Twenty-eight subjects were interviewed and 9 subjects participated in the FGD. The mean age of the participants was 47.89 (± 5.2) years (range: 34 to 60). The socio-demographic characteristics of the participants are presented in Table 1. Based on the IMB model constructs, 5 themes and 17 sub-themes were extracted (Table 2). The participants also expressed a number of intervention preferences for CSE.
In the IMB model, two constructs of information and motivation have a great influence on each other. In this study, their overlap was very high, so the themes extracted for these constructs were jointly reported. These themes included:
Theme 1: Role Of Institutions (information And Motivation)
This theme was divided into four sub-themes, which reflected the participants' viewpoints on the factors related to the implementation of a sexuality education program in schools.
The participants emphasized the role of the family and formal educational institutions. One of the male teachers with 30 years of work experience said;
“Education is formed primarily in the family and it is much better to be offered by the same-sex parent. Unfortunately, this form of education is not possible for boys in our society because the father does not have a very active presence in the home and school due to his economic responsibilities” (p. 1, 55 y).
“If the family disagrees with sex education at school, they oppose and resist. But if they are trained and aware, they will strengthen the educational efforts” (p. 5, 42 y).
- Educational institutions
Educational centers offer training in cognitive, emotional, and behavioral areas to adolescents, so they play an important role in their sexuality education.
A school manager with 27 years of work experience said, “We have to use all the capacities of our educational system to offer appropriate and correct education; we need to strengthen the role of teacher counseling” (p. 7, 50 y).
"Peer groups are very important, especially children who are somehow popular with other children, such as children who are elected for the school council. This child speaks and knows the rules and can influence other children” (p. 9, 47 y).
Religious institutions should be directly and indirectly effective in implementing the program through forming beliefs of the family and friends. In this way, they can be both barriers and facilitators in implementing sexuality education programs.
A clergyman with 23 years of experience who was adviser to the director of the Department of Education said, “Islam is a religion that emphasizes sexuality education. It is not right to use religion to intimidate and create guilt in order to instill personal ideologies, because it drives adolescents away from religion and is also detrimental to everyone”(p. 15, 43 y).
- Cultural institutions
These institutions can be very active in sexual education by informal teaching and extracurricular activities in the form of training camps, stage plays, books, and computer games. They may be more acceptable to adolescents because of the nature of their entertainment.
“Extracurricular activities, sports competitions, and music classes fill their time and help them learn” (p. 17, 54 y)- Male teacher
“Unfortunately, culture sometimes causes physical and psychological harms to adolescents, for example, female genital mutilation or puberty in boys in some African tribes”(p. 27, 51 y).
Theme 2: Role Of Organizations (information And Motivation)
At a macro level, organizations can play a significant role in implementing programs by pursuing sexuality education policies. They play their role by unifying the educational content and guaranteeing the implementation of the program.
- National organizations
A woman with 24 years of work experience who represented the adolescent education at the ministry of health said, “The first factor that hinders the implementation of a sexuality education program is the Ministry of Education, which has built a wall around itself and defines values for itself that are completely different from the needs of the society. It has also been weak in its interaction with the Ministry of Health. The next culprit is the Ministry of Health because it has not tried enough to create this interaction, and the service packages provided for the adolescent health do not consider their basic needs” (p. 24, 54 y).
Most of the participants considered the role of the Islamic Republic of Iran Broadcasting, as the only national medium in the country, very important in creating culture and breaking taboos, “The media, especially the radio and television, are also very important because their target group is the whole society. People become aware and do not resist sexuality education in schools” (p. 9, 47 y). -Male manager.
“It is good idea to have sexuality education for all adolescents, including the sexual minority and the disabled. You should also have a program for disabled children supported by the Welfare Organization to reduce social harms by addressing their needs”(p. 13, 57 y).
The majority of the participants believed that laws should be backed by legal sanctions and enacted based on human rights to protect their job security.
“An adolescent has the right, as a human being, to be aware of his or her own sexual issues as well as other parts of his or her body” (p. 6, 51 y). -Consultant and therapist
“A new project like the SSCS (Student Social Care System), which has been running in the country for three years, has been able to address some of the fears of school masters and help to empower families and school authorities because it is sanctioned and is a cross-organizational plan. More work can be done” (p. 23, 47 y).
“Laws should be revised according to the needs of the society. There is not much scientific work because policymakers believe that other sexual orientations are not natural and humane and are harmful to human survival. Moreover, from religious and legal points of view, people with other sexual orientations are guilty and deserve punishment and imprisonment, which means they practically do not consider any rights for the sexual minority group” (p. 23, 47 y).
- International organizations
Most of the participants believed that the experiences of successful countries and credible international organizations should be used because reproductive health needs of adolescents are the same all over the world, and the way each country meet them should be determined by according to its cultural context. The director of the research center of the Education Department said, “We don't need to do anything new; we are human beings like other people in the world, we have common needs; therefore, we need to use their experiences without prejudice and prepare our own educational content” (p. 16, 43 y).
Theme 3: Need For Stakeholder’s Partnership (information And Motivation)
Before designing any training program, a stakeholder analysis should be done to benefit from the existing opportunities to reduce threats. In this way, the opinions of all stakeholders will be taken into account and the possibility of implementing the program will be increased. In this regard, the comments of the participants were categorized in four sub-themes, including:
- Reaching the common definition
Before designing an educational program, a stakeholder analysis should be done; therefore, the stakeholders need to reach a common definition of sexuality education. Depending on their specialization, each authority views the issue from a different perspective, claiming that they are doing the best they can for adolescents. Therefore, it seems that achieving a holistic view can meet the demands of all stakeholders. A psycho-sexology fellowship who was an effective member of the policymaking team said, “Fortunately there have been interactions between colleagues from the Supreme Council of the Cultural Revolution, the Ministry of Health, and the Vice Presidency for Women and Family Affairs in recent months. However, we have to see if the original text of the sexual health document is approved and if everyone can do what they are supposed to do in the document”(p. 27, 50 y).
- Applying changes to macro policies
In order to make changes at the macro level, the attitude of the society and policymakers toward the needs and dangers that threaten the target community should change. Accordingly, a male teacher that specialized in sociology said, “From politicians to teachers and parents, they all believe that men will not be harmed in a relationship, so there is no specific program for boys and men although they are more at risk” (p. 14, 50 y).
- Designing context-based educational content
“An educational program should be age-appropriate, culture-based, and evidence-based, with proper evaluation during and the end of the program. Based on the results, it will be introduced in the school curriculum”(p. 25, 53 y).
“Unfortunately we are asked to consider the general population of adolescents without high-risk behaviors and give them limited training. This incomplete package does not pay much attention to the boys; moreover, another problem is our statistics, which is often inaccurate and prevents the publication of real statistics” (p. 26, 52 y).
- Piloting and implementing the program
Before an educational program can be developed, that program should be piloted to consider all aspects of the work. Then, it can be performed on a larger scale.
“A program should be piloted to correct the problems. The goals of the target group should be considered in the program, and then it should be implemented in more cities” (p. 16, 43 y).
Theme 4: Need for adolescent sexuality socialization management (behavioral skills)
Sexuality socialization is a process through which individuals acquire cultural beliefs, values, symbols, meanings, and concepts related to sexuality. This theme consisted of four sub-themes, including
- Society's expectations and conflicts regarding sexual issues
Increased information, attitude and educational gap between the generations have caused problems and lack of proper communication between parents, teachers and adolescents. This difference in expectations creates conflicts for the adolescents that should be managed and resolved. A policymaker said, “Old training methods are not suitable for training today's generation. In the communication age, kids have access to all the good and bad information at the touch of a button” (p. 27, 50 y).
“Adolescents are confused by the conflict between formal education and the realities of the society. Also, the society's expectations from them are not proportional to their current situation”(p. 6, 51 y).
- Adolescent vulnerability and the need to acquire skills
Adolescence can be the age of vulnerability due to the peak of hormones and lack of control over emotions. Therefore, training and acquiring skills can help adolescents to pass this phase with less damage and good experiences to continue their lives.
“The managers' propensity for sexuality education programs is unfortunately based on harm, while we should have created cultural sensitivity based on comprehensive management and a positive view of sexuality education 10 years ago” (p. 27, 50 y).
"Our children often enter a relationship in an ambiguous environment based on their curiosity and personal experiences or what they learn from their peers without any skills, which is very unfortunate ” (p. 7, 50 y).
- Challenges and features of the SSCS (Student Social Care System)
In Iran, a new plan has been implemented to prevent social harms for three years. With the implementation of this plan, the existing problems and educational needs of teachers, parents and students have been partially revealed.
“The symbolic plan is one of the good things that have started. In this plan, the managers' view of social harm has changed and their desire to cooperate has increased”. (p. 23, 47 y).
"The SCCS design does not have a separate item for sexual discussion but sexual education can be included along with other subjects. The families and teachers have asked to be trained in some areas because of the challenges they face in their lives.” (p. 10, 52 y).
- Consequences of sexual taboos
Tabooing health related issues may have devastating effects on the society. Concealment, embarrassment, and fear of stigma cause problems and lay the groundwork for further problems.
“Taboos make the statistics incorrect, because either the school master publishes wrong statistics out of fear or the students who have problems do not come forward.” (p. 3, 40 y).
“Breaking taboos and talking about sexual issues can prevent many problems, which require the skills of managers and policymakers.”(p. 25, 53 y).
Theme 5: Need for enhancing the teachers’ professional competence (behavioral skills)
It is a complex of knowledge, attitude, and skills that enables a person to perform tasks successfully and solve problems. This theme had three sub-themes, including
- Appropriate educational content
Appropriate educational content means educational content that is accepted by the public and is helpful in achieving predetermined goals. In this regard, a participant said, “We have to be very careful in preparing the educational content. It must be in accordance with our culture and age appropriate. Moreover, it should continue from the beginning of schooling until the last academic year.” (p. 3, 40 y).
“In preparing the content, clear concepts, photographs and examples of what is happening in real life should be used to make it attractive to students.” (p. 3, 40 y).
- Choosing a suitable executive approach
An executable method can help make the program more effective. Most of the available resources should be considered to determine the approach. The first one is for a trained specialist to teach sexuality education in schools, and the other is for several teachers to teach parts of the topic depending on their field of study. In this regard, a participant said, “Because of the interconnection of science, teachers from different fields should contribute to sexuality teaching.” (p. 15, 43 y).
A health policymaker said, “In order for an expert to be able to teach an educational curriculum, there is a need for complete infrastructure in the country's education system, which is not currently available in our country”. (p. 27, 50 y).
- Skill-based teaching
It is important to train professional teachers who can provide the right educational content correctly and skillfully.
“We need to be able to provide a safe situation for students in the class to enter sexuality discussions without any fears”. (p. 3, 40 y)
“A teacher must have mastered and applied life skills to be able to teach these lessons. They should also be able to use technology in teaching”. (p. 10, 52 y)
“Expertise, commitment, and effort are three important factors for people who want to teach in this field” (p. 24, 54 y).
Diagram 1 shows the model constructs and their effects on one another.
Perceptions Regarding Intervention Preferences For Sexuality Education
All participants had work experience in the field of adolescence. They made suggestions for the feasibility and acceptability of such programs in the country, which could be categorized into three categories based on the IMB model constructs. It was argued that designing interventions based on the constructs of this model could be effective in promoting sexual health (26, 35).
This section of the model consisted of two sub-categories, specific behavior information and cognitive myths influencing decision-making. Most of the participants believed that teachers, parents, and adolescents had very limited information about sexual health and that appropriate educational content needed to be designed to address the educational needs of each group separately. Since most of the resistance is due to misunderstanding the concept of sex education, it is better to use the term “sexuality education” and define it correctly. Because issues related to sexual health are taboo according to cognitive myths, one of the suggested solutions is to break the taboo on sexual issues using educational capacities, religious leaders and the media. One of the cognitive myths held by all participants from parents to policymakers was that boys were less likely to be harmed in a relationship. For this reason, less attention has been paid to their reproductive health needs in educational programs
This section also consisted of two sub-categories, including personal motivation (motivation for a particular behavior, confidence in the outcome of the intervention) and social motivation (perceived social support, social norm for engaging in a behavior). For personal motivation, strengthening religious beliefs, using peer groups, breaking taboos, preparing educational content, and acquiring life skills can motivate parents and teachers to engage in sexual health issues; moreover, they can motivate adolescents to engage in healthy behaviors. For social support, the participants proposed establishing youth-friendly centers, moderating the society's expectations from adolescents, holding celebrations for entering adulthood, setting up virtual education networks, enacting right-based laws, and giving teachers and administrators access to accurate statistics and information.
This section also consisted of two sub-categories, including strengthening the individual's objective skills and increasing perceived self-efficacy. The participants emphasized the need for skill-based training for all three groups (parents, teachers, adolescents). They also believed that parents and teachers, like their children, needed to be expert in the use of technology and improve their media literacy to help adolescents choose the proper educational videos and content. Improving the teachers’ professional competence and self-efficacy were other suggestions made by the participants. They argued that policies should change at the macro level, i.e., instead of determining sexual education policies from a religious point of view, they should be formulated based on health and conscious and responsible acceptance and beside other domains, attention should also be paid to the religion.