Sexual health and education

Before making investments in this strategy, city and county leaders should ensure it addresses local needs.

The Urban Institute and Mathematica have developed indicator frameworks to help local leaders assess conditions related to upward mobility, identify barriers, and guide investments to address these challenges. These indicator frameworks can serve as a starting point for self-assessment, not as a comprehensive evaluation, and should be complemented by other forms of local knowledge.

The Urban Institute's Upward Mobility Framework identifies a set of key local conditions that shape communities’ ability to advance upward mobility and racial equity. Local leaders can use the Upward Mobility Framework to better understand the factors that improve upward mobility and prioritize areas of focus. Data reports for cities and counties can be created here.

Several indicators in the Upward Mobility Framework may be improved with investments in reproductive health and education. To measure these indicators and determine if investments in these interventions could help, examine the following:

• Access to healthcare: Ratio of residents to primary care physicians. These data are available from the U.S. Department of Health and Human Services’ Area Health Resource File.

• Neonatal health: Share of low-weight births. These data are available from the CDC’s National Center for Health Statistics.

Mathematica's Education-to-Workforce (E-W) Indicator Framework helps local leaders identify the data that matter most in helping students and young adults succeed. Local leaders can use the E-W framework to better understand education and workforce conditions in their communities and to identify strategies that can improve outcomes in these areas.

Several indicators in the E-W Framework may be improved with investments in this strategy. To measure these indicators and determine if investments in this strategy could help, examine the following:

• Physical development and well-being: Percentage of students meeting benchmarks on self-rated surveys of physical health, such as the California Healthy Kids Survey Physical Health & Nutrition module.

• Access to health, mental health, and social supports: Percentage of programs offering health, mental health, and social services, or staff or consultants providing infant and early childhood mental health consultation (IECMHC) services.

• Increase the availability of and access to direct sexual healthcare services: Increasing residents’ access to sexual healthcare services is central to improving their overall wellbeing. Key types of services that are generally offered at sexual health clinics include testing, prevention (e.g., PrEP for HIV prevention), and treatment for sexually transmitted infections (STIs), contraceptive counseling, and vaccinations, among others. In some communities, local governments – including cities, counties, and school districts – may operate clinics. Alternatively, or in concert, local governments may fund healthcare systems and/or smaller community based organizations to operate clinics at low- or no-cost to residents. Prioritizing operational funding for these clinics is key to preserving or expanding access to these services. Beyond funding, co-locating sexual health clinics with general primary care services, or other common destinations for the clinics’ patient population, can increase uptake by making the services more accessible. Mobile clinics, often focused on STI testing and sexual health education, can also be an effective way to bring services directly to community members.

• Implement an effective comprehensive sexual health education policy: To the extent permitted under state law, school districts should both mandate and set standards for sexual health education for K-12 students. The most effective approach to sexual health education is comprehensive sexuality education (CSE), which takes a holistic, rights-based approach to sexual health, educating students on the physical, biological, emotional, and social aspects of sexuality. CSE curricula generally cover a wide-range of topics, including human anatomy and physiology, consent and healthy relationships, contraception and pregnancy, sexuality and gender identity, and STIs, among others. The National Sex Education Standards, developed by the Future of Sex Education Initiative, is considered a gold-standard for identifying or developing effective CSE curriculum. In addition to setting curricular standards, school district leaders may define training standards for educators who deliver CSE. Regardless of a policy’s exact approach, experts advise that district-level leaders focus on establishing a mandate and standards for both curricula and educator training, while leaving school building leaders and sexual health educators with latitude on implementation (e.g., mandating educator training requirements but providing flexibility on which educators may deliver the curriculum). Additionally, while sexual health education mandates are necessary, they are often not sufficient on their own. Mandates should be backed by a budget for quality assurance, including funding for independent evaluation of schools’ implementation of curricular standards, student outcomes, and other measures of quality.

• Run community health promotion initiatives: Local public health departments and their partners can design and implement (or contract out for) health communication campaigns focused on sexual health. Campaigns may use a combination of print, broadcast, digital, and out-of-home (e.g., transit bus ads) media to inform residents and encourage behavioral change. Generally, effective health communication campaigns have a well-defined target audience and a clear, measurable action for that audience to take that will improve health outcomes. (To learn more about principles of health communication design, see the WHO’s resource). Health communication campaigns may occur alongside other health promotion efforts, like in-person outreach and education. Regardless of the approach to health promotion that a community takes, experts emphasize the importance of establishing clear connections between promotion efforts and direct sexual healthcare services (e.g., providing referrals to a nearby clinic when conducting outreach at a community event).

• Protect access to sexual health care services: In some communities, changes to state and federal law have curtailed access to family planning services, like abortion and emergency contraception. While local governments and their partners are limited in how they can respond to these restrictions, they can take steps to meaningfully preserve access to family planning services, even in states that have passed laws to the contrary. As employers, local governments may be able to both ensure sick and family leave policies allow paid time off for abortion care and, if self-insured, provide health insurance that covers abortion-related expenses. More broadly, local governments may provide funding to abortion funds, which help individuals overcome cost and/or logistical barriers (e.g., travel arrangements) to accessing abortion care, particularly in communities where residents must travel out-of-state to access these services. (For examples of this approach, see Austin (TX) and Atlanta (GA), where city governments provided financial support to community-based organizations focused on abortion access.) Lastly, in states that enforce abortion bans, local governments may be able to take steps to reduce the risk that residents will face enforcement actions when accessing abortion care. Cities like Phoenix (AZ), for example, have passed resolutions or ordinances directing local law enforcement to deprioritize or otherwise limit enforcement of state abortion bans.

• Prioritize resources based on need: In most communities, public health efforts – including those focused on sexual health care and education – face real resource constraints. As such, experts advise local leaders to use data to understand the disparities in sexual health outcomes in their communities and prioritize resources where they are most needed. For example, school district leaders may first launch a new comprehensive sexuality education program in schools with sexual and behavioral health risk factors, like a higher incidence of teen pregnancy or STIs.

• Use resources that support patient- and learner-centered programming for all: National public health organizations offer tools to support communities in closing disparities in sexual health outcomes by providing more inclusive and accessible programming. For guidance on increasing inclusiveness in clinical settings, see this resource from the National Coalition for Sexual Health. For resources on providing inclusive sexual health education, particularly for sexually and gender diverse learners, see resources from the National LGBTQIA+ Health Education Center.

• Prepare for disruptions in funding for sexual health programming: Consistent funding for sexual health programming, like Title X, which supports family planning services, is under threat, particularly at the federal level. When these programs are cut, it is a particular problem for low-income individuals, who disproportionately rely on programs these funding streams support. In this environment, local leaders should prepare to respond to potential cuts. When local governments can step in with funding to replace that lost from the federal government, services may continue with limited disruption. However, this may not be realistic in most communities where budgets are already tight. Two lower-cost alternatives include: (1) focusing on preventative measures that may lessen future need for costlier direct healthcare services (e.g., PrEP for HIV prevention), and (2) making one-time investments to promote continuity of care from programs facing cuts (e.g., notifying and transitioning clients from a program that is ending to other services in the community).

• Municipal or county public health departments: City or county public health departments have expertise around and often administer and/or fund sexual health promotion and healthcare services.

• Healthcare systems and other healthcare providers: Both larger healthcare systems and smaller community-based clinics provide sexual health education and healthcare services directly to clients.

• Community-based organizations: In many communities, non-profit organizations, both local and national organizations with local affiliates, may focus on health promotion or provide other non-healthcare services to residents. These organizations can support efforts to reach populations with which larger institutional actors may have more limited connections.

• School district leaders: School district leaders are central to mandating and setting standards for sexual health education in K-12 settings. They may also be key partners in broader sexual health promotion efforts.

• Individuals served by programming: Clients can provide actionable feedback to improve sexual health programming in a community. For school-based programming, like sexual health education, engaging students and parents may be particularly important to ensure buy-in and uptake of services.

• Colleges and universities: Researchers and other staff at colleges and universities may be able to support sexual health programming in a community, such as by providing technical assistance on program design, supporting evaluations of interventions, and more.

• Adopt a rights-based approach: A rights-based approach to sexual health programming emphasizes and supports individual autonomy over sexual and reproductive health decisions. This approach can have practical implications, as when service providers focus on clients’ preferences, clients may be more receptive to and have higher uptake of those services. As an example, during contraceptive counseling, a client may have circumstances that make “more effective” (in terms of preventing pregnancy) contraceptive methods less desirable for them, and those factors should be incorporated into the process of deciding the “best” form of contraception for them. In this example, the rights-based approach could inform both program design (e.g., the approach to counseling services) and how the program would be evaluated (e.g., by a metric like uptake of preferred contraceptive method).

• Integrate sexual health programming: Experts recommend integrating both across sexual health programming (e.g., between health promotion and associated direct healthcare services) and between sexual health programming and broader healthcare services (e.g., linking sexual health clinics to broader primary care services). Integration can take several forms, such as developing formal referral processes between organizations, intentionally co-locating services, or working toward providing a wider range of services at the same organization. All of these approaches reduce the burden placed on clients to access the full range of sexual health programming from which they may benefit. For an example of integrating sexual health education and school-based health clinics, see Results for America’s case study on sexual health education in Minneapolis (MN).

• General, population-level sexual health outcomes: Common metrics focused on sexual health outcomes include incidence of HIV and other STIs, reproductive autonomy and sexual violence, among others. Local leaders may create a composite of several relevant metrics to better understand overall sexual health conditions in a community, as well as disparities across social groups and geographic areas.

• General, population-level access metrics: Metrics that speak to residents’ access to and uptake of sexual health services include rates of STI testing, preferred contraceptive method use, and health insurance coverage, as well as measures of geographic proximity to sexual healthcare providers.

• Programmatic data for sexual health education: There can be significant lag time between when sexual health education is delivered and high level health outcome measures shift. Programmatic measures, like the number of schools offering comprehensive sexuality education, the number of schools meeting established standards for sexual health education, and qualitative feedback from students, can be effective ways to understand the effectiveness of school-based sexual health education.

• Outcome metrics for sexual health education: Ultimately, sexual health education aims to shift similar outcomes as other sexual health programming, like incidence of HIV and other STIs, reproductive autonomy, and sexual violence, among others. Qualitative metrics may include students’ understanding of and ability to practice bodily autonomy, self-advocacy, and consent, as well as acceptance of diverse gender and sexual identities.