Sexually transmitted diseases (STDs) are the major health problem that affects a significant part of sexually active population globally. The most prevalent STDs are genital herpes (HSV), papillomavirus (HPV), chlamydia, gonorrhea, syphilis, and trichomoniasis (World Health Organization [WHO], 2016). Adolescents and young adults are the most vulnerable population. This group of people acquires nearly half of new cases of STDs (Centers for Disease Control and Prevention [CDC], 2017). In particular, the problem of STDs in school-age children appears urgent. Thus, it is highly important to develop a preventive primary health plan focused on school-age children sexual education and promotion of safe sex for increasing the knowledge of children about STDs and decreasing the rate of infections in the target population.
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Identification of the Problem and the Population
STDs are infectious diseases transmitted from one person to another through unprotected sexual contact, including heavy petting and vaginal, anal, and oral sex. STDs include viral, bacterial, and protozoan infections. Diseases might have no or mild symptoms, which prevent their timely diagnosis. Despite being asymptomatic, STDs might cause severe health problems in people. In particular, infections can lead to pelvic inflammatory diseases and female infertility. STSs can be transmitted to a child during pregnancy and cause congenital abnormalities, preterm birth, or child’s death. Finally, herpes virus infection might lead to cervical cancer development (WHO, 2016). Consequently, STDs adversely affect the health of people, including the reproductive ability; however, infections are frequently asymptomatic and remain non-diagnosed.
The most vulnerable population for STDs is sexually active adolescents. According to CDC (2017), nearly a half of new cases of STDs are registered in adolescents and young adults aged between 15 and 24 years. The reason for this tendency is that adolescents have low knowledge regarding infections and ways of protection against them (Borawski et al., 2015). Consequently, it is important to develop interventions focused on improving the knowledge of high-school students about safe sexual behavior, STDs, and ways of protection. Thus, the target population for the intervention is high-school students (14-18 years old).
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Project Question
It is important to formulate the PICOT question for the preventive primary care project.
P – population – high-school students aged 15-18 years.
I – intervention – sexual education provided by school nurses.
C – comparison – no sexual education.
O – outcomes – improved knowledge about safe sexual behavior, STDs, and protection from infections.
T – time – one year.
In high school students aged 15-18 years old (P), does sexual education provided by school nurses (I), comparing to no sexual education (C), improve knowledge about safe sexual behavior, STDs, and protection from infections (O) during one year after the intervention (T)?
Description of the Proposed Solution
Sexual education is a popular intervention for the improvement of knowledge about safe sexual behavior and STDs (Manlove, Fish, & Moore, 2015). According to Borawski et al. (2015), school-based education is the effective measure for knowledge dissemination. Parents believe that children could learn more from healthcare professionals during school-based education than in private conversation. Thus, it is important to involve school nurses in the educational process. Borawski et al. (2015) demonstrate that teaching provided by nurses is more efficient than that provided by schoolteachers. In particular, significant changes in beliefs, attitudes, and efficacy were demonstrated in school students after education. Thus, health professionals should conduct the appropriate educational intervention.
Therefore, the intervention focused on the sexual education and safe sex promotion among high school students is the proposed solution. School nurses will conduct the education. Nurses are personnel that have appropriate knowledge related to the problem of STDs. They are more qualified in medical issues. Moreover, the information provided by healthcare professionals might attract more attention and trust of students (Hoekstra, Young, Eley, Hawking, & McNulty, 2016). Health education and promotion are an essential part of nursing work. Thus, school nurses should be prepared for educating children about the urgent health problems and promoting a healthy lifestyle.
It is important to develop the appropriate health education for children. The educational intervention will consist of six sessions lasting for 50 minutes. Borawski et al. (2015) demonstrate that this type of educational program is successful. The program will include information about sexual practices, STDs (infection routes, symptoms, health consequences, and ways for diagnosis), safe sexual behavior, and condom use. Educational sessions will include several teaching strategies: lections, group discussion, watching videos, and practical exercises for the condom use. Sessions will be conducted once a week. Thus, the common duration of the education will be six weeks. The assessment of students’ knowledge, beliefs, and attitudes regarding the problem of safe sex and STDs will be conducted before the intervention, immediately after it, and one year after it. The proposed school-based educational intervention might significantly improve students’ knowledge about STDs and attitudes toward safe sexual behavior.
Literature that Supports the Project
As it was stated above, adolescents are the most vulnerable population to STDs development. They have a low level of knowledge and personal experience in sexual behavior and ways of protection. In particular, condoms use is the only way for protection from STDs. However, a significant part of adolescent population does not have the appropriate knowledge of this procedure. They also report different failures with the use of condoms such as condom breaking and slipping (Hall et al., 2016). Thus, the education is focused on the improvements of this knowledge is essential for adolescents. Next, the target population demonstrates inappropriate knowledge about STDs. Subbarao and Akhilesh (2017) estimate the knowledge of college students about STD. They reveal that only 64% or respondents have heard about STDs other than HIV, and less than 50% of respondents are aware of symptoms of infections and their effects on the health. Importantly, the main sources of information for students are mass media, the Internet, and teachers but not health professionals (Subbarao & Akhilesh, 2017). Evidently, improvements in the level of students’ knowledge regarding STDs and protection are required.
For improving the situation, sexual education should be used. The review of Manlove et al. (2015) is dedicated to school-based educational programs on the safe sexual behavior and reproductive health. It was shown that the majority of them have a consistent impact on reproductive health and sexual behavior. Thus, school-based educational interventions could be applied for improving the problem of the high rate of STDs among adolescents.
The proposed educational intervention is also based on evidence. The study of Borawski et al. (2015) should be cited. The authors applied HIV/STD curriculum “Be Proud! Be Responsible!” for teaching high school children. They compared the effectiveness of education provided by school nurses and schoolteachers. The authors revealed improvements in condom use knowledge in both groups immediately after the teaching. However, education provided by nurses was more efficient because students demonstrated improvements in beliefs, attitudes, and efficiency one year after the intervention. Thus, based on this study, it is possible to suppose that education provided by school nurses will be efficient for improving the knowledge and attitudes of the target population.
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Implementation of the Plan
The implementation plan is based on the TeamSTEPPS model developed by the Department of Defense and the Agency for Healthcare Research and Quality (2014).
Step 1. Identifying the Audience and Training Requirements
- Who will be educated? The audience for the educational intervention is high school students aged 15-18 years old.
- When? The education will be conducted once a week for 6 weeks.
- About what? Education will be dedicated to the topic of safe sexual behavior, the appropriate use of condoms, and STDs and their roots of transmission, symptoms, health consequences, and importance of timely diagnostics.
Step 2. Specifying the Instructors
- Who will educate? School nurses will provide education.
- What is needed to prepare the instructors? It is expected that school nurses are aware of the issue and are ready to conduct the education. However, two 6-hour training sessions will be provided for nurses-educators to prepare them for the intervention (Borawski et al., 2015). On these training sessions, nurses will be provided with materials for education and instructions. Particular topics of education and training methods will be discussed and approved. Thus, the complete educational procedure will be established.
Step 3. Developing a Training Plan
- Who will attend the education? Students of 10-12 grades will attend education sessions. Each grade will attend the training separately. Boys and girls will be educated together.
- When? Education will be performed once a week for 50 minutes after school lessons.
- Where? Education will be school-based. It will be conducted in school classrooms.
- What will be trained? First, education will be focused on safe sexual behavior, importance of agreement of both persons, the need for the use of condoms, and possible consequences of unprotected sex, including pregnancy and STDs. Next, the appropriate use of condoms will be demonstrated. Students will have an ability to practice this skill using and demonstrate their understanding. In addition, education will be focused on STDs. Nurses will explain what type on infections can be transmitted, routs of their transmission, symptoms of STDs, possible consequences for health, and the need for screening in case of unprotected sex. The treatment of infections will not be discussed except for general information with the purpose to avoid possible self-diagnostics and self-treatment.
- How? Different educational methods will be used including lections, watching video, group discussion, and practical sessions.
- Developing the logistics. Educational sessions will be conducted once a week in a particular day and time. The schedule of education will be prepared, including particular topics and activities of each session. For the training, presentations and educative video will be prepared or found. Thus, projector will be needed for each session. For practical lessons, condoms and penis replica will be required.
Step 4. Determining whether the Refresh Training Is Required
Refresh training is not planned for this project. One of its goals is to determine whether the educational intervention provides long-term knowledge and attitudes improvement. However, after a one-year period and repeated knowledge assessment, the education can be refreshed in case of necessity.
Step 5. Developing the Timeline
- Week 0. Assessment of knowledge, beliefs, attitudes, and efficacy of participants in relation to safe sexual practices and STDs.
- Week 1.Intimate relationship between two people. The importance of agreement in sex. Sexual relationship as the expression of love.
- Week 2. Types of sexual practices: petting, vaginal, anal, and oral sex. Possible consequences of sex: pregnancy and STDs.
- Week 3-4. Types of STDs. Roots of transmission. Symptoms of STDs. Health consequences. Diagnostics procedure.
- Week 5. Safe sex and the use of condoms. Practical sessions.
- Week 6. Group discussion of the materials of previous weeks and the summary of educational sessions.
- Week 7. Repeated assessment of knowledge, beliefs, attitudes, and efficacy of participants in relation to safe sexual practices and STDs.
The next assessment will be conducted in a year after finishing the program. Still studying students will be assessed at schools, while graduates will be assessed online via a survey.
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Theory of Change to be Used
The theory of changes is widely used for preparing health programs for the community. It allows determining how the intervention proposed might result in planned long-term outcomes (Breuer, Lee, De Silva, & Lund, 2016). It consists of the following parts: long-term outcomes, the process of change, assumptions, contextual factors, beneficiaries, and indicators.
Long-term Outcomes
The desirable long-term outcome is the decrease of the rate of STDs among high school students.
Process of Change
Educational intervention improves students’ knowledge and beliefs about safe sexual practices, the use of condom, and STDs prevention. Students implement obtained knowledge in sexual practice. Based on the knowledge, the attitude toward safe sex and own health is also changed. Students use condoms and do not demonstrate risky sexual behavior. As a result, the spread of STDs is decreased.
Assumptions
It is assumed that (1) improvements will be sustained, and (2) students will implement the obtained knowledge in practice.
Contextual Factor
The education will be provided by healthcare workers (school nurses), which improves its efficiency.
Beneficiaries
High-school students and the community in general will benefit from the plan.
Indicators
The decreasing rate of new cases of STDs among adolescents and young adults in communities where the plan is implemented will indicate the efficiency of the intervention.
Evaluation of the Plan
Evaluation of the plan is a highly important step. It is needed to determine whether the education was efficient and changed students’ knowledge and beliefs regarding safe sex, the use of condoms, and STDs, attitude toward safe sexual practices, and efficacy in the appropriate use of condoms and practicing safe sex. For students’ assessment, a questionnaire will be prepared. Two domains of knowledge assessment will be included: knowledge about the condom use and knowledge about STDs. Students will be asked to choose the correct answer from multiple variants. For beliefs assessment, true and false statements about sex, STDs, and condom use will be prepared. Students will be asked to agree or disagree with the statements. For the attitude assessment, statements that include intentions will be prepared. Again, students will be asked to agree or disagree with these statements. Finally, condom use and safe sex practicing efficacy assessment will be conducted. For this purpose, statements which include activities will be listed. Students will be asked to determine how frequently they act as stated. The assessment will be anonymous. For the evaluation, statistical methods of analysis will be used. The distribution of data will be determined. Fisher’s analysis and t-test will be used for assessment of the difference between data. The intervention will be considered as effective if significant improvements will be observed in a year after the intervention.
Practical Recommendations
If successful results of the project are obtained, educational intervention will be recommended for implementation in community schools. Trainings for school nurses can be organized on a regular basis. After training, school nurses might develop their educational sessions and teach high school students. It is expected that the rate of STDs among adolescents will be decreased due to this intervention.
Conclusion
STDs are considered as a significant problem in the modern world. The most vulnerable population is adolescents and young adults, in particular sexually active high school students. The reason for this tendency is the lack of students’ experience and knowledge of safe sexual behavior and STDs. This project introduces the possible school-based intervention for improving the knowledge, beliefs, attitudes, and efficiency of high school students about the stated issue. The educational intervention includes six 50-minute educative sessions for students of 10-12 grades aged 15-18 years. School nurses will be the educators because it has been proven that education conducted by healthcare professionals is more efficient. In particular, it causes sustained changes and lasts for longer time. The project implementation will be based on TeamSTEPPS model. It includes five steps: determining the audience, the instructors, developing a plan, determining the need for refreshing of knowledge, and developing the timeline. The evaluation of the efficiency of the project is highly important. It includes the assessment of students’ knowledge, beliefs, attitudes, and efficiency before, immediately after, and one year after the intervention. If the plan implementation provides sustained positive changes in assessed measurements, this intervention will be recommended for implementation in all community schools.