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 .
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 9th 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.’