Promoting Healthier Behavior
Education programmes related to sexual and reproductive health have gone through a number of changes over the past several decades, many related to sensitivity about addressing sexuality. The topic has been called variously education for parenthood (especially for pregnant teens), family life education (which has sometimes omitted sexuality aspects altogether), population education (with a wide range of contents and approaches) or, more recently, life planning or life skills education (which may or may not include sexuality).
Since the ICPD, sexuality, reproductive health, life skills and life planning have all been acknowledged as key components of reproductive health education. Gender issues, which were missing from many of the earlier efforts, now also receive priority attention.
Instruction methods have also changed, from a didactic approach to one with a greater emphasis on student participation and the acquisition of skills, particularly communication skills.
Based on a review of U.S.-based sexuality education programmes, one expert concluded that school-based programmes are most successful when they give a clear, consistent message based on accurate information; focus on reducing sexual behaviours that lead to unintended pregnancy and infection; are specific to age and culture; are based on a theoretical framework proven to change health behaviours; use teaching methods that involve students, are skill-based and address social pressures; and motivate and train teachers to participate.(10)
Teachers need to be prepared to deal with the sensitive issues surrounding HIV transmission. A study of school-based AIDS programmes in Botswana, Malawi and Uganda found that lack of time, resources and teacher training undermined curriculum-based education as well as counselling and peer education.(11) A study in Colombia found that, “teachers are often unprepared to discuss sexuality with adolescents”.(12) An evaluation of a successful and now-compulsory AIDS education programme in Zimbabwe found that curricula writers and teachers needed more training in participatory techniques.(13)
A study in Mexico, South Africa and Thailand in 2000 found that students have a lot to learn about HIV and safer sex.(14) The Colombian study found that “young people tend to be poorly informed regarding their own sexuality and health including contraception, family planning and HIV/AIDS matters”.(15)
Yet a recent study of 107 countries found that 44 did not include AIDS education in their school curricula.(16)
Sexuality education has great potential to reach a large audience, at least in countries where a high proportion of young people attend school. A major challenge is to expand the use of approaches and curricula that have been successfully tested on a small scale.
HOW SCHOOLS CAN REDUCE HIV INFECTION
from Mexico, South Africa and Thailand have identified
some key attributes of successful school-based programmes
to address HIV/AIDS:
- Teachers need to be prepared for students with a range
of sexual experiences, from those who have not yet had
sex to those who have experienced forced sex.
- Strategies for negotiating or refusing sex should take
into account the intermittent nature of adolescent sex.
- Courses should examine peer pressure to have sex and
norms about masculinity, femininity and self-esteem.
- Programmes need to address condom use so young
people who do begin having sex can protect themselves
and feel confident about using condoms correctly.
- Students need to be taught to accurately assess their
personal risk of infection.
- Teachers and curricula planners need to recognize that
students know some things about HIV/AIDS but misunderstand
or are unaware of other aspects.
- Programmes need to talk about people living with HIV
A common misconception among parents and community leaders is that providing sexuality education will lead young people to become sexually active at an early age. Evaluations have shown such fears to be unfounded. In the two most exhaustive reviews of studies on school-based programmes, WHO and the U.S. National Campaign to Prevent Teen Pregnancy both concluded that sexuality education programmes do not promote or lead to an increase in sexual activity among young people.(17) The U.S. study also found that HIV programmes were more likely to reduce the number of sex partners and increase the use of condoms.
Still, there continues to be a debate, particularly in the United States, about the virtues of teaching only about abstinence as a means of preventing unwanted pregnancy and STIs, versus providing more comprehensive information on prevention.
THE ABCS OF HIV/AIDS PREVENTION Turning back the pandemic will require a variety of approaches incorporating both prevention and treatment. The costs of prevention—financial, social and personal—are significantly lower than the costs of treatment. An approach that has become increasingly popular, particularly in Africa, is the “ABC” approach—Abstain from sex, Be faithful to one partner, and use Condoms correctly and consistently. A fourth part of the message, “D”, refers to harm reduction in areas of high drug use (either injecting drug use or recreational use of alcohol). Some also refer to ABC+, which includes the message to get tested and treated for STIs (which increase the risk of transmission of HIV in unprotected sex).
Evidence suggests that many young people are changing their behaviour as they become more aware of HIV/AIDS and how to avoid it. HIV prevalence in Uganda has been reduced, in large part because young people abstain, have their first sexual relations later and have fewer sexual partners than they did a few years ago, and those who engage in sexual activity are more likely to use condoms.
The ABC(D) message is straightforward, but social, cultural and gender norms make its implementation in some places a challenge. Young women in many cases do not have the freedom to choose to abstain or to negotiate condom use with their partners.(18)
Each component of the ABC message should be presented in a comprehensive and balanced way. Promoting abstinence alone ignores the likelihood that some young people will engage in risky sexual behaviour—for example, young men who visit sex workers or young men and women who do not acknowledge their own risk of infection and have multiple partners. Promoting condoms as providing 100 per cent protection could inadvertently encourage high-risk behaviour.(19)
PROGRAMME ACHIEVEMENTS In Namibia, girls who participated in a school course called “My Future is My Choice” were more likely to remain virgins 12 months after the programme than were girls who had not participated.(20)
In Mongolia, with UNFPA support, the Government made an explicit policy decision to support sexuality education for all, every year beginning in grade three, stressing gender as a key concept.(21) Some 60 per cent of secondary schools now teach the course. Teachers and students have given strong positive feedback, while voicing the common concern that too little time is available to spend on the curriculum.(22)
Colombia began its efforts before the ICPD: sexuality education was made mandatory in all primary and secondary schools in 1993. While the programme has faced funding shortages and teacher training delays, most schools are now implementing the curriculum.(23) A school-based programme from 1997 to 1999 increased 8,000 young people’s knowledge about HIV/AIDS and changed attitudes.(24) The Ministry of Health, Education and Family Welfare, working with NGOs, has developed national tools for sexuality education based on the experience.
In South Africa, national departments of education and health have begun implementing “life skills” training in public secondary schools.(25) In Mexico, a variation of this approach, called Planeando Tu Vida (Planning Your Life), has been tested in secondary schools; afterwards, parents, teachers and students favoured its inclusion in the formal curriculum. Students learned about contraception and were no more likely to become sexually active than those who did not participate. Sexually active students who took the course were more likely to use contraception than those who did not.(26)
Combining school efforts with other community activities, a UNFPA-supported project in the Occupied Palestinian Territories integrated reproductive health and gender issues into school curricula, adult education, and youth education programmes. Teachers and supervisors became community advocates and youth leaders were able to generate discussion on formerly restricted topics.(27)
In countries that do not mandate sexuality education, pilot projects are often undertaken. In six primary and secondary schools in Rio de Janeiro and Recife, BEMFAM (Brazil’s family planning association) helped incorporate sexuality education and STI/HIV prevention into the curriculum, including on-site counselling and referrals to clinics. The use of condoms and the number of students knowing where to obtain reproductive health services increased as a result. Communication between students and teachers and between children and parents also improved.(28)
LEGAL AND POLICY CHANGES A number of countries have recently changed laws or policies to support in-school programmes:
- In 2000, Gabon passed legislation that ensures provision of information and training to girls and boys on hygiene, nutrition, and prevention of STIs.(29)
- In 2002, Panama passed a law guiding policy on pregnant adolescents. One provision requires that the Ministry of Health train and provide information to teachers so they can advise pregnant adolescents on sexual and reproductive health.(30)
- In 2001, China enacted a Law on Population and Family Planning that provides in-school education on physiological health, puberty and sexual health.(31)
- Honduras passed a law in 2000 on equal opportunities for women, which in part, requires the Government to include population education in schools, including information on sexuality, reproduction and prevention of STIs and unwanted pregnancy.(32)
INVOLVING PARENTS Many parents do not know how to communicate about sexual and reproductive health with their children, although they would like to. A survey of Mexican parents in the late 1990s found that 87 per cent supported age-appropriate sexuality education to be taught in schools.(33) Similar findings have been reported in other countries. However, even where supportive, parents are ambivalent and concerned that the contents of education be appropriate to their cultures. Involving them in design and monitoring of these programmes can ease their concerns.
UNFPA and others have developed programmes to help parents communicate effectively with adolescents about sexuality. Family Care International and the International Planned Parenthood Federation/Africa Region have produced materials aimed at facilitating such communication; young people are encouraged to allow plenty of time, not to let embarrassment stand in the way, to show respect for parents and to learn what they can about their parents’ experiences.(34)
INFORMAL SCHOOLING Where school enrolment is low or special needs exist, informal education can be tailored to a target group. For example, the Bangladesh Rural Advancement Committee established informal primary schools for rural youth aged 10-15 who have never attended school, 70 per cent of whom are girls. The programme prepares students to join regular schools. Reproductive health topics are integrated into the curriculum. Special emphasis is placed on involving parents.(35) At least 350 schools have become involved. This project has also built awareness of adolescent needs and influenced community norms.(36)
In Egypt, New Horizons involved community leaders, health workers, religious leaders and parents in designing an informal programme to communicate essential information on life skills and reproductive health to girls aged 9-20. Since 1995, more than 100 NGOs have implemented the programme in seven governorates.(37)