Promising practices for the design and implementation of sexuality education programmes for youth in India: a scoping review

Abstract

Sexual violence and HIV/AIDS are major public health concerns in India. By promoting bodily autonomy, wellbeing, and dignity through knowledge and skills, comprehensive sexuality education for young people can help prevent adverse sexual and reproductive health outcomes. While there is increased recognition globally regarding young people’s need for sexuality education, translating this recognition into accepted programmes in India has been challenging. This scoping review aims to examine recommendations for promising practices for the design and implementation of sexuality education programmes and resources aimed at youth in India. A systematic search and review of the literature was conducted from June to August 2020. Of the total 5312 citations identified and screened, 622 advanced to full-text screening, and 39 were included in the final analysis. Promising practices include the need to: tailor content to serve the needs of the specific youth population being targeted; use engaging and participatory methods to teach sexual health content; work in partnership and collaboration with local experts and organisations; address potential barriers to participation and work to mitigate those barriers for marginalised youth; be youth friendly, flexible and convenient; and to be developmentally and culturally appropriate for the Indian youth context. Sexuality education programmes should integrate into existing community services and link with local reproductive health services to help provide youth with access to the services they may need. Continued work and efforts are required to address the interrelated and broad structural factors, including political, financial, social, and cultural factors that affect youth sexual health and wellbeing.

Résumé

La violence sexuelle et le VIH/sida sont des problèmes majeurs de santé publique en Inde. En promouvant l’autonomie corporelle, le bien-être et la dignité par le biais des connaissances et des compétences, l’éducation complète à la sexualité des jeunes peut contribuer à prévenir les effets néfastes sur leur santé sexuelle et reproductive. S’il est de plus en plus admis dans le monde que les jeunes ont besoin d’une éducation sexuelle, il s’est révélé difficile de traduire cette prise de conscience dans des programmes acceptés en Inde. Cette étude de portée vise à examiner les recommandations relatives à des pratiques prometteuses pour la conception et la mise en œuvre de programmes et de ressources d’éducation sexuelle à l’intention des jeunes en Inde. Une recherche et un examen systématiques des publications ont été menés entre juin et août 2020. Sur les 5312 citations totales identifiées et examinées, 622 sont parvenues à l’examen du texte intégral et 39 ont été incluses dans l’analyse finale. Parmi les pratiques prometteuses, il convient de citer la nécessité: d’adapter le contenu pour répondre aux besoins de la population de jeunes spécifique visée; d’utiliser des méthodes engageantes et participatives pour enseigner le contenu relatif à la santé sexuelle; de travailler en partenariat et en collaboration avec des organisations et experts locaux; d’éliminer les obstacles potentiels à la participation et de s’employer à atténuer ces obstacles pour les jeunes marginalisés; d’être adaptées aux jeunes, souples et pratiques; et d’être appropriées du point de vue du développement et de la culture au circonstances de la jeunesse indienne. Les programmes d’éducation à la sexualité doivent s’intégrer dans les services communautaires existants et établir des liens avec les services locaux de santé reproductive pour aider à fournir aux jeunes l’accès aux services dont ils peuvent avoir besoin. Il faut poursuivre le travail et les activités afin de traiter les facteurs structurels d’ensemble interdépendants, notamment de nature politique, financière, sociale et culturelle, qui influent sur la santé et le bien-être sexuels des jeunes.

Resumen

La violencia sexual y el VIH/SIDA son graves problemas de salud pública en India. Al promover la autonomía corporal, el bienestar y la dignidad por medio de conocimientos y habilidades, la educación integral en sexualidad para las personas jóvenes puede ser útil para evitar los resultados adversos de la salud sexual y reproductiva. Aunque cada vez hay más reconocimiento a nivel mundial de la necesidad de las personas jóvenes de recibir educación en sexualidad, ha sido un reto traducir este reconocimiento a programas aceptados en India. Esta revisión de alcance pretende examinar las recomendaciones de prácticas prometedoras para el diseño y la ejecución de programas de educación en sexualidad y recursos dirigidos a jóvenes en India. Entre junio y agosto de 2020, se realizó una búsqueda y revisión sistemáticas de la literatura. Del total de 5312 citas identificadas e investigadas, 622 avanzaron a la revisión del texto completo y 39 se incluyeron en el análisis final. Entre las prácticas prometedoras se encuentran la necesidad de: adaptar el contenido para atender las necesidades de la población específica de jóvenes bajo estudio; utilizar métodos interesantes y participativos para enseñar contenido sobre salud sexual; trabajar en alianza y colaboración con expertos y organizaciones locales; abordar las posibles barreras a la participación y trabajar para mitigar esas barreras para jóvenes marginados; tener en cuenta las necesidades de la juventud y ser flexible y conveniente; y ser adecuado para el desarrollo y la cultural del contexto de la juventud de India. Los programas de educación en sexualidad deben integrarse en los servicios comunitarios existentes y vincularse con los servicios locales de salud reproductiva para ayudar a proporcionar a la juventud acceso a los servicios que podrían necesitar. Es imperativo continuar el trabajo y los esfuerzos por abordar los factores interrelacionados y estructurales generales, entre ellos factores políticos, financieros, sociales y culturales, que afectan la salud sexual y el bienestar de las personas jóvenes.

Keywords:

• Sexuality education
• health promotion
• reproductive health
• comprehensive sexuality education
• youth
• India

Introduction

Properly-designed and properly-executed comprehensive sexuality education (CSE) programmes and resources for youth are an important component in sexual health promotion and in public health efforts to combat the global AIDS epidemic.¹ CSE “imparts critical information and skills for life. These not only include knowledge on pregnancy prevention and safe sex, but also understanding bodies and boundaries, relationships and respect, diversity and consent” (p. 7).¹ CSE has a positive impact on sexual and reproductive health, notably in contributing to reducing rates of sexually transmitted infections (STIs), HIV/AIDS and unintended pregnancies.¹ Contrary to popular myths, it does not hasten the onset of sexual activity in youth but rather has a positive impact by promoting the adoption of safer sexual behaviours and can even delay sexual debut.^2,3 A 2014 review of school-based sexuality education programmes found that students demonstrated increased HIV knowledge, increased self-efficacy related to refusing sexual activities, increased contraception and condom use, a lower number of sexual partners and delayed onset of sexual activity and intercourse.⁴ CSE is also important for effectively addressing issues such as sexual and gender-based violence, gender-based discrimination, as well as homophobia/ transphobia.³ In addition to individual and population health, CSE is integral to the human rights upheld in United Nations instruments including the International Covenant on Economic, Social and Cultural Rights,⁵ the Convention on the Elimination of Discrimination Against Women,⁶ and the Convention on the Rights of the Child.⁷ Comprehensive sexuality education:

“… enables young people to protect and advocate for their health, well-being and dignity by providing them with a necessary toolkit of knowledge, attitudes and skills. It is a precondition for exercising full bodily autonomy, which requires not only the right to make choices about one’s body but also the information to make these choices in a meaningful way.”⁸

While there is increased recognition at a global level regarding young people’s need for sexuality education, translating this recognition into nationally accepted and implemented programmes in India is difficult to do.^3,9 Many young people find that they are often unable to access basic information regarding sexual and reproductive health and rights.^3,9–11.

This scoping review aims to examine recommendations for promising practices for the design and implementation of sexuality education programmes and resources aimed at youth in India.

Sexual and reproductive health in India

India has the third largest HIV epidemic in the world, with over 2.1 million people living with HIV.¹² The epidemic is concentrated among key affected populations, including sex workers, men who have sex with men, people who inject drugs, transgender people, migrant workers, and truck drivers.¹² However, other strata of society are also affected. Notably, rates are growing among married, monogamous, heterosexual women who are infected by their husbands engaging in extramarital or paid sex; in this regard, there is a noted intersection with intimate partner violence.¹³ HIV incidence, prevalence and AIDS-related death rates remain among the highest in the world, and a number of issues limit further progress, including HIV-linked stigma, low levels of education regarding HIV among people living with the illness, limited awareness about sexual health and prevention of HIV, and limited awareness regarding freely available antiretroviral therapies.¹⁴

Sexual violence is also a prevalent issue in India, especially rape and sexual violence against women.¹⁵ According to UN Women, 35% of women worldwide have experienced either physical or sexual violence at some point in their lives.¹⁵ However, this value increases dramatically across various states in India, reaching a staggering 88.95% in certain areas.^15–17 In concert with patriarchal gender norms, the effective lack of open discussion in Indian society about healthy sexuality, consent in sexual activity, and sexual assault contributes to these overwhelming numbers.^16,17

Adolescent pregnancy and its consequences also present a major challenge. Pregnancy at an early age can put both the mother and the baby at risk for many related health complications.^18,19 The social consequences of adolescent pregnancy can include dropping out of school, lower educational attainment, decreased social and employment opportunities, reduced lifetime earnings, and even violence via suicide or homicide in some cases.¹⁸ The WHO Guidelines on Preventing Early Pregnancy and Poor Reproductive Outcomes Among Adolescents in Developing Countries highlights the key role of sexuality education in achieving its goals.²⁰

Comprehensive sexuality education and the Indian context

India was a signatory to the Programme of Action (PoA) of the 1994 International Conference on Population and Development (ICPD) where the sexual and reproductive health needs of youth as a group were officially articulated and identified as an area for further action. The PoA from the ICPD states in paragraph 7.47: “Governments, in collaboration with non-governmental organizations, are urged to meet the special needs of adolescents and to establish appropriate programmes to respond to those needs.”²¹ India’s efforts to operationalise the PoA began with the launching of the Reproductive and Child Health Programme in 1997. In 2000, adolescent reproductive and sexual health was recognised as a top priority in the National Population Policy of 2000 and in the Reproductive and Child Health II programme of 2005.²²

In India, a two-pronged approach is being used to implement sexuality education. For youth that are currently enrolled in school, the national Adolescent Education Programme (AEP) is being delivered in school, reaching students between the ages of 13-18.²³ The AEP was launched in 2005 by the Ministry of Human Resource Development and the National AIDS Control Organization (NACO).²³ The AEP seeks to provide accurate, age-appropriate and culturally-relevant information regarding sexual health, gender, sexuality, communication skills, and navigating relationships. Unfortunately, serious reservations have been expressed in India about the sexuality component of the programme.²⁴ Following the pushback, efforts were made by several stakeholders, including governmental departments, the NACO, the National Council of Educational Research, and civil society organisations, to review the original curriculum and generate support for the implementation of the programme in general. They provided states flexibility to modify the existing curriculum if necessary, while reiterating the need to keep the AEP overall.²³ The revised curriculum consisted of four sections: (a) changes from childhood to adolescence; (b) adolescent reproductive and sexual health; (c) mental health and substance misuse; and (d) life skills and HIV prevention.²³ The AEP has been widely implemented in high schools in partnership with state and national educational organisations as well as civil society organisations.²³

There are other programmes that have been designed to provide sexual health education to youth, including the School Health Programme under the National Rural Health Mission; Red Ribbon Clubs under the National AIDS Control Project; the University Talk AIDS Program; the Youth Unite for Victory on AIDS campaign; and Yuva, which is a network of seven youth organisations working to provide youth with sexual health education and life skills training in partnership with the Ministry of Youth Affairs and Sports and NACO.²³

There is no formal programme for educating youth that are not enrolled in school, but information and counselling are available through the adolescent health clinics created through the Ministry of Health and Family Welfare’s Reproductive, Maternal, Newborn, Child and Adolescent Health initiative.¹ There are also several key programmes run by the National AIDS Control Program and the Ministry of Health and Family Welfare, including the Village Talk AIDS Program which is an educational programme designed for out-of-school youth; Red Ribbon Clubs which serve to provide counselling, life skills training, and recreational activities; awareness campaigns and counselling through Accredited Social Health Activists; and teen clubs to provide youth with life skills experiential learning and education on reproductive and sexual health.^23,25 In 2014, the Government of India started a national programme entitled “Rashtriya Kishor Swathya Karyakram.” The aim of the programme is to expand outreach to youth and their communities, especially the most vulnerable and at-risk, including adolescents not enrolled in schools. The programme includes the establishment of adolescent-friendly health clinics, nutritional supplementation, peer education programmes, and menstrual product provision.²⁶

The reach and the quality of sexuality education programmes, however, are questionable. Open discussion of sexuality remains largely taboo in India, due partially to Victorian-era mores inserted into society during British colonial rule. In the present day, conservative attitudes towards sexuality are framed as intrinsic to Indian cultural identity.^9,11 As of 2019, there is a ban on the AEP in at least five states across India due to mass outrage about the notion of teaching youth about sexuality. Moreover, there is no uniformity in how the subject is approached across the country, with actual content regarding sexuality frequently diluted or absent due to parental and community concerns about teaching youth about sexuality, and due to teacher embarrassment or discomfort.^9,11,27 Generally, implementation of the AEP is uneven and reach remains limited. There is also limited follow-through, monitoring, and evaluation of adolescent health programmes across India.^23,28,29

Research question, objectives, and definitions

This research sought to answer the following question: What are promising practices for the design and implementation of sexuality education programmes aimed at youth in India?

In this research project, we engaged with a definition of “promising practices” as practices described by programmes that report successful outcomes. Promising practices are differentiated from best practices as there is not yet enough research evidence to definitively establish the practice as the standard guideline for effective implementation across all settings.³⁰

There are several articles that have assessed sexuality education programmes in other countries and even “developing countries” as a whole.^31–37 They advocate for and present guidelines for comprehensive sexuality education, including elements such as curricular objectives, guidance on topic inclusion, the development of activities, and the process of developing educational resources. However, in this review, the focus is on youth sexuality education programmes based out of India only. By looking at programmes carried out within the Indian context only, we hope to identify characteristics of successful programmes that are specific to the Indian setting and the youth living within this environment.

There is a myriad of micro- and macro-level upstream factors that can contribute to adverse sexual health outcomes for youth. Micro-level factors include influences on an individual level that can affect choices youth make, such as family traditions, local community norms, and economic circumstances. Macro-level factors can include regional or national norms, laws, policies, and overarching culture. Legal and regulatory frameworks can facilitate or hinder these choices and behaviours made by youth, such as the enforcement of laws concerning child marriage, harm reduction, human trafficking, sexual exploitation, intimate partner violence, and sexual assault.³⁸ Micro- and macro-levels provide a framework for understanding socioeconomic determinants of health that can impact the sexual health and overall wellbeing of youth. Each of these levels interacts with and influences the others, and they can be visualised as being linked together via a feedback loop in which changes at one level will influence events at another level.³⁹ In order to promote the wellbeing of youth, changes are required at these local, regional, and national levels by different sectors to bring about lasting improvement in outcomes and promote healthy practices.¹⁸ In this review, we endeavoured to analyse the selected papers through this lens, with a focus on the social determinants and upstream factors that influence youth health, which include socioeconomic and cultural factors, as well as the characteristics of social spaces and physical environments.

In the research presented in this paper, we engaged with definitions of key constructs. We engaged with a definition of gender as the social identity that encompasses the norms, behaviours and roles with which an individual identifies. While this can correlate with biological sex assigned at birth, it does not need to. Sexual identity is defined as the romantic and/or sexual orientation that an individual identifies with.⁴⁰ Sexual and reproductive health refers to the state of overall physical and emotional well-being in relation to sexuality, including positive relationships free from coercion or violence.²⁰

Methods

A scoping review aims to map out key concepts and knowledge in a particular area, by looking at the “extent, range and nature” of work done, to “summarize and disseminate” what is known, and to identify gaps for further research or action. The methodological framework of Arksey and O'Malley⁴¹ was drawn upon to guide the scoping review process, based on five main stages: (a) identifying the research question, (b) identifying relevant articles, (c) article selection, (d) charting the data, and (e) summarising and analysing the results. After the focused research question was identified and developed (namely: What are promising practices for the design and implementation of sexuality education programmes aimed at youth in India?), the selected relevant articles were examined in order to analyse the field, summarise and report results, as well as identify gaps and areas for further research.

A systematic search of the literature was conducted. The inclusion criteria were articles discussing and examining programmes for youth based in India that sought to improve their reproductive and sexual health knowledge, published from the year 1995 onwards. This threshold was chosen as this year marked the landmark decision within the field to officially include youth sexual health in the ICPD’s Programme of Action²¹ and the subsequent signing of the Programme by India, officially marking youth sexual and reproductive health as a national area for further action. Articles published in English from peer-reviewed sources and grey literature, were included. The following databases were searched: MEDLINE, EMBASE, PsychINFO, COCHRANE, CINAHL, ProQuest (Sociology, Nursing & Allied Health), and Google Scholar. References of selected papers, and websites of relevant non-governmental organisations (NGOs) and other groups, were also scanned to identify additional potential papers that could be included.

We used various combinations of keywords and all possible associated terms in English. The search terms are listed in Table 1. The complete search strategy is provided in the online Supplemental Material. Our search strategy was validated by a librarian from the Health Sciences Library at Queen’s University. All selected documents were saved in Covidence software.⁴²

Table 1. Search terms utilised^a

1. (teen* OR adolescent OR youth OR young adult OR college student OR students)

2. AND (India)

3. AND (intervention OR best practices OR development OR program development OR program evaluation OR program or Practice Guidelines as a Topic)

4. AND (*Sex Education OR *Sexual Health).

^a Note: The above search terms represented the starting point in tailoring our search strategy according to each database’s features and processes. Subject headings, truncation and keywords specific to each database were employed under the guidance of a university research librarian.

The initial search process picked up many duplicates, reinforcing the completeness of the search. To add to the rigour of the search strategy, two reviewers independently conducted an initial title-abstract screening of all articles; results were compared and any discrepancies were reviewed to derive a clear and reproducible protocol. All articles that passed this screening moved onto full-paper screening. The search and review process started in June 2020 and ended in August 2020. Articles were excluded if they were not specific to India, did not include any youth, were not discussing a specific programme or intervention that was conducted, did not include any promising practices or lessons learned for sexuality education programmes, or were not available in full-text versions despite contacting authors to request full text. Data from the final set of papers included in the review were extracted and recorded in an Excel spreadsheet. The programmes described in the final included papers were sorted and mapped according to the location, target population, type of programme, elements/components of the programme, and subjects covered within the programme. Promising practices were identified from the conclusions reported by the authors of the individual studies.

Results

Our search strategy yielded a total of 5312 citations. That number was reduced to 3275 after excluding 2037 duplicate records. 626 of these moved onto full-text screening on the basis of their titles and abstracts. A final set of 35 articles met all inclusion criteria and were included in our scoping review. Figure 1 is our PRISMA chart of the selection process and Table 2 includes the characteristics of the programmes of the selected papers. Key themes are presented below.

Figure 1. PRISMA diagram

Table 2. Characteristics of individual sexual health education programmes for youth conducted in India

#	Location in India	Target audience	Setting	Teaching delivery	Components of programme	Subjects covered in programme
1	Impact of health education on knowledge and practices about menstruation among adolescent school girls of rural part of district Ambala, Haryana. Arora et al, 2012^Citation43
	Haryana	Adolescent females of classes IXth and Xth of government secondary schools	School-based	Health-worker led	Structured teaching programme with: Lectures A/V aids Question and answer sessions conducted afterwards	Menstruation (Physiology of menstruation, role of hygiene, myths in society about menstruation)
2	The acceptability, feasibility, and effectiveness of a population-based intervention to promote youth health: an exploratory study in Goa, India. Balaji et al, 2011^Citation44
		Youth aged 16-24	Community-based	Peer and teacher-led	“Yuva Mitr” programme: Peer education, teacher delivered education and counselling, community peer education Distribution of health information materials distributed to youth through house to house visits Street plays Posters in prominent locations	Communication skills, decision-making skills, violence, general sexual and reproductive health, menstruation, sexual abuse
3	Participatory Approaches to Message Design: “Jeevan Saumbh,” a Pioneering Radio Serial in India for Adolescents. Bhasin & Singhal, 1998^Citation45
	India- wide	Older adolescents	Community based (radio programme)	Health-worker led	Radio series 13 episodes of radio series, which addressed various problems faced by adolescents, discuss solutions Utilised participatory message design (used the actual “voices” of the youth, parents, health experts; high degree of involvement and feedback from listeners) Interactive exercises: parallel interaction programmes, quiz contests, awards, Q&A	Teenage sexuality, gender bias, puberty, masturbation, menstruation, reproductive physiology, homosexuality, STDs, commercial sex, self-confidence, social norms, peer pressure, relationships with the opposite sex, unplanned pregnancy inter- generational conflicts, career choices, personality development
4	Talking about love and sex in adolescent health fairs in India. Capoor & Mehta 1995^Citation46
	Gujarat	Adolescents aged 11-18	Community-based	Health worker-led	Adolescent health “mela” or fair organised by NGO (CHETNA) Ice-breakers and rapport building exercises Small group learning in individual “stalls” with trained facilitators Interactive exercises (ex. songs, games, Q&A, case studies, role play, skits, group discussions) Learning materials provided (ex. charts, puppets, cartoon books and exhibits)	Myths and misconceptions about adolescent reproductive and sexual health, personal experiences with sexual activity, puberty, menstruation, abortion, STDs, contraception
5	What did it take to scale up and sustain Udaan, a school-based adolescent education programme in Jharkhand, India? Chandra-Mouli et al, 2018^Citation47
	Jharkhand	Youth in grades 9 and 11	School-based	Teacher-led	Structured teaching programme entitled “Udaan” Teacher led education “Udaan clubs” for life skills activities Interactive group activities (ex. poster competitions, group/panel discussions, games, case studies, brainstorming exercises, field visits, storytelling, debates, poster creation, role playing) Larger campaigns and events to raise awareness	Communication skills, interpersonal relationships, puberty, masturbation, menstruation, sexual maturity, myths and misconceptions about sexual health, dating, friendships, sexual abuse, domestic violence, rape, gender roles, gender equity, early marriage, sexual decision-making, marriage, parenthood, STIs, HIV/AIDS
6	Adaptation of an alcohol and HIV school-based prevention programme for teens. Chhabra et al, 2010^Citation48
	Himachal Pradesh	Youth aged 13-16	School-based	Peer-led	STEP (School-based Teenage Education Program) programme Sessions taught by trained peer educators Included visual aids Created a community advisory board for their ongoing feedback. Conducted quality and attendance recording throughout the programme to make sure the programme was being implemented correctly.	HIV/AIDS, communication skills, alcohol abuse, social pressures, social skills, self-confidence, individual values, assertiveness training, coping skills. (Acknowledged need to introduce gender roles as a topic in future programmes.)
7	PRACHAR: Advancing Young People’s Sexual and Reproductive Health and Rights in India. Daniel et al, 2013^Citation49
	Bihar	Adolescents aged 12-19	Community-based	Health worker-led	“PRACHAR” structured teaching programme Trained governmental frontline health workers to deliver educational sessions, group discussion, interactive skill-building activities, narrative/dialogue-based exercises Community wide initiatives (ex. street theater, wall paintings, puppet shows, distribution of educational materials, community meetings, home visits)	Reproductive health, family planning, STIs, HIV/AIDS, puberty, menstruation, personal hygiene, myths surrounding contraception and conception, gender norms, delaying early marriage, societal/parental pressures, communication and negotiation skills, personal agency
8	The effect of community- based health education intervention on management of menstrual hygiene among rural Indian adolescent girls. Dongre & Garg, 2007^Citation50
	Maharashtra	Adolescent females aged 12-19 years	Community-based	Health worker-led	Group based teaching programme Pre-tested flip book containing needs-based key messages on the management of menstrual hygiene distributed to youth Education delivered by trained healthcare professionals at monthly village group meetings Participants encouraged to share their knowledge and recruit more village youth	Awareness of menstruation, importance of its acceptance as a normal biological process, menstrual hygiene
9	Sexual Behaviour of Rural College Youth in Maharashtra, India: An Intervention Study. Ghule & Donta, 2008^Citation51
	Maharashtra	Youth aged 18-24	School-based	Teacher and peer-led	Structured teaching programme Trained teachers and peer educators delivered education, counselling Programme included group discussions, AV aids, posters, flipcharts, street plays, demonstrations of contraception products, Q&A sessions, distribution of print health education materials Large-scale exhibitions during “AIDS Week” Creation of “Youth Friendly Center” staffed by trained counsellors in college for education, counselling, referrals to health services	Self-awareness, decision-making, general reproductive health
10	Impact of reproductive health education on the knowledge of mid adolescents boys of urban population of India. Jadon, 2017^Citation52
	Haryana	Adolescent males aged 14-16 in grades 9, 10, 11	School-based	Health worker-led	Structured teaching programme Included AV aids, interactive lecture sessions, group discussions, Q&A sessions	Puberty and changes during adolescence, attraction to others, male and female reproductive system, menstrual cycle, marriage, pregnancy, motherhood, newborn health, family planning, contraception, night emissions, masturbation, HIV/AIDS
11	Catalysing change: Improving youth sexual and reproductive health through DISHA, an integrated programme in India. Kanesathasan et al, 2008^Citation53
	Bihar and Jharkhand	Youth aged 10-24	Community-based	Peer and health worker-led	“DISHA” programme Partnered with local NGOs Trained peer educators provided education, counselling, referrals Group discussions, livelihood component aimed to create income-generating opportunities Large-scale activities: street plays, wall writings, thematic fairs, rallies, mobile health clinics, sporting events Establishment of youth groups and youth resource centres with youth-friendly services Trained healthcare professionals and youth depot holders to provide confidential counselling, contraception education, and other services	Changes during adolescence, gender and sexuality, fertility awareness, contraception, HIV/AIDS, safe motherhood, reproductive health services
12	Seeds of prevention: the impact on health behaviors of young adolescent girls in Uttar Pradesh, India, a cluster randomised control trial. Kapadia-Kundu et al, 2014^Citation54
	Uttar Pradesh	Adolescent females aged 10-14 years	School-based	Teacher-led	“Saloni” pilot intervention Delivered by trained teachers, sessions conducted in groups Utilised AV aids, posters, personal journaling and reflection, interactive exercises (ex. role play, group discussions) Promotion of adolescent health services provided at the school level	Physical health, nutrition, daily genital hygiene, menstruation, menstrual hygiene, legal age at marriage, childbearing, and family planning
13	Efficacy of focused group discussion on knowledge and practices related to menstruation among adolescent girls of rural areas of RHTC of a medical college: An interventional study. Kokiwar & Nikitha, 2020^Citation55
	Telangana	Adolescent females aged 10-19	Community-based	Health worker-led	Structured teaching programme Didactic session with AV aids Interactive focused group discussion in small groups	General knowledge on Menstruation, hygienic practices during menstruation
14	A psychosocial resilience curriculum provides the “missing piece” to boost adolescent physical health: A randomised controlled trial of Girls First in India. Leventhal et al, 2016^Citation56
	Bihar	Adolescent females aged 9-18	School-based	Peer-led	“Girls First” intervention Facilitated peer support group sessions and facilitated peer support group sessions Trained local leaders to facilitate group sessions Sessions combined didactic learning, peer-led discussions, and problem-solving exercises	Personal goal-setting, emotional awareness, assertive communication, conflict resolution, problem solving, self-esteem, opposing violence, personal confidence, gender constructs, the reproductive system, menstruation and hygiene, relationships, physical intimacy, gender-based violence
15	Knowledge and attitude about reproductive health among rural adolescent girls in Kuppam Mandal: An intervention study. Malleshappa et al, 2011^Citation57
	Andhra Pradesh	Adolescent females aged 14-19 years	School-based	Health worker-led	Structured teaching programme Didactic lecture Interactive sessions with group discussion Utilised AV aids, videos, charts, posters	Anatomy and physiology of male and female reproductive system, physical and psychological changes during puberty, conception, various methods of contraception, STDs including HIV/AIDS
16	An educational intervention study on adolescent reproductive health among pre-university girls in Davangere district, South India. Manjula et al, 2012^Citation58
	Karnataka	Pre-university adolescent females (XI and XII standard)	School-based	Teacher-led	Structured teaching programme Delivered by teachers Utilised AV aids, posters, printed health education materials, flip charts, overhead projections Group discussions with students conducted	Growth and development during adolescence, puberty, pregnancy, STIs, HIV/AIDS, communication and relationship management skills
17	Effectiveness of a community based intervention to delay early marriage, early pregnancy and improve school retention among adolescents in India. Mehra et al, 2018^Citation59
	Uttar Pradesh and Bihar	Youth aged 10-24 years	Community-based	Peer-led	Peer education programme Trained local youth conducted peer education sessions in small groups Posters, games, picture cards Development of “Youth Information Centre” to facilitate peer communication, monthly activities, group sessions, access referrals, counselling	General reproductive health and rights, gender and sexuality, early marriage, early pregnancy, importance of completing school education, learning vocational skills, delaying marriage and pregnancy
18	Preparing girls for menarche. Minimol, 2003^Citation60
	Karnataka	Pre-adolescent females	School-based	Teacher-led	Structured teaching programme Delivered by teachers Utilised AV aids	Female reproductive system, menstrual cycle, menstrual hygiene practices, management of pain during menstruation
19	Effectiveness of a reproductive sexual health education package among school going adolescents. Nair et al, 2012^Citation61
	Kerala	Adolescents aged 13-17 years	School-based	Health worker-led	Structured teaching programme Led by trained project leaders Utilised interactive discussion format Q&A sessions School-wide exhibitions and quizzes conducted related to sexual health education	Puberty, changes when growing up, nutrition, reproductive and sexual health hygiene, body image, sexuality and risk taking behaviour, gender and interpersonal relationships, STIs and HIV/AIDS, life skill development and scholastic achievement
20	Effectiveness of video assisted teaching module on knowledge of adolescent girls regarding polycystic ovarian syndrome in Gayatri Women’s + 2 Science College, Berhampur Ganjam, Odisha. Nayak, 2017^Citation62
	Odisha	Adolescent females aged 16-19 years	School-based	Health worker-led	Structured teaching programme Delivered by healthcare professionals Assisted with video modules Included health education module, manual, printed materials	Polycystic ovary syndrome (symptoms, diagnosis, treatment), importance of maintaining healthy lifestyle habits
21	Reproductive health education intervention trial. Parwej et al, 2005
	Chandigarh	Adolescent females of classes X, XI, XII	School-based	Peer and health worker-led	Bi-pronged structured teaching programme Didactic teaching by public health nurse Distribution of print health education materials Peer education delivered by trained peer educators Group and individual counselling available	Anatomy and physiology of male and female reproductive system, physical and sexual changes during adolescence, menstrual cycle, conception, contraception, child marriage, abortion, laws regarding reproductive rights, STDs, HIV/AIDS
22	Improving Adolescent Health: Learnings from an Interventional Study in Gujarat, India. Patel et al, 2018^Citation63
	Gujarat	Adolescents aged 11-18 years	Community and school-based	Teacher and health worker-led	Structured teaching programme Delivered by trained teachers, social health activists, health workers, Anganwadi workers, local mentors Peer education delivered by trained peer educators Development of health resource centres “Adolescent Health Days” organised for wide-spread awareness, physical check-ups, referrals, counselling	General sexual and reproductive health, nutrition, substance abuse, communication skills, gender equality, menstrual cycle and menstrual hygiene practices, adolescent pregnancy, changes during adolescence, HIV/AIDS, STDs
23	Effectiveness of interventional reproductive and sexual health education among school going adolescent girls in rural area. Phulambrikar et al, 2019^Citation64
	Maharashtra	Adolescent females from 9th-12th standard	School-based	Health worker-led	Structured teaching programme Didactic presentations using AV aids, videos, health education print materials Q&A sessions conducted	Mental and social changes taking place during adolescence, changing relationships, peer pressure, values and attitudes, decision-making, body image, reproductive anatomy and physiology in both males and females, puberty, physiology of menstruation, ways to maintain menstrual hygiene, common menstrual disorders, seeking medical help, myths about menstruation, human reproduction, contraception, legal age of marriage, STDs including HIV/AIDS
24	Impact of planned health education programme on knowledge and practice regarding menstrual hygiene among adolescent girls studying in selected high school in Puducherry. Premila et al, 2015^Citation65
	Puducherry	Adolescent females in grade 8 and 9 (aged 13-15 years)	School-based	Health worker-led	Structured teaching programme Didactic lecture, included use of AV aids Group discussions Q&A sessions	Menstruation, physiology and anatomy of female reproductive system, menstrual cycle, menstrual hygiene
25	School health promotion programmes in India: a casebook. Rajaraman, 2015^Citation66
	Rajasthan	Youth in grades 7-8	School-based	Teacher-led	“DRISHTI” structured programme Education provided by trained teachers Included fact sheets and posters Interactive activities such as case studies, field visits, debates, panel discussions, storytelling, role play, games, worksheets, projects Community wide initiatives such puppet shows, rallies and fairs (mela)	Communication skills, healthy relationships, resolving conflicts, physical hygiene, STDs, HIV/AIDS, gender roles and stereotypes
26	The acceptability, feasibility and impact of a lay health counsellor delivered health promoting schools programme in India: a case study evaluation. Rajaraman et al, 2012^Citation67
	Goa	Youth aged 9-17 years, in grades 5-12	School-based	Health worker-led	“SHAPE” structured school programme Class-level: structured teaching sessions by trained school health counsellors, promotion of skills-based education,interactive exercises, counselling School-wide initiatives: school mapping and needs assessment, screening camps, “speak-out box” for Q&A, health camps, workshops	Physiological and sexual and reproductive health, STI/STDs, HIV/AIDS, general physical hygiene, conflict resolution, mental health, puberty, changes associated with adolescence
27	Effectiveness of reproductive health education among rural adolescent girls: a school-based intervention study in Udupi Taluk, Karnataka. Rao et al, 2008^Citation68
	Karnataka	Adolescent females aged 16-19 years	School-based	Health worker-led	Structured teaching programme Didactic lecture followed by interactive sessions, Q&A AV aids, charts, posters and video films used	Reproductive health, contraception, ovulation, menstruation, menstrual hygiene practices, pregnancy, fertilisation, antenatal care
28	Health awareness of rural adolescent girls: an intervention study. Sharma et al, 2009^Citation69
	Himachal Pradesh	Adolescent females aged 14-18	School-based	Health worker-led	Structured teaching programme Didactic lecture followed by interactive sessions Group discussions, narrative-based teaching, storytelling xxx	Changes during puberty, menstrual cycle, pain during menstruation, childbearing, immunisations, family size, birth spacing, family planning methods, safe birthing practices
29	The development and pilot testing of a multicomponent health promotion intervention (SEHER) for secondary schools in Bihar, India. Shinde et al, 2017^Citation70
	Bihar	Adolescents in secondary school	School-based	Peer and health worker-led	“SEHER” structured school programme Class-level: peer group education, interactive workshops, counselling, referrals School-wide initiatives: school mapping and needs assessment, cleanliness drive, skit presentations, wall-magazines, extra- curricular competitions, “speak-out box” for Q&A, school assemblies, debates, storytelling, panel discussions, role playing, monthly competitions	Social skills, decision-making processes, sexual health, gender, gender-based violence, reproductive health
30	Study of the effect of information, motivation and behavioural skills (IMB) intervention in changing AIDS risk behaviour in female university students. Singh, 2003^Citation71
	Delhi	Female youth aged 18-22 years	School-based	Health worker-led	Structured multicomponent intervention Didactic lecture AV aids, slide shows, take home booklets, videos Interactive exercises: demonstration and practice with contraceptive methods, role playing, skits Group discussions	HIV/AIDS, misconceptions associated with sex, safer sex practices, personal attitudes and social norms that hinder preventive practices, communication skills, negotiation skills
31	Impact assessment of school-based sex education programme amongst adolescents. Thakor and Kumar, 2000^Citation72
	Gujarat	Adolescents aged 15-18 years	School-based	Health worker-led	Structured teaching programme Trained healthcare professionals delivered curriculum to small groups Group discussion time Q&A sessions	Anatomy and physiology of the reproductive systems, STDs and how to prevent them, myths about sex, sexual behaviour, contraception, conception, HIV/AIDS
32	Effectiveness of a health educational package for AIDS prevention among adolescent school children. Tilak & Bhalwar, 1998^Citation73
	Pune	Youth in classes IX to XII	School based	Health worker-led	Structured teaching programme Didactic lecture AV aids, overhead projections, video showings Group exhibition Q&A session	HIV/AIDS: transmission, prevention, treatment, common misconceptions
33	Empowering the people: Development of an HIV peer education model for low literacy rural communities in India. Van Rompay et al, 2008^Citation74
	Tamil Nadu	Youth (ages not reported)	Community based	Peer-led	Structured teaching programme Peer education delivered by NGO outreach workers, peer educators of women’s groups, barbers Peer educators given “Health Education Kits” with flipcharts, info booklets, fact sheets, pamphlets, stickers, condoms, referral slips, reporting forms Distribution of printed educational materials adapted to match needs of community Referrals offered for diagnosis and treatment of HIV/AIDS and other STDs Community wide: street theatre productions, songs, folk dances, humorous skits, awareness rallies	HIV/AIDS, masturbation, safe sex practices, sexual anatomy, reproductive physiology, STDs, proper contraception use
34	Promoting gender equity as a strategy to reduce HIV risk and gender-based violence among young men in India. Verma et al, 2008^Citation75
	Maharashtra and Uttar Pradesh	Male youth aged 15-24 years	School based	Peer-led	“Yaari-Dosti” programme Peer-led group education sessions Interactive exercises: role playing, games, discussion, debate, critical thinking exercises Lifestyle social marketing campaigns Community wide: street plays, posters, pamphlets, comic strips, community- based discussions, T-shirts Creation of mobile booth as distribution centre for condoms, communication materials	Gender norms, IPV, gender and sexuality, STDs, HIV/AIDS, violence, reproductive system, alcohol and risks, stigma and discrimination
35	Health Training Programme for Adolescent Girls: Some Lessons from India's NGO Initiative. Visaria & Mishra, 2017^Citation76
	Gujarat	Adolescent females	Community based	Health worker-led	Structured teaching programme Trained instructor delivered education in groups Inclusion of AV aids, pamphlets Group discussions Guest lectures from medical professionals	Menstruation (symptoms, cause, menstrual hygiene), unsafe sex, contraception, reproductive tract infections, family planning, reproductive health

Programmes vary greatly across India

There is wide diversity in interventions and intervention-delivery mechanisms. Programmes were conducted either at the individual level, small-group level, or community/village wide. They were either implemented within the context of a school environment (majority of programmes – 24/35), or within a local community (10/35), or both (1/35). Overall, there is a great variety in the types of programmes that have been developed across the Indian context to provide sexual and reproductive health education to youth; no clear consensus was found across articles reviewed on which type of programme or programme components should be implemented within a specific setting.

Most programmes included a central didactic teaching component. There were differences across programmes in who taught the programme, with most programmes having health worker-led programming (19/35); 5 programmes were teacher-led, 5 were peer educator-led, 3 programmes were health worker and peer-led, 2 programmes were peer and teacher-led, and 1 programme was health-worker and teacher-led. Some programmes included a peer education component as the main method of information delivery (5/35), and a few included peer education as an additional supplement to their central delivery method through teachers or health professionals (5/35).

In our review, we charted the subjects covered by the included programmes. Certain topics were widely included in most programmes, such as: anatomy and physiology of male and female reproductive systems, changes during adolescence/puberty, sexual maturity, personal sexuality, navigating relationships, menstruation, pregnancy and family planning, STIs, and HIV/AIDS. Other topics were not as commonly included, such as: gender equity (9/35 programmes), gender-based violence (4/35), communication and personal skills development (7/35), and societal pressures faced by youth (3/35). In certain regions, local myths and misconceptions were addressed and debunked in the teaching, such as: popular myths surrounding STIs (gupt roga), nocturnal emissions (swapnadosh), the sex determination of the fetus, and culturally specific conditions like koro.* The number of programmes that included each individual topic is shown in Table 3.

Table 3. Topics covered by the included programmes

Subject	Number of programmes covering topic
Anatomy and physiology of male and female reproductive system	28
Changes during adolescence/puberty (physical, sexual, mental, emotional)	27
Menstruation (physiology, symptoms, hygienic practices)	22
HIV/AIDS (transmission, prevention, treatment, common misconceptions)	19
STI/STDs (transmissions, prevention, risky behaviours)	18
Pregnancy and family planning (conception, pregnancy, contraception, abortion, childbearing, birth spacing, antenatal care)	18
Sexual maturity (masturbation, navigating sexual situations and feelings, navigating personal sexuality)	14
Relationships and friendships (communication skills, navigating dating, healthy relationships, resolving conflicts)	12
Gender equity (gender norms/stereotypes, gender inequality, gender discrimination, reproductive rights)	9
Personal skills and life skills training (personal confidence, goal setting, individual values, personal skill development)	7
Physical hygiene practices (for males and females)	6
Addressing local myths/misconceptions about: STDs/STIs (Gupt roga) Koro Nocturnal emissions (Swapnadosh) Sex determination of the fetus	6
Violence (intimate partner violence, sexual violence/abuse, gender-based violence)	4
Societal/parental pressures faced by adolescents	3
Polycystic ovary syndrome (symptoms, diagnosis, treatment)	1
Immunization (purpose, schedules, vaccines for newborns)	1

Diverse methods for delivering information increase programme success

Programmes that included time for group discussions found that attendees found the discussions beneficial, regardless of whether it was a structured focus group discussion or a more informal group discussion. Group discussions were reported to be a good opportunity to share personal experiences, ask questions, engage in conversation over similar experiences, and learn from others.^33,47,50,52 Successful programmes also included visual aids, such as posters, diagrams, drawings and videos.^2,60,64,66 Interactive and participatory exercises such as demonstrations, role-playing exercises, creating skits in groups, playing trivia games, and engaging in debates on relevant topics were also found by youth to be helpful in consolidating information they had learned.^44,47,59 Another important component that was found to be very appreciated by youth was the inclusion of some form of “question and answer” period; this could be through a formal discussion session or an anonymous submission box with answer provision sessions later on.^2,43 Successful programmes also had the inclusion of take-home handouts or pamphlets to reinforce learning and potentially help extend the learning process to family members at home.^67,74,75,77 Lastly, several programmes included the option of booking individual counselling sessions with trained counsellors or healthcare professionals for any personal concerns or topics they wanted to discuss in private.^44,59,67

Programmes that addressed a larger audience, such as a community as a whole, employed several elements to impart educational messaging. Some programmes included a large health “fair” or “mela,” youth health camps or festivals, rallies or parades to engage large groups of people.^46,53,66 Successful programmes, similar to the smaller programmes, included interactive and participatory exercises such as community plays, puppet shows, and street shows to engage youth and share information.^66,70 Several programmes included visual aids such as posters, flyers, T-shirts, badges, and buttons to spread awareness throughout the community.^{44,49,66,74,75} A few programmes included home-to-home visits to provide education and counselling on a more personal level, and others also set up youth health clinics in order to serve as a designated space for youth to access accurate information, connect with healthcare services, and discuss sexual health topics in a confidential setting.^53,63,78

Monitoring and evaluation is critical to programme success and sustainability

We also identified several recommendations from the reviewed articles regarding the development of all programmes, regardless of type. The importance of preliminary assessment of knowledge levels and needs of youth in the target community prior to the development of the programme was emphasised by all programmes. Including continuous quality monitoring and evaluation of programme delivery was very important to ensure that the programme curriculum was being delivered correctly.⁶⁶ Through the process of monitoring, programmes were able to determine whether a certain curriculum was making progress towards its specific goals and objectives. Furthermore, by checking-in with programme educators, programmes were able to address educator feedback, provide them with support and answer any questions or concerns they may have as these come up.^48,56 In some programmes, refresher training sessions were conducted for educators at set intervals during the programme duration.^{48,53,63,66,67} Other components of monitoring included assessment of inputs and required resources (i.e. programme funding, employees, duration of programme activities, needed equipment/supplies, and facilities) and programme outputs (i.e. student knowledge, skills developed, feedback received).^47,48,66,70 Evaluation is the process of examining whether the programme’s objectives have been achieved. Evaluation processes, typically conducted at the conclusion of the programme delivery, provided valuable information on longer-term impacts of the programme and feedback for future iterations or expansion of programme delivery. Thorough assessment and evaluation of programme delivery provide information on who was actually reached by the curriculum and the measurable impact made, such as changes in knowledge, attitudes, and skills among participants, through methods such as document analysis, participant interviews, focus group discussions, and surveys.^33,59,67,70

Resources and time allocated by educators make a difference

There is a great diversity in the educators that lead the programmes identified in our review, including community members, youth group leaders, peer educators, and formal school teachers. There are benefits and drawbacks for each type of instructor choice, and there is no established preferred option in the literature. Drawing on existing staff resources, such as school teachers, ensures sustainability and allows for rapid implementation and potential scale-up of activities. At the same time, if the educators delivering the programme have another primary responsibility, the effectiveness of the programme may be compromised. A major recommendation that emerged from the literature was making sexuality education a core subject within the regular school curriculum.^47,52,64,66 This would help emphasise the importance of sexual health and reproductive health education for youth, ensure that adequate time and resources are allocated to its teaching, and could allow students to study the topics covered without worrying about sacrificing study time for their other classes.⁶⁶

Some programmes delivered their programme through health professionals and health counsellors. Since these educators were solely assigned to the programme delivery, their time to dedicate to the programme was protected and was greater than programmes that relied on school teachers, for example. The “SHAPE” programme was delivered by school health counsellors⁶⁷ and the “SEHER” programme utilised lay counsellors for the delivery of their intervention activities.⁷⁰ Both programmes found that one of the greatest strengths of counsellor-led delivery was the focused time and coverage they were able to provide. However, the “SEHER” programme noted that there was an increased cost associated with the hiring and training of counsellors in their delivery model compared to a teacher-led programme.⁷⁰

Several successful programmes have also utilised peer-led education as their primary method of delivery. Peer educators may require considerable training before they have the knowledge and skills to implement an educational programme. Overall, the evidence on the utility of peer educators is mixed.⁷⁹ Youth may be more receptive and open to peer educators given the similarity in age and stage in life. Peer education can be helpful in terms of promoting peer-to-peer support and an open environment for the discussion of sensitive topics.⁸⁰ One systematic review of literature from the Indian context found overall mixed results for peer education and its effects on behaviour, but proposed that, while it has its limitations, it can be a valuable component of sexual health education efforts.⁷⁷ Peer education may be most beneficial when it is included as a part of a multicomponent, holistic intervention for youth.^78,81

Community and youth involvement increase the acceptability of programmes

The importance of fostering and engaging local organisations and community resources was emphasised across the reviewed literature as a key component for ensuring success and longevity of the implemented programme and curriculum within the Indian context. Engaging community leaders, community stakeholders and local experts in the creation, development and implementation process were vital to the success and feasibility of all programmes.⁷⁹ Programmes that included local leaders such as principals, school teachers, village council leaders and local NGOs or organisations were able to develop and run programmes effectively and were well-received by the community with which they were working in partnership. Fostering a supportive and receptive environment is critical for the successful initiation and continuation of sexuality education programmes. By working with and mobilising the community, empowerment of participants, support for programme expansion, the involvement of a greater range of stakeholders, wider awareness through mass media and local channels, as well as advocacy for greater social issues can be established.⁷⁹

Several programmes established partnerships with local organisations and community leaders to provide feedback, assist in the programme development, and monitor implementation.^{56,59,63,64,70} Certain programmes even established a formal advisory board composed of local stakeholders, local organisation leaders and community representatives to provide continuous feedback on a regular basis throughout programme implementation.^44,48,67,74 Establishing community support can help to promote sustainability and increased engagement from community members.⁴⁸ Several programmes conducted needs assessments and consulted with local stakeholders such as parents and teachers during the development process.^{43,50,58,60,67,69} However, consultation with local youth is especially important, as youth perspectives can often be overlooked in decision-making processes.⁹ Youth themselves can play an integral role in identifying and advocating for their own needs.⁷⁹ Among the 35 individual programmes, only 4 reported consulting with local youth in the development and initiation of their programmes. For example, in the “DISHA” programme, a confidential access point for individualised counselling and provision of contraceptive products was established based on input from youth.⁵³

Furthermore, partnerships with local NGOs and health centres were found to play a significant role in ensuring buy-in from diverse stakeholders in 13/35 of the reviewed programmes. They were also found to help programmes liaise with various school systems, communities, villages, agencies, and institutions. These organisations provided valuable assistance in the development of tools and systems for the implementation, monitoring, and evaluation of educational programmes. Furthermore, partnering with local health services helped to strengthen community and youth access to sexual health information and clinical services.^49,51,53

Access to high-quality education enhances reproductive health outcomes

Limitations of school-based sexuality education provision include the underlying assumptions that (1) all or most youth we are trying to reach are in fact attending school and have been able to attend school uninterrupted since childhood, and (2) their education up to this point has been of satisfactory quality, and has provided them with the opportunity to develop the required literacy, numeracy, critical thinking and communication skills necessary to build a solid foundation in sexual health decision-making and navigating relationships. Several articles in the reviewed literature raised concerns about the applicability of school-based approaches to promoting sexual and reproductive health because of these limitations.⁸² One working paper published by the Population Council found that the implementation of sexual health education programmes has little impact in Indian schools where teachers require more training and where students have not attained basic skills such as literacy and numeracy. The authors also found a strong overlap between youth most at-risk for poor health outcomes and youth who were most disadvantaged educationally. They postulated that for many of these students, improvement in their basic literacy and numeracy skills may itself be the most significant and promising intervention in terms of their reproductive health outcomes.⁸²

Access to schooling itself can play a great role in sexual health outcomes for youth and young adults. Prevention of early marriage, in particular, is important in ensuring continued access to schooling for youth, especially for women and girls in India. Keeping Indian youth enrolled in school is an effective way to prevent early marriage, as many studies completed in the Indian context and across the world have shown that youth enrolled in school are less likely to be married at an early age.¹⁸ They are more likely to continue their post-secondary studies, apply for employment, and become financially independent. It is important to ensure access to high-quality education for all youth, and provide economic and social support for families to help prevent child marriage. One example of this was conducted through the Indian “DISHA” programme, where in addition to providing education on sexual health to youth, the programme introduced “livelihood groups” to address some of the socioeconomic barriers that youth face. The livelihoods component set up income-generating opportunities for youth along with training in employment-oriented skills. Some examples included training youth in skills such as pottery, tailoring, vegetable cultivation, rice production, candle-making and bangle decoration. The programme also linked youth to micro-saving and credit groups.⁵³

Reaching vulnerable youth requires out-of-school programming

For an intervention to have an impact on youth knowledge and behaviour, it must be able to reach them. A significant proportion of Indian youth, especially those who are most marginalised or vulnerable, are not being reached by interventions intended for them. These groups include: youth with disabilities, youth engaged in sex work, youth experiencing homelessness, youth with low literacy levels, migrant youth, and youth involved in the justice system. Most existing programmes focus on youth enrolled in schools and colleges rather than those outside the school system. Within our review 24/35 programmes were primarily school-based in their delivery. In India, there are higher rates of drop-out from school in girls than boys, and in those belonging to socioeconomically disadvantaged households over advantaged households. As a result, the most vulnerable youth are often not enrolled in school or involved in youth groups, so it can be difficult to reach them through these standard routes.^23,78 For example, youth living in slum areas are less likely to be in school, are more likely to have significant stressors in their life, and they may live within a social system unique to slum communities (e.g. council of Elders, workers at Anganwadi rural childcare and community health centres). Therefore, it is important to reach them by developing and implementing interventions that involve and empower the existing community structure, local NGOs and available health services. For this reason, some programmes have tried unconventional delivery methods like providing education through barber-shops, wine shops, and radio shows.^45,74,83

Addressing gender inequality is essential to mitigating violence

While there is a growing body of work on programmes specifically focused on gender-related topics that are making targeted efforts to engage youth in understanding gender-based inequity, inclusion of this topic into comprehensive sexuality education is limited. Only one of the programmes included in the review incorporated gender equity and gender-based violence into their comprehensive sexual health curriculum. The programme consisted of peer-led group education activities, and participatory activities such as role-playing, debates, and critical thinking exercises. The programme was supported by monthly meetings where facilitators, field supervisors, as well as experts in the field of gender equity, met to discuss programme progress and implementation.⁷⁵ While many sexual health education programmes have acknowledged the importance of including discussion about gender inequity, gender-based norms, reproductive rights, LGBTQ+ rights and gender-based violence as part of their curriculum, resistance from individuals such as local school officials and parents, combined with the general taboo surrounding such topics, can make implementation difficult.^46,84 Furthermore, the persistence of gender-based or sexuality-based inequity, especially if explicitly visible among staff at school or within the local environment, can undermine the utility of many sexual and reproductive health programmes.

One extensive review and analysis of a wide variety of evaluation studies of comprehensive sexuality education programmes from different global contexts and settings, including India, found that programmes that included gender and gender-based rights in their curriculum were more successful in improving sexual health outcomes for youth than “gender-blind” programmes. They also found that youth who adopt more egalitarian stances on gender and gender-based norms, are more likely to have a delayed sexual debut and use protection during sexual activity, and are less likely to be involved in intimate partner violence.¹⁰ On a nation-wide scale, there is a need for greater inclusion, open discussion, and teaching of these topics in programmes for youth.

Supportive environments for comprehensive sexuality education are crucial for delivery

Interventions related to the upstream factors influencing youth health can be challenging to evaluate and develop. Barriers related to individual behaviour can be at the household, school, local community, regional or national level. Socioeconomic capital, access to required resources, healthcare service delivery, school and educational systems, social capital and social norms can all influence the sexual health of youth. It is important for youth to have a supportive environment that supports their educational and vocational attainment, in addition to socioeconomic security and social supports.³⁸ Along with sexuality education programmes aimed at increasing personal knowledge and related skills, interventions addressing these broader factors are concurrently required, in order to also increase employment, school retention, financial security, and social support for youth. Integrated programmes like these result in better outcomes and greater impact. For example, in the “Saloni” pilot programme, multiple upstream preventative health interventions for adolescents were introduced through the school system that addressed multiple areas of youth health including nutritional deficiencies, reproductive health, and physical hygiene. The “Saloni” programme included 10 in-school sessions and take-home activities for their participants. The study team reported approximately 65% of the girls in the intervention group had adopted 13 or more new positive preventative health behaviours in the areas of nutrition, hygiene and reproductive health, by the end of the programme compared to 4.5% in the control group and 5% at baseline.⁵⁴

Discussion

This review has demonstrated that there is a wide variety of interventions and programmes that have been developed and implemented to address the need for sexuality education for youth in India. There are many different types of programmes and there is no consensus within the literature with regard to which are the most successful with youth, although what is most feasible and useful is likely driven by the specific context and needs of the population being targeted. The main take-aways are summarised in Figure 2. We found that successful programmes required a diverse team to support development, including experts in sexuality education, local community leaders, parents, youth, NGOs, and community organisations. Prior to programme debut, it was important to complete a needs assessment of the target population in order to create a personalised programme tailored to meet the needs of the community. With regards to curricular development, it was important to develop specific objectives for the programme, and to deliver programming using culturally appropriate messaging that was also tailored to the literary and developmental level of the participants. Having a variety of methods for delivering information was also highlighted, for example: the use of visual aids, interactive exercises, participatory activities, reflection exercises, group projects, and community/village-wide activities and events. Providing youth with follow-up by way of connection to local sexual health services and/or take-home resources was also found to be helpful for youth. Implementation of the programme should be delivered over a sufficient length, duration, and level of intensity via well-trained educators with ongoing monitoring and support for their performance. Overall, engagement in continuous ongoing feedback and quality monitoring of the programme is vital for the understanding of programme impact, assessing the potential for long-term continuation and/or expansion, and developing further partnerships and collaborative linkages with related organisations and stakeholders.

Figure 2. Main take-aways for programme development and implementation

Few programmes identified in the scoping review explicitly addressed gender inequity and gender-based violence in their content. Gender – a societal construct - can permeate all aspects of youth health, especially sexual and reproductive health. In ancient Indian society, women were treated and valued as having equal status to men.⁸⁵ Patriarchy entered Indian society in the post-Vedic era, with Victorian gender norms and puritanical principles notably imposed by the colonial rule of Britain, including the penal code. Youth of all genders are impacted by limited access to sexual health information, and by societal norms that dissuade open dialogue on sexual violence, consent, and respect in intimate relationships; however, the impact is arguably more pronounced for women, who face enhanced gender-based oppression through the patriarchal norms of post-Vedic Indian society and are correspondingly more likely to face sexual violence.

When comparing the promising practices identified in our review with the globally-defined best practices for CSE established by the United Nations Educational, Scientific and Cultural Organization (UNESCO), we found many similarities between the two, and no contradictions. Our review corroborated several practices also recommended by UNESCO. Specifically, the UNESCO guidelines also emphasise the importance of sufficient preparation and groundwork within the target community before implementation, with the development of links to existing community resources and partners in order to support future sustainability of the programme. This is especially important in the Indian context, due to unique sociocultural settings of various communities across the country. The vast diversity in sociocultural norms, language, religious, financial, and economic conditions necessitates that new programmes are developed specifically for the individual setting for which they are planned. Specific areas of focus unique to India for new sexuality education programmes include the topics of gender-based equity, gender-based violence, as well as local culture-bound syndromes such as koro. Both the UNESCO guidelines and our review support the importance of consulting stakeholder groups, establishing a local steering committee supported by community organisations, conducting an assessment of local youth needs, determining focused and measurable programme goals and outcomes, and developing a framework for curricular activity based on the population reference values and existing educational resources. As stated in the UNESCO guidelines, and also confirmed by the studies in our review, after the development of the programme, it is key to pilot test before launching the programme, and then continue to monitor and evaluate the programme on an ongoing basis to assess outcomes and scale-up as possible. Both UNESCO and our review also found that the programme itself should be specific to the needs of the community, with use of participatory teaching methods, targeting risk and protective factors that may be present while also providing youth with practical skills and scientifically accurate information about sexual and reproductive health.³ As previously discussed, providing youth with practical skills is especially important in the Indian context, where providing youth with practical skills that they can leverage to improve their socioeconomic status is key in breaking the cycle of lower educational attainment, decreased social and employment opportunities, and negative sexual and reproductive health outcomes.

Areas of paucity and goals for the future

We aim for the results of this paper to help guide educators and public health organisations in the creation, implementation, and evaluation of CSE programmes for youth within the context of India but also any other similar settings. Our work also provides an example of a framework for evaluating sexuality education programmes and provides a comprehensive overview of factors that are important to consider in the development and assessment of these initiatives. This review offers educators, programme planners, and policy makers an in-depth look into the current state of sexuality education programmes in India, and various strengths, weaknesses, and key lessons learned by these various groups in their endeavours to deliver sexuality education for youth. Sexuality education must be shaped by awareness of what works for youth and be adaptable according to the changing needs of young people. For example, we identified the specific need for greater incorporation of education surrounding gender-based stereotyping and prevention both on the individual and community level for the prevention of gender-based violence within the Indian context.

We identified several gaps and areas for future work and research in the literature. There is a need to generate more robust and standardised data on the outcomes of sexuality education programmes. Much of the global literature on interventions to promote sexual and reproductive health among youth has noted a need for more rigorous and theory-based research to evaluate the effectiveness of interventions in improving youth knowledge and changing health behaviours and outcomes.^78,86–88

One of the limitations of our review is the restricted ability to accurately compare programmes across different settings and target population groups. Even within the context of India alone, there is a huge diversity across programmes in the types of activities, components, curricula, outcomes measured and methods of implementation. Due to this variety in the outcomes and reported measurement methods, it is understandably difficult to draw accurate conclusions about the field and cross-compare between different programmes. There is currently no consensus on whether teacher-taught, peer-taught, counsellor/health worker-taught programmes are all effective or if one of these methods is better in a given context, largely because of lack of meaningful evaluation approaches that are standardised while also context-specific. Similarly, there is no consensus currently on which programme length, duration of sessions, or number of sessions is most effective in a given context, although it has been shown that any type of intervention when delivered piecemeal or with inadequate dosage is not as successful.^2,53,78

Further research on the costs and benefits, using validated and context-specific measures of effectiveness, will be important for decisions on how to allocate resources for programmes for health promotion. Longer-term tracking of health and social outcomes for the participants of a programme is also important, as many of the potential benefits may not be measurable in the short term.² Standardised and validated outcome measures should be utilised to allow for effective comparability between programmes. Research should be conducted across a wide variety of sociocultural contexts to identify feasible and effectual programmes that work among youth to reduce negative sexual health outcomes, especially in resource-limited settings.⁸⁶ Evidence-based and successful programmes should be scaled up, delivered with adequate intensity and sustained long-term.^2,78,89

Conclusion

Personal knowledge and skills development related to sexuality is an important determinant of health during adolescence and young adulthood. As part of a broader sexual health promotion strategy addressing both downstream and upstream determinants of healthy sexuality, the delivery of CSE for young people has a significant impact on promoting overall wellbeing. It serves as a crucial prevention tool for adverse sexual and reproductive health outcomes, including unwanted pregnancy, unsafe abortions, sexually transmitted infections, HIV/AIDS, and sexual violence. Moreover, CSE is an integral prerequisite to full-body autonomy and thus intimately tied to human rights.

In this scoping review, we endeavoured to identify components and characteristics of successful sexuality education programmes, to inform promising practices for the development of programmes for youth in India. CSE programmes, in combination with access to sexual health services, are vital for providing youth with comprehensive knowledge on the topic as well as providing youth with the skills to navigate sexual and reproductive health-related decisions. The Indian context is very diverse, and not all identified promising practices may be applicable for all locales and populations. It is important for existing programmes and those looking to develop new programmes to tailor their content to serve the needs of the specific youth population being targeted; to work in partnership with local experts and organisations; to address potential barriers to participation and work to mitigate those barriers for marginalised youth; to be youth-friendly, flexible and convenient; and be developmentally and culturally appropriate for the Indian youth context.⁵¹

A myriad of micro- and macro-level factors can lead to negative sexual health outcomes among youth and young adults, from family and community pressures, social norms and expectations, to educational attainment and financial constraints. Continued efforts are required by different sectors and stakeholders to address the interrelated and broad structural factors, including political, financial, social, and cultural, that affect youth sexual health and wellbeing.

Acknowledgements

Sandra Halliday from Bracken Health Sciences Library at Queen’s University provided guidance in developing and implementing the search strategy. Natalie DiMaio assisted in the citation screen as the second reviewer.

Disclosure statement

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

Supplemental data

Supplemental data for this article can be accessed online at https://do.org/10.1080/26410397.2023.2244268.

Additional information

Funding

N. Pattathil received summer studentship funding from the Department of Medicine at Queen’s University and the Dr. Samuel S. Robinson Charitable Foundation to conduct this research.

Notes

* Koro is a psychiatric culture-bound syndrome characterised by intense fear that the sexual organs (i.e. penis, breasts) will retract into the body. It has been found to be most prevalent in populations within South Asia and South East Asia.