Findings

Summary tables of the four in-depth studies

The following pages summarise the main findings from the four country case studies, enabling the reader to compare current policy and practice on health and AIDS education in these different settings. The first matrix provides an overview of health education. The second matrix draws together the specific findings related to AIDS education.

To date, evidence from textbooks, teachers, parents and young people suggests that where AIDS education is included in school health education, it focuses only on the basic information of the nature of the disease, its transmission, and strategies for prevention. There is no evidence of AIDS education focused on the additional recommended objectives of skills development for delaying onset of sexual activity, or for establishing "safe sex" practices, and only limited evidence from Uganda of AIDS education targeted at developing more positive and supportive attitudes towards people with AIDS.

Health education: general context

	PAKISTAN	INDIA	UGANDA	GHANA
Population	124.7 million	844 million	17.6 million	15.55 million
Core health education provision: Links between the health and education sectors and donor and NGO interest in Health Education	· Ministry of Health: IEC (Information, Education and Communication) centre within the MoH at Provincial level. Primarily involved in production of materials for mass media campaigns. · Minimal school health service (does not appear to be operational), · Ministry of Education: no individual or group with responsibility for liasing with the health sector, or for guiding/developing health education · No structures or staff in place, either in schools or within the health sector, to support health education in schools at any level. · Limited interest from UNICEF in school health education (focused mainly on basic resource for water supply and sanitation). · Some examples of innovative health education work through NGOs (e.g.: Health Education and Adult Literacy, Lahore),	· Ministry of Health: school health service in place, but not very active; Central IEC (Information, Education and Communication) facilities · Ministry of Education: no specific focus for health education within the Ministry at state level, · Some coordination between health and education for curriculum development. · District level committees to plan school health services, which could be strengthened and focused also on health education · UNICEF has expressed interest in strengthening the school health education programme by supporting the Directorate of Health Services and the Institute of Education in developments (as yet still at a planning stage)	· Ministry of Health: Health education division within the MoH which is responsible for the Health Education Network (HEN), which includes 40 district health educators, 66 assistants, and has plans to train further assistants, so there is one per sub-county (760 in all), A key task for these staff is to train teachers in health education. HEN is coordinated through a National Health Education Steering Committee. Also school health service run by MCH division (not fully operational), · Ministry of Education and Sport: Responsible for the School Health Education Programme (SHEP), with support from the Inter-Ministerial Advisory Panel (IMAP), involving MoH, MoAgric., MoWomen in Development, MoLocal Gov. and donor/NGO reps. · Considerable donor (UNICEF, SIDA, CIDA, USAID and World Bank) and NGO involvement in health education - supporting Child-to-Child (implemented by the Institute of Teacher Education, Kyambogo); diploma in health education; book scheme for SHEP; other SHEP activities; major focus on HIV/AIDS	· MoH: Technical Co-ordination and Research Division responsible for health education - working through a central resource centre in Accra. Also school health service run by the MCH/FP wing. · MoE: School Health Programme within the Ghana Education Service, Recently established, No staff with training in health education. · Steering committee in place, but little activity on the ground as yet, · No staff at regional or district level in either health or education with special responsibility for or training in health education. Only one other health education resource centre, in Kumasi, operating within the Metropolitan Authority. · Some donor interest (UNICEF and ODA) in developing Child-to-Child in schools, and in testing a deworming and micronutrient supplementation programme in schools.
Health needs assessment related to young people	· No large scale work apparent at any level to address the health needs or future health education of school students. · UNICEF report on Primary Education Reform in North West Frontier Province highlighted diarrhoeal disease, iodine deficiency disorders, eye and hearing problems and malaria. · Upper respiratory tract infection and diarrhoea indicated as problems for young people in Lahore (anecdotal evidence)	· No comprehensive, large scale studies available for Kerala · Important diseases are malaria, URTI, measles, gastrointestinal tract infections, non communicable diseases and accidents.	· No comprehensive school health survey has been carried out. · Wide range of studies available on adolescent sexuality (see AIDS matrix for details)	· school heath survey, involving 16 schools, 1,620 JSS pupils, and 104 teachers indicated dental caries, URTI, ringworm, head lice, and intestinal worms to be problems, Survey highlighted poor school health environment and minimal time devoted to teaching around health issues. · Further survey planned to assess health needs of both in and out of school youth.

Health education in schools: curriculum activities

	PAKISTAN	INDIA	UGANDA	GHANA
CONTENT AND METHODS
Health education in Primary Schools	Class I-V: Health education is covered within the "Physical and health education" curriculum. However, this is non-examined, and hence more apparent in theory than practice. Methods: didactic.	· Health education integrated in health and physical education; part also in biology. 7 subjects taught. · Health education is examined as part of the biology and health science exam. Emphasis is on theory. · Teaching methods are didactic despite suggested interactive learning methods in syllabus.	· Health education integrated and examined into basic science curriculum; 7 subjects taught · Health education is examined in the primary leaver examinations. Positive in that it receives time; problematic in its emphasis on exams rather than life skill training. · Teaching methods are generally didactic and teacher centred despite input on different methods in teacher training colleges.	P1-P6 (6-11yrs) 9 subjects taught. Health education "integrated" into various subjects, especially Life Skills, but also touched on in Agriculture, Science, Social Studies, Cultural Studies. Methods: syllabus recommends interactive teaching, with practical elements, In practice, this is the exception rather than the rule.
Health education in Junior Secondary Schools	Not applicable	· Similar to above	· A special syllabus for health education was developed but not yet implemented. Teachers question if space will be available in the curriculum.	JSS 1-3 (12-14yrs). Curriculum similar to primary. Most substantial "health input" can be seen in JSS Life Skills textbook 3, chapter 9.
Health education in Secondary Schools	As at primary level, there is "Physical and Health education". Where it is scheduled, it is basically PE.	· Health education integrated in biology and population education. 9 subjects in biology and 4 in population education.	· Same as for secondary junior	SS 1-3. 7 core subjects plus 5 areas of specialisation. Health again covered in the "core", especially Life Skills, and within the vocational specialisation, Management for Living,
Examples of available innovative health education materials and approaches	HEAL (Health Education Adult Literacy) project has developed a participative materials production process. Ideal for small scale development projects - and may provide fruitful starting point for larger scale curriculum development.	· Slides and photographs used to illustrate different diseases.	· Special school health kits for teaching in primary schools on AIDS, water and sanitation, diarrhoeal disease and immunisation were developed and are used by teachers. · Syllabi and textbooks were evident in schools visited in Kampala but might not be as well distributed in rural areas.	Key textbooks and syllabi available in all the schools visited (though this may not reflect practice in rural areas). No further support material evident.
TEACHER PREPARATION
Health education in teacher training: baste and in-service provision.	· No evidence of health education preparation during teacher training. As with the school curriculum, health education is seen as synonymous with physical education. · No evidence of in-service training focused on health education	· Included in curriculum for biology and science. · Apparently no orientation to health education takes place as this is said to be done by health personnel. · 1000 teachers trained in 2 day training programme initiated by UNICEF. · HEAL also provides some orientation for teachers.	· Training of teachers in health education was carried out through in service training until 1992. · Health education will become a special subject area. The syllabus is nearing completion and 50 tutors of teacher training colleges are trained.	· While Life Skills is a core subject throughout primary, junior and secondary education, and includes a reasonable health element, it is not a compulsory part of teacher education. Hence teachers may have little or no preparation for teaching health related issues. · Limited evidence of any teacher training encouraging teachers to use practical/interactive teaching methods in class. · No evidence of in-service training focused on health education.
SUPPORTIVE ENVIRONMENT
Additional support for health education within the school context	· Non-operational school health service, which is perceived by teachers, parents and health officials as "medical care". · UNICEF studies from North West Frontier Province indicate extremely poor hygiene standards in schools, with minimal provision of basic water and sanitation services, · No further evidence is available.	· Action plan developed to implement health clubs, Implementation in starting phase. · Population education movement organises competitions for students (writing essays, painting, public speaking, quizzes); has implemented a 'village adoption' scheme. · Health checks and immunisation planned for all schools once a year. Implementation is irregular. · Schools in Trivandrum have basic water and sanitation facilities. Unable to comment more broadly.	· Innovative activities sponsored by a range of organisations especially on HIV/AIDS. · Not so evident are activities related to other subject areas except the Child-to-Child extra curricular activities. · Health personnel do provide some input in the schools both through the provision of immunisation and yearly health check services, and through teaching specific health issues in schools. However, services are irregular. · School environments differ substantially in terms of sanitation and water, Some school environments in the rural areas are very poor.	· School health service 1992 indicates "coverage" of 25% of schools. Included 3,464 health talks". · Some evidence of certification of food vendors on school compounds · Ad hoc school health clubs can be found, but no general provision · Some local NGO work (primarily church related) on moral education, using schools as their venue. · Pilot studies in progress testing specific school health interventions on deworming and micronutrient supplementation.

Health education: issues and opportunities

	PAKISTAN	INDIA	UGANDA	GHANA
THE CONCERNS OF YOUNG PEOPLE
Issues/concerns highlighted by the young people (only issues mentioned by 20%+ included).	n=625 52% Dirty environment (including general unhygenic surroundings, problems with refuse/rubbish and contamination of water sources) 44% Flies and mosquitoes 33% Food hygiene 31 % Pollution (traffic/industrial)	n=1341 39% problems with parents 36% problems at school 34% food hygiene 29% diseases 26% personal worries 25% environmental hygiene 25% pollution	n=688 50% - uncovered food, contaminated drinking water and unwashed food 49% - broken latrines, dirty water sources and dirty pit latrines 49% - relationship with parents 38% - local environmental hygiene 36% - specific diseases including 23.5% AIDS 30% - not enough food and unbalanced diet 30% - vectors 24% - fear of failure in school and problems with teachers 24% - accidents 23% - political\social issues 20% - relationships with friends	n=478 47% - Relationships with parents 45% - Personal/emotional problems 45% - Diet 37% - Environmental sanitation 34% - Relationships with friends 32% - Problems at school 31% - Being "sick" 30% - Social/political concerns 28% - Personal hygiene
OPPORTUNITIES FOR DEVELOPMENT
Evaluation of health education in schools	None (nothing to evaluate)	· No systematic baseline on school aged children in Kerala. · No evidence of evaluation of health education programmes carried out.	· Evaluation of SHEP and Child-to-Child is carried out and acted on: (1991 internal and 1993 external review of SHEP) Action taken includes: teacher training syllabus developed; material development now involves stakeholders; plans to decentralise material distribution, monitoring and evaluation.	· None yet undertaken on the general health education provision. Study of family life education in Kumasi schools indicated limited implementation, constrained by resources, and by parental and teacher resistance - with the commonly held view that "sex education increases promiscuity".
Teacher and parent support for developments in health education	· No suggestion from teachers of need to develop on current (minimal) provision, Teachers also mention several constraints-lack of training, resources, syllabus, or time within current overcrowded curriculum. · Parents reflect these views - simply indicating that hygiene education is important. Only one out of 49 mentioned sex education, and stressed that the religious context should be considered at all times.	· Teachers support a more practical approach to teaching HE. They also point out constraints; pressure to teach exam issues, lack of resources. · There is a general feeling that no real change is needed. Some suggested more emphasis on hygiene and 2 mentioned the need for sex education. · Parents support the subjects currently taught, None mentioned sex or HIV\AIDS education without prompting.	· Teachers support current approaches and suggest changes to make teaching more relevant and practical. · Hygiene, prevention and treatment of disease are emphasised by teachers. · AIDS is seen as important and is clearly supported by teachers. Many feel that sex education and relationships should be part of the curriculum. · Teachers stress the need "to practise what they teach", i.e. smoking; for schools to create healthy environments; and for parents and teachers to support healthy activities.	· Current health education teaching considered to be sufficient. Teachers stress the importance of hygiene education. Teachers express embarrassment and some reluctance about teaching sex education - but agree that it should be in the curriculum. · Parents support the importance of hygiene education - but again suggest little further, A small number suggested the importance of sex education (none seemed opposed to it), Several, when probed on specific diseases, felt AIDS should be addressed.
Promising options for development	· Essentially starting from a "clean slate" · UNICEF involved in pilot studies on the development of a Lifeskills curriculum, where health is included. · Given the" medical model" of school health which pervades, targeted health interventions may have better chance of success than more general preventive health education work. Here, provision of basic water and sanitation facilities is clearly a priority which it will take many years and substantial resources to address. · It is unlikely that schools would, on a large scale, be able to adapt or develop the more participative education required for the development of 'health promoting' skills and attitudes. It may prove more beneficial to explore NGO involvement on specific issues, in targeted areas, for this type of more interactive learning.	· Important to strengthen existing initiatives and develop these further: · In particular: · Support development of health clubs by providing sufficient resources and support for follow up, monitoring and evaluation. · Take up the suggestion to establish coordination committees at national and district level between State health services and education. · Support and strengthen school health services.	Strengthen and build on existing developments rather than attempting further innovation. In particular: · Improve co-ordination at district level · Formulate objectives in behavioural terms · Improve distribution of materials and supervision at district level. · Improve school health services · Ensure basic water and sanitation facilities. · Develop the initiative for male and female teachers to take the role of counsellors in schools and establish public codes of conduct for teachers and pupils. · Strengthen Child-to-Child and SYFA initiatives through improved coordination at district level. · Implement comprehensive sex education through Child-to-Child, SYFA, TASO and other NGO's. Continue training of teachers, especially female teachers and emphasise interactive methods.	Important to build on and develop existing structures and provision further, rather than attempting further innovation. In particular: · strengthening the School Health Programme (SHP), and developing its link with the Ministry of Health · ensuring that the SHP makes full use of the available needs assessment data for curriculum planning and materials development · strengthening the School Health Service, again in close collaboration with the SHP · ensuring widespread dissemination through both health and education of the results of the school health intervention initiatives, in order to assess its future potential.

AIDS education: general context

	PAKISTAN	INDIA	UGANDA	GHANA
AIDS cases, and availability of data on sexually transmitted disease and teenage pregnancy	· 24 AIDS cases acknowledged (August 1992). · No available data on STDs or teenage pregnancy	· First AIDS cases reported in 1987. Since then 242 cases reported (1992). · Kerala has reported 17 AIDS death, 154 sero positive cases and 26 AIDS cases. However under reporting is generally accepted. · Estimates run from 500,000 to 2.5 million sero positive cases for India as a whole. · No estimates or health information data was available for teenage pregnancies or STD rates in Kerala.	· 24,977 cases officially reported (June 1991) with cases doubling every 8-12 months. Seen as top priority being the leading cause of adult death. AIDS incidence peaks in the 25-29 yr. age group for males and 20-24 yr. age group for females. · Teenage pregnancy is acknowledged as a problem. Average age for first sexual experience shows wide variety per region. An average between 13.6 and 15,7 was reported in studies carried out in Kampala	11,000 AIDS cases (April 1993). Acknowledged as an important emerging disease; over 40% of cases in people under the age of 30yrs. · Teenage pregnancy acknowledged as an important issue concerning schools.
Extent to which AIDS is perceived as a priority by government and by donors	· Denial (1993) at central level that there are more than a handful of cases of HIV/AIDS. · Some evidence that there is growing acknowledgement that it may be more of a problem than is currently accepted. · However, not seen as" priority" - certainly not priority for young people.	· Acknowledged by MoH as important disease and general IEC activities prioritised. · Education sector has started looking at the need to teach about it but not a strong priority as yet.	· AIDS is number one health priority in Uganda, The MoH see education on HIV\AIDS as an important contribution to the prevention of this disease. · The Ministry of Education share this view. This is shown through the integration of teaching on HIV/AIDS in the school curriculum and the special teacher training programme for HIV/AIDS education. · Many donor agencies are involved in funding education on HIV/AIDS including AIDS education in schools	· Acknowledged by MoH as an important emerging disease, but not a major priority as yet. · Similar view within the education sector that it is an issue that schools should start to address.
Agencies involved in AIDS education and the structures within which they operate	· The National AIDS Control Programme has so far focused on training for medical specialists, and religious leaders, not on public education. · UNICEF is working with the government on an AIDS education programme - but this is still at the planning stage. · Some NGOs (eg: Pakistan Crescent Youth Organisation; Health Education and Adult Literacy project) starting small scale work in AIDS education, · No co-ordination appears to be in place, and no direct link made with between the health and education sectors.	· National AIDS Control Programme established in 1987. Started initial surveillance and awareness raising IEC activities. · A start was made to teach health personnel about the disease. · In education sector no concrete programmes to teach HIV\AIDS exist, however the intention is there. · Initiative by HEAL India to start teaching in schools.	· The National AIDS Control Programme started in 1987. including IEC mass media campaigns, patient care and counselling. · In 1991 the Uganda AIDS Commission was established to co-ordinate the efforts of different sectors to cope with the impact of AIDS. · The school health education programme of the MoE has developed a special programme in collaboration with the MoH and other agencies involved in AIDS education. Main activities include AIDS education in the school curriculum, training of trainers and teachers and the development of drama competitions by schools performing plays on AIDS. · Many smaller initiatives involving school children: Examples are the Child-to-Child programmes and the Safeguard Youth From AIDS (SYFA) initiative.	· The National AIDS Control Programme was established in 1987. The medium term plan ('89-'93) included IEC, with a mass media campaign targeted at 15-30yr olds. · The plan included work in schools (mainly one-off sessions by HWs). · An external review of the NACP highlighted poor co-ordination between MoH and MoE as one of the programme constraints and recommended the development of a policy on AIDS education in schools. · This co-ordination has not yet been developed. However there is clearly a growing body of evidence to indicate both the need for this co-ordination, and the beginnings of dialogue between the sectors, which now need to be strengthened and formalised (e.g.: linkage between the GES School Health Programme, the NACP, and the MoH School Health Service),
Evidence of needs assessment related to young people on sexual health, STDs/AIDS	No data available on STDs, nor on anything to do with the sexual health or sexual activity of young people.	· No data available on STDs or sexual activity of young people, · HEAL India conducted very small scale study which shows concern and interest of young people around sexual issues. · Baseline study on HIV/AIDS has been conducted but data not available at time of study.	· No data available on STD's among young people. · Many studies pertinent to AIDS education needs of young people including KAP studies have been carried out. (See case studies for details.) · A comprehensive review of studies into issues around adolescent sexuality (Barton and Olowo Freers 1992) show marked differences between districts in number of young people who are involved in pre marital sexual experiences (Range 18-61.5% reporting sexual activity) and age of first experience 13.6 -15.7, with some as early as 10 years of age The KAP studies show a high level of knowledge about HIV transmission. In one study 49% of the sexually active girls and 22% of the boys reported forced sexual intercourse.	· Range of studies available on teenage pregnancy, teenage sexuality, AIDS awareness and education for out of school youth, KAP studies on AIDS awareness. (See case studies for details).

AIDS education in schools

	PAKISTAN	INDIA	UGANDA	GHANA
METHODS AND MATERIALS
HIV/AIDS education in the school curriculum	Brief mention in secondary school science text.	· Some mentioning of AIDS in reproductive health teaching in secondary schools.	· Teaching on HIV\AIDS is well integrated in the school curricula and evidence that this is actually taught is everywhere. · Education on HIV/AIDS is integrated in grade 6 and 7 of primary schools as part of the teaching on STD's, In secondary schools it forms part of the teaching on common diseases in the biology curriculum.	·. Limited mention of HIV/AIDS in the JSS Lifeskills textbook 3. Addresses basic information only - not skills for sexual health, or attitudinal work concerning care of people with AIDS. · Evidence of one-off "AIDS information" sessions run by health workers (along with other sessions on STDs and teenage pregnancy) - mainly directed at senior secondary level, though some at JSS level.
Extra-curricular work related to sexual health	None apparent	· None apparent.	There is a wide range of innovative activities initiated, In particular: · Health workers and specially trained counsellors visit schools on request · SHEP produces a magazine which encourages kids to talk about health issues including AIDS · Drama activities are initiated countrywide by SHEP · Essay competitions were organised · Clubs are being established by a variety of organisations such as SYFA, TASO.	· Small scale examples of work with street youth, and of AIDS awareness dramas.
Special materials available for HIV/AIDS education	· Set of posters from National AIDS Control Programme, focusing on non-sexual forms of transmission of HIV.	· Wide variety of posters. · Newspaper and television coverage by journalists. · HEAL India and Red Cross are developing information materials. · Materials which explicitly refer to sexual activity are not easily accepted.	· A wide variety of posters, leaflets and other IEC materials are available. · Special AIDS kits for primary schools have been developed to help the teachers teach HIV/AIDS. · There is an AIDS pack available for secondary schools,	· Wide variety of posters, TV, radio input from NACP. · Save the Children Fund; Snakes and ladders game · Kumasi Health Education Unit: Sorting cards; flash cards
TEACHER PREPARATION
Teacher preparation for AIDS education	None	· Some plans to start training teachers in selected schools in how to teach about AIDS. None implemented yet.	· How to teach about AIDS is included in the special training of teachers through the SHEP (1 day out of 10) · MoH trains health educators who become facilitators in the SHEP training programme for 5 days. · Secondary school teachers were given a crash course. · AIDS education is being integrated as a special subject area in teacher training colleges and 50 tutors of teacher training colleges were trained.	· None to date - but acknowledge as something which should be addressed,

AIDS education: the understanding of young people

	PAKISTAN	INDIA	UGANDA	GHANA
Summary of data from young people, showing issues raised by 20% + of the sample.	N=625 · 2 young people in the sample referred to AIDS as something which makes them unhappy/unhealthy · Questionnaire to 38 young people indicated that the majority had heard of AIDS. However, very few could describe anything about the disease. Only 3 said it is sexually transmitted, four that it is passed through male/male or male/female contact. 5 thought it was transmitted through urine/stools. Note: The draw and write exercise about AIDS was not attempted due to official discouragement of direct discussion about AIDS with pupils. The local researcher made some attempt to gather information about children's knowledge of AIDS through a structured questionnaire administered to a limited number of older respondents who had already expressed an awareness of AIDS.	N=1314 · 7 in the sample referred to AIDS when writing about what makes them unhappy and unhealthy, Question: Draw and write about what you have heard about AIDS. Responses: 11 % do not know anything about AIDS 38% see AIDS as dreadful killer disease 28% think AIDS is spread though air, water, touch, spit, urine, vomit and dirt. 27% emphasise the need to ensure that doctors use clean\new needles. 26% refer to AIDS being sexually transmitted	N=695 ·. 194 (28%) refer to AIDS as something that makes them unhappy\unhealthy (before they knew they were to write about AIDS) · Secondary school children were much more likely to mention AIDS (40%) than primary school children (8%) Question: How can you protect yourself from AIDS? Response: 60% using condoms for protection 56% ensuring good medical practice 46% checking blood and having HIV test before sex or marriage 34% abstaining; one faithful partner; avoiding casual sex, adultery, promiscuity 25% Avoiding people with AIDS (PWA): majority means avoiding sex with PWA; 15 (2%) suggests segregating certain groups e.g.. prostitutes, people with AIDS; only 22 (3% of total) suggest avoiding close contact, i.e., sharing food, standing close to people with AIDS NOTE: a very small number mention misconceptions, eg, 11 suggest that you can protect yourself through diaphragm, pill, coil and tampon.	n=478 · 8(1.7%) refer to AIDS as something which makes them unhappy/unhealthy (before they knew they were to write about AIDS) Question: What do you know about AIDS? Draw write, especially anything you know about how to protect yourself from AIDS. Response: 77% AIDS transmitted sexually/prevented by limiting sexual partners/avoid casual sex/stick to your partner. 50% Using condoms prevents AIDS 36% Ensure sterile techniques are used in hospitals/AIDS spread through use of contaminated needles 32% Avoid sharp things (razors/tooth brushes)/AIDS spread by open wounds and cuts 31% Misconceptions (mainly focused on transmission of HIV either through poor hygiene (not washing enough, living in a dirty environment) or through casual contact with people with AIDS (hand shakes, kissing))

AIDS education: opportunities for development

	PAKISTAN	INDIA	UGANDA	GHANA
Evidence of evaluation work on AIDS education	None	Nothing to evaluate yet. Formative studies just started.	· The many KAP studies carried out, some specifically with school children, show a general high awareness of HIV\AIDS with some misconceptions. Preliminary results of the drama competition evaluation showed for example that many pupils think HIV/AIDS is only transmitted by women and also that a person who is happy and fat cannot get AIDS, · Most programmes are evaluated and recommendations are acted upon. · A general outcome is that knowledge levels are high but evidence for change in sexual practices is not there.	· Evaluations carried out of the NACP mass media campaigns show a general basic awareness of AIDS, but confirm that there are still misconceptions (e.g.: feeling that people are not convinced that they are vulnerable; belief by some that AIDS is curable). · Local study (Kumasi) of family life education in JSS schools indicated that whilst the curriculum is there, there is resistance to implementing it from teachers and parents, plus major resource constraints in schools.
Teacher and parent support for developments in AIDS education	· 35/52 teachers interviewed said they had heard of AIDS, but felt their knowledge was very limited. · 24/49 parents had heard of AIDS (with clear split between literate professionals and others). · Neither group felt AIDS to be an issue. Teachers felt they have neither the knowledge nor the skills to teach about it,	· There seems to be a general agreement between teachers and parents that AIDS should be taught in schools. · Concern is expressed that it should start at the appropriate level, e.g. class 10 (13-15yrs) and in accordance with cultural and moral values held in public in Kerala. · Teaching about condoms was seen as problematic. Students themselves had many questions mainly about the spread and origin of the disease, diagnosis and symptoms, possibilities for cure, transmission route and prevention.	· Knowledge about HIV/AIDS is well established. More emphasis needs to be placed on life skill teaching, e.g.. How to negotiate sexual relationships, how to say no etc. Teachers agree with the need for this kind of teaching although some are cautious about teaching how to use condoms. · Young people agree but still have many questions. Main questions for boys are: How to use condoms properly; advantages and disadvantages of blood testing; AIDS symptoms; Education on dangerous cultural practices; alternative behaviour to sex; how to know blood is safe. · Main questions for girls are: suffering at home under stepmothers; rape by drunken parents; how to prevent pregnancy; how to prevent men from disturbing them; effect of contraceptive pills on fertility, · Agreement between teachers about the need to teach same gender classes by teacher of the same gender. · No resistance from parents is expected as long as teaching about sex is not too explicit.	· Agreed by both teachers and parents that AIDS should be addressed through schools - with age 12yrs being seen as the time to start teaching "in detail". · Teachers accept that sexual aspects of AIDS must be addressed - but feel they need help on this (and prefer to involve health workers) · Parents express full diversity of views, from some happy for their children to be given explicit and practical detail on (for example) condom usage, through to others who feel that information on how to prevent sexual transmission of HIV should not be addressed until late on in senior secondary school - believing that mentioning this earlier will lead to experimentation by young people.
Promising options for development	· Unlikely that AIDS education in schools would be able to go beyond the provision of basic information. Even here, clear resistance to any mention of sexual transmission. · Some possibility to NGOs concerned with youth developing innovative programmes (eg: All Pakistan Youth Federation).	· There is a need to address HIV/AIDS with school children and teachers urgently, considering the widespread misconceptions which are held. · Develop teacher training in how to teach about AIDS. · Start developing a programme with help of NGO's such as UNICEF and HEAL India. · Intensify formative qualitative research programme to develop appropriate materials and programmes.	· Strengthen and consolidate existing programmes rather than developing new initiatives. · Train more female teachers so that the teaching of HIV/AIDS in same gender groups becomes more feasible. · Train and designate female and male teachers in schools to take a counselling role for girls and boys who are put under pressure or face sexual abuse, · Follow the example of the model school and establish public rules for code of conduct of teachers and pupils. · Support Child-to-Child, SYFA and other NGO's to strengthen and expand extra curricular activities to help pupils to put info practice what they have learned and discuss difficulties they face in protecting themselves. These programmes need to include comprehensive sex education.	· There is a need to address a current over emphasis in AIDS education of transmission of HIV through blood (eg: open cuts, shared razors at barbers etc.), and to re-focus on sexual transmission. (This may be an NACP mass media issue.) · Also a need to highlight individual susceptibility to HIV (currently seen as something effecting "other" - not "me"). · General support for AIDS education from teachers and parents needs to be capitalised on, through in-service training of teachers. · It may be worth exploring developing the guidance and counselling service in schools, to address a wider range of personal issues, rather than only school subject choice. · As with health education generally, current work (eg: existing textbooks and syllabus) to be supported further, rather than trying to develop new ideas from scratch,