Background
School-based comprehensive sexual health education programs can successfully promote adolescent sexual health [
1,
2]. Evidence-based programs have been shown to delay sexual debut, reduce the number of lifetime sexual partners, increase condom use during sexual activity, and reduce sexually transmitted infections (STIs), teen pregnancy, and risky sexual behaviors [
1‐
3]. Despite these positive outcomes, sexual health programming in the USA remains inconsistent. Less than half of states require sexual health education to be taught in schools, and just 13 states require that the information taught be medically accurate [
4,
5]. Many schools are not required to implement evidence-based programs, and less than half of school districts provide professional development funding for teachers to support learning how to teach sexual health education [
6], which can result in inconsistent, inaccurate, and biased instruction.
The sexual health programming that is taught in secondary education seldom includes information beyond abstinence, contraception, and HIV/STIs [
5]. Topics such as healthy relationships, consent, dating violence, and gender role stereotypes all play a role in shaping adolescent sexual health and should be included in comprehensive sexual education programming [
7‐
17]. Adolescents who do not learn about healthy relationships or consent may be at increased risk for dating violence, sexual assault, and sexual abuse [
18,
19]; gender role expectations can influence youth decision-making to engage in risky sexual behavior and put gender minority youth at a greater risk for poor health outcomes [
9,
20]. Therefore, there is a need for comprehensive evidence-based programs for sexual and relationship health promotion among adolescents that can be implemented with fidelity in schools.
An important influence on adolescent sexual health that is often overlooked in sexual health education is media influence. Teens spend an average of 9 h a day using entertainment media [
21]. They are exposed to copious amounts of sexual content, which is often inaccurate, incomplete, and unhealthy [
22]. Media have been found to influence adolescent sexual attitudes, perceptions, and behaviors [
23], and can even act as a “super peer” during sexual identity development [
24,
25]. Exposure to sexually explicit material is linked to stricter gender role attitudes, more permissive sexual norms [
26], increased support for the objectification of women, increased acceptance of violence against women, rape myths, and sexual harassment [
23]. Youth exposed to sexual media are also more likely to report having had sex than youth who have little to no exposure [
27,
28].
Media literacy education (MLE) has been shown to be an effective pedagogical approach to sexual and relationship health promotion. MLE aims to improve critical thinking skills so that individuals do not simply accept media messages but, instead, evaluate them for realism and accuracy. MLE has been shown to positively affect youth cognitions including their media knowledge, criticism, and attitudes [
29,
30]. Youth who receive MLE are more aware that media perpetuate inaccurate sexual messages than youth who do not receive MLE [
31,
32]. MLE has been shown to redress teens’ inaccurate normative beliefs about their peers, including norms about the frequency of sexual activity and abstinence [
31,
33,
34]. In studies assessing MLE’s effect on health behaviors, youth receiving MLE reported higher levels of self-efficacy regarding their own sexual behavior [
31,
35], increased intentions to use a condom, if they decide to have sex [
32], and reductions in risky sexual behaviors [
34].
Given barriers to implementing traditional sexual health education programs and the commonly narrow focus of curricula that exclude information about the important influence of media on sexual health, there is a need for a comprehensive sexual health education program that integrates education about media influence and does not rely on teacher-led instruction for delivery. In order to address the many important topics frequently omitted from traditional sexual health education programs, including media influence, and to reduce variability in the content presented across instructors, Media Aware, a web-based media literacy and comprehensive sexual health education program, was developed. The program is designed to teach media literacy skills, reduce risky sexual behavior among high school students, and positively affect attitudes and cognitions that promote sexual health. Media Aware is designed to be completed individually by students using a web-based application that is self-paced, thereby allowing students to control the pace of their own learning. The web-based nature of the program also means that the educational content is standardized for all learners and free from individual teacher bias. The main objective of this study is to evaluate both the immediate and short-term effectiveness of Media Aware on adolescent sexual health and media-related outcomes. The study will also help to evaluate factors associated with fidelity of implementation and adoption, including acceptance and satisfaction as reported by both teachers and students.
Discussion
It is important that sexual health education programs be rigorously evaluated to ensure that they are effective in enhancing student health. The program being evaluated in this study, Media Aware, has the potential to be an innovative evidence-based program that high schools can implement to promote adolescent sexual and relationship health. In addition, this program has the potential to enhance adolescents’ critical thinking about media messages. The study design, specifically including students’ data collection at three time points (pretest, immediate posttest, and 3 months follow-up), allows for evaluation of the immediate effects of the program on student outcomes, as well as any behavioral effects that may occur during the 3 months after the students receive the program. In addition, this study will gather student and teacher feedback on the program, which will help determine the likelihood of program adoption by schools.
Potential barriers to study recruitment
There are a few potential barriers to study recruitment. First, it can be difficult to obtain school approval to allow research studies to take place. District or school policy may not allow research studies to be conducted in the schools, and some do not allow the collection of data pertaining to sexual health, specifically. If research is permitted in schools, there may be a rigorous approval process, which includes demonstrating that the research will not cut into instructional time. Schools will be informed that this program can be used as a substitute for other sexual health education lessons and should take less time to complete than traditional sexual health education programs.
Second, some schools require a period during which parents can review a sexual health education curriculum prior to it being taught in the classroom. Parental review of traditional print materials often requires parents to come to the school or district offices to review the curriculum materials, which can be a burden on parents, particularly if they are working and have to visit the school during the workday. Furthermore, there is no way for parents to know exactly how a teacher-led program will be implemented in the classroom (e.g., teachers could add their own content or opinions). The self-contained, web-based nature of Media Aware is expected to streamline the parental review process by allowing teachers to send parents a link to the program via an email for review. Furthermore, parents can be assured that the content they review is exactly what their child will be exposed to in class.
Third, schools may also decline to allow this research study to be conducted in their school because changing a school curriculum may elicit teacher pushback. Implementing a new program may require additional effort on the part of their teachers. Teachers have limited class time in which to cover material mandated by the state and school district, and they may view learning a new curriculum as a difficult task. However, given the web-based nature of Media Aware, teachers do not have to teach a new curriculum. This feature of utilizing web-based program delivery should minimize teacher resistance to implementing a new curriculum.
Study strengths and limitations
There are many strengths to the study design. The study is designed as a randomized controlled trial, a rigorous design for program evaluation. Randomization will increase the likelihood that the intervention group and delayed-intervention group are evenly balanced with respect to many characteristics like student diversity and socioeconomic status of the students in the school district. Because only one teacher per school will be participating in the study, there will be little chance of cross contamination between groups. Participating teachers and students from one school will likely have little to no contact with teachers and students in another school. Because the questionnaires will be completed during school hours, study attrition is minimized.
Implications for the field
This study has many implications for the field of sexual health education. This study will evaluate the feasibility and efficacy of using web-based programming to deliver comprehensive sexual health and media literacy education (MLE) to promote students’ sexual health outcomes. There are few, if any, evidence-based comprehensive sexual education programs for high school students that use an MLE approach, and, to the best of our knowledge, none that used a web-based format to deliver content. Additionally, this program expands the definition of comprehensive sexual health to include topics such as gender, consent, healthy relationships, and communication with partners, parents, and medical providers.
Trial status
The protocol is Version 1, dated July 29, 2019. The trial is registered on ClinicalTrials.gov, NCT04035694, with public title Media Aware High School Study and scientific title Web-based High School Media Literacy for Healthy Relationships. Secondary identifiers are iRT IRB 19-002-1-EFF and NICHD NIH R44HD088254. The date of first enrollment was September 5, 2019. The trial is currently recruiting; recruitment is slated to be completed by the end of the 2019–2020 school year. Enrollment is in the USA; the problem of study is adolescent sexual health. The trial sponsor is innovation Research & Training (iRT), which may be contacted for public queries (5316 Highgate Drive, Suite 121, Durham, North Carolina, USA 27713).
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