The Effect of Comprehensive Sexual Education on Adolescent Behavior in Using Contraception : A Systematic Review

Adolescence is a transition period from childhood to adulthood. This period is crucial because there are many physical and psychological changes. One issue that is quite rife in Indonesia is teenage pregnancy, which will ultimately lead teenagers to have abortions. The case above proves that it is essential to equip adolescents with the knowledge and skills to make responsible choices. Comprehensive Sexual Education (CSE) is believed to help solve this problem and achieve the Sustainable Development Goals (SDGs) by 2030, when CSE also conveys the importance of contraception and its benefits. The lack of systematic reviews of studies that highlight the effect of implementing Comprehensive Sexual Education on current contraceptive use makes researchers interested in conducting this systematic literature review. This research uses a Systematic Literature Review (SLR) using PICO (Population, Intervention/Issue, Comparison/Context, Outcome), and Boolean operators are used to facilitate searching studies. PRISMA flowcharts were used in this research until two studies were included in the analysis. Literature quality assessment was conducted using the quality assessment tool for quantitative studies from EPHPP (Effective Public Health Practice Project). Two cross-sectional studies were based in the United States. The sample sizes in studies range from 5000 to 7000. The results of this study show that comprehensive sexual education influences the use of contraceptives today, although it is not very significant. However, there are still many biases in this research. There is a need to conduct randomized controlled trials or multicenter cohort studies that use the same evaluation parameters to strengthen future systematic review research.

INTRODUCTION

Adolescence is a transition period from childhood to adulthood^1,212. This period is crucial because there are many physical and psychological changes³³. These changes often cause many problems for teenagers, one of which is that too many teenagers receive information that is inaccurate, incomplete, or full of judgments that affect their physical, social, and emotional development both within and outside the scope of Sexual Reproductive Health (SRH)⁴⁴. One issue that is quite widespread in Indonesia is teenage pregnancy. 2020 People’s Welfare data shows that as many as 45.1% of Indonesian women aged ≤ 20 years have experienced their first pregnancy⁵⁵. This will ultimately lead teenagers to have abortions. In many cases, due to insufficient preparedness from health, emotional, mental, educational, socio-economic, and reproductive aspects, adolescent girls are more likely to self-abort or seek unsafe abortion services⁶⁶. Abortion cases in Indonesia are estimated to increase every year. Data from the 2017 Indonesian Demographic and Health Survey shows that the incidence of abortion in Indonesia reached 30% per 100 thousand live births⁷⁷. Unsafe abortion globally, every year, approximately 3 million girls aged 15 to 19 years undergo hazardous abortion⁸⁸.

The above case is evidence that it is essential to equip adolescents with the knowledge and skills to make responsible decisions in their lives, especially as they are increasingly exposed to sexually explicit material through the Internet and other media^{9–129101112}. Comprehensive Sexual Education (CSE) is believed to help solve these problems and achieve Sustainable Development Goals (SDGs) by 2030^{13–15131415}.

Comprehensive Sexual Education (CSE) is a curriculum-based teaching and learning process about the cognitive, emotional, physical, and social aspects of sexuality^2,16216. Comprehensive Sexual Education also conveys the importance of using contraception and its benefits^4,17417.

Literature shows that contraceptive use among sexually active adolescents varies widely around the world, with behavioral, cultural, social, and health system factors playing a huge role in that^{18-2118192021}. For example, changes in adolescent behavior, such as increased use of contraceptives, are associated with a lower pregnancy risk among adolescents.

The lack of systematic reviews of studies that highlight the effect of implementing Comprehensive Sexual Education on current contraceptive use makes researchers interested in conducting this systematic literature review.

MATERIALS AND METHODS

This study utilizes a systematic literature review (SLR). It is a research methodology that reviews multiple studies that identify, investigate, evaluate, and interpret all available research in a topic area of ​​an interesting phenomenon with a specific related research question²²²². In systematic review research, research questions are compiled using Population, Intervention/ Issue, Comparison/ Context, outcome (PICO). PICO in this study is as follows:

Table 1.PICO Compilation

Population	Adolescent
Intervention/Issue	Comprehensive Sexual Education
Comparison/Context	Non-Comprehensive Sexual Education
Outcome	Current contraceptive use

Figure 1.Example caption for this image

There are inclusion and exclusion criteria in determining studies, which are as follows:

Table 2.Inclusion and Exclusion Criteria

Inclusion Criteria	Exclusion Criteria
Studies/literature in English and/or Indonesian	Sources come from Non-Research Studies (conference papers, book chapters, reports)
Using studies from the last 10 years	The source is in the form of a systematic review/review article
Full text

In this research literature search, electronic databases used ScienceDirect, Wiley Cochrane Library, PubMed, and Scopus to identify relevant studies. In this step, search for keywords (search terms) using Boolean Operators (search commands), including AND / OR / NOT. The keywords (search terms) used are (Comprehensive Sexual Education OR Comprehensive Sexuality Education) AND practical AND effect AND contraception.

Based on search results using predetermined keywords, a total of 1688 studies were obtained. Then, 47 studies were eliminated due to duplication, leaving 1641 studies to be screened. At the screening stage, 1583 studies were excluded due to unmatched titles and abstracts, leaving 58 articles to be assessed for eligibility. In the eligibility assessment, 56 articles were excluded because PICO was unsuitable, did not meet the inclusion and exclusion criteria, did not provide complete data analysis, or did not meet the literature quality assessment criteria. Literature quality assessment was done using the quality assessment tool for quantitative studies from the Effective Public Health Practice Project (EPHPP)²³²³. The results of the literature quality assessment are attached in Table 3.

Data extraction was carried out using a modified data collection form from Cochrane. The data researchers collect from the articles reviewed includes author, article title, research setting, research methods, year of publication, time of research implementation, research sample, independent variable, dependent variable, results, and article quality previously assessed. This data is attached in Tables 4, 5, and 6.

Table 3.Caption ...

Author	Component Ratings						Global rating
	Selection bias	Study design	Confounders	Blinding	Data collection method	Withdrawals and dropouts
(Cheedalla, Moreau, and Burke, 2020)2424	1	3	1	1	1	2	2
(Rasberryet al., 2022)2525	1	3	1	1	1	2	2

No.	Author	Journal, Year, Volume, Page	Title	Place and Time of Research	Research Methods	Research Sample	Independent Variables	Dependent Variables
1.	(Cheedalla, Moreau, and Burke, 2020)2424	Contraception: X, 2020, 2, 1000048	Sex education and contraceptive use of adolescent and young adult females in the United States: an analysis of the National Survey of Family Growth 2011–2017