Acknowledgements
Dedication
Abstract
List of Figures and Tables
Chapter 1: Study background
1.1. Global overview of HIV/AIDS
1.1.1. Incidence and prevalence of HIV/AIDS
1.1.2. Global Impacts and interventions
1.2. Sub-Saharan Africa
1.2.1. Incidence and prevalence of HIV/AIDS
1.3. HIV/AIDS in Malawi
1.3.1. The influence of Malawian cultural and religious contexts on HIV/AIDS intervention efforts
1.3.2. Impacts and interventions of HIV/AIDS in Malawi
1.3.3. The context of HIV/AIDS education within the secondary school education system in Malawi
1.4. Conclusion
Chapter 2: Literature Review
2.1. HIV/AIDS education and young people
2.2. School-based approaches to HIV/AIDS education
2.3. Life Skills Education
2.3.1. What is Life Skills Education?
2.3.2. Life Skills and behaviour change
2.3.3. Perspectives on HIV/AIDS education within Life Skills
2.3. Effective approaches to HIV/AIDS education
2.3.1. Establishing safe learning environments
2.3.2. Recognising gender differences
2.3.3. Supporting pupils affected with HIV/AIDS
2.3.4. Linking with other service providers
2.3.5. Being culturally sensitive when responding to the needs of the pupils
2.3.6. Developing conceptual understanding
2.3.7. Participatory approaches to teaching and learning
2.3.8. Supporting teachers
2.4. HIV/AIDS education in Malawi
2.4.1. Responses within the MOEST
2.4.2. Life Skills education in Malawian schools
2.4.3. Policy guidelines for HIV/AIDS education in Malawi
2.5. Research rationale
2.6. Conclusion
Chapter 3: Research design and methodology for data collection and analysis
3.1. Rationale for research design
3.1.1 The Case Study
3.1.2 Data collection tools
3.2 Study sample
3.3 Data collection
3.3.1 Framework for data collection and analysis
3.3.2 Design and use of data collection instruments
3.4 Data analysis
3.4.1 Approach to data analysis
3.4.2 Evaluation of the methodology
3.5 Ethical considerations
3.6 Conclusion
Chapter 4: Young peoples’ perceptions of their needs
4.1 Young pupils’ needs in HIV/AIDS Education
4.1.1 Gender of HIV/AIDS teacher
4.1.2 Young peoples’ openness to discuss HIV/AIDS issues with their class teacher
4.1.3 Additional issues for discussion in classroom HIV/AIDS Education
4.1.4 Preference for external speakers
4.1.5 Young peoples’ preference for pupil-led group discussions
4.1.6 Young peoples’ preference for grouping by gender
4.1.7 Suitability of the classroom environment for discussing HIV/AIDS issues
4.1.8 Contact time
4.1.9 Other needs
4.2 Conclusion
Chapter 5: In what ways do classroom practices meet the needs of the young people?
5.1 Open discussions on HIV/AIDS issues
5.1.1 Use of group discussions and whole class discussions
5.1.2 Openness of the discussions
5.1.3 Supporting participatory strategies
5.1.4 Creating a safe environment for open discussions
5.2 The need for explicit and accurate knowledge on HIV/AIDS issues
5.2.1 Transmission
5.2.2 Basic and personal health needs
5.3 The use of external speakers
5.4 Skills for prevention
5.5 Recommended contact time and curricula
5.6 Conclusion
Chapter 6: What factors are influencing classroom provision of HIV/AIDS education?
6.1 Openness of the discussions
6.1.1 Supporting participatory strategies
6.1.2 Use of group discussions and whole class discussions
6.1.3 Creating a safe environment for open discussions
6.2 The need for explicit and accurate knowledge on HIV/AIDS issues
6.2.1 Transmission
6.2.2 Basic and personal health needs
6.3 Skills for prevention
6.4 Involvement of external speakers
6.5 Contact Time
6.6 External and internal supervision of HIV/AIDS classes
6.7 Other influences
6.8 Conclusion
Chapter 7: Discussion
7.1 The needs of the young people
7.1.1 Open discussions on HIV/AIDS issues
7.1.2 Explicit and accurate knowledge on HIV/AIDS issues
7.1.3 Skills for HIV prevention
7.1.4 External speakers
7.1.5 Low prioritization of HIV/AIDS education
7.1.6 What should be done
7.2 Key policy implications
7.3 Ensuring that intended policy is put into practice
7.3.1. Internal and external supervision of HIV/AIDS Education
7.3.2. Continuing professional development of the teachers
Chapter 8: Conclusions and Recommendations
8.1 Research questions and outcomes
8.2. Contribution of the study to literature
8.3. Future research
References
Appendices
Appendix 1: Questionnaires for pupils
Appendix 2: Questionnaires for teachers
Appendix 3: Samples of completed questionnaires
Appendix 4: A summary of questionnaire responses from Teachers
Appendix 5: The lesson observation instrument
Appendix 6: A sample Lesson Observation report
Appendix 7: A summary of lesson observations
Appendix 8: Interview guidelines for teachers
Appendix 9: Guidelines for focus group discussions
Appendix 10: Semi-structured interview guidelines for head teachers
Appendix 11: Semi-structured interview guidelines for Methods Advisors
Appendix 12: A samples of the teachers Schemes and Records of work
Appendix 13: AREA Faculty Research Ethics Committee approval
Appendix 14: Permission to conduct research in the South East Education Division in Malawi
Appendix 15: Interview consent form for head teachers and teachers
Appendix 16: Selected Health Promotion Models
Figure 1.1: Global statistics on people living with HIV/AIDS (no data on women in 2003)
Figure1.2: People living with HIV and deaths in Sub -Saharan Africa (no data for deaths in 2002)
Figure 1.3: National HIV/AIDS prevalence rates in Malawi from 1995-2007
Figure 1.4: Rural and Urban HIV prevalence rates in Malawi
Figure 1.5 HIV prevalence rates by gender among 15-49 year olds in Malawi
Figure 1.6: Percentage condom use among 15-24 in Malawi
Figure 1.7: Factors influencing the condom divide
Figure 2.1: Interfacing elements of Life Skills Education
Table 2.1: Categories of skills in Life Skills Education
Table 2.2: An example of content organisation around skills
Table 3.1a: School parameters in Zomba City
Table 3.1b: Schools selected for this study
Table 3.2: Framework for data collection and analysis
Table 3.3: A summary of time lines for the design of data collection tools and actual data collection
Table 4.1a: Would you prefer to discuss HIV/AIDS issues in class with a teacher of the same sex as yourself?
Table 4.1b: Reasons for same-sex teacher preference by pupils
Table 4.1c: Reasons for not preferring same-sex teacher
Table 4.2: Did you find it difficult to discuss HIV/AIDS issues freely with your teacher?
Table 4.3a: Are there other issues on HIV/AIDS you would prefer to discuss in class?
Table 4.3b: Preferred topics according to class level, gender and school type
Table 4.4a: Are there individuals whom you would like to speak to your class on HIV/AIDS?
Table 4.4b: Categories of individuals whom participants would like to speak to their classes
Table 4.4c:Topics which participants would like speakers outside their class to address
Table 4.5a: Would you prefer to discuss HIV/AIDS issues with other pupils only, without the teacher?
Table 4.5b: Young peoples’ reasons for preferring teachers’ presence in HIV/AIDS discussions
Table 4.6a: Would you prefer boys and girls to discuss HIV/AIDS issues in single-sex groups?
Table 4.6b: Young peoples’ reasons for preferring groups of mixed sexes
Table 4.6c: Young peoples’ reasons for preferring single-sex groups
Table 4.7: Do you think your classroom was a good place for pupils to freely discuss HIV/AIDS issues?
Table 4.8: Do you think more time was needed for HIV/AIDS lessons?
Table 4.9a: Ways in which teachers can make HIV/AIDS lessons interesting and helpful
Table 4.9b: Ways in which classmates can make HIV/AIDS lessons interesting and helpful
Table 5.1: Did you use group discussions in class when learning about HIV/AIDS issues?
Table 5.2a: A teacher’s Scheme of Work 1
Table 5.2b: A teacher’s Scheme of work 2
Table 5.2c: A teacher’s Scheme of work 3
Table 5.2d: A teacher’s scheme of work 4
Table 5.2e: A teachers’ Record of Work 1
Table 5.2f: A teachers Record of Work 2
Table 5.2g: A teacher’s Record of Work 3
Table 5.2h: A teacher’s Record of Work 4
Figure 5.2a: Usefulness of group discussions to the teacher
Figure 5.2b: Usefulness of group discussions to the teacher
Table 5.3: Use of classroom rules
Table 5.4: Were you given a chance to ask questions on HIV/AIDS in your class?
Table 5.5a: Did your teacher invite people outside the school to come and talk about HIV/AIDS in your class?
Table 5.5b: External organizations sending speakers to each school
Table 5.6: LS&SRH content coverage by teachers as indicated by the pupils
Table 5.7: Were you taught how to say ‘no’?
Table 5.8: Subject period allocation in the schools
Table 5.9: Syllabi design
Table 6.1: Recommended distribution of classroom activities for HIV/AIDS education
Table 6.2: Content coverage in the curricula
Table 6.3: Recommended skills on the topics pupils prioritised
Figure 6.1: Subject period allocation circular from the Ministry of Education
Table 6.4: Trained LS&SRH teachers actually teaching
Figure 8.2: Diagrammatic representation of the contribution of this study to knowledge
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.
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 fluctuations 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.
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Figure 1.1: Global statistics on people living with HIV/AIDS (no data on women in 2003). Source: UNAIDS 2001, 2002, 2003, 2004, 2005, 2006, and 2007).
Global Impacts include among others:
- high morbidity and mortality rates, with the women bearing the brunt (Academy for Educational Development, 2000; UNDP, 2003; Abt Associates Inc. and Health Economics and HIV/AIDS Research Division of the University of Natal/World Bank, 1999, WELL, 2001 ; Jayne, 2004);
- overstretched health services (http://www.avert.org/aafrica.htm);
- collapsing education systems, (Coombe, 2002; Commission on HIV/AIDS and Governance in Africa, 2001, Southern Africa Development Community (SADCC), 2000, UNDP, 2003, Kelly, 2000 a and b, and Kinghorn, et al, 2000);
- deepening poverty (Commission on HIV/AIDS and Governance in Africa, 2001 and Academy for Educational Development, 2002);
- threatened food security (Academy for Educational Development, 2000), and
- disintegration of social cohesion, (Strickland and Heard, 2002 and Kinghorn, et al, 2000).
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 (McKee, 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; Academy 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 (McKee, 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 population groups at risk, particularly among those aged 15-25 years (McKee, 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.
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 comprises 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).
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Figure1.2: People living with HIV and deaths in Sub -Saharan Africa (no data for deaths in 2002) [Source: UNAIDS, 2001, 2002, 2003, 2004, 2005, 2006, 2007].
In 2001, Malawi was among the most highly infected countries in sub-Saharan Africa with a prevalence rate of 16% in the 15-49 years age bracket (UNDP, 2002). Cases of high-risk behaviour were more common in adults between the ages 15 and 49, who constituted 44% of the population (UNDP/UNGASS, 2001), than in younger adolescents. By the end of 2003, over 900,000 people were living with the virus and an estimated 850,000 children had been orphaned (NAC, 2004). Comprehensive data on prevalence indicated a general rise between 1995 and 1998 and a steady decline between 1999 and 2003 with stabilisation thereafter (see Figure 1.3). Despite the significant drop from 16.2 % in 1998 to 14.2% in 2007, the prevalence level remains high in Malawi.
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Figure 1.3: National HIV/AIDS prevalence rates in Malawi from 1995-2007. Source: Malawi Government (2007) and http://www.indexmundi.com/malawi/hiv_aids_adult_prevalence_rate.html.
Further, this prevalence was higher in the urban than the rural areas (see Figure 1.4), with females being disproportionately affected (see Figure 1.5).
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Figure 1.4: Rural and Urban HIV prevalence rates in Malawi. Source: Malawi Government (2007)
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Figure 1.5 HIV prevalence rates by gender among 15-49 year olds in Malawi. Source: Munthali, et al, (2006) cited in Chinkhata (2006)
It is estimated that young people initiate sex as early as 10 years of age (McAucliffe’s, 1994; Bandawe and Foster, 1996 in Kadzamira, et al, 2001). A national survey by McAuliffe, 1994, cited in Kadzamira, et al, (2001) revealed that up to 66% of secondary school pupils admitted being sexually active and that most of them had initiated sexual activity between 10 and 14 years. Nation-wide studies by Bisika, 1999 and Phiri, et al, 1997 (in Kadzamira, et al, 2001) estimated sexual activity among secondary school pupils at 78% and 65% respectively. Further, a study by Kadzamira, et al (2001) showed continuing high levels of sexual activity in secondary school pupils. The study revealed that up to 70% of pupils acknowledged the occurrence of love relationships in their schools.
In Malawi young men and women aged 15-25, the majority of whom are secondary school pupils (EdAssist, 2007), have been particularly vulnerable to the HIV/AIDS epidemic and within this group women are more vulnerable than men. Data published by the Malawi Government (2005) showed that the majority of young people in Malawi aged 15-24 were sexually active. Ministry of Health (MOH) (2000) showed that 46% of the new infections clustered within this age group, with female adolescents being 4-6 times more vulnerable than their male counterparts and according to UNICEF (2003), 67% of the HIV positive cases in Malawi comprised females aged 15-24. Studies spanning more than a decade reveal low compliance with messages on condom use within this age group in Malawi (McAuliffe, 1994, McAuliffe and Ntata, 1994, Bisika, 1996, Phiri, et al, 1997, in Kadzamira, et al, 2001 and the Malawi Government, 2005). A study by Maluwa-Banda (1999) showed that just 43 % of sexually active secondary school pupils claimed to have used a condom during their first intercourse while 16% admitted contracting a sexually transmitted disease once. The 2005 report from the Malawi Government showed that 56% of this age range in 2000 and 62 % in 2004 reported having engaged in unprotected sex with non-regular partners and UNAIDS (2004) noted that 71% of males in Malawi aged 15-24 had engaged in high-risk sex in 2003, despite having acquired knowledge of where to obtain condoms. More females than males within this age group reported having engaged in risky sex (Kadzamira, et al, 2001) and the Malawi Government (2005) showed that condom use was lower amongst women in this age (see Figure1.6). These practices posed a serious challenge to the effectiveness of the condom distribution efforts to adolescents in previous years, which aimed at facilitating ‘safer sex’ practices (UNAIDS/WHO 2004).
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Figure 1.6: Percentage condom use among 15-24 in Malawi. Source: Malawi Government ( 2005)
Based on the statistics above, it is clear that preventive efforts need to target young people aged between 15 and 24 if the prevalence of HIV/AIDS is to be lowered.
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 compounded 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 seriously 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 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 partners 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 manly.’
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 encounters. The desire to have many sexual partners among Malawian boys has also been underscored (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, evidenced by weekly attendance at church services. Young people with Christian beliefs have also claimed less likelihood to initiate sex early (WHO, 2001, cited in McKee, 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).
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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 discrepancies 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 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.
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 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 Education, 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).
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 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 designated core subjects. Each school is required to offer these. The other 14 subjects are designated 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
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 departmental 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.
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.
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 prevalence 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.
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 McKee, 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 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 importantly, 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 prevention 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 programmes 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, 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.
Currently there are four school-based approaches, each with its own advantages and disadvantages (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).
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 and 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).
In this study, Life Skills Education refers to a curriculum with three main interfacing elements, namely; ways of living and coping with self, ways of living and coping with others, and ways of taking effective decisions (McKee, et al, 2004) - See Figure 2.1.
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Figure 2.1: Interfacing elements of Life Skills Education [Source: Carnegie and Birell Weisen, adapted from McKee, et al (2004)].
The table below classifies and outlines some of the skills in Life Skills Education, which are also relevant to HIV/AIDS education, listed under the three aforementioned interfacing key areas in Figure 2.1.
Table 2.1: Categories of skills in Life Skills Education. Source: WHO (2004)
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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)]
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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 contexts, 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 ).
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).
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 reduction 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 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 Abstinence–plus HIV prevention 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 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 example, 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).
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 practices/strategies unveiled by literature review in this study.
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, discrimination, 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 approaches. For example, in some cases, teachers engaged young people in question and answer didactic interaction in which only teachers asked questions.
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 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).
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.
In many societies in developing countries, teachers resist discussions about sex with adolescents 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).
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 approaches 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 suggests 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 involvement 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 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 factors 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 support 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).
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 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. Vygotsky, 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 experienced 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 development. 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 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 Zemblyas, 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 alternative 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 misconceptions 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.
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 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 understandably, 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 questioning. 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 collaborate 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 multimedia 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).
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 behaviours 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 sensitive 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 ‘first hand information and experiences on HIV/AIDS’ (Sukati, et al, 2010, p. 107). This need was also identified in a study by Griessel-Roux, et al, (2005). This study showed that social and healthcare workers can be more effective than teachers in the delivery of HIV/AIDS education.
Members of the medical community are up-to-date regarding the latest HIV/AIDS information compared to teachers, so it is highly recommended that these make their presence felt in the classroom to help both teachers and pupils come to grips with the facts surrounding HIV/AIDS (Tonks, 1996).
According to McKee, et al, (2004), people living with HIV/AIDS (PLWHAs) are effective in communicating HIV/AIDS messages and in ‘breaking the silence’. Notable examples in this regard are the Ugandan Philly Bongoley Lutaya (Kyenkya-Isabire, 1990), the American basketball player Magic Johnson (McKee, et al, 2004), the South African, Nkosi Johnson (Singhal and Rodgers, 1990), and the Ghanaian Douglas Sem (Twedie, et al, 2002), who have openly declared that they are HIV+. According to Tonks (1996), individuals infected with the HIV virus can effectively bring the reality of its consequences to the pupils. Apart from giving practical facts about HIV/AIDS, such individuals can help change the negative attitudes and beliefs of young people regarding their vulnerability and susceptibility. According to the Health Belief model, individuals are unlikely to adopt health behaviours that can prevent specific diseases unless they:
‘believe they are susceptible to the disease or disorder in question, believe it is serious, accept that the recommended preventive actions will be effective and that the benefits of their actions will outweigh any costs or disadvantages that they believe will be incurred as a result’
(Tones and Tilford, 1994, p.85).
In this regard, pupils are likely to develop positive health behaviours relating to prevention of HIV contraction if they believe that they are susceptible to HIV contraction, and if they see HIV/AIDS as a serious disease. In addition, central in the AIDS Risk Reduction Model is the need for individuals to recognise the behaviours that are risky and the commitment to reduce high-risk sexual contacts and to increase low-risk activities (Catania, et al, 1990). The foregoing, therefore, highlights the critical role, which the HIV+ individuals can play in providing information regarding the risks involved with the HIV/AIDS pandemic.
According to the Theory of Reasoned Action, societal models provide the standards of behaviour for individuals (Hansen, 1986 in Naidoo and Wills, 2000). These individuals act as role models of young people who also happen to be at the centre of the epidemic. It is, therefore, important that in the implementation of HIV/AIDS education, teachers should involve models of society, such as footballers, musicians, athletes, TV and radio personalities, in order to present effective instruction on HIV prevention. Although speakers from outside the class may not teach in the classroom on a regular basis, their exclusion in the learning process would be a lost opportunity to influence the behaviour of young people.
Teachers are key players in HIV/AIDS education as evidenced by the various roles they play. They are important sources of information and skills, confidants to young people, role models, mentors and custodians of healthy school environments (UNESCO, 2008b). Despite their critical roles, they are often left unsupported. Most ministries of education focus on learning and curriculum (UNESCO, 2008b); the teachers unions are not consulted and teachers face widespread stigma and discrimination in the teaching work places where HIV/AIDS policies are undeveloped (UNESCO, 2008c). Given this scenario UNESCO (2008b) identifies a number of issues that need to be addressed to ensure that teachers are effectively supported.
Promoting teachers’ awareness of the needs of their learners and their environments
This awareness for teachers is two-pronged. They need to be aware of and informed of the prevailing HIV risky behaviours among young people and the reasons or the beliefs that facilitate them. A number of studies on young people have shown that they engage in risky behaviour because they do not consider themselves likely to contract HIV. A study by Cliffs, et al (1989) found that young people estimated their own risk of contracting HIV lower than that of their peers. In Botswana, a study showed that the majority of young people believed there is either a traditional or a modern medicine that prevents an individual from contracting HIV (Sekgoma, 1994). A study undertaken in Zambia (Garbus, 2000) revealed that the youth did not regard AIDS as a threat to their lives. These studies underline the urgent need for effective HIV/AIDS education to help young people perceive the dangers of unprotected sex. ‘ In the absence of perceived risk, the perceived costs of using a condom–loss of pleasure, expense, interruption of lovemaking-may be seen as greater than any benefits’ (Naidoo and Wills, 2000 p. 224). Information on contextual factors facilitating the spread of HIV among young people is, therefore, vital when helping teachers to develop strategic pedagogical approaches aimed at dealing with the same.
Training of teachers and provision of on-going support
Before educators can help learners to acquire skills necessary for prevention of HIV infection, they themselves must acquire skills to employ participatory learning activities to enable their learners to develop the necessary social skills (UNESCO, 2008c). According to UNESCO (2008a), current efforts to develop effective HIV/AIDS education curricula for pupils far outweigh the same for training teachers of HIV/AIDS education. For instance, in Malawi, where this study was conducted, no formal training in HIV/AIDS education took place at the teacher training colleges and no in-service training was conducted in 2007 (UNESCO, 2008a). Despite the infusion of topics on LS and SRH in the social studies curricula at Domasi College and Chancellor College (Chakwera and Gulule, 2007), HIV/AIDS education is not a standalone curriculum in any Malawian teacher training college.
One of the best ways to ensure that many teachers are equipped with skills for effective HIV/AIDS education is to integrate HIV/AIDS education into pre-service and in-service training for teachers. Successful efforts in this regard are the CARICOM HFLE Project in Trinidad and Tobago, the Pre-and in-service Life Skills training for teachers in Vietnam, the Pre-service Life Skills Education for primary schools in Zimbabwe, and the SHAPE (Strengthening Partnerships in Education) programme in Ghana (UNESCO, 2008b). Lessons from these initiatives showed that there is need for teachers to examine their own values, attitudes and beliefs before they can help the learners develop the same. However, as members of their own societies and cultural settings, teachers may feel uncomfortable when addressing issues about sex in the same way society in general is reluctant to focus on HIV (UNESCO, 2008a).
UNESCO, (2008b) recommends training those teachers who have strong communication skills and the capacity to build strong relationships with young people. It is believed that such teachers can discuss issues related to sexual experiences with ease, respect confidential information, and be easily approached by young people. It is, however, not clear how such individuals can be identified. Given this apparent challenge, it seems reasonable to expose many teachers to training opportunities. Since individuals are known to open up gradually in discussing HIV/AIDS issues, a number of teachers may fall back on the knowledge and skills they gained earlier as the need becomes apparent.
In order to ensure the continued effectiveness of HIV/AIDS education, there is need to provide the teachers with ongoing support. Regular supervision by custodians of standardised teaching methods and refresher courses will help teachers improve their skills and build on their knowledge base. Other forms of support could include provision of distance-learning materials, such as videos and interactive learning modules to enhance in-service training and continuing education, and the use of ICT and radio (UNESCO, 2008b).
Establishing a supportive environment for teachers of HIV/AIDS education
Even with the aforementioned support, HIV/AIDS education teachers cannot effectively deliver in a hostile teaching environment or one that is not supportive. Support to teachers in this regard can take three forms: development and implementation of policies that support classroom practice, support from head teachers, and support from parents.
In most countries, there is concern about the lack of sector-specific policies on HIV/AIDS Education. UNESCO (2008b) reported that only 40% of countries with high prevalence had HIV/AIDS sector policies. The absence of policies from ministries of education means that schools lack specific guidelines from which to contextualise their own policy initiatives. In some cases, policies developed at ministerial level have not found their way into the schools. In Malawi, for instance, although the HIV/AIDS Strategic plan was developed in 2005, none of the head teachers in this study had seen a copy of the plan (personal communication). This means that school administrators lack guidelines, which they can use together with community leaders in-order to draw up culturally responsive school-specific polices. Teachers will feel confident delivering a curriculum backed by policy guidelines jointly developed by teachers and parents.
For effective delivery, HIV/AIDS education teachers also need the support of their head teachers, administrators or directors. School directors are pivotal in ensuring effective implementation of HIV/AIDS education because they:
- are often influential people in the community, and may deal with the community resistance (including religious groups),
- are instrumental facilitators in the establishment of ‘Youth clubs’ or other extra-curricular activities,
- are often responsible for following up on policies and guidelines from the central or provincial level, and
- can play a major role in mobilising resources in under-resourced environments (UNESCO Bangkok, 2005b, cited in UNESCO, 2008b p.16).
It has been noted in Section 2.3.5 that communities have the potential to influence the effectiveness of HIV/AIDS education in the schools. It can, therefore, be said that parents represent the opinions of the communities within which HIV/AIDS education is being taught. It is, therefore, important that parents endorse the nature of delivery of HIV/AIDS education. Such support will give teachers confidence. Further, when parents have endorsed the nature of HIV/AIDS education in their schools, they can reinforce the acquisition of knowledge and skills in the young people outside the classroom.
This section intends to give a picture of the response to HIV/AIDS within the education sector. As will be seen, this response was not rolled out at one particular point, but comprises a series of progressive responses as challenges from the epidemic within the sector unveiled. It would appear that in most parts, the MOEST was responding to challenges identified by research efforts. Therefore, to understand the development of HIV/AIDS education in Malawian secondary schools, it is useful to capture the chronology of research efforts and related mitigations and interventions. The significance of this section is that it allows one to compare the Malawian responses with the recommended efforts globally, and to identify gaps within the research efforts in order to show the location of this present study.
Initial responses were in form of projects and co-curricular activities and were not classroom based. Further, the emphasis on knowledge acquisition undermined acquisition of skills. The first response was a United States Agency for International Development (USAID)-funded Control and Prevention project in the 1980s, which was followed by a United Nations Fund for Population Activity (UNFPA)-funded Population Education Project in 1993 (Kadzamira, et al, 2001). The USAID project issued booklets on AIDS-related topics for Malawian secondary school pupils. The UNFPA project developed age–specific teaching and learning materials aimed at responding to the rising incidence of HIV/AIDS and school dropouts due to pregnancies. It was an integrated curriculum approach in the junior secondary schools. At about the same time a co-curricular approach (The WHY WAIT? programme) was emerging (Kadzamira, et al, 2001). Available evidence suggests that none of these approaches were very successful. The USAID project did not succeed in terms of imparting the necessary HIV/AIDS knowledge to the pupils, as most teachers felt uncomfortable to discuss sexual behaviours with their students and did not use the booklets. Incidences of unprotected sexual activity amongst young people remained high (McAuliffe, 1994, McAuliffe and Ntata, 1994, Bisika, 1996 and Phiri, et al, 1997 in Kadzamira, et al, 2001) which suggested that the efforts were also less successful than intended.
Based on the HIV/AIDS challenges facing the education sector, Kadzamira, et al, (2001) made a number of recommendations for HIV/AIDS education in the schools. They recommended:
- the teaching of HIV/AIDS Education as a separate subject called Life Skills,
- mainstreaming of family education and Life Skills into teacher education,
- provision of guidance and counselling services to pupils,
- linkages between schools and referral services,
- effective utilization of peer education,
- a clear policy on condoms,
- enforcement of regulations governing sexual misconducts by staff or pupils, and
- support to pupils directly affected by the epidemic.
The recommendation to introduce HIV/AIDS education through the Life Skills approach, ignored the WHY WAIT? Life Skills co-curriculum, which already existed.
Currently two Life skills curricula are used to implement HIV/AIDS education: a carrier curriculum (Life Skills and Sexual Reproductive Health Curriculum-LS and SRH) and a co-curriculum (WHY WAIT? Life Skills), indicating a notable shift in emphasis from knowledge to skills acquisition - an emphasis mirrored across the globe.
The MOEST endorsed the WHY WAIT? Life Skills Curriculum for the first three forms of the secondary schools in Malawi in 1994 (Chimombo, 2000). In February of the following year, a national inauguration of the WHY WAIT? curriculum by the then head of state, His Excellency, Dr. Bakili Muluzi, was held at Sanjika Palace in Blantyre (Chimombo, 2000). The WHY WAIT? Life Skills curriculum is faith-based and draws exclusively on the teachings in the Holy Bible for its core content. This curriculum aims at addressing the major social, health, and economic challenges facing Malawi due to the HIV/AIDS epidemic. The advocates of the WHY WAIT? Curriculum believe that its strength lies in a generally shared view, that historically, religion has proved to be the major drive across cultures in orienting people’s values and behaviours (Chimombo, 2005b). They further contend that the Bible is used as the main text because it is historically reliable, and it teaches sound principles that are vital to basic human needs. They argue that Jesus Christ is an excellent model because his life style exemplifies the embodiment of good character that should be emulated. The curriculum aims at moulding the individual’s beliefs, values and behaviour, based on biblical principles. It uses pupil-centred participatory approaches, focussing on sexual purity in adolescence and subsequent matrimonial sexual fulfilment in adulthood (Chimombo, 2000, 2004, 2005a, 2005b and 2007). Thus, it uses an Abstinence-only approach.
According to the Kadzamira, et al, (2001), LS and SRH Education started as a UNICEF sponsored project in 1997 and was being coordinated by the Ministry of Education Science and Technology. By February 2001, the LS&SRH Curriculum had been introduced in Standard 4 of the primary school, with plans to extend it to standard 8, and later at the secondary school level (Kadzamira, et al, 2001). Although the exact date of the introduction of LS and SRH Education in the secondary schools is not clear, the pupils’ books for the senior secondary schools were published in 2001 (Mhlanga, et al, 2002). It may therefore be reasonable to date the actual implementation just before or around this period.
The LS and SRH Curriculum aims at developing the pupils’ character, attitudes, and interests required for a sound mind and healthy body. According to the writers, the design was arrived at after an analysis and a synthesis of similar curricula from neighbouring countries and extensive consultation with Malawian stakeholders in youth development. Although the theoretical basis of this curriculum is not explicit, it seems reasonable to implicate the Social Psychology domain, since pupils learn skills such as self-esteem and assertiveness, decision-making, values clarification, stress and anxiety management, peaceful conflict resolution, effective communication, interpersonal relationships and good health habits (Mshlanga, et al, 2002). This curriculum is broad as it covers other issues not directly related to HIV/AIDS prevention, e.g. environmental degradation and democracy. Teachers use a variety of pupil-centred participatory approaches with respect to teaching HIV/AIDS issues of the curriculum. This curriculum uses the Abstinence-Plus approach, which uses the A, B, C approach: standing for Abstain, Be faithful and Condom use. This curriculum prioritises sexual abstinence as the safest behaviour of choice for preventing HIV infections, but it also recognises that not all pupils can abstain, and, therefore, mentions the use of condoms as a useful ‘safer sex’ strategy. The curriculum and the teaching guidelines, however, are unclear on how far teachers should go in handling the issue of condom use. There is, however, some indication that MOEST and the major faith communities do not consent to the teaching of condom use in the classrooms. In a paper which the education sector, the Episcopal Conference of Malawi and the Malawi Council of Churches presented jointly at a Sectoral Mobilization Workshop held in Pretoria, South Africa in 2001 (MOEST, 2001b), the Ministry of Education Science and Technology expressed its stand against teaching secondary school pupils about the use of the condom. Despite the Ministry’s explicit stand, there are no documented policy guidelines on this restriction.
The foregoing shows that two curricula are recommended by MOEST for the schools side by side. According to Ross, et al, (2006), delivery of curricula with differing content and theoretical bases to the same learners can have varied impacts. In Malawi, a study by Chinkhata (2006) showed that the delivery of abstinence-only and abstinence-plus programmes to young people need to consider the sexual activity of the pupils. In her study, pupils who were sexually active indicated that the Abstinence-only programme was not suitable for them. However, some literature underscores the need to strategically synergise messages on abstinence and condom use for young people (UNAIDS, 1998; Seligson and Peterson, 1992).
Another survey by MOEST in 2003 showed that the sector continued to face more challenges on top of the aforementioned. These included:
- insufficient monitoring,
- lack of teacher training,
- limited resources,
- poor content coverage,
- poor pupils’ attitudes towards HIV/AIDS education,
- absence of learning requirements for orphans, and
- lack of support for teachers living with HIV/AIDS (see MOEST, 2003 for a detailed description of these).
Other shortfalls included subject overloading on the part of the teachers, loss of interest by the teachers, the subject not being examined and, therefore, seemingly requiring no emphasis, and lack of support by the school administration (Gulule, 2003).
A study by Chinkhata (2006) in one of the urban schools in Blantyre district revealed that programmes delivering HIV/AIDS messages to learners were encountering a number of challenges. These included:
- teacher shortage, no teaching of HIV/AIDS education lessons by some teachers despite the classes being time-tabled (also found by Maganga 2005, in Chinkhata, 2005),
- reluctance by teachers to cover content on sexual issues,
- poor management of clubs mostly in the form of non-attendance of patrons to club meetings, and
- lack of emphasis on HIV/AIDS education due to the subject not being examinable (also reported by Dzilankhulani and Chilemba, 2006, in Chakwera and Gulule, 2007 & Chakwera and Gulule, 2007).
Based on her findings, Chinkhata (2005) recommended pre-and in-service training for teachers, training of teachers (also recommended by Chakwera and Gulule, 2007), and research to unveil teaching strategies being used by HIV/AIDS education teachers. This was an important recommendation considering that Chakwera and Gulule (2007) found that pupils failed to recognise behaviour change and the need to reduce the spread of HIV and STIs as major goals of LS/SRH education. This probably meant that the teaching of appropriate skills was still a major challenge in HIV/AIDS education. Chinkhata (2005) also recommended monitoring and evaluation of HIV/AIDS education. This recommendation was also echoed by Chakwera and Gulule (2007). Another recommendation was the need to provide adequate resources for the implementation of HIV/AIDS education. Dzilankhulani and Chilemba (2006), in Chakwera and Gulule (2007), echoed this need.
In the previous section, there was a mention of unclear teaching guidelines regarding the teaching of the use of condoms. This section, therefore, gives a brief outline regarding the development of the policies available in MOEST to see if the lack of clarity in the guidelines given to teachers mirrors the HIV/AIDS Education policies as a whole.
The Ministry launched a Policy Investment Framework (PIF) for the period 2000-2012 (Ministry of Education Science and Technology, 2001a). The education sector noted that earlier policy changes in this sector were partial and constituted immediate responses to the emerging problems but rarely sought to plan for the challenges that lay ahead. It was, therefore, necessary to draw up a comprehensive visionary policy document that would allow the education system to make significant responses to the challenges facing the Malawi nation. In this regard, it can be noted that the Malawi Government’s main challenge was poverty alleviation. It was therefore conceived that the PIF should address a number of challenges facing the education sector, which threatened the goal of poverty alleviation. Prior to the drafting of the PIF, the education sector revisited the 1995-2005 education strategy in a bid to identify the factors that would influence a national review of priorities for educational investments (MOEST, 2001a). It is interesting to note that during the review, the threat posed by HIV/AIDS to the education system was not identified and this same oversight was mirrored in the PIF. The PIF placed priority on access, equity, quality, relevance, management and planning as the main challenges to poverty alleviation and, therefore, requiring policy intervention at this point in time (MOEST, 2001a). It is, therefore, understandable that the policies in the PIF are silent on Life Skills Education, and in particular HIV/AIDS education. It seems reasonable to conclude that at this stage those framing the policies in the PIF did not consider HIV/AIDS as a threat to poverty alleviation and hence the need for the education sector to mitigate the impacts of HIV/AIDS through HIV/AIDS Education. As a result, the PIF lacked policies specific to classroom practice on HIV/AIDS education.
Up to 2004, the education sector had, therefore, no comprehensive policy on HIV/AIDS education. As a response to this deficiency, the Ministry of Education developed its HIV/AIDS Strategic Plan covering the period 2004-2007 (MOEST, 2005). Part of the rationale of this strategic plan clearly scores this point.
Although the education Policy and Investment Framework (PIF) 2000-2012 guides the development of the education sector in Malawi, it is not comprehensive and exhaustive on HIV and AIDS intervention. This strategic plan is, therefore, a response to the need for a deliberate and defined HIV and AIDS intervention in and for the education sector in Malawi. Thus it sets out strategies for HIV and AIDS mitigation and prevention in the education sector.’
(Ministry of Education Science and Technology, 2005, p. 1.).
It is, therefore, clear that, the strategic plan aimed at expanding the PIF and making it responsive to HIV/AIDS.
In developing the strategic plan, one of the key principle themes was particularly instructive and is quoted below:
Educators and fellow employees may be the key to carrying messages about AIDS to learners and colleagues-through the curriculum, co-curricular activities, guidance and counselling, and as role models- but they are not prepared for this responsibility. They need better information, up-to-date materials and training in interactive methodologies, encouragement to be disciplined, peer-education and guidance and counselling in order to address their own fears and biases.
(Ministry of Education Science and Technology, 2005, p.12).
The Ministry of Education Science and Technology believed that HIV/AIDS was an issue of ‘life and death’ and that ‘education is the best defence’ (MOEST, 2005, p. 14). Among other recommendations, the plan made specific and important recommendations relating to HIV/AIDS education (indicated by * below). It recommended:
- *the development of appropriate Life Skills education for behavioural change for pupils,
- *the inclusion of HIV/AIDS issues in all subjects,
- *the provision of adequate resources and materials,
- *an effective monitoring and evaluation system for HIV/AIDS education,
- *pre-and-in-service teacher training for HIV/AIDS education,
- support to teachers and pupils infected with HIV,
- elimination of sexual relationships between teacher and students,
- *involvement of the youth in the continued development of the HIV/AIDS education curriculum, and
- *provision of counselling services in the schooling environment (MOEST, 2005 pp. 34-54)
The strategic plan was, therefore, more focused on HIV/AIDS education than the PIF and took into account a number of recommendations from earlier studies on HIV/AIDS education. Despite this focus, the strategic plan gave no clear policies regarding examinations on HIV/AIDS education although all the studies underpinned this need. The plan also lacked a policy regarding teaching on the use of condoms in the schools. There is also no policy regarding how best schools can deal with HIV/AIDS issues, which are considered culturally sensitive. It is also silent on the recommended curriculum for the schools between the WHY WAIT? and the LS and SRH.
The challenges facing the implementation of education and the recommendations to improve the same, suggest that the teachers’ task in an HIV/AIDS education classroom is equally challenging. At present, our understanding of the teaching and learning process is also limited as research efforts have concentrated in this area. The researches reviewed in this study have shown a number of gaps regarding the process of teaching and learning HIV/AIDS education. In identifying these gaps, the recent studies done by Kadzamira, et al, (2001), Gulule (2003); MOEST, (2003), Chinkhata (2005) and Chakwera and Gulule (2007) have been found very useful. As noted above, these studies identified potential challenges and made useful recommendations on how to make HIV/AIDS education effective. However, an analysis of these studies, revealed that they:
- were not based on the LS and SRH which is currently recommended for the Malawian schools,
- did not consider whether gender, age group (class level), and school-type were variables in the teaching and learning of HIV/AIDS education: all of these are key contextual factors in HIV/AIDS education.
- relied on information reported by participants (no classroom observations were done): consequently the studies recorded neither the teaching strategies which the teachers employed nor why the teachers preferred to use those strategies.
- did not establish what the pupils themselves believed they needed, and the extent to which these were met through classroom practice and policy provision.
The present study employs a number of data collection strategies, which include classroom observations. The study aims at establishing what the pupils consider their needs to be with respect to learning of HIV/AIDS education. Drawing on these needs, the study will establish the extent to which classroom practice was meeting these needs and what factors are influencing this practice. The study will investigate gender, age group (class level), and school-type, as potential variables in dictating the differences among the participants. Below are the aim and the objectives of my study:
Research aim and objectives
Aim: To improve HIV/AIDS education in Malawian secondary schools.
Objectives: The following were my objectives:
1) To identify what secondary school pupils in Zomba Urban perceive to be their needs in HIV/AIDS education.
2) To establish the extent to which current classroom practice meets these needs.
3) To identify factors influencing classroom practice on HIV/AIDS Education.
Research questions
Drawing from the objectives above, the following were the research questions:
1) What are the needs of secondary school pupils in Zomba Urban with regard to HIV/AIDS education?
2) To what extent does current classroom practice meet these needs?
3) What factors are influencing classroom practice on HIV/AIDS education?
Having established the research objectives and questions above, the next chapter gives an account of the methodology that was used to achieve these objectives.
The chapter has shown that young people aged between 15 and 24 hold the keys to stemming the tide of HIV infections. This age group predominantly comprises secondary school students. Secondary schools are, therefore, key settings in equipping student with the necessary skills and knowledge for preventing HIV/AIDS. There is now a consensus that knowledge alone cannot help to curb the spread of HIV. As such, current school-based curricula focus on the development of life skills needed to help change sexual behaviours that young people at risk of HIV infections. The literature reviewed in this study has suggested a number of effective approaches recommended for skills-based HIV/AIDS education in the classroom. There is need to establish safe learning environments where teachers are supported, use gender and culturally responsive curricula, use participatory teaching and learning approaches supported by a conceptual understanding on learning.
Although research efforts in Malawi have unveiled potential challenges facing the implementation of HIV/AIDS education and made recommendations for improvement, our understanding of the actual process of teaching and learning is limited. In particular, it is not clear how classroom practice is responding to the pupils needs.
Introduction
Chapter 2 reviewed a number of recommended practices for effective skills-based HIV/AIDS education. The review of literature for the Malawian context suggested the need for an in-depth study to identify the needs of the young people in Malawi, establish the extent to which HIV/AIDS education is meeting these needs, and factors influencing classroom practise.
Chapter 3 gives details of the methodology used to investigate the three issues above. The first section provides the rationale for the research design. It justifies why a case study approach and the data collection tools used are suitable for addressing the research questions of this study. The second section describes how the schools and the participants were selected for this study. The last section shows how data were collected and analysed. It specifically shows how the framework for data collection and analysis informed the design of data collection instruments, collection and analysis of data, and ethical guidelines.
According to Pring (2001), the unit in a case study can be an individual person, an institution or a collection of institutions. The case study was considered relevant to this study for a number of reasons. This approach offered an opportunity to carry out a detailed investigation (Pring, 2001; Wellington, 2000). It is suitable for identifying a number of factors influencing the delivery of the content in question (Bell, 1999). The approach also lends itself well to the use of a variety of data collection strategies (Wellington, 2000), such as interviews, observations, questionnaires, and document analysis. Using a variety of data collection strategies enables triangulation of data, which in turn helps to ensure the validity of the findings. The approach was also suited to the limited period of this study. ‘ The case study approach is particularly appropriate for individual researchers because it gives an opportunity for one aspect of a problem to be studied in some depth within a limited time scale’ (Bell 1999, p. 10). The aspect of HIV/AIDS in this case is the relevance of the current provision of HIV/AIDS education to the needs of the pupils and the factors affecting the same.
One of the main criticisms of case studies has been their lack of generalisability to the population. Case studies however embrace the important aspect of relatability. A study is relatable when the details, such as settings, people and situations of a study are sufficient and appropriate to enable a teacher working in a similar situation to relate his or her decision to that in the case study (Bassey, 1981). According to Bassey it is ‘the relatability of a case study that is more important than its generalisability’ (Bassey, 1981, p. 85). He further argues that case studies aimed at improving education, if systematically and critically executed, and if they are relatable, can result in extending the boundaries of existing knowledge, rendering them valid pieces of educational research. While the case for relatability in case studies has been argued, ruling out generalisability would not be entirely correct in some circumstances. Denscombe (1998) observes that the extent to which findings from the case study can be generalised to other examples depends on the extent to which the case study example is similar to others of its type. Bogdan and Biklen (1982), argue that the threat of lack of generalisability in a case study does lessen when one takes into account the settings, the people and the situations to which the findings might be generalisable.
Similarly, a number of researchers tend to see some form of generalisability in a case study. I have quoted two such researchers below to illustrate this point.
‘What can we learn from studying only one of anything? The answer: all we can... Each case study is not so unique that we cannot learn from it and apply its lessons more generally’
(Wolcott, 1995, p. 17).
‘Every man is in certain respects, like all men, like some men, like no other man.’
Kluckhohn and Murray (1948, p.35).
Accepting the truth of the second quotation despite the gender insensitive language, we can also rewrite it: ‘Every school is in certain respects, like all schools, like some schools, like no other school.’ Thus, the findings from this case of urban schools will have both relatability and some generalisability. The other strength in this case study was that the data were drawn intentionally from a variety of schools, which served to widen its generalisability boundary.
This study employed the following methods for data collection: questionnaire administration, classroom observations, interviews, focus group discussions and document analysis. These are justified below.
According to Wilson and Mclean (1994), questionnaires are useful in providing structured, particularly numerical data, which usually makes data analysis straightforward. They are used to obtain information from which patterns can be drawn and comparisons made (Bell, 1999). Where patterns are drawn, the findings of a case study can be generalised to cases similar to its type (Denscombe, 1998).
Observations form an important part of a case study because, together with the use of interviews and documents, they generate data that enable the researcher to paint a clearer picture of the case being studied (Stenhouse, 1979). They enable the researcher to capture ‘live’ data from ‘live’ situations (Cohen, et al, 2000). Patton (1990) gives two reasons why looking at what is taking place ‘in situ’ rather than second hand information is particularly illuminating. First, observations allow the researcher to discover issues and see things that participants may not talk about in structured interview situations. Interviewees may also misrepresent their actions and views. As such, observations have the advantage of complementing self-reporting. Secondly, the less predictable nature of observed incidents yields certain freshness in the collection of data that cannot be obtained from other forms of data collection, like the questionnaire. Finally, observations give the researcher insights to issues needing further exploration during subsequent interviews. This study endeavoured to employ non-participant observation. This meant that the researcher never ‘manipulated’ the participants or the classroom situation. Although observations can be classified as non-participant, it is important to understand that some kind of observer effect on the phenomena being observed cannot be ruled out (Adler and Adler, 1994).
Interviews are an important part of a case study because they, together with the use of questionnaires, observations and documentary evidence, enable the researcher to paint a clearer picture of the case being studied (Stenhouse, 1979). A semi-structured interview guide according to the classification by Patton (1980), was used in the interviews in this study.
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