3.1 The general context
3.2 Health and AIDS education: curriculum activities
3.3 The concerns of young people
3.4 Opportunities for development
The Uganda study was conducted in July 1993 in collaboration with the Institute of Public Health, Makarere University. The study focuses on Kampala, but the basic policy information is relevant to the country as a whole.
Health and AIDS situation
The current population estimate for Uganda is 17.6 million, with an annual growth rate of 2.9% (Census 1991). Roughly 50% of the population are in the age group of 0-15 years.
The infant mortality rate reported from the 1991 national census is 122 infant deaths per 1000 live births. Diseases which affect children especially are related to nutrition, water and sanitation, and natural and domestic environments. Overall, about 45% of all children in Uganda are chronically undernourished and stunted. The common causes of child and infant illnesses are malaria, acute respiratory infections and diarrhoea. Leading causes for under five mortality are malaria, nutritional deficiencies, diarrhoea acute respiratory infections and measles.10
10 Uganda National Situation Analysis of Women and Children, Issue paper August 1993.
Most women (80% in several studies) are aware of one or more contraceptive methods but only 21% have ever used a contraceptive and only 50% are currently using a method.11
11 UHD's 1988/89 in issue paper on Uganda National Situational Analysis of Women and Children, August 1993.
Unlike the other three countries included in this study, AIDS is the number one health priority in Uganda12, being the leading cause of adult death with reported cases doubling every 12 months, and the sixth leading cause of death among the children under five. In mid-1991 an estimated 1.5 million Ugandans (20% of the sexually active population) were HIV+. AIDS cases officially reported were 24,977. AIDS incidence peaks in the 25-29 yr. age group for males and in the 20-24 yr. age group for females - almost six times as many girls as boys have AIDS in the 15-19 yr. age group, and almost twice as many in the 20-24 yr. age group. Although it is known that some young girls do have older partners, there is as yet insufficient understanding as to why the disparity is so great.
12 Subsequent data on AIDS in Uganda are taken from: UNICEF's response to HIV/AIDS in Uganda Update February 1993.
There is enormous geographical variation, with infection rates as low as 2% of sexually active adults in some areas, and as high as over 30% in others (including urban Kampala, where the-in-depth school studies were carried out). Rates are also high in areas which have suffered considerable civil unrest in the past ten years. A consequence of both the civil unrest and AIDS is the very high level of children who have lost one or both parents. The 1991 census recorded 1.5 million children below 19yrs. who had lost one or both parents. USAID, UNICEF and SCF estimate that there are now in the region of 115,000 AIDS orphans, and that this will increase five-fold in the next five years.
Health education in Uganda: an overview
Health education in Uganda is implemented through the Health Education Division of the Ministry of Health. As well as having a central health education unit, the division is responsible for the Health Education Network (HEN), which is coordinated by the National Health Education Steering Committee. HEN was established in 1987, to give health education a more prominent role in supporting ongoing and new health projects within the primary health care strategy. Key concerns when HEN was set up were to reduce mortality and morbidity among children and promote other health activities among the general public.
HEN has started to create a cadre of health educators at district level. At the moment 40 district health educators and 66 assistant health educators are based in the districts. The target is to train enough assistant health educators to place one at each sub-county (totalling 760 AHEs). Health educators are involved in a wide range of activities which are implemented at district level, including school health education programmes aimed at AIDS prevention, water and sanitation, communicable disease control. Health educators are members of the training teams for school teachers. Health educators are supposed to support school health through school visits and monitoring of what is taught.
The Ministry of Health is also responsible for school health services - but does not have a fully operational programme.
Within the Ministry of Education and Sport there is the School Health Education Project (SHEP). SHEP, like HEN, was launched in 1987. Its objectives are:
· To develop a curricula for health education in schools and integrate health education into the existing primary school curricula.· To teach school children life-skills in health in a way that will stimulate them to change their behaviour and also to pass their knowledge on to parents and other children.
· To integrate AIDS prevention in the school curriculum
SHEP is coordinated by the Inter-Ministerial Advisory Panel (IMAP). Members of IMAP include technical staff from the Ministry of Education and Sports (MoES), Ministry of Health (MoH), Ministry of Agriculture (MoA), Ministry of Women In Development (MWID), Ministry of Local Government (MoLG), and representatives of UNICEF, WHO, AMREF, Child-to-child, the Medical School of Makerere University, and Uganda Red Cross.
There appear to be some disagreements about the role and status of IMAP. However, one important viewpoint is that the coordinating office of SHEP should be confined to organising national level training courses, production and distribution of SHEP materials. Responsibility for supervision and monitoring of the project implementation should be at the District Education Office with funds for fuel and vehicles managed at district level. This seems a worthwhile proposal.
Both SHEP and HEN attract substantial donor support. UNICEF, CIDA, SIDA and USAID are covering programme costs, with the government funding staff salaries. The World Bank is expected to fund a new diploma course in health education in Makerere University.
In addition to SHEP and HEN, there is also an extensive Child-to-Child programme. This is primarily a donor-driven programme, (ODA, UNICEF and a Norwegian agency) implemented by the Institute of Teacher Education in Kyambogo (ITEK) Kampala. It is based on the UK Child-to-Child Trust ideas aimed at promoting the health of children, their families and communities, through the active participation of children in health issues.
Child-to-Child again has a national steering committee, chaired by the principal of ITEK. Other members include representatives from the MoH, MoES, MoLG, NGO's, the Vice Chancellor of Makerere University and the Head of the Child Health Development Centre. Several of these members are also part of the IMAP.
Child-to-Child also has a National Coordination Committee which consists of 15 zone coordinators plus the coordinator of the Child-to-Child programme and 4 members of the steering committee. Decentralisation of monitoring and supervision is recommended by the Child-to-Child programmes and the ones implemented in Kabale and Jinja, where Child-to-Child programmes work in close cooperation with the District Education Office, are perceived as doing well.
Child-to-Child collaborates with a number of other non-government organisations - for example:
· AMREF on Child-to-Child and health education in schools,· RED BARNA on AIDS orphans,
· SCF on Child-to-Child in children's homes
· Uganda Red Cross on Safety, AIDS Control Programme,
· Minds Across on children writing for children,
· International Christian Children on Productive Education, self confidence building and self reliance for out of school children.
Two teacher training colleges along with eight associated schools are involved in the Child-to-Child project: Buloba Teachers college and Nzigo Teachers College. They work through child-to-child activities across the curriculum, explore collaboration with MoH activities and stimulate outreach activities.
At least 181 known schools participate in so called "self-generated" Child-to-Child activities. These schools take it upon themselves to organise Child-to-Child activities which are recorded in school action plans. Activities are chosen to be in line with the SHEP health education curriculum. Children make posters, songs and drama related to health education messages.
Links between the AIDS control programme and education
It is not coincidental that 1987, the year that the health education initiatives described above were started, is also the year that the Uganda AIDS Control Programme (ACP) was started. AIDS has been seen by several key informants to have been the catalyst for many of the health education developments and innovations, which have yet to emerge in the other countries included in this study.
Public health education was a major ACP component from the start, and has been subjected to monitoring and evaluation at several points. Recommendations from the 1991 review13 indicated that public awareness of the disease is high, but that
"AIDS educational activities should move from the focus of information provision to the open discussion of sexuality and sexual behaviours and the personalization of risk of HIV/AIDS so that all efforts are concentrated on supporting and maintaining realistic and culturally relevant options of sexual behaviour.The information collected in this evaluation exercise...indicates very strongly the need to offer a multiplicity of behaviourial options in order to control the spread of AIDS"
13 An evaluation study of Uganda AIDS Control Programme's IEC activities Draft report 1991 ACP/MoH and WHO/GPA
This statement has important implications for the content and style of AIDS education in schools, stressing as it does the importance of moving on from transmission of the basic facts about HIV/AIDS, to discussion of sexual behaviour.
There are close connections between the ACP and SHEP, and HIV/AIDS is addressed in the school curriculum.
The other main connection between school education and AIDS work is the Safeguard Youth From AIDS (SYFA) movement. This is a combined initiative of UNICEF, Uganda AIDS commission, the AIDS control programme and the AIDS information Centre, which aims to reach in and out of school adolescents. Schools are stimulated to help establish health clubs, hold drama competitions, establish fellowships. SYFA is supporting research into how young people can protect themselves against AIDS, and organisations whose target group is working with young people.
Health and AIDS education needs assessment for curriculum development
To date, neither the Ministry of Health nor the Ministry of Education and Sport have undertaken any kind of detailed health survey focused on school-aged children. Main causes of mortality and morbidity can only be extrapolated from general population data. However, there is a considerable body of evidence on adolescent sexuality which could be used by curriculum planners. Much of this has been brought together in a comprehensive review carried out by Barton and Olowo Freers (1992). It shows that acknowledgement of pre-marital sexual experiences differs by region (for example 18.5% in Northern Madi, 44% in Kampala). Findings of different studies carried out in Kampala show an average age for first sexual experiences ranging between 13.6 and 15.7, with some children starting as young as 10yrs.
There are many Knowledge, Attitude and Practice (KAP) studies related to HIV/AIDS. An example of such a study was carried out by AMREF among primary school students in Kabale District (Bagarukayo et al 1992). This study also shows that there is a high level of sexual activity in Primary level 7 (average age 13.94) with 38.5% of females and 61.5% of males stating that they had already experienced sexual intercourse. A worrying factor is the stated increase of forced sexual activity since 1989. 49% of the sexually active girls and 20% of the males reported being forced to have sexual intercourse and 22% of the females said they had received gifts or rewards.
Health education curriculum and textbook contents
In 1987 health education was integrated into the basic science curriculum on a basis of 40% health education and 60% science. A syllabus, teacher guide, pupil text books, school health kits (on AIDS, water and sanitation, diarrhoeal diseases, and immunisation), Primary Leaver Examination (PLE) syllabus and specimen paper, and a consolidated PLE syllabus 1991-1995 were developed.
Subjects taught as part of the Basic Science and Health Education Curriculum at primary schools are:
Hygiene and Sanitation
Common Diseases
Primary Health Care
Food and Nutrition
Immunisation
Family Health and Social Problems
Accidents and First Aid.
Education on HIV/AIDS is integrated in grade 6 and 7 of primary schools as part of the teaching on STD's.
At secondary level, health education does not form a distinct part of the curriculum, but is integrated into science subjects (especially biology).
AIDS is included in the biology syllabus, within a section on common diseases. A special AIDS pack, A safer living, safer loving has been produced for secondary level students by Macmillan's publishers, in conjunction with TASO (the AIDS support organisation).
Evidence from the policy analysis and from the teachers suggests that most of the teaching around health focuses on:
1) issues concerned with personal health and hygiene, such as mention of specific diseases, disease vectors, personal cleanliness, diet and food hygiene, drugs (including smoking and alcohol), exercise, accidents2) issues concerned with personal relationships (with parents, with friends, and with self
3) issues concerned with the environment (both local - such as sanitation facilities, housing, refuse disposal, water quality and more general - such as pollution from traffic and industry, and deforestation)
Health and AIDS education practice
Teachers perceptions of what is taught
Evidence from discussions with teachers confirms the conclusions of the "policy" document that health issues are quite extensively covered within the school curricula - both primary and secondary.
Health issues specifically mentioned by teachers included:
- nutrition: how to obtain food; why is it important; balanced; diet nutrition related diseases- diseases: how caused (eg: bacteria, viruses, houseflies, mosquitoes); the different organs affected; diseases like AIDS, common diseases like diarrhoea, typhoid, cholera etc. Also diseases caused by poor conditions of living, dirty water and the like
- cleanliness, personal hygiene, sanitation,
- physiology of humans. How different parts work. We discuss reproduction, how to build up a good family, control of birth.
Teachers also confirm their role in AIDS education, with some being very clear of its importance:
"It is a matter of survival so then it must taught. If you want to perish then leave it. Be it in or outside class. A class environment is ideal. " (primary school teacher)
Teachers from the SHEP "model" school, and from one other secondary school also confirmed their involvement in extra-curricular activities, including "Hydra", a drama competition (this is picked up later in the children's responses).
General teaching methods
In general, teaching methods in Ugandan schools are didactic and teacher centred. Large classes (for example 100150 children in one class in a Kampala school), and limited teacher training and resources militate against innovation. Reviews of in-service training where participatory methods have been introduced show that, when teachers are subsequently followed up, the majority have lapsed back to basic "chalk and talk". However, this general picture should not overshadow the efforts of some teachers, who attempt more participatory teaching styles (eg: involvement in the Hydra drama competition mentioned above).
There are examples also of support for more active teaching in the SHEP materials. The secondary level book: A safer living, safer loving, for example, encourages "participatory learning through the use of active learning methods, such as role play, small group discussions, case studies and interactive radio and community action projects, which go beyond the classroom and can help pupils to explore and practice positive health behaviours."
Teacher preparation
Pre-1987, teacher preparation for health education was limited, and ad hoc. With the start of SHEP, a 5-day in-service programme was introduced for primary school teachers. This was extended to a 10-day course in 1989. There are 37 facilitators at national level available to run these training courses.
There are now moves to introduce health education into basic teacher training, as a specialist subject area. Work on this was started in 1992, and was due for implementation in 1993/4. Already, 50 college tutors have received training.
Preparation for teaching about AIDS takes up one day in the 10-day primary teacher programme. Secondary teachers were given a "crash course" by a Ministry of Health task force in 1989.
The other form of teacher preparation is for the Child-to-Child programme. The Institute of Teacher Education (ITEK) provides a one week course for zonal coordinators, who then train teachers in their own zones. Two other training colleges are also involved in this programme.
There is clearly a lot of activity and thought that has gone into teacher training for health, and especially for AIDS education. However, there are still problems with it. SHEP requires considerable adaptability and energy on the part of teachers, and appears to work most effectively in areas where there is good NGO support to schools. Another problem is that there are few female teachers involved in AIDS education in schools - they rarely are selected for in-service training.
Supportive environments
School environment
Teachers see the problem of teaching children about health in an essentially unhealthy environment - and when teachers and parents themselves often demonstrate unhealthy behaviour:
"Smoking is bad but..." [teachers still smoke]"Pollution is bad and yet when they go out the students see that nobody cares"
"We talk about balanced diet - when the school meal is beans and posho (maize meal); tell them to drink boiled water when the school itself does not provide boiled water."
During visits to schools researchers made a note of toilet facilities for the children. Numbers ranged from 150-200 children per toilet - and cleaned at best once per day. Whilst all the schools visited were in good condition and quite well maintained, the comparison between urban and rural schools indicates quite different standards.
Additional support for health and AIDS education within the school context
There are a wide range of innovative activities - either organised as extracurricular or out of school activities sponsored by a range of government and non-government organisations
Health workers and specially trained AIDS counsellors do special sessions on AIDS in schools. For example, TASO (the AIDS Support Organisation) has trainers who will go to schools on request.
SHEP produces a magazine, which, amongst other things, encourages children to talk about different health issues, including AIDS.
Drama is seen as an important medium for AIDS education. In 1991 a drama competition was organised. Two plays were written: Hydra for secondary schools and the Riddle for Primary schools. The primary school drama script was prepared by a group of professionals and given an open ending. The children are then expected to design their own endings. Drama is seen as a medium to address issues that cannot be addressed in the classroom. Situations out of control of the children such as sexual abuse and economic needs are addressed in the play the Riddle. TASO is also planning to use drama in AIDS education.
Essay competitions have been organised These could provide a fascinating data base of children's experiences of AIDS, if analysed carefully.
Clubs are also proving popular. Both TASO and the Safeguard Youth from AIDS (SYFA) movement are actively involved in establishing and maintaining these clubs. TASO has just started forming Youth AIDS challenge clubs. The initiative started with young secondary school youth who had lost at least one parent. The methods used are participatory and start with what the participants want to know. Discussion is focused on expelling myths about the disease and providing a comfortable climate in which to discuss questions about their own sexuality: How do they feel? What do they think about having sex at this time in their lives?
At least 181 known schools participate in so called "self-generated" Child-to-Child activities. One encouraging initiative is AMREF's special project in collaboration with SHEP (1992-95) to combat the spread of AIDS in the primary schools of Kabale District, using a Child-to-Child approach.
3.3.1 General Health concerns
Table 9: What do children think makes them "unhappy and unhealthy"?
|
Issue (including most salient sub-issues. Note: a pupil may mention more than one sub-issue) |
Total number of pupils who mention the issue |
% frequency N=688 |
|
food hygiene |
344 |
50% |
|
uncovered food/flies on food |
224 |
|
|
contaminated drinking water |
196 |
|
|
unwashed food |
75 |
|
|
latrines/water sources |
339 |
49% |
|
broken latrines/urinating outside |
170 |
|
|
dirty water sources |
159 |
|
|
dirty pit latrines |
135 |
|
|
relationships with parents |
336 |
49% |
|
death of parents (actual and feared) |
173 |
|
|
beating/abuse from parents |
92 |
|
|
local environmental hygiene |
265 |
39% |
|
dirty surroundings |
140 |
|
|
poor housing |
105 |
|
|
rubbish everywhere |
61 |
|
|
specific diseases |
246 |
36% |
|
AIDS |
162 |
|
|
diet |
207 |
30% |
|
not enough food/starvation/famine |
115 |
|
|
unbalanced diet |
70 |
|
|
vectors |
206 |
30% |
|
flies |
93 |
|
|
mosquitoes |
60 |
|
|
problems at school |
166 |
24% |
|
fear of failure/bad marks |
68 |
|
|
problems with teachers (beating; teachers absent; favouritism) |
47 |
|
|
accidents |
164 |
24% |
|
road traffic accidents (cars and bicycles) |
115 |
|
|
political/social issues |
161 |
24% |
|
poverty |
83 |
|
|
relationships with friends |
140 |
20% |
|
quarrelling/bad friends/bullying |
95 |
|
|
drugs |
135 |
20% |
|
smoking |
80 |
|
|
alcohol |
63 |
|
|
pregnancy |
130 |
19% |
|
pregnancy/lack of family planning |
72 |
|
From the summary in table 9 it is clear that the children associate many of the issues taught and raised by the teachers with what makes them unhappy/unhealthy. Whether they raise these issues because they are taught or because they are concerned about them cannot be distinguished easily. However it is more likely that issues which are not taught but spontaneously raised by the children are issues that they strongly associate with health and happiness.
The summary statistics mask the richness of the children's responses. The following extracts from children's drawings and comments give some flavour of their views and an idea of how health teaching is conducted.
Children's concerns related' to familiar health education
Hygiene
Someone who is eating hates seeing someone who is defecating in front of him because it is unhygienic. - it flies carry germs from faeces and urine to the food another person is supposed to eat, that person may come without washing the hands and eats the food. On eating the food, the germs go into the person's stomach and can easily cause disease" (boy, 12yr..)
The health environment of schools and localities
The views expressed in the following quotations give some insight into the "health environment" of schools and of localities.
Our school toilets should be repaired, the pits are broken there is no water for cleaning the toilets after use, our urinals are so dirty to look at, they have green plants grow on them the urine can't pass through because where the urine is to pass it is blocked....our latrines should be built far away from water source because when the urine is blocked all the faeces will move to the water source. (boy 12yrs)Things that make me sick and unhappy are: dust bins which are not cared for by city council, poor sanitation, unprotected container filled filled with garbage, these things make me sick in the way that if these things are not cared for well, people around this place will get diseases e.g.: i) diarrhoea ii) malaria iii) cholera iv) trachoma etc." (boy 14yr.)
Figure 12 Children's awareness of personal hygiene, diet and health (Uganda)
Figure 13 Children's concern with environment hygiene (Uganda)
Concerns which are not directly related to health education teaching
Problems with parents
Of the concerns mentioned which are not directly related to the textbooks almost 50% of the young people involved in the study describe concerns about their parents. Many express a general worry about parents dying. In most cases this appears to be something which worries them rather than something which has actually happened to them. Another common concern is with "beatings", for example:
What can make me unhappy is over beating in both homes and schools. Most parents and teachers do like beating too much. And the beating is not the one to three they say the least is three If eel that beating a child without making he/she understand that he has done is bad. (boy 15yr.)
Another source of unhappiness is related to how the children see their status in relation to others in the household:
we some of us who are staying with in laws - sisters - you find that you can be coming from school you are very hungry but you find your sister in law taking evening tea. Instead of welcoming you just say get a paper bag to go to the market to buy food....Not only that but again when you will come back from market, you will still get her on her mat and tell you I want to take a bath. And meanwhile you have finished taking water she goes to bath only bathing will finish 3hrs. You will prepare supper to take to the bedroom for her afterwards. She will start complaining that the food is not ready is even burnt, who will eat this, then she say go and buy for me bread. Quickly even if its dark but you have to go. If you refuse she start abusing you then I start crying after that she say I count 1,2 when all your tears has disappeared." (girl 15yrs)What mostly makes me unhappy is a family in which I come from. I am living with a cousin of mine but his wife makes me sick. She doesn't want me to sit down and concentrate on my books. All the time she wants me to do house work when I try to sit and read my books she comes pointing at me pouring out bitter words, really my dear friend I don't know what to do about this."(boy 16yr..)
Figure 14 Worries about parents and relationships
Concern about drugs
19.6% of respondents included various forms of drug addiction in their views of what makes them unhappy and unhealthy. Smoking predominated, followed by alcohol. Some also mention passive smoking and related smoking to diseases, especially cancer.
Most images and comments on alcohol were general. However, several associated it with fathers drinking beer and then becoming abusive with their wives and children. In the children's comments on AIDS, alcohol is also seen as a "danger problem" as it is associated with discos, other drugs and sex.
Figure 15 Children's awareness of the dangers of drugs and alcohol (Uganda)
Concern about accidents
Just under a quarter of the pupils involved in the draw and write exercise refer to accidents - the majority of these being road traffic accidents. Other accidents include getting burnt on fires, injuries from playing and poisoning
Figure 16 Worry about accidents (Uganda)
Concern about pregnancy
Unwanted pregnancy was a concern expressed by about a quarter of the girls in the sample. Fears around this focus on the isolation of the girls: several of the images of pregnant teenagers show a girl on her knees in front of an angry parent, ready to beat her, others talk of persuasion tactics of young men trying to encourage them to have sex - and then dumping them when they become pregnant; some mention how pregnant girls can be "chased away from school".
For the care of the pregnant girl, I think she need more love that ever because in her solitude she fails to notice any love - which she needs most - the whole world is against her - so death is the solution she gets which is very unfair (girl 16yrs)
Some of the boys also mentioned pregnancy as a problem but their view of it appeared to exclude the role of boys in teenage pregnancies. It appears to be seen as "their (i.e. girls) problem":
They are brought into troubles because they cant say no to sex or they tell their faithful partners to get rid of the use of a condom (boy 16yrs)...school girls who produce unwanted babies and then throw then in pit latrines after seeing that they are bad (boy 16yr..)
Figure 17 Fear and worries about pregnancy (Uganda)
3.3.2 Children's understanding of AIDS/HIV
194 (28.2%) of the young people who took part in the draw and write exercise specifically mentioned AIDS as something which makes them unhappy/unhealthy - before they were aware that they were going to be asked to give further information on their awareness of AIDS. Secondary school children were much more likely to mention AIDS (40% of them raised it as an issue compared with only 8% of primary school children).
If one combines mention of use of condoms, HIV testing before sex, and other comments on sexual practice, over 80% of the sample specifically talk about the connection between sex and AIDS - and most of those who don't mention sex directly imply it.
Ideas about prevention
When asked to draw and write about how they can protect themselves from AIDS, all were able to write something, and the majority of the sample could put forward at least six different ideas on how to protect themselves. Girls tended to put forward more ideas than boys.
Table 10: Ranking of ideas put forward by the total sample
|
School pupils' ideas on how they can protect themselves from AIDS (Issues raised by 20% or more of the children). |
Number of pupils raising the idea |
% Frequency N=688 |
|
using condoms for protection |
417 |
60.6% |
|
taking care in hospitals - ensuring new needles used/equipment properly sterilised |
391 |
56.8% |
|
having blood tested (blood transfusions and also HIV testing for sexual partners) |
317 |
46% |
|
abstaining from sex/keeping to one faithful partner/avoiding casual sex, |
233 |
33.9% |
|
promiscuity, adultery avoiding people with AIDS (PWA)/segregating certain groups eg: prostitutes and PWA |
177 |
25.7% |
|
HIV tests (NB: subset of the third item. referring to frequent testing of sexual partners/testing before sex or before marriage) |
137 |
19.9% |
One thing which is significant to note is the very small number of pupils who put forward misconceived ideas about how to protect themselves from AIDS. A total of 11 suggest that you can protect yourself through contraceptives other than the condom (the diaphragm, coil and pill are mentioned), or by using tampons. Only 22 talk about avoiding close contact with people - eg: not sharing food, standing close to people, etc. The students who put forward these ideas were from across the seven schools, with only two or three per school.
Protection against AIDS: use of condoms
60% of the children participating in the draw and write exercise talked about the use of condoms in AIDS prevention. There was some difference between primary and secondary groups but the difference is not significant when you compare by age group (using 14yrs as the cut off point) - indicating that the difference is more "school related", with one of the primary schools showing a substantially lower frequency of mentioning condoms than the other.
Boys were more likely to talk about condoms than were girls. In many cases the idea was simply portrayed by writing "using a condom", often with an image of a male with erect penis, or of a condom packet. Several of those who drew condoms or condom packets also included brand names - especially "protector" and "sultan", and quite often with "made in the USA" written on them. A few boys gave long lists of condom brand names. There is also some confirmation from teachers, through the focus group discussions, that boys not only know about but buy and use condoms:
"at least every week five pupils buy condoms in a nearby shop - the pregnancy rate has dropped tremendously, maybe it is because of HIV infection, use of condoms, financial hardships of male students i.e.: they don't go in for female students"
A number of boys expressed some distrust in the safety of condoms, believing that "A condom may be 90 percent safe but not a hundred correct safe because it may be dangerous to use a condom which has past from date shown on the bag" and that condoms can have perforations which renders them unsafe.
Figure 18 Children's knowledge about condoms
Ensuring good practice in hospitals, and testing blood for HIV
56% of the sample include one or more ideas related to the use of sterile instruments in hospital - ensuring that new needles are used, that instruments are properly sterilised, or that you take your own needles to hospital. The girls mentioned these ideas more than the boys and they were also mentioned more frequently by primary school children than secondary school children.
46% also mention the importance of checking blood for HIV. Around half of these refer to checking blood used in transfusions. The rest talk of HIV testing before sex, before marriage, or regular testing for couples. Neither the general issue of blood testing, nor testing connected with sexual relationships differ significantly by age or sex.
Arising out of this data are two issues which may cause concern to educators:
i) a number of comments associated with the notion that some health personnel are actively trying to infect people with AIDSii) the apparent trust in HIV testing as a form of "protection" - and, if these young people actually follow through what they are saying with action, the massive strain there would be on HIV testing.
Figure 19 Hospitals, blood tests and AIDS/HIV
Protection by abstinence ('avoiding temptation') and monogamy ('zero grazing')
One third of the sample talk about abstaining from sex, sticking to a single partner, not indulging in casual sex or committing adultery. This view is more common amongst primary than secondary school children.
It would be best for one not to play sex at all then when you've got a partner who has proposed marriage and your willing, you go for an HIV test and if you are both negative you can get happily married. 3. Avoid accepting boyfriends who have so many other girl friends and indulge into promiscuous sex exploits when they are still young because if your to marry such a man with a teenage background of that kind he is very likely to be unfaithful during your marriage life." (girl 15yrs)
Only 7% specifically talk about avoiding sex with prostitutes or homosexuals.
17% of the sample make the connection between sex and discos bars drinking - saying that to avoid AIDS you need to avoid places where you are likely to be tempted to have sex.
There are a few pictures of the media phrase "zero grazing" showing a tethered cow - with explanation to its meaning.
Figure 20 Protection through abstinence and monogamy (Uganda)
Girls' perception of their vulnerability, and their ideas on how to protect themselves
It is interesting to note the that girls' feelings of vulnerability to the threat of pregnancy is frequently linked to a fear of becoming infected with HIV/AIDS. The threat of rape, persuasion tactics of young men, material "bait" offered by adult men (a couple specifically mention teachers getting sexually involved with pupils) are some of the concerns expressed in the images and comments.
...I feel unhappy when a boy runs after me really also me feel sick because this time is an aids era when you see like boy wanting to make love to you, you know he wants you to die which I dislike so much. On addition to that it is so amusing to that a boy can make a girl pregnant and afterwards denies the pregnancy. (Girl 19yrs)Being raped by adult people who some times have got aids... some parents don't give their children things they need when sometimes their useful so children end up looking for people who will provide then money where by they get pregnancy because you cant take peoples money for nothing who is not our mother or father. You can imagine nowadays thing changed even cousins don't respect each other (girl 15yrs)
What can girls do to protect themselves?
Inform adults of boy's advances
Some try to protect themselves by telling their parents or teachers.
...By giving any letter I receive from a boy to my mother because I don't fill with a letter from a boy. I give it to my mother to know the boy who disturbs me, he can rape me and I get pregnant and he refuses the baby. I will have evidence to show that he is the father of the baby my mother will know everything that he used to write and talk. (girl 15yrs)
Avoid bad company
Some recommend avoiding bad company:
You may have a friend of yours who is very interested in sex affairs. This friend is not a good friend because she might lead you into problems. Supposing she might be a victim, and she might want you to also get affected. So what she does is to find you a boyfriend whom she is sure is a victim. She might also tell you that the guy is HIV negative. In the end you end up by getting affected too. This can be avoided by abstracting from such friends and stay with those who are interested in studies." (girl 17yr)
Figure 21 Girls' perception of their vulnerability and what they can do to protect themselves
Where do children learn about AIDS?
Children from all schools volunteer the idea that you can protect yourself from AIDS through learning more about it from school and images of AIDS education in a formal classroom setting are common. However, there are also very many references to mass media AIDS slogans - such as "zero grazing" and "love carefully", and it is impossible in this study to be able to assess what the children have picked up from the media, what they have picked up from friends and through hearsay, and what they have learnt at school.
Figure 22 Where children learn about AIDS (Uganda)
Evaluation of health and AIDS education in schools
There is plenty of evidence to show that evaluation is included in both the School Health Education Project (1991 internal review and 1993 external review), and in the AIDS control programme IEC efforts (1991 external review).
The internal review of the SHEP programme in 1991, as was mentioned earlier, highlighted problems in teacher training. The discovery of problems in teacher training has led to the development of a health education training module.
The 1993 review of SHEP indicated the success of the project, but also highlighted some problems which need to be addressed. These include: involving a much wider range of people in the initial development of syllabi and materials; establishing effective follow-up support mechanisms; addressing the gender problem - where there are few female teachers involved in the project.
On the issue of materials development the 1993 review states that the target audience, school inspectors, National Curriculum Development Council staff, SHEP project staff and teachers should be involved in the development of the secondary school syllabus and teacher training guides, and in the revision of materials which have already been produced.
The 1993 review also raised the problem of materials getting to the right place fading that some schools get too many books and others not enough. In some areas books intended for free distribution are sold in commercial book stores. A co-ordinated district focused system of distribution of materials to all schools needs to be put into place.
A number of key informants reiterated problems of follow-up mentioned by the 1993 review team. Sustainable follow-up of schools by a team of school inspectors and health educators at district level has failed, due to a complex of reasons: lack of transport and finances for allowances; under staffing at district level; and lack of training in follow-up of SHEP activities.
SHEP has also evaluated the impact of specific activities. For example, a study was carried out as a follow-up to the drama competition.
Child-to-Child has also undertaken an evaluation (1992).
From the above, it is clear that evaluation reports are seen as important for further programme development, and do lead to change and development. One example of this is the developments in-service training in the SHEP programme. Another is SHEP's involvement of teachers and teacher trainers in current work on the health education curriculum and materials for secondary schools.
Teacher support for developments in health education
The general view of teachers is that there should be more of what is already taught. Some also say that there should be a separate health science subject in secondary school.
Teachers do suggest changes to current teaching, to make it more relevant and practical. They also put a strong emphasis on prevention, especially focused on hygiene (which, from the draw and write, appears to be important already). Several refer to the importance of teaching about AIDS - with some feeling it should start from the first year of primary school. Others talk more generally of teaching related to sexual health and relationships. The constraints they mention are primarily to do with resources - for example: lack of suitable textbooks, lack of sufficient information about certain "killer" diseases, lack of practical equipment, lack of visual aids, no curriculum guidance on family planning and not clear syllabus.
Teacher support for development in AIDS education
From discussions with the teachers, there is general agreement of the need to tackle "all aspects of AIDS" (in which they include: causes, transmission, behaviour change, care of people with AIDS). Teachers feel that AIDS teaching must take into account the age of the child, but could start at P1.
Some teachers are still cautious about teaching the use of condoms - expressing the fear, which seems common the world over, that young people will experiment with sex if they are taught "too much".
"For example about the condom - the children should be given the knowledge but as for demonstration on how it should be used, it should be left to the adults.""Students are inquisitive. Once they taste the facts they want to find out more. Then they want to experiment. You encourage them."
"Condoms were never made to prevent AIDS. They were made for family planning. It is not advisable to teach students about the use of condoms".
However, others agree that condoms must be taught and taught practically:
"...the condom is not the problem, but how it is used. Even adults don't know how to use it....adolescents should be given time to know how a condom should be used and its shortcomings. But information on condoms should not be given prominence or priority.""I feel on the issue of condoms. Condoms bought should have a model. Shows how to use it. If somebody has the guts to go and buy them they should be taught."
Teachers seem to be prepared to continue with AIDS education but add the following suggestions:
· outsiders with special expertise may be useful, and people with AIDS could be encouraged to become involved.· children should learn about AIDS from same sex teachers (which therefore means that the gender disparity in in-service training on AIDS must be addressed).
· parents do not have a major role to play in AIDS education because of the difficulties parents seem to have in talking to their children about sex.
· resistance from parents on teaching about AIDS is unlikely - except possibly if there is explicit teaching on the use of condoms
Promising options for development of health education including AIDS education in Uganda
Before highlighting a number of promising options for further development, it is useful at this stage to summarise some of the current constraints:
· There is still considerable ambivalence about discussing sex openly in school (and, for example, to ensure that young people know about and are able to make proper use of condoms). There are also potential barriers from both religious quarters and from parents.· The large classes, limited human resources and low salaries of teachers makes it unlikely that small discussion groups of same sex pupils and teachers can be held on a regular basis. The curriculum is already full and teachers are unlikely to spend time outside school hours without some incentives.
· Voluntary action by teachers who get involved in clubs and other extra curricular activities does take place but cannot be expected to take place on a large scale unless a reward is offered.
· Few female teachers are trained which also limits the number of small groups that can be organised for female pupils.
· Involvement of male teachers to discuss sensitive issues around sexuality with girls is not recommended for two reasons:
1. the potentially mixed role of a trusted counsellor who may at the same time be having sexual contact with girls and2. the difference in experience of and outlook on sexuality between men and women.
That said, we can look optimistically at opportunities for consolidation of school health education programmes and development of extra curricular activities which have already started. The opportunities mentioned here are presented in relation to on going programmes and activities and are intended to strengthen these activities rather than provide a range of new initiatives.
1. SHEP programme
Recommendations for the SHEP made by the external review in 1993 need to be put into place. Special emphasis should be placed on formulating objectives in behavioural terms, improving distribution of materials, decentralising supervision and monitoring, and co-ordinating responsibility for teacher in-service training.
A review of the relevant studies into sexuality and adolescents, and an analysis of students' essays submitted for the competition could provide valuable information on which to base behavioural objectives. The action research strategies developed by AMREF and SYFA could help in formulating specific objectives in the different districts and regions.
2. Review of the health education syllabus
Some of the teachers indicated that not all of the content in the syllabus is relevant. A careful review of the teaching content might provide some space in the already full curriculum.
3. School health services
The potential of school health services and environmental conditions need to be looked at in greater depth than was possible in this study. Collaboration at district level between MCH teams, assistant health educators and schools could be improved to ensure at least one school check and immunisation programme per school per year. Another recurrent issue is the availability of sufficient functioning toilets and water points for pupils.
4. Counselling roles of female teachers in schools
Opportunities for increased training of female teachers should be sought. Establishment of counselling roles for female and male teachers should be encouraged. The initiative of the Shimono Model school in Kampala is a promising example. This school has a deputy female director to whom pupils can go on a confidential basis to discuss problems they encounter with teachers, other adults and peers who pressurise them into sexual activities. The school has established a public code of conduct which discourages pupils to be alone with teachers. Result of these improvements are likely to produce a more open climate to discuss difficulties pupils have to protect themselves from HIV/AIDS.
5. Extra curricula activities
The formal didactic style of teaching constitutes a serious barrier to the introduction of more interactive methods for discussing problems students have raised in this study. E.g.: relationships with parents and teachers, questions around use of condoms, sexuality, and social political issues. The best option seems the further development of extracurricular activities.
The Child-to-Child programmes, SYFA, and the drama project of SHEP offer promising opportunities to develop youth clubs and extra curricular activities.
Comprehensive sex education, which includes:
· small group discussions between members of the same sex about public, peer and personal codes of conduct; negotiating sexual relationships and use of condoms;· public discussions on the radio, within the resistance councils, and between other community leaders, teachers and health workers.
6. Use of study findings to trigger discussions in schools and between schools and communities
Research programmes need to ensure sufficient resources for dissemination of results to all relevant institutions. The discussion of results by community groups, youth clubs, parent and teacher associations and teachers would provide a basis to develop further initiatives and, especially in relation to HIV/AIDS, would help schools, communities and individuals to create a supportive environment to protect each other and themselves better. ODA could play a leading role and start with making money available for the discussion of this study with the schools and pupils involved. The experience in operational research being developed in the SYFA programme in collaboration with Universities and the training programmes already developed by the Child and Development Institute, could provide the basis for the development of training programmes in action research methods.
7. Take account of the views of teachers, parents and pupils on how to move forward on AIDS education
From the draw and write data, it would seem that children from Primary 6 upwards already have quite detailed knowledge about AIDS and how to protect themselves from it. Several describe different situations in which they might find themselves faced with saying "no" to sex, and appear to have given some thought to their responses. They want to know more and a number of them spontaneously volunteer teachers as a source of information. They also respond to the drama events concerned with AIDS.
There is little evidence of commonly held misconceptions - which are clearly evident in the data from other countries. There is a strong focus on the sexual transmission of HIV, and hence on condom use or on the need to change/limit sexual behaviour. There is also an understanding that whilst condoms are better than no protection, they do not afford 100% protection. Underlying much of what is written about sexual contact is some understanding that people who are infected with HIV may well look healthy.
From this it can be concluded that AIDS education - whether it is coming from the mass media, from school or from other sources, has certainly been effective in awareness raising. The question now is whether both students and teachers feel ready to take AIDS education further - with a much clearer focus on developing practical skills such as dealing with sexual relationships, making proper use of condoms, and ensuring safe treatment by health personnel.
As for the young people themselves, they still have many questions they want answered. During focus group discussions they put forward a number of questions, some of which go beyond standard factual information. The girls in particular are asking for help to deal with problems in the home and with dealing with their relations with men.
These questions echo some of the concerns they raise in the "unhappy" data - suggesting a need for paying rather more attention to a more individualised counselling and guidance service in schools, as well as continuing to develop formal classroom teaching around AIDS.
Table 11: Questions asked by boys and girls
|
Questions asked by boys |
Questions asked by girls |
|
· proper use of condoms |
· what advice can you give to girls to avoid suffering at home |
|
· advantages and disadvantages of blood testing |
· how can the step mother problem be solved? |
|
· life span of the virus |
· how to get men to stop disturbing them |
|
· AIDS symptoms |
· how to prevent pregnancy |
|
· educator on dangerous cultural practices that can transmit the virus |
· do contraceptive pills cause infertility? |
|
· alternative behaviour to sex |
· advise parents not to mistreat their children: e.g.: "Some children have parents who are very free with their children and give them freedom as if they are big girls. And most of those parents use alcohol. When he is drunk, he will rape her" |
|
· how to know if blood is safe |
|
The debate about who should teach children about sexual matters is already openly aired. Many of the comments offered during the study carry a sense of urgency; in the words of one teacher "time is running out" and "with the high rate of spread and the death toll", all avenues to educate young people in the broadest sense must be exploited.
Figure 23
