Core Intervention 3: Skills Based Health Education

The challenges facing children growing up in the 21^st century, especially the poorest and most disadvantaged children living in low income countries, are greater than ever. Millions of children are affected by problems of poor nutrition, infectious diseases, inadequate access to clean water and sanitation, violence, substance abuse and the increasing threat and burden of living with HIV/AIDS. Children and young people need to be equipped with the knowledge, attitudes, values and skills that will help them face these challenges and assist them in making healthy life-style choices as they grow. Skills based health education delivered through schools is one of the ways through which children can be helped to face these challenges and make such choices.

1 Why Skills Based Health Education?

The application of skills based health education, in particular life skills, to areas such as HIV/AIDS prevention, reproductive health, early pregnancy, violence, tobacco and substance abuse is becoming increasingly widespread. In areas such as these, individual behaviour, social and peer pressure, cultural norms and abusive relationships may all contribute to the health and lifestyle problems of children and adolescents. There is now increasing evidence that in tackling these issues and health problems, a skills based approach to health education works , and is more effective than teaching knowledge alone.

There are numerous studies indicating that providing information about issues such as sex, STDs and HIV (transmission, risk factors, how to avoid infection) is necessary, but not sufficient, to lead to healthy behavioural change (Hubley, 2000). Programmes that provide accurate information, to counteract the myths and misinformation that often surround HIV/AIDS, frequently report improvements in knowledge and attitudes, but this is poorly correlated with behavioural change related to risk taking and desirable behavioural outcomes (Gatawa 1995, UNAIDS 1997a). Skills-based health education can be effective in the more difficult task of achieving and sustaining behaviour change

The skills based approach extends traditional methods of teaching about health, that tend to be knowledge based and didactic in approach. In contrast, skills based health education focuses upon the development of Knowledge, Attitudes, Values, and Skills (includinglife skills such as inter-personal skills, critical and creative thinking, decision making and self awareness)needed to make and act on the most appropriate and positive health-related decisions. Health in this context extends beyond physical health to include psycho-social and environmental health issues. This approach utilizes student centred and participatory methodologies, giving participants the opportunity to explore and acquire health promoting knowledge, attitudes and values and to practice the skills they need to avoid risky and unhealthy situations and adopt and sustain healthier life styles.

HIV/AIDS – a critical need for skills based health education

HIV/AIDS is an area where the scale and impact of the problem is such that the urgency of implementing preventative measures, including skills based health education, is critical. Skills based health education programmes are being increasingly adopted as means of reaching children and young people to help halt the spread of this crippling epidemic. Studies from African countries show that children between the ages of 5 and 14 have the lowest prevalence of HIV infection. Below the age of 5 they are prey to mother to child transmission, and after they become sexually active, the rate of infection increases rapidly – especially for girls (Kelly, 2000). Children aged 5-14 need to be reached at this critical stage in their lives and offer the ‘window of hope’ in stopping the spread of HIV/AIDS.

2 Skills Based Health Education Does Change Behaviour

New York City – Sexuality and HIV education: This study was implemented in 4 schools using 9^th and 11^th grade students (867 students), in intervention (AIDS prevention program) and control classes (no AIDS prevention program). The program focused on correcting facts about AIDS, teaching cognitive skills to appraise risk of transmission, increasing knowledge of AIDS-prevention resources, changing perceptions of risk-taking behaviour, clarifying personal values, understanding external influences and teaching skills to delay intercourse and/or consistently use condoms. An evaluation carried out three months after the end of the program found that the intervention group showed the following positive behavioural outcomes when compared with the control group: decrease in intercourse with high risk partners, increase in monogamous relationships and an increase in consistent condom use. (Walter & Vaughan, 1993).

Nigeria - HIV/AIDS prevention : Health education programmes are being implemented in many schools in Nigeria to increase levels of knowledge, influence attitudes and encourage safe sexual practises among secondary school students. A study to evaluate one such programme was conducted comparing 223 students who received comprehensive sexual health education with 217 controls. Students in the intervention group received 6 weekly sessions lasting 2-6 hours, with activities including lectures, film shows, role-play stories, songs, debates, essays and a demonstration of the correct use of condoms. Following the intervention, students in the intervention group showed a greater knowledge and increased tolerance of people with AIDS compared to the control. The mean number of sexual partners also decreased in the intervention group, while the control group showed a slight increase. The programme was also successful in increasing condom use (Fawole et al., 1999).

New York, USA. A cognitive-behavioural approach to substance abuse prevention: The effectiveness of a 20 session cognitive-behavioural approach to substance abuse prevention was tested on seventh grade students (n=1,311) from 10 suburban New York junior high schools. The prevention strategy attempted to reduce intrapersonal pressure to smoke, drink excessively, or use marijuana by fostering the development of general life skills as well as teaching students tactics for resisting direct interpersonal pressure to use these substances. Additionally, this study was designed to compare the relative effectiveness of this type of prevention program when implemented by either older peer leaders or regular classroom teachers. Results indicated that the prevention program had a significant impact on cigarette smoking, excessive drinking, and marijuana use when implemented by peer leaders. Furthermore, significant changes were also evident with respect to selected cognitive, attitudinal, and personality predisposing variables in a direction consistent with non-substance use. These results provide further support for the efficacy of broad-spectrum smoking prevention strategy and tentative support for its applicability to the prevention of other forms of substance abuse. (Botvin et al., 1984).

USA – School based drug abuse prevention program: A randomised control trial involving over 3,000 students in 56 public schools, implemented a drug abuse prevention program, teaching general life skills and skills for resisting social influences to use drugs. Follow-up data were collected 6 years after the initial baseline survey. Significant reductions were found for both drug and polydrug (tobacco, alcohol and marijuana) use in the groups that received the prevention program, compared to the control groups. The conclusion from this study was that drug abuse prevention programs conducted during junior high school, can produce significant and durable reductions in tobacco, alcohol and marijuana use if they 1) teach a combination of social resistance and general life skills, 2) are properly implemented, and 3) include at least 2 years of booster sessions. (Botvin et al. , 1995).

3 Context for implementing a Skills Based Health Education with HIV/AIDS prevention.

Although there is strong evidence that skills based HIV/AIDS prevention is effective when properly applied and supported, implementing this approach and achieving this success on a larger, county-wide scale is one of the greatest challenges to be faced. To be effective, HIV/AIDS prevention programmes must address the following areas:

Reassure stakeholders that these messages will do more good than harm: Talking and teaching about reproductive health and HIV/AIDS issues does not result in earlier initiation of sex or promiscuity. The evidence suggests that well implemented skills-based programmes, conducted in an atmosphere of free discussion of all the issues, is likely to lead to young people delaying the initiation of intercourse and reducing the frequency of intercourse and number of sexual partners (Kirby et al. 1994, UNAIDS 1997a).

Provide support to teachers: The lack of support for implementation of new programmes is one of the most important factors affecting success. For most teachers both the content and methods of HIV/AIDS prevention programmes are new and perhaps sensitive, and yet the approach has great potential to assist teachers both in their work and also their personal lives since HIV/AIDS is, of course, also affecting teachers. Sufficient support, training, practice and time needs to be available to teachers, in both pre- and in-service training sessions and workshops, to motivate them to apply their new knowledge and skills, rather than continue with the more didactic, traditional teaching methods, which are often focused on information alone (Gatawa 1995, Gachuhi 1999). In addition, sufficient time and an appropriate place must also be given in the curriculum so that all students have access to HIV/AIDS prevention.

Start early: As well as targeting adolescents, programmes need to be targeted at children at an early age, with developmentally appropriate messages, before they leave school (Gachuhi 1999, Partnership for Child Development 1998). Because younger children are generally not sexually active, these programmes will address the building blocks for healthy living and avoiding risk, rather than the very specific issues related to sexual relationships and HIV/AIDS which are progressively introduced to programmes for older ages. However, the large number and diverse age range of children within primary schools is an enduring challenge, especially when addressing sensitive issues (Partnership for Child Development 1998). Active and self-directed learning methods which are commonly used in skills-based health education can be helpful in overcoming these classroom management issues to some extent.

Provide a supportive environment: Schools need to have strong policies and a healthy supportive environment in terms of behaviour of students towards each other, teachers and school personnel. Sexual abuse can occur in schools, with both boys and girls reporting abuse by school staff (Kinsman et al. 1999, Lowensen et al. 1996). Programmes need to address this potential problem by reaching teachers, so that they can become role models rather than neutral or adverse figures in relation to sexual behaviour.

Respond to local needs: Many of the models for HIV/AIDS prevention have been developed in western, developed countries. The available evidence from developing countries, although more limited in scope than the studies from non-developing countries, supports skills-based health education for HIV/AIDS and reproductive health (Hubley, 2000). The main issue is that wherever programs are to be implemented they must be shaped to meet the local sociocultural norms, values and religious beliefs, and need to include ongoing monitoring (Kirby et al 1994, UNAIDS 1999, Kinsman et al. 1999)

4 Content of a Skills Based Health Education for HIV/AIDS prevention.

Reviews of school-based HIV/AIDS prevention programmes (23 studies in the USA (Kirby et al . 1994), 37 other countries (reported in UNAIDS 1999) and 53 studies in USA, Europe and elsewhere (UNAIDS 1997a) have identified the following common characteristics of successful programmes:

• Focus on a few specific behavioural goals , (such as delaying initiation of intercourse or using protection), which requires knowledge, attitude and skill objectives.
• Provision of basic, accurate information that is relevant to behaviour change, especially the risks of unprotected intercourse and methods of avoiding unprotected intercourse.
• Reinforcement of clear and appropriate values to strengthen individual values and group norms against unprotected sex.
• Modelling and practice in communication and negotiation skills particularly, as well as other related “life skills”.
• Use of Social Learning theories as a foundation for programme development.
• Addressing social influences on sexual behaviours, including the important role of media and peers.
• Use of participatory activities (games, role playing, group discussions etc.) to achieve the objectives of personalising information, exploring attitudes and values, and practising skills.
• Extensive training for teachers/implementers to allow them to master the basic information about HIV/AIDS and to practise and become confident with life skills training methods.
• Support for reproductive health and HIV/STD prevention programmes by school authorities, decision and policy makers, as well as the wider community.
• Evaluation (e.g. of outcomes, design, implementation, sustainability, school, student and community support) so that programmes can be improved and successful practises encouraged.
• Age-appropriateness, targeting students in different age groups and developmental stages with appropriate messages that are relevant to young people. For example one goal of targeting younger students, who are not yet sexually active, might be to delay the initiation of intercourse, whereas for sexually active students the emphasis might be to reduce the number of sexual partners and use condoms.
• Gender sensitive , for both boys and girls.

Case Studies

Zimbabwe - AIDS Action Programme for Schools . Zimbabwe has one of the highest AIDS prevalence rates in Africa and young people are particularly at risk from HIV infection and other unwanted effects of unprotected sex. By the age of 19, 44% of adolescent females are either pregnant or have given birth, indicating a high rate of unprotected sex (Ndlovu & Kaim, 1999). In 1992 the Ministry of Education and Culture initiated a Life Skills education programme, in collaboration with UNICEF, for schools (AIDS Action Programme for Schools). The programme is aimed at students and teachers in grades 4-7 in all primary schools, and in grades 1-6 in all secondary schools. It aims to develop pupils’ life skills such as problem solving, informed decision making and avoidance of risky behaviour, using participatory and experiential teaching and learning processes.

Over 2000 teachers have been trained (using pre-service and a cascade model of in-service training) and the programme is taught in over 6000 schools, with equal status as other curriculum subjects. Supporting textbooks and teaching materials have been developed and the programme has the full support of Government and other influential groups such as Churches. (Gatawe, 1995; Gachuhi, 1999).

Challenges for this programme include level of teacher training, skills, experience and confidence. A review in 1995 found that only a third of teachers had received any in-service training. Teachers were unfamiliar with life skills participatory and experiential learning techniques. Many found sensitive topics of sex and HIV embarrassing and difficult to teach.

Zimbabwe - ‘Auntie Stella’ Reproductive Health Education. The ‘Auntie Stella’ health education pack for secondary school students was developed following research by the Training and Research Support Centre (TARSC) in their Adolescent Reproductive Health Education Project (ARHEP) as well as drawing on the experience of the AIDS Action programme. Using participatory research methodology, the ARHEP programme identified knowledge and major concerns of students (e.g. fear of rape and sexual harassment, unwanted pregnancy, lack of money leading to coercive sexual relationships, fear of STDs and AIDS) regarding reproductive health, along with sources of help and information available to the students.

‘Auntie Stella’ is a classroom-based pack consisting of question and answer cards, based on the format of magazine helpline letters (identified by ARHEP as among the chief sources of information for reproductive health for adolescents). This format helps students identify and analyses their behaviour, including risk taking behaviour and situations. Students then take part in exercises to help them devise ‘Action Plans’ and suggest ways that their behaviour could change to reduce risk. ‘Auntie Stella’ has been field tested in eight pilot schools and based on the evaluation and recommendations of this, the program will be expanded to a national level, by taking ‘Auntie Stella’ to other schools throughout the country (Ndlovu and Kaim, 1999).

The initial reaction to the ‘Auntie Stella’ pack by both students and teachers has been positive and encouraging. Expanding the programme has the support of the Ministry of Education and Culture. The next phase of programme evaluation will concentrate on the impact of ‘Auntie Stella’ on behaviour, in areas such as whether the students are actually implementing the Action Plan points developed through ‘Auntie Stella’. Challenges for the programme include helping the students devise and practise realistic strategies and skills for avoiding risky behaviour.

Lima, Peru – HIV/AIDS prevention in secondary schools: A skills based education programme on sexuality and HIV/AIDS prevention was designed taking into account Social learning Theory and constructs of machismo and openness towards sexuality. 14 schools were randomly assigned as interventions and controls. The intervention schools implemented seven weekly two hour sessions, which included discussions, verbal exercises, role playing, familiarization with condoms/contraceptives and lectures. Homework promoted interaction with family, friends and local health institutions. Trained teachers from the schools facilitated the programme. When compared with the control group, the intervention group showed significant changes in knowledge on sexuality and AIDS, openness towards sexuality, acceptance of contraception, tolerance of people with AIDS, self-efficacy and prevention orientated behaviours. (Caceres et al., 1994).

Colombia - Risk factors for adolescents: Life skills trainingis promoted by the Department of Human Development of the Ministry of Health, as part of a health promotion strategy that addresses some of the most important risk factors of children and adolescents, including school drop out, child labour, early sexual activity and adolescent pregnancies, delinquency, violence and substance abuse. In 1996 Fe y Alegria, an international NGO, began implementation of a pilot project using WHO Life Skills training materials, adapted to a Colombian context. The pilot covered 6 schools in 3 regions (1,260 students, aged 10-15, 500 parents and 45 teachers. The project included teacher training and workshops, extra curricula activities and work with parents. Although full evaluation of the project has not yet been completed, teachers, parents and pupils have indicated initial positive outcomes, including; positive changes in behaviour, decreased levels of aggression, greater ability to speak openly and cope with emotions, high degree of acceptance of life skills methods. (Meresman et al., 2000)

Vietnam – HIV/AIDS prevention: A skills based HIV/AIDS prevention project was begun as a UNICEF-assisted HIV/AIDS prevention project of the Vietnam Ministry of Education and Training (MOET) in 1997. The project was undertaken in the context of rapid social and economic change in the last decade, with problems in the health sector of access and equity, and a growing concern amongst health officials of the threat of HIV/AIDS. The primary goal of this project was to equip young people with the information and skills needed to make, often difficult, decisions that would allow them to lead healthy lives, especially in relation to HIV/AIDS/STD risk. A pilot life skills teaching approach was implemented in schools, with teachers being trained and supported in skills based health education. The major focus was on student knowledge, attitudes, values and behaviours – with an anticipated outcome that the programme would also have a positive impact on teaching staff.

Evaluation at the completion of the pilot phase of the project showed that students demonstrated increased knowledge of HIV/AIDS and its transmission, and increased knowledge of how to avoid infection, improved tolerance and improved decision making skills. Teachers also showed an improved level of knowledge and found that the interactional teaching techniques were a great improvement over more traditional didactic methods. A UNAIDS evaluation of the project also confirmed that there the programme was effective for both students and teachers in terms of building confidence, knowledge and abilities. This evaluation also suggested that there was a need to gather future information on student sexual behaviour such as contraceptive use, community and national pregnancy rates and rates of STD infection, to evaluate the impact of the project on behaviour change. (UNAIDS, 2000)

Tanzania - The Lushoto Enhanced Health Education Project : In 1998, the Tanzania Partnership for Child Development carried out a study in the Lushoto district of Tanzania (the Lushoto Enhanced Health Education Project – LEHEP), focusing on worm infection and personal hygiene, involving teacher-led, innovative, active, participatory health education methodology. A randomly selected group of schools was chosen to implement the project and compared with a set of randomly selected schools that were not adopting the LEHEP approach. When results of the programme were evaluated, there was good evidence of improved knowledge and practices in the intervention schools, but not in the control schools, particularly with reference to provision of safe drinking water, water for hand washing, general environmental cleanliness and health awareness. At the outset of the project, no schools provided drinking water, or water for hand washing after using the latrine. By the end of the first year all schools in the intervention area were doing both. A follow up survey fifteen months after the end of the project year found that many of the healthy behaviours adopted in the intervention schools were still being maintained. (Lansdown et al., 2000).

5 The way forward

Skills based health education, promoted in a supportive framework such as that offered by the FRESH schools initiative, offers a new approach to equipping children and young people with the knowledge, attitudes and skills that they need to help them avoid risk taking behaviour and adopt healthier life styles. The scope of skills based health education means that it can be applied to a wide range of areas, especially STD and HIV/AIDS prevention, but also including violence, substance abuse, unwanted situations such as early pregnancy, water and sanitation related diseases, and all areas where knowledge attitudes and skills play a critical role in combating disease and promoting a healthy lifestyle for children and young people growing up in the 21^st century.

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