Social media utilisation and sexual health education. What are the issues? A systematic review

Young people are at a greater risk of poor sexual health and hence, require comprehensive, effective sexual health education. These cohort are constant users of social media which presents many innovative possibilities for sexual health education. Methods A guided search was conducted on scientic and medical databases. Selected publications within the last ve years on sexual health education were classied according to their study designs, sexual health promotion/education as the main subject, target audience age, and social media use. In all, 25 publications met the inclusion criteria out of which 60% were observational studies, 12% randomised controls and 28% non-randomised. About 96% publications reporting on the main subject sexual health promotion or education. Sixty (60%) of the included publications reported specically on young people between the ages of 12-30 years. behaviour, and

have direct implications for health communication programs, prompting efforts to identify new opportunities of using social media to impact population health. [8,9] Previous reviews have had a course to address Harnessing Social Media for Health Promotion and Behaviour Change but do not address sexual health. [10] Another review was on social media use by clinicians; this review was tailored to clinicians alone. [11] A systematic review of social networking sites: Innovative platforms for health research targeting adolescents and young adults, conducted that become a valuable platform to access, recruit, and costeffectively deliver health interventions to youth populations as well as hard-to-reach minority or underserved populations. This review also does not treat networking sites and social media, speci cally. [12] Recent reviews conducted on the impact of health education transmitted via social media or text messaging platforms regarding adolescent and young adult risky behaviours showed that; 59% of adolescents reported seeking health information online. [13,14] Thirty one percent 31% of teens reported accessing health information online and that 17% of teens used the internet for information on sensitive health matters. [13,15] Many of the above publications agreed that the use of social media for health promotion should be given the needed priority.
There is, therefore, a growing need for an up-to-date review of literature that is not limit us to peer-reviewed publications or youth, networking sites or a speci c type of outcome or study designs that examines the literature on the use of social media for STI prevention and health promotion. The objective of this review is to describe the scienti c literature in the last ve years on the utilisation of social media for sexual health education/promotion.

Materials And Methods
To effectively analyse utilisation of social media and sexual health promotion, Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was adopted for use.
[16] An electronic search strategy was employed to include all published papers from 2015 to the end of September 2020 that have either the terms' sexual health education' or 'sexual health promotion' together with the following words: 'social media'; 'social networking'; 'Twitter'; 'Facebook'; 'YouTube'; 'Instagram'; and 'Snapchat'.
The main criteria for selecting a publication for the review were: Empirical studies reporting results and papers written in English. Papers that did not meet the above criteria were excluded. Papers as that did not deal with the subject matter but only mentioned the keywords of the search strings were also excluded.
In ensuring thorough review, duplicates of papers were removed, the review included examining all titles, abstract to make sure that each paper met the inclusion criteria. After which full-text articles were retrieved and re-examined to exclude any material that does not meet the inclusion criteria. The papers that met the inclusion criteria proceeded to the data extraction phase and the following data extracted; authors, date of publication, title, methodology, social media used, key ndings, conclusions, and country. Included studies were furthered classi ed based on their study designs and those who reported on young people using social media platforms.

Sample
A total of 23,337 publications were identi ed. After applying the inclusion criteria and screening the identi ed papers, 25 papers were included for the qualitative synthesis. Table 1 shows the search strategy and its results. All the included papers were from 2015 to September 2020. For paper selection procedure in the review (see Fig. 1)

Design of included papers
Out of the 25 included publications, 3 reported on randomized control studies, 7 reported on non-randomized controls, and 15 reported on observational studies (see Table 3). For a summary of all the publications included in this review (see Table 2).

Results
Use of social media Social media has shown to have both positive and negative effects on behaviour and attitudes of young people; however, the positive effects far outweigh the negatives (see Table 4). Participants in the study of Jones, Williams, Sipsma and Patil [17] all had Facebook accounts and about (91%) reported seeking sexual health information between 1-2 times each week through Facebook. General Social Media (SM) and dating apps used to access or receive sexual health information among men-whohave -sex -with men (MSM) constituted the SM use in the study of Kesten et al. [18], with most participants perceived using SM and dating apps acceptable especially receiving information when browsing these platforms. Macapagal et al. [19] also examined 'hookup apps' used by MSM as they use the apps to meet new sex partners. Participants (n = 105) reported using MSM-speci c apps to meet partners for sex.
Age contributed a high score in explaining SM involvement (de ned as the number and types of SM used), Park,Rodgers,McElroy and Everett [20] along with the variables such as several internet access locations, ownership of a mobile phone with internet connectivity, and transgender. According to Park et al. [20], Social Networking Sites (SNS), such as Facebook, MySpace, and LinkedIn.com; blogs, Twitter or another service constituted the SM involvement with 85% study samples been SM users to one degree or another.
The majority of participants in the paper of Alber, Paige, Stellefson, and Bernhardt [21] had access to the internet at work (n = 292, 82.7%), yet less than half reported having full access to SM (n = 171, 48.4%). Almost half of the participants reported that their employer either monitored or blocked certain websites (n = 175, 49.6%).
According to (Stevens et al., 2017), the most used SM sites at the time of their study were Facebook (64.4%), Instagram (18.7%), and Twitter (5.5%). Participants also reported using other sites, including Vine and Snapchat (11%), and they varied greatly on the frequency of their SM usage, with 8.8% (n = 22) reported not using social media at all, 5.6% (n = 14) every few weeks, 10.9% (n = 27) weekly, 17.3% (n = 43) daily, and 57.0% (n = 142) multiple times each day. SM served as the fourth most commonly cited source of sexual risk reduction information, with slightly less than half of the sample reporting it as a source of recent sexual risk reduction information (45-47%, n = 112-117).
Facebook was the technology with the greatest number of users and most frequently used, with around 58% (n = 119) of participants reporting daily use, and only 4.4% (n = 9) reporting never using Facebook as reported by the study of (Reynolds, Sutherland & Palacios, 2019). The study further indicated that text messaging (n = 131) had 16 more than WhatsApp to place second in user number. WhatsApp was the second most frequently used with 25.5% daily users compared to text messaging's 14.7%, but also 43.6% of participants never used WhatsApp. Instagram, Snapchat, and Twitter were used signi cantly less than the three other modes of technology, with daily uses at 13%, 5%, and 3% respectively. SNS were the primary focus of participants' general internet use in the study of Patterson, Hilton, Flowers and McDaid. [22] According to Patterson et al. [22], general SM use was sort of the platforms to receive sexual health information online with participants identifying the barriers to getting credible sexual health information on these SNS platforms.
Patel, Masyukova, Sutton and Horvath [23] reported that, most participants (87.3%) in their study owned an internet-enabled cell phone or mobile device, and the majority (67.6%) used these devices as their primary mode of accessing the internet and SM. All participants reported having at least one SM pro le, with most having multiple pro les (83.3%). The vast majority (87.3%) accessed the internet and SM sites multiple times per day. Over a third (34.3%) primarily used SNS to meet new people o ine versus about half (52%) that used more general SNS (e.g., Facebook, Twitter) to meet new people, and a smaller proportion (13.7%) did not use SM to meet new individuals.
Aragão et al. [24] used Facebook to investigate the perception of adolescent students about health education. The results revealed that Facebook as an environment for learning in sexual and reproductive health for adolescents, their interaction in the online environment favoured the sharing of knowledge and experiences about sexual and reproductive health with both peers and the nurse in educational intervention programme using Facebook.
Facebook was the only SM platform used in the study of Card et al.
[25] to analyse the content of 10 community-based organisations (CBOs) that uses Facebook to promote the well-being of gay and bisexual men (GBM). The results of Card et al.
[25] indicated that 14,071 posts were shared and 21,537 users engaged with these posts, with the number of posts and the number of CBOs users engaged having a moderate correlation with (r = .53, P < .001).
Witzel, Guise, Nutland, and Bourne, [26] targeted Facebook, Twitter or Tumblr for gay and bisexual men and African people and sought to explore how the online environment shapes end-user engagement with sexual health interventions. The results revealed that participants express privacy concerns related to the ecology of social networking sites, issues with implied disclosure and discrimination, as well as uncertainty over control of data.
Harlow et al.
[27] focused on Twitter use to discuss Sexual Violence (SV) prevention due to several high-pro le SV cases. The study examines Twitter discourse on SV prevention through the hashtag #HowIWillChange, so users can come out to report plans to engage in bystander prevention. Results of Harlow et al. [27] indicated that 1,493 #HowIWillChange tweets from October 2017 were analysed and participants had discussed a range of prevention strategies, including the spread of misinformation, and the perpetuation of the myth that only strangers commit rape, and that only male children need lessons on consent, and that SV prevention vili es men. Contents from lesbian-oriented conception, pregnancy, and parenting Facebook groups by Ruppel et al. [35] were examined for comparison purposes drawn from groups that appeared to serve heterosexual women primarily 400 discussions were made containing 1764 total instances of text, and many participants in the lesbian-oriented Facebook groups sought and provided medical information. Their queries focused on the insemination process, and frequently related to posters' speci c situations, while heterosexual women tended to seek general advice about the conception and pregnancy process. Sexual health-related subject Accessing sexual health information, Jones, Williams, Sipsma and Patil, [17] showed that Google had been proven to be the strategy out as the go-to search strategy for nding online resources for sexual health information. The sexual health information relates to general STDs provided in the Caryn Forya Facebook (CF) sexual health intervention site. Sexually transmitted infections (STIs) like HIV and HIV testing constituted the main sexual health subject in the study of Kesten et al.
[18] On a ip side, the study of Park et al. [20] focused on the preference of sexual health information (SHI) through SM involvement, where SM users preferred to receive SHI through SNS as against direct telephone calls for non-media users.
Alber et al. [21] identi ed speci c training and resources need related to social media use in health education. Health education professionals can engage community-based organisations and build their capacity to effectively launch and sustain SM-based outreach with community members when additional SM training opportunities are provided. Contraception information and HIV/STD prevention information were the main sexual health subjects in the study of Stevens et al. [39] According to them, the most common sources of sexual risk reduction information reported were television and movies (63%, n = 157), school (56%, n = 140), and parents (47-48%, n = 117-120).
Sexual health subjects discussed in the study of Reynolds, Sutherland and Palacios [40] were contraceptive use, with only about 40% of students reporting that they "always used protection during intercourse", and nearly 30% of participants reported "never." More than 80% identi ed one method of contraception, but less than half could name multiple. Although nearly 65% of the participants reported access to information about STDs, including HIV and Zika, only about 35% correctly identi ed how STDs are transmitted.
Many participants in the study of Patterson, Hilton, Flowers and McDaid [22] mentioned that there is huge content available online that serves as a barrier to effectively seeking sexual health information online. Most opposed engaging with sexual health promotion content on SNS like Facebook and Twitter, because liking a sexual health content will result in judgement from peers. The body that gets sick -STDs / HIV / AIDS; The body that reproduces itself -Pregnancy in Adolescence; and Safer sex.
The following health messages were primary the sexual health-related subjects in Card et al. [25] study; pre-exposure prophylaxis, stigma, mental health, treatment, testing, research, condoms, and dating. It Starts With Me (ISWM), a sexual health promotion intervention was evaluated by Witzel et al. [26] regarding privacy and stigma dealing with sexual health interventions on social media. HIV testing and status among general sexual health information were discussed with most participants having concerns about involving in such online interventions as disclosure could lead to discrimination. included (e.g., last sexual encounter, number of partners, testing, clinic utilisation). The attitudes, norms, and perceived control were (e.g., condom use behaviours, HIV/STI transmission).
Jones, Carter, Wilkerson and Kramer [29] examined general thoughts and experiences with HIV and or STI testing, students' awareness of HIV testing campaigns and related activities, their critique of potential messages for an HIV testing campaign, and communication of HIV testing messages through social networking sites. Topics related to sexual health included in Whiteley et al.
[31] study were; puberty, basic anatomy, HIV/STI information (including gonorrhoea, chlamydia, syphilis, trichomoniasis, genital warts/HPV, herpes), contraception, pre-and post-exposure prophylaxis, personal risk assessment, the in uence of peer norms, HIV's impact on minority communities, bene ts of abstinence and protected sex, condom skills, communication skills, and dangers of substance use.
HIV status and testing, condom use, and group sex engagement constituted the sexual health-related information discussed with the young black men who have sex with men (YBMSM) in the study of Young, Fujimoto & Schneider.
[32] Varma, Chung, Townsend and Power [42] examined Patient information lea ets (PILs) relevance and some of the information included in the lea ets used were HIV testing and Visiting a Sexual Health Clinic. Results of Varma et al. [42] indicated that, PILs, a clinic website and the Sexual Health Information Link (SHIL), a state-wide website and telephone line, were ranked signi cantly higher as a means of sexual health-related information (SHRI) delivery on a Likert scale than newer technologies including Facebook (P < 0.001), email (P < 0.001), mobile phone applications (P < 0.001), TVs in waiting rooms (P < 0.001) and business cards (P < 0.001).
Notions of women as sex objects in the study of Maes et al.

Discussion
Achieving sexual health is portrayed to be a struggle for young adults.
[36] The ndings in this study suggest that internet use has penetrated nearly all age and socioeconomic groups and have served and continue to serve as a means for sexual health interventions programmes targeting young individuals. Park et al. [20] indicates that online health information consumers are more likely to be younger, better educated and more a uent than consumers who use traditional communication channels. SM use is perceived as positive by individuals who nd it di cult to seek medical information from health practitioners, especially sexual health-related information due to shyness or stigma related reasons which is usually characteristics of young people. In some part of the world, particularly Sub-Sahara Africa (SSA) adolescent and youth-friendly health facilities such as adolescent centres and safe spaces are either not available or available but not adequately resourced for use. SM will, therefore, be essential for sexual health education or information in such situations. Facebook has a leading forum among other social media platforms as it is included in most of the studies. Gold et al.
[43] points out that, SNS has received speci c attention for public health activities and discussions, with Facebook leading these SNS.
These SM platforms are strategically good for online sexual health education through the sexual health intervention programmes carried out by various health institutions and organisations. A recent study Burns and Arnault [44], con rms that SM sites are best used in educating young black males, especially to promote the use of condoms. One challenge to access these SM sites could come from internet providers who could monitor and approve sites access. SM could also serve as the source of sexual risk reduction information, and with increasing privacy awareness among the youth on SM, seeking sexual health information could be anonymous without fearing of stigmatisation. Having said this, attracting huge users by SM could mean they are cost-effective.
Stevens et al.
[45] con rmed that, SM sites are cost-effective and are frequently used by black youth. Countries with a larger number of SM users are likely to have higher cases of STDs given that other groups used these SM sites to promote their sexual content (e.g. Pornographic posts) without any sexual risk reduction information. SHCs websites are primarily a good starting point for providing adequate sexual health information to adolescents, especially regarding STDs and their preventions. Individuals could then verify any contradicting sexual information received or viewed on SM platforms. More interestingly, young individual use SM to have their way through simple sexual controls from parents and guidance, as indicated in the study of Fongkaew and Fongkaew. [38] Limitations of the study With the criteria used to select studies in this review, only 25 primary research publications met the criteria. We do appreciate that the search terms used only allowed us to capture relevant publications identi ed in the eld. We might have as well missed publications that were not published in the journals or databases that were searched and those written in other languages. Most sexual health promotion or education interventions and programs using social media were excluded from the review because they were not primary research hence we could not report study ndings. The study focused on publications within the last ve (5) years from 2015 to September 2020. Given the number of studies included in this review that reported effects and differences among the included studies, it was not possible to conduct a meta-analysis.

Conclusions
Some studies used social media platforms for sexual health promotion/education or STDs prevention as an intervention. These interventions were either stand-alone or integrated. Social media provides great potential to reach and engage young people for sexual health promotion or education. However, further evidence is required to improve sexual health program implementation and audience reach as well as determine the effectiveness of social media in changing knowledge, attitudes, and behaviours.           Figure 1 Selection procedure ow chart