A Realist Synthesis of Implementation of School-based Comprehensive Sexuality Education Programs in Mozambique

Adolescent sexual and reproductive health remains a critical concern in Mozambique, where access to accurate and inclusive education is limited by social, structural, and cultural barriers. In response, school-based Comprehensive Sexuality Education (CSE) has been positioned as a key strategy to address these challenges. Although the Mozambican government has committed to nationwide implementation, outcomes vary significantly across schools and regions. In this thesis, a realist synthesis is used to explore how, for whom, and under what conditions CSE programs are successfully or unsuccessfully implemented in Mozambican schools. The synthesis focuses on identifying generative mechanisms that shape implementation processes, influenced by broader institutional and contextual factors. An iterative, theory-driven review of 33 peer-reviewed and grey literature sources published between 2013 and 2023 was conducted. Through this process, 154 context–resource–mechanism–outcome (CRMO) configurations were developed and used to refine an initial program theory, supported by Normalization Process Theory. The resulting program theory demonstrates that successful implementation depends not on isolated interventions but on the alignment of system-wide conditions. The synthesis shows that contextual conditions such as cultural resistance, limited teacher capacity, misaligned policies, and inequitable resources interact with key implementation resources and strategies, including culturally responsive curricula, inclusive environments, intersectoral partnerships, curriculum integration, and teacher training. Introduced in enabling contexts, these resources activate mechanisms like cultural legitimacy, trust within communities, student motivation and agency, teacher confidence and identity, institutional coherence, shared ownership, policy legitimacy, feedback responsiveness and psychological safety. These mechanisms influence key implementation outcomes, including social and institutional acceptance, student participation, consistent program delivery, institutionalization, sustainability. This realist synthesis provides a context-sensitive, mechanism-driven explanatory account of how CSE functions in Mozambican schools. Although developed in the context of Mozambique, the refined program theory identifies mechanisms that are transferable across settings, offering insights for CSE implementation in other contextually complex environments.

Name thesis:degree_name

Master of Science (M.Sc.)

Level thesis:degree_level

Masters

Discipline thesis:degree_discipline

Community and Population Health Science

Grantor

University of Saskatchewan

Year dc:date.issued

2025

Author dc:creator

• Joshi, Anagha Pradeep

Advisor dc:contributor.advisor

• Muhajarine, Nazeem

Committee members dc:contributor.committeemember

• Groot, Gary
• Carr, Tracey
• Janzen, Bonnie

• Realist Synthesis
• Mozambique
• Comprehensive Sexuality Education
• School
• Sexual and Reproductive Health and Rights
• Realist Research

Language dc:language.iso

en

Handle dc:identifier.uri

https://hdl.handle.net/10388/17102

OAI identifier oai:identifier

oai:harvest.usask.ca:10388/17102