Quality Provision of Comprehensive Sexuality Education and Sexual and Reproductive Health in Resource Constrained Higher Education Institutions: A Case of Mukuba University

In an effort to ensure that Institutions of Higher Learning provide quality Comprehensive Sexuality Education (CSE) and Sexual and Reproductive Health (SRH) at the level of Universities and Colleges, in developing countries such as Zambia, some universities have engaged in offering programmes and services in CSE and SRH. However, the provision of such programmes has had some limitations in terms of resources to ensure quality delivery. As a result, there was a need to examine the provision of CSE and SRH in a resource constrained Mukuba University. The study has three research objectives: 1) to examine the CSE and SRH programmes and services that are available at Mukuba University; 2) to determine the actual resources available for the University to ensure quality provision of CSE and SRH to students; 3) to use views and opinions of students and academics to examine the extent to which the CSE and SRH are reflected as standards by UNESCO and universities and colleges. The study took a pragmatic philosophy stance and convergent parallel research design of mixed methods; the primary approach is qualitative which will be analysed using thematic analysis, while the quantitative approach was secondary and the data was analysed using descriptive statistics. The study envisaged some implications that include the rise in communicable diseases such as Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS), gender based violence, general lack of information on matters relating to CSE and SRH among students at Mukuba University. The policy implication is that policy makers will be able to formulate policies that address the needs and challenges of students in providing quality CSE and SRH programmes and services for a university that is constrained with resources. The study found that there was a need to contextualize the quality provision of CSE and SRH at an institutional level, for instance , Mukuba University has created an enabling environment for quality provision of CSE and SRH activities and programmes through training of the stakeholders. Further, it was found that in any successful programme, it is expected to meet certain challenges that might in some cases make it difficult to implement the programme as envisaged. In other words, this study has revealed that there are some drawbacks as well as lessons that Mukuba University could learn from other universities that offer CSE and SRH. The study provides a synergistic conceptual model that could be used in the implementation of CSE and SRH in colleges and universities for sustainability. It is hoped that this study has proved that even with limited resources a university can provide CSE and SHR programmes and services without depending on support from other external funders and cooperating partners.

• Quality
• Comprehensive Sexuality Education
• Sexual and Reproductive Health

1. Introduction/Background to the Study

This study was necessary to be conducted to provide that even with limited resources, public universities have the capacity to provide quality Comprehensive Sexuality Education (CSE) as well as Sexual Reproductive Health (SRH) activities and programmes that benefit their students and the surrounding communities. Although in the last few decades, there has been a surge of interest in CSE and SRH, it is not clear how institutions of higher learning manage various activities related to CSE and SRH. Comprehensive Sexuality Education (CSE) is a curriculum-based process of participatory teaching and learning about aspects of sexuality aimed at equipping children and young people with knowledge, skills, attitudes and values that empower them to realise their sexual and reproductive health well-being and rights; develop a healthy interpersonal relationship; reflect on the impact of their choices on self and societal well-being; and secure and protect their rights throughout their lives [1] . Therefore, CSE is necessary in ensuring universal access to sexual and reproductive health and rights as well as advancing gender equality.

Sexual and Reproductive Health (SRH) are not only core components of the right to health and sustainable development but also necessary for achievement of gender equality and elimination of discrimination.

Zambia acknowledges that Comprehensive Sexuality Education is an essential part of any good curriculum and comprehensive response to HIV&AIDS; the country acknowledges that CSE can provide age-appropriate, culturally-relevant and scientifically accurate information to teachers and learners alike.

The aim of this study was to investigate what measures Mukuba University had put in place to provide CSE and SRH programmes for the students despite being constrained with resources. Therefore, the objectives of this study were as follows:

1) To ascertain the practical measures that Mukuba University has put in place to offer CSE and SRH programmes.

2) To determine the challenges involved in the implementation of CSE and SRH in resource poor settings.

3) To determine the lessons that universities constrained with resources could borrow from similar settings within or outside the country.

2. Literature Review

This section reviews the literature relating to two concepts in the title: Comprehensive Sexuality Education, and Sexual Reproductive Health. The use of key concepts was more applicable in the initial stages of the literature review to help locate the available research studies on the subject of CSE and SRH. Furthermore, the structure of this section was informed by the research objectives for this study. Equally, the literature reviewed included scholarly articles, books and policy documents on the implementation of CSE and SRH in higher educational institutions.

This literature reviewed helped to justify why this study was undertaken as well as to narrow the knowledge gap especially for Zambia which is a developing country and where some of the public universities are constrained with resources to undertake various activities.

2.1. Enabling Environment for Implementation of CSE and SRH Programmes

In order to successfully implement CSE and SRH programmes at university level, an enabling environment is crucial and these encompasses a number of factors which includes among others; positive cultural norms and values, infrastructure needs such as youth-friendly, youth-responsive SRH services, counselling services, supportive media, and links between schools and the community, as well as strong policy-level and community-level support [2] . In other ways, an enabling environment act as the foundation to successful CSE and SRH programmes. Furthermore, Pound [3] states that there is need for the school to provide an enabling environment that is safe from all forms of harassments for both the teachers and the students if CSE is to be implemented successfully.

2.2. Quality Dissemination of CSE and SRH Information to Students

It is difficult to assure quality if this concept is not properly understood from the outset. Quality is a conceptual tool through which QA is implemented. Quality has various meanings and is a relative term, depending on the context and institution [4] . According to Kenwright and Wilkinson [5] , Quality is used as a descriptor at all levels of a course or curriculum; we want the best “quality teaching”, good “quality assessments”, a high “quality medical curriculum”. On the same score, dissemination of quality CSE information to the students is more likely to improve sexual knowledge, self-confidence and esteem which positively changes their attitudes towards gender, including social norms and ultimately strengthens decision-making and communication skills and builds self-efficacy. Therefore, before quality is measured, it is important to set standards. These will then be used to measure against it.

2.3. Engagement with Stakeholders

As indicated earlier, in order to successfully implement CSE and SRH programmes at university level, there is need for concerted efforts by all the players involved; in other words, stakeholders must work together for the common good. According to Bjørkquist, [6] as quoted by [4] , the term “stakeholding” has recently become more popular, not only in management literature but in higher education and policy studies. Moreover, the purpose of an organisation is to represent the ideas and to safeguard the interests of its stakeholders, in this case CSE and SRH. According to Bonjour & van der Vlugt [7] , the quality of a CSE programme in most cases should also be measured in terms of reach, indicating whether it is inclusive for the most vulnerable populations as well as looking outside the school settings by establishing partnerships with the community.

2.4. Expectations of Stakeholders in Quality Provision of CSE and SRH at University Level

In initial stages of this study, the researcher identified a number of stakeholders but concentrated on those that are necessary in the implementation of CSE and SRH. These included the following: academic and support staff, students, student counsellors and medical staff from the university clinic.

Academic staff: The role of academic staff in the implementation of CSE programmes at university level is crucial and should not be downplayed. Academics will deliver CSE in terms of teaching its core components and provide the necessary study materials to the students as well as guide them throughout the course, which in this case is examinable to all students in the school of education at second year level at Mukuba University. What this means is that academics are expected to possess the necessary pedagogical content knowledge on CSE through various trainings [8] . On the same score, Bonjour and van der Vlugt [7] , accentuates the need to have highly qualified teacher educators to be able to deliver quality CSE as well as addressing the contextual barriers teachers might face when implementing CSE programmes. This view is supported by Vanwesenbeeck et al. [9] that teachers’ motivation, attitudes and skills are essential programme fedility and effectiveness in talking about sexuality.

Students: This group of stakeholders is equally critical to successful implementation of CSE programmes and activities in the university. To begin with, some students have high expectations on CSE related matters and others are inexperienced to make meaningful decisions regarding their sex life. Altbach et al. [10] observe that the more students there are in a university, the more varied are the demands that they present. The students’ expectations are more likely to be helpful in shaping the local CSE curriculum and what areas need more emphasis.

Medical staff: These stakeholders are essential particularly in the provision of SRH programmes, services and activities for the students. The medical staff at the university clinic are expected to provide expert-knowledge for better service delivery. Gatti et al. [11] accentuates that in order to provide quality CSE and SRH there is need for medical staff such as nurses and clinical officers to upscale their competencies through trainings. These training can be conducted through Continuous Professional Development (CPD).

Promotion of CSE and SRH through the education and health sectors can help to increase credibility among the stakeholders within the university and draw support in rolling out CSE. Furthermore, Mwape [12] stresses collaborations among the stakeholder as this helps to strengthen the importance of the CSE programmes.

2.5. Synergistic Conceptual Model for CSE and SRH

The Synergistic Conceptual model for CSE and SRH can help in the implementation of CSE and SRH programmes and activities at university level. In the model proposed, inputs from various stakeholders within the university as well as collaborations with the university clinic and engagement with management and the students provides the means through which CSE and SRH programmes and activities can be actualised with minimal locally generated resources. The assumption in this model is that the input from all the stakeholders will be premised on three principles: sustainability, effectiveness and efficiency.

This proposed model’s emphasis is on the synergistic approach, and each stakeholder’s concerns are taken on board with team work. Therefore, the model takes note of the other factors especially those that are related to point such as CSE national curriculum and content. It is expected that using this model would help the university to identify CSE competitive needs as well determine the strategies to use within its limited resources. The increasing complexity of CSE requires the close cooperation of stakeholders within the organisation.

3. Research Design and Methodology

This section presents research design and methodology that was employed in this study. It begins with the research design and then the methodology, data sources, sampling techniques and sample size, data collection, data analysis and ethical considerations.

3.1. Research Design

This study utilised convergent parallel design or concurrent mixed methods design. This means that data was collected simultaneously but separately for both qualitative and quantitative data [12] . The aim was to honor the integrity for the paradigm as well as solicit certain information, confirm questions to divergent views from various participants. This enabled the researchers to compare data from both sets.

3.2. Methodology

The methodology employed in this study was informed by its philosophical underpinnings. This section first presents the philosophical stance for this study and then followed by the methods used for data collection, location of the study, target population, sampling techniques, sample size and procedures for data analysis.

The study took a pragmatic stance and employed mixed methodology in its philosophical approach. Mixed methodology in conducting research is a model that contains elements of both quantitative and qualitative approaches within the context of a paradigm [13] [14] [15] .

By using the concurrent mixed methodology, the data was collected using mixed methods approach [16] . The qualitative and quantitative data were collected at various hierarchal levels within Mukuba University and later on integrated the results.

3.3. Data Sources

In this study the participants were drawn from Mukuba University and to some extent its surrounding community. These included one academic staff, 39 students mostly third and fourth years and one medical staff from the university clinic.

3.3.1. Sampling Techniques and Sample Size

The aim was to elicit data from various identified participants with regard to the topic at hand on CSE and SRH. The study employed purposive sampling to select two senior administrative management officers, two academic staff involved in the teaching of CSE and one student counsellor. The rationale for using purposive sampling was to select information-rich cases for in-depth study. Moreover, to make sure that the sample used in this study was sufficiently representative to allow inferences to be drawn for the target population for Mukuba University, simple random sampling was used to select 39 students that were picked from a list of 266 comprising 110 fourth years and 156 third years who were given randomly administered questionnaires. These two cohorts were targeted because they had covered CSE course in first year and stayed long on the university campus.

3.3.2. Data Collection

The qualitative and quantitative data from key informants were collected between 1^st October, 2022 and 6^th November, 2022 using structured in-interviews, while quantitative data from the students was collected using randomly administered questionnaires. For the purpose of validity and readability, all the instruments were peer piloted and reviewed as well as to remove ambiguities in some of the question items (variables). Table 1 below shows how the variables used in the study were defined and recoded for the purposes of this analysis.

3.3.3. Data Analysis

The primary method of analysis was qualitative and all the data from the interviews were analysed using thematic analysis [17] . These Interviews were coded into pre-determined high-level codes based on the themes of interest regarding quality provision of CSE and SRH in resource constrained higher education institutions. On the other hand, quantitative data was analysed using descriptive statistics.

3.3.4. Ethical Consideration

In research, ethics are generally held to deal with beliefs about what is right or wrong, proper or improper, good or bad. According to White [18] , ethics are a set of moral principles suggested by an individual or group and subsequently widely accepted. This study was approved by the university ethics committee and assurance was given to all the participants regarding anonymity and confidentiality.

4. Results

This section presents the findings related to all the three research objectives of this study, starting with research objective number one that focused on the practical measures that Mukuba University has put in place to offer CSE and SRH programmes with its limited resources. The raw codes from the transcribed interviews gave rise to the sub-themes identified, the main as well as the meta themes appear in the results and discussion sections respectively.

Table 1

Operational definitions of variables

Variable	Definition and measurement
CSE learning materials provided	Students study materials; 1 = strongly disagree; 2 = disagree; 3 = neither agree nor disagree; 4 = agree; 5 = strongly agree.
Time to discuss CSE and SRH matters with students.	Academic staff time to discuss CSE and SRH to students; 1 = strongly disagree; 2 = disagree; 3 = neither agree nor disagree; 4 = agree; 5 = strongly agree.
Local clinic has been helpful to raise awareness on SRH and general adolescent health services	Provision of SRH services by the clinic; 1 = strongly disagree; 2 = disagree; 3 = neither agree nor disagree; 4 = agree; 5 = strongly agree.
Enough information on gender equality and power relations on posters and brochures on campus	Awareness campaigns on gender and power relations on campus; 1 = strongly disagree; 2 = disagree; 3 = neither agree nor disagree; 4 = agree; 5 = strongly agree.
Counselling rooms and “student’s friendly corners” for CSE at the university are adequate	Specific infrastructure in which student’ counselling takes place; ; 1 = strongly disagree; 2 = disagree; 3 = neither agree nor disagree; 4 = agree; 5 = strongly agree

4.1. Institutional Environment

It should be noted that the university has the responsibility of creating an environment that has strong CSE policies and programmes that also supports networking of all the stakeholders.

4.2. Training of Stakeholders at Implementation Stage

All the medical staff at Mukuba University Clinic have received sufficient training to handle SRH activities and programmes. This makes it easy to provide the expected quality services for all the students. On this matter, P1 stated that “in terms of training of medical staff, we are way above 70% and this puts us in a position to provide SRH services to our students”. On the same score, P2 stated that “all the three lecturers that teach CSE have received sufficient training to handle CSE which is a compulsory examinable course to all the students in the School of Education”.

4.3. Local Medical Supplies

This section examines the local medical supplies necessary to conduct SRH services by the university clinic. These medical supplies are useful for successful implementation of quality SRH services. On this matter P1 said:

We do receive enough medical supplies from the Ministry of Health through the District Health Office. These include male and female condoms, family planning pills, posters and any other material we request from them. For family planning we use various methods such as injectable, implants and barrier methods; orals, we also have flyers which we issue to the students. Some of the students prefer to read these materials on their own. So we are well covered in terms of SRH services to our students. On similar lines P2 said that: “Yes, we do have the necessary teaching and learning materials to lecture CSE to my students. I would say yes, because basically when you look at teaching about male and female reproductive organs, that is what I lecture, that is my job and looking at STIs that is microbiology”.

4.4. Counselling Services for CSE and SRH

The issues of counselling services are vital to the well-being of the students on campus. Students must feel safe and protected at all times. These services must keep pace with the growing number of students at the university. Highlighting the CSE and SRH counselling services at the university clinic, P1 stated that:

We do provide counselling regarding the prevention of HIV and STIs, prevention of pregnancies and just in case they had unprotected sexual intercourse, sometimes they cannot just stand it and so they are counselled and tested for HIV and pregnancy and any other counselling depending on their questions. And so counselling is provided.

In line with the findings above on the practical measures that Mukuba University has put in place to offer CSE and SRH programmes, students were asked to rate the same practical measures in place. The idea was to compare their responses with information from other participants. Table 2 indicates students’ rating of the CSE and SRH measures that Mukuba University has put in place for Implementation.

By combining the “strongly agree” and “agree” responses, Table 2 shows that the majority of respondents (74.3%) agreed that CSE learning materials provided were mind capturing and stimulating. On the other hand, results show that more than 46% of the respondents either disagreed or strongly disagreed with the rest of the questionnaire items displayed in Table 2. Although this is not an impressive indication for the institution, the rating was higher on agree than disagree.

4.5. Challenges in Implementation of CSE and SRH

This section presents some of the challenges encountered in the planning and implementation of CSE and SRH activities and programmes.

4.6. Support from Parents/Guardians on CSE and SRH

The process of providing quality CSE and SRH demands a synergistic approach from all the stakeholders involved. In this case, parents are expected to play a significant role in quality provision of CSE and SRH of their children who are students at the same time. On this issue, P1 said:

The parents also have a role of what is obtaining on the ground, because usually, youths learn new things either from the media, the friends and the school. So the parents have a role to learn those new ideas and support them. So students must be told the exact truth and not telling them the myths. Therefore, there are some mis-matches between what we teach the students and what they are taught at home. In some cases, parents want to over protect their children, for example, you cannot just say no to sex yet their children have already tested sex.

Table 2

Students’ perceptions on measures put in place to offer CSE and SRH programmes (n = 39)

Code	Statement	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
CSE1	CSE learning materials provided are mind capturing and stimulating	10 (25.6%)	19 (48.7%)	3 (7.7%)	5 (12.8%)	2 (5.1%)
CSE2	Academic staff have time to discuss CSE and SRH matters with students	6 (15.5%)	8 (20.5%)	7 (17.9%)	12 (30.8%)	6 (15.4)
CSE3	The local clinic has been helpful to raise awareness on SRH and general adolescent health services	5 (12.8%)	10 (25.6%)	6 (15.4%)	8 (20.5%)	10 (25.6%)
CSE4	Enough information on gender equality and power relations on posters and brochures on campus	1 (2.6%)	8 (20.5%)	6 (15.4%)	13 (33.3%)	11 (28.2%)
CSE5	Counselling rooms and “student’s friendly corners” for CSE at the university are adequate	3 (7.7%)	7 (17.9%)	5 (12.8%)	13 (33.3%)	11 (28.2%)

4.7. Inadequate Funding

Adequate funding is crucial to quality delivery of CSE and SRH programmes at university level. P1 said: “We cannot fail to provide quality SRH services and we have successfully managed to do so. However, more funding will result in more activities as well as more innovations”. On the same subject, P2 stated that: “I will not talk much on funding but there is need for us to be meeting more often so that we review what we are teaching our students especially that those who teach CSE are drawn from different departments”.

4.8. Lessons from Other Universities in the Provision of CSE and SRH Practices

The view from this section addresses research question number three that focused on the lessons that universities constrained with resources could borrow from similar settings within or outside the country. Therefore, interviews from P1 revealed the following regarding some of the lessons that could be picked from universities with similar characteristics as Mukuba University. P1 said that:

Yes, other universities do a lot of activities like drama, sensitizations in the community when there is a public holiday, the peer educators will have some road shows but due to lack of financial support those have been missing. At the moment I would say we have started and we are trying with inadequate resources. We cannot provide lunch for the peer educators, even the vehicles which are supposed to be used for such activities must be provided. So Mukuba should learn from the Copperbelt University (CBU). CBU can manage to do so many things under CSE and SRH. Through peer to peer arrangements, our students can go and learn some good practices if transport was available.

5. Discussion of the Findings

This study was guided by the proposed synergistic conceptual model for implementation of CSE and SRH. The elements in the model helped to sharpen the question items in all the three instruments that were administered to the participants in order to address the research objectives of this study.

5.1. Institutional Contextualization of CSE and SRH

This section represents the meta theme to address research objective number one on the practical measures that Mukuba University has put in place to offer CSE and SRH programmes. It is important to note that CSE and SRH have been provided by a number of universities and colleges over the world for more than a decade now. However, the contexts in which these CSE programmes have been delivered are different. This therefore means that each educational institution should first contextualize the CSE and SRH programmes so they fit in the respective context. In the same way Mukuba University has created an enabling environment for quality provision of CSE and SRH activities and programmes through training of the stakeholders who included medical staff from the university clinic as well as the academic staff that teaches CSE to all the first year students in the School of Education. Moreover, the university may utilise the proposed synergistic conceptual model as indicated in Figure 1 to ensure quality delivery of CSE and SRH programmes and activities. This is in line with the literature review that states the need to have highly qualified teacher educators to be able to deliver quality CSE as well as addressing the contextual barriers teachers might face when implementing CSE programmes [7] . Furthermore, the proposed synergistic conceptual model for this study also emphasizes on collaborations among the stakeholders within the university community for successful implementation of CSE and SRH programmes through sustainability, effectiveness in terms of planning as well as efficiency of delivery. Literature reviewed indicated collaborations among the CSE players within the university [12] . The involvement of students in planning of CSE activities is equally cardinal. Literature reviewed indicates that the more students at the university, the more varied are the demands that they present. For Mukuba University, students’ participation in CSE programmes is one of the factors that have seriously been considered.

With regards students’ SRH counselling services, the university clinic is adequately staffed to handle the students as well as provide the necessary supplies that include all forms of family planning, HIV drugs, posters and broachers as indicated by P1. On the same score, Table 2 also indicates that students are alive to the fact that a lot more is being done to provide quality CSE and not withstanding areas that require more improvement.

5.2. Drawbacks in the Implementation of CSE and SRH

This section represents the meta theme to address research objective number two and three on the challenges involved in the implementation of CSE and SRH in resource constrained settings and the lessons that universities constrained with resources could borrow from similar settings within or outside the country respectively. In any successful programme, it is expected to meet certain challenges that might in some cases make it difficult to implement the programme as envisaged. In the case for Mukuba University, although CSE and SRH provision is adequate with limited resources, there are areas that require improvements as well as sustainability. The participants in this study indicated low funding to enable expansion of activities within Mukuba University community. Moreover, some of the parents over protect their children thinking that they have never been involved in sexual activities and they should not. This creates a mismatch, because at Mukuba University, students are taught about the alternatives for protecting themselves under SRH, should they feel the need to engage in sexual activity but not be able to without protection (refer to Page 1 of the results). On similar lines, there is a need for Mukuba University to benchmark with other universities and learn how CSE and SRH services are provided to the students. For example, P1 said that Mukuba University should learn from Copperbelt University how CSE programmes are managed. One specific reference that was mentioned is peer-to-peer arrangement for our students to go and learn some good practices.

This study has revealed that there are some drawbacks as well as lessons that Mukuba University could learn from other universities that offer CSE and SRH.

6. Conclusion

The general outlook obtained from the participants and literature reviewed in this study is that higher education institutions that are resource-constrained, such as Mukuba University, can still provide quality CSE and SRH programmes using their limited resources. The major resources required are the key stakeholders who have a strong interest in the CSE and SRH programmes, and who can lead to successful implementation through a synergistic approach, as indicated in the proposed conceptual model (Figure 1) of this study. However, such programmes cannot be undertaken without challenges that hinder their expansion and sustainability.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

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