Development of a survey instrument to evaluate sex education in Utah

Sexually transmitted infection (STI) rates, teen pregnancy rates, and unwanted pregnancy rates are accessible ways to evaluate the efficacy of sex education programs. However, this data may not always reveal the full impacts of a given sex education program. Additionally, legislators in a position to enact sex education policies may not find this data sufficient or usable in the process of policy formulation. Following a review of existing measures, a new survey instrument was developed to comprehensively evaluate the quality of existing sex education programs. The study produced a five-page survey instrument divided into four measurement categories; these categories are demographic factors, perceptions of sex education, sex myth knowledge, and sexual behaviors. Utilization of this tool in state and local contexts may provide a more multidimensional picture of sex education program impacts and lead to specific guidance on program improvement.

ABSTRACT Sexually transmitted infection (STI) rates, teen pregnancy rates, and unwanted pregnancy rates are accessible ways to evaluate the efficacy of sex education programs. However, this data may not always reveal the full impacts of a given sex education program. Additionally, legislators in a position to enact sex education policies may not find this data sufficient or usable in the process of policy formulation. Following a review of existing measures, a new survey instrument was developed to comprehensively evaluate the quality of existing sex education programs. The study produced a five-page survey instrument divided into four measurement categories; these categories are demographic factors, perceptions of sex education, sex myth knowledge, and sexual behaviors. Utilization of this tool in state and local contexts may provide a more multidimensional picture of sex education program impacts and lead to specific guidance on program improvement. This work was supported by funding from the Undergraduate Research Opportunities Program at the University of Utah awarded to Lauren Gleave. ii TABLE OF CONTENTS ABSTRACT ii INTRODUCTION 1 DEVELOPMENT OF SURVEY INSTRUMENT 8 DISCUSSION 23 REFERENCES 28 APPENDIX 1 34 APPENDIX 2 39 INTRODUCTION 1 Quality sex education programs can be a vital tool in improving public health, particularly among the young. There is a correlation between sex education program type and STI and unwanted pregnancy rates; in the US, the comprehensive programs are the most effective at lowering these statistics (Stanger-Hall, 2011). Research has found additional benefits to quality sex education, including improvement of academic outcomes, heightened acceptance of LGBTQ+ peers, and lowered risk of “experiencing sexual assault during college” (Future of Sex Education Initiative, 2020). Given the importance a quality sex education to student health and wellbeing, it is vital for the policymaking that influences these programs to be robust and well thought out. The Role of the Policymaker Policy change can be one of the most potent measures in effecting meaningful, long lasting public health improvement. With this in mind, it is important that public health policy be research backed. Without a strong understanding of the potential impact of a given proposed policy, that policy may be ineffective or even actively harmful. On the other hand, “evidence-based policies can lead to dramatic short-term and long-term improvements in public health” (Pollack Porter et al., 2018). In 2013, Dodson et al. worked to evaluate the factors that state legislators take into account when determining which health issues to prioritize. The study found that by and large, legislators rated “constituents’ needs or opinions” as the most important factor and “evidence of scientific effectiveness” as the second most important factor. Additionally, over 50% of social conservatives and 33% of social moderates rated “data on health impact of an issue in their local area…very important in determining” these 2 priorities (Dodson et al., 2013). This data suggests that researchers can play an important role in helping legislators determine which health policy issues to prioritize. Researchers can work to translate research to the public, effectively educating constituents and helping them gain an informed profile of their needs, and in turn influencing legislators. Research can also provide the “evidence of scientific effectiveness” (Dodson et al., 2013) suggested to be important in the aforementioned study. Finally, and most importantly to the aims of this study, researchers can focus on providing local level health data. Though this may not be as important in determining policy priorities as the other two mentioned factors, it does still have a meaningful role, particularly in socially conservative settings. In regards to sex education policies in the US, local data becomes all the more important. Sex education policy is driven by state and local level legislators, there are “no federal laws (that) dictate what sex education should look like or how it should be taught in schools” (Planned Parenthood, n.d.). Because sex education guidelines are formulated largely on the local level, local level data becomes all the more valuable in driving the direction of these policies. Standard Measurements For legislators looking to gain insight into sex education efficacy for their constituency, STI, teen pregnancy, and unintended pregnancy rates are often the most easily found data available. Data on each of these measurements can be accessed through several avenues, including individual state health departments (which often keep public health databases), the CDC, and individual researchers and research organizations (Centers for Disease Control and Prevention [CDC], 2021b; Guttmacher Institute, 2019; 3 Khan, 2022; Rhode Island Department of Health, n.d.; Utah Department of Health, n.d.b). Using this data, research has found that education is a primary factor in safe sex behaviors; the more comprehensive a sex education program is, the lower STI and unwanted pregnancy rates are. The most effective programs tend to be abstinence plus programs, which promote abstinence as a primary health measure while also educating students comprehensively on STI prevention and birth control (Kirby, 2007; StangerHall, 2011). These findings, and the data they source from, are useful in providing a broad idea of the form sex education policies should take in the US. However, when it comes to local legislation, they can fall short of evidence needs for program development. This is because sex education program goals are typically multidimensional, and opinions on what those goals ought to be differ from legislative body to legislative body. Though in many cases the goal of sex education may be summed up as preparing students to live healthy adult sex lives, what constitutes a healthy adult sex life can contain a plethora of disparate behaviors, knowledge, and mindsets, dependent upon who you ask. Statewide data on STI rates, unwanted pregnancy rates, and teen pregnancy rates will always be important tools in evaluating the health impacts of sex education. However, this data should never be the only data used in program evaluation or development. This is where the role of local level data collection, and the evaluative tools or survey instruments used in that data collection, becomes vital. Sound research done on the local level, and the research tools that support that research, can be a key 4 factor in the decision making that goes into health legislation. This becomes particularly relevant in cases where individual states buck national trends Contradiction as Basis for Complacency Despite the data backing comprehensive sexuality education, many states remain abstinence only. There are many potential reasons why a state may teach an abstinence only curriculum, including ideological. In regards to abstinence only states with low teen birth and STI rates, they may choose to remain abstinence only with the impression that that teaching methodology is effective in their state. Utah’s sex education program, like many other programs in the US, is abstinence only, prohibiting “the advocacy or encouragement of the use of contraceptive methods or devices” (UT admin Code R277-474, 2020). Despite this fact, Utah has relatively low rates of STIs and unintended pregnancy (CDC, 2015). Within the United States, Utah ranks 43rd in syphilis, 36th in HIV, 48th in chlamydia, and 44th in gonorrheal infection (CDC, 2015). Utah also has low rates of unwanted pregnancy. Between 2016 and 2018, 21.2% of women “reported that their birth resulted from an unintended pregnancy” (Utah Department of Health, n.d.-a). This is much lower than the national rate of 45% (Guttmacher Institute, 2019). One factor that may explain these low rates is the high religious population in Utah. Sexual behaviors have been shown to be influenced by religion, high religiosity is typically associated with avoidance of sexually risky behaviors (i.e. hooking up, having friends with benefits, cheating) (Hall et al., 2020). Sexual behavior can also be impacted by other identity influences (Hall et al., 2020). Roughly 62% of Utah’s population identifies as members of the Church of Jesus 5 Christ of Latter-Day Saints (LDS), with 11% other Christian, 4% as non-Christian faith, 22% as unaffiliated, and 1% as unknown (AP, 2019). Members of the Church of Jesus Christ of Latter-Day Saints (LDS) tend to have premarital sex at rates 20-30% lower than the national average (Moore, 2002). Utah’s culture has been built around the LDS faith, which stresses premarital abstinence; though laws surrounding premarital sex went largely unenforced, prior to 2019 premarital sex was technically illegal in Utah due to Utah’s 1973 Fornication law (Ingber, 2019). There is also reason to believe that situation in a religious community would contribute heavily to perceptions surrounding contraception. A 2020 study found that “social and cultural factors play a large role in shaping one’s attitude and awareness of contraceptives. Interpersonal relationships between students and their friends and families play a large role in both the amount and accuracy of the information they are given” (Kamimura et al., 2020). Because of religion serving as a confounding variable, statewide statistics may not portray a complete picture of the impacts of Utah’s sex education system. Those raised within the LDS church and identifying as church members may have significant gaps in their education. This may manifest through misconceptions surrounding sexual health for all young church members, and result in risky sexual behaviors for those church members who choose to be sexually active. Utah is not the only state where more detailed data may be necessary in understanding the efficacy of sex education policies. States or regions with similar data profiles to Utah (i.e. states with abstinence only sex education and rates of STI infection and teen pregnancy lower than the national average) may also benefit from deeper 6 analysis of sex education program efficacy, particularly if there is reason to believe demographic factors are serving as confounding variables. More notably, even states with comprehensive sex education in the US may benefit from deeper examination of program goals and outcomes—this is because “while states with comprehensive sex education have lower teen pregnancy rates, even in these states rates are much higher than seen in Europe” (Stanger-Hall, 2011). In cases such as these, comparing state level data with national statistics may lead to complacency, when in fact continued detailed evaluation ought to be considered. The Need for a Novel Tool Detailed, data driven evaluation of local sex education programs is the ideal. Unfortunately, this data is neither easily available nor easily attainable in most cases. In circumstances where a novice researcher, program director, or local legislator is interested in driving data collection, evaluative tools are often difficult to access, overly broad, or difficult to translate to a layman setting. Additionally, it can be difficult to find a tool that evaluates sex education program goals and outcomes comprehensively, which is necessary in developing well-fleshed out programs. In order to solve this problem, this project reviews existing measures to systematically develop a more comprehensive instrument for evaluating sex education programs, one which accounts for individual experiences and behavioral patterns that may not be displayed in larger data. In creating this instrument, adaptability was a particular concern. Though some elements of evaluating a given sex education program may remain static, because of the differing nature of sex education programs and the 7 populations they are meant to serve there is an inherent need for flexibility in formulating a widely usable instrument. Later breakdown of the instrument will establish where changes to the provided survey may be necessary in evaluating unique or nonreligious populations. DEVELOPMENT OF SURVEY INSTRUMENT 8 Review of Existing Instruments Prior to establishing development of a new survey instrument as a goal of this project, a review of existing instruments was conducted. This review served two purposes; first, to establish whether or not existing measures would be suitable for the type of comprehensive and accessible measurement advocated for by this project, and second, to review aspects of sex education and sexuality commonly measured in both broadly and narrowly dedicated instruments. Particularly useful was Meltzer’s 1993 review of instruments used to “examine and measure sexual knowledge, attitudes, and behavior” (Meltzer, 1993, p. 9) up to that point. Measurements in this review included the Sex Knowledge and Attitude Test (SKAT); the Sex Knowledge and Attitude Test for Adolescents (SKAT-A), the Sexual Attitude Scale developed by Hudson, Murphy, and Nurius; Hendrick, Hendrick, SlapionFoote, and Foote’s 1983 instrument focused on sexual attitudes; the Sexual Opinion Survey developed by Fisher, Byrne, White, and Kelley; and the Sexuality Scale developed by Snell and Papini (Meltzer, 1993, p. 9-15). Based on Meltzer’s review, these instruments were determined to be either too unidimensional in scale or too long for the intended aims of this study (as was the case with Hendrick, Hendrick, Slapion-Foot, and Foote’s 102-item instrument). The SKAT-A was given additional consideration, specifically in light of its evaluation sections of knowledge, attitudes, and behavior (Meltzer, 1993; Motedayen et al., 2019). The SKAT-A was deemed an unsuitable length at 113 items. Instrument accessibility was also a concern, as policymakers may be beholden to a specific timeline in setting sex education legislation. Access to the SKAT-A requires researchers to mail 9 in a request for a PDF copy of the instrument, waiting for this could cut into valuable research time (LARS Research Institute, n.d.). More recently developed instruments were found using the Measurement Instrument Database for the Social Sciences (MIDSS). The database was searched using the keywords “sex”, “sex myth”, “sexual risk behavior”, “sexual”, and “sexual behavior”. The following survey instruments were found, and are as described; The Acceptance of Modern Myths About Sexual Agression (AMMSA) scale is used to measure rape myth acceptance (Gerger et al., 2007). In depth understanding of these beliefs can be important in evaluating healthy mindsets surrounding sexual activity, but the narrow focus of the instrument on beliefs and attitudes surrounding rape was not suitable for an end goal of multidimensional program evaluation. Similarly, the Brief Sexual Attitudes Scale developed by Hendrick et al. was a suitable length at 23 items, but focused too narrowly on sexual attitudes to be ideal in evaluating the many factors and outcomes of a given sex education program (Hendrick et al., 2006). Another considered instrument from this search was the General Sexual Knowledge Questionnaire (QSKQ), which focuses on evaluating levels of sexual knowledge and was developed to assess sexual knowledge differences in populations with and without intellectual disabilities and populations who have and have not committed sexual offenses (Talbot & Langdon, 2006). This questionnaire was deemed unsuitable because it is written for in-person administration, something that may not be possible for researchers on limited timelines and which can be logistically challenging in certain situations (i.e. as in the current global pandemic). Furthermore, the questionnaire 10 focuses narrowly on levels of sexual knowledge, which was not deemed comprehensive enough for full program evaluation. Finally, there is the National Sexual Health Survey (NSHS), which was validated in 1992 (Catania et al, 1992) and measures a broad range of sexual health topics with an especial focus on HIV risk and prevention. This measure was unsuitable primarily because at 118 pages, or 180 items, the measure was considered too long to be useful in evaluating individual sex education programs quickly and efficiently. In addition to the above measures the CDCs YRBSS 2021 questionnaires were reviewed. These questionnaires were considered unsuitable because they were too broad, containing a mixture of questions on health that did not always pertain to sexual behavior. Those questions that did focus on sexual health were found to be too broadly focused to be of use in evaluating specific sex education program criteria (CDC 2020). The CDC has also developed the Health Education Curriculum Analysis Tool (HECAT). The HECAT is aimed at individual curriculum analysis from an educator perspective and, while useful in evaluating how well a curriculum covers specific desired health education topics, does not provide the type of population data called for by this project (CDC, 2022). Based on this review, a new survey instrument to evaluate sex education programs was deemed necessary. This is because available tools often come with significant barriers to usage or do not cover a broad enough range of topics to be useful in wholesale evaluation of a given sex education program. Common evaluation topics found in the instruments reviewed for this project can be summarized as focusing on 11 sexual behaviors, knowledge, and beliefs; evaluation categories that were considered in the development of the new survey instrument. Development of Survey Characteristics Following this review, a survey instrument was developed (Appendix 1). Because, as reviewed on pages 4-6 of this project, Utah is an example of a state where typical sex education evaluation data and program type do not line up, this instrument was formulated with Utah (or other highly religious populations) in mind. Despite this, it is intended for researchers to utilize the instrument outside of that setting through adjustment of survey questions where appropriate, typically in the demographic factors section. Target Age Group This instrument was developed with undergraduate college students in mind. This is because college students tend to be young, roughly 92% of college students in the US are younger than 24 (Hansen, 2022). This youth situates undergraduate students temporally closer to their state sponsored sex education, and increases the likelihood that their primary form of formal sex education will be state sponsored. From a human development perspective, undergraduates are a desirable survey population because they straddle the line between adolescence and adulthood. Adolescence is “a phase of transition during which major developments of sexuality take place” (Kar et al., 2015). Adolescence has been defined as lasting till age 19, and, in recent years, as late as 24 (Silver, 2018). Individuals in the undergraduate age group are either in this “phase of transition” (Kar et al, 2015) or have recently moved out of it. This converges with newfound independence and legal adulthood in ways that can be particularly significant from the perspective of human sexuality. In fact, data suggests 12 “that between 60 percent and 80 percent of North American college students have had some sort of hook-up experience” (Garcia et al., 2013). This suggests that college students in the US are socially and developmentally in the position to utilize the sex education concepts they learned in high school broadly in the college context. Further advantages to surveying an undergraduate population can be found in the research approval process. Conducting human subjects research for populations under the age of 18 (as would be the case if the survey focused on students still receiving their public education) requires parental consent. In administering questions on human sexuality, the presence of parents can complicate the process of receiving honest answers from respondents, and reduce the number of respondents available to survey. Research on sexual topics can be sensitive, even when minor participants are not surveyed, because “sexual behavior is a largely private activity, subject to varying degrees of social cultural, religious, moral and legal norms and constraints” (Fenton et al., 2001). Survey Length A particular difficulty of human sexuality research can be found in achieving a high enough survey response rate to generalize findings, as “25-35% of people refuse to engage in…interviews designed to investigate sexual attitudes and lifestyles, and nonreturn rates of 40% in postal surveys of this nature are common” (Fenton et al., 2001). In order to maximize potential response rates, the survey instrument was limited to 5 pages. This is because in a study done on generalized health survey responses in 2016 it was found that questionnaire length (in this case 10 vs. 30 minutes) was “associated with statistically significant differences in response rates” (Guo et al., 2016), with shorter 13 surveys receiving higher rates of response. A shorter instrument may also be beneficial from a data quality perspective, Fenton et al. found in 2001 that in sexuality research, “long questionnaires may lead to poor data quality with missing data and inconsistent answers” (Fenton et al., 2001). Administration Type Sexual health research faces issues of social desirability bias, especially where self-reported behaviors are concerned. Specifically, this bias is likely to occur “in the direction of overreporting by men and/or underreporting by women” (Fenton et al, 2001). To account for this, the survey is self-administered, and written for administration in both computerized and in-person formats. This is because “most studies indicate that selfadministration” of surveys leads “to higher reports of sensitive behaviors” (Schroder et al., 2003). While some studies have found a correlation between computer administration and social desirability of answers, this is likely a result of selfadministration acting as a confounding variable (Schroder et al., 2003). Development of Survey Evaluation Categories Evaluation categories for the survey were determined following the review of existing measures of sexual health and sex education quality done earlier in this section. The aforementioned HECAT (CDC, 2022) was given special consideration as a curriculum evaluation tool. The 2020 National Sex Education Standards released by The Future of Sex Education Initiative were also reviewed (Future of Sex Education Initiative, 2020). 14 The developed survey contains four evaluation categories; they are demographic factors, perceptions of sex education, sex myth knowledge, and sexual behaviors. Demographic Factors Demographic questions are fairly standard in survey research. This section was included in the interest of providing researchers with a way to evaluate how demographic factors such as race, religion, economic background, political affiliation, etc. may impact survey outcomes. The sample instrument is aimed especially at evaluating the interplay of religious background and sex education. This was done with states like Utah in mind, where religious populations are high and STI, teen pregnancy, and unwanted pregnancy rates are low. Depending on the population a researcher aims to evaluate, this section is likely to need adjustment. Researchers are encouraged to consider how and when it may be appropriate to ask a given subject demographic questions regarding their parents, especially in cases where the role of parent given sex education is of interest. Standard demographic questions were included in the survey after a brief review of existing demographic measures (Rasmussen et al., 2020; Sumerau et al., 2017, United States Census Bureau, 2021). This particular iteration of the instrument focuses on how religion relates to sexual education outcomes. Appropriate demographic questions to measure religiosity and religious affiliation were developed following a more targeted review of existing literature and measures focused on religiosity measures, these measures were sourced primarily from a combination of MIDSS and EBSCO database searches, and included the Religious Commitment Inventory-10 (Worthington et al. 2012), the Hiding the World measure for religiosity and sexual behavior (Young et al., 2015), the measure utilized by Penhollow, Young, and Denny in their 2005 study of 15 religiosity and sexual behavior of college students (Penhollow et al., 2005), the Centrality of Religiosity Scale (Huber & Huber, 2012), and the measure of religiosity, sexual behaviors, and sexual attitudes utilized by Lefkowitz et al. in 2004 (Lefkowitz et al., 2004). Search criteria focused primarily on funding instruments focused on how religiosity and sexuality intersect. While no questions were directly sourced from these instruments, this review of existing instruments and the studies conducted with them served two functions. First, to establish a range of standard religiosity measures to be referenced when writing religiosity questions for the new instrument, and second to establish that prior studies of the type proposed in this project on the correlation between religiosity and sex education had not been conducted. In addition to following the standards found in these instruments, the newly written questions for this instrumentation paid especial attention to focusing on the religious background of parents as influencing educational factors. Perceptions of Sex Education The perceptions of sex education portion of the survey instrument seeks to evaluate how subjects perceive the quality of their sex education, this section also includes questions on where subjects believe they have received a majority of their sex education. Understanding the student experience of sex education can be valuable for multiple reasons. How students view their education may help determine areas where instructors need to improve their teaching methodology or increase their focus. This can aid in determining whether or not the classroom experience reflects sex education program requirements laid out by legislators. In states where gaps in education are presumably taken up by the parent, questions focused on perceptions of parent provided sex education, particularly when split along categorical lines mirroring program goals, 16 can also be beneficial. Finally, if students in a region where sex education is viewed as successful based on health outcomes (i.e. Utah) view their sex education as insufficient in coverage, it may be beneficial for educators and program directors to reevaluate the way their courses are being taught. Such a scenario may also provide grounds for deeper study and reveal unexpected insights into programs that would otherwise remain unexamined. The HECAT tackles the question of program subject coverage from a teacher/administrator perspective (CDC, 2022), this section of the survey reverses that dynamic to evaluate program subject coverage from a student perspective. The survey utilizes a series of Likert type scales to measure how well students believe a series of sexual health topics were covered in their classroom and parent provided education, as well as whether or not sex education received in school covered topics that most interested students. These scales were adapted from a study on “factors associated with middle school students’ perceptions of the quality of school-based sexual health education” (Byers et al., 2013). Additional sexual health topic categories were added to the scale following a review of the 2020 National Sex Education Standards (Future of Sex Education Initiative, 2020). Further survey items include questions aimed at determining where subjects primarily learned about sex and evaluating how well they believe their sex education prepared them for adulthood. Sex Myth knowledge Measuring sexual knowledge can be uniquely valuable in measuring the efficacy of sex education programs. This is because measuring sexual knowledge can help 17 evaluate how effective sex education programs are for students who remain abstinent. It can also help identity non-abstinent students who have yet to face serious health impacts from uninformed sexual activity. Furthermore, sexual knowledge is a valuable asset for students who never engage in traditionally risky sexual behaviors, for example, students who choose to have one exclusive sexual partner for the entirety of their lives. Finally, sexual knowledge can impact levels of sexual satisfaction, sexual knowledge has been positively correlated with sexual satisfaction in women (Soltani et al., 2017). Regardless of sexual activity, a student who has participated in a successful sex education program will have a base level of knowledge about sex and sexual health. One way to measure this knowledge is through survey questions focused on sex myths. Evaluation of sexual knowledge through sex myths presents a particular challenge in that scientific understanding of course content is ever evolving. Furthermore, commonly held sex myths may vary from region to region, demographic group to demographic group, and year to year. Because of this, future researchers may need to take especial care in updating questions used in the sex myth portion of this survey tool according to the individual circumstances of their research and the most current medical knowledge available. To this end, many of the surveys reviewed for this project contained sections concerned with sexual knowledge. Based on this finding, additional sex myth evaluation tools were reviewed (Johnston, 1998; Meltzer, 1993; Raizada et al., 1997; Sirohi et al., 1997). 10 myths were selected from the Human Sexuality Questionnaire, a 30 item sexual myths measure developed from “a literature review of sexual myths,” reviewed by a number of medical experts, and tested for reliability (Meltzer, 1993, p. 30). Five items (questions 3, 5, 7, 9, and 10) were selected because previous study had shown a 18 statistically significant difference in sex myth belief between test groups who had not taken a sex education course and test groups who had (Meltzer, 1993, p. 35-36). The remaining five items were selected for cultural relevancy. These questions appear in the survey instrument as true/false questions. The answer key for these questions can be found in appendix 2. Sexual Behaviors Sexual behaviors are an important measure of how successful a given sex education program may be. They can also be challenging to measure, as direct measurement of sexual behaviors presents both ethical and logistical impossibilities. Regardless, accurate measurement of sexual behavior through survey measures can help legislators know how exactly sex education is being applied in the real world. This measurement can be useful beyond statistics of STI infection, teen pregnancy, and unwanted pregnancy. In many cases, STIs go undetected and thus unreported (CDC, 2021a). Unwanted pregnancies are also at risk of going unreported. Because of this, measurement of the behaviors that often lead to these outcomes can be helpful in evaluating sex education program efficacy. Furthermore, identifying specific unsafe behaviors may explain where educators need to target—there are multiple behaviors that could lead to a given STI, so understanding the exact health behaviors that are occurring can be helpful in defining program needs. A condensed version of the Sexual Risk Survey (SRS) developed by Turchik and Garske was used in the sexual behaviors section of the survey. This instrument was developed as a “broad and psychometrically sound measure of sexual risk taking” (Turchik & Garske, 2009) and revalidated with updated scoring guidelines in 2015 19 (Turchik et al., 2015). Use of the SRS for this instrument was especially desirable given its rigorous validation, which found that “social desirability was not found to be related to sexual risk-taking scores and threat of sexual disclosure was only weakly related”. This is particularly important in the behaviors section of the instrument, which has a higher chance of being influenced by social desirability bias due to the more intimate nature of the questions. Items used in this instrument should use the standardized scoring developed in 2015 (found in appendix 2), with the exception of item 7, which is newly adapted for this survey and may require further research before standardized scoring can exist. An item was also included to determine if respondents have ever engaged in sexual behaviors they personally would consider risky to their health. Pilot and Refinement of New Instrument The instrument was piloted with a convenience sample of 8 undergraduate aged students. All but one of these students was located in the state of Utah. The individual located outside of Utah was not currently enrolled in a postsecondary institution, but at 22 fit the age profile of the provided instrument. Two of these students were raised outside of the Utah sex education system. This pilot group included multiple sexualities and sexes. It is important for future researchers to note that the group was racially homogenized, with all respondents identifying as white, which may impact how the survey is received in racially diverse populations. The group was asked to complete the survey in a digital format, responses were not recorded. Completion times from the survey ranged from 5-10 minutes. In practical applications of the instrument, survey time may differ depending on the subject. 20 Respondents who are sexually active in riskier ways are likely to spend a longer period of time filling out the sexual behaviors portion of the survey when compared to survey respondents who are not sexually active, and therefore do not have to spend as much time reviewing the frequency of their sexual behavior, as they know it to be at 0. To account for this, as well as to encourage respondents to take their time filling out the survey, it is recommended that future researchers allot 10-15 minutes for subjects to complete the survey. Pilots were asked if the survey questions felt comprehensive and relevant to their lives insofar as they were or were not sexually active. All students responded yes to this question. Furthermore, students were asked if the survey instrument felt overly invasive. Each piloting student responded in the negative. No structural concerns were found with the survey, pilots observed that the questions were well ordered to the aims of the survey. Pilots were invited to share concerns they had with the survey, as well as any particular subjects or topics they felt were not sufficiently covered in the survey items. The additional comments gathered from this line of questioning provided guidance on several edits made to the survey. Specifically, clarified instructions were incorporated into the sexual perceptions Likert type scales to aid students who received no sex education in selected topics from home or school in filling out the survey correctly. Based on conversations with the pilot group, it is also recommended that researchers using this instrument provide clear instructions on what resources students should use if they come across terminology they are unfamiliar with. Though a majority of respondents had no terminology questions, one respondent asked the researcher to 21 provide a specific word definition while taking the survey. With this in mind, in the case of in-person administration, informing subjects that the researcher is available to define terms is best practice. Subjects should also be informed that internet dictionaries (available to respondents with access to smartphones or laptops) can and should be accessed by respondents to provide definitions of unknown terms in the event that they are needed. In the case of online administration, this explanation may be included in the front materials for the survey, possibly following consent documentation. A Utah resident in their late 50s served as a ninth pilot. This was to provide perspective on how age groups outside of the intended survey population would respond to the instrument. Though the survey was not developed for older demographics, sex education is relevant at all ages, and researchers may wish to adapt portions of the survey to older populations. Having a basic understanding of how drastically the instrument may need to change in such a case may be useful to future researchers, and was therefore included in the pilot. The ninth pilot also provided a parent’s perspective on the survey instrument, valuable in light of the parent provided nature of some respondents’ sex education experience. Most importantly, the ninth pilot’s participation served to gain a basic idea of whether or not the instrument would be appealing to the typical legislator age demographic, given that legislators may wish to examine the instrument. The average age of lawmakers across the US is 56 (Beitsch, 2015), so ensuring the instrument is understandable and appealing to that particular age demographic may be useful in real world application of the study. The ninth pilot was asked the same questions as the 8 undergraduate pilots, and 22 similarly found the survey comprehensive and relevant to their life. The pilot was asked if the instrument appeared scandalous, lewd, or unapproachable from the perspective of a parent, and if so, what in particular gave that impression. The pilot responded that the survey was overall good, and the questions felt necessary; however, some terminology felt inappropriate. Particularly, the use of the words “fisting”, “fuck buddies”, and “anilingus” in the behavioral portion of the instrument. Their viewpoint was that this was a generational difference, rather than an inherent fault with the survey, and that researchers seeking to adapt this instrument to age groups outside of the intended undergraduate audience would need to change utilized terminology to reflect their target population (i.e. changing “fuck buddies” to “one night stand”). Overall, this pilot ensured that the final survey product was polished, not overly invasive, comprehensive, and appropriate for the intended target audience. Based on the impressions collected from piloting respondents, these goals were met. DISCUSSION 23 The Instrument A new survey instrument was developed by this project, necessitated by a number of factors. These factors include the legislative nature of sex education policy, which is determined largely on the local level (Planned Parenthood, n.d.), the use of broad measures of sex education efficacy like STI and teen pregnancy rates without supplementation of more specified data leading to complacency (as in the case of Utah, which has low rates of STIs and unintended pregnancy despite the lack of a comprehensive sex education program (CDC, 2015; UT admin Code R277-474, 2020), and a lack of brief but comprehensive evaluation tools aimed at sex education program efficacy. The developed instrument allows researchers to evaluate where students are receiving their education, how they perceive their education, the knowledge they gain from their education, and the sexual health behaviors they exhibit following their education, as well as how demographic factors influence those experiences. This survey is intended to be used in populations of undergraduate students to gain in-depth data on how demographic variables may confound larger measures of sex education efficiency. It could also be used to evaluate programs that are currently effective in order to target more specified areas for improvement in a given curriculum. This survey instrument was developed with Utah and other religious populations in mind. It is useful for this aim, focusing on parent/guardian as well as individual relationships to religious faith in the demographic section. Researchers wishing to use this tool outside of such a population may find it useful to edit the demographic section to 24 reflect their own study population. Changes to this section may also be helpful outside of the university context. Usage of sex education does not and should not end with college, older populations may be of interest. In such a case, changes to demographic questions particularly aimed at the university experience would be appropriate. Limitations In the interest of maintaining approachability and usability, the survey instrument was limited to a five-page length. Many of the items on the survey are abbreviated, and could certainly be expanded upon in cases where more in-depth knowledge is required. It is additionally important to note that sex education program goals and potential outcomes are extensive and varied, and the presented survey instrument does not cover all possible research queries. The sex myths section may require editing as medical knowledge progresses and common cultural beliefs change. This may require researchers to review which myths are common in their area at the time of study and make appropriate changes. Further consideration ought also to be made to validation. Though portions of this instrument have seen use in prior studies or have been subject to rigorous validation in their original form, this instrument does include novel questions and adaptations of existing measures. With this in mind, an independent validation study may be a helpful future avenue for research. There are also many categories in this survey, researchers should take care to review results holistically, and avoid cherry picking data. Despite these challenges, this instrument, and its four-sectioned approach, can provide researchers and legislators with a solid basis from which to collect information, 25 particularly where they are concerned with population characteristics influencing sexual health results. Potential Opposition Despite a longstanding body of evidence showing that “students in abstinenceonly programs are no more likely to abstain from sex than their peers who are in comprehensive sex education programs” (Doan & Williams, 2008), and that comprehensive sex education is effective “across a range of topics and grade levels” (Goldfarb & Lieberman, 2020), abstinence only sex education programs remain popular across many regions of the US. Though this project is a proponent of evidence-based legislation, particularly where sex education is concerned, the reality is that evidence is not always considered in setting health policy in the US, the continued commonality of abstinence only sex education supports this view. There is a not insignificant chance that policies informed by data collected from this measure will face heavy political opposition, particularly as human sexuality can be a controversial topic politically. From 1997 to 1997, “more than 500 local disputes over sexuality education occurred in all 50 states” (Donovan 1998), disputes were led primarily by a small number of parents or “members of a local conservative church, often with backing and support from national organizations” including “Focus on the Family, the Eagle Forum, Concerned Women for America, and Citizens for Excellence in Education” (Donovan, 1998). Furthermore, sex education programs have been morally and ideologically targeted pushed particularly by the right-wing, and described as “’Smut,’ ‘immoral’ and ‘a filthy communist plot’” (Donovan, 1998) as far back as the 1960s. A 2015 study focusing on how positions on sex education are formed found that “political elites, in 26 tandem with partisan media, cement morality policies to viewer identities as conservatives” and that “this close connection between identity and policies may explain how beliefs persist in spite of contrary evidence” (Hindman & Yan, 2015). The study further commented that “creating health policies based on beliefs rather than science may be a successful political strategy. It is not, however, sound health policy” (Hindman & Yan, 2015). Despite a history of strong opposition to evidence-based sex education policies, ideological challenges to sex education can be overcome. As reviewed in the beginning of this project, past studies tell us that social conservatives in particular rate “data on health impact of an issue in their local area…very important in determining” legislative priorities (Dodson et al., 2013). Sex education policies also have a history of being targeted by interest groups (Donovan, 1998), a dedicated, evidence-based response to those groups focused on educating the public may stand a significant chance of redirecting legislative opinion. The Role of Evidence Informed Policy in Improving Sexual Health A robust sex education program should be aimed at giving “young people the opportunity to receive information, examine their values and learn relationship skills that will enable them to resist becoming sexually active before they are ready,…prevent unprotected intercourse, and…become responsible, sexually healthy adults” (Donovan, 1998). When developed correctly, these programs can help mitigate the harms of sexual assault and improve the academic and social lives of students (Future of Sex Education Initiative, 2020). This is on top of more obvious health benefits, which include reducing 27 STI rates, reducing teen pregnancy rates, and reducing unwanted pregnancy rates (Kirby, 2007; Stanger-Hall, 2011). The best and most effective way to enable students to access these benefits is through policy reform. The US has a strong history of utilizing policy to create public health success that would otherwise have been out of reach, the CDC’s “list of ‘Ten Great Public Health Achievements’—including motor vehicle safety, tobacco control, and maternal and infant health—all involved policy change” (Pollack Porter et al., 2018). Because sex education is legislated largely on the local level, policy change in regards to these programs will likewise also need to be local. Research has an important role to play in this equation—“sound research evidence should serve as the public health community’s starting point when it designs and advocates for public health policy solutions” (Pollack Porter et al., 2018) In the case of sex education, it is vital that research aimed at program evaluation be accessible to legislators. Comprehensive and user-friendly survey instruments like the one developed for this project can be used as a first step in transforming educational curriculum in a way that will have lifelong sexual health benefits for students enrolled in those programs. This can be especially beneficial in states like Utah, where a lack of specific and local health data informed by demographic divisions in the state population has led to a sex education curriculum that embraces program components that have been shown to be ineffective elsewhere. REFERENCES 28 AP. (2019, January 27). Mormons account for nearly 90 percent of state legislature. Retrieved March 01, 2021, from https://apnews.com/article/286983987f484cb182fba9334c52a617 Beitsch, R. (2015, December 23). In State Legislatures, millennials are often left out. The Pew Charitable Trusts. 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G., Hight, T. L., Ripley, J. S., McCullough, M. E., Berry, J. W., Schmitt, M. M., Berry, J. T., Bursley, K. H., & OConner, L. . (2012) . The Religious Commitment Inventory-10 (RCI-10) . Measurement Instrument Database for the Social Science. Retrieved from www.midss.ie Young, M., Denny, G., Penhollow, T., Palacios, R., & Morris, D. (2015). Hiding the word: examining the relationship between a new measure of religiosity and sexual behavior. Journal of religion and health, 54(3), 922–942. https://doi.org/10.1007/s10943-013-9777-z APPENDIX 1 34 35 36 37 38 39 APPENDIX 2 SRS Scoring Categories—utilize table to recode frequencies noted by participants. From (Turchik et al., 2015) Recoding Category 1. Number of sexual behavioral partners 2. Left social event with someone 3. Unexpected sexual experience 4. Number of sex partners 5. Vaginal sex without a condom 6. Vaginal sex without birth control 8. Anal sex without a condom 9. Unprotected anal penetration 10. Analingus without protection 11. Sex with uncommitted partners 12. Sex with someone did not know well 13. Sex before discussing risk factors 14. Sex with untested partners 15. Partners with other current partner 0 Raw # 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 Raw # 1 1 1 1 1-4 1-3 1-2 1-2 1-2 1 1 1-2 1 1 2 Raw # 2-3 2-3 2 2 5-19 4-10 3-4 3-5 3-5 2-3 2-3 3-4 2-3 2 3 Raw # 4 4 3-5 3-6 20-64 11-49 5-10 6-10 6-9 4-5 4 5-8 4 3-4 4 Raw # 5+ 5+ 6+ 7+ 65+ 50+ 11+ 11+ 10+ 6+ 5+ 9+ 5+ 5+ Sex Myth Answers Question There is a risk of pregnancy when intercourse takes place during the menstrual period Masturbation is practiced almost exclusively by men Childhood involvement with a homosexual is not an important cause of homosexuality as an adult The absence of the hymen (cherry) proves that a girl is not a virgin There is a risk of pregnancy if a man withdraws his penis before he ejaculates For most women sexual intercourse without other stimulation is not the best method for producing orgasm Sexual intercourse should be avoided during pregnancy Healthy, sexually active people masturbate Regular douching is not necessary to keep the vagina clean The removal of the prostate does not reduce a man's sexual capabilities Answer T F T F T T F T T T 40 Name of Candidate: Lauren Gleave Date of Submission: May 9th, 2022