Table 2.
A systematic review of factors influencing integration of comprehensive sexuality education in educational systems in low- and middle-income countries
| No | 1st Author/Year/[Citation] | Country | Study type/design | Study aim | Study participants | Key issues/findings |
|---|---|---|---|---|---|---|
| 1 | Mbeba et al. (2012) | Tanzania | Qualitative case study | This study aimed at gaining insights on barriers to the utilization of SRHS in Mtwara district | Girls (10–18 years), community leaders and adults | The study revealed that a good number of health facilities do not have skilled service providers (SPs) on sexual reproductive health rights-included; education, family planning and voluntary counselling and testing. However, the services were inaccessible due to lack of privacy, confidentiality, equipment’s and negative attitudes from SPs. Initiation ceremonies, early marriages and gender disparities were mentioned as social-cultural barriers to SRH rights |
| 2 | Venkatraman Chandra-Mouli, (2018) [16] | Pakistan | Programme evaluation | This review aims to answer the following questions: (1) How did Aahung and Rutgers Pakistan work to understand Pakistani society and culture and shape their programmes to build community support? (2) How did Aahung and Rutgers Pakistan overcome resistance to their efforts? | Documents and publications |
The success of Aahung and Rutgers Pakistan was grounded in their readiness to understand the nuanced context within the communities, collaborate with groups of stakeholders—including parents, school officials, religious leaders, media personnel, and adolescents themselves—to ensure support, and stand up to forces of resistance to pursue their goals. Specific strategies included working With communities to select content, tactfully selecting and framing issues with careful consideration for sensitivities, engaging adolescents' influencers, strengthening media presence, showcasing school programmes to increase understanding and transparency, and choosing opportune times to introduce messages |
| 3 | Herat et al. (2018) [2, 18] | Uganda | Qualitative study (natural setting) | exploring the challenges faced by male and female persons with physical disabilities in accessing SRH services in Kampala, Uganda | Advocates for and persons with disabilities | The study findings show that PWPDs face a multitude of challenges in accessing SRH services including negative attitudes of service providers, long queues at health facilities, distant health facilities, and high costs of services involved, unfriendly physical structures and the perception from able-bodied people that PWPDs should be asexual |
| 4 | Keogh et al. (2018) [15] | Ghana, Kenya, Peru and Guatemala | Mixed Method study (natural setting) | This paper analyses the challenges to the implementation of national CSE curricula in four LMICs: Ghana, Kenya, Peru and Guatemala | It presents qualitative findings from in-depth interviews with central and local government officials, civil society representatives, and community level stakeholders ranging from religious leaders to youth representatives |
Programme planning-related challenges included insufficient and piecemeal funding for CSE; lack of coordination of the various efforts by central and local government, NGOs and development partners; and inadequate systems for monitoring and evaluating teachers and students on CSE Curriculum implementation-related challenges included inadequate weight given to CSE when integrated into other subjects, insufficient adaptation of the curriculum to local contexts, and limited stakeholder participation in curriculum development |
| 5 | Browes (2015) [3] | Ethiopia | Qualitative study (natural setting) | Understanding CSE, culture and gender: the effect of the cultural setting on a sexuality education programme in Ethiopia | Teachers and students, both male and female | Results show that CSE teachers and students, both male and female, were able to discuss issues of sexuality after the course. However, the cultural context was seen to affect interpretation of programme information, influencing the nature of this discussion. For impactful implementation, it is recommended that sexuality education aims to engage with and involve the wider community, to reduce contradictory messages and increase programme support. Furthermore, teachers should undergo extensive and comprehensive pre-programme training that addresses their attitudes and values, not just their knowledge |
| 6 | Emambokus et al. (2019) [34] | Mauritius | Qualitative case study (natural setting) |
The aim of the study was to explore parents’ and teachers’ perspectives of socio-cultural factors that can act as enabling factors or potential barriers |
parents and teachers | Analysis of the interview transcripts revealed that the enabling factors were perceived as the importance of school-based SE by parents and teachers, contribution of external organizations, and a two-way communication process with adolescents. The potential barriers were perceived as a resistance from some teachers and students, the gender of the parent, and religion. Generation gaps and information communication technology were found to be both enablers and barriers. The findings have implications for the design and implementation of school-based SE within a multicultural context and pave the way for similar studies on a larger scale |
| 7 | Mhlauli and Muchado (2015) [48] | Botswana | Qualitative study using grounded theory (natural setting) | The purpose of this study was to explore the teachers’ and students’ perceptions on issues of sexuality in primary schools in Botswana | teachers and students | The major finding of the study revealed that there is an intergenerational conflict of ideas and views between teachers’ and students’ pertaining to issues of sexuality in primary schools in Botswana |
| 8 | Chavula et al. (2021) [23] | Zambia | Qualitative study (CRCT) | Experiences of teachers and CHWs implementing sexuality and life skills education in youth clubs in Zambia | CHWs and teachers | The teachers and CHWs reported that the use of participatory approaches and collaboration between them in implementing CSE enabled them to increase girls' and boys' participation youth clubs. However, some teachers and CHWs experienced practical challenges with the manuals because some concepts were difficult to understand and translate into local language. The participants perceived that the youth club increased knowledge on CSE, assertiveness and self-esteem among the learners. Training and providing a detailed teaching manual with participatory approaches for delivering CSE, and collaborative teaching enabled teachers and CHWs to easily communicate sensitive SRH topics to the learners |
| 9 | Le Mat et al. (2019) [40] | Ethiopia | Qualitative study (natural setting) | We aim to improve understanding of the ways in which teachers enact and re-contextualise CSE policy, and their reasons for doing so | Young men and women, teachers, school administrators, parents/community and local leadership | Implementation of CSE was influenced by School context, Socio-economic environment, Relations with the community, Socio-cultural roles and responsibilities |
| 10 | Bylund et al. (2020) [46] | Tanzania | A qualitative and cross-sectional study (natural setting) |
This study has aimed to explore and understand health professionals’ perceptions and attitudes regarding the provision of adolescent sexual and reproductive health care in a selected national sexual and reproductive health programme in the Arusha region and Kilimanjaro region, Tanzania |
Health care workers (nurses, social worker, clinical officer, midwife, HIV officer etc.) |
Concern about the stigma directed towards adolescents, Over-medicalisation of Services, Difficulty involving adolescent Males, Ambiguous policies and contradictory messages |
| 11 | Muhwezi et al. (2015) [52] | Uganda | Qualitative study (natural setting) | Exploring perceptions and experiences of adolescents, parents and school administrators regarding adolescent-parent communication on sexual and reproductive health issues in urban and rural Uganda | Students, school administrators and teachers | Parents to be foundational for a healthy adolescent- parent communication, onset of menstruation and perceived abortion in the neighbourhood, Peers at school and mass media were perceived to the main source of sexuality information |
| 12 | Chandra-Mouli (2013) | Tanzania | Document review | Exploration of Standardizing and scaling up quality adolescent friendly health services in Tanzania | Review of plans and reports from the MOHSW | There was no standardized definition of CSE, poor quality of the CSE being provided by some organizations, problems by mapping existing CSE services, to improve their quality and expand their coverage, integrating CSE within wider policy and strategy documents and programmatic measurement instruments |
| 13 | De Haas and Hutter (2019) [37] | Uganda | Qualitative Study (natural setting) | Teachers’ conflicting cultural schemas of teaching comprehensive school-based sexuality education in Kampala, Uganda | Teachers and NGOs staff, religious leaders, public staff, students and private organisations | Young people are both innocent and sexually active; sexuality education both encourages and prevents sexual activity; and teachers need to teach sexuality education, but it is considered immoral for them to do so. In countries such as Uganda, supportive school regulations and a mandate from society could help teachers feel more comfortable adopting comprehensive approaches to sexuality education |
| 14 | Panchaud et al. (2018) [28] | Ghana, Peru, Kenya and Guatemala | Qualitative case study |
Exploration towards CSE: a comparative analysis of the policy environment surrounding school-based sexuality education in Ghana, Peru, Kenya and Guatemala |
The study shows that all four countries benefit from a policy environment that, if properly leveraged, could lead to a stronger implementation of CSE in schools However, each faces several key challenges that must be addressed to ensure the health and wellbeing of their young people. Latin American and African countries show notable differences in the development and evolution of their CSE policy environments, providing valuable insights for programme development and implementation | |
| 15 | Kunnuji et al. (2020) [36] | Nigeria | Qualitative study | Understand the Variable Implementation of Sexuality Education in Three Nigerian States |
government officials, Non-governmental organizations, Funders, Researchers, Principals/Teachers and civil society opponents of sexuality education |
In summary, the interaction of socio-cultural context, domestic champions, adaptive capacity of state bureaucracies, and international funders explains variable implementation of family life health education FLHE. The Nigerian experience highlights the need for sexuality education proponents to anticipate and prepare for local opposition and bureaucratic barriers. Socio-cultural/ religious [Islam] context was a strong opposition to the implementation CSE. Cosmopolitan socio-cultural context in Lagos presented a supportive atmosphere for the implementation of the curriculum |
| 16 | Zulu et al. (2019) [10] | Zambia | Qualitative case study (natural setting) | This paper explores how teachers perceive the curriculum and practice discretion when implementing the CSE in mid-level schools in Nyimba district in Zambia | teachers | This discretion implies holding back information from the learners, teaching abstinence as the only way of preventing pregnancy or cancelling sexuality education sessions altogether. Teachers’ choices about the CSE programme were linked to lack of guidance on teaching of the curriculum, especially with regards to how to integrate sexuality education into existing subjects. Limited prioritization of CSE in the educational sector was observed. The incompatibility of CSE with local norms and understandings about adolescent sexuality combined with teacher-parent role dilemmas emerged as problematic in implementing the policy. Limited ownership of the new curriculum further undermined teachers’ motivation to actively include CSE in daily teaching activities. Use of discretion has resulted in arbitrary teaching thus affecting the acquisition of comprehensive sexual and reproductive health knowledge among learners |
| 17 | Gudyanga et al. (2019) [33] | Zimbabwe | Qualitative study (natural setting) | Exploring Zimbabwean secondary school Guidance and Counselling teachers teaching sexuality education in the HIV and AIDS education curriculum | Guidance and Counseling teachers |
Engaging with culture in relation to healthy sexuality, Strengthening the guidance and counselling teachers Professionally, Leadership support, Creating a space for teacher reflexivity and agency to teach sexuality education, sensitised towards cultural diversity, to teach and not to preach, Seeing possibilities for a new participatory method of teaching |
| 18 | Godia et al. (2013) | Kenya | Qualitative study (natural setting) | health service providers’ experiences in Sexual reproductive health service provision to young people in Kenya | Clinical officers Nurse/Midwives Counsellors |
The majority of health service providers were aware of the youth friendly service concept but not of the supporting national policies and guidelines. HSP felt they lacked competency in providing SRH services to young people especially regarding counselling and interpersonal communication. HSPs were conservative with regards to providing SRH services to young people particularly contraception. HSP reported being torn between personal feelings, cultural and religious values and beliefs and their wish to respect young people’s rights to accessing and obtaining SRH services |
| 19 | Tabong et al. (2018) [31] | Ghana | Qualitative Study (natural setting) | Acceptability and stakeholders’ perspectives on feasibility of using trained psychologists and health workers to deliver school-based sexual and reproductive health services to adolescents in urban Accra, Ghana | adolescents aged 12–17 years, teacher group, teachers, managers of schools, health workers, clinical psychologists, as well as ASRH programme managers | Acceptability of school-based SRH services, challenging for parents and/or teachers to provide adolescents with SRH information, have health workers and psychologists provide SRH information and services to adolescents in school, many of the respondents disagreed with distribution of condoms in schools as they believed that availing condoms would encourage adolescents to experiment with sex |
| 20 | Kemigisha et al. (2019) [30] | Uganda | Qualitative study (programme evaluation) | Process evaluation of a CSE intervention in primary schools in South Western Uganda | students, teachers, student educators and parents | Delivery of the anticipated 11 CSE lessons occurred in all target schools with moderate to high student attendance, however the duration of sessions was often shorter than planned. Facilitating factors for implementation included establishment of a community advisory board, use of multiple interactive delivery methods and high acceptance of the programme by key stakeholders. Socio-cultural norms, geographical access, time constraints and school related factors were barriers |
| 21 | Renju et al. (2010) [29] | Tanzania | Qualitative study (programme evaluation) | Scaling up a school-based sexual and reproductive health intervention in rural Tanzania: a process evaluation describing the implementation realities for the teachers | teachers, head teachers, ward education coordinators and school committees | Training was well implemented and led to some key improvements in teachers’ ASRH knowledge, attitudes and perceived self-efficacy, with substantial improvements in knowledge about reproductive biology and attitudes towards confidentiality. The trained teachers were more likely to consider ASRH a priority in schools and less likely to link teaching ASRH to the early initiation of sex than non-trained teachers. Facilitating factors included teacher enjoyment, their recognition of training benefits, the participatory teaching techniques, support from local government as well as the structured nature of the intervention. Challenges included differential participation by male and female teachers, limited availability of materials and high turnover of trained teachers |
| 22 | Rijsdijk et al. (2014) | Uganda | mixed methods design (programme evaluation) | Implementation of The World Starts with Me, a comprehensive rights-based sex education programme in Uganda. Health education research | Teachers, | Supportive factors of implementation (their students, head teachers, school management, and other teachers. Teachers felt less supported by parents, health-care providers and religious institutions and supported by their own family). (Non) supportive beliefs and norms towards rights-based sex education [disapproved of their students having sexual intercourse and were in favour of abstinence until the age of 18, preferably until marriage]. Some teachers said they did not promote condom use because of their religious views |
| 23 | Chirwa-Kambole et al. (2020) [39] | Zambia | Qualitative case study (CRCT) | Acceptability of youth clubs focusing on comprehensive sexual and reproductive health education in rural Zambian schools: a case of Central Province | Students and teachers | The perceived advantage and simplicity of the clubs related to the use of participatory learning methods, films and role plays to communicate sensitive reproductive health information made the learners like the youth clubs. Further, the perceived compatibility of the content of the sessions with the science curriculum increased the learners’ interest in the youth clubs as the meetings also helped them to prepare for the school examinations. However, cultural and religious beliefs among teachers and parents regarding the use of contraceptives complicated the delivery of reproductive health messages and the acceptability of youth clubs’ information among the learners |
| 24 | Adekola et al. (2021) [44] | South Africa | Qualitative study | Exploration Of Addressing Learner-Centred Barriers to Sexuality Education in Rural Areas of South Africa: Learners’ Perspectives on Promoting Sexual Health Outcomes | Learners (grade 10–11) | Learner-centred barriers to effective school-based sexuality education identified in this study were attitudes, age disparity, psychological status, peer pressure, socio-economic status, the exploratory attitude of learners, media, lack of role models, previous experiences, socio-economic status, and lack of parental love. These factors could reduce good sexual health. Learner-targeted interventions such as campaigns, using guest professionals, condom distribution, videos, on-site family planning, formal demonstrations, and on-site counselling could address these barriers |
| 25 | Ogolla et al. (2019) [41] | Kenya | Mixed method study | Assessment of the implementation of CSE in Kenya | Teachers | The study found low awareness in key topics such as HIV/STIs, condom use, benefits of abstinence and contraception. Most teachers were not trained in CSE, and CSE is not included in the curriculum. Personal biases, opinions and values related to sexuality education threaten the delivery of CSE. Resource materials are also unavailable. The study concluded that teachers acknowledged the need for CSE. However, its delivery is severely inhibited by lack of training, non-inclusion of CSE in the curriculum, inadequate time allocation for CSE lessons, and lack of teaching resources |
| 26 | Pokharel et al. (2021) [45] | Nepal | Document review | Understand Current Perspectives on Adolescent Sexuality Education in Nepal: | Documents | sex education in schools is a sensitive issue. Adolescents in Nepal are affected by taboos surrounding sexuality which are the main socio-cultural challenges to gain sexual health education. Lawmakers and curriculum developers claim that sexuality education corrupts young people and violates “Nepalese values”, leading to promiscuity, experimentation, and irresponsible sexual behaviour |
| 27 | Zaw et al. (2021) [19] | Myanmar | Mixed method | determine the preferences for type of sexuality education at high schools, compare the level of knowledge of reproductive health among actors | Students, parents and teachers | Focus group discussions were held to explore their insights on sexuality education for Reproductive health knowledge was low, particularly among students, and particularly with respect to knowledge of sexually transmitted infections. Cultural issues, training and manpower emerged as key themes from the focus groups. Over half of the students said that they were not receiving any form of sex education at school. Reproductive health knowledge was unsatisfactory among all participants reflecting the insufficiency of current sexuality education classes. Training and support for teachers should be provided |
| 28 | Melgar (2021) [47] | Philippines | Document review | Assessment of country policies affecting reproductive health for adolescents in the Philippines |
Contradicting laws, some support and others prohibit provision of ASRHR services. Non-discrimination in information and services. Integration of contraceptives, including emergency contraception, into essential medicines. Teacher training in delivery of adolescent sexual reproductive health is still neglected |
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| 29 | Ha et al. (2021) [42] | Vietnam | Qualitative study | The provision of sexual and reproductive health education to children in a remote mountainous commune in rural Vietnam | Parents, youth leaders and teachers | The head of the Youth Union and lecturers at secondary school stated that they were not capable of providing SRH training as none of their staff were specifically trained in SRH and they had no access to appropriate SRH educational materials. Meanwhile, there was no public library or bookstore in the commune where young people could have access to SRH reading material. There is a major gap between the SRH education needs of parents and children in remote rural areas of Vietnam and the resources required to address these needs |
| 30 | Larsson et al. (2021) | Nicaragua | Qualitative study | Exploring sexual awareness and Decision-making among adolescent girls and boys in rural Nicaragua | Girls | Girls turned to parents on topics of sexuality while boys turned to peers. Social stigma hinders adolescent’ access to sexual and reproductive health services. Social media appears to influence how adolescents develop sexual awareness. Sexual education represented a reliable source of information about sex. Adolescents challenged social and cultural norms by developing sexual agency |