School-based Sexual and Reproductive Health Education and Its Challenges to Adolescents in Ethiopia; A Qualitative Study

Introduction

Adolescents  Sexual  and  Reproductive  Health  Education  (SRHE)  will  help  teenagers  to  make  informed  decisions and choices regarding  their  sexuality (1). The goals  of  Comprehensive  Sexual  Education  (CSE)  programs,  which  are  taught  in  schools  in  countries  with  low  or  middle  incomes,  are  to  advance  gender  equality,  human  rights,  and  the  prevention  of  teenage  risky  sexual  conduct  (2). 

Sexual  and  Reproductive  Health  (SRH)  is  defined  by  the  World  Health  Organization  (WHO)  as  a  complete  condition  of  mental,  emotional,  physical,  and  social  well-being  in  connection  to  sexuality,  rather  than  just  the  absence  of  illness,  dysfunction,  or  infirmity  (3).  Thus,  every  person  has  the  freedom  to  choose  a  lifestyle  and  conduct  that  will  eventually  safeguard  and  advance  their  SRH (4).  In  particular,  teens  have the  right  to CSE,  counseling, access to variety of contemporary  contraceptives, safe  abortion  services,  treatment  for  the  consequences  of  unsafe  abortion,  protection  from  sexual  and  gender based  violence,  and  prevention  of  sexually  transmitted  infections  (STIs)  including  HIV/AIDs  (5). 

The people, groups, institutions (such as schools and hospitals), legislators, and other stakeholders are all accountable for advancing SRHE. Students must receive the SRH instructions listed in curriculum and policy papers from their schools (2). Focusing on the individual as a whole and expressing sexuality as a good aspect of life, sexuality education emphasizes a wide approach to sexuality. From biological to psychological to social to economic, it encompasses all facets of being and being a sexually gendered individual. With an aim to promote SRH, it examines values and cultivates social skills. In order to prevent harmful sexual behavior and because attitudes toward sex are typically formed (6).

Numerous young people are utterly excluded from school-based SRHE both domestically and abroad as a result of inconsistent and frequently inadequate SRHE implementation and interpretation of curriculum and policy guidelines (7). Because of this, a lot of young men and women start their early adult lives without realizing the importance of SRH to general health and welfare (8).  One persistent and problematic issue is the inconsistent and/or insufficient delivery of school-based SRHE.  Multiple research studies indicated that students' understanding of sexual health and contraception was much increased by school-based SRHE in addition to information from parents, peers, clinics, and technology (8-9).  This could therefore contribute to a decrease in Ethiopia's high incidence of adolescent pregnancies and unsafe abortions. Furthermore, it helps to  develop  effective  school-based   SRHE and  to  understand  both  health  care  workers  and  teachers’  views  on the existing sexual  health  education. However, there are no studies conducted on school based SRHE among school-going adolescents in Ethiopia. Hence,  the  study was  intended  to  explore the school teachers,  adolescent students  and  HCWs  opinions on  the  status  of  school based SRHE  and  Its  challenges  in Arsi zone, Ethiopia.

Materials and Methods

Using a conventional content analysis approach, this qualitative study was carried out in the Arsi zone of Ethiopia between April and May of 2021. The goal of applying content analysis was to produce reliable and valid findings from the pertinent data in order to offer the study's new perspective and body of knowledge (10). In five secondary schools and four health centers, purposeful sampling was employed to choose participants with the greatest possible diversity. Before starting data collection  permission  was  obtained  from  the  Arsi  zone  education  office  and  Health  office  of  Research  Centre  Scientific  Review  Committee.  Also,  the  University  of  South  Africa  (UNISA)  approved  the  study  (REC  O127  14-039  (NHERC)). Twelve key informants (teachers and healthcare professionals) participated in individual in-depth interviews (IDIs), and four focus group discussions (FGDs) with secondary school students (six participants in each group) were used to gather data. We kept sampling until the point of data saturation was achieved. When more sampling is no longer possible for the researcher to gather fresh data, the data saturation point is reached.  The individuals were chosen to represent the widest possible range of characteristics, including location, sex, field of study, and kind of institution (public).  The subjects for the study were residents of the Arsi zone, free from mental diseases, and gave their consent. Then, data  collection  was  performed  using  a  semi-structured  interview  guides  adapted  from  previous  studies  (1,  8,11). Finally, with the participants' consent, the in-person interviews were conducted. All the interviews were tape-recorded and transcribed verbatim. The  interviews  were  performed  in  a  suitable  place,  in  which  the  participants  felt  comfortable.

During the interviews we asked the following questions:

• In your  opinion,  how  important  is  school  based  SRHE  for  the  health  of  adolescents?
• What is your opinion about the current SRHE for adolescent?
• What are the challenges of providing SRHE for adolescents?
• What do  you  suggest  to  improve  school  based  SRHE  for  adolescents?

The approximate duration of the interviews for IDIs and FGDs was 45-60 minutes.  Four    FGDs were held with students.  It was  performed  during  break  time  at  private  class  to  collect  valuable  information.  The  groups  included  a  total  of  24  secondary  school  students. The conversations were taped after getting the participants' consent.  In the course of the interviews, the researcher acting as a mediator addressed questions, and the assistant researcher oversaw the interviewing process and took notes when necessary to ensure that nonverbal data was not lost. To safeguard the study participants' ethical concerns, participants were told of the study's purpose and their freedom to discontinue participation at any time.  Regarding the privacy of their data, they received guarantees.  Before the interviews, the subjects gave their informed written consent.

The  data  were  analyzed  using  the  conventional  content  analysis  method  using  Atlas.ti  8.1  software.  The key codes that were related to a certain phenomenon were grouped together and classified into several groups based on their shared characteristics.  At last, the concepts were developed.

Guba and Lincoln's (1989) credibility, dependability, confirmability, and transferability criteria were applied to make sure this study was trustworthy. Data credibility was achieved through long-term interaction with the participants, immersion in the data, participant verification of the findings, supervisor evaluations, and a high degree of participant diversity. Transferability was facilitated by preparing the study's setting and culture, participant requirements, data collection techniques, data analysis methodology, and sample participant statements, allowing others to access the study's methodologies and population. Dependability was ensured as the researchers attempted to avoid introducing their assumptions into the data gathering and analysis process enhancing reliability. Additionally, the data analysis process utilized code-recode and external auditing techniques. Conformability was enhanced by incorporating the perspectives of experienced SRH researchers who were not part of the research team at every level of the investigation, including data collection, analysis, interpretation, and sampling.

Results

A  total  of 24 adolescent students in  four  FGDs  and  12  IDIs  with  (teachers=6  and  HCWs=6)  participated  in  this  study.  The  age  range  of  students  was  14-19  years  where  the  teachers  and  HCWs  were  between  30-50  year (Table 1).

According to this study, school-based reproductive health education is associated with improved reproductive health outcomes, such as postponed sexual initiation, fewer sexual partners, and higher usage of contraceptives. Increasing risk awareness and knowledge about STIs and pregnancy, values and attitudes toward sexual topics, self-efficacy (managing condom use or refusing unwanted sex), and intentions to abstain or limit the number of sexual partners are just a few of the positive effects that many programs have had on the factors that determine risky sexual behaviors.

Theme1:  Current   school-based SRHE

As described in table 2,  the  first  theme  consisted  of  three  sub-themes:  curriculum  contents,  teaching  approach  and  students’  knowledge  of  SRH. The study provides an overview of an incomplete list of subjects taught in the curriculum.  Majority  of  teachers  and  HCWs stated  that  the  implementation  of  SRHE  is  neither  mandatory  nor  comprehensive  as  other  subjects  in  normal  public  secondary  schools. 

1.1 Curriculum content

Teachers disclosed during IDIs that the curriculum did not cover topics such as the anatomy and physiology of the reproductive system, preconception, physical and psychological changes associated with puberty, family planning and contraception, infertility, and SRH rights. Thus, they were obliged to teach the  limited  contents  of  SRH  lessons  which were  only  taught  in  biology  or  natural  science.  Additionally, It  was  reported  that  the  time  given  and  content  lesson  were  insufficient to SRH lessons.

One of schoolteacher confirmed as:

“In  our  curriculum,  the  SRH  contents  are  very  limited  and  non-compressive.  For  example,  in  our  school  students  unable  to  learn  about  menstruations  and  contraceptives  methods  detail.”[Female, teacher]

One HCW participant reflected as:

‘‘I think the access to SRHE at school is limited.  This  may  be  either  limited  content  of  subject  or  teachers’  ignorance  in  delivering  the  lesson.’’  [Female, HCW]

All the participants suggested that the curriculum should emphasize the integration of sexuality education into various year-level curricula and in primary or secondary schools.

1.2 Teaching approach

The  study  found  that  none  of  schools  offered  CSE  separately  as  an  independent  subject.  There  were  some  contents  (HIV/STIs)  integrated  in  biology  subjects  and  delegated  to  biology  (natural  science)  teachers.  Additionally,  both  male  and  female  students  were  taught  without  gender  separation.  This  may  create  discomfort  to  teachers  and  students  during  discussion  openly. The majority of participants recommended that the Ethiopian health policies should support and encourage classroom discussions and teaching of SRHE.

As expressed below:

‘‘As  the  biology  teacher,  we  focused  more  on  the  main  subject  [biology]  since  the  SRHE  is  not  given  adequate  time  as  a  separate  subject.  I  think  it’s  also  not  focused  by  government  and  most  of  us  ignore  it.’’[Male teacher] 

‘‘It  is  mandatory  to  teach  adolescents  CSE  in  school  separately  as  one  subject  and  the  curriculum  should  be  revised  in  this  way’’  (Male,  HCW).

1.3 Adolescent knowledge of SRH

Research has demonstrated that teenagers, particularly girls, are a susceptible group dealing with a number of severe issues related to SRH, such as unwanted pregnancy, gender inequity, sexual abuse, and STDs including HIV/AIDs (2, 13).  These  problems  are  caused  due  to  the  limited  knowledge  adolescents  possess  of  SRH.  SRHE  for  adolescents  are  of  utmost  significance  to  prevent  any  sexual  risks  (9).  However,  the  findings  revealed  that  adolescents  had  limited  knowledge  of  SRH  services  and  choices.  In  FGDs,  the  majority  of  adolescents  in  selected  schools  were  unable  to  list  contraceptives  methods  and  emergency  contraceptives.  The  only  thing  they  know  is  about  delaying  sexual  intercourse  or  abstinence.

The  following  quotes  illustrate  their  understanding  what  reproductive  health  services  are  all  about:

“As  a  student  [adolescent],  all  I  know  is  not to  having  sex  until  we get  married.  We  have  no  knowledge  or  skills  on  how  to  use  and  choose  the  contraceptive  methods  that  would  prevent  us  from  becoming  pregnant”  [Female,  students].

Even though the students eager to know about the reproductive health system, the study revealed that they couldn’t gain the adequate information.

As stated by one of school student:

“ I  want  to  know  about  all  human  reproductive  anatomy  and  systems  but  no  one  taught  us.  I  didn’t  know  that  in  adolescence  a  boy  can  make  a  girl  pregnant.”  [Male, Student]

Overall this study shows that SRHE is a neglected subject in school as confirmed by students:

"In the past, we used to hear a lot about HIV, but I haven't heard much about STIs, contraceptives, and other topics.  I'm not exactly sure how to protect ourselves against STIs and unintended pregnancies.’’[Female student]

Moreover, schoolteachers confirm that:

‘‘We  have  seen  many  adolescent  girls  dropout  of  school  because  of  unplanned  pregnancy  and  early  marriage.  I  think  this  is  because  of  they  had  lack  of  knowledge  about  their  sexuality  and  pregnancy  prevention  methods.’’[Male, Teacher]

When  we  asked  teachers  and  HCWs  during  the  IDIs  they  reported  that  most  of  the  students  had  limited  knowledge  of  SRH  issues.    It  is  clear  that  they  did  not  get  adequate  information  about  it  both  in  school  and  out  of  it.  Also,  the  participants  believed  as  if  CSE  lessons  are  delivered  to  students  they  can  understand  body  changes  and  keep  their  personal  hygiene,  enabling  them  to  handle  these  changes  during  puberty.

Theme 2:  Implementation obstacles of SRHE

The  second  theme,  challenges  in  delivering  of  SRHE,  included  four  subthemes:  dealing  with  teachers’  confidence,  lack  of  resources/reading  materials, culture and religious and  discomfort  with  sexual  health  terminology.

2.1 Teachers’ confidence

The  finding  shows  that  the  majority  of  school  teachers  are  not  confident  to  provide  SRHE. This could be the result of ignorance and unfavorable attitudes on sex education.  The majority of teachers had not received formal CSE training, and their ability to teach sex education depended on their level of expertise.

One teacher said,

‘‘It seemed to me that I lacked the confidence to impart the SRH lessons. We have limited knowledge and skill about it.’’[Male teacher]

They expressed similar thoughts when students questioned if the lecturers were confident enough to convey the teachings on sexual health.  Numerous pupils expressed their dissatisfaction with the lecturers' lack of confidence in their ability to honestly discuss the lessons.

One student stated,

‘‘I  noticed most  of  the  time our teachers  afraid  to  openly  discuss  with  us  and  rush  when  the  content  in  other  subject  linked  it.’’  [Male, student]

2.2 Lack of resources and training materials

Teachers at the schools stated in the interview that they have not yet received official training. Also, they have been complaining the  lack  of  reading  material  and  special  training  on the  subject.

“A  handbook  or  reading  materials  for  SRHE  was  not  found  in  our  library.”  [Female Teacher]

Health professionals gave similar answers when asked if the instructors had sufficient training and experience to impart the sessions on sexual health.  They believed that the lesson should be taught by qualified educators or specialists.

One health worker stated that:

‘‘I  think  well  trained  teachers  should  teach  the  lesson,  and  they  must  get  trusted  reading  materials  to  refer  to’’  [Male,  HW].

Furthermore, students  reported  that  none  of  them  trusted  reading  materials  or  books  found  in  their  library  to  refer. But  they  read  some  times  from  internet  or  learn  from  peers,  this  may  not  be  trusted  and  could  negatively  affect  their  life.

2.3 Discomfort with sexual health terminology

During  individual  interviews  several  school  teachers  stated  how  it  was  difficult  to  teach  the  sexual  health  terminology  (language  for  the  female  and  male  anatomy)  in  terms  of  emotional  reactions  from  the  students.  When  talking  about  the  appropriate  sexual  health  terminology, teachers have  experienced students' immature  behavior,  reaction  and  discomfort.

One schoolteacher reflected as:

‘‘Students know them differently than their scientific term. They [students] thought  it  funny  and  offensive because  of  the  language  or  the  words is  culturally  taboo”  [Male  teacher]

According to other health care workers, societal norms and the local setting still view sexual content as a sensitive topic.  It was uncomfortable to discuss openly about sex education with teachers, students, and healthcare workers. 

“ I  think  not  only  students  but  also  some  teachers  and  HCWs  fear  using  scientific  terminologies  appropriately.  Influenced  by  their  culture,  maybe  some  of  them  might  have  found  it  funny  and  offensive  word  to  discuss  openly’’  [Female  teacher]

2.4 Cultural and religious barriers

We identified that religion and social norms may be the cause of teenagers' inability to learn about sexual health, have conversations about it, or receive services that encourage high-risk behavior. 

One of the health workers said:

‘‘Many people were embarrassed to talk about their sexual problems. So,  government  and  NGOs  should  focus  on  to  create  awareness  in  community.’’[HCW, Female]

Theme 3 Suggestions to improve SRHE

The third subject, which emerged from the three sub-themes (health promotion policies, creation supportive environments, and Avoiding obstacles) were the identified sub-themes. All participants suggested that several places where health promotion can be carried out, including community centers, schools, and health posts. Remembering that various young people require varied methods and messages based on their age, living and family arrangements, and educational standing is crucial in all circumstances.

3.1 Health promotion policies

Effective school health programs are one of the key tools for addressing significant health risks among teenagers and including the education sector in efforts to alter the social, cultural, and educational environments that place adolescents at risk. Accordingly, most of the key  informants  suggested  that the curricula should be comprised and revised to deliver the  following contents: reproductive  anatomy  and  physiology, fertility,  family planning, pregnancy  and  childbirth and  STIs/STDs including HIV  as  one  subject  independently. Adolescent health promotion can take many forms, such as family life education, peer education, community dialogue, and school-based instruction. Promotional events can be held at the health post, in the community, and in schools.

3.2   Creating supportive environment

During  IDIs  and  FGDs majority of  the  participants  regarded  the  development  of  religious,  community  and  family  involvements  as  the  essential  components  to  improve  school  based  SRHE. In order to influence good behavioral changes, we must actively train or raise awareness of SRH among elected officials, kebele officials, religious leaders, and community leaders. This will enable adolescents to support access to services and information. It  was  suggested  that  educators  should  be  supported  by  special  training  and  accessing resources/ materials that support them. Additionally, it was suggested that an instructor should be able to build rapport with the pupils, grab their interest, and inspire trust in him.

3.3 Avoiding obstacles

According to this study school-based reproductive health education was affected by misperception and misunderstanding the risks of SRH issues. Therefore, various stakeholders-community members, parents and religious leaders– along with government and NGO support, should be involved in supporting adolescents’ SRHE both in schools and outside of them. 

Discussion

This study aimed to explore  the  school-based  sexual  and  reproductive  health  education  and  its  challenges  among adolescents  in  selected  five  secondary  schools  and  four  health  centers  in  Arsi  zone,  Ethiopia. Based on the study's findings, nearly all participants thought that providing school-based SRHE would improve the sexual health of teenagers.  Furthermore, some of the participants pointed to age-appropriate education that takes personal values and views into account. To enable teenage students to preserve and promote, SRHE that is customized based on age, knowledge and skill demands, and cultural and religious values is required.  However,  the  study  showed  that  the  CSE  was  not  introduced  to  the  curriculum  to  address  sexual  health  problems  for  adolescents.  Findings  from  the  Iran  and  Chile  studies  (quoted  above) demonstrate  that  age  related  SRHE  is  essential  to  prevent  adolescents  from  any  sexual  risk  behaviors(11,12).  The  present  study  showed  that  the  existing  curriculum  had  not  included  pertinent  lessons  like  contraceptive  methods,  anatomy  and  physiology  of  SRH  in  detail. This result is in line with other studies where participants felt that anatomical and physiological aspects of the genital organs should be considered as crucial components of SRHE.  They felt that a lack of understanding about sexual and reproductive health, specifically the structure of the reproductive organs, could encourage situations that harm these organs and jeopardize people's health (11). Studies reveal that condoms and hormonal birth control are not permitted to be provided in schools by several school-based health programs because they focus on abstinence for adolescents (13). 

According to the study's findings, every participant said that SRHE needed to address the psychological and physical changes that come with puberty.  Specifically, every health care worker came to the conclusion that describing the physical and mental changes that happen during this time is essential when teaching adolescents about puberty.  Further, the majority of the  key informants reported the  necessity  of  teaching  about  high-risk  behaviors  for  adolescents  and  revising  the  curriculum  content.  School  teachers  explained  that  in  the  Ethiopian  education  system,  SRHE  is  not  adequately  delivered  and  offered  to  students.  These  findings  are  similar to previous  studies  conducted  in  India(14).  In  the  sub  theme  of  current  school  based  SRHE,  the  approach  of  teaching,  curriculum  content  and  students’  knowledge were justified by the participants as being essential. The effectiveness of SRHE was found to be significantly influenced by education, brainstorming, discussion, and idea sharing among the participants. This  is  similar  with  the  previous  studies  conducted  in  India  and  Fiji  (14,15).  However,  it  is  suggested  by  several  literature  that  the  key  focus  of  the  SRHE  should  be  comprehensive  and  strategic  (11,16,17).

In  this  study  the  theme was extracted  as  implementation  obstacles  in  SRHE.  There  are  several  factors  that  influenced  the  delivery of SRHE  like  lack  of  teacher’s  confidence  and  knowledge,  lack  of  resources,  discomfort  with  terminology,  cultural  and  religious  barriers  were  identified  as  sub-themes.  This  is  also  in  line  with  the  study  conducted  in  different  countries  using  systematic  review  and  meta-analysis (2).

The school-based reproductive health education is associated with improved reproductive health outcomes, such as postponed sexual initiation, fewer sexual partners, and higher usage of contraceptives. Increasing risk awareness and knowledge about STIs and pregnancy, values and attitudes toward sexual topics, self-efficacy (managing condom use or refusing unwanted sex), and intentions to abstain or limit the number of sexual partners are just a few of the positive effects that many programs have had on the factors that determine risky sexual behaviors (4,16,18). However, the  study  described  more  barriers  in  the  providing  of  SRHE  and  teaching  approach  factors.  The  key  barriers  were  the  availability  of  guidebooks and  syllabus  for  teaching, lack of teachers knowledge and skill on the subject matter(19). Further obstacles to the implementation of SRHE include the topic not being required, teachers' discomfort delivering SRHE since they are not well-trained, a lack of resources, parents' fear of a bad reaction, and the fact that the subject is not examinable.  These obstacles are comparable to those in other nations with low and medium incomes. According to a different systematic review and meta-analysis study on school-based SRHE, successful CSE begins in primary schools (18).

This  study  used  a  diverse  group  of  study  participants  including  school  teachers,  students  and  HCWs  to  explore  the  school  based  SRHE  and  its  challenges  for  adolescents.  It contributes to the richness and integrity of data.  One drawback of the current study was that it did not take into account the opinions of parents, civil society organizations, the ministry of education, or policy makers. Another of this study's shortcomings, similar to previous qualitative research, is the non-generalizability of the findings.

Conclusion

This study showed that school-based reproductive health education improves reproductive health outcomes, such as delayed sexual initiation, fewer sexual partners, and higher contraceptive use. It increases awareness and knowledge about STIs and pregnancy, values and attitudes toward sexual topics, self-efficacy, and intentions to abstain or limit sexual partners. However, the current SRHE is neither compulsory nor comprehensive. Its  implementation is hindered by  structural  and  individual  factors, such as  lack of appropriate  curriculum, teachers’  confidence  and  knowledge,  teaching  aids  /resources,  and  cultural  and  religious  beliefs.  Further studies should focus on curriculum analysis and community perceptions to enhance SRHE practices.

Acknowledgements

This article is part of a PhD thesis, approved and supported by the University of South Africa (Unisa). The authors are thankful to the study participants who volunteered to participate by sharing their views. The authors are also thankful to UNISA and Research Directorate of the Department of Health and Education of Arsi zone for granting permission to conduct the study.

Conflicts of interest

Authors declared no conflicts of interest.

Funding

Financial support was done by Arsi University (CoHS/2020). The funding agency played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Ethical approval

Permission to conduct the study was obtained following ethical approval from the Higher Degrees Committee of Department of Health Studies at the University of South Africa (UNISA) (Ethics Code:REC O127 14-039 (NHERC)). All ethical aspects were adhered to, and the Arsi zone Education and Health Office. Zonal Department of Health and Education Research Directorate granted permission to conduct the study. Strict conditions of confidentiality were maintained. To assure confidentiality, trained data collectors were sourced from the university. Higher Degrees Committee of Department of Health Studies at the University of South Africa approved the protocol of this study (code number REC O127 14-039 (NHERC).

Authors’ contribution

All authors contributed to the conception and design of study. DB drafted the first version of the manuscript. HD revised the manuscript and critically reviewed the manuscript for important intellectual content. All authors read and approved the final manuscript.