The need for booster sex education: findings of a formative evaluation in rural Fresno County, California

ABSTRACT

Despite national guidelines advocating a comprehensive, age-appropriate, and sequential approach to sexual health education in schools, many young people in the USA do not receive sexual health information until high school. To date, there has been little research on the need for a supplemental round of sexual health education – a ‘booster’ – later in adolescence to reinforce and expand upon information and skills previously provided. In rural California, we conducted six focus groups with young people (N = 22, ages 14–20) and key informant interviews with youth-serving professionals (N = 10) to examine the sexual health education needs of youth as they complete high school. Five themes were identified, indicating a need for booster education that 1) reinforces existing sexual health knowledge; 2) expands beyond traditional areas of sexual health education; 3) addresses community stigma about adolescent health; and 4) prepares young people for the transition to adulthood. In addition, booster education should 5) be established within the school system to promote an environment that addresses and normalises health issues throughout the school year. Providing booster sexual health education may meet critical gaps in efforts to support the healthy sexual development of young people, especially those living in rural communities.

KEYWORDS:

• Adolescent
• sex education
• sexual health
• school health
• rural health

Introduction

Providing adolescents with information to understand their sexual health is critical to promote healthy sexual development, reduce the negative consequences of risky sexual behaviours, and create a foundation for healthy adulthood. In the USA, national standards have been developed to provide guidance to local school districts on the minimum essential content and skills that students should receive from kindergarten through to the later stages of high school, emphasising an approach that is comprehensive in content and sequential in execution across grade levels (Future of Sex Education Initiative 2020). However, there are no federal requirements directing school-based sexual health education for youth, and state and local decisions on content vary dramatically (Guttmacher Institute 2022; Hall et al. 2016). As a result, most youth in the USA report receiving some formal sexual health education by age 18, but the content is generally limited in scope and implementation is inconsistent in both quantity and quality (Guttmacher Institute 2022; Lindberg and Kantor 2022). Many young people do not receive sexual health education until high school (Centers for Disease Control and Prevention 2019; Lindberg and Kantor 2022) and cover only a fraction of topics listed in the standards, typically with an emphasis on preventing pregnancy and sexually transmitted disease (Kantor and Lindberg 2020). National data also indicate increasing gaps in receipt of sexual health education, with notable disparities in content received by gender, race/ethnicity, poverty status, and urbanicity (Lindberg and Kantor 2022; Lindberg, Maddow-Zimet, and Boonstra 2016).

Within this context, sexual health professionals have encouraged the provision of education to younger ages – in middle or early high school – so that young people receive information prior to engaging in their first sexual relationships (Goldman 2011; Coyle and Glassman 2016; Dinaj-Koci et al. 2015). This move to earlier ages likely reflected national concern with high rates of unintended pregnancies and sexually transmitted infections (STIs) among adolescents (Hall et al. 2016), as well as evaluation studies showing positive effects on reducing associated risk behaviours among youth who have not yet become sexually active (Goldfarb and Lieberman 2021; Mueller, Gavin, and Kulkarni 2008). As a result, the most commonly used interventions are designed for and implemented during the middle school to early high school years. For example, a review of 88 evaluation studies found that most programmes targeted youth ages 13 years and younger (44%) and ages 14 to 17 years (44%), with fewer focused on older youth (Goesling et al. 2014). Similarly, the majority of interventions included in the US Department of Health and Human Services’ vetted Teen Pregnancy Prevention Review have been designed for and tested with these age groups (U.S. Department of Health and Human Services 2017).

While there are benefits to providing sexual health education earlier in adolescence, there may also be drawbacks to this singular timing. Because sexual health education is typically offered in the USA once during the middle and/or high school years, young people receive their ‘dose’ at a relatively young age without further repetition or refinement. Yet there are a number of reasons why young people may need a supplemental round of education – in the form of a ‘booster’ – later in adolescence to reinforce and expand on information provided previously. For one thing, adolescence is a period of significant developmental growth, marked by physical, cognitive, emotional and social changes that affect their decision-making about sex and relationships. As they grow older, youth are also able to engage in increasingly sophisticated reasoning, which provides new opportunities to discuss situations they may encounter. They are also more likely to engage in sexual behaviours and romantic relationships. Nationally, one-fifth (19%) of 9^th grade students (typically aged 14–15) report having had sex, compared with more than half (57%) of 12^th grade students (typically aged 17–18) (U.S. Department of Health and Human Services 2020). Older youth may need to refresh their knowledge of topics and resources that were not previously relevant to them. In addition, spaced or distributed learning increases information retention and students’ abilities to apply the information to new situations (Dunlosky et al. 2013; Kang 2016).

Furthermore, young people face a host of needs that are connected with their sexual health. Increasingly, there is growing recognition of the need to address adolescent health more holistically and from a positive youth development framework (Gavin et al. 2010). This requires that sexual health education goes beyond the traditional focus on pregnancy prevention to include developing life skills such as fostering healthy relationships, managing stress, and goal setting (National Academies of Sciences Engineering and Medicine 2020). In addition, the COVID-19 pandemic has highlighted the importance of supporting adolescents’ mental health and well-being (Jones et al. 2022). To date, research on booster sexual health education has been quite limited (Haberland, McCarthy, and Brady 2018). A few studies have examined booster components in specific adolescent health fields (e.g., HIV/STI prevention, dating violence, other adolescent risk behaviours), although the modality has varied using brief written materials, videos, telephone contacts, or in-person activities (Charron-Prochownik et al. 2013; DiClemente et al. 2014; Foshee et al. 2004; Gaydos et al. 2008; Wu et al. 2003). Within sexual health education, several research studies have indicated better outcomes for programmes that are designed to build on prior lessons and those of longer duration (e.g.,(Goldfarb and Lieberman 2021; Kirby, Laris, and Rolleri 2007). However, the impact of separate sexual health education interventions provided at two distinct developmental stages has not been explored. In HIV prevention, Dinaj-Koci and colleagues conducted trials to understand the separate and synchronous effects of a risk reduction intervention provided to 6^th and 10^th grade young people in the Bahamas (Dinaj-Koci et al. 2014). Participants in the earlier intervention showed significant gains in knowledge and skills; those who also participated in the later intervention reported the greatest increases in condom-use skills, relative to control groups. The authors concluded that young people gain the most protection with early and repeated exposure to interventions that reinforce and expand upon earlier lessons.

To our knowledge, there has been limited research on the appropriate structure for or content of a booster sexual health education programme for older youth and, more specifically, for those growing up in rural settings despite the fact that access to sexual health information and services is more limited and birth rates are higher (Lindberg, Maddow-Zimet, and Boonstra 2016; Orimaye et al. 2021; Yarger et al. 2017).

Purpose of the study

The present study was undertaken as part of the Rural Education and Development for Youth (READY) project, a federally funded initiative to develop and implement a systems-thinking approach to meeting the sexual health information and service needs of underserved youth in rural, predominantly Latino communities of Fresno County, California. The project involved multiple components, including an evidence-based sexual health education curriculum for 9^th grade students (typically ages 14–15), workshops for parents/guardians, capacity building for school staff, and training for local health clinics to promote access to services. The project was led in partnership by two community organisations, the Fresno County Superintendent of Schools and the Fresno Economic Opportunities Commission, and the research team at the University of California, San Francisco.

As part of the project, the research team conducted formative evaluation activities to support the development of an additional component – a booster curriculum for 11^th and 12^th grade students (typically ages 17–18) living in the target communities. The project was initiated with a focus on sexual health education and adult preparation, but deliberately open to learning about the broader needs of young people. Based on focus groups with young people and key informant interviews with youth-serving professionals, this paper examines the sexual health and related needs of older youth that could be met through a new curriculum. More broadly, the study aims to address the gap in research on the need for and content of booster sexual health education by centring the perspectives of young people and the professionals who support them.

Materials and methods

Setting

The rural communities prioritised in this study are located in the Central Valley of California, the most productive agricultural region in the state and country. These communities predominately comprise Latino immigrants from Mexico and Central America with higher than average rates of school dropout, unemployment and poverty (Advancement Project California 2017), as well as adolescent births and STIs (California Department of Public Health 2018). The California Education Code mandates that public school districts provide comprehensive, age-appropriate sexual health education to students at least once in middle school and once in high school, although parents are able to opt their children out of the lessons until they reach age 18. Minors are eligible to receive sexual health services at no cost and without parent permission through the California’s Family PACT programme; however, many smaller communities, especially in rural areas, are served by only one health clinic with few or no youth-friendly providers.

Participant recruitment

Between January and July 2021, we conducted focus groups with young people living in rural communities of Fresno County to understand their sexual health education needs and the gaps in services in their communities. At the outset, we aimed to recruit six focus groups across three communities where the READY Project would be implemented. We purposively sought to capture the perspectives of particular groups of young people, including those identifying as LGBTQ, those who were pregnant or parenting, those who primarily spoke Spanish, and younger students. Focus groups were not divided by gender. Young people were approached and invited to participate by the project’s community partners. Youth were eligible if they were aged 14–20, lived in the target communities, and spoke English or Spanish. Focus group respondents were given an information sheet describing the study aims and procedures at the start of the focus group and received a $20 gift card for their participation.

Between April and August 2021, we conducted key informant interviews with youth-serving professionals working in rural communities of Fresno County. We aimed to reach professionals who worked in education, social services, health education and mental health services to gather their perspectives on the issues facing young people in rural areas of the county. Respondents were eligible if they were currently providing relevant services to young people in the county. We adopted a purposive sampling strategy, identifying potential respondents through the project’s community partners and referrals from other respondents (i.e., snowball sampling), and contacting them by email or phone. Interview respondents were sent an information sheet describing the study aims and procedures in advance of the interview and received a $40 gift card for their participation.

Study procedures

For focus groups, we developed a semi-structured guide that asked youth respondents to reflect on their experiences growing up in their community. The guide was organised into key domains, asking respondents about their community, their parents and other trusted adults, experience with sexual health education, and awareness of sexual health and other local support services. Focus groups lasted 28 to 46 minutes.

For key informant interviews, we developed a semi-structured guide that asked respondents to reflect on their perspectives working in the target communities. The guide addressed their experience working with youth, insights about the communities, knowledge of sexual health education and adulthood preparation subjects in schools, the local availability of health and social services, and recommendations for how to better support youth. Interviews lasted 28 to 57 minutes.

The project was proposed prior to and implemented during the COVID-19 pandemic. Due to the pandemic, all focus groups and interviews were conducted using Zoom videoconferencing software. Focus groups and interviews were audio-recorded and transcribed verbatim. One focus group was conducted in Spanish; the content was transcribed and then translated into English. The institutional review board of the University of California, San Francisco approved the study protocol (#20-32633).

Analysis

We used a hybrid approach to thematic analysis that included both deductive coding based on the research questions and inductive coding of themes that we identified in the data (Braun and Clarke 2013). In collaboration with another member of the research team, the second author reviewed a subset of transcripts and generated a preliminary list of thematic codes for both focus groups and interviews; these were reviewed and adjusted iteratively. Throughout the process, the team discussed and resolved any differences through consensus. The first and second authors applied the final codes to all focus groups and interviews using Dedoose qualitative data management software (SocioCultural Research Consultants 2016) and then analysed the data for thematic patterns, including recurrence of themes and differences across focus groups and interviews. The team selected quotations to highlight the core themes and variations that emerged from the analysis. To protect the confidentiality of respondents, we aggregated demographic data and therefore do not present demographic details with the quotations.

Results

Respondent characteristics

Based on saturation of main themes, we ended data collection after six focus groups and nine key informant interviews with 10 respondents (i.e., one interview was conducted jointly with two respondents). Among the 22 young people who participated in focus groups, most identified as female and Latino. Most were 14 to 17 years old (mean 16.6). The youth-serving professionals who participated in the interviews represented a range of fields. See Table 1.

Table 1. Description of sample.

	n (%)
Focus Group Respondents (N = 22)
Age
14–15 years	4 (18%)
16–17 years	9 (41%)
18–20 years	3 (14%)
Not provided	6 (27%)
Gender
Female	16 (73%)
Male	6 (27%)
Ethnicity
Latino/Latina	16 (73%)
Not provided	6 (27%)
Pregnant or Parenting
Yes	4 (18%)
No	18 (82%)
Interview Respondents* (N = 10)
Professional Field
Secondary education	2 (20%)
Post-secondary education	4 (40%)
Health education/services	4 (40%)
Social services	3 (30%)

*Interview respondents work may fall under multiple categories.

Thematic analysis

We identified key themes in the focus group and interviews. These indicated that booster sexual health education in these communities should 1) review and reinforce existing sexual health knowledge; 2) expand beyond traditional areas of sexual health education; 3) address community stigma about adolescent health; and 4) prepare young people for the transition to adulthood. In addition, such programming should 5) be established within the school system to promote an environment that addresses and normalises health issues throughout the school year.

We did not find conflicting perspectives between the youth and youth-serving professionals. However, we note that the groups emphasised different points based on their own expertise. For example, young people spoke more often about the information they had received in classes, whereas youth-serving professionals were more likely to discuss transitions to adulthood and the role of the school system. This is reflected in the presentation of results.

Review and reinforce existing sexual health knowledge

Although most young people remembered having received sexual health education in middle school and/or early in high school, the majority could not recall the detail of what has been presented. Most described only vaguely what they been taught years ago: ‘They talk[ed] to us about AIDS and STIs and everything like that, but I forgot about it. Like I don’t remember what they told us.’ Only a few participants could name specific content such as abstinence, condoms and contraceptive methods, consent, and accessing sexual health services. Some young people expressed frustration regarding the extent of the content provided in their sexual health education class. As one explained, ‘I also remember like, not learning enough. I feel like I should have learned more about it.’

A few young people noted that their peers might have missed the information provided in the earlier class. One described their fellow students as not paying attention and not taking the class seriously: ‘They just want to get it over with, so they didn’t ask questions or anything … . Or, they weren’t paying attention. They were mostly joking around and messing around.’ Youth also noted that some parents opted their children out of the sex education provided in school. One youth suggested these earlier absences necessitate additional education later, saying: ‘Well, I feel like the sex ed classes, they should be at least two times because there’s people that miss school and don’t really get to hear about that.’

The youth-serving professionals who were knowledgeable about sexual health education classes in the local schools also expressed concern about the limits of content and quantity provided. One noted that the sexual health unit within the 9^th grade class (typically ages 14–15) was the only time young people would be learning about sexual health at school: ‘And after that, it’s not really talked about at all … . They just forget about it.’ Some youth-serving professionals were concerned about the credibility of youth’s sources of sexual health information, specifically the misinformation they might find from friends and social media, in the absence of further education in school. Those who worked at local community colleges expressed concern about the gaps in their students’ knowledge about pregnancy, contraception and the availability of sexual health services, which they tried to meet through group presentations and individual counselling for their young adult students.

Expand beyond traditional areas of sexual health education

While some of the knowledge gaps raised by respondents were topics addressed in sexual health education classes that needed review and reinforcement, other issues went beyond the typical content provided. As one youth stated, ‘I feel like there’s more to it than just AIDS, you know.’ A youth-serving professional similarly noted that pregnancy, STIs, and condoms were commonly covered, but ‘that’s as much as they go into. I don’t think they go over the other things.’ Both youth and youth-serving professionals raised additional topics they saw as critical to youth’s health that could be addressed through sexual health education.

Some respondents expressed the need for education about broader areas of sexual health, such as healthy relationships and LGBTQ inclusivity. For example, one young person shared, ‘I wish they could have been more focusing on like, what you’re really going into, like into a loving relationship … like knowing that if it’s a healthy one or not healthy relationship.’ Youth-serving professionals also noted the need for ‘education on the relationship side, too.’ Discussions in earlier sexual health education classes may have touched on issues of consent, but did not explore relationships in depth. In addition, young people who identified as LGBTQ did not see their experiences or needs addressed in their sexual health education classes, even when they found support from school counsellors or a Genders and Sexualities Alliances (GSA) club. One youth reflected on their sexual health education saying, ‘All I remember is that they’re only talking about things like condoms and sex. I don’t remember them mentioning the word gay or LGBTQ.’ Youth voiced a need for further education on sexuality and gender identity in the school, particularly in communities where people are ‘mostly accepting’ but ‘there are still people out there who don’t understand or just don’t want to learn.’

Even more commonly, respondents – both youth and youth-serving professionals – raised concerns about adolescents’ mental health, especially during the COVID-19 pandemic, and discussed young people’s limited knowledge about mental health issues and available support. A few young people mentioned recent suicides among young adults in their community over the past year, noting that ‘we don’t have any [resources] except like our school counsellors.’ The importance of further education and resources on mental health was raised often by the youth-serving professionals. As one of them explained, ‘We know mental health for students, it’s probably not good. [They’re] suffering. But yet, there’s not a lot of kids coming forward saying I need help.’ The youth-serving professionals saw ongoing education as critical to encouraging young people to understand and address their growing health needs. Some of the youth raised this point as well, agreeing that ‘If there is more education on [mental health], like awareness of those things, it would prevent a lot.’

Address community stigma about adolescent health

Both youth and youth-serving professionals described how community stigma affects young people’s access to information, social support, and health services. In particular, respondents mentioned traditional cultural views towards adolescent sex and relationships in the rural communities of Fresno County, which include many families who are recent immigrants, monolingual Spanish speakers, and practicing Catholics or evangelical Christians. One professional described the families that her organisation served as follows: ‘They still carry a lot of traditions … about what a sexual relationship should be, or when it should be, more than anything … . It’s still uncomfortable for them to talk about it, it’s still not accepted to some.’ This has particular effects on LGBTQ people living in communities where ‘you don’t accept it, or if you accept it, then you don’t talk about it.’

Respondents noted that parents are often uncomfortable talking to their adolescent children about sex and relationships, which hinders conversation at home and keeps youth from seeking the information and resources they need. One young person described how premarital sex is frowned upon by many families, ‘so talking about [sex] with your parent, they’ll just kind of be like “No, you shouldn’t be having sex right now,” instead of giving you actual help and the resources you need.’ Another agreed that ‘there’s a lot of shame around teens having sex’ which leaves young people ‘embarrassed and scared to actually reach out.’ While sexual health education can fill information gaps, address questions, and connect youth to resources, some parents choose to opt their children out of these lessons. Some youth-serving professionals believed that this was due to parents’ own lack of experience with sexual health education and limited awareness about the content being covered; they felt that additional resources for parents might help address these concerns and allow for more youth to receive sexual health education.

Both youth and youth-serving professionals also raised the issue of the communities’ and families’ stigmatisation of mental health. Mental health was seen as a problem that should not be openly discussed, rather ‘you keep your problems in house.’ In contrast, young people wished that adults in their communities would be ‘a little more open and understanding’ and ‘more considerate of what teens sometimes have to go through.’ One youth-serving professional described how these community attitudes affect young people: ‘When it comes to mental health, there is still that stigma. And the kids are well aware [of] that … . Kids are afraid to come forward and are afraid to seek out mental health and afraid of their parents, afraid of how others will see them.’ Many of the youth-serving professionals noted the particular challenges brought on by the COVID-19 pandemic, which intensified issues of social isolation in communities that were already facing stigma and lack of resources.

Many youth-serving professionals, and a few young people, saw ongoing education in the schools as a means to address mental health stigma and promote health-seeking behaviours. One youth-serving professional, for example, emphasised the importance of prevention education: ‘If we could get [to youth] earlier and reduce the stigma, they’ll grow up with seeking out and wanting help, and talking to other people and learning how to regulate [their emotions].’ Another youth-serving professional described the need to address community stigma around both mental health and sexual health through ongoing education: ‘The more we talk about it, the more comfortable we will feel having those conversations … normalising it.’

Prepare youth for the transition to adulthood

Alongside sexual and mental health information, respondents highlighted the need for other types of supports as young people complete high school. In interviews, youth-serving professionals emphasised that young people growing up in these rural communities – particularly those in lower-income families who have recently immigrated to the USA – face additional obstacles in navigating the transition to adulthood. Whether or not they move away from their communities, young people need to gain skills and be able to identify resources without the structure of high school to support them.

Due to limited services in their small communities, few young people in focus groups knew where to access sexual health services, or that these were available in some locations at no cost and without parental permission. The exceptions were pregnant/parenting youth, who had more experience working with case managers, identifying medical and dental care, and seeking community resources as a result of the adult responsibilities they had already assumed. Many young people in these communities attend local two-year community colleges or vocational programmes after they leave high school. While these schools have services to support students, youth do not often seek them out. As one youth-serving professional at a community college noted, ‘A lot of students don’t seem to know they have a health centre on campus, no matter how we advertise.’

In interviews, youth-serving professionals – especially those working at local community colleges – listed a broad range of skills that young people need as they enter adulthood. In particular, they emphasised the importance of learning time management, balancing school and work, career planning and financial decision-making, especially for youth who will be juggling school, work, and family obligations. One youth agreed, ‘I’m going to have to get a job soon, and I’m not sure how to conduct myself in an interview. We’ve never had to train for that or anything. So I think [we need education on] how to get a job, how to pay taxes, how to save money, how to not waste your money on useless stuff.’ The youth-serving professionals agreed that, in under-resourced communities, ‘there’s always areas that can continue to be enhanced … . Basically any additional information is always welcome.’

Establish ongoing sexual health education in the school system

As described primarily by youth-serving professionals, having ongoing sexual health education and referrals based within the school system provides a safe and supportive environment to discuss and normalise health issues. Many spoke positively of the small ‘tight-knit,’ ‘hard-working,’ and ‘community focused’ towns in the Fresno County, where schools often played ‘a hub role’ for resources to support young people and their families. As one youth-serving professional noted, ‘What we found is, even with our undocumented families, that the school is usually the safe place in the community. [Families] trust the school normally, and that’s where the kids show up every day.’

Youth-serving professionals also described the school as a regular place of support for young people, seeing youth as ‘most comfortable with their teachers, because they have that rapport and they see them the most often.’ Although young people reported that they often go to their close friends or older siblings for advice, many said they knew of a trusted adult at school to reach out to if they needed support. This was reflected in comments on dealing with complicated issues such as parenting or their sexual identity. These youth, in particular, mentioned counsellors and teachers who supported them throughout their school years. One parenting youth described how her counsellor ‘kept getting on my back about [passing my classes] so I could finish. And I did, thanks to her.’ Another youth shared, ‘I look up to my teachers a lot. You know, they helped me get my life back on track. Helped me accept myself.’ In addition to personal support, these youth knew that school staff could provide referrals to other resources: ‘If [we] want to seek out more information, we go to go to our counsellors … to actually give information [or] to tell us where we can get better information.’

While youth-serving professionals described the many challenges faced by school systems, and how local control affected decisions about the content and extent of sexual health education, most described how schools were a natural place to offer sexual health information and referrals in rural settings. In describing the challenges of sustaining youth opportunities in rural communities, they noted that schools provided a stable base. When schools are well-supported, they can become the centre of information and resources for youth over a longer period of time: ‘If these communities have a school system that has the budget and resources dedicated to be able to support young adults and adolescents … then those communities have the opportunity to flourish.’

Discussion

Despite national guidance around the content, frequency and sequencing of sexual health education in schools, young people in the USA often fail to receive the information and resources they need to support their transition to healthy adulthood. In this study, respondents gave voice to the inadequacies of youth’s experience with sexual health education in rural communities of Fresno County, California. According to young people and the professionals who support them, the sexual health education provided in middle school or early high school was limited in scope and hard to recall years later. Both youth and youth-serving professionals identified several topics that they felt would support the transition to adulthood. These findings highlight critical gaps in sexual health education in general and, we believe, reinforce the need for a booster class that scaffolds and builds upon the foundation of sexual health education received earlier in school.

Notably, both youth and youth-serving professionals spoke of information and resource gaps that would require sexual health education to address topics beyond the typical focus on preventing pregnancy and STIs. They suggested more content on healthy relationships, consent, and gender and sexual identity – all topics that are advocated by many in the field as part of a truly comprehensive approach to sexual health education (Goldfarb and Lieberman 2021; Kantor and Lindberg 2020; Kantor et al. 2021). In contrast, some of the content needs raised by respondents are not typically considered within the domain of sexual health education. Mental health, in particular, was described as a critical concern for youth, and the stigma of addressing mental health was raised as a considerable challenge in these communities. National data have highlighted the serious mental health challenges facing youth, with nearly 40% reporting feelings of sadness or hopelessness on a regular basis (U.S. Department of Health and Human Services 2020). Locally and nationally, the COVID-19 pandemic has compounded these existing challenges (Jones et al. 2022). Both youth and youth-serving professionals explicitly identified mental health education and services as key to the development of young people’s health and well-being. They also described the need to prepare youth for taking on adult roles and responsibilities, through career/college planning and financial education. While these areas may seem disconnected from sexual health topics, there is a history of sexual health education programmes addressing similar ‘life skills’ content, with the theory that these skills promote healthy decision-making and increase opportunities (Gavin et al. 2010). An additional round of education covering a broad base of topics may offer an opportunity to confront current and future obstacles to information and services. Further work is needed to examine whether mental health topics are more appropriate and effective if embedded in a comprehensive sexual health education curriculum or as a separate mental health and wellness programme.

In interviews, youth-serving professionals noted the importance of schools as a hub for sexual health education and other supportive services, especially in rural communities. Youth growing up in rural areas have fewer opportunities and resources and are less likely to know about and seek out sexual health services (Yarger et al. 2017). Schools are able reach youth ‘where they are’ and are staffed by trusted adults who build rapport with young people and bring expertise in the developmental changes of adolescence. In a school context, reinforcing sexual health information over time has parallels with the sequential reinforcement of other academic topics, such as maths and language development. However, the limits of the education system in taking on additional responsibilities must be acknowledged. Today’s schools are pressed with academic requirements, limited resources and political pressures, and often lack teachers trained specifically in health education (Birch et al. 2019). Adding an additional round of sexual health education may not be feasible in many schools. Further research is needed to understand what factors within individual schools support the expansion of such programmes, promote the involvement of school leadership, and enable access to health services for students.

To date, research on booster sexual health education remains limited (Haberland, McCarthy, and Brady 2018). Additional research is needed to understand the most effective exercises, activities, and pedagogies for older youth, as these likely differ from those most appropriate to their younger peers (Dinaj-Koci et al. 2014; Goldman 2011). Rigorous longitudinal studies like those conducted by Dinaj-Koci et al. (2015, 2014) need to be designed to examine the separate and synchronous effects of booster programmes relative to foundational content. Future research and programme development should centre the perspectives and priorities of youth and the community-based professionals who support them to ensure relevance to different age and developmental stages. Recent research has identified human-centred or youth-centred design as a critical component of successful programme development (Fakoya et al. 2022), yet it is still rare for young people – especially rural youth – to be engaged in the formative phases of sexual health education curriculum design (Harris, Shields, and DeMaria 2021). In the subsequent phase of the READY project, we integrate the insights of these focus groups and interviews into the development of a new booster curriculum with the support of a Youth Advisory Council.

We note this study’s limitations. First, the focus groups and interviews were designed with the broader goals of understanding community needs for the overall READY project, and we did not explicitly ask respondents to name what specific components should be taught in booster sexual health education. Our findings are drawn from their descriptions of their communities’ needs and resources. Notably, the independent assessment of our Youth Advisory Council has reflected many of the same themes raised here. Second, all data collection was conducted during the COVID-19 pandemic. The use of online video software may have limited participation, rapport and discussion, and our findings may reflect these gaps. Our findings were likely also affected by the pandemic itself; for example, recent attention to the mental health of young people likely made this issue more salient, although we note that this has been a national and local concern long before the pandemic. Third, while we aimed to capture a diverse set of perspectives across rural Fresno County, respondents did not represent the views of all youth and youth-serving professionals in these communities. Furthermore, this study was not designed to be generalisable to other communities, including other rural areas. Given variation of state laws and local policies on sexual health education as well as local context, young people’s information and resource needs will vary considerably across the USA.

This study’s findings highlight the ongoing equity gaps in sexual health education for many youth, especially in under-resourced communities, that have been identified in other research (e.g., Lindberg and Kantor 2022). To have a positive impact, sexual health education needs to reflect the needs of youth, build knowledge and skills by developmental progression, and promote awareness of local sexual health services. There is a need for expanded reach of existing evidence-based sexual health education curricula developed for younger adolescents, and these should be supported, not supplanted, by a booster model. Moreover, while sexual health education is necessary to support healthy adolescent development, by itself it is not sufficient (Svanemyr et al. 2015). Issues of community stigma and availability of high-quality youth-friendly services must also be addressed (Brittain et al. 2015; Decker et al. 2021). Nonetheless, providing booster sexual health education may help meet critical gaps in efforts to support healthy sexual development. As the US National Sex Education Standards note, ‘building an early foundation and scaffolding learning with developmentally appropriate content and teaching are key to long-term development of knowledge, attitudes, and skills that support healthy sexuality’ (Future of Sex Education Initiative 2020). By reinforcing previously learned lessons, bringing attention to additional issues of well-being, and addressing specific community needs, sexual health education can sustain and expand upon the knowledge and skills that young adults need as they navigate the transition to adulthood.

Acknowledgments

We thank Natasha Borgen, Salish Harrison and Amanda Mazur for their support with data collection and preliminary analyses; Julio Romero, Manuel Escandon, Kayla Wilson, and Kayla Angeles for their ongoing project partnership and support with participant recruitment; and Antonia Biggs and members of the Early Career Investigators Works in Progress seminar at UCSF’s Bixby Center for Global Reproductive Health for their comments on earlier versions of this manuscript. We send special appreciation to the young people and youth-serving professionals who shared their perspectives with us.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Office of Population Affairs, US Department of Health and Human Services under Grant TP1AH000233. The funder had no role in study design, data collection and analysis, the interpretation of the results, or the preparation of the manuscript.