a. Aims of the in-depth studies
There were two basic aims for the in-depth studies:
1) to describe current policy and practice within four selected countries (two in Africa: Uganda and Ghana and two in Asia: India and Pakistan)2) to explore the potential for development within those countries in health education generally, as well as in AIDS education specifically, within the formal primary and secondary school curricula.
In order to describe policy and practice the in-depth studies set out to:
· collect evidence from policy makers, in health, education and other relevant government departments, non-government organisations donor agencies on both stated policy and current implementation plans for health and AIDS education in schools;· compare this evidence with data collected directly from schools (from teachers, students and parents), to see whether polices and plans are actually put into practice.
In order to present reasonable suggestions for future development, the in-depth studies set out to:
· describe those issues which young people, teachers and parents consider important in health and AIDS education;· collect evidence from government offices, donors and NGOs on their perceptions of priorities for health and AIDS education;
· collect evidence from both the field level and policy level of likely constraints to future development in health and AIDS education.
The overall study design was determined by the Liverpool research team. Collaborating centres within each of the countries then helped to refine instruments, and undertook local organisation of data collection. Analysis was carried out in Liverpool.
The four collaborating centres were:
|
Pakistan: |
The College of Community Medicine, Lahore |
|
India: |
The Institute for Management in Government, Trivandrum, Kerala |
|
Uganda: |
The Institute of Public Health, Makerere University, Kampala |
|
Ghana: |
The Health Research Unit, Ministry of Health, Accra |
b. The Policy Studies
The two main approaches to data collection on policy and central planning related to health and AIDS education were:
a) key informant interviews
b) analysis of documentary evidence.
Table 3 summarises the key informants interviewed in the four countries. Wherever possible, documentary evidence was collected to substantiate information collected through interviews.
c. The schools studies
Five approaches to data collection were used to shed light on "practice".
The primary data collection tool was:
the draw and write technique, undertaken with a selection of pupils from each of a small selection of schools in each country.
This data was then supplemented with:
Focus group discussions with subgroups of the pupil samples.Focus group discussions with selected teachers from the same schools.
An observation checklist/interview schedule to collect basic information about the schools, with special emphasis on the health environment of the schools.
Focus group discussions interviews with a small sample of parents.
The draw and write technique
The 'Draw and Write' technique is a novel, but increasingly accepted approach to data collection for curriculum design for health education. It has been used extensively in the UK (e.g.: Williams, Wetton & Moon 1989; Oakley 1995) and has been adapted elsewhere in Europe (e.g. Zivkovic et al 1994). To date there are no published accounts of its use in developing countries. However, the research team had had some experience of related approaches, including work by Francis on school children's understanding of eye health in Ghana, Zambia and Kenya. The use of drawing tasks to explore health issues is also now being developed within the participatory rapid assessment field (see, for example, Wallerstein 1992; Welbourn 1992). Some preliminary work from the research team, along with methodological guidance, is reported in Shaver, Francis and Barnett (1993).
The method engages young people in a relatively open-ended exercise, in which they are invited to draw pictures on some aspect of health, and then label or describe their drawing. Children unable to write are encouraged to whisper what they want to write to the facilitator, who then writes their ideas down verbatim.
In this case, the young people were first asked to draw and write about what makes them unhappy and unhealthy. They were then asked to draw and write about AIDS. The AIDS "invitation to draw" was varied across the four countries, according to advice from collaborators on the level of AIDS awareness in the country. In India, young people were asked to draw and write what they knew about AIDS. In Ghana, they were asked to draw and write what they knew about AIDS, especially about how to protect themselves from AIDS. In Uganda, they were asked to draw and write about how to protect themselves from AIDS. In Pakistan, this part of the study was not attempted at all. This is because the condition of access was that children not be questioned directly about their knowledge of AIDS or sexual awareness. In addition, the local researcher felt that it would be improper to introduce the topic of AIDS with children unless they themselves indicated that they had heard about it. Similar problems with gaining permission to conduct anthropological studies with an AIDS component in rural villages were mentioned by our key informant at UNICEF. A more flexible time-frame to conduct this research might have enabled us to explore some of the official concerns and negotiate access to conduct inquiry on these sensitive topics.
Responses to the first question shed some light:
a) on what young people are taught about health (through school/parents media)b) those things which most worry and upset young people - which may suggest areas for future development in health education in schools
c) whether AIDS is seen as an important aspect of the lives of young people (the issue of AIDS was not raised by the researchers in the early stages of the exercise. An initial indication of the level of awareness was the extent to which AIDS/HIV was spontaneously mentioned).
Responses to the second questions provided insight into the main messages young people can put forward about AIDS (rather than whether or not they can answer set questions). These spontaneous comments can also highlight areas of misunderstanding.
A major advantage to this approach to data collection is that it enables young people to express their ideas on health in their own words and images - rather than imposing an external structure (as is the case in closed-question questionnaires). The use of the visual medium can provide insight into how information and concepts are understood, often capturing facets of children's understanding which they would be unable to express in words.
e. Sampling
Given the exploratory nature of the study, purposive sampling was used throughout - from selection of countries down to the selection of pupils and teachers within schools. In none of the countries was it possible to do more than canvass the views of a small selection of parents - therefore, the data from parents should be treated with caution.
Between six and eight schools were included from each country - with the main sample coming from one major city in each country. Whilst this undoubtedly gives a distorted view in terms of countries as a whole, our concern was mostly focused on what may be possible to achieve in the relatively privileged urban sector. It was not within the scope of this study to extend the study into remote rural areas where the quality of schooling is likely to be poorer.
In selecting schools the basic principle used was to ensure variety. Here, collaborating institutions provided guidance on major differences in urban schools - for example:
· co-educational single sex
· having a particular religious affiliation
· public or private sector
· serving different socio-economic groups within the population
· 'model' schools where educational innovation, if it is happening, should be most obvious.
Within schools, pupils were selected from across grades and classes. Small groups of students were taken from each class. Teachers were asked to make the selection of pupils at this stage, but were asked not to select only their most or least able pupils, but again, to give a variety. The exercise was conducted with all small groups together.
Immediately following the draw and write exercise, a subsample of the group was asked to remain with the researchers for a group discussion, which further developed ideas from the draw and write exercise, and explored other aspects of health education and AIDS in school.
Discussions with groups of teachers focused mainly on science, physical education, home economics and (if available) health education teachers - i.e.: a selection of teachers which the head teacher felt would be most likely to be involved in teaching related to health.
Finally, where possible, parents were interviewed individually or in group discussions. In some countries it was possible to contact parents of children in the study schools. In other cases, adults who had children at school were canvassed (e.g.: in the market place, or though church meetings). Table 3 summaries the samples for each country.
f. Data analysis
The data from the school studies resulted in over 3,000 sets of open-ended drawings and text from young people, plus the interview and group discussion scripts. Parts of the student data from both India and Pakistan were written in Malayam and Urdu respectively, and required translation. The vast majority of the Ghana and Uganda data were in English, although in some cases colloquial terms needed to be translated. Translation was undertaken by the collaborating centres, and some cross checking subsequently undertaken in Liverpool.
The complete data sets were sent to Liverpool for analysis, with the main burden of the analysis being the students' drawings and texts. A coding frame was developed for the student data. This was developed initially from a thematic analysis of around 100 scripts per country, and then subsequently ordered in the light of recommended curricula contents on health and AIDS education proposed by WHO (refs). In addition a simple "YES/NO" analysis was carried out on the "unhappy/unhealthy" scripts coding whether or not HIV/AIDS appeared at this stage.
Three people were involved in coding. Coders coded both text and visual material - but only took from visual material any new insights which the text left out. Substantial cross checking of coding was carried out, to ensure the accuracy of the data. The data (now in numerical form) was subsequently entered into SPSSpc for analysis. Simple frequency and cross tabulation data were generated.
Following the basic statistical analysis, it was possible to return to the original data to select both "typical" and "exceptional" quotations and images, to bring the text to life, and to enable the young people to speak for themselves.
Given the relatively small quantity of data from interviews, discussions and observations, this data was simply typed up verbatim, and then analysed by hand.
Table 2: Summary of key informants met in each country
|
Type of organisation |
Pakistan |
India |
Uganda |
Ghana |
|
Health |
Collaborating institution: College of Community Medicine, Lahore (includes AIDS screening lab) |
Collaborating institution: Institute of Management in Government Trivandrum India. |
Collaborating institution: Institute of Public Health, University of Makerere, Kampala |
Collaborating institution: Health Research Unit, MoH |
|
|
· Director General Health Services, Punjab |
· Additional Director of Health Services and AIDS Control Programme Officer. |
· Permanent Secretary Health, Health Education and AIDS Control Programme, MoH. |
· Director, Parasitic Disease Control Programme. |
|
Education |
· Municipal education department: |
· Institute for Education: Director; Population Education Department Project Officer; Co-ordinator School Health Education Programmes of UNICEF Assisted Schemes. |
· Commissioner for Education and Acting Permanent Secretary and Acting Permanent Secretary, MOE. |
· Deputy Minister, Ministry of Education |
|
Donor agencies |
· UNICEF Islamabad (Project Officer: Water, Sanitation, and Hygiene Education; Project officer (Child Health) & focus person for AIDS, UNICEF; Project officer: Education of Children in Especially Difficult Circumstances; Project Officer, Safe Motherhood; Project Officer, Basic Education,) |
· British Council |
· Health and education planner ODA (currently in Zambia; formerly working for UNICEF in Uganda) |
· USAID: Chief, Education and Human Resource Development |
|
Other |
· Health Education and Adult Literacy Project (HEAL) |
· Health Education and Adult Literacy Project (HEAL) |
· AMREF: Director |
· Principal researcher, school health intervention programme (Imperial College, London) |
Table 3: Summary of the samples for the four school studies
|
|
Pakistan |
India |
Uganda |
Ghana |
Grand total |
|
Number of schools |
7 |
7 |
7 |
8 |
29 |
|
Total number of pupils involved in draw and write exercise |
625 |
1341 |
688 |
478 |
3132 |
|
Total number of pupils involved in group discussions |
38 |
48 |
65 |
60 |
211 |
|
Number of group discussions |
|
6 |
7 |
8 |
21 |
|
Total number of teachers in group discussions |
52 |
22 |
49 |
30 |
153 |
|
Total number of parents (individually and in groups) |
49 |
33 |
0 |
48 |
130 |
