Jurnal Experimental-Consort (Bela, Juniarti, Tharisya, Rizka, Merry)

CONSORT 2010 checklist of information to include when reporting a randomised trial *
Item Reported
Section/Topic No Checklist item on page No
Title and abstract
1a Identification as a randomised trial in the title 116
1b Structured summary of trial design, methods, results, and conclusions (for specific guidance see CONSORT for abstracts) 116
Introduction1
Background and 2a Scientific background and explanation of rationale 117
objectives 2b Specific objectives or hypotheses 117
Methods
Trial design 3a Description of trial design (such as parallel, factorial) including allocation ratio 117
3b Important changes to methods after trial commencement (such as eligibility criteria), with reasons 117
Participants 4a Eligibility criteria for participants 117
4b Settings and locations where the data were collected 117
Interventions 5 The interventions for each group with sufficient details to allow replication, including how and when they were 118-119
actually administered
Outcomes 6a Completely defined pre-specified primary and secondary outcome measures, including how and when they 120
were assessed
6b Any changes to trial outcomes after the trial commenced, with reasons 120
Sample size 7a How sample size was determined 117
7b When applicable, explanation of any interim analyses and stopping guidelines 119
Randomisation:
Sequence 8a Method used to generate the random allocation sequence 120
generation 8b Type of randomisation; details of any restriction (such as blocking and block size) 117
Allocation 9 Mechanism used to implement the random allocation sequence (such as sequentially numbered containers), 117
concealment describing any steps taken to conceal the sequence until interventions were assigned
mechanism
Implementation 10 Who generated the random allocation sequence, who enrolled participants, and who assigned participants to 117
interventions
Blinding 11a If done, who was blinded after assignment to interventions (for example, participants, care providers, those 117
CONSORT 2010 checklist Page 1

assessing outcomes) and how
11b If relevant, description of the similarity of interventions 119
Statistical methods 12a Statistical methods used to compare groups for primary and secondary outcomes 120
12b Methods for additional analyses, such as subgroup analyses and adjusted analyses 120
Results
Participant flow (a 13a For each group, the numbers of participants who were randomly assigned, received intended treatment, and 120
diagram is strongly were analysed for the primary outcome
recommended) 13b For each group, losses and exclusions after randomisation, together with reasons 117
Recruitment 14a Dates defining the periods of recruitment and follow-up 120
14b Why the trial ended or was stopped 120
Baseline data 15 A table showing baseline demographic and clinical characteristics for each group 121
Numbers analysed 16 For each group, number of participants (denominator) included in each analysis and whether the analysis was
by original assigned groups
Outcomes and 17a For each primary and secondary outcome, results for each group, and the estimated effect size and its 120
estimation precision (such as 95% confidence interval)
17b For binary outcomes, presentation of both absolute and relative effect sizes is recommended -
Ancillary analyses 18 Results of any other analyses performed, including subgroup analyses and adjusted analyses, distinguishing -
pre-specified from exploratory
Harms 19 All important harms or unintended effects in each group (for specific guidance see CONSORT for harms) -
Discussion
Limitations 20 Trial limitations, addressing sources of potential bias, imprecision, and, if relevant, multiplicity of analyses 122
Generalisability 21 Generalisability (external validity, applicability) of the trial findings 122
Interpretation 22 Interpretation consistent with results, balancing benefits and harms, and considering other relevant evidence
Other information
Registration 23 Registration number and name of trial registry 117
Protocol 24 Where the full trial protocol can be accessed, if available -
Funding 25 Sources of funding and other support (such as supply of drugs), role of funders 117
*We strongly recommend reading this statement in conjunction with the CONSORT 2010 Explanation and Elaboration for important clarifications on all the items. If relevant, we also
recommend reading CONSORT extensions for cluster randomised trials, non-inferiority and equivalence trials, non-pharmacological treatments, herbal interventions, and pragmatic trials.
Additional extensions are forthcoming: for those and for up to date references relevant to this checklist, see www.consort-statement.org.
CONSORT 2010 checklist Page 2

Received: 25 February 2021 | Revised: 30 March 2021 | Accepted: 31 March 2021
DOI: 10.1111/phn.12914
P R O G R A M E VA L U AT I O N
Chinese adolescents’ sexual and reproductive health education:

1.a A quasi-experimental study
Xing Ma RN, BSN, MMed1 | Yuanyuan Yang RN, BSN, MMed1 |

Ka Ming Chow RN, BN, PGDip (Midwifery), MN, DN2 | Yuli Zang RN, BMed, MMed, PhD2
1
School of Nursing, Shandong University,
Jinan, China Abstract
2
The Nethersole School of Nursing, Faculty Objective: This study investigated the effectiveness of an interactive sexual and re-
of Medicine, The Chinese University of
productive health education program in aspects of knowledge, attitudes, and self-
Hong Kong, HKSAR
efficacy among adolescents.
Correspondence
1.b Design: Quasi-experimental study underpinned by social cognitive theory.
Yuli Zang, F8 Esther Lee Building, The
Nethersole School of Nursing, Faculty of Sample: A stratified cluster sample of 469 students from the two-branch middle
Medicine, The Chinese University of Hong
school in a city in eastern China who were assigned to the experimental (n = 233) and
Kong, Shatin, Hong Kong.
Email: amyylzang@cuhk.edu.hk control (n = 236) groups.
Measurements: Students’ sexual knowledge, attitudes, and refusal self-efficacy were
assessed before (T0), immediately after (T1), and 1 month after the intervention (T2),
KELOMPOK
respectively.
SUKA-SUKA
Intervention: Students in the experimental group received two 40-min sessions of
1. BELLA NURINDALIA the educational program while the control group received the usual mode of sexual
2. RIZKA AMAYU and reproductive health education.
3. JUNIARTI
4. THARISYA Results: Compared with the control group, students in the experimental group ac-
5. MERRY AFRILIANA quired more sexual knowledge (p < .01), and developed more positive sexual atti-
SARI tudes (p < .05) and stronger sexual self-efficacy (p < .05) across the study period.
Conclusions: The proposed sexual and reproductive health education program in-
corporating various interactive activities was effective and could be used for school-
based implementation led by nurses and other health care workers.
KEYWORDS
adolescent, health education, program evaluation, reproductive health, sexuality
have become more liberal, compounding problems related to

1 | BAC KG RO U N D sexual and reproductive health (SRH), including unplanned preg-
nancy, abortion, and sexually transmitted infections (STIs) (Liang
Rapid social and economic development produces abundant re- et al., 2019). In 2014, 2 million adolescents around the world were
sources for adolescents to grow and complete physical and psy- found to have AIDS, while the number of adolescent HIV cases
chosocial maturity rapidly. Adolescents now enter sexual maturity in the Asia-Pacific region rising substantially in the past decade
earlier than previous generations. Their attitudes toward sex (United Nations Children’s Fund, 2018). The most recent statistics
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2021 The Authors. Public Health Nursing published by Wiley Periodicals LLC
116 Health
Public Nurs. 2021;00:1–10.
wileyonlinelibrary.com/journal/phn wileyonlinelibrary.com/journal/phn | 1
Public Health Nurs. 2022;39:116–125.
MA et2
MA |
Al . et al. |MA3 et Al .
117
FIGU R E 1 anFlow
reveals chart on growth
astonishing participant
of AIDS cases among youth of 15 effectiveness in improving adolescents’ sexual knowledge, attitudes,
recruitment and dropout Enrollment Assessed for eligibility (n = 469)
to 24 years old in China, increasing from 6.0% in 2007 to 28.7% in and self-efficacy. We hypothesized that adolescents who receive
2015 (He et al., 2018). the interactive SRH education program would have better sexual
2.b
Globally, it was estimated by the World Health Organization knowledge (primary outcome), more positive attitudes, and stronger
that approximately 12 million girls of 15 to 19 years and 1 million sexual self-efficacy (secondary outcomes) compared with those who
girls under 15 years give birth every year in developing countries, engage in usual mode of SRH education, that is, self-study of the
Allocation
Allocated
causing roughly 3.9 million unsafe abortions among thoseto aged
the experimental
15 to group Allocated to the control group
same written and audiovisual materials.
(n = 233) (n = 236)
19 years (WHO, 2018). Pregnancy and childbirth among adolescents
is a major factor contributing to maternal mortality and morbidity. In
China, recent evidence shows an increasing pregnancy rate among 2 | M E TH O DS
adolescents, with half of the abortions occurring among
T0: 233 unmarried
included in the analysis T0: 236 included in the analysis
adolescents (Xiao & Chen, 2017). 2.1 | Study design
Sexual and reproductive health education is an important form Follow-Up
of health promotion action to optimize adolescent health and
T1: 228 included in thede-
analysis;The quasi-experimental controlled
T1: 232 trial wasinconducted
included the analysis; in a two-
velopment (Garzón-Orjuela et al., 2020). Using an 5 appropriate the- (attended
lost to follow-up branch middle school in a place4 exemplifying
lost to follow-upthe large
(took part majority
in
oretical framework in such education is critical instudent meeting) and
development school
middle-size cities in mainland China activities)
according to the TREND guide-
effectiveness of any intervention (Albarracin et al., 2005). Social lines (Des Jarlais et al., 2004).
2.a
cognitive theory or social learning theory is a widely referred con-
ceptual framework for SRH educational interventions, stressing the
T2: 223 included in the analysis; T2: 225 included in the analysis;
interaction among personal (e.g., knowledge, self-efficacy), environ- 2.2 | Setting and sample 7 lost to follow-up (participated
5 lost to follow-up (participated
mental (e.g., exposure to risky situations), and behavioral
in school influences
academic testing) in school academic testing)
(e.g., dating relationships) (Bandura, 2004). Several SRH education The target city in Shandong Province in eastern China had a sexu-
4b
programs for adolescents have demonstrated encouraging positive ally conservative culture and was experiencing urbanization at a
outcomes using social cognitive theory. Interventions with positive slower paceAnalysis
compared with metropolitan or municipal cities (Yan
Analysis (n = 225)
outcomes for adolescents have been documents inAnalysis
Africa, (n = 223)
Nepal, et al., 2017). A stratified cluster sampling strategy was used to re-
Spain, and the United States (Acharya et al., 2017; Espada et al., 2017; cruit participants. As estimated by G*Power 3.1 (Faul et al., 2007), to 7a
Mmbaga et al., 2017; Peskin et al., 2015; Winskell et al., 2018). detect an effect size of 0.5 (Cohen's d) at a type I error rate of 0.05, 8b
and their parentsinto
However, obtain
places like their respective
mainland written
China, which consent.
are characterized scoreand
ranges
with afrom
two-11 to t-33,
sided testwith higher
having scores
a power indicating
of 0.80, more
128 participants
Permission to useconservative/suppressive
by a sexually the instruments was obtained fromthe
culture under prolonged positive
original attitudes.
needed The internal
to be recruited, withreliability
64 in each(Cronbach's
of the studyalpha,
groups was ratio
α)(size
influence of Confucianism, SRH education remains implicit or cir- 0.74.of experimental to control group = 1:1). Given an average class size
developers.
cumvented. Educational efforts often resort to cartoons or other The Sexual
of 60 Self-Efficacy
students, 2 of 20Scale (secondary
classes outcome
were selected measure)
in each used
grade (Grades
“quiet” methods, or the education is handled in private environments three7presumed sexual situations
and 8), depending on their to assess the
availability degree
during ofstudy
self- certainty of in
sessions 3a
2.4 or| within
Instruments
families (Liang & Bowcher, 2019). A large majority of ado- refusing
the or saying “no”
afternoon, to each
from each of
of the
the two
following
schoolsituations:
branches,watching
respectively.
lescents in mainland China do not receive any formal SRH education a pornographic video,
The coin toss sharing
method wasaused
kiss with one'swhether
to decide best friend of thestudents
to assign op-
A sociodemographic
or have access toinformation sheet,
essential SRH including
services. Thisitems
was mainly age, by posite
aboutcaused in sex, and acquaintance
the smaller- numbered sexual
class toaggression (Zuo et or
the experimental al.,control
2017). group.
A 9,10,
gender,
theparents’ education,
incompatibility smoking,
between SRH drinking, and SRH-demands
and the contextual on the 5-point
related ex- Likertparticipants
Student scale ranging from
were “1 = certainly
blinded cannot”
to the group to “5 = cer-
assignment, but the 11a
perience,
virtueand the following
or noble system ofthree instruments
morality, includingwere selected
sexual propriety in pub- tainlynurses
given can” was
whoused, with the
delivered higher scores indicating
intervention were notstronger
blinded.refusal
their lic
appropriateness for
social interfaces middle
(Zhao school
et al., students,
2019). Withoutnational
adequate education, self-efficacy.
applica- The internal
Participants werereliability
aged 10 (Cronbach's
to 19 years alpha, was 0.83.
in theα)selected classes, 3b
bility,adolescents
and convincing
maycontent validity established
have difficulties through
in tackling the expert
SRH-related matters, and able to communicate and read in Chinese. Parental consent to
4a
panelincluding
approach.sexual temptations and risky sexual behaviors, face-to- participate voluntarily was obtained. Excluded were those who had
The Sexual
face, Knowledge
online, Scale
or virtually. (primaryteaching
Different outcome measure)
and learninghas 27
modalities 2.5 severe
| SRH education
mental or communication problems or other SRH education
true/false statements
(e.g., expert assessing
lectures, knowledge
leaflet of reproductive
distribution) physiol- to
have been attempted experiences according to class supervisors’ screening. The recruit-
13b
ogy (n = 11),SRH
deliver pregnancy andprograms
education birth control (n = 8),adolescents
for school and awareness of
in mainland 2.5.1 | and
ment Thereasons
intervention
for dropping out were recorded in the flow chart
sexual harassment
China (Chen etand
al., assault (n = 8) (Yeh
2016). However, & Chen,
these 2012).
programs The total
seldom clarified (Figure 1).
scorethe
(0–guiding
27) is the sum of the
framework tocorrect answers’ scores,
link educational with
contents andhigher
expected The SRH educational program was constructed with reference to
scores indicating
outcomes a better
through understanding
delivery modes, orofhave
sexual knowledge.
they The
provided standard social cognitive theory (Bandura, 2004). Multiple components ad-
internal reliability
materials (Cronbach'soralpha,
for replication was 0.88.
widerα)dissemination. 2.3 determinants
dressed | Ethical considerations
of the sexual behavioral change process
The Considering
Sexual Attitudes Questionnaire
Chinese (secondary
culture about outcome we
sexual propriety, mea-
devel- related to knowledge, attitudes, and self-efficacy, presented in a
sure)oped
contains 11 questions
the interactive SRH using a mixed
education 2-point
program (three ques-
by referring to others’ supportive socialwas
This study environment
approvedinbythe school
the setting. The
institutional participa-
ethical committee
23
tions), 3-point
success in(five questions),
delivering or 4-point (three
SRH educational questions)
intervention scoring
under the guid- tory (No.
strategy,
2017-advocated
R-106) in by the Worldwith
compliance Health
theOrganization, infusedin the
principles outlined
scheme
ancetoofcapture various
the social attitudes
cognitive toward
theory different
(Acharya et al.,sexual
2017;be-
Espada not only SRH knowledge
Declaration and skill
of Helsinki. Withdevelopment
the supportbut
of also
the psychoso-
middle school
haviors (e.g.,2017;
et al., student romance,
Mmbaga one-
et al., night Peskin
2017; stands,et
prostitution, sex-
al., 2015; Sommart cial well- being into
executive planned teaching
management andinformed
committee, learning activities (Lopezwere
consent forms 25
ual propriety, and HIV/AIDS
& Sota, 2013; Winskell in
et aal.,
partner)
2018). (Wu,
This 2007).
study The total the et al.,sent
examined 2016).
to the school principal, class supervisors, recruited students,
118 |
MA et2Al. |
MA etMA
al3. et Al .
FIGU R E 1 anFlow
reveals chart on growth
astonishing participant
of AIDS cases among youth of 15 effectiveness in improving adolescents’ sexual knowledge, attitudes,
girls under 15 years give birth every year in developing countries, engage in usual mode of SRH education, that is, self-study of the
Allocation
Allocated to the experimental
causing roughly 3.9 million unsafe abortions among those aged 15 to group Allocated to the control group
same written and audiovisual materials.
(n = 233) (n = 236)
19 years (WHO, 2018). Pregnancy and childbirth among adolescents
is a major factor contributing to maternal mortality and morbidity. In
China, recent evidence shows an increasing pregnancy rate among 2 | M E TH O DS
adolescents, with half of the abortions occurring among
T0: 233 unmarried
included in the analysis T0: 236 included in the analysis
adolescents (Xiao & Chen, 2017). 2.1 | Study design
Sexual and reproductive health education is an important form
Follow-Up
of health promotion action to optimize adolescent health and de- The quasi-experimental controlled
T1: 232 trial wasinconducted
included the analysis; in a two-
T1: 228 included in the analysis;
velopment (Garzón-Orjuela et al., 2020). Using an5 appropriate the- (attended
lost to follow-up branch middle school in a place4 exemplifying
lost to follow-upthe large
(took part majority
in
oretical framework in such education is critical instudent
development
meeting) and middle-size cities in mainland China according
school to the TREND guide-
activities)
interaction among personal (e.g., knowledge, self-efficacy), environ- 2.2 | Setting and sample
5 lost to follow-up (participated 7 lost to follow-up (participated
mental (e.g., exposure to risky situations), and behavioral influences in school academic testing)
in school academic testing)
(e.g., dating relationships) (Bandura, 2004). Several SRH education The target city in Shandong Province in eastern China had a sexu-
programs for adolescents have demonstrated encouraging positive ally conservative culture and was experiencing urbanization at a
outcomes using social cognitive theory. Interventions with positive slower paceAnalysis
compared with metropolitan or municipal cities (Yan
outcomes for adolescents have been documents inAnalysis
Africa, (n = 223)
Nepal, Analysis
et al., 2017). A stratified cluster sampling (n = 225)
strategy was used to re-
Spain, and the United States (Acharya et al., 2017; Espada et al., 2017; cruit participants. As estimated by G*Power 3.1 (Faul et al., 2007), to
Mmbaga et al., 2017; Peskin et al., 2015; Winskell et al., 2018). detect an effect size of 0.5 (Cohen's d) at a type I error rate of 0.05,
However,
and their parentsinto
places like their
obtain mainland China, which
respective are characterized
written consent. scoreand with afrom
ranges two-11
sided testwith
to t-33, having a power
higher of 0.80,
scores 128 participants
indicating more
by a sexually
Permission to useconservative/suppressive culture under
the instruments was obtained fromthe prolonged positive
original needed to be recruited,
attitudes. withreliability
The internal 64 in each(Cronbach's
of the studyalpha,
groups
α)(size
was ratio
influence of Confucianism, SRH education remains implicit or cir- 0.74.of experimental to control group = 1:1). Given an average class size
developers.
cumvented. Educational efforts often resort to cartoons or other of 60
The students,
Sexual 2 of 20Scale
Self-Efficacy classes were selected
(secondary outcomein each grade
measure) (Grades
used
“quiet” methods, or the education is handled in private environments three7presumed
and 8), depending on their to
sexual situations availability
assess theduring
degreeself-
ofstudy sessions
certainty of in
2.4 or| within
Instruments
families (Liang & Bowcher, 2019). A large majority of ado- refusing
the or
afternoon, from
saying “no” to each
each of
of the
the two schoolsituations:
following branches,watching
respectively.
lescents in mainland China do not receive any formal SRH education a pornographic
The coin toss method
video, wasaused
sharing to decide
kiss with one'swhether to assign
best friend of thestudents
op-
or have access toinformation
A sociodemographic essential SRH services.
sheet, Thisitems
including was mainly
aboutcaused
age, by posite in sex,
the smaller- numbered sexual
and acquaintance class toaggression
the experimental
(Zuo et or
al.,control
2017). group.
A
theparents’
gender, incompatibility between
education, SRH drinking,
smoking, and the contextual
and SRH-demands on the 5-point
related ex- Student
Likertparticipants were
scale ranging fromblinded to the group
“1 = certainly assignment,
cannot” but the
to “5 = cer-
virtueand
perience, or noble system ofthree
the following morality, includingwere
instruments sexual propriety
selected in pub- tainlynurses
given whoused,
can” was delivered
with the intervention
higher were notstronger
scores indicating blinded.refusal
their lic social interfaces
appropriateness for(Zhao et al.,
middle 2019).
school Withoutnational
students, adequate education, self-efficacy.
applica- Participants werereliability
The internal aged 10 (Cronbach's
to 19 years alpha,
in theα)selected classes,
was 0.83.
bility,adolescents maycontent
and convincing have difficulties in tackling
validity established SRH-related
through matters,
the expert and able to communicate and read in Chinese. Parental consent to
panelincluding
approach.sexual temptations and risky sexual behaviors, face-to- participate voluntarily was obtained. Excluded were those who had
face,
The online,
Sexual or virtually.
Knowledge ScaleDifferent
(primaryteaching
outcomeand learninghas
measure) modalities
27 2.5 severe
| SRH education
mental or communication problems or other SRH education
(e.g., expert
true/false lectures,
statements leaflet
assessing distribution)
knowledge have been attempted
of reproductive physiol- to experiences according to class supervisors’ screening. The recruit-
deliver
ogy (n = 11),SRH education
pregnancy andprograms for school
birth control (n = 8),adolescents in mainland
and awareness of 2.5.1ment
| and
Thereasons
intervention
for dropping out were recorded in the flow chart
China
sexual (Chen etand
harassment al., assault
2016). However, these
(n = 8) (Yeh programs
& Chen, seldom
2012). clarified
The total (Figure 1).
scorethe
(0–guiding framework
27) is the sum of the tocorrect
link educational contents
answers’ scores, andhigher
with expected The SRH educational program was constructed with reference to
outcomes
scores through
indicating a better delivery modes, orofhave
understanding they
sexual provided standard
knowledge. The social cognitive theory (Bandura, 2004). Multiple components ad-
materials
internal for replication
reliability (Cronbach'soralpha,
widerα)dissemination.
was 0.88. 2.3 determinants
dressed | Ethical considerations
of the sexual behavioral change process
The Considering Chinese
Sexual Attitudes culture about
Questionnaire sexual propriety,
(secondary outcome wemea-devel- related to knowledge, attitudes, and self-efficacy, presented in a
sure)oped the interactive
contains SRH using
11 questions education program
a mixed by referring
2-point to others’ supportive
(three ques- This study
socialwas approvedinbythe
environment the institutional
school ethical
setting. The committee
participa-
success
tions), in(five
3-point delivering SRH educational
questions), intervention
or 4-point (three under
questions) the guid- tory strategy,
scoring (No. 2017- R-106) in by
advocated compliance
the Worldwith theOrganization,
Health principles outlined
infusedin the
ancetoofcapture
scheme the social cognitive
various theory
attitudes (Acharya
toward et al.,sexual
different 2017;be-
Espada not only
Declaration of Helsinki.
SRH knowledge Withdevelopment
and skill the supportbut
of also
the psychoso-
middle school
et al.,
haviors (e.g.,2017; Mmbaga
student et al.,
romance, one-2017;
night Peskin
stands,et al., 2015; Sommart
prostitution, sex- executive
cial well- management
being into committee,
planned teaching and informed consent forms
learning activities (Lopezwere
& Sota, 2013;
ual propriety, Winskell in
and HIV/AIDS et aal., 2018). (Wu,
partner) This 2007).
study The
examined
total the et al.,sent to the school principal, class supervisors, recruited students,
2016).
MA et4
MA |
119
FIGURE 1 topical
The Flow chart on participant
contents (Table 1) for the proposed SRH education important role in evaluating the organization of the teaching and
11b program were outlined according to the national standard and guide- learning activities.
lines for SRH education for primary and secondary schools in China The theoretical lectures were interwoven with case scenarios,
(China Sexology Association, 2017; National Health Commission group discussions, quizzes (i.e., competitively answered questions
of the People’s Republic of China, 2011; The Central People’s to assess the acquisition of important concepts), and an audiovisual
Government of the People’s Republic of China, 2017) and further demonstration to engage students in dynamic activities stimulating
Allocation
Allocatedreview
consolidated by referring to a comprehensive literature to the experimental
(Salam group Allocated to
physical, cognitive, social, and emotional the control(the
responses group
educational
(n = 233) (n = 236)
et al., 2016). Following the PRISMA guide (Shamseer et al., 2015), components in Table 1). Such synchronized multiple sensory stim-
we conducted a literature review and compared the contents, deliv- uli are very effective in attracting children—from infants to adoles-
ery modes, and outcome measures in the identified studies guided cents—to commit to active learning (Levine & Munsch, 2016).
by social cognitive/learning theories (Acharya
T0:et233
al.,included
2017; Espada
in the analysis The interactive SRH education programinwas
T0: 236 included pilot tested in a
the analysis
7b
et al., 2017; Mmbaga et al., 2017; Peskin et al., 2015; Sommart & class of 58 students in Grade 8 in one of two school branches on
Sota, 2013; Winskell et al., 2018). We then selected the most feasi- November 20, 2017. Minor revisions were made to the administra-
Follow-Up
ble and corresponding standardized materialsT1:
in Chinese (i.e., in
228 included textual
the analysis;tion of the self-report questionnaire (i.e., providing
T1: 232 included more guidance)
in the analysis;
supporting materials) as well as the most accepted5delivery
lost to modes
follow-up to (attended
and knowledge quiz game (i.e., explaining the rule(took
4 lost to follow-up of “answer
part in with
ensure consistency and future wide dissemination student meeting)
of the proposed reasoning” more clearly). school activities)
intervention (Peskin et al., 2015; Sommart & Sota, 2013). Concise For students in the experimental group, two 40-min sessions of
statements about adolescent SRH were derived from the textual an interactive SRH education program were delivered face-to-face
5
materials, expressed in neutral and plain language, and enriched with in the classroom during the self-study session in the late afternoon.
selected cartoons and embedded videos in the form of Microsoft The first session focused on basic SRH
7 lost knowledge,
to follow-up while the sec-
(participated
5 lost to follow-up (participated
PowerPoint slides for classroom delivery (Marie Stopes International
in school academic testing) ond session targeted communication,
in school academic testing)and gender
decision making,
China, 2017). matters. Each session started with a 20-min lecture, followed by a
A five-expert panel evaluated the interactive SRH education knowledge quiz game and group discussion, and then moving to a
program to determine the appropriateness and adequacy of topi- video (TableAnalysis
1). Sessions 1 and 2 were implemented 1 week apart.
Analysis (n = 223) Analysis (n = 225)
cal contents in slides and supporting textual materials, structure of Two registered nurses (RNs) delivered the SRH education program
contents, and modalities of delivery for classroom teaching. Three in collaboration with school facilitators, separately for boys and girls.
health professionals working in SRH-related specialties focused This same-sex student arrangement was consistent with the usual
and their
their evaluation
parents toonobtain their respective
the contents, writtenschool
while the deputy principal scorepractice
consent. ranges for
from 11 to 33,
education withtohigher
related sexualscores indicating
topics to more
reduce embarrass-
Permission toofuse
in charge the instruments
student wasclass
matters and one obtained fromplayed
supervisor a more positive
original mentattitudes.
or other The internal entailed
discomforts reliability
by(Cronbach's alpha,interactions.
mixed-sex social α) was
developers. 0.74.
The Sexual Self-Efficacy Scale
TA(secondary outcomeof
B L E 1 Contents measure) used
the sexual and
Duration
three presumed sexual situationsreproductive health
to assess the education
degree program
of certainty of
Session Topical contents Mode of delivery (Min)
2.4 | Instruments refusing or saying “no” to each of the following situations: watching
1 Adolescence and basic SRH Lecture 20
a pornographic video, sharing a kiss with one's best friend of the op-
knowledge
A sociodemographic information sheet, including items about age, posite sex, and acquaintance sexual aggression (Zuo et al., 2017). A
Case scenario Group discussiona 7
gender, parents’ education, smoking, drinking, and SRH-related ex- 5-point Likert scale ranging from “1 = certainly cannot” to “5 = cer-
(foci: pubertal changes and
perience, and the following three instruments were selected
gender given
issues) tainly can” was used, with higher scores indicating stronger refusal
their appropriatenessSTIs
for (including
middle school students, national
HIV/AIDS) applica-
Knowledge self-
quiz game b efficacy. The internal reliability (Cronbach's alpha, α) was 0.83.
3
bility, and convincing Puberty
content and
validity established through
diseases theb expert
Video 10
panel approach.
2 Communication and decision Lecture 20
The Sexual Knowledge Scale
making (primary
about outcome measure)
sexuality (foci: skills 27peer 2.5 | SRH education
hasfor
true/false statements assessing knowledge of reproductive physiol- sexual refusal,
relationships,
and sexual
ogy (n = 11), pregnancy and birth control (n = 8), and awareness of assault 2.5.1
prevention)
| The intervention
a
Case
sexual harassment and scenario
assault Group
(n = 8) (Yeh & Chen, 2012). discussion
The total 13
(foci: skills to tackle sexual
score (0–27) is the sum of the correct answers’ scores, with higher The SRH educational program was constructed with reference to
assault)
scores indicating a better understanding of sexual knowledge.
b
The social cognitive theory (Bandura, 2004). Multiple components ad-
Sexual assault Video 7
internal reliability (Cronbach's alpha, α) was 0.88. dressed determinants of the sexual behavioral change process
Note:
The SRH, sexual
Sexual and Questionnaire
Attitudes reproductive health; STIs, sexually
(secondary outcometransmitted
mea- infections.
related to knowledge, attitudes, and self-efficacy, presented in a
a
sure) Topical
containscontents for discussion
11 questions usingoriginated
a mixedfrom the national
2-point (three guideline
ques- forsupportive
adolescentsocial
healthenvironment in the school setting. The participa-
education developed by the China Family Planning Association (China Family Planning Association,
tions), 3-point (five questions), or 4-point (three questions) scoring tory strategy, advocated by the World Health Organization, infused
2014).
scheme
b to capture various attitudes toward different sexual be- not only SRH knowledge and skill development but also psychoso-
Video and knowledge quiz game were used from materials created by Marie Stopes International
haviors (e.g.,
China forstudent romance,
Participatory one-
Training onnight stands,Sexual
Adolescent prostitution, sex-
Health Education cial well-
(Marie being into planned teaching and learning activities (Lopez
Stopes
International
ual propriety, andChina, 2017). in a partner) (Wu, 2007). The total
HIV/AIDS et al., 2016).
MA et2Al.
120 | |
MA etMA
al5. et Al .
revealsthe
To ensure anfaithfulness
astonishingofgrowth of AIDS cases these
the implementation, amongtwo RNSof 15 3.2 effectiveness
youth | Effects on SRH knowledge
in improving adolescents’ sexual knowledge, attitudes,
17a
to 24 years old in China, increasing from 6.0% in 2007 to 28.7%
had experience in health education and were trained for the deliv- in and self- efficacy. We hypothesized that adolescents who receive
2015
ery of the (He et al., 2018).
proposed SRH education program before the pilot test, the interactive
Repeated- SRH education
measures ANOVA revealedprogram would
significant have
group better sexual
differences
using theGlobally, it was
predesigned estimatedmaterials
supporting by the that
World Health
were basedOrganization
on the knowledge
in the (primary
effects of outcome),
the program on more
sexualpositive attitudes,
knowledge (F =and stronger
21.51,
that protocol.
teaching approximately 12 million girls of 15 to 19 years and 1 million p < .01;
sexual self-
Table 3).efficacy (secondary
The sexual outcomes)
knowledge comparedsignificantly
score increased with those who
girls under 15 years give birth every year in developing countries, (p < .001)
engageacross the study period (Table 3, Figure 2) for bothstudy
in usual mode of SRH education, that is, self- of the
groups.
causing roughly 3.9 million unsafe abortions among those aged 15 to However,
same written and audiovisual
the control materials.
group exhibited a significant decrease be-
2.5.2 | The
19 years comparison
(WHO, activity
2018). Pregnancy and childbirth among adolescents tween T1 and T2 (p = .046 and <.05), which was not observed in the
is a major factor contributing to maternal mortality and morbidity. In experimental group (p = .204 and >.05, Figure 2).
China,
Students in recent evidence
the control groupshows an increasing
only received basic pregnancy rate among
health education; 2 | M E TH O DS
that adolescents,
is, they werewith half ofself-
provided thestudy
abortions occurringand
textual/slides among unmarried
audiovis-
adolescents
ual materials that(Xiao
were&the
Chen, 2017).
same as those used with the interven- 3.3 2.1 | Study
| Effects ondesign
sexual attitudes
Sexual
tion group. and reproductive
No interpersonal health education
interactions, is an component
the essential important form
of health promotion
of participatory actionincorporated
learning, were to optimize adolescent
to facilitatehealth and de- Students
students’ The quasi-
in theexperimental
experimental controlled trial awas
group showed conducted
significantly in a two-
greater
velopment (Garzón-Orjuela et al., 2020). Using an appropriate the- improvement
self-study. branch middle schoolmean
(i.e., higher in a score
place and
exemplifying the large
larger positive majority
change)
oretical framework in such education is critical in development and in sexual
middle- size cities
attitudes in did
than mainland
those China
in theaccording to the(FTREND
control group guide-
= 13.91,
effectiveness of any intervention (Albarracin et al., 2005). Social p < .01,
linesTable
(Des 3).
Jarlais
Theet al., 2004).
sexual attitudes score increased significantly
2.6 cognitive
| Datatheory
collection and
or social analysis
learning theory is a widely referred con- (p < .05) across the study period in the experimental group, but not
ceptual framework for SRH educational interventions, stressing the in the control group (p > .05, Figure 2).
Frominteraction
Novemberamong personal
22, 2017, (e.g., knowledge,
to January 10, 2018, self- efficacy),were
students environ- 2.2 | Setting and sample
mental
guided (e.g., exposure
to complete to risky
the study situations),inand
instruments thebehavioral
classroominfluences
be-
6a fore (e.g., dating relationships)
the intervention (Bandura,after
(T0), immediately 2004).
theSeveral SRH education
intervention (T1), 3.4 The
| Effects oninsexual
target city self-
Shandong efficacy
Province in eastern China had a sexu-
and 1programs for adolescents
month after have (T2).
the intervention demonstrated
Data wereencouraging positive
analyzed using ally conservative culture and was experiencing urbanization at a
14a SPSSoutcomes
25.0 (IBMusing
Crop.,social cognitive
Armonk, theory.standard
NY). Mean, Interventions withand
deviation, positive A significant
slower pace
groupcompared
differencewith
was metropolitan orincrease
revealed in the municipal cities (Yan
in sexual
14b outcomes
frequency for adolescents
analyses have been
were conducted documents
to describe in Africa, Nepal, self-efficacy
the background et al., 2017).
acrossAthe
stratified cluster sampling
three measurement strategy
points waspused
(F = 9.65, < .01,to re-
Spain, and the
characteristics. United States
Independent (Acharya
t-tests, et al., 2017;
chi-square tests,Espada et al., 2017; Tablecruit
and Fisher's 3). participants. As estimated
The sexual efficacy scorebyincreased
G*Powersignificantly
3.1 (Faul et al., 2007), to
across
12b
exactMmbaga et al.,
tests were used2017; Peskin etparticipants’
to compare al., 2015; Winskell et al., 2018).
characteristics and detectperiod
the study an effect size
in the of 0.5 (Cohen's
experimental d) at
group (p a<type
.05), Ibut
error
notrate of 0.05,
in the
However,
SRH-related in places
measures like mainland
between China, which
the two groups are characterized
at baseline. Group andgroup,
control with awhich
two-sided t-test
showed having
a slight a power
increase of 0.80,
without any128 participants
statistical
12a
by a sexually
differences in theconservative/suppressive culture
educational effects on SRH- underoutcomes
related the prolonged significance
needed (p
to>be.05,
recruited, with 64 in each of the study groups (size ratio
Figure 2).
8a influence
across of Confucianism,
the three time points SRH
were education
examinedremains implicit or cir-
using repeated- of experimental to control group = 1:1). Given an average class size
cumvented.
measures analysisEducational
of varianceefforts often
(ANOVA). Theresort to cartoons
significance or other
level was of 60 students, 2 of 20 classes were selected in each grade (Grades
set at“quiet” methods,
0.05 (two- or the education is handled in private environments 4
sided). D I8),
|7 and S CU SSION
depending on their availability during self-study sessions in
or within families (Liang & Bowcher, 2019). A large majority of ado- the afternoon, from each of the two school branches, respectively.
lescents in mainland China do not receive any formal SRH education Consistent
The coinwith
toss method was used(Harper
other studies to decideet
whether to assign
al., 2018; students
Peskin
3 R E Saccess
|or have U LT Sto essential SRH services. This was mainly caused by et al.,in2015),
the smaller- numbered
this SRH class intervention
educational to the experimental or control
demonstrated group.
pos-
the incompatibility between SRH and the contextual demands on the itive Student
effects participants were blinded
on middle school to the
students’ group
SRH- assignment,
related knowledgebut the
virtue
Of the 469orrecruited
noble system of morality,
participants, including
95.5% (N =sexual
448; propriety
experimen-in pub- that nurses
emergedwho delivered the
immediately intervention
after were notwhich
the intervention, blinded.
persisted
lic social
tal group: N =interfaces (Zhao
223; control et al., N
group: 2019). Without
= 225) adequate
completed education, 1 monthParticipants
the study. were aged 10
later. The effectiveness to 19related
of SRH- years in the selected
knowledge amongclasses,
adolescents
Twenty- may have
one students difficulties
dropped in tackling
out at T1 SRH-related
or T2 because matters, adolescents
of other and ablemight
to communicate and
be influenced byread
twoin Chinese. Parental
conditions. First, theconsent
edu- to
including
school sexual(Figure
engagements temptations and risky
1), resulting in ansexual behaviors,
attrition face-to- cational
rate of 4.5% participate voluntarily
materials was were
in our study obtained. Excluded
prepared were those
in simple, who had
plain lan-
face, online, or virtually. Different teaching and learning modalities guage
(21/469). severe mental or communication
and integrated colorful cartoonsproblems or othervideos
and animation SRH education
in a
(e.g., expert lectures, leaflet distribution) have been attempted to way experiences
consistent with usual formats or styles. Second, a variety recruit-
according to class supervisors’ screening. The of
deliver SRH education programs for school adolescents in mainland participatory
ment andstrategies
reasons for(i.e.,
dropping out were
quiz game recorded inknowledge
[alternatively the flow chart
3.1 China
| Participants’ baseline
(Chen et al., 2016). characteristics
However, these programs seldom clarified cognitive
(Figure 1).
competition], group discussions, and audiovisual tools)
the guiding framework to link educational contents and expected catered to adolescents’ inclination for more dynamic and less ab-
outcomes
Participants in through delivery modes,
the experimental or have
and control they provided
groups standard stract learning stimuli (Levine & Munsch, 2016). This design made
were compa-
rablematerials for replication
with respect or wider dissemination.
to their sociodemographic characteristics, SRH- 2.3to disseminate
it easy | Ethical considerations
the established SRH education program to
Consideringand
related experience, Chinese
outcomeculture about(Tables
measures sexual2propriety, we devel- more middle school students.
and 3). Overall,
13astudents
opedwere
the interactive
aged 11 to SRH education
15 years, program
with nearly theby referring
same numberto others’
of This study
Positive was approved
changes to sexualby the institutional
attitudes were moreethical committee
noticeable
success in delivering SRH educational intervention under the
female and male participants. Few reported potentially risk experi- guid- among students in the experimental group, although there was ain the
(No. 2017- R-106) in compliance with the principles outlined
6b
enceance of the social
of smoking, cognitive
drinking, sex, ortheory (Acharya
romance. et al.,half
More than 2017; Espada decrease
of the Declaration of Helsinki.
in the scores 1 monthWith
afterthe
thesupport of thesuggesting
intervention, middle school
et al., 2017;
respondents Mmbaga
reported et al.,
that their 2017;education
parents’ Peskin etwas
al.,above
2015;junior
Sommart that executive management
reinforcement strategiescommittee,
should be informed
attemptedconsent formsorwere
to increase
high & Sota,level.
school 2013; Winskell et al., 2018). This study examined the sustain sent to the school
attitudinal principal,
changes. class
In fact, supervisors,
not all recruited
SRH education students,
programs
MA et6
MA |
121
F I G U R E 1 Flow chart on participant TA B L E 2 Participants’ background

Total Experimental group
Enrollment Control group Assessed for eligibility (n = 469) 15
recruitment and dropout characteristics at baseline
Variables (n = 469) (n = 233) (n = 236) p
Age (years), Mean 12.77 (0.65) 12.80 (0.66) 12.75 (0.64) .422
(SD)
Gender, n (%)
Female 233 (49.7) 115 (49.4) 118 (50.0) Allocation
.889
Allocated to the experimental group Allocated to the control group
Male 236 (50.3) 118 (50.6) (n = 233) 118 (50.0) (n = 236)
Mother's education, n (%)
Below primary 24 (5.1) 10 (4.3) 14 (5.9) .193
school
T0: 233 included in the analysis T0: 236 included in the analysis
Primary school 50 (10.7) 22 (9.4) 28 (11.9)
Junior high 146 (31.1) 84 (36.1) 62 (26.3)
school Follow-Up
Vocational/ 184 (39.2) T1:
84 228 included in the analysis;
(36.1) 100 (42.4) T1: 232 included in the analysis;
senior high 5 lost to follow-up (attended 4 lost to follow-up (took part in
school student meeting) school activities)
University or 65 (13.9) 33 (14.2) 32 (13.6)

above
Father's education, n (%)
Below primary 9 (1.9) 4 (1.7) 5 (2.1)
5 lost to follow-up (participated .789 7 lost to follow-up (participated
school in school academic testing)
in school academic testing)
Primary school 21 (4.5) 8 (3.4) 13 (5.5)
Junior high 159 (33.9) 78 (33.5) 81 (34.3)
school Analysis
Vocational/ 202 (43.1) 105 (45.1) Analysis (n = 223)97 (41.1) Analysis (n = 225)
senior high
school
University or 78 (16.6) 38 (16.3) 40 (16.9)
and their parents to obtain their respective written consent. score ranges from 11 to 33, with higher scores indicating more
above
Permission to use the instruments was obtained from original positive attitudes. The internal reliability (Cronbach's alpha, α) was
Smoking, n (%)
developers. 0.74.
Never 452 (96.4) 225 (96.6) 227 (96.2) 1.000
The Sexual Self-Efficacy Scale (secondary outcome measure) used
Little 12 (2.6) 6 (2.6) 6 (2.5)
three presumed sexual situations to assess the degree of certainty of
2.4 | Sometimes
Instruments 3 (0.6) 1 (0.4) 2 (0.8) or saying “no” to each of the following situations: watching
refusing
Often 2 (0.4) 1 (0.4) 1 (0.4)
Drinking, n (%) information sheet, including items about age,
A sociodemographic posite sex, and acquaintance sexual aggression (Zuo et al., 2017). A
gender, parents’
Never education, smoking, drinking, 204
405 (86.4) and (87.6)
SRH-related ex- 5-point
201 (85.2)Likert scale
.067ranging from “1 = certainly cannot” to “5 = cer-
perience,Little
and the following three instruments were
42 (9.0) selected given
23 (9.9) tainly can” was used, with higher scores indicating stronger refusal
19 (8.1)
their appropriateness
Sometimes for middle
21 school
(4.5) students,5 national
(2.1) applica- self- efficacy. The internal reliability (Cronbach's alpha, α) was 0.83.
16 (6.8)
bility, andOften
convincing content validity
1 (0.2)established through
1 (0.4) the expert -
panel approach.
Ever had a romantic relationship, n (%)
The Sexual Knowledge Scale (primary outcome measure) has 27 2.5 | SRH education
No 451 (96.2) 225 (96.6) 226 (95.8) .651
true/false statements assessing knowledge of reproductive physiol-
Yes 18 (3.8) 8 (3.4) 10 (4.2)
ogy (n = 11), pregnancy and birth control (n = 8), and awareness of 2.5.1 | The intervention
Intimate behaviors, n (%)
sexual harassment and assault (n = 8) (Yeh & Chen, 2012). The total
Hold hands 48 (10.2) 20 (8.6) 28 (11.9) .178
Hug
scores indicating 19 (4.1)
a better understanding 6 (2.6)
of sexual knowledge. The 13 (5.5)
social cognitive theory (Bandura, 2004). Multiple components ad-
Kiss
internal reliability 1 (0.2)
(Cronbach's alpha, α) was 0.88. - 1 (0.4) determinants of the sexual behavioral change process
dressed
Touch Attitudes Questionnaire
The Sexual 3 (0.6) (secondary
1 (0.4)
outcome mea- 2 (0.8) to knowledge, attitudes, and self-efficacy, presented in a
related
sure) contains
None 11 questions 398
using a mixed 2-
(84.9) point
206 (three ques-
(88.4) supportive
192 (81.4) social environment in the school setting. The participa-
tions), 3-point
Note: The t-(five questions),
test was used foror
age4-comparison,
point (threewhile
questions)
the chi-scoring tory
square test or strategy,
Fisher's exactadvocated
test was by the World Health Organization, infused
scheme
usedtoforcapture various attitudes toward different sexual be-
other comparisons. not only SRH knowledge and skill development but also psychoso-
haviors (e.g., student romance, one-night stands, prostitution, sex- cial well-being into planned teaching and learning activities (Lopez
ual propriety, and HIV/AIDS in a partner) (Wu, 2007). The total et al., 2016).
122 |
MA et2Al. MA etMA|
al7. et Al .
TA Breveals
L E 3 Results of the repeated-
an astonishing growth measures ANOVA
of AIDS cases for sexual
among youthand reproductive
of 15 health-related
effectiveness outcomes
in improving (N = 448)
adolescents’ sexual knowledge, attitudes,
Repeated-measure statistics Within-group Between-group Interaction
2015 (He et al., 2018). Mean (SD) the interactive SRH education
comparison program would
comparison have better sexual
effect
Outcome measures T0 T1 T2 F p F p F p
a a a
Sexual
girlsknowledge
under 15 years give birth every year in developing countries, 181.27 in usual
engage 21.51
<.01mode of <.01
SRH education, 85.71
that <.01 of the
is, self-study
Experimental group
causing roughly 12.31
3.9 million (6.31)
unsafe 18.84
abortions (6.32)
among 19.1815
those aged (5.70)
to same written and audiovisual materials.
19 years
Control (WHO, 2018). Pregnancy
group and childbirth
13.37 (6.28) among adolescents
15.04 (7.00) 14.28 (7.37)
is a attitudes
Sexual major factor contributing to maternal mortality and morbidity. In 3.80 .024a 13.91 <.01a 3.91 .021a
China, recent
Experimental evidence shows
group an increasing
26.28 (2.79) pregnancy
27.10 (3.68) rate among
27.06 (3.44) 2 | M E TH O DS
adolescents,
Control group with half of25.73
the abortions
(3.64) occurring among unmarried
25.70 (4.20) 25.75 (4.21)
adolescents (Xiao & Chen, 2017).
Sexual self-efficacy
2.1 | Study
13.03
design 9.65
<.01a .002a 7.03 .01a
Sexual and reproductive health education is an important form
Experimental group 4.43 (0.96) 4.77 (0.57) 4.72 (0.74)
of health promotion action to optimize adolescent health and de- The quasi-experimental controlled trial was conducted in a two-
Control group 4.40 (0.93) 4.42 (0.99) 4.50 (0.91)
velopment (Garzón-Orjuela et al., 2020). Using an appropriate the- branch middle school in a place exemplifying the large majority
SD, standard
oreticaldeviation;
framework T0,inbefore intervention;
such education is T1, immediately
critical after intervention;
in development and T2, 1 month
middle- after in
size cities intervention.
mainland China according to the TREND guide-
a
p < .05.
interaction among
for adolescents have personal
generated(e.g., knowledge,
positive self-efficacy),
attitudinal 2.2support
environ- parental
outcomes. | Setting and
was key sample participation in the SRH edu-
to students’
Fridamental (e.g., (2011)
et al. and’s exposure to risky
program situations),
failed and behavioral
to improve influences cation program; otherwise, none of the students would attend non-
sexual attitudes
(e.g.,being
despite dating relationships)
able to improve(Bandura, 2004). Several
sexual knowledge and SRH education academic
behaviors The target cityeducation.
focused in ShandongThe Province in eastern
involvement China
of school had a sexu-
managers,
programs
among for adolescents
adolescents, unlike ourhave
SRH demonstrated encouraging
education program positive including
and those ally conservative
the principal, culture and to
was critical was
theexperiencing urbanization
success of this SRH pro- at a
outcomes
tested using
by others social cognitive
(Constantine theory.
et al., 2015;Interventions
Krugu et al.,with positive gram.slower
2018). pace compared
They coordinated and with metropolitan
facilitated or municipal
all arrangements, cities (Yan
including
outcomes
According for adolescents
to social psychology,have been documents
attitudes in Africa,
are the intrinsic Nepal, the selection
psy- et al., 2017). A stratified
of time cluster
slots, venues forsampling
the SRHstrategy wasand
education, useden-to re-
Spain, tendencies
chological and the United
for States (Acharyatoward
an individual et al., 2017; Espada
people et al., 2017; gagement
and things. cruit participants. As estimated
of school facilitators, by G*Power
which 3.1 (Faul
helped create et al., 2007), to
a supportive
TheyMmbaga et al.,
are shaped by2017; Peskin
various et al.,
factors over2015; Winskell
a long et (Lu,
period al., 2018).
2011). socialdetect an effectfor
environment size of 0.5
this (Cohen's
school- at a type
basedd)sexual I error
health rate of 0.05,
promotion
However,
Therefore, in places like
SRH educational mainland China,
interventions shouldwhich are characterized endeavor.
be implemented and with a two-sided t-test having a power of 0.80, 128 participants
for aby a sexually
longer periodconservative/suppressive culture
to bring about and sustain under
positive the prolonged
changes to needed to be recruited, with 64 in each of the study groups (size ratio
influencesexual
adolescents’ of Confucianism,
attitudes. SRH education remains implicit or cir- of experimental to control group = 1:1). Given an average class size
cumvented.
Like Educational
others’ work, our SRHefforts often program
education cartoonsinoranother 4.1 of| 60
resort toresulted Strengths
students, 2and
of 20limitations
classes were selected in each grade (Grades
“quiet”
increase in methods, or efficacy.
sexual self- the education is handled
Constantine etinal.,
private environments
(2015) tested 7 and 8), depending on their availability during self-study sessions in
SRH or within in
courses families (Liang & Bowcher,
10 secondary schools in 2019).
the A large majority
United States andof ado- The present
the afternoon, from eachthe
study examined of effectiveness
the two school ofbranches,
developing respectively.
an in-
lescents in mainland China do not receive any formal
found that students receiving education had higher self-efficacy SRH education teractive SRH education program that took into consideration students
The coin toss method was used to decide whether to assign the
21
or have access
in managing to essential
risky situations SRH
(e.g., services.
knowing Thistowas
how saymainly
‘no’ to caused
sex). by cultural
in the smaller-
context andnumbered class
participants’ to the experimental
developmental or control
characteristics group.
(i.e.,
theetincompatibility
Peskin between
al., (2015) reported SRH
that and the
middle contextual
school demands
students showed on the preference
Studentfor
participants
simple andwere blinded to
interesting the group
materials andassignment, but the
participatory
virtue or noble
improvements system
in sexual of morality,
self- efficacy including sexual an
after receiving propriety
SRH ed-in pub- teaching
nurses
andwho delivered
learning the intervention
activities). were not
This program blinded.
demonstrated en-
lic social
ucation interfaces
program. In our(Zhao et the
study, al., 2019).
sexualWithout adequate
self-efficacy scoreeducation,
de- Participants
couraging were aged
positive outcomes 10 torelated
in SRH- 19 years in the selected
knowledge, classes,
attitudes,
adolescents
creased to a greatmay have
deal difficulties
1 month afterinthe
tackling SRH-related
intervention matters, and self-
(i.e., T2), and efficacy
able to communicate andwe
skills. However, read
didinnot
Chinese.
assessParental consent to
actual roman-
whichincluding
might be sexual
causedtemptations and of
by the rarity risky sexual behaviors,
encouraging face-to- tic orparticipate
or reinforc- voluntarily
sexual behaviors givenwas obtained.
that Excluded
very few were
students hadthose who had
or would
face, online,
ing social or virtually.
interactions at in Different teaching
participants’ and learning
proximal modalities report
environments severe
such mental or communication
experiences. There might problems or other
have greater SRH
positive education
effects
(e.g., school
including expert and
lectures,
homeleaflet distribution)
settings, have been
where parents attempted to on sexual
and teachers experiences according
knowledge, to class
attitudes supervisors’
and self- screening.
efficacy if The recruit-
the intervention
useddeliver
to keepSRH education
close programs
eyes on their for school
conduct. Weakadolescents
self-control,ina mainland
sign ment
lasted for and reasons
a longer for dropping
period (i.e. moreout were
than tworecorded
40-min in the floworchart
sessions)
of lowChina (Chen et
willpower, al., also
may 2016). However,
play a role inthese programs of
the reduction seldom clarified reinforcement
the pos- (Figure 1). strategies (e.g. more social media based interactions)
itive the guiding
changes framework
caused by thetoSRH
link program
educational contents
(Spano, andGiven
2004). expected were implemented.
outcomes
the impact through
of the delivery
perpetual modes,
sexual or have they
conservative provided
context, standard
posted- Two deliverers of the SRH education program were not
materials
ucation for replication
reinforcement or wider
should dissemination.
be integrated into the program to 2.3to |theEthical
blinded considerations
group assignment of students, the delivery and as-
Considering Chinese
sustain adolescents’ efficacy culture about
in refusal sexual
decision propriety,
making we devel- sessment of the intervention might be compromised. Additionally,
in various
riskyoped the interactive
situations (Leung etSRH education program by referring to others’ academic
al., 2019). This study was approved
engagement by the
and success wereinstitutional ethical for
primary concerns committee
the
success
To in deliveringwith
keep consistent SRHthe
educational intervention
contextual or culturalunder the guid- school
conserva- (No. 2017-
and R-106)
families in in
thecompliance withStudents
local society. the principles outlined
in Grade 9 werein the
anceinofthe
tiveness thelocal
social cognitive
society, theoryfemale
we placed (Acharyaandetmale
al., 2017; Espada not involved
students Declaration of Helsinki.
because Withoccupied
they were the support of the middle
by focused school
study for
20
et al., 2017;
in separate rooms Mmbaga
and used et al.,
sex- 2017; Peskin
sensitive teachingetmaterials.
al., 2015;Given
Sommart the city-
executive management for
wide examinations committee,
an entryinformed consent
to an ideal forms were
high school,
& Sota,
students’ tight2013; Winskell
schedule et al.,study
and heavy 2018).load,
Thisstrong
studyschool
examined
and the whilesent to theresources
limited school principal, classthe
influenced supervisors,
access torecruited students,
other middle
MA etMA
8 |
Al . et al. |MA3 123
et Al .
F I G U R E 1 Flow chart on participant

Enrollment recognized, culturally
Assessed adapted,
for eligibility and gender- as well as develop-
(n = 469)
recruitment and dropout
mental stage appropriate strategies aforementioned. The teach-
ing materials and associated delivery methods as used in our SRH
education program might be applicable to other contexts with a
similar cultural background surrounding sexual conservativeness.
More engagingAllocation
technologies might be adopted to further improve
Allocated to the experimental group Allocated to the control group
(n = 233) the outcomes like what others did (Peskin
(n = et al., 2015; Winskell
236)
et al., 2018).
In our study it was nurses who delivered the SRH education
program, which consolidates nurses’ roles in public health nursing
in face of the severe shortage of doctors in school and community
settings. School-based SRH education is beneficial to youth growth
and health Follow-Up
service development for any country. School nurses
T1: 232
T1: 228 included in the analysis;may make full use of educational included in thetoanalysis;
opportunities apply what they
5 lost to follow-up (attended 4 lost to follow-up (took part in
learned to increase the impact in SRH among adolescents.
student meeting) school activities)
5 | CO N C LU S I O N
5 lost to follow-up (participated 7 lost to follow-up
This interactive SRH education program (participated
was effective at improv-
in school academic testing)ing middle school adolescents’ in schoolknowledge,
sexual academic testing)
attitudes, and
self-efficacy across a 1-month period. The educational contents and
implementation protocol were in harmony with the local sexually
Analysis
conservative culture and usual educational practice regarding sensi-
tive topics. The SRH interventional study is an encouraging attempt
suggesting promising approaches to school health promotion and
disease prevention with a cultural impact.
AC K N OW L E D G M E N T S
developers. 0.74.
We are truly grateful for all student participants as well as their
parents and class supervisors. The study would never be possible
without the strong school-wide support under the leadership of the
principal and his managerial team's efforts. Also, we would like to
take this opportunity to thank our statistician colleague's contribu-
tion to the statistical components.
perience, and the following three instruments were selected given tainly can” was used, with higher scores indicating stronger refusal
C O N FL I C T O F I N T E R E S T
their appropriateness for middle school students, national applica- self-efficacy. The internal reliability (Cronbach's alpha, α) was 0.83.
The authors declare that there is no conflict of interest.
bility, and convincing content validity established through the expert
panel approach.
DATA AVA I L A B I L I T Y S TAT E M E N T
F I GSexual
The U R E Knowledge
2 Sexual knowledge, attitudes,
Scale (primary outcomeandmeasure)
efficacy has
score
27 2.5 Data
| SRH education
will be available upon request.
changes by group over time
ogy (n = 11), pregnancy and birth control (n = 8), and awareness of 2.5.1O R|C I The
D
intervention
schools, which threats the generalizability of this study should Xing Ma https://orcid.org/0000-0003-0158-4880
be cautious.
scores indicating a better understanding of sexual knowledge. The social cognitive theory (Bandura, 2004). Multiple components ad-
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Allocated Sexual
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group Yang Y,toChow
Allocated KM, Zang
the control group Y.
and reproductive health related knowledge, attitude(n and be-
= 233) (n = 236)health
Chinese adolescents’ sexual and reproductive
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s1124531
Follow-Up
5 lost to follow-up (attended 4 lost to follow-up (took part in
student meeting) school activities)
5 lost to follow-up (participated 7 lost to follow-up (participated
in school academic testing) in school academic testing)
Analysis
developers. 0.74.
perience, and the following three instruments were selected given tainly can” was used, with higher scores indicating stronger refusal
their appropriateness for middle school students, national applica- self-efficacy. The internal reliability (Cronbach's alpha, α) was 0.83.
bility, and convincing content validity established through the expert
panel approach.
The Sexual Knowledge Scale (primary outcome measure) has 27 2.5 | SRH education
ogy (n = 11), pregnancy and birth control (n = 8), and awareness of 2.5.1 | The intervention
scores indicating a better understanding of sexual knowledge. The social cognitive theory (Bandura, 2004). Multiple components ad-
The Sexual Attitudes Questionnaire (secondary outcome mea- related to knowledge, attitudes, and self-efficacy, presented in a
sure) contains 11 questions using a mixed 2-point (three ques- supportive social environment in the school setting. The participa-
tions), 3-point (five questions), or 4-point (three questions) scoring tory strategy, advocated by the World Health Organization, infused
scheme to capture various attitudes toward different sexual be- not only SRH knowledge and skill development but also psychoso-
haviors (e.g., student romance, one-night stands, prostitution, sex- cial well-being into planned teaching and learning activities (Lopez

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CONSORT 2010 checklist of information to include when reporting a randomised trial *

CONSORT 2010 checklist Page 1

CONSORT 2010 checklist Page 2

Chinese adolescents’ sexual and reproductive health education:

Xing Ma RN, BSN, MMed1 | Yuanyuan Yang RN, BSN, MMed1 |

adolescent, health education, program evaluation, reproductive health, sexuality

have become more liberal, compounding problems related to

F I G U R E 1 Flow chart on participant TA B L E 2 Participants’ background

University or 65 (13.9) 33 (14.2) 32 (13.6)

F I G U R E 1 Flow chart on participant

FIGU R EB.1J., Flow

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