School-based sexual health education is commonly used to promote the sexual health of young people and guide them in their relationships. This thesis reports on research that aimed to provide evidence-based recommendations to optimise the effectiveness of school-based sexual health education in sub-Saharan Africa (sSA). There are six chapters in the thesis. Chapter 1 introduces the thesis, Chapters 2 to 5 consist of four empirical studies, and Chapter 6 provides an overall discussion and looks at the strengths, limitations, and implications of the findings. Chapter 2 is a systematic review and meta-analysis of school-based sexual health education in sSA. It provides some evidence of the interventions in promoting self-reported condom use. However, it shows there are no harmful or beneficial effects with respect to sexually transmitted infections (STI) as evidenced by biomarkers. It highlights the paucity of evaluated interventions using biomedical markers, and reports on the process of evaluation, which limits our understanding of why interventions work or do not work. Features associated with effective interventions are noted. Chapter 3 is a case study involving MEMA Kwa Vijana, an adolescent sexual and reproductive health intervention implemented in Tanzania. This study highlights the influence of structural factors in schools and wider environmental factors on the effectiveness of school-based sexual health interventions. Furthermore, it identifies the social and cultural factors that influence young people’s sexual behaviours and that must be addressed beyond the education and health sectors. Chapter 4 is a multiple case study of seven school-based sexual health interventions implemented in five sub-Saharan African countries. It 4 identifies the design, implementation, and evaluation features that differentiate between effective and ineffective interventions. Chapter 5 is a qualitative study of researchers’ experiences of school-based sexual health education in sSA. This study extends previous work by generating a set of valuable recommendations based on researchers’ experiences of interventions that could improve future interventions in sSA. Overall, this research project demonstrates the potential of school-based sexual health education in promoting sexual health and preventing STIs in sSA. It provides a series of recommendations for the design, implementation, and evaluation of school-based sexual health interventions.

The purpose of this study was to describe the sexual health knowledge and attitudes of a sample of Saskatchewan post secondary freshmen aged 17-19. Three primary questions guided this research: What do Saskatchewan freshmen know about the general sexual health topics of physiology, contraception, and sexually transmitted infections? What are common attitudes about sexual activity, risk behaviors, and relationships? What were the main sources of sexual health information for these freshmen, and do they express a need for more education and resources? The study design was a qualitative web-based survey. Participants were volunteer freshmen aged 17-19 from the University of Saskatchewan and Saskatoon Institute of Applied Science and Technology, and 515 responded. Sixty-two percent were sexually active. Condoms were seen as helpful (98%) but only 57% saw them as effective for preventing pregnancy. Only 47% saw condoms as effective for preventing HIV/AIDS. Knowledge of reproductive physiology and STI symptoms and consequences were low with an average knowledge score of 26%, while HIV and AIDS knowledge scores averaged 80%. Knowledge of long acting contraceptives was much lower than birth control pills. Human papilloma virus was poorly understood, and many wanted more information about HPV vaccination. Attitudes were mixed about safe sexual activities, with respondents identifying condoms (94%), withdrawal (18%) and anal sex (15%) as safer sex. Condoms were used at last intercourse by 57%. A variety of attitudes were expressed about condom use, sex in relationship, and social pressures. Topics concerning to respondents were sexual violence, HIV/AIDs, STIs, unintended pregnancy, and the influence of alcohol/ drugs on sexual activity. Very few respondents had heard of or accessed sexual health websites designed and promoted to teens. An interest was expressed for more information from doctors and public health nurses, more guest speakers for SBSHE, and easier access to sexual health clinics. The information gathered in this study highlighted many areas for further detailed inquiry, and topics that can be better addressed in physician’s offices and sexual health curriculum. Additionally, the results could guide sexual health educators, policy makers and direct physicians towards collaboration and advocacy projects, and ultimately contribute to long term improvement in sexual health of Saskatchewan teens.