The Journal of School Nursing
© The Author(s) 2020
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DOI: 10.1177/1059840520950438
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2022, Vol. 38(3) 299–305
We compared sexual/reproductive health services and sexuality education topics provided in Texas alternative high schools (AHSs) with the prevalence of sexual risk behaviors among students in AHS. Using cross-sectional data from convenience samples of 14 principals, 14 lead health educators, and 515 students, we calculated descriptive statistics for 20 services and 15 sexuality education topics provided by AHSs and seven sexual risk behaviors among students in AHS. AHSs provided few sexual/reproductive health services and limited educational content, despite high levels of sexual risk taking among students. For example, no AHSs taught students about proper condom use, yet 84% of students have had sex. Findings provide preliminary evidence of unmet needs for school-based sexual/reproductive health services and comprehensive sexuality education in AHS settings. Future investigation with larger, representative samples is needed to assess the provision of sexual/reproductive health services and sexuality education in AHSs and monitor sexual risk behaviors in the AHS population.
teen pregnancy/parenting, high school, policies/procedures, health disparities, alternative high schools, sexual/reproductive health
In 2018, the United States reached a historic low birth rate among adolescents aged 15–19 years (17.4 births per 1,000 women; Martin et al., 2018). Yet the U.S. teen pregnancy rate continues to be substantially higher compared to other Western industrialized nations (Centers for Disease Control and Prevention [CDC], 2019a), and racial/ethnic, sociodemographic, and geographic disparities in sexual and reproductive health among U.S. adolescents persist (CDC, 2019a, 2019b, 2020a). For instance, the teen pregnancy rate in Hispanic and non-Hispanic Black teens is more than twice that of White teens (Martin et al., 2018). Adolescents in the child welfare system are also more likely than the general population to experience a pregnancy (Boonstra, 2011; Combs et al., 2018; Garwood et al., 2015). Additionally, over half of the 20 million sexually transmitted infections (STIs) diagnosed each year occur among youth aged 15–24 years (CDC, 2017b). Alarmingly, 41% of new HIV diagnoses occur among adolescents and young adults, with the highest rates among youth of color and young men who have sex with men (CDC, 2018; Guillermo-Ramos et al., 2019).
Alternative high schools (AHSs) serve a disproportionate number of low-income youth, youth of color, and lesbian, gay, bisexual, transgender, and queer youth (Lehr et al., 2009) and address specific student educational needs that typically cannot be met in a mainstream school (National Center for Education Statistics, 2017). Students enrolled in AHSs are often at risk of academic failure due to individuallevel (e.g., chronic truancy), family-level (e.g., unstable home environments), and system-level factors (e.g., unequally enforced zero tolerance policies; Johnson et al., 2017). AHSs tend to offer a more flexible and individualized learning environment where students, who are often stigmatized, can continue or complete their education (McNulty & Roseboro, 2009).
While little public health surveillance data exist for students in AHS, existing data suggest they engage in higher levels of risky sexual behaviors than their peers in mainstream high schools (Grunbaum et al., 2001; Johnson et al., 2013), putting them at high risk of teen pregnancy and STIs including HIV. Students in AHS have been shown to be more likely to have ever had sexual intercourse and almost twice as likely to be currently sexually active than students in mainstream high schools (Grunbaum et al., 2001; Johnson et al., 2013). Grunbaum et al. (2001) found that of those students in AHS currently sexually active, over half did not use a condom at last sexual intercourse. In Johnson et al.’s (2013) study, 26% of male students attending an AHS reported having four or more sexual partners in the past year compared to 12% of males attending a mainstream high school. Additionally, among approximately 500 students enrolled in dropout/prevention recovery alternative schools in Texas, 82% reported ever having sex, 68% reported having intercourse with one or more persons in the past 3 months, and 41% of female students indicated having been pregnant one or more times (Weller et al., 1999).
Given that students in AHS have been shown to engage in more risky sexual behaviors (Grunbaum et al., 2001; Johnson et al., 2013) and the persistent socioeconomic and racial/ethnic inequities in sexual/reproductive health outcomes among U.S. youth, AHSs are an important setting for monitoring and addressing sexual and reproductive health. School-based sexual/reproductive health services have long been viewed as a promising way to reduce inequities and increase access for teens who are at high risk of unplanned pregnancy and STIs/HIV and often have no other source of care (Boonstra, 2015). Comprehensive sexuality education programs have been shown to reduce sexual risk behaviors and delay sexual intercourse (Santelli et al., 2017). However, the amount and type of sexuality education and services offered in schools vary significantly across the United States (Maziarz et al., 2019).
Texas is one of 26 states that does not mandate sexuality education in public schools yet maintains high teen birth rates, repeat birth numbers, and STI/HIV diagnoses, compared to other U.S. states (CDC, 2017a; Satterwhite et al., 2013; Texas Freedom Network [TFN], 2017). In 2016, Texas public schools taught abstinence-only curriculum (58.3%), abstinence-plus curriculum (16.6%), and no sexuality education (25.1%; TFN, 2017). When available, sexuality education must present abstinence from all sexual activity as the preferred choice of behavior and as the most effective way to prevent pregnancy and STIs including HIV (TFN, 2017). However, several studies show that increasingly strict abstinence policies actually result in higher rates of pregnancy, teen births, and STIs. Additionally, abstinence only until marriage education programs have been shown to be ineffective in delaying initiation of sexual intercourse or changing other sexual risk behaviors (Santelli et al., 2017).
At present, no known studies have examined sexuality education and sexual/reproductive health services in AHSs. Therefore, the purpose of this study was to assess sexual/reproductive health services and sexuality education in Texas AHSs relative to the prevalence of risky sexual behaviors among students in AHS.
We used cross-sectional data from the 2015 Texas Alternative School Health Study, which comprised three selfadministered surveys conducted in 14 AHSs in one geographic region of Texas. To be eligible, AHSs had to serve some combination of Grades 9–12 and either be a school of choice serving academically at-risk students or a disciplinary alternative education program where students were placed involuntarily for behaviors deemed disruptive to the learning environment. The first two surveys, one given to principals (n = 14) and one to lead health educators (n = 14), measured school-level variables and were derived from the CDC’s School Health Profiles (Profiles), a surveillance system used to monitor school health policies and practices (e.g., school health education requirements, school-based health services; CDC, 2017b). Fourteen AHSs serving 1,646 enrolled students (mean: 219 students, range: 14–415) participated. Principals answered a 63-item survey about school health policies and activities including sexual/reproductive health services. Lead health educators answered a 26-item survey about health education requirements and content, collaboration, and professional development. Principals and lead health educators received a US$50 incentive for participating. This study was approved by the first author’s university institutional review board.
The third survey in our study assessed student-level health risk behaviors. A modified 129-question Youth Risk Behavior Survey (YRBS) was administered to 515 students in AHS across Central Texas (mean age 17.1 years; 51.3% female; 58.4% Hispanic, 21.7% White, 13.4% Black, 6.4% Other; 63.8% low socioeconomic status). It included all core YRBS items (CDC, 2020b)—including questions about sexual risk taking—with additional questions about risk and protective factors. We obtained parental consent and assent from students under 18 years old and direct consent from those 18 years or older. All students received a US$5 incentive regardless of whether or not they agreed to participate; those who took the survey received an additional $10 incentive. We calculated a cooperation rate of (i.e., number of students participating in the survey/number of consent forms distributed), which was 41% because chronic absenteeism is common in the AHS population (Johnson et al., 2017). Our methods are described in detail elsewhere (Johnson et al., 2017).
We examined the prevalence of seven sexual-risk-taking behaviors from the student survey (Table 1) and answers were dichotomized (yes/no) based on the student’s selfreported behavior. We examined 20 questions from the Profiles principal survey regarding the provision and referral of various sexual/reproductive health services and 15 questions from the Profiles lead health educator survey regarding sexual/reproductive health topics taught in AHSs. All questions from the Profiles surveys had “yes/no” answer options. We calculated descriptive statistics for each variable from each survey.
The majority of students in AHS (84%) reported ever having sex. One in 10 (11%) reported first intercourse before age 13. Approximately one third (33.5%) of students reported having four or more sex partners during their lifetime and less than half (43%) used a condom during last sexual intercourse. Almost 30% of female students in AHS had one or more pregnancies (Table 1).
In contrast, no AHSs offered school-based sexual/reproductive health services, with the exception of prenatal care, which was offered by three of 14 AHSs (21.4%). None provided HIV/STI testing or treatment, pregnancy testing, HPV vaccine, or condoms to students in school. Five of 14 (35.7%) AHSs referred students to STI/HIV testing and treatment, while seven of 14 (50%) referred for pregnancy testing, and eight of 14 (57.1%) for prenatal care. Four of 14 (28.6%) referred students for condoms and three of 14 (21.4%) for condom-compatible lubricants (Table 2).
Sexuality education in nine of 12 (75%) AHSs included information about the consequences of pregnancy and STIs/ HIV. Six of 12 (66.7%) discussed how to access information and services related to pregnancy and STIs/HIV. None explained how to correctly use a condom, and very few discussed the efficacy of condoms (25%), the importance of using a condom or another form of contraception (16.7%), or how to obtain condoms (8.3%; Table 2).
This is the first known study to assess the provision of sexual/reproductive health services and sexuality education in AHSs relative to risky sexual behaviors among students in AHS. Our findings, based on this small regional sample, provide preliminary evidence of an unmet need for schoolbased sexual/reproductive health services and comprehensive sexuality education among students in AHS and warrant further investigation.
Similar to other studies examining sexual risk behaviors in students in AHS (Grunbaum et al., 2001; Johnson et al., 2013), most students in our sample engaged in sexual intercourse and a substantial proportion reported risky sexual behavior. Despite higher levels of risky sexual behaviors than the general adolescent population (Grunbaum et al., 2001), few AHSs in our sample offered services related to STI/HIV testing and treatment or pregnancy and STI prevention for students. While many AHSs offered sexuality education content covering general information (e.g., health consequences of HIV, STIs, pregnancy) and social skills information (e.g., negotiation skills to reduce risk), markedly fewer offered content about condoms and contraception. Given the high prevalence of sexual activity among students in AHS, information about how to obtain and correctly use condoms and contraception is vital to reducing the risk of STIs, including HIV, and pregnancy for students in AHS. This disconnect, if replicated in other AHS samples, has population-level implications for reducing racial/ethnic and socioeconomic disparities in STIs and pregnancy among U.S. adolescents, given that AHSs serve a disproportionate number of youth of color and low-income youth (Lehr et al., 2009). It also raises important questions regarding where—if not through school—students in AHS obtain sexual/reproductive health services and information. More research is needed to understand the extent of this gap and how to increase appropriate school-based sexuality education and services to this underserved population.
Our findings were similar to national trends indicating that the number of schools that provide sexuality education is declining (Santelli et al., 2017). In a recent study of geographically representative high schools, 63% of high schools reported that they teach comprehensive sexuality education, yet only 7% had condoms available on campus and over 70% did not make referrals for contraception (Maziarz et al., 2019). Our findings also align with statewide trends showing few schools in Texas offer any health education, no sexuality education, or are likely to provide abstinence-only education (Texas Campaign to Prevent Teen Pregnancy, n.d.).
This study provides a preliminary assessment of schoollevel efforts to address sexual and reproductive health among students in AHS, but substantial gaps in our knowledge remain. Future large-scale epidemiological studies are needed to assess the provision of sexual/reproductive health services and sexuality education in AHSs and monitor sexual risk behaviors among the AHS population. Such data could then be linked to determine the relationship between school-level policies and student-level outcomes and identify best practices for AHSs to meet student needs around sexual and reproductive health. Yet, there are no known sources of national epidemiological data on AHS health policies and practices and very few sources of data on students’ sexual risk behaviors. The only nationally representative data on the AHS population are over 20 years old, and few states consistently collect information about health risk behaviors in AHSs (Grunbaum et al., 2001).
In addition to the need for state and national data sources that collect information at the school and student levels, additional in-depth studies should assess barriers and facilitators to providing sexual and reproductive health services and sexuality education in the AHS setting and how such barriers are similar to and different from barriers faced by traditional schools. In Texas, barriers exist at multiple levels to ensure students in AHS have access to sexual/reproductive health services and comprehensive, developmentally appropriate sexuality education. These likely include restrictive state/district policies, cultural beliefs about adolescent sexual activity, and the marginalization of the AHS population (TFN, 2017). For example, AHS staff may be supportive of providing such resources to students but feel as though they do not have the support (e.g., from the district, parents, or community) or authority to take action. Once barriers are identified, further study is needed to understand the feasibility of addressing them among stakeholders and to identify policy levers that are likely to facilitate change.
For example, contrary to common belief, Texas state law does not forbid comprehensive sexuality education. Authority to make such decisions resides at the district or local level with the school board which is typically advised about health education content by a School Health Advisory Council (SHAC; Texas Education Code, n.d.; TFN, 2017). Therefore, local SHACs are a potentially important agent of change in providing sexual and reproductive health services and sexuality education in AHSs that is matched to student need. Further assessment is needed to understand the level of awareness that SHACs have about the unique needs of students in AHS and what sorts of recommendations are currently made by SHACs that are specific to the AHS setting. If not doing so already, SHACs should consider working with adolescent health experts and AHS staff to design and implement sexuality curricula that can better serve students in AHS. For example, in our study, the percentage of students in Texas AHSs who had sex before age 13 (11%) was higher than students in mainstream Texas high schools (3%; CDC, n.d.), indicating a need for targeted services and education.
School nurses are in a pivotal position to improve sexual/reproductive health outcomes among at-risk youth. The National Association of School Nurses (NASN, 2016) recommends that school nurses promote evidence-based sexuality education and advocate for the health needs of students. Nurses working in AHS are uniquely positioned to build relationships with students who may feel disconnected from other adults or service providers. Students may approach the nurse with questions and needs related to their sexual/reproductive health. Even if state- or local-level policies do not support comprehensive or limit the direct provision of services, school nurses should consider using this as an opportunity for prevention and intervention. For example, nurses could provide medically accurate information and access to sexual/reproductive health services through referrals.
School nurses should also leverage their positions as trusted health experts in the community to advocate for state- and district-level policies that require comprehensive sexuality education and expand sexual/reproductive health services in schools. They should inform decision makers about the challenges in reaching and difficulties in accessing care among at-risk youth. For example, nurses can serve on SHACs and provide evidence-based recommendations regarding sexual and reproductive health services and education, as well as advocate for adequate nurse staffing in AHSs. Policies that require adequate RN staffing in all AHSs should be considered as part of a strategy to meet the sexual/reproductive health needs of students in AHS. In determining adequate nurse staffing for the AHS setting, policy makers should follow NASN recommendations and assess need at least annually using data specific to the health needs of students in AHS including student acuity, student care needs, and social determinants of health (NASN, 2015). Presently, more research is needed to understand the staffing patterns of nurses in AHS, as well as current and ideal practices around addressing sexual/reproductive health in AHSs. In our current study, only six of the 14 schools we sampled (43%) had a school nurse, underscoring the need to understand the ideal role and staffing patterns for nurses in alternative schools to be optimally effective in meeting the sexual/reproductive health needs of students at the individual, community, and systems levels.
Our study is limited by its use of a small convenience sample from one Texas region with a low student-level participation rate. Due to the small sample size of schools, we were unable to link school-level data with student-level data to determine whether a relationship exists between AHS-level efforts to address sexual/reproductive health and student-level behaviors, which would be an important contribution to our understanding of the impact of sexual/reproductive health services and sexuality education in AHSs. Nonetheless, our data set is among the few modern data sets available for assessing health risk behaviors among students in AHS and the only known study to analyze AHS-level practices relative to student behaviors. Additionally, our findings regarding the high prevalence of sexual risk behaviors among students in Texas AHSs mirror those from the one available source of representative AHS student data (Grunbaum et al., 2001). Future studies with larger, representative samples at the state and national levels are needed to better understand and address student needs for sexual/reproductive health services and education in the AHS setting, and how school health policies and practices can effectively meet these needs.
Karen E. Johnson has contributed to conception, design, acquisition, analysis, and interpretation; drafted the manuscript; critically revised the manuscript; gave the final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Kathryn L. Conn has drafted the manuscript; critically revised the manuscript; gave the final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Cynthia Osborne has contributed to acquisition, analysis, and interpretation; drafted the manuscript; critically revised the manuscript; gave the final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Kelly L. Wilson has contributed to acquisition, analysis, and interpretation; critically revised the manuscript; gave the final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Lynn Rew has contributed to conception, design; critically revised the manuscript; gave the final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The contents are solely the responsibility of the authors and do not necessarily represent the official views of the Robert Wood Johnson Foundation.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by the Nurse Faculty Scholars program grant number 72111 (PI: Johnson) from the Robert Wood Johnson Foundation.
Karen E. Johnson, PhD, RN, FSAHM, FAAN https://orcid.org/0000-0002-3935-9067
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Karen E. Johnson, PhD, RN, FSAHM, FAAN, is an Associate Professor at The University of Texas at Austin School of Nursing.
Kathryn L. Conn, MSN, MPH, is a PhD student at The University of Texas at Austin School of Nursing.
Cynthia Osborne, PhD, is an Associate Dean for Academic Strategies at The University of Texas at Austin LBJ School of Public Affairs.
Kelly L. Wilson, PhD, MCHES, is a Professor at Department of Health and Kinesiology, College of Education and Human Development, Texas A&M University.
Lynn Rew, EdD, RN, FAAN, is a Professor at The University of Texas at Austin School of Nursing.
1 The University of Texas at Austin, TX, USA
2 Department of Health and Kinesiology, College of Education and Human Development, Texas A&M University, College Station, TX, USA
Corresponding Author:Karen E. Johnson, PhD, RN, FSAHM, FAAN, The University of Texas at Austin, Austin, TX 78701, USA.Email: drkj@utexas.edu
