Study setting.

Data were collected from June to August 2019 in Dar es Salaam, Tanzania. Dar es Salaam was the logical choice for the site of study, given the sexual health curriculum being tailored was for medical, nursing and midwifery students at the Muhimbili University of Health and Allied Sciences (MUHAS), which is located in Dar es Salaam. MUHAS is a leading health university in East Africa and students attend from all parts of Tanzania and beyond. This study is a collaboration between two universities and was conducted under the oversight of the Institutional Review Boards, of the Muhimbili University of Health and Allied Sciences (MUHAS) in Dar es Salaam, the University of Minnesota in the US, and the [Tanzania] National Institute of Medical Research, all of whom deemed the study as exempt from human subjects review since the focus of the interviews was on clinical practice and cultural perceptions (Common Rule Exemption Category 2).”

Sampling and data collection process. Eleven key sexual health stakeholders were interviewed for the current study. Three were religious leaders (one imam, one priest and one pastor), three experts in sexual health, two community leaders from (NGOs), two cultural experts and one politician. Eight of the stakeholders were male and three were female, aged 40 to 76 years, with between 8 and 43 years of experience working in their area of specialty.

Purposeful sampling was implemented to identify key stakeholders for the study. The study team identified health, cultural, political and religious leaders who were known to deal with sexual health issues. Stakeholders were contacted with an overview of the study and study purpose and invited to participate. All stakeholders contacted for the study agreed to participate and were interviewed either on the MUHAS campus or at the stakeholders’ office (whichever they preferred). All interviews were undertaken in a private room to ensure convenient access and privacy. This allowed the team to capture stakeholders’ experiences, and to identify the training needs of current students in each respective discipline.

In-depth interviews were chosen as an effective method to explore, in-depth, the interviewee’s information, perceptions and experience of the topics under study. Each interview lasted between 45 to 60 minutes.

The interviews were conducted by three bilingual interviewers (co-authors: GGL, LRM, and SL) in English, Kiswahili, or a mix of both languages. The interviewers were clinical faculty in medicine and midwifery from MUHAS and ranged in age from 35 to 60 years. Each interviewer had more than ten years of training in sexual health. For each interview, the team decided in advance who would be the most appropriate person to interview each stakeholder. To promote comfort in being interviewed about sexual health, wherever possible, we matched the interviewer and stakeholder by gender, age, and other key characteristics.

At the start of the interview, the stakeholder was invited to respond in either English or Swahili, with most preferring to use English. Before commencing the interview, the interviewer highlighted that the interview was voluntary, that the interviewee could discontinue at any time, that all responses would be kept confidential (meaning not attributed to them personally), and that the session was being audiotaped. Stakeholders reviewed the consent form and written informed consent was provided. Each stakeholder also completed a short demographics form before commencing the interview.

The interview guide [see attached file] consisted of nine questions that addressed three broad areas. Sexual health problem identification, unmet sexual health needs, and the impact of sexual health policies in Tanzania. The semi-structured interview was formulated to cover multiple areas, and tailored to the expert’s area of expertise. This paper reports the responses to the questions about common myths and misconceptions about sexual health.

We interviewed a minimum of two individuals from each category of stakeholders except for the politician category. Stakeholders were chosen based on many years of experience working in their roles. This likely meant they were more informed about the sexual health in their jurisdiction, knew their communities well, and so, could identify common myths and misconceptions. Data collected from each group and across all stakeholders yielded similar findings. After analyzing the transcripts, the coding team did not encounter new themes or codes, therefore, reaching saturation. We were unable to confirm saturation in the political group as we interviewed the only politician who was available.

Data management and analysis.

After each interview, audio files were labelled with the interview ID and uploaded onto a secure server. The audio files were transcribed verbatim and then translated into English (where necessary). In addition, notes taken during the interview were typed on a shared password-protected drive.

Coding approach. Both inductive and deductive codes were derived to develop the codebook and code the transcripts. A team-based approach to coding and codebook development was implemented [29, 30], beginning with open coding and followed by two coding cycles [29]. This approach to data analysis enabled a process of debate and reflection that generate a richer understanding of the stakeholder’s experiences in serving their community, in relation to sexual health.

Coding team. The coding and data analysis team were composed of health professionals currently practicing in their respective fields and conducting research. These providers contributed their experiences as practitioners and researchers to the team enriching the data analysis process, and serving as important member checks during the development of code definitions and data interpretations.

Codebook. Codebook development was an iterative process that was initiated with the creation of a list of deductive codes derived from the interview guide. Both deductive and inductive codes continued to be generated and added to the codebook iteratively during the three phases of coding. This was accomplished via regular team meetings and the use of a Google Doc where coders engaged in a process of continuous written feedback and updates to the codes and definitions that led to the reconciliation of disagreements and refinement of the codebook.

Open coding/discovery of themes. Open coding was conducted during a regular meeting with the team of interviewers. Open coding involved reading several times four hard-copy transcripts of the interviews and coding the interviews manually. During this meeting, the team identified early ideas and emerging themes using an open-ended coding format, without predetermined codes or categories. Pens, color highlighters, sticky notes, and large flip charts were used during this stage to gather the early ideas and organize the codes under emerging themes. Teams were organized in groups of two coders and specific questions were assigned to the team based on expertise, background, and interests. Each group manually coded the transcripts individually and compared notes and codes at the end of the open coding stage. Teams had an 80% or higher initial agreement. Codes generated during the open coding were entered into the main codebook.

The team members who conducted the interview continued with the coding. Each team coded questions pertaining to these areas of expertise and interests. All responses to questions in those topics were assigned to each sub-team. Each team coded between 2–3 questions across all interviews. Each sub-team met regularly to consult on the meaning of codes, reconcile differences, reach agreements, and update the codebook on the team document housed on the shared drive.

First coding cycle. During the first coding cycle, the team coded all transcripts. A holistic/segmentation process was followed to code the transcripts. In this coding process, meaning was ascribed to responses by each question contained in the interview.

Axial coding. During axial coding, each sub-team generated larger categories based on the findings of the first coding cycle. Codes were grouped accordingly under these larger findings.

Societal misconceptions.

Stakeholders described different communities as having specific misconceptions related to sexual health (see Table 2). These myths and misunderstandings were based on inadequate knowledge in a particular community or society. One interviewee explained that in some communities, people have wrong perceptions about family planning methods and vaccine usage. When health professionals encourage people to use family planning or to get a vaccine, the recipients tend to refuse. Alternatively, they fear that the family planning methods or a vaccine will be harmful to them. Some may articulate that family planning or vaccines are a white racist conspiracy to weaken Africa.

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Table 2. Common community myths and misconceptions about sexual health in tanzania, as reported by stakeholders.

https://doi.org/10.1371/journal.pone.0264706.t002

“They think family planning is not of good intention. They say they (white people) want to decrease the size of the population in sub-Saharan [Africa].” (Non-Government Organization Representative 2)

Similarly, the distribution of human papilloma vaccine to adolescent school girls in Tanzania is not effective because parents decline administration, fearing that these vaccines will cause infertility in their daughters and because they do not believe the vaccine will prevent cervical cancer.

“As usual in some African countries, you find parents are refusing to give consent and say that there is some hidden agenda behind the vaccine. They don’t believe that it is there just to protect their children from cancer… Well, they say, that we (the vaccine providers) want to stop their girls from getting children, aaah sterilizing them.” (Non-Government Organization Representative 2)

However, in some cases, community members can become confused when the information they research from their health professional conflicts with the information they head from politicians and other leaders.

“I have a client whom I was counselling for family planning. Then, the client was like you (health professionals) are telling us to use family planning methods, but our president said we should bear kids because education is free.” (Non-Government Organization Representative 1)

While there is an assumption that sex is voluntary, stakeholders said that this is not always true in some African cultures. A sexual act may be misinterpreted and may carry different meanings within a particular society. For instance, some traditional healers would require either their patients or young boys and girls to have sex with them as a means of treating an illness.

“If you go to a traditional healer and [he] tells you must go have sex with him or a young girl or a young boy, for you that’s tricky. For me, that is sex and a ritual … parents play around with the penis of the young boys, and then they say, ahaaa, and the boy would laugh, in fact, and that…that…when I now think about it that was sex socialization.” (Cultural expert 2)

In other African cultures, in order for a parent to ascertain his son’s manhood or sexual arousal, a child’s parent may rub his son’s penis and observe the young boy’s reaction. This is considered normal in some African cultures.

“These are cultures which exist in this country, where we have the elderly when they are socializing with young girls, they have means where one tribe pulls the labia so that they become big, the others pull the clitoris until when it looks like a little penis” (Cultural expert 2).

Given the taboo of talking about sex, and at the family level, the absence of parental sex education, it is difficult for young people to know what is right or wrong. As one stakeholder explained, a man may rub himself against a woman’s behind to the point of ejaculation in a congested public place like in a bus or at the market without her being aware. Without education that this is not normal, and that frotteurism is diagnostic of paraphilia, the youth may end up either with others minimizing his behavior or being taken into custody instead of being referred for assessment and treatment.

“For example, when you talk about parent-youth communication, when they want to talk about sexual health-related issues, so this norm of not talking is a misconception … It is really difficult for a father [in Tanzanian culture] to start talking with his child, daughter, about sex so it is a part of that challenge.” (Health Expert 2)

A public health expert emphasized misconceptions regarding HIV patients. Some community members maintain a misconception that once someone is infected with HIV they cannot get married to anyone or bear children because they will infect the partner or the baby. In this era of antiretroviral therapy (ARV), women who are on successful on ARV treatment can be married and have children without infecting their partner.

“People need to know that even people who are HIV positive, once they are on treatment, their viral load is suppressed and they can get married and they can have babies who are very fine. So, that is something regarding sexual health which I think they are still some misconceptions and misunderstanding.” (Health Expert 3)

Political misconceptions.

Politics does have its contribution towards sexual health misconceptions, which affects the community. Stakeholders described a tendency where politicians use community misunderstandings, or the reserved culture, to advance their agenda. Stakeholders pointed out that there are occasions where political representatives contribute to community misunderstanding towards HIV prevention. For example, the Tanzanian government banned the sale of K-Y gel lubricant by pharmacies. The stated reason behind the ban was key populations (i.e., men who have sex with men) use lubricant. The politician’s stated concern was that the lubricant violates the law by facilitating same sex relations which are illegal. But stakeholders noted that lubricants can also be used by heterosexuals, women may need them for gynecological exams, and lubricant reduces friction during sexual intercourse for menopausal women and lowers the risk of HIV transmission.

“For example, a lubricant such as K-Y gel, they have to buy from a pharmacy or whatever and once upon [a time] it was forbidden by the ministry. Is that not a misunderstanding that we want to stop transmission of HIV and then you, as a boss, you stop using this, and this is one of the tools that one has to use to minimize the friction, sometimes the rate of transmission of HIV.” (Health Expert 2).

Stakeholders stated that many politicians avoid speaking about the actual reality of sexual health to the communities. Most politicians were perceived as pretending to be against key populations such as sex workers or men who have sex with men and overstate their contribution to HIV epidemic in the country caused by having multiple sex partners while minimizing heterosexual risk behaviors.

“They [are] pretending that they are against sex workers, but yet sex workers are really few here in Dar es Salaam during parliamentary proceedings in Dodoma (the capital city).” (Cultural Expert 2)

Stakeholders said some politicians in Tanzania use the excuse that sex education might influence innocent youth to practice such behaviors. While politicians are supposed to be role models, they deny or stigmatize some behaviors while engaging in them privately. Stakeholders saw this as a deception to the community because it makes the politician look good while depriving the community of receiving important information regarding sexual health.

“So, with the politicians, … many of them will oppose the very behaviors they practice, and particularly because the practices are private and no one will know. But when they are in public, that is the language they speak which is different.” (Cultural expert 2₎

Some politicians advocate that people who are homosexual have psychological problems and should be given medical or psychological help to become normal (i.e., heterosexual), while others advocate that since they choose to practice same sex relations, then they should be punished.

“There are people who believe that there are people who are born like that, with those maybe I would say physiological or psychological impairment hence attracted to same sex… or if they have decided to be like this, they need to be punished because this is something which is against our community as well as our laws… But what I know is with a proper education they can become good people with acceptable behaviors. But mind you it needs time to see the impact.” (Political leader)

Professional misconception.

Stakeholders reported that conflicts emerge when professionals claim one reality when the community members experience another. For example, in family planning, the professionals are vulnerable to believing the science that a medication tested elsewhere in the world is fine, while the community members are reporting side effects. This can lead to the professionals minimizing the community’s experience.

“But, here, the science will say there are no problems but users had seen those problems, so for you coming from MUHAS (i.e., the Health Sciences University), what you hear from these individuals those are misconceptions. But these are reality in their own world and you’re the one who has misconceptions about what they are saying.” (Cultural Expert 1)

In less developed countries like Tanzania, most of the health services are donor funded. When members of the community report problems with the inefficiency of a particular service or the quality of the item donated to them (e.g., mosquito nets), the health professionals may deny, minimize or disregard the concern raised by the community and condemn them for expressing concern. Instead, health professionals support the donors who supply the items and the funds because of the risk of destroying the political or professional relationships and losing the funding. Health professionals must be accountable, however, to research and confirm the communities’ concerns to better engage sponsors about the needs of the community.

“Yeah, politicians are the results of science. Because even if I will go and ask for money for doing research, if insect-treated nets are reducing manpower, they won’t give it. They will end up saying WHO [the World Health Organization] they have already said that this is safe, [so] who are you by the way? Do you want to reinvent the wheel? WHO, they have already [said] its safe for malaria prevention, man power for what while people are dying of malaria? But again, they are pushed by funders too, and they need that fund [so] they have no option. And when they bring us, we have to take it to the intended area.” (Cultural Expert 1)

There are several myths and misconceptions associated with high risk or key populations (i.e., sex workers, men who have sex with men, transgender persons, prisoners, and individuals with substance use disorders). First, both the community and health professionals may hold significant misgivings about what is appropriate sexual health care for these populations. For example, they may worry that providing condoms may encourage behavior they disapprove of. Second, healthcare providers face being stigmatized if they become known for treating key populations. Community members and other health care providers may wonder if providers who treat men who have sex with men are gay themselves or engage in homosexual behavior. This is guilt by association and can lead to discrimination and segregation from other care providers. Similarly, if a politician supports human rights and equal health care services to all, they may be (mis)perceived and labelled as an activist by the community and by opposition politicians rather than as someone interested in the promotion of quality care for all to better the health of the overall population.

“The other misconceptions are if society sees you working with key populations (KPs), they consider you as one of the KP also. So, even in health care facilities other health works, start to segregate you… Even within the government, there are people who would view us as puppets, and others say we are fighting for KPs rights because of donors only and they even went further and say we are being paid to promote” … (Political leader)

Religious misconceptions.

Religious leaders also identified barriers and misconceptions regarding sexual health in those they serve. Regardless of the religion or denomination, they said discussion about sexual health topics in churches or mosques was considered shameful and taboo. Religious stakeholders considered sex a private matter while acknowledging the importance of talking about it. Many sexual health issues were considered unmentionable because of the belief that sex is a sacred act reserved for marriage. This view was not only held by the religious stakeholders but also, in their experience, by their congregations. In addition, behaviors like same sex relationships and anal sex were highly regarded as immoral behaviors which were against their religious values.

“People think that this (sex) is something which is so private, very private you cannot speak about it. So sacred, we do not need to talk about it … We do not say it [talk about it] at church and parents at home also they do not say it… We do not talk about sex of the same sex… It is an abomination in our context but this is something people are doing and it has effects.” (Religious leader 2)

Stakeholders acknowledged that many sexual practices and health concerns are common in our society, but people do not talk about them. Hence, no help is provided to those with the concern They acknowledged the role of religious leaders in confronting the silence around sexual health concerns.

“I have encountered some cases whereby there was a religious school and people are complaining that kids are introduced issues related to anal sex by either staffs, or other peers from suburbs. You find children are congested together in rooms…. So, we need to talk about these issues. Because we as nation there is nobody who is exempted when you are talking about sex, these staffs cover everybody and we need to help.” (Religious leader 3₎