The Current Situation and Issues of Sexual Health Education by School Nurses in Muntinlupa City, Philippines

Cases of sexually transmitted infections (STIs) and teenage pregnancy have been increasing among adolescents in the Philippines. School nurses (SNs) are expected to deliver quality healthcare services and provide relevant sexual health education for students. This study explores the current situation of providing sexual health education by SNs in Muntinlupa City toward health promotion and gains understanding of school health issues in the Philippines. This study employed a cross sectional research design using anonymous self-administered questionnaires, which were distributed to 23 SNs. Then, a semi-structured interview was conducted with them in Muntinlupa City. Among the 23 SNs, 30.4% of them were affiliated to high schools. The most frequent health issues experienced by primary school students were malnutrition, gastrointestinal pain due to hunger, upper respiratory tract infection, and poor hygiene. In high schools, the most frequent health issues were poor mental health, malnutrition and early pregnancy. SNs lacked knowledge on STI, mental health, sex education, safe sex, teenage pregnancy and nutritional care for children. In conclusion, SNs lack knowledge about sex education (early pregnancy and STIs) and mental health. Therefore, seminars should be provided for all SNs to gain adequate knowledge and skills to teach students of all types of school.


Introduction
In the Philippines, the average number of people newly diagnosed with HIV per day is 31. The proportion of HIV positive cases in the 15-24-year-old age group increased from 25% in 2006-2010 to 29% in 2011-2018 [1]. Alternatively, it has been reported that the rate of teenage pregnancy is one in ten Filipino women aged 15-19 [2]. The low level of sexual knowledge and the risky sexual behavior of the Filipinos contribute to the increased prevalence of sexually transmitted infections (STIs) and 186 The Current Situation and Issues of Sexual Health Education by School Nurses in Muntinlupa City, Philippines teenage pregnancy [3]. Sex education by health professionals may be necessary to prevent STIs and teenage pregnancy among the younger population in the Philippines [4]. A health center in Muntinlupa City has grappled with health issues among adolescents using the Adolescent and Youth Health Program by the Department of Health in the Philippines since 2001 and has started a peer education program on HIV/AIDS and teenage pregnancy for young people in the community since 2017 [5,6]. While the Department of Education has started providing health education in schools using MAPEH since 2010, students only learned about sexual behavior and STIs when they reach grade eight (13 years old) and learned about pregnancy when they reach grade 10 (15 years old) [7][8][9]. However, the incidence of STIs and teenage pregnancy remained still high in the Philippines [10][11][12][13][14]. Not only health centers and teachers but also school nurses (SNs) should play an important role in health promotion for students in the Philippines [15]. An SN is defined as a specialized health professional who promotes the well-being, academic success, and lifelong achievement of students and provides public healthcare services and health education [16]. However, there is a possibility that SNs play a crucial role in offering health education to prevent STIs and teenage pregnancy in students. Until now, the nursing practice in the school setting in promoting health for younger generations in the Philippines has not been fully explored and studied.
Therefore, this study examines the health problems frequently experienced by students and the current situation and issues regarding sexual health education by SNs in the Philippines.

Materials
In this study, 23 SNs who worked at public schools (primary school and high school) and participated in conference for SNs organized by the Muntinlupa City Health Office were enrolled.

Study Design
This was a cross sectional study conducted to identify the current situation and issues of health education by SNs in Muntinlupa City, Philippines. In addition, 30-minute semi-structured interviews in English were conducted on two groups of SNs (elementary and high school). The survey was conducted on December 4, 2018.

Questionnaire
The questionnaire contained items on the SNs' characteristics (sex, age, working experience, and affiliated school type), students' health problems, and health education. Health education was evaluated based on a 5-point Likert-type scale: 1, not at all; 2, rarely; 3, sometimes; 4 almost always; and 5, always. The Cronbach's coefficient alpha was 0.914 derived from Japanese school nurses. Its internal validity was confirmed through school nurse leaders in "A" city, education division, and Professors of school nurses program in the Philippines.

Semi-structured interview
The interview guide had two major topics: health education on the prevention of STIs and teenage pregnancy for students and the presence or absence of cooperation between the SNs and other persons in providing health education and conducting health activities.

Statistical Analysis
The collected data were analyzed using Statistical Package for the Social Sciences, ver. 23.0 (IBM Corp., Chicago, IL, USA). A chi-square test was used to determine the differences in the distribution of the baseline characteristics. Interview data were analyzed according to the health problems experienced by the students and persons who provide health education. The interviews were conducted by two health center nurses who were contributors to this study.

Ethical considerations
Participation in this study was voluntary, and the privacy and confidentiality of the participants were strictly protected. This study was conducted in cooperation with the Mayor, Muntinlupa City Health Officer, principals of each public school, and SNs in Muntinlupa City and was approved by the ethical committee of Tokushima University Hospital, Tokushima, Japan (No. 2961) and the Faculty of Nursing, St. Paul University Philippines, Tuguegarao City, Cagayan, Philippines. Table 1 shows the characteristics of the subjects. Among the 23 subjects, 19 (82.6%) were women and 3 (12.5%) were men. Of the 23 SNs, 53.2% were less than 35 years old. With regard to working experience as a school nurse, 74% of the SNs have worked for less than 10 years. Sixteen SNs (69.5%) were affiliated to primary schools, whereas 7 (30.4%) worked in high schools. With regard to the number of students covered by the SNs, the average was 2,784 students (range, 613-5,700). The average number of students for whom SNs provide healthcare services was 29 per day (range, 10-70).  Table 2 shows the health-related problems faced by primary school and high school students. In primary schools, the cumulative rate of dizziness, headache, abdominal pain, and stomachache was 62.5%. The rates of malnutrition, wound, poor hygiene, toothache, immunization/deworming, and upper respiratory tract infection/fever were 31.3%, 18.8%, 18.8%, 12.5%, 12.5%, 12.5%, and 12.5%, respectively. However, in high schools, the rates of mental health, malnutrition, poor hygiene, early pregnancy, poor lifestyle, and common ailments were 57.1%, 42.9%, 14.3%, 14.3%, 14.3%, and 14.3%, respectively. Table 3 shows the items and frequency for health education programs provided by the SNs. In primary schools, education regarding proper nutrition and infectious diseases was always provided to students. Health education lessons regarding hand washing, immunization, dental health, visual health, tobacco and alcohol use, excise/physical activities, and drug use were almost always taught to students, while lessons on menstruation and puberty were sometimes taught in primary schools. However, education regarding mental health, sex, family abuse, dating, STIs, pregnancy, and marriage was not provided for students by SNs in all schools.

Health Education by SNs
Alternatively, in high schools, all health education lessons were taught to students. Lessons on hand washing, proper nutrition, immunization, infectious disease, and drug use were always taught to students. Furthermore, education on STIs, mental health, and tobacco and alcohol use was almost always provided for students. Lessons on pregnancy and family abuse were sometimes taught, while education on sex, dating, and marriage was rarely provided for students. Significant differences in marriage between primary and high schools (p<0.05) were observed. In addition, differences in STIs and pregnancy were noted between primary and high schools (p=0.055 and p=0.089, respectively). 188 The Current Situation and Issues of Sexual Health Education by School Nurses in Muntinlupa City, Philippines    Table 4 shows the methods of health education used by SNs. In primary schools, 93.8% of the SNs provided health education for the teachers. However, 62.5% of the SNs provided health education for students by themselves. In high school, SNs provided health education for teachers; they have health education classes, and they educated students one by one. Table 5 shows the health education issues that SNs seek to solve. SNs in primary schools sought to provide knowledge about STIs/HIV (37.5%), mental health (31.3%), adolescent reproductive health (18.8%), teenage pregnancy, child food care for parents and counseling (6.3%). All SNs in high schools sought to provide knowledge about mental health (depression and stress) (100%), safe sex/teenage pregnancy (28.6%), and STIs/HIV (14.3%). Table 6 shows the SNs' perception of the problems in providing health education on the prevention of STIs and teenage pregnancy. In primary schools, "poverty," "lack of parental cooperation," "lack of budget," "lack of materials (handouts)," "time constraints," "lack of training/seminars," and "lack of support from staff/manpower" were the problems perceived by the SNs in providing health education. However, in high schools, "poor nutrition," "lack of cooperation from the students and their parents," "lack of budget," and "time constraints" were the problems perceived by the SNs. SNs had health education and activities with method, followings. They were health teachers, guidance teachers, guidance counselors, feeding coordinators, and teaching personnel not only in schools but also in private health offices, non-governmental organizations, and the World Health Organization (WHO).

Discussion
School nurses (SNs) in Muntinlupa City, the Philippines, have been providing public health education for students along with their dependent on a variety of health problems caused by poverty, based on their developmental age. However, sexual education such as prevention of teenage pregnancy and sexually transmitted infections (STIs) was not adequately provided.
Students in public schools face various health problems due to poverty such as malnutrition, developmental disorders, poor mental health, and injury. In particular, students' tendency to miss meals due to poverty during elementary and high school education was deemed as the primary cause of nutritional deficiencies, such as anemia and Vitamin A deficiency, which lead to poor mental health including anxiety [17,18]. In high school, in addition to poor mental health including depression, students face problems related to sexuality, such as teenage pregnancy. The Department of Health of the Philippines reported that malnutrition, teenage pregnancy, STIs, smoking, alcohol dependency, drug abuse, risky sexual behavior, and violence including victimization through sex crimes were prevalent health problems during childhood and adolescence. Students in Muntinlupa City are no exception [19]. UNICEF is raising the alarm that victimization through sex crimes is a barrier to the physical and mental development of children in the Philippines [20]. 190 The Current Situation and Issues of Sexual Health Education by School Nurses in Muntinlupa City, Philippines Table 6. School Nurses' perception on the problems in health for STIs and teenage pregnancy prevention Primary School

Poverty
Poverty is a major factor for our children. Sometimes they might be understood or unhygienic it is because of poverty affecting their lifestyle.

Lack of Cooperation with the parents
Obtaining parent's consent Lack of parents/guardians Deworming-participation of parents parents cooperation on some program of the school Cooperation with the parents and budget for the materials Lack of budget Lack of time and budget, Teachers should also be trained for some programs related to health especially for children.

Lack of materials( handouts)
Lack of materials( handouts)

Time constraints
With so many health programs to be implemented, it is hard to find adolescent and quality time to provide for each program. Thus, SNs are expected to be equipped to promptly address various public health problems, including mental health and sexuality-related problems that students are facing [21]. In the Philippines, the present situation of health education by SNs is as follows. One SN has responsibility to a large number of students. The maximum number of enrolled students in elementary and high schools are 5,700 and 3,886, respectively, whereas the number of students that visit healthcare rooms is 70 and 60, respectively. SNs provide health education centered on public health such as appropriate nutritional guidance, hand washing instructions, prevention of infectious diseases, and vaccination. All SNs in high schools provide sex education; however, such information in elementary schools is lacking.
Why do SNs in elementary schools fail to provide sufficient sex education including prevention of teenage pregnancy and STIs? Lack of knowledge is a possible reason. Several SNs lack awareness of the increase in teenage pregnancy and STIs and their effect on health, whereas other SNs lack knowledge on the symptoms, treatment, and prevention of STIs. One possible reason is that SNs lack the opportunity to attend seminars, from which they can gain new expertise, due to the excessive workload in schools [22]. The department of education also had no plans for sexual education to prevent teenage pregnancy and STIs for SNs.
Second, the cultural context renders the promotion of sex education difficult [23]. In the Philippines, sex-related issues are regarded as taboo for religious reasons [24], which led to the inadequate promotion of sex education. The Philippines is predominantly Catholic, where premarital sex, contraception, and abortion are prohibited in society. Myths and misperceptions as regards sex and sexuality might be widespread among adolescents, which has a negative impact on their service-seeking behavior [25]. Thus, obtaining the understanding and cooperation of parents to collaborate with teachers in terms of sex education in schools is difficult. Lastly, a lack of collaboration between SNs and teachers and experts is observed. For the prevention of teenage pregnancy and STIs, collaboration is required not only with teachers but also with health centers and hospitals. However, only a few SNs have such a collaboration. These points are considered the main factors for the inadequate sex education provided to students. Some schools are afraid that sexual education may lead to earlier sexual initiation and risky sexual activity among less-informed young adults [26]. Therefore, SNs had offer health education to students in several ways to compensate for the lack of sexual health knowledge and time constraints. SNs must provide health education for health teachers, guidance teachers, guidance counselors, feeding coordinators, and teaching personnel not only in schools but also in private health offices, non-governmental organizations, and the World Health Organization (WHO). Therefore, although the SNs' role is public health nursing in schools, they are also expected to be health educators and coordinators to promote sexual health education.
What form of support, then, is necessary for the promotion of sex education via SNs? First, the education division and health division should pool resources and hold seminars to enable SNs to gain new expertise and improve their ability to carry out instruction and education. Second, researchers and health centers should provide support for the creation of a cooperative environment between SNs and health experts. Finally, in college courses for pre-service SNs, the contents of the curriculum should include strategies for mental health and sex education, which are necessary for the promotion of the mental and physical health of students.

Limitations of the Study:
The sample size is small, and the Questionnaires' reliability could not be confirmed. It is recognized that conducting reliability tests on the questionnaire is needed against a larger sample to confirm its reliability for SNs in the Philippines.

Conclusion
Many students with various health problems require the health services provided by SNs. However, the current scenario of sex education in the Philippines is insufficient to mitigate the increase in teenage pregnancy and STIs among students. There was socio-cultural barrier for adolescents to access sexual information in the Philippines. Addressing this issue would require SNs to play an important role not only in public health nursing but also in school health nursing as health educators. SNs should be empowered through competency in sexual health education. Therefore, city health centers should collaborate with the City Education Division to set up an environment conducive for sex and health education for all SNs in which to gain knowledge and teaching skills.