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School-Based Programs INHL 681 Design and Implementation of Reproductive Health Programs. Ilene S. Speizer November 26, 2001. Demographic Trends. Today, 30% of the world’s population is between the ages of 10-24 years; 83.5% of the world’s young people live in developing countries;

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School-Based ProgramsINHL 681 Design and Implementation of Reproductive Health Programs

Ilene S. Speizer

November 26, 2001


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Demographic Trends

  • Today, 30% of the world’s population is between the ages of 10-24 years;

  • 83.5% of the world’s young people live in developing countries;

  • In a number of countries in sub-Saharan Africa there are 5 times the number of people <15 years than over 55;

  • In many developing countries young people make up 20-25% of the population; in Japan and France it is 13% and 14%, in China, 16%.


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Education and Marriage

On average, there is a 30% spread in teen marriage when girls with more years of schooling are compared with less

Education

Region > 6 years < 6 years

Sub-Saharan Africa 38.4 71.4

Near East/North Africa 18.5 49.8

Asia 19.8 56.0

Latin America/Caribbean 30.0 62.1


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Education, Age and Birth

Education

Region > 6 years < 6 years

Sub-Saharan Africa 37.0 63.8

Near East/North Africa 8.6 35.0

Asia 17.1 45.7

Latin America/Caribbean 21.3 53.1

Percentage of women aged 20-24 who gave birth before age 20, by region, according to residence and years of education, 1980s-90s.


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Consequences of Education

  • Delay in age of marriage;

  • Rise in out-of-wedlock births;

  • Rise in clandestine abortions;

  • Rise in number of sexual partners with associated risks of AIDs and other STDs.


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Secondary School

School enrollment rates in secondary school, by region and year, ages 12-17

East Asia/Pacific

Near East/North Africa

Latin America/Caribbean

South Asia

Sub-Saharan Africa


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Adolescent Risk-Taking: Early Age of Sexual Debut

  • Adolescent boys and girls having sex early: 56% of males, 32% of females 15-19 ever had sex in Paraguay (76% and 29% for Brazil age 11-19;

  • About half of young people age 10-24 are sexually experienced in sub-Saharan Africa (Togo, Ghana, Zambia, South Africa), exception Zimbabwe.

  • FOCUS results


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51- 60%

Burkina Faso 54.1%

Ghana 59.0%

<20%

Philippines 8.1%

Rwanda 14.2%

Peru 18.4%

31- 40%

Paraguay 30.1%

Senegal 35.4%

61- 70%

Zambia 60.5%

Niger 60.9%

Uganda 61.6%

Central African Republic 62.0%

Mali 66.0%

Cote d’Ivorie 68.1%

Cameroon 68.5%

21- 30%

Kazakstan 20.5%

Brazil (NE) 22.5%

Bolivia 22.9%

Guatemala 25.0%

DominicanRepublic 26.9%

Colombia 29.6%

Haiti 29.0%

Zimbabwe 29.7%

41- 50%

Namia 42.4%

Kenya 46.1%

Tanzania 49.9%

Adolescent Sexual Activity

% of adolescents who have ever had sex


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11- 20%

Kenya 12.5%

Madagascar 13.7%

Senegal 15.8%

Tanzania 16.5%

Uganda 16.9%

Bolivia 14.8%

DominicanRepublic 14.2%

Haiti 14.3%

21- 30%

Peru 22.7%

Columbia 25.6%

Brazil (NE) 22.5%

Zimbabwe 20.5%

Namibia 22.5%

Mali 25.6%

Ghana 22.4%

C. AfricanRepublic 20.4%

Burkina Faso 21.3%

<10%

Malawi 7.9%

Niger 8.4%

Rwanda 7.5%

Zambia 3.5%

Guatemala 6.1%

Paraguay 9.2%

31- 40%

Nigeria 30.7%

Cote d’Ivoire 34.9%

Kazakstan 39.0%

40% +

Cameroon 52.7%

Adolescent Risk-Taking: Contraceptive Use

Percent of sexually active 15-19 year olds using any method of contraception

Low use at first sex


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Adolescent Risk-Taking: Other Outcomes

  • Multiple sexual partners

  • Exchange of sex for money - “commercial sex”, sugar daddies

  • Non-RH risk-taking behaviors - alcohol, drug use (deviant behaviors)

  • Multitude of antecedents related to RH outcomes


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Antecedents - factors associated with risk-taking

  • Three Broad Groups:

    • Biological - age, gender, testosterone - direct

    • Attitudes and beliefs related to sexual activity

      • commonly addressed by sexuality programs

  • Social disorganization - violent crime, poverty, unemployment, etc.

    • youth development programs


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Why Are School Based Programs Attractive?

  • Where education is mandatory, get high exposure to program

  • Provide information early, before adolescents become sexually active.

  • Attentive audience in a structured environment


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Why Are School Based Programs Controversial?

  • We are talking about SEX here, and that is controversial

  • Fear that providing information in the schools will encourage early sex

  • Discomfort of teachers and administrators to talk about sex

  • Role of school nurse in teaching and provision of services unclear


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Who should decide what is taught?

Government (national or local)

School administration

Teachers: play a role because they implement

Parents

School nurse

Based on stated needs of adolescents

Unclear what should be taught

Family life education (euphemism for something?)

General biology or anatomy

STD/HIV information (facts, or prevention messages?)

address homosexuality, masturbation, premarital sexual activity, abortion

Decisions About Implementation Are Unclear


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Decisions About Implementation, continued

  • Who should be taught?

    • What is the right age to begin programs

    • Should kids be required to have permission slips

    • Should boys and girls be split up for sessions?

    • In formal classes or as after-school activities

    • One time sessions versus longer-term programs

    • Only the ‘high – risk’ kids?

  • I bet we have disagreement in the room on these issues


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What Works? Types of S-B Programs (U.S. Facts First)

  • Abstinence only education

    • Impacts on delaying sex inconclusive, but not encouraging; sexually experienced not affected

  • Abstinence based sexuality and HIV educ.

    • Abstinence not stressed as ONLY acceptable behavior, also describes benefits of cont.

    • No impact on increasing sexual intercourse

    • Out of 28 studies:

      • 9 delayed initiation; 18 no impact; 1 hastened initiation

    • Some impacts on increasing contraceptive use

    • Condom impacts with AIDS education (esp. high-risk males)


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Common Characteristics of Effective Curricula (Kirby)

1) Focus on reducing one or more sexual behaviors that lead to unintended pregnancy or HIV/STD infection

2) Use theoretical approaches that influence health related risky behaviors – social cognitive theory, social influence, reasoned action, or theory of planned behavior.

3) Clear message on sexual activity and condom or contraceptive use and reinforce the message.

4) Provide basic, accurate information on risks of teen sexual activity and methods to avoid intercourse or use protection.

5) Include activities to address social pressures that influence sexual behavior


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Characteristics of Effective Curricula (Kirby), cont.

6) Provide modeling and practice of communication, negotiation, and refusal skills (e.g., role playing)

7) Employ a variety of teaching methods to involve students and facilitate them to personalize info.

8) Use age appropriate and culturally appropriate goals, teaching methods and materials.

9) Last a sufficient length of time – 14 or more hours, or a smaller number of hours but youth who volunteered and worked in small groups.

10) Train and select teachers and peer leaders who are motivated.


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School-Based or School-Linked Clinics

  • Most school clinics provide minimal RH services

  • Few actually give prescriptions or dispense contraception or condoms.

  • Ideal, in theory (if well run and well staffed):

    • location convenient

    • reach both males and females

    • provide comprehensive health services

    • confidential

    • staff selected and trained to work with youth

    • easy to provide follow-up

    • services are free

    • easily integrate education, counseling and services

    • Exception – don’t reach out of school or older youth


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School Condom Availability Programs

  • Importance of HIV/AIDS

  • Making condoms available in schools - by school nurse, counselor, or vending machines

  • Results inconclusive due to varying designs and samples


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What Do We Know About S-B Programs in Developing Countries?

  • Overwhelming number of the impact studies found were on school based programs (22 out of 39)

  • Most programs had impacts on knowledge and attitudes, less had impacts on behavs.

  • Little is known on long-term impacts on KASB


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AIDS Education in Nigeria - Fawole et al.

  • Comprehensive health ed. curriculum - six weekly AIDS/HIV ed sessions (2-6 hrs each) - lectures, film, role-play, stories, songs, debates, essays.

  • 2 experimental schools, and 2 control

  • Baseline and follow-up data from a random sample of classes in each school. Follow-up 6 months later


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Baseline:

No differences in demographics

No differences in knowledge and attitudes

No differences in sexual behaviors

Follow-up:

knowledge greater in experimental group

attitudes more positive in experimental group

behaviors of experimental group less risky at follow-up (no control for demog distinctions between)

Nigeria Results


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Sexuality Education in Jamaica The Grade 7 Project

  • Sexuality and FLE for ads. 11-14 (grade 7)

  • Abstinence promotion and risk reduction/safer sex program

  • Nine month curriculum, coeducational sessions once per week (45 min each)

  • Lectures, visual aids, and small group discs.

  • 5 intervention, 5 matched comparison schools, longitudinal design - 9 mo (92%) and 21 mo (76%) follow-up


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9-month follow-up

Improved knowledge (4/7 items)

More conservative attitudes (sex activity and adolescent parenthood)

No impact on sexual initiation

Slight impact on use at 1st sex

21-month follow-up

Knowledge impacts not sustained

Attitudinal impacts not sustained

No impact on sexual initiation

No difference in use among those who initiated sex in f.u.

Jamaica Results


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FOCUS Results on S-B Programs

  • Effective in influencing sexual-reproductive health knowledge and attitudes

  • Roughly 50% have had an impact on short-term behaviors.

  • Extent to which they influence long-term behaviors is less certain

  • Research is needed to identify/verify the key elements of effective sexual-reproductive health education programs in school settings in developing countries



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What Do We Know About Peer Education Programs?

  • Peer influences have important impact on RTB of youth (both positive and negative).

  • Train youth who serve as counselors and role models for their peers.

  • Many programs include trained peer educators or leaders as one component of a program (e.g. school-based, mass media, workplace, etc.)

  • U.S. literature indicates that enthusiasm for peer-based programs may run ahead of research on effectiveness.


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Peer Education Programs in Developing Countries

  • Three peer educator studies evaluated: 1 school-based, 1 school and community based, 1 community based.

    • School-based in Peru – impacts on male contraceptive behaviors observed, no impact measured on females as too few were sexually experienced. (Magnani et al)

    • School and community based in Nigeria – impacts observed in secondary and post-secondary school samples, no impact in out-of-school sample – possibly because out-of-school sample is less easy to target or identify. (Brieger et al.; Speizer et al)

    • Community based in Cameroon – Impacts on male and female behaviors whether or not in-school (Speizer et al.)



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PE Programs Still Inconclusive

  • Most impacts are on peer leaders themselves (not bad, just expensive)

  • Are programs effective because of resources expended or peer education activities

  • Adults versus peers, no difference - U.S.

  • Difficult to tease apart impact of peers in most programs

  • Other key questions require further investigation (i.e., “reach” of peer leaders; level of training and supervision required; sustainability)



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FOCUS Conclusions on Other Types of Programs

  • Mass media-based interventions appear to be able to influence adolescent knowledge and attitudes, but there is less evidence that they influence sexual and contraceptive behaviors, and health service use.

  • Youth development approaches appear promising, but need more rigorous evaluation in multiple settings

  • Workplace-based programs indicate potential for reaching out-of-school youth in settings where youth are employed in the formal sector in large numbers, but the evidence concerning impact on behaviors is very thin


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FOCUS Conclusions on Other Types of Programs, Cont.

  • “Youth friendly services” initiatives on their own do not appear to be effective at attracting youth (in the short-term at least). Outreach and linkage with efforts to mobilize community support for providing ARH services to youth appear to be necessary

  • Youth centers do not appear to increase the use of RH services by adolescents

  • Community outreach approaches entailing multi-component strategies appear to have the greatest potential for improving KASB and increasing use of health services


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