Promoting Sexual and Reproductive Health in Young People: A Systematic Review of Reviews

Abstract

Background: Sexual and reproductive health promotion is a political and social process that involves not only individual actions but also strategies to change social, environmental and economic factors. It is necessary to know the characteristics of effective interventions in order to design new evidence-based programmes. However, programmes need to follow a holistic approach, hence the importance of Comprehensive Sexuality Education. Methods: An extensive bibliographic search was carried out. Twenty systematic reviews between 2015 and 2025 were selected following PRISMA 2020. Results: This review shows that interventions to promote SRH are effective and have significant results in increasing SRH knowledge, attitudes and skills, the competencies of professionals and improving access to SRH services. It has been possible to extract that it is necessary to promote SRH with the inclusion of young people, the adaptation of interventions according to the needs of each person, the coordination between different areas, the application of the intersectional and gender perspective, the application of a rights-based approach, the use of comprehensive and inclusive education models, the training of professionals and the carrying out of evaluations to disseminate the results. Furthermore, there are shortcomings in the evidence, such as the lack of an intersectional perspective, the lack of inclusion of certain groups and the lack of rigorous evaluations following quality standards. Conclusion: Programmes based on Comprehensive Sexuality Education are effective and have certain common characteristics.

1. Introduction

The concept of Sexual and Reproductive Health (SRH) has evolved over time. The World Health Organization (WHO) first defined sexual health in a report: “sexual health is the integration of the somatic, emotional, intellectual and social elements of the sexual being through means that are positively enriching and that enhance personality, communication and love” [1] (p. 6). Subsequently, in 1994, the International Conference on Population and Development (ICPD) held in Cairo, included sexual health in the definition of reproductive health. It was established that its objective is the promotion of personal development and relationships, rather than being limited to counselling and treatment related to reproduction and sexually transmitted infections (STIs) [2]. Since the ICPD, various countries have developed strategies and policies on sexual health aimed at adolescents and young people. For instance, Kenya introduced the National Adolescent Sexual and Reproductive Health Policy [3] to promote SRH in adolescents. India established the National AIDS Control Programme (NACP) for prevention and control of HIV in the country [4]. Finally, Brazil proposed the Diretrizes Nacionais para a Atenção Integral à Saúde de Adolescentes e de Jovens na Promoção, Proteção e Recuperação da Saúde [5]. They want to raise awareness among public health policy makers to acquire a holistic view and address the needs of young people.

However, today, various institutions such as UNESCO [6] and WHO [7] promote a more holistic approach that recognises sexuality as a social construct that is diverse in its functions, practices and orientations. This transition has been accompanied by the recognition of sexual and reproductive rights. This approach argues that we are sexual beings from birth [8].

Adolescence is not the beginning of sexuality but the continuation of the process [8]. However, it is important to study sexual and reproductive health in adolescence as it includes the changes of puberty and the need to establish one’s own identity. Studies point to a list of obstacles to the sexual and reproductive rights of adolescents and young people. Among these, the lack of information stands out. Recent studies with large samples have consistently shown that adolescents want more information about romantic relationships, relational sexuality, consent, sexual experiences and pleasure [9,10]. The systematic review of Silva et al. [11] shows that the main topics adolescents search for are sexual intercourse, contraception, relationships, and LGBTI issues. This occurs because these topics are not usually addressed in sex education programmes and other settings.

1.1. Intersectional Perspective

The intersectional perspective holds that there are multiple axes of inequality in society, such as racism, sexism, and LGBTIphobia, among others. These axes do not act independently, but are interrelated with other groups of discrimination, creating a unique situation. The concept of intersectionality was developed in the late 1980s from various social movements, especially black feminism in the United States. Activist Kimberlé Crenshaw [12] described the relationships between race and gender in the context of violence against black women.

Social and structural inequalities prevent the achievement of sexual rights. Therefore, SRH must be analysed considering social contexts, so that changes can be made to the elements that generate these inequalities. Gender is one of the main axes of inequality. Gender mandates entail a series of inequalities, such as women’s access to sexual and reproductive health services [13]. On the other hand, there are groups that identify with a gender identity different from their biological sex, known as trans identities. The diversity of sexual orientations and the demands of LGBTI groups must be acknowledged. The systematic review of Allen et al. [14] shows that trans and gender-diverse individuals also encounter significant barriers in accessing sexual and reproductive health services, which limits the full realization of their reproductive rights. Another axis of discrimination is related to social class. The links with sexual and reproductive health are historical. For example, it has been found worldwide that the most socioeconomically disadvantaged social groups are at greater risk of certain types of cancer, especially cervical cancer [15]. The persistence of structural racism and xenophobia should also be highlighted. In fact, the prototype of person who transmits the hegemonic model of sexuality is that of a white, heterosexual person from a high social class [16]. Cultural and religious diversity is another axis of inequality related to religious customs and practices [17]. Likewise, people with disabilities do not fit into the normative apparatus of the sex/gender system. In the case of women, there are also prejudices towards their sexuality and reproduction. However, we must consider the variety of experiences depending on other social factors and not reduce them to women with physical disabilities [18].

1.2. Sources of SRH Information

According to the National Survey on Sexual Health and Contraception among Spanish Young People aged 16 to 25 [19], young people obtain information mainly from the Internet (47.8%) and friends (45.5%), ahead of school (28%), mother (23%) or father (12%). Twelve per cent had not received any information about sexuality. Most of those surveyed agree that the information provided at school is scarce, inconsistent and poorly focused. They report feeling embarrassed when discussing these issues with their families and therefore tend to do so only as a last resort and only in emergencies. All of this allows us to distinguish between different educational agents depending on the place and context in which they operate: on the one hand, formal sex education (regulated education system), non-formal (voluntary learning within a structured environment but outside the regulated education system, such as interventions by associations, local councils and non-governmental organisations) and informal (not structured or planned but within the experiences of each person in the family and community) [20]. Therefore, interventions and programming must cover several levels, from the clinical and educational spheres to the social sphere and public policy reform [7].

1.3. Sexual Education Models

There are different models of sex education depending on the approach taken. Comprehensive Sexual Education (CSE) is defined as teaching and learning about the cognitive, emotional, physical and social aspects of sexuality [6]. Its aim is to equip children and young people with the knowledge, skills, attitudes and values that enable them to achieve health, well-being and dignity; develop respectful social and sexual relationships; consider how their choices affect their own well-being and that of others; and understand and ensure the protection of their rights throughout their lives. It can be delivered in formal and non-formal settings and will be based on scientific evidence. CSE should be taught in the context of the range of values, beliefs and experiences that exist in each culture. However, not all CSE programmes follow these guidelines, as many continue to focus exclusively on the prevention of STIs and unwanted pregnancies [21].

Programme evaluation is essential for identifying shortcomings and designing new interventions. However, many programmes are not rigorously evaluated or evaluated over the long term [21]. Furthermore, the experimental designs and indicators currently used are not adequate for analysing the effectiveness of CSE-based programmes [22]. Therefore, while there is ample evidence on risk-focused interventions, the effectiveness of interventions with a comprehensive approach and a rights-based perspective has not been analysed using these types of methods. For this reason, Ketting et al. [23] propose triangulating quantitative and qualitative methods.

Although there are previous reviews on interventions that promote SRH, there is still a lack of synthesis that adopts a holistic perspective on SRH promotion across diverse settings, including educational, community, and healthcare contexts, while also integrating intersectional and rights-based approaches. To address this gap, the objective of this review is to analyse the most rigorous evaluations of the impact of interventions and policies to promote sexual and reproductive health among young people. This will allow us to synthesise the characteristics of the interventions and identify possible gaps in the evidence. However, the concept of “effectiveness” is not uniformly defined. While some studies equate it with knowledge gains or reduced risk behaviours, others adopt broader perspectives that include empowerment, gender equity, or access to services. This ambiguity must be acknowledged when reviewing the existing evidence. Therefore, the purpose of this review is not only to synthesize the available findings, but also to critically highlight this lack of a shared definition of effectiveness, and to reflect on how different conceptualizations shape both evidence and practice. To this end, systematic reviews of programmes that promote SRH will be analysed.

2. Materials and Methods

A review of systematic reviews was conducted following PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines [24]. The review is structured in accordance with PRISMA Checklist (Table S1). The review protocol has been registered on PROSPERO with the registration number CRD420251127810.

An extensive literature search was carried out in the following databases: Web of Science, Scopus, ScienceDirect, Dialnet, and Google Scholar. The SIDA STUDI database was also consulted. Search strategies combined terms related to sexual and reproductive health, interventions and evaluation. For example, in Scopus the following search string was applied:

TITLE-ABS-KEY ((“sexual and reproductive health”) AND (program OR intervention) AND (“systematic review” OR “meta-analysis”)) AND (LIMIT-TO (LANGUAGE, “English”) OR LIMIT-TO (LANGUAGE, “Spanish”))

Equivalent strategies were adapted for each database. A time filter (2015–2025) and language filter (English, Spanish) were applied. This time frame was selected for two main reasons. First, 2015 marks the adoption of the Sustainable Development Goals [25], which positioned SRH, gender equality, and CSE as global priorities. Second, focusing on the most recent decade allows this review to capture updated approaches that integrate rights-based, gender, and intersectional perspectives.

To focus the purpose of the study, the PICOS (population, intervention/exposure, comparator, outcome, study characteristics) strategy was used, as recommended by PRISMA. Its components are:

• Population: Young people.
• Intervention: interventions to promote SRH from any country.
• Comparator: interventions with a control or other interventions.
• Outcome: Knowledge and attitudes about sexual health, risk behaviour, self-confidence and social skills and other non-biological outcomes.
• Study characteristics: Systematic reviews or meta-analyses.

The inclusion criteria were as follows:

• Systematic reviews or meta-analyses of interventions evaluated to promote SRH in young people. To ensure the rigour of the studies, priority was given to those that offered experimental or quasi-experimental evidence. These designs provide stronger evidence regarding programme effectiveness.
• Interventions not focused exclusively on risks, with a comprehensive approach.
• Interventions aimed at young people. However, reviews that included both young people and adults were included to broaden the studies addressing certain topics.

All reviews focusing exclusively on HIV and STIs were excluded. This decision was consistent with the aim of the present study. Including only HIV/STI reviews would have meant over-representing biomedical or risk prevention interventions, which would have limited comparability and shifted the focus of the results towards more reductionist strategies. However, reviews in which HIV prevention was addressed as part of a broader SRH programme were included.

Applying this search strategy, 19 articles were selected and reviewed in the analysis. Given the heterogeneity of SRH interventions, most are systematic reviews that do not perform meta-analyses.

Data extraction was performed manually. Although software tools such as EndNote, Covidence, or Rayyan are commonly used in systematic reviews, manual extraction was considered appropriate given the relatively small number of included reviews and the author’s experience with this approach.

A descriptive approach was used to present the characteristics of the included studies. A meta-analysis could not be performed due to the heterogeneity of the results and study designs.

Risk of Bias and Study Quality

Review quality was assessed with AMSTAR II checklist [26]. It is an update of AMSTAR that allows for the evaluation of randomised and non-randomised interventions. It has 16 items in total and includes seven critical domains which are essential for evaluating the methodological quality. For each item, responses were coded as ‘Yes’, ‘Partial Yes’, or ‘No’, following AMSTAR II guidelines. Overall confidence in the results of each review was then classified as high, media, low, or critically low. The results of the quality assessment are summarised in Supplementary Material (Table S2), providing a transparent overview of the reliability of the included evidence.

3. Results

3.1. Literature Search

The search yielded 1163 records. The process is shown in Figure 1. Nine hundred and thirty-four articles were excluded after reading the title and abstract. Two hundred and ten articles were reviewed, of which 19 met the inclusion criteria. One hundred and ninety-one were excluded because they did not fit the age range and did not include CSE-based interventions.

3.2. Risk of Bias

Most studies obtained low scores according to AMSTAR II quality assessment tool [26]. Only one study obtained a medium score. This should be considered when interpreting the results (Table S2).

3.3. Characteristics

The characteristics are summarised in Table 1 and Table 2.

3.3.1. Study Design

With regard to who should be involved in the design of interventions, the evidence reviewed suggests that it is important to involve young people in the design of SRH interventions, as this makes it easier to address their real needs [27].

The review by Bohren et al. [28] concludes that it is important for interventions to be designed with the participation of representatives from each community to ensure that all needs are addressed.

Similarly, Stewart et al. [29] and Barriuso-Ortega et al. [21] argue that interventions should be designed by people from different professions, i.e., by multidisciplinary teams.

Regarding the process of designing effective interventions, Martin et al. [30] recommend following a protocol for programme design and implementation called Intervention Mapping. This protocol can be used to create a systematic framework for making effective, evidence-based decisions at each step of the process. Theories that explain behaviour and its changes in the face of potential problems that may arise should be used. In fact, Torres-Cortés et al. [31] state that it is important for interventions to be based on a theoretical model that includes the context and elements of the community.

Table 1. Systematic reviews included.

Systematic Review	Number of Studies	Scope and Model	Methodology	Participant Profiles	Outcomes	Geographic Area
Bailey et al. (2015) [32]	19	Meta-analysis. Comprehensive digital sexuality education interventions.	Online.	Ages 13–24.	SRH knowledge. Self-efficacy.	United Kingdom
Barriuso-Ortega (2022) [21]	47	Meta-analysis. CSE focused on risk and abstinence in schools.	In-person and online.	Adolescents (10–19 years).	Attitudes and knowledge about sexuality. Self-efficacy. Intention to use condoms. Abstinence.	United States, China, Iran, South Africa, and other countries.
Bohren et al. (2022) [28]	12	Strategies to reduce stigma and discrimination in SRH healthcare services.	In-person.	Young people and adults.	Reduction of healthcare provider biases. Decrease in perceived stigma among racialized women.	United States, Bangladesh, Canada, South Africa, United Kingdom, Zambia, Sub-Saharan Africa
Bouaddi et al. (2023) [33]	47	Interventions to improve access and use of SRH services among migrant populations, mostly community-based.	Varied, peer education.	Young people and adults.	SRH knowledge, attitudes, and skills. Access to healthcare institutions.	United States, China, Uganda, Netherlands, Sweden, Guinea, Thailand
Denno et al. (2020) [34]	18	Training for health personnel to promote SRH among youth.	In-person.	Training for trainers in adolescent programs.	Healthcare professionals’ skills and attitudes. Youth satisfaction. Increased contraceptive use.	African countries, India, China, Brazil
Evans et al. (2022) [35]	24	Meta-analysis of 11 studies. Menstrual health education in schools.	In-person and online.	Ages 10–14.	Menstrual health knowledge. Attitudes toward menstruation. Product use skills. Access to hygiene (water, soap) and medication for dysmenorrhea.	Iran, Turkey, Indonesia, Ethiopia, India, Bangladesh, Uganda, United States, Nepal, Kenya, China
Goldfarb et al. (2020) [36]	80	CSE in schools.	In-person.	Children and adolescents.	- Sexual diversity (homophobic attitudes, gender stereotypes, social justice). - Prevention of gender-based violence (knowledge, attitudes, incidence). - Affective relationships. - Sexual abuse. - Self-esteem and body image. - Media literacy.	United States, Canada, Mexico, Australia, China, United Kingdom, Netherlands
Gonsalves et al. (2017) [37]	45	SRH promotion in pharmacies (information, contraceptive dispensing, pregnancy and HIV testing). Youth and pharmacy staff experiences.	In-person.	Under 25 years.	Risk behaviors and contraceptive use among young people accessing pharmacies.	United States, United Kingdom, African countries, Ireland, Australia, Switzerland, Belgium
Haberland (2015) [38]	22	CSE in schools, health and community settings.	In-person.	Young people.	SRH knowledge. STIs and unplanned pregnancy incidence.	Mostly United States
Hameed et al. (2020) [39]	18	SRH promotion interventions for people with disabilities in schools and health institutions.	In-person.	Young people and adults with disabilities.	Knowledge and attitudes on menstrual health, STIs, unplanned pregnancy, sexual violence. Access to SRH services.	South Africa, Brazil, Iran, Ecuador, Turkey, Azerbaijan, Philippines
Liu et al. (2023) [40]	15	Digital interventions for LGBTI youth in school, community, and healthcare settings.	Online.	Ages 12–22. LGBTI individuals.	Mental health in LGBTI youth.	United States, United Kingdom, Netherlands, Australia
Martin et al. (2020) [30]	60 articles, 37 interventions	Online participatory interventions in different settings.	Online.	Ages 10–24.	SRH knowledge and behaviours. Condom use.	United States, Canada, United Kingdom, Netherlands, Europe, Australia, Uganda, Brazil, Chile, Asia
Mazur et al. (2018) [41]	20	Youth-friendly SRH service interventions.	In-person.	Ages 12–24.	Access to youth-friendly centres. Professional skills. Confidentiality.	Sub-Saharan Africa, North America, Europe, Asia
O’Farrell et al. (2020) [42]	24	Inclusive and CSE in schools.	In-person and online.	Ages 16–23.	Not specified; program analysis only.	Israel, United Kingdom, United States, Australia, Netherlands, Sweden
Orte et al. (2022) [43]	33	CSE in schools and community settings.	In-person, use of ICT, and peer education.	Youth (10 to 25 years). Inclusion of families.	Knowledge about SRH.	United States, United Kingdom, Netherlands, and Spain
Sell et al. (2023) [27]	19	CSE in schools with a gender perspective promoting empowerment.	In-person.	Ages 10–18.	Knowledge. Condom use. Gender stereotypes.	Europe, Africa, North America, Australia
Stewart et al. (2021) [29]	71	All types of interventions on gender stereotypes in relation to SRH (education, community, public policies, campaigns).	Varied.	Youth.	Attitudes and behaviors related to gender stereotypes.	United States, India, Africa, South America, Nepal, Europe, Australia, China, Pakistan, Sri Lanka, United Kingdom
Torres-Cortés et al. (2023) [31]	27	Sexual education of various models (72% CSE, 22% risk-based, 6% abstinence-plus), mostly in schools.	In-person.	Adolescents.	Attitudes toward condom use. Partner communication. HIV testing. Gender-based violence incidence. SRH knowledge. Condom use.	Africa, Europe, North America
Zaneva et al. (2022) [44]	33	Meta-analysis of 8 studies. All types of SRH interventions that include pleasure. Intersectional perspective in several articles.	In-person.	Youth. Includes one article on adults over 35.	Condom use.	United States, South Africa, Brazil, Spain, United Kingdom, Singapore, Nigeria, Mexico

Table 1. Systematic reviews included.

Systematic Review	Number of Studies	Scope and Model	Methodology	Participant Profiles	Outcomes	Geographic Area
Bailey et al. (2015) [32]	19	Meta-analysis. Comprehensive digital sexuality education interventions.	Online.	Ages 13–24.	SRH knowledge. Self-efficacy.	United Kingdom
Barriuso-Ortega (2022) [21]	47	Meta-analysis. CSE focused on risk and abstinence in schools.	In-person and online.	Adolescents (10–19 years).	Attitudes and knowledge about sexuality. Self-efficacy. Intention to use condoms. Abstinence.	United States, China, Iran, South Africa, and other countries.
Bohren et al. (2022) [28]	12	Strategies to reduce stigma and discrimination in SRH healthcare services.	In-person.	Young people and adults.	Reduction of healthcare provider biases. Decrease in perceived stigma among racialized women.	United States, Bangladesh, Canada, South Africa, United Kingdom, Zambia, Sub-Saharan Africa
Bouaddi et al. (2023) [33]	47	Interventions to improve access and use of SRH services among migrant populations, mostly community-based.	Varied, peer education.	Young people and adults.	SRH knowledge, attitudes, and skills. Access to healthcare institutions.	United States, China, Uganda, Netherlands, Sweden, Guinea, Thailand
Denno et al. (2020) [34]	18	Training for health personnel to promote SRH among youth.	In-person.	Training for trainers in adolescent programs.	Healthcare professionals’ skills and attitudes. Youth satisfaction. Increased contraceptive use.	African countries, India, China, Brazil
Evans et al. (2022) [35]	24	Meta-analysis of 11 studies. Menstrual health education in schools.	In-person and online.	Ages 10–14.	Menstrual health knowledge. Attitudes toward menstruation. Product use skills. Access to hygiene (water, soap) and medication for dysmenorrhea.	Iran, Turkey, Indonesia, Ethiopia, India, Bangladesh, Uganda, United States, Nepal, Kenya, China
Goldfarb et al. (2020) [36]	80	CSE in schools.	In-person.	Children and adolescents.	- Sexual diversity (homophobic attitudes, gender stereotypes, social justice). - Prevention of gender-based violence (knowledge, attitudes, incidence). - Affective relationships. - Sexual abuse. - Self-esteem and body image. - Media literacy.	United States, Canada, Mexico, Australia, China, United Kingdom, Netherlands
Gonsalves et al. (2017) [37]	45	SRH promotion in pharmacies (information, contraceptive dispensing, pregnancy and HIV testing). Youth and pharmacy staff experiences.	In-person.	Under 25 years.	Risk behaviors and contraceptive use among young people accessing pharmacies.	United States, United Kingdom, African countries, Ireland, Australia, Switzerland, Belgium
Haberland (2015) [38]	22	CSE in schools, health and community settings.	In-person.	Young people.	SRH knowledge. STIs and unplanned pregnancy incidence.	Mostly United States
Hameed et al. (2020) [39]	18	SRH promotion interventions for people with disabilities in schools and health institutions.	In-person.	Young people and adults with disabilities.	Knowledge and attitudes on menstrual health, STIs, unplanned pregnancy, sexual violence. Access to SRH services.	South Africa, Brazil, Iran, Ecuador, Turkey, Azerbaijan, Philippines
Liu et al. (2023) [40]	15	Digital interventions for LGBTI youth in school, community, and healthcare settings.	Online.	Ages 12–22. LGBTI individuals.	Mental health in LGBTI youth.	United States, United Kingdom, Netherlands, Australia
Martin et al. (2020) [30]	60 articles, 37 interventions	Online participatory interventions in different settings.	Online.	Ages 10–24.	SRH knowledge and behaviours. Condom use.	United States, Canada, United Kingdom, Netherlands, Europe, Australia, Uganda, Brazil, Chile, Asia
Mazur et al. (2018) [41]	20	Youth-friendly SRH service interventions.	In-person.	Ages 12–24.	Access to youth-friendly centres. Professional skills. Confidentiality.	Sub-Saharan Africa, North America, Europe, Asia
O’Farrell et al. (2020) [42]	24	Inclusive and CSE in schools.	In-person and online.	Ages 16–23.	Not specified; program analysis only.	Israel, United Kingdom, United States, Australia, Netherlands, Sweden
Orte et al. (2022) [43]	33	CSE in schools and community settings.	In-person, use of ICT, and peer education.	Youth (10 to 25 years). Inclusion of families.	Knowledge about SRH.	United States, United Kingdom, Netherlands, and Spain
Sell et al. (2023) [27]	19	CSE in schools with a gender perspective promoting empowerment.	In-person.	Ages 10–18.	Knowledge. Condom use. Gender stereotypes.	Europe, Africa, North America, Australia
Stewart et al. (2021) [29]	71	All types of interventions on gender stereotypes in relation to SRH (education, community, public policies, campaigns).	Varied.	Youth.	Attitudes and behaviors related to gender stereotypes.	United States, India, Africa, South America, Nepal, Europe, Australia, China, Pakistan, Sri Lanka, United Kingdom
Torres-Cortés et al. (2023) [31]	27	Sexual education of various models (72% CSE, 22% risk-based, 6% abstinence-plus), mostly in schools.	In-person.	Adolescents.	Attitudes toward condom use. Partner communication. HIV testing. Gender-based violence incidence. SRH knowledge. Condom use.	Africa, Europe, North America
Zaneva et al. (2022) [44]	33	Meta-analysis of 8 studies. All types of SRH interventions that include pleasure. Intersectional perspective in several articles.	In-person.	Youth. Includes one article on adults over 35.	Condom use.	United States, South Africa, Brazil, Spain, United Kingdom, Singapore, Nigeria, Mexico

Table 2. Characteristics of effective programs.

Category	Core Characteristics
Design	- Youth participation [27]. - Multidisciplinary teams [21,29].
Approach	- Intercultural perspective [33]. - Comprehensive approach. - Critical awareness and feminism [27,38,43]. - Intersectional perspective [28,36]. - Inclusion of pleasure [44].
Scopes	- Multi-level and cross-sectoral strategies [34]. - Educational: family involvement [21,27,43]. - Health: youth-friendly centres and pharmacies [41]. - Community: participation of leaders and key community stakeholders [37]. - Digital: personalization of interventions [30].
Duration	- Higher number of sessions [21,29,31]. - Sexual education throughout the curriculum [36]. - Starting from childhood [36].
Implementation	- Training for trainers [21,27,31,34,43]. - Peer education [29].

Table 2. Characteristics of effective programs.

Category	Core Characteristics
Design	- Youth participation [27]. - Multidisciplinary teams [21,29].
Approach	- Intercultural perspective [33]. - Comprehensive approach. - Critical awareness and feminism [27,38,43]. - Intersectional perspective [28,36]. - Inclusion of pleasure [44].
Scopes	- Multi-level and cross-sectoral strategies [34]. - Educational: family involvement [21,27,43]. - Health: youth-friendly centres and pharmacies [41]. - Community: participation of leaders and key community stakeholders [37]. - Digital: personalization of interventions [30].
Duration	- Higher number of sessions [21,29,31]. - Sexual education throughout the curriculum [36]. - Starting from childhood [36].
Implementation	- Training for trainers [21,27,31,34,43]. - Peer education [29].

3.3.2. Approach

Goldfarb et al. [36] state that few studies apply the social justice approach or intersectional perspective in their review. Those that did apply it increased knowledge and improved attitudes towards gender equality and sexual rights and towards racism, classism, homophobia and misogyny.

Additionally, interventions based on critical awareness and feminism were more effective according to Orte et al. [43], Sell et al. [27] and Haberland [38]. They also advocate the need for open discussions about gender and empowerment, encouraging critical thinking and personal reflection. Zaneva et al. [44] advocate the incorporation of pleasure into interventions.

3.3.3. Scope

The interventions included in the reviews analysed were mainly promoted in the educational sphere (14 studies), followed by the community sphere (7 studies), the digital sphere (3 studies) and finally the health sphere (9 studies). In any case, the evidence suggests that strategies that act at multiple levels and in an intersectoral manner are more effective than those promoted from a single setting [34].

The educational setting encompasses most of the programme evaluations in young people. Schools play a major role in providing formal sex education. However, some interventions have been delivered outside the school environment, for example in healthcare and community centres, or youth organizations. Interventions should follow a comprehensive model, ensure that teachers are properly trained, be delivered throughout the curriculum, and involve families [27]. It is striking that, even though the family is a key agent in promoting SRH, very few interventions are carried out in this area. In fact, in the Barriuso-Ortega et al. [21] review of sex education programmes, only 21.3% of programmes included families. The review by Orte et al. [43] points out that educational interventions that incorporated home-based interventions were more effective.

Within the health sector, youth-friendly centres stand out for their ease of access, the services they provide, the skills of their staff and their guarantee of confidentiality [41]. Pharmacies are also confirmed as an effective agent for promoting SRH [37].

The review by Orte et al. [43] includes interventions carried out in both educational and community settings and concludes that those that included the participation of key leaders and agents from the young people’s community were more effective in increasing knowledge about SRH. These mechanisms are effective in improving access to SRH for LGBTI people, as they allow them to create a safe space and find a like-minded community.

Continuing with interventions in the digital sphere, various reviews confirm that online methodology is effective in the indicators analysed [30,32,40]. Martin et al. [30] state that digital interventions allow for greater personalisation of interventions according to the needs of adolescents, such as interventions for the LGBTI community and racialised people. Liu et al. [40] also highlight the importance of social connection and community involvement in achieving better results in digital interventions, in combination with the presence of trained professionals. O’Farrell et al. [42] conclude that it is necessary to increase inclusive and comprehensive online interventions, as they are effective and allow for greater inclusivity and ease of access.

3.3.4. Participant Profile

The age range is between 10 and 35 years old. Therefore, the analysis is based on a broad definition of youth that goes beyond the purely age-based definition at both ends of the spectrum. In any case, it should be noted that, in most reviews, the interventions analysed focus on adolescence, which generally covers the ages of 10 to 19 years old. On the other hand, the review by Denno et al. [34] analyses interventions for the training of trainers in programmes aimed at adolescents.

Furthermore, the interventions integrate the participation of diverse profiles in terms of ethnicity, gender, sexual orientation, socioeconomic status and disability. Certain interventions are cross-cutting and do not focus on a specific profile, while others do target specific groups, such as the review by Hameed et al. [39], aimed at people with disabilities, or the review by Bouaddi et al. [33], on SRH interventions aimed at migrants.

3.3.5. Strategies

The reviews describe different strategies for promoting SRH. Most of them include CSE-based programmes in different settings. However, health interventions [37,41], interventions to improve access to SRH services [28,33], awareness campaigns [29] and training for professionals [34] are also described.

3.3.6. Duration

Torres-Cortés et al. [31], Stewart et al. [29] and Barriuso-Ortega [21] state that the most effective interventions have a greater number of sessions. Specifically, in sex education, it is important that it be carried out continuously throughout the curriculum and not in isolation [45]. Evidence supports the start of sex education from childhood, as well as inclusive education throughout the curriculum [36].

3.3.7. Methodology

Most interventions use active methodologies that involve young people. Currently, the use of innovative tools and digital media, such as simulators or virtual reality, stands out.

One aspect that several studies identify as a determinant of the effectiveness of interventions is the quality of professional training [21,27,31]. In this regard, Denno et al. [34] analyse training interventions for health professionals that promote SRH in young people and conclude that they must have the skills and attitudes to provide evidence-based SRH care without judgement or discrimination. The results of the interventions in the review were very heterogeneous, but they conclude that the skills and attitudes of healthcare professionals increased from the pre-test to the post-test and that young people were satisfied with the care and information they received. Regarding the characteristics of the training (received by trainers), they highlight the importance of an active and participatory methodology, small groups, several sessions and the presence of a supervisor with the necessary skills.

Beyond training, the skills of those implementing SRH interventions also determine their effectiveness. O’Farrell et al. [42] describe the positive attributes of trainers for inclusive interventions to be effective: interpersonal skills development, active listening, acceptance, and the ability to provide emotional support.

It is also worth mentioning that several reviews include programmes in different settings that apply the peer training methodology, in which certain young people are trained and then go on to train their peers [21,29,33]. Although Barriuso-Ortega’s meta-analysis [21] found no relationship with effect size, the interventions that used it obtained significant results in increasing knowledge, attitudes and skills in SRH. Stewart et al. [29] state that 31 studies out of a total of 55 used this methodology and obtained statistically significant results.

3.3.8. Outcome Indicators

The outcomes evaluated in interventions to promote SRH are highly heterogeneous and varied. As specified in the Introduction, effectiveness in interventions is conceptualized differently across studies. Some evaluations equate effectiveness with improvements in knowledge, as measured by pre- and post-intervention tests, while others consider changes in attitudes, such as more equitable views on gender or reduced homophobic attitudes. Certain studies measure behavioural outcomes, including delayed sexual debut and increased condom use. These varying definitions mean that an intervention deemed “effective” in one study may not be directly comparable to another. This makes it difficult to conduct meta-analyses and to extrapolate and generalise the results.

• Changes in knowledge:

Almost all the interventions analysed aimed to increase knowledge about SRH. The results suggest that, in general, the interventions were effective in achieving this increase [21,27,30,31,32,33,39,43]. In this regard, the evidence points to an increase in knowledge about gender-based violence [36,39], emotional relationships, personal safety and sexual abuse [36], menstrual health [35,39] and use of health services [33].

• Changes in beliefs and attitudes

Regarding interventions aimed at young people, changes in risk prevention attitudes were identified, such as positive attitudes towards condom use. Positive attitudes have been shown to encourage condom use [21,31]. Beyond biological aspects, interventions also promoted broader social and relational attitudes. Evidence points to reductions in homophobic attitudes and bullying, improvements in attitudes towards emotional relationships, communication, personal safety, and sexual abuse [36], as well as more equitable views and behaviours related to gender norms and stereotypes [27,29]. Additional studies reported shifts in attitudes towards gender-based violence [36,39] and more positive perceptions of menstruation [35].

With regard to interventions aimed at professionals, the studies analysed show improvements in the skills and attitudes of healthcare professionals who promote SRH [34,41]. In the review by Bohren et al. [28] on interventions to reduce stigma, it was found that the programmes succeeded in reducing racial prejudice among trained professionals, but it was impossible to verify whether this led to changes in practice. These interventions also achieved an increase in the satisfaction of young people cared for by trained healthcare professionals [28,34], as well as a decrease in perceived stigma [28].

• Behavioural changes

Haberland [38] shows that half of the interventions analysed led to significant reductions in the incidence of STIs and unplanned pregnancies. However, these biological outcomes are evaluated in few studies as they involve long-term assessments. These interventions included gender perspective and empowerment. In contrast, condom use is a much more common indicator. Several studies point to an increase in condom use of around 29% because of the interventions. In most cases, this was measured through self-reported questionnaires or surveys. Others point out that interventions that incorporated pleasure [44] and gender perspective and empowerment [27,38] were particularly effective.

One of the reviews concludes that interventions promote the use of menstrual cups and other menstrual products [35]. On the other hand, several meta-analyses show a reduction in the incidence of cases of gender-based violence, with effects lasting up to four years after the intervention [31,36]. Finally, the development of skills to deconstruct information from the media was demonstrated, understanding how the media affects both the self-perception and norms of young people. This allows them to acquire and put into practice a critical perspective on the media [36].

• Changes in psychological aspects

Barriuso-Ortega et al. [21] show in their meta-analysis that interventions increase self-efficacy. Bailey et al. [32] also observe an increase in self-efficacy in comprehensive digital interventions. Other studies identify an improvement in empathy, self-esteem and a positive body image for interventions aimed exclusively at people with disabilities [36,39]. Finally, a single study demonstrates a reduction in levels of depression, stress and anxiety among young LGTBI people.

4. Discussion

The interventions analysed in the reviews are very heterogeneous given the broad focus of SRH. Therefore, it makes no sense to analyse only their results; rather, the specific mechanisms that enable the interventions to be effective must be studied. In this regard, Ketting et al. [23] point out that the results or impact of interventions that promote SRH should be interpreted according to the characteristics of the programme and the evaluation of its implementation. Therefore, in addition to analysing the effectiveness of the interventions, this review also presents the characteristics of effective programmes. Thus, the effectiveness of CSE-based programmes is demonstrated and the key elements of these interventions are presented, which allows for the generation of new evidence-based interventions and serves as a guide for different professionals and policy makers.

The heterogeneity of the interventions included in this review not only prevented the performance of a meta-analysis but also has important implications for the interpretation of the results. Variations in intervention design (community, school, healthcare and digital settings), target populations (adolescents, young adults or healthcare professionals) and outcome measures (knowledge, attitudes, behaviours, psychological aspects or access to services) make it difficult to generalise “effectiveness” across all contexts. In addition, factors such as the cultural and political environment, as well as the duration of programmes, may moderate the results. All of this suggests that effectiveness is not a uniform outcome but rather depends on the appropriateness of interventions to the characteristics of each population and context. Future reviews could advance by more systematically mapping the characteristics of interventions in relation to observed outcomes, which would allow for the identification of which strategies work best in each setting.

The main outcome assessed by most interventions is knowledge. However, many of the studies analysed are vague when it comes to specifying exactly what knowledge they intended to expand. In addition, each study uses different indicators, which makes comparative analysis difficult. It is necessary to standardise the indicators used to measure the effect of SRH interventions [41]. In addition, indicators with a comprehensive approach should be used in the field of sex education. In the same vein, the review identifies that many studies use only risk-focused indicators: knowledge, attitudes and skills about STIs and condom use. This confirms Michielsen et al.’s [22] assertion that the predominant indicators continue to be those related to public health and behaviour change, even in programmes that adopt a comprehensive perspective. There is a lack of consensus on the standardisation and application of indicators related to sexual well-being. However, as certain selected reviews show, there is beginning to be more evidence on the effectiveness of CSE.

Future evaluations could adopt a core set of comprehensive indicators that balance risk reduction with holistic outcomes. Existing frameworks provide useful guidance: the Future of Sex Education Initiative [46] standards define learning objectives related to consent, healthy relationships, gender identity, sexual orientation and equity. UNESCO [6] recommends monitoring the inclusion of essential CSE topics (e.g., consent, healthy relationships, gender identity, sexual orientation, and equity), access to SRH services, quality of education, community participation and program evaluation. Similarly, UNFPA [15] emphasizes indicators for service coverage, quality, equity in access and community engagement. Adoption of such indicators would enable more comparable evaluations and inform evidence-based policy and practice. Complementing these frameworks, the Sexuality Education Review and Assessment Tool (SERAT) offers a practical Excel-based instrument for evaluating CSE programmes, identifying strengths and gaps, and ensuring alignment with UNESCO standards, with a focus on gender and human rights [15].

This is closely linked to the lack of coverage of certain content in programmes. Many interventions are still carried out without a comprehensive perspective or a sexual and reproductive rights perspective. They do not incorporate aspects such as pleasure, relationships, gender perspective and sexual diversity. Nor do they incorporate topics related to endometriosis, non-normative bodies, fertility, pregnancy or assisted reproduction techniques. Integrating a gender perspective allows programmes to address structural inequalities and power relations that influence sexual and reproductive health behaviours, promoting more sustainable changes in practices and norms. Similarly, the inclusion of sexual pleasure contributes to framing sexuality not only in terms of risks or disease prevention, but also as a positive, holistic aspect of wellbeing. This approach can increase young people’s motivation to engage with interventions and encourage changes in knowledge and attitudes. This translates into more lasting behaviours.

Goldfarb et al. [36] conclude that the intersectional perspective should be incorporated into the curriculum, education, and assessment. This coincides with the current recommendations of the Future of Sex Education Initiative [46]. The intersectional perspective was not applied in all the reviews included. Studies generally do not consider power relations and the structural dimension, which generates inequalities. The article by O’Farrell et al. [42] is the only one that analyses interventions that are inclusive and aimed at all types of people. Liu et al. [40] analyse interventions aimed exclusively at the LGTBI population, while the rest of the reviews take a cisheteronormative view. On the other hand, only Hameed et al. [39] and Evans et al. [35] mention people with disabilities. With regard to migrants, Bohren et al. [28] conclude that, in general, interventions that focus on describing the problem of stigma and discrimination do not address it in their design; on the other hand, those that promote equality, access and quality of care for certain groups do so without mentioning stigma or discrimination. They also identify interventions that focus on the stigma perceived by migrants in healthcare institutions but ignore the structural and social conditions that perpetuate this discrimination. Therefore, there is much evidence of existing stigma but little evidence on how to reduce it. Another aspect to highlight is that the results sometimes tend to homogenise the population, without disaggregating it into categories such as age, ethnicity, sexual orientation, gender identity or other categories that should be considered depending on the context [47]. This omission can lead to inequalities, as certain programmes considered effective for majority groups may not meet the needs of specific populations. It is therefore necessary to integrate intersectionality more strongly into the design and evaluation of interventions, to ensure not only effectiveness but also equity. Future evaluations could benefit from incorporating established frameworks that explicitly address intersectionality and equity. For instance, the Intersectionality-Based Policy Analysis (IBPA) framework provides guidance for researchers, health professionals, civil society and policymakers seeking to address health inequalities [48]. The Health Equity Impact Assessment (HEIA) tool offers an approach to measure differential effects across groups in a program or policy [49]. Finally, the disaggregation of outcomes by sociodemographic variables (e.g., gender, sexual orientation, disability, migration status) should become a standard practice to capture inequities. However, in certain policies, intersectionality is erroneously reduced to a list of axes of inequality that vary according to context. In other words, the focus is placed on each of these axes of inequality in isolation. It is not just a matter of addressing identities in a fragmented way, but of linking them to structures of oppression [50].

Most reviews highlight the lack of training among professionals. Gonsalves et al. [37] state that there are still barriers to accessing SRH services in pharmacies, as some pharmacists are unwilling to provide advice and distrust the judgement of young people. Sell et al. [27] conclude that teachers unconsciously reinforce gender stereotypes. O’Farrell et al. [42] conclude that trainers do not have sufficient resources or training to deliver inclusive digital programmes, and that they even must resort to the Internet to obtain the appropriate information. Therefore, the lack of training for professionals in all areas remains a weakness that needs to be addressed.

Most evaluations focus on short-term results or impacts, as long-term results are complex and costly to analyse. This completely conditions the available evidence and explains why more information is available on the effect of interventions on young people’s knowledge or attitudes than on their behaviour, as the latter takes longer to change. However, both knowledge and attitudes may diminish over time if they are not reinforced, so this may affect long-term results. Therefore, interventions should include strategies for ongoing reinforcement and follow-up. Moreover, longitudinal studies are needed to track behavioural and structural changes over time, such as reductions in gender-based violence, improved access to services, or shifts in social norms. Methodological challenges such as participant attrition, funding constraints and program fidelity must be addressed. This requires specific strategies. To reduce attrition, studies can establish strong participant follow-up systems, employ digital tools and include incentives that encourage long-term participation. Funding limitations may be mitigated by integrating evaluation into existing health and education infrastructures and fostering partnerships with governments. Ensuring fidelity in program implementation requires standardized training for professionals, continuous quality assurance mechanisms and participatory monitoring that involves both educators and young people [51]. Barriuso-Ortega et al. [21] meta-analysis on the effectiveness of sex education programmes includes primary studies that successfully provide long-term results (more than 18 months after the intervention). However, only 10% of the primary studies carried out these long-term evaluations.

In addition, it is necessary to increase programme evaluations to design new evidence-based programmes. Many innovative interventions with potential are not rigorously evaluated, and therefore the results obtained cannot be disseminated.

There are not many reviews of systematic reviews conducted with this approach. Much of the information obtained in this review coincides with the study by Lameiras et al. [52]. They analysed reviews of interventions to promote SRH from 2015 to 2020. These interventions were in the digital, educational and blended learning programme fields. They also concluded that many programmes only focus on risky behaviours, neglecting aspects such as pleasure or gender diversity. Also noteworthy is the review by Salam et al. [53], which reviewed all types of interventions to promote SRH in adolescents. They also included interventions to prevent female genital mutilation and gender-based violence. They concluded that more rigorous studies were needed, with long-term evaluations and standardised indicators. On the other hand, the review by Denford et al. [54] included 37 reviews with interventions that exclusively evaluated risk behaviours in the educational setting. However, they did not obtain clear results regarding the effectiveness of the interventions in terms of attitudes, skills and behavioural changes.

The findings of this review have important implications for policy and practice. Evidence indicates that CSE and approaches based on rights and intersectionality are most effective when embedded in supportive policy frameworks. Policymakers can strengthen their impact by integrating these interventions into national SRH strategies, ensuring adequate funding and promoting intersectoral collaboration between education, health, and community. In practice, this means tailoring programmes to the needs of diverse groups, investing in professional training, and ensuring equitable access to SRH services. In addition, establishing rigorous evaluation and results dissemination mechanisms can contribute to policy learning and improved implementation of interventions.

Limitations of the Study

This review of reviews provides relevant results and information. However, it has certain limitations that should be considered. On the one hand, the interventions have very heterogeneous characteristics and results, which prevents the performance of a meta-analysis or the establishment of certain comparisons. On the other hand, although the search has been carried out exhaustively in the main databases, relevant studies may have been excluded, particularly reviews published in languages other than English or Spanish. Furthermore, most of the included reviews assess short-term outcomes. This limitation should therefore be considered when interpreting the findings and underscores the need for long-term-evaluation. Another limitation is that the exclusion of reviews focusing exclusively on HIV/STIs may have introduced selection bias, even if justified by the aims of this study. Finally, as this review analyses published reviews, the findings are subject to the limitations of those reviews, including potential publication bias and variability in methodological quality.

5. Conclusions

This review shows the specific mechanisms that enable the interventions to be effective. The meaning of “effectiveness” varies considerably across studies. Results often focus primarily on risky behaviours, without taking into account other aspects such as pleasure, emotional relationships or gender diversity. This effectiveness observed is linked to certain characteristics in the design and implementation of the programmes, so it is necessary to explore them in greater depth and take them into account when designing future programmes and public policies. In terms of policy, the findings underscore the importance of incorporating comprehensive, rights-based and intersectional approaches into national SRH strategies, ensuring sustainable funding and intersectoral collaboration. In practice, it is essential to tailor programmes to the needs of diverse populations, strengthen professional training and ensure equitable access to SRH services. The gaps identified in the evidence should also be considered for future research. To this end, it is necessary to standardise the design and evaluation of interventions.