Scaling up sexuality education in Senegal: integrating family life education into the national curriculum

Abstract

In Senegal, school-based sexuality education has evolved over 20 years from family life education (FLE) pilot projects into cross-curricular subjects located within the national curriculum of primary and secondary schools. We conducted a literature review and semi-structured interviews to gather information regarding the scale and nature of FLE scale-up. Data were analysed using the ExpandNet/WHO framework, conceptualising scale-up from a systems perspective as composed of interrelated elements and strategic choices. Key enabling factors that facilitated the scale-up of FLE included (1) programme clarity, relevance and credibility; (2) programme adaptability to young people’s evolving sexual and reproductive health priorities; (3) the engagement of a strong and credible resource team comprising government and civil society agencies; (4) a favourable policy environment; and (5) deliberate strategic choices for horizontal and vertical scale-up. Barriers included sociocultural conservatism that creates resistance to content areas deemed to be culturally sensitive, resulting in partial scale-up in terms of content and coverage, as well as structural barriers that make it difficult to find space in the curriculum to deliver the full programme. Lessons learned from Senegal’s experience can strengthen efforts to scale-up school-based sexuality education programmes in other culturally conservative low- and middle-income countries.

Résumé

Au Sénégal, l'éducation sexuelle en milieu scolaire a évolué sur une période de 20 ans des projets pilotes d'Éducation à la Vie Familiale (EVF) aux domaines transversaux dans le programme scolaire national des écoles élémentaires et secondaires. Nous avons procédé à une analyse documentaire et mené des entretiens semi-dirigés afin de rassembler des informations concernant la mise à l'échelle de l'EVF. Nous avons analysé les données en nous appuyant sur le cadre ExpandNet/OMS qui conceptualise le passage à grande échelle des innovations selon une approche systémique examinant les éléments liés et les choix stratégiques. Les facteurs clés ayant simplifié l'extension de l'EVF étaient (1) la clarté, la pertinence et la crédibilité du programme; (2) l'adaptabilité du programme nécessaire à l'évolution des priorités en matière de santé sexuelle reproductive de l'adolescent; (3) l'implication d'une équipe d'appui forte et crédible composée d'acteurs de la société civile et du gouvernement; (4) un contexte politique favorable; et (5) des choix stratégiques réfléchis pour l'extension horizontale et verticale. Les obstacles incluaient le conservatisme socioculturel qui créa une résistance aux domaines de contenu jugés culturellement sensibles, entraînant une expansion partielle en termes de contenu et de couverture, ainsi que des obstacles structurels qui ont rendu difficile le fait de trouver de la place dans le curriculum pour mettre en œuvre le programme complet. Les leçons tirées de l'expérience du Sénégal peuvent renforcer les efforts de mise à l'échelle des programmes d'éducation sexuelle à l'école dans d'autres pays culturellement conservateurs aux revenus faibles et moyens.

Keywords:

• Senegal
• young people
• comprehensive sexuality education
• school sex education
• scale-up

Mots-clés:

• Sénégal
• adolescents
• éducation sexuelle complète
• éducation sexuelle à l'école
• mise à l'échelle

Introduction

Comprehensive sexuality education (CSE) can improve the sexual and reproductive health (SRH) of young people, and is recognised as a human right (UN 2010, 2012). Despite recognition of CSE’s importance, many low- and middle-income countries have struggled to implement and sustain scaled-up national programmes. This paper describes the scale-up of school-based reproductive health education in Senegal, which evolved over a 20-year period (1990–2010) from family life education (FLE) pilot projects into a cross-curricular programme implemented as part of the national curriculum in primary and secondary schools.

Several studies have assessed the components and results of Senegal’s FLE programmes, yet little literature examines how these programmes have been brought to scale. This paper aims to identify key factors that have affected FLE scale-up and to offer recommendations for future efforts to enhance the quality and coverage of reproductive health education in Senegal and in other culturally conservative low- and middle-income countries.

The terms sexuality education, family life education and reproductive health education have been used in Senegal as operational definitions at different stages of the scale-up process examined here. While these terms have internationally recognised definitions, the way in which they have been understood and used in Senegal evolved in response to changes in the national context (Figure 1). The choice of terms was also motivated by a strategic approach to avoid resistance.

Figure 1. International definitions.

Some national stakeholders do not readily accept the term ‘sexuality education’ and prefer the use of other terms (Valerio and Bundy 2003; UNESCO 2011). In recent advocacy efforts, national actors have adopted the term ‘reproductive health education’ to refer to what is understood internationally as CSE, so as to mitigate resistance, while maintaining the full content and pedagogical approaches of CSE.

Methods

Data collection

Data for this study were collected using a multi-pronged search strategy. Literature was identified through a systematic search of academic and grey literature databases (PubMed, POPLINE, African Index Medicus, Persee, Memoire Online, Google Scholar); the websites of UN agencies, non-governmental organisations and international development partners; through meetings with national stakeholders; through the sourcing of key policy documents from Senegalese Government websites; and through reviewing bibliographies to identify additional relevant citations. Search terms used included Senegal, education, sexuality, sex, reproductive health, sexual health, life skills, family life, HIV, primary, secondary, sexuelle, santé de la reproduction, santé sexuelle, compétences de la vie courante, vie familiale, VIH, primaire, moyen and secondaire. The search was implemented using Boolean Operators.

The search identified 80 citations, which were reviewed to assess relevance and quality using the following criteria:

•	Original research or programme evaluations conducted in Senegal or secondary data analysis published in a peer-reviewed journal.
•	Examines school-based FLE, reproductive health education or CSE programmes implemented in Senegal by government or civil society.
•	Evaluations or research of school-based programmes implemented between 1990 and 2010.
•	Full text available in English or French.

Following this process, a total of 27 papers were retained for review.

Data were then collected through semi-structured interviews with informants from the Ministry of Education and the Ministry of Health at national level, UN agencies and civil society organisations. Finally, Demographic and Health Surveys’ (DHS) data were analysed for trends in adolescent and youth sexual and reproductive health indices occurring during FLE scale-up efforts.

Analytic framework

The ExpandNet/WHO framework defines scale-up as ‘deliberate efforts to increase the impact of successfully tested health innovations so as to benefit more people and to foster policy and programme development on a lasting basis’ (WHO 2010, 2). The framework conceptualises scale-up as a system consisting of the following interrelated elements: innovation, a resource team responsible for promoting wider application, user organisations that seek or are expected to adopt and implement the innovation on a larger scale and the effects of surrounding environmental factors. The framework also directs attention towards strategic choices, specifically: dissemination and advocacy, organisational processes, resource mobilisation and monitoring and evaluation to facilitate scale-up. This paper analyses these elements and strategic choices in relation to the scale-up of school-based FLE in Senegal. Reference is also made to UNESCO’s document entitled Comprehensive Sexuality Education: The Challenges and Opportunities of Scaling-up, which identifies a number of dimensions of scale-up that are specific to sexuality education (DeJong 2014).

Results

Context

Senegal is a secular democratic West African country, in which 94% of the 13.5 million population are Muslim, and over 50% are below the age of 18 years (ANSD Senegal and ICF International 2013; ANSD 2014). The national gross enrolment rate for primary school is 80%, which drops for lower secondary (59.4%) and upper secondary school (41.5%) (ANSD 2014). Gender parity is almost achieved in primary school, yet fewer girls continue into secondary school. Senegal’s maternal mortality is highest amongst girls aged 15–19 years (629 deaths per 100,000 live births, compared to 434 per 100,000 among adult women) (ANSD 2014). Approximately 25% of young women aged 20–24 years were married prior to age 20, and one-third of all young women aged 15–19 years report being sexually active (ANSD Senegal and ICF International 2013).

The innovation

In 1990, the national Ministry of Education introduced the Éducation à la Vie Familiale/Éducation en matière de Population¹ (EVF/EmP) pilot project, aimed at increasing pupils’ knowledge and skills regarding the social, economic and environmental determinants of population growth (Agbekponou 2008). In 1994, the national Ministry of Education approved a pilot project for lower and upper secondary schools called the Projet de renforcement de l’Éducation à la Vie Familiale dans les établissements d’enseignement moyen et secondaire du Sénégal. The national Ministry of Education delegated a local NGO, Groupe pour l’Étude et l’Enseignement de la Population² (GEEP), to manage the pilot project, a milestone partnership between Senegal’s national government and civil society.

The FLE pilot projects in primary and secondary schools shared three components: a classroom curriculum, teacher training and supervision and community sensitisation. The secondary school project had an additional component which consisted of extracurricular clubs.

The classroom curriculum for the primary school EVF/EmP pilot project was developed by the national Ministry of Education, and was introduced as a non-examinable cross-curricular programme with content designed for integration into different ‘carrier’ subjects (history, geography, French language, science and moral education) (Agbekponou 2008). Specific sexual and reproductive health and rights content included relationships, communication and refusal skills, sexual abuse, anatomy and physiology, and understanding health and illness, including basic information about HIV. The programme’s approach centred on problem-solving and values clarification in pursuit of specific cognitive and behavioural outcomes, including behaviours related to non-discrimination, gender-equitable relationships and the prevention of sexual abuse and HIV (Camara, Habib, and Tall 2005). A core curriculum document and several teaching aids were produced (Agbekponou 2008). It is important to note that, as a cross-curricular programme, teachers and school principals had autonomy to choose the extent of content integration in carrier subjects.

For secondary schools, the GEEP produced a population education curriculum and an adolescent sexual and reproductive health curriculum designed as interdisciplinary cross-curricular programmes to address population issues using an integrated approach (Valerio and Bundy 2003; Agbekponou 2008). The following topics were addressed: relationships; communication, refusal and negotiation skills; gender-based violence (including sexual abuse); sexual and reproductive anatomy and physiology; human reproduction; sexuality; pregnancy prevention; and reducing the risk of STIs and HIV. Teachers of the main carrier subjects (geography, family economics and earth and life sciences) were encouraged to collaborate when planning and assessing curricular integration.

Teacher training for the two programmes was decentralised. Cascade in-service training was conducted via existing regional- and district-level pedagogical units, and consisted of an introduction to the curriculum documents and pedagogic aids, training on participatory and skills-based learning techniques and guidance on integrating FLE activities into lesson planning (Agbekponou 2008).

Community sensitisation, a key component of both projects, aimed to increase parental and community support for FLE, as well as to sensitise key stakeholders concerning adolescent sexual and reproductive health. For primary schools, open days for parents and community members were organised and a sensitisation guide and documentary film were produced. In addition, various community-level activities were organised as part of the primary and secondary school projects (Valerio and Bundy 2003; Camara, Habib, and Tall 2005; Agbekponou 2008).

Secondary school extracurricular clubs were GEEP-created, school-based, teacher-supervised FLE clubs led by peer educators. They ran regular activities to share information with the community and to increase students’ knowledge and skills relating to adolescent sexual and reproductive health (Valerio and Bundy 2003; Agbekponou 2008).

ExpandNet/WHO scalability characteristics of the innovation

Clarity: The FLE programmes had well-articulated aims, objectives and components. In line with internationally recommended standards, the curricula followed a logic model for achieving desired health outcomes. External evaluations found that the pedagogical materials were well-designed and provided practical guidance for use (Agbekponou 2008).

Relevance: The FLE programmes responded to national and international needs, remaining relevant to evolving priorities as the programmes were scaled-up. Initially, the primary school programme addressed population and demographic concerns, but later it incorporated elements relevant to the national response to HIV and youth SRH. The secondary school programme was developed using findings from research on sexual behaviour and fertility among students in Senegal (Lutulala 1992; GEEP 1994, 1995a, 1995b, 1996; Valerio and Bundy 2003). The programmes also aligned with the global prioritisation of adolescent sexual and reproductive health articulated at the ICPD.

Credibility: Both primary and secondary school pilot projects were evaluated and well documented, lending credibility to the interventions and facilitating scale-up. Midterm evaluations were conducted of the primary school FLE programme (1995, 2001) (Agbekponou 2008), while the secondary school had regular programme evaluations conducted by the GEEP and external evaluations by UNFPA and UNESCO (Agbekponou 2008; UNESCO 2013a). These evaluations provided a sound assessment of results, including increased student knowledge of reproductive health and family-life issues (Valerio and Bundy 2003; Camara, Habib, and Tall 2005; Agbekponou 2008). International evidence of CSE’s positive results reinforced the credibility of the Senegal pilot projects (UNESCO 2009).

Compatibility with local norms: FLE programmes are frequently perceived as incompatible with Senegalese social norms; sexuality is considered a taboo topic in Senegal, especially for children and young people. Some parents, teachers and school heads opposed discussions on sexuality and contraception, fearing it would encourage sexual activity (Barboza 1993; Valerio and Bundy 2003). A recent study revealed that while many teachers are supportive of reproductive health education and recognise that some pupils are sexually active, they feel restricted to discuss sexuality in classrooms due to conservative social and cultural norms, as well as feel personally uncomfortable discussing sexuality-related issues (Jourdan et al. 2010). Religious leaders were therefore consulted as part of the development of the curriculum, drawing on two national conferences, during which Muslim and Christian leaders produced statements supporting access to full and accurate information about HIV and AIDS for young people. Nevertheless, conservatism remained a challenge; some teachers omitted sensitive topics when delivering the FLE programmes and certain components were not integrated into national curriculum documents.

An emphasis on participatory skills-based learning was compatible with the national Ministry of Education’s shift from an objectives-based to a competency-based pedagogical approach (DPRE 2004). Ministerial acceptance of the utility of participatory pedagogy is recognised by UNESCO as an important factor for scale-up sexuality education (DeJong 2014).

Ease of installation: Installation of the FLE programmes encountered several challenges. As interdisciplinary cross-curricular programmes, it was important to train teachers from various disciplines. The in-service training strategy successfully reached large numbers of teachers during the pilot phase, with 1,200 teachers from 112 primary schools being trained by 2000 (Agbekponou 2008). However, pre-service training would have been necessary for national coverage and sustainable scale-up (Camara, Habib, Tall and 2005).

Finding time within carrier subjects to introduce the additional content was another challenge, resulting in incomplete delivery of FLE components (Camara, Habib, and Tall 2005; Agbekponou 2008; Diop 2012). An insufficient number of didactic support materials was also identified as a challenge (Camara, Habib, and Tall 2005; Agbekponou 2008). Partnerships with civil society organisations helped to overcome some of these challenges. Several NGOs trained teachers on FLE (Camara 2011; One World UK 2013; UNESCO 2013a), while others supported the national ministries of education and health to produce teaching materials. The GEEP’s extracurricular FLE clubs helped compensate for incomplete classroom delivery.

Quality: While not a specific element in the ExpandNet framework, the quality of Senegal’s FLE and reproductive health education programmes is an important consideration for scale-up. The quality of the programmes was negatively affected by the factors noted above, namely sociocultural conservatism, lack of space in the curriculum, insufficient teacher training and lack of teaching materials. In fact, both the content and the implementation of the current national curriculum have significant gaps. It focuses primarily on biological and physiological aspects of reproductive health, while omitting important topics including: rights, gender, personal values, interpersonal relationships, gender-based violence, skills-building related to SRH (e.g. negotiating condom use) and critical thinking skills to assess social norms (UNESCO 2011, 2013a). The factors listed above also limit the quality of how FLE and reproductive health education are delivered. Many teachers omit sensitive topics and/or do not apply skills-based pedagogical approaches in classrooms, resulting in partial implementation of the programmes.

Resource teams

The resource teams for the FLE programmes included credible government and non-governmental entities with capacity and authority to support FLE introduction and scale-up. For the primary school EVF/EmP project, the resource team included a multidisciplinary technical committee and a national coordination team supported by UNFPA (Camara, Habib, and Tall 2005; Agbekponou 2008). The multidisciplinary technical committee was responsible for managing the pilot project and its members were trained in FLE by UNESCO and UNFPA. The national coordination committee was composed of representatives from key national Ministry of Education departments who oversaw and directed scale-up efforts. UNFPA provided technical and financial support throughout the pilot and scale-up phases.

At the secondary school level, the GEEP led the Resource Team, supported by UNFPA. A steering committee and a project management committee were also created to ensure technical leadership and coordination (Camara, Habib, and Tall 2005; Agbekponou 2008). Committee members, already experts in their fields, participated in experience sharing sessions organised by the GEEP on population, health and education to further build the committee’s expertise in FLE and adolescent sexual and reproductive health.

The Resource Team received support from the national Ministry of Education’s Division of School Health (DCMS), which was responsible for the health and nutrition subcomponent of Senegal’s 10-year Education and Training Programme (2000–2010). In this capacity, the DCMS created teaching and learning materials and technically supported teachers to deliver the FLE programmes (Niang 2003; Ministère de l’éducation nationale 2011). The Ministry of Health’s Department of Reproductive Health and Child Survival also supported the resource teams at both primary and secondary levels by providing technical know-how on adolescent sexual and reproductive health and HIV. Collaboration between the national ministries of health and education was an important element for the scale-up of FLE programmes. International NGOs and UN system agencies, including UNESCO, UNICEF and the World Bank, provided additional support (Valerio and Bundy 2003; Gannon 2005; Agbekponou 2008; Diop and Diagne 2008; Joyce et al. 2008).

User organisations

Three categories of user organisations assisted FLE scale-up: (1) The national Ministry of Education’s Department of Elementary Education, Department of Middle and Secondary Education and General Inspectorate of Education provided oversight for the FLE programmes by monitoring the delivery of school-based FLE activities, assessing teacher training needs and overseeing actions to improve the quality of FLE teaching. Representatives from these departments were also members of the resource team as described above. (2) The national Ministry of Education’s regional and district pedagogical units were responsible for in-service teacher training on FLE, with support from the GEEP for secondary school teachers. (3) Primary, middle and secondary school teachers were responsible for the delivery of FLE programmes in their respective classrooms. The GEEP was also responsible for coordination between the extracurricular FLE clubs and the classroom curriculum.

Credibility: The national Ministry of Education departments cited above are mandated to implement and monitor governmental education policies and programmes, and are responsible for centralised planning and monitoring of educational activities. Therefore, they had credibility and authority to oversee the delivery of FLE. The national Ministry of Education’s regional and pedagogical units are responsible for performance improvement of teachers, including disseminating didactic materials and training on pedagogical methods (DEMSG 2011). These units therefore had the credibility to assure the in-service teacher training. The GEEP held credibility, because its members were education experts, many of whom were part of the national Ministry of Education’s curricular commissions possessing detailed knowledge of the education system and the specific carrier subjects (Valerio and Bundy 2003). The GEEP was also a recognised leader in the field of adolescent sexual and reproductive health due to its leadership in organising a series of Population and Development conferences in the mid-1990s. Furthermore, the GEEP had a strong working relationship with UNFPA, the main funder for the FLE programmes. Including the GEEP as a user organisation ensured collaboration between the national Ministry of Education and civil society, which facilitated the scale-up process, and remains an important element today.

Capacity: The various entities of the national Ministry of Education had previous experience overseeing cross-curricular education programmes. They also received capacity building support from the FLE programmes’ technical, pedagogical and coordination teams for running the pilot projects and supporting the scale-up process (Agbekponou 2008). One capacity restraint in terms of teacher training derived from the user organisations’ lack of pre-service teacher training institutes. The EVF/EmP programme ran a one-week seminar at two pre-service training institutes, yet an evaluation found that the module’s format and short duration limited its ability to build necessary skills and capacity among future teachers (Agbekponou 2008).

The GEEP had both strengths and shortcomings in terms of capacity as a user organisation. It possessed a thorough understanding of Senegal’s cultural context, had technical expertise on adolescent sexual and reproductive health and participatory pedagogy, and, as an NGO, was less subject to formal political control or bureaucratic processes than the national Ministry of Education. These factors enabled the GEEP to mitigate cultural resistance to FLE. However, as an NGO, its capacity to ensure national coverage for scale-up was limited.

Commitment: The national Ministry of Education displayed fairly strong commitment to the FLE programmes throughout the scale-up process, having prioritised FLE and HIV education as part of the national response to HIV in the early 1990s (Pisani 1999; DCMS and INEADE 2001). The programmes were later anchored in Senegal’s 10-year Education and Training Programme (2000–2010) (Agbekponou 2008). However, some individuals within the national Ministry of Education were reticent about content areas considered sensitive or taboo, resulting in an incomplete integration of FLE topics into national curriculum documents (DCMS and INEADE 2001; UNESCO 2013a). Teachers’ commitment to delivering FLE and reproductive health education was influenced by conservative social norms that limited their ability to address sensitive topics with pupils (Jourdan et al. 2010).

Policy environment

The international and national policy environment had a largely facilitating influence on FLE and reproductive health education in Senegal.

International: The ICPD was the stimulus behind the GEEP’s population and development conferences, which formed the basis of the secondary school FLE programme (Camara, Habib, and Tall 2005; Agbekponou 2008). The Dakar World Education Forum in 2000 further facilitated the introduction of FLE and reproductive health education in Senegal, launching the Focusing Resources on Effective School Health (FRESH) framework, which increased attention to the education sector’s role in health promotion and HIV prevention (Niang 2003). Global attention to HIV created opportunities for additional funding and technical expertise for responding to HIV through the education sector (Gannon 2005).

National: In 1988, Senegal made a landmark political declaration on population, which laid the foundation for school-based FLE, being the first national policy document to address adolescent sexual and reproductive health and mandating the introduction of FLE (Mane and Ndiaye 1999). The onset of HIV and Senegal’s early and rapid response also facilitated scale-up (Pisani 1999). HIV education and the sensitisation of young people were cornerstones of the national strategy (DCMS and INEADE 2001). Another significant environmental factor was the government’s increased prioritisation of youth sexual and reproductive health, evidenced by the 2005 Sexual and Reproductive Health Law and the first national strategy on adolescent sexual and reproductive health (République du Sénégal Primature 2005; Guèye Ba, Ndianor, and Sembène 2009). These factors helped shift the focus of FLE programmes from narrow population concerns towards a broader range of topics and skills related to the sexual and reproductive health of young people, including HIV.

Despite the favourable policy environment, social and religious conservatism in Senegal contributed to resistance against FLE. Many communities, leaders and religious organisations held conservative values that opposed FLE. This resistance limited the comprehensiveness and coverage of the programmes during the scale-up process.

Strategic choices for scale-up

Vertical scale-up refers to policy, political, legal, regulatory, budgetary or systems’ changes required to institutionalise an innovation at national or sub-national levels. Several efforts were made to institutionalise FLE. In 2005, the Senegalese government developed an education policy paper identifying FLE and HIV education as a priority for improving the education sector’s quality and performance (République du Sénégal 2005). The creation of the new national Basic Education Curriculum (2005–2010) offered additional opportunity for vertical scale-up, as it set national standards for primary education. Efforts were made to integrate FLE into the national Basic Education Curriculum, including reference to FLE in the official memorandum mandating the creation of the new curriculum³ and a ministerial order outlining the FLE programme’s organisation within the new Basic Education Curriculum⁴ (Agbekponou 2008).

In the health sector, the most relevant vertical scale-up measures were the 2005 Reproductive Health Law, recognising young people’s rights to the highest standard of SRH (République du Sénégal Primature 2005), and the national Ministry of Health’s first adolescent sexual and reproductive health strategy, which included references to reproductive health education (Ministère de la Santé et de l’Action Sociale 2005; Joyce et al. 2008). Additionally, Senegal’s 2002–2006 and 2007–2009 HIV/AIDS Strategic Plans included guidance regarding delivery of reproductive health and HIV education in schools (Bundy et al. 2010).

Horizontal scale-up refers to expansion of an innovation to additional geographic sites and/or a larger number of people. The primary school FLE programme was horizontally scaled-up in a four-step process. During the initial phase (1990–1992), a coordination structure was established and formative research and capacity building were conducted. During the second scale-up phase (1992–1996), the programme was launched and tested in 10 schools across 4 regions. By 1995, the programme expanded to 22 additional schools across all regions in Senegal (Camara, Habib, and Tall 2005). The third phase (1997–2001) was characterised by intensified sensitisation activities with parents, students and community stakeholders. By 2000, 80,000 primary school pupils were reached by the FLE programme (8% of the primary student population). The fourth phase (2002–2006) involved further horizontal scale-up with a focus on the regions of Tambacounda and Kolda, which had high rates of HIV and adolescent pregnancy. By the end of this phase, the programme was introduced into 30% of primary schools in Senegal and 90% of primary schools in the two focus regions (Agbekponou 2008).

The secondary school programme was horizontally scaled-up from 1994 to 2003. It was piloted in 40 secondary schools across 5 regions, followed by focused scale-up in Tambacounda and Kolda regions (Agbekponou 2008). Capacity building, sensitisation activities, community festivals and summer camps were key features of the scale-up strategy (Valerio and Bundy 2003). Secondary schools could also request support from the GEEP to introduce the FLE programme, which is an example of spontaneous, user-driven scale-up. The programme expanded from 30 FLE clubs in its first year, to 283 in 2004, with a coverage rate of 94% in Tambacounda and Kolda, and 65% nationally (Camara, Habib, and Tall 2005). The expansion of the FLE clubs was accompanied by expanded use of the population education and adolescent sexual and reproductive health curricula in classrooms. The secondary schools’ high demand sometimes exceeded the GEEP’s capacity to introduce the programme; the national coverage rate may have been higher had the national Ministry of Education been more engaged in the scale-up process.

FLE integration into Senegal’s new Basic Education Curriculum (2010), and the new national curriculum documents for the family economics programme and the life and earth sciences programme (2008), were opportunities for horizontal scale-up beyond the pilot projects’ lifespans. FLE components, drawn from the two pilot projects, were integrated into the new national curriculum documents following a series of national workshops (Agbekponou 2008). Teachers, educational inspectors and school principals across Senegal were trained on the new curriculum documents, including FLE components, through a cascade in-service training strategy.

It is important to note that certain elements of the primary and secondary school FLE programmes were not integrated into the national curriculum documents, mainly due to sociocultural opposition to young people’s sexuality. At primary school level, omitted topics included intimate relationships, sexual abuse, comprehensive information about the sexual transmission and prevention of HIV and communication and negotiation skills to avoid sexual coercion and abuse. At the secondary school level, topics related to sexuality, intimate relationships, sexual abuse and negotiation skills to avoid unwanted sexual activity or to use condoms and were not integrated into the official curriculum. Expanding coverage at the expense of ensuring fidelity and quality is a common dilemma for the scale-up of sexuality education programmes (DeJong 2014). The decision to externalise the delivery of FLE at the secondary school level through an NGO may have also contributed to this partial integration since the process to develop the new national family economics and earth and life sciences guidance documents was primarily led by national Ministry of Education entities. As an NGO, the GEEP had limited influence on decisions about the final content of the new curriculum documents.

Managing the scale-up strategy

Dissemination and advocacy: The advocacy strategy for FLE scale-up involved actions aimed at different entities within the national Ministry of Education and community-level advocacy. The Ministry of Education’s Division of School Health and the GEEP played a central role in advocating for FLE’s inclusion into the national curriculum. Their intimate knowledge of the education sector was an important facilitating factor for advocacy efforts. Community-level advocacy and sensitisation activities with school principals, head teachers, parents and community leaders were also central components of the advocacy and dissemination strategy. These activities helped achieve buy-in from reticent stakeholders, including parents, teachers and community leaders, which is recognised by UNESCO as an important dimension for CSE scale-up (Valerio and Bundy 2003; DeJong 2014).

Managerial and organisational choices: A managerial choice was made to focus scale-up efforts in Tambacounda and Kolda due to their high HIV prevalence, adolescent pregnancy and maternal mortality rates. While effort was made to scale-up FLE in other regions, coverage rates were highest in Tambacounda and Kolda.

An organisational choice was made to create specific project management bodies to pilot the programmes and oversee scale-up. These project management bodies were either part of the national Ministry of Education or worked in close collaboration with the Ministry, thereby facilitating scale-up (Agbekponou 2008). These management bodies functioned well during the project implementation period; however, the national Ministry of Education was unable to fully absorb them after the completion of the projects, resulting in human resource capacity gaps.

Costs and resource mobilisation: The implementation and scale-up of FLE was supported by funding from the Senegalese government (the Ministries of Education and of Health), USAID, United Nations system agencies (UNFPA, UNESCO, UNICEF, the World Bank) and international NGOs (Camara, Habib, and Tall 2005; Gannon 2005). Funding was sufficient to pilot the FLE programmes; however, resource constraints limited the scope of horizontal scale-up (Agbekponou 2008).

Monitoring and evaluation: Monitoring and evaluation mechanisms were established to assess progress and scale-up of the FLE programmes, including the midterm and external evaluations cited earlier. Additionally, some horizontal scale-up elements were included in the routine monitoring and evaluation frameworks. A number of youth SRH studies in Senegal produced additional data relevant to the scale-up process. For example, a study carried out in 2003 on SRH in school settings provided recommendations for how to strengthen collaboration between the education and health sectors (Niang 2003). However, the monitoring and evaluation frameworks were not able to measure the direct effect of the FLE programmes on population health outcomes.

Impact of the innovation

Evaluations of the FLE programmes suggest that they contributed to improved student knowledge on reproductive health. An external evaluation showed that 63% of primary students and 80.2% of secondary students in Tambacounda and Kolda were knowledgeable about reproductive health issues (Agbekponou 2008). However, in the absence of baseline figures and control groups, the evaluation was unable to demonstrate changes in the levels of knowledge attributable to FLE. Nevertheless, qualitative data suggested that students had an increased interest in reproductive health and acquired new knowledge that helped them adopt healthy behaviours (Agbekponou 2008).

National DHS data demonstrate improvements in youth SRH indicators at a national level since the introduction and scale-up of FLE. Among young people aged 15–19, those with knowledge of at least one modern method of contraception increased from 59.5% in 1993 to 83.1% in 2010 (Ndiaye, Diouf, and Ayad 1994; ANSD Senegal and ICF International 2012). During the same period, condom use increased by 16% among unmarried sexually active young men, while almost doubling among unmarried sexually active young women (Ndiaye and Ayad 2006; ANSD Senegal and ICF International 2012). These trends contributed to reductions in pregnancy rates among young people aged 15–19 years from 23.8% in 1993 to 18.7% in 2010 (Ndiaye, Diouf, and Ayad 1994; ANSD Senegal and ICF International 2012). HIV prevalence rates were always low among young people aged 15–24 years in Senegal and saw a slight reduction from 0.3% in 2005 to 0.2% in 2010 (Ndiaye and Ayad 2006; ANSD Senegal and ICF International 2012).

Interestingly, trends in young people’s sexual and reproductive health were mixed in the focus regions of Tambacounda and Kolda. Knowledge regarding modern methods of contraception increased in both regions (Ndiaye, Diouf, and Ayad 1994; ANSD Senegal and ICF International 2012), yet pregnancy rates increased between 2005 and 2010, from 35.9% to 39.5% in Tambacounda and from 35.7% to 43.4% in Kolda (Ndiaye and Ayad 2006; ANSD Senegal and ICF International 2012) among young people aged 15–19 years. HIV prevalence amongst young people aged 15–24 years also increased during the same period from 0.6% to 0.7% in Tambacounda and from 1.2% to 1.4% in Kolda (Ndiaye and Ayad 2006; ANSD Senegal and ICF International 2012).

The FLE scale-up strategy did not collect phased data from control groups, thereby restricting the ability to establish attribution to health outcomes. Thus, these mixed outcomes cab not be directly attributed to FLE programmes themselves. Additionally, several related initiatives were implemented nationally at the same time as the FLE and HIV education programmes, such as youth-friendly services, sensitisation activities and social and behaviour change communication projects. Therefore, direct causal pathways between FLE and health or behavioural outcomes are difficult to establish. Furthermore, during this period, net primary school enrolment rates in Tambacounda and Kolda were low. Nearly half of primary school-aged girls were not enrolled, and therefore did not have access to the potential protective benefit of school-based FLE.

Discussion and recommendations

Using the ExpandNet/WHO Framework, this study has identified factors that facilitated and hindered the scale-up process of FLE in Senegal. Overall, the experience offers a successful example of national-level scale-up of FLE, yet several gaps remain in terms of scaling up a comprehensive reproductive health or sexuality education programme. Characteristics that facilitated FLE scale-up included clarity of the programmes’ aims, objectives and components; responsiveness to felt needs at the national and international levels; and credibility of the programmes based on sound data.

The FLE programmes’ adaptation to the evolving SRH priorities of young people was a principal enabling factor for scale-up. Incorporating content and skills-based objectives related to HIV and adolescent sexual and reproductive health enabled the programmes to remain relevant over time. This adaptability remains critical for future efforts to improve the coverage and quality of reproductive health education in Senegal.

Collaboration between government and civil society was central to success, particularly at the secondary school level. Mandating an NGO to lead the secondary level programme helped to address capacity gaps, while also expanding the technical expertise of the Resource Team and User Organisations. Additionally, using an NGO-led, demand-driven approach to horizontal scale-up helped to mitigate sociocultural opposition. However, delegating an NGO as a user organisation limited the programmes’ institutionalisation. These constraints contributed to the incomplete integration of FLE into national curriculum documents and to coverage gaps across the country. The Senegal experience therefore suggests that NGO-led sexuality education programmes can lay a strong foundation for scale-up efforts, but achieving national coverage requires governmental leadership for vertical and horizontal scale-up. Additional investments to build the capacity of the government user organisations on reproductive health education can help to bolster and maintain commitment to scale-up.

The decision to use a decentralised approach for training and supervision helped to foster a greater sense of ownership and to build capacity amongst stakeholders across the country. Nevertheless, the need for improved teacher training on FLE and reproductive health education persists, especially to address individual teachers’ reticence about sensitive topic areas and their lack of confidence to deliver reproductive health education. An emphasis on teacher training and supportive supervision is therefore important to address for improved coverage and quality of FLE. Building and maintaining the capacity of decentralised pedagogical committees can play an important role for strengthening in-service teacher training for future scale-up efforts. Greater investment in pre-service teacher training will also be necessary.

Concentrating horizontal scale-up on two focus regions helped attain high coverage levels in regions with the highest adolescent sexual and reproductive health needs. However, more robust monitoring and evaluation would have resulted in a better understanding of the FLE programmes’ impact on population health outcomes. Since these regions had particularly low school enrolment rates, stronger linkages with out-of-school sexuality education efforts may have helped to improve population health outcomes.

Despite the successes, it is also important to highlight how sociocultural and structural barriers hindered the scale-up process and also negatively affected the quality of current-day FLE and reproductive health education. The conservative sociocultural context in Senegal created resistance among community members and within the user organisations to scale-up FLE programs that address a full range of SRH issues. As a result, Senegal’s current curriculum has important content gaps. This form of social conservatism is not unique to Senegal. It has been observed in many other sub-Saharan countries, including predominantly Christian countries (UNESCO 2013b). In Senegal, it will be important to strengthen the influence of progressive national stakeholders to improve the quality of reproductive health education. For example, several national civil society organisations have developed and tested new content under the supervision of the national Ministry of Education (GEEP 2006; Click Info Ado 2011; UNESCO 2013a). A recent assessment suggested that these locally developed resources could effectively fill content gaps in the national curriculum, improving comprehensiveness and the quality of reproductive health education (UNESCO 2013a).

Strategic investments by the resource team in community sensitisation and advocacy were critical to overcome resistance, increase community buy-in and facilitate scale-up. Addressing conservative opposition, including by building support among religious leaders, remains a priority for continued efforts to improve the quality and coverage of Reproductive Health Education (RHE) in Senegal. The bottom-up, demand-driven approach of the secondary school FLE programme was also an effective strategy to respond to youth needs while mitigating resistance to FLE. Thus, community sensitisation, advocacy and a demand-driven approach are critical features to retain in future scale-up efforts.

Deliberate, strategic choices were made for vertical and horizontal scale-up, including advocacy resulting in policy changes that supported vertical scale-up efforts. Currently, Senegal is moving towards a model of comprehensive reproductive health education to address gaps in the FLE programme. Additional vertical scale-up measures are required for institutionalising comprehensive reproductive health education. Specific opportunities include building on the National Action Plan for Adolescent Sexual and Reproductive Health in Senegal (2014–2018), the National Action Plan for Family Planning (2012–2015), Senegal’s FP2020 commitments, and results from the 2014 Assises de l’Éducation du Sénégal, all of which make specific reference to SRH education and information for young people.

Limitations

There are limitations to the analysis offered here. First, much of the FLE and sexuality education literature in Senegal is grey and non-peer reviewed. The current FLE programme has yet to be subjected to a rigorous evaluation of its effectiveness and impact. Consequently, there is a lack of robust data about performance and results. Beyond this, the public health impact metrics were based on data that were not collected specifically within the context of the FLE or reproductive health programmes. As a result, there is an absence of baseline data specifically from the two focus regions. Nevertheless, the facilitating and hindering factors identified in this analysis are in line with findings from other countries, including Nigeria (Huaynoca et al. 2014), and contribute to a deeper understanding regarding how to scale-up sexuality education programmes in culturally conservative low- and middle-income countries.

Conclusion

Senegal’s experience in scaling up FLE has laid a foundation for the potential to introduce more comprehensive forms of education. Senegal now has the opportunity to build on lessons learned from the successful scale-up to date to further improve the coverage and quality of school-based reproductive health education. Key recommendations drawn from this analysis include maintaining and strengthening intersectoral collaboration between the national Ministry of Education, the national Ministry of Health and civil society organisations. It is also important to strengthen linkages between sexuality education and adolescent health services, to ensure that young people can access the SRH services that they need, while also having access to comprehensive SRH information and education. Beyond this, it is important to (i) develop a more comprehensive approach to reproductive health education that addresses content gaps by consolidating existing local civil society curricula with the national curriculum; (ii) maintain a strong focus on community sensitisation and building support among religious leaders, prioritising approaches with the greatest potential to overcome sociocultural barriers; (iii) develop an actionable strategy to reproductive health education in pre-service teacher training, alongside continued efforts to strengthen in-service training; and (iv) leverage policy environment opportunities to advance the vertical and horizontal scale-up of comprehensive reproductive health education.

Acknowledgements

The preparation of this analysis was supported by the WHO/RHR/Implementing Best Practices Initiative using funds provided by USAID. The authors thank Joanna Herat (UNESCO), Xavier Hospital (UNESCO) and Khady Tall Thiam (GEEP), who provided insight and expertise that greatly improved the quality of the manuscript.

Funding

This work was supported by the United States Agency for International Development.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1. Family life education/population education.

2. Group for Population Studies and Teaching.

3. Note de service n° 01833/ME/DPRE/MT/mdd, 24 April 2003.

4. Arreté n°2005–4054 of 8 August 2005.