Sexuality is a central part of human identity, integrity, well-being, and satisfaction with life in general, in addition to being vital for human reproduction (Kågesten & van Reewijk, 2021; OECD 2020). Therefore, sexual health promotion across age groups and settings is crucial from an individual as well as a societal perspective. The most widespread and established definition of sexual health is developed by the World Health Organization (WHO 2006a), which defines it as a concept of physical, emotional, mental, and social well-being in relation to sexuality. Thus, according to this definition a holistic perspective on sexuality and sexual health promotion is crucial. Furthermore, an important element of sexual health promotion is sexual health literacy – a component of the broader concept of health literacy (Vongxay et al., 2019), which in practice means to take responsibility for one's own and one's family/ community health (Sørensen et al., 2012). More precisely it is a combination of skills in various dimensions of sexual health, which enables an understanding and application of sexual health information and communication (Dehghankar et al., 2022; Kågesten & van Reeuwijk, 2021). Focusing on health literacy as a health promotion action is a holistic, sustainable, and cost-effective strategy (Okan et al., 2020). Therefore, alongside the concept of sexual health defined by WHO (2006), sexual health literacy will be a central concept for the sexual health promotion perspective in this review study. 

Sexual health programs and interventions in schools constitute a multidisciplinary and primary health promoting method. School is a crucial platform for students to learn about sexual health and develop a capacity to make informed decisions regarding their sexual health (WHO, 2015). It is furthermore one of the few arenas that reaches nearly all adolescents, regardless of socio-economical background. When healthy adolescent sexuality development and a positive understanding of the self in relation to others is promoted, it will not only be beneficial in this specific period in life but also regarding the future of the adolescents (Kågesten, et al., 2021). Numerous previous review studies have however measured the effects of sexual health interventions in schools from a risk-perspective, although it is not considered to be an optimal nor an effective health promotion approach (McCracken et al., 2016; Lameiras-Fernández et al., 2021). A risk-approach does not either cover the positive sexuality content that adolescents themselves wish to learn more about (Fowler, Schoen, Smith & Morain, 2022; OECD 2020). Furthermore, most of the existing reviews on sexual health interventions includes all international studies or studies exclusively conducted in North America or Australia (e.g., Wang, Lurie, Govindasamy, and Mathews 2018), although school systems, culture as well as political context differs a lot depending on continent as well as country. Previous studies have argued that for sexual health promotion in schools to be effective, various contextual socio-economical as well as political dimensions need to be taken into consideration (McCracken et al., 2016; Vongxay et al., 2019). To the authors’ knowledge, there are no previous systematic review studies evaluating sexual health-promotion interventions, with a focus on the positive sexuality, conducted in Europe. Therefore, this review aims to systematically gather and synthesize the current evidence on sexual health-promoting interventions in order to assess the effectiveness of sexual health-promoting programs conducted in schools in Europe.

Systematic database searches were performed in the PubMed, CINAHL, ERIC, Web of Science, Scopus, PsycINFO databases in the spring of 2022. The terms used in the search strategy can be categorized into population terms (e.g., adolescents, students), geographic terms (e.g., Europe), context terms (e.g., school), program terms (e.g., intervention, action study), and finally outcome terms (e.g., sexual health, sexual well-being, sexual health promotion). Boolean operators and MeSH terms were used as appropriate in the different databases. Studies that met the following inclusion criteria were considered eligible: (a) published between 2012–2022; (b) conducted in a European country/countries; (c) targeting adolescents (age 12–19); (d) interventions carried out in high school and upper secondary school/ vocational school by teachers, health professionals or non-governmental organizations (e) reported on at least one outcome connected to sexual health-promotion and/or positive aspects regarding sexual health. Exclusion criteria covered e.g., study design (cross-sectional studies, case studies and review studies were excluded) and focus (studies with a risk-perspective throughout and/or only measuring the risk aspects of sexual health such as knowledge about STIs or that were focusing on a specific group of adolescents such as special education classes, were excluded). After initial identification of records (10 897), duplicate removal and initial screening and subsequent full-text assessment a sample of 17 records were included in the review, reporting on 16 individual studies. The risk of bias of the included studies in relation to study design, conduct and analysis was assessed and rated according to principles for critical appraisal. Data coding was performed according to a protocol and included study characteristics, content as well as methodological components and outcomes relevant for the current review. Furthermore, a thematic narrative analysis was performed, based on identified commonalties and patterns among the included studies

This systematic review study will offer a rare, if not the first overview, of research on school-based sexual health promotion interventions conducted in Europe. Most studies found through the systematic searches had a risk-approach and the number of records included is therefore, despite solid systematic searches in several databases, limited. Nevertheless, the synthesized evidence provides an overview of holistic and positive focused sexual health promotion interventions, reflecting an emerging sexual health promotion approach that moves beyond prevention of STI and unplanned pregnancies, and instead highlights the importance of pleasure, equality, respect, communication skills and other positive aspects of sexuality and sexual health. Previous review studies have primarily focused on North America or a fully global perspective as context for the interventions. Europe differs in many ways from North America, for instance, politically and socio-economically which affects education as well as sexual health approaches in schools (Federal Centre for Health Education BZgA, 2010). In North America there has, for example, a long time been an abstinence-only focus on sexual health interventions although abstinence-only programs are proven not to be an effective sexual health prevention method (Santelli, et.al., 2017). By focusing on Europe as context the expected outcomes for this review study is to gather culturally relevant as well as context customized evidence of effective sexual health interventions for the European countries.

Dehghankar L, Panahi R, Khatooni M, Fallah S, Moafi F, Anbari M, et al. (2022). The association between sexual health literacy and sexual function of women in Iran. Journal of Education and Health Promotion.11:11. https://doi.org/10.4103/jehp.jehp_414_21 Federal Centre for Health Education, (2010). Standards for Sexuality Education in Europe. A framework for policy makers, educational and health authorities and specialists. https://www.icmec.org/wp-content/uploads/2016/06/WHOStandards-for-Sexuality-Ed-in-Europe.pdf Kågesten, A.E., Pinandari, A.W., Page, A., Wilopo, S.A., & van Reeuwijk, M. (2021). Sexual wellbeing in early adolescence: a cross-sectional assessment among girls and boys in urban Indonesia. Reproductive Health 18, 153. https://doi.org/10.1186/s12978-021-01199-4 Kågesten, A.E., and van Reeuwijk, M. (2021). Healthy sexuality development in adolescence: proposing a competency-based framework to inform programmes and research. Sexual and Reproductive Health Matters, 29:1, 104-120, doi:10.1080/26410397.2021.1996116 Lameiras-Fernández, M., Martínez-Román, R., Carrera-Fernández MV., Rodríguez-Castro, Y. (2021). Sex Education in the Spotlight: What Is Working? Systematic Review. International Journal of Environmental Research and Public Health, 18(5), 2555. https://doi.org/10.3390/ijerph18052555 McCracken, K. et al. (2016). Sexual and reproductive health and rights: study. Brussels: European Parliament. https://www.europarl.europa.eu/RegData/etudes/STUD/2016/571392/IPOL_STU(2016)571392_EN.pdf OECD (2020). Love & let live. Education and sexuality. https://www.oecdilibrary.org/education/love-let-live_862636ab-en Okan, O., Messer, M., Levin-Zamir, D., Paakkari, L., & Sørensen, K. (2022). Health literacy as a social vaccine in the COVID-19 pandemic. Health promotion international, daab197. https://doi.org/10.1093/heapro/daab19 Santelli, J. S., Kantor, L. M., Grilo, S. A., Speizer, I. S., Lindberg, L. D., Heitel, J., Schalet, A. T., Lyon, M. E., Mason-Jones, A. J., McGovern, T., Heck, C. J., Rogers, J.& Ott, M.A. (2017). Abstinence-Only-Until-Marriage: An Updated Review of U.S. Policies and Programs and Their Impact. The Journal of adolescent health: official publication of the Society for Adolescent Medicine, 61(3), 273–280. https://doi.org/10.1016/j.jadohealth.2017.05.031 Sørensen, K., Van den Broucke, S., Fullam, J. Doyle, G., Pelikan, J., Slonska Z., & Brand. H. (2012). Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health 12, 80. https://doi.org/10.1186/1471-2458-12-80 Vongxay, V., Albers, F., Thongmixay, S., Thongsombath, M., Broerse, J. E. W., Sychareun, V., & Essink, D. R. (2019). Sexual and reproductive health literacy of school adolescents in Lao PDR. PloS one, 14(1), e0209675. https://doi.org/10.1371/journal.pone.0209675 Wang T, Lurie M, Govindasamy D, Mathews C. (2018). The Effects of School-Based Condom Availability Programs (CAPs) on Condom Acquisition, Use and Sexual Behavior: A Systematic Review. AIDS Behaviour; 22(1), 308-320. https://doi.org/10.1007/s10461-017-1787-5 World Health Organization WHO (2006a). Sexual and Reproductive Health and Research (SRH). https://www.who.int/teams/sexual-and-reproductive-health-and-research/key-areas-of-work/sexual-health/defining-sexual-health World Health Organization WHO. (2015). Sexual health, human rights, and the law. https://apps.who.int/iris/handle/10665/175556