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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 4: Ghana
4.1 The general context The Ghana study was conducted in October 1993, in collaboration with the Health Research Unit in Accra. The study focuses primarily on Accra, although data was also collected from schools in a rural area between Accra and Kumasi. The policy information is generally applicable to the country as a whole. 4.1 The general contextEducation and health Ghana has a population of around 15.55 million with 45% aged between 5-19yrs. 67% of 6-11 yr. olds are enrolled in school, and 51% of 12-14 yr. olds. There are over 21,600 schools around the country. The government is increasing the percentage of GDP it is investing in education. There is also substantial donor investment. This is an attempt to overcome several years of severe underfunding, during which the education system reached near collapse. Despite the current activity, there is still a long way to go in re-establishing a functioning education system. Evidence suggests that, especially in rural areas, whilst there may now be buildings, the teaching that goes on within them is at best rudimentary. Turning to health, by far the most serious problem, in terms of out-patient and in-patient statistics, is malaria. Main causes of morbidity include respiratory infection and diarrhoea. Anaemia is the most frequently recorded cause of death, followed by malaria, with pneumonia and diarrhoea also presenting a serious threat. Sexually transmitted diseases are not recorded amongst the top ten causes of either mortality or morbidity. AIDS does not yet feature high on the mortality or morbidity statistics, but is clearly on the increase, and is seen as an important emerging disease. The first case was identified in 1986, with over 11,000 recorded AIDS cases by April 1993. Health education in Ghana: and overview Health education in Ghana is at an early stage of development. This is evident from the limited resources and staff with responsibility for it, the lack of any established, operational policies, and the weak linkage between the health and education sectors. At central level, there are three bodies with some responsibility for health education: · the Technical Co-ordination and Research Division (TCRD) of the Ministry of Health, which has overall responsibility for health education within the ministry. There is a School Health Steering committee, with representatives from both health and education. However, it is not clear from this committee where responsibility for action and development lies. TCRD's involvement appears to be limited to a central health education resource at the main teaching hospital in Accra. The School Health Service has more obvious grass-roots contact with schools (although no clear linkage with the education sector at central level). The School Health Programme is very new, and at the time of the study had no staff with specialist training or expertise in health education. The only other evidence of health education activity at regional level is the health education unit in Kumasi (partially funded by ODA). This operates within the Metropolitan Authority. There are few regional health staff and no district staff with special expertise in health education, either in the health or the education sectors. Donor interest and support for health education programmes is limited. UNICEF has some involvement both with curriculum development related to lifeskills in primary education, and in Child-to-Child developments. The ODA teacher education project is working with UNICEF on developments in Child-to-Child. Links between the National AIDS control programme and the education sector. The picture already described of the link between education and health is repeated when looking at the link between education and AIDS control. The National AIDS Control Programme was set up following first case identification in 1986. A medium term plan was prepared. This included objectives related to Information, Education and Communication (IEC), but did not make special reference to schools. It did, however, target 15-30 yr olds, and saw schools as a possible vehicle for its mass media efforts. In addition to the mass media campaign, there have been a variety of other activities focusing on young people including a workshop for Youth Leaders, a materials development workshop for street youth, a street youth education programme, a drama group for AIDS education and an AIDS poem cassette. None of these link directly with schools - focusing as they do on out-of-school youth. Reviews of the National AIDS Control Programme have made specific mention of the lack of co-ordination between the Ministries of Health and Education, noting that teachers have not been well briefed or trained in guidance and counselling. They include in their recommendations the need for a policy on AIDS in schools, and more collaboration between researchers and implementers around AIDS. Health and AIDS education needs assessment for curriculum development Although policy development and co-ordination between the health and education sectors appears weak, there is a growing body of research data available in Ghana on the health of school children, and on the sexual health knowledge and practices (including AIDS awareness) of young people. Some of this has been undertaken specifically to inform the development of school health education. Others provide data which could be used in this way. The current study is the first of which we are aware that focuses on the views and concerns of young people, rather than taking a more "directive" approach, aimed at measuring pre-defined issues. The health survey to inform school health policy was undertaken in 1990. The study involved 1,620 junior secondary school pupils and 104 teachers, from 16 schools, in four different regions. Results indicated poor environmental conditions in the schools, and minimal time devoted to teaching around health issues. The study also noted low involvement of parents in school life. Health issues identified in the study included: dental caries, upper respiratory tract infection, ringworm, head lice and intestinal worms. Solutions suggested included: 1) provision of health information to schools (on diseases, sex, drug abuse, nutrition) These recommendations have yet to be implemented - but indicate an understanding amongst those concerned of a range of important components in establishing an effective school health education programme. A more comprehensive and systematic study of the health needs of school aged children (both those in and those out of school) is underway. This study is connected to a health intervention programme in schools, concerned with deworming, and micronutrient supplementation. Both studies have been carried out by the Health Research Unit, within the Ministry of Health, in close co-operation with the School Health Programme - forming a useful alliance between the two sectors. On sexual health, there have been studies on the sexual experiences of junior secondary school pupils (Adomako 1991) and adolescent pregnancy. These studies suggest that by 15yrs, at least one third of girls are sexually active, and that education on contraception is very limited. On AIDS, Anarfi14 (1993) carried out a baseline study amongst 15-20 yr. olds in two regions, repeated twelve months later following a mass media campaign. This found awareness of AIDS focused on sexual transmission and condom use. Another study (Ametwee 1993) of universities and secondary schools found high awareness of AIDS prevention, low condom promotion, and a wide range of negative attitudes towards people with AIDS. 14 From: 3rd National Seminar on AIDS. MoH Ghana, September 1992. The sexual health and AIDS studies are available to curriculum planners - but it is not clear whether they are actually used in this way. They certainly provide the potential for increasing the relevance of what is taught, by focusing health education on the health priorities identified. 4.2 Health and AIDS education: Curriculum activitiesHealth education curriculum and textbook content Schooling has recently been restructured into a three tier system of primary (P1-P6), junior secondary (JSS1-JSS3) and senior secondary (SSS1-SSS3). At primary and junior secondary level there are nine subjects taught: Maths, English, Agriculture, Science, Social Studies, Cultural Studies, Ghanaian languages, Life Skills, PE. All teachers teach all subjects. Health education is "integrated" into various subjects, but is most prominent in Life Skills. The most substantial "health input" can be seen in the JSS Life Skills book 3 (see below).
As can be seen in the Book 3 section on health care, all the elements of the Facts for Life book are incorporated which was achieved with encouragement from UNICEF. There is a lot in here of why you should do healthy things, but rather less on what to do or what to expect. At SSS level, students have seven core compulsory subjects (English, Ghanaian, Science, Maths, Agriculture and Environmental Science, Life Skills, PE). They then choose from 5 broad programmes of specialisation: agriculture, technical, vocational, business, general arts/science - within which there are various options (e.g.: under "science" you can select and combine any three of the following: biology, chemistry, maths, physics). Under the "vocational" home economics option, you select and combine: management in living (which has quite a strong health component), clothing and textiles, food and nutrition, general art. All students receive some input on health in the Life Skills classes, and those taking the vocational options (especially management in living, and food and nutrition) and science options (especially biology) will get further input. Whilst this coverage looks quite comprehensive, and there appears to be quite a substantial amount of health input across the curriculum, a quotation from the Director General of GES on sex education is worth keeping in mind: "Well, we are not talking about it very openly" The sections where sex education and contraceptive education might seem relevant do not address these issues. AIDS education in the curriculum and text books AIDS does get mentioned in existing textbooks - again, as part of the Life Skills course. The box below gives an outline of what is included.
Health education: Practice Teacher, parent and pupil evidence on how the curriculum is implemented. Taking an overview of the data from: · what teachers say they teach there seems to be general agreement at grassroots level that issues around personal hygiene, local environmental sanitation, and the basics of diet and food hygiene do receive some attention - all of which appear in the textbooks. These issues also relate to some of the health problems highlighted in the school health survey. Coverage, or reference to major communicable and locally endemic diseases is very limited. It certainly gives no impression that young people are aware that malaria is the major cause of mortality or morbidity in the country indeed when groups were asked what the major health problems in Ghana today are, AIDS and Burueli ulcer were top of the list. This indicates the power of the media - given that these two diseases have received considerable mass media coverage. There is limited sex education provision within the Life Skills textbook, and several teachers mention covering this material with students. However, they acknowledged that coverage is at best superficial and "avoids any practical details". Many teachers express embarrassment about teaching sex education. They note that where possible, external speakers are brought in to give "special sessions". Only one parent mentioned sex education. Amongst the young people, there were clear differences by grade, with only 5% of the primary and junior secondary students referring to issues around sex and pregnancy, as compared with 19% of the senior secondary students. Other issues which are generally recommended for inclusion in school health education programmes get little attention. Drugs (including smoking, alcohol) is referred to in the curriculum, but not mentioned at all by parents, referred to by very few teachers (who again say it is dealt with by outside speakers) and raised by only 18% of the young people. There is virtually no reference to exercise or accidents. The above description covers the traditional "health education" topics one might expect to find within the curriculum. However, it masks an important emphasis in the data from the Ghanaian school students. In many cases, they made a clear distinction between what makes them "unhappy" and what makes them "unhealthy". Under "unhealthy" there tended to be a somewhat cursory list, with a heavy emphasis on personal hygiene. Under "unhappy" came many issues to do with personal relationships, worries and concerns, as well as broader social and political concerns. Whilst some of these were simply presented as lists of ideas, a substantial proportion included quite detailed thought - as can be seen from the images and views presented in the section reporting on The concerns of young people. Teacher, parent and pupil evidence on AIDS education. The "priority" given to AIDS by young people can to some extent be seen in the small numbers (8 students (1.7%)) who specifically referred to it in the initial "unhappy/unhealthy" data. Reviewing the data from teachers, textbooks, parents and the young people confirms the findings of other studies in Ghana that there is a basic level of general awareness about HIV/AIDS. However, all parties also agree that this awareness comes primarily from the mass media effort, and from discussion at home and with health workers, rather than from school. Whilst there is some school coverage, it is minimal. At best, it takes the form of health workers coming to provide one-off sessions. 4.3 The concerns of young people4.3.1 General health concerns Table 12: Things which make the children "unhappy and unhealthy"
As can be seen from the above summary, personal problems at home and at school present much greater challenges to the young people than do issues around physical health and hygiene. The following quotations by the children illustrate the strength of some of these concerns. Problems at home
Problems at school
Emotional/sexual worries
Figure 24 Problems with parents (Ghana)
Issues relating to physical health and personal hygiene
Issues relating to environmental hygiene What makes me unhappy is when my surroundings are dirty and the gutters choked with rubbish and mosquitoes. To see children eating by rubbish and people dumping rubbish around.... Some people don't know what they are doing, but others know and just don't care and that makes me very unhappy. (girl 10yrs) Gender and age differences in the data Detailed analysis of the young people's data showed no obvious sex differences. There were some differences in emphasis by grade - with older students talking more about diet, environmental sanitation, and issues around sex and pregnancy. Younger children (primary and JSS level) talked more about problems with parents (64% vs. 49%). One school stood out as very different from the others in terms of the quality and type of response from the young people. This was a Moslem school, in a low income area. This may partly be a problem of the data collection approach used - since the children seemed unable to express themselves as well in writing as those from the other primary schools. It may however also be indicative of a school which does not use the standard school curriculum, but instead places much greater emphasis on religious teaching. 4.3.2 Children's understanding of AIDS/HIV For the draw and write exercise, young people were asked to say what they knew about AIDS, especially about how they could prevent themselves from catching it. The majority could put forward between four and eight distinct ideas about HIV/AIDS, often including details on prevention, transmission, and on how the disease affects the body. There was no obvious sex difference in responses about AIDS. On the issues raised there were also no apparent age differences - indicating the likelihood that the majority are getting their information from the same (mass media) source. The only apparent difference was in terms of variety of ideas put forward - with senior secondary pupils tending to express a wider variety of ideas than did primary or junior secondary pupils. Table 13: Most commonly expressed idea on AIDS
Sexual transmission From the data it is clear that the majority are aware that HIV is passed between men and women, and many talk and draw about sexual transmission, for example:
Coupled with this they talk about sticking to a single partner, avoiding "bad women" or "discos" or "bad men".
Some of the drawings clearly show a basic understanding of sexual intercourse. However, discussion groups often showed some confusion about the exact nature of sexual transmission which suggests that the understanding some young people have is superficial, and has either not been explained at all, or only in very general terms. Figure 27 Children's understanding of sexual transmission of HIV (Ghana)
Other ideas of transmission Whilst basic knowledge that AIDS is sexually transmitted is clearly evident in what the students say, it is dealt with in very little detail. On the other hand, when it comes to discussing the spread of AIDS through blood contamination and the sharing of sharp things (such as razors), many students go into lengthy stories of somewhat unlikely series of events. This is a very distinctive feature of the Ghanaian data, which is not found to anything like this degree in Uganda or India. This example gives a flavour of what is written:
Other circumstances in which children think AIDS is transmitted via non-sexual contact include: · Drinking from same cup...if the fellow is suffering from gum bleeding Figure 28 Children's ideas about non-sexual transmission of AIDS/HIV Misconceptions about how AIDS is spread Almost one third of the sample show evidence of misunderstanding about how AIDS is transmitted. Most of these are related either to basic hygiene and cleanliness, or more specifically on the kind of contact which is "safe" to have with people with AIDS. · Kisses also is one of the ways you can affect by AIDS Prevention: condoms A similar picture emerges when the young people talk about condoms - in the majority of cases, they simply state that condoms protect you from AIDS, but offer no further detail (unlike Uganda, where young people can name many different brands, and frequently provide graphic illustrations of condom use). Where young people do supply more details on condom use, it frequently takes the form of highlighting problems with the safety of condoms. Others come up with suggestions for distribution - possibly indicating that they might use them if they were easy to get hold of.
Prevention: abstinence I will recommend that every student abstaining from premarital sex which is possible, because personally I'm still a virgin and hope to keep it till my marriage with the help of God. (boy) Figure 29 How children think they can protect themselves Misconceptions about treatment for AIDS At the time of the study, there were many references on the radio to a herbal cure said to have been found by a Ghanaian, Nana Drobo, who subsequently died. In the programmes, the point was made that if he had indeed found a cure, the recipe had gone with him - and that there is still no cure for AIDS. This point had clearly been taken up by the young people, with a number of them talking about Nana Drobo. Attitudes towards people with AIDS Through much of the data there was indirect reference to people with AIDS, and of the need to avoid having sex with them, or of having anything to do with them. A small proportion (13.6%) took this a step further, expressing particularly hostile views about people with AIDS, saying they should be isolated, or even killed. AIDS patients should be dumped elsewhere. NO, they should be imprisoned with hard labour." (focus group discussion) Only 6% expressed the view that AIDS is not spread through normal daily contact with people with AIDS, and the following quotes on caring for people with AIDS were extremely rare:
Reference to AIDS education: School Only 10% of the sample make any reference to AIDS education. A few talk about the AIDS education they have got through school and from parents - noting in some cases that this has not been as detailed or helpful as it might have been!
Reference to AIDS education: media There are also some mentions of media input, both in text and in some of the illustrations, with the slogan: "Don't be careless, get protection". ...a lot of programmes and talks are been held on the TV, radio and especially in our schools and not least from my parents.. (girl 15yrs) Young people's expressed desire to learn more about AIDS There were a number of requests and suggestions for improving AIDS education - with a notable emphasis by the young people on a desire to be able to talk to their parents more openly about such matters: If I get AIDS I will start a programme to educate other people about the disease Aids. I will tell everybody how Aids can be got, and how to protect themselves (girl 11yrs) Other concerns around AIDS Students raise a number of other issues concerning AIDS - for example many talk about what a dreadful disease it is, and how it is affecting many people. HIV testing is raised, but not in detail. The issue of ensuring good practice, in hospital is also present, along with the recommendation of avoiding "quack" doctors. However, the view that health workers are actively negligent, or even guilty of maliciously spreading the disease - which is found in the Uganda data - is absent here. 4.4 Opportunities for developmentResearch and evaluation To date there has been no evaluation of the impact of teaching on health education generally - either in terms of its educational quality, or its impact on health. Rouse15 (1992) carried out a detailed study of the JSS family life education programme (which encompasses family planning, STDs, human biology, teenage pregnancy) in Kumasi. The results of the study indicate that lack of resources, parental disapproval and teachers' attitudes are major blocks to development - with the view that "sex education increases promiscuity" being commonly held. 15 Rouse, F. An analysis of the practice of family life education in JSS schools of Kumasi District, Ghana. Msc dissertation, Leeds Polytechnic, June 1992. There have been a number of AIDS knowledge, attitudes and practice (KAP) evaluation studies related to the National AIDS Control Programme. A review of these studies (1988 to 199116) indicates a quite high degree of AIDS awareness, but also a number of misconceptions - including belief that AIDS is curable, and that it only affects "high risk groups". 16 Health education experiences in the Kumasi district 1991-1994. Kumasi Health Education Project. As the School Health Programme developes, it will be important to use the findings of these studies, along with the needs assessment work which has also been done. Current health education teaching is considered to be sufficient. Teacher and Parental support for health education in schools Teachers stress the importance of hygiene education and express embarrassment and some reluctance about teaching sex education - but agree that it should be in the curriculum. Parents support the importance of hygiene education but again suggest little further. A small number suggested the importance of sex education (none seemed opposed to it). Several, when probed on specific diseases, felt AIDS should be addressed. The following points summarise the main points for consideration if school health education is to be strengthened: · Possibilities for implementation are frequently constrained by resources, and by parental and teacher resistance with the commonly held view that "sex education increases promiscuity". Promising options for development It is important to build on and develop existing structures and provision further, rather than attempting further innovation. In particular: · strengthening the School Health Programme (SHP), and developing its link with the Ministry of Health.
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