Against a backdrop of changing sexual repertoires, young people report higher levels of unsafe sex and higher rates of sexually transmitted infections (STIs) than any other age group.1,2 Early intervention is required to prevent risks converting to poor lifetime sexual health, and schools are particularly well placed to facilitate these interventions.3 Young people who cite school as their main source of information about sex are less likely to report unsafe sex and previous STI diagnosis.4 The proportion of people citing school as their main source is increasing,5 but the content and quality of provision of sex education in UK schools is variable.6 Over two-thirds of young people report inadequate knowledge when they first felt ready for sex,5 suggesting significant room for improved delivery of school-based sex education.
Young people are susceptible to powerful social influences that could enhance or undermine school-based sex education. These include norms and values that are transmitted both offline and online via peer networks. With respect to the latter, social media can increase social connectedness, strengthen social identity and facilitate access to health information, but it also adds risk of exposure to harmful messages, social pressures and bullying.7
Against this background, we sought to develop and assess a novel school-based intervention that addresses limitations of existing peer-led sex education, while unlocking the potential of peer influence and social media.
Sexual health of young people
Almost one in six young people (aged 16–24 years) report unsafe sex, defined as at least two partners with whom no condom was used in the past year. This is higher than in any other age group.8 In England in 2015, 15- to 24-year-olds accounted for 62% of heterosexual people diagnosed with chlamydia, 52% of heterosexual people diagnosed with gonorrhoea, 51% of heterosexual people diagnosed with genital warts and 41% of heterosexual people diagnosed with genital herpes. The diagnostic rate of chlamydia was 824 per 100,000 in males aged 15–19 years and 2436 per 100,000 females of the same age.9 In Scotland, 65% of all diagnoses of chlamydia are among young people aged < 25 years; and among women, 75% of diagnoses were in those < 25 years.9 There has been a significant shift in young people’s sexual repertoires over recent decades. The proportion of young people (aged 16–24 years) in the UK reporting all three types of intercourse (oral, vaginal and anal) rose from 10% in 1990 to 20% (females) and 25% (males) in 2012, primarily reflecting an increase in those experiencing oral and anal sex.1
A narrow focus on risk avoidance ignores key inter-relationships between risk and other aspects of sexual health and well-being. Young people’s sexual behaviour is influenced by social factors, including gender stereotypes, peer pressure and social expectations.10 It is therefore important to look beyond the biological markers of sexual health and focus on outcomes that are more meaningful to young people, such as the quality of sexual relationships, in particular the reduction of sexual violence (including discrimination) and improved sexual experience.11 Positive romantic relationships are associated with both good physical health and good mental health, and supportive social networks, lending support to the notion of synergistic benefits between these aspects of young people’s lives.12 There are calls to place greater emphasis on sexual enjoyment to reduce sexual risks (e.g. promoting the pleasurable use of condoms).13
Reframing adolescent sexual health as a positive developmental process offers a focus on outcomes that may be more meaningful to young people.14 Sexual health interventions should consider both risk taking and risk reduction, and how pleasure (as an underpinning mechanism) can account for both. Ideally, intervention development should be driven by sexual health policies that promote positive sexual health and well-being, in addition to reducing risks.13
Sexual health policy in the UK
All four countries in the UK have sexual health strategies that emphasise the importance of prevention and treatment of sexual health problems among young people. A central focus is to develop and reinforce positive cultural norms, openness, respect and responsibility as key drivers of improving sexual health.15–18
These strategies also indicate the need to implement digital platforms to improve access to sexual health resources and services, including social media for sexual health promotion.16 School-based sex education is compulsory in England and Wales, but not in Scotland and Northern Ireland. All UK policies focus on developing sexual health knowledge and attitudes in relation to biological outcomes (e.g. STIs and pregnancy). All UK policies include the emotional, social and relational aspects of sexual health.
In addition, Scotland has The Curriculum for Excellence, which seeks to build an educational environment in which young people can become successful learners, confident individuals, responsible citizens and effective contributors to society.19 The emphasis is on more rounded development, which values personal and social growth in addition to academic achievement, including benchmarks to evaluate sexual health promotion. This fits into the Scottish Government’s broader policy for child and family support and development known as Getting it Right for Every Child20 and a national resource titled Relationships, Sexual Health and Parenthood for use in a range of educational settings.21
Sexual health interventions: evidence of effectiveness
School-based interventions
Most sexual health interventions for young people are school based, as this setting facilitates access to the widest range of young people in terms of socioeconomic background and vulnerability to poor sexual health. Schools provide a major context for social development22 and are ideally placed to challenge unhealthy and inequitable norms underpinning sexual risk behaviours.23 For interventions attempting to diffuse change through social networks, schools provide a ‘captive audience’ and naturally occurring friendship groups.24
School-based interventions tend to comprise one or both of:
- sexual health education and training to improve knowledge, exploring emotions and sexual norms, developing sexual negotiation skills and self-efficacy, and making informed choices3,25
- providing access to sexual health services either in or out of school, including condoms or access to other forms of contraception (e.g. hormone-based medication).26–29
Evidence from older systematic reviews suggests that school-based sex education has an effect on sexual health knowledge and attitudes, but only some programmes delay sexual behaviour and increase condom use.3 Shepherd et al.25 are cautious about the impact of such programmes in bringing about behavioural change, acknowledging that significant changes in sexual health knowledge and self-efficacy (e.g. knowing how to use a condom) are more common.
More recent systematic reviews suggest that combining education with contraceptives or access to sexual health services may be more effective. For example, Oringanje et al.27 found that providing education alongside contraceptives increases condom use and may reduce unintended pregnancies. Interventions that combine education with interactive techniques to improve condom use, teaching how to negotiate sex and providing a range of contraceptives can lead to an increase in knowledge and effective use of contraceptives, delay sexual initiation and improve condom use.28 Owen et al.26 found that school-linked sexual health services did not encourage sex or risk-taking, and may at best reduce chlamydia infection (males only) and pregnancy; however, the evidence is based on a small number of mainly US studies of variable quality. Studies rarely show an impact on biological markers, such as human immunodeficiency virus, herpes and syphilis, partly because these are relatively rare outcomes and require extremely large samples to detect an effect.29
A number of contextual factors affect these outcomes. A review of process data from trials30 suggests two key influences: (1) fidelity, influenced by the extent to which the school has a supportive culture, a flexible administration, and enthusiasm and expertise among those delivering the sexual health content; and (2) acceptability and engagement, influenced by enthusiasm, credibility and expertise of intervention providers, and relevance and enjoyment to young people. Another systematic review31 noted the diversity in approaches of effective interventions, suggesting that a range of mechanisms exist.
Peer interventions
Peer education is a method of disseminating knowledge, values or achieving behaviour change through a social network, delivered by someone of a similar age and standing in that network.32 The theoretical appeal of peer involvement lies in its potential to reinforce positive values and beliefs, thereby strengthening social norms that might influence sexual behaviour.33,34 The key mechanisms include role-modelling,35 a shared identity between the peer workers and their peer group, and the ability of the peer workers to influence their networks.32 There is a range of peer-led roles and approaches, including educator or assistant educator,35 peer supporter (PS) and, occasionally, peer leader.32
Evidence from systematic reviews on the evaluations of peer sexual health interventions for young people demonstrates a weak effect on sexual attitudes, knowledge and intentions, and ‘unconvincing’ evidence for the impact on sexual behaviour.32,35,36 Methodologically, reviews have highlighted a paucity of peer-based sexual health interventions for young people that are evaluated using randomised control trials.32
Two notable studies in the UK33,34 engaged peer educators to replace teaching staff, at least in part; however, in the other studies peer educators assisted teachers. Across peer-led interventions, the dominant model is one of a peer educator (teacher) rather than peers as supporters of positive norms and behaviour.32–36 Involving youth peers as ‘influencers’ within their sexual networks has been under-researched in the field of sexual health.36 In a review of peer interventions aimed at addressing a range of health and social issues, Harden et al.37 identified five studies that compared the effectiveness of peer leaders with teachers in delivering the same intervention. In one sexual health evaluation from the USA, peer leaders were found to be generally more effective than teachers. More specifically, peer leaders are thought to be more effective at establishing conservative (non-risky) norms, but less effective than adults at imparting factual information and getting students involved in classroom activities.34 A formal teaching role may undermine credibility with peers38 and may be less effective than informal social support work.39
Participation rates in peer interventions vary and further research is required to optimise the most appropriate level of peer participation, which should consider the level of social ease experienced by peer workers, establish how participation affects peer networks and include theoretically informed outcome measures.32,35,36
How peer educators are chosen and their reputation among peers is important.32,33 Most studies rely on self-selection or teacher selection, but both these strategies may result in educators who are not particularly credible and find it difficult to reach high-risk students.40 The Students Together Against Negative Decisions (STAND) study used peer nomination and diffusion of innovation theory in a youth-focused sexual health intervention in schools.41 Peer leads delivered an education-based programme to ‘opinion leaders’, who were then asked to engage with their networks (although not via social media). Awareness of the STAND study intervention was high. The intervention was effective at improving knowledge and behaviour among those trained, but had mixed success in diffusing risk reduction practices to other non-trained students.41
Digital media interventions
Digital media offer inspiration for rethinking sexual health promotion.42 There has been an exponential increase in the use of digital media by young people in the last decade, including social networking, mobile applications (apps), video sharing, podcasts, online games and video or photo communications.43 Most (95%) young people in the UK use social networking sites at least once per week, most commonly Instagram (URL: www.instagram.com; Facebook, Inc., Menlo Park, CA, USA), Snapchat (URL: www.snapchat.com; Snap Inc., Santa Monica, CA, USA) and Facebook (URL: www.facebook.com; Facebook, Inc., Menlo Park, CA, USA).7 Technologies such as smartphones give unprecedented mobile access to the internet.44 New internet-based platforms, including social media, offer greater opportunity for more interactive communication, possibly at the point of health-related decision-making. Digital media can deliver interventions conveniently and anonymously to young people using personalised information.45
In theory, digital media offers the potential to deliver sexual health messages to those who are already making use of these technologies and are confident in using them.46 Recent systematic reviews on the impact of digital media on young people found that it can improve sexual health knowledge (of STIs and emergency contraceptives) and self-efficacy (condom use and STI testing), and reduce sexual risk behaviour, but there has been no demonstrated impact on biological outcomes.42,47–50
The popularity of social networking sites among young people render these as obvious candidates for sexual health promotion, although those in the health and research communities have been slow in using this approach.51 A review of early interventions indicated that these sites were mainly used to heighten awareness of online sexual health programmes.52 Few studies have examined the impact of social networking sites on the sexual health of young people. One cluster randomised controlled trial53 found that a peer-led community-based Facebook intervention called ‘Just/Us’ increased condom use over a 2-month period, although the effect diminished by 6 months. Another pilot study54 reported a potential increase in condom use and reduction in chlamydia infection.
Recommendations from systematic reviews highlight the need to involve young people in the design of digital interventions, the importance of using theory to inform intervention development and the importance of using stronger research designs,42,50 including research in the use of social media for sexual health promotion.45 Few digital media programs provide tailored advice and none assesses social network interventions in school settings.42,47,48 On a pragmatic level, findings from the evaluation of the FaceSpace project highlight the importance of securing sufficient resources for developing social network platforms and maintaining a high profile, reach and engagement with young people.55,56
Summary and scientific rationale
It is over 10 years since Kirby et al.3 published their seminal review of sex education in schools, and the substantial growth in evidence since then suggests that school interventions have a consistent effect on sexual health knowledge and attitudes, but less so on sexual risk behaviours. A key question, therefore, is how to enhance these effects.
Digital media offer an exciting opportunity to work with young people through their networks using social media platforms. Few digital media programs provide tailored advice and, to our knowledge, none has assessed social network interventions in school settings to tackle sexual health.42,47,48
Peer interventions could be combined with online social networking sites to enhance effects. The weight of evidence on the effectiveness of peer interventions suggests a similar or weaker pattern to that of traditional school-based interventions.32,35,36 Four important issues are often overlooked: (1) how peer educators are recruited,30,32 (2) the nature of their influence,36 (3) their position within their network20,40 and (4) the need to establish outcomes that are theoretically informed.32,35,36 These are issues we sought to address in this study.
The intervention in the current study [Sexually Transmitted infections And Sexual Health (STASH)] builds on a peer-led smoking prevention intervention [A Stop Smoking In Schools Trial (ASSIST)], which recruited and trained ‘influential’ students (aged 12 or 13 years) as PSs in schools to spread and sustain non-smoking norms through informal interactions with peers.40 A cluster randomised control trial57 found that smoking was reduced over a 2-year period. The intervention is recommended by National Institute for Health and Care Excellence (NICE)58 and is now disseminated under licence in hundreds of schools, in over 30 areas in England, Wales, Scotland and France (see Chapter 2, Developing a theory-informed young people’s sexual health intervention).
ASSIST is based on diffusion of innovation theory, which explains how new ideas are adopted across social networks.59 Instrumental to this is the influence of early adopters (peer leaders), who seek to bring about change in others. Critically, the peers are tasked with changing (or reinforcing positive) norms and competence. ASSIST also draws on implementation theory (IT), which includes normalisation process theory60 and accounts for how, and to what extent, interventions are embedded in the existing school environment.
Following the Medical Research Council (MRC)’s guidance on the development and evaluation of complex interventions,61 there are five key reasons why a feasibility study is required here. First, our proposed intervention is novel in that it comprises elements that have not been combined in previous sexual health interventions for young people, namely setting (secondary schools) and method of delivery (influential peer leaders, social networking and social media). Second, there are a number of design challenges and uncertainties specific to our proposed approach (detailed in Chapter 2). Third, we need to better understand the extent to which the intervention works as intended, including the facilitators of and barriers to implementation. Fourth, there is the need to establish a theoretical understanding of the mechanisms that may lead to improved sexual health for young people and thereby identify the most appropriate intermediate and outcome variables for a trial. Finally, given the lack of controlled trials and drawing from guidance regarding the best use of resources,61 we need to consider the resource and methodological implications of conducting a large trial, including the feasibility of an economic analysis.
In conclusion, given the popularity of social media platforms among young people and their potential to access and influence social networks, this is an opportune time to integrate these with peer-based approaches in a closed social system, such as a school. Theoretically, these may act synergistically to develop and strengthen cultural values, thereby supporting social norms that influence sexual behaviour.
Aims and objectives
The aim of this study is to develop and test the feasibility and acceptability of a school-based intervention delivered by PSs (the STASH study) to reduce transmission of STIs and improve the sexual health of secondary school students aged 14–16 years in the UK.
The objectives of the study are to:
- finalise the design of a school-based STI prevention intervention, in which influential PSs use online social networks and face-to-face interactions to influence norms, knowledge, competence and behaviour, and promote the use of sexual health services
- assess the recruitment and retention of PSs, as well as feasibility and acceptability of the intervention among PSs, participants and key stakeholders
- assess the fidelity and reach of intervention delivery by trainers and PSs, including barriers to and facilitators of successful implementation
- refine and test the programme theory and theoretical basis of the intervention
- enhance understanding of the potential of social media, when used by influential peers, to diffuse norm change and facilitate social support for healthy sexual behaviour
- determine key trial design parameters for a possible future large-scale trial, including recruitment, retention rates and strategies, outcome measures, intracluster correlation (ICC) and sample size
- determine the key components of a future cost-effectiveness analysis and test data collection methods
- establish whether or not pre-set progression criteria are met and if a larger-scale trial is warranted.