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School-based comprehensive sexuality education (CSE) can help adolescents acquire crucial knowledge and skills to achieve their full potential, particularly in low- and middle-income countries with higher rates of negative sexual and reproductive outcomes. While many low- and middle-income countries have developed CSE curricula, little is known about how these are implemented in the classroom. This multi-country mixed-methods study analysed challenges to the implementation of national CSE curricula in schools in Ghana, Kenya, Peru and Guatemala, based on surveys of secondary school principals, teachers and students aged 15-17 years, and in-depth interviews with central and local government, NGOs and youth organisations. In all four countries, inadequate teacher training remained a major hurdle to effective implementation, manifesting in teacher discomfort and inaccurate messaging. This was compounded by a lack of comprehensive teaching resources. CSE classes were focused mainly on biology at the expense of contraception, gender and rights, despite students' desire for greater coverage of these topics. Teaching methods lacked interactive activities necessary to develop skills and values. Findings offer useful lessons to improve school-level implementation in these and other countries facing similar challenges. Increasing teacher training and distributing comprehensive CSE materials responsive to adolescents' needs remain priorities in all countries.

Comprehensive sexuality education (CSE) is a key component of efforts to improve sexual and reproductive outcomes for young people. While many governments have established policies and curricula for CSE, there are no quantitative measures of the quality of their implementation in schools. We describe the construction of a school-level index to measure CSE implementation quality using data from Peru, Guatemala, Kenya and Ghana for validation. The composite index represents seven key components of a successful programme: range of topics, values imparted, teaching methods, teacher training, resources available, monitoring and evaluation, and the school environment. These components are combined into two sub-indices (curriculum content and implementation context), which together provide a summary index of implementation quality. We present scores for the seven components, the two sub-indices and the summary index for each country. Ghana scored highest on the summary index, while Guatemala scored lowest, but country rankings varied within the different components. The paper discusses the implications of the findings for improving school-based CSE in these countries. An assessment of the validity and reliability of the index indicates it can be used in other settings and could be a useful tool for educationalists, researchers and programme implementers to measure CSE implementation quality.

The successful implementation of comprehensive sexuality education (CSE) programmes in schools depends on the development and implementation of strong policy in support of CSE. This paper offers a comparative analysis of the policy environment governing school-based CSE in four low- and middle-income countries at different stages of programme implementation: Ghana, Peru, Kenya and Guatemala. Based on an analysis of current policy and legal frameworks, key informant interviews and recent regional reviews, the analysis focuses on seven policy-related levers that contribute to successful school-based sexuality education programmes. The levers cover policy development trends; current policy and legal frameworks for sexuality education; international commitments affecting CSE policies; the various actors involved in shaping CSE; and the partnerships and coalitions of actors that influence CSE policy. Our analysis shows that all four countries benefit from a policy environment that, if properly leveraged, could lead to a stronger implementation of CSE in schools. However, each faces several key challenges that must be addressed to ensure the health and wellbeing of their young people. Latin American and African countries show notable differences in the development and evolution of their CSE policy environments, providing valuable insights for programme development and implementation.