Introduction

Adolescence is a stage of the life cycle between 10 and 19 years of age, considered one of the most complex due to the biological, psychological and social changes it entails.¹ It is characterized by impulsivity, emotional and/or behavioral instability of adolescents and lack of self-care, making them more prone to engage in risky sexual behaviors. ² The latter are defined as vaginal, anal or oral sexual practices in which no contraceptive or barrier methods have been used, also accompanied by promiscuity, intravenous drug use during intercourse and premature sexual debut. ³

Risky sexual behaviors are a worldwide public health problem due to the consequences they produce, such as the increase in sexually transmitted infections (STIs) ⁴ and unwanted pregnancies (UWP) that account for 40 million abortions and the deaths of approximately 800 women per day as a result of complications. ⁵ A study conducted in the Los Lagos Region, Chile, indicates that 65 % of adolescents have already started their sex life, but they use contraceptive methods infrequently. On the other hand, 21 % stated that they had experienced an unplanned pregnancy, a similar percentage observed for the country (22 %). ⁶ These prevalent health problems in Chile are associated with self-care needs or requirements of development and other unresolved health deviations. ⁷ This self-care deficit can generate long-term negative consequences in adulthood and consequently illness and death.

UNESCO pointed out that 87% of young people live in developing countries, so that access to opportunities, rights, quality education and health services is inappropriate or deficient. ⁸ The lack of sex education is one of the problems with the greatest impact on the child population and one of the barriers to providing comprehensive sexuality education (CSE) is the resistance imposed by the communities. ⁹ CSE provides knowledge and values to children and adolescents so that they can establish respectful and conscious sexual relationships that do not threaten their health and dignity. It has been proven that it delays the age at which sexual relations begin and their frequency and reduces the presence of risky behaviors, increasing the use of contraceptive methods and condoms. ¹⁰ Sex education at school is a right for all boys and girls. ¹¹ In European countries, the existence of sex education programs in schools is guaranteed because it has been proven that the rates of STIs and UWP in adolescents have remained low and sustainable due to the existence of sex education in schools. ¹²

In Chile in 2010, Health Law No. 20.418 was enacted, which obliges educational establishments recognized by the State to implement a Sex Education Program at the high school level, materializing in the Sexuality, Affectivity and Gender Program. ¹³ This education should be based on meaningful learning, which requires an active, interactive and integrative pedagogical approach, allowing the adolescent to cope well with this stage full of changes.¹⁴ A study conducted in Costa Rica on the adolescent population showed that group educational strategies generate greater interest, participation and interaction in carrying out activities. ¹⁵ The Chilean General Education Law establishes that this is a task that corresponds to the family, since it is the family that delivers values in accordance with its cultural context. ¹⁶ However, there are no models of education aimed at parents to train them in this type of education, which creates ignorance and insecurity in them when addressing these issues with their children, being necessary the help of health and education services for such educational work to be carried out. ¹⁰

In this context, nursing care management, conferred by the Health Code in the areas of health promotion and prevention, has health education as one of the basic premises of the profession, and is therefore jointly responsible for improving the quality of life of the adolescent. ¹²⁾ Nursing should be immersed in schools with educators, the family and various health professionals, to guide young people in their transition to adulthood. ¹⁷ It has been proven that school nurses have the necessary competencies to provide care throughout life, strengthening self-care behaviors and healthy habits through education aimed at promotion and prevention. ¹⁸

Dorothea Orem states that self-care corresponds to all the actions that human beings carry out to maintain their own health and wellbeing, which are learned throughout life. ⁷ Its main purpose is to promote health by empowering the person and making him/her responsible for decisions about his/her health status. It states that nurses can intervene by compensating for the self-care deficit. ¹⁹ Nursing support is fundamental in guiding adolescents in their decision making, as it can educate them according to their needs, promoting healthy sexuality. ²⁰

The background presented above leads to the following research question: What nursing interventions have been successful in sex education in the adolescent school population? The general objective of this work is to analyze the scientific evidence that exists on successful nursing interventions in the framework of sex education oriented to the adolescent school population.

Methodology

The literature review was carried out in the Dialnet, LILACS and Pubmed databases. The following descriptors were used: adolescent, sex education, nursing, sexual behavior, health education, educación sexual, adolescente, enfermería. The Boolean operators used were AND and OR. The inclusion criteria considered documents on school nursing interventions in sex education with different types of study design for exploratory purposes, studies on the adolescent population, published in the last 6 years, both nationally and internationally, and which complied with ethical aspects of research such as informed consent and assent and approval by the Ethics Committee, also regulated by the journal in which they were published. Regarding the selection by methodological quality, we resorted to critical reading by means of critical reading checklists widely used in health sciences such as CASPe. ²¹ Studies with other types of populations, with interventions by professionals who do not correspond to the discipline and studies that did not meet the methodological quality requirements according to CASPe ²¹ were excluded. For the analysis of the documents, content analysis techniques were used, performing a coding process for each document by selecting quotes from the articles and assigning them a code referring to each objective aspect of the study. Finally, the results were presented in tables.

Results

Eleven studies met the inclusion and methodological quality criteria for the review. Most of them were extracted from Pubmed, a database specialized in health sciences. ²² The predominant study design was descriptive.

The results obtained are presented in Table 1.T2 T3

Table 1: Review results 

^Source: Own elaboration (2023)

Table 2 presents a synthesis of the most important results from Table 1. The topics that stand out are: Parental role and needs of adolescents in sex education (SE), nursing Interventions in SE in adolescents and successful pedagogical strategies in SE in adolescents.

Table 2: Synthesis of the results 

^Source: Own elaboration (2023)

Discussion

Risky sexual behaviors are frequent in the adolescent population and have a negative impact on their health. ³³ Sex education is considered a right in several countries. ¹¹ However, a review of the literature shows the lack of knowledge about sexuality in the adolescent population, ^15,24,27 with the consequent burden of disease in adulthood and deterioration of quality of life.

In Chile, sex education has traditionally been taught in the educational establishments themselves, with the teachers who work there as rapporteurs, who have no or insufficient training in health. This has been recognized by the employees of these establishments themselves, who verbalize the importance of a permanent nurse in the school to meet these educational needs, since nursing professionals have the appropriate training to perform this function. ³⁴

The success of educational nursing interventions in the adolescent school population was documented in this international literature review, demonstrating their benefits on adolescent sexual health. In Korea, the importance and impact of having a school nurse in educational establishments was demonstrated by providing educational interventions for adolescents and significantly reducing the probability of committing risky behaviors. ²⁹ In Spain, the results of the research showed that the nurses have all the necessary tools to provide education, resolving the doubts of adolescents with clear and understandable language, which also led them to show interest in sex education, asking themselves new questions. ²³ In addition, two studies conducted in 2021 and 2023 in Slovakia and Singapore, respectively, demonstrated the acceptance of nurses by students in relation to the sex education provided. ^28,32 En In Mexico, educational interventions by nursing professionals improved knowledge about sexually transmitted infections, identifying condoms as the most effective barrier method. ²⁷

On the other hand, in the field of educational interventions, meaningful learning goes hand in hand with active, integrative and participatory pedagogical strategies.¹⁴ In the present literature review, the strategy that generated the greatest interest and participation in the adolescent population was the group type. ^15,27 This coincides with the literature, which also states that when these activities are creative, playful and anonymous, they can create an atmosphere of confidence for the adolescent, who can ask questions and clarify their doubts without fear of being judged. ^13,24,27,32 Likewise, a study from 2023 proposes the application of educational technology on sexuality aimed at adolescents, showing the benefits in terms of facilitating greater knowledge, participation and autonomy of the adolescents involved. ³⁰ Other authors also agree in valuing this technology as another form of meaningful and collaborative learning. ³⁵

At the same time, the family plays a key role in ensuring that adolescents avoid risky sexual behaviors that lead to pregnancy, STIs or other negative health outcomes. ³⁶ In Chile, according to the General Education Law, sex education is an area that corresponds to the family, since it is the family that decides the form and content to be taught according to its cultural context. ⁸ In the present literature review, a study showed the benefits of educating families about sexual and reproductive health issues, with children expressing interest in parents talking more with them about these issues. ²⁷ In contrast, a recent study shows that parents transfer the responsibility of talking about sexuality to others, either because they think it is not their role, or because of lack of knowledge. ³¹ This position hinders the sexual education of their children and the promotion of healthy sexuality.

It is striking that in Chile there is no evidence of studies on the impact of educational interventions by nurses on adolescents, despite the fact that Chile has a sex education policy.⁴ Also, the health code establishes that nursing work includes the development of people from birth to death, caring for their health, improving their quality of life, ³⁷ with emphasis on at-risk populations such as adolescents. On the other hand, in Chile, school nursing is defined as “university-trained health professionals who lead and perform the link between the health and education systems (...). Their training has the necessary competencies to provide care throughout the life course, allowing them to solve most of the health problems presented by students at school, from the preschool, school and adolescent stages”.¹⁸ Consequently, the nursing professional is the ideal health agent to intervene in the health of schoolchildren, providing health education and promoting self-care behaviors, preventing the development of risky sexual behaviors in adolescents. ³⁸ Thus, nursing should be present in a more integrated way in educational establishments together with teachers, the family and other health professionals, allowing the strengthening of protective health factors and reducing risks for students in the area of sexuality. ¹⁷

An issue that has been observed to be absent is the effective involvement of the family in the sexual health of adolescents. It is necessary for the state to support and strengthen families and communities through the creation of policies that favor sexual education provided by nurses in educational establishments in order to improve social, cultural and economic conditions to reduce risk factors in adolescents such as violence in relationships, unwanted pregnancy (UWP), abortions, STIs, etc. ³⁹⁾ Es urgente entonces que el estado fortalezca la educación sexual y aminore las deficiencias existentes en el conocimiento, ^11,17 creating jobs for nurses in educational establishments.

This review is a contribution to nursing. However, we recognize the limitation that it lacks a considerable number of studies to ensure a robust literature review and generalization of the results. Also, this and most of the literature reviews in the area tend to analyze descriptive studies. A future improvement would be to complement the evidence with studies of other type of methods, for a larger and more complex investigation.

Conclusion

This literature review shows that the 11 documents retrieved from the search show interventions with positive results in adolescents in increasing their knowledge of their sexual and reproductive health. This could attribute to nursing a position with a critical view on decision making and guide the management of self-care in adolescents. The demands of children for better communication with their parents on sexuality issues is a point to be addressed. Similarly, criticisms of sex education in schools could suggest greater communication and relational empowerment, as well as consideration of the felt needs of adolescents in the planning of sex education in institutions.

Nursing professionals play a fundamental role in this sexual education, as they are the professionals who can intervene throughout the life cycle, incorporating the family in this process and having all the tools to guide the adolescent to the full development of his or her sexuality. Early detection of the onset of sexual relations, together with adequate support and education of the family by the nursing professional, can significantly increase the overall health of adolescents.

It is important to continue conducting nursing research in the field of adolescent sexual and reproductive health, providing evidence and demonstrating the need for the implementation of a school nurse. These professionals, in addition to researching, guiding, accompanying and supporting school education institutions, adolescents and parents, would guide the empowerment of the latter as responsible for the self-care of their adolescent children, promoting healthy sexual development and improving their quality of life.