Editorial

The State of Sex Education in the United States

Integrating digital technologies into sexual health education can offer advantages for connecting with adolescents, particularly populations who may be underserved through common school-based approaches. This study assessed the effectiveness of In the Know, an in-person, group-based sexual health education program integrating digital technologies, codesigned with adolescents.

The study design was a cluster randomized trial with 1,263 adolescents aged 13-19 in 95 cohorts, implemented in community-based organizations and schools throughout Fresno County, California. Participants completed a baseline survey and a follow-up survey 3 months later. Two-level mixed-effects regression models with random intercepts for cohort were used to estimate the intervention's impact on unprotected sex, use of clinical health services, knowledge of local sexual health services, technology use to find or schedule services, and sexual health knowledge at the 3-month follow-up.

The average age of participants was 15.7 years, and the majority identified as Hispanic (71%). In adjusted analyses, intervention group participants were more likely to use clinical services (42.7% vs. 33.2%, p = .009) and reported greater sexual health knowledge at 3 months (57.6% of items answered correctly vs. 50.7%, p = .001). No significant differences were observed in the other outcomes by study group.

In the Know participants demonstrated greater use of clinical health services and sexual health knowledge at 3 months. The study findings show the potential for incorporating user-centered design and technology into sexual health education to better support adolescents who may have limited access to this important information.

Youth face barriers to sexual and reproductive health (SRH). Few states require the delivery of comprehensive sex education in schools, and youth report challenges with accessing clinical care. We sought to identify youth's perceived barriers and facilitators to SRH in their communities.

We utilized photovoice, a community-based participatory research methodology. Youth were recruited from high schools in Baltimore, Maryland. Participants were given a tutorial on Photovoice methodology and photography. In groups of 5–7 participants, youth brainstormed questions relevant to their perspective of SRH. Three months were allocated to taking photographs. Participants wrote brief narratives to accompany their photographs, and group level assessment was used for participants to comment on others' photographs. Participants discussed the narratives and comments, created themes, and generated action steps to address barriers to SRH. Further thematic analysis was conducted using NVivo.

There were 30 participants aged 14–19 years with 26 self-identifying as female and four nonbinary. Self-identified race/ethnicity included 50% Black/African American, 30% Asian American, and 20% White or Hispanic/Latino. Four domains emerged: desire for societal-level change, community-level change, peer-level change, and positive examples of SRH within their communities (e.g., gender-inclusive spaces and free menstrual products).

Youth photographs shed light on a strong desire for an improved school environment, in terms of safety, cleanliness, gender-inclusivity, menstrual product access, and SRH education.

Mobile technology allows delivery of sexual and reproductive health (SRH) information directly to youth. We tested the efficacy of Crush, a mobile application aimed at improving sexual health by promoting the use of SRH services and contraception among female adolescents.

We recruited 1,210 women aged 14–18 years through social media advertising and randomized them into a Crush intervention group and a control group that received a wellness app. At 3 and 6 months post randomization, we compared changes from baseline in behaviors, attitudes, self-efficacy, perceived social norms, birth control knowledge, perceived control and use intentions, and SRH service utilization. Odds ratios were estimated with multivariable logistic regression and adjusted for baseline outcome, age, race/ethnicity, mother's education, and sexual experience.

There was no difference in accessing SRH services according to study group. Three months post baseline, Crush users had higher odds (p < .05) than control participants of reporting confidence in accessing SRH services (adjusted odds ratio [aOR] = 1.6, 95% confidence interval [CI]: 1.1–2.3) and of believing that it is a good thing to use birth control consistently (aOR = 2.3, 95% CI: 1.4–3.8). Six months after baseline, Crush users had higher odds than control participants of reporting they can control whether birth control is used every time they have sex (aOR = 1.8, 95% CI: 1.2–2.6) and perceiving they would get pregnant if they did not use birth control (aOR: 1.5, 95% CI: 1.1–2.2). Impacts on other behavioral constructs were also found.

Crush was associated with improvements in knowledge, attitudes, and self-efficacy related to key SRH behaviors and may be a strategy to deliver SRH education to adolescent women. Studies including larger numbers of sexually active adolescents are needed to demonstrate behavioral impacts.