Introduction
A model of health education
Does health education affect health knowledge, attitudes and behaviour, and influence health outcomes?
Health education in the curriculum
Conclusion
When one studies mortality and morbidity figures, the case for placing emphasis on the health of young people is not instantly compelling, since the 6-24 year age group tends to carry a relatively low burden of disease. On the other hand, the majority of death and disease in this age group is preventable. Work, particularly in terms of establishing a sound educational base, should bring future health gains, as young people grow up and become the parents and the workforce of the future.
With over one billion children in school, forming an easily accessible target group, the use of schools as an entry point for health activities is proving increasingly interesting to governments and donor agencies alike. Several key documents have stressed both health gains and cost effectiveness of organising health activities through the school system (e.g. World Bank 1993; Nakajima 1992). Other documents stress the educational importance of school health interventions. Much of this evidence is summarised in a major World Bank study (Lockheed and Verspoor 1991) entitled Improving Primary Education in Developing Countries. Taking evidence from a wide range of countries, they highlight protein energy malnutrition, temporary hunger, micronutrient deficiency and parasitic infection as important factors getting in the way of student learning in school. They recommend school breakfasts, deworming programmes, and micronutrient supplementation - combined wherever possible both with health education and with improved school sanitation resources - as cost effective ways of increasing learning achievement in schools.
Turning to the specific case of AIDS, it is acknowledged that the search for affordable vaccines and treatment therapies may take years. In the meantime, the main strategy for holding back the spread of the HIV virus is education, with consequent behaviour change on the part of individuals. Education must reach those who are at highest risk. Evidence suggests that a primary group for such education is teenagers and young adults:
"in many developing countries more than half the population is below the age of 25 years. In many countries over two thirds of adolescents aged 15-19 years, male and female, have had sexual intercourse. Adolescents and young adults (20-24 years of age) account for a disproportionate share of the increase in reported cases of syphilis and gonorrhea world-wide... In addition, at least one fifth of all people with AIDS are in their twenties, and most are likely to become infected with HIV as adolescents." (School Health Education to prevent AIDS and sexually transmitted diseases. WHO AIDS Series no. 10 p. 1.1992.)
What then are the most appropriate ways of reaching these groups? What potential do schools have to provide a base for AIDS education?
The aim of the study reported here is to provide insights into policy, practice and potential for health education within school systems in Africa and Asia, combining detailed case studies from four countries with a broader analysis of reported activities from the two continents. 1
1 For details of the literature and document search see Section 2: Case studies.
Explanatory models of health education generally propose a link between health information and health behaviour, but agree that the link is not a direct one. For example, a review of nine studies on AIDS education (Witte 1992) concludes that "adolescents and young adults know about AIDS and how to prevent it, yet they don't".
There are three main health education models, each with a number of variants. Behaviouristic models (such as the health beliefs model and the theory of reasoned action) focus closely on the individual, looking at the positive and negative forces which play on him her, and hence mould behaviour. Social reaming models (eg: Green 1991) add to this the context of social networks and the environment in which the individual operates. Here, the individual is seen as an active agent who plays a role in creating a social and physical environment. Thirdly, there are 'education for liberation models' which focus on empowerment and community action (e.g. Werner & Bower 1982, Freire 1970, Wallerstein 1992).
In exploring the practical implications of these different models for curriculum development, it is clear that several elements are important in developing health education interventions.
First, for information to be translated into behaviour, there must be an intention to act on that information. The intention to act is the result of a complex interplay of factors, including:
· having the knowledge to understand that one is at risk· believing yourself to be at risk, and seeing that risk to be serious
· valuing the outcome and costs of different (health promoting) actions more than the benefits of current (less healthy) actions.
Research shows, for example, that information which emphasises the behaviour of certain "high risk" groups (eg: sex workers in connection with HIV/AIDS), makes it more cliff cult for people who are outside that group to believe they too are at risk. Alternatively, where an individual acknowledges risk, but feels powerless to do anything about it, then s/he may cope by denial of the risk. Therefore, people do not only need to know "what" to do, they need to know "how" - and to have the opportunity to practice and feel they are capable of change.
Secondly, assessment of risk and of the cost of changing to more health - promoting behaviour does not take place in isolation of others. It is often the case that current actions are supported and valued by friends, relatives and others who are important to the individual. Where this is the case, the individual will need to be able to negotiate any change in behaviour without fear of losing support from these key people. In educational terms, this stresses the importance of activities which enable young people to reflect on and discuss values, and reasons for behaving in different ways.
Third, discussion of risk also needs to take on board the fact that physical health is not the only concern (or even a major concern) of young people. As will be clear from the results of this study, young people stress priorities to do with personal relationships with friends and families; survival at school and home; thoughts of who they are and what they will be, and concerns about much bigger and broader social and political issues. Their concerns will influence how much time and energy they are willing to spend taking health issues seriously. The more health education is able to connect with their concerns, the more likely it is to be successful.
Finally, environmental factors have a substantial influence on the extent to which people can adapt their behaviour. Accessibility and availability of health facilities are key components in supporting health promotion. Policies and practice in schools, for example, food provision, or water supply and sanitation practices, can do a lot to support school health. Figure 1 (Adapted from Green 1991 p.369). summarises the main elements outlined above, and provides a helpful model for curriculum development in health education:
Figure 1 (Adapted from Green 1991 p. 369).
As will be seen from the evidence presented in this paper, achieving this combination is far from straightforward. It involves:
· establishing clear links between the health and education sectors centrally, which promote co-ordinated policy development and implementation· basing the health education curriculum on the health needs and concerns of school students
· ensuring that teaching methods used are relevant to the development of skills, and do not focus simply on the transmission of knowledge
· ensuring that teachers are adequately prepared, both in terms of knowledge and in terms of the teaching skills necessary for the development of skills in their pupils
· ensuring that, at the very least, the health environment of the school is reasonable - and that the general health environment is also being developed.
Where health education focuses on sexual health, including AIDS, the whole equation is made that much more difficult in that the subject matter, attitudes and "skills" are frequently "taboo" topics, embedded in a complex array of traditional cultural and religious values.
a. Arguments for strengthening health education in schools
Health education presents a special challenge to policy makers, in that it necessitates the development of strong linkages between two important government sectors - health and education. Any developments in health education have to weigh up the relative public health advantages of including health in the school curriculum, against the educational and pedagogic concerns of increasing "curriculum overload" - diverting attention from the key areas of literacy and numeracy. If health education is to be strengthened, its public health advantages will need to be clear. This section summarises available evidence on this issue. It makes some reference to evidence from developed countries, given the very limited evidence currently available from developing countries.
There are at least four practical arguments for considering strengthening health education in schools (British Council Feb. 1992):
· feasibility (in theory you know where the schools are, when they operate, what numbers you can anticipate, and what systems you must go through to gain access either on a one-off basis or in terms of developing more systematic programmes)· linkage to communities (with schools often providing a community focus, a meeting place, and a channel of communication i.e.: from school children to their families and to their out-of-school peers)
· increasing the use of a possibly under-utilised resource (i.e.: "schooling", with a little imagination, can go beyond the development of basic numeracy and literacy skills, and school buildings and (where they exist) other school resources can be extended to provide a broader community resource)
· sustainability (de: when it is possible to introduce health activities into general school life, without the introduction of new staff or special resources, but simply by adapting what is taught, such interventions are, in theory, sustainable.)
Education systems in many parts of the world have already made significant in developing school health (education) programmes. For example, the British Council report (1992) presents a number of case studies of innovatory projects (e.g. oral self-care in Delhi, an integrated development project in Kenya, health in mathematics in Kenya, health promotion in Nepalese schools, Child-to-Child in Burkina Faso).
Whilst some of these projects have had a national impact, the majority are on a small scale, tackling one aspect of health or one area of the school curriculum.
b. Evaluation studies of general health education programmes
Literature searches of key databases highlighted only one large scale, school health education evaluation study, concerned with broad ranging health education curricula. This is from the US (Cornell et al 1986). It compared four different school health education programmes, each implemented in a large number of schools. It evaluated the programmes over a two year period, and looked for influences on health behaviours, attitudes and knowledge. The study concludes that:
"school health programs for primary grade students have important effects on students' self-reported behaviour, knowledge and attitudes. The largest and most consistent effects were found in the domain of health knowledge effects for both health attitudes and practices were less powerful the impact of health programmes may fade unless reinforced and amplified through family practices as well as continued effective school health programming." (p. 249)
The study acknowledges that the methodology used provides very limited evidence on health behaviours and none on health outcomes. But it highlights the methodological dilemmas of attempting both to collect and then explain such data, as well as the prohibitive costs of such data collection.
A UK review on the effects of school health education on health-related behaviour (Reid and Massey 1986) presents a more positive picture, drawing on evidence from a wide range of small and larger scale interventions. They conclude that "given suitable methods, used in appropriate contexts, schools can favourably affect teenage health-related behaviour in relation to smoking, oral hygiene, rubella immunisation and teenage fertility. There is also some evidence for potential success in the field of diet and exercise...and indications that some health education lessons travel home and affect family health behaviour." The initial provision of "appropriate contexts and methods" is worth keeping in mind, as is the fact that many of the programmes referred to are limited either to a given health issue, or to a specific geographical area.
Turning to developing country literature, Loevinsohn (1990) has reviewed journal articles (1966-1987) evaluating all types of health education interventions in developing countries. Of 67 articles reviewed, only seven make reference to school health education programmes - two of which focus on dental health. He concludes that "From the few well conducted studies it appears that health education can sometimes lead to changes in behaviour and in health status although there remains room for legitimate scepticism." Looking at the quality of these studies overall, Loevinsohn could find only three which he considered to be methodologically sound, none of which were from the school studies.
An overview of school health education in India (WHO/UNESCO/UNICEF 1992) notes that "Though evaluation of learning outcomes is a major recommendation of the National Policy on Education, this is not done because of inadequate implementation of the programme." Other studies described in the same publication indicate some pupil assessment on health, and some processes in place for materials' design and development work. But none address the problem of looking at the effect such programmes have on the health behaviours of young people.
The study reported in this document provides some comparative evidence of variations in apparent health understanding of young people in different countries. For example, in Pakistan (where health education is virtually absent from the school curriculum, and is certainly not implemented), the "picture of health" provided by young people, encompasses a narrow range of issues, often in little or no detail. In comparison, the Ugandan children (who receive a much more substantial health input) address a much broader range of issues; and, through both words and images, provide greater detail, suggesting a greater depth of understanding; however, this study has not attempted to link this understanding to health outcomes.
There is no further evidence from the in-depth country studies to suggest any wide scale evaluation of school health education either completed or in progress.
c. Evaluation studies of "subject specific" health education programmes
There is more tangible evidence available on specific programmes, but again, the developing country literature is thin. Ford et al (1992) have reviewed literature on the health and behavioural outcomes of population and family planning education programmes in school settings in developing countries. They start with reference to an American study (Kirby 1984), which concludes that:
· most programmes included in the study improve knowledge· there does not seem to be much change in attitudes to various aspects of sex and family planning. However, "permissive attitudes" do increase with age, but longer programmes appear to prevent students becoming more permissive
· there is limited impact on social skills decision making relating to sexual matters
· there is no impact on sexual behaviour (this is significant, given the prevalent public perception that sex education increases promiscuity)
· there is no impact on contraceptive use or pregnancy, except where education is closely linked to service provision. Where this is the case, there appears to be a significant decrease in pregnancy.
On developing country literature, Ford et al conclude that there is minimal implementation of family life/sex education in Africa, hence no systematic evaluation. A somewhat different picture is given by Muito (1993) suggesting that by 1989 eleven African countries had on-going population education programmes, and a further eight were being prepared. However, this initial assertion is countered by later observations that, in the majority of cases, programmes show an absence of firm policy, and major constraints to implementation.
Ford et al found no published accounts of evaluations from Asia, and only two examples from unpublished work from Thailand and Vietnam. The Thai work indicated improved knowledge on contraception, and some evidence of increased contraceptive use. The Vietnamese study also notes improvements in knowledge, but little else.
d. Evaluation of AIDS education programmes
There is a growing body of literature attempting to evaluate the impact of AIDS education programmes. Oakley et al (1995b) have reviewed a wide range of HIV/AIDS prevention studies from the English language literature. Of 815 studies reviewed, there were reports of 68 evaluations of "outcome" measures. Oakley et al then analysed these 68 reports for "methodological soundness" - using the following criteria: 1) aims clearly stated 2) randomised controlled trial 3) replicable intervention 4) numbers recruited provided 5) pre- and post-intervention data provided for all groups 6) attrition discussed 7) all outcomes discussed. Using these criteria, only 18 of the 68 studies were considered methodologically sound. Only nine of these concerned interventions with young people (none from Africa or Asia). The results from the review in general "suggest that sound and effective interventions are most likely to be skill-based interventions... in community settings using interviews and role play, and targeting behaviour or combined behaviour and knowledge outcomes" (Oakley et al 1995b: 484).
The Oakley review does not include evaluations of mass media campaigns - where the possibility of conducting randomised controlled trials is problematic. Reports from national AIDS control programmes focus on knowledge/attitudes practice studies concerned with the impact of mass media programmes. These studies indicate that in many parts of Africa, AIDS awareness is growing, but that this awareness has yet to be translated into potentially health-promoting behaviours (eg: reduction in number of sexual partners, or increased condom usage).
We found no published examples of evaluations of schools AIDS education programmes in developing countries.
However, evidence emerging from AMREF in Uganda suggests that increased levels of knowledge of HIV/AIDS taught through the school curriculum has had little impact on teenage pregnancy and STD rates. There are increasing numbers of studies in some countries (eg: Uganda and Ghana) which are starting to look at the sexual practices of young people, but the vast majority continue to focus only on knowledge and attitudes.
The Ugandan findings may put funders off investment in health education. However, it will be important to explore the extent to which countries which have a low prevalence of HIV can harness the benefits of education (in terms of its effect on knowledge) at an early stage.
e. Key factors thought to affect programme implementation
Several of the studies referred to above have also considered those factors which influence programme success. To date, the following points are worth considering:
· Links with health services: those studies which have been able to demonstrate influences on health behaviour and impact on health outcomes have been directly linked to locally available health services (eg: immunisation services, dental services, contraceptive services). The link with the health sector is also seen as vital for in-service training (for example, in the UK, the majority of teacher in-service training in health education is provided through the National Health Service).· Teacher training: Some studies stress the value of in-service training in health education. One UK review (Reid and Massey 1986), however, concludes that, in some cases, teachers with little health education preparation may provide results that are as effective as "specialist teams". However, from the Connell study it is clear that the costs of in-service training (which tend to be the only substantial "additional" implementation costs) often act as a major constraint to implementation.
· Time devoted to health education: Connell concludes that the largest improvements are found where more time is spent on the programme. Ford, looking at sex education, does not find this to be a factor.
· Parent participation in the classroom: Several studies indicate the importance of linking home and school, ideally through involvement of parents in school.
· Timing health education input: UK studies emphasise the 11-14yr. age range as crucial.
· Peer support/activity: this again is seen as a positive strategy for both general health education and sex education programmes.
Operational school policies: these can help improve implementation, where they are supportive of healthy behaviour (eg: school meal nutrition, smoking etc.).
f. Some methodological problems with evaluation studies of health education programmes
As has been mentioned above, evaluation of this nature presents some important methodological problems:
· Programmes often encompass a diverse selection of issues (eg: basic hygiene, sanitation, food safety and diet, accidents, drugs, sexual development, STDs, pregnancy, family planning). Given the complexity of each, in terms of possible short and long-term health outcomes, the selection of appropriate indicators would present a major challenge.· Health education is often concerned with long-term "health habits" - the benefits of which may not be apparent for several years. Hence timing measurement of health outcomes becomes problematic.
· Health education is only one of a wide range of factors influencing health behaviour, and is hard to disentangle.
· Many studies use "before/after" measurements - but with no control group. This renders attribution of effect open to debate.
Oakley et al (1995b) and Loevinsohn (1990) identify the need to implement more randomized controlled trial evaluations, which include behavioural outcomes. Given that health education is generally poorly funded, it may be worth investing time and effort in producing clear evidence of its' benefits. It should be quite feasible to use the randomised control trial approach in testing out school health education curricula and their implementation. However, unlike (for example) drug trials, the range of cultural, social and economic factors involved in education provision would still make interpretation of results problematic (eg: is any effect found due to programme "content", teacher factors, student factors, external confounding events such as media coverage etc.). A further difficulty with using such trials as a basis for deciding on wider implementation of a (successful) programme is the extent to which a limited trial can be '"scaled up" effectively into a regional or national programmes.
g. Conclusions on the health impact of school health education programmes
To conclude this section, three points are worth highlighting:
1. Whether one looks at developed or developing countries' literature, the available public health evidence of the value of school health education is limited. This gives policy makers little to go on, and indicates an important area of research (which is acknowledged to be methodologically problematic).
2. The evidence that is available suggests that, at best, health education is most effective in improving health knowledge.
3. The only examples where there is a clear effect on health behaviour and health outcomes, appear to be where there is a strong link between schools and health service provision.
Health input is identifiable in the curricula of all four countries involved in this study, at both primary and secondary levels. There is also some documentary evidence from a range of other countries in Africa and Asia, to show where and how it is located in the curriculum. The two main models are:
· treating health education as a distinct "subject" area (e.g. India, Nigeria, Pakistan, early secondary level in Sri Lanka)· integrating health education into other areas, but usually with a block of input within some form of life-skills or social studies programme (e.g. Uganda, Ghana, Kenya, Namibia, Zambia, Philippines, and primary level and later secondary level in Sri Lanka).
Those countries which say they have an integrated model mention science (especially biology and physiology), home science home economics, social education social studies/cultural studies ethics, agriculture/environmental education, and physical education (PE), as the main subject areas in which health education is included.
Recommendations from the literature as to which of these models is more effective are not conclusive. British and American literature suggest that integration can help "protect" health education time - but this approach does require careful co-ordination, and some element of a core programme (eg: within social studies life skills), to avoid fragmentation. Evidence from the in-depth studies reported in this document supports this view. Uganda and Ghana, which both have an integrated approach, indicate that they have greater health awareness and coverage, than is the case in either India or Pakistan - where teachers acknowledge that health education is not examined, and is often "squeezed out" of the timetable, in the face of competing pressures from examined subjects.
Whichever model is used, finding space in the curriculum for health education is a dilemma that has beset schools world wide. This comes across clearly as much in the four countries included in this research, as it does in the literature. Lockheed and Verspoor (1991) refer to work by Benavot and Kamens (1989) on curriculum time devoted to major content areas in 90 countries. Of nine content areas listed, hygiene education comes bottom of the list, accounting for only 1% of curriculum time. Physical education and moral education each accounted for 5-7% of curriculum time. The other two areas where health education is commonly integrated, science and social studies, each account for around 8-10% of curriculum time.
During the period of the study, we have been unable to find detailed information on the place of AIDS education within curricula. However, what has emerged from the country studies is that where it is included in the curriculum, it is generally to be found alongside health education on specific diseases, and is limited in content to provision of basic information The wider objectives suggested by WHO (1994), of developing interpersonal skills for delaying the start of sexual activity and negotiating safe sex, plus attitudinal work on care of people with AIDS, are not yet part of general practice. Possible exceptions to this can be seen in two sets of materials: from Uganda (the "Secondary School Health Kit on AIDS control" and "Training for AIDS Prevention Education") and from the South Pacific ("Education to Prevent AIDS/STDs in the Pacific: a Teaching Guide from Secondary Schools").
Ford's review (1992) indicates the limitations in provision of sex education in much of Africa and Asia, making it unlikely that AIDS education would stand out as a clear subsection of sex education. The obvious "home" for AIDS education is within the context of broader sexual health and development.
a. Curriculum content
WHO guidelines on comprehensive health education in schools suggest a number of distinct "health issues" which may reasonably be included. These are presented in summary form in the first column of Table 1 below. The remainder of the table summarises some of the data collected in this study. This provides some insight into the breadth of the curricula, the extent to which teachers and parents acknowledge that the issues are covered, and the extent to which those same issues are raised by students.
From this very simple overview, the paucity of health education in Pakistan is quite apparent. The India data suggests a broad curriculum, which is not yet implemented for the most part. There is some suggestion, however, that health education is clearly linked with "disease" in the minds of teachers and parents, and this is echoed by pupil perceptions of what makes them "unhealthy". The Ghana and Uganda summaries suggest a greater degree of curriculum implementation, with combined data from Ghana stressing the personal hygiene/sanitation elements, and Uganda showing a much broader range of issues being recognised and commented specifically on by both teachers and students.
Dental hygiene, exercise/rest and accidents appear to get minimal attention in any of the countries (although dental hygiene may well be incorporated in personal hygiene). Drugs education, including smoking and alcohol, also gets little mention. These points may well reflect the very different health priorities of developed and developing countries (although accidents is possibly an area to which developing country health education programmes could pay greater attention). Of the four countries, Uganda is the only one where AIDS gets more than a passing mention in textbooks, and is recognised as important by both teachers and students.
Table 1: Health education curriculum content in the four ease studies
|
Issue |
Pakistan |
India |
Uganda |
Ghana | |
|
personal hygiene |
|
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|
| |
|
dental hygiene |
|
|
|
| |
|
food safety |
|
|
|
| |
|
nutrition/diet |
|
|
|
| |
|
exercise/rest |
|
|
|
| |
|
sanitation (including latrines/water sources) |
|
|
|
| |
|
pollution (from traffic/industry) |
|
|
|
| |
|
drugs (including: smoking and alcohol) |
|
|
|
| |
|
accidents |
|
|
|
| |
|
sex education |
|
|
|
| |
|
diseases/"being sick/ill" |
|
|
|
| |
|
AIDS |
|
|
|
| |
|
Additional issues raised by young people, but not referred to by teachers or parents: | |||||
|
|
problems with parents |
|
|
|
|
|
|
problems with friends |
|
|
|
|
|
|
problems with teachers/studies/school |
|
|
|
|
|
|
personal worries |
|
|
|
|
|
|
political/social concerns |
|
|
|
|
Key
- included in a key text box
- referred to a specifically by most of the teachers consulted
- referred to a specifically by most of the parents consulted
- included in their "draw and write" responses by 20% or more the young people consulted
- note: no parent data was collected in Uganda
b. Teacher preparation
There are four key questions to consider on teacher preparation, related to health and AIDS education:
· to what extent are teachers trained in the "content" of health and AIDS education, and how important is specialised training in this area?· to what extent are teachers trained to implement recommended (participative) teaching and learning methods?
· should training be an essential element of basic training, or is it better presented through in-service training?
· to what extent do teachers feel able and willing to take on responsibility for health and AIDS education?
The Connell (1986) study highlights the importance of teacher preparation in both "content" and "methods". Where teachers have been adequately trained, students show improved learning. Lewis (1993), reviewing 50 years of health education in schools in the UK suggests that, as yet, no conclusion has been reached as to whether schools provide a better quality of programme by using a "specialist team" of staff in the school with health education expertise, or by encouraging all staff to get involved (with much more limited training). He comments that "Anecdotal evidence suggests that either system can be equally successful or equally calamitous".
Again, the developing country literature on teacher preparation for health education is extremely limited. Lockheed and Verspoor (1991) indicate that across developing countries generally, basic teacher training is weak, didactic, and suffers from an overcrowded curriculum. This view is echoed by an ODA study in Ghana on teacher training for the junior secondary school level. From the in-depth country studies it is clear that health education is not included in the teacher training curriculum. Even where there is a broader based "life skills" curriculum element (e.g. Ghana, where the subject is part of the core curriculum in schools) it is not core curriculum in teacher training.
In Uganda teacher training for health education has been carried out during a 10 day special training programme. The training guides teachers in what to teach on health education subjects, including AIDS education. Some attention is given to how to teach. Special training workshops on AIDS prevention are conducted for health educators who, in turn, become trainers of teachers. Central to the approach taken in this training is the concept of self awareness and learning to facilitate group discussions. Interactive teaching methods, such as games and role plays, are an important aspect of this training. However, one of the problems recognised in Uganda and Zambia, during follow-ups of teachers who were introduced to interactive teaching methods, is that the majority lapse back into didactic teaching.
As to how teacher training should be provided, Lockheed and Verspoor emphasise in-service training as being of more practical value, rather than a further extension of basic training; however, this presents a number of logistical difficulties. This is highlighted in the American evaluation study (Cornell 1986), where the (limited) additional cost of in-service training was perceived as a key barrier to the effective implementation of programmes.
c. School as a "health supportive" environment
Beyond the formal curriculum, there are at least four further levels at which health education may operate within schools:
· via school health services· through planned extracurricular activities
· through broader environmental features of the school (eg: presence of some kind of school health policy; health regulations governing sanitation provision or school meals; the extent to which the school provides a "health supportive" environment).
· through active contact between schools and the community - especially children's families.
This study has not attempted to address these issues in great detail, but some insight into them is possible from the literature and from the country studies.
School health services
UK and US studies stress the importance of effective linkage between health services and school health education programmes, if behavioural change and health outcomes are to be achieved.
Different countries include varying levels of provision. For example, in Namibia, children in grades 1 and 6 should get a physical examination, and it should be ensured that their immunisation records are up to date. In the Philippines there is a system which includes medical and dental services, as well as school health nursing. There is also a system of "school health guardians" who are teachers trained to monitor the health of pupils (WHO/UNESCO/UNICEF 1992).
None of the countries visited for this study appears to have a consistent, on-going school health service, which has regular contact with large numbers of schools. In Pakistan, there is some reference centrally to such a service, but it is non-operational. Teachers' perception of the service is that it is there to provide medical care for pupils taken ill during school. They do not mention any form of preventive service at all. In India school health checks should take place once per year - in practice, the service is, in Kerala, again mainly non-operational. The picture for Uganda appears similar. In Ghana the school health service may be more operational than in the other countries. According to a Maternal and Child Health report for 1992, the school health service visited 25% of schools during the year, and gave 3,500 health talks (which must be set beside the total of over 21,500 schools). This data is, to some extent, confirmed in school studies, many of which say that they have health workers come in to talk to pupils from time to time.
Specific health intervention programmes
An alternative approach to linking health education to services is through a targeted combined programme, focused on a given health intervention. Again, the Philippines has examples including special programmes on deworming, TB control, and school sanitation (WHO/UNESCO/UNICEF 1992). This approach is being planned on a pilot basis in Ghana - as part of a multi-country study - and had been tried in the past (for deworming, for yellow fever vaccination and for epidemic control).
In both the "special intervention" programmes, and school health service programmes, there is usually a "health education" element included. This tends to take the form of "one-off" talks, or possibly several sessions around a particular area (e.g. hygiene and sanitation), unless a more comprehensive approach to health education is already in place.
From the literature there is no evidence of an intervention approach being used to tackle AIDS. (A possible idea for such an approach would be to provide condom distribution or STD services through schools; however, the likelihood of this proving acceptable in much of Africa or Asia, at present, seems remote.)
Quite how such programmes are implemented varies. In some cases, the intervention is planned and implemented entirely by the health service, basically only using schools as an easily accessible venue for a given intervention. In others, school teachers are more actively involved; for example they may actually administer the de-worming tablets, or be trained to monitor aspects of pupils health, or be involved in teaching on a particular issue.
Extra-curricular activities
Health clubs
In order to take these one-off events a step forward, some countries have started to experiment with health clubs. These tend to be more regular extra-curricular activities (e.g. weekly or monthly), attended voluntarily by a subsection of the school. From this study, some evidence of health clubs was found in Uganda, India and Ghana. In India and Uganda the setting up of health clubs is in the first implementation phase, and little evidence of active health clubs was found in the areas included in the study. In Uganda health clubs are starting to be organised by the Safeguard Youth From AIDS movement, and include in and out of school youth. The AIDS support organisation (Taso) just started to form a youth AIDS club for youths who have experienced the loss of at least one parent. The young people are enabled to share experiences and develop initiatives for peer education on AIDS.
In Ghana, one of the Eastern Region schools has a health club, run by a local GP. Topics are selected by the pupils, and the afternoon's programme is then arranged by the GP. This often takes the form of an activity, followed by a question and answer session.
A similar format is described for Sri Lanka, where open discussions, peer-learning, self-enhancement and community services are part of club activities. The Sri Lanka health club development, like India, is being supported by UNICEF.
In Zambia Dr Baker initiated the Anti-AIDS project under the umbrella of the National Family Health Trust. Anti-AIDS clubs are mainly school-based, initiated and led by students, and supported by interested teachers. Support is also provided by Provincial AIDS support workers and health educators. One example of activities established is recruitment of local youth clubs to develop drama performances.
NGO activities
In several countries, in particular schools or districts, non-government organisations take an active role in health activities connected with schools. This can take many forms (e.g. from working together with teachers in a particular school during school time; using the school simply as an entry point, or as a meeting base for extra-curricula activities). Several religious organisations work in this way, as do planned parenthood groups, youth organisations and the like. A number of the programmes noted both in the countries visited, and through the literature, focus on personal relationships, sexuality and the problems faced by adolescent girls (especially pregnancy/poverty/exploitation).
Examples of involvement of NGOs from the country studies include the Pakistan Youth Organisation's work on AIDS; the Scripture Union's work in Ghana on healthy relationships (which includes reference to AIDS); HEAL, in co-ordination with a number of other NGO's in India works around sex education which includes the development of sex and AIDS education sessions integrated in a module on personal development for schools. In Uganda the Safeguard Youth From Aids (SYFA) movement co-ordinates the activities of NGO's, e.g. community organisations such as scouts, churches, mosques, social and sports clubs, and governmental organisations to help young people in and out of school to protect themselves from HIV infection. Special activities related to the prevention of HIV infection through blood, infections and needles, organised by small clubs or "clans", are encouraged.
WHO's Adolescent Health Programme has produced a lengthy compendium of projects and programmes in adolescent health (WHO/International Youth Foundation 1992). This includes many examples of ways in which NGOs are working together with education and health ministries to address health issues pertinent to young people. Many of these programmes focus on the sexual and emotional health of young people.
Extra-curricular activities of this nature obviously have some advantages over formal schooling, in terms of being more able to introduce innovative communication techniques; however, these need to be additional to rather than instead of core health education teaching if they are to reach a wide range of school-going students in a consistent way.
School health environment
US and UK studies also stress the importance of the school environment in promoting health, and the problems created where "theory and practice" do not match up. A Tanzanian study of a dental health programme (Nyandindi et al 1994) has highlighted this issue, showing the problems (in this case) in teaching children about oral hygiene and avoidance of sugary food, in a situation where few children can afford the tooth brushes and paste recommended, come to school with no breakfast, and can turn only to local vendors for snacks during the day.
The evidence from this study indicates that many of the schools visited have minimal water and sanitation facilities. Those that provide school meals offer a very limited (starch based) diet. Whilst there was talk in some places of regulations controlling food hawkers, these were often either not enforced, or simply meant the hawkers moved a few yards from the school entrance. As is clear from the comments below, the contradiction between health education teaching and school practice does not go unnoticed by the young people. This highlights the importance of paying attention to the school health environment at the same time as working on curriculum development.
"We should eat a balanced diet at school but at school we only eat posho and beans year after year." (boy 12yrs P6)"Our school toilets should be repaired, the pits are broken there is no water for cleaning the toilets after use, our urinals are so dirty to look at, they have green plants grown on them the urine can't pass through because where the urine is to pass it is blocked our latrines should be built far away from water source because when the urine is blocked all the faeces will move to the water source." (boy 12yrs P6)
School/community links
One further feature stressed in the literature is the importance of parental involvement in health education programmes, to ensure that what is learnt at school can be reinforced and developed at home. Evidence that this happens in the four countries studied is generally limited to initiatives already described under the heading of "extracurricular activities". Teachers from the Lahore schools generally feel that parents are unconcerned uninterested in their children's' schooling. There is some evidence of Parent-Teacher Associations being operative in some (more affluent) schools in Uganda and Ghana; however, on the whole, these focus on fund raising for the school, and do not get involved in anything to do with student learning.
d. Teaching methods and materials
Curricula outlines and textbooks give little indication of what actually happens in the classroom in terms of the teaching methods and materials used. For the purposes of this study, it was not possible to include much classroom observation. However, anecdotal evidence and reports on school education suggest that, in all four countries, health education, like other aspects of the curriculum, is taught didactically, with little encouragement of student interaction. This, as indicated in the models of health education discussed earlier, provides limited opportunity for young people to develop health-promoting skills and attitudes.
From the literature, it would appear that there are plenty of small and medium scale examples of more active approaches to learning in schools, signifcantly encouraged by the Child-to-Child movement. A British Council seminar report, "Community Health and the Primary School" (1992) includes details of Child-to-Child work in India, Kenya, Nepal, Burkina Faso, Sierra Leone, Uganda and Zambia. Developments in this area will no doubt be encouraged by the recent publication of a new Child-to-Child book, Children for Health: Children as Communicators of Facts for Life (Hawes and Scotchmer (eds). Child-to-Child Trust UNICEF, 1993).
The Child-to-Child programmes often help to integrate health education in a range of relevant subject areas, and to develop appropriate and lively teaching materials. For example, in Zambia, the integration of health education in the national curriculum has benefited from the Child-to-Child pilot programmes. The experience developed through these pilot programmes has influenced the decision to integrate health in a variety of subject areas: science, languages, social studies and home economics.
Outreach activities to be carried out by teachers, however, are often beset with problems. Reflection on Child-to-Child programmes in Zambia, for example, show that teachers have to be highly motivated to sustain time consuming outreach activities, which often take place in their free time.
Within AIDS education there are also a growing number of examples of teaching which is moving away from purely didactic approaches, to more interactive approaches, though it is not always clear to what extent such sessions are an established part of school life, or are occasional special events, initiated by external agencies.
Some examples of games used include:
"ZigAIDS: an educational game about AIDS for children". This game was developed in Latin America, and is described in Hygie (1991), Vol. 10(4), pp. 32-35."1-4-1 AIDS game" (1992) TALC (Teaching AIDS at Low Cost). This is a game for reaming about HIV/AIDS and sexual health in a social context for children, adolescents and adults, in particular teachers, parents and youth leaders.
Some examples of videos, of which there are now several available for use with school-aged students, include:
"It's not easy" (1991) produced by The Federation of Uganda Employees and The Experiment in International Living Uganda with Uganda Television."Unmasking AIDS" (1991) produced by IPPF (International Planned Parenthood Federation), London.
"Karate kids" (1990) produced by Street Kids International, Toronto (cartoon format).
The last two examples are designed for school-aged teenagers, but are, in fact, more suitable for out-of-school youth.
An example of drama can be found in the Uganda study, which highlighted the use of drama activities in schools, with the draw and write data giving some indication of the impact this has on young people. South Africa has also developed this approach, such as described by Lynn Dalrymple in "A drama approach to AIDS education: A report on an AIDS and lifestyle education project undertaken in a rural school in Zululand", (1992). In Ghana, theatre has been used with out-of-school youth.
e. The relevance of health education curricula to the lives of young people.
Assessing the relevance of health education curricula can be considered from a number of perspectives:
· Do they address the health issues which affect young people (short and long term)?
· Do they address the health issues which concern young people?
· Do teaching materials reflect the context in which the young people live?
These three questions in turn suggest the use of a variety of techniques for needs assessment for curriculum development. The first emphasises the value of health surveys of young people, and epidemiological analysis indicating long-term health behaviours and their impact on health outcomes. The second emphasises the value of involving young people in curriculum design, through exploring with them their health concerns and priorities. The third question again indicates the importance of involving young people - or at least people familiar with the living conditions and experiences of young people - in the design of educational materials. This section provides an overview of the techniques already developed, and the extent to which they have been implemented and used for curriculum development in Africa and Asia. It includes reference to specific work on AIDS as well as general health.
Surveying the health of young people
Two obvious approaches to establishing the health needs of school students are special surveys, and analysis of school health service statistics.
From the four in-depth studies, only Ghana appears to be developing a significant body of expertise in assessing health priorities for schools, on a national scale. It has already conducted one school health survey and is currently planning another. Health issues identified include dental caries, upper respiratory tract infection, ring worm, intestinal worms and head lice. Whilst this data is intended to inform the school health curriculum, it has not yet been used for this purpose.
The WHO (1992) guidelines on school health education describe several other examples of health survey work. Nigeria conducted a survey of the health status of school children in 1986, the Philippines has carried out specific surveys as a basis for health intervention programmes (e.g. for anaemia, goitre prevention and deworming). Sri Lanka has also used research on factors affecting reaming achievement to validate specific health interventions. WHO is also supporting an on-going multi-country study of the health and health behaviours of adolescents (Smith, Wold and Moore 1992). This uses a standardised self-completion questionnaire, administered in schools, under exam conditions. To date, there are no developing countries participating in this research.
India provides an example of the use of school health service data. The medical sector in the Department of Education of the Municipal Corporation in Greater Bombay in India, compiles morbidity data from the school health service visits, to inform on special topics for health education during school health visits.
Finding research studies which may be of benefit to the development of AIDS education proved rather more fruitful than needs assessments on the general health of young people. Such studies were noticeably very much more frequent in Africa than Asia and, within Africa, much more frequent in Eastern and Southern Africa than West or North Africa. In Zambia a questionnaire has been developed to find out what the impact of AIDS is on teachers and students, and what they know about AIDS. The results will be used to develop a curriculum on AIDS education in schools.
Evidence from the country studies indicates that Uganda has developed the most extensive body of literature on AIDS awareness and the sexual behaviours of young people - although on the latter point, Ghana also has a good body of literature (especially focused on teenage pregnancy). Many reported studies are likely to be KAP studies, often evaluative rather than formative, looking at the impact of media campaigns. However, many include useful elements (e.g. summarising important local misconceptions around AIDS or sexual intercourse).
WHO has produced proto-type survey instruments for schools studies on AIDS awareness and health behaviours relevant to AIDS. (WHO Global Programme on AIDS 1989). Whilst this proved too detailed and comprehensive for the current study (which also encompasses other aspects of health education), it includes useful ideas, particularly in looking at the health environment of the school.
Exploring the health concerns of young people
There is rather less evidence, from either the literature or the country studies, of attempts on the part of curriculum planners to explore the health concerns of young people, and build teaching on these concerns. One major development in this area is the pioneering work of Wetton and Moon in the UK, who developed the 'Draw and Write' technique (Williams, Wetton and Moon 1989). The technique was used in the in-depth country studies, and is described in more detail on page 20. It has been used extensively in the UK to explore a range of health concerns (for a recent example see Oakley et al 1995). There are now a growing number of examples of its application in other countries appearing in the literature (Yugoslavia: Zivkovic et al 1994; Australia: Hughes 19??). Five country European study: (Newton, Bishop et al 1995). The technique is also promoted in a recent WHO training manual (Weare and Gray 1994) and a publication on AIDS education in schools (Collyer and Lee 1994).
In the in-depth studies, young people were asked to draw and write about what makes them unhappy and unhealthy. Key concerns highlighted by young people in the four countries include:
from Pakistan:
concerns about the quality of the environment with considerable attention paid to pollution from traffic and industry
from India:
most frequently mentioned are concerns about potential death of a parent, beatings by parents, and problems at school, e.g. failing exams and problems with teachers. This is followed by concern about food hygiene and diseases
from Uganda:
strong evidence that AIDS is high on the agenda of young people, but that this concern is well embedded in a wide range of other health concerns, many of which the young people are able to describe in considerable detail
from Ghana:
a preoccupation with personal hygiene, coupled with much more heartfelt concerns related to family relationships, school friendships, success and failure at school and personal worries.
The young people were also asked to draw and write about AIDS. Detailed results are presented in Section 2. The variations are striking: in Pakistan researchers were unable to undertake work; the India data showed a wide range of misconceptions and very limited understanding; a much more detailed understanding was seen in the Ghana data, although greater emphasis is given to transmission through cuts than sexual intercourse; in Uganda students described many ways of protecting themselves from HIV, including graphic details of how to use condoms and avoid rape.
One noticeable outcome of using the draw and write exercise in this study was the surprise expressed by many adults (including teachers) of how effectively the young people could express their ideas, and how much more they knew than had been anticipated. Such insight can be built on to prepare materials which are much more likely to touch young people and make them responsive to reaming, rather than working only from an "adult" perspective of the world.
Another technique which has already proved fruitful in exploring the sexual practices of young people is the "narrative method", commissioned by the WHO Adolescent Health division (WHO 1992). This involved getting groups of young people in different parts of West and East Africa to create "boy meets girl, girl gets pregnant" stories - through role play and discussion - which were then translated into questionnaires. This enabled young people to piece together their own versions of these stories, and at the same time asked them their own experiences of some of the events in the story (e.g. age of first sexual experience, experience of STDs, pregnancy and abortion.).
Results from this work give very detailed insights into both the sexual experience of young people, and the dilemmas they regularly face, with boy/girl friends, peers and parents, as they become sexually active.
Again, this approach to data collection was too specific for this study - but at the same time demonstrates the richness of insight that can be gained from actively involving young people in research about their (sexual) health.
Involving young people in materials design and development
Even if curriculum planners choose not to involve young people in helping to set the agenda for health education, it can be beneficial to involve them in materials development. This might avoid the common problems of including images and advice in textbooks, which are impractical in the context in which the young people live. One interesting example of this is a formative study in the development of AIDS Education for secondary school students conducted by the National AIDS Research Programme of the Medical Research Council in Cape Town, South Africa. Focus group discussions were conducted with young people to gain an understanding of their experiences of relationships and sexual health needs.
The study provided the basic information for the production of a photo novella "Roxy: Life, love and sex in the nineties", and other resource materials such as a chart illustrating the use of condoms. The materials were based on authentic experiences of young people and aimed at "... addressing issues relating to students' needs to cope with experiences of sexuality and risk situations and addressing safer sex" (Mathews et al 1993). Problems subsequently arose when trying to implement the materials, because they were seen to conflict with "teacher's values, concerns and perceived moral responsibilities". As a consequence many teachers refused to use the resources provided. This is perhaps a salutary tale - but one worth reflecting on further. How can educators hope to influence the lives of young people if they are unable to accept where those young people are coming from?
Opportunities for development
To what extent do teachers feel both willing and able to take on the tasks of health and AIDS education?
Evidence from the literature on health education generally provides little insight into this. The country studies asked teachers about their views on providing health education. In Pakistan and India they do not feel it to be a problem mainly because it is barely implemented, and they see little likelihood of it becoming a priority. In Ghana, teachers do not see teaching round health to be problematic. They stress the importance of providing adequate hygiene education, but do not go much further in developing their ideas. In Uganda, teachers indicate that they feel children should be taught in more depth, but covering the same issues already addressed. Some of the teachers stress the importance of making the curriculum and textbooks more relevant to the local context. They also put strong emphasis on prevention. They see lack of syllabi, textbooks, teaching resources and training as constraints to further development. They also recognise the difficulties of teaching about health in an essentially unhealthy environment. The range of comments from these teachers indicates a much greater level of awareness and readiness for development than is apparent in the other countries.
Focusing on the specific aspect of AIDS education, a somewhat different reaction is apparent generally. Most teachers express some hesitation to become involved, because of the embarrassment many feel in tackling issues related to sex. The consensus statement on AIDS in schools by the World Consultation of Free Teachers' Unions on education for AIDS prevention, organised by UNESCO in 1990, noted that whilst teachers felt they had a role to play in AIDS education, they felt they would be unlikely to have much effect on young people's behaviour. They also unanimously supported the idea of involving non-teaching personnel as resource persons. Whilst this certainly makes sense in developing their own skills, what it may also be saying is that teachers would rather have health professionals tackle the issue - which would almost inevitably relegate it to being a "one-off" annual session in the majority of cases.
Looking at the case study data, teachers' views cover the full spectrum of response, from indicating ignorance of HIV/AIDS, and disinclination to take it on board, through to making innovative suggestions as to how the use of condoms can be promoted and taught practically, and how people with AIDS can be invited into schools, to help overcome negative attitudes.
In Pakistan, teachers have no real views on the matter - through lack of insight themselves. Those who did comment feel that specialists must be involved, since teachers have no knowledge.
In India, teachers expressed general embarrassment about dealing with sex and AIDS in school. They feel sexual transmission of AIDS should not be talked about as this would just encourage the children to take an interest in sex. They also feel any teaching in this area should be left to health science teachers, and that they should be trained.
Ghanaian teachers echo the embarrassment, but are more willing to talk about that embarrassment. They agree they should teach "the basic information and start in primary schools". Teachers (like the young people) currently put much greater focus on the transmission of HIV by blood (open wounds shared needles/transfusions), than on sexual transmission. Here again they caution against going into detail for fear of encouraging promiscuity. Several teachers feel that outside specialists (health workers) should deal with the issue - to answer questions they are unable or embarrassed to address.
In Uganda teachers accept AIDS education as a priority, and generally feel that it should start from Primary 1. Some continue to express the view that, for example, focus on condom usage will promote promiscuity. But several feel that this and other issues should be taught, and taught practically. They agree they need further support, but see "outside agents" as additional to rather than instead of their own efforts, and suggest including people with AIDS in school programmes. They also feel they are more appropriate providers of AIDS education than parents. They indicate the importance of the subject being taught by same sex teachers (de: girls taught by women and boys by men).
All the evidence from the country studies seems to suggest that whether you are talking about health education generally or AIDS in particular, the degree to which teachers express concern and indicate understanding of the issues, is clearly influenced by the level of programme implementation. The more developed the programme, the more readiness there appears to be on the part of teachers to consider further development.
Policy makers in developing countries need to address a range of issues if health education in schools is to have a significant effect on influencing the awareness and behaviour of young people. The health education model proposed earlier in this section is used again in figure 2 to summarise graphically the complex issues to be considered.
Figure 2 Issues facing policy makers.
