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Table 5 Analytical and descriptive themes

From: Teachers’ conflicts in implementing comprehensive sexuality education: a qualitative systematic review and meta-synthesis

Analytical theme

Sub-theme (ST)

Descriptive theme

Supporting quotations/meaning units

Theme 1: Hesitancy in talking about sex education among teachers due to the cultural and religious context

ST 1-1: The topic of Sexual and Reproductive Health (SRH) is a still taboo

A teacher hesitated to talk about reproductive health to students at school

I think this problem [to not speak openly about reproductive health]... culture, the society’s culture. [CSE] is a rich mission to minimise this. (D2, school4, FGD with teachers, participant5, male) [20]

Teacher’s belief that students still cannot make the right decisions, so they need directions from teachers to choose the right way

As [teachers] we believe that giving a free choice to these very young children is dangerous. SRH is sensitive issue that determines the future life of the youth. So as a teacher, we need to show them the right way. Just discussing the options and leaving the choice to them is dangerous because they are kids who do not know what is right and wrong (Validation workshop, teacher) [20]

Lack of interest to facilitate CSE implementation

According to me, the main problem is that the school administration lacks interest to facilitate [CSE] like that of regular programmes. They have no interest to facilitate these issues. (D2, school4, FGD with teachers, teacher3, male) [20]

The teacher felt shy to teach about sex education, but it's a huge challenge

Some of the teachers feel shy to teach about sex education and I think this is a huge challenge. (School-based Coordinator, School Two) [21]

Sexuality education has not been reinforced at home because it was not opened topics

Firstly, the facts discussed on this topic are not reinforced at home. Therefore, it is easily forgotten. Sexuality is also not an open topic at home (grade 12 teacher, black female, 10 to 20 years teaching experience) [25]

Teaching sexuality education in a school is taboo due to culturally inappropriate

The controversy is also about the place, where such information is delivered from not being culturally appropriate, it’s taboo to teach sexuality education in a school (IDI, Teacher 11) [30]

ST 1-2: Concerns that sexuality education might encourage unhealthy curiosity and experimenting sexual behaviors

Some of the parents have not yet acknowledged talking about sexuality at school because they felt about sexuality education becomes 'sexual awake' to the children

Some parents do not give permission to the school to talk about sexuality to the children because some parents feel that the teacher will ‘awake’ something in their child and make the child curious to experiment (grade 5 teacher, coloured female, 10 to 20 years teaching experience) [25]

Teachers use their knowledge on sexuality to discourage students from engaging in sexual behaviors

Now, when, eh, I did give a talk to students how… they have a habit of standing in corners and then kissing and then, we call it coupling, boy and girl, huh? And I wanted to discourage them so I got… I talked about HPV, the cancer virus, and all that, and somehow I really scared them into thinking if you kiss, […] you can get cancer and something like that! [chuckles] […] [But] it’s not fair to the students; we should not scare them into doing what we think is right. And another thing what I realised, after that talk, there could have been a change in the first week, but after, these kids are going to go back to their old ways, so… (Female, age 29) [24]

The most dangerous one is becoming active in sex matters at the adolescence stage

Those ones who are just becoming active, in sex matters, adolescence stage, is the most dangerous one. Because if the kid is not well guided, can land into many problems […]. When you’re guiding, you show them the bad, the problems, then you put them right. […] You show them the proper ways […] to live with this future. (Male, age 25) [24]

Sexuality education is complicated because of a heavy workload to educate children on the sexual topic

It’s complicated, we already have a heavy workload to have to then educate children in a topic for which we have not been prepared, to be honest (worried face). (E9) [29]

ST 1-3: Concerns/Fear that teacher would lose moral authority and control over the students

The teacher recommended students to practice abstinence

I normally encourage young girls and boys to abstain from sex because I know the dangers… For us we are victims of what our parents did… So normally when we are teaching some of, eh, these topics, huh? We basically use the Bible … how can … a Christian … how can a youth abstain from sex? (Peter, age 28) [22]

Especially young girl has sexual weaknesses and should not expose outside

I made a resolution: never to have sex with anybody I teach. […] If I choose to […] then I should do it in another school. […] Once I stand before somebody, I always want to command respect before that… young girl […]. I have sexual weaknesses, I should not expose them in the work place. That became my only guiding principle. But still, it did not help me because out there… I would still engage into sex relations with VARIOUS [with emphasis] other people, not necessarily those who were in school. (Male, age 31) [24]

Concerns about violating professional code of conduct as a teacher

Yes, there are times when they ask you something, when […] you are ignorant about it, other times, you may be knowing… but you feel explaining it to them as a teacher, […] it’s like […] you have gone against your professional code of conduct, other times you don’t know the… the language, how to phrase it, such that it does not appear too obscene. (Female, age 35) [24]

Respect the authority of teachers at schools as an educator

In schools, teachers are superior because they are the ones in authority, and the students have to respect authority. […] The academic bit of it… lowers them [students] […] and understand that this one must be […] better than us’ (Female, age 35) [24]

The teachers try to maintain hierarchy of respect with their students and this led them to believe their students know nothing about sexuality

So many of them [teachers]… have maintained that culture of… erm… keeping that distance… from the student. But I think it’s also a deception really to, to begin thinking that you can keep these children young… and you know, innocent, and they should not speak anything! […] They want to maintain that […] hierarchy of respect. […] (Female, age 37) [24]

Relationships between students and educators have not been established because teachers are looked at as disciplinarians

Teachers are looked at as disciplinarians, they are very tough, they are very strict. […] So one is just to command without any question, without any challenge. So you find that, eh, there is no relationship established. (Female, age 37) [24]

The teacher fight to maintain their integrity and is afraid of losing the moral authority to control students

If you have to talk to a Form 1, huh? You have to be very careful about… what you say out because… behind there is integrity. Once somebody loses it as a teacher, then… you have virtually no control over this person… because you’ve lost the moral authority. […] So in a way we fight to maintain that integrity, to allow us chance to address them… on certain issues and earn their trust… (Male, age 30) [24]

ST 1-4: Providing information on contraceptive methods is depending teachers’ perceptions and experiences

The teacher applied different teaching about contraception to different audiences based on their faith

If I’m addressing a congregation of strictly Saved girls and boys, I will not mention a condom… But if I’m talking to these lay people … I would warn them and tell them: [chuckles a bit] ‘You had better use a condom’. Me, I believe it is much safer, because one it will protect, it will protect somebody from … HIV but also pregnancy. (Grace, age 37) [22]

Worries/concern that teaching how to use condom will be understood as encouraging sexual behaviors due to autocratic teaching style

We just tell them: don’t have sex … or use a condom. But so much it is that when you teach a kid how to use a condom, then the kid will go and, and use it! … So … that idea of sharing … information, it’s more of ordering, I think, it’s from the side of the teachers, because we are used here more to give in commands rather than discussing and sharing experiences. (Paul, age 32) [22]

Teacher did not teach different methods of contraception as expected from them

We are expected to discuss types of contraception such as oral contraceptive pill and depo-provera through injectable method, implant, but I do not teach them such things (IDI, Teacher 10) [30]

One thing is, we fear, for example, if you demonstrated how … eh, a condom is used in a secondary setting, we fear that maybe a student … they go and practise [laughs]… So, we prefer that you’d rather keep … a student in the dark, when they don’t know particular things. (Grace, age 37) [22]

ST 1-5: Religious and cultural norms as inhibitor in implementing sex education

Sexuality education is still inhibited due to both backgrounds culture and religion, and multiple pressures might be impacted the educator (insulator)

You may say it at the risk of your job. Because if you do it … consistently, you may be looked at as a person who is spoiling … you need some insulator, something to insulate you from … the culture and the religious and the other … the other pressures that try to inhibit people doing such sexuality education. (Paul, age 32) [22]

The teachers are providing sex education based on the Catholic bible at the Catholic-founded school

Yes, because first of all this is a Christian school, it’s a Catholic founded school, and … those [accepted sexual acts] are the principles we teach in the school … we base our teaching on the Bible… (Vivienne, age 43) [22]

The teacher belief that teaching students about morality is their duty to the nation

We [teachers] also feel … that … we have a duty to the nation… Because then what will be the use of … educating them … [if] you’re sending out … very immoral people, you’re sending out corrupt people … who are very reckless with their lives, so they can’t do anything for the nation at all. (Barbara, age 26) [22]

The traditional view of sex as a secrecy that only being discussed among married people and not for the young people

You know, in our culture … sex is supposed to be kept … a secret, such that these young people are not supposed to know anything about it… Traditionally, things related to sex were not supposed to be … to be exposed to the young people until they have reached the age of marriage. (Jane, age 32) [22]

ST 1-6: Abstinence education as inhibitor of CSE implementation

The teacher hopes to share the belief of the benefit of abstinence education with students

I’ve seen the good things [...] that come from abstinence and at least I would like to share them with my students because apart from mending my students, they are my friends. So, I would like to tell them that erm... if one abstains, [...] you’re free like a bird, [...] you do anything you want. (Sandra, age 22) [28]

The main message is abstinence when teaching contraception at school

In the school setting, when I teach about preventing pregnancy, the main message is only about abstinence (IDI, Teacher 16) [30]

Emphasized promoting abstinence education to avoid the vicious cycle of poverty

Of course, I emphasise abstinence … we have to emphasise it, because when we do this, I’m sure we will have, eh, a better living population, hmm? … There should be an end of suffering… The vicious cycle of poverty should stop… If they manage to go through the academic ladders, of course, they will be financially stable. (Steven, age 29) [22]

A dilemma of teaching contraception to students because of the teacher's role and value as a parent that wants to promote abstinence

It is very difficult for me. As a parent I need to promote abstinence, but as a teacher this curriculum wants me to talk about the importance of using condoms. One topic for example requires us to describe the steps that one has to follow when using a male or female condom. Now, how do I demonstrate such steps to learners who are almost the same age as my child? No, that’s like teaching children to be ‘sex experts’ (IDI, Teacher 7) [30]

The female teacher provided sexuality education based on her experience, because she wanted to teach appropriate relationships to her students

I think I made a mistake, I shouldn’t have got... gotten into a relationship at the university. [...] Perhaps if I had waited... I would not have married the person I married [...]. Because I acted out of... emotions, not out of... reasoning, [...], it was too early for me to do that. Hmm... I believe [...] if I had got the information, I should have acted differently. So, in most of the times my... my information I give to the students is out of my own experience to stop them from... going through with my experience, so even making worse mistakes. Yeah... Because me, I was lucky, [...] I believe... he married me because I got pregnant. [...] That means I married for wrong reasons. So, I believe I talk out of my own experience to the children so that they don’t make the same mistake. (Vivienne, age 43) [28]

Theme 2: Non-integration of traditional sex education into comprehensive sexuality education

ST 2-1: Challenges of implementation in school the traditional sex education

The rigid structure of the curriculum and supplemental nature of sex education did not encourage teachers to deliver sex education optimally

The non-flexible nature of the timetable, as well as the non-compulsory nature of sex education activities does not compel teachers to engage to the fullest extent and potential of sex-related discourse and activities. (Head teacher, School Two) [21]

Some teachers felt difficulty integrating existing subjects into sex education

The problem we have is that most teachers do not integrate or infuse sex education into the subjects they teach…I think some of them find it difficult to do it. (School-based Coordinator, School Three) [21]

The gap between old and young generations when it comes to conversations about sex

These days, kids tend … to know about sex … culture has created a gap between the … the young and the old. Simply because the old fear to talk about sex. They always want to keep it as a secret, yet it can never be a secret in today’s society. (Samuel, age 26) [22]

Some parents complained to the school principal because a teacher provided a sexual topic (CSE curriculum) to students at school

Having seen the assignment, which I gave to the learners, parents came in numbers to the school in the morning and demanded to see the headmaster. I was called to attend the meeting. The parents then complained to the headmaster that the initiation ceremony is something special which should not be handled at the school (IDI, Teacher 6) [30]

ST 2-2: Consideration for the minorities

Intellectually disabilities learners have some challenges to learn sexuality

Teaching sexuality in any form is challenging to us educators who teach intellectually challenged learners. I teach the foundation phase learners, and their ages are 6 to 7 years old. They function on a level of 2 to 3 years. Their level of IQ does not allow them to understand fully the context around sexuality, HIVand AIDS (grade 2 teacher, coloured female, 10 to 20 years teaching experience) [25]

Children had aware of sexual behavior depending on the level of intellectual disability

I found that when you start talking about sexuality that some of our children (depending of the level of intellectual disability) become more aware on a negative way, as if the sexual behaviour becomes more upfront (grade 7 teacher, white female, 30 to 40 years teaching experience) [25]

For HIV/AIDS education, there is difficult to talk with the HIV positive adolescents

The other challenge is that we are having difficulty in talking to the HIV positive adolescents. We do not have any approach or skills on how to take them aside and talking to them is difficult. As a result, some of them leave school and get married to healthy partners further spreading the scourge. (Kate 28) [23]

Homosexuality and gender diversity has not been recognized by the government in the whole country

Homosexuality is…, since the whole country is against that, I believe that, when somebody tempers, you know, to encourage homosexuality, particularly in school, which is actually at a mission, which is under church mission, definitely, it may end your job (laughing). Yes, so we’re not actually talking and eh telling them that it is good practice to have homo sexuality. (Alex, boys’ boarding school) [27]

Theme 3: Fostering effective facilitation of CSE among teachers

ST 3-1: Foster effective facilitation of the CSE in the school setting

The problem of ‘old learning aids’ and ‘the need to introduce new one’ for effective facilitation

…The old nature of teaching and learning aids and the need to introduce new ones will kindle student interest in sex education and foster effective facilitation of sex education. (School-based Coordinator, School Two) [21]

The PIASCY (Presidential Initiative on AIDS Strategy to Youth) was well implemented and not occurred the stigmatization

Even the children who are HIV positive they are also gaining; the stigmatisation is not there anymore and they stay with others freely because of the PIASCY (Presidential Initiative on AIDS Strategy to Youth) that we have. (Kate 28) [23]

It's time to introduce sex education by the Ministry of Education and should allow providing education on contraceptive methods generally

I think it is high time that the ministry of education introduced sex education, so that our young girls and boys can understand what happens. Teaching on sexual education, and even on the use of condoms, should be allowed. (MT7) [26]

The comprehensive content such as communication, assertiveness, and decision-making skills that are good for learners are taught repeatedly by the teacher

I skipped the whole topic on pregnancy prevention. Instead of teaching about condom use, I moved to another topic. I repeated sessions which I thought were good for learners such as communication, assertiveness and decision-making skills (IDI, Teacher 9) [30]

ST 3-2: Contents of the traditional sex education should be specified to consist of the CSE

Students from both sexes should be taught about physical changes during puberty to prevent unwanted pregnancy

In my opinion, girls and boys should be taught on the changes their bodies are undergoing, because some of them are unaware. So, they go out there and they don’t know what happens, and then they end up having unwanted pregnancies. (FT6) [26]

Abstinence is seen as the only method to avoid teen pregnancies and STIs

We have a song about the importance of abstinence, we sing it before we start each session on CSE. I also tell them repeatedly that abstinence is the only method that can help them avoid teen pregnancies and STIs including HIV (IDI, Teacher 14) [30]

Theme 4: Determining the appropriate age to start  sex education

ST 4-1: Recommendation to provide sex education at the beginning of the early adolescent

The teacher concerned about the ways of delivering sex education to children of different age

Now there are those who are still very young and very innocent… So, for example, if there is a child of 13 years old … and there is another one of 16 in S1 … are [we] going to give this child the same session with the one who is 13? … this child is going to ask you more challenging questions … that a child of 13 might not be comfortable with, might not even understand. (Salimah, age 39) [22]

Sexuality education should start at the age, where students start to have their first sexual encounters

(...) At a later age, from 10 to 14, they change dramatically, they start having their first sexual encounters and I think that is when you should start talking to them about sexuality. (E14) [29]

ST 4-2: Lack of educational material based on the development period among students

Need to update the current guidebook because of easy to access sexual information by students’ selves

So, those who have written the book concerning the subject they should update their books because nowadays children have easy access to much more information when compared to what the books have. The books we are using are now very old. (Lily 48) [23]

Lack of guidance on how to provide sexual education within other subjects

So when I am teaching home economics or religious education, when and how do I introduce sexuality issues in these subjects? This framework does not provide guidance on such issues. This makes teaching very difficult (IDI, Teacher 5) [30]

The teacher expressed confusion about ways to integrate learning about relationship in science teaching

When I am teaching science, how do I bring in issues relating to differences between love, affection and infatuation? It does not work for me (IDI, Teacher 10) [30]

Theme 5: Roles of stakeholders outside the school

ST 5-1: Lack of collaboration with parents and health workers

Involving parents in counseling for students to enhance behaviors

My role basically is to form them. Hm? To help them change, behaviour change. That is my role. I do it in many ways. I talk to them. I’ve told you when we needed a reprimand, we do that… when it need counselling, we do that, we involve parents… […] Because… you know, when you are dealing with discipline, changing somebody’s behaviour is not simple. (Male, age 37) [24]

Health personnel people should be involved because they know how to tell the children the detailed things

I think besides teachers the health personnel people should be involved because for them they know how to tell the children the things in details; with us, we simply read from the books. (Kate 28) [23]

Some topics could be taught not only by teachers but also by health workers from outside

Some topics can be taught by teachers and other topics can be taught by people outside the school such as health workers or community health workers (IDI, Teacher 7) [30]

The teacher expresses the lack of training in CSE to teach it effectively to students

The headmasters attended a 2 days training in CSE, and then they briefed teachers in schools on CSE for only one to 2 h. So how do you expect us to effectively teach? (IDI, Teacher 2) [30]

ST 5-2: Unclear roles of teachers in CSE implementation

As community members, teachers have roles to support and protect students

As the member of the community also, teachers play role in making people aware on what is good and what is wrong. And again if there are problems with students, we support them as much as we can, for example, like early marriage, abduction, etc., by communicating with police on conditions that students reported to us. (D20, school2, teacher3, male) [20]

The teacher hoped to complete academic achievement without unwanted pregnancy

Because to a young girl, when you get involved into sex, you’re still school-going, you need to fulfil your goal, you need to complete your education, and now you are pregnant, there is a way you become stuck and your goals are not meant to be achieved as expected. (Beatrice, age 35) [22]

ST 5-3: Positive impact of the in-service training

Teacher training had a positive impact to change the behavior and confidence of teacher self

First of all, the training changed my behaviour, before that I have no confidence to discuss about this issue, because of the culture I came through. But now I discuss freely with my children and I teach my neighbours about discussing freely with young children about sexuality issues, and I see the change. (D19, school2, teacher2, female) [20]

Integrated in-service training for teachers of adolescent reproductive health was provided

We have what we call enhanced SHEP (school health education program) and under this, we train all teachers in the school on ARH (adolescent reproductive health) through workshops and seminars at the district assembly and sometimes in schools, and by doing this we equip them with the knowledge and skills to impart them in the classrooms…Because we are doing integration and infusion we train all teachers to infuse sex education in the classrooms and also train School Health Education coordinators to handle clubs in the schools. (Municipal School Health Education Coordinator) [21]

The training program by UNICEF was targeted at teachers, headteachers, and students in all the school community

UNICEF gives training to all the school community in three sessions for teachers, headteachers, and students. So, no teacher can have any excuse when asked to support the school based coordinator for help on sex education issues such as the School Health Club. (School-based Coordinator, School One) [21]

ST 5-4: School-based CSE program

School Health Education Program (SHEP) included the content of sexuality education which focused on all teachers, headteachers, and students at the district level

We (teachers) were trained at workshops on the SHEP program and sex education was part of the training’ (School-based Coordinator, School Two) “…teachers are very supportive and make work less difficult…I think this is because all teachers, headteachers, and students partake in training activities at the district level. (School-based Coordinator, School Three) [21]

The manuals and materials by UNICEF are used currently, but it's necessary to bring a new one to enhance teaching and learning under e-SHEP

The manuals and materials given to us during the initial training by UNICEF are what we are still using (elaborating by showing the researcher an old manual and a leaflet on e-SHEP). I think new ones should be brought in to enhance teaching and learning under e-SHEP. (School-based Coordinator, School Three) [21]

The PIASCY (Presidential Initiative on AIDS Strategy to Youth) of the school club had a positive impact on students

In our school, PIASCY is still going on well and the children like to participate in it a lot. There is a club, a PIASCY club for the children and they are the ones who mobilise their friends when it is time for them, but we the teachers just give them instructions that the theme for this week is like this and they formulate the play or role play or recite a poem. So, it’s healthy and sometimes the peers teach one another. (Kate 28) [23]