Full article: School-based relationships and sexuality education programmes in primary schools: contexts, mechanisms and outcomes

Introduction & background

Searching for evidence about ‘what works’ has been pervasive in the fields of relationships and sexuality education (RSE)¹ (Grunseit et al. Citation1997; Jones et al. Citation2009; Kirby, Laris, and Rolleri Citation2007; Poobalan et al. Citation2009; Pound et al. Citation2017). Programme evaluations have contributed vital insights into RSE programme development, implementation, and evaluation (Denford et al. Citation2017; UNESCO Citation2018; UNFPA Citation2014). Some recent reviews suggest that experimental designs dominate in this field (Ivanova et al. Citation2020; Rocha, Silva, and Duarte Citation2022), while others highlight the diversity of methodologies and methods used (Goldfarb and Lieberman Citation2021). Despite varied evaluation efforts, there is a gap in evidence concerning RSE programmes for younger children in primary (elementary) schools,² with most programme evaluations having been undertaken with older children in secondary (high) schools (Roien, Graugaard, and Simovska Citation2018). This is important because writers have stressed that RSE should be a lifelong process (Ketting, Friele, and Michielsen Citation2016). Therefore, programme evaluations must be time- and context-sensitive (Michielsen et al. Citation2016).

For many years, researchers have emphasised that preparing students to manage the physical, social and emotional changes associated with puberty is fundamental (Crockett et al. Citation2019; Goldman Citation2010). At the very least, it is important because students have the right to education about their bodies and relationships consistent with their evolving capacities (Ketting and Winkelmann Citation2013). Given that the onset of puberty occurs at an earlier age than in past decades and behavioural norms change, providing developmentally and culturally appropriate RSE in primary schools is crucial (Collier-Harris and Goldman Citation2017; Gilbert and Lamb Citation2019; Suleiman et al. Citation2017). Negative socio-emotional outcomes for students who begin puberty before their peers may be prevented via the provision of early and universal puberty education (Warren and Yu Citation2016). Similarly, RSE programme effectiveness can be maximised when students experience RSE before they engage in ‘sexual activity’ (Goldfarb and Lieberman Citation2021). Yet relatively little is known about the features of RSE programmes in primary schools and how programme evaluations can best be conducted.

Against this background, we conducted a review of RSE programmes implemented in primary schools using a systematic search and screening process (Moher et al. Citation2009). The review was informed by principles of realist evaluation (Pawson and Tilley Citation1997), which involves identifying contexts, mechanisms, and outcomes to generate programme theories that can explain why, how and for whom programmes may work (Greenhalgh et al. Citation2015). The purpose of the review was to generate from existing research, programme theories about the functioning of RSE in primary school. By programme theories we mean ideas about the conditions and ways in which programmes may influence change in participant behaviour or reasoning at the individual student level (Marchal, Kegels, and van Belle Citation2018; Pawson and Tilley Citation1997). We searched for contexts in which school-based RSE programmes might trigger (i.e., influence) mechanisms that can change outcomes for primary school students: a chain of effects that is central to realist evaluation. We focused on upper primary school (Years or Grades 4 to 6, or ages 9–12.5 years) because the review was conducted to guide the research design for an evaluation of an established Australian RSE programme for upper primary school children known as the All School programme, developed and delivered by True Relationships and Reproductive Health in Queensland, Australia (see https://www.true.org.au/all-school). The research was conducted in partial fulfilment of a doctoral degree study by the first author and supervised by the co-authors.

The review

We used an existing RSE reference database established for a systematic review of universal school-based RSE for children aged 4–18 years, led by this paper’s third author and conducted by the paper’s co-authors. This database houses search results from six academic databases: ERIC (EBSCOhost), Education Source (EBSCOhost), Academic Source Elite (EBSCOhost), APA PsycInfo (EBSCOhost), A+ (Informit), and Education Database (ProQuest). The original search strategy included the keywords ‘respectful relationships’ as well as ‘sex education’ and ‘school*’ not ‘higher education’. Searches were conducted between August and September 2019.

Results

Table 3 provides details of the included studies.

Discussion

We conducted a literature review and identified nine relevant studies of relationships and sexuality education (RSE) programmes for primary school students. Adopting a theory-generating approach informed by realist evaluation enabled us to identify contexts, mechanisms and outcomes that could be formulated into programme theories to explain the functioning of RSE programmes. Our findings will interest a range of audiences wishing to use to utilise RSE programme theories in research and practice, including evaluators, researchers, RSE programme designers and practitioners.

We identified several contextual factors that influence RSE programmes and that could be incorporated into programme theories. At a structural level, findings suggested that decisions made at the highest level in educational bureaucracies and government policies are crucial to RSE programme implementation in many ways (e.g., by promoting specific RSE approaches, allocating funding, and creating teaching materials). In school, supporting teachers and guiding teaching practices were identified as the most relevant structural factors, consistent with the existing literature (O’Brien, Hendriks, and Burns Citation2021). At a cultural level, decisions regarding when, how and how much to discuss with children about relationships and sexuality were identified as values associated with perceived programme effectiveness, consistent with previous reviews (Mullis et al. Citation2021). At an individual level, we noted that only gender tended to be used as variable in data analysis (as evident in reporting of study data) despite the myriad of other individual factors that mightinfluence RSE programme outcomes (e.g., puberty experience, children’s interest in RSE, exposure to sexual themes in media). Additionally, all included studies reporting on gender used a binary approach thereby failing to capture diverse gender identities (e.g., non-binary gender identities) which may be out of step with international guidelines on sexuality education (UNESCO Citation2018) and human rights conventions which promote non-discrimination on the basis of gender identity (UN Citation1989). This is especially important because the time approaching puberty is recognised as challenging for children who may be questioning their gender identity (UNESCO Citation2018). Overall, programme evaluations could do better by incorporating data collection modules to account for a wider range of cultural, structural and individual factors that may influence programme mechanisms and thereby affect programme outcomes.

The approach to mechanisms that we adopted revealed the need to seek children’s opinions about how different mechanisms influence the effectiveness of RSE (i.e., the reasons why children think RSE programmes may work). One example of this type of research is provided by Robinson and Davies (Citation2014), who used image-guided interviews and focus groups to elicit children’s perspectives. Despite sparse data on children’s opinions in the included studies, we were able to derive nine mechanisms. Our findings add to recent research on mechanisms within RSE programmes (e.g., Sell, Oliver, and Meiksin Citation2021; Taylor Citation2020). These mechanisms should be tested in further theory-driven evaluations to inform programme logic models. A challenge for future evaluators is to find ways to elicit children’s thoughts on the reasons why RSE programmes can work. Congruent with the United Nations Convention on the Rights of the Child (UN Citation1989), children should be facilitated to give their opinions on issues that affect them, and adults must take these opinions seriously.

We found in papers that RSE programme evaluations focused largely on individual and short-term outcomes. This has also been reported in previous reviews (e.g., Levy et al. Citation2020; Rocha, Silva, and Duarte Citation2022). Outcomes were frequently limited to improving students’ understandings of the biological aspects of sexuality (e.g., puberty, body parts, and human reproduction). Investigating children’s understandings of gender and gender equality appears neglected in evaluations of RSE programmes, even though these outcomes have been recognised as key to sexual health and wellbeing outcomes (Haberland and Rogow Citation2015; UNESCO Citation2018). While several reasons may explain why evaluations have focused on a narrow range of outcomes, this tendency may lead to missed opportunities to assess broader structural and cultural RSE outcomes. From the perspective of a health promoting school, for example, the whole school can be seen as an environment to reinforce individual outcomes through structural and cultural change (Ollis and Harrison Citation2016; WHO/UNESCO Citation2021). Therefore, programme evaluations should intentionally gather evidence on the influence of RSE on both structure and culture (e.g., capturing data on attitudes in school communities towards preparing children for puberty at a younger age and prior to the onset of puberty). Longitudinal designs are required to understand the long-term effects of RSE programmes on individuals, structures and cultures.