Interventions to Promote a Healthy Sexuality among School Adolescents: A Scoping Review

Schools are particularly suitable contexts for the implementation of interventions focused on adolescent sexual behavior. Sexual education and promotion have a multidisciplinary nature. Nurses’ role and the spectrum of the carried-out interventions is not clear. We aimed to identify interventions that promote a healthy sexuality among school adolescents. Our review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews and was registered in the Open Science Framework. Published articles on sexuality in adolescents in school contexts were considered. The research limitations included primary studies; access in full text in English, Spanish, or Portuguese; and no data publication limitation. Research was carried out on the EBSCOhost, PubMed, SciELO, and Web of Science platforms; gray literature and the bibliographies of selected articles were also searched. A total of 56 studies were included in the sample. The studies used a broad range of research methods, and 10 types of interventions were identified. Multi-interventional programs and socio-emotional interventions showed a greater impact on long-term behavioral changes, and continuity seemed to be a key factor. Long-term studies are needed to reach a consensus on the effectiveness of interventions. Nurses’ particular role on the multidisciplinary teams was found to be a gap in the research, and must be further explored.


Introduction
The World Health Organization [1] considers sexuality as a central aspect of human beings. It is influenced by psychological, social, biological, religious, spiritual, political, legal, economic, ethical, and historical issues.
Sexual development is considered a multidimensional process that is experienced more intensely by adolescents as they go through the changes of puberty, develop the capacity for intimacy, and experience sexual thoughts [2]. Adolescence is a complex stage of life that brings several challenges to health professionals. By traditional definition, it includes individuals from 10 to 19 years old. However, the definition has long posed a conundrum, and recently Sawyer at al. [3] suggested an extension to 10-24 years to correspond to a more current and updated concept. Regardless of age limits, it is a period of important biological growth, psychological development, and social role transitions.
The World Health Organization and other agencies consider sexual education as a priority within this age group due to sexual behavior implications, such as maternal mortality or sexually transmitted infections [4], and aspects such as gender-based violence and gender inequality. Since sexuality is an all-encompassing concept, there is no consensual definition of it. However, Goettsch [5] suggested a preliminary definition that includes: sexuality as an individual capacity, its experiential nature, body-oriented, and directed to genital excitation. The World Health Organization [1] gives a more comprehensive definition of sexuality that includes reproduction, sex, sexual orientation, gender identities lescents. This methodology proved to be advantageous, as it allowed identifying gaps in the literature, mapping the available evidence [16] that will support the planning of interventions to promote a healthy sexuality among adolescents in schools. The following research question was defined, according to PICo: which are the interventions that promote a healthy sexuality among school adolescents? (Population: adolescents; Interest: interventions to promote a healthy sexuality; Context: school).

Materials and Methods
The steps defined by Tricco et al. [15] for the scoping review were followed as detailed below.
Protocol and Registration. The protocol was drawn according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) and registered prospectively with the Open Science Framework on 18 June 2021 (https://osf.io/v97ek/?view_only=).
Eligibility criteria. Considering the scarcity of studies on specific nursing interventions, and keeping in mind the multidisciplinary scope of health promotion, for the purposes of this study, we selected studies focused on multidisciplinary interventions. Published articles on nurses, teachers, psychologists, and social care professionals integrated in work groups on sexuality in adolescents from school context were considered for analysis. Empirical studies with quantitative, qualitative, and mixed methods were included to maximize the coverage of evidence available. Peer-reviewed papers available in open access and full text and written in English, Spanish, and Portuguese were included. As to the publication date, no time frame was established. Manuscripts were excluded if studies were performed in specific contexts and specific health conditions (for example, hospitalization or adolescents with mental disorders). Letters to the editor, editorials, literature reviews, theoretical studies, protocols, methodological studies (for example, instrument validation/construction), blog articles, advertising, and opinion articles were excluded. Studies in which subjects were family members or health professionals that did not identify or suggest any interventions were also excluded.
Information sources. A three-step approach was used, as recommended in the literature [17]. The search was initially performed in two databases: Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Then, an analysis of the words contained in the titles and summaries was performed to understand the best terms to be used in the review. The purpose was to identify the keywords to be included in search equation.
In step two, after identifying the MeSH keywords to be used, research was conducted on the electronic platform EBSCOhost in the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL) (complete); MEDLINE (complete); Nursing & Allied Health Collection (comprehensive); Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; Cochrane Methodology Register; Library, Information Science & Technology Abstracts (LISTA); and MedicLatina. Additionally, PubMed, SciELO, ScienceDirect, and Web of Science were also searched. For grey literature, we used Open Grey, MedNar, and WorldWideScience.org-The Global Science Gateway.
In step three, the list of references from the articles selected in step two were systematically searched to find additional relevant literature for this review.
Search. The research equation, designed with keywords and Boolean operators, was: ((Adolescen *) AND (Sexuality) AND (Nurs *)). An asterisk operator (*) was used, so that the database could identify variants of the original word. Research was performed in March 2021 by all the authors, working in groups of two (F.L. and V.A.; P.O. and M.F.). Considering inclusion criteria and fields available in databases, the sample initially obtained was limited, as shown in Table A1 (Appendix A).
Selection of sources of evidence. Articles were selected initially by title, and when it was not clear if the article fitted this review, the abstract was read. Duplicates were removed, and inclusion/exclusion criteria were applied. Reviewers in groups of two (F.L. and P.O.; V.A. and M.F.) screened the same publications to increase consistency. Any disagreements between reviewers were resolved through discussion with all reviewers until consensus was reached.
Data-charting process. The variables to be extracted were decided by all researchers, and a data-charting table was developed. The process was initially performed individually by each author. Then, working groups of two were formed (F.L. and P.O.; V.A. and M.F.) to compare the extracted data, resolve disagreements, and increase accuracy. In cases in which the articles contained insufficient information, the authors were contacted. The final extraction chart was discussed by all authors until reaching unanimity.
Data items. Data were extracted related to article characteristics such as reference, country, and methods (aim, population and sample, type of study). We also included the intervention implemented, as well as the main findings.
Critical appraisal of individual sources of evidence. To describe the quality of the selected articles (n = 56), studies were appraised by all authors. Divergent views regarding the critical appraisal were reviewed until consensus. The Hawker et al. [18] assessment tool, with a four-grade scale (1 = very poor; 2 = poor; 3 = fair; 4 = good) was used. The total score ranges between 9 and 36, and higher scores indicate higher quality. An article's quality appraisal was centered on the following items: 1-abstract and title; 2-introduction and aims; 3-method and data; 4-sampling; 5-data analysis; 6-ethics and bias; 7-results; 8-transferability or generalizability; and 9-implications and usefulness.
Synthesis of results. Results were synthetized in a table that included all information extracted individually and approved by all authors. The data collected summarized studies and interventions that were identified in this review. Information was collected related to article reference, country where the study was applied, methods, intervention, and findings.

Results
Selection of sources of evidence. A total of 149 articles were identified by title. From those, 93 were excluded by abstract. Articles excluded were mainly those that did not identify interventions. Manuscripts that presented only data concerning descriptive statistics for a diagnostic purpose in a particular context were also excluded. The process of study selection is summarized below in Figure 1 using a PRISMA flow chart.
Characteristics of sources of evidence. This review allowed the identification of a broad set of interventions to promote a healthy sexuality among adolescents in the school context. Through the International Classification of Health Interventions (ICHI), the World Health Organization [19] defines a health intervention as an act that has the purpose of assessing, improving, maintaining, promoting, or modifying health, functioning, or health conditions. These interventions can be performed for, with, or on behalf of a person or population. According to ICHI descriptors, interventions regarding sexuality can be mostly framed as interventions on body systems and function (ICHI code 1) or interventions on health-related behaviors (ICHI code 4). In this review, both types were retrieved from articles; however, interventions predominantly were oriented toward behaviors. On the other hand, it was not always clear which type of intervention was implemented; therefore, we categorized them as presented in Table A2 (Appendix A). The interventions were grouped by ascending order of frequency found in sample studies (n = 56).
Critical appraisal within sources of evidence. The results demonstrated that overall, the studies' quality was high. Quality appraisal ranged from 18 to 35. Sampling, ethics, and bias, as well as transferability, were the main limitations of the studies (Table A3-Appendix A).
Results of individual sources of evidence. The results from each study selected in this scoping review are synthetized in Table A4 (Appendix A). Characteristics of sources of evidence. This review allowed the identification of a broad set of interventions to promote a healthy sexuality among adolescents in the school context. Through the International Classification of Health Interventions (ICHI), the World Health Organization [19] defines a health intervention as an act that has the purpose of assessing, improving, maintaining, promoting, or modifying health, functioning, or health conditions. These interventions can be performed for, with, or on behalf of a person or population. According to ICHI descriptors, interventions regarding sexuality can be mostly framed as interventions on body systems and function (ICHI code 1) or interventions on health-related behaviors (ICHI code 4). In this review, both types were retrieved from articles; however, interventions predominantly were oriented toward behaviors. On the other hand, it was not always clear which type of intervention was implemented; therefore, we categorized them as presented in Table A2 (Appendix A). The interventions were grouped by ascending order of frequency found in sample studies (n = 56).
Critical appraisal within sources of evidence. The results demonstrated that overall, the studies' quality was high. Quality appraisal ranged from 18 to 35. Sampling, ethics, and bias, as well as transferability, were the main limitations of the studies (Table A3-Appendix A).
Results of individual sources of evidence. The results from each study selected in this scoping review are synthetized in Table A4 (Appendix A).
Synthesis of results. A total of 56 studies published between 1998 and 2021 were selected for final analysis. All studies had adolescents as subjects except for Barnes et al. Synthesis of results. A total of 56 studies published between 1998 and 2021 were selected for final analysis. All studies had adolescents as subjects except for Barnes et al. [20], who studied nurses; and Valli and Cogo [21], whose study was related to school blogs on sexuality. Sample sizes ranged from 10 [22] to 11840 [23]. As to publication date, more than half of our article sample (n = 32) were published in the last 10 years. Regarding the country where studies were applied, we verified that there were studies from all around the world; however, three countries stood out: Brazil, with 16 articles; the USA, with 13 articles; and the UK, with 6 articles. Of the studies, 32 were of a quantitative nature, 18 used a qualitative approach, and 6 used mixed methods. Surveys were the most used form of collecting data (28), followed by combined techniques. These techniques included the use of surveys combined with interviews [24][25][26], focus groups [27,28], and an online environment [29]. A field diary and participating observation were also found as combined data collection techniques [22,30].

Discussion
Summary of evidence. The results indicated that adolescent sexuality is a relevant, current, and growing interest theme for health professionals, as we found articles from all around the world, and the great majority were recently published.
Evidence was mapped regarding the type of interventions performed in the school context, the factors that may influence their effectiveness, and a few considerations that were found on the multidisciplinary nature of school-based interventions.
Although studies that described an isolated intervention were found, mostly articles reported the findings of multiple interventional programs, such as SHARE [31][32][33] and Cuídate [34][35][36], or combined interventions, as stated above. The diversity of interventions found also reinforced the idea that adolescent health is still an evolving area [37] that requires a multidisciplinary approach.
Innovative approaches were also described, such as the use of blogs [21], Facebook [29], and online games [27,38], as they seemed to have greater acceptance by adolescents. As technologies continue to expand, online resources are becoming progressively relevant and used by adolescents, which raises concerns regarding vulnerability, but also presents opportunities for important impacts on healthy learning [39].
Interestingly, mobile phone intervention was found in six studies. Given the access and amount of time spent by adolescents with these devices, this intervention seems particularly suitable for the adolescent population. As an intervention that uses existing resources, mobile phone intervention is cost effective and sustainable, with the ability to reach many adolescents even in low-income countries. Furthermore, there is evidence that the use of mobile text messages may lead to improved adolescent sexual and reproductive health [40].
Interventions delivered through school-based health centers (SBHCs) are described in two studies. The existence of SBHCs has proven to have an impact on adolescents regarding satisfaction with their health and adherence to health-promoting behaviors [41]. Not all countries have SBHCs, since they are not part of their health and education systems. Nevertheless, policy makers should consider including this strategy in their agendas, as it is a more comprehensive and integrated approach. It has proven to raise adolescents' access to health care services, overcoming identified barriers such as charges, transportation, accessibility, availability, and privacy concerns [23].
Sex education sessions, group discussions, and workshops can be framed as the more traditional interventions. They can be implemented alone, simultaneously, integrated in a broader program, or used combined with other interventions. The studies that addressed them were mostly descriptive, with few considerations of their effectiveness as isolated interventions. With respect to sex education sessions, nurses often have a prominent role, particularly school nurses, as they have a broader knowledge of health-related issues. Brewin et al. [42] reported barriers related to privacy, time, confidentiality, and fear of conflict.
Peer education was only mentioned in four studies. This is an intervention that creates greater expectations around its impact on adolescent sexual behavior because, when performed and conveyed by peers with a similar age or status, it becomes more appealing and credible [43]. However, no study could demonstrate peer education effectiveness by itself.
Stephenson et al. [43] argued that it should be considered as part of a broader program.
Concerning interventions' effectiveness, some studies did not assess interventions' impact on adolescent behavior or knowledge, only describing the implementation experience in the school context. Even so, a more comprehensive approach that includes multiple types of interventions seems to be more effective in promoting positive changes in sexual behavior [44]. These findings were aligned with the multidimensional scope of adolescent sexuality.
In general, the articles evaluating the effectiveness of programs demonstrated a very low sustainability in the modification of risk behaviors [31,36,43,45,46] of young people and adolescents. Of the articles included, only one showed maintenance of the positive effects in terms of reduced pregnancies, delayed sexual debut, and intentions to use condoms. Again, it described a more comprehensive approach: a training intervention for children's social competence, classroom management and instruction, and parenting practices without interventions specifically aimed at sexuality [47].
In addition, interventions focused on psycho-affective and socio-emotional skills showed a greater impact on long-term behavioral changes. These findings were in line with the growing interest in socio-emotional skills learning (SEL) that, especially since the beginning of this century, has shown a positive impact on school success, well-being, and health of the participants [48], and which are at the base of health-promotion programs in schools such as the Collaborative for Academic, Social, and Emotional Learning (CASEL) (Chicago, IL, USA) or the Schools for Health in Europe Network Foundation (SHE) (Haderslev, Denmark).
Furthermore, we believe that the fact that programs are mostly implemented in local and regional contexts and only in a specific period of time limits their long-term effectiveness. Continuity seems to be a key factor in maintaining the change in adolescent behavior with regard to their sexuality.
The fact that so many studies and so many different interventions were found, with little evidence of their effectiveness, may also signify a difficulty in officially instituting and operationalizing them in the long term.
It is worth noting the difficulties in categorizing the domains of sexuality and standardizing the language regarding interventions. Despite the evident effort of the scientific community, there is still no universal consensus on them. Thus, there seems to be agreement on the multidisciplinary nature of interventions that promote adolescent sexuality.
As to limitations, we must consider the possibility of having excluded or missed some relevant studies due to the databases used, and the exclusion of studies written in languages other than English, Spanish, or Portuguese.

Conclusions
As previously mentioned, nurses are often involved in schools' health-promotion programs in general, but their role in these programs is not always clear or visible. This research did not allow us to draw conclusions about this topic. Nonetheless, it is interesting to note that most studies had nurses or nursing professors as their first author, although they did not focus exclusively on the role of nurses/nursing care. Again, this can be explained by the multidisciplinary nature of the interventions.
Finding which interventions worked best to promote a healthy sexuality among school adolescents was challenging. As the studies were carried out in very different contexts, and there are few long-term evaluations of the implemented interventions, it was not possible to make considerations about their effectiveness.
This review allowed the identification of interventions implemented in schools to promote adolescents' healthy sexuality; namely, event history calendar, group discussion, interventions delivered through SBHC, peer education, online intervention, mobile phone intervention, combined interventions, workshops, sex education sessions, and multiple interventional programs. These findings were in line with the multidimensional scope of adolescent sexuality. The studies found were recent and were published all around the world, which sustained the idea that this is a relevant and evolving theme.
Although most authors were nursing professionals or nursing students, the particular role of nurses on the multidisciplinary team was not explored. This is clearly a gap in the evidence that requires further investigation. However, this review gave a clear picture of the interventions that can be implemented to promote adolescent sexuality. The effectiveness of those strategies should be further explored. Decision makers should integrate these strategies in their agendas and use them as collaboration measures between the health and education sectors.

Conflicts of Interest:
The authors declare no conflict of interest.

Online interventions (Facebook)
Virtual spaces on the Internet offer potential for the production of health care, especially among adolescents, as it contributes to the sexual and reproductive health education in an interactive, playful, and practical way. The intervention improved self-reported resilience to risky sexual behaviors, though not with a reduction in those behaviors. Face-to-face education delivery by health care providers, such as school nurses, is a highly feasible and effective way to increase adolescents' beliefs and behavior toward primary prevention of HPV, regardless of socioeconomic status, ethnicity, or cultural background. The model of intervention reported in this paper was presented not as an ideal, but as an exemplar that other researchers might utilize, modify, and improve. Using games for HIV prevention was found to be appealing and acceptable, but it was not found to be the best approach to HIV prevention with the target population. To evaluate the effect of organizing interactions using peer education in schools on the knowledge and attitude toward sexual health.
Quantitative 282 teenagers (14 to 18 years) Peer education The use of peer education in schools informally could enhance the knowledge and approach toward aspects of physical health, sexual behaviors, and social and mental changes among female adolescents. Quasiexperimental 302 female students (mean age 12.9) Sex education sessions Performing educational programs during puberty has a crucial role in young girls' knowledge increase.

(Okanlawon and Asuzu, 2013) Nigeria
To involve adolescents in school-based health-promotion activities that would improve their perception of risk in sexual behavior.

Quasiexperimental 519 adolescents
Peer education Adolescents' active participation in health-promotion activities should be encouraged, as it improves the perception of risk in sexual behavior among adolescents.

(Valli and Cogo, 2013) Brazil
To analyze the structure of school blogs on sexuality and their utilization by adolescents.
Quantitative 11 blogs about sexuality Online interventions (blog) The blog is a virtual interaction tool common among adolescents that allows the adolescent to establish relationships with other teens interested in the topic, decreasing feelings of doubt, isolation, and shyness.  The intervention allowed adolescents to explore and discuss many subjects that involved their sexuality, and it was also a moment to take actions on health education with the objective to prevent risks. The workshops favored the discussion of attitude changes in the adolescents through the information, reflection, and expression of ideas and feelings, representing a process to be complemented by the family, school, and local social politics.  The analysis demonstrated a reconstruction /redefinition of meaning for the ideas related to sexuality, to gender, and to the wider social context.

(Barnes et al., 2004) Australia
To evaluate the impact of changes in the health system and services on the roles and responsibilities of child health nurses and to identify professional development needs.

Qualitative 10 nurses
Combined interventions: health education and health information displays.
The school-based youth health nurse program provides nurses with a new, challenging, autonomous role within the school environment, and the opportunity to expand their role to incorporate all aspects of the health-promoting schools' framework.

(Stephenson et al., 2004) UK
To examine the effectiveness of one form of peer-led sex education.
RCT 8000 students (13 to 14 years) Peer education Peer-led sex education was effective in some ways, but broader strategies are needed to improve young people's sexual health. The role of single-sex sessions should be further investigated. To determine whether a theoretically based sex education program for adolescents (SHARE) delivered by teachers reduced unsafe sexual intercourse compared with current practice.  To determine the short-term effect of a middle and high school-based AIDS and sexuality intervention (RAPP) on knowledge, self-efficacy, and behavior intention.

Nonrandomized controlled trial
Middle and high school students (n = 3635) Multiple interventional program (RAPP): games, role playing, take-home exercises At short-term follow-up, the RAPP intervention had a powerful effect on knowledge for all students and a moderate effect on sexual self-efficacy and safe behavior intention, particularly for high school students.
(Stephenson et al., 2008) UK To assess the long-term effects of a peer-led sex education program. RCT 9000 students (13-14 years) Peer education Compared with conventional school sex education at age 13-14 y, this form of peer-led sex education was not associated with a change in teenage abortions, but may have led to fewer teenage births, and was popular with pupils. It merits consideration within broader teenage-pregnancyprevention strategies.