Birdthistle, Vince-Whitman, 1998
With more children than ever in school, these institutions are an efficient way to reach young people and their families. In the last five years alone, the number of children enrolled in primary school in developing countries has jumped by some 50 million.1
There is substantial evidence to show that education has a profound effect on the reproductive health of young people. An extra year of schooling for girls reduces fertility rates by 5-10 percent.2 Young women who are in school generally delay marriage and childbearing, which enables them to develop their decision-making and negotiating skills, self-esteem and economic earning potential.
Introducing reproductive health programs at schools can have added benefits. At relatively low cost, these programs can help prevent early pregnancy, HIV/AIDS and STDs.3 School staff can also refer students to local health or counseling services when appropriate. By providing reproductive health programs early, it is possible to encourage the formation of healthy sexual attitudes and practices. This is easier than changing well-established unhealthy habit later.4 Finally, many of the elements needed to build school-based programs already exist. Some countries have ongoing school health programs that can be expanded to include reproductive health.5
What has been learned about building support for school-based ARH programs?
School health programs vary tremendously. Building support for ARH programs among government leaders, parents and the community at large can be a challenging task. Through research and program development work conducted by the Health and Human Development Program at Education Develop-ment Center, Inc. (EDC) the following eight factors were identified to be key in bringing about organizational change.6
Vision
It is a challenge to move school administrators and teachers away from daily practices to adopt new ones. More often than not, change occurs as a result of outside pressures. A vision about the ways in which schools can improve their quality and efficiency is an important factor in galvanizing human interest and motivation.
National Guidelines
In numerous projects directed at changing policies and practices within schools, the existence of national guidelines and the involvement of respected leaders have been primary reasons cited by state and local agencies for their participation. The World Health Organization (WHO) suggests that school health programs be introduced by a country’s ministry of education in collaboration with its ministry of health.7
Leadership Skills
To guide planning, implementation and evaluation of a school-based program, it is important to establish a leadership team of committed individuals who have a stake in seeing their vision become a reality. This team should consist of school administrators, students, parents, teachers and community leaders.
Data-Driven Planning and Decision-Making
Data are invaluable in all phases of school-based reproductive health programs. At the outset, timely data can help ensure that programs focus on the real health needs, experience, motivation and strengths of young people, rather than on problems as perceived by others.8 Findings from the assessments can help to frame the main objectives of the program.
Supportive Norms
It is important to consider the social norms of school practitioners — their beliefs, daily practices, and view of young people — as well as their individual responsibilities and roles. Conflicts over values and norms are likely to arise and to be in a position to respond, schools need to involve parents and community leaders in the design and delivery of programs.9 Parent-teacher associations, adult education classes, formal presentations, open houses, religious center activities and community group meetings are appropriate settings for fostering collaboration.
Administrative and Management Support
Advancing the reproductive health of young adults through schools often requires the creation of multi-disciplinary and multi-agency management structures. Clearly defined roles, responsibilities and communication channels in structures that cut across territorial boundaries and the traditional roles of agencies are an important part of the implementation process.
Adaptation to Local Concerns
For innovative programs to become rooted in individual institutions—whether it is within one ministry, one school or one clinic—requires local ownership. This is often achieved through involvement and adaptation of ideas and strategies to local concerns. Few programs, if any, are truly replicated. Almost all, like evolving organisms, are adapted and thrive in a specific culture or milieu.
Dedicated Time and Resources
Implementation of any new program in schools takes at least three to five years. Patience is required in the change process. When teachers or health workers try to master new skills, there is often an initial dip in proficiency, followed by improvement and mastery. Too often policymakers, planners and evaluators attempt to measure changes as a result of innovations too early in the experiment learning phase. Dedicating adequate time and resources to the process affects the success of implementation and ultimately the impact of the program.10
What are the elements of ARH curricula offered in schools?
Students should not only receive sexuality/ reproductive health information in the classroom, but also explore their own values and attitudes to acquire the personal skills they need to maintain healthy behavior. Effective programs provide teachers with training in the use of the health curriculum. In many countries it is possible to select from existing curricula and make minor adaptations to meet local needs. Elements of some school-based curriculum include:
Values Clarification
By exploring and clarifying their values through debates and discussions, students are able to reflect on the implications of their sexual decisions and the attitudes and values that influence them. This clarification can help equip them with the knowledge and skills necessary to negotiate safer sex.
Skill building
Many existing programs are information-based and focus on anatomy, the biology of reproduction and symptoms of STDs. This information alone rarely equips young people with the resources they require to lead healthy sexual lives. Learning activities are needed to focus on skills for responsible behavior in the context of specific reproductive health issues and to build confidence in using the behaviors.
Age and Development Appropriateness
Curricula that are designed as a sequence from the primary through secondary levels respect the idea that sexuality is an evolving life experience. They should be age appropriate both in content and teaching methods and take into account changing physiology and sociology.
Placement in School Curricula
Strategies include (1) implementation of a separate course or unit; (2) infusion of material into core subjects taught by different teachers; (3) utilization of outside educators willing to discuss sexual matters and help students gain access to community health services; and (4) introduction of reproductive health issues through new or existing HIV/AIDS-prevention programs.
What are the issues in training teachers to implement ARH programs?
Active, informal, personalized and participatory teaching methods have been shown to be most effect in influencing the development of attitudes and changes in sexual behavior. Learner-centered and interactive teaching methods have a positive impact on the relationship between teachers and pupils and help to improve classroom behavior, young people’s enjoyment of learning, attendance rates and teachers’ job satisfaction. To ensure ARH programs are successful, the following issues for training teachers should be considered:
Selection of Instructor
Teachers, parents, youth, and medical and health professionals can potentially fill the role of a reproductive health educator. Not all individuals within these groups, however, are ideal candidates for the responsibility. Knowledge, skill, enthusiasm, character and ability to create trust with students are key factors.
Pre- and In-Service Training for Teachers
Teachers can function as healthy role models, advocates for healthy school environments, gatekeepers for students in need of services, resource people for accurate information, and effective instructors. They generally need training, however, to assume these roles. A valuable means of preparing teachers is through reproductive health programs in teacher training institutions and universities. If teachers have not received this training, they should participate in extensive in-service courses, continuing education classes or intensive seminars. Teacher interest can be stimulated by involving them in planning of training sessions, paying for release time, offering continuing education units or re-certification credit, providing free materials and offering reimbursement.
Content of Teacher Training Programs
Included in training should be a review of national and local policies; concept of the health promoting school; mechanisms for program delivery; when, how and to what extent staff should be involved in the prevention and/or early intervention of pregnancy, STD infection, and HIV/AIDS; and an understanding of behavior change principles and techniques.
Innovative learning techniques such as role plays, cooperative group activities, community involvement activities and games and case studies should also be addressed. Content should include such issues as risk factors; policies and procedures for handling sensitive matters; mechanisms for referrals to community-based services; and reassurance that classes and presentations among educators will vary. A critical component of training is to help instructors feel comfortable discussing sexual topics. There should be a mechanism for them to raise questions after they have tried out new subject matter in the classroom. Newsletters, informal get-togethers and meetings enhance their skills and relevant knowledge
Teacher Training Materials
Numerous guides and materials are available to assist individual teachers, institutions and governments develop training sessions. Multinational assistance organizations provide diverse materials for appropriate for different age groups and urban, rural and remote settings. In-country ministries of health and education are also good sources for materials. Teachers and students themselves can generate teaching and learning aids.
How can health services be linked to school-based ARH programs?
Schools can link education to services so that students may bridge knowledge and attitudes with action. School nurses and counselors can help overcome barriers that discourage young people from utilizing health centers, including lack of confidentiality, transportation, inconvenient appointment times, prohibitive costs and general apprehension about discussing personal health matters. They can help young people clarify their feelings and make responsible decisions. WHO’s materials in this area have been used in more than 60 countries since 1986.11
There are creative ways in which schools can provide contraception to students and promote availability among community sources. Condoms can be provided in bathrooms and promoted in posters. Male and female peer promoters can distribute them to their fellow students. Ideally condom distribution should be supplemented with education and counseling.
The promotion of young people’s reproductive health through a coordinated school-based approach is desirable for financial, developmental and practical reasons. By building on what is known in this field, policy and program planners can tailor specific efforts to their own cultural, economic and political realities.
References
- UNESCO. 1996. "Education for All: Significant Progress in All Regions." UNESCO Education News No. 5.
- UNICEF. 1996. "Commentary: Keeping Girls in School." The Progress of Nations 1996.
- WHO/UNESCO. 1992. "School Health Education to Prevent AIDS and STDs: A Resource Package for Curriculum Planners." WHO AIDS Series 10. Geneva: WHO.
- Kirby, D. 1994. "A Proposed Adolescent Reproductive Health Initiative." POPTECH Report No. 94-004-012.
- WHO. 1996. "The Status of School Health." (A report prepared for WHO/HQ HEP Unit by Education Development Center, Inc., Newton, MA.)
- Vince-Whitman, C. 1996. HHD's Approach to Changing Policy and Practice in Systems. Health and Human Development Programs (HHD). Newton, MA: Education Development Center, Inc.
- WHO. 1996. "Promoting Health through Schools: The World Health Organization's Global School Health Initiative." (A report prepared for WHO/HPR/HEP by S. Cohen and C. Vince-Whitman, Education Development Center, Inc., Newton, MA.)
- Baldo, M. 1994. "Prevention of HIV and STD: Are Girls and Women Involved?" In The Kangaroo. (Bibliographic Archives for MCH).
- WHO. 1995. "HIV/AIDS, STD and School Health." (Report of the Expert Committee on Comprehensive School Health Education and Promotion.)
- WHO. 1996. "Research to Improve Implementation and Effectiveness of School Health Programmes." (Report prepared for WHO/HQ HEP by S. Cohen, Educational Development Center, Inc., Newton, MA.)
- WHO/ADH. 1996. Counseling Skills in Adoles-cent Sexuality and Reproductive Health: A Facilitator’s Guide. Geneva: WHO.
The In Focus series summarizes for professional working in developing countries some of the program experience and limited research available on young adult reproductive health concerns. This issue overviews a longer paper prepared by Isolde Birdthistle and Cheryl Vince-Whitman of the Education Development Center, Inc. for the FOCUS on Young Adults Program as part of a publication series presenting the key elements of young adult reproductive health programs.
