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Health & HIV/AIDS education in primary & secondary schools in Africa & Asia - Education Research Paper No. 14, 1995, 94 p. [Previous Page] [Table of Contents] [Next Page] Case study 2: India
2.1 General context The India study was conducted in June 1993 in conjunction with the Institute for Management in Government in Trivandrum. The study focuses on Trivandrum, Kerala. However some more general information was also collected 2.1 General contextHealth and AIDS situation in India India has an estimated population of around 840 million (1991). From a 1981 census, 39.6% of the population are under 15yrs. Important diseases include malaria, URTI, measles, gastrointestinal tract infections, non-communicable diseases and accidents. Important causes of death are infectious and parasitic diseases, diseases of the circulatory system, accidents, poisoning and violence, diseases of the respiratory and digestive systems. The first case of AIDS in India was reported in May 1986. Since then, 242 cases have been recorded. However, projections estimate a current seropositivity of 500,000 to 2.5 million, and that by the year 2,000 there may be as many as 5 million HIV positive and 1 million AIDS cases in India. Currently, Kerala (where the current study was undertaken) has detailed 17 AIDS deaths, 154 seropositive HIV cases and 26 cases of full blown AIDS7. Kerala is seen as being particularly vulnerable due to its large number of economic migrants. 7 Information provided by Dr Modhavar Nair 1993. Health education in Kerala: an overview Health education in India is more commonly known as IEC (Information, Education and Communication), with central services in the health sector. In Kerala there is a school health unit, focused on basic health services for schools. This does not yet appear to be operational. The general picture of health education in schools in Kerala is that people at senior levels, in both health and education, can describe what in theory should be happening. This includes a health education curriculum, and school health clubs. To date this is very much at a planning stage and does not yet appear to be high on the agendas of either the education or health departments. However, there is a small nucleus of committed individuals, supported by UNICEF and by a local NGO, HEAL8. There is also some evidence of co-ordination between health and education on curriculum planning, with experts from the Directorate of Health Services included in the teams which formulate syllabi and write textbooks for health education, science and technology and health science courses. 8 HEAL: Health Education and Adult Literacy: an NGO. Again in theory, there is some co-ordination between health and education at district level, with committees meeting annually to talk about the school health programme. This focuses mainly on school health checks, but could potentially be used to co-ordinate health education activity. UNICEF is clearly influencing the strengthening of health education activities and has a key role to play in furthering school health education in collaboration with the Directorate of Health Services and the Institute of Education. Links between the AIDS control programme and education The National AIDS Control Programme in India was established in 1987. To date, it has focused mainly on training of clinicians, establishing AIDS units for symptomatic treatment of people with AIDS and setting up HIV testing centres. The health education, or IEC, developments have been co-ordinated through the Central Health Education Bureau, with some mass media advertising (mainly posters). As yet, there are no clearly stated plans to develop AIDS education through schools, other than passing reference to the need to develop curricula. There is some interest from UNICEF to develop AIDS education more broadly, and also from two local NGOs, HEAL and the Red Cross.. Health and AIDS education needs assessment for curriculum development There appears to be minimal data on the general health problems of school-aged children available in Kerala and no plans for any kind of school health survey. The Directorate of Health Services have undertaken a baseline study on HIV/AIDS - but results of this study were not available at the time of this study. The one source of information which does provide some insight into the health education needs of young people is a small study undertaken by HEAL. This study explored what Class 10 children (10-15 year old children) know about sex. From a sample of 100 children (half boys, half girls): 75 had heard about sex from magazines, films and friends. During the study we gathered some anecdotal evidence of sexual activity amongst young people (from around the age of 14 years). Others felt that this is the exception rather than the rule, due to cultural factors. There is a notable lack of available data on STD's. 2.2 Health and AIDS Education: curriculum activitiesHealth education curriculum and textbook content In 1983 a curriculum for health education was implemented in all primary, middle, high and higher education schools. This was developed by the Ministry of Education in collaboration with health service staff. Health is integrated in the science curriculum in Biology and in health education in the Health and Physical Education curriculum. A document9 summarising health education in the biology and the health and PE syllabi notes the following: "Health and Physical Education are recommended as an integral part of the school curriculum. At the lower primary stage "activities to develop proper health and hygienic habits should be considered" (page vii). In the high school curriculum topics on health and health education are included in classes 8, 9, 10. In summary subject areas in health education taught in classes 8,9 and 10 (High school) are: Integrated in the biology curriculum: Nutrition, food and hygiene, first aid, addictive drugs and dangers of drug use, infectious and communicable diseases including prevention and causes, use of health services, importance of exercise, consumer education and home nursing. Population education including the reproductive system and contraceptives is an important part of the social science and life sciences curriculum. Subject areas integrated in population education: Population dynamics, health nutrition and population growth, reproductive system, family life and population growth Health education is examined as part of the biology and health science exam at the end of class 10. It was decided to examine it in order that it "be taken seriously". However, a corollary of this is that anything in the syllabus which is not examined tends to be dropped or given very limited coverage. Health Education Practice Teachers and parents perceptions of what is taught on health education There was general agreement among teachers that health is taught within biology and science for standard 8-10. This includes teaching on specific diseases (e.g.: kidney problems, hypertension, heart disease, injuries, problems due to smoking, TB, cholera, dysentery, leprosy). Some teachers also mention that this includes information on disease prevention (e.g.: malaria control). One school referred to the role of chemistry teachers in dealing with topics such as pollution (water, dirt, sound). It appears that there is one session taught on reproduction. Discussions with parents revealed a lack of awareness about what children are learning about health from school. Views ranged from "a lot" to "there doesn't seem to be anything taught". One group thought that hygiene teaching was included. Some mentioned specific diseases they think the children are taught about, such as: viral diseases, diarrhoea, typhoid, TB, measles, diphtheria, polio, vitamin deficiencies, beri beri, cold, cough, pneumonia, indigestion, malaria, filariasis, skin disease, malnutrition, and ulcers. In group discussions pupils were asked who helps them to stay healthy. All groups mentioned teachers who teach about health in school, and several referred to textbooks which include health topics. Parents were also mentioned and a couple of groups spoke of health workers.. AIDS education AIDS does not feature in the current curriculum. Contraception and reproductive systems are included in population education. Contraceptives are mentioned but not explained. Sex education is kept very theoretical. "It is not done to speak about sex in our society in school classes." Neither students, teachers nor parents currently see school as a major source of information about HIV/AIDS although in group discussions with students, two groups said they had been taught about it in school. Those children who mentioned education in the draw and write exercise refer mainly to newspapers, TV and radio. Student group discussions also said they had heard about AIDS from "common talk" with friends or in the community. General Teaching methods The observations and discussions with students and teachers suggest that most teaching is didactic despite the recommendations in the syllabus for more interactive methods. Extracts of the syllabus recommend: Table 6: Health education activities in schools
However, this evidence must be set beside the general agreement that in health education it is "Only theoretical aspects that are taught nothing practical". In some cases, teachers invite doctors to give talks on health issues and diseases - suggesting their reluctance to tackle health issues themselves. Teacher preparation Health education forms part of the Health and Physical education curriculum. Marks for health education constitute 2.5% of the total curriculum marks. It was not possible to see the curriculum for health but one informant commented that: "health education is not integrated in the teacher training colleges. Orientation of teachers to teach health education is done by IEC staff responsible for school health education." and noted that over the last five years no orientation in health education has taken place as there has been no money for training. Where teacher orientation has been done, it has been carried out by doctors. It comprises a 2 day training. So far 1000 teachers have been trained in 20 courses in some selected districts: Karny, Wanar, Trivandrum. The training is conducted at (Sub) District level. The teachers trained are science teachers and in-charges of health clubs in schools. The topics covered are: communicable diseases (HIV/AIDS will be integrated here), health habits, immunisation, nutrition, first aid and health problems such as seeing, hearing. This programme was started in 1991 by UNICEF. UNICEF has started intensive health education programmes providing training to teachers and health club leaders in the primary schools in Vizhinjam Panchayat and Vihura Panchayat. HEAL has also arranged an teachers' orientation course with an emphasis on interactive methods. There was no evidence in the teacher training colleges of any training related to AIDS education. Supportive environments Additional support for health and AIDS education within the school context Health clubs are the most frequently mentioned co-curricular health education activity in schools. The health club initiative was started in 1992. It is organised by the Deputy Director of Education (a district level officer), with the curriculum put together by the Institute of Education. At school level, head teachers select one teacher representative. S/he is given a one day orientation seminar, conducted by health personnel. This teacher then establishes a school health club, starting with 50 selected students. These students organise activities and campaigns with their peers, and with the parent teacher association. Activities can include: holding exhibitions, health camps and medical check-ups. Some medicine is provided, and selected schools receive a UNICEF health kit. There are plans to extend the activities further to incorporate HIV/AIDS teaching, but these are not yet ready for implementation. Key informants at central level suggested that some 6,000 schools in Kerala have school health clubs, or are starting them up. However, school visits failed to provide any evidence that health clubs are yet active, and further informants, when probed, agreed that for the most part, health clubs are not yet operational, and lack necessary funding. In addition to the Health Clubs initiative, there is some evidence of NGO activity concerned with health education, using schools as a base or entry point. There are also plans to arrange seminars for volunteers of the National Service Scheme Programme to initiate AIDS information activities in colleges. The Population Education movement organises a range of out-of-class activities, including competitions (e.g. writing essays, painting, public speaking, quizzes on themes on popular education related issues); a "village adoption scheme" whereby selected schools adopt local villages, carry out surveys and look after the family life problems in the village. Population education clubs are also organised (i.e. different from health clubs). Population education also celebrates World Population Day using it to educate people about the population explosion and during the Population Education Week, exhibitions, processions, placards and banners carry the same message to schools. School health services For all schools there is supposed to be a health scheme programme. 12-16 medical officers are responsible for school health checks. Doctors are supposed to do a school health test once a year. However, the system is not fully operational - one person commented that school health checks may happen only once in three years. 2.3 The concerns of young people2.3.1 General health concerns Table 7: Frequency showing the key issues which the sample say make them "unhappy/unhealthy"
Table 7 shows the issues mentioned by the pupils in the draw and write exercise. It is of interest to note that the young people are putting concerns with family and school at the top of the list, and only then fuming to more typical "health" issues. Environmental hygiene stands out much more clearly than personal hygiene (mentioned by only 13% of the sample), as does a concern about pollution. The pollution data has some similarities with findings from Lahore, Pakistan - showing the consequences for young people of living in overcrowded urban environments. The summary statistics mask the richness of the children's responses. The following extracts from the data provide a flavour of their views. Problems with relationships and problems at school Coming top of the list of concerns expressed by young people in Kerala were issues related to their relationships with parents, and worries about school. As with the Pakistan data, girls are more likely to describe problems with their parents family than are boys. Family problems frequently refer to death in the family - of parents and of other relatives. In many cases, this was expressed as a fear, rather than something that had actually happened. The other issue raised by many young people is of being scolded or beaten by their parents, for example:
In pictures this is usually shown involving a stick. Parental discord is also sometimes depicted as a source of unhappiness for the children. Figure 6 Worries at home (India)
The punishment of children is often associated with not doing well at school, thus leading to a vicious circle as the following quotation illustrates:
A number of the comments carry a sense that the children feel "wronged": when the elder brother is given priority... Another expression of this sense of injustice is suggested by one child who hints at a 'lost youth':
The fear of failure at school appears to produce strong feelings amongst the children in this sample. They fear getting low marks and not meeting parents' expectations, one said that low examination marks are "the greatest unhappiness" and one goes so far as to say "when the result in exams is not good, I feel like killing myself" (girl 13yrs). Memories of failure are poignant and, as the following quotation illustrates, can be recounted in detail:
Figure 7 Worries about school (India)
Concerns related to 'traditional' health education topics taught in the classroom Food and hygiene Food hygiene ranks third in frequency with many references to the dangers of uncovered food and water an contamination by flies. Many children elaborate on how germs are spread and some mention specific diseases such as cholera and typhoid that are spread through food and water. The data shows a clear difference between the sexes in terms of mentioning food hygiene, with girls mentioning it twice as frequently as boys. There is no difference between the two grade groups (i.e.: those have been taught about health and those who have not). Figure 8 Awareness of food and hygiene and their connection with health (India)
Diseases and environment Just over a quarter of the sample lists diseases in their accounts of what makes them "unhappy/unhealthy". Many of these simply refer to being sick generally. Many also mention specific disease such as TB, malaria, diarrhoea, skin problems, coughs, kidney problems and cancer. Diseases tend to be mentioned in association either with a vector (e.g.: malaria being caused by mosquitoes) or with environmental conditions. Seven young people (all boys) specifically mentioned AIDS in what makes them unhappy and unhealthy, including one illustration for example:
Accidents Other issues related to what was taught and frequently mentioned is accidents - with the lower grades referring to accidents more frequently than higher grades. (24% of grades 6-7 vs. 16% of grades 8-10). The majority refer to road traffic accidents - with several involving bicycles. Figure 9 Accidents (India)
Drugs and alcohol One issue which does not show up strongly in numerical terms, but does get quite strong and detailed comment by those who raise it is the issue of drugs especially smoking. They worry about the cost, and they worry about the effects of passive smoking. The effect of alcohol is also noted by some of the children:... "when someone gets drunk and smiles in a mocking way we feel sad drinking can make a person mad" Boys were substantially more likely to talk about drugs than girls (32% vs. 14%). Environmental health This sample expressed considerable concern, both about local environmental conditions and about the broader problems of pollution from vehicles and from industry. Many of these were accompanied by graphic illustrations, and several included lengthy texts, indicating very strong feelings on these issues. There were clear differences between the two grade groupings, with around 30% of the older children referring to one or both of these issues, as compared with around 15% of the younger group. The girls in the sample were particularly keen to highlight the problems created by pollution with 32% of girls vs. 18% of boys focusing on pollution in their texts and drawings. The following quotation gives a feel for the strength of opinion on these issues:
Figure 10 Concerns about pollution (India)
Summary of difference between gender and ages Anticipated sex differences did show up on food-related issues, with girls mentioning both food hygiene and diet, and problems with relationships (especially with parents) more often than boys, and exercise and drugs rather less frequently than boys. Some of the data gives support to the evidence from teachers that health is taught to older children, with the grade 810 group discussing diseases, environmental health and the effects of pollution much more frequently than their younger school mates. This grade difference is not apparent for problems at school or with relationships with friends. Very few of this sample expand their view of "unhappy/unhealthy" to include the broader social and political context in which they live (such as poverty, war, social unrest etc.). It is not possible to detect any evidence in this material of extracurricular health activities (i.e.: the health clubs which are supposed to be starting up). 2.3.2 Children's understanding of AIDS/HIV Table 8: Frequency table showing what children say they have heard about aids
Despite lack of systematic AIDS education in schools, or a particularly active AIDS awareness campaign, many children have heard something about AIDS with only 10.7% responding that they know nothing, or simply leaving their paper blank. There are others who are able to give quite detailed information on AIDS, showing an awareness of the three main ways it is spread, how it affects the immune system, the fact that a person may be a carrier without showing symptoms of the disease for many years and the extent of the global crises.
The "don't knows" are more likely to be boys (13% of boys and 7% of girls were unable to respond to the AIDS question), and more likely to be in grades 6 and 7 (17% of grades 6&7 unable to respond vs. 6% of grades 8-10). Misconceptions about AIDS Over a quarter have misconceived ideas about AIDS being spread through daily contact with people, through the air, through food and through dirty environment. This view is significantly more prevalent amongst girls than boys (34% vs. 24%) and amongst grade 8-10 pupils than amongst grade 6/7 children (35% vs. 21%). Misconceptions about transmission and prevention of infection include: ... through the clothes, the food, water etc. (girl 13yrs) Some misconceived ideas of causation include: · vomiting of the aids patient. Some misconceived ideas about cure include: · eating jackfruit is a good treatment for aids... On the other hand, there are children who are already quite clear that AIDS is NOT caused by close proximity with people, dirt etc. Transmission through sharp objects 27.4% of the sample know about the dangers of unsterile needles, often also tying this up with dangers of blood transfusions. There are a few stories about AIDS being passed on through unfortunate coincidences (i.e.: a person with AIDS being shaved by a barber, and getting a cut, and then someone else coming along and having the infection passed on). These are quite infrequent (compared, for example, with Ghana, where this is a common concept). In most cases, the infected person is seen to be a "foreigner" - with Europe, the USA and Africa being seen as the places AIDS comes from. Transmission through sexual contact Around a quarter of the sample know that AIDS is sexually transmitted, or at least transmitted through man/woman relationships. Several of these don't directly refer to sex, but talk of "mingling", "bad connections with women", "private contact of one person with another" - the majority including a connotation that it is only "bad women" (and rather less often "bad men") who are at risk. Pregnant women are seen to be particularly at risk. Children's ideas about who is at risk: · mostly people who are in hotels Children's ideas on how you can protect yourself: · Not doing sex Even though a number of these young people have some awareness of sexual transmission, very few talk about condoms, and those who do simply mention them rather than showing any insight into how they are used As anticipated, boys are more likely to mention condoms than girls (6.3% of boys vs. 0.3% of girls), and older students more likely to mention it than younger ones. Children are clearly quite frightened by what they have heard about AIDS, and some think it is an infectious disease, with infection caused by day to day contact, for example: Don't befriend AIDS patients. AIDS patients should not sit or sleep with others. AIDS patients, while travelling in bus, should not smoke, because it has bacteria in it. When AIDS patients speak to others, germs will spread to others (girl 13yrs) However, there is very little outright rejection of people with AIDS, and these are outweighed by those who say that we must treat people with AIDS with compassion:
Summary of what school pupils know about AIDS in Kerala From the draw and write data on AIDS, there is clearly a lot of basic ground work on AIDS awareness still needed in Kerala (the Bombay data is also similar) - although those who took part in the research were surprised at what young people do already appear to know. Level of schooling is clearly significant, with pupils in higher grades having both more correct understandings and more misconceptions than their younger school mates. Whilst this may be because the older ones are more prepared to guess at how the disease is transmitted - and to base it on their understanding of how other common diseases are transmitted, there are some suggestions in the data that parents and the media are either passing on incorrect information, or that the young people are misunderstanding what they hear. Figure 11 Children's understanding of AIDS (India. Kerala) 2.4 Opportunities for developmentResearch and evaluation of health education in schools As already noted, there has been no systematic baseline work on the health of school aged children, or on the potential of the school system to sustain an effective comprehensive health education programme. There has been a preliminary survey to support AIDS IEC work, in a health centre where HIV/AIDS is suspected to be relatively high. The survey consisted of a structured questionnaire, initially formulated by the medical school, adapted and pre-tested by the IEC department. Following the pre-test, some questions, such as "Have you had any pre-marital sex and, if so, how often with how many partners?" were deleted because they were regarded as too sensitive. No qualitative research was carried out to develop the questionnaire. Results of this study are not yet available. Although there is no evidence of any current monitoring and evaluation work related to health in schools, monitoring of health clubs initiative is anticipated. Teacher, parents and pupils support for development in health education When teachers were asked about what they feel children should learn about health at school, the general view was that there should be a bit more, made more practical. Some suggested improving teaching on hygiene, others see no real need to change what they are doing - as the general opinion put forward by teachers is that teaching on health is "no problem" - with the common comment:
The only issue which did get special mention in three of the schools was sex education, with two of those groups mentioning difficulties with embarrassment on the side of both teacher and pupils. Two of the schools specifically raised the need for sex education, and a third talked of the need for guidance of girls coming into puberty. Amongst parents, all groups agreed that children should be taught disease prevention and health promotion. Particular topics mentioned were: food and nutrition (especially for girls), first aid, contagious/common diseases, water borne disease, pollution, sanitation, functions of the human body. Specific mention of sex education was absent. Teacher, parent and student support for development in AIDS education When asked what school students should be taught about AIDS, teachers seemed to agree that AIDS should be taught, with Standard 10 (13-15 year old) being suggested as the appropriate age to start. Two said they already mentioned it - though with very little detail (mainly emphasising that it is a disease without a cure). These same teachers also felt that children already had some awareness of AIDS from the media, but did not know how much children know. One teacher mentioned that the health science text is going to be revised, and a topic on AIDS is going to be included, in which case "we can give the students more information about this disease". When questioned more deeply on whether teachers should tackle the sexual transmission of AIDS, and prevention through use of condoms, teachers expressed reluctance. Perhaps most important are the views of those who already teach about reproduction: "We can teach them but there are certain things that they have not experienced so they will find it difficult to understand these facts and we will find it difficult to clear their doubts.... Biology teachers were felt to be the most appropriate ones to teach about AIDS (as part of the health science text). However, it was felt that they themselves would need some further training and information. There seemed to be general agreement amongst parents that children should be taught about AIDS - causes, spread, prevention and consequences of the disease. They emphasised that it should be taught at the appropriate level and with appreciation of the highly conservative culture in Kerala. One group noted that children already get a lot of information through the media about AIDS, and they are inquisitive. It is better that they are taught by the teachers in the school rather than gaining incorrect or partial information from the media. Another group noted that the children should be allowed to ask questions and details about AIDS infection and consequences. Teachers also did not anticipate problems with teaching about AIDS in schools - since they say that parents "do not interfere" in school activities. This is mainly explained as being due to the illiteracy of the parents, who are only happy that their children are being educated. From the point of view of the school students themselves, like the groups in the other countries, they had many questions they wanted answered about AIDS. The questions young people have centre around: the spread and origin of the disease; diagnosis and symptoms; if there is a cure; how HIV\AIDS is transmitted and how it can be prevented. Promising options for development Despite constraints there are possible entry points for strengthening the innovative initiatives already started in school health education and for developing a programme in AIDS education in schools. 1. Strengthening existing initiatives in health education. There is a clear interest in the Directorate of Education and the Directorate of Health Services to strengthen the health education component in schools. The school health education unit of the Directorate of Health Services has recently been established, the new school health education programme has just started and the health clubs as planned seem a worthwhile initiative. To enable these programmes to be implemented successfully it will be important to increase the expertise of key staff in the use of interactive teaching methods and also to ensure proper resourcing of health clubs. UNICEF is already supporting further development of school health education through the financing of training seminars. The following possibilities seem to be valuable to explore further: · Develop greater collaboration between the new school health programme in the Directorate of Health Services and the UNICEF School health scheme in the Directorate of Education. 2. Developing AIDS education programmes. The threat of HIV/AIDS could provide a new motivation to look seriously at a new approach to health education in schools. In Bombay, where HIV/AIDS is more widespread and urbanisation is more explicitly changing sexual practices of young people, the need for sex education is strongly promoted by the medical school health services which are based in the Institute of Education. At State level in Kerala there is a clear commitment to include HIV/AIDS education in schools. The emphasis at the moment is merely on providing correct knowledge and information although some key informants realise that effective health education needs to go beyond didactic teaching of facts. It is likely that emphasis will be put on responsible behaviour i.e.: delaying sex (abstinence) which is already strongly promoted by parents and teachers. However, the information about use of condoms and sexual practices disseminated by the media will leave young people with questions that need to be clarified. There is also concern that this type of education will leave the growing group of sexually active young people at risk without a chance to reflect on and discuss how to negotiate sexual behaviour and practices. Therefore there is a need to start looking at ways to enhance the ability of pupils and students to discuss issues around sexuality and interpersonal relationships. The best option forward seems to be: a) Urgently develop a teacher training and AIDS education programme which provides basic knowledge on HIV/AIDS for standard 10 onwards. The following possibilities seem valuable to investigate: · Identify key personnel involved in school health education to be trained in interactive methods to address health education issues with an emphasis on sex education in relation to HIV/AIDS.
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