Developing Effective Policies for HIV/AIDS Education practice in Sub Saharan Africa: The Case of Urban Schools of Malawi: A synergy of pupils needs, policies and practice
©2014
Textbook
251 Pages
Summary
HIV/AIDS has been named the Sub Saharan disease. In countries that have achieved significant declines in HIV prevalence, young people have registered the biggest behavioural changes. It means they hold the keys not only to our understanding of the epidemic, but more importantly, to the efforts required to stem the tide of infections. However, the majority of young people are ignorant of how to prevent transmission, have low compliance to condom use, which is in some cases accentuated by misconceptions about HIV/AIDS transmission and have insufficient knowledge regarding transmission and avoidance behaviours. As such, consensus on feasible preventive interventions target young people, particularly those in schools. It is on this premise that the book unlocks the key pillars in effective HIV/AIDS education policies and practices.The study has drawn upon the experiences of selected Urban Schools in Malawi to explore the needs of young people in classroom, the extent to which the classroom practices respond to the needs, and the factors influencing these using questionnaires, interviews, lesson observations, and document analysis. Malawi typically represents most Sub Saharan African countries in terms of challenges faced by education systems. Given the similar cultural settings of the people of Sub Saharan Africa, the findings and recommendations of the study generalises to the education systems of Sub Saharan Africa to a greater extent. The book shows the need for open discussion climates on HIV/AIDS issues despite a conservative cultural and religious adult world that is not open. It has also identified a need for explicit and accurate knowledge on HIV/AIDS issues, opportunities to acquire behavioural skills for HIV prevention, and involvement of external speakers in classroom HIV/AIDS education.Current classroom practice does not address the pupils‘ needs adequately. Factors influencing this can be linked to lack of policies responsive to culture and religion, ineffective and inadequate teaching policy guidelines, and lack of a policy prioritising HIV/AIDS education.<br>The findings suggest that in future, effective HIV/AIDS Education needs to be informed by the pupils’ needs. To address these needs, support from the wider society and related policies, coupled with appropriate management and classroom practice will be required. The book is therefore an indispensable tool for education systems in Sub Saharan Africa. It provides an effective model for […]
Excerpt
Table Of Contents
viii
Table of contents
Acknowledgements _________________________________________________________ v
Dedication ________________________________________________________________ vi
Abstract _________________________________________________________________ vii
Table of contents _________________________________________________________ viii
List of Figures and Tables ____________________________________________________ xii
1.
Chapter 1: Study background ____________________________________ 1
1.1.
Global overview of HIV/AIDS
________________________________________ 1
1.1.1.
Incidence and prevalence of HIV/AIDS __________________________________________ 1
1.1.2.
Global Impacts and interventions _______________________________________________ 2
1.2.
Sub-Saharan Africa
_________________________________________________ 3
1.2.1.
Incidence and prevalence of HIV/AIDS __________________________________________ 3
1.3.
HIV/AIDS in Malawi
________________________________________________ 4
1.3.1.
The influence of Malawian cultural and religious contexts on HIV/AIDS intervention
efforts 8
1.3.2.
Impacts and interventions of HIV/AIDS in Malawi _______________________________ 12
1.3.3.
The context of HIV/AIDS education within the secondary school education system in
Malawi 13
1.4.
Conclusion
_______________________________________________________ 15
2.
Chapter 2: Literature Review ____________________________________ 16
2.1.
HIV/AIDS education and young people
_______________________________ 16
2.2.
School-based approaches to HIV/AIDS education
_______________________ 18
2.2.1.
What is Life Skills Education? _________________________________________________ 20
2.2.2.
Life Skills and behaviour change _______________________________________________ 21
2.2.3.
Perspectives on HIV/AIDS education within Life Skills ____________________________ 22
2.3.
Effective approaches to HIV/AIDS education
__________________________ 24
2.3.1.
Establishing safe learning environments ________________________________________ 25
2.3.2.
Recognising gender differences ________________________________________________ 25
2.3.3.
Supporting pupils affected with HIV/AIDS ______________________________________ 26
2.3.4.
Linking with other service providers ___________________________________________ 26
2.3.5.
Being culturally sensitive when responding to the needs of the pupils _________________ 27
2.3.6.
Developing conceptual understanding __________________________________________ 28
2.3.7.
Participatory approaches to teaching and learning ________________________________ 31
2.3.8.
Supporting teachers _________________________________________________________ 36
ix
2.4.
HIV/AIDS education in Malawi
______________________________________ 39
2.4.1.
Responses within the MOEST _________________________________________________ 39
2.4.2.
Life Skills education in Malawian schools _______________________________________ 40
2.4.3.
Policy guidelines for HIV/AIDS education in Malawi ______________________________ 44
2.5.
Research rationale
_________________________________________________ 46
2.6.
Conclusion
_______________________________________________________ 47
Chapter 3:
Research design and methodology for data collection and analysis _____ 49
3.1.
Rationale for research design
________________________________________ 49
3.1.1
The Case Study _____________________________________________________________ 49
3.1.
2
Data collection tools ________________________________________________________ 51
3.
2
Data collection
___________________________________________________ 57
3.
2.1
Framework for data collection and analysis _____________________________________ 57
3.
2.2
Design and use of data collection instruments ___________________________________ 58
3.
3
Data analysis
_____________________________________________________ 64
3.
3.1
Approach to data analysis ___________________________________________________ 64
3.
3.2
Evaluation of the methodology _______________________________________________ 68
3.
4
Ethical considerations
_____________________________________________ 71
3.
5
Conclusion
______________________________________________________ 74
4.0
Chapter 4: Young peoples' perceptions of their needs _______________ 75
4.1
Young pupils' needs in HIV/AIDS Education
__________________________ 75
4.1.1
Gender of HIV/AIDS teacher _________________________________________________ 75
4.1.2
Young peoples' openness to discuss HIV/AIDS issues with their class teacher. _________ 78
4.1.3
Additional issues for discussion in classroom HIV/AIDS Education __________________ 79
4.1.4
Preference for external speakers _______________________________________________ 84
4.1.5
Young peoples' preference for pupil-led group discussions _________________________ 87
4.1.6
Young peoples' preference for grouping by gender ________________________________ 88
4.1.7
Suitability of the classroom environment for discussing HIV/AIDS issues _____________ 90
4.1.8
Contact time _______________________________________________________________ 90
4.1.9
Other needs ________________________________________________________________ 91
4.2
Conclusion
_______________________________________________________ 96
5.0
Chapter 5: In what ways do classroom practices meet the needs of the
young people? 97
5.1
Open discussions on HIV/AIDS issues
_________________________________ 97
5.1.1
Use of group discussions and whole class discussions _____________________________ 101
5.1.2
Openness of the discussions __________________________________________________ 104
5.1.3
Supporting participatory strategies ___________________________________________ 110
5.1.4
Creating a safe environment for open discussions ________________________________ 111
x
5.2
The need for explicit and accurate knowledge on HIV/AIDS issues
_______ 116
5.2.1
Transmission ______________________________________________________________ 116
5.2.2
Basic and personal health needs ______________________________________________ 118
5.3
The use of external speakers
________________________________________ 118
5.4
Skills for prevention
______________________________________________ 120
5.5
Recommended contact time and curricula
____________________________ 124
5.6
Conclusion
______________________________________________________ 126
Chapter 6:
What factors are influencing classroom provision of HIV/AIDS education?
129
6.1
Openness of the discussions
________________________________________ 129
6.1.1
Supporting participatory strategies ___________________________________________ 135
6.1.2
Use of group discussions and whole class discussions _____________________________ 135
6.1.3
Creating a safe environment for open discussions ________________________________ 139
6.2
The need for explicit and accurate knowledge on HIV/AIDS issues
_______ 139
6.2.1
Transmission ______________________________________________________________ 139
6.2.2
Basic and personal health needs ______________________________________________ 140
6.3
Skills for prevention
______________________________________________ 141
6.4
Involvement of external speakers
____________________________________ 143
6.5
Contact Time
____________________________________________________ 144
6.6
External and internal supervision of HIV/AIDS classes
_________________ 148
6.7
Other influences
__________________________________________________ 150
6.8
Conclusion
______________________________________________________ 152
Chapter 7:
Discussion __________________________________________________ 154
7.1
The needs of the young people
______________________________________ 154
7.1.1
Open discussions on HIV/AIDS issues _________________________________________ 154
7.1.2
Explicit and accurate knowledge on HIV/AIDS issues ____________________________ 160
7.1.3
Skills for HIV prevention ____________________________________________________ 164
7.1.4
External speakers __________________________________________________________ 167
7.1.5
Low prioritization of HIV/AIDS education _____________________________________ 169
7.1.6
What should be done _______________________________________________________ 171
7.2
Key policy implications
____________________________________________ 171
7.3 Ensuring that intended policy is put into practice
______________________________ 174
7.3.1 Internal and external supervision of HIV/AIDS Education ___________________________ 175
7.3.2 Continuing professional development of the teachers ________________________________ 179
Chapter 8:
Conclusions and Recommendations _____________________________ 181
8.1 Research questions and outcomes
_____________________________________________ 181
xi
8.2 Contribution of the study to literature
_________________________________________ 182
8.3 Future research to improve school based HIV/AIDS Education in Malawi
__________ 184
References ______________________________________________________________ 189
Appendices ______________________________________________________________ 197
Appendix 1: Questionnaires for pupils
____________________________________________ 197
Appendix 2: Questionnaires for teachers
__________________________________________ 203
Appendix 3: Samples of completed questionnaires
__________________________________ 209
Appendix 4: A summary of questionnaire responses from Teachers
__________________ 211
Appendix 5: The lesson observation instrument
____________________________________ 215
Appendix 6: A sample Lesson Observation report
__________________________________ 217
Appendix 7: A summary of lesson observations
____________________________________ 218
Appendix 8: Interview guidelines for teachers
_____________________________________ 221
Appendix 9: Guidelines for focus group discussions
________________________________ 225
Appendix 10: Semi-structured interview guidelines for head teachers
_________________ 226
Appendix 11: Semi-structured interview guidelines for Methods Advisors
______________ 227
Appendix 12: A samples of the teachers Schemes and Records of work
________________ 228
Appendix 13: AREA Faculty Research Ethics Committee approval
___________________ 229
Appendix 14:
Permission to conduct research in the South East Education Division in
Malawi.
231
Appendix 15: Interview consent form for head teachers and teachers.
_________________ 232
Appendix 16: Selected Health Promotion Models
___________________________________ 233
xii
List of Figures and Tables
Figure 1.1: Global statistics on people living with HIV/AIDS (no data on women in 2003)
________________ 2
Figure1.2: People living with HIV and deaths in Sub -Saharan Africa (no data for deaths in 2002)
_________ 4
Figure 1.3: National HIV/AIDS prevalence rates in Malawi from 1995-2007
___________________________ 5
Figure 1.4: Rural and Urban HIV prevalence rates in Malawi
______________________________________ 5
Figure 1.5 HIV prevalence rates by gender among 15-49 year olds in Malawi
__________________________ 6
Figure 1.6: Percentage condom use among 15-24 in Malawi
_______________________________________ 7
Figure 1.7: Factors influencing the condom divide
______________________________________________ 11
Figure 2.1: Interfacing elements of Life Skills Education
__________________________________________ 20
Table 2.1: Categories of skills in Life Skills Education
___________________________________________ 20
Table 2.2: An example of content organisation around skills
_______________________________________ 21
Table 3.1a: School parameters in Zomba City
__________________________________________________ 53
Table 3.1b: Schools selected for this study
_____________________________________________________ 54
Table 3.2: Framework for data collection and analysis
___________________________________________ 57
Table 3.3: A summary of time lines for the design of data collection tools and actual data collection
______ 57
Table 4.1a: Would you prefer to discuss HIV/AIDS issues in class with a teacher of the same sex as yourself?
75
Table 4.1b: Reasons for same-sex teacher preference by pupils
____________________________________ 76
Table 4.1c: Reasons for not preferring same-sex teacher
__________________________________________ 76
Table 4.2: Did you find it difficult to discuss HIV/AIDS issues freely with your teacher?
_________________ 78
Table 4.3a: Are there other issues on HIV/AIDS you would prefer to discuss in class?
__________________ 79
Table 4.3b: Preferred topics according to class level, gender and school type
_________________________ 80
Table 4.4a: Are there individuals whom you would like to speak to your class on HIV/AIDS?
_____________ 84
Table 4.4b: Categories of individuals whom participants would like to speak to their classes
_____________ 84
Table 4.4c:Topics which participants would like speakers outside their class to address
_________________ 86
Table 4.5a: Would you prefer to discuss HIV/AIDS issues with other pupils only, without the teacher?
_____ 87
Table 4.5b: Young peoples' reasons for preferring teachers' presence in HIV/AIDS discussions
__________ 88
Table 4.6a: Would you prefer boys and girls to discuss HIV/AIDS issues in single-sex groups?
___________ 88
Table 4.6b: Young peoples' reasons for preferring groups of mixed sexes
____________________________ 89
Table 4.6c: Young peoples' reasons for preferring single-sex groups
________________________________ 89
Table 4.7: Do you think your classroom was a good place for pupils to freely discuss HIV/AIDS issues?
____ 90
Table 4.8: Do you think more time was needed for HIV/AIDS lessons?
_______________________________ 90
Table 4.9a: Ways in which teachers can make HIV/AIDS lessons interesting and helpful
________________ 94
Table 4.9b: Ways in which classmates can make HIV/AIDS lessons interesting and helpful
______________ 95
Table 5.1: Did you use group discussions in class when learning about HIV/AIDS issues?
_______________ 97
Table 5.2a: A teacher's Scheme of Work 1
_____________________________________________________ 98
Table 5.2b: A teacher's Scheme of work 2
_____________________________________________________ 98
Table 5.2c: A teacher's Scheme of work 3
_____________________________________________________ 98
xiii
Table 5.2d: A teacher's scheme of work 4
______________________________________________________ 99
Table 5.2e: A teachers' Record of Work 1
_____________________________________________________ 99
Table 5.2f: A teachers Record of Work 2
______________________________________________________ 99
Table 5.2g: A teacher's Record of Work 3
____________________________________________________ 100
Table 5.2h: A teacher's Record of Work 4
____________________________________________________ 100
Figure 5.2a: Usefulness of group discussions to the teacher
______________________________________ 101
Figure 5.2b: Usefulness of group discussions to the teacher
______________________________________ 103
Table 5.3: Use of classroom rules
___________________________________________________________ 111
Table 5.4: Were you given a chance to ask questions on HIV/AIDS in your class?
_____________________ 117
Table 5.5a: Did your teacher invite people outside the school to come and talk about HIV/AIDS in your class?
______________________________________________________________________________________ 118
Table 5.5b: External organizations sending speakers to each school
_______________________________ 119
Table 5.6: LS&SRH content coverage by teachers as indicated by the pupils
_________________________ 120
Table 5.7: Were you taught how to say `no'?
__________________________________________________ 121
Table 5.8: Subject period allocation in the schools
_____________________________________________ 125
Table 5.9: Syllabi design
__________________________________________________________________ 126
Table 6.1: Recommended distribution of classroom activities for HIV/AIDS education
_________________ 136
Table 6.2: Content coverage in the curricula
__________________________________________________ 140
Table 6.3: Recommended skills on the topics pupils prioritised
____________________________________ 141
Figure 6.1: Subject period allocation circular from the Ministry of Education
________________________ 145
Table 6.4: Trained LS&SRH teachers actually teaching
_________________________________________ 150
Figure 8.2: Diagrammatic representation of the contribution of this study to knowledge
________________ 185
1
1.
Chapter 1: Study background
Introduction
HIV/AIDS continues to be a global health crisis facing us today, as it continues to defy efforts
to find a cure. In this chapter, I have outlined the statistical scale of the epidemic globally, in
Sub-Saharan Africa and in Malawi, where this study is set. The data highlight the population
groups at risk in order to underline the significance of the focus of this study. The chapter
points to HIV/AIDS education as a critical intervention needed to target the population group
mostly at risk. The chapter also gives a summary of the management and organization of
secondary school education, and the cultural and religious norms in Malawi in order to
illustrate the context of HIV/AIDS education provision.
1.1.
Global overview of HIV/AIDS
1.1.1.
Incidence and prevalence of HIV/AIDS
Available statistics on the occurrence and spread of HIV/AIDS indicate that progressively it
has turned into a global humanitarian crisis. The total number of people, adults, women and
children living with HIV/AIDS has remained high between 2001 and 2007 (UNAIDS/WHO,
2001; 2002; 2003; 2004; 2005; 2006; 2007). Data of adults living with HIV showed fluctua-
tions between 2001 and 2006, and a considerable drop in the year 2007 (see Figure 1.1). The
data shows that the biggest fluctuations occurred in women. Literature also show that young
people aged between 15 and 24 years are worst affected by the epidemic (UNAIDS/WHO,
2001; 2002; 2003; 2004; 2005; 2006; 2007 and Monasch and Mahay, 2006). It is, therefore,
likely that the dynamics of the epidemic may point to factors affecting both women and this
age group. UNAIDS/WHO, (2007) attribute the decline in 2007 to HIV/AIDS programmes,
particularly preventive efforts. However, despite the decline, global incidence and prevalence
remains high, suggesting the need for continued, expanded and intensified interventions.
2
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Initially, most of the mitigating efforts were biomedical in nature and were, therefore, not
appropriate for behaviour change (Dovan and Ross, 2000). At the heart of these interventions
was blood screening, which was being supported by messages on HIV/AIDS awareness
through the mass media. Notably, there was less emphasis on promotion of safer sexual
practices, particularly the use of condoms (M
c
Kee, et al, 2004). These initial interventions
included expansion of access to HIV/AIDS treatment (UNDP, 2003 and UNESCO, 2002) and
reduction of vulnerability (Kinghorn, et al, 2000). Other interventions included:
improvement of access to public services especially among groups that had high rates
of infections (Kinghorn, et al, 2000, Boler and Carrol, 2003);
formulation of relevant policies for the poor and vulnerable;
social mobilization (UNDP, 2003);
introduction of food security and structural agricultural reforms (UNDP, 2003; Acad-
emy for Educational Development, 2000) and
food assistance programmes, specifically targeting people living with AIDS, orphans,
lactating and pregnant women (Kadiyala and Gillepsie, 2003).
In the 1990s, voluntary counselling and testing (VCT) took centre stage as a bridge between
prevention and care, support and treatment (M
c
Kee, et al, 2004). Currently, the global
responses to the epidemic have diversified and among these is the deliberate response from
ministries of education to include HIV/AIDS prevention in the curricula of primary and
secondary schools. With no HIV vaccine in sight, there is now specific emphasis on
HIV/AIDS education as the only `vaccine' in stemming the tide of infections in the popula-
tion groups at risk, particularly among those aged 15-25 years (M
c
Kee, et al 2004). The
literature reviewed in the next chapter focuses on the nature, significance, and delivery of
HIV/AIDS education to these young people.
1.2.
Sub-Saharan Africa
1.2.1.
Incidence and prevalence of HIV/AIDS
The occurrence and spread of HIV/AIDS in this region is so prominent that it has been called
a Sub-Saharan disease. The region has just over 10% of the global population, yet it compris-
es over 60% of all people living with HIV/AIDS globally (http://www.avert.org/aafrica.htm ;
UNAIDS/WHO, 2007). Overall, between 2001 and 2007, the numbers of people living with
HIV and those being newly infected had generally dropped. Mortality figures showed
fluctuations (see Figure 1.2). In Sub-Saharan Africa women and young people aged between
15 and 24 bear the brunt of the epidemic (UNAIDS/WHO, 2001 2002, 2003, 2004, 2005,
2007, 2006, UNESCO, 2002, Monasch and Mahay, 2006).
4
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8
1.3.1.
The influence of Malawian cultural and religious contexts on HIV/AIDS
intervention efforts
Some elements of the Malawian culture impact significantly on the spread or the prevention
of HIV/AIDS as these practices have the potential to influence young peoples' response to
HIV/AIDS education. By Malawian culture, I am referring to the value systems, beliefs and
practices that characterise Malawian society (Kondowe and Mulera, 1999). Sex takes centre
stage in most of the cultural practices of Malawi, in matters of marriage, procreation, and
sensual satisfaction in love affairs (Kondowe and Mulera, 1999), and in defining masculinity
(Mwale, 2008, Izugbara and Undie, 2008; Kondowe and Mulera, 1999). Such a definition,
which is consistent with, and perpetuates sexual domination of women is in Malawi com-
pounded by a number of harmful cultural practices, to which I now turn.
Initiation ceremonies in Malawi are rites of passage from adolescence into adulthood. Such
practices are more common in southern Malawi than the north. After the ceremony, the
initiates are encouraged to have sex as a way of putting into practice what they have learned
theoretically (Mwale, 2008, Kondowe and Mulera 1999). The proponents of the practice
among the Yao tribe contend that youths need sexual cleansing which has to be through
unprotected sex (Mwale, 2008). This cleansing may be a hurried and unplanned venture,
leaving the initiates with no chance to ponder the consequences (personal observation). The
initiates are warned of unexplained repercussions should they not be cleansed (Mwale, 2008;
personal observation).
Gender inequalities prevailing particularly in rural communities in Malawi have also serious-
ly aggravated the spread of HIV/AIDS over the years, through other harmful traditional
practices (Arrehag, et al, 2006). One such practice is polygamy, which is practiced among
many communities in Malawi. The decision to enter into a polygamous marriage is in most
cases the prerogative of a man. Culturally women have no control over the decisions of men.
`Dry sex' is another cultural practice that is of concern in Malawi. In dry sex, women are
encouraged to use herbs to dry out the vagina in order to increase friction during the sexual
act. This causes tears and lacerations, and increases the probability of infection, putting the
female more at risk of infections than the man. A number of communities in Malawi also
engage in a practice called Chokolo. This is a widow inheritance practice, where a widow is
`inherited' by the late husband's brother. Related to this is a practice called widow sexual
cleansing, where a man has sex with a widow in order to cleanse her `impurity' because of
her husband's death. Another practice of concern is called fisi. In this practice, fisi ( literally
9
hyena) is a man who engages in sex with a woman who is failing to conceive, or a young girl
who has just experienced menarche. In all these practices, females are expected to comply
culturally. This makes them vulnerable to HIV infections since no provision is made for VCT
(voluntary counselling & testing) prior to the sexual encounters.
While the foregoing illustrates the influence of cultural practices in aggravating the spread of
HIV/AIDS in rural Malawi, it does not fully explain the prevalence of risky practices among
young people, particularly in the urban areas. Available evidence implicates the beliefs held
by the young people as being the major cause of such behaviours. A study by Izugbara and
Undie (2008) has unveiled a number these beliefs held by Malawian adolescents summed up
below:
`Malawian young men are ultimately steered towards high risk sexual practices and part-
ners by their anxieties about the potential humiliation , loss of reputation, and feeling of
powerlessness that go with being refused sex or engaging in sexual practices which offer
them little or no control and power over women or which make them feel less than man-
ly.'
Izugbara and Undie (2008) pp. 282
The need to exercise control in sexual practices appears central in influencing the risky
practices among Malawian young males. Such control implies that the young females are
expected to be passive. According to Izugbara and Undie (2008)
young boys in Malawi
believe that men (boys) were created to have sex, and that control over women and receiving
pleasure from them is normal and outweigh any risks posed by sexually transmitted diseases.
They hold the belief that they have a duty to protect their manhood through sexual encounters
otherwise, they run the risk of losing it. There is also a belief in Malawi that condoms reduce
sexual pleasure and most people think that using condoms undermines trust between partners
(Adams, 2006). In this study, a number of boys reported that they preferred to have sex with
sex workers, bar girls, and street girls. Sex with such partners (prostitutes, sex workers etc.) is
preferred as it allows the boys to have greater control over the sexual acts. Influenced by the
desire to be in control, most boys do not approve of using a condom. According to them the
use of condoms, leaves them feeling out of control and denied of their natural right to
maximum sexual pleasure. Further, boys felt that agreeing to such a request from a girl means
succumbing to rules set by a girl, which to them is `unmanning' (Izugbara and Undie, 2008)
.
In all this, we see males asserting their dominance and power over females in sexual encoun-
ters. The desire to have many sexual partners among Malawian boys has also been under-
10
scored (Kadzamira, et al, 2001, Mwale, 2008, Izugbara and Undie, 2008). There is a sense of
pride that underlies such behaviour that also makes them feel like champions.
Malawian girls are also known to engage in sexual activity in order to get financial support
(Kadzamira, et al, 2001and Adams, 2006). In such relationships, the need for financial
supports far outweighs the threat of HIV infection.
The foregoing illustrates that the desire in boys to dominate in sexual relationship and the
need for financial support in girls are some of the factors facilitating unsafe sexual practices
among young people in Malawi.
In Malawi, religious leaders are moral authorities and opinion leaders in most communities
(personal observation). They, therefore, have a duty to educate the public about caring for the
sick or orphans and about appropriate sexual practices, alongside religious values. In the
same vein, religious institutions are a major influence of cultural issues surrounding sexual
practices, marriage rituals and health issues. They are in this sense expected to define
boundaries of moral aspects surrounding these issues in the Malawian culture. Estimates
show that 50% of the population are Protestants, 20% are Roman Catholics, and 15% or
fewer are Muslims, while the remaining 10% accounts for those belonging to African
traditional religion (Rankin, et al, 2005). A study carried out by Wittenburg, et al, (2007)
showed that most of the young people regarded religion as being important to them, evi-
denced by weekly attendance at church services. Young people with Christian beliefs have
also claimed less likelihood to initiate sex early (WHO, 2001, cited in M
c
Kee, et al, 2004).
Ugandan `born again' Christian girls claim to have refused sex outside marriage (Wimberly,
1994). Similarly, in Malawi, `born again' Christian adolescents have voiced a strong stand
against sex outside wedlock (personal observation). In view of these observations, religious
institutions appear strategically placed to influence the youth in matters of sexual and
reproductive health and to collaborate with the government in educating the young people
about sexual and reproductive health. However, religious institutions and the government in
Malawi hold opposing stances regarding some of the messages intended for young people. At
the helm of the controversy is the issue of the condom and hence, `the condom divide' (see
Figure 1.7).
11
Figure 1.7: Factors influencing the condom divide. Source: Rankin, et al (2008)
All religious institutions in Malawi are invariably consistent in their messages on premarital
abstinence and marital fidelity, although they ascribe the virtue of fidelity to women (Rankin,
et al, 2008). This attitude towards women serves to exacerbate the existing power discrepan-
cies and to put the responsibility of being faithful in marriage to women only. Leaders of
these institutions believe that messages about the use of condoms promote infidelity and
undermine the message of abstinence. They have a clear stand against the distribution of
condoms let alone their use by young people outside marriage. The central message from all
faith-based organisations is that sex outside marriage is immoral. As a result, most of the
religious leaders view the government messages that encourage condom distribution and use
by young people negatively. The leaders, however, share the position of the government on
abstinence and being faithful. Although government accepts and encourages abstinence as the
priority behaviour of choice, it also recommends messages on correct use of condoms and
subsequent distribution of the same as being pivotal in the fight against HIV/AIDS. The
Malawi government believes that the only way to assist young people to avoid catching the
HIV virus is to make condoms available to them (personal communication with Ministry of
CONDOM
DIVIDE
Religious messages
Government messages
AB:
Abstinence
ABC:
Abstinence
Be faithful
Being faithful
is a female
Condom
promotes sin
Demonization
of
government
HIV prevention
messages:
Use and
distribution of
12
Health officials, 2006), since not all young people can abstain. Therefore, while the statistics
of HIV occurrence and spread above implicate young people as dictating the dynamics of the
HIV/AIDS epidemic in Malawi, young people are faced with contradictory messages on how
to prevent HIV/AIDS. Such controversy has the potential to influence their classroom
learning of HIV/AIDS.
1.3.2. Impacts and interventions of HIV/AIDS in Malawi
In Malawi, some of the notable impacts of the HIV/AIDS epidemic include:
rising medical and funeral expenses;
deepening poverty at house hold levels;
widening of the already existing gender inequalities in many sectors of the society;
reduction of productivity levels in the urban centres due to labour loss;
closing down of companies due to loss of skilled labour, and
a steady decline in the fertility rate (Arrehag, et al, 2006).
In addressing the impacts, Malawi has policy reforms in the agriculture and land sectors to
benefit women, children, and the disabled (Ministry of Agriculture, 2003, Enemark and
Ahene, 2002). Other interventions include establishment of centres for voluntary testing and
counselling, prevention of mother to child transmission using drugs, condom distribution and
a significant roll out of Anti-Retroviral Therapy (ART)
(
Keating and Johns, 2007).
HIV/AIDS and the education sector
The impacts of HIV/AIDS on the education sector in Malawi mirror those in most Sub-
Saharan states. One of the major impacts is the decline in quality due to serious shortages of
staff at all levels of the education systems. Such shortages result from reduced teacher supply
caused by deaths of teachers and staff in education divisions, districts and local education
authorities and teacher training colleges, coupled with the impairment of management of
education and financial planning through sick leave requests, early retirements and ever-
increasing unbudgeted funeral expenses (Jackson, 2002, Kelly, 2002a, UNECA, 2000, and
World Bank/ UNAIDS, 2002).
The demand for education has also been affected through the reduction of the numbers of
school-going children as a result of deepening poverty levels, as families lose income earners
and are not able to afford schooling costs, and the creation of many orphans who cannot
afford the cost of schooling (Jackson, 2002, Kelly, 2002a, UNECA, 2000 and World
Bank/UNAIDS, 2002). In Malawi, the breakdown of cohesion in family units has resulted in
13
child-headed homes (personal observation). These children are usually young people in their
teens.
The Education Sector is pivotal in matters of HIV/AIDS prevention because it is inevitably
networked to most homes through the young people. According to the Ministry of Education
Science and Technology (MOEST) (2001a) the Education sector had over 4 million students
in primary, secondary and colleges of higher learning representing a quarter of Malawi's
population. This sector was and continues to be the biggest in Malawi. Out of a population
of 13 million in 2006 (http://www.prb.org/Countries/Malawi.aspx), 2 million were secondary
school students most of whom were within the 15-24 age bracket (EdAssist, 2007). Since
HIV prevalence is high within the 15-49 age bracket (see section 1.3 above), it can be said
that the Malawian secondary schools students comprise most of the sexually active young
people.
Given the apparent vulnerability of secondary school pupils in Malawi shown above, it is
imperative that any strategic intervention has to target this group in order to lower the
prevalence of HIV/AIDS in Malawi. Kadzamira, et al, (2001) suggested several interventions
to the Ministry of Education in Malawi, which included the teaching of HIV/AIDS education
through Life Skills subject in schools and mainstreaming of HIV/AIDS, Family Life Educa-
tion, and Life Skills into the curricula of training colleges.
Although the initial mitigations in Malawi, just like on the global scale, were biomedical in
nature, with less emphasis on prevention intervention strategies, there is now a deliberate
emphasis on HIV/AIDS education particularly in the secondary schools. A chronology of
efforts to introduce and implement HIV/AIDS education in Malawi is given in Chapter 2
(Literature Review).
1.3.3.
The context of HIV/AIDS education within the secondary school educa-
tion system in Malawi
Organization of the secondary school system
Pupils go to the government-controlled secondary schools when they pass the Primary School
Leaving Certificate Examination (PSLCE). In some private secondary schools, entry is
through entrance examinations, although in some cases they accept pupils provided they can
afford the fees. The secondary school system in Malawi comprises four levels called forms.
Forms 1 and 2 are called the junior secondary school forms while 3 and 4 are the senior
forms. Ages range from 11-15 years in the lower secondary school and 15 - 24 years in the
14
upper secondary school. To move from the junior secondary school into the senior, pupils are
required to pass the government's Junior Certificate Examination (JCE). In most of the
private schools, pupils progress to the senior section even after failing JCE. At the end of the
fourth form, pupils write the Malawi School Certificate of Education Examination (MSCE),
which is the equivalent of the GCSE in the United Kingdom. Those who achieve good grades
are required to pass university and college entry examinations before being offered a place to
study at one of the universities and colleges in Malawi. In some universities, selection is
based on MSCE subject grades. Apart from these government-controlled examinations,
pupils sit for end of term examinations in each of the three terms at each level. Given the
foregoing, it can be seen that the system is assessment oriented.
Twenty-one subjects are offered at secondary school level in Malawi. Of these, 7 are desig-
nated core subjects. Each school is required to offer these. The other 14 subjects are designat-
ed elective subjects. In addition to the core subjects, schools are supposed to offer additional
subjects from the elective group depending on the available resources. Two of the seven core
subjects are not examinable-Physical Education and Life Skills & Sexual Reproductive
Health (LS&SRH). LS&SRH is the subject through which HIV/AIDS education is taught.
Four universities and one college of higher education provide teacher-training programmes
for secondary school teachers in Malawi. Most of the subjects offered in the curricula of these
colleges are the ones pupils study at secondary school level. In this manner, teachers are
equipped with specific skills to teach their preferred subjects. Although LS&SRH is a core
secondary school subject, no curriculum at any of these institutions has included it on a stand-
alone basis. A recent development has been the infusion of LS&SRH (Life Skills & Sexual
Reproductive Health) issues into the Social Studies curricula at the University of Malawi and
Domasi College of Education (Chakwera and Gulule, 2007). Other training opportunities for
teachers of HIV/AIDS education are through in-service courses by curriculum specialists at
the Malawi Institute of Education (M.I.E.), who developed the LS&SRH Curricula. The Sub
Saharan Africa Family Enrichment (SAFE) programme, a faith-based non-governmental
organisation, also offers in-service training courses in HIV/AIDS education through the
WHY WAIT? Life Skills Curricula. The head teachers nominate participants to both in-
service programmes.
Management of secondary school education
15
Head teachers manage the day-to-day affairs in each school. Depending on the school
population, the head teachers are deputised by one or more teachers. Below these are depart-
mental heads. These individuals together make up the management team within a school.
Head teachers and their deputies carry out both administrative and academic functions while
heads of departments usually function as academic advisors. The management team is
required to monitor the teaching standards and these are weighed against examination
requirements. In Malawi, the best indicator of a school's success is the number of pupils that
it sends to universities. Because of this, the teaching of core examinable subjects is monitored
highly. A possibility, therefore, exists for schools not to put emphasis on non-examinable
subjects e.g. the LS&SRH. As a requirement, head teachers observe classroom teaching in
order to acquire a feel of the standards and challenges at their schools. They hold regular
meetings with teachers to ensure that the required standards are being met.
The Senior Methods Advisors (SEMAs) provide external supervision.
1.4.
Conclusion
The chapter has shown that women and young people are at the centre of the dynamics of
HIV/AIDS. Although initial interventions were biomedical in nature, with little emphasis on
HIV/AIDS education, current global and national emphasis is to use HIV/AIDS education as
a major intervention in the prevention of HIV.
Both globally and in Malawi young people aged between 15 and 24 engage in high-risk sex
and are, therefore, particularly vulnerable to HIV/AIDS. The bulk of this age group is in
secondary schools making an appropriate HIV/AIDS Education curriculum critical in curbing
the spread of HIV. In Malawi, successful implementation of such a curricula will be strongly
influenced by culture, religious and the education system. The next chapter discusses the
centrality of HIV/AIDS education as an intervention both globally and in Malawi.
16
2.
Chapter 2: Literature Review
Introduction
Chapter 1 outlined the prevalence and the impacts of the HIV/AIDS epidemic globally, in
Sub-Saharan Africa and in Malawi, and ended by implicating HIV/AIDS education as the
best means to mitigate the impacts. Drawing on the statistics that show the highest preva-
lence of HIV/AIDS within the 15-24 age groups, Chapter 2 begins by showing the centrality
of schools in HIV prevention. The chapter then describes the various school-based models of
HIV/AIDS Education and the significance of skills education for behavioural change. The
chapter then proceeds to discuss a number of classroom teaching strategies considered
effective for skills-based HIV/AIDS education.
Lastly, this chapter explores the development of HIV/AIDS education in Malawi. It presents a
combination of the chronology of research efforts and the interventions done within the
education sector. Within this chronology, a number of gaps have been identified which have
helped to set the context of this study.
2.1.
HIV/AIDS education and young people
UNESCO (2004) argues that lack of effective HIV/AIDS education for population groups
mostly affected accounts for the rapid spread of the epidemic in the worst affected countries.
Global statistics point to young people as being at the centre of the epidemic in terms of
prevalence and new infections. Young people generally refer to those aged 10-24 years
(Dick, et al, 2006; Hoffman, et al, 2006 and M
c
Kee, et al, 2004). The group is conventionally
divided into early adolescence (10-14 years), middle adolescence (15-19 years) and young
adults (20-24 years) (James-Traore, 2001 cited in Kirby, et al, 2006). An estimated 50% of
global infections have occurred in young people under 25 years of age (Chipeta and Luhanga,
2001, Dick, et al, 2006). In some developing countries, 60% of the new cases occur in 15-24
year olds (Rivers and Aggleton, 2000). It is estimated that 50% of the 6,800 daily infections
(UNAIDS/WHO, 2007), have occurred in young people aged 15-24 years (UNAIDS/WHO,
2006), with the females being the bigger percentage. In most countries, adolescents do not
practise safer sex (Buga, 1996, Flisher, et al, 1993, Kuhn, et al, 1994, Richter, 1996 and
Harvey, 1997). Although these studies have demonstrated that generally, the majority of
young people are ignorant of how to prevent transmission, other studies have specifically
17
shown that the proportion of young people using condoms is small (Garbus, 2000 and
Monasch and Mahy, 2006). Such low compliance to condom use is in some cases accentuated
by misconceptions about HIV/AIDS transmission (Sekgoma, 1994, Cliffs, et al, 1989, and
Garbus, 2000). In Malawi, for example, the knowledge level of pupils entering the secondary
school is above 50% regarding transmission and avoidance behaviours, but less than 40%
regarding myths and misconceptions (Dolata, 2011).
In countries that have achieved significant declines in HIV prevalence, young people have
registered the biggest behavioural changes (Monasch and Mahy, 2006). This shows that
young people hold the keys not only to our understanding of the epidemic, but more im-
portantly, to the efforts required to stem the tide of infections. Young people are at the age
when they are considering sexual experiences or may have just started having sex (Kirby, et
al, 2006), and are, therefore, much more likely than older people to adopt and maintain
preventive behaviours (Monasch and Mahy, 2006). As such, consensus on feasible preventive
interventions target young people, particularly those in schools. In this study, schools refer to
any educational institutions that offer formal training to young people below 25 years (Kirby,
et al, 2006). Schools are pivotal in preventive intervention efforts because, in many countries
and societies, they are regularly attended by large numbers of young people (Kirby, et al,
2006, Ross, et al, 2006 and UNESCO, 2007). They are therefore among the key places where
young people can be reached with messages on HIV/AIDS. Schools are important providers
of information since they can help young people develop life skills necessary for the preven-
tion of HIV infection.
The UNGASS (United Nations General Assembly Special Session) on HIV/AIDS for young
people recommended that school-based interventions should `provide young people with
access to information (goal 1), with skills to avoid becoming infected with HIV (goal 2), with
access to services (goal 3) and to decrease their vulnerability to infection (goal 4), as well as
decrease the prevalence of HIV among young people (goal 5)' (Kirby, et al, 2006 p. 104).
While a number of studies have shown the effectiveness of school based interventions in
achieving goal number 1, there is little evidence to support the effectiveness of such pro-
grammes in achieving the remaining goals (Kirby, et al, 2006). In addition to the difficulty of
formulating and assessing outcomes such as skills, vulnerability and prevalence (MacPhail
and Campbell (1999), most school environments in the developing world lack the teaching
techniques and the culture necessary for the teaching of refusal, and negotiation skills (Baker,
18
et al, 2003, cited in Kirby, et al, 2006 and Chege, 2006). Resistance to teaching about
condom use is also widespread ( James-Traore, et al, 2004, cited in Kirby, et al, 2006).
Given the status quo, there is need for contemporary school-based approaches to deliberately
focus on the achievement of the remaining goals.
2.2.
School-based approaches to HIV/AIDS education
Currently there are four school-based approaches, each with its own advantages and disad-
vantages (UNESCO, 2008b).
Co-curricular-HIV/AIDS education
Co-curricular-HIV/AIDS education is provided in settings outside the classroom. Pupils
learn HIV/AIDS issues through informal teaching forums such as assemblies, clubs and other
extra-curricular activities. Since attendance by pupils at most of such activities is usually
voluntary, not all young people access the intended messages. Additionally, most school
teachers in the developing world find it too demanding to take up extra loads in the form of
management of extracurricular activities, which are outside the school timetable on top of
their classroom loads (personal observation).
Integration across curriculum
In this approach, HIV/AIDS education issues are included in all subjects and are examined
alongside the core issues of those subjects. This approach has not been effective for the
teaching of skills in most in countries because of the examination-oriented curricula. The
approach encourages teachers and pupils to concentrate on scientific knowledge only, since
the attitudes and skills involved in HIV/AIDS education are difficult to examine in a formal
examination setting (UNESCO, 2008c).
Stand alone subject
Here, HIV/AIDS education is a separate examinable subject. Such an approach has raised
some concern from parents who want to know what it is about HIV/AIDS that their children
are learning. They feel that such emphasis on HIV/AIDS issues may lead to discussions of
issues, which are considered suitable only for married or cohabiting partners (Bahri, 2001).
Such concerns relate to resistance from the communities to let children learn explicit details
about sex and the use of the condom (UNESCO, 2008a, UNESCO, 2008b, and Muriel and
Sass, 2008).
19
Carrier Subject
HIV/AIDS education is incorporated into an existing subject such as Health, Life Skills, Life
education and Behavioural education. UNESCO, (2008c) recommends that lessons on
HIV/AIDS should be grafted into issues of personal development, health and general life
skills. In most countries of the developing world, the carrier subject approach is favoured for
the delivery of HIV/AIDS education possibly because it includes skills other than only those
of HIV prevention. In Malawi, for example, life skills education includes communication,
creative thinking, and conflict resolution skills, amongst others (Mshlanga, et al, 2002 a, b).
Ministries of Education in a number of countries have realised that knowledge alone is not
enough to address the vulnerability of the youth to the HIV/AIDS epidemic (UNESCO, 2008
a, b, and c). As a result, curricula on HIV/AIDS education in formal schooling have almost
invariably made skills acquisition a focus, with the ultimate goal being behaviour change.
Initially it was labelled sex, family life or reproductive health education (Bahri, 2001). The
labels met with resistance from parents as they implied that pupils would be engaged in
exclusive sexual matters, most of which were generally considered appropriate to married
and cohabiting partners only. To ensure acceptance, skills based HIV/AIDS education is now
termed variously as Life education, Behavioural education, Skills for living, Skills for life
education, Education for citizenship and Life Skills Education. Malawi uses the term `Life
Skills and Sexual Reproductive Health' (LS and SRH).
20
2.2.1.
In this
ments,
and way
Figure 2
from M
c
The tab
also rel
areas in
Table 2.1
Exam
Socia
Comm
Nego
skills
Asser
Interp
skills
health
Coop
What is Li
study, Life
namely; wa
ys of taking
2.1: Interfacin
c
Kee, et al (20
ble below cl
levant to HI
n Figure 2.1
1: Categories
mples of Life
al Skills
munication sk
otiation/refusa
s
rtiveness skill
personal
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peration skills
Ways of
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ife Skills Ed
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004)].
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s Education
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g skills:
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oblem solving
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eative thinking
ith three m
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ee Figure 2.
rnegie and B
ife Skills Ed
foremention
2004)
Emotional S
Managing st
Managing f
anger.
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locus of
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.1.
Birell Weisen,
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21
These skills are not mutually exclusive as shown in the three major elements of the definition
of Life Skills in Table 2.1 above. Curriculum developers carefully select content to match or
cover these skills. Below is a simplified illustration of how content can be organised around
these skills:
Table 2.2:
An example of content organisation around skills [Adapted from WHO (2004)]
Content area
Structured content detail
Relevant Skills
Sexual and reproductive
health
Information about STIs, HIV,
and AIDS.
Myths and conceptions about
HIV/AIDS.
Myths about gender roles/body
image perpetuated by media.
Gender relations (gender equity
or lack of it) in society.
Social influences regarding
sexual behaviours
Dating and relationships
Interpersonal skills
Cooperation skills
Negotiation/refusal skills
Communication skills
Decision making/problem
solving skills
Managing stress
Critical-thinking skills for
increasing internal locus of
control
Managing feelings, including
anger.
2.2.2.
Life Skills and behaviour change
Studies have shown that knowledge alone is not enough to influence the desired behavioural
changes necessary to stem HIV infections (Rogers 1995, Poland, et al, 2000, Atkin, 2001,
Bertrand, 2004 and Duggan, 2006). In order to control the epidemic, education systems need
to engage in preventive interventions, which will target vulnerable groups in specific con-
texts, in order to help them acquire appropriate skills and develop the positive attitudes,
leading to behaviours that will stem the tide of infections. As noted already, young people
comprise one of the vulnerable groups. It is for this reason that skills-based HIV/AIDS
education specifically targets behavioural change in these people.
Evidence from skills-based education shows that it promotes and enhances positive attitudes
and behaviours, improves communication, healthy decision making and effective conflict
resolution (Bhari, 2001). Life Skills education is appropriate for addressing the health issues
that children and young people encounter in the school setting which includes the use of
alcohol, tobacco and other drugs, reproductive and sexual health, and HIV/AIDS prevention
(http://www.who.int/school_youth_health/media/en/sch_skills4health_03.pdf).
22
Despite the current emphasis on HIV/AIDS education through Life Skills Education, there is
no standardised internationally comparable method for assessing directly whether young
people have developed sufficient skills in order to effectively deal with the epidemic
(Monasch and Mahy, 2006). Unlike biological mechanisms by which therapeutic drugs work,
little is understood of the forces underlying the social world through which behavioural
interventions work (Ross, et al, 2006). Further, the age, sex of a participant, ethnicity,
cultural community and sexual orientation are some of the caveats that make skills education
contextual, and, therefore, difficult to scale-up and replicate. Despite these difficulties, skills
education is still preferred in a formal school setting because of its cost effectiveness,
potential for less adverse effects, acceptability, size effect, and more importantly, health and
social benefits (Ross, et al, 2006).
2.2.3.
Perspectives on HIV/AIDS education within Life Skills
Curriculum-based approaches are usually based on theory and research findings and usually
undergo pilot testing prior to their use (Kirby, et al, 2006). Classroom teachers are the main
implementers in the classroom. These curriculum-based approaches are intended to help
teachers overcome their negative teachers and to circumvent their fears, limitations and
negative beliefs towards the teaching of the skills involved in HIV/AIDS Education (Kirby, et
al, 2006). The teaching approach in curriculum-based interventions could take any of the
following three forms: Abstinence-only, Abstinence-plus, and Safer-sex. The word `sex'
refers to vaginal, oral, anal or any combination thereof. `Abstinence' here means refraining
from any acts of protected or unprotected sex.
Abstinence-only approaches
In Abstinence-only interventions, abstinence is the only recommended behaviour of choice
for HIV prevention. The proponents of this approach are spurred on by the success of an
experimental study done in the Ugandan district of Soroti by Shey, et al, (1999). According
to the study, access to information, enhanced interaction among pupils, and between teachers
and pupils on AIDS, sexuality and health issues, together with improved quality of the
existing school-health education system, combined to influence a reduction in sexual activity
among 14-year-old students. However, others have questioned the attribution of this reduc-
tion in sexual activity to sexual abstinence, arguing that such reductions were most likely due
to the synergistic influence of abstinence and other factors e.g. reduced sexual partners, and
increased condom usage (Roehr, 2005 and USAID, 2003). The effectiveness of abstinence
has generally been questioned elsewhere. Others contend that sexual abstinence is only
23
theoretically effective as it is imperfectly practised (Auerbach, et al, 2006). To them, the most
effective prevention technology is the use of the male latex condom, which accounts for an
estimated 80-90% risk reduction subject to correct and consistent use. Further, a systematic
review of abstinence-only programmes in low-income countries yielded no effects on
behavioural outcomes (O'Reilly, et al, in Underhill, et al, 2007). According to UNESCO
(2008c) interventions that advocate abstinence as the only option to HIV prevention fail to
provide an alternative for those students who are already sexually active, and those who
become sexually active later (Kirby, et al, 2005).
Abstinence-plus approaches
Abstinence-plus programmes prioritise abstinence as the safest behaviour of choice, but
realising that not all young people can abstain, the use of condoms is also encouraged.
Underhill, et al, (2007) carried out a comprehensive review of Abstinenceplus HIV preven-
tion programmes in high-economy countries. Their findings suggested that such programmes
do reduce short-term and long-term HIV risk behaviour. These findings may, however, not
apply to countries with poor economies due to cultural, religious, and other differences.
However, it has been noted that data from countries and communities that have attributed the
reduction of HIV risk behaviour to the effectiveness of abstinence-plus interventions, fail to
show which of the three, (delayed sexual debut, partner reduction, or condom use), is
dictating the dynamics of the epidemic (Auerbach, et al, 2006).
Household surveys in developing countries also indicate that the proportion of young people
using condoms is quite low, even when they have sexual encounters with non-regular
partners (Monasch and Mahy, 2006). For instance, in Malawi, where 1 out of 6 people aged
15-49, are HIV+, only 32% of young women and 38 % of the young men reported using a
condom last time they had sex with a non-cohabiting partner (Monasch and Mahy 2006).
There is however evidence to show that contrary to the popular belief that sex education
using the abstinence-plus approach can lead to sexual experimentation among young people,
it delays sexual debut and reduces the number of sexual partners (Kirby, et al, 2005). A
number of declines of the epidemic in the countries of Zambia, Senegal and Cambodia
implicate the effectiveness of Abstinence-plus approaches (USAID 2003, Bertrand 2004 and
Feldblum, et al, 2003) combined with community support (Munodawafa, et al, 1995). Such
successes are, however, localised. According to Auerbach, et al (2006) investigations of
interventions on risky behaviour are specific to a population, with the reference groups
24
defined by age, sex of the participant, sexual orientation, ethnicity, cultural community (also
pointed out by Ross, et al, 2006), geographical setting or exposure category. Secondly,
almost all behavioural outcomes are self-reported. This places a high premium on the veracity
and validity of the outcomes. Discrepancies between self-reported behaviours and biological
markers e.g. pregnancies and STIs have also been reported in studies based on self-reported
behaviours (Auerbach, et al, 2006).
Safer-sex approaches
Safer-sex educational approaches do not prioritise abstinence over condom use and generally
promote the use of the latter. Safer-sex interventions have been criticised for downplaying
messages on abstinence (Haskins and Bevan, 1997 in Underhill, et al, 2007). However, a
study of African American adolescents showed that safer-sex interventions
may be especially
effective with sexually experienced adolescents
and may have longer-lasting behavioural
effects (Jemmott, et al, 1998). In some cases, safer-sex approaches have led to significantly
higher rates of
condom use by adolescent boys (Dilorio, et al, 2007). Safer-sex interventions
are, however, unpopular in most developing countries because of cultural and religious
barriers (UNESCO, 2008 a, UNESCO, 2008b, and UNESCO, 2008c). In Uganda for exam-
ple, some of the reasons for the teachers' reluctance to teach about the condom and its use
using participatory approaches, were due to the belief that such approaches would encourage
promiscuity, fear of being dismissed by head teachers, and the influence of the Roman
Catholic Church (UNESCO, 2008c).
2.3.
Effective approaches to HIV/AIDS education
Since prevention is currently the only effective `vaccine' against HIV/AIDS, it is imperative
for HIV/AIDS education to promote behaviours that will help to stem the tide of infections in
young people. Literature on HIV/AIDS education identifies several effective strategies in
HIV/AIDS education. Most of these strategies reflect what are believed to be the needs of
learners in HIV/AIDS Education. Below is a discussion of the recommended practic-
es/strategies unveiled by literature review in this study.
25
2.3.1.
Establishing safe learning environments
Although schools are supposed to be environments where young people are safe, there is
substantial evidence that instead, they are places where bullying, verbal abuse, intimidation,
physical harm, sexual harassment and rape are common (UNESCO, 2008c). WHO (2002)
reported that many young women experienced sexual coercion and harassment at school.
There is need, therefore, to establish safeguards within the learning environment in the form
of legislation and school policies, aimed at curbing teacher-student sexual relations and
sexual harassment among learners. Relevant policies should address inclusion, discrimina-
tion, sexual harassment, the right to education, protection of HIV infected and affected young
people and teachers, and the enforcement of codes of conduct with the aim of making the
learning environment safe (Muriel and Sass, 2008). Safe learning environments should also
take the form of promotion and respect for human rights, in order to remove stigma and
discrimination among young people. Such promotion of human rights should provide for
inclusive education and a rights-based learning environment, emphasise gender issues, clearly
outline roles and practices of teachers, and consider teaching on HIV treatment as a priority
(UNESCO, 2008a).
The resistance of teachers to discuss sensitive issues about HIV/AIDS (James-Traore, et al,
2004, cited in Kirby, et al, 2006) suggests that classrooms do not provide safe environments
where both teachers and young people can openly discuss HIV/AIDS issues. A study of
selected countries from the Eastern and Southern Africa (Chege, 2006), suggested that
teachers of HIV/AIDS were not ready to discuss sexuality issues openly. As a way of
circumventing open discussions, they resorted to using moralistic and authoritarian approach-
es. For example, in some cases, teachers engaged young people in question and answer
didactic interaction in which only teachers asked questions.
2.3.2.
Recognising gender differences
Since it is commonly known that young women bear the brunt of HIV/AIDS in terms of new
infections, prevalence and impacts, HIV/AIDS education should seek to address the plight of
girls in the schooling environment. UNESCO (2008a) suggests that gender-responsive
HIV/AIDS education should deal with stereotypes, and gender-based violence, enable
development of communication, negotiation and critical thinking skills needed to confront
gender norms and peer-pressure, and facilitate healthy decisions about sexual behaviour. In
this regard, HIV/AIDS education should address gender inequalities that deter young women
26
from making informed choices about sexual experiences. Images of masculinity, which are
reinforced through role models, peer pressure and the media, make both girls and boys
vulnerable to HIV/AIDS and must be challenged (UNESCO, 2008a).
2.3.3.
Supporting pupils affected with HIV/AIDS
A number of pupils are grappling with the effects of HIV/AIDS and look to the school as the
place that can give them support to cope with these challenges. There are growing numbers of
young people with special needs, some of whom have lost one or both parents, are living
away from their homes in institutions, while others are victims of sexual abuse and are
grappling with emotional and psychological problems. Some may actually be sick, evidenced
by their being frequently absent from class. HIV/AIDS education must, therefore, respond to
challenges such as motivation, health, lack of family support, trauma and bereavement,
poverty, stigma and nutritional status before such pupils can effectively respond to intended
academic challenges.
A study done in Zambia by Baggaley, et al, 1999 (in UNESCO, 2008b) showed that pupils
suffering the effects of HIV/AIDS were poverty-stricken, affected by death and illness of
parents and fellow pupils or teachers, had suffered domestic violence, and that girls in
particular had low esteem. HIV/AIDS education can, among other things, respond by
providing psychological support, and the establishment of school feeding programmes
(UNESCO, 2008a). Provision of HIV/AIDS counselling is also important in this respect
given the nature of the challenges faced by the pupils.
2.3.4.
Linking with other service providers
In many societies in developing countries, teachers resist discussions about sex with adoles-
cents in the classroom (Kirby, et al, 2006). In particular, most of the information given to
young people in classrooms is aims at discouraging the use of condoms and encouraging
abstinence (Maticka-Tyndale, et al, 2004 in Kirby, et al, 2006). Given this scenario, pupils do
not access all available information on HIV prevention. HIV/AIDS education programmes
should therefore be linked to other referral centres such as health centres, voluntary testing
and counselling centres, and sexual and reproductive health centres, where pupils can obtain
further support and information (UNESCO, 2008a). However, this becomes a challenge
where HIV/AIDS education implementers and the referral centres are giving contradicting
messages on HIV/AIDS prevention (see the next section).
27
2.3.5.
Being culturally sensitive when responding to the needs of the pupils
As noted, open discussions about sexuality have remained a big challenge in many cultures
and societies. The major challenge is that most of the issues in HIV/AIDS education have the
potential of contradicting strongly held taboos about sex, gender, illness and death
(UNESCO, 2008a). Such taboos have a strong influence on the behaviour of both adults and
young people in the community. Therefore, HIV/AIDS education using biomedical ap-
proaches has the potential of being in direct conflict with contextual beliefs. As members of
their societies, HIV/AIDS teachers are constrained by their cultural and religious norms. As a
result, teachers have shown resistance to engaging in discussions of sexual behaviours with
adolescents (Smith, et al, 2003 and Baker, et al, 2003 in Kirby, et al, 2006). For instance, the
use of the condom is discouraged, while abstinence is encouraged in the classroom (Maticka-
Tyndale, et al, 2004 in Kirby, et al, 2006). In contrast, young people appear to prefer more
open talk about sexuality issues (Chege, 2006).
According to Ross, et al, (2006), the acceptability of an intervention requires the approval of
religious leaders, community leaders and the wider community. Therefore, for HIV/AIDS
education to be effective, it must be accepted in the cultural context of the learners, teachers,
and the wider community. Suggestions to this effect have been discussed below.
There is a need for use of local languages and dialects and employ culturally acceptable
words and terms when discussing HIV/AIDS issues in class. Implementers of HIV/AIDS
education need to take extra precautions regarding the language they use, as this has to take
into account the age, and the cultural context of the learners (UNESCO, 2008b). There is a
delicate balance here, as teachers try to be open and scientifically accurate, while at the same
time being culturally sensitive. Identifying appropriate language may also need to take into
account cultural and religious boundaries, which may vary in different contexts. This sug-
gests that parents and young people need to collaborate and compromise on what language
they believe is suitable in their context. Communities should be given an opportunity to
examine and discuss their cultural practices with a view of adopting those that are safe.
Therefore, in designing a culturally acceptable curriculum there is need to ensure involve-
ment of the cultural and religious leaders in order for them to suggest elements from their
culture which can safely be incorporated into an HIV/AIDS education curriculum. Culturally
relevant HIV/AIDS education has the potential to facilitate more open discussions on
HIV/AIDS issues. When communities are aware of and involved in developing what their
children are learning in class they are likely to offer out of school support when reinforcing
28
skill building in young people. In particular, parents have a strong influence on the sexual
behaviour and attitudes of their children (Hutchinson, 2002, Hutchinson, et al, 2003,
Pequegnat and Szapocznik, 2000, Whitaker and Miller, 2000).
UNESCO (2008b p. 25) has suggested important steps in designing a culturally sensitive
HIV/AIDS education. These include:
identifying cultural resources that can facilitate HIV prevention, as well as those fac-
tors that promote vulnerability,
identifying culture-specific ideas and perceptions about health and examining their
relationship to HIV/AIDS, and inclusion of those aspects of culture that facilitate
prevention in pre-and in-service training of teachers,
ensuring strong linkage between the school and the community, and gaining the sup-
port of traditional, religious and opinion leaders on HIV/AIDS issues, and
drawing upon the interesting traditions and practices, e.g. music, poetry and drama to
make the messages culturally relevant.
There is also need to involve young people in the design and production of materials to
ensure that they are age-appropriate and relevant to the social and cultural contexts in which
they find themselves in (UNESCO, 2008c). Such an involvement gives young people an
opportunity to suggest the content and teaching methods most appropriate to their needs. This
review failed to establish any specific contexts in which the involvement of young people
influenced the design of an HIV/AIDS curriculum. In Malawi, for instance, the design of the
LS and SRH was influenced by what the stakeholders in the youths' sexual and reproductive
health perceived to be the needs of the young people. The young people themselves were not
directly consulted (personal communication with curriculum designers).
2.3.6.
Developing conceptual understanding
Constructivist theories of learning
The conservative traditional pedagogical approach is based on the idea that the learner comes
to class as a tabula rasa (without preconceived ideas), and that the job of the teacher is to `fill'
them with knowledge. The philosophy and theory of constructivism is, however, built on the
premise that pupils have ideas (including alternative concepts regarding various scientific
phenomena) when they enter the classroom. Based on this theory, it is now widely accepted
29
that learners come to class with a wealth of ideas organised in tacit theories, which are based
on everyday experiences. Such alternative concepts are in some cases different from the
conventional concepts of the scientific community. Given the misconceptions surrounding
the HIV/AIDS epidemic, a constructivist view of learning has important implications for
teaching about HIV/AIDS.
The personal constructivist accounts stem from the seminal work of the Swiss psychologist
Jean Piaget where learners are understood as constructing their own meanings from the
sensual world (Scott, et al, 2007). Contemporary science education is however focussing its
attention to a more encompassing theory of learning called Social Constructivism. This
perspective views learning as taking place within a social context, unlike the personalised
understanding of meanings from the sensual world by Piaget. The theory underscores
Vygostsky's views regarding the role of social interaction and the role of language. Vygot-
sky, a Russian psychologist, held the view that language is a key player enhancing the social
context of cognitive development (Hodson and Hodson, 1998). He believed that children
conceptualise cognitive and communicative tools of their culture through social interactions;
first with parents, or other caregivers, later with peers, teachers and other knowledgeable
adults (Hodson and Hodson 1998). According to Vygotsky, these significant others are a
social plane on which children base their understandings. In this theory, words, gestures, and
images are examples of the semiotic devices in the social exchange that play vital roles in the
individual's thinking. He held the view that with appropriate assistance from a more experi-
enced adult, the learners can solve problems that are ahead of their developmental norm. The
distance between the normal cognitive developmental level and the level of cognitive
potential gained through the guidance of an adult or a more capable peer is the zone of
proximal development (Hodson and Hodson, 1998). Wood, et al, (1976) cited in Hodson and
Hodson (1998) assigned the term `scaffolding' to this process of guided cognitive develop-
ment. The teacher's role is to assist the learner to scaffold learning.
Conceptual learning
Drawing on the constructivist philosophies, a number of perspectives on what constitutes
learning in Science put emphasis on `conceptual learning' and the need to provide learners
with an opportunity to examine and change their alternative (mis-) conceptions (Zemblyas,
2005). Conceptual learning hinges on the premise that learners construct their own
knowledge based on everyday experiences (Ausubel, 1968, Driver, 1983, 1989; Duit and
30
Treagust, 2003, Erickson, 1979, Nashon and Anderson, 2004, in Mutonyi, et al, 2007 and
Butler, et al, 2004). Using the platform of alternative conceptions drawn from their everyday
experiences, pupils interpret and understand new encounters (Ausubel, 1968; Clement, 1993;
Cohern, 1996; Driver, 1989; Kelly, 1955; Nashon, 2000; 2003, in Mutonyi, et al, 2007 and
Aikenhead, 1996). It is important to realise that dialogue, when offered, provides the learners
with the opportunities to reconstruct their alternative frameworks. Where pupils are denied
open dialogue, they tend to have persistent misconceptions (Asera, et al, 1997, Kinsman, et
al, 2001, in Mutonyi, et al, 2007). When learners perceive the limitations of their current
views (Hodson and Hodson, 1998), they accept alternative concepts provided they are
intelligible, plausible and fruitful (Posner, et al, 1992, Hodson & Hodson, 1998 and Zem-
blyas, 2005). According to Posner, et al, (1982), learning or `conceptual change' is likely to
take place when the learner reaches a dissatisfaction threshold concerning their prior ideas
and beliefs, thereby being well disposed to accept new alternative conceptions. When learners
experience this cognitive dissonance (Hewson, 1992), they engage in knowledge seeking
(Edelson, 2001). In this regard, we see teachers as being indispensable in identifying alterna-
tive frameworks, creating opportunities for them to explore, develop and modify their ideas
and where necessary, change them (Hodson and Hodson, 1998).
The constructivist theories and perspectives on conceptual change, therefore, implicate a
number of teaching strategies. First, they underline the need for teachers to use diagnostic
tasks or questions in order to solicit the learners existing, and build a platform for effective
instruction. The centrality of small group discussions is also underscored. In these groups,
learners can question their beliefs and search for alternatives that are satisfactory. Whole
class discussions are also important as the effective means of reflecting on ideas arising from
group work in order to reach consensus about scientific explanations. Given the misconcep-
tions surrounding HIV, the centrality of diagnostic tasks/questions, group and whole class
discussions cannot be overemphasised. According to Harrison (1999), sex education should
focus on dealing with misconceptions surrounding sexually transmitted diseases. University
students in Botswana (Sukati, et al, 2010) indicated the need for HIV/AIDS education to deal
with misconceptions that fuel the spread of HIV. A study by Mutonyi, et al, (2007) on
Ugandan secondary school pupils showed that learners were capable of perceiving cognitive
dissonance between their alternative frameworks on HIV/AIDS issues and scientific theories
when they engaged in open dialogue.
31
2.3.7.
Participatory approaches to teaching and learning
In addition to the effective approaches described above, teachers need to use interactive
teaching strategies aimed at assisting pupils to acquire skills aimed at reducing the risk of
HIV infections. A study by Sukati, et al, (2010) showed that learners prefer interactive rather
than transmission approaches to learning about HIV/AIDS issues. A number of interactive
classroom teaching strategies considered effective in helping pupils to acquire skills and
develop attitudes and beliefs necessary for behaviour change are outlined below.
Use of classroom questions
In many cultures, the phrase `breaking the silence' indicates the centrality of open discussions
on HIV/AIDS issues. Evidence from research has shown that questioning is an important
factor in breaking classroom silence and ensuring effective interaction (Bennet, et al, 1981,
Brothy and Good, 1986, and Cooper, et al, 1987). According to Cunningham (1977), cited in
Weigand (1977), most of the participatory teaching methods suggest that the teacher should
take the role of a facilitator, and underscore the effective use of questions. According to
Kiger (2004), classroom questions enable the teacher to understand the level of pupils'
knowledge, and their attitudes and feelings. With respect to HIV/AIDS, knowledge, attitudes
and feelings seem to be the forces behind risking-taking, fear and denial, self-esteem and
peer-pressure (Tonks, 1996). Further, a number of models on behaviour change implicate
knowledge and attitudes as precursors to decision-making and prevention of risky behaviour
[see the Health Belief Model, and the Theory of Reasoned Action (Naidoo and Wills, 2000),
and the AIDS Risk Reduction Model (Catania, et al, 1990) in Appendix 16]. Drawing on the
constructivist theories, we note that that use of diagnostic questions is key in dealing with the
knowledge, attitudes and feeling of learners regarding HIV/AIDS. More specifically, they can
assist teachers to understand and deal with the pupils misconceptions regarding HIV/AIDS.
Questioning also allows for sustained interaction between teachers and the pupils and among
pupils. This is necessary in facilitating scaffolding in the zone of proximal development
according to Vygotsky's theory of Social Constructivism (Muiji's and Reynolds, 2005). This
guided cognitive development is crucial in helping pupils to achieve cognitive dissonance
between their alternative concepts and accepted scientific theories on HIV/AIDS.
The culture of secrecy surrounding HIV/AIDS has raised unanswered questions from the
young people. Tonks (1996) recommends that teachers should build time into every
HIV/AIDS lesson to answer questions because this also helps to assuage the fears and the
32
misconceptions that young people may have. As such, teachers need to realise that giving
young people an opportunity to ask frankly honest questions about HIV/AIDS will go a long
way to remove myths surrounding the disease.
Enhancing clarification of values and a positive perspective to HIV prevention
There is need to provide young folk with opportunities to understand the importance of their
lives in both the present and the future, as this helps them to take their current decisions
seriously (Tonks, 1996). Further, this helps pupils set and focus on goals, which in turn
boosts their self-esteem and self-confidence. `If students posses a strong sense of self, they
are less likely to fall into line behind perceived peer expectations. Apart from the benefits
students might receive from self-esteem, it has also been tied to the avoidance of unprotected
sex among teenage males' (Hernandez and DiClemente, 1992, p. 445). It is recommended
that teachers of HIV/AIDS education present the material clearly, concisely and understanda-
bly, allowing time for young people to discuss and perceive that their present decisions could
shape the course of their health (Tonks, 1996). Teachers, therefore, have the opportunity to
facilitate the realisation of the sense of personal worth, which will empower young people to
make decisions to promote healthy-life styles. This will enable young people to realise that
they themselves hold they keys to preventing HIV infections. Once young people perceive
that HIV infections can be avoided, they will be much more willing to engage in various
feasible efforts in order to avoid it (Tonks, 1996). Therefore, HIV/AIDS teachers have an
opportunity to assist young people to discuss the various practicable behavioural strategies
they can employ in order to avoid contracting the virus.
Cooperative group work
Cooperative learning in small groups (4-6 people) has been shown to be successful in
HIV/AIDS education (Tonks, 1996). According to Woolnough and Alssop (1985), group
work is appropriate for science teaching aimed at equipping the individual with knowledge
and skills necessary for the demands of everyday life. Muijis and Reynolds (2005) note that
the strategy has several advantages over individual practise. First, it helps pupils develop
empathetic abilities, by accommodating other's opinions. Second, young people have an
opportunity to develop social skills (see also Kiger, 2004). Further, they also note that young
people assist one another with scaffolding in ways that a teacher might not during question-
ing. This advantage (scaffolding) is central in Vygotsky's theory of Social Constructivism
(Hodson and Hodson, 1998). Finally, they argue that group work helps young people collabo-
33
rate in solving problems of common interest. According to Linn and Barbules, 1993 and
Battistich, et al, (1993) group members can assist one another to consider and respond to
feelings, ideas and opinions of others. Effective group work helps learners develop sharing,
participation communication and listening skills (Muijis and Reynolds, 2005). It can,
therefore, be noted that cooperative learning is central to HIV/AIDS education since it will
facilitate the acquisition of social skills required to prevent HIV infections.
Ensuring openness in classroom discussions
If participation of young people in class discussions on HIV/AIDS education is critical in
their learning processes, then the teacher needs to employ strategies that will ensure issues
will be discussed openly. According to Tonks (1996), establishing and following ground rules
or class rules helps the young people to deal with uneasiness and contribute to the creation of
an environment fruitful for classroom discussion and/or debate. As such, he recommends that
such rules be on a wall or bulletin board for all to see and use. He also recommends that such
rules should be developed by the young people themselves and be used to guide discussions
on HIV/AIDS issues.
Use of multimedia also helps teachers to open up in discussing sensitive issues on HIV/AIDS
and Tonks (1996) recommends young people to be exposed sensitive issues through multi-
media prior to HIV/AIDS lessons. According to him, effective use of videotapes, films,
overhead projectors, bulletin boards and other media not only make HIV/AIDS education
lessons interesting but are also important as starting points for classroom discussions on
sensitive HIV/AIDS issues. This approach acts as an icebreaker and helps teachers to engage
in discussions on sensitive issues surrounding HIV/AIDS. A study of the needs of Swaziland
University students, (Sukati, et al, 2010) revealed that they wanted access to multimedia
resources on HIV/AIDS even after class contact time.
According to UNESCO (2008c), the choice of a group type needs to be dictated by the nature
of the topic to be discussed in order to facilitate openness. In this regard, single-sex groups
are recommended for topics on reproduction while mixed-sex groups are recommended
topics that address communication and respect between boys and girls. Mixed-sex group
discussions have the potential to challenge gender power discrepancies in relationships
(UNESCO, 2008c).
34
It is important that groups make presentations to the class at the end of group work. This
gives an opportunity to the rest of the class to access their information, and allows them to
interact over certain facts (Tonks, 1996). This is an aspect called reflection and is important
in the constructivist teaching methodology (Mujis and Reynolds, 2005). Teachers can use
these opportunities to provide counter examples to the views presented by the young people
in order to stimulate more thoughtful debates (Duffy and Jonassen, 1992), and to make young
people develop more effective ways of solving problems (Muijis and Reynolds, 2005).
Teaching and modelling skills
The ultimate goal for offering HIV/AIDS education to youths is to help them avoid behav-
iours that put them at risk of HIV infection. According to Tonks (1996), changes in behaviour
can only occur when pupils' beliefs and attitudes about safer behaviour change. When pupils
develop healthy attitudes and beliefs regarding HIV/AIDS, they will be willing to learn the
skills required to prevent it. Skills development in young people is a key challenge in the
teaching of HIV/AIDS education. However, there is evidence to show that in most countries
HIV/AIDS education usually focuses on knowledge and facts without comprehensive
treatment on skills development (UNESCO, 2008a), in order to respond to examination
requirements. There is, therefore, need for HIV/AIDS education that will provide young
people with opportunities to acquire skills for HIV prevention [See Tonks (1996) for a
detailed description of these skills]. The teaching of refusal, negotiation, and condom use
skills may however require teaching strategies that are often unusual in school settings of the
developing world, as they demand openness between teachers and pupils in handling sensi-
tive issues (Baker, et al, 2003, cited in Kirby, et al, 2006 and Chege, 2006). Teaching of
skills should be followed by the teacher's modelling of the skills and an opportunity for the
pupils to practice them using role-play (Tonks, 1996). Modelling of the skills by the teachers
and subsequent practise by the pupils helps them to develop social skills (Brothy and Good,
1986, and Muijis and Reynolds, 2005). While teachers might initially model a social skill, the
pupils will increasingly gain confidence with time, and the modelling can be gradually
withdrawn (Muijis and Reynolds, 2005). Such scaffolding `helps to develop independent
learners' (Muijis and Reynolds, 2005, p. 64).
Use of external speakers
The involvement of external speakers in classroom discussions has some support in literature.
In Botswana, university students underscored the need to be addressed by guest speakers with
Details
- Pages
- Type of Edition
- Erstausgabe
- Publication Year
- 2014
- ISBN (eBook)
- 9783954897124
- ISBN (Softcover)
- 9783954892129
- File size
- 4.9 MB
- Language
- English
- Publication date
- 2014 (November)
- Keywords
- HIV/AIDS Education policies Pupils‘ needs in HIV/AIDS Education Classrom practice in HIV/AIDS Education
