Reaching consensus: a review on sexual health training modules for professional capacity building

Background: Professional capacity building (PCB) is the focus point in health-related subjects.The present study was conducted to systematically review the existing sexual health training modules for health care providers. Methods: The following keywords were used to search: training, education, professional capacity, practitioner, sexual health, skill education, module, course, package and curriculum.The term MESH is referred to Medical Subject Headings and the following databases were investigated: MEDLINE, EMBASE, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), The Cochrane Library and Web of Science, Scopus, Google Scholar, SID,Magiran, and Iranmedex. All articles from 1980 to 2015 were extracted. Online modules were excluded. Considering that lesson plan was the basis of instruction, the modules were selected based on the characteristics of the lesson plans. Results: A total number of 38 published training modules in the field of sexuality we redetermined. In total, more than half of the modules (58%) were designed for medical doctor sand allied health professionals and the remaining (42%) were for nurses and midwives. Almost all the modules (97%) were introduced and utilized in developed countries, and only 3% were disseminated in developing countries. Conclusion: There are invaluable modules to build professional capacity in the field of sexual health. As a number of modules have been designed for nurses and midwifes, as the first-line health care providers, the use of these groups in sexual counseling and empowerment for sexual health is essential. No sexual health training program was designed in Iran. Therefore, designing such modules according to Iranian culture is strongly recommended.


Background
Recent interest in consensus building to improve professional capacity for sexual health has its origins in the field of medical education. Medical education plays an important role in increasing the confidence and skills of healthcare providers to address the clients' sexual health needs. 1 There are also variations among medical educators in the degree of agreement necessary to finalize a decision on building sexual training capacity. 2 Capacity building in health realm is the development of sustainable skills, organizational structures, resources and commitment to health improvement in all sectors to prolong and multiply health gains. 2 In professional development or capacity building efforts, focus is on systemic approaches which may dramatically increase the quality of professional learning, as the final outcome. 3 Professional capacity building (PCB) is the center of focus in health-related subjects and becomes seminal when sexuality is the subject matter. 2 Sexual health, as an essential aspect of personal health, has influences on the overall health of an individual, throughout his/ her life. Sexual health is a broad subject with many aspects including reproduction, contraception, sexually transmitted diseases prevention and healthy sexual relationships. These aspects are basically covered by both sexual health services and sexual health promotion interventions. 4 The World Health Organization (WHO) has recommended the integration of sexual health into primary health care services, sexuality education and PCB. 5 Sexual healthcare has been proposed by National Prevention Strategy and Healthy People 2020 to increase access to reproductive and sexual healthcare services. 6 Literature has shown the high prevalence of sexual dysfunction in both developed and developing countries. 7,8 Despite the high prevalence of sexual problems, sexual health have poorly been managed in the primary health care services which is likely due to the insufficient levels of skills, attitude and knowledge of health care providers in the field of sexuality. 9,10 A previous study revealed that despite the willingness of patients to discuss sexual health with their care providers, the healthcare providers often have difficulties in addressing sexual health needs for reasons like shame and lack of sufficient training. 11,12 Conway showed that general practitioners (GPs) would have the skills and the ability to manage patients with sexual health problems in primary care, only if they had received the appropriate training and support. 12 Similarly, Nakopoulou et al clarified that sexual health assessment and intervention should be an integral part of nursing practice, which necessitates the introduction of modules into nursing curriculum in order to address the multidimensionality of sexuality. 13 A study from Iran also reported that, in spite of providing a broad range of reproductive health programs in the health care system, comprehensive sexuality education has not yet been utilized. 14 Many studies have highlighted the need for sexuality health education programs on the favor of clients and health care providers. 15,16 Due to the sensitivity in the matters related to sexuality, cultural competence of health professionals is important when they provide their patients with sexuality-related health care. All societies need culturally sensitive sexual health modules from which Iran is not an exception.
Despite establishing a wide range of sexual and reproductive seminars and congresses in Iran, 17,18 no modules is known for PCB in the field of sexual health care in the country. The relevant materials are not considered in the medical education curricula. There is only one credit course namely "Sexual Function and Dysfunction" for midwifery students in universities. 19 No doubt, there is a great need to develop sexual health training modules based on the Iranian culture in the medical education curricula. Development of training modules specific to health professionals as well as building professional capacity in health-care systems are essential efforts to address primary sexual health needs. To do so, having a comprehensive understanding on the issue is required. However, there is a paucity of systematic appraisals of the existing modules with focus on sexual health. Therefore, the purpose of the present study was to critically review the existing sexual health training modules aiming at PCB.

Materials and Methods
The present study was conducted to review the educational and training modules for PCB in the field of sexual health. The term 'module' in the present paper means a fractional part of a health professionals' education experience. In an entire program, each class represents a module focused on a given subject.

Search strategy
The following keywords were used to search: training, education, capacity professional, practitioner, sexual health, skill education, module, course, package and curriculum. The term MESH is referred to Medical Subject Headings and the following databases were investigated: MEDLINE, EMBASE, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), The Cochrane Library, Web of Science, Scopus, Google Scholar, SID, Magiran, and Iranmedex. All articles from 1980 till 2015 were extracted. We also investigated some key organizations and associations including the Ministry of Health in different countries, and some university webpages, as well. We utilized various key combinations of words such as: "training" OR "education" AND "practitioner" OR "specialist" AND "sexual health".

Inclusion criteria
Packages, modules or programs concerning education in sexual health were identified and the target groups were also determined as health care professionals including physicians, midwives, nurses, and allied health professionals. The studies published in English were included. In order to prevent any insufficiency in the reported results of the investigated articles, the corresponding authors were contacted for further details.
PICO (patient, intervention, comparison and outcome) question was included in our review as P: health care provider I: sexology training and education C: routine medical education O: sexual health promotion.

Exclusion criteria
The online modules were excluded considering that sexually-related modules need to be interactive, constructive and informative to reduce learners' vulnerability and confusion.

Assessment of modules
Considering the fact that the lesson plans are the basis for instruction, the selection criteria for the modules in our study were as follow 20 : Specification of duration, location, goal and content of the program, as well as the target group, teaching method, and assessment procedures. The search results were screened independently by 2 reviewers using a predefined inclusion criteria form. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) checklist was applied for processing the steps of study.

Results
Investigating the databases a total number of 1421 records were identified within which 52 modules were found. Thirty-eight out of 52 modules met the inclusion criteria. As mentioned above, 17 online modules were excluded due to different structures. Figure 1 clarifies the detailed processing of these datasets for final inclusion in this review.
The modules obtained in this study are summarized in Table 1. The modules were mostly (58%) for physicians, and about 73% had a lesson plan. A majority (97%) of the modules were introduced and utilized in developed countries and only 3% were disseminated in developing countries. About 18% were implemented in Australia. There were many theoretical and empirical subjects in these modules. A majority of the courses were implemented in a university with various times of duration. Assessment procedures in the modules included pre-test-post-test, solving case reports, as well as clinical and practical functions.
The modules' characteristics varied by countries. However, there were some similarities: all the modules included anatomy and physiology of male and female reproductive organs, sexually transmitted diseases, methods of contraception, and counseling in sexual health. The main focuses of many programs (28.9%) were contraception methods and sexually transmitted diseases. Content of the modules are summarized in Table 2.

Discussion
Through the present review we found invaluable and efficient training modules for PCB in the field of sexual health. A number of modules were designed for nurses and midwifes (Table 1). According to the findings, it seems that nurses and midwifes are considered to be the firstline healthcare providers who play an important role in providing sexual services to patients or clients. The role of practice nurses (PNs) is essential in sexual health care as their role in some areas like chronic disease management and immunization. 15 Moreover, nurses are considered as the first-line health care providers even in the treatment of sexually transmitted infections which are relatively new concepts in developed societies such as the United Kingdom. 15 Some of the modules were also found targeting midwives (Table 1). This may be considered as a strong point for these modules because the role of midwifery profession in women's sexual health promotion has been recognized worldwide. Nematollahzadeh et al, in a systematic review pointed out to the role of a midwife in women's sexual health promotion as undeniable, and concluded that   This module is designed to prepare practitioners to be competent in the safe and effective administration of contraception and associated sexual health promotion 1. Competently take a sexual and contraceptive history to inform a holistic client assessment. 2. Demonstrate a sound knowledge and understanding of and apply legal, professional and ethical frameworks for contraceptive and reproductive sexual health advice 3. Critically analyse your development and application of detailed knowledge of methods of contraception and issues surrounding their administration. 4. Critically evaluate and apply evidence-based health promotion and health prevention approaches to reduce risk and maintain sexual and reproductive health. 5. Demonstrate a sound knowledge of local and national services and referral pathways to enable joined up care and facilitate choice.

Sexual Health Module: University of Surrey (in England)
This module aims to develop and enhance a student's knowledge and skills in relation to sexual health • Demonstrate a clear understanding of the social context in which sexuality and sexual health is experienced as well as critically examine the policy context including historic influences.

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Examine the images and media construction, culture and demographic influences on sexual health in contemporary Britain and immunized their relationship to public perception.

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Demonstrate evidence based knowledge of contraception, sexually transmitted infections, blood borne viruses, gynecology, sexuality & psycho-sexual issues. • Discuss medico-legal & ethical issues associated with sexual health care and critically analyze their impact on practice with specific reference to consent and confidentiality.

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Demonstrate a broad understanding of the needs of specific groups such as teenagers and other high risk or vulnerable groups.  59 It has been documented that those sexual modules with focus on preventing unintended pregnancies or STD/ HIV infection are of important consideration. 60 It may be considered as another strength for this modules because appropriate sexual education programs should cover STDs prevention and unwanted pregnancies. 61 The most of modules' contents reviewed in our study had focus on the biology of sex, only. This may be a weakness for these training programs considering that effective sexual training programs should have a good coverage on the psychological, social and biology aspects of sexuality. 61 Offering biological aspects of sexuality as the only content of a module (for example CASH module and SH&FPA module) might reduce the value and depth of the module in a courses.
Most of these modules are being hold in developed countries. Despite the great need for sexual-health services in developing countries, especially for women regarding topics of family planning and screening for STDs, a small number of sexuality training modules is established in these countries to educate and train the health professionals. With the hope to improve health outcomes, the department of reproductive health in the WHO has had some community based initiatives especially in such countries. 3 As a limitation for our study, the effectiveness of these programs was not evaluated. The effectiveness of these modules may be evaluated through assessing the changes in knowledge, attitude and practice of health care providers as well as the changes in the rate of sexual problems.
Formative evaluation should be taken place before or during a project's implementation with the aim to improve the project's design and performance. Lack of formative evaluation may be a notable limitation for implementing these modules.
To build professional capacity, sexuality training modules need to be evidence-based and systematically evaluated, culturally sensitive, and skillfully implemented. It is, however, challenging to deliver culturally sensitive and appropriate sexuality-related health care in a context without training modules integrated in medical education programs. Merghati Khoie et al manifested that religion is an important aspect of cultural foundations of sexuality among Muslim Iranian women. 62 As a sexologist, she argued that professionals working in the fields of health and sexuality need to be sensitive and apply culturally appropriate therapies for Iranian population. 63 In Iran, midwives have a key role in promoting reproductive health of women in various settings. 14 in clinical settings, while educating midwives on women health issues, sexual problems are generally discussed, as well. However, midwives seem to not have enough knowledge and skills in sexual consultation. 14 This lack of knowledge and skill among healthcare providers in Iran urges the need for development and implementation of specific sexual health modules for capacity building among Iranian care providers. It is also recommended to integrate sexual health consultation courses into medical students' curricula, as they are at the first line of encountering patients with sexual problems.
Based on this review, we suggest that a sexual module should undergo validity process to ensure users from the best selection of both professional goals and the ways to achieve the goals. There was a scarcity of modules designed to improve sexual health of specific groups of patients. This might help professionals to tailor their education targeted at those groups to enhance effectiveness of sexual programs.

Conclusion
There are invaluable and efficient training modules for PCB in the field of sexual health. Considering the small number of developing societies employing such modules to educate and train their health professionals, the need to design sexuality modules in these countries is outstanding. A number of modules in different countries have been designed for nurses and midwifes as the first-line healthcare providers for communities. Therefore, more employment of these groups of health professionals in sexual health counseling and empowerment is suggested. Moreover, family health care providers should be focused as one of the main target groups of health professional while designing sexual health modules. To promote PCB of health care providers, a culturally adaptive module with a clear and valid content, especially in developing countries, seems to be necessary.

Implications for Practice
Sexual health practitioners may greatly benefit from the results of this study while designing needs assessment and/ or designing, implementation and evaluation of sexual health promotion programs, especially in the contexts of developing countries like Iran. Our results might also be applied by health authorities for developing a sexual module compatible with the Iranian culture.

Competing interests
Authors declare no conflict of interest.

Authors' contributions
All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be submitted for publication. EMK had full access to all of the data in the study and takes responsibility for the integrity of data and the accuracy of data analysis. ZA, EMK and SAA participated in study conception and design. Acquisition of data was done by ZA, MA, SA and finally analysis and interpretation of data was conducted by ZA, NJ, RM and EMK.

Funding
Funding for this study was provided by Shahroud University of Medical Sciences.