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NIHR Signal Teaching sexual health at school improved knowledge but not safe sex practices

Published on 29 August 2017

doi: 10.3310/signal-000472

School-based sexual health interventions improved knowledge and attitudes in school students up to 18. However, they failed to consistently improve safe sex practices or reduce unwanted pregnancies. Abstinence-based messages were least effective.

This review of reviews included 37 systematic reviews of school-based sexual health interventions. It excluded low-quality reviews and spanned 1990 to 2016, so is likely to reflect the best evidence available on the topic.

Intervention types included programmes focused exclusively on sexual abstinence (from the US), those aimed at preventing pregnancy or HIV, and comprehensive programmes tackling multiple dimensions, including relationships.

There was evidence of improved knowledge across all intervention types, but effects on behaviour were inconsistent. Some interventions such as the abstinence programmes were associated with negative changes, like higher pregnancy rates.

As there were no consistently successful individual interventions to recommend, the review identified 32 features associated with programme success. These can help guide the design, implementation and evaluation of school-based sexual health interventions to maximise the chance of success.

  •   Child Health, Public Health, Sexual health, Nursing, Schools and colleges
Teaching sexual health at school improved knowledge but not safe sex practices

Why was this study needed?

Young people at school are at risk of sexually transmitted infections (STIs) and unwanted pregnancies. And while not always the case; children born to teen parents tend to have poorer educational attainment, behaviour and health throughout their lives.

Data from the Office for National Statistics show an encouraging decline in under-16 conceptions, which have more than halved in England and Wales from 1998 to 2015.

Yet in 2015 there were still 3,466 conceptions under 16, with 60% leading to termination, indicating a continued need to prevent risky sexual behaviour and unwanted pregnancies.

A huge range of studies has tried to reduce STIs, delay first sexual experience, increase condom use, and otherwise reduce risky sexual behaviour and unwanted pregnancies. Yet with so much disparate research, it is difficult to understand what works consistently; and how. This NIHR-funded review aimed to identify and summarise all the review evidence available.

What did this study do?

This was an overview of 37 systematic reviews covering school-based interventions targeting sexual health in young people aged four to 18 in full-time education. Only reviews containing randomised control trials or quasi-experimental study designs were included.

Interventions were one of five main types: abstinence-only, comprehensive programmes tackling multiple dimensions of sexual health, pregnancy prevention, HIV-prevention and school-based or school-linked sexual health services.

Comparison groups received usual care or a simplified version of the intervention. The overview reported the number of positive and negative trials, without further quantitative analysis.

The search for reviews spanned 1990 to 2016. To reduce bias only reviews of moderate (26) or high quality (11) were included.

Very few studies came from the UK. Most were from the US or low- and middle-income countries which may limit relevance to UK schools.

What did it find?

  • Interventions that focused exclusively on sexual abstinence were effective in improving knowledge about how abstinence can protect against sexually transmitted infections (STIs), and about the risks and consequences of unprotected sex and pregnancy. However, they were not effective in changing the sexual behaviour of school students. Furthermore, two reviews found that some abstinence-only programmes were associated with higher pregnancy rates.
  • Comprehensive interventions aimed at promoting safer sex and preventing STIs including HIV were consistently effective in changing knowledge, attitudes and skills, but not behaviour. Some studies found improvements in self-reported sexual behaviour, but others found no or negative effects on outcomes such as age at first intercourse or frequency of intercourse (though limited information whether this was protected). Some studies showed different results for young men and women.
  • Programmes designed at preventing unwanted pregnancy were effective in improving knowledge about contraception, sexual risk and STIs, but again showed inconsistent effects on attitudes and behaviour. Most programmes had little effect on pregnancy rates, with the exception of one review of studies in socially disadvantaged teenagers where high-quality trials showed a reduction in pregnancy rates.
  • HIV-prevention interventions had a positive benefit for HIV/AIDS knowledge, though there were mixed findings for attitude, behaviour and skill change.
  • Reviews looking exclusively at school-based healthcare services (mostly US-based) found no evidence for an effect on contraceptive use and limited evidence for an effect on sexual activity and pregnancy rates.
  • As there were few off-the-shelf interventions to recommend, the authors gathered the findings from all 37 reviews to list 32 features associated with programme success. This provides guidance on appropriate programme content and how to develop, implement and evaluate a school-based sexual heath intervention. 

What does current guidance say on this issue?

NICE has produced an interactive flowchart (pathway) on preventing sexually transmitted infections and under-18 conceptions, but this doesn’t address school-based sexual health interventions specifically. Neither does 2013 Department of Health best practice guidance for local authorities on Commissioning Sexual Health Services and Interventions.

The NICE pathway advises commissioners to ensure that sexual health services, including contraceptive and termination services, are in place to meet local needs. All services are advised to include arrangements for the notification, testing, treatment and follow-up of partners of people who have an STI.

There are specific recommendations about condom distribution schemes and STI testing for specific groups.

What are the implications?

This overview of reviews itself does not give a clear sense of which off-the-shelf programmes to implement in all situations. Though there are some indications of what does not work and in the detail of each review some ideas for design.

Future evaluation of the structures, processes and outcomes of school-based sexual health interventions could provide new UK relevant data, knowledge and insight with which to improve existing practice.

The 32 features linked with programme success can guide the planning of such interventions, such as the use of trained educators, rather than peers and the recruitment of youth advisors if necessary.

Citation and Funding

Denford S, Abraham C, Campbell R, Busse H. A comprehensive review of reviews of school-based interventions to improve sexual-health. Health Psychol Rev. 2017;11(1):33-52.

This study was funded as part of National Institute for Health Research’s School for Public Health Research (NIHR SPHR) project with additional support from the NIHR Collaboration for Leadership in Applied Health Research and Care of the South West Peninsula (PenCLAHRC).


DH. Commissioning Sexual Health Services and Interventions Best Practice Guidance for Local Authorities. London: Department of Health; 2013.

NICE. Preventing sexually transmitted infections and under-18 conceptions – everything NICE says in an interactive flowchart. NICE Pathways. London: National Institute for Health and Care Excellence; 2017.

ONS. Conception Statistics, England and Wales 2015. Newport: Office for National Statistics; 2017.

Expert commentary

What stands out from this review is that sexual health programmes need to be consistent, engaging and clear. As young people in this day and age we receive most of our sexual health education from the internet or media, and it is crucial that dependable support from trained educators or health practitioners is available, who are trustworthy to deliver this from our perspective.

Reliable healthcare centres within close proximity to schools can provide effective support as evidenced in the report, but this needs to be explored further in the UK with a focus on understanding young people’s perspective and exploring the wider picture of relationships.

Susie Williams, Student, Health Blogger and NHS Youth Forum Member


The five categories of intervention identified in this review of reviews.

  1. Abstinence-only: promoting not having sex.
  2. Comprehensive programmes: aiming to prevent, stop, or decrease sexual activity, but also promote condom use and other safer-sex strategies as alternatives for sexually active participants.
  3. Pregnancy prevention: strategies specifically to prevent unwanted pregnancy.
  4. HIV-prevention: programmes focused on HIV prevention and HIV risk behaviour.
  5. School-based health services: services or clinics provided in schools; services located near schools that conduct outreach work within those schools; or services located near schools which liaise formally with those schools.