1.1 General Context
1.2 Health and AIDS education: Curriculum activities
1.3 The concerns of young people
1.4 Opportunities for development
The Pakistan study was conducted in January 1993 in collaboration with the College of Community Medicine. The study focuses on Lahore in the Punjab. However, some more general information was also collected.
Health and Education
Pakistan's population is moving rapidly towards 124.8 million, with an annual growth rate of 2.84. Of the four countries in the study, it has the lowest adult literacy rates for both men and women (with 15 million illiterate adults) and, apart from India, the highest student:teacher ratio in schools. Only 50% of children enrol in school and 25% have dropped out by class 2 - resulting in around 75% of children failing to receive basic schooling. Nonetheless, given the population size of 5-17 year old children, this still gives a large school population. Given the poor uptake of education, current donor focus is on primary education, and on improving female access to and uptake of education. There are at least ten major donors involved in primary educational development.
As with the other four countries government expenditure on education exceeds that of health - but is still only set at around 2% of government expenditure.
The country as a whole has a high under 5 mortality rate (134!1000). Health priorities for young people are seen to be URTI and diarrhoea. Typhoid, nutritional problems and infectious diseases are also a priority2. Data on STDs is not available, and neither is information on teenage pregnancy - both of which can be used as important indicators of sexual activity, especially amongst young people.
2 Personal communication with Professor Naeem Ul Hameed, Principal, College of Community Medicine, Lahore.
AIDS awareness and education
Information on AIDS is hard to find. One informant described Pakistan as still being in the "denial stage" as far as acknowledgement of AIDS is concerned. This view was endorsed in discussions with a wide range of people, and evident from statistics - which showed only 24 reported cases in 1992. Of these, around 48% were described as "foreigners". Those who expressed concern about AIDS mainly referred to the problem of infection from migrant workers and from imported contaminated blood products. A few people expressed the fear that Pakistan is unlikely to escape the pandemic that is "ballooning" elsewhere and that this is a problem waiting to happen.
There is evidence that AIDS is on the agenda in both Government plans and the activities of international organisations and NGOs - but has a low profile. In terms of actual implementation, the main Government activities to date have been concentrated on conferences with medical specialists and religious leaders, establishing an AIDS surveillance system, developing plans of action, and some materials production - 4 posters and some handbills have been printed (though none was seen by the researcher on public display anywhere).
Health and AIDS education: a clean slate?
Health education within Pakistan generally is undeveloped - and is virtually non-existent within the public education sector. In the Ministry of Health it comes under the heading of Information, Education and Communication (IEC) most often taking the form of mass media campaigns (e.g.: in support of diarrhoeal disease control programmes and immunisation campaigns). Available plans for development give no indication of emergent policy in this area, nor any reference to more systematic work with schools. The main focus is on developing personnel and undertaking basic research. There is no mention in the health education plans for 1993-1999 on anything to do with AIDS or sexual health.
Quite who might take a catalytic initiative from the government side is unclear. School health services are minimal. The National AIDS control programme has yet to move forward on EC. UNICEF does express interest in school health and health education - and notable successes in public health education stem from UNICEF supported work around immunisation and ORS. However, for sustainability, the initiative really needs to come from within.
There are a wide variety of non-government groups concerned with health and education and health education, with a focus on young people - but these again have difficulty in providing an adequate nucleus for nation-wide or even province-wide development.
As a consequence of the lack of any clear mandate or guidance from central or provincial level, what activity there is appears fragmented, and under-developed. Another limitation expressed by curriculum developers was that changes to the school curriculum tend to be slow and lengthy.
Health education needs assessment for curriculum development
There is no evidence of systematic work by or for government to explore children's health needs, the current health situation in schools, or teaching content, methods or resources relevant to health. The only relevant material found during this study was some UNICEF reports3 on health education within the Primary Education Curriculum Reform project in North West Frontier Province - which noted the poor health environment of schools, and advocated the development of integrated health education work across the curriculum. This work highlighted diarrhoeal disease, iodine deficiency disorders, eye problems, hearing disability and malaria as health issues most relevant to school children.
3 UNICEF Reports by Juliette von Siebold (1990) & Nicola Harford (December 1990).
Curriculum content
"Health Education" content is not a specific subject in the school curriculum of either private or state schools. In theory there is a subject in the primary schools called "Physical and Health Education" and health information forms part of the science curriculum in high schools. In secondary schools, the science curriculum includes some health education. Even though there is some timetable space for teaching about health, this is very limited. The majority of teaching is theoretical. Introduction of more practical teaching methods is seen to be impractical - teachers are low paid, relatively low status, and have little support.
Table 4 gives brief details of the primary health education syllabus4.
4 Extract from Draft Curriculum of Health and Physical Education in Pakistan for Classes 1 - V. National Bureau of curriculum and textbooks, Ministry of Education and Provincial Coordination. Most schools are likely to have one copy of this which is used as a reference.
Table 4: Primary Health Education syllabus
|
|
Personal Hygiene |
|
Class I |
Elimination habits |
|
Food and nutrition |
|
|
Class II |
Environmental sanitation |
|
Class III |
Accident prevention |
|
Communicable diseases - control of |
|
|
Class IV |
Growth and Health |
|
Class V |
Human physiology |
There is apparently brief mention of AIDS in a secondary science textbook - but it was not possible to get a copy of this.
Evidence from teachers, parents and pupils suggests that even this minimum input is often missing. Around half the teachers interviewed echoed the sentiment expressed by this teacher:
"No health education is given in this school as a subject because we have no teachers, no tendency to learn about health, no syllabus."
Parents are equally ambivalent - with half saying that either health is not taught, or they have no idea whether it is taught or not. Clearly health is by no means high on the agenda in schools, although there may be specific schools where it is given some attention.
Of the teachers who said that health education was taught in their schools, most reported physical exercise and hygiene/cleanliness as the most common aspects covered. Hygiene and cleanliness education is reported usually in conjunction with inspections:
"We also check the bodies of children; they should be clean, socks, shoes, ears, eyes, hair."
In some cases it appeared as if this emphasis on cleanliness had negative effects leading some teachers to conclude that such "health education" should not be stressed because:
"if we stress health education too much, the children don't come back to school. They are told to wear proper shoes and a sweater in the winter. The parents don't take care. Fear and financial problems. If we are strict with health it increases the drop out rate. We discuss when the child is not wearing a proper dress. They say we will go to the city and buy medicines. Parents say they do not have the time."
A few teachers mention including food and nutrition education. This is centred mostly around the need to warn children of the dangers of buying food from street hawkers.
"We ask people to take proper food. When hawkers come we ask them to go away." (Focus Group Discussion)
There is minimal reference to disease prevention or health promotion, and a prevailing view that "health" education should actually be "medical services".
Teachers seemed reluctant to deal with sexuality or AIDS at all, believing that this sort of teaching should come from doctors.
Teacher preparation
There are a range of public and private teacher training institutes in Lahore. Notable in the public sector are three Teacher Training Colleges for men, The Government Education College for Girls, a college for science teachers, a specialist Health and Physical Education college and a pre-service training institution. The Education Department of some Teacher Training Colleges also conduct refresher courses. However, the emphasis in training seems to be more on physical education and very little, if any on health awareness. Some anecdotal confirmation of this came from talking to primary school teachers who had left college 3 - 6 years before - none could remember having been taught anything about health. Another secondary school teacher who had graduated in physical education considered the physical education activities to be synonymous with health education.
Supportive Environment
School health services
Many government officials, head teachers, class teachers and health personnel, when asked about health education in the schools, associated this with a school health service. There is a schools health programme, with over 1,000 doctors employed to visit schools for a few hours a day. How operational this programme is was unclear - the general view was that whilst school health services was once seen as a priority, it is no longer so, and in most schools is not evident. Nevertheless the conceptual link between health education and medical services seemed to be widespread.
School health environment
UNICEF has started to look at the question of the health environment of primary schools5 though this work has not been undertaken in the Punjab. The general findings indicated low levels of hygiene - with toilets in only 4% of schools, lack of adequate clean water, and no attention to food provision.
5 Report on Health Education within the Primary education Curriculum reform project, NWFP Teacher training activities, Nicola Harford, December 1990.
A second report6 noted that water in the schools is collected in large concrete tubs in the school grounds and is used for washing hands, cleaning takkiboards and drinking. The sanitary conditions are hazardous. Girls and teachers are not at liberty to leave the school compound and go to the fields so an area behind the classroom has been delegated for this purpose. There is no provision for cleaning. There is insufficient and ventilation. While some of the public sector schools visited as part of the study in the Lahore area had excellent and well maintained facilities, these seemed to be generally described as the exceptions rather than the norm.
6 Report on Health Education within the Primary Education curriculum Reform Project. NWFP. School Curriculum Activities. Juliette von Seibold 1990 - UNICEF REPORT.
There is some evidence that innovation is possible at the local level, especially in private schools, but also in state schools. At the most basic level, health workers may be invited in to talk about a particular health topic. One school visited had a health club. Another noted that in the past she had invited a lady doctor to lecture to the girls and speak to them individually. She felt this was important and useful - especially to talk to the girls about their menstrual periods. However, these events are likely to be the exception rather than the rule, and rely on individual interest and motivation.
School-community relationships
There was little evidence of active involvement of parents in school matters. This was confirmed through the difficulty of organising parent discussion groups. The few informants who mentioned parents suggested they were more likely to act as a constraint to innovation, rather than as support for it.
1.3.1 General Health Concerns
Table 5: Children's health concerns: Pakistan (Lahore)
|
issue |
frequency |
percentage (total n=625) |
|
dirty surroundings |
232 |
37.1% |
|
flies |
214 |
34.2% |
|
mosquitoes |
198 |
31.7% |
|
traffic |
130 |
20.8% |
|
rotten food |
114 |
18.2% |
|
dirty food |
97 |
15.5% |
|
rubbish |
84 |
13.4% |
|
smoking |
37 |
11.7% |
|
industry |
69 |
11% |
The strongest message coming from the young peoples' drawings and writing is a concern about dirt - dirty surroundings, dirty people, dirty food, dirty air, dirty water. Associated with these are vectors (mainly flies and mosquitoes). These concerns are simply, but quite graphically drawn and described by the children - from across the age groups, and with minimal differences between boys and girls. Selected examples provided in the following pages illustrate the strength with which some of these concerns are expressed.
Dirty surroundings
Filth and stench things make us ill. We become unhappy due to filth and illnessI think children are very sensitive. They think about their surroundings
Positive images of health and happiness also emphasise the importance of beautiful surroundings - parks, flowers, trees etc.
Dirty people
A human being himself is responsible for his sickness. If we take dirty things we will fall ill. If we don't keep our teeth clean a bad odour would come from our mouths and we will fall ill. Nails and body cleanliness is essential. If' we take food with dirty hands we will fall ill. By dirty atmosphere and lack of' cleanliness in our homes could lead to sickness.
Dirty water
Standing dirty water in front of house which gives rise to mosquitoes
Dirty food
By eating dirty things the germs enter into our body which make us ill
Some students also show a little understanding about the relationship between diet and health, and the need for a balanced diet, and also the relationship between sweets and tooth decay. The visual images often include sweets and chocolate. On the issue of diet a sex difference is apparent, with girls being rather more likely to talk about dietary issues than boys.
Figure 3 Things that make children "unhappy and unhealthy" - things related to dirt (Pakistan)
Dirty air
I think that the first thing that makes us sick is "POLLUTION"...Good food and good dress is not so necessary for us as good air because we inhale in air. Our lives depends on fresh airThe bad environment, sounds of vehicles make us unhappy and sick...Pollution also makes us ill and weak. The smoke which comes out of the cars makes us sick. It is very harmful to our lungs
Figure 4 Children's concern about pollution (Pakistan)
Problems with parents and personal relationships
Concerns to do with personal relationships do feature, but to a quite limited degree. Girls are more likely to express concerns about problems with parents (10% of girls vs. 3% of boys). Older children are more likely to express these problems than younger ones (under 14 years: 5%, 14 years+: 10%,). These worries are articulated as: "discouragement of the child"; "Parents harsh behaviour"; "rebuke from parents and teachers"; the "environments of the house", particularly quarrels and lack of-co-operation in the home which can lead to people becoming "unhappy and unhealthy"; "burden of studies" and "differences with friends"
Figure 5 Children's concerns about parents, friendships and schools (Pakistan)
1.3.2 Children's understanding-of HIV/AIDS
Out of the total sample of children, only one referred to sex and one to AIDS (both were girls):
[people who] don't wash their hands before eating and they don't enjoy sex with those who are neat and clean and after sexual intercourse they don't take bath which is not a good thing" (girl)Due to diseases like AIDS, measles and whooping cough we remain unhappy (girl)
Thirty eight students also completed an open ended questionnaire on the subject of AIDS. Of these, the majority said they had heard of the disease - saying that it is a dangerous disease, is infectious and is spread by a virus or germ.
Out of the 38, only three mentioned that it is sexually transmitted, and four others that it is passed from man to man or by male-female contact. Five thought it is transmitted through urine/stools. Four described the main symptom as being having an enlarged belly.
From this extremely limited evidence it is none the less evident that some information is reaching these Lahore school children about AIDS. One teacher mentioned that it is in the general science curriculum for ages 15-16 where they are simply told that it is caused by a virus. Three pupils confirmed that AIDS does get a mention in a school text book, others said they had heard about it from the newspapers and TV.
Out of a total of 52 teachers interviewed, only 35 said they had heard about AIDS, and even then commented:
"Even teachers have heard little about AIDS; They don't know much about it."
Parents also showed little evidence of knowing about AIDS. When asked to mention names of serious diseases, TB was mentioned most often, followed by diarrhea Neither AIDS nor any other STD was referred to. Whilst approximately half of a sample of 49 said they had heard of AIDS, there was a clear split in terms of education with literate professionals saying they had heard of the disease and illiterate non-professionals saying they had not.
Research and evaluation
Given the above, it is not surprising that we were unable to find any studies - either baseline work or formative or summative evaluations related to school health education. One curriculum evaluation was mentioned, concerning the health and physical education curriculum, which again confirmed the lack of sanitation facilities in schools.
Clearly more research is needed both to explore children's perceptions of AIDS and to understand the strong opposition to sex education from various levels. From the experience of this research we recommend that future researchers attempting work in this field should expect to devote time to official negotiation in gaining access.
Views of teachers and parents on how health and AIDS education should develop
When teachers were asked what they felt children should be taught about health, the main response was that "they should know about health generally" i.e.: they should know about pollution, about balanced diet, about living "neat and clean" and about the advantages of exercise. Only one teacher mentioned that they should be taught about sex, also commenting that this must be "according to our religion". When asked directly if children should be taught about AIDS, teachers tended to speak in euphemistic terms such as "it can be taught but you must not give strong details" "AIDS can be introduced but with limits".
Parents reflected these views. 19 of the 49 said children should be taught about cleanliness. Again, the importance of maintaining the religious context of any teaching on health was mentioned.
Constraints to further developments in health teaching were seen to be related to lack of syllabus, lack of trained staff, lack of teaching resources, and lack of time available to take on a "new" area of teaching. Some teachers acknowledged that even the current physical and health education syllabus does not get properly covered, but is squeezed out to make time for "more important" subjects.
Teachers did not have much to say about teaching related to AIDS. Those who did comment expressed their own lack of knowledge, and therefore of the necessity to provide specialist support:
"I have very little knowledge and little knowledge is dangerous. So we must be provided some specialists if you want that we may get sound knowledge about AIDS and what measures we take for its prevention. "
Teachers feel that parents do not present a major constraint to developing new teaching ideas. Several teachers felt that parents basically are not interested: "In this area parents are not interested in education. They are interested in certification" Others felt that parents will be happy with whatever the schools provide.
Of the parents, those from professional backgrounds (who were the ones who said they actually had heard of AIDS) raised no objections to having it taught in school - and some even suggested it could be mentioned in primary school. In the group discussion with women from an adult literacy class, one woman expressed the following view:
We should tell unmarried girls also. Because there are some girls who have sexual relations before they are married. So they should also inform the unmarried girls because there are some "Naughty girls amongst them" (translation)
Pupil's health concerns
Much of the "draw and write" data gives a strong message from the young people of Lahore of concern about the health of the environment in which they live. It presents a strong case for improvements in sanitation, garbage disposal and tackling pollution issues - all of which go far beyond the bounds of individually oriented health education. Possibly the challenge for health education here is twofold:
a) how to harness these feelings of young people to encourage them to work towards collective action on such issuesb) how to also help young people recognise what they as individuals can do to protect themselves from an unhealthy environment.
