Introduction
Sexual health is a state of physical, emotional, mental, and social well-being about sexuality. In other words, it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships [1]. Health education is a primary prevention method for promoting changes in behavior and achieving healthy habits [2]. Adolescence is a transitional period in one’s lifetime in rapid physical growth, and sexual development lead to the physical ability to reproduce [3, 4]. During sexual maturation, adolescents undergo major changes and increased sexual instincts and face many questions in their minds. Receiving inappropriate answers or wrong education can profoundly affect their life and future [5]. 
To achieve adequate sexual health, sex education programs are necessary to promote healthy sexuality by transmitting a variety of topics such as puberty, sex, gender identity, gender roles, sexual orientation, healthy relationships, contraception, and sexually transmitted infections (STIs) [6, 7, 8]. The majority of adolescents tend to have sex education. Unfortunately, this request is often ignored or places too much emphasis on the biological aspects of reproduction and lacks the focus on acquiring healthy behaviours [7]. The education should result from teamwork comprising sexologists, health professionals, teachers, and family [9]. Lack of maturity during the first sexual relations, also specific characteristics of teenagers (need for independence, impulsiveness, and emotional lability) increase risky behaviors [10, 11, 12]. Teenagers are at increased risk of STIs and HIV, so innovative, youth-focused sexual health promotion programs are needed [13, 14]. Sex education effectiveness is greater before the beginning of sexual relations [15, 16]. Sex education can be an actual effort for the promotion of healthy sex habits and the prevention of STIs [16, 17]. 
Studies have suggested various methods for sexual education for adolescents. In some studies, the parents of the adolescents were educated, and the effect of sex educational intervention was determined on the adolescents [18, 19, 20, 21, 22, 23, 24, 25, 26]. One of the related methods is theater-based sex education [27]. Since the theater’s inauguration in 2008, the theater has been considered a major social or theoretical mover. For decades, theater-based approaches have been implemented as a method of health education and a strategy for changing behavior. Theater performances can engage the audience and influence the knowledge, attitudes, and behaviors of audience members. Also, adolescents find theater-based interventions more acceptable and memorable than traditional didactic teaching methods [27]. Also, the theater performance program for sexual education to adolescents was significantly impactful and improved attitudes related to sexual issues, including STIs [13, 25, 28, 29, 30] mental health [31], increased sexual health self-efficacy [25, 32], and behavior change concerning contraception devise [29, 32].
Lameiras-Fernández et al. reported the effectiveness of sex education programs and thereby informed better public policy-making in this area [33]. This study aimed to deliver a detailed summary of all the available primary research for determining the theater-based methods, sex education contents, and outcomes in theater-based interventions for sexual health.

Materials and Methods
This systematic review assessed the studies conducted on the impact of a theater-based intervention on the health of adolescence. The study’s findings were reported using the PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis) protocol. 
The inclusion criteria were determined based on PICOS (P: Population, I: Interventions, C: Comparisons, O: Outcomes, and S: Study design). The selected resources were those whose study participants were adolescents/teenagers aged 11-19 years, and theater-based sex education was determined as an intervention program. Each interventional study was selected, regardless of the type of study. For example, randomized controlled trials, quasi-experimental, before-after studies, and qualitative studies determining the impact of intervention were accepted. Also, only the resources with a full text published in English or Farsi were selected as high-quality studies. 
This review included a severe systematic search of the peer-reviewed literature. Resources were searched systematically in the electronic databases, including Web of Science, PubMed, Scopus, ScienceDirect, and ProQuest, and national databases such as Magiran and Scientific Information Database (SID). Furthermore, the dissertations of doctoral and master students of Iranian universities and Iranian students who graduated from foreign universities were searched in the IranDoc website. This site belongs to the Iranian Ministry of Science, Research, and Technology; the full text of Iranian students’ theses is available on this site. In addition, the researchers also checked the citation lists of included studies. 
Resources were searched with English keywords such as “theatre,” ‘theater,” “sexual,” “sex education,” and “sex training,” and their equivalent Farsi words. There were two spellings of “theater” and “theatre” in the literature. In American English, the spelling is “theater”; in Britain and the rest of the English-speaking world, “theatre” is used. So, both spellings were used for the search. Databases were explored with time limitations between 2011 and 2021 to find newer methods.
The electronic databases were searched for titles and abstracts with the key terms in all the databases: (“sexual” OR “sex education,” OR “sex training,”) AND (“theatre” OR “theater”). Then, the titles and abstracts of all retrieved papers were screened based on PICOS criteria, and the selected resources were assessed for methodological validity using the Newcastle Ottawa Scale (NOS) checklist. Two independent authors conducted study selection, quality assessment, and data extraction. Data extracted included the first author’s name, publication date, the aim of the study, context including the name of the country, sample size, participant characteristics (gender, age), study design, intervention (duration, sex education content, theater performance) and key findings were developed. 
Results
We identified a total of 802 studies through the initial search in databases of Web of Science (183), Scopus (249), PubMed (45), ScienceDirect (144), ProQuest (179), Magiran (0), SID (0), and IranDoc (2). After excluding 135 duplicates, the other papers were screened according to the title and abstract. Then 10 studies were selected based on the inclusion criteria, and their full texts were reviewed. Finally, 7 papers had the eligibility criteria and were carefully chosen to be included in this review. Figure 1 shows the flowchart of the search process in the PRISMA flow diagram.

The characteristics of the selected studies are presented in Table 1. 


The research methods of the studies were as follows: two mixed methods, one qualitative method, and four quantitative methods. The sample size of qualitative studies was 19-20 individuals, and quantitative studies varied from 159 to 1143. The research environment was in 7 contexts (i.e. Sweden, Canada, and 4 different states of the USA). Except for one case where the gender was not stated, in all other studies, both girls and boys participated; the number of girls was slightly higher than that of boys. The age of the participants ranged from 11 to 18 years. 

The content of sex education was different in the 7 included studies. So we summarized the findings and divided the topics of sexual education in the studies into four categories: 1) “sexual activity,” including STIs, contraception and pregnancy options, delaying sexual activity, 2) “psychological issues related to sexual health,” including gender and sexuality, religion/culture, personal identity, puberty, sex-related stigma, women’s apparel, increasing self-efficacy in refusal skills, building confidence, facilitating decision making about setting physical boundaries and limits, 3) “sexual violence,” including rape culture, sexual violence, and 4) “communication,” including peer, partner‏ and parent communication, and social media. All 7 studies determined the effect of the intervention on “sexual activity,” 3 studies on each of “psychological issues related to sexual health” [25, 29, 32] and “communication” [25, 30, 32], and only one study on “sexual violence” [32].
Two studies determined the effect of theater performance without considering sex education content [30, 32]. Taylor et al. reported that sex education by theater (SExT) improved personal/social development (personal growth, social inclusion, and social engagement) in pear educators, and their qualitative analysis identified 5 theater pedagogy mechanisms (pleasure, creative engagement, personal relevance, role-play and embodiment, vicarious role-play and modeling), and development of context-mechanism-outcome configurations [32]. In addition, Kim et al. argued about the impact of theater-based-sex education as follows: feeling empowered to educate their peers and advocate for changes on campus in response to their acquired sexual health knowledge and comfort and confidence in discussing sexual health, feeling more comfortable with performing on stage, facilitating learning environments that allow students to more openly share and engaging in dialog about sexual health [30]. Also, in one study the appropriate method of using theater for sexual education was determined by research design [32]. 
In seven included studies, the theater performance as the intervention lasted 1-10 sessions, each session for 60-120 minutes and mostly one session per week. The theater performance method was different in selected studies. Education in three studies was based on art-based, multiple-component, and peer education (AMP) [13, 28, 29]. AMP uses a theater-based approach for sexual health education for high school students in school settings [25]. AMP consists of three components facilitated by undergraduate students [13, 25, 28]. Another method was SExT. Adolescents were trained as peer educators by participating in workshops designed with the adolescents’ input. Peer educators designed and performed a play on the selected sexual health topics for their peers [32]. STAR LO program embeds theater within a classroom-based curriculum and uses professional young adult actors/educators as teachers [34]. Also, the High School Sex Squad (HSSS) programs facilitated by AMP staff and sex squad students (divided based on their culture) mentors involving workshops, interactive games, and rituals [30]. SAFETY is performed in school by professional actors and school nurses [29]. These methods are explained in Table 1. 


Discussion 
This systematic review determined the effect of theater-based sex education on the health of adolescents. In this review, all interventions were performed in developed countries. Also, the setting of the 5 studies was high schools. Interestingly, all students received standard health education curricula, and the intervention groups received additional theater-based-sex education. Studies show that sex education for adolescents is necessary and accepted, and many countries offer this education to students at school.‏ Sex education in school can be effective in promoting sexual health and preventing violence [19].
In all selected studies, the intervention was designed for both boys and girls. Some have suggested that boys and girls have different intervention needs, and some studies have presented that the effect of reproductive health interventions varies by gender [34]. Therefore, the number of girls and boys was almost equal in all interventions of the included studies in this review. The content of sex education was different in these 7 selected studies; all of them determined the effect of the intervention on sexual activity and sexually transmitted diseases, while fewer studies were about the other issues of sexual education content. 
After years of debate, there is little agreement on the content of sex education [35]. There is much scientific evidence examining educational programs to improve sexual activity and prevent STIs [36, 37]. Sex education must not only focus on STIs and their prevention, but a more comprehensive vision of sexuality that addresses topics such as puberty, sexual identity, sexual diversity, and healthy relationships must also add to sex education [7, 8]. In Iran, some studies have been conducted about the education on puberty and sexual problems, the necessity of sex education, the content of the education, educators, and the training time [4]. No interventional studies meet the WHO-defined criteria for proper, comprehensive sex education [7]. 
Sexual health education for adolescents increases the tendency to investigate more related questions in this regard using suitable sources [38]. Also, sex education programs for adolescents do not lead to an increase in sexual practice; they certainly increase with age, regardless of whether the teenagers have participated in an intervention [4]. 
The theater performance and content of sex education were different in the 7 selected studies. All of the studies determined the impact of the intervention on sexual activity and sexually transmitted diseases, while fewer studies were about the other issues of sexual education content. Theater has been recognized globally as an educational strategy for changing the behavior of adolescents and their parents on health issues [39]. Previous research has shown that theater-based techniques, such as storytelling and role-play, allow for the gaining of knowledge and skills as well as opportunities to practice and develop educated information [40]. Studies have consistently suggested that well-designed theater performances can engage audience members, impact the knowledge, attitudes, and behaviors of audiences, and positively influence peer, cultural, and social norms [41, 42, 43, 44, 45, 46, 47, 48]. 
For example, theater-based programs have reduced anxiety, depression, isolation, and physical complaints [49, 50]. Also, the effects of school sex education are patchy and often short-term. Classroom sex education is challenging because schools emphasize academic-presentation issues [21]. It seems that other approaches, such as theater-based programs, can address these weaknesses in current sex education. 
As a key limitation of our review, only the studies published in English or Persian language were included in our study. As the strength of this study, to our knowledge, this is the first systematic review to determine the impact of theater-based interventions for sexual health education on adolescents. It is recommended that further interventional theater-based studies on adolescents should not only emphasize the biological aspects of reproduction but also focus on acquiring healthy behaviours and topics such as sexual violence, healthy relationships, sexual identity, sexual diversity, and puberty. It is also suggested to use theater as an attractive and effective method in sexual education for adolescents.

Ethical Considerations
Compliance with ethical guidelines
This systematic review is part of a PhD thesis explaining the model of pedagogical theater with the aim of sex education to adolescent girls, registered with number 1651510 at Tarbiat Modares University. 

Funding
The article was supported by Tarbiat Modares University, Tehran, Iran.

Authors' contributions
Study concept and design: Faezeh Daemi, Hassan Ali Pourmand, Farhad Mohandespour, Raziyeh Maasoumi; Acquisition, analysis, and interpretation of data: Faezeh Daemi, Raziyeh Maasoumi, Farhad Mohandespour; Writing the first draft: Faezeh Daemi; Revising the article critically for important intellectual content: Farhad Mohandespour, Raziyeh Maasoumi, Hassan Ali Pourmand, and Sayed Najmedin Amir Shahkarami; Final approval: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors thank Tarbiat Modares University for approving the PhD thesis and supporting the study.


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