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1. Evaluating school-based sexual health education programme
in Nepal: An outcome from a randomised controlled trial
Dev Acharya*, Malcolm Thomas, Rosemary Cann
School of Education,[79_TD$DIFF] Aberystwyth University, Penbryn 5, Penglais Campus, Aberystwyth, SY23 3UX, UK
A R T I C L E I N F O
Article history:
Received 13 June 2016
Received in revised form 2 February 2017
Accepted 6 February 2017
Available online xxx
Keywords:
Randomised controlled trial
Sex education
Intervention
School
Adolescent
Knowledge
[81_TD$DIFF][77_TD$DIFF]A B S T R A C T
This study explored the effectiveness of teaching sex education programme to the
secondary school children in Nepal.The study included four schools which were
randomised to two groups; control and experimental schools. The teachers in the control
schools delivered the sex education curriculum in a conventional way whereas the trained
health facilitator in the experimental schools used a participatory teaching approach. The
results were analysed by using z-score to identify the distribution patterns of pupils’
responses. There was significant number of school children reporting the increment of
sexual health knowledge in the experimental schools. This suggests that the health
facilitator led sex education programme is more effective in improving the sexual health
knowledge of the school children.
© 2017 Elsevier Ltd. All rights reserved.
1. Introduction
Adolescents in today’s developing countries are very different compared to the past generations. They are more
independent, spend more time in school, and have widespread access to communication (Boonstra, 2011). However, such
kinds of differences have also provided them with the opportunity to get into early sexual activities including postponing
marriage and childbearing. A recent UNICEF report (2016) has highlighted that about two million adolescents were living
with HIV worldwide during 2014 and the highest numbers of HIV positive adolescents were from sub-Saharan Africa and
South Asia. In another note, WHO (2011) stated that about sixteen million adolescent girls (aged fifteen to nineteen) give
birth each year, which is roughly 11% of all births worldwide, with 95% occurring in developing countries. In addition,
Sexually Transmitted Infection (STI) is another major concern of adolescent sexual health. An earlier report published by
WHO (2005) estimated that 333 million new cases of curable STIs occur worldwide each year with the highest rates among
20–24 year olds, followed by fifteen to nineteen year olds.
In Nepal, unsafe sexual activity among adolescents is very common which underscores the importance of access to
contraceptive services (Andersen et al., 2015). Another study conducted in rural Nepal identified that 46% of young women
had experienced sexual violence at some point and 31% had experienced sexual violence in the past twelve months (Puri,
Frost, Tamang, Lamichhane, & Shah, 2012). Many Nepalese adolescents engage in unsafe sexual practices due to the lack of
proper information about sexual health and the poor accessibility of sexual health services (Regmi, Van Teijlingen, Simkhada,
& Acharya, 2010). They are at acute risk of Sexually Transmitted Infections (STIs), Human Immunodeficiency Virus (HIV)
* Corresponding author.
E-mail addresses: dra1@aber.ac.uk (D. Acharya), mlt@aber.ac.uk (M. Thomas), ooj@aber.ac.uk (R. Cann).
http://dx.doi.org/10.1016/j.ijer.2017.02.005
0883-0355/© 2017 Elsevier Ltd. All rights reserved.
International Journal of Educational Research 82 (2017) 147–158
Contents lists available at ScienceDirect
International Journal of Educational Research
journal homepage: www.elsevier.com/locate/ijedures

2. infection and unplanned pregnancies (Dahal, 2008). Despite the increase in general awareness, comprehensive knowledge of
sexual health and Sexual and Reproductive Health (SRH) service use are very low among these adolescents (Bam et al., 2015).
WHO (2006) defines sexual health as a state of physical, emotional, mental and social well-being in relation to sexuality;
it is not merely the absence of disease, dysfunction or infirmity. Adolescents require a positive and respectful approach to
sexuality and sexual relationships which is free from coercion, discrimination and violence. Sexual health is also described as
the ability to embrace and enjoy sexuality throughout life, which is an important part of adolescents’ physical and emotional
health (ASHA, 2016). Le and Kato (2006) have clearly highlighted that sexual behaviour of adolescents is one of the most
important social and public health issues in developing countries. The issue of sexual and reproductive health is not only the
main reason of ill health among adolescents worldwide but is also of major concern in Nepal (Adhikari & Tamang, 2009).
According to CBS (2014) data there are nearly nine million young people (10–24 years) in Nepal of which adolescents (10–
19 years) make up 24.2% of the population. This indicates that the adolescents comprise a significant proportion of Nepal’s
population. In Nepal, the total number of secondary school aged children (14–15 years) is 671,183 of which the Net Enrolment
Rate (NER) is only 35% (MoE/DoE Nepal, 2008). This means that 65% of secondary age children do not continue in mainstream
formal education. Of the total number of teachers at secondary level, only about 70% are trained and are working in
appropriate positions.
In Nepalese society, marriage is a traditional phenomenon and family members organise it at an early age for boys and
girls. Early marriage has numerous adverse effects on the well-being of children, who are mentally, psychologically,
emotionally and physically unfit for married life (Plan International, 2012). However, recent data indicates that the median
age at first marriage among females has gone up from 16.4 years in 1996 to 17.5 years in 2011(NDHS/New Era Nepal, 2011).
One possible explanation behind the age increase for marriage is that adolescents are receiving education and are living in an
urbanised culture. A study investigating sex education and reproductive health among in-school adolescents has mentioned
that the majority of Nepalese girls typically stop going to school when they are married very young (Pokharel, Kulczycki, &
Shakya, 2006).
1.1. The sex education curriculum in secondary schools
In 2000, Ministry of Education Nepal launched Health, Population and Environment (HPE) education as a core subject at
the secondary level (Grades Nine and Ten) which is taught four sessions per week, each session lasting for 45 min (MoE/CDC
Nepal, 2005). The Curriculum Development Centre (CDC) is the body responsible for developing the school level curriculum
which works under the Ministry of Education. CDC has formed subject committees to develop, update and provide technical
approval to the school curricula. In general, CDC organises workshops and gathers feedback from subject teachers which is
then widely discussed among the subject committee members. The finalised prototypes and recommendations are then sent
to the National Curriculum Council for final approval. More often, the Higher School Education Board (HSEB) forms technical
committees to discuss unresolved or emerging issues. CDC considers the political condition, commission reports and the
urgency of matters to design sex education curricula. It also takes into account the opinions of teachers, students and parents
as the main source of information.
A UNESCO Nepal (2009) report further stated that student-learning materials on sexual health education are inadequate
at secondary levels. The report added that the Curriculum Development Centre (CDC) was given the mandate to develop and
disseminate student-learning materials at the school level, but it lacks the capacity to do so. As a result, students have to rely
just on school textbooks as their primary source of learning material. The second reason for the inaction is a lack of
coordination amongst the funding agencies who promote sex education in schools. Very few schools have adopted life skills
and sex education related teaching materials into their secondary education curriculum which is developed by Non-
Governmental Organisations (NGOs), aiming to improve young people’s health and well-being (UNESCO, 2002; UNICEF,
2003).
1.2. Gaps and challenges in sex education delivery
Considering the importance of school-based sex education for adolescents, Nepal’s formal education system is not free
from caveats and constraints. The lower secondary level (four to eight) and secondary level (nine to ten) stand at the focus of
sex education but the curriculum design and structure is inconsistent and ineffective in promoting sexual health to these
pupils (MoE/CDC Nepal, 2005). The curriculum is planned to deliver sex education as biological facts, which are provided in a
didactic approach (Stone, Ingham, & Simkhada, 2003). It also lacks comprehensive information on sexual health, social
issues, sexual behaviours, sexual attitude and life skills. Therefore, sex education appears to be disjointed across many
subjects. Many other issues such as sexual harassment, gender inequalities, and stigma and discrimination have not been
considered in the curricula.
1.3. Rationale of the study
There is a lack of relevant research on the effectiveness of teaching sex education to school-aged adolescents in Nepal.
Conducting research into adolescents’ sex and sexual health could attract many researchers of different backgrounds,
including sociologists, educationalists, epidemiologists, public health professionals and demographers, due to the identified
148 D. Acharya et al. / International Journal of Educational Research 82 (2017) 147–158

3. relationships between sexual behaviours and certain sexual and reproductive health outcomes. The effectiveness of teaching
sex education, including fertility and family-planning research in Nepal, has relied on quasi-experimental design (Shrestha
et al., 2013). In addition, many of these kinds of studies have often focused on a single unit of the study such as one school or
one community group. Additionally, the Nepalese government has invested a huge amount of resources to enhance sexual
and reproductive health programmes for adolescents. Nevertheless, the impact of these programmes in improving
adolescents’ sexual health knowledge and behaviour is still in question.
In Nepal, there is a common view that adolescents are concerned about their attitudes towards the opposite sex,
friendships and sexual relationships (Regmi, Simkhada, & Van Teijlingen, 2008). These concerns may have resulted in
coerced sexual activities, aggression, unwanted pregnancies, induced abortion and STIs/HIV infection. Different studies show
that Nepalese adolescents are engaged in unsafe sexual practices (Adhikari & Tamang, 2009; NDHS/New Era Nepal, 2011;
NAYS, 2012). However, health facilities have failed to provide specialised sexual health information and sexual and
reproductive health services to them (Acharya, Van Teijlingen, & Simkhada, 2009). This suggests that there is a need to
understand the barriers to adopting safe and responsible sexual and reproductive behaviour, and that this information would
also be important in designing policies for sex education in schools.
Efforts to understand the issue of sexual health knowledge and behaviour of adolescents are perhaps the first step to
formulating better intervention, and this should be based on rigorous research. Research into the effectiveness of teaching
school-based sex education is crucial for policymakers and programme designers and ultimately for adolescent welfare. The
main aim of this study is to evaluate the effectiveness of the school-based sex education programme used to promote
adolescent sexual health knowledge and understanding in Nepal. The study used a mix of three learning theories
Bandura’s social learning theory, Vygotsky’s zone of proximal development and Piaget’s cognitive theory (Bandura 2001;
Davydov Radzikhovskii, 1999; Piaget, 1968). These theories take into account the social factors at both the cultural and
interpersonal level and consider that knowledge development is critical in measuring progress (Tudge Winterhoff, 1993).
2. Methods
This study is an experimental research known as a Randomised Controlled Trial (RCT) and engenders substantial
confidence in the robustness of causal findings (Schulz, Altman, Moher, 2010). In recent years, there has been a substantial
use of RCT design in the social and educational research (Hutchison Styles, 2010). None of the previous studies have applied
RCT design to explore the effectiveness of sex education delivery in Nepalese schools (Acharya et al., 2009). The design of
randomised controlled trials has the ability to manipulate independent variables and replicate the findings that could
influence the educational policy and practice in Nepal.
2.1. Study participants
This is a cluster randomised controlled trial that was conducted among secondary school students aged fourteen to
eighteen in Hetauda, Makwanpur of central Nepal during May-July 2011. In this type of trial, groups of people rather than
individuals are randomly allocated to the intervention to avoid the contamination threat (McKenzie, Ryan, Di Tanna, 2014).
Four community-based mixed urban secondary schools, with no previous implementation of a sex education programme
were selected for the intervention with the support of the District Education Office (DEO) in Makwanpur. The intervention
lessons were developed by the health facilitators with the support from the main researcher and sexual health expert from
the DEO Makwanpur. A teaching guideline was also developed to ensure that the facilitators deliver the same programme to
the intervention schools.
2.2. Training to health facilitators
Two female staff nurses were selected to act as health facilitators to deliver the sex education programme in the
experimental schools. In May 2011, they received one-day orientation training delivered by sexual health experts from the
DEO Makwanpur. The orientation training had one pre-training meeting and one follow-up meeting. In this training, health
facilitators were provided with information about the sexual health issues of adolescents and were presented with the
opportunity to develop participatory learning activities such as role-play, games, quizzes, discussions, and chart display. The
training also addressed the techniques of classroom management and group facilitation including communication clarity,
rapport-building and skills delivery.
2.3. Procedures
Prior to the intervention, a letter describing the purpose of the research was sent to the parents and their consent was
obtained to involve their children in this study. Pupils were also asked to give their consent to take part in the study prior to
the intervention. They had the right to withdraw from the research study itself or to not respond to any question they did not
wish to answer. In the experimental schools, health facilitators delivered sex education programmes to grade nine pupils
following the schools’ existing sex education curricula. In the control school, conventional teachers did the same. The time
period between the pre-test and the post-test was seven weeks. The data was collected by self-administered questionnaires
D. Acharya et al. / International Journal of Educational Research 82 (2017) 147–158 149

4. developed in the Nepali language which was piloted prior to the intervention (Acharya, Thomas, Cann, 2016). These
questionnaires (pre-test and post-test) were completed by the pupils themselves in the classroom setting when the teachers
were not present. Students were only identified by their code number written at the top of the questionnaire and only the
main researcher had access to this information. Questionnaire items were kept brief and on-going progress evaluations were
conducted to monitor the problems of dropping out. The data collection in this study was kept confidential and no school or
individual were identified in the results presented. Ethics approval for the study was obtained from the Nepal Health
Research Council (NHRC) and from the Aberystwyth University Ethics Committee, as highlighted by BERA guidelines for
educational research to be conducted within an ethical respect (BERA, 2011).
2.4. Sampling frame and sample size
In Nepal, the Ministry of Education (MoE) publishes a Flash Report every two years, which provides details about the
schools, including class size at secondary level (DoE Nepal, 2008). This Flash Report was used to calculate the number of
schools to be enrolled in this study. The report described that there are nine community-based secondary schools in Hetauda
municipality in Makwanpur. The average number of pupils per Year Nine class per school was 62 which were considered to
be a sampling frame.
The main outcome of this study was to assess the knowledge and attitude gained about preventive measures against HIV
and AIDS, STIs and teenage pregnancy. This knowledge was based on ABC: Abstinence means to avoid sex (A); Be faithful to
your sex partner (B) and; Correct and consistent condom use for safer sex (C). A total of 24 questionnaires including these
three main questions were given to the participants in the pre and post-test. A previous study conducted in Nepal showed
that 40% of Nepalese school students had knowledge of the ABC preventive measures (Gautam, 2004). However, the pilot
study of this research showed a slightly different picture: 45.7% of pupils knew that abstinence means to avoid sex (A); 61.9%
knew about being faithful to a sex partner (B); and 52.8% responded that they knew that condoms should be used correctly
and consistently for safer sex purposes (C). These two pieces of evidence suggested that an average of 45% of pupils know
about ABC which was considered as the pre-test knowledge to calculate the sample size.
The study aimed to increase the ABC knowledge from 45% to 65%to observe the significance differences from the
intervention. So, for the two-sided test of 5% significance and 80% power, the sample size per group (control versus
experiment) required was:
N ¼ K
p1ð1 p2Þþp2ð1 p2Þ
ðp1p2Þ2
Where K = 7.9 for 80% power, p1 and p2 are the proportions estimates (Chan, 2003; Fox, Hunn, Mathers, 2007). Thus, from
the above details, p1 = 0.45 (for 45% knowledge on ABC) and p2 = 0.65 (for expected 65% knowledge on ABC) the number of
participants required was 94. Hence, for the two-sided tests a total of 188 participants were needed. However, there was a
chance that some participants would not complete the questionnaire. So, the sample size was increased by a quarter to 235.
The sampling frame indicated that the average number of pupils per Year Nine class in the secondary schools were 62. This
means the study required 235/62 = 3.79 schools (four schools) to conduct the study. By tossing a coin, these four schools were
randomly assigned into either control (conventional teacher-led) or experimental (health facilitator-led) groups.
2.5. Participant flow
A total of 482 pupils were reached from four secondary schools (Fig. 1). Out of this total, 34 pupils were excluded from
further consideration. This was due to the following factors; inappropriate age (n = 15), pupils declining to participate (n = 8),
and parents declining to give their consent (n = 11). Therefore, 448 pupils were randomised from four schools, of which 201
pupils were in the experimental schools (health facilitator-led) and 247 in the control schools (conventional teacher-led). In
the experimental schools, seventeen pupils did not receive the allocated exposure because of the consent withdrawal (n = 3)
and failure to attend the session (n = 14). In the control schools, ten pupils did not receive the allocated exposure due to
consent withdrawal (n = 2) and failure to attend the session (n = 8).
2.6. Intervention
This study was unblinded in nature, since the participants and the main researcher together had common and positive
expectations about the quality of the intervention (Boutron et al., 2006). Nevertheless, the participants were not aware
whether they would be assigned to a control or experiment school prior to the random assignment. The ‘International
Guidelines on Sexuality Education’ emphasised that school sex education should comprise at least twelve classroom
sessions, each lasting around 45 min (UNESCO Nepal, 2009). In this study each health facilitator and teacher delivered
sixteen sexual health education classroom sessions to Year Nine pupils for six weeks (three lessons for five weeks and one
lesson for week six); each session lasted for 45 min. These sessions were focused in a logical sequence in order to match the
objectives of the intervention and scheduled with Health, Population and Environment (HPE) subjects in accordance with
the usual school practice for the provision of sex education.
150 D. Acharya et al. / International Journal of Educational Research 82 (2017) 147–158

5. Regular sex education teachers did not attend the classroom during the intervention sessions in the experimental schools.
Health facilitators employed educationally sound methods that actively involved participants and assisted them in
personalising information. They adopted a less formal approach than conventional teachers, and made more use of
participatory classroom teaching techniques. These included games and small group work, discussions, brainstorms, role-
play and demonstrating how to use condoms. In the experimental schools, pupils received a more participatory learning
session compared to the control schools. During the intervention, all the participating pupils were informed that they would
be contacted for a post-test after seven weeks. The main researcher monitored the fidelity to make sure that all components
of the intervention were delivered properly within the given time period.
2.7. Data analysis
Comparison of pre-test and post-test characteristics and response rate were obtained from the cross tabulation and
presented in the frequency table. The exploratory analysis of the main questionnaire from the Kolmogorov-Smirnov (K-S)
and Shapiro-Wilk tests confirmed that a non-parametric test is to be considered for the data analysis. The distribution
patterns of pupils’ responses were used (z-score) to examine the significance level at 95% Confidence Interval (CI). The
questionnaire variables were distributed in the ordinal scale and were not undertaken on paired samples. Therefore, Mann-
[(Fig._1)TD$FIG]
Fig. 1. Flow diagram of progress through randomised trial of two groups of schools.
D. Acharya et al. / International Journal of Educational Research 82 (2017) 147–158 151

6. Whitney (U) analysis was used to observe any differences between two time points at pre and post-test, and an approximate
effect size (r) of these responses were also calculated.
3. Results
3.1. Comparison of pre-test and post-test characteristics and response rate
A total of 421 pupils responded in the pre-test and 366 responded in the post-test (Table 1). There were more pupils in the
control schools than the experimental schools. More than a quarter of pupils’ fathers had completed a school-leaving
certificate education, followed by secondary education, which was closely followed by primary education. In contrast, pupils’
mothers’ education was highest at the primary level, closely followed by illiteracy. Mothers’ education was slightly higher in
the informal/non-formal category compared to secondary level and school leaving certificate. Very few pupils reported that
their mothers had completed college/university education.
Table 1
Comparison of pre-test and post-test characteristics and response rate.
Particulars Comparison Response rate (%)
Pre-test (n = ) Post-test (n = )
Schools
Control school-A 150 139 92.7
Control school-B 87 82 94.2
Experiment school-C 110 72 65.5
Experiment school-D 74 73 98.6
Control/Experiment
Control 237 221 93.2
Experiment 184 145 78.8
Gender
Male 193 175 90.7
Female 228 191 83.8
Age
14 years 176 146 82.9
15 years 113 99 87.6
16 years 92 88 95.7
17 years 28 22 78.6
18 years 12 11 91.7
Ethnicity
Brahman/Chhetri 203 175 86.2
Magar/Gurung/Rai/Limbu 48 46 95.8
Newar 48 39 81.2
Tamang 66 55 83.3
Madhesi 22 20 90.9
Others 34 31 91.1
Father’s Education
Illiterate 39 35 89.7
Informal/non-formal 33 24 72.7
Primary education 87 82 94.2
Secondary education 99 81 81.8
School leaving certificate 109 99 90.8
College/university 54 45 83.3
Mother’s Education
Illiterate 107 88 82.2
Informal/non-formal 73 52 71.2
Primary education 110 104 94.5
Secondary education 62 58 93.5
School leaving certificate 59 54 91.5
College/university 10 10 100
Total 421 366 86.9
Pearson Chi-Square, p 0.05 sig. (2-sided).
152 D. Acharya et al. / International Journal of Educational Research 82 (2017) 147–158

7. 3.2. Distribution patterns of pupils’ responses (z-score)
Pupils’ responses to the sexual health questionnaires were analysed using cross tabulation and z-score to observe any
significant differences between control and experimental schools. The z-score determines how many standard deviations
the responses are from the mean. This score was calculated for each questionnaire by gender in the control and experimental
school.
3.2.1. Sources of sexual health information
The cross tabulation and z-score analysis shows that there were significant differences between male and female
responses in four questionnaire variables in the control and experiment schools. Of those responses, friends/peers in control
group (z = 4.165, p 0.001), relatives of similar age in control group (z = 3.059, p 0.05), youth volunteer worker in the
control group (z = 2.982, p 0.05), chemist or pharmacy in the control group (z = 4.324, p 0.001) and chemist or pharmacy
in the experimental group (z = 2.859, p 0.05) were significantly different.
3.2.2. Sexual health awareness level
The analysis of the cross tabulation and z-score shows that there are three main questionnaire variables that showed a
significant difference between males and females in the control/experiment school. The parental counselling is important for
young people's sexual health development question showed a significant difference in the control group (z = 4.660, p 0.001).
Similarly, fertilisation is a natural process that takes place in a fallopian tube in the experiment group (z = 3.002, p 0.05),
adolescent experience growth of height during physical change in the control group (z = 3.754, p 0.001) and in the
experiment group (z = 2.878, p 0.05) also showed a significant difference between male and female responses.
3.2.3. Sexual health knowledge and understanding
The cross tabulation and z-score analysis shows that there was only one questionnaire variable that showed a significant
difference between the males and females in the control school. The variable was STIs may cause infertility (z = 2.232,
p 0.05).
3.2.4. Sexual health norms and beliefs
The cross tabulation and z-score analysis shows that this section had two questionnaire variables that showed significant
differences in pupils’ responses in the male and female group in the control/experiment school. These questions were females
should be considered untouchable during menstruation in the control group (z = 1.965, p 0.05), a girl loses her dignity if she
has sex before marriage in the control group (z = 2.635, p 0.05) and in the experiment group (z = 2.367, p 0.05).
3.3. Effectiveness of sex education intervention programme
3.3.1. Control schools
Pupils’ scoring in the pre-test was significantly different to the post-test for five questionnaire variables, as shown in
Table 2. This illustrates that for all these variables, the intervention (teacher-led sex education) had a significant positive
impact on pupils’ sexual health knowledge and understanding. In the post-test, the mean rank scores increased significantly
Table 2
Effectiveness of sex education intervention in control schools.
Variables Pre-test /Post-test Mean Rank Sum of Ranks Mann Whitney (U) z-score P
value
Effect Size (r)
Section One - Sources of sexual health information
Chemist or pharmacy pre-test 217.28 51496.5 23293.5 2.321 0.020* 0.108^
post-test 242.6 53614.5
Section Two - Sexual health awareness level
Parental counselling is important for
sexual health development
pre-test 239.09 56663.5 23916.5 2.237 0.025* 0.104^
post-test 219.22 48447.5
Fertilisation is a natural process that takes
place in fallopian tube
pre-test 217.41 51525 23322 2.228 0.026* 0.104^
post-test 242.47 53586
Section Three - Sexual health knowledge and understanding
Loneliness occurs as a result of emotional
change
pre-test 217.74 51605.5 23402.5 2.922 0.003* 0.136^
post-test 242.11 53505.5
Section Four - Sexual health norms and beliefs
I believe in abstinence which means to
avoid sex
pre-test 213.59 50620.5 22417.5 3.097 0.002* 0.144^
post-test 246.56 54490.5
Note: *p 0.05; **p 0.001; ^ = small effect (r 0.3); ^^ = medium effect (r 0.3); ^^^ = large effect (r 0.5).
D. Acharya et al. / International Journal of Educational Research 82 (2017) 147–158 153

8. in all variables except for ‘parental counselling is important for sexual health development’ in Section Two. It decreased from
239.09 in the pre-test to 219.22 in the post-test. This demonstrated that pupils were not confident about their parents
offering sexual health information.
3.3.2. Experimental schools
In the experimental schools, more responses showed significant differences between the pre-test and post-test scores as
shown in Table 3. In the first section, pupils’ responses to four variables were significantly different between the pre-test and
post-test. In the second section, only two variables were found to be significantly different between the pre-test and post-
test responses. Pupils’ responses to the third section showed that three variables had significant differences in the pre-test
and post-test responses. The fourth section also showed three variables that had significantly different scores between the
pre-test and post-test. The mean rank score of ‘females should be considered untouchable during menstruation’ is decreased
from pre-test (173.31) to post-test (154.46).
3.4. Participants’ knowledge about preventive measures
3.4.1. Control schools
Pupils’ knowledge on I believe in abstinence which means to avoid sex (A) increased from 55.3% in the pre-test to 70.1% in
the post-test, a total of 14.8% increase, as shown in Fig. 2. The second measure It is better to have only one sex partner for sexual
relationship (B) was 92% in the pre-test and 93.2% in the post-test, showing a very slight increase of 1.2%. Conversely, the third
measure Condom is used correctly and consistently for safer sex purpose (C) showed a decline trend in the post-test. It was
86.90% in the pre-test and 82.4% in the post-test, a total decline of 4.5%.
3.4.2. Experimental schools
Pupils’ knowledge on I believe in abstinence which means to avoid sex (A) was increased from 50% in the pre-test to 75.9% in
the post-test, showing a 25.9% increase, as shown in Fig. 3.
The second measure It is better to have only one sex partner for sexual relationship (B) was 79.3% in the pre-test and 93.8% in
the post-test, which showed another strong increase of 14.5%. The trend of increase was also observed in the third measure
Condom is used correctly and consistently for safer sex purposes (C). It was 53.8% in the pre-test and 86.9% in the post-test, a
Table 3
Effectiveness of sex education intervention in experimental schools.
Variables Pre-test/ Post-
test
Mean
Rank
Sum of
Ranks
Mann Whitney
(U)
z-
score
P value Effect Size (r)
Section One Source of sexual health information
Friends/peers pre-test 147.33 27108.00 10088.00 4.989 0.000** 0.275^
post-test 187.43 27177.00
Health professional such as doctor/nurse pre-test 156.40 28778.50 11758.50 3.647 0.000** 0.201^
post-test 175.91 25506.50
Visitor from outside such as health facilitator pre-test 151.79 27930.00 10910.00 4.409 0.000** 0.243^
post-test 181.76 26355.00
Chemist or pharmacy pre-test 151.61 27896.00 10876.00 3.177 0.001* 0.175^
post-test 181.99 26389.00
Section Two Sexual health awareness level
Parental counselling is important for sexual health
development
pre-test 156.44 28784.50 11764.50 2.564 0.010* 0.141^
post-test 175.87 25500.50
Fertilisation is a natural process that takes place in fallopian
tube
pre-test 153.08 28167.00 11147.00 2.996 0.003* 0.165^
post-test 180.12 26118.00
Section Three Sexual health knowledge and understanding
Unsafe sexual behaviour is adolescent’s current problem pre-test 153.62 28266.00 11246.00 3.740 0.000** 0.206^
post-test 179.44 26019.00
Loneliness occurs as a result of emotional change pre-test 150.77 27742.00 10722.00 4.221 0.000** 0.232^
post-test 183.06 26543.00
It is better to have only one sex partner for sexual
relationship
pre-test 154.26 28384.00 11364.00 3.799 0.000** 0.209^
post-test 178.63 25901.00
Section Four Sexual health norms and beliefs
I believe in abstinence which means to avoid sex pre-test 147.97 27226.50 10206.50 4.213 0.000** 0.232^
post-test 186.61 27058.50
Females should be considered untouchable during
menstruation period
pre-test 173.31 31888.50 11811.50 2.110 0.035* 0.116^
post-test 154.46 22396.50
A girl can suggest a boy uses a condom if he suffers from an
STI
pre-test 153.45 28234.50 11214.50 4.084 0.000** 0.225^
post-test 179.66 26050.50
Note: *p 0.05; **p 0.001; ^ = small effect (r 0.3); ^^ = medium effect (r 0.3); ^^^ = large effect (r 0.5).
154 D. Acharya et al. / International Journal of Educational Research 82 (2017) 147–158

9. total increase of 33.1%. Comparing the two figures (Figs. 2 and 3) it was clearly seen that ABC knowledge increase was more
consistent and robust in the experiment group than in the control group.
4. Discussion
In comparison with the conventional teacher-led sex education, properly developed sex education led by a health
facilitator had a significant impact on the improvement of quality knowledge and understanding of sexual health for the
adolescent. The findings could be interpreted as evidence of the success of the school-based sex education intervention
programme. Kirby (2011) noted that the school-based sex education intervention programme is effective in changing sexual
behaviour and reducing unprotected sex among school children. It has also led to an improvement in knowledge and
attitudes and to decrease the frequency of sex (Paul-Ebhohimhen et al., 2008; Thato, Jenkins, Dusitsin, 2008).
In Nepal, students are taught basic sex education in secondary level. It covers basic reproductive health facts concerning
safe motherhood, family planning, reproductive physiology, STIs, HIV and AIDS, infertility, adolescent health, health
problems of post-menopausal women and reproductive rights. However, there is very little known about the extent to which
this content is practically covered in classrooms to address the issues of adolescents’ sexual health concern (Acharya et al.,
2009). Hindin and Fatusi (2009) have strongly suggested designing an intervention that could provide evidence about the
quality and content of school-based sex education programme.
This study was effective to increase adolescents’ sexual health knowledge because of three main reasons. First, it
identified and trained the health facilitators who had an interest in sex education delivery and classroom management. The
training provided them a sense of confidence and ownership of the intervention. They developed professional relationships
with students to support the teaching of sex education. This finding is in line with a report published by Department of
Health (DoH, 2014) where sex education sessions are delivered by school nurses who are trained appropriately and
supervised regularly to build trusting and enduring professional relationships with school children. It is also helpful to
standardise and simplify curriculum delivery and build the tutor’s capacity to deliver the programme (Dlamini et al., 2012).
A second possibility is that the study used a participatory learning approach to provide sex education in the classroom.
The health facilitators adopted an informal approach than the conventional teachers, and made more use of participatory
classroom teaching techniques. These included games and small group work, discussions, brainstorms, role-play and
demonstrating how to use condoms. These approaches are used in describing facts about sex and sexuality, identifying
adolescents’ sexual health problems and promoting their active participation. Spanier (1976) highlighted that this kind of
approach is useful in tapping into the unique perspectives of the respondents’ ideas on realistic solutions and has
significantly more impact on pre-marital sexual behaviour.
[(Fig._2)TD$FIG]
55.3
92
86.9
70.1
93.2
82.4
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
A B C
pre-test
post-test
Knowledge
%
Fig. 2. ABC knowledge scores between pre-test and post-test.
[(Fig._3)TD$FIG]
50
79.3
53.8
75.9
93.8 86.9
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
100.00
A B C
pre-test
post-test
Knowledge
%
Fig. 3. ABC knowledge scores between pre-test and post-test.
D. Acharya et al. / International Journal of Educational Research 82 (2017) 147–158 155

10. Third, the health facilitators and teachers followed the international guidelines on sexuality education and delivered
sixteen planned classroom sessions to grade nine pupils for six weeks, each session lasted for 45 min. The international
guidelines on sexuality education emphasises that school sex education should comprise at least twelve classroom sessions,
each lasting around 45 min (UNESCO Nepal, 2009). The sex education sessions were focused in a logical sequence in order to
match the objectives of the intervention. The sessions were scheduled with Health, Population and Environment (HPE)
subjects in accordance with the usual school practice for the provision of sex education. Emmerson (2010) emphasised the
development of collaboration between education providers and health institutions to formulate a planned curriculum that
could encourage schools to become health promoting.
Adolescents’ sexual health knowledge and understanding is influenced by a variety of interrelated factors, such as
parental influence, gender roles, language and culture, myths about sex and sexuality, peer pressure, media and
communication, family support and involvement of external experts in school. McCabe (2000) clearly noted that sex
education should include different partners who have various roles, since it is a family and social responsibility. Adolescents
require sexual health information, advice and access to sexual health services. A recent study conducted in rural Nepal has
shown that a large proportion of adolescents are satisfied with the reproductive health services provided (Van Teijlingen,
Simkhada, Acharya, 2012). However, the health professionals should be aware that these services are delivered in a
confidential manner. Health professionals who have worked in schools and have developed a good relationship with the
teachers and students are mostly liked by the schools.
In Nepal, there is a need for participatory teaching programmes to improve sexual and reproductive health awareness in
schools. A study conducted in four schools in Eastern Nepal have also shown the positive impact of a participatory structured
teaching approach to students compared to the conventional teaching methods (Dhital, Badhu, Paudel, Upreti, 2005).
Participatory and interactive sex education programmes implemented in other geographical settings have also brought
beneficial advantages on both educational outcomes and reproductive health of adolescents (Nsakala, Coppieters,
Kayembe, 2014).
It is also important to discuss one other outcome of this study. For example, in the result Section 3.3.2, the mean rank
score of ‘females should be considered untouchable during menstruation’ decreased from pre-test (173.31) to post-test (154.46).
The possible explanation for this outcome is the health facilitator-led sex education intervention to change pupils’
perception about the conventional belief that prevents Nepalese women from doing certain household jobs. This clearly
indicates that the health facilitator-led sex education intervention had a significant positive impact on pupils’ sexual health
knowledge and understanding. Menstruation is a monthly reality for two billion women and girls worldwide. However, in
many low-income countries they are forced to skip school during their period as they are embarrassed or do not have access
to the facilities they need (Plan International, 2015).
This study has considered some possible challenges to the intervention such as selecting research area, collaboration with
stakeholders (schools, educational authority, local community, local NGOs), time arrangement for teaching staff, monitoring
the classroom, managing teaching materials, developing sex education curricula, and daily reporting and recording of the
activities. However, the main researcher being a local person was a great advantage to get support from schools, community
members and local organisations. This led to save a significant amount of time and effort to help build a successive
intervention programme. Jaycox et al. (2006) also highlighted that the cultural awareness and flexibility into the
implementation plan are key to the successive aspect of any school-based intervention. Another issue was the higher
dropout rate in the experimental schools than in the control schools which indicated that there was a lack of sufficient
relevant information to the experimental schools. Department for Education (DfE, 2013) also mentioned that students are
most likely to drop out from participation if schools feel uncertain about the topic.
5. Conclusions
This study recognises the need of school-based intervention aimed at developing the knowledge and understanding of
sexual health in Nepal. It also suggests that the collaboration between schools and external agencies, such as health
authorities, District Education Office (DEO) and community groups is an important aspect of enhancing sexual health
knowledge and understanding of adolescents. The trained people from these agencies are able to deliver appropriate and
effective sex education programme to these adolescents as shown in the findings.
This study identified four main approaches that schools could follow to effective sex education programme. First, the
schools need to adopt a more informal approach of teaching such as use of group discussions, role-play, quizzes and
demonstrations. The details of these approach needs to be described in the school curricula for sex education. Second, the
parent-child relationships are most important in enhancing the sexual health knowledge of the adolescent which is also
highlighted in a recent sex education evaluation report (Wight, 2011). Therefore, schools need to develop relationships with
the parents and community members and allow closer and more trusting relationships with them. Such relationships could
influence their children’s attitudes by forming beliefs and values concerning personal identity, sexual health knowledge,
intimacy and sexual relationships. Third, the social patterning of stigma and discrimination towards girls suggests that the
socio-economic factor needs to be addressed at macro level. Fourth, the mass media in particular the internet has played a
significant role in increasing sexual violence among school going children. Therefore, it is necessary to develop an
intervention that could highlight the negative sexual content and develop an adolescent friendly message to be broadcasted
156 D. Acharya et al. / International Journal of Educational Research 82 (2017) 147–158

11. in the media. Future studies employing a combination of these four approaches are urgently needed to have a greater effect
on further improvement of sex education in Nepalese secondary schools.
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