Methods: Five focus group discussions (n = 40) were conducted among various stakeholders including at-risk adolescent students, school nurses, counselors, pediatrician and social workers in Hualien, Taiwan. Focus group discussions were audio-recorded and transcribed verbatim. Data were analyzed inductively using grounded theory and were coded involving three phases: (1) The research team identified key words from the participants’ transcripts to generate initial, low inference codes; (2) research team met weekly to refine, combine or add codes; and, (3) The team adopted a high-inference coding process (axial coding) and all final transcripts were read into Dedoose for analyzing data.
Results: Qualitative results show that barriers to effectively promote safe sex education in rural schools are identified in four aspects – unsupportive rural school’s system, conservative teachers’ attitudes for teaching, negative parental attitudes towards safe sex education, and poorly school-community partnership for intervention. Many participants discussed that school system has overlooked the importance of safe sex education for preventing teen pregnancy. Large class size with more than 100 students per session, insufficient class length and school teachers’ interference with community providers’ prepared educational materials affected learning outcomes among students. In addition, parents’ attitudes significantly affected promotion of safe sex education including their conservative attitudes’ for condom use and indigenous culture’s influence on students’ sex attitudes. Some participants suggested that a mobile app for safe sex intervention may overcome some barriers. The featured functions of a new mobile app include interactive forum, education comics, maze games for condom use and pregnancy prevention.
Conclusion and Implications: Our findings identify a wide array of barriers that affect effectiveness and quality of safe sex education among at-risk adolescents in rural schools. Implication of this study suggest that developing a mobile app with designated functions from user-centered perspectives may overcome the barriers. Mobile intervention might be a new venue to address currents issues that traditional school/community-based approach has faced in rural areas and effectively reach out at-risk adolescents to reduce their engagement in sexual risk behaviors.