School-Based Sex Education in Western Nepal: Uncomfortable for Both Teachers and Students

Abstract

The National Adolescent Health and Development Strategy (2000) of Nepal considers adolescents a key target group for information and services. The extent to which sex education is being provided in schools has received little attention, however. At higher secondary level, students are supposed to be taught basic sex education using a chapter in a textbook called Health, Population and Environment. Little is known about how or how well this material is covered. In a study in 2002 among adolescents in eight schools in the Nawalparasi District in the Western Region of Nepal, we interviewed eight teachers responsible for teaching this subject. We also collected survey data from 451 students and held four focus group discussions with 26 of them. We found that adolescents in these schools did not appear to be getting the information they needed. Most of the teachers did not want to deal with sensitive topics and feared censure by their colleagues and society. Some lacked the skills to give such instruction. Many students also felt uncomfortable with the topics. The challenge is to strengthen sex education, make it more appropriate for the students and ensure that teachers are more comfortable and able to give instruction on the topic.

Résumé

Au Népal, la Stratégie nationale de santé et de développement de l’adolescent (2000) considère les adolescents comme un groupe cible essentiel pour les informations et les services. Néanmoins, l’éducation sexuelle dispensée dans les écoles n’a guère reçu d’attention. Dans l’enseignement secondaire du deuxième cycle, les élèves sont censés étudier les notions d’éducation sexuelle avec un chapitre d’un manuel intitulé « Santé, population et environnement ». On sait peu de choses sur la manière dont cet enseignement est réalisé. Dans une étude de 2002 auprès d’adolescents dans huit écoles du district du Nawalparasi, dans la région occidentale du Népal, nous avons interrogé huit professeurs chargés d’enseigner cette discipline. Nous avons aussi recueilli des données auprès de 451 élèves et organisé quatre discussions par groupes d’intérêt avec 26 d’entre eux. Nous avons constaté que, dans ces écoles, les adolescents ne semblaient pas recevoir les informations dont ils avaient besoin. La plupart des enseignants ne voulaient pas aborder des questions sensibles et craignaient les critiques de leurs collègues et de la société. Certains n’avaient pas les compétences requises pour assurer cet enseignement. Beaucoup d’élèves étaient également gênés par les thèmes traités. L’enjeu consiste à renforcer l’éducation sexuelle, l’adapter aux élèves et veiller à ce que les enseignants soient plus à l’aise et plus aptes à l’assurer.

Resumen

La Estrategia Nacional de Salud y Desarrollo de la Adolescencia (2000) de Nepal considera a los adolescentes un grupo objetivo clave para recibir información y servicios. No obstante, no se conoce mucho acerca de la enseñanza de educación sexual en los colegios. En el nivel secundario superior, se supone que los estudiantes reciban educación sexual básica, usando un capítulo del libro de texto titulado La salud, la población y el ambiente. Poco se conoce en cuanto a cómo o cuán bien es abarcado este material. En un estudio realizado en 2002 entre adolescentes en ocho colegios en el Distrito Nawalparasi de la Región Occidental de Nepal, nos entrevistamos con ocho profesores responsables de enseñar esta materia. Además, recolectamos datos de la encuesta entre 451 estudiantes y llevamos a cabo cuatro discusiones en grupos focales con 26 de ellos. Encontramos que los adolescentes en estos colegios no parecían estar recibiendo la información que necesitaban. La mayoría de los profesores no querían tratar temas delicados y temían la censura de sus colegas y la sociedad. Algunos carecían de las habilidades para impartir tal enseñanza. Muchos estudiantes también se sentían incómodos con los temas. El reto es fortalecer la educación sexual, adaptarla al contexto de los estudiantes y asegurar que los profesores se sientan más cómodos y capacitados para enseñar esta materia.

Key Words:

• sex education
• adolescents
• secondary school teachers
• Nepal

Nepal adopted its first National Reproductive Health Strategy in 1998 and a National Adolescent Health and Development Strategy in 2000.^{1 2 3} Both envisaged adolescents as a key target group for integrated reproductive health services, with interventions planned to increase knowledge about reproductive health issues and service availability. School adolescents attending the eighth and ninth grades, who are typically about 15 years old, would for the first time receive sex education. This paper provides a preliminary assessment of the content and quality of the provision of sex education, both from the perspective of teachers and students.

Existing studies of adolescent and reproductive health in Nepal are limited in number and scope.², ^{4 5 6} What is known is that by age 20, over half (52%) of all adolescent girls were already mothers and only 12% of deliveries among them were in a health facility. Moreover, among married girls aged 15–19, only 12% practised contraception, with barely 9% using a modern method.⁷

In 2001, fewer than one-third of Nepali adolescents (31%) who should have been attending secondary school were in school at that level, more of whom were boys (35%) than girls (27%).⁷ Girls typically stop attending school if they marry early. The school learning environment has been overlooked in existing studies, though that is the only place where adolescents can get sex and reproductive health education at the present time. The authors of one study reported having trained teachers as part of a youth reproductive health intervention,⁵ but not on how they incorporated training into the intervention, or the outcome.

In the higher secondary class (ages 14–16), students are now taught basic sex education using a chapter on reproductive health contained within the textbook Health, Population and Environment.⁸ This covers basic reproductive health facts concerning safe motherhood, family planning, reproductive physiology, STIs/HIV, infertility, adolescent health, reproductive health problems of post-menopausal women and reproductive rights. The material was endorsed by the Ministry of Education and Sports in 1998–99. However, very little is known about the extent to which this material is covered in classes in private or government schools in urban or rural areas.

Data and methods

The study formed part of a broader investigation of sex education and reproductive health among in-school adolescents, with fieldwork conducted in 2002. The overall study was designed to be representative of Nawalparasi District in the Western region of Nepal. Stratified random sampling was used to select eight schools from the district’s four electoral constituencies, including two governmental and two private schools drawn from the urban area and two governmental and two private schools from rural areas. Survey data were collected by a self-administered and pre-tested questionnaire completed by 451 eighth and ninth grade students (174 female, 277 male) aged 12–19. Up to 60 students (half male, half female) were selected from each of the eight schools using systematic random sampling. If there were fewer than 30 female students in a particular school, we still sampled 60 students in the school by selecting additional boys from the same classes to make up the desired sample size. Questionnaire items included socio-demographic characteristics; knowledge of reproductive biology; knowledge of and attitudes towards STDs, HIV/AIDS, abortion, family planning, and service use; menstrual practices (asked of girls only); and contraceptive use. This paper reports only those results with direct bearing on sex education.

We found that although adolescents in schools are said to receive the new sex education course, they may not get the information they need. To examine this situation further, we conducted in-depth interviews with eight teachers, each responsible for implementing sex education in the selected schools. We asked the teachers what they actually taught, whether they felt comfortable teaching this material and how their classes responded to the information they gave. In addition, four focus group discussions were held with 26 of the 451 students from the same schools who had answered our questionnaire, in two same-sex groups each and with same sex facilitators. These focus groups allowed participants to discuss the sex education class in more detail and comfort than the questionnaire allowed, as well as other issues relevant to their reproductive health. Focus group participants were recruited with the help of teachers and students who recommended those they considered representative of their class in both private and government schools.

Teachers’ perspectives

The government school teachers were all reluctant to discuss the content of the chapter on sexuality and reproductive health in any detail with their students, and several of the private school teachers also said that they rarely mentioned reproductive health terms. They did not want to deal with such sensitive topics and feared censure by their colleagues and society for doing so in the absence of more support. Some also had their own prejudices about teaching the topic. Some teachers were reticent about presenting the material. These observations are apparent in the following comments made by teachers:

“We teachers can’t do everything. We need the support of others such as the principal, parents and community.”

“It is very hard to convince people that reproductive health and sex education is important for adolescents. It is believed that this kind of information can spoil their children.”

“Sexuality is a private matter and it is unpleasant to discuss personal matters. The students are too young to discuss this issue.”

Some teachers suggested that students should be left to learn these things by themselves:

“Students of this generation are very fast learning. They are very curious and enthusiastic to know about this. We don’t have to teach them, they already know more than what we are supposed to teach. There is no need to worry too much about this issue.”

“I say to them: It’s very easy, read it by yourself and only ask me if there is any difficulty.”

Teachers who did try to teach this class properly often faced problems. Some clearly lacked the skills needed. Several said that the mischievous attitudes of some boys placed girls, who were a minority in their classes, in an uncomfortable position.

“Even my teacher friends and students call me ‘reproductive sir’ satirically.”

“There is no environment for any kind of discussion, questions or answers during this class. All the girls have their heads down because they feel uneasy.”

“I try to teach it thoroughly, but if I spend more time on this class, boys start to show naughty attitudes and behaviours which later become difficult to control. That’s why I complete this topic as quickly as possible.”

When asked for their ideas on how to improve this particular class, several teachers felt that it might be easier to teach the subject if they and all the students were the same sex:

“It would be better if there were separate classes for girls and boys on reproductive health. We would feel more comfortable to teach it.”

One of the teachers thought that even if teachers were more comfortable with the topic, health workers might make better instructors:

“It would be more informative if the school could arrange guest lecturers for this subject, such as health workers, or for students to visit health centres. I think health workers could explain this material more comfortably than teachers like us.”

Others complained about the lack of teaching aids:

“There are not enough audiovisual materials so that we can learn about reproductive health and sexuality. It is only the textbook that we have. I feel very shy to ask them to read it.”

“I have been one of the teachers for this subject from the beginning. This is the only subject I feel uncomfortable teaching. Each year I try to make the class work better, but I haven’t been able to do it. The biggest problem is the lack of appropriate teaching tools like audiovisual aids or case studies.”

Students’ perspectives

Despite the introduction of sex education, reproductive health knowledge was poor among students. Only about half the students knew that the main purpose of family planning was to space (43%) or prevent (63%) births, while 5% thought it caused infertility and 4%, mostly from government schools, knew nothing at all about it. Only 43% knew of a contraceptive used by men and 37% of one used by women. Among those who knew about contraception, however, 93% recognised the condom as a male method. Virtually all adolescents (99%) had heard about STIs and HIV/AIDS, but only 15% answered correctly on signs and symptoms of STIs and only 54% answered correctly a question about HIV transmission. Mass media (radio, TV and newspapers) were the main source of information on HIV/AIDS and STIs, followed by teachers and health workers.

The survey findings gave some indication of the poor quality of communication between teachers and students when material from the reproductive health chapter was covered in class; only 57% of students surveyed said some of their questions were answered. Two per cent of the adolescents surveyed had no idea whether they had had a reproductive health class or not. Although students were supposed to be taught about reproductive physiology, the male and female reproductive organs could only be identified by name correctly by 72% and 86% of those surveyed, respectively. As one focus group participant put it:

“Our teachers usually focus on the biological facts but I still don’t know about the fertile and infertile times of a woman’s cycle.”

Focus group participants did not think that their teachers could effectively teach reproductive health or communicate with students on this subject:

“Teachers come to the class, write the lecture title on the blackboard, and then leave the classroom.”

“I was very keen to learn about this subject, but when my teachers said this topic will not be covered in the exam, I got so disappointed.”

At the same time, however, it became clear that in-class discussion was limited partly because many students were too shy to ask their teachers anything on this topic. Participants also commented that their teachers did not work towards creating an atmosphere that would allow them to speak openly in class on these issues. However, many of the students were also reluctant to learn about this subject, or to learn from their teachers.

“We have to obey the teachers in every respect, and there is a big gap between teachers and students. They are like our parents, not like friends with whom we feel comfortable discussing any issue. How can you imagine I can get answers to my questions on reproductive health and sex with them? To do that, I need to have a lot of courage and I also have to think about the consequences.”

Others said they did not want to do so because society did not consider it appropriate; some also feared unspoken consequences.

“How can I discuss these things! I have stitched all the pages together of that chapter.”

Adolescent school students attend World Population Day exhibition, Kathmandu, Nepal, 2004

Discussion

This study found evidence that sex education is being poorly implemented in all eight secondary schools sampled. The quality of sex and reproductive health education was found to be poor because of inadequate preparation of teachers for such instruction, lack of adequate teaching materials and lack of school and community support for teachers to provide this instruction. Emphasis is only given to presenting anatomical facts, while other issues are dealt with in a rapid and cursory manner, if at all. Findings also revealed a judgemental attitude among teachers, which posed a critical barrier to improving young people’s access to information. At the same time, many school-going adolescents found it difficult to approach the subjects easily.

School-based sex education that provides accurate instruction in reproductive and sexual health is associated with delayed sexual debut and lower rates of unwanted pregnancy and STIs in many countries.^{9 10 11} Such programmes can have long-term beneficial impacts, especially as school enrolment ratios for both boys and girls are increasing. Unfortunately, many Nepali adults think that providing information about reproductive health can increase adolescent sexual activity. Moreover, Nepali girls typically stop attending schools upon marriage. Even if they are not compelled to do so, increased household work and responsibilities inherent in early marriage and motherhood often make it difficult for them to continue school.⁵⁶ Although school attendance ratios are slightly higher in the study region than elsewhere in Nepal, they are still low overall and fall far short of gender equality.

Nevertheless, the school setting can be an appropriate environment, if managed wisely, to provide adolescents with sex education and disseminate reproductive health information. The challenge is to expand and strengthen school-based programmes, to make them more appropriate for students. Teachers need to receive culturally appropriate training on the importance of reproductive health information for adolescents and practical training on how to teach this subject to them. For example, they need to develop a less formal and restrained contact with students that could make such instruction more effective. Both teachers and students suggested that the provision of relevant teaching materials would allow for more effective instructional material. Another recommendation was to provide separate classes for boys and girls. Guest lectures by local health workers could be arranged in an effort to allay the discomfort of teachers with the topic. On the other hand, health workers are also not trained to teach sex education and the focus group discussions indicated that most adolescents considered most health providers judgemental towards them. Thus, substituting health workers for teachers is not an obvious solution either.

We have shown that the recent introduction of school-based sex education has contributed little thus far to improving reproductive and sexual health knowledge among youth. A great deal of work is needed to provide sex education in a way that is accurate, acceptable and non-threatening for both teachers and students. Participatory approaches have been developed elsewhere for this purpose and policies already exist to improve the delivery of adolescent-friendly services.², ⁴, ⁵ More effort is also needed to build parental and community support for schools to provide sex education. In addition, peer education and other community-based approaches are required to ensure that all adolescents are covered, including young married women and those unable to attend school.

Acknowledgements

The authors gratefully acknowledge the financial and logistical support of the Nepal Health Research Council.