Changes in high school students' perception of sexual education based on preconception care

The study addresses how sexual education that incorporates preconception care influences high school students’ awareness, attitudes, and intentions regarding sexuality, relationships, and future life planning. The context is rising concerns about adolescent sexual health in Japan, including stagnant abortion rates among teens, persistent or increasing trends in sexually transmitted infections, dating violence prevalence, and high rates of unplanned pregnancies. Preconception care—recommended by the CDC (2006) and WHO (2013)—aims to improve the health of young women and men prior to pregnancy and to enhance outcomes for the next generation. The purpose was to deliver midwife-led sexual education integrating preconception care concepts to high school students and to analyze, via text mining, how this education affects their need for information on preconception care and pregnancy and their attitudes and potential behavioral changes toward independent decision-making.

Prior evidence indicates substantial adolescent sexual health risks in Japan: births to mothers under 20 persist, abortion rates among girls under 20 remain stagnant, and STI burdens (e.g., chlamydia, genital herpes) have not declined, with syphilis cases sharply increasing since 2010. Surveys report notable prevalence of dating violence among youth. A study in Koshu, Japan, found 46.2% unplanned pregnancies and identified associated factors (maternal age, smoking, parity ≥3, depressive status), suggesting a need for enhanced sexual education and comprehensive care for high-risk women. Sexual education is understood to encompass reproductive rights and preconception care. International bodies (CDC, WHO) endorse preconception care to improve future reproductive outcomes for all youths, regardless of immediate pregnancy intentions. Previous research shows that sexual education increases sexual knowledge and contraceptive use. Comprehensive interventions that include preconception care can reduce first-time and repeat pregnancies. National surveys of junior high school sex education content emphasize gender differences, equality, love, contraception, and intercourse, with less focus on consent and building trusting, non-violent relationships—areas targeted in this study’s intervention.

Design: Cross-sectional study. Participants and setting: 502 first-year students from two high schools in Shiga Prefecture, Japan, which requested sexual education from midwives affiliated with Shiga University of Medical Science. Data collection occurred between November 2018 and October 2019 (timed to school schedules). Intervention: A single 60–90-minute midwife-led presentation at each school covering weight loss, smoking, dating violence, teenage/unexpected pregnancy, STIs, HIV, substance abuse, menstruation, and morals/ethics regarding sex and the opposite gender. Content emphasized preconception care concepts and life planning. Data collection: Immediately post-intervention, students completed an anonymous, self-administered paper questionnaire including demographics (gender), prior sexual education (elementary and junior high school), dating experience, and a 5-point Likert assessment of whether their sexual awareness and thoughts changed. Open-ended responses solicited reflections in four domains: life plan, self-actualization, mutually trusting relationships with friends/opposite gender, and preconception care (self-care), plus overall thoughts/feelings about sex. Text processing and analysis: Descriptive statistics summarized participant characteristics. Freely written text was analyzed via Word Miner text mining software. Preprocessing included tokenization, removal of symbols/prepositions/punctuation/directives, synonym unification, and deduplication. Cluster analysis used Ward’s method (agglomerative hierarchical) and x-averaging (divisive hierarchical) to group components; cluster labels were determined by a PhD-level nursing researcher and a sexual education expert based on significantly frequent components per cluster. Correspondence analysis (principal components for qualitative data) examined associations between reported change categories and component frequencies; significance level 5%. Ethical approval was obtained from Shiga University of Medical Science (K30-018), and informed consent was implied by questionnaire submission.

Sample: 492 questionnaires returned (98.0%); 417 valid (83.3%) analyzed. Gender: 211 men (50.6%), 204 women (48.9%), 2 non-binary (0.5%). Dating experience: 165 (39.6%) yes, 251 (60.2%) no. Prior sexual education: elementary school—206 (49.4%) yes, 206 (49.4%) no, 3 (0.7%) unknown; junior high school—360 (86.3%) yes, 56 (13.4%) no. Change in sexual attitudes/thoughts: 209 (50.1%) reported ‘changed’ or ‘somewhat changed’; 91 (21.8%) ‘cannot say’; 117 (28.1%) ‘not changed’ or ‘not changed much’. Correspondence analysis (p < 0.05):

• ‘Not changed’: ‘middle school’, ‘class’, ‘originally’, ‘received’, ‘unchanged’, ‘generally’, ‘freedom’.
• ‘Not changed much’: ‘middle school’, ‘content’, ‘heard’, ‘similar’, ‘few’.
• ‘Cannot say’: ‘don’t know’, ‘learned’, ‘middle school’, ‘originally’.
• ‘Somewhat changed’: ‘dating violence’, ‘could’, ‘various’, ‘important’.
• ‘Changed’: ‘sex’, ‘life’, ‘oneself’, ‘serious’. Text mining—Sex category: 4246 components extracted; 145 (≥2 occurrences) analyzed. Frequent terms: ‘know’, ‘think’, ‘sex’, ‘myself’, ‘middle school’, ‘originally’, ‘understood’, ‘important’, ‘learn’, ‘partner’. Six clusters (p < 0.05): [understanding of sex and partners] (think, myself, sex, partner, person, various, important, know); [fertility] (can, baby, low); [universality of sexual education content] (middle school, content, learned, class, unchanged, received, similar, most, before, same, heard, health preservation, learn, lecture); [gender] (obvious, gender, prejudice, different, society); [miracle of pregnancy] (ovum, low); [fear] (scary). Life planning: 3891 components; 118 analyzed. Frequent: ‘think’, ‘myself’, ‘future’, ‘establish’, ‘important’, ‘properly’, ‘life’, ‘now’. Eight clusters (p < 0.05): [vision of the future]; [close relation to sex]; [ruin]; [healthy life valued by partner]; [risk of sexual intercourse]; [step]; [create]; [adult]. Correspondence analysis indicated significant associations: for men—‘life’, ‘partner’, ‘waiting’; for women—‘childbirth’; for non-binary—‘protecting’, ‘person’. Self-actualization: 2422 components; 87 analyzed. Frequent: ‘myself’, ‘think’, ‘self-actualization’, ‘important’, ‘properly’, ‘partner’, ‘have’, ‘crucial’. Six clusters (p < 0.05): [unimaginable]; [life]; [relations]; [step towards the future]; [unrealistic]; [consideration]. Mutually trusting relationships: 3835 components; 124 analyzed. Frequent: ‘important’, ‘partner’, ‘think’, ‘myself’, ‘relationship’, ‘friend’, ‘opposite gender’, ‘person’, ‘mutually trusting relationship’, ‘each other’, ‘feeling’. Many components fell into a single cluster without any appearing at significantly high frequency; no clusters named. Preconception self-care: 2495 components; 92 analyzed. Frequent: ‘important’, ‘myself’, ‘properly’, ‘crucial’, ‘know’, ‘think’, ‘children’, ‘pregnancy’, ‘care’, ‘self-care’. Eight clusters (p < 0.05): [valuing myself] (important, myself); [understanding] (didn’t know, understood, glad, meaning); [luxury grocery items] (cigarettes, drugs, drinking alcohol); [difficulties of women] (difficulties, women); [understanding the menstrual cycle] (app, insert, menstrual cycle); [method] (method); [stress] (stress); [contraceptive method] (condom, wear). Overall, approximately half reported increased awareness; those reporting change emphasized seriousness about sex, dating violence, and life planning, while those without change cited overlap with junior high content.

The findings indicate that midwife-led sexual education incorporating preconception care principles can positively shift high school students’ awareness about sexuality, relationships, and future planning. Students who reported change reflected on mutual respect, understanding partners, gender, the wonder of pregnancy, and risks of sexual activity—aligning with goals of preconception care to improve present health and future reproductive outcomes. Those without reported change likely experienced content redundancy with junior high curricula, which often focus on gender differences, equality, contraception, and intercourse, with less emphasis on consent, dating violence, and trust-building. Integrating preconception care into earlier education may address this gap. Life planning emerged as salient; envisioning future education/employment and reproductive intentions relates to delayed sexual debut and improved reproductive knowledge. The intervention also appeared to enhance understanding of self-care before pregnancy (e.g., effects of smoking, alcohol, drugs, menstrual cycle awareness, contraception), suggesting potential for long-term benefits in reproductive health and avoidance of unintended pregnancies. These results support and extend prior literature showing sexual education improves knowledge and contraceptive behaviors, and that comprehensive preconception-focused interventions can reduce first and repeat pregnancies.

A single-session, midwife-led sexual education intervention grounded in preconception care increased students’ awareness of sexuality, mutual respect in relationships, and the importance of self-determination and life planning from adolescence. Students recognized the value of pre-pregnancy self-care and future planning, which may reduce sexual violence harms and unintended pregnancy, contributing to better reproductive health for both women and men in Japan. Such education aligns with WHO preconception goals to reduce perinatal and infant mortality. Future work should include quantitative and mixed-methods designs with pre/post assessments and longer-term follow-up of behaviors and outcomes (e.g., pregnancy, STIs) to establish causal effects and durability.

The study lacked pre-intervention assessment, precluding before–after comparisons of change attributable to the intervention. There was no long-term follow-up to assess sustained changes or actual behaviors (e.g., contraceptive use, STI incidence, pregnancy). Generalizability may be limited to similar school contexts, and text mining relies on self-generated open-ended responses which may reflect response biases.