Description of the intervention
The training model is based on best practices for a Comprehensive Sexuality Education. CSE is built on a framework of rights; it aims to provide adolescents with knowledge, skills, attitudes and values that allow them to enjoy their physical and emotional sexuality on an individual level and in their relationships. CSE views sexuality in a holistic manner, as an integral part of adolescents’ emotional and social development. It recognizes that information alone is not enough; sexual education should provide the opportunity to acquire essential life skills and develop positive attitudes and values towards sex [23]. CSE was implemented in Mexican public schools in two stages. The first focused on teachers and the second on students.
The first stage consisted of two phases. In the first phase, we defined objectives, designed the content and prepared evaluation instruments. In the second phase, teachers were invited to participate in training through the Institute of Basic Education of the State of Morelos (IEBEM). The training workshop was held to improve teachers’ knowledge and skills in CSE for adolescents. The workshop lasted 3 days and focused on four theoretical-methodological axes, which are defined by the following concepts and content: 1) Gender perspective, which distinguishes the differential characteristics, attitudes and behaviors that society attributes to men and women that must be recognized in order to achieve equity [24] (Gender and its expressions in the community, expectations and life-plans, gender inequalities, empowerment, assertive communication); 2) Adolescence and sexuality, which refers to the period of life between 10 and 19 years when sexuality is explored [25] (sexual debut, mythos in sexuality, sexually transmitted infections, Internet and appropriate information sources); 3) Teenage pregnancy and responsible sexuality, which refers to pregnancies during ages 10 to 19 and the responsibility that adolescents must assume when exercising their sexuality [26] (anatomy of pregnancy, implications of teenage pregnancy, sexual self-care); and 4) Teenage contraceptive methods, which focuses on adolescents’ right to know about contraceptive methods and how to use them [12] (contraceptive methods, advantages and disadvantages). The workshop was developed using participatory and innovative methodology with a Gestalt philosophy that included reflection and discussion of each topic [25]. On the basis of the teachers’ tacit knowledge (knowledge embedded in the human mind through experience and jobs) [26] in each theme, a reflective process was carried out and misconceptions and myths were identified. A technique was developed to facilitate teacher-student communication, so that the teacher could learn how to use it and replicate it in class. The workshop facilitators were expert researchers in the subject, knowledgeable about assertive communication skills, and had work experience with teenagers. At the end of the workshop, each teacher was given a kit of materials (electronic folder with the themes developed in the workshop, a flip chart, a poster and leaflets).
The second stage also had two phases. In the first phase, the trained teachers selected the order in which the themes they learned in the workshop (from all four theoretical-methodological axes) would be taught in the classroom (35–40 adolescents from second and third secondary grade). All the topics were addressed in 24 sessions. The methodology employed in each session was diverse, using questions that adolescents proposed and cases that described their sexuality problems, as well as theatrical performances or fairs. Regardless of the technique used, each topic began with a reflection process to recognize positive and negative aspects. Each discussion developed according to the adolescents’ knowledge, while teachers clarified erroneous ideas and myths. To close, teachers and students identified healthy behaviors they should adopt. The teachers covered the themes in the classroom for an average of 8 months, in weekly sessions of 1 h (a total of 24 sessions). In the second phase, the evaluation was performed. At the end of the school year, students who received CES in intervention schools and students from comparison schools were selected to answer a questionnaire. The comparison schools used traditional public-school sex education (TSE) [27], which is requiered for all students in all schools in Mexico. Exceptions are only made for students whose parents have requested exemption due to cultural or religious reasons. The themes in the school curriculum are adjusted according to grade level, although the topics are discussed at the teacher’s discretion. Classes are usually given 1 h a week for an average of 8 months. The themes are oriented towards the anatomy of sexual organs and the use of contraceptives.
Population and sample
The intervention was designed for teachers and students in second and third grade in public secondary schools in Morelos, Mexico. It was carried out during October 2015–June 2016. For the intervention, 45 schools were randomly selected and 45 for comparison schools. Technical secondary schools are similar to general secondary schools; however, technical secondary emphasizes technological education, according to the economic activity of each region (agriculture, fishing, forestry or services), both in rural and urban communities. Tele secondary is an educational option for communities of less than 2500 inhabitants.
To participate in training of CSE, two teachers who taught sex education were randomly selected from each intervention school. The sample of students who received training in CSE was estimated at 693 (from 3540 students in intervention schools) and for students who received TSE, 738 (4329 students from comparison schools). The questionnaires were answered by randomly selected students in both intervention and comparison schools (Fig. 1).
Outcomes
For teachers, the outcome was knowledge of comprehensive sexuality education, which includes knowledge of gender, adolescence, pregnancy prevention, contraceptive use and sexually transmitted diseases. For adolescents, the outcome was sexual debut, which was measured by self-report of their first sexual intercourse.
Evaluation design
The change in the knowledge of the trained teachers was evaluated before and after the workshop. We used the questionnaire by the Mexican Foundation for Family Planning, made up of 22 questions [28]. It explored the perspective of gender equality, adolescence and sexuality, teenage pregnancy, responsible sexuality and contraceptive methods. Additionally, it included sociodemographic information like age, sex, the teacher’s main duty (teaching, principal or assistant principal), and type of school (general, technical or tele secondary). The answers to the questions were multiple choice and only one answer was correct; where 0 = incorrect and 1 = correct. The score obtained by each teacher was transformed into a 10-point scale; the score for each methodological axis was multiplied by 10 and divided by the maximum possible score of each methodological axis. To estimate the global score, we added up the scores obtained in all methodological axes, multiplied by 10 and divided by the maximum possible score (twenty two). We classified the score between 0 and 5 as: inacceptable, 5.1–6: regular, 6.1–7: acceptable, 7.1–8: very acceptable, and 8 or more: excellent.
For students, to estimate the effect of CSE, we measured sexual debut as 0 = if the first sexual intercourse occurred more than 6 months prior to the time of answering the questionnaire and 1 = if the first sexual intercourse occurred less than 6 months prior. We applied a questionnaire with 20 items that included sociodemographic variables and explored their reproductive knowledge (gender differences, ITS, Knowledge of contraceptive methods, social effect of pregnancy) and sexual behavior (sexual debut, use of contraceptive in the first and last sexual interaction). The questions to explore reproductive knowledge were multiple choice, e.g. what is the recommended method that provides double protection against pregnancy and sexually transmitted infections? 1 = Abstinence, 2 = Intrauterine device, 3 = Condom, 4 = Hormonal method 5 = I don’t know. The questions to explore sexual behavior were dichotomous, e.g. did you use contraceptive methods during your sexual interaction? 1 = yes 2 = not. The instrument was applied at the end of the school year to both intervention and comparison schools after they had received orientation and counseling in sexual education.
Data collection
Teachers answered the self-administered questionnaire electronically on a computer provided by the research team before and after the workshop. At the end of the school year, the students received the questionnaire in their e-mails. After answering it, their responses were linked to the google docs platform. The questionnaires from teachers and students were answered anonymously.
Analysis of information
Teachers’ overall knowledge was estimated with the sum of correct answers. The average level of knowledge about the four theoretical-methodological axes was also estimated. Descriptive statistics were estimated for all study variables (percentages, means, medians and confidence intervals). To analyze differences by sex, the Cohen Chi2 test was used. To estimate the change in teacher knowledge, the paired Student t-test was used when the scores presented a normal distribution. The Wilcoxon rank sum test for paired data was used when the distributions did not have a normal distribution. We fit a Generalized Estimation Equations model with mixed effects to analyze the characteristics associated with the change in the overall rating. The model was adjusted considering the effect of conglomerates at the school level.
Sociodemographic information, knowledge and reproductive behavior was reported for students. To compare the percentages between intervention and non-intervention schools, the Cohen Chi2 statistic was used. We fit a logistic regression model using sexual debut as the dependent variable and used age, sex, school grade and type of school as covariates. Robust variance estimators were calculated by adjusting for the cluster effect at the school level.
Ethical considerations
The Ethics and Research Committee of the National Institute of Public Health of Mexico (record number 767) approved this project and authorized verbal informed consent for all informants. Therefore, we requested verbal consent from teachers, parents of minors (under the age of 18), and adolescents. Only those informants who freely agreed to participate were included in the study.
