Skip to main content
NCBI home page
HHS Author Manuscripts logoLink to HHS Author Manuscripts
. Author manuscript; available in PMC: 2021 Apr 23.
Published in final edited form as: Am J Sex Educ. 2018;14(4):466–489. doi: 10.1080/15546128.2019.1626311

Key factors influencing comfort in delivering and receiving sexual health education: Middle school student and teacher perspectives

India D Rose 1, Lorin Boyce 1, Colleen Crittenden Murray 1, Catherine A Lesesne 1, Leigh E Szucs 2, Catherine N Rasberry 3, J Terry Parker 3, Georgi Roberts 4
PMCID: PMC8064695  NIHMSID: NIHMS1673043  PMID: 33897308

Abstract

Sexual health education (SHE) provides students with knowledge and skills to establish healthy relationships, understand sexual development, and prevent risk behaviors; therefore, it is critical to understand how to optimize the delivery and receipt of this education. Using a grounded theory approach, interviews with middle school health education teachers (n=13) and focus groups with students (n=41) were conducted to examine factors that influence perceived comfort delivering and receiving SHE in a public school district. Findings identified key barriers including disruptive behavior, insufficient time, and lack of dedicated classrooms. Some key facilitators to comfort included professional development and establishing ground rules.

Introduction

Young people in the United States are at disproportionate risk for human immunodeficiency virus (HIV), sexually transmitted infections (STIs), and unintended pregnancy in comparison to other age groups (Centers for Disease Control and Prevention [CDC], 2017). The evidence on the positive impact that sexual health education can have on behavioral outcomes is quite strong (Haberland & Rogow, 2015; Kirby, Laris, & Rolleri, 2007). Sexual health education aims to impart young people with information they need to make informed decisions about their sexual health (Mueller, Gavin, & Kulkarni, 2008), and provides students with the knowledge and skills necessary to understand sexual development, establish healthy relationships, prevent HIV/other STIs, and unintended pregnancy, and become healthy adults (Buston, Wight, Hart, & Scott, 2002). Sexual health education has been shown to delay initiation of sexual intercourse, reduce sexual activity and number of sexual partners, increase condom or contraceptive use, and improve academic achievement (Kirby, Laris, & Rolleri, 2007; Ma, Fisher, & Kuller, 2014).

Schools provide a natural setting for young people to receive information about sexual health, as one of the primary functions of school is to educate. Specifically, middle schools have access to youth early in adolescence (ages 11 to 13 years), a time of exploration as well as a time when youth develop abstract thinking and a sense of identity, and engage in risk-taking behaviors (Kar, Choudhury, & Singh, 2015). Middle school represents a developmental period of growth, adjustment, and change for students both academically and physically. For many students, middle school is also their first exposure to a health education class that may include lessons on sexual health topics such as puberty, the reproductive system, abstinence, and the development of healthy relationships, making it even more important to create a comfortable environment to begin engaging students in this critical topic. The prevalence of sexual risk behavior among high school students highlights the importance of providing sexual health education during middle school (CDC, 2018). Sexual health education for middle school students may mitigate factors that place them at risk for HIV, STDs, and pregnancy. Previous research identifies two key benefits to including sexual health education at this age. First, intervening during middle school will allow the intervention to occur prior to the onset of the behavior for many students (Marsiglia, Kulis, Yabiku, Nieri, & Coleman, 2011). Youth Risk Behavior Survey data shows that among high school students, a sizeable portion have engaged in sexual risk behaviors and experiences (CDC, 2018). Second, middle school students are developmentally different than high school students and may be particularly receptive to prevention messages and skill-building activities (Marsiglia et al., 2011). This evidence suggests that middle school provides an important opportunity for sexual health education aimed at reducing sexual risk behaviors (Byers, Sears, & Foster, 2013).

The landscape of sexual health education in the United States is changing. A recent study showed a significant reduction in students’ receipt of formal sexual health education (Lindbert, Maddow-Zimet, & Boonstra, 2016) and a decline in the number of states requiring formal sexual health instruction (Guttmacher Institute, 2019). According to Guttmacher Institute (2019), 24 states and the District of Columbia mandate sexual health education in schools and 37 states require that information on abstinence be provided. Given these recent declines in receipt of formal sexual health education, it is important to ensure teachers are adequately prepared and comfortable to deliver sexual health education to middle school students. Additionally, previous studies show that there are a number of factors that could impact teachers’ delivery of health education (Vamos & Zhou, 2007) and, more specifically, their delivery of sexual health education (Eisenberg, Madsen, Oliphant, & Resnick, 2012; Fisher & Cummings, 2016). Comfort has been identified as one of those factors (Cohen, Byers, & Sears, 2012).

Sexual health education works best in classrooms where there is mutual trust and comfort for both teacher and student (Mkumbo, 2012). In terms of sexuality education teaching, comfort has been expressed in the context of teacher’s knowledge about sexual health as well as their comfort in teaching and discussing sexual health topics (Cohen, Byers, & Sears, 2012; Mkumbo, 2012). In addition, teachers’ comfort has also been associated with their coverage of sexual health topics and ability to address student reactions to sexual health content as well as other classroom management issues (Mkumbo, 2012; Ninomiya, 2010). The majority of studies that examine teacher comfort in delivering sexual health education have included quantitative measures (Cohen, Sears, Byers, & Weaver, 2004; Mkumbo, 2012). Cohen and colleagues (2004) conclude that a clearer picture of teacher’s perceptions and experiences is needed and that qualitative research would be a better way to elucidate the challenges teachers face when teaching sexual health education.

Highly qualified and trained teachers are necessary to help young people gain the functional knowledge and skills necessary to become healthy and productive adults (CDC, 2012). Successful implementation of educational curricula rests, in part, with the health education teachers that deliver them (Escribano, Espada, Orgiles, & Morales, 2016; LaChausse, Clark, & Chapple, 2014). Previous research suggests that sexual health education needs to be taught by individuals who are comfortable discussing sexuality, use multiple teaching strategies, and encourage young people to ask questions (Byers et al., 2003; Byers et al., 2013). It was found that middle school students, in particular, have a more favorable perception of sexual health education when their teacher is comfortable with the subject matter (Byers et al., 2013).

Although many factors, including amount of training received, teacher’s knowledge level, resources available, and personal beliefs, affect sexual health education implementation, obtaining greater insight into what increases comfort among middle school students during sexual health education may lead to increased student engagement, improved knowledge and skills about sexual health, and subsequently, the development of safer sexual health behavior practices (Byers et al., 2013). Quantitative studies have examined young people’s perceptions of the quality of the sexual health education they receive at school (Byers et al., 2013); however, fewer studies have qualitatively examined factors that specifically influence their comfort in the classroom.

Given the impact that sexual health education can have on student health outcomes (Kirby, Laris, & Rolleri, 2007; Ma, Fisher, & Kuller, 2014), it is imperative to identify key factors that influence both teachers’ and students’ level of comfort with sexual health education. Building on previous work conducted by Murray et al. (in press) that examined the influence of health education teacher characteristics on students’ health-related knowledge gains, the present study goes a step further to identify how comfort, in particular, impacts teachers’ delivery of sexual health education. This study had two primary aims: (1) identify factors that diminish or enhance middle school health education teachers’ comfort implementing sexual health education, and (2) identify factors that diminish or enhance middle school students’ receipt of this education. For the purpose of this paper, the authors’ use of middle school refers to sixth grade students and health education teachers.

Methods

Health Education Curriculum

Middle school students from a large, urban school district in the southern region of the United States were provided health education in a year-long class using HealthSmart (ETR, Kane, & Telljohann, 2012), a packaged curriculum which was then further adapted to meet additional content requirements and to fit into the allotted class time. The curriculum included a subset of 10 sexual health lessons taught to all sixth grade students over the course of the 2015–2016 and 2016–2017 academic years. The sexual health lessons were delivered to both same- and mixed-gender classes in accordance with individual middle school administration preferences. Middle school lessons included topics on puberty, personal health, male and female reproductive system, healthy relationships, benefits of abstinence and pregnancy prevention. The curriculum is aligned with the Characteristics of an Effective Health Education Curriculum (CDC, 2015a), and National Health Education Standards (CDC, 2015b). All teachers that delivered the curriculum received extensive professional development opportunities provided by both internal and external professional development providers, including training on the curriculum and personalized coaching.

Eligibility Criteria

A convenience sample of middle school health education teachers and middle school students were recruited for this study. To be eligible for an in-depth interview, teachers must have (1) taught health education for at least one semester using the adapted curriculum and (2) attended at least two of the school district’s four PD events focused on the implementation of the sexual heath lessons during the 2015–2016 academic year. For student focus groups, the participating school district identified four middle schools to serve as study sites. These schools were selected based on key characteristics including school size, number of students, location, socioeconomics, and racial/ethnic makeup of the student body. Students must have been enrolled in a health education class in the last 12 months to be eligible for a student focus group. Due to a small sample of middle school students participating in the spring 2016 data collection, additional student data were collected in spring 2017. The eligibility criteria remained the same for the 2016–2017 academic year focus groups. The study was approved by ICF’s Institutional Review Board (IRB) and the Research Review Board of the participating school district.

Procedures

Health Education Teachers

Using input from district staff, interview participants were selected in a purposeful manner, trying to include (1) teachers from multiple schools, ensuring representation from the schools where student focus groups were conducted, (2) teachers that the district perceived to cover a range of skill-level and experience, and (3) a roughly equal number of teachers with and without health-related degrees, with and without dedicated classrooms, and who did and did not serve as athletic coaches. Of the 46 middle school health education teachers, 8 did not attend at least two PD events during the 2015–2016 academic year. Of those remaining, 18 were invited to participate in interviews. Of the 18 invited teachers, 13 agreed to be interviewed, and all 13 semi-structured, in-depth interviews were conducted in spring 2016 in a private location at the respondent’s school, usually in the teacher’s classroom during their planning period. Prior to the start of each interview, informed consent was obtained from each participant. Each interview lasted approximately 45 to 60 minutes and was audio recorded for transcription and thematic analysis. Following each interview, participants received a $20 gift card for their time and participation.

Students

In spring 2016, middle school students were recruited for focus group participation through their health education classes. To increase student participation in spring 2017, students were recruited from afterschool programs in their respective middle schools. An active parental permission form, which included the purpose of the study, was sent home with all 6th grade students in spring 2016 and all 6th grade students who participated in the after-school program in spring 2017. Each student was responsible for obtaining their parent’s signature and returning the form to school in order to participate. Of the 59 signed permission forms received, a total of 41 middle school students (n=11, spring 2016; n=30, spring 2017) participated in one of seven focus groups between spring 2016 (n=3 groups) and spring 2017 (n=4 groups).

Focus groups were purposefully segmented by gender in order to facilitate open discussion among the participants. Four groups included only female students and three groups included only male students. Focus groups were held after school in a designated classroom. In addition to obtaining parental permission for each student, verbal assent was obtained from each student prior to the start of each group discussion. Focus groups lasted approximately 60 to 90 minutes and were conducted by two experienced data collectors, one serving as the focus group moderator and the other serving as the note taker. All focus groups were audio recorded for transcription and thematic analysis. At the conclusion of each discussion, students received an incentive valued at $30 (i.e., gift card, water bottle, and/or movie tickets) for participation.

Participant Characteristics

The interview sample included eight male and five female middle school health education teachers. Of these 13 teachers, five reported having a health-related degree (e.g., health education, public health). Teachers’ self-reported experience teaching health education ranged from 1 to 15 years. The majority (n=10) of health education teachers reported that they were also physical education (PE) or athletic coaches and almost half (n=6) reported they did not have a dedicated classroom for teaching health education. The student focus group sample included 41 middle school students, of whom 16 were male and 25 were female. All students were in 6th grade and ranged in age from 11–13.

Instruments

Teacher Interviews

Teacher interviews examined teachers’ perceptions of and experiences with teaching the adapted curriculum with a focus on the sexual health education content. A semi-structured teacher interview guide was developed through an iterative process of reviewing existing measures (Perez, Luquis, & Allison, 2004), extant literature, consultation with experts in the field, and pilot testing with a convenience sample of former health education teachers. The pilot test was conducted to examine comprehension of the interview guide questions in an effort to adjust the guide accordingly before embarking on the full study. Based on feedback from the pilot test, the interview guide was modified prior to data collection. The final guide consisted of 19 open-ended questions focused on the following domains: teacher background/experience, teacher attitudes, comfort and confidence related to sexual health education, and teacher delivery of sexual health education lessons. Table 1 presents sample questions from the teacher interview discussion guide.

Table 1.

Sample teacher interview discussion guide questions

Discussion guide domain Interview questions
Teacher background/experience What grade level are you currently teaching?
How many years have you taught health education to youth in school? What about sexual health education?
Teacher attitudes, comfort, and confidence related to sexual health education When you were asked to teach about sexual health for the very first time, how prepared did you feel to help students develop the skills they need to prevent STDs/HIV and pregnancy?
How comfortable are you with teaching sexual health education?
Overall, how confident would you say you are with teaching sexual health education to middle school students?
Teacher delivery of sexual health lessons Was there anything about the sexual health lessons that you felt made it more difficult to effectively teach your students about sexual health?
Were there any specific sexual health lessons or parts of lessons that you did not teach according to the district’s pacing guide?
Were there any additional lessons or activities that you incorporated into your teaching that were not included in the district’s planned curriculum (or the supplemental materials provided by the district)?
Open in a new tab

Student Focus Groups

Student focus groups gathered students’ perceptions about their teachers’ delivery of the sexual health lessons and focused on understanding students’ experiences of the sexual health education lessons specifically. The student focus group guide was developed through an iterative process of reviewing existing measures, extant literature, consultation with experts in the field, and pilot testing with students of similar age. Minor modifications were made to the discussion guide to enhance comprehension and expand on themes for the spring 2017 focus groups, but the general question content was not changed. The final discussion guides included 17 (spring 2016) and 14 (spring 2017) open-ended questions in the following domains: student background and knowledge of sexual health topics, student perspectives on how teachers taught sexual health lessons, and student attitudes and perceptions about abstinence, puberty, and healthy relationships. Table 2 presents sample questions from the 2016 and 2017 student focus group guides.

Table 2.

Sample student focus group discussion guide questions

Discussion guide domain Focus group questions
Student background and knowledge When you found out you were going to talk about abstinence, puberty, and relationships in your health class, how did you feel? What were you hoping to learn?
Student perspectives on how teachers taught sexual health lessons Did you like the way your teacher taught health? Why or why not?
Tell us about any questions that your teacher would not answer or could not answer?
Other than the teacher reading information to you, what types of class activities do you remember doing in the abstinence and puberty lessons?
How did your teacher make the classroom a comfortable place to talk about these things?
Student attitudes/perceptions about abstinence, puberty, and relationships What are some of the benefits to being abstinent that you learned about in your class?
What did you learn that helped you feel more confident you can wait to have sex?
What did you learn in health class that changed the way you think about risky situations?
Open in a new tab

Data Analysis

The study team utilized a grounded theory approach with constructivism as an interpretive framework (Glaser & Strauss, 1967; Polit & Beck, 2014). Grounded theory is a qualitative approach that was designed to capture the experiences of participants. Constructivist grounded theory emphasizes the multiple realities and complexity of individuals (Charmaz, 2006). The essence of this constructivist paradigm is to develop a data-driven understanding of facilitators and barriers which influence teachers’ comfort while teaching and students’ comfort while learning about sexual health education.

Audio files from the teacher interviews and student focus groups were transcribed verbatim. Qualitative data were managed and analyzed using Atlas.ti, a qualitative data management software (Muhr, 2013). Initial codebooks were developed based on the key questions of interest and relevant constructs from existing literature. Team members discussed each code to reach agreement on a final code list, and developed an accompanying coding dictionary. To reach inter-coder agreement, team members were given segments of text from randomly selected interview and focus group transcripts and applied relevant codes to each segment of text. Inter-coder reliability was achieved at Fleiss Kappa =.90. Coders discussed three codes that had a kappa statistic of less than 0.75. Once discrepancies were resolved and inter-coder reliability was established, two experienced team members coded data using an inductive, open coding analysis approach. Next, reviewers applied axial coding techniques to categories and sub-categories to identify relationships among coded segments (Denzin & Lincoln, 2005; Corbin & Strauss, 1990; Corbin & Strauss, 2008).

Lastly, constant comparison strategies were used to compare and contrast the data (Corbin & Strauss, 1990). Coded segments within the teacher interviews and student focus groups were then grouped into themes. Similarities and differences in themes between teacher and student data were explored, and coders compiled a list of quotations which represented salient themes. Triangulation using interview and focus group data, extant literature, and study team expertise and experiences allowed for a deeper understanding of the key factors influencing comfort teaching and student learning about sexual health (Patton, 2002).

Results

Several parallel, recurrent themes emerged from the teacher interviews and student focus group data. Findings were grouped into three thematic categories which are described in the sections that follow: gender-related factors that impact comfort in sexual health education; barriers to comfort in delivering and receiving sexual health education; and facilitators to comfort in delivering and receiving sexual health education. Although the purpose of this research was to examine the barriers and facilitators to comfort in delivering and receiving sexual health education, gender-related factors were pulled out as a separate theme given that they emerged as impacting comfort in the classroom under discussion of both barriers and facilitators. Factors associated with each theme are presented in Table 3.

Table 3.

Mention of interview and focus group themes by participant group

Themes and subthemes
 Health Education Teachers (n=13) Middle School Students (n=41)
Gender-Related Factors that Impact Comfort in Sexual Health Education
Teacher-student gender discordance ✓ ✓✓
Mixed-gender classrooms ✓ ✓
Barriers to Comfort in Delivering and Receiving Sexual Health Education
Dealing with disruptive behavior ✓✓ ✓
Not having a dedicated classroom ✓
Not having sufficient time for sexual health lessons ✓✓ ✓
Discomfort with sexual health terminology ✓ ✓
Answering student questions about sexual health ✓ ✓
Facilitators to Comfort in Delivering and Receiving Sexual Health Education
Professional development ✓
Establishing ground rules ✓✓ ✓
Normalizing lesson content ✓
Use of the question box ✓ ✓
Open in a new tab

Note: ✓ indicates that the subtheme was mentioned by a particular group (teacher and/or student). ✓✓ indicates that the subtheme was more prominently mentioned by one group versus the other (teacher vs. student).

Theme 1: Gender-Related Factors that Impact Comfort in Sexual Health Education

The first theme, gender-related factors that impact comfort in sexual health education, consisted of two subthemes: teacher-student gender discordance and mixed-gender classroom. Our findings suggest that gender influences teacher and student comfort with the sexual health lessons.

Teacher-Student Gender Discordance.

Several male health education teachers expressed discomfort teaching sexual health lessons, specifically lessons about the reproductive system, to female students. One male health education teacher specifically mentioned feeling “somewhat uneasy” about the idea of teaching this to the female students in his class. Another male health education teacher shared that, “Some of the female students wouldn’t feel comfortable with me teaching them this [sexual health] lesson” [Male teacher, 1 year teaching health education]. These findings were complementary to what was shared in the student focus groups. Both male and female students perceived that their health education teachers showed more discomfort when talking to students whose gender is different than their own about certain lessons such as puberty and the reproductive system. It is important to note that not only were these students and teachers not necessarily from the same classes, a student’s perception of a teacher’s discomfort does not necessarily mean the teacher was uncomfortable teaching sexual health education. Some middle school students shared:

“I think she was uncomfortable because she has a woman’s body and she had to explain the parts about the boys.” – Female student

“The one thing I think that she really wasn’t comfortable talking about was the male reproductive system.” –Male student

Mixed-Gender Classrooms.

Having mixed-gender classrooms also appeared to influence students’ comfort level during the sexual health lessons. Middle school students indicated that being in mixed-gender classrooms during the sexual health lessons was uncomfortable due to the disruptive and immature behavior of the male students. A few male students and several female students stated that they preferred that boys and girls be separated for the lessons on sexual health but also expressed interest in learning the same content including both male and female anatomy. One student noted: “The girls can learn both of the things [male and female anatomy] but wouldn’t have to be worried about the boys” [Female student]. These views were expressed by many students including those who were in same gender classes and those who were in mixed-gender classes. In response to asking students how the teacher made the classroom more comfortable, a student stated that the teacher, “separated the boys and girls before [they] started the [sexual health] lesson” [Male student].

There were mixed perceptions about gender-related factors and sexual health education among teachers. One teacher noted, “the gender mixing was probably something that stood out to me as kind of a barrier, that it might’ve been more effective if we would’ve been able to have the boys separate from the girls” [Male teacher, 7 years teaching health education], while other teachers reported being “confident” and experiencing little to no discomfort with teaching mixed-gender classes. Although male teachers expressed some discomfort teaching female students about sexual health education, teachers overall indicated that the professional development offered by the school district helped address their discomfort in the classroom and helped them to alleviate discomfort for their students.

Theme 2: Barriers to Comfort in Delivering and Receiving Sexual Health Education

The second theme, barriers to comfort in delivering and receiving sexual health education, included 5 subthemes: dealing with disruptive behavior, the need for a dedicated classroom, insufficient time for the sexual health lessons, discomfort with sexual health terminology, and answering student questions about sexual health.

Dealing with Disruptive Behavior.

Challenges with classroom management were a major barrier to comfort when teaching the sexual health lessons. Several health education teachers discussed how dealing with disruptive behavior impacted their ability to deliver the sexual health lessons. Health education teachers mentioned that there was diversity of maturity among students and there were instances when students would disrupt the rest of the class. Some health education teachers focused on the young age of the middle school students. One health education teacher stated:

“With this age group, they’re 11, 12, 13 years old. Most of them, mostly my students are mature enough to handle it, however, I do have a few that don’t handle it as well or they’ve never had any exposure to anything sex related and they just don’t know how to respond to it.” – Male teacher, 2 years teaching health education

Similar to health education teachers, students also expressed parallel concerns that some of their peers might be too immature or “not ready” for the sexual health topics. Students shared that “a lot of people [in their class] were immature” which resulted in students not paying attention. Students perceived their teacher to be “somewhat comfortable” during the sexual health lessons, but indicated that their “classmates didn’t feel comfortable because they’re just too immature and they play around too much” [Male student]. Another student shared, “she [the teacher] really didn’t feel comfortable talking to us about it [sexual health education], because a lot of kids in the classroom were immature” [Male student].

The Need for a Dedicated Classroom.

Health education teachers indicated that not having a dedicated or permanent classroom space assigned to teach health education, not only impacts their ability to deliver the sexual health lessons, but it also heightens student discomfort with the lesson content.

“We don’t have a classroom. We don’t have a set health classroom where we can go. The girls have a class of 52 [and are taught] in the upper cafeteria, which if you think about it, imagine how chaotic it is. It is crazy with a capital C.” – Male teacher, 2 years teaching health education

“It’s just chaos. It’s loud. They’re cleaning, and they’re cooking. It’s a distraction. On top of trying to teach some of this stuff [sexual health education], you’ve got all this noise and distractions in the cafeteria. People are coming in and out all the time. That makes it a little bit more difficult.” – Female teacher, 3 years teaching health education

Health education teachers shared that it is sometimes difficult to create a safe and supportive learning environment for students when they do not have a dedicated classroom space.

Insufficient Time for the Sexual Health Lessons.

Lack of time was a major barrier to teaching the sexual health lessons. Several health education teachers mentioned needing more time to complete the lessons and activities. Health education teachers noted that for several lessons, they would run out of time before teaching all of the material. One teacher shared, “I felt like I didn’t have enough time to teach it [sexual health lessons] all” [Male teacher, 3 years teaching health education]. Several teachers shared that there was not sufficient time to implement the sexual heath lessons due to a mismatch between curriculum requirements and available class time. Some teachers were on block scheduling (i.e., 90 minute class periods), while other teachers had a shorter class period. Teachers with shorter class periods shared that they needed more time to cover sexual health topics, such as the reproductive system, and stressed the importance of having a slower pacing guide for the curriculum for middle school students especially. Health education teachers also specifically mentioned that there was little time for students to practice skills taught in class. One teacher commented, “Most of the lessons where it has us practicing the skills—like refusal skills, I feel like we run out of time at the end to really have the kids practice that” [Female teacher, 5 years teaching health education]. Several teachers described the sexual health lessons as being “time constrained” and “rushed” and felt that they weren’t able to devote “quality time” to these lessons.

When students were asked whether or not the teachers had enough time to cover the sexual health lessons, they shared similar responses. Several students indicated there was not enough time to finish the lessons. One student stated, “We didn’t spend much time on it [sexual health lessons], on the abstinence, or the puberty part, or whenever we talk about the body parts” [Female student].

Discomfort with Sexual Health Terminology.

Health education teachers discussed how the sexual health terminology (e.g., language for female and male anatomy) included in the lessons was challenging to teach because of students’ reactions and responses. Teachers perceived students’ immature behavior during the sexual health lesson as an expression of discomfort, and this was most evident when using correct sexual health terminology. One health education teacher commented, “These are roughly 11-, 12-year-olds, maybe some 13-year-old kids. They know what certain words are. I know they know them differently than their scientific term and how they would react to those words” [Male teacher, 3 years teaching health education]. Another health education teacher mentioned:

“Well, I don’t know. Maybe some of the verbiage in there. The students, they wasn’t used to the verbiage, and when they would hear certain words, hear me say certain things, it just was disturbing for them. Some of them might have found it funny; some of them might have found it offensive. That was a difficultly, maybe sometimes the verbiage or words.” – Male teacher, 1 year teaching health education

This finding is complementary to the student focus groups where students indicated that using proper or correct sexual health terminology, particularly related to behaviors or anatomy made them uncomfortable. Young people often use slang or vague terms to discuss sex and anatomy. One student stated, “Because sometimes it’s just hard for me to say a word, even though I know it’s not a bad word, but in my brain, it’s just an uncomfortable word to say” [Female student]. Another student described how students would avoid using sexual health terminology in class, “Instead of saying to not do sexual activity for abstinence, we’ll just say not to do it” [Male student].

Answering Student Questions about Sexual Health.

In addition to using sexual health terminology, answering student questions about sexual health served as a barrier to comfort teaching about sexual health. Some health education teachers indicated that they were knowledgeable of sexual health content, but shared they were not always comfortable answering student’s questions, specifically questions about sexual orientation and gender identity. Some teachers noted that they received more questions during sexual health lessons than in the other content areas. One health education teacher commented, “I think I’ve had more questions from them about basically every little thing about sexual health than I had from my previous four units” [Male teacher, 2 years teaching health education].

Similarly, students perceived teachers did not answer some questions because they did not feel comfortable answering and were nervous about students’ responses. One student noted, “She did speak on it [reproduction]; but only once, because kids, over and over asked to hear about it, and they would be very immature” [Male student].

Theme 3: Facilitators to Comfort in Delivering and Receiving Sexual Health Education

In addition to sharing barriers to comfort, health education teachers and students provided examples of facilitators that increased their comfort delivering and receiving sexual health education. These are captured in the third theme,, which included four subthemes: professional development, establishing ground rules, normalizing content, and using the question box.

Professional Development.

The majority of health education teachers indicated that the professional development provided by the school district helped increase their comfort in the classroom. Teachers shared that the professional development offered by the school district helped them address disruptive behavior, manage classroom dynamics, and discuss sensitive sexual health topics. Teachers also mentioned that the professional development helped them to create a safe learning environment for students. Specifically, health education teachers felt that professional development better prepared them to teach the sexual health lessons:

“After my professional development I would say though, I felt more prepared to teach and to implement classroom management techniques for the unit specifically and as well to create that safe and positive learning environment for the students for the human sexuality instruction.” – Male teacher, 1 year teaching health education

“Then the in-services, I think, really helped with comfort in terms of presenting material that might be uncomfortable to talk to sixth graders about. The in-services where we did teach backs and practiced with our own age people was really, really helpful because it pointed out some things that you could do and think about. It just made you more comfortable with the subject.” – Female teacher, 2 years teaching health education

Establishing Ground Rules.

In addition to professional development, most health education teachers perceived that they established a safe and supportive environment in their classroom, conducive for teaching the sexual health lessons. The majority of teachers shared that ground rules were established at the start of each semester and helped teachers manage students’ immaturity, described as a barrier to comfort in the aforementioned themes. Although ground rules may not necessarily eliminate that barrier, this management technique helped set behavioral expectations for the sexual health education lessons. Several teachers commented on the importance of ground rules:

“I do feel like we do make a, we are good at creating a comfortable, safe learning environment. When you go over the rules, everything, before even getting into the topic. I definitely feel like we can make it safe for the kids.” – Male teacher, 3 years teaching health education

“When you have those ground rules and those expectations at the very beginning, it eliminates 99 percent of your problems. Because you tell them, “If you’re not mature enough to stay in my class and hear this, you’re out. We can talk about anything we need to talk about as long as you use the proper terminology, and you’re mature enough to handle it.” – Female teacher, 2 years teaching health education

“In the beginning, we had to have a talk about it’s a mature subject, and I expect you to behave in a mature fashion.” – Female teacher, 15 years teaching health education

Although it was not explicitly asked in the student focus group discussion guide, several students mentioned their teacher setting rules at the beginning of class and felt that this helped students feel more comfortable in class.

Normalizing Lesson Content.

Students indicated when teachers were relatable and normalized discussions about sexual health they felt more comfort during the lessons. For example, teachers reflecting on when they first learned about sexual health in school and how they were uneasy about the material helped normalize content and alleviate discomfort among students. Students expressed that their teacher emphasized the material they were discussing as important to their growth and development and would reiterate this whenever students appeared to be uncomfortable during the lessons. Students found the teacher’s positive reinforcement very helpful during the sexual health lessons.

Using a Question Box.

In addition to establishing ground rules and normalizing content, use of a question box, a designated space in the classroom where students place questions related to sexual health, also facilitated comfort in the classroom. The majority of teachers used this tool, which allowed students to avoid asking uncomfortable questions aloud by writing their questions on an index card that was placed in the box before, during, or after class. To mitigate discomfort and potential judgement from peers, teachers would later read and answer the questions collectively for the class. As needed, teachers followed up with individual students to clarify information and explanation with any student who identified themselves via name on the index card. Several health education teachers commented on their use of the question box:

“I think it [the question box] really made a big difference. The anonymous question box where they can put an anonymous card. Some students used it, and I answered them. It was interesting giving them an outlet.” – Male teacher, 3 years teaching health education

“What we do, if it pertains to sex or sexual activity, they have a question; they have to write on a piece of paper. They put into this box. Then, after class, we would approach the kid who wrote that question.” – Male teacher, 2 years teaching health education

Most students reported that their teacher used a question box. One student described, “she had this little box thing with question marks all around it, and she give you a little card to write down the question that you have, and then she would talk to you after the class about it, your question” [Female student]. Students indicated that using the question box helped ease their anxiety about asking questions in class. One student shared, “I loved the question box. It really solved a lot of problems [i.e., asking uncomfortable questions about sexual health] for me” [Male student].

Discussion

This exploratory study was one of the first to examine key influencers of comfort with sexual health education from both the teacher and student perspectives. Our study found several factors that influenced comfort in the delivery and receipt of sexual health lessons. The first factor was gender, including matching the gender of the health education teacher and the gender of the students. This finding is consistent with previous research examining gender implications for teaching sexual health education which found that male teachers are sometimes less comfortable teaching sexual health education (McNamara, Geary, & Jourdan, 2011). Allen (2005) found that girls in single gender sexual health education classes felt able to talk more openly about sexual health and better focus on the information presented in class in comparison to mixed gender classes. Another study reported that female students were more likely to prefer single-gender classes in comparison to male students (Strange, Oakley, & Forrest, 2003). In the present study, female students noted a preference for same-gender versus mixed-gender classes when learning about sexual health content. Although there is variation in the literature regarding the benefits of separating students by gender during sexual health education class (Strange, Oakley, & Forrest, 2003), our findings suggest that it is worth further exploration as students’ reported maturity level may differ in single versus mixed-gender classrooms. This may be particularly salient among middle school-aged students who may be experiencing the physical and emotional changes of puberty while learning about it. There can be challenges to addressing sexual health in mixed-gender middle school classes. Ideally, efforts to support effective sexual health education should be designed to give teachers and students the skills they need to be more comfortable having important conversations about sexual health even when they are in mixed-gender settings. Our findings highlight a need to better understand how to support health education teachers in increasing student comfort and creating a safe and supportive environment within all classes, but particularly within mixed-gender settings. Findings further suggest that sexual health education teachers may have varying degrees of comfort or apprehensions about teaching sexual health content to students of a different gender. If this discomfort in fact leads to poorer delivery of the content, it may warrant further research and action to better support teachers to overcome or work through this discomfort. In particular, training may need to include classroom management skills to address disruptions and challenges specific to sexual health education to students in mixed-gender classes. Opportunities to practice these skills during professional development may also help improve teachers’ own comfort and better prepare them to improve students’ comfort in mixed-gender classes.

In addition to gender-related factors, dealing with disruptive and immature student behavior affects the sexual health education experience for both teachers and students. Teachers described seeing such behavior when teachers would correct sexual health terminology to discuss female and male reproductive anatomy in class. Students expressed increased discomfort when sexual health terminology was used in class and teachers attributed student reactions to maturity level. This finding underscores the need to ensure teachers have the tools to manage student reactions helping students use correct terminology and continuing to normalize the language for them. Students’ maturity level when participating in sexual health education may have a direct impact on both student and teacher comfort in the classroom but students’ reactions to sexual health terminology may sometimes be a response to discomfort and can be appropriately addressed by a well-trained teacher. Our study focused on middle school students who are in early adolescence. Students at this age vary in their growth and development. Developmentally, middle school students may express their discomfort with sexual health lessons in a variety of ways including acting immature or displaying disruptive behavior (Landry, Singh, & Darroch, 2000). Cohen, Byers, and Sears (2012) found that teachers’ willingness to teach sexual health education is greatly influenced by their comfort with addressing differences in students’ maturity and reactions. Increasing teachers’ comfort with dealing with varying maturity levels and classroom management issues may result in improved delivery of the sexual health lessons.

Health education teachers also noted logistical challenges such as not having a dedicated classroom or sufficient time for lessons and the influence these challenges can have on making the environment comfortable and supportive for students to learn. Teachers emphasized the importance of having a dedicated classroom space, especially for the sexual health lessons. Previous research highlights the influence classroom environment has on student learning (Hannah, 2013). Teachers with a dedicated classroom are able to tailor the learning environment to reflect curriculum content as well as integrate technology, which can be challenging without dedicated classroom space (Hannah, 2013).

In addition to not having a dedicated classroom, some health education teachers indicated that they did not have adequate time to complete the sexual health lessons. A possible explanation for this finding is that there is too much content to cover in the allotted class time or teachers are having to use class time to deal with disruptive behavior. Teacher discomfort may arise due to concerns that students are not receiving crucial sexual health content. A future consideration may include allowing teachers to practice an entire sexual health lesson, especially those lessons that cover a great deal of content, in an effort to ensure that all areas of the lesson are covered in the allotted amount of time. Given the impact that teacher delivery has on student-level outcomes, it is essential to ensure teachers have adequate time to teach the sexual health lessons as well as sufficient time for students to practice skill-building activities (Buston, Wight, Hart, & Scott, 2002).

Several health education teachers reported feeling uncomfortable answering students’ questions about sexual health, including questions related to sexual orientation and gender identity. Some health education teachers may not be knowledgeable about topics related to sexual orientation and gender identity. Teachers may also be unsure of how students would react to this content. Our findings underscore the need for on-going professional development and in-service trainings that provide teachers with continued opportunities to learn about sexual health content specific to sexual orientation and gender identity, but also provide teachers with skills-building activities that allow them to role play or practice responding to student questions. Previous research supports providing teachers with high-quality trainings to better prepare them to deliver sexual health education (Murray et al., in press; Wilson, Wiley, Housman, McNeill, & Rosen, 2015; Wood, Rogow, & Stines, 2015). Comfort with answering students’ questions about sexual health may result in increased dialogue between teachers and students about important sexual health topics.

In addition to sharing barriers, health education teachers and students also described facilitators that increased their comfort in delivering and receiving sexual health education. Health education teachers indicated that professional development had a positive impact on their level of comfort teaching. Notably, previous research found that teachers responsible for sexual health education have received little to no formal training or professional development focused on this content area (Eisenberg, Madsen, Oliphant, Sieving, & Resnick, 2010). Other authors support that professional development influences teacher knowledge, perceptions, confidence, and comfort level regarding sexual health education (Cohen, Byers, & Sears, 2012; Rhodes, Kirchofer, Hamming, & Ogletree, 2013).

Establishing ground rules, normalizing content, and using the question box were identified as possible facilitators to comfort in the classroom. The present study found establishing ground rules, collectively agreed upon by the class, allowed students to feel comfortable and open participating in class activities and discussions. In addition to establishing ground rules, normalizing lesson content may help ease student discomfort with some of the sexual health lessons. Consistent with previous research, students feel more comfortable in sexual health education when the content is personalized and the teacher is relatable (Kirby, Laris, & Rolleri, 2005). The present study found that using a question box helps address the barriers associated with asking and answering student questions. Health education teachers should strive to create a safe learning environment that fosters student comfort discussing sensitive sexual health topics (Allen, 2005; Byers, Sears, & Foster, 2013). Professional development opportunities should continue to focus on these strategies given the impact they have on comfort levels for both health education teachers and students.

Limitations

Although these findings provide important insight, this study is not without limitations. Due to the nature of the convenience sample and recruitment from a single school district in a southern region of the United States, the results are not generalizable to a broader set of teacher or student populations. The selection and composition of the teacher and student study samples may have influenced the results of this study. Furthermore, sexuality education state laws and local school policies may vary, impacting what topics can be covered in sexual health education class. This study was limited in its sample size, including 13 health education teachers and 41 middle school students. Albeit small, this study does provide a baseline understanding of factors that influence comfort in delivering and receiving sexual health education in a public middle school setting. Furthermore, our teacher sample was slightly overrepresented by male teachers. Additionally, our study did not match middle school students with their respective health education teachers. Matching health education teachers and students would allow for more meaningful comparisons of the data. Future research should examine student responses in the context of teacher perceptions for the same classes.

Conclusions and Implications for Practice

Collectively, our findings have notable implications for practice. Our study identified several prominent factors that influence comfort, teaching and learning about sexual health. The dual perspectives provide an opportunity to explore ways to increase comfort from the lens of both teachers and students. Although not all teachers in our study sample were dedicated or trained health educators, our findings suggest the importance of having qualified health educators to teach sexual health education. In terms of hiring, school districts may find it helpful to recruit candidates who have a degree or certification in health education. This study also highlights the importance of considering how the following barriers may impact comfort for teachers and students in a sexual health education class and offers considerations for the development of strategies to address them: teacher and student gender-related factors, student immaturity and disruptive behavior, not having a dedicated classroom, insufficient time to cover sexual health content during class, answering student questions, and discomfort with using sexual health terminology. These barriers can be substantial for teachers, and some researchers have explored ways to incorporate online approaches and computer-assisted instruction into sexual health education to enhance student learning experiences and minimize some of these barriers (Chen & Barrington, 2017; Roberto, Zimmerman, Carlyle, & Abner, 2007). Although sexual health education incorporating online platforms has demonstrated some success in shifting student’s sexual health knowledge and attitudes (Evans, Edmundson-Drane, & Harris, 2000), such approaches are best utilized as part of a comprehensive instructional design that uses multiple delivery systems, both teacher- and student-led. Our findings suggest that although barriers exist, they are not insurmountable, and this paper presents facilitators that could help increase teachers’ comfort with delivering sexual health education to middle school students. This study highlighted facilitators that may help increase comfort levels in the classroom including the establishment of ground rules, using a question box, and offering professional development opportunities for teachers to improve classroom management.

To maximize the value of sexual health education, it is critical to understand how to optimize comfort in the delivery and receipt of this education. Creating a comfortable, safe and supportive environment is essential, and this type of environment has been identified by researchers as a key characteristic of effective sexual health education curricula (Kirby, Laris, & Rolleri, 2007). The present study supports that having a safe and supportive environment can enhance comfort in teaching and learning about sexual health education.

Acknowledgements:

The authors thank the staff of the Fort Worth Independent School District for their support of this evaluation. We would also like to thank Thearis Osuji, Noah Drew, Paula Jayne, Pete Hunt, Susan Telljohann, Kelly Wilson, and Healthy Teen Network for their contributions to this project.

Funding details:

This project was supported by funding from the Division of Adolescent and School Health (DASH) in the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) at the Centers for Disease Control and Prevention (CDC), Contract #HHSD-200-2013-M53944B Task Order #200-2014-F-59670.

Disclaimer statement:

The findings and conclusions in the manuscript are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Footnotes

Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

  1. Allen L (2005). ‘Say everything’: Exploring young people’s suggestions for improving sexuality education. Sex Education, 5(4), 389–404. [Google Scholar]
  2. Buston K, Wight D, Hart G, & Scott S (2002). Implementation of a teacher-delivered sex education programme: Obstacles and facilitating factors. Health Education Research, 17, 59–72. [DOI] [PubMed] [Google Scholar]
  3. Byers ES, Sears HA, & Foster LR (2013). Factors associated with middle school students’ perceptions of the quality of school-based sexual health education. Sex Education, 13(2), 214–227. [Google Scholar]
  4. Byers ES, Sears HA, Voyer SD, Thurlow JL, Cohen JN, & Weaver AD (2003). An adolescent perspective on sexual health education at school and at home: II. Middle school students. Canadian Journal of Human Sexuality, 12(1), 19–33. [Google Scholar]
  5. Centers for Disease Control and Prevention. (2012). Health Education Curriculum Analysis Tool (HECAT). Retrieved from https://www.cdc.gov/healthyyouth/hecat/
  6. Centers for Disease Control and Prevention (2015a). Characteristics of an Effective Health Education Curriculum. Atlanta, GA. http://www.cdc.gov/healthyschools/sher/characteristics/index.htm [Google Scholar]
  7. Centers for Disease Control and Prevention (2015b). National Health Education Standards. Atlanta, GA. http://www.cdc.gov/healthyschools/sher/standards/index.htm [Google Scholar]
  8. Centers for Disease Control and Prevention. (2017). Youth risk behavior survey: Data summary and trends report, 2007–2017. Retrieved from https://www.cdc.gov/healthyyouth/data/yrbs/pdf/trendsreport.pdf.
  9. Centers for Disease Control and Prevention. (2018). Youth Risk Behavior Survey Data Summary and Trends Report, 2007–2017. Retrieved from https://www.cdc.gov/healthyyouth/data/yrbs/pdf/trendsreport.pdf
  10. Charmaz K (2006). Constructing grounded theory: A practical guide through qualitative analysis. Thousand Oaks, CA: Sage. [Google Scholar]
  11. Chen E, & Barrington C (2017). “You Can Do it Anywhere”: Student and Teacher Perceptions of an Online Sexuality Education Intervention. American Journal of Sexuality Education, 12(2), 105–119. [Google Scholar]
  12. Cohen JN, Byers ES, & Sears HA (2012). Factors affecting Canadian teachers’ willingness to teach sexual health education. Sex Education, 12, 299–316. [Google Scholar]
  13. Cohen JN, Sears HA, Byers ES, & Weaver AD (2004). Sexual health education: attitudes, knowledge, and comfort of teachers in New Brunswick schools. Canadian Journal of Human Sexuality, 13, 1–15. [Google Scholar]
  14. Corbin JM, & Strauss A (1990). Grounded theory research: Procedures, canons, and evaluative criteria. Qualitative Sociology, 13(1), 3–21. [Google Scholar]
  15. Corbin JM, & Strauss A (2008). Basics of qualitative research: Techniques and procedures for developing grounded theory (3rd ed). Thousand Oaks, CA: Sage. [Google Scholar]
  16. Denzin NK, & Lincoln YS (2005). The SAGE handbook of qualitative research. Thousand Oaks, CA: Sage Publications. [Google Scholar]
  17. Eisenberg M, Madsen N, Oliphant J, Sieving R, Resnick M (2010). “Am I qualified? How do I know?” A qualitative study of sexuality educators’ training experiences. American Journal of Health Education, 41(6), 337–344. [Google Scholar]
  18. Eisenberg M, Madsen N, Oliphant J & Resnick M (2012). Policies, principals and parents: multilevel challenges and supports in teaching sexuality education. Sex Education, 12(3): 317–329. [Google Scholar]
  19. Escribano S, Espada JP, Orgiles M, & Morales A (2016). Implementation fidelity for promoting the effectiveness of an adolescent sexual health program. Evaluation and Program Planning, 59, 81–87. [DOI] [PubMed] [Google Scholar]
  20. ETR, Kane WM and Telljohann SK 2012. HealthSmart middle school: Program foundation. Santa Cruz, CA: ETR. Retrieved from https://www.etr.org/healthsmart/about-healthsmart/ [Google Scholar]
  21. Fisher CM, & Cummings CA (2016). Assessing teacher confidence and proficiency with sexuality education standards: Implication for professional development. Pedagogy in Health Promotion, 2 (2): 101–107. [Google Scholar]
  22. Glaser BG, & Strauss AL (1967). The discovery of grounded theory: Strategies for qualitative research. Chicago, IL: Aldine. [Google Scholar]
  23. Guttmacher Institute. (2019). State Laws and Policies: Sex and HIV Education. Retrieved from https://www.guttmacher.org/state-policy/explore/sex-and-hiv-education.
  24. Haberland N, & Rogow D (2015). Sexuality education: Emerging trends in evidence and practice. Journal of Adolescent Health, 56, S15–S21. [DOI] [PubMed] [Google Scholar]
  25. Hannah R (2013). The effect of classroom environment on student learning. Honors Theses. Paper 2375. Lee Honors College at ScholarWorks at Western Michigan University. Retrieved from http://scholarworks.wmich.edu/cgi/viewcontent.cgi?article=3380&context=honors_theses [Google Scholar]
  26. Kar SK, Choudhury A, & Singh AP (2015). Understanding normal development of adolescent sexuality: A bumpy ride. Journal of Human Reproductive Sciences, 8(2), 70–74. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Kirby D, Laris BA, & Rolleri L (2005). Impact of sex and HIV education programs on sexual behaviors of youth in developing and developed countries. Youth Research Working Paper, 2. Research Triangle Park, NC: Family Health International. [Google Scholar]
  28. Kirby DB, Laris BA, & Rolleri LA (2007). Sex and HIV education programs: Their impact on sexual behaviors of young people throughout the world. Journal of Adolescent Health, 40, 206–217. [DOI] [PubMed] [Google Scholar]
  29. LaChausse RG, Clark KR, & Chapple S (2014). Beyond teacher training: The critical role of professional development in maintaining curriculum fidelity. Journal of Adolescent Health, 54, S53–S58. [DOI] [PubMed] [Google Scholar]
  30. Landry DJ, Singh S, & Darroch JE (2000). Sexuality education in fifth and sixth grades in U.S. public schools, 1999. Perspectives on Sexual and Reproductive Health, 32(5), 212–219. [PubMed] [Google Scholar]
  31. Lindberg LD,Maddow-Zimet I, & Boonstra H (2016). Changes in adolescents’ receipt of sex education, 2006–2013. Journal of Adolescent Health, 58(6), 621–627. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Ma Z, Fisher MA, & Kuller LH (2014). School-based HIV/AIDS education is associated with reduced risky sexual behaviors and better grades with gender and race/ethnicity differences. Health Education Research, 29(2), 330–339. [DOI] [PubMed] [Google Scholar]
  33. Marsiglia FF, Kulis S, Yabiku ST, Nieri TA, & Coleman E (2011). When to intervene: Elementary school, middle school or both? Effects of keep it REAL on substance use trajectories of Mexican heritage youth. Prevention Science, 12, 48–62. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. McNamara PM, Geary T, & Jourdan D (2011). Gender implications of the teaching of relationships and sexuality education for health-promoting schools. Health Promotion International, 26(2), 230–237. [DOI] [PubMed] [Google Scholar]
  35. Mkumbo KA (2012). Teachers’ attitudes towards and comfort about teaching school-based sexuality education in urban and rural Tanzania. Global Journal of Health Science, 4(4), 149–158. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Mueller TE, Gavin LE, & Kulkarni A (2008). The association between sex education and youth’s engagement in sexual intercourse, age at first intercourse, and birth control use at first sex. Journal of Adolescent Health, 42(1), 89–96. [DOI] [PubMed] [Google Scholar]
  37. Muhr T (2013). ATLAS.ti 7.0 [Version 7]. Berlin, Germany: ATLAS.ti Scientific Software Development GmbH. Available from http://www.atlasti.com/ [Google Scholar]
  38. Murray CC, Sheremenko G, Rose ID, Osuji T, Rasberry CN, Lesesne C, Parker JT, & Roberts G (in press). The influence of health education teacher characteristics on students’ health-related knowledge gains. Journal of School Health. [DOI] [PMC free article] [PubMed]
  39. Ninomiya MN (2010). Sexual health education in Newfoundland and Labrador schools: junior high school teachers’ experiences, coverage of topics, comfort levels and views about professional practice. Canadian Journal of Human Sexuality, 19(2), 15–26. [Google Scholar]
  40. Patton MQ (2002). Qualitative Research and Evaluation Methods (3rd ed.). Thousand Oaks, CA: Sage. [Google Scholar]
  41. Perez MA, Luquis R, & Allison L (2004). Instrument development for measuring teeachers’ attitudes and comfort in teaching human sexuality. American Journal of Health Education, 35, 24–29. [Google Scholar]
  42. Polit DF, & Beck TC (2014). Essentials of nursing research. Appraising evidence for nursing practice. 8th edition. Philadelphia, PA: Lippincott Williams & Wilkins. [Google Scholar]
  43. Rhodes DL, Kirchofer G, Hammig BJ, & Ogletree RJ (2013). Influence of professional preparation and class structure on sexuality topics taught in middle and high school. Journal of School Health, 83, 343–349. [DOI] [PubMed] [Google Scholar]
  44. Roberto AJ, Zimmerman RS, Carlyle KE, & Abner EL (2007). A computer-based approach to preventing pregnancy, STD, and HIVin rural adolescents. Journal of Health Communication, 12(1), 53–76. [DOI] [PubMed] [Google Scholar]
  45. Strange V, Oakley A & Forrest S (2003) Mixed-sex or single-sex sex education: how would young people like their sex education and why? Gender and Education, 15(2), 201–214. [Google Scholar]
  46. Vamos S & Zhou M (2007). Educator preparedness to teach health education in British Columbia. American Journal of Health Education, 38:5, 284–292. [Google Scholar]
  47. Wilson KL, Wiley DC, Housman J, McNeill EB, & Rosen BL (2015). Conceptualizing and implementing a professional development pilot program for public school teachers to strengthen sexuality education. Pedagogy in Health Promotion, 1(4), 194–202. [Google Scholar]
  48. Wood SY, Rogow D, & Stines F (2015). Preparing teachers to deliver gender-focused sexuality/HIV education: A case study from Nigeria. Sex Education, 15(6), 671–685. [Google Scholar]

RESOURCES