Beyond risk and restraint: promoting positive interpersonal relationships to support adolescent sexual health and wellbeing

Abstract

Relationships across different contexts (family, peers, romantic, and sexual) contribute to adolescent development and an individual’s sexual health and wellbeing. In particular, social connectedness, which highlights the importance of feeling care for and having a sense of belonging, provides further context to these relationships’ significance. The social world in which adolescents reside is continuously evolving, and alongside this, the challenges and opportunities for adolescent sexuality. Earlier research has demonstrated the importance of comprehensive sexuality education in supporting positive adolescent sexual health, however, young people’s perspectives on the content of their education regarding relationships and consent is limited. Additionally, whether school-based programmes can support the development of positive interpersonal relationships to support adolescent sexual and reproductive health, and the degree of young people’s understanding of relationships are areas that require further investigation. Young people’s perspectives and experiences are essential to ensure programmes and interventions aimed at supporting their sexual health and wellbeing reflect their needs. Overarching aim: To describe the perspectives of young people on the importance of interpersonal relationships and social connectedness for their sexual health. The aims of this thesis are: 1. To systematically review the evidence from high-income settings about the impact of school-based interventions to promote connectedness to improve adolescent sexual and reproductive health and wellbeing. 2. To describe student perspectives of a sexuality education programme in South Australian schools between 2006 and 2017, drawing particular attention to changing topics of importance. 3. To describe teacher experiences of sexuality education training provided by South Australia’s major sexual and reproductive health organisation. 4. To explore adolescents’ understanding and conceptualisation of healthy relationships, including peer, family and intimate relationships. 5. To explore adolescents’ understanding of consent and how different contextual factors contribute to navigating and identify consent. Methods 1. A systematic review was conducted capturing school-based interventions and programmes that involved a component of social connectedness to improve adolescent sexual and reproductive health. 2. Student perspectives were captured from an annual survey conducted by SHINE SA. Descriptive statistics and regression analyses were undertaken to investigate student perspectives of a sexuality education programme, including an investigation of student ratings of the programme, and topics considered most useful and important. 3. A qualitative exploration was undertaken to explore teacher perspectives on a sexuality education training course. Changes in teachers’ confidence and competencies were explored through descriptive statistics and Wilcoxon signed rank tests. Content analyses was selected to investigate free-text responses to the usefulness of training sections on sexual health topics. 4. Semi-structured interviews were conducted with diverse young people aged 14-20 years residing in South Australia. The interview guide comprised of the following topics: healthy relationships (Aim 4), consent (Aim 5), and sexuality education (Aim 4 and 5). Inductive thematic analysis was undertaken for both the healthy relationships and consent analyses. The interview guide and consent scenarios referred to for this research is available in Appendix 1 and 2, respectively. a. Positive Youth Development framework informed the analysis on healthy relationships (Aim 4). b. The conceptual framework on reproductive autonomy and sexual script theory informed the analysis on consent (Aim 5). Results 1. The systematic review identified 18 studies that comprised 10 individual programmes. Programmes that were most effective included multiple constructs of social connectedness, social skill building and had sufficient intensity. Improvements were identified for condom use, delayed initiation of sex and reduced pregnancy rates, with differences between ethnicity and gender. 2. The student feedback on a sexuality education programme captured the perspectives of over 20,000 secondary students. There was a positive association between the survey year and providing a ‘good/excellent’ rating for safe and supportive classroom environment. Socio-emotional topics, including consent and gender stereotypes, were increasingly selected over a 5-year period. Contrastingly, there was a decrease in selecting more traditional sexual health topics, such as contraception, during this period. 3. The qualitative exploration of teacher perspectives on their sexuality education training identified gender and power, same-sex attraction, and violence in relationships as areas that teachers’ appreciated guidance on. Ongoing and targeted professional development is needed to support the complex skill set needed to teach sexuality education. 4. Eighteen diverse young people (61% self-identified as female, 50% Caucasian, 41% public school education) participated in semi-structured interviews. Findings demonstrated that young people could articulate which qualities indicated a healthy relationship but this rarely reflected lived experiences, and that peer pressure and social norms are pervasive regarding expectations to date and engage in sex. Participants relied on personal experience to learn about healthy relationships, and had discrepant experiences on relationship content within their sexuality education. 5. The same eighteen young people who participated in the semi-structured interviews provided insights on consent. All participants were able to provide a definition of consent, with those with more relationship or sexual experience providing definitions reflective of the affirmative model of consent; however, there was a gap between theory and practice when discussing real life situations. In real life, the presence of sexual scripts were prevalent and the mutable nature of consent became apparent in young people’s accounts. The depth and content of consent was variable in young people’s sexuality education, young people made several recommendations to improve education including greater engagement in discussions of the reality of consent and moving away from a binary understanding typically taught in school. Conclusion To support adolescent sexuality development, sexuality education should continue to have a broad scope to include socio-emotional topics and continue moving away from traditional approaches focusing on risk. This thesis has demonstrated strong interest from young people on these topics, including relationships and consent, but sexuality education requires further refinement in the depth and content of these topics and the training teachers receive. Young people demonstrated comprehensive understanding of relationships and consent, though within both instances, there was a greater reliance on personal experience and observation for learning over formal education. Implementing skill-based learning, deconstructing social and gender norms, and discussing the realities of relationships and consent within sexuality education are suggested as relevant approaches to supporting young people achieve healthy relationships, and subsequently, positive sexual health.