Parents’ and teachers’ perspectives on children’s sexual health education

Sex education is taught to secondary school students in Nepal. Nevertheless, there are concerns that the school-based sexual health education is not effective and adequate to address young people’s necessities. We carried out a qualitative study comprising key informant interviews with teachers (n=8) and parents (n=6) in Makwanpur district in Nepal. Interviews were recorded, transcribed and translated into English. Thematic analysis was performed to identify patterns or themes within the qualitative data. Most participants (both teachers and parents) had a thought of delivering sex education preferably from grade seven to avoid the effects of globalised mass-media and internet. The practical aspects of school sex education programme and the importance of parent-child communication were of major concerns. Comprehensive training to health teachers, an informal approach to teaching sex education and seeking outside health professionals, such as health facilitators were the frequently reported issues. There is a need to offer sexual health services along with sex education to protect young people from potential dangers of STIs including HIV infection. Particularly, health teachers should be trained properly to mitigate the social and cultural impacts, and to allow a smooth sex education discussion in the classroom. The curriculum for sex education should be relevant, engaging and developmentally suitable with clear progressive avenues for learning experience.


Introduction
School-based sex education can offer an age-appropriate education about sexuality and relationships that offers scientifically accurate information to the pupils [1]. Delivering sex education appropriately can have a positive impact on individuals' Sexual and Reproductive Health (SRH) and help avoid unintended pregnancy and reduce Sexually Transmitted Infections (STIs) including Human Immunodeficiency Virus (HIV). A systematic review showed that the use of school-based sex education programmes in low-and middle-income countries (LMICs) have contributed to increased HIV knowledge, increased self-efficacy, increased contraception and condom use and reduction in the number of sexual partners [2]. Similarly, findings from a Cochrane review of 41 randomised controlled trials (RCTs) suggested that sex education is capable of helping to prevent unintended adolescent pregnancies [3]. It also empowers young people to reflect critically on their environment and behaviours and promotes gender equality and equitable social norms.
Sex education programmes along with youth-friendly services can have a considerable impact in increasing the knowledge and understanding of adolescents around SRH issues [1]. However, effectiveness of sex education such as how this is delivered or who does the delivery can play a significant role for effective school sex education. For example, Pound and colleagues [4] recommend Abstract Sex education is taught to secondary school students in Nepal. Nevertheless, there are concerns that the school-based sexual health education is not effective and adequate to address young people's necessities. We carried out a qualitative study comprising key informant interviews with teachers (n=8) and parents (n=6) in Makwanpur district in Nepal. Interviews were recorded, transcribed and translated into English. Thematic analysis was performed to identify patterns or themes within the qualitative data. Most participants (both teachers and parents) had a thought of delivering sex education preferably from grade seven to avoid the effects of globalised mass-media and internet. The practical aspects of school sex education programme and the importance of parent-child communication were of major concerns. Comprehensive training to health teachers, an informal approach to teaching sex education and seeking outside health professionals, such as health facilitators were the frequently reported issues. There is a need to offer sexual health services along with sex education to protect young people from potential dangers of STIs including HIV infection. Particularly, health teachers should be trained properly to mitigate the social and cultural impacts, and to allow a smooth sex education discussion in the classroom. The curriculum for sex education should be relevant, engaging and developmentally suitable with clear progressive avenues for learning experience.
Keywords: parents, school teachers, sex education, adolescent, Nepal Tweetable Abstract: Sexual and reproductive health issues of school children in Nepal-parental and school teachers suggestion for further improvement. that sexual health educators who maintain a clear rapport with the students should deliver school-based sex education [4]. Thus, sex education is a special subject and young people's engagement in the classroom is a crucial factor in potentially improving their sexual health and well-being.

School-based sex education in Nepal
A significant proportion of Nepal's population (about 22% of 28.5 million) are adolescents aged 10-19. Teenage pregnancy is relatively common in Nepal with about 17% of women aged 15-19 have begun childbearing and contraceptive prevalence is relatively low (15 percent) among them [5]. Poor SRH status is considered to be the main causes for health problems among the adolescents in Nepal [6,7]. Currently, SRH education in Nepal is focused at secondary level (grades 9-10) students aged 14-15 under the Health, Population and Environment (HPE) subject. However, mass-media often report that many Nepali adolescents hesitate to talk and ask questions about SRH issues in the classroom. As these issues are not openly discussed, adolescents may not get support to obtain SRH information at home either.
In an attempt to address the SRH issues of adolescent, Government of Nepal implemented a five-year national programme in 2010, known as Nepal Health Sector Programme (NHSP), to provide adolescent-friendly sexual and reproductive health (ASRH)  [8]. The programme was propelled in the period of the Millennium Development Goals; however, it is in the essence of the Sustainable Development Goals (SDGs) 2030 to emphasise the universal access to health care to everyone [9]. The Nepal Health Sector Programme (NHSP) is accompanied by a comprehensive sexuality education programme in schools as part of the national curriculum which was initiated amid 2002 and 2006. A mid-term evaluation of National Adolescent Sexual and Reproductive Health however suggests that there should be more coordination between the ASRH programme and school sex education programme to meet the demand for ASRH services among adolescents [10].
The design and structure of the current school sex education curriculum, which was updated in 2011, is considered to be inconsistent and ineffective in promoting sexual health at the adolescent age [11]. The curriculum approach is the delivery of sex education as biological facts which are still embedded within a didactic context. There is a lack of comprehensive information on SRH including sexual behaviours, relationships, social issues, and life skills [12]. Consequently, sex education appears in a disjointed manner across many subjects e.g. lack of quality, not implemented uniformly, minimal teacher training, lack of effective implementation etc. Many other important issues, such as sexual harassment, gender inequality, and stigma and discrimination are not given a proper place in the curricula in the practical term as highlighted by a previous report [13].
Limited studies in Nepal have shown that the prevalence of multiple sexual partners and high-risk sexual behaviours among adolescents is high along with the number of STIs and unwanted pregnancies [14,15]. However, in South Asia, it is common for parents to perceive that adolescents and unmarried individuals are hardly involved in sexual relationships [16]. The proportion of unmarried young women and men has increased over the past decade in Nepal. They have now more opportunities to spend time in intimate (sexual) relationships before marriage [6]. They may be more vulnerable to unsafe sexual practices if no effective sex education programmes are designed, developed and implemented. Tamang and colleagues [17] found that a majority (54%) of sexually active youth aged 15-24 years had not used contraception at the time of their first sexual intercourse. The low level of contraceptive use among young people could be related to cultural barriers, unemployment, lack of proper knowledge and skills, and inaccessibility, as reported previously [8,6].
Sex education in Nepal overlooks issues such as feelings and relationships and focuses primarily on easily taught factual and biological issues [7]. According to the World Health Organisation, sex education should be named as 'Sexuality and Relationships Education' that emphasises on rights, health, equality and equity of the young people [18]. The sex education curriculum should be practical, interesting and developmentally suitable with clear progressive avenues for learning experience. In this paper, we discuss findings of a qualitative study which explored: a) Nepali parents' and teachers' perceptions of school-based sexual health education; and, b) how different parents and teachers consider and understand why they have certain views.

Methods and materials
During May-June 2012, we conducted this qualitative study [19] in central Nepal, namely Makwanpur district. A total of 14 interviews (six with parents and eight with health subject teacher) were carried out at four government secondary schools. Most of the participants were male (n=11). The inclusion criteria for parents (with no age limit) were that they should have at least one child studying in the participating school. The school teachers were the head teachers who were familiar with the sex education curricula or health subject teachers who had been teaching sex education for at least two years from those participating schools. We coordinated with school and district education authority prior inviting participants.
Considering the research question, we used a topic guide to facilitate the interviews with teachers and parents [20].The interview guidelines were pretested to check for appropriateness and comprehensibility of language used and coherence of information (e.g. training to school teachers, parental involvement, issues about sex education programmes, attitude towards sex education, school policy, partnership etc.) All the interviews were conducted in Nepali by the main researcher in a comfortable environment, i.e. peaceful and closed room to assure clarity and confidentiality.
All the interviews were audio recorded with participants' permission [21] and lasted for about 1.5 hours in average. Non-verbal communications were also note taken. We collected the data up to the saturation point. We transcribed the recording [22]and translated them into English. Each transcript had a covering note describing the setting, how the session was developed, any errors or differences to other interviews, particular incidents, the environment and the issues recognised in the interview [23]. A careful consideration was taken to ensure the consistency of coding such as reading through the initial notes, reading data repeatedly, reviewing codes, and making sure that it was as inventive and imaginative as possible [24]. We performed a thematic analysis to recognise the common themes from the discussions [25]. Relevant quotes are presented to support the themes.
Our research was carried out in compliance with research ethics involving human subjects in sensitive research [26,27]. Ethical approval for this study was granted by the Nepal Health Research Council (NHRC) and Aberystwyth University's research ethics committee. Participants' information and agreement sheet were developed in Nepali language. Participants were informed about the aims, objectives, risk and benefits of this study. They had the right to withdraw from the research study itself or withdraw responses to questions they did not want to reply to. No identifier (e.g. participants' name) was collected.

Results
Our analysis identified four key themes: a) parental attitude towards sex education; b) discussions of sex and sexual health matters with children; c) partnership with schools; and d) suggestions for further improvement. Each of the themes is discussed below and quotes are presented as appropriate.

Parental attitude towards sex education
Parents argued that sex education should be delivered from Grade seven, since teenage boys and girls have a growing interest in sex and sexual content due to modernisation. They had a notion that the lack of proper sex education has allowed a shift in their attitudes and behaviours towards unsafe sexual activities. They emphasised that male and female student should be kept together while delivering sex education: "I have a positive attitude towards sex education in school students. My opinion is that sex education should be delivered to school students as early as Grade seven. Only then they can have enough time to know and understand the bigger picture of sexual health's impact on the society. "(Parent, Male) There was an agreement among the participants that sex education at the school level is very effective. As they said, at an early stage young people would be able to know what to do or what not to do. Some even mentioned that Nepalese young girls are trafficked to other countries (e.g. India) for sex trade, especially from rural areas. Many of them have little knowledge about sexual health matters. One female parent commented, "It is very effective when sex education is delivered in the school level. There was a consensus among the participants that the delivery of sex education in schools is poor. They argued that sex education policy is not practically applied which led to sex education programmes being badly understood and inadequately delivered in schools. As a result, pupils have low levels of knowledge and understanding about sexual health matters. One young parent remarked as, "Despite our intention that pupils acquire the right sex education, it is not taught sincerely and effectively in the schools. This is because the education policy, especially sex education to the young people, is poorly considered and understood by the educationalists and policymakers. " (Parent, Male)

Discussion of sexual health matters with children
Most participating teachers agreed that due to socio-cultural factors, parents do not talk about sex and sexuality with their children. Due to the poor household infrastructure facility (e.g. shared house, room), sexual relationships between husbands and wives may not be confidential. Teachers stated that young people have more curiosity about sexual matters. This view is apparent in the perceptions stated by one of the male health teachers, "We know that young people have curiosity about sex and sexual matters, but the societal and cultural factors do not allow us to talk about it. In addition, children also learn about sexuality from the conversation of their parents, while the sexual environment for the husband and wife in most Nepalese homes is not confidential. " (Health Teacher, Male) Only a few participants claimed that they have tried to talk about sex and sexuality with their child, but they felt very shy. One male school health teacher noted, "I have tried to talk to my child about sex and sexuality, but they feel shy. This created an uncomfortable situation among us. I have talked a lot about sexual health issues with many other young people. The social structure and the context have stopped us (parent and child) from being open to talk about sex. " (Health Teacher, Male) Some female participants argued that it is easier and more comfortable to provide sexual health information to daughters compared to sons. However, the majority of both male and female participants agreed that mothers are far more effective than fathers in educating their children on sexual health matters. One female parent shared as, "It is better to provide sexual health information to sons and daughters by the mother rather than the father. Educating mother is more effective than educating father. Children see mother as a friend, and it becomes more comfortable to communicate with each other. " (Parent, Female)

Partnership with schools
Most participants had a concern about forming partnerships with the Junior Red Cross Circle (JRC) which is a student initiative group in many Nepalese schools. Normally, they organise campaigns by visiting schools and deliver programmes on sexual health. Schools do not take any initiative to organise such programmes. This was explained by one of the female school health teachers, "The Nepal Red Cross Society (NRS) is an established organisation in Nepal and they have different programmes designed for youths through Junior Red cross Circle. They also organise school-based sex education programmes in partnership with local organisations. Schools should seek help and advice from these organisations. " (Health Teacher, Female) There were different views among participants about forming a partnership with an external agency. They reported that some schools work in partnership with other NGOs, but most of these NGOs have their own agendas in coming to the school irrespective of school policy. In this case, NGOs are more likely to approach the schools rather than schools to NGOs. One school head teacher commented, "Some schools work in partnership with other NGOs, but most NGOs have no partnerships with others. In this case, an NGO is more likely to approach schools than the school doing so. " (Head Teacher, Male) Interviews with participants revealed that there is no partnership between schools and local communities to enhance sex education programmes. Sometimes, they invite local people to take part in the school programmes, such as Parents' Day and Saraswati puja (Worshipping Goddess of Wisdom), as one male parent expressed, "There is no formal partnership between school and our community. The school management committee decides most of the things related to the school, except teaching. However, they can suggest what is to be considered while delivering sexual health information to the pupils. " (Parent, Male)

Suggestions for further improvement
Most participants agreed that the delivery of sex education is old fashioned and traditional in government (public) schools. The current school sex education policy does not allow for the involvement of peer educators and health professionals to deliver sex education. In addition, teachers also lack proper skills to teach in an interactive and informal way, as reported by a head teacher, "Today's world is globalised, and young people know many thing from sources such as the internet. Every year, they shift from one class to another. However, our teachers remain the same and updates are not observed among them as it should be. Authorities should also allow the involvement of health professionals from other organisations to deliver sex education in schools. " (Head Teacher, Male) One participant strongly emphasised that healthy school and healthy children are everyone's concern. He also advised school management committee to be bold and bring new ideas with regards to effective school sex education programme, "Healthy school and healthy children are everyone's concern. School management committees should be bold enough to bring new ideas and take any Vol 18 | Issue II | September 2019 decision to make sex education programme effective in their school. " (Head Teacher, Male) Some participants emphasised that open discussions about sex education in schools could reduce undue hesitation among pupils and health teachers. Pupils could also feel comfortable discussing sex issues at home. Information related to the appropriate age for sex, and legal issues like abortion, marriage and giving birth could help young people improve their reproductive health as exemplified by this quote, "We know that sex education is a sensitive issue, but open discussions about this topic could reduce the hesitation between teachers and pupils in school. They can freely talk about any sex related issue at home. " (Health Teacher, Male) Most participants agreed that sex education programmes in school are not sufficient. If there are NGOs that have expertise in sexual and reproductive health, then they should be mobilised to deliver effective sex education in schools. Participant also suggested strict school policies on sexual health issues. One male parent noted, "Schools should develop strict sex education policies for their schools. This is to ensure that every child in their school is protected for their sexual health. This also generates a message for other schools and stakeholders to value their child and provide accurate and effective sexual health information. " (Parent, Male) Some parents also served to school management committees. They suggested that schools should describe the delivery and importance of sex education programmes in schools. School management committees should also receive information about sexual health education. Every couple of years the school management committees are reformed and new committee members join in the team. The new members should also be updated about sex education issues. Here is a quote from a parent who is also a member of school management committee, "I am a member of school organising committee; however, I have never known that our school has a school sex education policy. I strongly raised this issue in our previous meeting. Another thing, every year new member joins the committee. In this case, the new members should be updated about what's happening in our school. " (Parent, Male)

Discussion
To our knowledge, this is first Nepali study to explore the parents' and teachers' perspectives on children's sexual health education. We found that some participants were concerned about sex education programme to be delivered from grade seven, since the globalisation and access to the internet has influenced young peoples' curiosity in sex and sex related content. Also, young girls who get better nutrition are more likely to menstruate as early as possible from 10-11 years (grade 5 or 6), therefore the early school sex education is required. This finding is linked with the observations of Pound et al [4], who reported how internet (sexting, cyberbullying) has been used by the young people to obtain sexual content and pornographic sites that lead to sexual exploitation and sexual coercion [4]. Young people receive unwanted online sexual comments from the adults which is a matter of concern for the parents and the school teachers. Globalisation and the increasing influences of modern culture have a greater effect on many Nepalese young people to challenge the traditional norms and values around sex and sexuality [10]. Also, they have now more chances to spend time in intimate sexual relationships before they got married [6]. They may be more vulnerable to unsafe sexual practices if no effective sex education programmes are designed, developed and implemented.
The lack of proper use of internet and age appropriate sex education permits a move in young peoples' attitudes and behaviours toward unsafe sexual activities. The age of puberty onset has decreased dramatically in low and middle income countries in the 20th centuries [38]. A recent report has also identified that young girls as young as of age 11, from poor socio-economic status and having adiposity are linked to early onset puberty [39]. Therefore, school-based sex education is an effective strategy to inform young people and children about the sex and sexuality issue from the early age [28]. However, a careful step should be taken while developing sex education curriculum.
In Nepal, sex education policy is not practically applied in the classroom which led to sex education programmes being poorly understood and inadequately delivered. Sex education is a key component in a multifaceted approach to address the high need for sexual and reproductive health education and services among adolescents. A UNESCO report [29] clearly highlights that there are scopes to practically apply the sex education programmes; the content of sex education could vary substantially between the regions of a country. For example, these contents could be; scope of the curricular approach (information, behaviour, life skills, etc.), the levels of education targeted (primary, secondary, etc.), the approach of content delivery (in-school, peer education, community/ parental involvement), the target groups for the interventions (inschool and/or out-of-school youths), whether there was a specific focus on issues related to girls, and/or to gender, whether there was a specific focus on issues of rights/stigma/discrimination (related to HIV and AIDS and/or more generally).
Parents have a vital role and are also a significant impact on young people's sexual health attitudes and behaviours. They prefer to talk about SRH issues with their children and this trend is in increase [30]. However, it is common for Nepalese parents not to talk about SRH issues with their children due to the social and cultural factors. This finding is in line with an African study which found that the parent-child communication in relation to the sex education is overwhelming [31]. Nevertheless, most female parents in our study surprisingly said that mothers can discuss sex and sexuality with their children than fathers. A previous study also found that mothers feel comfortable to discuss about sexual health information with their children compared to the fathers [32]. But, the problems for these mothers are as to what they could communicate with their children since they lack proper knowledge about SRH.
Most of the participants were concerned about forming partnerships with external agencies. Schools can develop partnership with Non-Governmental Organisations (NGOs) and School Management Committee (SMC) to enhance school-based sex education programme. To enhance young people's knowledge and understanding of sexuality education, schools should explore what kinds of teaching and learning methods could be developed and implemented. Partnership with external organisations could help to develop professional protocols among these organisations to work together to sustain an effective school-based sex education programmes if the sex education programme is culturally suitable [33].
Nepalese schools should develop partnerships with external Parent's and teachers' perspectives on childrens' sexual health education organisations, such as health authorities, education authorities, and community groups to promote young peoples' sexual health knowledge and understanding [7]. There is evidence that sex education related sessions delivered by school nurses from external organisation are effective in sustaining changes in attitudes, beliefs, and efficacy, whereas those taught by health education teachers reported far fewer changes in improving sexual health knowledge and understating [34]. These nurses were trained appropriately and supervised regularly to build trusting and enduring professional relationships with school children. Schools can also adopt and intensify peer education approach to sex education as recognised by World Health Organisation, which is also used in ASRH programme in Nepal [40]. It is one of the most effective and extensively accepted health promotion strategies used with young people [35]. However, a careful design and planning of the intervention is necessary to closely monitor the progress of school sex education programme. Anecdotal evidence often questions the standards of teaching of sexual health education in Nepalese schools. This is thought to be related to teachers' embarrassment, lack of knowledge and poor teaching methods [7]. Many schools do not have effective, acceptable, sustainable and capable sex education programme. In a synthesis on best practice in sex education report, Pound and colleagues [4] recommend four criteria to improve school-based sex education: school sex education should be linked to the sexual health and advice services; it should be age appropriate and should start in primary school; it should be 'sex-positive' that is it should be open, frank and informative, and culturally sensitive; and the sex education should be delivered in a safe environment to protect young people. The report further highlights that many young people in schools disliked having their teachers deliver sex education, despite the professionals feeling that teachers should be involved in sex education delivery.
School teachers in Nepal still seem to lack appropriate knowledge about sexual health as observed previously [36]. In the classroom, they follow inadequate and poor teaching methods to address young peoples' curiosity about sexual health. It may be vital for teachers to consider discussing the wider issues of sexual health such as feelings and relationships as a way of overcoming issues of embarrassment and bashfulness of the student in terms of implications for pedagogy [7].For example, teachers could use a variety of participatory approaches to the delivery of sex education such as group discussions, role-plays, and quizzes. Young people could be greatly benefited by providing age appropriate sexual health related information to improve their reproductive health such as legal issues like abortion, marriage and giving birth. These methods and information could be described in school guidance for sexual health education as a means of supporting teachers.
This study offers an important insight in the vicinity of parents' and teachers' views around sex education. However, there are few limitations which should be taken into account. This study was conducted in only one district of central Nepal and there were only fourteen participants from the parents and teachers' group. Also, the selected schools were the public schools which may not represent the views of the participants from the private schools. Thus, our findings should be cautiously interpreted. Future research should be more inclusive with outcome evaluation, long-term follow-up and comparison of different assessment methods to observe the overall picture of the effectiveness of the schoolbased sex education programme [37]. Sex education studies could further explore: the national impact of the current sex education curriculum on learning and experience; the development of effective pedagogy and assessment for a rights and gender equity based, inclusive, holistic, creative, empowering and protective sex education curriculum; and availability of training, leadership, resources, support and a robust research base to ensure high quality sex education provisions in schools.

Conclusion
This exploratory study has described the views of Nepalese parents and teachers about school-based sexual health education. The early sex education should be delivered preferably from grade seven to avoid the effects of media and the internet. It should be relevant, engaging and developmentally suitable with clear progressive avenues for learning experience for students. Sexual health education teachers should be trained properly to mitigate the social and cultural impacts and allows a smooth sex education discussion in the classroom. They should use more informal approach to teaching sex education such as use of media, stories, sex education websites, discussions etc. Schools should also develop partnership and involve local community people such as parents in the design and delivery of sex education programme. Particularly, mothers should be encouraged and provided with proper knowledge about SRH to pass onto their children. Getting support from external health professionals could bring further improvements in adolescent's sexual health knowledge and understanding.