Effects of the school environment on adolescent sexual behaviour: a mixed methods assessment of the theory of human functioning and school organisation

Context: Current school-based strategies to improve adolescent sexual health face logistical and political challenges and have limited long-term impact, possibly because they do not address upstream determinants. The theory of human functioning and school organisation proposes that schools can promote student health by increasing commitment to school through improving school processes and strengthening young people’s engagement. While it has been assessed for other health behaviours, this thesis is the first to assess and refine the theory for application to adolescent sexual health. Methods: Three systematic reviews concerning sexual health outcomes were conducted, including a synthesis of qualitative studies of young women’s accounts of school experiences, a synthesis of observational studies examining school-related factors, and a meta-analysis of evaluations of school environment and educational assets interventions. A multi-level, longitudinal analysis explored associations of school- and student-level engagement with the school environment and subsequent sexual behaviour. Results: Synthesis of qualitative studies revealed that young women’s education and life trajectories were shaped by their commitment to school values, experiences with teachers and curriculum, and perceptions of how to achieve adulthood status. Synthesis of observational studies suggest that some school-related factors, such as enrolment, educational plans, and attitude to school, are associated with subsequent sexual health outcomes. Multi-level analysis indicates that higher levels of school- and student-level commitment to learning, sense of belonging and relationships with teachers are associated with reduced sexual risk behaviour. Meta-analysis provides evidence that school environment interventions may delay sexual debut, while narrative synthesis suggests that educational assets interventions may reduce risk of pregnancy and STIs. Discussion: Findings provide support for the theory as it relates to young people’s sexual health. Proposed refinements consider parallel school-student value systems, greater emphasis on school leadership, the developmental context of school experiences and sexual behaviour, and application to varying social and economic settings.