1

Sex Education and Its Impact on Teenage Pregnancy

Madeline Barbato, Mia Bruno, Samantha DiTosi, and Ashley Fabian

Department of Nursing Youngstown State University

NURS 3749: Nursing Research

Danielle Class

April 6, 2022
 2

Introduction

According to the Center for Disease Control (2021), US teen birth rates have seen a

steady decline since 1991. Between 2018 and 2019, teen births per 1000 females decreased from

17.4 to 16.7 (Center for Disease Control, 2021). Although evidence supports that teen pregnancy

is continuing to decline, the reason for this change is unknown. Researchers have hypothesized

that factors including access to birth control, increase in abstinence from sexual intercourse, and

reform to sex education programming could be contributing to the decline. Significance of teen

pregnancy prevention remains a public health priority as it correlates with increased risks for

complications such as preterm birth and low birth weight according to the World Health

Organization (2020).

PICOT

This literature review was conducted to determine what factors influence teen pregnancy.

The following PICOT question was developed: “For adolescent females, does the

implementation of safe sex-centered education in schools reduce the risk of teen pregnancy

compared with no safe centered sex education in public schools?”

Methods

Using Maag library databases, three nursing-related databases were used such as

ProQuest, MedLine, and CINAHL. Criteria for selecting articles was that it needed to be in

English originally, peer-reviewed, in academic journals, and research papers. The literature also

needed to be published in the last five years to be considered. For the ProQuest database, the

initial search included “Teen Pregnancy” and “Comprehensive sex education” which yielded 56

results. For the CINHAL database the terms “comprehensive sex education” “teen pregnancy”

and “school nursing'' yielded 60 results. For the Medline database, the terms were “Sexual
 3

education” and “teen pregnancy” which yielded 156 results. Abstracts were reviewed to

determine if the articles related to sexual education and the impact on teen pregnancy. The

articles were selected by a review of abstracts and relevance to this topic. Eight articles were

used in this review.

Literature Review

After reviewing the eight articles there are three common themes. The themes include

abstinence-only education programs in schools, school nurse involvement along with

after-school programs, and comprehensive sex education. There has been a focus on these

themes throughout the research on how it impacts pregnancy rates among adolescents. Each

theme was reviewed to determine if comprehensive sex education reduces teen pregnancy rates.

Abstinence-only education (AOE) programs in schools

The role of policy on sexual health education has had an impact on the type of sex

education that is provided in schools. Although abstinence-only education programs in schools

had shown to be ineffective in decreasing teen pregnancy and STDs, federal funding continued to

support these programs primarily. Even though many states have favored AOE compared to

comprehensive sex education (CSE) in schools, CSE programs had shown the potential to

decrease the prevalence of teen pregnancy and even delay the initiation of sex to later years.

While sexual health education has evolved over the last 50 years, there had been

controversy regarding the growth rates of teen pregnancy despite the policies set in place by

schools. The biggest setback occurred in the 1980s due to the HIV epidemic. The promotion and

expansion of CSE halted in the 1980s in response to the HIV epidemic and efforts of the

religious right (Huber & Firmin, 2014). The legislation was enacted encouraging states to discard

CSE and adopt AOE (Carr & Packham, 2017). In 1981, the Adolescent Family Life Act was
 4

passed with the primary goal to promote chastity and self-discipline; in 1996, the welfare reform

law enacted Title V of the Social Security Act that provided grants to states that adopted AOE

and its tenets (Lerner & Hawkins, 2016). The succession of these events acted as the promotion

of AOE rather than CSE curricula in schools across the U.S., all stemming from the HIV

epidemic. The problem arose when leading health organizations and experts were promoting

CSE while schools and policy reform continued to support AOE education.

To assess the efficacy of these programs, three studies have been conducted. These

studies focused on abortion or teen birth rates to determine a difference in outcomes between

states that offered AOE and CSE curricula. Although a majority of the outcomes from these

studies reflected no statistical difference in teen birth or abortion rates between states, another

study reviewed a drastic increase in STIs after the change back to AOE programs in schools.

This is due to the lack of education provided in CSE or the belief that condoms work, which

proved to be a major factor leading to unintended pregnancies. These studies also revealed that

teen pregnancy and STI rates are higher in states that mandate an emphasis on AOE.

In a study analyzing the correlation between AOE funding and teen birth rates by state

from 1998 to 2016, researchers found that, overall, AOE had no effect on the incidence of teen

pregnancy (Fox, et al., 2019). The study further distinguished how AOE programs affected states

in correlation to the state’s political ideologies and whether or not CSE was offered alongside

AOE. In conservative states, which had significantly higher teen birth rates compared to

moderate and liberal states, AOE proved to be counterproductive in lowering birth rates when no

CSE was instituted in addition. The conclusion was that promoting abstinence to teens without

also teaching about contraceptive use had a negative effect on efforts to reduce teen pregnancy.
 5

Not only had AOE programs been ineffective at preventing teen pregnancy, but left

students feeling publicly shamed through fear-inducing tactics and refusals to answer the

questions that students ask about sex and pregnancy. The University of Texas set out to collect

stories from college-age students who had gone through some type of AOE program while in

high school (Hoefer & Hoefer, 2017). Sixteen students were interviewed during the study and

asked to recall personal experiences in an AOE program and reflect on the impact the curriculum

had on individual views of sex. One student shared that the teacher used the analogy of a “fish

out of water” to describe what pregnancy in high school would be like (Hoefer & Hoefer, 2017,

p. 269). Five of the sixteen students interviewed in the study remembered instances where

educators refused to answer a question that had been asked in class. When the students were

denied answers, interviewees explained that the instructors did so “in a way that publicly shamed

the student for daring to ask such a question by implying that the question was too inappropriate

to even bring up” (Hoefer & Hoefer, 2017, p. 268).

Evidence from this study had shown that the fear tactics and lack of clarity offered to

students through AOE programs could be contributing factors to why the curriculum is

ineffective at reducing teen pregnancy and overall sexual preparedness.

School Nurse Involvement and After School Programs

School nurses have been a resource for healthcare and health education in schools

throughout the U.S. Along with this role, school nurses are also a source of support and

confidentiality for teens in regard to STDs and unintended pregnancies. School nurse

involvement in sex education including condom availability and use, has been crucial in

decreasing STIs and unintended pregnancies when applied in school curricula. Although, this
 6

component involving school nurses as having a role in condom access has been in part

overlooked.

After-school programs have had an active role in the education of adolescents who

participated in sexual behaviors in a dangerous way. A study was conducted to examine if

after-school programs had been beneficial in the reduction of sexual behavior while being able to

provide safe sex education (Bogan et al., 2020). A sample had been conducted to evaluate sexual

behaviors among adolescents compared in three different states. Adolescents who had

participated in sexual behaviors prior to thirteen years of age in Mississippi was 8.3%, in New

Hampshire was 2.0% and the United States as a whole was 3.9%. The study had been measured

by the collection of data representing statistics of teen birth rates per 1000 births. Both young

boys and young girls were assigned to participate in an educational program. “Be a Responsible

Teen” (BART) was an educational program created to lower sexually transmitted diseases, lower

human immunodeficiency virus (HIV), and lower teen pregnancy rates.

Individuals were randomly assigned to a control educational program which involved

meeting one time for a total of two hours to discuss topics that consisted of HIV and acquired

immunodeficiency syndrome (AIDS) which occur with unsafe sexual behavior or met once a

week for a total of eight weeks to attend the BART course. The results from the study had shown

that individuals who attended the BART program had lowered sexual activity and were already

sexually active. Individuals who had participated in the BART program also had been detained

from beginning sexual activity altogether (Bogan et al., 2020). Overall, the study suggested that

there be more of a focus on reducing sexual activity during after-school hours compared to being

focused most on sexual health programs themselves.

Comprehensive sex education (CSE) decreases teen pregnancy

A study was conducted to determine whether students felt sexual education was adequate.

The study was titled “Perceptions of a School-Based Sexuality Education curriculum: Findings

from Focus Groups with Parents and Teens in a Southern State.” The study surveyed four

schools in Arkansas that had high teen pregnancy and STI rates. In those four schools, the

researchers surveyed parents and students about the quality of comprehensive sex education

(CSE) (Marshal et al., 2020). One of the main themes of the study was that “sex education

should be comprehensive and is currently inadequate” (Marshal et al., 2020, p. 37). These

schools with high teen pregnancy rates had some form of CSE but it was not comprehensive

enough in the eyes of the students and parents.

According to the study, “Both parents and students desired a comprehensive curriculum

including contraception, STI, and pregnancy prevention” (Marshal et al., 2020, p. 40). Many of

the students felt that topics such as pregnancy and STIs needed to be covered more extensively.

The conclusion from this study was that the quality of CSE in these schools was poor and did not

cover enough material. Many students in the study felt as though there was not enough education

being taught to make healthy decisions about sexual health and relationships (Marshal et al.,

2020, p. 46). The main recommendations from this research were to use evidence-based CSE on

a variety of sexual health-related topics to provide better quality information to the students

(Marshal et al., 2020).

Another study was conducted to determine the effectiveness of CSE programs in

decreasing teen pregnancy and sexually transmitted infections among adolescents. The research

“Comprehensive Sexual Education: A Comparison Study of Effectiveness in an Urban School

District,” looked at high-risk sex behaviors, such as no condom usage at Niagara Falls High
 8

School when there was sexual education and three years after the implementation of a CSE

program (Hall, 2020). The study was conducted in this school district due to high rates of risky

sexual behavior according to the research. “In 2015, among Niagara Falls High School students

who reported having had sex, 55.4% had sex before the age of 14, 37% did not use a condom,

12.3% did not use any pregnancy prevention method, 16.6% used alcohol and/or drugs during

last sexual intercourse, and 47.3% have had more than three partners in their lifetime” (Hall,

2020, pg. 1) This information was taken before implementation of a CSE program.

The study was conducted by survey over the course of 2015-2019. The results were a

decrease in students who have had more than three sexual partners and a decrease in engaging in

sexual activity early in life, while there was still an increase in students not using condoms and

pregnancy prevention. The researchers noted that the study could be improved by considering

demographic characteristics and other factors impacting safe sexual behavior. Overall, the study

concluded that “Evidence shows that a CSE program has positive effects on knowledge, skills,

and efficacy” (Hall, 2020, p. 2). Another point discussed was that these programs do not

eliminate unhealthy sex practices from occurring among youth, but do provide evidence-based

knowledge to make healthier decisions about sexual health.

A research study was conducted to evaluate research that compared how sexual education

taught by teachers in public schools helped teachers understand how to educate adolescents

about sexual encounters in addition to the effects of advising students about sexual awareness

(Ramírez et al., 2021). The sample included teachers and adolescents within grade schools of

second and third grade in Morelos, Mexico that were measured to evaluate the sexual education

program, CSE. Two teachers that were in second and third grade who taught sexual education

within public schools were chosen out of a total of 45 randomly selected schools. N=693 were
 9

students who had completed the CSE program while N=738 were adolescents who had received

traditional sexual education within public schools. (Ramírez et al., 2021).

To measure the data, a questionnaire created by the Mexican foundation contained

twenty-two questions that focused on teenage pregnancy and contraceptive usage. The

questionnaire results were evaluated on a 10 point scale with each person’s score multiplied by

ten points and divided by the number of questions which equaled twenty-two questions. The

adolescents that scored between 0-and 5 had scored unacceptable while adolescents that scored 8

or greater had an excellent score. (Ramírez et al., 2021). The results represented eighty-nine

teachers that took part in the CSE program with 36% being women who averaged 49 years old

while 63% of the other women averaged 40-59 years old. The teachers that participated in the

CSE program had an increase of 0.9 points based on multiple factors. The teachers received

better knowledge in understanding pregnancy among adolescents and contraceptive usage and

methods. Overall, the study suggested that teachers who had received CSE training understood

sexual education better. The study also suggested that students' sexual behaviors had decreased

as well. Further studies indicated that teachers must be better prepared as sexual educators for

adolescents. (Ramírez et al., 2021).

Recommendations for Practice

Based on the literature reviewed there is a recommendation for CSE in schools. The

evidence throughout the review is strong that AOE education is not as effective at preventing

teen pregnancy as CSE. Good quality CSE needs to be implemented in schools to prevent teen

pregnancy. The recommendation could also be more school nurse involvement in providing

condoms and education to adolescents. The literature reviewed also emphasizes the need for

after-school programs such as the BART program to reduce the onset of sexual activity in
 10

addition to halting the continuation of sexual activity in adolescents. The recommendation could

also focus more on how to prevent sexual activity beyond normal school hours.

Conclusion

The three major themes among the eight literature articles reviewed were abstinence-only

education in schools, school nurse involvement in sexual education in addition to after-school

programs, and comprehensive sex education. The literature showed that AOE is known to be

ineffective at preventing teen pregnancy while good quality CSE has had positive impacts on

preventing teen pregnancy. CSE also benefits from after-school programs and school nurse

involvement to further educate teenagers on sexual education. The significance of teen

pregnancy prevention has shown a decline with the inclusion of sexual education programs.
 11

References

Bogan, D. R., Aranmolate, R., & Mawson, A. R. (2020). Confronting the impact of teen

pregnancy in mississippi: The need for after-school programs. International Journal of

Adolescent Medicine and Health, 32(5), 1-4

doi:http://dx.doi.org/10.1515/ijamh-2017-0210

Centers for Disease Control and Prevention. (2021, November 15). About teen pregnancy.

Centers for Disease Control and Prevention. https://www.cdc.gov/teenpregnancy/about/

Fox, A. M., M.A., Himmelstein, G., B.A., Khalid, Hina, M.P.P., & Howell, Elizabeth A,M.D.,

M.P.P. (2019). Funding for abstinence-only education and adolescent pregnancy

prevention: Does state ideology affect outcomes? American Journal of Public Health,

109(3), 497-504. doi:http://dx.doi.org/10.2105/AJPH.2018.304896

Hall, K. L. (2020). Comprehensive sexual education: A comparison study of effectiveness in an

urban school district. Available from Nursing & Allied Health Premium. Retrieved from

https://www.proquest.com/dissertations-theses/comprehensive-sexual-education-compari

son-study/docview/2466049127/se-2?accountid=29141

Hoefer, S. E., & Hoefer, R. (2017). Worth the wait? the consequences of abstinence-only sex

education for marginalized students. American Journal of Sexuality Education, 12(3),

257–276. https://doi.org/10.1080/15546128.2017.1359802

Marshall, S. A., Hudson, H. K., & Stigar, L. V. (2020). Perceptions of a school-based sexuality

education curriculum: Findings from focus groups with parents and teens in a southern

state. Health Educator, 52(1), 37–51.

Rabbitte, M., & Enriquez, M. (2019). The role of policy on sexual health education in schools:

Review. Journal of School Nursing, 35(1), 27–38.

https://doi.org/10.1177/1059840518789240

Ramírez-Villalobos, D., Monterubio-Flores, E. A., Gonzalez-Vazquez, T. T., Molina-Rodríguez,

J. F., Ruelas-González, M. G., & Alcalde-Rabanal, J. E. (2021). Delaying sexual onset:

outcome of a comprehensive sexuality education initiative for adolescents in public

schools. BMC Public Health, 21(1), 1439. https://doi.org/10.1186/s12889-021-11388-2

Smith, S., Platt, J. M., Clifford, D., Preston, M., Satterwhite, C., Kelly, P. J., & Ramaswamy, M.

(2020). A state-level examination of school nurses’ perceptions of condom availability

accompanied by sex education. Journal of school nursing, 36(5), 386–393.

https://doi.org/10.1177/1059840518824728

World Health Organization. (2020, January 30). Adolescent pregnancy. World Health

Organization. https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy