Unmet Needs for Comprehensive Sexuality Education: A Qualitative Study Among Secondary School Students in Western Kenya

Abstract The aim of this qualitative study was to explore desired ways to deliver comprehensive sexuality education (CSE) and topics, among secondary school students in a low-resource setting in Western Kenya. One school (n = 440) has received 8–9-h CSE intervention, while the other school (n = 496) served as a control. After one-year follow-up the students were asked (one open-ended question) to suggest desired topics of CSE, with a response rate of 93% (n = 867). The following topics were suggested by the students: abortion, contraception, sexual rights, abstinence and STI/HIV, and preferred CSE delivery means were school-based teaching, online resources and social media, community-based elements or trusted individuals. The students who had not received the intervention were more in favor of an abstinence-only approach and demonstrated more negative attitudes toward abortion.


Introduction
In 2021 about 15.5% of the world's population was between the ages of 15-24 years old, representing the large generation of young people (United Nations, Department of Economic & Social Affairs, Population Division [UNPD], 2022).The vast majority live in low-and middle-income countries (LMIC) (UNPD, 2022), where they constitute the human capital and have the potential to drive economic growth (Sheehan et al., 2017).Ensuring that young people achieve their full potential by providing them CONTACT Marlene Makenzius marlene.makenzius@ki.seTomtebodav€ agen 18A, Stockholm, 171 77, Sweden.
Supplemental data for this article can be accessed online at https://doi.org/10.1080/15546128.2023.2189194.
with education and skills and investing in their physical, mental and sexual health will help these countries attain sustained, inclusive and equitable development (Sheehan et al., 2017).However, young people in LMIC are vulnerable to a range of sexual and reproductive health problems (Bearinger et al., 2007;Morris & Rushwan, 2015), which are preventable, and education is a key component of prevention (Chandra-Mouli et al., 2013;Haberland & Rogow, 2015; United Nations Population Fund [UNFPA], 2014).
According to the Kenya National Bureau of Statistics (2015) Kenya's population is young with an estimated 10.5 million adolescents ages 10-19, corresponding to a quarter of the country's total population.More than a third of Kenyans ages 15-19, whether married or not, have had sexual intercourse (KNBS, 2015).The majority of unmarried sexually active adolescent girls want to avoid pregnancy; however, only 37% are using a modern contraceptive method (KNBS, 2015).Consequently, the adolescent fertility rate in Kenya is relatively high at 82 live births per 1,000 women ages 15-19 in comparison with the global fertility rate of 44.6 per 1,000 women ages [15][16][17][18][19], n.d.).The abortion law ratified in Kenya in 2010 permit abortion only under limited circumstances, such as if the mother's life is endangered (National Council for Law Reporting [NCLR], n.d.).As a result, Keats et al. (2017) indicated that unsafe abortion still remains one of the leading causes of death in adolescent girls.Furthermore, pregnancy forces girls to curtail their education, resulting in sustained poverty and increased vulnerability (Neal et al., 2015).
There is clear evidence that comprehensive sexuality education (CSE) positively impacts adolescent sexual and reproductive health, including delayed initiation of sexual intercourse, reduced risk taking and increased use of condoms and other contraceptives, thus preventing unintended adolescent pregnancies (Fonner et al., 2014;Oringanje et al., 2016;United Nations Educational, Scientific & Cultural Organization [UNESCO], 2018).Kenya is one of the 21 east and south African countries who affirmed the UN ministerial commitment on CSE and sexual and reproductive health services for adolescents and young people; where they commit to ". . .ensuring access to good quality, comprehensive, life skills-based HIV and sexuality education (CSE) and youth-friendly sexual and reproductive health services for all adolescents and young people" (UNESCO, 2013).In addition, the countries agreed to initiate and scale-up CSE during primary school education, train and support teachers, and also incorporate CSE program in their curriculums.However, Kenya, as well as many other LMIC, still struggle to implement CSE in national school curricula, often due to limited political support, religious impediments, lack of coordination between the central government and local authorities and insufficient funding (Keogh et al., 2018).The study of Keogh et al. (2018) also showed that CSE was not prioritized as a standalone school subject in Kenya.Furthermore, education sector policies largely promote an abstinence-only approach.Teachers lack time, resources and knowledge of SRHR topics, and the communicated messages to students have been reported as fearinducing and judgmental (Sidze et al., 2017).Similarly, a study on implementation of CSE in Kisumu indicated that teachers had low awareness on CSE topics like HIV/STIs, condom use, benefits of abstinence and contraception (Ogolla & Ondia, 2019).The study also indicated that CSE is not included in the curriculum and teachers were not trained.In addition, Guttmacher Institute (2017) showed even in schools where CSE is said to be included in their curriculums, students claim that they receive learning with emphasis on reproductive physiology and HIV/STI prevention only and abstinence is the highly covered topic.Sidze et al. (2017) highlighted that most Kenyan secondary school students (99%) want CSE; however, less is known about how they prefer to receive it and preferred topics (Rehnstr€ om Loi et al., 2019).The aims of this study were to explore desired ways to deliver CSE and topics, among secondary school students in a lowresource setting in Western Kenya.

Study design
This was a qualitative study, nested in a pre-and post-test intervention study with the aim of reducing stigma related to abortion and contraceptive use among secondary school students in a suburban area in Kisumu, Western Kenya (registered at ClinicalTrials.govNCT03065842).Two schools, one intervention (I) school and one control (C) school.The Ischool received a one-month sexuality education intervention (eight to nine hours in total) in February 2017, while the C-school did not.It was a school-based intervention delivered in three different sessions.The purpose of the intervention was to help students understand the myths and reality surrounding the provision of abortion services and abortion caretakers.It also aimed to help participants evaluate their views and possibly alter their opinions on stigma related to sexual and reproductive health and rights (SRHR) topics.The CSE intervention was designed grounding on the preliminary findings of the initial phase activities (workshops, FGDs, baseline study) and based on International Planned Parenthood Federation (2016) guidelines and covered various SRHR topics with a main focus on unintended pregnancy, abortion and contraception among adolescents.The pedagogic intervention included group discussions, chart writing, role-playing, lecturing, presentations and anonymous question and answer sessions methods.To evaluate the effectiveness of the intervention, an endpoint survey was performed one year after (February 2018) the intervention.Trained research assistants administered the closed classroom questionnaires.In the follow-up questionnaire, the students were given the option to answer one (1) open-ended question about preferred delivery of CSE and identify desired topics.The aim of the current study was to analyze these answers.The reporting was done in accordance with O'Brien et al. (2014) guideline standards for reporting qualitative research.

Study setting
The study was conducted in a low-income area of the Kisumu East and Kisumu Central sub-counties in Kisumu, Western Kenya.Consistent with national numbers, about 25% of the total population in Kisumu County are between 10 and 19 years old (KNBS, 2015).Primary school enrollment in Kisumu County is high (95%); however, only 61% transition to secondary school (KNBS, 2015).HIV prevalence in the adult population ages 15-49 is estimated at 20%, which is high compared to the national HIV prevalence of 5.9%.More than half (51%) of all new HIV infections in Kenya in 2015 occurred among young people ages 15-24 (Ministry of Health, Kenya, n.d.).The majority (90%) of the Kenyan population are Christian, while around 7% are Muslim (KNBS, 2015).Two secondary schools were selected for the study based on a cluster-randomized procedure.Both schools were public secondary schools run with Christian values and principles, similar to most public schools in Kenya.

Study respondents
The respondents comprised all female and male students studying at the selected schools who were present during the data collection.At baseline, a total of 1207 students (I-school ¼ 574, C-school ¼ 633) participated and of those, 936 students (I-school ¼ 440, C-school ¼ 496) participated in the one-year follow-up (endpoint survey).The form four students (n ¼ 271) who participated at baseline graduated before the endpoint survey, therefore they were not included in the study, neither were the new form one students included at the endpoint survey.

Data analysis
The comments on the open-ended question were analyzed using manifest content analysis in accordance with Graneheim and Lundman (2004), to determine the existence and frequency of concepts in the text.The first, second and last authors read through all comments several times, to obtain a sense of the whole and extract meaning units related to the objectives.The meaning units of the comments were condensed, and each was labeled with a code.The codes were compared for differences and similarities and grouped into several subcategories and then into categories.The categories were refined by the whole research team through a process of reflection and discussion to improve the consistency and accuracy of the coding and interpretation process.

Ethics
Ethics approval was given by the Jaramogi Oginga Odinga Teaching and Referral Hospital Ethical Review Committee (ERC.1B/VOL.I/263) and the National Commission for Science, Technology and Innovation, Nairobi, Kenya (NACOSTI/P/18/68231/25970).Ministry of Education and ethical review committee in Kenya has approved the study.Parents were provided information about the study with two arranged school meetings when they were given the option to refuse consent for their children participation in the study and provided oral consent.Children had also taken written information about the study to their parents with information how to withdraw from the study if needed.Oral and written consent was obtained from all participants and it was made clear in the consent form that participation was voluntary and withdrawal was granted at any point.The written consent for those under 18 years old who agreed to participate was also signed by their teachers.This was acceptable procedure according to Gallo et al. (2012) justified by the relationship that existed between the teacher and student.No analysis was performed separately by class or grade of students with the aim to strengthen the confidentiality.

Results
In total, 936 secondary school students completed the endpoint questionnaire (468 females, 468 males); of those students, 867 (93%) responded to the open-ended question of this study.The comments varied in length from single words to full paragraphs.Few students stated one-word suggestions, while most students took the opportunity to express opinions on CSE and SRHR topics in general.Together, the students generated a total of 925 suggestions about preferred delivery of CSE, and 569 suggestions of desired topics to be discussed.
Participant ages ranged from 13 to 21 years old with a mean age of 17.1 years at the I-school and 17.3 years at the C-school Table 1.

Suggested ways to deliver CSE
Table 2 shows the comments suggesting ways to deliver CSE were organized into 12 subcategories and further grouped into four broader categories: school, online, community and trusted individual.At the I-school, 315 students (72%) gave 452 suggestions, while 361 C-school students (73%) contributed with 473 suggestions.
School (quotes see supplemental appendix 1) The most common preference among all students was to receive CSE at school.Some students asked for teacher-led lessons on a regular basis.Other students claimed they were uncomfortable discussing SRHR topics with their teachers, and suggested that external organizations, such as healthcare professionals, could provide CSE at the school.Other students preferred interactive group discussions rather than traditional lectures.Some students highlighted the importance of separating groups based on gender and age to feel more comfortable.Suggestion boxes in the classroom was recommended when teaching and discussing sensitive issues to overcome the fact that students might be afraid to ask their teachers questions about SRHR.
Online (quotes see supplemental appendix 2) On social media, students believed they could share their private thoughts and questions openly among their friends, while avoiding stigmatizing attitudes from teachers, parents and society.Social media was also considered an easy way of disseminating information to a large number of people, and students suggested that the schools and healthcare professionals could use it as a platform to communicate SRHR messages.In total, 925 suggestions were given.Note 1. CSE: comprehensive sexuality education; SRHR: sexual and reproductive health and rights.Note 2. Some respondents had multiple responses, and that the n is always for the number of responses (not the number of respondents).
Community (quotes see supplemental appendix 3) For confidentiality reasons, some preferred a professional counselor.Students expressed trust in doctors' and nurses' knowledge and skills, and appreciated the confidentiality youth-friendly healthcare professionals offered.It was also suggested that SRHR information should be disseminated through mass media and public events at the local community level, as well as nationally.Some students suggested having discussions about SRHR topics in church.They stated that they would turn to their religion and elders at the church to guide them to make the right life decisions.
Trusted individual (quotes see supplemental appendix 4) Some students stated that SRHR topics should not be discussed in public, but preferred private conversations with individuals they trust, such as teachers, friends and family members.

Desired topics for CSE
The identified CSE topics were organized in five categories: abortion, contraception, sexual rights, abstinence, and sexually transmitted infection (STIs) incl.HIV.Comments regarding abortion and contraception were further divided based on whether the students expressed supportive views on the topics or not Table 3.In total, 194 I-school students (44%) gave 223 suggestions, while 268 C-school students (54%) contributed with 346 suggestions.About 22% (I-school: 47; C-school: 55) simply stated "SRHR" as their preferred topic.These comments were not included in the analysis since SRHR is a general term covering all the other topics.
Abortion (quotes see supplemental appendix 5) Some students suggested talking about abortion in school to raise awareness about the issues adolescent girls face if they become pregnant, while other students wanted CSE to focus on how to avoid abortion.Reasons for being against abortion was the restrictive Kenyan abortion law and the consequences an abortion might have on a young girl, such as negative health outcomes and loss of status for the girl and her family due to cultural and religious norms.
Contraception (quotes see supplemental appendix 6) Most students had positive comments about contraception.Many students were aware of the benefits of contraceptives but expressed that they lacked practical knowledge of how to use them and wanted more information on different contraceptive methods.Negative attitudes toward contraception were based on beliefs that contraceptives promote promiscuity and have negative health effects for young people.
Sexual rights (quotes see supplemental appendix 7) Comments supporting discussions about sexual rights mainly highlighted the need to increase awareness about stigma surrounding several SRHR issues, such as abortion; contraceptive use; lesbian, gay, bisexual and transgender (LGBT) rights; and sexual and gender-based violence (SGBV).In total, 569 suggestions were given.Note 1. HIV: human immunodeficiency virus; LGBT: lesbian, gay, bisexual and transgender; SGBV: sexual and gender-based violence; STI: sexually transmitted infection.Note 2. Some respondents had multiple responses, and that the n is always for the number of responses (not the number of respondents).
Abstinence (quotes see supplemental appendix 8) Some students, predominantly from the C-school, wanted CSE to focus on abstinence and expressed that young people should avoid premarital sex since it is considered a sin and a crime against their religion (Christianity).
Premarital sex was also related to irresponsibility and loss of status for the girl and her family.
STIs incl.HIV (quotes see supplemental appendix 9) Students commented that they lacked knowledge on common STI symptoms, how to avoid contracting STIs and where to seek help if they got infected.Some students raised the issue of HIV and the stigma surrounding people living with HIV.

Discussion
This study explored how secondary school students in a low-resource setting in Kenya preferred to receive CSE and identified the topics they found most important.The findings also indicate knowledge gaps regarding basic SRHR, for example about contraception, usage, benefits and possible side-effects.Judgmental attitudes, gender stereotypical norms, and misconceptions about contraception and abortion were common, and students' comments reflected ideas based cultural and religious norms in this community.
Countries throughout the world are increasingly acknowledging the importance of equipping young people with the knowledge and skills needed to make responsible and healthy choices (Goldfarb & Lieberman, 2021).This study verifies that CSE is still surrounded by controversies, in line with statements from UNESCO (2018).How to measure progress and quality in CSE program implementation in low-resource settings is challenging (Keogh et al., 2018;Vanwesenbeeck et al., 2016).
The students suggested several different forums within and outside the school environment for learning about and discuss SRHR topics.This is in line with previous findings that CSE has the greatest impact when schoolbased programs are complemented by community elements, such as distributing condoms; training healthcare providers on delivering youthfriendly services; and involving parents, teachers and religious leaders (Achora et al., 2018;Chandra-Mouli et al., 2015;Fonner et al., 2014).Some students did not trust their teachers to provide accurate information in CSE and were uncomfortable asking them about sensitive topics.Like other members of society, teachers live within a network of cultural and religious beliefs and might be uncomfortable or unwilling to teach SRHR-related topics (Achora et al., 2018;Helleve et al., 2009).It is in a context where most adults, including parents and trained healthcare providers, might be hesitant to talk about these issues (Hakansson et al., 2018).This could be one explanation for why a third of all students preferred using online resources.
Many comments indicated that students already are using online resources as their main source of SRHR-related information similar to the finding of LGBTQþ students who lack need-based information in the standard sexual education (Bloom et al., 2022).However, online media may not necessarily provide age-appropriate and evidence-based facts, and it can be difficult for young people to distinguish between accurate and inaccurate information (UNESCO, 2018).CSE can support young people in safely navigating the internet and social media and making sense of the images and information they find online.However, digital media and online resources can potentially reach diverse youth populations and could be an important tool as a part of school-based CSE (Guse et al., 2012).Accordingly, the findings showed students' demand for evidence-based online resources created by schools and health organizations.
There is support for CSE from the Kenyan government but the policies have largely promoted an abstinence only approach.Consequently, it has resulted in lack of comprehensiveness in the range of CSE topics offered in the secondary school curricula (Sidze et al., 2017).Experts at UNESCO (2018) concluded that the following topics are essential for CSE, relationships; values, rights, culture and sexuality; understanding gender; violence and staying safe; skills for health and well-being; the human body and development; sexuality and sexual behavior; sexual and reproductive health.According to both teachers and students in Kenya, HIV and AIDS topics are thought in schools, but less emphasis is placed on essential topics regarding contraception and pregnancy prevention, as well as on gender relations, equity and rights (Sidze et al., 2017).The current study clearly emphasizes the desire for CSE to include contraception, pregnancy prevention and abortion.It should be noted that this study did not fully capture all UNESCOs suggested topics.However, this study was based on one (1) open-ended question and the respondents might have been influenced by the quantitative questions, presented else were (Rehnstr€ om Loi et al., 2019).
There is strong support for teaching CSE among principals, teachers and students alike, but the topics that are integrated into compulsory and examinable subjects are limited in scope, and there is little incentive for teachers and students to prioritize them (Sidze et al., 2017).However, in June 2022, UNESCO is organizing a Regional Webinar in Nairobi, to launch the newly revamped CSE online course for teachers.The webinar is organized by UNESCO regional offices for eastern and southern Africa and is bringing together stakeholders from the region.Teachers are acquiring adequate knowledge, skills, and attitudes that are critical for effective CSE delivery.The purpose of this Platform is to encourage knowledge sharing and learning across countries, promoting the health and well-being of adolescents and young people.The Learning Platform provides a unique opportunity for countries to exchange and strengthen the delivery of good quality Comprehensive Sexuality Education (UNESCO, 2022).
It can be difficult to conclude any implications from this study, as Young people's perspectives are not always rights-based and therefore, difficult to align their perspectives without reflections.CSE alone cannot shift norms.Rather, CSE is part of wider efforts aimed at advancing the rights of young people that also include advocacy, health service provision, community outreach, norms change, and much more.

Strengths and limitations
One important strength of this study is the large number of respondents to the study question, which is a sensitive topic in the study setting.The credibility of this study was further strengthened by the representative quotations from the transcribed text, and the findings were confirmed by nonparticipating adolescents from the study area.However, there are some limitations.Another limitation when researching sensitive topics is that respondents might not reveal their honest opinions but answer in ways viewed favorably by others (social desirability bias) (Stuart & Grimes, 2009).
The findings revealed a variation in students' topic preferences between the I-school and the C-school.While more students in the I-school were supportive of abortion and interested in learning more about contraception and sexual rights.C-school students in general had more conservative views on abortion and tended to want CSE to promote abstinence.Whether this clear variation between schools was merely an effect of the intervention cannot be determined based on the present study design.However, it is possible that students in the I-school were exposed to information that expanded their knowledge, values and attitudes.It is also a limitation to capture all the important CSE topics with only one open-ended question, as this was a sub-study of a larger study with another objective.

Conclusions
Secondary school students need to be equipped with evidence based CSE on a variety of topics, not least to dispel myths and misconceptions on abortion and contraception.The education capacitates the young people to make informed, responsible, and healthy decisions.CSE curriculum should be contextualized to enable consideration of local factors like religion, norms, and tradition in order to avoid negative impact CSE acceptance.However, it is also important not to forget that the CSE should contribute to the necessary norm shifting toward supporting young people's SRHR in the society.Methods of delivery to CSE programs should be selected according to the access and preferences of the target group.The findings indicated that CSE programs could be delivered through school-based programs combined with online resources and community-based elements.A holistic approach seems to be the ideal package for CSE.

Table 2 .
Suggested ways to deliver CSE according to 676 secondary school students (I-school n ¼ 315, C-school n ¼ 361).