Redefining and Scoping Sexuality Education for RHU

With only one in five secondary-school aged children attending secondary school, a quarter of teenaged girls being pregnant or already having a child (Uganda Bureau of Statistics, 2012), and one out of every five people living below the poverty line in Uganda (CIA, 2013) statistics show the ever prevalent need for sexuality education. As an organisation working in the field of sexual and reproductive health and rights, Reproductive Health Uganda wants to standardise and integrate sexuality education in all their projects through developing and rolling out a sexuality education intervention. The challenges faced in this are the concept of ‘comprehensive sexuality education’ being questioned by the government, and the implementer being the main determinant of what information is provided because they have no handbook to follow. To address these challenges, Reproductive Health Uganda needed to redefine and scope sexuality education. Based on the field and desk research sexuality education was defined as follows: ‘providing age-appropriate information on the aspects of sexuality in order to increase knowledge and build (life) skills which enables the individual to understand oneself and make informed decisions’. Based on the outcomes of this research, eleven recommendations for the future sexuality education intervention were made which can be related to either the preparation or sustainability of the intervention.


Background
In Uganda, less than twenty per cent of the secondaryschool aged children actually attend secondary school, one in four teenaged girls is pregnant or already has a child (Uganda Bureau of Statistics, 2012), and almost twenty per cent of the population lives below the poverty line (CIA, 2013). An investment in sexuality education will not only benefit the individual's sexual health, but the society at large at many different levels. Reproductive Health Uganda (RHU) is a member association of the International Planned Parenthood Federation (IPPF) and active in the field of sexual and reproductive health and rights (SRHR). Providing information and services on SRHR to the Ugandan communities is one of RHU's main activities and is done through several projects, and the complementary clinics and youth centres from the branch offices. Sexuality education is often an element of these projects. However, there is no standardised way of working, and therefore the content of projects strongly depends on the implementer -often a peer educator. This is problematic because it can lead to inaccurate or incomplete spreading of information. Likewise, making it difficult to monitor and evaluate its overall impact and thus effectiveness.
To address this problem, RHU intends to integrate sexuality education into all the programmes they deliver nationwide and create and implement a standardised sexuality education intervention. Two problems were identified. Firstly, the trained peer educators do not have a step-by-step guide when providing sexuality education sessions; leading to different information being communicated. Secondly, the concept ' comprehensive sexuality education' (CSE) as used by the IPPF cannot be used by RHU. CSE as used by the IPPF is a holistic approach whereby not only knowledge but also life skills, positive attitudes and values related to sexuality are taught. Since CSE also includes sexual diversity it is seen as controversial and thus not accepted by the Ugandan government. Therefore, the objective of this research is to develop a definition and scope of sexuality education that can be used by RHU to design and implement their sexuality education intervention.

Conceptual Model
The conceptual model used is based on the theory of planned behaviour from Ajzen (1985) with additions from the social ecological model for health promotion from McLeroy, Bibeau, Steckler & Glanz (1988). The theory of planned behaviour is adapted based on the perspective of the organisation RHU instead of the individual. Through the use of the theory of planned behaviour the outcome of this research will be limited to redefining and scoping sexuality education. This outcome is dependent on the variables: attitudes of RHU staff, expectations of the target group and other SRHR oriented organisations, and existing government policies. These variables are influenced by each other, but also dependent on the socio-economic background of each individual. By adding the social ecological model for health promotion, the independent variables concerning the socio-economic background are added. Including some of these important socio-economic background variables allows for a comparison between individuals and enables the description of their similarities and differences. Due to the limited resources, only sex, residence, and employment were included in the scope of this research.

Problem Definition
Based on the conceptual model, the main research question became 'What should be the definition of sexuality education within RHU and what should it entail?' for which the four sub questions are: (1) What are the existing policies in Uganda concerning sexuality education?; (2) What are the attitudes of the RHU staff members towards sexuality education?; (3) What are the expectations from the target group and other SRHR oriented organisations towards sexuality education?; And (4) What are the similarities and differences in perspectives of the different stakeholders?

Research Strategy
To answer these questions both desk-and field research was done. The desk research consisted of a stakeholder analysis and document review, while the field research included 9 in-depth interviews with RHU staff in the headquarters in Kampala and two branches in respectively Iganga and Luwero, 4 focus group discussions with the target group in the same two branches, 3 key informant interviews with staff from other SRHR oriented organisations in Kampala, and 4 observations of actual sessions in Iganga and Luwero too. Content analysis of the transcribed and coded data was done through categorising it into fourteen categories based on open coding. A table was created with the use of excel that enabled seeing patters within and among the interviews. Validity was ensured through peer reviewing and reliability through both data and methodological triangulation.

Results
Several Ugandan policies were found to be related to sexuality education. This research included the Uganda gender policy, the Uganda national youth policy, the adolescent health policy guidelines and service standards, the national HIV prevention strategy, the HIV prevention strategic plan 2011-2015 for the education and health sector, the national population action plan 2010-2015, the marriage and divorce bill (2009) that is still pending, the anti-pornography act (2014), and the anti-homosexuality act that was struck down on a technicality in 2014. Several elements in these documents are relevant to redefining and scoping sexuality education as well as important to consider during the design of the sexuality education intervention. These include gender equality (including equal right during marriage and its dissolution), women's empowerment, youth empowerment, YFS and a good referral system (increasing the likelihood that adolescents actually seek these services), sustainable human development, HIV/AIDS prevention, and appropriate knowledge on the content of existing laws and policies.
Although most policies are supportive and can therefore be seen as a positive reinforcement on the importance of such an intervention, appropriate knowledge on the content of policies such as the anti-pornography act and anti-homosexuality act is essential to determine restriction and implications. For example, according to the antipornography act one will need to seek written permission from the ministry of education science technology and sports (MoESTS) prior to the use of visual methods such as film or demonstration. Furthermore, due to existing anti-homosexuality legislation RHU is not allowed to fully implement the ideas of IPPF since sexual acts between same sexes is a punishable offence in Uganda, as well as, including sexual orientation or sexual identity in sexuality education interventions might be seen as promotion of such.
The overall attitudes of the RHU staff towards sexuality education were rather homogenous, as many similar answers were given during the interviews. However, minor differences were found between the answers of the peer educators and other staff members. It became apparent that the knowledge and skills of peer educators needs continues maintenance and improvement to ensure correct transferring of information. All in all, sexuality education was seen as being about one's feelings and behaviour throughout life, about oneself and in relation to others, whereby the purpose of sexuality education is to provide information on the aspects of sexuality in order to increase knowledge and gain life skills so that one is able to address the challenges faced such as unsafe sex, unwanted pregnancy, and STI's. The topics that should be included within sexuality education were too many to comprehensively mention in the interview according to many, however examples included most were STIs, sexual intercourse, pregnancy, gender and/or sex, life skills and relationships. The main barrier was thought to be the negative attitudes of stakeholders, attributable to ignorance on both community and governmental level.
The teaching methods should be participatory, interactive, and possibly visual, however, observations showed mainly one-way teaching as current preference. The structure of time, build-up of the programme, and location were mentioned to depend on many different factors and thus seemed to miss the correct context for the answers to completely reflect the RHU staff's attitudes. However, it was found that most thought sexuality education should be ongoing and well prepared, and the location should mainly depend on who is the beneficiary. The latter was also observed in practice. The beneficiaries should be primarily youth between 10 and 24, but also married people and everybody were included, the provider should be health workers, trained people, teachers and peer educators -the latter also observed -and other stakeholders to involve should be government, parents, and religious and community leaders. Furthermore, monitoring and evaluation should make use of tools such as interviews and questionnaires in order to measure behavioural change, whereas sustainability should be ensured through training others, establishing partnerships with other SRHR oriented organisation, and guaranteeing sufficient funding -being it internally or externally generated.
The target group -being the young people targeted in the current projects -expected sexuality to be about interaction, behaviour, and feelings however, sexuality education was thought to be mainly about sexual intercourse and also the topics mentioned were mainly the possible (in) direct outcomes of sexual intercourse. Language and resistance against providing sexuality education were expected to be the main barriers, structure of time would depend on several aspects, schools were seen as the main location and training peers or community was seen as idea for ensuring sustainability. Looking at the stakeholders, youth and married people were seen as the beneficiaries, parent and peers as the provider, and the government, artists, religious leaders, and parents as other key stakeholders.
In the expectations of staff from other SRHR oriented organisations sexuality education provides the knowledge and skills needed to relate to others, to make informed decision, and understanding oneself. The topics Life skills and growth and development were mentioned by all, the main expected barrier was attitude, and teaching methods should be learner centred, participatory, practical and experiential. Additionally, the beneficiaries should be youth, the providers should be teachers and parents, and other stakeholders expected to be involved were government, the health sector, schools, and religious and cultural institutions. Furthermore, monitoring and evaluation was expected to include operational research, beneficiary involvement, and report, whereas sustainability should be assured through generating (an own) income and stakeholder engagement.
When comparing the stakeholder groups and looking at the individual socio-economic background -sex, residence, employment -many similarities and a few differences were found. Everybody saw sexuality education as important because it expands current knowledge, contributed to prevention, and teaches life skills. Sexuality was seen as being about relating to others, feelings, and being present throughout life. The latter not mentioned by the target group. Sexuality education was described as delivering information or knowledge, and should include topics such as STIs, pregnancy, sexual intercourse, gender and/or sex, and life skills. Of these, gender and/or sex was not mentioned by the target group and STIs and gender and/or sex not by the employed males. All agreed negative attitudes towards providing sexuality education among youth would be the main barrier and the teaching methods should be participatory/experiential and learner centred.
The programme should be ongoing and the design and implementation of the intervention will depend on a lot of factors according to many. For the location a variety of possibilities were given, but a comfortable environment was essential whereby one feels free to speak and privacy is guaranteed. The youth was seen as the primary beneficiary -whereby age-appropriate information even within this group is crucial -the main providers included were health workers, teachers, parents and peer educators, and other key stakeholders highlighted were government, parents, schools, the health sector, religious, cultural and community leaders. The most named monitoring and evaluation methods were questionnaires, making report, and operational research, whereas sustainability was suggested to be achieved through training others, building partnerships and/or advocacy, and both external and internal funding.

Limitations and Shortcomings
All questionnaires were discussed with another researcher, however, due to the limited time of the research they were not pre-tested. As a result, it was not until the field research that the question 'How should the intervention be build up?' was found to be unclear. Also probing could not change this. Fortunately this has little effect on the final outcomes as it was largely beyond the scope of this report. Using one and the same in-depth questionnaire for interviewees no matter their position within the organisation might have been a shortcoming as specific questions towards ones expertise might have brought forward more information on relevant attitudes. Nevertheless, one questionnaire was less time consuming and more logical for analysis purposes. With RHU active in the whole of Uganda it was a limitation that only three locations could be included due to restricted time and finances, but favourably locations were in two kingdoms and one focus group discussion included youth from many different ethnicities. Furthermore, including the government, namely the HIV/AIDS unit from the MoESTS, no earlier than the discussion-stage could have limited the research, however, the policies included reflect the government's position and their feedback carried a heavy weight for the conclusions and recommendations.

Conclusions
Based on the outcomes of the research the new definition suggested is 'Sexuality education is providing age-appropriate information on the aspects of sexuality in order to increase knowledge and build (life) skills which enables the individual to understand oneself and make informed decisions'. Sexuality education is an ongoing process, since a new generation, which should be educated, is coming up every time. Youth (aged 10 to 24) should therefore be seen as the primary beneficiary of sexuality education, for whom needs to be determined what information is appropriate at what age. Secondary beneficiaries are those who are no longer youth, but have insufficient knowledge and skills due to the fact that they did not receive (sufficient) sexuality education when they were younger.
Although the list of topics found is not exhaustive, several key topics were emphasised by the interviewees.
These essential topics are sexuality transmitted diseases (including HIV/AIDS), pregnancy, sexual intercourse, gender and/or sex, and life skills. It is however also vital to realise that the understanding of key concepts such as sexuality will create the basis for a thorough understanding of what is taught during the sexuality education sessions. The teaching methods should be participatory, learner centred and if possible visual and creative. A comfortable environment which is favourable for the beneficiaries is essential. Furthermore, effectiveness should be ensured through a variety of aspects: stakeholder involvement, addressing negative attitudes, monitoring and evaluation, ongoing training of the provider and training others, partnerships, and sufficient funding.

Recommendations
Based on the outcomes of this research, eleven recommendations are made which can be categorised in two focus areas; those related to the preparation phase of the intervention and those for sustainability purposes. Within the area of preparation these are 1) to reach full agreement and internalisation of the new definition; 2) To determine who the stakeholders are and decide on how to involve them; 3) to recognise the needs of the beneficiaries; 4) to comprehensively train the providers and develop a plan for their ongoing training; 5) to research which of the stakeholders has a negative attitude towards sexuality education and from where this originates so that it can be addressed appropriately, and 6) to explore why the expectations on teaching methods are not the current practice and address this accordingly. For the area of sustainability the recommendations are: 7) to decide upon the monitoring and evaluation methods; 8) to determine upon and build partnerships to increase effectiveness of the intervention; 9) to ensure a solid referral system; 10) to enable training of others so they can also provide sexuality education, and 11) to establish an income generating project alongside the intervention.