, inclusive of abstinence as a desirable behavior directly correlates
to positive shifts in self-reported sexual risk behaviors, delayed onset of sexual activity,
and decreases in STD and HIV incidence rates.
Summary
Sexual health education has been recognized as a discipline since the early
1900’s. A number of organizations that support sexual health education were established;
guidelines developed to support the implementation of sexual health education programs;
sexual health education defined and identified as a vital part of comprehensive health
education programs; and barriers to the implementation and ways to overcome these
barriers identified. Studies reporting the need for comprehensive sexual health education
programs have been completed. However, despite the many efforts and the vocal nature of
sexual health education advocates consistency in the implementation of comprehensive
sexual health education is not standardized throughout the state of Illinois.
All adolescents have the right to the knowledge, skills, and abilities to make
rationale and well informed decisions; the ultimate purpose of comprehensive health
education, by virtue of default sexual health education, is to equip adolescents with the
tools needed to evaluate different ways of life and choose intelligently among the options
in front of them (FoSE, 2012; Corngold, 2011).
According to Atkins and Bradford (2013), a significant road block of existing
literature that evaluates the effect of comprehensive sexual health education on youth is
the potential for “endogenous selection effects” (p. 6). Youth who engage in high risk
sexual behaviors may be more likely to receive sex education than youth who do not
engage in high risk sexual behaviors (Atkins & Bradford, 2013).
My research study employed a correlational research model utilizing secondary
analysis of YRBS data from CPS. This study examined the correlational relationship
between the consistent implementation of comprehensive sexual health education, before
and after the enactment of CPS’ sexual health education policy, and the sexual risk
behaviors of Chicago high school youth in grades 9–12. This study contributed to the
body of literature by helping to inform the influences comprehensive sexual health
education policy has on Chicago high school youths’ sexual risk behaviors.
Chapter 3: Research Method
Introduction
The purpose of this correlational study was to explore the statistical relationship
between the consistent implementation of comprehensive sexual health education, before
and after the enactment of CPS’ sexual health education policy, and the sexual risk
behaviors of Chicago high school youth in grades 9–12. I analyzed sexual risk behavior
data obtained from CPS’ YRBS, between the years of 2007 and 2013. In this chapter, I
begin by discussing the research design and rationale of the study. Next, I present the
methodology I used to conduct the study, and then move to a discussion of potential
threats to the validity of the study. I conclude with a brief summary of the information
discussed throughout the chapter.
Sexual health education is the foundation on which instruction on STD and
HIV/AIDS prevention programs were built (Francis, 2009; Galson, 2008). Access to
effective comprehensive sex education supports the development of well-rounded,
balanced, and sexually healthy youth (SIECCAN, 2010). Most states have policies
requiring HIV education as a complement to a broader comprehensive sexual health
education program (Guttmacher, 2016). There are clear guidelines and standards to assist
schools, located in states without sexual health education policies, in the design and
development of sexual health education programs as a part of a comprehensive school
health education approach (FoSE, 2012).
In this study, comprehensive sexual health education was the independent variable
and sexual risk behaviors were the dependent variables, measured before and after the
enactment of CPS’ sexual health education policy. Sexual risk behaviors, as defined by
the YRBS, are sexual behaviors that contribute to unintended pregnancy and
STDs, including HIV infections (CDC, 2016).
Research Design and Rationale
I used a correlational study design to explore statistical relationship between
comprehensive sexual health education as the independent variable, and sexual risk
behaviors, the dependent variables, before and after enactment of CPS’ sexual health
education policy, in 2008. I considered demographic data (i.e., race/ethnicity and gender)
the covariate variables, when analyzing the data to determine the possible relationship
with the independent variable, comprehensive sexual health education. Furthermore, the
analysis of the covariate variables allowed me to further explore if the consistent
implementation of comprehensive sexual health education influenced the sexual risk
behaviors of specific demographic populations.
Time and resource constraints were limited to my analysis of the secondary data
from the YRBS conducted among CPS high school youth in grades 9–12.
According to the CDC (2016), “priority health-risk behaviors, behaviors that
contribute to the leading causes of morbidity and mortality among youth and adults, are
often established during childhood and adolescence, extend into adulthood, and are
interrelated and preventable” (p. 1). The YRBS, a national school-based survey developed
by CDC and administered by state and local education and health agencies, monitors six
types of health-risk behaviors that contribute to the leading causes of death and disability
among youth and adults, including: (a) behaviors that contribute to unintentional injuries
and violence; (b) sexual risk behaviors that contribute to unintended pregnancy and
STDs, including HIV infection; (c) alcohol and other drug use; (d) tobacco use; (e)
unhealthy dietary behaviors; and (f) inadequate physical activity. The
CDC uses YRBS data to measure progress toward achieving national health objectives
(as outlined in Healthy People 2020), to assess trends in priority health-risk behaviors
among high school students, and to evaluate the impact of school and community
interventions at the national, state, and local levels.
Although the literature is limited in regards to studies that examine the
relationship between the consistent implementation of sexual health education per state
and/or local policy and the sexual risk behaviors of youth, Atkins and Bradford (2013)
conducted a study in which they employed a methodology similar to the methodology I
used for this research. Atkins and Bradford (2013) utilized YRBS data for 39 states to
estimate the impact of state-level sex education policies. They also used demographic
data to further examine the relationship between sexual health education and the sexual
risk behaviors of youth. However, they were not able to determine and thus account for
how students received sexual health education, how their sexual risk behaviors change
over time in response to state policy, how state laws change over time, or how the
implementation of sex education policies affect youth sexual behaviors over time. The
researchers used the linear probability and probit models to show the statistical
associations between state policies and sexual risk behaviors. While methodologically
similar to the Atkins and Bradford study, my study was not focused on the direct
association of state sexual health education policies, but rather on the consistent
implementation of sexual health education before and after enactment of local policy.
Methodology
Population
The target population, as defined by the YRBS, was CPS high school youth in
grades 9–12. More specifically, I analyzed data obtained from CPS high school youth in
grades 9–12 from 2007, one year prior to the implementation of the sexual health
education policy, to 2013 to answer my study’s research questions. The YRBS target
population size included all high school youth in attendance at school during the time in
which the YRBS was administered. Because this study spanned four YRBS cycles, the
target population size varied based on participation of CPS during any given cycle.
Sampling and Sampling Procedure
The timeframe for data collection for this secondary analysis was a four-cycle
period beginning in 2007 and ending in 2013. I extracted sexual risk behavior data
provided by high school youth in grades 9–12 from the larger dataset, and used subsets
that included students who reported ever having sex to conduct the logistic regression for
Hypothesis 1. I stratified the analyses by race/ethnicity and gender, the covariate
variables. Additionally, I excluded incomplete YRBS data from the analysis so as not to
skew the outcomes.
Recruitment, Participation, and Data Collection
Although the data that I analyzed came from four different YRBS cycles, the
recruitment processes remained consistent. The YRBS utilized a two-stage sample design
to produce a sample representative of public and private school students in grades 9–12
in states (e.g., Illinois) and large urban school districts (e.g., Chicago). More specifically,
in the first sample design, schools with any of the grades 9–12 were sampled based upon
probability in relation to the school’s enrollment numbers. In the second sample design,
classes for required subjects, such as English or social studies, or a required learning
period, such as homeroom, were sampled randomly. All students in the sampled classes
were eligible to participate.
The YRBS administered by the CDC for the national, state, and large urban school
district surveys were designed to ensure students’ anonymity and supported participation
in the survey on a voluntary basis (CDC, 2012f). Prior to the administration of the survey,
schools were required to follow the documented parental permission processes to ensure
parental consent for participation. There were 86 standard questions on the survey;
however, each school was able to include additional questions as appropriate. The
questions added by each school district were not included in the national analysis to
ensure consistency in data analysis. High school students completed the selfadministered
questionnaire during one class period and recorded their responses directly on a
computer-scannable form. The CDC’s Institutional Review Board approved the
protocol for the national YRBS.
My use of data specific to the YRBS conducted in Chicago for the timeframe of
2007–2013, did not require special permissions. The data I used were available to the
general public via the 2013 YRBS National, State, and District Combined Datasets found
at http://www.cdc.gov/healthyyouth/data/yrbs/data.htm. Each participating state and city
could elect to give the CDC permission to release the data directly to the requestor or
require that an official request be made with the respective state or urban school district.
CPS gave the CDC permission to release requested data directly to the requestor on their
behalf (Appendix A). The most recent YRBS conducted in Chicago was completed in
2015. However, CPS did not use weighted data; the CDC does not release unweighted
data.
Instrumentation and Operationalized of Constructs
The CDC developed its first YRBS in 1990 to monitor priority health risk behaviors
that contribute significantly to the leading causes of death, disability, and social problems
among youth and adults in the United States (CDC, 2014a). The YRBS is conducted
biannually, and data is made available to the general public on the national, state, and
local levels. In this study, I explored whether there was a statistical relationship between
the consistent implementation of comprehensive sexual health education, before and after
the enactment of CPS’ sexual health education policy, and the sexual risk behaviors of
Chicago high school youth in grades 9–12. The YRBS provides generalizable findings on
the sexual risk behaviors of high school students in grades 9– 12; however, these same
behaviors may be influenced by the implementation of comprehensive sexual health
education programs throughout Chicago. The data from the CPS’ YRBS allowed for a
comparison of the sexual risk behaviors of high school youth before and after the
enactment of CPS’ comprehensive sexual health education policy in
2008.
Reliability and Validity
Representatives from the Departments of Education in each state, including the
District of Columbia and four U.S. territories, reviewed the initial YRBS questionnaire
along with 16 local education agencies then funded by the CDC (CDC, 2013a). To further
ensure reliability and validity, the questionnaire was disseminated to the National
Center for Health Statistics (NCHS) for review and recommendations. The revised
version of the YRBS questionnaire was administered to a national sample of students in
grades 9–12. Subsequently, the second version of the questionnaire was sent to the
Questionnaire Design Research Laboratory at NCHS for laboratory and field-testing with
high school students. CDC later conducted two test retest reliability studies in 1992 and
2000 with groups of high school students throughout the United States (CDC, 2013a).
The third and final version of the YRBS questionnaire was revised to include questions to
assist with the monitoring of national health objectives, such as those outlined in Healthy
People 2020 (U.S. Department of Health and Human Services, 2014).
Definition of Variables
Independent variable. Comprehensive sexual health education was the
independent variable. This variable was determined based upon the existing sexual health
education policy that was in place within CPS and the presumed correlation between the
independent and dependent variables.
Dependent variable. Sexual risk behaviors were the dependent variables. The
sexual risk behaviors analyzed in this study were broken down into nine sub-behaviors.
These sub-behaviors represented facets of the empirical domain of high school youth
sexual risk behaviors in the Unites States. Eight of the sub-behaviors measure the
prevalence of high school youth who engage in the following sexual risk behaviors: (a)
ever had sexual intercourse, (b) had sexual intercourse for the first time before age 13
years, (c) had sexual intercourse with four or more persons during their life, (d) currently
sexually active (had sexual intercourse with at least one person during the 3 months
before the survey), (e) use of a condom (during last sexual intercourse among students
who were currently sexually active), (f) use of birth control pills (before last sexual
intercourse to prevent pregnancy among students who were currently sexually active), (g)
use of any method to prevent pregnancy (during last sexual intercourse among students
who were currently sexually active), (h) drank alcohol or used drugs before last sexual
intercourse (among students who were currently sexually active); and (i) were never
taught about AIDS of HIV in school.
Data Analysis Software
Statistical Analysis System (SAS 9.3) was the software used to complete the data
analyses described in this section. CPS high school youth in grades 9–12 sexual risk
behaviors were included in the data set and used for analyses in reference to the
established research questions and hypotheses. The race/ethnicity and gender of the high
school youth were coded to allow for the covariate data analysis previously described. All
analyses were conducted with the consideration of survey sampling design and
weightings.
Research Questions
The research questions represented facets of the empirical domain on comprehensive
sexual health education discussed in the vast amounts of literature related to the
effectiveness and implementation of comprehensive sexual health education. The below
research questions guided this study, and added to the literature using a comprehensive
sample of students in high school throughout the City of Chicago. The research questions
were:
1. How does the implementation of comprehensive sexual health education
influence (increase or decrease) the following sexual behaviors of Chicago high
school youth in grades 9–12 :
• Ever had sexual intercourse
• Sexual intercourse before the age of 13 years (for the first time)
• Sexual intercourse with four or more persons during their life
• Currently sexually active (sexual intercourse with at least one person
during the 3 months before the survey)
• Did not use a condom (during last sexual intercourse among students who
were currently sexually active)
• Did not use birth control pills (before last sexual intercourse to prevent
pregnancy among students who were currently sexually active)
• Did not use any method to prevent pregnancy (during last sexual
intercourse among students who were currently sexually active)
• Drank alcohol or used drugs before last sexual intercourse (among
students who were currently sexually active)
• Were never taught about AIDS or HIV in school
2. How does the implementation of comprehensive sexual health education
influence (increase or decrease) sexual behaviors of Chicago high school youth in
grades 9–12, by race/ethnicity (covariate)?
3. How does the implementation of comprehensive sexual health education
influence (increase or decrease) sexual behaviors of Chicago high school youth in
grades 9–12, by gender (covariate)?
Hypotheses
The hypotheses were in alignment with the purpose of the study and
representative of the three research questions outlined above. The null hypotheses
indicated there was no relationship between the independent and dependent variables,
thereby countering the research hypotheses. These hypotheses were measured using
statistical tests at the 0.05 significance level and 95% confidence level.
Null Hypothesis (H01): The consistent implementation of comprehensive sexual
health education is not significantly related to the sexual risk behaviors among Chicago
high school youth in grades 9–12.
Research Hypothesis (H1): The consistent implementation of standardized
comprehensive sexual health education is significantly related to the sexual risk behaviors
among Chicago high school youth in grades 9–12.
Null Hypotheses (H02): The consistent implementation of comprehensive sexual
health education does not significantly influence (increase or decrease) the sexual risk
behaviors among Chicago high school youth in grades - 12.
Research Hypothesis (H2): The consistent implementation of comprehensive sexual
health education does significantly influence (increase or decrease) the sexual risk
behaviors among Chicago high school youth in grades 9–12.
Data Analysis
Due to the complex sampling design of YRBS, all statistical analyses were
conducted using weighted data as suggested by the CDC. A weight based on gender,
race/ethnicity, and grade was applied to each record to adjust for missing responses and
oversampling of Black/African American and Hispanic/Latino students. Logistic
regression was conducted to estimate the prevalence and a 95% confidence interval of
each dependent variable before and after enactment of the sexual health education policy
in 2008 for Chicago high school youth. Logistic regression is used to test the predictive
power of a variable, comprehensive sexual health education (Pallant, 2010). More
specifically, using logistic regression, I was able to assess whether the consistent
implementation of comprehensive sexual health education (independent variable)
influenced the sexual risk behaviors (dependent variables) of high school youth and
whether there is a difference before and after enactment of the comprehensive sexual
health education policy in 2008.
Odds ratios and 95% confidence intervals were estimated to analyze how the
implementation of comprehensive sexual health education influenced (increased or
decreased) the sexual risk behaviors of high school youth. Odds ratios are a commonly
used measure in epidemiology to quantify associations between an exposure and an
outcome. Odds ratios are used to compare whether the odds of an occurrence of the
outcome of interest, sexual health education, decreases sexual risk behaviors of high
school youth, given exposure to the variable of interest (Szumilas, 2010). The odds ratio
can also be used to determine whether a particular exposure is a risk factor for a particular
outcome, and to compare the magnitude of various risk factors for that outcome. Specific
to this study, an odds ratio with confidence interval overlapping 1 indicated no significant
association between sexual health education and the sexual risk behaviors, or the null
hypothesis. Consequently, an odds ratio away from 1, either larger than 1 (increase of
sexual risk behaviors) or less than 1 (decrease of sexual risk behaviors), showed a
possible significant association with sexual health education. As stated in the previous
section, the above described analyses were performed for all high school students in
grades 9–12 and stratified by race/ethnicity (i.e., Black/African
American and Hispanic/Latino) and gender (i.e., female and male).
Threats to Validity
Researchers from the CDC (2013a) conducted a review in 2003 to assess the
cognitive and situational factors that might affect the validity of adolescent self-reporting
of behaviors measured by the YRBS questionnaire. These factors were found to not
threaten the validity of self-reported behaviors, thus, there was no threat to the validity of
the YRBS national questionnaire. However, there has not been a study conducted to
assess the validity of all self-reported sexual risk behaviors captured by the YRBS.
Furthermore, self-reports of sexual behavior can be influenced by both cognitive and
situational factors, but no standard exists to validate the behavior. According to the CDC,
“understanding the differences in factors that compromise the validity of self-reporting of
different types of behavior can assist policymakers in interpreting data and researchers in
designing measures that do not compromise validity” (p. 6).
Ethical Procedures
This study used secondary data obtained from the CPS’ YRBS. Therefore, there
was no threat of violating study participants’ rights. Additionally, anonymity and
confidentiality for all educational institutions and participants of this study were
guaranteed; the Chicago YRBS dataset did not include personal identifiers. The survey
was completed anonymously and therefore reduced the potential for breaches of
confidentiality. The data analyzed for this study were used to answer the research
questions and hypotheses and the results and findings from data analysis are presented in
the next chapter. This study was approved by Walden University’s Institutional Review
Board (IRB). The IRB approval number is 02-11-16-0131445.
Summary
This study employed a correlational study design to explore the statistical
relationship between comprehensive sexual health education as the independent variable
and the sexual risk behaviors, the dependent variables. Demographic data, specifically,
race/ethnicity and gender, the covariate variables, were considered when analyzing the
data to determine the possible relationship with the independent variable, comprehensive
sexual health education. Logistic regression and odds ratios were estimated to explore the
relationship between comprehensive sexual health education and the sexual risk
behaviors of high school students.
Chapter 4: Results and Findings
Introduction
The purpose of this correlational study was to explore the statistical relationship
between the consistent implementation of comprehensive sexual health education, before
and after the enactment of CPS’ sexual health education policy, and the sexual risk
behaviors of Chicago high school youth in grades 9–12. I analyzed sexual risk behavior
data obtained from the YRBS that was collected during the administration of CPS’
YRBS, for years 2007, 2009, 2011, and 2013.
Research Questions
The research questions that guided this research study were:
1. How does the implementation of comprehensive sexual health education
influence (increase or decrease) the following sexual behaviors of Chicago high
school youth in grades 9–12:
• Ever had sexual intercourse (S1)
• Sexual intercourse before the age of 13 years (for the first time) (S2)
• Sexual intercourse with four or more persons during their life (S3)
• Currently sexually active (sexual intercourse with at least one person
during the 3 months before the survey) (S4)
• Did not use a condom (during last sexual intercourse among students who
were currently sexually active) (S5)
• Did not use birth control pills (before last sexual intercourse to prevent
pregnancy among students who were currently sexually active (S6)
• Did not use any method to prevent pregnancy (during last sexual
intercourse among students who were currently sexually active) (S7)
• Drank alcohol or used drugs before last sexual intercourse (among
students who were currently sexually active) (S8)
• Were never taught about AIDS or HIV in school (S9)
2. How does the implementation of comprehensive sexual health education
influence (increase or decrease) sexual behaviors of Chicago high school youth in
grades 9–12, by race/ethnicity (covariate)?
3. How does the implementation of comprehensive sexual health education
influence (increase or decrease) sexual behaviors of Chicago high school youth in
grades 9–12, by gender (covariate)?
Hypotheses
The hypotheses were in alignment with the purpose of the study and
representative of the three research questions outlined above. The null hypotheses
indicates there is no relationship between the independent and dependent variables,
thereby countering the research hypotheses. The hypotheses were measured using
statistical tests at the 0.05 significance level and 95% confidence level.
Null Hypothesis (H01): The consistent implementation of comprehensive sexual
health education is not significantly related to the sexual risk behaviors among Chicago
high school youth in grades 9–12.
Research Hypothesis (H1): The consistent implementation of standardized
comprehensive sexual health education is significantly related to the sexual risk behaviors
among Chicago high school youth in grades 9–12.
Null Hypotheses (H02): The consistent implementation of comprehensive sexual
health education does not significantly influence (increase or decrease) the sexual risk
behaviors among Chicago high school youth in grades 9–12.
Research Hypothesis (H2): The consistent implementation of comprehensive sexual
health education does significantly influence (increase or decrease) the sexual risk
behaviors among Chicago high school youth in grades 9–12.
In this chapter, I present the results of the statistical analyses I performed to
answer the research questions. First, I present the results from the preliminary analysis to
estimate the prevalence rates for the sexual risk behaviors among Chicago high school
youth. Next, to answer Research Question 1, I present the results from the analysis of the
potential influences of comprehensive sexual health education on the sexual risk
behaviors of Chicago high school youth. Finally, to answer Research Questions 2 and 3, I
provide an analysis of results of the potential influences of comprehensive sexual health
education on the sexual risk behaviors of Chicago high school youth by race/ethnicity
(i.e., African-American/Black and Hispanic/Latino) and gender. This chapter concludes
with a summary of the findings from the data analysis and an overview of Chapter 5.
Data Collection
I used existing data from the CDC YRBS dataset that was available to the general
public, and was collected during designated CPS high school classes. The data were
collected from CPS students in grades 9–12 who were in attendance at school on the day
the YRBS was administered. Data from CPS’ YRBS 2007, 2009, 2011, and 2013 cycles
were used in the analyses for this study. I extracted sexual risk behaviors data provided by
high school youth in grades 9–12 from the larger YRBS dataset.
Results
CPS is the third largest school district in the United States. In fiscal year 2016,
392,285 students were in CPS, of which 111,167 were enrolled at a CPS high school.
Black/African-American and Hispanic/Latino students comprise approximately 86% of
the total high school student enrollment (CPS, 2016). A total of 5,898 surveys were
completed by Chicago high school youth. It is important to note that I included only
surveys completed in their entirety in the analyses. Black/African-American students
accounted for approximately 39% (2,329) of the respondents, and Hispanic/Latino
students accounted for approximately 44% (2,589) of the respondents. Of the students
who provided their gender, females accounted for approximately 58.6% (3,123) of the
respondents, and males accounted for approximately 48.4% (2,738) of the respondents.
Thirty-seven students did not identify as male or female.
Research Question 1: Prevalence of Sexual Behaviors Among all Chicago High
School Youth
To analyze the potential influences of sexual health education, I estimated the
prevalence of nine sexual risk behaviors using available YRBS data from 2007 - 2013
(see Table 1). Results indicated that there were large variances across different sexual risk
behaviors among all Chicago high school youth. Approximately 90% of Chicago high
school youth did not use birth control pills before their last engagement in sexual
intercourse to prevent pregnancy, while approximately 12% of the youth had sexual
intercourse for the first time before the age of 13 at baseline. Over the 6-year period from
which I analyzed YRBSS data (2007–2013), the prevalence of these sexual risk behaviors
was relatively stable, as shown in Table 1. However, according to my analysis of sexual
risk behavior prevalence rates, the rate of Chicago high school youth who reported they
were never taught about AIDS or HIV in school increased after 2007, from 15.9% in 2007
to 23.1% in 2013. Additionally, according to my analysis of sexual risk behavior
prevalence rates, the rate of Chicago high school youth who reported drinking alcohol or
using drugs before their last sexual encounter increased after 2007, from 12.5% to 18.8%
in 2013.
Table 1
Prevalence of Sexual Behaviors among High School Students in Chicago, IL, Youth Risk Behavior Survey 20092013
2007 (Baseline)
2009
2011
2013
Sexual Behaviors
%
95% CI
%
95% CI
%
95% CI
%
95% CI
Ever had sex
56.9
[52.7 - 61.1]
53.6
[48.2 - 59.0]
52.2
[47.0 - 57.3]
51.8
[46.6 - 57.0]
Had sex before 13
11.5
[8.2 - 14.9]
12.0
[8.7 - 15.2]
11.9
[9.9 - 14.0]
9.6
[6.6 - 12.6]
Had sex with 4+ people in
life
18.1
[14.8 - 21.4]
19.5
[15.3 - 23.6]
17.5
[14.3 - 20.8]
16.4
[12.7 - 20.2]
Were currently sexually
active
39.8
[35.7 - 43.8]
39.3
[33.5 - 45.2]
37.8
[33.8 - 41.7]
36.8
[32.0 - 41.6]
Did not use a condom
32.2
[25.1 - 39.3]
34.9
[28.4 - 41.4]
35.7
[30.8 - 40.5]
38.7
[33.3 - 44.2]
Did not use birth control pills
90.5
[86.1 - 94.9]
89.0
[85.5 - 92.5]
88.2
[85.1 - 91.2]
89.4
[86.8 - 92.1]
Did not use any method to
prevent pregnancy
14.9
[9.9 - 19.9]
15.7
[11.4 - 20.1]
17.3
[12.6 - 22.0]
17.6
[13.3 - 21.9]
Drank alcohol or used drugs 12.5
before last sex
[7.9 - 17.0]
18.1
[12.6 - 23.5]
21.3
[17.3 - 25.4]
18.8
[14.4 - 23.2]
Were never taught about 15.9
AIDS or HIV in school
[11.9 - 19.8]
16.4
[13.1 - 19.7]
27.1
[23.5 - 30.6]
23.1
[19.1 - 27.1]
I examined the potential influences or the direction of change (increase or
decrease) for the nine sexual risk behaviors, based on the enactment of CPS’ sexual health
education policy in 2008, by estimating the odds ratios and associated confidence
intervals (see Figure 1). Comparing the data from each of the three CPS YRBS cycles
administered post-enactment of CPS’ sexual health education policy to the data from the
2007 YRBS cycle (baseline), I found that the majority of the sexual risk behaviors were
relatively stable without significant changes over the 6-year timeframe. However, as I
expected from the prevalence estimates previously described, the likelihood of high
school students who drank alcohol or used drugs before their last sexual encounter and
who reported never being taught about AIDS or HIV in school increased. The likelihood
of Chicago high school students who drank alcohol or used drugs before their last sexual
encounter ranged between 1.5 and 1.8, indicating a possible association with
comprehensive sexual health education. Additionally, the likelihood of high school
students who reported never being taught about AIDS or HIV in school ranged from 1.1
to 1.9, again indicating a possible association with comprehensive sexual health
education. Further analyses to explore this association are described below.
Research Questions 2: Prevalence of Sexual Behaviors among Black/African-
American and Hispanic/Latino High School Students
To further explore the potential confounding effects of race/ethnicity, I performed
similar prevalence and odds ratio analyses stratified by Black/African American and
Hispanic/Latino high school students. Tables 2a and 2b show the prevalence rates for nine
sexual risk behaviors for Black/African American and Hispanic/Latino students,
respectively. Approximately 60% of Black/African American students reported ever
having sex, while Hispanic/Latino students who reported ever having sex was
approximately 50%. Conversely, approximately 28% of Black/African American students
did not use a condom during their last sexual intercourse encounter, in comparison to
47% of Hispanic/Latino students. Over the 6-year period for which I analyzed YRBS
data, the prevalence of the sexual risk behaviors were relatively stable for both
Black/African American and Hispanic/Latino students. Interestingly, and unlike with
other sexual risk behaviors, the prevalence rate associated with not using birth control
pills before the last sexual intercourse encounter to prevent pregnancy decreased from
94% in 2007, to as low as 85% in 2011 for Black/African American students. The
prevalence increased to 90% in 2013. For Hispanic/Latino students, the prevalence of
ever having sex decreased from 53.6% in 2007, to as low as 45% in 2013, and the
prevalence associated with having sex with 4 or more people during their life decreased
from 14.9% in 2007, to as low as 9.5% in 2013. These findings were consistent with odds
ratio the analyses shown in Figures 2a and 2b.
Table 2a
Prevalence of Sexual Behaviors among Black Students in Chicago, IL, Youth Risk Behavior
Survey 2009-2013
2007 (Baseline)
2009
2011
2013
Sexual Behaviors
%
95% CI
%
95% CI
%
95% CI
%
95% CI
Ever had sex
63.3
[57.0 - 69.6
60.2
[54.4 - 66.0]
59.9
[51.1 - 68.7]
65.9
[60.2 - 71.6]
Had sex before 13
15.6
[11.1 - 20.1]
16.5
[13.3 - 19.8]
16.2
[13.0 - 19.4]
15.0
[9.5 - 20.5]
Had sex with 4+ people in
life
22.0
[16.1 - 27.8]
25.2
[19.4 - 31.0]
22.8
[16.2 - 29.5]
27.0
[21.3 - 32.8]
Were currently sexually
active
47.8
[43.0 - 52.6]
42.3
[35.0 - 49.5]
45.2
[37.9 - 52.5]
48.1
[42.1 - 54.2]
Did not use a condom
24.1
[16.1 - 32.0]
28.9
[22.6 - 35.3]
29.7
[23.2 - 36.3]
39.3
[31.1 - 47.5]
Did not use birth control pills
94.1
[91.1 - 97.1]
89.8
[85.3 - 94.3]
85.4
[80.3 - 90.5]
90.0
[86.2 - 93.9]
Did not use any method to
prevent pregnancy
14.4
[8.7 - 20.1]
15.6
[9.2 - 22.1]
16.5
[9.7 - 23.4]
20.3
[11.8 - 28.7]
Drank alcohol or used drugs
before last sex
8.6
[4.5 - 12.7]
16.2
[11.1 - 21.3]
17.7
[12.6 - 22.7]
19.2
[13.0 - 25.5]
Were never taught about
AIDS or HIV in school
15.3
[9.6 - 20.9]
14.3
[10.3 - 18.4]
25.3
[20.1 - 30.5]
24.1
[16.2 - 32.0]
Table 2b
Prevalence of Sexual Behaviors among Hispanic Students at Chicago, IL, Youth Risk Behavior Survey
2009-2013
2007 (Baseline)
2009
2011
2013
Sexual Behaviors
%
95% CI
%
95% CI
%
95% CI
%
95% CI
Ever had sex
53.6
[47.9 - 59.3]
52.1
[45.3 - 58.8]
47.4
[41.8 - 53.0]
45.1
[40.1 - 50.2]
Had sex before 13
9.0
[4.8 - 13.2]
7.0
[3.2 - 10.7]
7.6
[5.7 - 9.6]
6.6
[4.3 - 8.8]
Had sex with 4+ people in
life
14.9
[10.9 - 19.0]
14.6
[10.2 - 19.1]
11.7
[9.0 - 14.3]
9.5
[6.2 - 12.9]
Were currently sexually
active
34.6
[28.6 - 40.6]
38.3
[31.9 - 44.7]
33.4
[28.7 - 38.1]
29.7
[24.2 - 35.2]
Did not use a condom
41.8
[30.1 - 53.4]
47.4
[38.8 - 55.9]
43.0
[36.6 - 49.3]
44.4
[38.6 - 50.2]
Did not use birth control pills
88.3
[81.2 - 95.4]
88.1
[82.6 - 93.5]
90.9
[87.4 - 94.5]
90.5
(86.2 - 94.7]
Did not use any method to
prevent pregnancy
18.3
[8.4 - 28.2]
20.8
[13.9 - 27.8]
18.6
[13.3 - 24.0]
18.3
[11.9 - 24.7]
Drank alcohol or used drugs 14.9
before last sex
[6.7 - 23.1]
21.4
[10.3 - 32.6]
21.7
[17.0 - 26.5]
17.2
[11.7 - 22.6]
Were never taught about 17.0
AIDS or HIV in school
[12.6 - 21.5]
19.0
[16.2 - 21.9]
26.8
[23.0 - 30.7]
25.1
[21.2 - 28.9]
As shown in Figures 2a and 2b, when the data from each of the three CPS YRBS
cycles administered post enactment of CPS’ sexual health education policy were
compared to the data from the 2007 YRBS cycle (baseline), the majority of the sexual
risk behaviors were relatively stable with odds ratios around 1. However, the likelihood
of not using birth control pills before the last sexual intercourse encounter decreased,
after the implementation of comprehensive sexual health education among Black/African
American students. The odds ratio ranged from .5 to .6. Similarly, the likelihood that
Hispanic/Latino students ever had sex and had sex with four or more people in their life
decreased to an odds ratio below 1 during the timeframe of 2009 to 2013.
Research Question 3- Prevalence of Sexual Behaviors among Female and Male High
School Students
I further explored the potential confounding effects of gender by estimating the
prevalence rates, odds ratios, and 95% confidence intervals, stratified by male and female
students. Table 3a and 3b show the prevalence of the nine sexual risk behaviors for
female and male students, respectively. As high as 5.8% of female students reported
having had sex before age of 13, while as low as 17% of male students had sex before age
13. Again, comparing the data from the three CPS YRBS cycles administered after the
enactment of CPS’ sexual health education policy, with 2007 indicated at the baseline
year, the prevalence of the sexual risk behaviors were relatively stable for male students.
However, for female students, different sexual behaviors exhibited variant patterns
after the implementation of comprehensive sexual health education. The prevalence rates
for some sexual risk behaviors, including ever having had sex, had sex before age 13, and
being currently sexually active, decreased after 2007. The prevalence for female students
who were currently sexually active decreased from 40.6% in 2007 to 33% in 2013. The
prevalence for female students who reported ever having sex decreased from 53% in
2007 to 45% in 2013. The prevalence of female students who reported having four or
more sexual partners decreased after 2007. However, there was a variance in the
prevalence from 2009 (9.6%), 2011 (10.5%), and 2013 (7.7%). Conversely, the
prevalence associated with never being taught about HIV or AIDS in school increased
from 12% in 2007 to 25% in 2011; a potential area of ambiguity that needs to be
addressed within the sexual health education policy. These findings were consistent with
the odds ratio analyses shown in Figures 3a and 3b.
Table 3a
Prevalence of Sexual Behaviors among Female Students at Chicago, IL, Youth Risk Behavior Survey 2009-2013
2007 (Baseline)
2009
2011
2013
Sexual Behaviors
%
95% CI
%
95% CI)
%
95% CI
%
95% CI
Ever had sex
53.0
[47.9 - 58.0]
45.3
[38.6 - 52.0]
45.7
[39.7 - 51.6]
45.0
[39.0 - 51.1]
Had sex before 13
5.8
[3.8 - 7.9]
5.1
[3.3 - 6.9]
4.2
[2.5 - 5.9]
3.0
[1.8 - 4.2]
Had sex with 4+ people in
life
10.7
[8.1 - 13.3]
9.6
[7.2 - 11.9]
10.5
[7.6 - 13.5]
7.7
[5.0 - 10.3]
Were currently sexually
active
40.6
[36.0 - 45.2]
35.5
[29.4 - 41.6]
33.4
[28.6 - 38.3]
33.4
[28.0 - 38.8]
Did not use a condom
36.5
[28.8 - 44.2]
42.4
[33.7 - 51.2]
40.2
[32.4 - 48.1]
48.1
[40.1 - 56.2]
Did not use birth control pills
88.5
[83.4 - 93.7]
88.8
[84.3 - 93.4]
87.2
[82.8 - 91.5]
88.9
[85.1 - 92.7]
Did not use any method to
prevent pregnancy
14.7
[9.3 - 20.1]
20.5
[14.4 - 26.6]
19.2
[13.6 - 24.8]
22.1
[16.3 - 28.0]
Drank alcohol or used drugs
before last sex
8.7
[4.2 - 13.3]
12.3
[7.7 - 16.9]
16.5
[12.6 - 20.5]
13.1
[7.4 - 18.7]
Were never taught about
AIDS or HIV in school
12.3
[8.0 - 16.6]
14.2
[11.6 - 16.8]
25.0
[20.6 - 29.5]
22.2
[17.2 - 27.1]
Table 3b
Prevalence of Sexual Behaviors among Male Students at Chicago, IL, Youth Risk Behavior Survey 2009-2013
2007 (Baseline)
2009
2011
2013
Sexual Behaviors
%
95% CI
%
95% CI
%
95% CI
%
95% CI
Ever had sex
61.9
[55.8 - 68.1]
61.9
[54.4 - 69.4]
60.3
[54.9 - 65.8]
59.6
[53.7 - 65.5]
Had sex before 13
18.7
[11.8 - 25.6]
18.4
[12.6 - 24.2]
21.5
[17.5 - 25.6]
17.1
[10.6 - 23.5]
Had sex with 4+ people in
life
27.4
[20.2 - 34.5]
29.0
[21.3 - 36.7]
26.3
[21.6 - 31.0]
26.4
[19.6 - 33.3]
Were currently sexually
active
38.7
[32.7 - 44.6]
43.0
[34.9 - 51.0]
43.3
[38.4 - 48.1]
40.7
[34.5 - 46.8]
Did not use a condom
26.4
[16.4 - 36.4]
29.0
[20.9 - 37.0]
30.8
[25.7 - 36.0]
29.7
[23.2 - 36.2]
Did not use birth control pills
93.2
[88.1 - 98.4]
89.0
(84.1 - 93.9]
89.1
[85.0 - 93.2]
89.9
[85.9 - 93.8]
Did not use any method to
prevent pregnancy
15.3
[7.1 - 23.4]
12.0
[7.0 - 16.9]
15.2
[8.8 - 21.5]
13.3
[8.3 - 18.3]
Drank alcohol or used drugs 17.4
before last sex
[9.7 - 25.1]
23.1
[15.1 - 31.1]
25.8
[20.2 - 31.5]
23.9
[17.9 - 30.0]
Were never taught about 19.7
AIDS or HIV in school
[13.4 - 26.0]
18.1
[12.9 - 23.3]
29.0
[25.0 - 33.0]
24.1
[19.7 - 28.6]
As shown in Figures 3a and 3b, when the data associated with gender from each
of the three CPS YRBS cycles administered post enactment of CPS’ sexual health
education policy were compared to the baseline data, the majority of the sexual risk
behaviors were relatively stable with odds ratio intervals overlapping 1 for male students.
However, for female students, there were four sexual risk behaviors with odds ratios
below 1, including ever had sex, had sex before age 13, had sex with four or more people,
and being currently sexually active.
Summary
In summary, my analyses of the prevalence and odds ratio suggested a complex
pattern for the nine sexual risk behaviors of Chicago high school students, before and
after enactment of CPS’ comprehensive sexual health education policy. The prevalence
for some of sexual risk behaviors increased after comprehensive sexual health education
was implemented, possibly challenging the promotion of safe and healthy sexual
behaviors. The decrease of sexual risk behaviors over the years suggested an influence
and benefit of comprehensive sexual health education in schools. In addition,
race/ethnicity and gender were important confounding factors that appear to have
influenced the prevalence for some of the sexual risk behaviors.
Chapter 5: Discussion, Conclusions, Recommendations, and Future Research
Introduction
The purpose of this correlational study was to explore the statistical relationship
between the consistent implementation of comprehensive sexual health education, before
and after the enactment of CPS’ sexual health education policy, and the sexual risk
behaviors of Chicago high school youth in grades 9–12. I analyzed sexual risk behavior
data obtained from the CDC’s YRBS and collected during the administration of CPS’
2007, 2009, 2011, and 2013 YRBS cycles. In this chapter I provide a summary of the
study and then: (a) discuss the findings and my interpretation of the results, (b) identify
the study’s limitations, (c) make recommendations for future research, and (e) offer a
conclusion to the study.
Findings from this study indicated a complex pattern of sexual risk behaviors
among Chicago high school students in grades 9–12 before and after implementation of
the comprehensive sexual health education policy. According to my analysis of data from
the four YRBS cycles (2007, 2009, 2011, and 2013), the prevalence of sexual behaviors
remained relatively stable. However, I found that the prevalence for some of the sexual
risk behaviors increased after the mandatory implementation of comprehensive sexual
health education. The prevalence of students who reported drinking alcohol or using
drugs before their last sexual encounter increased from 12.5% in 2007, to 18.8% in 2013.
Although, comprehensive sexual health education was mandated beginning in 2008, the
prevalence of students reporting never being taught about AIDS or HIV increased from
15.9% in 2007, to 23.1% in 2013.
I conducted analyses to explore the influence of confounding factors by
race/ethnicity and gender. Analyses I performed to explore the sexual risk behaviors of
Black/African American and Hispanic/Latino students showed that the sexual risk
behaviors of Black/African American and Hispanic/Latino students remained relatively
stable. However, the prevalence of not using birth control pills before the last sexual
encounter to prevent pregnancy among black students decreased from 94% in 2007, to
85% in 2011. Although the prevalence increased in 2013, the odds ratio remained below
1, indicating a positive influence and benefit of comprehensive sexual health education in
schools. Among Hispanic/Latino students, the likelihood of ever having had sex and
having four or more sexual partners decreased and resulted in an odds ratio below 1.
These analyses found that the implementation of comprehensive sexual health education
influenced the sexual risk behaviors of females. Specifically, the odds ratios for: (a) ever
had sex, (b) had sex before age 13, (c) had four or more sexual partners, and (d) currently
sexually active were less than 1. These results indicated a possible significant association
between comprehensive sexual health education and decreases in sexual risk behaviors.
The decrease of sexual risk behaviors over the years indicates an influence and benefit of
comprehensive sexual health education in schools. Race/ethnicity and gender were
important confounding factors that appear to have influenced the prevalence for some of
the sexual risk behaviors.
Interpretation of the Findings
High school students often engage in behaviors that place them at risks, whether
knowingly or unknowingly (CDC, 2014a). Additionally, the prevalence of many risk
behaviors varies by race/ethnicity, gender, geographic location (e.g. urban versus rural
school districts), and grade (CDC, 2014a). Consequently, results from CDC’s 2015
national YRBS indicated that high school students engaged in risk behaviors that were
associated with the leading causes of death among persons aged 10–24 years (CDC,
2016).
In this study, I explored the statistical relationship between the consistent
implementation of comprehensive sexual health education, before and after the enactment
of the CPS’ sexual health education policy in 2008, and the sexual risk behaviors of
Chicago high school youth in grades 9–12. My interpretation of the study finding are
presented below and arranged by research question. Data analysis results indicated that
there were variances across the different sexual risk behaviors among Chicago high
school youth in grades 9–12. These variances can be attributed to the diverse composition
of the CPS student population.
Over the 6-year period (2007–2013) for which I analyzed YRBS data, the
prevalence of the sexual risk behaviors remained relatively stable. However, there was a
notable increase in Chicago high school youth who reported drinking alcohol or using
drugs before their last sexual encounter and who reported they were never taught about
AIDS or HIV in school—from 12.5% in 2007 to 18.8% 2013 and 15.9% in 2007 to
23.1% in 2013, respectively. Kirby’s review of 115 sex education programs scientifically
supported research findings and showed a delay in the initiation of sex, the number of
sexual partners, and increased use of condoms during sexual intercourse (Advocates for
Youth, 2012; FoSE, 2012; CDC, 2009; Kirby, 2007). However, Kirby did not detail
specifics associated with the correlation between sexual risk behaviors and drug use, an
emerging concern of sexual health education professionals (Clayton, Lowry, August, &
Jones, 2016).
Atkins and Bradford (2013) conducted a study utilizing YRBS data for 39 states to
estimate the impact of state-level sex education policies. They used the demographic data
of the students to examine the relationship between sexual health education and sexual
risk behaviors of youth. The researchers found that states that required sexuality
education and contraceptive content, or states that mandated education but left the content
to the discretion of the local school districts, had higher rates of contraception use among
teens that were sexually active. When I analyzed data for all high school youth, the
reported use of contraception (i.e., condom use or use of birth control pills) remained
relatively stable from 2007 to 2013. However, when looking at the findings stratified by
race/ethnicity, I observed a noticeable decrease. More specifically, the prevalence rate
associated with not using birth control pills before the last sexual intercourse encounter to
prevent pregnancy decreased from 94% in 2007 to as low as 85% in 2011 for
Black/African American students. The prevalence rate associated with not using birth
control pills before the last sexual intercourse encounter to prevent pregnancy, however,
increased to 90% in 2013. For Hispanic/Latino students, the prevalence of ever having
sex decreased from 53.6% in 2007, to as low as 45% in 2013, and the prevalence
associated with having sex with four or more people during their life decreased from
14.9% in 2007, to as low as 9.5% in 2013.
A review of 62 CRR interventions by CDC’s Community Preventive Services
Task Force (2009) showed that the most effective programs to promote behaviors that
reduce risk of becoming pregnant and preventing STDs and HIV are comprehensive
programs that include a focus on delaying sexual behavior and provide information on
how sexually active adolescents can protect themselves. My analyses of sexual risk
behaviors stratified by gender, further supported existing research associated with the
effectiveness of comprehensive sexual health education. The prevalence for female
students who were currently sexually active decreased from 40.6% in 2007, to 33% in
2013. The prevalence for female students who reported ever having sex decreased from
53% in 2007, to 45% in 2013. The prevalence of female students who reported having
four or more sexual partners realized an overall decrease after implementation of CPS’
sexual health education policy in 2008. However, there was a variance in the prevalence
from 2009 (9.6%), 2011 (10.5%), and 2013 (7.7%). Conversely, the prevalence associated
with never being taught about HIV or AIDS in school increased from 12% in 2007 to
25% in 2011; a potential deficit of the current sexual health education policy.
When comparing the data associated with gender across the three YRBS cycles to
the 2007 baseline data, I found that the majority of the sexual risk behaviors were
relatively stable with odds ratio intervals overlapping 1 for male students. For female
students, there were four sexual risk behaviors with odds ratios below 1, including ever
had sex, had sex before age 13, had sex with four or more people, and being currently
sexually active. Trenholm, Devaney, Fortson, Clark, Quay and Wheeler (2008), examined
the impacts of four abstinence-only education programs on adolescent sexual activity,
risks of pregnancy, and STDs. The findings from this study showed no significant impact
on teen sexual activity, no differences in rates of unprotected sex, and some impact on
knowledge of STDs and perceived effectiveness of condoms and birth control pills.
Trenholm et al. (2008) found that youth in the program group were no more likely than
those in the control group to have abstained from sex. The study also showed that if youth
in the program group engaged in sex, they had similar numbers of sexual partners as
those in the control group. The stability in the rates of Chicago high school youth who
engaged in various sexual risk behaviors indicated that there was not a significant
association between comprehensive sexual health education and the sexual risk behaviors
of high school youth.
Consistent with the literature in support of comprehensive sexual health education
or abstinence plus programs, the results from this study showed variances in the influence
of comprehensive sexual health education on the sexual risk behaviors of youth.
Additionally, expansion of comprehensive sexual health education programs may be
warranted to address the multiple confounding factors that influence youth behaviors
including race, ethnicity, gender, and socioeconomic status (Benzaken, Palep, & Gill,
2011).
Limitations of the Study
In this study, I used survey research which provided an optimal method for
collecting standardized data about the sexual risk behaviors of high school students in
relation to the implementation of comprehensive sexual health education as mandated by
district policy in Chicago. While the results were representative of high school students in
the CPS system, and the sample was large enough to assure the results were valid and
generalizable, there were some limitations to this study.
• A secondary data source was used; therefore, there was no control over the
development of the instrument used to collect data and the data collection
processes.
• The data collected were limited to students who were in attendance at school
during the timeframe in which the survey was administered and, therefore, not
representative of all persons in the high school age group.
• The data collected were representative of all CPS high schools and did not allow
for the comparison of prevalence rates by school or geographic location within
CPS. Thus, the differences in curriculums utilized for the instruction of sexual
health education may have inadvertently influenced the relationship between the
implementation of sexual health education programs and the sexual risk behaviors
of high school youth in grades 9–12.
• The sexual health education policy was enacted in 2008; however, it does not take
into account the availability of professional development to provide guidance on
how to teach comprehensive sexual health education.
• The lack of a specified mandated sexual health education curriculum may have
inadvertently influenced the relationship between implementation of sexual health
education programs and the sexual risk behaviors of youth in grades 9–12.
• The policy may have been subject to the interpretation of the school administrator
(e.g., principal) responsible for approving the curricula.
Recommendations
Although the research found that comprehensive sexual health education
positively influenced some sexual risk behaviors of youth, questions and challenges still
remain. For example, this study focused on Chicago high school youth in grades 9–12.
However, additional research to explore grade as a confounding factor on the sexual risk
behaviors of youth is recommended. Data analyses of the sexual risk behaviors of
students as they matriculate through high school may help to inform the enhancements to
existing policies and the development of new policies that serve as the foundation for
comprehensive sexual health education programs.
I found that the majority of the sexual risk behaviors were relatively stable with
odds ratio intervals overlapping 1, when data for all students and male students were
analyzed. However, I also found that the sexual risk behaviors for females exhibited a
variant pattern after the enactment of the sexual health education policy. Learning style is
defined as the manner in which learners most efficiently and effectively perceive,
process, store, and recall what they are attempting to learn (Choudhary, Dullo, & Tandon,
2011). The variances in the sexual behaviors among female students suggest potential
differences in the learning styles among males and females. Therefore, I recommend that
CPS standardize the sexual health education curriculum being used in all high schools to
ensure students receive consistent and standardized information. Secondly, it is
recommended that consideration be given to the style in which the sexual health
education materials are presented to students. Additionally, future research to explore the
correlation between a coordinated multi-pronged approach to the delivery the sexual
health education curriculum and the sexual risk behaviors of specific subsets of students
(e.g., race, ethnicity, and/or gender) is recommended.
Sexual risk behaviors at a young age often have a lasting impact. I found that the
implementation of comprehensive sexual health education, influenced some of the
behaviors of high school youth. However, the enactment of sexual health policy at the
district level does not automatically translate to standardized implementation in schools
throughout the district. Based on the findings from this study, the prevalence of Chicago
high school youth who were never taught about AIDS or HIV increased post enactment of
CPS’ sexual health education policy in 2008. Therefore, I recommend future research be
conducted to explore school administrators’ (e.g., principals) perspectives, interpretations,
and influence on the implementation of mandated comprehensive sexual health
education.
Additionally, both the researchers responsible for the most recent national 2015
YRBS data (CDC, 2016) and I found that the majority of sexual risk behaviors remained
relatively stable since 1991. However, a quadratic trend showed increases in some sexual
risk behaviors (e.g., lack of condom use, nonmedical use of prescription drugs) have
occurred (Clayton, Lowry, August, & Jones, 2016; CDC, 2016). I recommended that
additional research be conducted to explore the scaling up of comprehensive sexual
health education. The scale-up of comprehensive sexual health education includes
standards for professional development, enactment of effective local and state policy to
guide the implementation of comprehensive sexual health education, and embedding
substance use prevention interventions into sexual health curriculum. In this study, I
reported a distinct increase in students who reported drinking alcohol or using drugs
before their last sexual encounter increased, from 12.5% in 2007 to 18.8% in 2013 among
all Chicago high school students.
Implications for Positive Social Change
The outcomes from this study have significant implications for positive social
change and indicate the need for legislators and school district leaders to increase support
for the enactment of comprehensive sexual health education policy that will help mitigate
the sexual risk behaviors of high school youth through the implementation of
standardized comprehensive sexual health education. Additionally, the results from this
study will contribute to the existing literature by informing how inequities experienced by
youth may influence the sexual risk behaviors they engage in. The health inequities
experienced by youth can be addressed as part of a comprehensive health education
program that is inclusive of standardized comprehensive sexual health education.
Research such as, the study described in this paper, have significant implications
for social change, in its ability to directly inform policies and programs geared towards
developing sexually healthy and well-rounded youth and decreasing the sexual risk
behaviors that often result in morbidity or mortality. By conducting this study, I was able
to demonstrate the correlation between the implementation of comprehensive sexual
health education as mandated by established policy and the sexual risk behaviors of high
school youth. Furthermore, through this research, I am able to provide additional insight
and suggest that there are additional influences, such as, gender and race/ethnicity, among
others, that are associated with the sexual risk behaviors of Chicago high school youth.
The implications for social change directly inform the enactment of comprehensive
sexual health education policy that will help mitigate the sexual risk behaviors of high
school youth and promote the implementation of standardized comprehensive sexual
health education.
Positive social change supports the implementation of significant alterations over
time in behaviors, cultural values, and norms. Comparatively, the theoretical foundation
for this study, salutogenic model, is based on the premise of salutogenesis. Salutogenesis
is the study of health development; creating, enhancing, and improving the physical,
mental, and social well-being (Becker, Glascoff, & Felts, 2010). The correlation between
positive health outcomes at the individual (high school youth), organizational (schools),
and population (state and local policy) levels emphasizes the importance of a structured
environment and people are encouraged to identify and use the resources available to
them to promote the health of the individual, community, and the nation (Mittlemark &
Bull, 2013; Lindstrom & Eriksson, 2009).
The practical significance of this study directly aligned with the statistical
significance, in that based on the results, I suggest the need to further explore the
influences of comprehensive sexual health education on the sexual risk behaviors of
youth. Human sexuality is unique to each individual and influenced by several factors,
including, socio-economic, cultural, and environmental factors (Benzaken, Palep, & Gill,
2011). Youth are a product of and deeply influenced by their environments (StrangerHall
& Hall, 2011). Based on the findings of this study, I recommend that local and state
legislators and CPS district administrators review the revised sexual health education
policy to: (a) ensure adherence with established guidelines that promote the development
of well-rounded sexually healthy youth, (b) ensure the policy appropriately responds to
health inequities experienced by youth of diverse backgrounds, and (c) ensure the policy
supports ongoing assessment and enhancements that address emerging behaviors (e.g.,
nonprescription drug use) as supported by research.
Conclusion
The literature was replete of studies documenting the effectiveness of schoolbased
sexual health education on helping youth reduce their risk for pregnancy, HIV, and STDs.
However, the purpose of this correlational study was to explore the statistical relationship
between the consistent implementation of comprehensive sexual health education, before
and after the enactment of CPS’ sexual health education policy, and the sexual risk
behaviors of Chicago high school youth in grades 9–12 via the analysis of YRBS data
collected by CPS between 2007 and 2013. Healthy public policy merges together the
spectrum of risk factors, protective factors, and promotion factors into a holistic model
that is focused on proactivity versus reactivity (Lindstrom & Eriksson, 2009). The
emphasis is on health promotion, which ignites control of personal health and
determinants of health, thereby informing overall quality of life (Bengt & Eriksson,
2009).
Through my research, I intended to further inform CPS’ new sexual health
education policy, which was adopted in 2013 and is scheduled to be fully implemented in
2016, and assist lawmakers with further defining public policy to support the
standardization of comprehensive sexual health education. Access to comprehensive
sexual health education that addresses the socio-cultural, biological, psychological, and
spiritual dimensions of sexuality by providing information; exploring feelings, values,
and attitudes; and developing communication, decision-making, and critical-thinking
skills is perceived to be a right of all people, including adolescents at various ages
(SIECUS, 2012). According to Lindstrom & Eriksson (2009), “public health has taken on
the challenge to establish co-operation between different sectors in society” (p. 17) in an
effort to make health an issue for society as a whole. Comprehensive sexual health
education is a shared responsibility of government, parents, community, school
administrators, and teachers and requires the attention of everyone to support the
development of sexually healthy youth.
