The study, led by Jacqueline Nkrumah, focused on functional SRH literacy, a concept adapted from Nutbeam’s health literacy framework and Mancuso’s conceptualization of health literacy. In practical terms, it measures whether a young person can read, process, and understand SRH information, including numerical details such as menstrual cycle calculations, well enough to make informed decisions. Low SRH literacy leaves adolescents vulnerable to misinformation, hampers their use of health services, and is linked to poorer reproductive health outcomes. It also reflects a failure of health and education systems to communicate in developmentally and linguistically appropriate ways.

The setting was carefully chosen. Effutu Municipality, home to 83,695 people including 20,433 adolescents aged 10 to 19, reports adolescent sexual activity above 60 percent and awareness of modern contraceptives at just 27 percent. National assessments indicate that most Ghanaian adolescents aged 10 to 14 read below grade level, yet textbooks and SRH resources are rarely adapted to their comprehension abilities. Although Ghana’s Adolescent Reproductive Health Policy, the National HIV and AIDS, STI Policy, and the Adolescent Health Policy and Strategy all endorse school-based SRH education, implementation has been hampered by sociocultural resistance, misinformation, and debates over content, leaving a persistent gap between policy and classroom reality.

To test whether literacy-sensitive materials could close that gap, the researcher developed three versions of an SRH educational resource, each containing six core lessons on pubertal changes, sexual activities, abstinence, friendship, sexually transmitted infections, and contraceptive methods. The standard text, serving as the comparison material, scored 66.0 on the Flesch Reading Ease scale. The simplified version was rewritten to achieve a mean score of 82.0, indicating easy readability, and a third version added pictures to the simplified text. All materials were compiled from existing digital and print sources, synthesized into a standard text, and then adapted to adolescents’ cognitive and reading levels, with the development process validated and published separately.

The trial enrolled adolescents aged 11 to 15 in grades 7 and 8 across 13 communities and schools spanning all four sub-municipalities. Schools were clustered by sub-municipality to prevent contamination between study groups: Winneba East continued routine school activities as the comparison group, Winneba West received the standard text, Essuekyir/Gyahadze received the simplified text, and Kojo-Beedu North received the picture-enhanced version. Before enrollment, participants passed a three-stage screening covering foundational literacy, visual acuity, and color perception. Foundational literacy was assessed with a 526-word passage adapted from the Progress in International Reading Literacy Study, plus numeracy items from the Trends in International Mathematics and Science Study, graded according to Ghana’s Basic Education Certificate Examination system.

Comprehension was measured with a purpose-built instrument, the Test of Functional Literacy in SRH (TOFL-SRH), a multiple-choice cloze-based tool modeled on validated approaches such as TOFHLA and OHL-AQ. It included 35 cloze items drawn from a 682-word passage and five numeracy questions requiring menstrual cycle calculations based on a two-month calendar. Two parallel forms with reshuffled item order minimized recall bias, and pretesting with 76 adolescents demonstrated acceptable reliability. The intervention itself ran for six weeks of weekly peer-supported reading sessions, with adolescents reading at home and then joining gender-segregated groups of 4 to 20 for one-hour sessions combining 40 minutes of guided reading with 20 minutes of questions and discussion, facilitated by trained near-peer research assistants aged 21 to 25.

The results were unambiguous. Of 408 projected participants, 317 completed baseline assessment and 249 completed the intervention, a 78 percent completion rate. At baseline, inadequate functional SRH literacy ranged from 68.4 to 95.4 percent across arms; by end-line it had fallen to between 19.7 and 72.7 percent. In difference-in-differences analysis, adolescents given the standard text showed no statistically significant gains over the comparison group (5.77 points; 95 percent CI: -2.42 to 13.97; p = 0.166). Those reading the simplified text gained 12.29 points (95 percent CI: 6.79 to 17.77; p = 0.001), and the picture-enhanced group gained 10.26 points (95 percent CI: 4.37 to 16.14; p = 0.001). A fixed-effects regression model, which accounts for stable participant and group differences, told the same story: gains of 13.87 points for simplified text and 13.06 points for picture-enhanced text, both highly significant, against a modest 7.11-point background learning effect in the comparison group.

Domain-specific analyses added nuance. Simplified texts produced the strongest gains in textual comprehension (14.59 points; p = 0.001), while picture-enhanced materials also drove significant improvements (13.49 points; p = 0.001). Numerical comprehension, however, improved significantly only among adolescents exposed to simplified texts (10.46 points; p = 0.027). The picture-enhanced group’s weaker numeracy gains may reflect the cognitive burden of its menstrual cycle chart, which required simultaneous interpretation of colors, day numbers, symbols, and cycle phases, or simply the difficulty of numeracy concepts for adolescents with weak foundational math skills. The author cautions that these explanations were not directly tested, but the practical implication is clear: visual elements must be carefully integrated with numerical information to avoid overwhelming young readers when explaining concepts like menstrual cycles, contraceptive effectiveness, and pregnancy risk.

Not everything went smoothly, and the study’s obstacles are themselves instructive. Attrition between baseline and end-line reached 21 percent, driven primarily by school-level withdrawal rather than individual dropout. In three schools, participation ceased after teachers raised concerns about condom- and sexuality-related content, reflecting the sociocultural resistance, stigma, and religious opposition that have long constrained SRH education in Ghana and similar settings. The study was also limited to a single municipality, and uneven distribution of public and private schools across arms may have introduced residual confounding. Still, baseline equivalence across the four arms was confirmed statistically, and standardized procedures, validated tools, and rotation of implementors during end-line data collection helped reduce bias. An eight-week follow-up of 215 participants showed significant differences in literacy across groups persisting over time, though retention patterns were similar across intervention formats.

The broader implications reach well beyond Effutu. Multivariable analysis revealed that foundational literacy was the only participant characteristic consistently associated with functional SRH literacy, meaning that even literacy-sensitive materials favor adolescents with stronger reading skills. Scaling up such interventions, the study suggests, may require complementary investment in basic literacy education, particularly for the most disadvantaged learners. For policymakers, the message is to shift focus from simply providing SRH information to designing and delivering it appropriately, especially in underserved communities where national data show reading levels lag far behind the materials meant to inform them. As Ghana and its neighbors grapple with how to make comprehensive sexuality education a lived classroom reality, this evidence points toward a deceptively simple lever: rewrite the materials so the students who need them most can actually read them.

Subject of Research: The effect of literacy-sensitive sexual and reproductive health educational materials on adolescents' functional SRH literacy in Ghana

Article Title: Literacy-sensitive sexual and reproductive health education for adolescents in Ghana: Evidence from a school-based quasi-experimental study

Article References: Nkrumah, J. (2026). Literacy-sensitive sexual and reproductive health education for adolescents in Ghana: Evidence from a school-based quasi-experimental study. Public Health in Practice, 12, Article 100854. https://doi.org/10.1016/j.puhip.2026.100854

Image Credits: AI Generated

DOI: 10.1016/j.puhip.2026.100854

Keywords: adolescent health, sexual and reproductive health, health literacy, Ghana, comprehensive sexuality education, health education materials, school-based intervention, quasi-experimental study, readability, numeracy, sub-Saharan Africa, public health

The research team, led by Virginia Villegas-José, Manuel Delgado-García and Antonio Daniel García-Rojas of the University of Huelva, built their analysis on a documentary design supplemented by a quantitative approach. The researchers used stratified sampling in which the various regional and national quality assurance agencies served as strata, selecting one or two institutions per agency from among Spain’s 50 public universities. In total, 1,673 teaching guides, the official planning documents that define each subject’s objectives, contents, competences, activities and assessment methods, were collected and examined. The aim was to determine to what extent the university curricula that train future infant and primary school teachers actually incorporate knowledge about sexuality, and to characterise how such content, when present, is integrated into course planning.

To analyse this vast corpus of documents, the team constructed an ad hoc instrument called the Analysis and Evaluation of Affective-Sexual Education, or AVEAS, comprising 20 variables that capture qualitative information about each guide: the quality agency, university, degree, subject, responsible academic area, course year, the nature of the subject, mentions of related content, specific sections of the guide and key concepts. Two university teaching professionals evaluated the clarity and relevance of each item using a five-point Likert scale, and Aiken’s V statistic confirmed strong internal validity, with coefficient values above .83 and concordance indices above .78. Each guide that mentioned sexuality-related terms was then assessed with a rubric classifying the level of involvement as low, moderate or high, depending on whether sexuality appeared tangentially, in limited detail, or as a key element across several sections of the document.

The search strategy itself combined traditional and emerging methods. Descriptors drawn from earlier research were organised into three levels. The specific level included terms that directly signal sexuality education, such as sex, sexuality, sex education and affective-sexual. The transversal level included concepts that may appear connected but do not guarantee explicit treatment, including affectivity, equality, equity, sexism and feminism. The global level captured broad notions such as health, citizenship, values and developmental psychology. Researchers conducted manual searches using Adobe Acrobat Reader and also employed NotebookLM, an artificial intelligence tool, as an auxiliary retrieval engine to scan the guides automatically with the same descriptors, a procedure designed to ensure comprehensiveness and reduce human error. Only guides containing at least one specific-level term were read in full and scored with the AVEAS instrument.

The results, processed with descriptive, comparative and correlational procedures using SPSS and JASP software, show a consistently low presence of explicit affective-sexual education content. Within the guides that did mention such content, the terms clustered heavily in the subject description, the contents section and the bibliography, appearing in roughly 68 to 76 percent of cases, while mentions in the sections that drive actual classroom practice were far rarer: 47.1 percent in objectives, 25.7 percent in learning outcomes, 18.6 percent in activities, 5.7 percent in methodology and 8.6 percent in assessment. In other words, sexuality appears in the paperwork of the course but rarely in the pedagogy, a pattern the authors interpret as evidence of superficial, non-systematic integration. Most subjects containing these concepts were basic, compulsory core courses concentrated in the first year of study, with the third year standing out as the point of least training across both degrees.

The disciplinary geography of the findings is equally revealing. Developmental and Educational Psychology accounted for 29 percent of the subjects addressing sexuality and contained the most guides judged to be at a high level of integration, followed by Didactics and School Organisation at 27.5 percent and Sociology at 21.7 percent. Areas such as Theory and History of Education, Research and Diagnostic Methods, Didactics of Experimental Sciences and Music contributed only marginal, mostly low-level, treatments. A content analysis based on a word cloud of the most frequent specific-level terms found that gender, sexuality, gender equality, coeducation and affective-sexual diversity dominated the vocabulary, with sexual abuse and child abuse also appearing, indicating that the guides that do address the topic tend to frame it through a socio-educational lens of equality, diversity and violence prevention rather than through the comprehensive, biopsychosocial model recommended by the World Health Organization and UNESCO.

Statistical tests added weight to these patterns. Spearman’s correlation revealed a statistically significant positive association between the level of integration of sexuality content and the number of curricular elements containing it, meaning that the more sections of a guide that address the topic, the deeper the treatment tends to be. A chi-square test showed a significant relationship between the academic year and the level of inclusion, with first-year subjects split between moderate and low levels, second-year subjects skewing toward moderate and high, and fourth-year subjects mostly classified as low. A k-means clustering analysis with three clusters, explaining 61.3 percent of the variance, further distinguished three subject profiles: a first group with high integration across many sections located in intermediate course years, a second group with sporadic, low-level content in the early years, and a third group with very low integration confined to isolated mentions in the final year, a distribution the authors describe as evidence of fragmentation and the absence of a strategic, sequential pedagogical trajectory.

Perhaps the most politically charged finding concerns the role of Spain’s quality assurance agencies, the regional and national bodies that mediate between state regulation and university autonomy by evaluating degree programmes. The frequency of sexuality-related mentions varied enormously by agency: guides under ACCUA registered the most mentions at 540, followed by ACSUG with 470, Madri+D with 438, QACUEE with 428 and AVAP with 425, while UNIBASQ, ANECA and especially AQUIB trailed far behind. When the analysis focused only on specific-level concepts, AVAP led with 19.51 percent, but AQU Catalunya managed only 0.26 percent, and ACPUA, the agency responsible for the University of Zaragoza, recorded not a single guide with explicit affective-sexual education content in either degree. No guides evaluated by AQUIB, AQU Catalunya, QACUEE, ACPUA, UNIBASQ or Madri+D reached the high integration level at all. This heterogeneity, the researchers argue, exposes a lack of common criteria in quality assessment that directly undermines national compliance with the law.

The authors situate their results within a longer institutional history. Unlike countries where sexuality education emerged earlier, Spain’s programmes date largely to the 1980s and were framed as affective-sexual education with a co-educational approach, partly reflecting the historical influence of the Catholic Church on the school system. Scholars have repeatedly called for comprehensive sexuality education to be made compulsory in Spain, and the United Kingdom’s regulation of such content as mandatory curriculum material offers a pointed international contrast. Compared with previous studies from the 2018/2019 academic year, which found universities such as the University of Huelva and the University of La Rioja with no sexuality-related concepts in their guides at all, the new data do show evolution and growing, if uneven, sensitivity. Yet the researchers conclude that the current picture is one of partial, superficial inclusion that fails to guarantee structured training and leaves Spanish universities short of the international standards set out by the WHO and UNESCO for comprehensive sexuality education.

The consequences of this curricular gap are concrete. Future professionals enter classrooms without formal, high-quality preparation to educate infants and primary pupils about healthy sexuality, in direct tension with the LOMLOE education law and its implementing royal decrees for pre-school and primary education, and with the Sustainable Development Goals on quality education, gender equality and reduced inequalities. The study proposes three lines of action: establishing common criteria among quality agencies so that affective-sexual education becomes an assessable requirement within the evaluation of teaching degrees, training university teachers in sexuality to ensure the quality of what is delivered, and reviewing and updating the curricula of Early Childhood and Primary Education degrees to guarantee the explicit inclusion of comprehensive sexuality education. The authors acknowledge that their documentary approach captures official planning rather than lived classroom experience, and they call for future research incorporating the perceptions of students and teachers. For now, the message to policymakers is unambiguous: the law requires sexuality education, the science supports it, and the curriculum, as written, does not yet deliver it.

Subject of Research: Curricular analysis of affective-sexual education content in Spanish university teacher training programmes

Article Title: Affective-sexual education in teacher training: a curricular analysis of the bachelor’s degree in primary and early childhood education in Spain

Article References: Villegas-José, V., Delgado-García, M., & García-Rojas, A. D. (2026). Affective-sexual education in teacher training: a curricular analysis of the bachelor’s degree in primary and early childhood education in Spain. Journal of New Approaches in Educational Research, 15(1), Article 7. https://doi.org/10.1007/s44322-026-00053-4

Image Credits: AI Generated

DOI: 10.1007/s44322-026-00053-4

Keywords: affective-sexual education, comprehensive sexuality education, teacher training, teaching guides, curricular analysis, Early Childhood Education, Primary Education, quality assurance agencies, gender equality, coeducation, Spanish public universities, LOMLOE