State Policy On School-based Sex Education: A Content .

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State Policy on School-based Sex Education:A Content Analysis Focused on SexualBehaviors, Relationships, and IdentitiesWilliam J. Hall, PhD, MSWBenjamin L. H. Jones, BSKristen D. Witkemper, BSTora L. Collins, BSGrayson K. Rodgers, BSObjectives: Adolescents in the United States face crucial sexual health behavior issues, including consequences of sexually transmitted infections and diseases, pregnancy, and sexual violence. Lesbian, gay, bisexual, and transgender youth are disproportionately affected by theseissues. State policies about sex education in K-12 schools shape what is taught to students aboutsexual health. In this study, we analyzed the content of school-based sex education policies ofall 50 states and focuses on sexual behaviors, relationships, and identities. Methods: Policiesanalyzed include state statutes, state board of education policies, and state department of education or public instruction curriculum standards. Data were analyzed using content analysis.Results: Most state policies emphasized abstinence from sexual behavior and did not requireeducation about contraceptive and barrier methods. Few policies required detailed information about contraceptive and barrier methods to prevent pregnancy and sexually transmittedinfections. Around half of states addressed relationship issues (ie, healthy relationships, sexualdecision-making, and sexual violence); however, few states required content on communicationabout sexual consent. Eight state policies explicitly stigmatized homosexuality. Conversely, 12states were inclusive of diverse sexual orientations and 7 states were inclusive of diverse genderidentities. Conclusion: Sex education policies should be evidence-based and inclusive of sexualdiversity.Key words: sex education; sexual health; sexual behavior; sexual orientation; sexually transmitted infections; sexuallytransmitted diseases; school; policy; adolescent; youthAm J Health Behav. 2019;43(3):506-519DOI: https://doi.org/10.5993/AJHB.43.3.6Sexual behavior takes a prominent positionin the lives of youth and has significant implications for health. Rates of sexual activityincrease significantly during adolescence. Nationaldata from the United States (US) show that 20% of9th grade students had sexual intercourse, whereas57% of 12th grade students had sexual intercourse.1Nearly 90% of young people have had sex by age24.2 Sexual behavior is intimately related to manyhealth issues, including unplanned pregnancy,sexually transmitted infections or diseases (STIs/STDs), and sexual violence and trauma. Giventhe significance of these health issues, schools havesought to educate youth about sexual health, andstate policy is a primary determinant of schoolbased sex education. However, relatively little pol-William J. Hall, Assistant Professor, School of Social Work and Cecil G. Sheps Center for Health Services Research, University of North Carolina atChapel Hill, Chapel Hill, NC. Benjamin L. H. Jones, Research Assistant, Cecil G. Sheps Center for Health Services Research, University of NorthCarolina at Chapel Hill, Chapel Hill, NC. Kristen D. Witkemper, Research Assistant, Cecil G. Sheps Center for Health Services Research, Universityof North Carolina at Chapel Hill, Chapel Hill, NC. Tora L. Collins, Research Assistant, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC. Grayson K. Rodgers, Research Assistant, Cecil G. Sheps Center for Health Services Research,University of North Carolina at Chapel Hill, Chapel Hill, NC.Correspondence Dr Hall; wjhall@email.unc.edu506

Hall et alicy research has been conducted in this area. Thisstudy reports findings from a content analysis ofschool-based sex education policies from all 50states in the US focusing on sexual behaviors, relationships, and identities.Sexual Health Behavior Issues among YouthSexual behavior during adolescence can have significant and even lifelong implications. The unintended pregnancy rate is higher among adolescentsthan any other age group.3 About 5% of womenbecome pregnant before they reach age 20.4 Teenage pregnancy can be problematic because adolescent parents are often unprepared for parenthood.Adolescent pregnancy and childbirth are associatedwith poor health and social outcomes, includinginadequate prenatal care, low birth weight, singleparenthood, poverty, welfare receipt, and childmaltreatment.5,6 Adolescents are also disproportionately affected by STIs/STDs. Experts have estimated that there are about 20 million new STI/STD cases each year in the US, and about half ofthem are among youth ages 15 to 24.7Problems in Sexual Relationships among YouthAn additional sexual health problem that arisesduring youth is sexual violence. Among survivorsof sexual assault and intimate partner violence, themost common ages of first victimization were 11 to24, with 67% of female survivors and 45% of malesurvivors being first victimized between 11 and 24years old.8 Results from the most recent Youth RiskBehavior Survey showed that 8% of high schoolstudents reported experiencing physical datingviolence (ie, being hit, slammed into something,or injured with a weapon or object) by someonethey had dated and 7% experienced sexual datingviolence (ie, being forced to do sexual acts theydid not want to do) by someone they had dated.9These traumatic sexual experiences can have adverse long-term effects including psychiatric problems (eg, post-traumatic stress disorder, depression,anxiety disorders, sleep disorders, and suicide attempts),10,11 interpersonal difficulties (eg, infrequent contact with friends and family, and limitedemotional support from others),12 and health riskbehaviors (eg, unhealthy weight control, cigarettesmoking, binge drinking, drinking and driving,and illicit drug use).13-16Am J Health Behav. 2019;43(3):506-519Sexual Identity Disparities in Sexual HealthOutcomesThere are also disparities in sexual health outcomes by sexual identity. Studies show that adolescent girls who identify as lesbian, gay, or bisexual(LGB) or reported same-sex contact had higherpregnancy rates compared to those who were exclusively heterosexual.17-21 In addition, bisexualadolescent boys were more likely to be involvedin a pregnancy than their heterosexual counterparts.19,20,22 There are additional sexual orientationdisparities in terms of STIs/STDs. Young bisexualand heterosexual women who had sex with women,as well as young gay and bisexual men were morelikely to have had a STI/STD.23 These disparitiesmay be explained by sexual minority youth morefrequently engaging in risky behaviors, includingearly age of sexual debut, multiple sexual partners,substance use before sex, and lack of condom orcontraceptive use.24,25 Finally, compared to theirheterosexual peers, LGB high school students areabout 3 times more likely to experience physicaldating violence (6% vs 17%) and sexual dating violence (6% vs 16%).25Research on sexual health outcomes amongtransgender youth is scarce; however, the existingstudies in this area indicate sexual health disparities. A study of transgender youth at a health centerin Boston, MA showed high rates of STIs/STDs(eg, HIV, chlamydia, and gonorrhea), particularlyamong transgender women.26 These findings alignwith results from meta-analytic and systematic reviews of STI/STD rates among transgender adultsacross the US.27,28 In terms of sexual violence, 2studies showed that transgender youth were nearly3 times more likely to experience dating violenceand intimate partner violence compared to theircisgender peers.29,30 Sexual harassment at school isalso prevalent among sexual minority and transgender students, with national data showing that 59%of lesbian, gay, bisexual, and transgender (LGBT)students reporting sexual harassment in the pastyear.31 Collectively, this evidence demonstrates disparities in sexual health outcomes for LGBT youth.Sexual Health Education and School PolicyGiven the sexual health risks facing adolescents,education that advances students’ knowledge,skills, and attitudes about sexual health is impera-DOI: https://doi.org/10.5993/AJHB.43.3.6507

State Policy on School-based Sex Education: A Content Analysis Focused on Sexual Behaviors, Relationships, and Identitiestive to prevent STIs/STDs, unplanned pregnancy,and sexual violence as well as to promote individualwell-being and healthy relationships. Schools playa major role in educating adolescents about sexual behavior and the content of the curriculum istypically guided by policy. According to the socioecological perspective on health promotion, publicpolicies can have significant effects on the healthof populations.32 A policy is a system of principlescreated by governing bodies or public officials toachieve specific outcomes by guiding action. Education policy can include statutes passed by statelegislatures, policies passed by boards of education,and regulations and standards set by departmentsof education or public instruction. Sex educationpolicies can regulate what is taught to studentsabout sexual behavior with a presumed aim of promoting health. Therefore, examining the contentof these policies is important because they guidewhat is taught to students and may influence sexualhealth outcomes.Currently, regulatory power over US K-12 schoolcurriculum content involves federal, state, and localactors; however, policymaking power lies primarilyat the state level. The federal government does notplay a direct role in curriculum content because theConstitution demarcates education as a state andlocal responsibility. Nonetheless, federal agenciescan still influence sex education through the allocation of funds, for example, distributing millions infederal funding to schools for abstinence-only sexeducation. On the other hand, state-level policy actors (ie, state legislatures, governors, state boards ofeducation, and state departments of education orpublic instruction) can determine curriculum content taught in public schools by way of mandatesor guidelines about topics to be covered, a specificcurriculum sequence, or specific textbooks to beused. At the local level, decisions and actions byschool boards, administrators, and teachers mustcomply with state regulations.Given the primacy of state policy over schoolbased sex education, this study focused on policyat the state level. The purpose of this study was toexamine the content of all 50 states’ policies aboutsex education in schools in the United States. Policy content analyzed focused on sexual behaviors,sexual relationships, and sexual identities becauseof the health implications associated with sexual508behaviors and relationships, as well as the sexualhealth disparities facing LGBT youth.METHODSData SourcesThe Sexuality Information and Education Council of the United States (SIECUS) is a national,nonprofit organization that provides education andinformation about sexuality and sexual and reproductive health. SIECUS hosts a website that provides an overview of the sex education policies ofevery state, which fall under several names (eg, HIVeducation, sex education, and health education)and types (ie, statutes, board of education policies,and department of education or public instructioncurriculum standards).33 The state-by-state overview consists of a summary of each state’s extantpolicies and the titles of the policy sources (eg,Alabama State Code § 16-40A-2, and New Hampshire Health Education Curriculum Guidelines).To compile the profiles of state policies each year,a team of SIECUS staff examined state statutes enacted, state board of education policies passed, andcurriculum standards posted on state departmentof education or public instruction websites. Thepolicy profiles used for this study were based onthose assessed by SIECUS between October 2014and September 2015. However, policy updateswere posted on the website in March 2016 basedon new developments in the prior 6 months. Weaccessed the policy profiles website in June 2016.To locate the source documents for all of the statesex education policies, the first author performedsearches in June 2016 based on the policy titlesnoted for each state by SIECUS (eg, Alabama StateCode § 16-40A-2). All of the source documentsfor the policies were found, typically on state legislature websites or state department of educationor public instruction websites. The text of the statepolicies was then compiled into 50 documents tofacilitate a state-level analysis.Data AnalysisPolicy document data were analyzed using qualitative content analysis with an inductive approach,which allows themes to emerge from the data andaims at description.34 The authors approached thedata using a social-behavioral science perspectiveand focused on content related to sexual behaviors,

Hall et alrelationships, and identities. Using a social-behavioral science perspective in the analysis stemmedfrom the authors’ disciplinary backgrounds in psychology, social work, education, and public health.Using this perspective allowed the authors to focuson individual human behavior, behavioral interactions between individuals, interpersonal communication, interpersonal relationships, personaland social identities (eg, LGBT), and social issuesrelated to discrimination and health equity withinthe policy data content.The data analysis involved several steps. First, theauthors independently read, wrote memos for, andopen-coded a pilot sample of 5 policy documents.Second, the group met and compared notes, discussed codes, and derived a coding scheme thatconsisted of 22 codes falling under 3 overarchingcategories and 2 subcategories. Third, each state’spolicy document was independently read andcoded by 2 coders using the established codingscheme. The initial coding results for each pair ofcoders were compared by the first author to assessinter-coder reliability, and coding pair agreementwas found 85% of the time. Cohen’s kappa statistics were calculated with SPSS (version 24), whichshowed substantial agreement: kappa 0.69, p .001. Next, to resolve disagreements, the codingpairs met together to examine the source documents, resulting in 100% inter-coder agreement.Several strategies for rigor were used to help ensure that the findings were valid and trustworthy:triangulation, peer debriefing and support, and useof an audit trail.35 First, we used investigator triangulation because all 5 authors coded and analyzedthe data, which provides cross-checking of data bymultiple investigators. Second, we used interdisciplinary triangulation because the investigatorsrepresented the disciplines of psychology, socialwork, education, and public health, broadeningthe understanding and interpretation of policycontent. Third, we used peer debriefing and support where members of the research team met todiscuss challenges related to the data and coding,provide feedback, and offer new ideas or alternative perspectives. Finally, we created an audit trailthat included the raw data, memos from the opencoding process, notes from discussions about codesand categories, the final coding scheme and instructions, and notes from discussions about coding issues and questions.RESULTSThematic results involved 3 overarching categories (ie, sexual behavior, sexual relationships, andapproach to sexual identity diversity), 2 subcategories for the sexual behavior category (ie, abstinenceand contraceptive or barrier methods), and 22codes falling within these categories. Table 1 showsthe categories and codes that emerged from thedata, as well as illustrative examples of policy statements for each code. Table 2 shows which statesincluded or excluded the sexual education policycontent themes.Am J Health Behav. 2019;43(3):506-519DOI: https://doi.org/10.5993/AJHB.43.3.6Sexual BehaviorResults show that 74% of states recommendedthat abstinence or abstinence-until-marriage bestressed to students. Over half of states (54%) didnot require that contraceptive and barrier methodsbe taught. Of the 23 state policies that did includecontent on contraceptive and barrier methods, almost all (N 19) included multiple strategies toprevent pregnancy and STIs/STDs. However, lessthan one-fourth of states required students to learnabout the effectiveness of preventive methods, theirpros and cons, and how to use contraceptive andbarrier methods.Sexual RelationshipsLess than half of states (42%) included policycontent related to healthy sexual or romantic relationships. Just over half (54%) of state policiesrequired content related to sexual violence, andabout one-third (36%) of states required contentrelated specifically to sexual consent.Approach to Sexual Identity DiversityEight states had policies that explicitly stigmatized homosexuality by describing it as a lifestylechoice, socially or morally unacceptable, unhealthy,and/or criminal. In addition, 5 states indicated thatsex education should be conducted separately forboys and girls, based on sex or gender. Conversely,12 states had policy statements that sex educationshould be inclusive of diverse sexual orientationsand 7 state policies were inclusive of gender identities and expressions. Two state policies were inclusive of diverse sexual activities (ie, penile-vaginal,penile-anal, and oral sex).509

State Policy on School-based Sex Education: A Content Analysis Focused on Sexual Behaviors, Relationships, and IdentitiesTable 1Sex Education Policy Codes, Illustrative Examples, and State PercentagesIllustrative ExamplePercentof States1. Stresses abstinence“The program of AIDS prevention education shall stress the life-threateningdangers of contracting AIDS and shall stress that abstinence from sexual activity isthe only certain means for the prevention of the spread or contraction of the AIDSvirus through sexual contact.” (Revised Code of Washington § 28A.230.070)30%2. Stresses abstinence untilmarriage“Abstinence from sexual intercourse outside of lawful marriage is the expected social standard for unmarried school-age persons” (Alabama State Code § 16-40A-2)44%3. Covers abstinence“Sexuality health education programs funded by the State shall provide medicallyaccurate and factual information that is age appropriate and includes education onabstinence” (Hawaii Revised Statute § 321-11.1)14%4. Abstinence notmentioned“ ” (Idaho Statute § 33-1608)12%1. Contraceptive or barriermethods included“Abstinence may not be taught to the exclusion of other materials and instruction on contraceptives and disease prevention.” (Revised Code of Washington §28A.300.475)46%2. Using multiple methods“All comprehensive human sexuality education must stress the importance of thecorrect and consistent use of sexual abstinence, birth control, and condoms to prevent pregnancy and sexually transmitted infections” (Colorado Statute § 22-1-128)38%3. Effectiveness of methods“Methods of contraception are analyzed in terms of their effectiveness in preventing pregnancy and the spread of disease.” (Virginia Department of Education .Family Life Education: Board of Education Guidelines and Standards of Learningfor Virginia Public Schools. Richmond, VA: Virginia Department of Education;2014)24%4. Pros and cons of methods“Students shall be provided with statistics based on the latest medical informationregarding both the health benefits and the possible side effects of all forms of contraceptives, including the success and failure rates for prevention of pregnancy.”(Oregon Revised Statute § 336.455)12%5. How to use methods“The abstinence-based education program shall provide youth with informationon and skill development in the use of protective devices and methods for the purpose of preventing sexually transmitted diseases and pregnancy.” (Hawaii RevisedStatute § 321-11.1)8%1. Healthy sexualrelationships“‘Comprehensive health education’ . includes the study of . how to recognizeand prevent sexual abuse and sexual violence, including developmentally appropriate instruction about promoting healthy and respectful relationships” (VermontStatute Annotated, Title 16 § 131)42%2. Empowered sexualdecision-making“Sexual behavior. Student work must be personalized and show progressionthrough a decision-making process: identify the decision to be made, consideroptions and consequences, take action or make decision, and evaluate or reflect onthe decision” (New Hampshire State Department of Education . New HampshireHealth Education Curriculum Guidelines. Concord, NH: New Hampshire StateDepartment of Education; 2003)52%Category or CodeI. Sexual BehaviorA. AbstinenceB. Contraceptive or BarrierMethods to Prevent Pregnancy and STIs/STDsII. Sexual Relationships510

Hall et alTable 1 (continued)Sex Education Policy Codes, Illustrative Examples, and State PercentagesCategory or CodeIllustrative ExamplePercentof States3. Communicating sexualconsent or refusal“Student will demonstrate the ability to use communication skills for dealing withsexual pressure from peers and from one’s girlfriend/boyfriend (pressure to dateand/or be sexually active; saying no and communicating limits, etc.)” (RhodeIsland Department of Education. Rhode Island Department of Education Comprehensive Health Instructional Outcomes. Providence, RI: Rhode Island Departmentof Education; 2015)34%4. Seeking sexual consent“Teach students that no form of sexual expression is acceptable when the expression physically or emotionally harms oneself or others and teach students not tomake unwanted physical and verbal sexual advances” (Oregon Revised Statute§ 336.455) “ consent is an essential component of healthy sexual behavior.”(Oregon Administrative Rule § 581-022-1440)20%5. Sexual violenceaddressed“The instruction and materials shall: (1) Focus on healthy relationships. (2) Teachstudents what constitutes sexual assault and sexual abuse, the causes of thosebehaviors, and risk reduction. (3) Inform students about resources and reportingprocedures if they experience sexual assault or sexual abuse. (4) Examine commonmisconceptions and stereotypes about sexual assault and sexual abuse.” (NorthCarolina General Statute § 115C-81)54%1. Homosexuality as alifestyle or preference“No district shall include in its course of study instruction which: (1) Promotes ahomosexual life-style. (2) Portrays homosexuality as a positive alternative lifestyle.” (Arizona Revised Statute § 15-716)6%2. Homosexuality is sociallyor morally unacceptable“Course materials and instruction relating to sexual education or sexually transmitted diseases should include that homosexuality is not a lifestyle acceptable tothe general public” (Texas Health and Safety Code § 163.002)12%3. Homosexuality isunhealthy“AIDS prevention education shall specifically teach students that engaging in homosexual activity, promiscuous sexual activity, and intravenous drug use or contactwith contaminated blood products is now known to be primarily responsible forcontact with the AIDS virus” (Oklahoma Statute § 70-11-103.3)10%4. Homosexuality ascriminal“Course materials and instruction that relate to sexual education or sexually transmitted diseases should include . that homosexual conduct is a criminal offenseunder the laws of the state” (Alabama State Code § 16-40A-2)4%5. Different forms ofsexual intercourse“‘Sexual intercourse’ means a type of sexual contact or activity involving one ofthe following: (A) Vaginal sex; (B) Oral sex; or (C) Anal sex.” (Oregon Administrative Rule § 581-022-1440)4%6. Inclusive of diversesexual orientations“Instruction and materials shall affirmatively recognize that people have differentsexual orientations and, when discussing or providing examples of relationshipsand couples, shall be inclusive of same-sex relationships.” (California EducationCode § 51933)24%7. Inclusive of diverse gender identities or expressions“The comprehensive plan of instruction shall include information that usesinclusive materials, language, and strategies that recognizes different sexual orientations, gender identities and gender expression.” (Oregon Administrative Rule §581-022-1440)14%8. Separate instructionbased on sex or gender“Instruction in pregnancy prevention education must be presented separately tomale and female students.” (South Carolina Code Annotated § 59-32-30)10%III. Approach to SexualIdentity DiversityAm J Health Behav. 2019;43(3):506-519DOI: https://doi.org/10.5993/AJHB.43.3.6511

512Separate instruction for boys andgirls Inclusive of diversegender identities Inclusive of diversesexual orientations Diversity in sexualintercourseHomosexualityas criminalü Homosexualityas unacceptableHomosexualityas unhealthy Homosexualityas a lifestyle Seeking consentSexual violence Communicatingconsent or refusal Empowereddecision-making CO CAHealthyrelationships ARUsing methods Effectivenessof methods AZ Multiple methods AKPros and consof methods Includescontraceptive andbarrier methodsAbstinence notmentionedCovers abstinenceStressesqabstinenceuntil marriageStresses abstinenceAL CT DE FL GA HI ID IL IN IA KS KYTable 2Sex Education Policy Content Across the 50 States LA ME MD MA MI MS MO(continued on next page) MNState Policy on School-based Sex Education: A Content Analysis Focused on Sexual Behaviors, Relationships, and Identities

Am J Health Behav. 2019;43(3):506-519 OH OK ORDOI: https://doi.org/10.5993/AJHB.43.3.6Separate instruction for boys andgirlsInclusive ofdiverse genderidentities Inclusive ofdiverse sexualorientations Diversity insexual intercourseHomosexuality ascriminal Homosexuality asunhealthy SCHomosexuality asunacceptable RI PAHomosexuality asa lifestyle Sexual violence Seeking consentCommunicatingconsent or refusal NDEmpowereddecision-making NC NY NM NJHealthyrelationships NHUsing methods NV NEPros and consof methods Multiple methodsEffectivenessof methods Includes contraceptive andbarrier methodsAbstinence notmentionedCoversabstinenceStresses abstinenceuntil marriageStressesabstinenceMTTable 2 (continued) SD TN TX UT VT VA WA WVü WI WYHall et al513

State Policy on School-based Sex Education: A Content Analysis Focused on Sexual Behaviors, Relationships, and IdentitiesDISCUSSIONAlmost all US adolescents (97%) receive formalsex education before they reach 18 years of age;however, there is variability in the content of instruction.36 This variability is due, in part, to differences in sex education policy content across states.This study examined policy content in all 50 statesfocusing on sexual behaviors, relationships, andidentities. The results and their implications will bediscussed according to these 3 thematic categories.Sexual BehaviorOur results show that about three-fourths ofstates recommended that abstinence or abstinenceuntil-marriage be emphasized in the classroom.Most states did not require that contraceptive andbarrier methods be taught. This is problematicbecause a strong body of evidence demonstratesthat abstinence-only sex education is ineffectiveat preventing unwanted pregnancy and the spreadof STIs/STDs.37-42 In addition, policies that emphasize abstinence until marriage are unrealisticbecause there is a 10-year difference between themedian age at first sexual intercourse (17) and median age at first marriage (27).1,43 Conversely, research on comprehensive sex education programsthat cover abstinence as well as contraceptive andbarriers methods shows a 31% reduction in STIs/STDs and an 11% decrease in pregnancy rates.37Comprehensive, accurate, and specific information about strategies to prevent pregnancy andSTIs/STDs are needed. Among sexually activehigh school students, at their last sexual intercourse, 43% did not use a condom and 73% didnot use birth control pills, an intrauterine device(IUD) or implant, or other hormonal methods(ie, shot, patch, or vaginal ring).9 Around 60% ofadolescents used the withdrawal method to preventpregnancy at last sexual intercourse and 15% usedfertility-awareness,44 which are among the least effective methods to prevent pregnancy.45 Another issue is condom use errors and failures, which occurtoo frequently among youth.46,47 Condom use errors and problems were significantly higher amongyouth who had not received instruction on correctcondom use.48 Providing youth with informationand skills related to the array of options to preventpregnancy and STIs/STDs will empower them tomake informed decisions if and when they choose514to become sexually active.The tendency in policy to place a greater emphasis on abstinence than a comprehensive approachto prevent pregnancy and STIs/STDs leaves youthpoorly equipped to manage and protect theirhealth. Policies that fail to include informationabout contraceptive and barrier methods bringinto question whether rights to accurate and complete health information are being violated withinpublic schools.49 This is especially concerning giventhe serious sexual health issues that are disproportionately affecting adolescents. There are also broadeconomic costs of adolescent pregnancy and STIs/STDs. In 2010, teen pregnancy and childbirthaccounted for at least 9.4 billion in costs to UStaxpayers.50 The direct medical costs of STIs/STDsin the US in 2008 was even greater at about 16billion.51Based on this evidence, we recommend thatstate policymakers revise current policies to requirethat comprehensive information related to sexualhealth behavior be taught to students. Postponingor refraining from sexual activity is an importantstrategy to prevent adolescent pregnancy and STIs/STDs; however, it should not be the principal focus of school-based sex education. The NationalSexuality Education Standards is a comprehensiveframework for K-12 sex education curriculum content, which addresses these issues.52 This frameworkoutlines basic core content for K-12 sexuality education and was developed t

508 tive to prevent STIs/STDs, unplanned pregnancy, . a team of SIECUS staff examined state statutes en-acted, state board of education policies passed, and . policy profiles used for this study were based on those assessed by SIECUS between October 2014 and September 2015. However, poli

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