Teachers’ Attitudes towards and Comfort about Teaching School-Based Sexuality Education in Urban and Rural Tanzania

Teachers’ attitudes towards sexuality education are among the important predictors of their willingness to teach sexuality education programmes in schools. While there is a plethora of studies on teachers’ attitudes towards sexuality in developed countries, there is a paucity of such studies in sub-Saharan Africa in general and Tanzania in particular. This study examined teachers’ attitudes towards and comfort in teaching sexuality education in rural and urban Tanzania. The results show that an overwhelming majority of teachers in both rural and urban districts supported the teaching of sexuality education in schools, and the inclusion of a wide range of sexuality education topics in the curriculum. Nevertheless, though teachers expressed commitment to teaching sexuality education in schools, they expressed difficult and discomfort in teaching most of the key sexuality education topics. This implies that declaration of positive attitudes towards teaching sexuality education alone is not enough; there is a need for facilitating teachers with knowledge, skills and confidence to teach various sexuality education topics.


Introduction
The effectiveness of school-based sexuality education depends on, among other factors, the effectiveness of teachers who implement it (Cohen, Sears, Byers, & Weaver, 2004). Furthermore, it has been argued that the extent to which teachers implement the school-based sexuality education curriculum is largely dependent upon and influenced by their attitudes towards it (Paulussen, Kok, & Schaalma, 1994). Indeed, one of the central characteristics of an effective sexuality education programme is the level at which teachers are willing and show positive attitudes towards teaching it (Kirby et al., 2005). It is in this context that several authors have recommended that teachers' attitudes and confidence about teaching sexuality education be assessed prior to engaging them in the delivery of sexuality education programmes (Paulussen et al., 1994;Oshi, Nakalema & Oshi, 2004;Mathews, Boon, Flisher, & Schaalma, 2006). In many countries, teachers are perceived by young people as the most credible and trustworthy source of information about sexuality and stand high in the list of young people's preferences of sexuality education deliverers (Milton, 2003). Thus it is important to take into account teachers' views and attitudes in the sexuality education programme development and implementation.
Studies have shown that, although teachers in different countries generally support the teaching of sexuality education in schools, they encounter several obstacles. Firstly, teachers often express difficulties in teaching some of the topics related to sexuality education, including condom use, masturbation, sexual orientation, abortion and contraception (Donovan, 1998;Milton, 2003;Munodawafa, 1991). Hudson (1999) has observed that most teachers have no problems delivering sexuality education that consists of biological facts, but they find it difficult facilitating topics related to psychological aspects of sexuality education, including discussion about young people's opinions, hopes, expectation and fears concerning relationships. An evaluation of the teacher training for AIDS prevention programme in South Africa revealed that teachers, like parents, expressed open resistance to the teaching of condom use on the grounds that condom promotion would encourage promiscuity (Ahmed et al., 2006). found to be effective in the teaching of sexuality education, such as discussions, group work and role -plays (Buston, Wight, Hart, & Scott, 2002).
Thirdly, teachers have expressed concerns that they do not receive enough support from their colleagues and parents when it comes to teaching sexuality education in schools. A study of teachers' views about teaching sexuality education in 17 secondary schools in one city in England found that teachers reported facing criticism and resentment from other staff and parents about having to teach sexuality education (Alldred, David, & Smith, 2003). This means that, without the support of fellow teachers and the community in general, most teachers may find it difficult teaching sexuality education to children.
It is clear therefore that, as much as teachers may support the teaching of sexuality education in schools, they may lack the knowledge, skills and confidence to handle sexuality education sessions in a classroom situation. Additionally, it has been observed that the training teachers receive in conventional teacher training colleges may be insufficient in so far as teaching of sexuality education is concerned (Vavrus, 2006;Csincsak, Bourdeaudhuij, & Van Oost, 1994). There is, therefore, a need to provide special training tailored to sexuality education if teachers are to handle sexuality education topics effectively and competently in the classroom. Furthermore, there is a need for a clear policy that supports the teaching of comprehensive sexuality education in schools as well as social support from colleagues and community members. The lack of a clear policy on sexuality education and social support from colleagues and teachers, alongside overcrowded classrooms, have been observed as critical barriers to teachers' successful implementation of school-based sexuality education (Csincsak et al., 1994).
Though there has been a plethora of studies that have examined the attitudes of teachers towards teaching sexuality education in schools in developed countries, there has been a paucity of such studies in sub-Saharan Africa. This study examined teachers' attitudes towards and comfort about teaching sexuality education in schools in rural and urban Tanzania. Specific objectives of the study were to: assess the attitudes of teachers towards teaching sexuality education; investigate their comfort and confidence in teaching sexuality education; examine the variation in attitudes towards sexuality education between teachers in urban and rural based schools; and assess the effect of demographic factors in influencing teachers' attitudes towards and comfort in teaching sexuality education.

Participants
A randomly selected sample of 102 teachers drawn from 12 schools in the urban district (Kinondoni) and 96 teachers in eight schools in the rural district (Sengerema) were requested to complete a survey, with an overall response rate for both districts being 81.4 percent. Table 1 summarises the demographic characteristics of responding teachers. The majority of teachers in the urban district were aged 25-35 (57.9 %), while the majority of teachers in the rural district were aged 46-55 (36.7 %) and 25-35 (30 %). In both districts, the majority of respondents were female (63.9% and 55.2 % of the respondents in the urban and rural districts were female respectively).
A majority of the responding teachers (42.1%) in the urban district reported belonging to Catholics, while the majority of those in the rural district (50%) reported belonging to Protestants. In both districts, more than 90 percent of the responding teachers reported attending religious services either every day or at least once a week and that religion was very important in their life.
The majority of teachers in the urban district (92.1%) and rural district (73.3 %) held a certificate in education (Grade A) as their teaching qualification. The majority of teachers in the urban district (42.1%t) had teaching experience of less than 5 years, while the majority of teachers in the rural district (53.3%) had teaching experience of more than 15 years. About 57 percent of teachers in the rural district indicated having attended some training programmes in teaching sexuality education, compared to 42 percent of teachers in the urban district.

The Instrument and Procedure
Teachers completed a questionnaire entitled Teachers' views and attitudes towards school-based sexuality education in Tanzania. The questionnaire was initially prepared in English; it was then translated into Kiswahili, which is the working language for the majority of participants in the study sites. The Kiswahili version was translated back into English to ensure that the original content in the questionnaire was preserved.
The questions used in the questionnaire were adapted from the questionnaire Weaver et al. (2002) used in a similar study conducted in Canada. Although most of the questions adapted were developed in the context of Canada, they were found to be applicable in measuring the views and attitudes of teachers in Tanzania; the items that were included in the questionnaire had a good reliability, with an average Cronbach's alpha of .93.
The questionnaire comprised three major sections. In section one, respondents were provided with two questions.
In the first question, on a five response option ranging from strongly disagree (1) to strongly agree (5), teachers were asked to indicate to what extent they agreed that sexuality education should be provided in schools in Tanzania. In the second question, teachers were asked to indicate the school 1 level at which they thought sexuality education should be introduced in schools; they were given five response options: Class 4, Class 5-7, Form 1-2, Form 3-4 and Form 5-6.
In the third section of the questionnaire, teachers were provided with a list of 44 sexuality education topics and, on a five response option ranging from Not at all important (1) to Very important (5), were asked to indicate the level of importance they attached to each. In the fourth section, teachers were requested to provide some personal information, including age, educational level, religion, sex and marital status.
Data were entered and analysed using SPSS statistical package Version 16 using a guide provided by Pallant (2005). The percentages of respondents in favour of various aspects of school-based sexuality education were computed and were used to assess the extent to which teachers supported the provision of sexuality education in schools. Independent samples t-test was performed to explore the variation in the views and attitudes towards school-based sexuality education between teachers in the urban (Kinondoni) and rural (Sengerema) districts. Logistic regression analysis was performed to examine the effects of teachers' demographic characteristics on their views and attitudes about school-based sexuality education. Multivariate statistical analysis (MANOVA) was conducted to explore the association between teachers' demographics and their perceived importance of sexuality education topics.  Figure 1. Percentage of teachers in the urban and rural districts agreeing with statements: sexuality education should be provided in schools and the school and teachers should share the responsibility As can be seen in Figure 1, in both districts, an overwhelming majority of teachers supported the provision of sexuality education in schools. For example, 92.2 percent of teachers in the urban district (Kinondoni) agreed (42.1%) or strongly agreed (50.1%) with the statement that sexuality education should be provided in schools. In the rural district (Sengerema), 90 percent of teachers either agreed (30%) or strongly agreed (60%) with the statement.

Teachers' Attitudes towards Basic Issues Related to School-Based Sexuality Education
When asked to indicate the class level during which sexuality education should be introduced in schools, 71 percent of the teachers in the urban district and 94 percent of the teachers in the rural district indicated that sexuality education should begin at primary school level between Class 4 and 7 (see Figure 2). The paired-samples t-test revealed a statistically significant difference in teachers' preference of the school level to introduce sexuality education between the primary school level (M=4.14, SD=1.12) and the secondary school level (

Teachers' Views on the Importance of Topics to Be Included In the School-Based Sexuality Education
Teachers were provided with a list of 44 sexuality education topics that are commonly included in a sexuality education curriculum, and were asked to rate the importance of each topic on a five-point scale ranging from Not important at all (1) to Very important (1).
As can be seen from Teachers in the urban district rated nine topics as somehow important (median score =3), whereas teachers in the rural district rated six topics as such. Only two topics were rated by teachers in both districts as not important at all, these were homosexuality and pornography. Sex as part of a loving relationship was rated by teachers in both districts as not important (median score=2). Additionally, teachers in the rural district rated five other topics as not important (median score=2); namely, masturbation, appropriate/inappropriate touching, sexuality as a positive aspect of self, common myths about sexuality and sexual feelings and expression. When the topics were classified into the three dimensions of sexuality education-cognitive, affective and behavioural dimensions-using a factor analysis (see Table 3 for items belonging to the three dimensions), it emerged that the affective dimension (encompassing topics on attitudes and values) was the least preferred by the majority of teachers in both districts. Whereas more than 90 percent of teachers in both districts rated cognitive (encompassing topics on facts and information) and behavioural (encompassing topics on skills and interpersonal relationships) dimensions as very important or important, less than 30 percent of teachers rated the affective dimension as such (see Figure 3).  Figure 3. Percentage of teachers in the urban and rural districts indicating the importance of sexuality education dimensions

Variation in the Attitudes towards Sexuality Education between Rural and Urban Teachers
An independent samples t-test was performed to investigate the variation in attitudes towards school-based sexuality education between rural and urban teachers, with location as independent variable and sexuality education should be provided in schools as dependent variable. There was no statistically significant difference in scores measuring the attitudes towards school-based sexuality education between rural teachers (M=4.43, SD= .86) and urban teachers (M=4.32, SD= .93); t(66)=-.534, p= .59, with a very small magnitude of the difference in the means (eta squared= .004).
A one-way between groups ANOVA was performed to investigate variation in the perceived importance of the three mostly commonly identified controversial topics in school-based sexuality education: homosexuality, masturbation and condom use. These are the topics that received the lowest rating, with clear percentage variation between urban and rural teachers. Preliminary assumption testing using homogeneity of variance-covariance matrices revealed no serious violation of this assumption. There was no statistically significant difference between urban and rural based responding teachers on the combined dependent variables: F(3, 57)= .90, p= .442; Wilkis' Lambda= .95; partial eta squared= .05. Thus, despite the actual percentage variation, there was no statistically significant difference in attitudes towards these topics between urban and rural based teachers.

Teachers' Preferred Class Levels to Introduce Sexuality Education Topics
Teachers were asked to indicate the class levels to introduce each of the 44 topics in the school-based sexuality education curriculum. There were five response options: Class 4 (age 10), Class 5-7 (age 11-13), Form 1-2 (age 14-15), Form 3-4 (age 16-17) and Form 5-6 (age 18-20). In accordance with the education system in Tanzania, primary and secondary education levels roughly correspond to ages 7-13 and 14-17 respectively. In practice, however, a significant number of children complete primary education much later than age 13.
Tables 4 summarises the teachers' preference of school levels for introducing 12 sexuality education topics that have been considered as constituting the minimum package for a school-based sexuality education programme (Byers et al., 2003;Lenderyou, 1993). The table shows that the majority of teachers wanted most of the topics to be introduced at some point during the children's primary education (ages 10-13). For example, in both districts, the overwhelming majority of the teachers wanted all but one topic (homosexuality) to be introduced during primary school between Classes 4 and 7 (ages 10 and 13). In both districts, the majority of teachers wanted STDs/HIV/AIDS to be introduced at a much earlier level than other topics; 55.3 percent of the teachers in the urban district and 43.3 percent of the teachers in the rural district indicated that this topic should be introduced at Class 4 (age 10).

Teachers' Confidence in Teaching Various Sexuality Education Topics
Teachers were asked to indicate the extent to which they would find it easy or difficulty to teach sexuality education topics in schools on a five response scale ranging from "very difficult (1) to very easy (5)". Table 5 summarises the teachers' responses regarding their views about the comfort in teaching each of the 12 basic sexuality education topics. As shown in the table, teachers were divided regarding their level of comfort in teaching sexuality education topics; in both districts, teachers expressed easiness in teaching some topics and difficulty in many others. Only four topics were seen by teachers in the urban district (Kinondoni) as easy to teach, with more than 80 percent of the teachers indicating that these topics were either very easy or easy to teach. The topics and the percentage (in brackets) of teachers indicating that they would find them very easy and easy to teach are personal safety (88.9%), puberty (83.3%), sexual decision making (83.3%) and sexual coercion and assault (83.3%). Teachers in the rural district (Sengerema) indicated five topics as very easy or easy to teach; namely, puberty (96.6%), reproduction and birth (90.0%), sexual decision making (89.75), STDs and HIV/AIDS (96.6%) and sexual coercion and assault (82.1%).
Teachers in the urban district expressed difficult in teaching correct names of genitalia, sexual pleasure and enjoyment, condom use, masturbation and homosexuality, with less than 40% of them indicating that they would find it very easy or easy teaching these topics. Interestingly, teachers in the rural district indicated only two topics (masturbation and homosexuality) as being very difficult or difficult in teaching, with less than 40 percent of them indicating that they would find it very difficult or difficult in teaching these topics.
As would be expected, homosexuality was seen by teachers in both districts as the most difficult topic to teach, with 50 percent of the teachers in the urban district (Kinondoni) indicating that they would find it very difficult (36.1%) or difficult (13.9%) teaching this topic. In the rural district (Sengerema), 48.1 percent of the teachers indicated that they would find it very difficult (25.9%) or difficult (22.2%) teaching homosexuality.
Again, the one-way between groups MANOVA revealed no statistically significant difference between urban and rural based responding teachers in their comfort about teaching the most three controversial sexuality education topics (homosexuality, masturbation and condom use): F (3, 55)= 1.473, p= .232; Wilkis' Lambda= .926.

Discussion
The results of this study show that an overwhelming majority of the responding teachers in both rural and urban districts supported the provision of comprehensive school-based sexuality education. Furthermore, the results show that the majority of the teachers who took part in the study wanted sexuality education to begin early during primary education (ages 10-13) rather than during secondary education (ages 14 and above).
Again, teachers supported a wide range of sexuality education topics to be included in the school curriculum. This implies that teachers view school-based sexuality education not only as an important strategy for protecting young people from HIV/AIDS and other sexual health problems (diseases prevention model), but as an important strategy for promoting healthy adolescent sexual development.
The results of this study have also shown that though teachers may be committed to teaching sexuality education in schools, they are currently incapacitated to do so by the low status of sexuality education in the school curriculum. Nevertheless, this may not be the only factor behind the poor teaching of sexuality education in schools as teachers also showed considerable anxieties in teaching several topics. For example, when the teachers were presented with the same topics they had rated as important and asked to indicate their comfort about teaching them, a majority of the teachers expressed uneasiness in teaching many of the topics. The majority of teachers in the urban district, for example, expressed comfort in teaching only four topics; namely, personal safety, puberty, decision making and sexual coercion and assault. Teachers in the rural district expressed comfort in teaching only five topics: puberty, reproduction and birth, decision making, STDs and HIV/AIDS and sexual coercion and assault.
These results show that though teachers may support the teaching of sexuality education and the inclusion of a number of topics in the school curriculum, they may not be comfortable and capable of teaching all the key sexuality education topics. This was particularly the case with regard to homosexuality and other controversial topics. This implies that adequate preparation in a way of training is required for teachers if they are to handle sexuality education in the classroom situation effectively. Therefore declaration of positive attitudes towards school-based sexuality education as well as change in policy alone may not be enough; these need to go hand in hand with providing teachers with the knowledge, skills and confidence to teach the various sexuality education topics.
The results of this study are in line with the findings of previous studies, both in developing and developed countries. For example, a study in Nigeria (Iyoke, Onah, & Onwasigwe, 2006) concluded that teachers' attitude was not an impediment to implementing sexuality education. Rather, it is the level of comfort and skills in handling the various sexuality education topics in the classroom context that may constrain teachers' effective delivery of the programme. Furthermore, a study in America (Bowden et al., 2003) came up with similar conclusions; the majority of teachers overwhelmingly supported the teaching of comprehensive sexuality education in schools, but they needed training to build their confidence and skills needed to handle sexuality education topics in classes.
The lack of variation in attitudes towards the provision of sexuality education in schools between urban and rural based teachers is revealing. This may indicate that the level of education about sexual health between urban and rural localities is now becoming uniform. Additionally, the apparent lack of variation may be attributed to increased access to electronic and print media in rural areas, where there is almost an equal access to these media between urban and rural residents. Further, in many African countries, the initial stages of HIV and AIDS campaigns were more intense in rural areas than in urban areas.

Conclusion
The results of this have clearly shown that the overwhelming majority of teachers, in both rural and urban localities, support the provision of sexuality education in schools, as well as the inclusion of a wide range of www.ccsenet.org/gjhs Global Journal of Health Science Vol. 4, No. 4;2012 sexuality education topics in the school curriculum. Nevertheless, the majority of teachers are not comfortable in teaching most of the topics to schoolchildren. This implies that there various strategies are needed in ensuring that the provision of sexuality education in schools in Tanzania is successful, including using other professionals such as physicians and nurses to assist teachers in facilitating some of the sexuality education topics, as well as retraining teachers in the area of sexual and reproductive health.