ARCHIVED - Canadian Guidelines for Sexual Health Education

Theory and Research in Sexual Health Education

Sexual health education can range from public health messages that provide basic information to comprehensive interventions with precise behavioural objectives. While most forms of sexual health education have potential benefits, many are still missing the main elements needed to effectively address the diverse sexual health needs that may be relevant to Canadians.

Research continues to make progress in distinguishing the essential elements required to develop more effective sexual health education programs that can meet the needs of its intended audience(s) and that can appropriately contribute to the reduction of negative sexual health outcomes. The approach to sexual health education presented in the Canadian Guidelines for Sexual Health Education is supported by such research. It demonstrates the importance and encourages the incorporation of current research and evaluation as the basis for further development of sexual health education programs and policy.

Programs that are exclusively directed at increasing the knowledge of an individual are often successful in reaching this objective. Although useful in this regard, focusing only on providing factual information about sexual health may not be sufficient or effective in reducing negative sexual health outcomes. While an individual exposed to this type of educational programming may possess a high level of sexual health knowledge, it is unclear whether that knowledge will translate into behaviours that can enhance sexual health.

Theoretical Models to Guide Effective Sexual Health Education

Theoretical models derived from research enable program planners to determine the teaching methods that most effectively result in behaviours that will enhance sexual health. In the case of STI/HIV prevention, one of the characteristics of nearly all effective interventions is the incorporation of theoretical models that are well supported by a body of research and that effectively encourage sexual health promotion and behavioural change.

In the process of creating and implementing sexual health education programs, it is important for program planners and policy-makers to rely on well-tested and empirically supported theoretical models as a foundation for sound program development.

Several theoretical models meet these standards and can be used to develop programs consistent with the Canadian Guidelines for Sexual Health Education. Examples of models which have provided the theoretical basis for behaviourally effective programs include the Social Cognitive Theory, Transtheoretical Model, Theory of Reasoned Action & Theory of Planned Behaviour, and Information, Motivation and Behavioural Skills (IMB) Model. A brief summary of these models is provided on the following below.

• Social Cognitive Theory

  Evaluation research indicates that health interventions informed by the Social Cognitive Theory (SCT) can help to positively modify an individual’s behaviour in a number of domains including STI/HIV prevention. ^{Reference Number 2424, Reference Number 2828}

  The Social Cognitive Theory ^{Reference Number 2929} states that people learn from one another by observation, imitation and modelling. The theory provides a framework for understanding, predicting and changing human behaviour. It identifies human behaviour as an interaction of:

  • personal factors (e.g., knowledge, understanding, expectations, attitudes, confidences),
  • behavioural factors (e.g., skills, practice, self-effi cacy), and
  • environmental factors (e.g., social norms, access in community, infl uence of others).

  Social Cognitive Theory can be applied to sexual health education in a number of ways. For example, a recent study applied SCT in an HIV prevention program for fathers and their sons. The program activities targeted fathers and were designed to promote the development of self-efficacy, positive expectations and intentions to discuss sexual topics with their sons. The program included relevant and current information about listening and communication skills, adolescent development, puberty, and HIV and STI risk-reduction practices. Consistent with SCT, it was found that developing an understanding about HIV and STI prevention practices among fathers and increasing their communication skills, resulted in more positive outcomes such as higher levels of self-efficacy in their sons’ decision making. ^{Reference Number 2727}

• Transtheoretical Model

  The Transtheoretical Model has also provided the basis for effective STI/HIV interventions. ^{Reference Number 3030, Reference Number 3232}

  This model considers behaviour change as a process rather than as an isolated event. According to the model, individuals participating in behaviour change interventions should be guided through a five-stage continuum ^{Reference Number 3333}:

  1. Precontemplation: little or no intention to change the behaviour in the near future;
  2. Contemplation: intention to change behaviour in the near future (e.g., within the next 6 months);
  3. Preparation: intention to take steps to changes (e.g., within the next month);
  4. Action: engaging in the health behaviour within the past 6 months; and
  5. Maintenance: consistent practice of desired health behaviour and working to prevent relapse (e.g., 6 months to 5 years).

  The transtheoretical model has been shown to have promise for use at an adolescent sexual health and STI/HIV clinic. In one study, having a supportive partner and being older in age made it more likely that the client would move forward through the stages of change. It was also noted that the transtheoretical model helped clinic staff to structure and personalize their counselling sessions. ^{Reference Number 3232}

• Theory of Reasoned Action & Theory of Planned Behaviour

  The Theory of Reasoned Action & Theory of Planned Behaviour is a well-tested model that has provided the theoretical basis for effective interventions targeting STI/HIV prevention ^{Reference Number 3434,} and condom use. ^{Reference Number 3535, Reference Number 3737}

  The Theory of Reasoned Action ^{Reference Number 3838, Reference Number 3939} is a theory that focuses on an individual’s intention to behave a certain way. This intention is determined by one or both of two major factors:

  • ATTITUDE – the individual’s positive or negative feelings towards performing a specific behaviour.
  • SUBJECTIVE NORM – associated with the behaviour. An individual’s perception of other people’s opinions regarding the defined behaviour will influence their behavioural intention.

  The Theory of Planned Behaviour ^{Reference Number 4040} is an extension of the Theory of Reasoned Action, which additionally considers that behavioural intention is a function of attitudes toward a behaviour, subjective norms toward that behaviour and perceived behavioural control, or the feeling that the individual can indeed perform the behaviour in question.

  A study guided by the Theory of Reasoned Action has demonstrated the theory’s applicability when targeting condom use in university students. The study found that students had greater intentions of using condoms when the educational intervention focused on: (1) positive attitudes towards condom use and their protective effect against STIs, including HIV, and also (2) students’ perceptions that their sexual partner(s) and peers were likely to approve of condom use. ^{Reference Number 3535}

• Information, Motivation and Behavioural Skills (IMB) Model

  Within sexual health education programs (including those informed by other models), evidence supports the inclusion of elements of information, motivation and behavioural skills. ^{Reference Number 4141} Information, motivation and behavioural skills are basic concepts that are easily understood by educators and program audiences. The Information, Motivation and Behavioural Skills (IMB) Model is well supported by research demonstrating its efficacy as the foundation for behaviourally effective sexual health promotion interventions. ^{Reference Number 4242, Reference Number 4444}

Integrating Theory into Practice: Utilizing the IMB Model

While there are a number of very good theoretical models that can be used in the development of sexual health education curriculum and programming, the Guidelines are based on the IMB model because there is significant empirical evidence which demonstrates the model’s effectiveness.

Evidence of the IMB model’s effectiveness in the area of sexual risk reduction has been demonstrated in a number of diverse populations including young adult men, ^{Reference Number 4545} low income women ^{Reference Number 4646, Reference Number 4747} and minority youth in high school settings. ^{Reference Number 4848} Furthermore, a meta-analysis strongly supports the need to include elements of information, motivation and behavioural skills in interventions that target sexual risk behavioural change. ^{Reference Number 4949}

Figure 2. The IMB Model

Note: Adapted from Fisher, W.A., & Fisher, J.D. (1998). Understanding and promoting sexual and reproductive health behavior: theory and method. Annual Review of Sex Research, 9,39-76.

The fundamental elements of sexual health education proposed by the Guidelines can be readily incorporated into an IMB model. Using the IMB model, sexual health education programs are based on the three essential elements:

• Information – helps individuals to become better informed and to understand information that is relevant to their sexual health promotion needs and is easily translated into action;
• Motivation – motivates individuals to use their knowledge and understanding to avoid negative risk behaviours and maintain consistent, healthy practices and confidences; and
• Behavioural skills – assists individuals to acquire the relevant behavioural skills that will contribute to the reduction of negative outcomes and, in turn, enhance sexual health.

The IMB model can help individuals to reduce risk behaviours, prevent negative sexual health outcomes and guide individuals in enhancing sexual health. Programs based on the three elements of model provide theory-based learning experiences that can be readily translated into behaviours pertinent to sexual and reproductive health.

Elements of the IMB Model

INFORMATION – For sexual health education programs to be effective, they need to provide evidence-based information that is relevant and easy to translate into behaviours that can help individuals to enhance sexual health and avoid negative sexual health outcomes.

Information included in sexual health education programs should be:

• Directly linked to the desired behavioural outcome and will result in the enhancement of sexual health and/or the avoidence of negative sexual health outcomes.

  Example: Acquiring information about how a specific form of birth control works, including how it is used effectively, how it may be paid for, how it may be discussed with a health care provider and with a partner, and information that is relevant to actual use of the method of contraception is essential for programs targeting pregnancy prevention. Acquiring such information may be directly linked to reducing cases of unintended pregnancies.

• Easy to translate into the desired behaviour.

  Example: Creating a directory of all local, easily accessible sexual and reproductive health centres may translate into a desired positive behaviour when it results in individuals identifying accessible, appropriate, user-friendly sexual health care resources and visiting such a health centre or clinic more frequently.

• Practical, adaptable, culturally competent and socially inclusive.

  Example: Programs targeting groups with diverse backgrounds must provide information that is clear, practical and situated within the social context and environment experienced by the target population. For example, a safer sex promotion program might identify risky behaviour–rather than membership in a sexual or ethnic minority–as the basis for the practice of prevention.

• Age, gender and developmentally appropriate.

  Programs should be tailored to meet the mental, physical and emotional needs of people at different ages and stages of their lives.

  Example: Programs targeting prevention of STI/HIV risk behaviours among adolescents with disabilities must take into account their unique needs.

MOTIVATION – Even very well informed individuals who have received sexual health information that is easy to translate into action need to be motivated sufficiently to act upon what they have learned to promote their sexual health. Accordingly, in order for sexual health education programs to achieve their goals, planners should address the motivational factors that are needed to bring about behavioural change.

Where sexual and reproductive health behaviours are concerned, motivation takes three forms:

• Emotional Motivation – An individual’s emotional responses to sexuality (the individual’s degree of comfort or discomfort with the issues surrounding sex and sexual health) as well as to specific sexual health-related behaviours, may heavily infl uence whether or not that individual takes the necessary actions to avoid negative sexual health outcomes and to enhance sexual health.

  Example: Men who have negative emotional responses to sexuality may be less likely to benefit from educational programs designed to encourage them to undertake a testicular self-examination.

• Personal Motivation – An individual’s attitudes and beliefs in relation to a specific sexual and reproductive health behaviour strongly predict whether or not that individual engages in that behaviour.

  Example: An individual who has strong negative feelings about a method of contraception (“condoms are awful because they reduce feeling,” “the pill is bad because it will make me gain weight”) are unlikely to adopt the method of contraception in question, unless they come to accept offsetting positive beliefs that alter their negative attitudes.

• Social Motivation – An individual’s beliefs regarding social norms, or their perceptions of social support pertaining to relevant sexual and reproductive health behaviours are also likely to infl uence behavioural change.

  Example: Individuals who are questioning their sexual orientation are more likely to seek out and speak openly in an environment they feel is supportive of all sexual orientations. In such a setting, they may realize that many individuals seek similar kinds of support and thereby be motivated to pursue information or services consistent with their needs.

BEHAVIOURAL SKILLS – Individuals should be aware of and acquire practice enacting the specific behavioural skills that are needed to help them adopt and perform behaviours that support sexual health.

While relevant information and motivation are essential elements infl uencing adoptionof behaviours that support sexual health, having appropriate behavioural skills to act effectively is also essential for behavioural change. This is why sexual and reproductive health skills training are key elements of effective sexual health education programs.

• Behavioural skills consist of the following:
  1. The practical skills for performing the behaviour (e.g., knowing how to negotiate); and
  2. The self-efficacy to do so (e.g., personal belief in one’s ability to successfully negotiate).

     Example: An individual who has been given information on how to use a condom, and is motivated to use it, must also have the technical skills to properly put it on, and the negotiation skills to get their partner to agree to use or to support the use of one.

Behavioural skills training for the prevention of STI/HIV and if applicable, unintended pregnancy, should include the skills to negotiate safer sex (e.g., condom use) as well as the ability and confidence to set sexual limits (e.g., to delay first intercourse). Behavioural skills for self-reinforcement and for partner-reinforcement for maintaining sexual health promoting behaviour over time is also critical in the long run.

Applying the IMB Model to sexual health education programs

A comprehensive application of the IMB model to sexual health education programs involves a basic three-step process:

ASSESSMENT AND PLANNING

• Identify the level of information, motivation and behavioural skills that the target population has related to specific health behaviours and outcomes. To assess this information, conduct focus groups, interviews or administer a survey questionnaire to a representative sub-sample of the target population.

  Example: In the assessment phase of a sexual health education program for pre-teens that includes the objective of delaying first intercourse, a sub sample of pre-teens may be selected to fill out a questionnaire to measure their:

  • knowledge related to the implications of first intercourse (Information);
  • attitudes and perceptions of peer pressure and social norms related to sexual activity (Motivation); and
  • skills as well as beliefs in their own ability to follow through on a decision to delay first intercourse (Behavioural skills).
• Make evidence-based decisions for program planning based on the current research, other program evaluations as well as assessment of need.
• Program evaluation is an integral part of program management. There are several types of program evaluation, both in the program planning and implementation stages. Program planners should consider conducting a needs analysis, and/or a feasibility study. Information from a needs analysis and a feasibility study will provide planners with information on the type of programming that is required, and if the program is appropriate in terms of timing, resources and audience. Program implementation evaluation consists of two forms: process and outcome evaluation. The purpose of process evaluation is to improve the operation of an existing program, and focuses on what the program does and for whom. The purpose of outcome evaluation is to assess the impact of a program, and focuses on examining the changes that occurred as a result of the program and whether it is having the intended effect.
• The plan for process and outcome evaluation should be built into the overall program plan, prior to its actual launch. This is especially important for outcome evaluation. In order to determine whether a program made a difference or not, there needs to be an understanding of how things were before the program was implemented (e.g., knowledge, attitudes, beliefs, etc).

INTERVENTION

• Design and implement the sexual health education program based on the assessment findings.
• For each target group, address where gaps exist in information, motivation and behavioural skills in relation to the program objectives and needs of the individual.
• Use assets that the group has in the area of information, motivation and behavioural skills. These assets should be used to reach program objectives.

  Example: The intervention phase of a sexual health education program is designed to increase the use of condoms among sexually active adolescents. This could fill knowledge gaps among the target group (Information), reinforce the group’s personal views about condom use and help them to personalize the risks of teen pregnancy and/or STI/ HIV (Motivation) and incorporate role playing exercises to help individuals learn how to negotiate condom use with sexual partners while also teaching them where to access free condoms (Behavioural skills).

EVALUATION

• Evaluation is required to determine if the program has had the intended effect on the target group’s information, motivation and behavioural skills in relation to the program objectives. Evaluation research enables program planners to identify strengths and weaknesses in the program so that, if necessary, modifications may be made to increase the program’s effectiveness. ^{Reference Number 50-5350-53}
• Evaluation should also include a mechanism to capture any unintended outcomes that emerge separate from the stated objectives of the program. Such unintended outcomes may also identify particular strengths and weaknesses in the program that are not revealed by an analysis of just the stated objectives.
• It is important for program planners to consider and address factors that can have an impact on the validity of the evaluation findings. When possible, the evaluation should include a control group to ensure that observed changes are actually the result of the program and not the result of external infl uences. Use of different types of measures can increase confidence in the evaluation data collected.

  Example: The evaluation phase of a sexual health education program focusing on cervical cancer prevention and screening might include the following steps:

  • At the beginning of the program, have participants fill out a questionnaire that assesses their knowledge of the prevalence, causes and preventive measures associated with cervical cancer (Information), their personal attitudes towards taking the necessary precautions to reduce their risk of cervical cancer (Motivation) and their perceived ability and skills to change risk behaviours and seek screening/ vaccination services to reduce the risk of cervical cancer (Behavioural skills).
  • The questionnaire should directly assess the occurrence and frequency of risk behaviours. In this case, the questionnaire would determine the participant’s level of behavioural risk for cervical cancer, whether the individual has received an HPV vaccine and whether they have been screened for cervical cancer and, if so, how frequently.
  • Randomly split individuals that have completed the questionnaire into two groups: a control group that does not receive the new sexual health education program and an intervention group that does.
  • As part of the evaluation process, re-administer the questionnaire to both groups after the program has been completed to measure the degree of effectiveness.
  • Identify parts of the program that require modification.
  
  

  Environments Conducive to Sexual Health

  The Guidelines identify “Environments Conducive to Sexual Health” as a fourth key element of sexual health education.

  A variety of environmental factors have been recognized as determinants of sexual and reproductive health. These include:

  • social and economic circumstances (e.g., income, education, employment, social status and social supports);
  • access to/knowledge of health services; and
  • community norms, values and expectations related to sexuality, gender identity, sexual orientation and reproduction. ^{Reference Number 5454}
• Programs based on the IMB model have the ability to infl uence sexual health promotion behaviour change. However, these programs must also address the infl uence of environmental factors on individual efforts to acquire and apply the knowledge, motivation and skills needed to maintain or enhance sexual health.

  Example: A study in Winnipeg found that teen birth rates were strongly related to socioeconomic status (the social and economic circumstances which include factors such as unemployment, high school completion and single parent households). The rate of teen births was over 13 times higher in the low socioeconomic status (SES) areas when compared to the high SES areas. ^{Reference Number 5555}

  Similarly, a geographic mapping study of census tracts in Toronto found that higher birth rates among teens and higher chlamydia and gonorrhea rates in young adults were associated with lower income. ^{Reference Number 5656} Income and access to services are only two of the many examples of the different ways in which the social environment, and particularly social inequality, can affect sexual health.

• International Comparisons. An in-depth international comparative study of adolescent sexual and reproductive health in five developed countries (Canada, United States, France, Great Britain and Sweden) has provided convincing evidence of the role of environmental factors in infl uencing sexual health. ^{Reference Number 5757}

  Example: Countries that scored high or very high in levels of economic equality, had access to reproductive health services and sexual health education, and used the media to promote responsible sexual behaviour were more likely to have lower teen pregnancy and STI rates compared to countries that scored low or very low on these indicators. Data collected for the Canadian component of the study suggested that in Canada, for both early teen pregnancies and STIs, rates vary by geographic region and economic status. Additionally, the age of first intercourse also varies by economic and social status as well as by region of residence. ^{Reference Number 58-6058-60,}

  In the United States a comprehensive review of research on teenage pregnancy found that environmental factors such as community disadvantage and disorganization, family structure and economic situation, as well as peer, partner and family attitudes towards sexuality and contraception are directly linked to determinants of adolescent sexual behaviour, use of contraception, pregnancy and attitudes toward childbearing. ^{Reference Number 6161}

• Media. The media, including television, movies, music, magazines and the Internet, have become an increasingly powerful force in communicating norms about sexuality and sexual behaviour. However, these messages are often barriers to the creation of environments conducive to sexual health.

  Example: Several studies have suggested that exposure to sexual content in the media is one of the many factors that may infl uence the timing of onset of sexual behaviours. ^{Reference Number 6262, Reference Number 6363} Effective sexual health education programming should address media messages and help individuals to evaluate critically what they see, hear and read in the mass media while simultaneously relating to diverse sexual norms and practices.

  Critical evaluation of the impact of the media, and of the environment that such information creates, should also be a key part of sexual health education in both the public and not-for-profit sectors.

• Community/Cultural Appropriateness. Research on program evaluation illustrates how sexual health education programs that are culturally appropriate and sensitive to community needs are more likely to be effective.

  Example: An effective STI/HIV risk reduction program for low-income women living in housing developments can be adapted to that environment by conducting elicitation research among its residents. This can also be done by identifying and using organizers within the housing developments as educators and by using housing development events as opportunities to provide effective sexual health education. ^{Reference Number 6464} Professionals who recognize that educational program participants are likely the most expert about what it might take to change their behaviour, might well turn to the participants and ask them what would have to happen in order for change to take place.