Skills for Health
Item
- Title
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Skills
for Health - extracted text
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Donated bv Dr. C M Francis in Feb. 2010
The World Health Organization's
INFORMATION SERIES ON SCHOOL HEALTH
documents
Skills
for Health
Skills-based health education including life skills:
An important component of a
Child-Friendly/Health-Promoting School
WHO gratefully acknowledges the generous financial contributions to
support the layout and printing of this document from: the Division of
Adolescent and School Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia, USA.
UNICEF
WHO
op i
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If 11 F
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UNFPA
WORLD BANK
The principles and policies of each of the above agencies are governed by the relevant decisions of its
governing body and each agency implements the interventions described in this document in accordance
with these principles and policies and within the scope of its mandate.
3
This document was prepared with the technical support of Carmen Aldinger and Cheryl
Vince Whitman, Health and Human Development Programmes (HHD) at Education
Development Center, Inc. (EDC). HHD/EDC is the WHO Collaborating Center to Promote
Health through Schools and Communities.
Amaya Gillespie of the Education Section at UNICEF and JackT. Jones of the Department
of Noncommunicable Disease Prevention and Health Promotion at WHO/HQ guided the
overall development and completion of this document.
This paper drew on a variety of sources in the research literature and on consultation with
experts from a previous paper, Life Skills Approach to Child and Adolescent Healthy
Development (Mangrulkar, L, Vince Whitman, C, and Posner, M, published by the Pan
American Health Organisation, 2001); on a survey questionnaire administered to many
international agencies at the global, regional and national levels; and on material
developed by UNICEF and WHO. The draft for this paper was circulated widely to UNAIDS
cosponsoring organisations and other partners identified below:
CONTRIBUTORS:
David Clarke, Department for International Development, London, UK
Don Bundy and Seung Lee, World Bank, Washington, DC, USA
Celia Maier, Partnership for Child Development, London, UK
Neill McKee and Antje Becker, and colleagues, Johns Hopkins University,
Baltimore, MD, USA
Isolde Birdthistle, Sara Gudyanga, Diane Widdus, Margareta Kimzeke,
Peter Buckland, Elaine Furniss, Noala Skinner, Andres Guerrero,Aster Haregot, Onno
Koopmans, Elaine King, Nurper Ulkuer, Anna Obura, Changu Mannathoko, Paul Wafer,
UNICEF/Headquarters, Regional and Country Offices
Francisca Infante, PAHO, Washington, DC, USA
Cecilia Moya and Kent Klindera, Advocates for Youth, Washington, DC, USA
Brad Strickland and Joan Woods, USAID, Washington, DC, USA
V. Chandra-Mouli, Child and Adolescent Health, WHO/HQ, Geneva, Switzerland
Charles Gollmar, CDC, Atlanta, GA, USA
Delia Barcelona, UNFPA/Headquarters, New York, NY, USA
Anna-Maria Hoffmann, UNESCO, Paris, France
WHO INFORMATION SERIES ON SCHOOL HEALTH
CONTENTS
4
PREFACE
5
1. INTRODUCTION
1.1. International support for school health.......................
1.2. Why was this document prepared?...........................
1.3. For whom was this document prepared? .................
1.4. What are skills-based health education and life skills?
1.5. What is the focus of this document?.........................
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9
2. UNDERSTANDING SKILLS-BASED HEALTH EDUCATION AND LIFE SKILLS
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12
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2.1.
Content.....................................................................................................
2.2.
Teaching and learning methods for skills-based health education..............
3.THEORIES AND PRINCIPLES SUPPORTING SKILLS-BASED HEALTH EDUCATION
3.1. Child and Adolescent Development Theories............
3.2. Multiple Intelligences................................................
3.3. Social Learning Theory or Social Cognitive Theory.....
3.4. Problem-Behaviour Theory........................................
3.5. Social Influence Theory and Social Inoculation Theory
3.6. Cognitive Problem Solving........................................
3.7. Resilience Theory.....................................................
3.8. Theory of Reasoned Action and Health Belief Model
3.9. Stages of Change Theory orTranstheoretical Model ..
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4. EVALUATION EVIDENCE AND LESSONS LEARNED.........................................................
4.1. Major research evidence concerning the effectiveness of skills-based health education
4.2. Which factors contribute to effective programmes?......................................................
4.3. Which factors can create barriers to effective skills-based health education?................
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5. PRIORITY ACTIONS FOR QUALITY AND SCALE
5.1. Going to scale ...................................................................................
5.2. Skills-based health education as part of comprehensive school health
5.3. Effective Placement within the curriculum ........................................
5.4. Using existing materials better...........................................................
5.5. Linking content to behavioural outcomes ..........................................
5.6. Professional Development for Teachers and support teams ..............
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6. PLANNING AND EVALUATING SKILLS-BASED HEALTH EDUCATION
6.1. Situation analysis.................................................................................
6.2. Participation and ownership of all stakeholders....................................
6.3. Programme goals and objectives.........................................................
6.4. Advocating for your programme...........................................................
6.5. Evaluating Skills-based Health Education..............................................
6.5.1. Process Evaluation...............................................................................
6.5.2. Outcome Evaluation.............................................................................
6.5.3. Assessing skills-based health education and life skills in the classroom
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Appendix 1: Documents in the WHO Information Series on School Health
Appendix 2: Resources ............................................................................
Appendix 3: Selected skills-based health education interventions ...........
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REFERENCES
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SKILLS FOR HEALTH
5
PREFACE
At the start of the 21st century, the learning potential of significant numbers of children
and young people in every country in the world is compromised. Hunger, malnutrition,
micronutrient deficiencies, parasite infections, drug and alcohol abuse, violence and injury,
early and unintended pregnancy, and infection with HIV and other sexually transmitted
infections threaten the health and lives of children and youth (UNESCO, 2001). Yet these
conditions and behaviours can be improved. Skills-based health education has been shown
to make significant contributions to the healthy development of children and adolescents
and to have a positive impact on important health risk behaviours.
At appropriate developmental levels, from pre-school through early adulthood, young
people can engage in learning experiences that help them prevent disease and injury and
that foster healthy relationships.They can acquire the knowledge and skills they need, for
example, to practise basic hygiene and sanitation; negotiate and make healthy decisions
about sexual and reproductive health choices; or listen and communicate well in
relationships. As they grow into young adults, they can play leadership roles in creating
healthy environments - advocating, for example, for a tobacco-free school or community.
Schools have an important role to play in equipping children with the knowledge,
attitudes, and skills they need to protect their health. Skills-based health education is part
of the FRESH framework (Focusing Resources on Effective School Health), proposed and
supported by WHO, UNICEF UNESCO, UNFPA, and the World Bank. This document was
published jointly by agencies that support the FRESH initiative, and emphasises the role
of schools, however this document will also be relevant to out of school settings. Its
purpose is to strengthen efforts to implement quality skills-based health education on a
national scale worldwide.
Pekka Puska
Director, Noncommunicable Disease
Prevention and Health Promotion,
WHO/HQ, Geneva, SWITZERLAND
Cream Wright
Chief, Education Section,
UNICEF New York, USA
it
Mary Joy Pigozzi
Director, Division for the Promotion
of Quality Education,
UNESCO, Paris, FRANCE
Cheryl Vince-Whitman
Director, WHO Collaborating Center to
Promote Health through Schools and
Communities,
Education Development Center Inc.
Newton, Massachusets, USA
L ■
Mari Simonen
Director, Technical Support Division,
UNFPA, New York, USA
Ruth Kagia
Director, Education
Human Development Network,
The World Bank, Washington DC, USA
X
Fred Van Leeuwen
General Secretary,
El, Education International,
Brussels, BELGIUM
Leslie Drake
Coordinator, Partnership for Child
Development,
London, UNITED KINGDOM
WHO INFORMATION SERIES ON SCHOOL HEALTH
1. INTRODUCTION
Purpose: to describe the rationale and audience for the document; define key concepts;
and explain how skills-based health education, including life skills, fits into the broader
context of what schools can do to improve education and health.
Ensuring that children are healthy and able to learn is an essential part of an effective
education system. As many studies show, education and health are inseparable. A child's
nutritional status affects cognitive performance and test scores; illness from parasitic
infection results in absence from school, leading to school failure and dropping out (Vince
Whitman et al., 2001). Structures and conditions of the learning environment are as
important to address as individual factors. Water and sanitation conditions at school can
affect girls' attendance. Children cannot attend school and concentrate if they are
emotionally upset or in fear of violence. On the other hand, children who complete more
years of schooling tend to enjoy better health and have access to more opportunities in
life. Equipping young people with knowledge, attitudes, and skills through education is
analogous to providing a vaccination against health threats. Educating for health is an
important component of any education and public health programme. It protects young
people against threats both behavioural and environmental, and complements and
supports policy, services, and environmental change.
Over the decades, educating people about health has been an important strategy for
preventing illness and injury. This approach has drawn heavily from the fields of public
health, social science, communications, and education. Early experiments with education
relied heavily on the delivery of information and facts. Gradually, educational approaches
have turned more to skill development and to addressing all aspects of health, including
physical, social, emotional, and mental well-being. Educating children and adolescents
can instill positive health behaviours in the early years and prevent risk and premature
death. It can also produce informed citizens who are able to seek services and advocate
for policies and environments that affect their health. While utilising both school and
non-school settings to reach children and young people will be essential, this document
emphasises school-based activities. Education for health is an important and essential
component of an effective school health programme, and it is likely to be most effective
when complemented by health-related policies and services and healthy environments.
1.1. INTERNATIONAL SUPPORT FOR SCHOOL HEALTH
At the World Education Forum in Dakar, Senegal, in April 2000, WHO, UNICEF UNESCO, and
the World Bank met and agreed to work collaboratively in promoting the implementation of
an effective school health programme: Their framework, called FRESH - Focusing
Resources on Effective School Health, calls for the following four core
components to be implemented together, in all schools:
• Health-related school policies
• Provision of safe water and sanitation as essential first steps toward a healthy
learning environment
• Skills-based health education
• School-based health and nutrition services
These components should be supported and implemented through effective partnerships
between teachers and health workers and between the education and health sectors;
through effective community partnerships; and through student awareness and
participation.
(From UNESCO/UNICEF/WHOfThe World Bank, 2000.)
SKILLS FOR HEALTH
6
7
1. INTRODUCTION
1.2. WHY WAS THIS DOCUMENT PREPARED?
This document, along with a complementary Briefing Package, can be used to orient
education and health workers to improve health among youth through skills-based health
education, including life skills. It is offered by UNICEF, WHO, the World Bank and UNFPA
and complements other documents available from their Web sites:
http://www.unicef.org/programme/lifeskills/,
http://www.who.int/school-youth-health/ ,
http://www.schoolsandhealth.org, http:// www.unfpa.org.
The supporting agencies, UNICEF; WHO, the World Bank and UNFPA, worked together to
prepare this document to encourage more schools and communities to use skills-based
health education, including life skills, as the method for improving health and education.
Together, these agencies are dedicated to fostering effective school health programmes
that implement skills-based health education along with school health policies, a healthy
and supportive environment, and health services together in all schools.
The commitment to skills-based health education as an important foundation for every
child is shared across the supporting agencies. They and their FRESH partners agree that
skills-based health education is an essential component of a cost-effective school health
programme.
FRESH supports Education for All (EFA) which originated in Jomtien, Thailand, where
world leaders gathered in March 1990 for the first EFA World Conference to launch a
renewed worldwide initiative to meet the basic learning needs of all children, youth and
adults. This commitment was renewed during the World Education Forum in Senegal,
Dakar, in April 2000. The resulting Dakar Framework for Action (2000) refers to life skills
in goal 3 ("ensuring that the learning needs of all young services; policies and codes of
conduct that enhance physical, psychosocial, and emotional health of teachers and
learners; and education content and practices that lead to the knowledge, attitudes,
values, and life skills students need to develop and maintain self-esteem, good health,
and personal safety. FRESH people and adults are met through equitable access to
appropriate learning and life skills programmes") and goal 6 ("improving all aspects of the
quality of education, and ensuring excellence of all so that recognized and measurable
learning outcomes are achieved by all, especially in literacy, numeracy and essential life
skills") and in strategy 8. As depicted in Figure 1, strategy 8 of the Dakar Framework calls
for countries to create safe, healthy, inclusive, and equitably resourced educational
environments. Such learning environments embody the four core components of FRESH.
The Dakar Framework for Action (2000) describes these components as follows:
adequate water and sanitation; access to or linkages with health and nutrition is further
supported by Health-Promoting Schools and Child-Friendly Schools and their respective
networks worldwide. Section 5.2.2. in Chapter 5 describes Health-Promoting Schools;
Child Friendly Schools are further described in Section 5.2.3.
1.3. FOR WHOM WAS THIS DOCUMENT PREPARED?
This document was prepared for people who are interested in advocating for, initiating,
and strengthening skilIs-based health education, including life skills, as their approach to
health education.
WHO INFORMATION SERIES ON SCHOOL HEALTH
1. INTRODUCTION
(a) Government policy- and decision-makers, programme planners, and
coordinators at local, district, provincial, and national levels, especially those in ministries
of education, health, population, religion, women, youth, community, and social welfare.
(b) Members of non-governmental institutions and other organisations who are
responsible for planning and implementing programmes described in this document,
including programme staff and consultants of national and international health, education,
and development agencies interested in promoting health through schools.
(c) Community leaders and other community members such as local
residents, religious leaders, media representatives, health care providers, social workers,
mental health counsellors, development assistants, and members of organised groups
such as youth groups and women's groups interested in improving health, education, and
well-being in schools and communities.
(d) Members of the school community, including teachers and their representative
organisations, counsellors, students, administrators, staff, parents, and school-based
service workers.
1.4. WHAT ARE SKILLS-BASED HEALTH EDUCATION AND LIFE SKILLS?
Skills-based health education is an approach to creating or maintaining healthy lifestyles
and conditions through the development of knowledge, attitudes, and especially skills,
using a variety of learning experiences, with an emphasis on participatory methods.
Life skills are abilities for adaptive and positive behaviour that enable individuals to deal
effectively with the demands and challenges of everyday life (WHO definition). In
particular, life skills are a group of psychosocial competencies and interpersonal skills
that help people make informed decisions, solve problems, think critically and
creatively, communicate effectively, build healthy relationships, empathise with others,
and cope with and manage their lives in a healthy and productive manner. Life skills
may be directed toward personal actions or actions toward others, as well as toward
actions to change the surrounding environment to make it conducive to health.
Health is a state of complete physical, mental, and social well-being (WHO definition).
For many decades, instruction about health and healthy behaviours has been described
as "health education." Within that broad term, health education takes many forms. Health
education has been defined as "any combination of learning experiences designed to
facilitate voluntary adaptations of behaviour conducive to health" (Green at al., 1980). At
school, it is a planned, sequential curriculum for children and young people, presented by
trained facilitators, to promote the development of health knowledge, health-related
skills, and positive attitudes toward health and well-being. Typically, health education
targets a broad range of content areas, such as emotional and mental health; nutrition;
alcohol, tobacco, and other drug use; reproductive and sexual health; injuries; and other
topics, with human rights and gender fairness as important cross-cutting or underpinning
principles. Skill development has always been included in health education. Psychosocial
and interpersonal skills are central, and include communication, decision-making and
problem-solving, coping and self-management, and the avoidance of health-compromising
behaviours. The attention to knowledge, attitudes, and skills together (with an emphasis
SKILLS FOR HEALTH
8
9
1. INTRODUCTION
on skills) is an important feature that distinguishes skills-based education from other ways
of educating about health issues.
As health education and life skills have evolved during the past decade, there is growing
recognition of and evidence for the role of psychosocial and interpersonal skills in the
development of young people, from their earliest years through childhood, adolescence,
and into young adulthood. These skills have an effect on the ability of young people to
protect themselves from health threats, build competencies to adopt positive behaviours,
and foster healthy relationships. Life skills have been tied to specific health choices, such
as choosing not to use tobacco, eating a healthy diet, or making safer and informed choices
about relationships. Different life skills are emphasised depending on the purpose and topic.
For instance, critical thinking and decision-making skills are important for analysing and
resisting peer and media influences to use tobacco; interpersonal communication skills
are needed to negotiate alternatives to risky sexual behaviour. Young people can also
acquire advocacy skills with which they can influence the broader policies and
environments that affect their health, including efforts to create tobacco- and
weapon-free zones, the addition of safe water and latrines to school grounds, or access
to reproductive and sexual health services including availability of condoms for the
prevention of HIV.
Skills-based health education is placed in a variety of ways in the school curriculum.
Sometimes it is a core subject within the broader curriculum. Sometimes it is placed in
the context of related health and social issues, within a carrier subject such as science.
Or it may be offered as an extracurricular programme (see Section 5.3). Regardless of its
placement, teachers and school personnel from a wide range of subjects and activities
need to be involved in skills-based health education in order to reinforce learning across
the broader school environment.
A note about life skills-based education and livelihood skills
The term life skills-based education is often used almost interchangeably with skillsbased health education. The difference between the two approaches lies only in the
content or topics that are covered. Skills-based health education focuses on "health." Life
skills-based education may focus on peace education, human rights, citizenship education,
and other social issues as well as health. Both approaches address real-life applications of
essential knowledge, attitudes, and skills, and both employ interactive teaching and learning
methods.
The term livelihood skills refers to capabilities, resources, and opportunities for
pursuing individual and household economic goals (Population Council, Kenya); in other
words, income generation. Livelihood skills include technical and vocational abilities
(carpentry, sewing, computer programing, etc.); skills for seeking jobs, such as
interviewing strategies; and business management, entrepreneurial, and money
management skills. Though livelihood skills are critical to survival, health, and
development, the focus of this document lies elsewhere.
1.5. WHAT ISTHE FOCUS OFTHIS DOCUMENT?
The focus of this document is skills-based health education for teaching children and
adolescents how to adopt or strengthen healthy lifestyles. It is concerned with the
knowledge, attitudes, skills, and support that they need to act in healthy ways, develop
healthy relationships, seek services, and create healthy environments.
WHO INFORMATION SERIES ON SCHOOL HEALTH
1. INTRODUCTION
10
This document specifically:
• defines the term skills-based health education, including life skills;
• describes the theoretical foundation;
• reviews the educational approaches of skills-based health education;
• presents evaluation evidence and practical experiences to make the case for
implementing skills-based health education as part of an effective school
health programme;
• reviews criteria for effective programmes and preparation for those who deliver
such programmes;
• describes available resources
School setting: Skills-based health education and life skills can and have been incorporated
in many settings and for a wide range of target groups. In this document, we focus on
school-based programmes. Education reform ensures a place for skills-based health
education in the curriculum and in various extra-curricular efforts. Special programmes for
students and parents, peer education and counselling programmes, and school/community
programmes offer ways for students to apply and practise what they learn.
Student participation in active learning can strengthen student-teacher relationships,
improve the classroom climate, accommodate a variety of learning styles, and provide
alternative ways of learning. Skills-based health education can and should be used to
address the health issues that children and young people can encounter in the school
setting, including the use of alcohol, tobacco and other drugs; helminth and other worm
infections; nutrition; reproductive and sexual health; and the prevention of violence and
of HIV/AIDS.
Figure 1: Links between EFA, FRESH, Health-Promoting Schools (HPS), Child-Friendly Schools (CFS),
Skills-Based Health Education (SBHE), Life Skills (LS)
EDUCATION FOR ALL (EFA)
Global initiative for Basic Education
Strategy 8 of Dakar Framework: "Create safe, healthy,
inclusive and equitably resourced educational environments..."
_________ f_________
FOCUSING RESOURCES ON EFFECTIVE SCHOOL HEALTH (FRESH)
Basic components of school health programmes world-wide
HEALTH-RELATED
SCHOOL POLICIES
SAFE WATER AND SANITATION
AND A HEALTHY ENVIRONMENT
7A
CHILD FRIENDLY
SCHOOLS (CFS)
Inclusive of all children,
protective and healthy for
children
SKILLS FOR HEALTH
SKILLS-BASED HEALTH
EDUCATION
KNOWLEDGE
ATTITUDES
HEALTH AND
NUTRITION SERVICES
SKILLS, INCLUDING
LIFE SKILLS
HEALTH-PROMOTING
SCHOOLS (HPS)
Foster health and learning
with all measures at their
disposal
11
2. UNDERSTANDING SKILLS-BASED HEALTH EDUCATION &
LIFE SKILLS
Purpose: to define the content and methods of skills-based health education, with examples.
Skills-based health education is good quality education per se and good quality health
education in particular. It relies on relevant and effective content and participatory or
interactive1 teaching and learning methods.
When planning skills-based health education, it is important to consider first the goals and
objectives, then the content and methods (see Figure 2). The goals of skills-based health
education describe in general terms a health or related social issue to be influenced in
some particular way. The objectives describe in specific terms the behaviours or conditions
(see Figures 3 and 4) that if positively influenced, will have a significant impact on the
goals. Many factors influence behaviour and conditions; skills-based health education is
one of them.
The content of skills-based health education is a clear delineation of specific knowledge,
attitudes, and skills, including life skills, that young people will be helped to acquire so
they might adopt behaviours or create the conditions described in the objectives. Once
the content is delineated, methods are chosen that are most suitable to the content. For
example, lectures are suitable methods for helping students acquire accurate knowledge;
discussions are suitable for influencing attitudes; and role plays are suitable for developing
skills. A wide range of teaching and learning methods can and should be used in enabling
students to acquire knowledge, attitudes, and skills (see boxed example).
EXAMPLE
Goals and objectives determine the content and methods of skills-based health education.
Let's suppose the goal is preventing health problems from the use of tobacco.
Objectives for this goal might include reducing young people's use of tobacco products
and changing conditions that affect tobacco use, such as the number of smoke-free
environments and the cost and accessibility of cigarettes. Content might therefore
address (1) knowledge of the health risks of smoking; (2) awareness of the insidious
tactics employed by the tobacco industry to persuade young people to use tobacco
and make them addicted; (3) attitudes that afford protection against harming one's
health and the health of others; (4 ) critical thinking and decision-making skills to assist
in choosing not to use tobacco; communication and refusal skills to withstand peer
pressure; and skills to advocate for a smoke-free environment. Teaching methods for
this content might include (1) a presentation that clearly and convincingly explains the
harmful effects of tobacco and how companies use marketing to make tobacco use
seem attractive; (2) a discussion and small group work using audio-visual materials to
convey the dangers of smoking; (3 ) an exercise to research strategies that the tobacco
industry uses to gain youth as replacement smokers; (4 ) role plays to practise refusal
skills; and (5) a school-wide activity to gain support for a smoke-free school
environment. By itself, skills-based health education has been shown to help many
young people avoid health risks such as exposure to tobacco smoke. However, in many
communities, social and economic policies and practices undermine the goals of skillsbased health education or glorify risk-taking behaviour. National and local strategies
that curtail the influence of such policies and practices are needed to achieve the full
benefit of skills-based health education.
’The words "participatory" and "interactive" are used interchangeably in this paper. They refer to teaching
methods that actively engage students in the process of education.
WHO INFORMATION SERIES ON SCHOOL HEALTH
2. UNDERSTANDING SKILLS-BASED HEALTH EDUCATION &
LIFE SKILLS
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Figure 2. Pyramid for Planning skills-based health education
PLANNING PYRAMID
OTHER
FACTORS
GOALS .
HEALTH
GOALS
& RELATED
SOCIAL ISSUES
GENDER
HUMAN RIGHTS
OBJECTIVES
BEHAVIOURS &
CONDITIONS
OBJECTIVES
............. *
CONTENT
METHODS
OTHER
INFLUENCES
KNOWLEDGE +
ATTITUDES +SKILLS
(LIFE SKILLS AND OTHER SKILLS)
CONTENT
TEACHING AND
LEARNING METHODS
PARTICIPATION
2.1. CONTENT
In skills-based health education, content refers to the specific health knowledge and
attitudes toward self and others, as well as the skills necessary to influence behaviour
and conditions related to a particular health issue. Skills-based health education should
enable a young person to apply knowledge and develop attitudes and skills to make
positive decisions and take actions to promote and protect one's health and the health
of others.
SKILLS FOR HEALTH
METHODS
II
13
2. UNDERSTANDING SKILLS-BASED HEALTH EDUCATION &
LIFE SKILLS
Knowledge refers to a range of information and the understanding thereof. To impart
this knowledge, teachers may combine instruction on facts with an explanation of how
these facts relate to one another (Greene & Simons-Morton, 1984). For example, a
teacher might describe how HIV infection is transmitted and then explain that engaging
in sexual relations with an intravenous drug user elevates the risk of HIV infection.
Attitudes are personal biases, preferences, and subjective assessments that predispose
one to act or respond in a predictable manner. Attitudes lead people to like or dislike
something, or to consider things good or bad, important or unimportant, worth caring
about or not worth caring about. For example, gender sensitivity, respect for others, or
respecting one's body and believing that it is important to care for are attitudes that are
important to preserving health and functioning well (adapted from Greene & SimonsMorton, 1984). For the purposes of this document, the domain of attitudes comprises a
broad range of concepts, including values, beliefs, social norms, rights, intentions, and
motivations.
Skills are grouped in this document into life skills (defined below) and other skills. In
general, skills are abilities that enable people to carry out specific behaviours. The
phrase other skills refers to practical health skills or techniques such as competencies
in first aid (e.g., bandaging, resuscitation, sterilising utensils), in hygiene (e.g., hand
washing, brushing teeth, preparing oral rehydration therapy), or sexual health (e.g.,
using condoms correctly).
Life skills are abilities for adaptive and positive behaviour that enable individuals to
deal effectively with the demands and challenges of everyday life (WHO definition). In
particular, life skills are psychosocial competencies and interpersonal skills that help
people make informed decisions, solve problems, think critically and creatively,
communicate effectively, build healthy relationships, empathise with others, and cope
with managing their lives in a healthy and productive manner. Life skills may be
directed toward personal actions or actions toward others, or may be applied to actions
that alter the surrounding environment to make it conducive to health.
Various health, education, and youth organisations and adolescence researchers have
defined and categorised key skills in different ways. Despite these differences, experts
and practitioners agree that the term "life skills” typically includes the skills listed in the
preceding definition. To these we have added advocacy skills, because they are important
in personal and collective efforts to make a strong case for behaviours and conditions that
are conducive to health. (For a case study on advocacy skills, see Section 2.2).
The process of categorizing various life skills may inadvertently suggest distinctions
among them (see Figure 3). However, many life skills are interrelated, and several of them
can be taught together in a learning activity.
WHO INFORMATION SERIES ON SCHOOL HEALTH
14
2. UNDERSTANDING SKILLS-BASED HEALTH EDUCATION &
LIFE SKILLS
Figure 3. Life skills for skills-based health education
COMMUNICATION AND
INTERPERSONAL SKILLS
• Interpersonal
Communication Skills
- verbal/nonverbal
communication
- active listening
- expressing feelings; giving
feedback (without blaming)
and receiving feedback
• Negotiation/Refusal Skills
- negotiation and conflict
management
- assertiveness skills
- refusal skills
• Empathy Building
- ability to listen, understand
another's needs and circumstances,
and express that understanding
• Cooperation and Teamwork
- expressing respect for others'
contributions and different styles
- assessing one's own abilities
and contributing to the group
• Advocacy Skills
- influencing skills and persuasion
- networking and motivation skills
DECISION-MAKING AND
F ^CRITICALTHINKING SKILLS
• Decision-making/Problemsolving Skills
- information-gathering skills
- evaluating future consequences
of present actions for self and
others-determining alternative
solutions to problems
- analysis skills regarding the
influence of values and of
attitudes about self and others
on motivation
• Critical Thinking Skills
- analysing peer and media
influences
- analysing attitudes, values,
social norms, beliefs, and
factors affecting them
- identifying relevant information
and sources of information
COPING AND
SELFMANAGEMENT SKILLS
• Skills for Increasing Personal
Confidence and Abilities to
Assume Control,
Take Responsibility, Make a
Difference, or Bring About
Change
- building self-esteem/
confidence
- creating self-awareness skills,
including awareness of rights,
influences, values, attitudes,
rights, strengths, and
weaknesses
- setting goals
- self-evaluation / self-assessment/
self-monitoring skills
•
-
Skills for Managing Feelings
managing anger
dealing with grief and anxiety
coping with loss, abuse, and
trauma
•
-
Skills for Managing Stress
time management
positive thinking
relaxation techniques
In efforts to achieve specific behavioural outcomes, programmes aimed at developing
young people's life skills without a particular context such as a health behaviour or
condition are less effective than programmes that overtly focus on applying life skills to
specific health choices and behaviours (Kirby et al, 1994). To influence behaviour
effectively, skills must be applied to a particular topic, such as a prevalent health issue.
Not to be overlooked, however, is the importance of building life skills to equip young
people in other aspects of their development as well, such as maintaining positive
interpersonal relations with teachers, students, and family members.
SKILLS FOR HEALTH
15
2. UNDERSTANDING SKILLS-BASED HEALTH EDUCATION &
LIFE SKILLS
Figure 4 shows how students can apply one or more life skills as they practise choosing
positive behaviours and creating healthy conditions in response to various health concerns.
Figure 4. Life skills made specific to major health topics
HEALTH
TOPICS
COMMUNICATION AND
INTERPERSONAL SKILLS
DECISION-MAKING AND
CRITICAL THINKING SKILLS
COPING AND SELF
MANAGEMENT SKILLS
ALCOHOL,
TOBACCO, AND
OTHER DRUGS
• Communication Skills:
Students can observe and
practise ways to:
- inform others of the negative
health and social conse
quences and personal reasons
for refraining from alcohol,
tobacco, and drug use
- ask parents not to smoke
in the car when they ride
with them
• Decision-making Skills:
Students can observe and
practise ways to:
- gather information about
consequences of alcohol and
tobacco use
- weigh the consequences
against common reasons
young people give for using
alcohol or tobacco
- identify their own reasons
for not using alcohol or other
drugs and explain
those reasons to others
- suggest a decision to drink
non-alcoholic beverages at a
party where alcohol is served
- make and sustain a decision
to stop using tobacco or
other drugs and seek help
to do so
• Skills for Managing Stress:
Students can observe and
practise ways to:
- analyse what contributes to
stress
- reduce stress through
activities such as exercise,
meditation, and time
management
- make friends with people
who provide support and
relaxation
• Empathy Skills:
Students can observe and
practise ways to:
- listen to and show under
standing of the reasons a
friend may choose to use drugs
- suggest alternatives in an app
ealing and convincing manner
• Advocacy Skills:
Students can observe and
practise ways to:
- persuade the headmaster
to adopt and enforce a policy
for tobacco-free schools
- generate local support for
tobacco-free schools and
public buildings
• Negotiation/Refusal Skills:
Students can observe and
practise ways to:
- resist a friend's repeated
request to chew or smoke
tobacco, without losing
face or friends
• Interpersonal Skills:
Students can observe and
practise ways to:
- support persons who are
trying to stop using tobacco
and other drugs
- express constructive positive
intolerance for a friend's use
of substances. "It is not
okay for you to do that... "
• Critical Thinking Skills:
Students can observe and
practise ways to:
- analyse advertisements
directed toward young
people to use tobacco and
see how they are playing
upon the need to seem
"cool," appeal to girls, or be
attractive to boys
- develop counter-messages
that include the cost of
buying cigarettes and how
else that money could be
used
- assess how tobacco use
takes advantage of poor
people
- analyse what may be driving
them to use substances and
aim to find a healthy
alternative
WHO INFORMATION SERIES ON SCHOOL HEALTH
2. UNDERSTANDING SKILLS-BASED HEALTH EDUCATION &
16
LIFE SKILLS
Figure 4. Life skills made specific to major health topics (continued)
HEALTH
TOPICS
COMMUNICATION AND
INTERPERSONAL SKILLS
DECISION-MAKING AND
CRITICAL THINKING SKILLS
COPING AND SELF
MANAGEMENT SKILLS
HEALTHY
NUTRITION
• Communication Skills:
Students can observe and
practise ways to:
- persuade parents and friends
to make healthy food and
menu choices
• Decision-making Skills:
Students can observe and
practise ways to:
- choose nutritious foods and
snacks over those less
nutritious
- convincingly demonstrate an
understanding of the
consequences of unbalanced
nutrition (deficiency
diseases)
• Self-awareness and
Self -management Skills:
Students can observe and
practise ways to:
- recognise links between
eating disorders and psycho
logical and emotional factors
- identify personal preferences
among nutritious foods and
snacks
- develop a healthy body image
• Refusal Skills:
Students can observe and
practise ways to:
- counter social pressures to
adopt unhealthy eating
practices
• Advocacy Skills:
Students can observe and
practise ways to:
- present messages of healthy
nutrition to others through
posters, ads, performances,
and presentations
- gain support of influential
adults such as headmasters,
teachers, and local
physicians to provide healthy
foods in the school
environment
SEXUAL AND
REPRODUCTIVE
HEALTH AND
HIV/AIDS
PREVENTION
• Communication Skills:
Students can observe and
practise ways to:
- effectively express a desire
to not have sex
- influence others to abstain
from sex or practise safe sex
using condoms if they
cannot be influenced to
abstain
- demonstrate support for the
prevention of discrimination
related to HIV/AIDS
• Advocacy Skills:
Students can observe and
practise ways to:
- present arguments for
access to sexual and
reproductive health
information, services, and
counselling for young people
• Negotiaton/Refusal Skills:
Students can observe and
practise ways to:
- refuse sexual intercourse or
negotiate the use of condoms
SKILLS FOR HEALTH
• Critical Thinking Skills:
Students can observe and
practise ways to:
- evaluate nutrition claims
from advertisements and
nutrition-related news stories
• Decision-making Skills:
Students can observe and
practise ways to:
- seek and find reliable
sources of information about
human anatomy; puberty;
conception and pregnancy;
STIs, HIV/AIDS, and local
prevalence rates; and
available methods of
contraception
- analyse a variety of potential
situations for sexual
interaction and determine
a variety of actions they may
take and the consequences
of such actions
• Critical Thinking Skills:
Students can observe and
practise ways to:
- analyse myths and
misconceptions about HIV/
AIDS, contraceptives, gender
roles, and body image that
are perpetuated by the media
• Skills for Managing Stress:
Students can observe and
practise ways to:
- seek services for help with
reproductive and sexual
health issues, e.g.,
contraception, condoms to
prevent HIV or unplanned
pregnancy, sexual abuse,
exploitation, discrimination,
(gender-based) violence, or
other emotional trauma
• Skills for Increasing
Personal Confidence and
Abilities to Assume
Control, Take
Responsibility, Make a
Difference, or Bring About
Change:
Students can observe and
practise ways to:
- assert personal values when
encountering peer and other
pressures
17
2. UNDERSTANDING SKILLS-BASED HEALTH EDUCATION &
LIFE SKILLS
Figure 4. Life skills made specific to major health topics (continued)
HEALTH
TOPICS
COMMUNICATION AND
INTERPERSONAL SKILLS
DECISION-MAKING AND
CR1TICALTHINKING SKILLS
SEXUAL AND
REPRODUCTIVE
HEALTH AND
HIV/AIDS
PREVENTION
• Interpersonal Skills:
Students can observe and
practise ways to:
- show interest and listen
actively to others
- be caring and compassionate,
including when interacting
with someone who is
infected with HIV
- analyse social-cultural
influences regarding sexual
behaviours
REDUCING
HELMINTH
(WORM)
INFECTIONS
• Communication Skills:
Students can observe and
practise ways to:
- communicate messages
about worm infection to
families, peers, and members
of the community
- encourage peers, siblings,
and family members to take
part in deworming activities
and to avoid reinfection
• Decision-making/problemsolving Skills:
Students can observe and
practise ways to:
- identify and avoid behaviours
and environmental
conditions that are likely to
cause infection, such as
ingestion of or contact with
contaminated soil, and
adopt behaviours that are
likely to prevent infection,
such as keeping human
faeces from polluting the
ground or surface water
- use safe water and
uncontaminated food
• Self-Monitoring Skills:
Students can observe and
practise ways to:
- engage in behaviours that
are not conducive to
contracting helminth and
worm infections, such as
avoiding contaminated water
• Decision-making Skills:
Students can observe and
practise ways to:
- understand the roles of
aggressor, victim, and
bystander
• Skills for Managing Stress:
Students can observe and
practise ways to:
- identify and implement
peaceful ways of resolving
conflict
- resist pressure from peers
and adults to engage in
violent behaviour
• Advocacy Skills:
Students can observe and
practise ways to:
- advocate for an environment
and behaviour that are not
conducive to helminth infections
- share positive results of
deworming activities
VIOLENCE
PREVENTION OR
PEACE
EDUCATION
• Communication Skills:
Students can observe and
practise ways to:
- state their position clearly and
calmly, without blaming
- listen to each other's point of view
- communicate positive messages
- use "I" statements and not
accuse others
• Negotiation Skills:
Students can observe and
practise ways to:
- intervene and discourage others
from conflict before it escalates
• Advocacy Skills:
Students can observe and
practise ways to:
- get involved in community
activities that promote non-violent
behaviour
- join, support, and inform others
about non-violent activities and
organisations
- advocate for programmes to buy
back weapons or create weapon
free zones
- discourage viewing violent tele
vision movies and video games
• Critical Thinking Skills:
Students can observe and
practise ways to:
- identify and avoid situations
of conflict
- evaluate both violent and
non-violent solutions that
appear to be successful
as depicted in the media
- analyse their own stereo
types, beliefs, and attribu
tions that support violence
- help reduce prejudice and
increase tolerance for diversity
COPING AND SELF
MANAGEMENT SKILLS
WHO INFORMATION SERIES ON SCHOOL HEALTH
2. UNDERSTANDING SKILLS-BASED HEALTH EDUCATION &
LIFE SKILLS
Optimally, skills-based health education will be utilised across a range of content areas.
Guidelines for addressing several of these content areas can be found in the WHO
Information Series for School Health (see Appendix 1).
Skills-based health education and human rights
Skills-based health education supports the basic human rights included in the
Convention on the Rights of the Child (CRC), especially those related to the highest
attainable standard of health (Article 24) and the right to education for the development
of children to their fullest potential (Articles 28 and 29). Children have universal and
indivisible rights, including the right to survival; to protection from harmful influences,
abuse, and exploitation; and to full participation in family, cultural, and social life.
Furthermore, children have rights to information, education and services; to the
highest attainable standard of physical and mental health; and to formal and non-formal
education about population and health issues, including sexual and reproductive health
issues (International Conference on Population and Development, 1999). States are
accountable to respect, protect, and fulfil the rights of children. Education must
address the best interests and ongoing development of the whole child in a nondiscriminatory way and with respect for the views and participation of the child.
Skills-based health education is a means to do so.
2.2. TEACHING AND LEARNING METHODS FOR SKILLS-BASED
HEALTH EDUCATION
To contribute to skills-based health education goals and achieve the objectives of skill
based health education, teaching and learning methods must be relevant and effective.
Effective skills-based health education replicates the natural processes by which children
learn behaviour.These include modelling, observation, and social interactions. Interactive
or participatory teaching and learning methods are an essential part of skills-based
health education.
Skills are learned best when students have the opportunity to observe and actively
practise them. Listening to a teacher describe skills or read or lecture about them does
not necessarily enable young people to master them. Learning by doing is necessary.
Teachers need to employ methods in the classroom that let young people observe the
skills being practiced and then use the skills themselves. Researchers argue that if young
people can practise the skills in the safety of a classroom environment, it is much more
likely that they will be prepared to use them in and outside of school.
The role of the teacher in delivering skills-based health education is to facilitate
participatory learning (that is, the natural process of learning) in addition to conducting
lectures or employing other appropriate and efficient methods for achieving the learning
objectives. Participatory learning utilises the experience, opinions, and knowledge of
group members; provides a creative context for the exploration and development of
possibilities and options; and affords a source of mutual comfort and security that aids
the learning and decision-making process (CARICOM & UNICEF; 1999).
Social learning theory provides some of the theoretical foundation for why participatory
teaching techniques work. Bandura's research shows that people learn what to do and
how to act by observing others. Positive behaviours are reinforced by the positive or
SKILLS FOR HEALTH
18
19
2. UNDERSTANDING SKILLS-BASED HEALTH EDUCATION &
LIFE SKILLS
negative consequences viewed or experienced directly by the learner. Retention of
behaviours can be enhanced when people mentally rehearse or actually perform
modelled behaviour patterns (Bandura, 1977).
Constructivist theory provides another rationale. Vygotsky argues that social interaction
and the active engagement of the child in problem-solving with peers and adults is the
foundation of the developing mind (Vygotsky, 1978). Many programmes capitalise on the
power of peers to influence social norms and individual behaviours. Adults and young
people tend to act in ways that they perceive to be normative or what most people their
age are doing. If youngsters perceive (correctly or incorrectly) that fighting is the way
most young people solve problems, then that becomes the norm or typical way most
youngsters in a setting will respond. If, on the other hand, students sense that the norm
is to talk problems through and that bystanders will intervene to stop a fight rather than
encourage it, most students will gravitate to that norm of behaviour. Through cooperative
work with peers to promote pro-social behaviours, the normative peer structure is
changed to support healthy, positive behaviours; it also may move some of the high-risk
peers who are more likely to engage in damaging behaviours toward the pro-social norms
(Wodarski & Feit, 1997). Setting positive standards in the school environment is key;
making students aware of those standards and then model them can lead more students
to behave in health-promoting ways (adapted from Mangrulkar et al., 2001, p. 27).
Figure 5 describes a model of skills development that can serve as a guide for
structuring classroom lessons.
Figure 5. Cycle of Skills Development
Defining and Promoting Specific Skills
- Defin ng the skills: What skills are most relevant to influencing a targeted behaviour
or condition; what wl! the student be able to do if the sk;ll-building exercises are
successful?
- Generating positive and negative examples of how the skills might be applied
- Encouraging verbal rehearsal and action
- Correcting misperceptions about what the skill i$ and how to do it
Promoting Skill Acquisition and Performance
- Providing opportunities to observe the skill being applied effectively
- Prov ding opportunities for practise with coaching and feedback
- Evaluating performance
- Providing feedback and recommendations for corrective actions
Fostering Skill Maintenance/Generalisation
- Providing opportunities kr personal practise
- Fostering self-evaluation and skill adjustment
(The text in Figure 5 was adapted from Mangrulkar et al., 2001, p. 27.)
WHO INFORMATION SERIES ON SCHOOL HEALTH
2. UNDERSTANDING SKILLS-BASED HEALTH EDUCATION &
LIFE SKILLS
Studies of approaches to health education have shown that active participatory learning
activities for students are the most effective method for developing knowledge, attitudes, and
skills together for students to make healthy choices (e.g., Wilson et al., 1992;Tobler, 1998).
Specific advantages of active participatory teaching and learning methods, and working in
groups, include the following:
• augment participants' perceptions of themselves and others
• promote cooperation rather than competition
• provide opportunities for group members and their trainers/teachers to recognise
and value individual skills and enhance self-esteem
• enable participants to get to know each other better and extend relationships
• promote listening and communication skills
• facilitate dealing with sensitive issues
• appear to promote tolerance and understanding of individuals and their needs
• encourage innovation and creativity
(from: CARICOM, 2000; CARICOM & UNICEF 1999)
Participatory teaching methods for building skills and influencing attitudes
include the following:
• class discussions
• brainstorming
• demonstration and guided practice
• role play
• small groups
• educational games and simulations
• case studies
• story telling
• debates
• practising life skills specific to a particular context with others
• audio and visual activities, e.g., arts, music, theatre, dance
• decision mapping or problem trees
Effective programmes balance these participatory and active methods with information
and attitudes related to the context (Kirby et al., 1994). Figure 6 describes content,
benefits, and how-to processes for some major participatory teaching methods. In the
following case study, young students used advocacy and action skills to change
conditions in the environment and promote health.
CASE STUDY
Elementary school students in Hibbing, Minnesota, in the United States participated in the
Skills for Growing Up programme developed by Lions-Quest, an initiative of Lions Clubs
International/Lions Clubs International Foundation to teach life skills to youth.The students
decided that the "Hey Man Cool" gum stick with a red tip that expelled puffs of sugar
"smoke" could easily be mistaken for a real cigarette, and that the manufacturer was
glamorizing smoking. They got two local candy stores to remove the candy from their
shelves and then made their case to the manufacturer, the Philadelphia Chewing Gum
SKILLS FOR HEALTH
20
21
2. UNDERSTANDING SKILLS-BASED HEALTH EDUCATION &
LIFE SKILLS
Corporation. The company agreed to change the packaging, remove the red tip, and
modify the shape of the gum. Encouraged by their success, the teacher said that the
students are now taking on a beef jerky company whose product resembles chewing
tobacco.
(From http://www.quest.edu/content/OurProgrammes/EvaluationRepor1/evalreport.html)
Figure 6: Participatory Teaching Methods
Each of the teaching methods in Figure 6 can be used to teach life skills.
TEACHING
METHOD
DESCRIPTION
BENEFITS
CLASS
DISCUSSION
(In Small or
Large Groups)
The class examines a problem
or topic of interest with the
goal of better understanding
an issue or skill, reaching the
best solution, or developing
new ideas and directions for
the group.
Provides opportunities for
students to learn from one
another and practise turning
to one another in solving
problems. Enables students to
deepen their understanding of
the topic and personalise their
connection to it. Helps
develop skills in listening,
assertiveness, and empathy.
BRAIN
STORMING
Students actively generate a
broad variety of ideas about a
particular topic or question in
a given, often brief period of
time. Quantity of ideas is the
main objective of brain
storming. Evaluating or
debating the ideas occurs
later.
Allows students to generate
ideas quickly and sponta
neously. Helps students use
their imagination and break
loose from fixed patterns of
response. Good discussion
starter because the class can
creatively generate ideas. It is
essential to evaluate the pros
and cons of each idea or rank
ideas according to certain
criteria.
• Designate a leader and a
recorder
• State the issue or problem
and ask for ideas
• Students may suggest any
idea that comes to mind
• Do not discuss the ideas
when they are first
suggested
• Record ideas in a place
where everyone can see
them
• After brainstorming, review
the ideas and add, delete,
categorise
ROLE PLAY
Role play is an informal
dramatisation in which people
act out a suggested situation.
Provides an excellent strategy
for practising skills; experienc
ing how one might handle a
potential situation in real life;
increasing empathy for others
and their point of view; and
increasing insight into one's
own feelings.
• Describe the situation to be
role played
• Select role players
• Give instructions to role
players
• Start the role play
• Discuss what happened
PROCESS:
• Decide how to arrange
seating for discussion
• Identify the goal of the
discussion and communicate
it clearly
• Pose meaningful,
open-ended questions
• Keep track of discussion
progress
WHO INFORMATION SERIES ON SCHOOL HEALTH
2. UNDERSTANDING SKILLS-BASED HEALTH EDUCATION &
LIFE SKILLS
22
Figure 6: Participatory Teaching Methods (continued)
TEACHING
METHOD
DESCRIPTION
BENEFITS
PROCESS
SMALL
GROUP/ BUZZ
GROUP
For small group work, a large
class is divided into smaller
groups of six or less and
given a short time to
accomplish a task, carry
out an action, or discuss a
specific topic, problem, or
question.
Useful when groups are large
and time is limited.
Maximises student input. Lets
students get to know one
another better and increases
the likelihood that they will
consider how another person
thinks. Helps students hear
and learn from their peers.
• State the purpose of
discussion and the amount
of time available
• Form small groups
• Position seating so that
members can hear each
other easily
• Ask group to appoint recorder
• At the end have recorders
describe the group's
discussion
GAMESAND
SIMULATIONS
Students play games as
activities that can be used for
teaching content, critical
thinking, problem-solving, and
decision-making and for
review and reinforcement.
Simulations are activities
structured to feel like
the real experience.
Games and simulations
promote fun, active learning,
and rich discussion in the
classroom as participants
work hard to prove their
points or earn points. They
require the combined use of
knowledge, attitudes, and
skills and allow students to
test out assumptions and
abilities in a relatively safe
environment.
Games:
• Remind students that the
activity is meant to be
enjoyable and that it does
not matter who wins
Simulations:
• Work best when they are
brief and discussed
immediately
• Students should be asked
to imagine themselves in a
situation or should play a
structured game or activity
to experience a feeling that
might occur in another setting
SITUATION
ANALYSIS AND
CASE STUDIES
Situation analysis activities
allow students to think about,
analyse, and discuss
situations they might
encounter. Case studies are
real-life stories that describe
in detail what happened to a
community, family, school, or
individual.
Situation analysis allows students
to explore problems and dilemmas
and safely test solutions; it provides
opportunities to work together,
share ideas, and learn that people
sometimes see things differently.
Case studies are power-ful catalysts
for thought and discussion.
Students consider the forces that
converge to make an individual or
group act in one way or another,
and then evaluate the conse
quences. By engaging in this think
ing process, students can improve
their own decision-making skills.
Case studies can be tied to specific
activities to help students practise
healthy responses before they find
themselves confronted with a
health risk.
• Guiding questions are
useful to spur thinking and
discussion
• Facilitator must be adept at
teasing out the key points
and step back and pose
some 'bigger' overarching
questions
• Situation analyses and case
studies need adequate time
for processing and
creative thinking
• Teacher must act as the
facilitator and coach rather
than the sole source of
'answers' and knowledge
SKILLS FOR HEALTH
23
2. UNDERSTANDING SKILLS-BASED HEALTH EDUCATION &
LIFE SKILLS
Figure 6: Participatory Teachi ng Methods (continued)
TEACHING
METHOD
I
DESCRIPTION
BENEFITS
PROCESS
DEBATE2
In a debate, a particular
problem or issue is presented
to the class, and students
must take a position on
resolving the problem or
issue. The class can debate as
a whole or in small groups.
Provides opportunity to
address a particular issue
in-depth and creatively. Health
issues lend themselves well:
students can debate, for
instance, whether smoking
should be banned in public
places in a community. Allows
students to defend a position
that may mean a lot to them.
Offers a chance to practise
higher thinking skills.
• Allow students to take
positions of their choosing.
If too many students take
the same position, ask for
volunteers to take the
opposing point of view.
• Provide students with time
to research their topic.
• Do not allow students to
dominate at the expense of
other speakers.
• Make certain that students
show respect for the
opinions and thoughts of
other debaters.
• Maintain control in the
classroom and keep the
debate on topic.
STORY
TELLING3
The instructor or students tell
or read a story to a group.
Pictures, comics and
photonovels, filmstrips, and
slides can supplement.
Students are encouraged to
think about and discuss
important (health-related)
points or methods raised by
the story after it is told.
Can help students think about
local problems and develop
critical thinking skills.
Students can engage their
creative skills in helping to
write stories, or a group can
work interactively to tell
stories. Story telling lends
itself to drawing analogies
or making comparisons,
helping people to discover
healthy solutions.
• Keep the story simple and
clear. Make one or two
main points.
• Be sure the story (and
pictures, if included) relate
to the lives of the students.
• Make the story dramatic
enough to be interesting.
Try to include situations of
happiness, sadness,
excitement, courage,
serious thought, decisions,
and problem-solving
behaviours.
Source: Health and Family Life Education (HFLE) Life Skills Training, Barbados, March/April 2001, compiled by
HHD/EDC, Newton, Mass.
’Source: Meeks, L. & Heit, R (1992). Comprehensive School Health Education. Blacklick, OH: Meeks Heit Publishing.
’Source: Werner, D. & Bower, B. (1982). Helping Health Workers Leam. Palo Alto, CA: Hesperian Foundation.
WHO INFORMATION SERIES ON SCHOOL HEALTH
3. THEORIES AND PRINCIPLES SUPPORTING SKILLS-BASED HEALTH
EDUCATION4
24
Purpose: to summarise the theories and principles that serve as a foundation for skillsbased health education, and to highlight how they are applied.
A significant body of theory and research provides a rationale for the benefits and uses
of skills-based health education. This section outlines a selection of these theories, with
brief annotations highlighting their implications for skills-based health education planning.
The theories share many common themes and have all contributed to the development
of skills-based health education and life skills.
Behavioural science, and the disciplines of education and child development, placed in
the context of human rights principles, constitute a primary source of these foundation
theories and principles. Those who work in these disciplines have provided insights acquired through decades of research and experience - into the way human beings,
specifically children and adolescents, grow and learn; acquire knowledge, attitudes, and
skills; and behave. Research and experience have also revealed the many spheres of
influence that affect the way children and adolescents grow in diverse settings, from
family and peer groups to school and community.
Most of the theories outlined below are drawn from Western or North American social
scientists and may or may not be equally relevant to other cultures and practices.
Therefore, programme designers, together with local social and behavioural scientists,
paediatricians, anthropologists, educators, and others who study child and adolescent
development, may want to consider the relevance of these ideas and their own cultural
basis for programme design.
3.1. CHILD AND ADOLESCENT DEVELOPMENT THEORIES
An understanding of the complex biological, social, and cognitive changes, gender
awareness, and moral development that occurs from childhood through adolescence lies
at the core of most theories of human development.
The onset of puberty constitutes a fundamental biological change from childhood to early
adolescence. An important component of social cognition in the transition from adolescence
to adulthood is the process of understanding oneself, others, and relationships. The ability to
understand causal relationships develops in early adolescence, and problem-solving
becomes more sophisticated. The adolescent is able to conceptualise simultaneously about
many variables, think abstractly, and create rules for problem-solving (Piaget, 1972). Social
interactions become increasingly complex at this time. Adolescents spend more time with
peers; increase their interactions with opposite-sex peers; and spend less time at home and
with family members. Moral development occurs during this period as well; adolescents
begin to rationalise the different opinions and messages they receive from various sources,
and begin to develop values and rules for balancing the conflicting interests of self and others.
Implications for skills-based health education planning:
(1) In the school setting, late childhood and early adolescence (ages 6-15) are
critical moments of opportunity for building skills and positive habits. During this time,
“Most of this chapter represents a summary of "Chapter II: The Theoretical Foundations of the Life Skills Approach," from Mangrulkar, L.,
Vince Whitman, C„ & Posner, M. (2001), Life Skills Approach to Child and Adolescent Healthy Human Development. Washington, DC: Pan
American Health Organisation.
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EDUCATION
children are developing the ability to think abstractly, to understand consequences, to
relate to their peers in new ways, and to solve problems as they experience more
independence from parents and develop greater control over their own lives.
(2) The wider social context of early and middle adolescence provides varied
situations in which to practise new skills and develop positive habits with peers and other
individuals outside the family.
(3) Developing attitudes, values, skills, and competencies is recognised as critical
to the development of a child's sense of self as an autonomous individual and to the
overall learning process in school.
(4) Within this age span, the skills of young people of the same age and different
ages can vary dramatically. Activities need to be developmentally appropriate.
3.2. MULTIPLE INTELLIGENCES
This theory, developed by Howard Gardner (1993), proposes the existence of eight
human intelligences that take into account the wide variety of human capacities. They
include linguistic, logical/mathematical, musical, spatial, bodily/kinaesthetic, naturalist,
interpersonal, and intrapersonal intelligences. The theory argues that all human beings are
born with the eight intelligences, but they are developed to a different degree in each
person and that in developing skills or solving problems, individuals use their intelligences
in different ways.
Implications for skills-based health education planning:
(1) A broader vision of human intelligence points toward using a variety of
instructional methods to engage different learning styles and strengths.
(2) The capacity of managing emotions and the ability to understand one's feelings
and the feelings of others are critical to human development, and adolescents can learn
these capacities just as well as they learn reading and mathematics.
(3) Students have few opportunities outside of school to participate in instruction
and learning for these other capacities, such as social skills. Therefore, it is important to
use the school setting to teach more than traditional subject matter.
3.3. SOCIAL LEARNINGTHEORY OR SOCIAL COGNITIVETHEORY
This theory is based largely upon the work of Albert Bandura (1977), whose research led
him to conclude that children learn to behave both through formal instruction and through
observation. Formal instruction includes how parents, teachers, and other authorities and
role models tell children to behave; observation includes how young people see adults
and peers behaving. Children's behaviour is reinforced or modified by the consequences
of their actions and the responses of others to their behaviours.
WHO INFORMATION SERIES ON SCHOOL HEALTH
3. THEORIES AND PRINCIPLES SUPPORTING SKILLS-BASED HEALTH
EDUCATION
Implications for skills-based health education planning:
(1) Skills teaching needs to replicate the natural processes by which children learn
behaviour: modelling, observation, and social interaction.
(2) Reinforcement is important in learning and shaping behaviour. Positive
reinforcement is applied for the correct demonstration of behaviours and skills; negative
or corrective reinforcement is applied for behaviours or skills that need to be adjusted to
build more positive actions.
(3) Teachers and other adults are important role models, standard setters, and
sources of influence.
3.4. PROBLEM-BEHAVIOUR THEORY
Jessor & Jessor (1977) recognise that adolescent behaviour (including risk behaviour) is
the product of complex interactions between people and their environment. Problem
behaviour theory is concerned with the relationships among three categories of
psychosocial variables. The first category, the personality system, involves values,
expectations, beliefs, and attitudes toward self and society. The second category, the
perceived environmental system, comprises perceptions of friends' and parents'
attitudes toward behaviours and physical agents in the environment, such as substances
and weapons. The third category, the behavioural system, comprises socially acceptable
and unacceptable behaviours. More than one problem behaviour may converge in the
same individuals, such as a combination of alcohol and tobacco or other drug use and
sexually transmitted disease.
Implications for skills-based health education planning:
(1) Behaviours are influenced by an individual's values, beliefs, and attitudes and by
the perceptions of friends and family about these behaviours. Therefore, skills in critical
thinking (including the ability to evaluate oneself and the values of the social environment),
effective communication, and negotiation are important aspects of skills-based health
education and life skills. Building these types of interactions into activities, with
opportunities to practise the skills, is an important part of the learning process.
(2) Many health and social issues, and their underlying factors, are linked.
Interventions on one issue can be linked to and benefit another.
(3) Interventions need to address personal, environmental, and behavioural
systems together.
3.5. SOCIAL INFLUENCETHEORY AND SOCIAL INOCULATION THEORY
These two theories are closely related. Social influence theory is based on the work of
Bandura (see above) and on social inoculation theory by researchers such as McGuire
(1964, 1968), and was first used in smoking prevention programmes by Evans (1976; et
al., 1978). Social influence theory recognises that children and adolescents will come
under pressure to engage in risk behaviours, such as tobacco use or premature or
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3. THEORIES AND PRINCIPLES SUPPORTING SKILLS-BASED HEALTH
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unprotected sex. Social influence and inoculation programmes anticipate these pressures
and teach young people both about the pressures and about ways to resist them before
youth are exposed. Usually these programmes are targeted at very specific risks, tying
peer resistance skills to particular risk behaviours and knowledge. Social resistance
training is usually a central component of social skills and life skills programmes.
Implications for skills-based health education planning:
(1) Peer and social pressures to engage in unhealthy behaviours can be dissipated
by addressing them before the child or adolescent is exposed to the pressures, thus
pointing toward early prevention rather than later intervention.
(2) Making young people aware of these pressures ahead of time gives them a
chance to recognise in advance the kinds of situations in which they may find themselves.
(3) Teaching children resistance skills is more effective for reducing problem
behaviours than just providing information or provoking fear of the results of the behaviour.
3.6. COGNITIVE PROBLEM SOLVING
This competence-building model of primary prevention theorises that teaching socialcognitive problem-solving skills to children at an early age can improve interpersonal
relationships and impulse control, promote self-protecting and mutually beneficial solutions
among peers, and reduce or prevent negative "health-compromising" behaviours. Poor
problem-solving skills are related to poor social behaviours, indicating the need to include
problem-solving and other skills in skills-based health education.
Implications for skills-based health education planning:
(1) Teaching interpersonal problem-solving skills at early stages in the developmental
process (childhood, early adolescence) develops a strong foundation for later learning.
(2) Focusing on skills for self-awareness and self-management, as in anger
management or impulse control, as well as generating alternative solutions to interpersonal
problems, can reduce or prevent problem behaviours. Focusing on the ability to conceptualise
or think ahead to the consequences of different behaviours or solutions can help children
make positive choices.
3.7. RESILIENCETHEORY
This theory explains the process by which some people are more likely to engage in health
promoting rather than health-compromising behaviours. It examines the interaction among
factors in a young person's life that protect and nurture, including conditions in the family,
school, and community, allowing a positive adaptation in young people who are at risk. The
importance of this theory is its emphasis on the need to modify and promote mechanisms
to protect children's healthy development. Resilience theory argues that there are internal
and external factors that interact among themselves and allow people to overcome
adversity. Internal protective factors include self-esteem and self-confidence, internal
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3. THEORIES AND PRINCIPLES SUPPORTING SKILLS-BASED HEALTH
EDUCATION
locus of control, and a sense of life purpose. External factors are primarily social supports
from family and community. These include a caring family that sets clear, nonpunitive
limits and standards; the absence of alcohol abuse and violence in the home; strong bonds
with and attachment to the school community; academic success; and relationships with
peers who practise positive behaviours (Kirby 2001; Infante, 2001; Luthar, 2000; Kirby
1999; Kass, 1998; Blum & Reinhard, 1997; Luthar & Ziegler, 1991; Rutter, 1987). According
to Bernard (1991), the characteristics that set resilient young people apart are social
competence, problem-solving skills, autonomy, and a sense of purpose. Today, there
seems to be agreement on the sets of factors that are present in resilient behaviours.
Research is focusing on identifying the types of interactions among these factors that
allow resilient adaptation to take place despite adverse conditions.
Implications for skills-based health education planning:
(1) Social-cognitive skills, social competence, and problem-solving skills can serve
as mediators for behaviour.
(2) The specific skills addressed by skills-based health education, and life skillsbased education for other learning areas, are part of the internal factors that help young
people respond to adversity and are the traits that characterise resilient young people.
(3) It is important that both teachers and parents learn these same skills and
provide nurturing family and school environments, modelling what they hope young
people will be able to do.
(4) Resilience focuses on the child, the family, and the community, allowing the
teacher or caregiver to be the facilitator of the resilient process.
While skills may protect young people, many larger factors in the environment play a role
and may also have to be addressed if healthy behaviour is to be achieved.
3.8.THEORY OF REASONED ACTION ANDTHE HEALTH BELIEF MODEL
The Theory of Reasoned Action and the Health Belief Model contain similar concepts.
Based on the research of Fishbein and Ajzen (1975), the Theory of Reasoned Action views
an individual's intention to perform a behaviour as a combination of his attitude toward
performing the behaviour and subjective normative beliefs about what others think he
should do. The Health Belief Model, first developed by Rosenstock (1966; Rosenstock et
al., 1988; Sheehan & Abraham, 1996) recognises that perceptions - rather than actual
facts - are important to weighing up benefits and barriers affecting health behaviour, along
with the perceived susceptibility and perceived severity of the health threat or
consequences. Modifying factors include demographic variables and cues to action which
can come from people, policies or conducive environments.
Implications for skills-based health education planning:
(1) If a person perceives that the outcome from performing a behaviour is positive,
she will have a positive attitude toward performing that behaviour. The opposite can be
said if the behaviour is thought to be negative.
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3. THEORIES AND PRINCIPLES SUPPORTING SKILLS-BASED HEALTH
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2) If relevant others (such as parents, teachers, peers) see performing a behaviour
as positive and the individual is motivated to meet the expectations of relevant others,
then a positive individual behaviour is expected. The same is true for negative behaviour
norms.
3.9. STAGES OF CHANGETHEORY ORTRANSTHEORETICAL MODEL
This theory, based on a model developed by Prochaska (1979; & DiClemente, 1982),
describes stages that identify where a person is regarding her change of behaviour. The
six main stages are precontemplation (no desire to change behaviour), contemplation
(intent to change behaviour), preparation (intent to make a behaviour change within the
next month), action (between 0 and 6 months of making a behaviour change),
maintenance (maintaining behaviour change after 6 months for up to several years), and
termination (permanently adopted a desirable behaviour).
Implications for skills-based health education planning:
(1) It is important to identify and understand the stages where students are in
terms of their knowledge, attitudes, motivation, and experiences in the real world, and to
match activities and expectations to these.
(2) Interventions that address a stage not relevant to students are unlikely to
succeed. For instance, a tobacco-cessation programme for people who mostly do not
smoke or who smoke but have no desire to change is not likely to lead to quitting smoking.
For more information, see Chapter II in Life Skills Approach to Child and Adolescent
Healthy Development, by Mangrulkar, L, Vince Whitman, C„ and Posner, M., published
by the Pan American Health Organisation in 2001. Available at
http://www.paho.org/English/HPP/HPF/ADOL/Lifeskills.pdf
WHO INFORMATION SERIES ON SCHOOL HEALTH
4. EVALUATION EVIDENCE AND LESSONS LEARNED
Purpose: to outline the body of research evidence and accumulated experience on
the effectiveness of skills-based health education.
4.1. MAJOR RESEARCH EVIDENCE CONCERNINGTHE EFFECTIVENESS
OF SKILLS-BASED HEALTH EDUCATION5
Education for health for young people has been referred to as health education, skillsbased health education, and a life skills approach. Evaluation research over the past
decade has revealed more about strategies for producing the desired knowledge,
attitude, skill, and behavioural outcomes that decrease risk behaviours and improve
health. Three findings are important for policymakers and programme planners:
(1) Health education that concentrates on developing skills for making healthy
choices in life, in addition to imparting health-related knowledge, attitudes, values,
services, and support, is more likely to produce the desired outcome.
(2) Skill development is more likely to result in the desired healthy behaviour when
practising the skill is tied to the content of a specific health behaviour or health decision.
(3) The most effective method of skill development is learning by doing - involving
people in active, participatory learning experiences rather than passive ones.
(UNESCO/UNICEF/WHO/The World Bank, 2000; Tobler, 1998 Draft; WHO, 1997;
WHO/UNFPA/UNICEE 1995; Burt, 1998; Vince Whitman etal., 2001)
Research shows that skills-based health education promotes healthy lifestyles and reduces risk
behaviours. A meta-analysis of 207 school-based drug prevention programmes grouped
approaches to prevention into nine categories: knowledge only; affective only; knowledge and
affective; decisions, values, and attitudes; generic skills training; social influences;
comprehensive life skills; "other" programmes; and health education K-12. The author found
that "the most effective programmes teach comprehensive life skills" (as defined in sections
1.4. and 2.1. of this document). Programmes were also grouped according to whether or not
they used interactive methods. The study concluded that "the most successful of the
interactive programmes are the comprehensive life skills-based education programmes that
incorporate the refusal skills offered in the social influences programmes and add skills such as
assertiveness, coping, communication skills, etc." (Tobler, 1992). Meta-analyses by Kirby (1997
1999, 2001) confirmed that active learning methods, along with other factors, were effective in
reaching students and led to positive behavioural results. Studies in developing countries have
also established the effectiveness of interactive and participatory teaching methods for skillsbased health education (e.g., Wilson et al., 1992). These findings together provide a clear basis
for establishing a focus on this approach to health education.
Skills-based health education has been shown by research to:
• reduce the chances of young people engaging in delinquent behaviour (Elias,
1991), interpersonal violence (Tolan & Guerra, 1994), and criminal behaviour
(Englander-Goldern et al, 1989)
• delay the onset age of using alcohol, tobacco, and other drugs (Griffin &
Svendsen, 1992; Caplan et al., 1992; Werner 1991; Errecart et al., 1991; Hansen,
Johnson, Flay, Graham, & Sobel, 1988; Botvin et al., 1984, 1980)
Tarts of this chapter are drawn from Vince Whitman, C., Aldinger, C., Levinger, B., & Birdthistle, I. (2000).
Education For All 2000 Assessment. Thematic Studies: School Health and Nutrition. Paris: UNESCO.
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4. EVALUATION EVIDENCE AND LESSONS LEARNED
Examples:
>Australia, Chile, Norway, and Swaziland collaborated in a pilot study on the efficacy of
the social influences approach in school-based alcohol education. The data show that
peer-led education appears to be effective in reducing alcohol use across a variety of
settings and cultures (Perry & Grant, 1991).
>ln South Africa, a smoking prevention programme, derived from social cognitive
theory, was implemented in schools in the Cape Town area. During the intervention,
children increased their self-confidence and decreased the use of tobacco compared
to children in the control schools. This evaluation led to a recommendation that the
Department of Education and Training consider making the programme part of the
formal school curriculum (Hunter et al., 1991).
>ln the United States, a study of nearly 6,000 students from 56 schools implemented
a Life Skills Training (LST) programme, based on a person-environment interactive
model that assumes that there are multiple pathways to tobacco, alcohol, and drug
use. The results of the three-year intervention study showed that LST had a
significant impact on reducing cigarette, marijuana, and alcohol use. Results of the
six-year follow-up indicated that the effects of the programme lasted until the end of
the twelfth grade (CDC, 1999).
• Reduce high risk sexual activity that can result in pregnancy or STI or HIV
infections (Kirby, 1997 and 1994; WHO/GPA, 1994; Postrado & Nicholson, 1992;
Scripture Union, n.d., Zabin et al., 1986; Schinke, Blythe and Gilchrest, 1981)
Examples:
>ln Uganda, an HIV/AIDS prevention programme in primary schools emphasised
improving access to information, peer interaction, and quality of performance of
the existing school health education system. After two years of interventions,
the percentage of students who stated they had been sexually active fell from
42.9% to 11.1%. Social interaction methods were found to be effective. Students
in the intervention group tended to speak to peers and teachers more often about
sexual matters. Reasons for abstaining from sex were associated with the
rational decision-making model rather than with the punishment model (Shuey
et al., 1999).
>Kirby and DiClemente (1994) found that negotiation skills enhance students'
ability to delay sex or to use condoms. Wilson and colleagues (1992) concluded
that interactive teaching methods are "better than lectures at increasing condom
use and confidence in using condoms and at reducing the number of sexual
partners." Their evaluation found that female student teachers in Zimbabwe who
participated in a skills-based AIDS intervention were more knowledgeable about
condoms and their correct use, had a higher sense of self-efficacy, perceived
fewer barriers, and reported fewer sexual partners four months after the
intervention than their colleagues who participated in a lecture.
• prevent peer rejection (Mize and Ladd, 1990) and bullying (Oleweus, 1990)
• teach anger control (Deffenbacher, Getting, Huff, and Thwaites, 1995;
Deffenbacher, Lynch, Getting, and Kemper, 1996; Feindler, et al 1986)
• promote positive social adjustment (Elias, Gara, Schulyer, Brandon-Muller, and
Sayette, 1991) and reduce emotional disorders (McConaughy, Kay and Fitzgerald, 1998)
• improve health-related behaviours and self-esteem (Young, Kelley, and Denny, 1997)
• improve academic performance (Elias, Gara, Schulyer, Brandon-Muller, and
Sayette, 1991)
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4. EVALUATION EVIDENCE AND LESSONS LEARNED
32
A matrix of evaluation studies in Appendix 3 summarises the evidence. The matrix lists
selected studies that used skills-based health education and achieved changes in knowledge,
attitudes, skills, or behaviour. Studies that show impact on behaviour tend to include more
comprehensive interventions that include but go beyond skills-based health education. The
next section describes key success factors in school-based programmes and lists barriers to
success by category.
4.2. WHICH FACTORS CONTRIBUTETO EFFECTIVE PROGRAMMES?
Skills-based health education will be most effective in influencing behaviour when applied as
part of a comprehensive, multi-strategy approach that delivers consistent messages over time.
Strategies need to be tailored to discrete aspects and stages of behaviour. A narrow focus on
skills-based health education is unlikely to sustain changed behaviour in the long term. More
powerful and sustained outcomes tend to be achieved when skills-based health education is
coordinated with policies, services, family and community partnerships, and mass media and
other strategies. For instance, research shows that a curriculum combined with youth
community service reduces risk behaviours such as fighting, early sexual behaviour, and
substance use more effectively than a curriculum alone (O'Donnell et al., 1998).
Indeed, the FRESH (Focusing Resources on Effective School Health) initiative emerged in
response to the need for more comprehensive programing rather than singular approaches for
which the expectations are often unreasonably high. For more information on FRESH, see
Sections 1.1. and 5.1.2. The success factors described in Figure 7 are derived from research
and experience in developing and more developed nations. Chapter 5 of this
document outlines ways to translate these evaluation results into effective programmes.
Figure 7: Critical success factors in school-based approaches
Gaining commitment
Intense advocacy is required from the earliest planning stages to influence key national
leadership; to mobilise the community to place skills-based health education on its
agenda; and to hold the community accountable for implementing national and
international agreements. Advocating with accurate and timely data can convince
national leaders and communities that prevention from an early age is important. It can
also help ensure that programmes focus on the actual health needs, experience,
motivation, and strengths of the target population, rather than on problems as
perceived by others.6-7 Communicating the evidence, listening and responding to
community concerns, and valuing community opinions can help garner commitment,
while effective resource mobilisation will underscore the success of such efforts.8-9
On the school level, effective skills-based health education programmes rely on the
larger vision of health promotion, which incorporates health into education reform.
They also rely on the extent to which the school itself makes a priority of promoting
health, that is, whether it links its own health policies and services to skills-based
health education and provides a healthy psychosocial and physical school environment.
UNICEF (2000). Involving People, Evolving Behaviour. Edited by McKee, N., Manoncourt, E„ SaikYoon, C., & Carnegie, R.
Webb, D. & Elliott, L, in collaboration with UK Department for International Development and UNAIDS. (2000). Learning to Live - Monitoring
and evaluating HIV/AIDS programmes for young people. Save the Children Fund.
UNESCO, PROAP Regional Clearinghouse on Population Education and Communication, UNFPA. (2001). Communication and Advocacy
Strategies: Adolescent Reproductive and Sexual Health: Booklet 3, Lessons Learned and Guidelines. Bankgok, Thailand: UNESCO, UNFPA.
’South Africa Ministry of Health and Ministry of Education. (1998). Life Skills Programme Project Report 1997/98.
SKILLS FOR HEALTH
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4. EVALUATION EVIDENCE AND LESSONS LEARNED
Figure 7: Critical success factors in school-based approaches (continued)
Theoretical underpinnings
"Effective programmes are based upon theoretical approaches that have been
demonstrated to be effective in influencing health-related risky behaviours"'0 (see
examples in Chapter 3). Common elements exist across these theories, including the impor
tance of personalising information and probability of risks, increasing motivation and readi
ness for change/action, understanding and influencing peers and social norms, enhancing
personal skills and attitudes and ability to take action, and developing enabling environments
through supportive policies and service delivery.” Social learning theories suggest that per
forming a behaviour will be affected by an understanding of what needs to be done (knowl
edge), a belief in the anticipated benefit (motivation), a belief that particular skills will be effec
tive (outcome expectancy), and a belief that one can effectively use these skills (self-efficacy)12
Content of programmes
The information, attitudes, and skills that comprise the programme content should be select
ed for their relevance to specific health-related risk and protective behaviours; for example,
resisting peer pressure to smoke or use drugs, delaying the initiation of intercourse or using
contraception, or identifying a trusted adult for support during depression. Programmes that
address a balance of knowledge, attitudes, and skills - such as communication, negotiation,
and refusal skills - have been most successful in affecting behaviour. Programmes with
heavy emphasis on (biological) information have had more limited impact on enhancing
attitudes and skills and reducing risk behaviours.13 Effective programmes focus narrowly on a
small number of specific behavioural goals and give a clear health content message by
continually reinforcing a positive and health-promoting stance on these behaviours.14 General
programmes and those that have attempted to cover a broad array of topics, values, and
skills without linking them are generally not recommended where prevention of a specific
risk behaviour is the goal.15
Methods:
Effective programmes utilise a variety of participatory teaching methods, address
social pressures and modelling of skills, and provide basic, accurate information.
Effective participatory teaching methods actively involve the students and target par
ticular health issues.16 For examples of participatory teaching methods, see Section
2.2 of this document. Programmes with a heavy emphasis on information can improve
knowledge, but are generally not effective in enhancing attitudes, skills, or actual
behaviour.17 However, effective programmes do need to provide some basic, accurate
information that students can use to assess risks and avoid risky behaviours.18
'°Kirby, D. (2001). Emerging Answers: Research Findings on Programmes to ReduceTeen Pregnancy. Washington, D.C.: National Campaign to Reduce Teen Pregnancy.
"UNICEF. (2000). Involving Raople, Evolving Behaviour. Edited by McKee, N„ Manoncourt, E„ SaikYoon, C„ & Carnegie, R.
’’Kirby, D. (2001). Emerging Answers: Research Findings on Programmes to Reduce Teen Pregnancy. Washington. D.C.: National Campaign to ReduceTeen Pregnancy (p.29).
WVilson, D„ Mparadzi, A., & Lavelle, E. (1992). An experimental comparison of two AIDS prevention interventions among young Zimbabweans. Journal of Social
Phsychology 132(3), 415-417
14Kirby, D. (2001). Emerging Answers.
’’Kann, L, Collins, J. L., Paterman, B. C., Small, M. L, Ross. J. G.. & Kolbe. L. J. (1995). The School Health Ftolicies and Programmes Study (SHPPS): Rationale for a
Nationwide Status Report on School Health. Journal of School Health. 65. 291 - 294.
’’Kirby D. (2001). Emerging Answers.
"Wilson, D.. Mparadzi, A., & Lavelle, E. (1992). An experimental comparison of two AIDS prevention interventions among young Zimbabweans. Journal of Social
Phsychology. 132(3), 415-417
’’Kirby D. (2001). Emerging Answers: Research Findings on Programmes to ReduceTeen Pregnancy Washington. D.C.: National Campaign to ReduceTeen Pregnancy (p.30).
WHO INFORMATION SERIES ON SCHOOL HEALTH
4. EVALUATION EVIDENCE AND LESSONS LEARNED
34
Figure 7: Critical success factors in school-based approaches (continued)
Timing and sequence
Effective education programmes are intensive and begin prior to the onset of risk
behaviours.'9-20 As a guide, at least 8 hours of intensive training or at least 15 hours of
classroom sessions per year will be required to provide adequate exposure and practise
for students to acquire skills. Subsequent booster sessions are needed to sustain
outcomes.21-22-23-24 A planned and sequenced curriculum across primary and secondary
school is recommended. The age and stage of the learner need to be considered.
Concepts should progress from simple to complex, with later lessons reinforcing and
building on earlier learning. Education and other prevention efforts need to be constant
over time to ensure that successive cohorts of children and young people are protected.
Multpstrategy for maximum outcomes
Programmes need to be coordinated with other consistent strategies over time, such
as policies, health and community services, community development, and media
approaches. Coordination within and among donor agencies and between regional and
national programmes is also important. Because the determinants of behaviour are
varied and complex, and the reach of any one programme (e.g., in schools) will be
limited, a narrow focus is unlikely to yield sustained impact on behaviour in the long
term. Only coordinated multi-strategy approaches can achieve the intensity of efforts
that yields sustained behaviour change in the long term.25-26
Teacher training and professional development
Teachers or peer leaders of effective programmes believe in the programme and receive
adequate training. Training needs to give teachers and peers information about the
programme as well as practise in using the teaching strategies in the curricula.27
Research shows that teacher training for the implementation of a comprehensive
secondary school health education curriculum positively affects teachers' preparedness
for teaching skills-based health education and has positive effects both on curriculum
implementation and on student outcomes.28-29
,9Kirby, D. & DiClemente, R. J. (1994). School-based interventions to prevent unprotected sex and HIV among adolescents. In R. J. DiClemente
& J. L. Peterson (Eds.), Preventing AIDS: Theories and methods of behavioural intentions (pp. 117 -139). New York: Plenum Press.
20Botvin, G. J. (2001). Life SkillsTraining: Fact Sheet. Available from http://www.lifeskillstraining.com/facts.html
2'Jemmott, J. B., Jemmott, L. S., & Fong, G. T. (1992). Reductions in HIV risk-associated sexual behaviours among black male adolescents:
Effects of an AIDS prevention intervention. American Journal of Public Health, 82(3), 372 - 377).
"Kirby, D. & DiClemente, R. J. (1994). School-based interventions to prevent unprotected sex and HIV among adolescents.
"Wilson, D., Mparadzi, A., & Lavelle, E. (1992). An experimental comparison of two AIDS prevention interventions among young Zimbabweans.
Journal of Social Phsychology, 132(3), 415-417
24Botvin, G. J. (2001). Life SkillsTraining: Fact Sheet. Available from http://www.lifeskillstraining.com/facts.html
"UNESCO, PROAP Regional Clearinghouse on Population Education and Communication, UNFPA. (2001). Communication and Advocacy
Strategies: Adolescent Reproductive and Sexual Health: Booklet 3, Lessons Learned and Guidelines. Bankgok, Thailand: UNESCO, UNFPA.
"South Africa Ministry of Health and Ministry of Education. (1998). Life Skills Programme Project Report 1997/98.
"Kirby, D. (2001). Emerging Answers: Research Findings on Programmes to Reduce Teen Pregnancy. Washington, D.C.: National Campaign
to Reduce Teen Pregnancy.
"Kann, L., Collins, J. L., Paterman, B. C., Small, M. L., Ross, J. G., & Kolbe, L. J. (1995). The School Health Policies and Programmes Study
(SHPPS): Rationale for a Nationwide Status Report on School Health. Journal of School Health, 65, 291 - 294.
"Ross, J. G., Luepker, R. V, Nelson, G. D., Saavedra, R, & Hubbard, B. M. (1991). Teenage Health Teaching Modules: Impact of Teacher Training
on Implementation and Student Outcomes. Journal of School Health, 61(1), 31 - 34.
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4. EVALUATION EVIDENCE AND LESSONS LEARNED
Figure 7: Critical success factors in school-based approaches (continued)
Relevance
Programmes must be relevant to the reality and developmental levels of young people
and must address risks that have the potential to cause most harm to the individual
and society. Issues that attract media attention and public concern may not be the
most prevalent or harmful. Issues of gender and violence should be integrated, along
with other cofactors in the lives of young people. Reinforcing clear values against risk
behaviour and strengthening individual values and group norms need to be central to
prevention programmes. The programme goals, teaching methods, and materials need
to be appropriate to the age, experience, and culture of children and young people and
the communities they live in, and need to recognise what the learner already knows,
feels, and can do.30
Participation
Develop mechanisms to allow involvement of students, parents, and the wider
community in the programme at all stages. A collaborative approach can reinforce
desired behaviour through providing a supportive environment for school programmes.
The participation of learners, parents, community workers, peer educators, and others
in the design and implementation of school health programmes can help ensure that
the needs and concerns of all these constituencies are met in culturally and socially
appropriate ways. Participants whose concerns are addressed are more likely to
demonstrate commitment to and ownership of the programme, which in turn
enhances sustainability and effectiveness.31-32
More detailed information on effective programmes is available from:
UNICEF at: http://www.unicef.org/programme/lifeskills/index.html
WHO at: http://www.who.int/school-youth-health
Life Skills Training Center, Inc. at: http://www.lifeskillstraining.org
4.3. WHICH FACTORS CAN CREATE BARRIERSTO EFFECTIVE SKILLSBASED HEALTH EDUCATION?
While it is important to capitalise on the success factors of effective programmes, it is
also helpful to be aware of, and to try to avoid, the barriers to effective skills-based health
education.
Barriers of focus tend to include the following:
• infusion of health issues across a range of subjects without providing a solid
foundation within one subject, where knowledge, attitudes, and skills can be linked
and developed in a sequential, reinforcing strategy
• inadequate orientation and training of administrators, teachers, and other support
staff
30Kirby, D. (2001). Emerging Answers:
3'UNICEF (2001). The Participation Rights of Adolescents: A Strategic Approach. Prepared by R. Rajani.
32Jemmott, J. B., Jemmott, L. S., & Fong, G. T (1998). Abstinence and safer sex HIV risk-reduction interventions for African American
Adolescents: A randomized controlled trial. JAMA, 279(19) (May 20, 1998), 1529 - 1536.
WHO INFORMATION SERIES ON SCHOOL HEALTH
4. EVALUATION EVIDENCE AND LESSONS LEARNED
• general programmes that are less directed toward specific contexts or risk
behaviours. For example, such programmes may use a model in which generic
decision-making steps are presented but are not applied to a specific context,
or are applied across a range of topics that are not necessarily linked.
• efforts to cover a broad array of topics, values, and skills while failing to
emphasise particular facts, values, norms, and skills that students need to
reduce risk or promote specific behaviour. For example, a programme may cover
the physiology of reproductive health and the value of positive personal
relationships but omit content on sustaining decisions to avoid unprotected sex;
building skills to avoid risky situations, negotiating with a partner not to
have sex, using a condom, or resisting peer pressure to use alcohol or drugs.
• presentations that are information-heavy, particularly with physiological
information, with little or no attention to feelings, relationships, skills, and
local situations
• too little concentrated time on the learning task
Barriers of coordination and consistency include the following:
• weak leadership, lack of genuine commitment and coordination from ministries
of health and education and from school officials; for example, lack of
well-defined national strategies for the promotion, support, coordination, and
management of school-based programmes and insufficient staff in the ministries
of education and health designated to the task of strengthening skills-based
health education and life skills programmes
• insufficient infrastructure for teacher training
• lack of quality teaching materials and participatory methods
• insufficient coordination in terms of time frames and plans, leading to
isolated and vertical programmes
• competition with other health topics or programmes within the school
environment or inconsistent messages and learning experiences
Barriers of intensity and scale include the following:
• failure to plan for expansion or to go beyond the pilot stage
• inadequate funding
• inadequate attention to related strategies that maximise success, such as
effectively implemented policies, access to related health services, and links
with the community and other sectors. For example, effective school-based
alcohol abuse prevention strategies may be linked to policies in the community
that restrict access to alcohol to minors and links to community-school
partnerships that help enforce such policies.
• inadequate mechanisms for supervising, monitoring, and evaluating programmes,
including a lack of detailed documentation.
(The preceding information on barriers to effective skills-based health education is adapted in
part from Mangrulkar et al., 2001, p. 41, and from a UNAIDS Inter-Agency working group, 2001.)
Applying proven methods of success and using available guidelines and tools, such as the
WHO Information Series on School Health, listed in Annex 1, can help address many of
these challenges.
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5. PRIORITY ACTIONS FOR QUALITY AND SCALE
Purpose: to focus on a set of key actions that can significantly improve the quality and
scale of skills-based health education programmes.
Very substantial evidence exists to support the benefits of skills-based health education.
However, too few schools implement programmes of good quality, and too few
programmes are implemented on a national scale.
The following chart lists priority actions that are recommended for shifting efforts away
from ineffective strategies and toward approaches that have the focus and intensity
which typify successful programmes. (For the research that forms the basis for these
recommendations, please refer to Chapter 4 of this document.)
I
Away from...
1. small-scale pilot projects...
Toward...Going to scale
• programing for a national scale
Away from...
2. education programmes developed
and delivered in isolation from other
health related efforts...
Toward... A comprehensive approach
• comprehensive and effective school health programmes
that combine skills-based health education with supporting
policies at the school and/or national level, clean water and
sanitation as a first step in a healthy environment, related
health services, and school-community partnerships
Away from...
3. attempts to infuse health topics
thinly across many subjects...
Toward...Effective placement within curriculum
• addressing a limited number of high-priority health issues
and teaching the necessary knowledge, attitudes, and skills
together in one existing subject (sometimes called a carrier
subject) in the context of other related issues and processes
Away from...
4. creating new teaching and learning
materials from scratch
Toward...Using existing materials better
• better distribution and adaptation of the many quality
materials that demonstrate research and evaluation
evidence of effectiveness
Away from...
5. generic life-skills programmes that
are not attached to specific objectives
and goals
Toward...Linking content to behavioural objectives
and changes in health-related conditions
• applying skills-based teaching and learning methods for the
development of knowledge, attitudes, and skills needed to
achieve objectives in terms of behaviours and conditions
that will lead to health and correlated social goals
Away from...
6. delivery by unprepared adults ...
Toward...Consistent, ongoing professional
development for teachers and support teams
• the use of key staff units identified within ministries,
schools, and communities dedicated to ongoing teacher
training, support for implementation, and collaborative
strategies such as partnerships with young people
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5. PRIORITY ACTIONS FOR QUALITY AND SCALE
5.1
GOING TO SCALE
"Going to scale" means implementing interventions nation-wide. It involves considering
a variety of expansion models and agencies for reaching the greatest number of schools
and students. Such considerations should be made from the beginning of the planning
process, once the importance and feasibility of skills-based health education are
understood. Expanding the reach of good-quality programmes on national and local levels
then becomes a priority. Since ample evidence supports the effectiveness of skills-based
health education, there is less need for further pilot projects than for nation-wide
coverage, which may coordinate several models, facilitators, and agencies.
Education agencies that are striving to go to scale may be able to adapt certain activities
already in use, thereby expanding community-based programmes for young people.
Smith and Colvin (2000) distinguish four major approaches for scaling up young adult
programmes. (1) Planned Expansion means a steady process of expanding the number
of sites and youth served by a particular programme once it has been pilot tested. (2)
Association consists of expanding programme size and coverage through a network of
organisations. (3) Grafting means adding a new initiative to an existing programme. (4)
Explosion involves sudden implementation of a youth programme at a large scale.
The following lessons were learned from scaling up young adult reproductive health
programmes:
• Programmes should prepare for scaling up by focusing on institutionalisation.
Support such as training curricula and a cadre of trained and committed service
providers is essential to institutionalisation. Changes in undergraduate- and
graduate-level training in colleges and universities may be required.
• Policy shapes programme development. Policy structures can support programme
efforts. However, momentum for scaling up can be gathered even without a
supportive political environment, especially when the issues can gain visibility
through allied groups. While certain programmes must engage the policy level
more than others, and pilot projects can stimulate policy development, even
government programmes may be vulnerable in a negative policy environment.
• Activists and programme planners should build on existing institutions and
infrastructure when scaling up. NGOs, which are often the first to initiate
young adult reproductive health programmes, can complement and reinforce
government initiatives. Programmes can take advantage of existing infrastructure
by forming and deepening collaborations with partner organisations. Programmes
with strong ties at the local level are better able to survive change, so
building a social marketing strategy is important for creating and maintaining a
community constituency.
• Committed leaders are needed to support, guide, and sponsor the scaling-up
process. A successful scale-up effort requires a major commitment of time and
energy on the part of leaders as well as a formal governance structure.
• Make scaling up participatory, and build in flexibility. Programmes aimed at
young people depend on their input for success.
• Anticipate obstacles and challenges. The environment in which a programme
develops and the availability of resources may influence its shape and the
effort to scale up. Programme developers and policy advocates in particular need
to be sensitive to these issues. This includes developing long range financing strategies.
• Data, research, monitoring and evaluation systems are critical to scaling up effective
programmes. Data and research are especially important for designing programmes,
scaling them up, advocacy and securing acceptance and support for programmes.
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5. PRIORITY ACTIONS FOR QUALITY AND SCALE
(These recommendations are adapted from Smith & Colvin, 2000, and from Stage Five:
Going to Scale, http://eric-web.tc.columbia.edu/families/TWC/stg5idx.html, December
18, 2001.)
Going to scale and creating a sustainable change in teaching practise in regard to skillsbased health education are described in the example that follows.
Example: Systems-level actions and support for sustainable change in teaching
practice
Evaluation of professional education has shown that initial training must be followed by
ongoing coaching and technical assistance to produce an impact on teachers in the
classroom. The lack of administrative support at the school and classroom levels, along
with a lack of ongoing support from expert teachers on substantive issues, sometimes
precludes sustainable change.
The following points on achieving sustainable change in classroom teaching emerged
from UNICEF's Mekong project in East Asia.
• From the beginning, plan to go to scale, rather than having small pilot projects.
• From the beginning, plan for a series of linked training workshops; avoid single,
unrelated training sessions.
• Model the interactive methods in all aspects of the training, and build in
opportunities for teachers to practise new skills within and after the training.
• Encourage professional peer-education support groups and coaching for mentoring
among teachers.
• Ensure ongoing, long-term implementation support from experts or experienced
teachers.
• Work with administrators and school communities to advocate and encourage
support for teachers to implement the new methods effectively.
(UNICEF/EAPRO, 1998).
5.2. SKILLS-BASED HEALTH EDUCATION AS PART OF COMPREHENSIVE
SCHOOL HEALTH
Skills-based health education is more effective when it is taught as part of a comprehensive
approach to school health than in isolation. The frameworks of FRESH and Health-Promoting
Schools (see Figure 1) offer approaches for implementing skills-based health education as
part of effective school health programmes.
5.2.1 THE FRESH FRAMEWORK
Focusing Resources on Effective School Health (FRESH), initiated by WHO, UNESCO,
UNICEF and the World Bank in 2000, is a framework for action that proposes four
components as a starting point for developing an effective school health programme as
part of broader efforts to design health-promoting, child-friendly schools. If all schools
were to implement these four components, there would be a significant, immediate
benefit in the health of students and staff and a basis for future expansion. The aim is to
focus on interventions that are feasible to put in place.
WHO INFORMATION SERIES ON SCHOOL HEALTH
5. PRIORITY ACTIONS FOR QUALITY AND SCALE
The four FRESH components, listed below, should be made available together, in all
schools:
• Health-related school policies. Health policies in schools can help ensure a
safe and secure physical and psychosocial environment; address issues such as
abuse of students, sexual harassment, and school violence; guarantee the further
education of pregnant schoolgirls and young mothers; and reinforce health
education for teachers and students.
• Provision of safe water and sanitation - the essential first steps toward a
healthy learning environment. It is a realistic goal in most countries to ensure
that all schools have access to clean water and sanitation. By providing these,
schools can reinforce health and hygiene messages and act as an example both to
students and to the wider community. Separate facilities for girls, particularly
adolescent girls, contribute significantly to reducing dropout.
• Skills-based health education. This approach to health, hygiene, and nutrition
education focuses on developing the knowledge, attitudes, values, and life
skills that young people need to make and act on the most appropriate and
positive health-related decisions. Health in this context extends beyond
physical health to include psychosocial and environmental issues. Individuals
who possess these skills are more likely to adopt and sustain a healthy
lifestyle during their school years and throughout the rest of their lives.
• School-based health and nutrition services. Health and nutrition services can
be effectively delivered by or through schools provided that the services are
simple, safe, and familiar and that they address issues that are prevalent and
recognised as important within the community. For example, micronutrient
deficiencies and worm infections may be effectively addressed with infrequent
oral treatment; and short-term hunger - an important constraint on learning can be addressed by changing the timing of meals or providing a snack. If
schools cannot provide services on school grounds they can refer to nearby
services in the community.
Several strategies can support the implementation of the four FRESH components:
• Effective partnerships between teachers and health workers and between the
education and health sectors
• Effective community partnerships
• Pupil awareness and participation
(This is summarised from UNESCO/UNICEF/WHO/World Bank, 2000, a tri-lingual
brochure explaining FRESH.)
5.2.2. HEALTH-PROMOTING SCHOOLS
Skills-based health education is one important component of a Health-Promoting School.
Through its Global School Health Initiative, WHO encourages the creation of
Health-Promoting Schools worldwide, a concept fully embraced by UNICEF and other
international agencies. Health-Promoting Schools foster health and learning with all
measures at their disposal and by engaging health and education officials, teachers,
students, parents, health care providers, and community leaders in efforts to improve the
health of students, schoolpersonnel, families, and community members. HealthPromoting Schools strive to blend a healthy environment, skills-based health education,
and school health services with school/community projects and outreach, health
promotion programmes for staff, nutrition and food safety programmes, physical
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Unsupported Personality: PCL
41
5. PRIORITY ACTIONS FOR QUALITY AND SCALE
education and recreation, reproductive and sexual health, and the promotion of mental
health, with opportunities for counselling and social support (WHO, 1998).
5.2.3 CHILD FRIENDLY SCHOOLS
WHO promotes the development of Health-Promoting Schools as a step toward
achieving the broader concept of UNICEF's Child Friendly School. UNICEF'S dedication to
Child Friendly Schools encourages and supports healthy, well-nourished children who are
ready to learn and who are supported by their family and community, as well as quality
teaching and learning processes that are child-centred and include life skills. Supported by
quality learning environments with adequate facilities, policies, and services. Child
Friendly Schools are inclusive of all children, protective and healthy for children, and, in all
aspects, gender sensitive. They address quality of learning with respect to the learners'
focus, experiences, and needs; the relevance of curriculum content and processes; the
quality of the classroom and broader school environment; the appropriateness of
assessment in literacy, numeracy, knowledge, attitudes, life skills, and other areas; and
the achievement of learning outcomes.
5.3. EFFECTIVE PLACEMENTWITHINTHE CURRICULUM
There are three primary ways for implementing skills-based health education
within schools:
• A core health education subject - Skills-based health education can be a core (or
separate) subject in the broader school curriculum.
• Carrier subject - Skills-based health education is sometimes placed in the context of
related health and social issues within an existing, so-called carrier subject that is
relevant to the issues, such as science, civic education, social studies, or population
studies.
• Infusion across many subjects - Health topics can be included in all or many
existing subjects by regular classroom teachers.
Figure 8 describes the benefits and disadvantages of all three approaches, though
localities may vary in their needs.
WHO INFORMATION SERIES ON SCHOOL HEALTH
Unsupported Personality: PCL
5. PRIORITY ACTIONS FOR QUALITY AND SCALE
42
Figure 8. Pros and Cons of ways to place skills-based health education within the curriculum
1. Core health-education subject: Skills-based health education (e.g., Health Education or Family Life
Education) is taught as a core subject for addressing important issues - This is a good long term option, requir
ing strong commitment over time.
PROS
CONS
- Likely to be taught by teachers who are focused on
health and who are more likely to be specifically trained
in health education and life skills.
- Possible that the subject is attributed very low
status and seen as unimportant.
- Likely to allow congruence between the content and
teaching methods.
- More likely to command the attention of students and
teachers than when presented as a sidebar to another
course lesson.
- Tends to have high teacher support owing to specific
focus on health and teacher's sense of professional
responsibility to health education and life skills
development.
-Allows health concepts to be sequenced smoothly from
primary levels to secondary levels, to reinforce previous
learning experiences, and to make links for new learning.
-Time is specifically allotted to health and related issues,
better ensuring the effective planning, implementation,
and evaluation of skills-based health education.
-Teachers can incorporate skills and materials from other
subjects, creating support and involvement from other
teachers.
- Easier to examine the subject than if infused, and
therefore teachers are more likely to be highly motivated
to teach it well.
SKILLS FOR HEALTH
- Difficulty of finding adequate time in the curriculum for
the subject.
43
5. PRIORITY ACTIONS FOR QUALITY AND SCALE
Figure 8. Pros and Cons of ways to place skills-based health education within the curriculum (continued)
2. Carrier subject: Skills-based health education is placed in an existing subject designed for another purpose but
relevant to the issues, such as civic/social studies or population education. - This is a good short-term solution.
PROSi
CONS
- Teacher support tends to be better than for infusion
across all subjects.
- Teachers of the carrier subject are likely to link the
relevance of the topic to other subjects.
-The selection of carrier subject may be inappropriate; for
example, biology may not be a suitable carrier unless the
social and personal issues and skills in biology can be
addressed.
-Training of teachers is faster and less expensive than via
infusion.
- Teachers may or may not be knowledgeable about or
comfortable with health content.
- It is faster and costs less to integrate skills-based health
education into materials of one principal subject than to
infuse across all.
- Health topics may receive less time than needed if
overshadowed by the carrier topic.
-The carrier subject can be reinforced by infusion through
other subjects.
3. Infusion across subjects: Regular classroom teachers integrate aspects of skills-based health education
across many existing subjects. -This approach is not recommended as it does not yield good results on its own.
PROS
CONS
- Lends itself to a whole-school approach.
-The issues can be lost among the higher-status elements
of other subjects.
- Many teachers are involved, even those not usually
involved in the effort to implement skills-based health
education.
- Potential for reinforcement.
- Too little time is dedicated to health content and skill
development.
-Teachers may maintain a heavy information bias in content
and methods used to teach the content, as is the case with
most subjects.
-Teachers are usually not adequately trained.
-The task of accessing all teachers and influencing all texts
is very costly and time-consuming.
- Some teachers do not see the relevance of the issue to
their subject.
- Potential for reinforcement seldom realised owing to
other barriers.
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5. PRIORITY ACTIONS FOR QUALITY AND SCALE
44
Figure 8. Pros and Cons of ways to place skills-based health education within the curriculum (continued)
4. Combination of approaches: Another option is the combined use of a carrier subject in the short term with
a separate subject in the long term. -This is a very long term option.
PROS
CONS
- Learning and changes can be addressed comprehen
sively through the carrier subject by trained teachers, and
then can be reinforced across the other subject area.
- A more intensive approach and outcome should be
achieved.
- Enables students who need knowledge and skills now to
acquire them while a separate subject is being developed.
-There is too much to achieve all at once; this approach
needs to be carefully planned.
- May require additional time.
Whichever option is chosen, it is important to understand that the effort to influence
behaviours and conditions associated with school-based priority health, education, and
development issues is a long-term and significant commitment. Skills-based health
education works best to affect behaviour where reinforcing strategies are in place. Every
effort should be made to combine skills-based health education with complementary
strategies such as policy development, health services, and a supportive psychosocial
environment. Given the factors vying for the attention of young people, it is unreasonable
to believe that a single positive strategy might prevail over the many competing
influences. Helping to ensure that teachers model health-promoting behaviours and that
the school environment supports these behaviours is important. Skills-based health
education should be considered but one of the four basic FRESH components of an
effective school health programme, and such programmes themselves are most effective
when complemented by community, national, and international strategies to support their
health, education, and development goals.
THE EVIDENCE AGAINST INFUSION
• Experience with infused skills-based health education in the United States has
shown that when teachers teach general life-skills programmes, they often do not
cover, in depth, the specific health issues that adolescents face. Evaluations of
programmes in the United States which emphasised generic decision-making skills,
general communication, and assertiveness found no effect on adolescent health,
especially sexual behaviour (Kann et al., 1995).
• A study by the Centers for Disease Control (CDC) in the United States (Kann et al.,
1995) showed that compared to "health educators", "infusion teachers" teaching
HIV/AIDS prevention were less likely to be trained and were trained on fewer of the
relevant topics; were less likely to cover the necessary topics, especially the more
sensitive and relevant topics regarding prevention; were more likely to cover the
science and biology of HIV/AIDS than prevention elements; and were less likely to
include family and community elements in their programmes. They spent less time on
the subject, were less likely to utilise recommended resources (including the formal
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5. PRIORITY ACTIONS FOR QUALITY AND SCALE
curriculum); used fewer interactive methodologies, and covered fewer of the skills and
offered less practise of skills than "health educators."
• More specific to developing countries, a UNICEEsupported review of skills-based
HIV/AIDS prevention programmes in East and South Africa (Gachuhi, 1999) found that
infusion approaches tended not to have the expected impact, often because teachers
are usually not sufficiently trained and do not implement the programme properly;
teachers especially overlook sensitive issues and realistic situations that would per
sonalise the risks that young people face. Not having a specific allocation in the
timetable was also a barrier to effective implementation.
• Uganda and Mozambique are moving away from an infusion approach in favour of
more specific approaches such as a carrier subject, after finding that the infusion
approach did not have an impact on the sexual behaviour and skills of adolescents for
many of the same reasons stated above (UNICEF; 2000, personal communications).
• Reviews in Zimbabwe question the integration approach. Teacher training appeared
to be inadequate, and the quality of implementation suffered as a result (Ndlovu &
Kaim, 1999; Kaim et al., 1997).
NON-FORMAL MODELS
In many countries, the formal curriculum time is overburdened and alternatives have been
developed which do not rely on formal curriculum time, for example, non-formal or extra
curricular programmes. Both the in-school and non-school population can be reached with
these activities. They may operate at or near schools, or separate from schools, and tend
not to rely on teachers to deliver them, for example, programmes operated by non
government workers, peer educators, community groups, youth organisations (e.g., Girl
Guides, Boys Scouts), or faith-based organisations. The Ministry of Education is often
responsible for both formal and non-formal mechanisms for reaching children and young
people so that these different mechanisms5 can be coordinated for maximum quality and
coverage. The case study below presents an (example of a successful programme that
taught life skills as part of a non-formal school subject.
CASE STUDY
SHAPE is a non-formal school subject in Myanmar, taught in grades 2 through 9, which uses
student-centred participatory teaching and learning methods and encourages
students to practise what they have learned in the classroom at home and in their
communities. SHAPE aims to equip young people with the knowledge, attitudes, and skills
they need to promote healthy living through the active participation and involvement of
teachers, students, school principals, education officials, parents, and other community
members. The content of the programme focuses on a range of health and social issues
relevant to children and young people, including personal health and hygiene, growth and
development, nutrition, alcohol and drugs, and HIV/AIDS. At least half of the content is
dedicated to activities designed to develop life skills, such as communication, cooperation,
coping with emotions and stress, decision-making, problem-solving, and counselling, and
these life skills are then applied in a specific way to each of the health and social issues. In
addition, peer education, child-to-parent dissemination of information, and collaboration
between schools and communities are important SHAPE strategies.
WHO INFORMATION SERIES ON SCHOOL HEALTH
5. PRIORITY ACTIONS FOR QUALITY AND SCALE
This programme has successfully encouraged children to share what they have learned
in the classroom with their parents and other family members and to improve health
conditions in their community. For instance, in one small village, children told their
families what they had learned about the need for iodised salt. Impressed by their
children's commitment to learning, parents got together and put enough pressure on
the shopkeeper to change the type of salt he sold, and the whole community
benefited from the availability and use of iodised salt. In another township, children told
their families what they had learned about the importance of using safe water and
sanitary latrines. After this information spread in the community, families and
community members got together and built enough latrines to greatly improve the
quality of sanitation in the community.
(This case study is based on information provided by Tin Mar Aung, UNICEF
Myanmar.)
5.4. USING EXISTING MATERIALS BETTER
It is often possible to work with existing resources rather than starting anew to create
appropriate materials for skills-based health education.
The following issues might be considered for selecting existing materials.
• Do the materials have goals that clearly describe health and related social issues to
be influenced in a particular way? Do the objectives clearly describe behaviours or
conditions that can be influenced to significantly impact the goals? Are these
relevant to our students' needs?
• Who is the target audience?
• What time investment is suggested (number and length of sessions)?
• Are the materials suitable for the available settings?
• Is the language used most appropriate for the target group/users of the materials?
• Have the materials been evaluated, and if so, with what audience and setting? What
is the evidence of effectiveness? What is the similarity between the "proven
programme" and the intended audience and cultural setting?
• How well is knowledge relevant to the health issue addressed? Is the information
clear? Does it provide accurate, up-to-date knowledge on the health issue?
• How relevant are the attitudes to the health issue addressed?
• How relevant are skills to the behaviours that are intended to be influenced?
• How appropriate are the methods for achieving the educational objectives (e.g.,
increasing knowledge, fostering health-supporting attitudes, building skills)?
• Are the materials gender-sensitive in content, methods, and language?
• Are the materials relevant to student needs and interests?
• How easy will it be for teachers, parents, and students to adapt and implement the
materials?
• Do the materials include sufficient learning experiences to achieve the objectives?
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5. PRIORITY ACTIONS FOR QUALITY AND SCALE
Existing materials may be available from local or regional UN agencies such as UNICEF
or WHO and from governmental and non-governmental agencies, educational institutions,
and the private sector. Many materials are available from these agencies on the World
Wide Web; for example, www.who.int,www.unicef.org,www.unesco.org,www.ei-ie.org,
www.cdc.gov,www.unfpa.org, and www.edc.org.
5.5. LINKING CONTENTTO BEHAVIOURAL OUTCOMES
Programmes aimed at helping young people to develop life skills without a particular
context are less effective in achieving specific behavioural outcomes. It is critical that
programme planners set objectives and select content on the basis of what is most
relevant to influencing the behaviours and conditions that are associated with priority
health issues (see Figure II in Chapter 2).
What: The central question is what behaviours or conditions must be sustained or
changed to influence the health issues. Then, what knowledge, attitudes, and skills will
be the most useful to address, given the behaviours and conditions to be changed? The
answers to these "whats" are then used to develop programme objectives. Setting
objectives for preventing or reducing risk behaviours and risk conditions and for
promoting protective behaviours and conditions is important. Such objectives are
required for clearly delineating the programme content, including knowledge, attitudes,
and skills that are important to achieve the behavioural and conditional objectives. The
physical, mental, emotional, and social dimensions of knowledge, attitudes, and skills
need to be explored to facilitate informed decision making, the ability to practise healthy
behaviours, and the creation of conditions that are conducive to health. Local factors and
conditions that affect the ability of the individual to take action must also be considered;
for example, using a condom properly may not be a feasible protective practise if
condoms are not available.
The situation assessment information should reveal the issues most relevant to the
health and development of the young people who will participate in the programme.
Using this information to identify the direct and indirect factors affecting morbidity (and
mortality to a lesser extent) can be particularly helpful in the process of setting priorities.
Issues that emerge for school-age children and young people throughout the world are
family issues; youth and interpersonal violence and conflict and seeking peace; alcohol,
tobacco, and other drug use; unintentional injuries; depression and mental health; diet
and physical activity; and hygiene and infectious disease, unwanted pregnancy,
HIV/AIDS/STIs and malaria. Aspects of these issues vary in relevance depending on the
age of the young person.
When: The needs and developmental abilities of young people vary with their age; thus
programmes must take these factors into account. This is commonly referred to as
"developmentally appropriate programing." For example, concepts in school curricula
should be sequenced smoothly from primary levels to secondary levels to reinforce
previous learning experiences and make links for new learning; this process is sometimes
referred to as a "spiral curriculum." For sensitive issues such as HIV/AIDS, sexual and
reproductive health, education should begin as interest begins to increase but before the
target group has become involved in the risk behaviours. The building blocks for dealing
with such sensitive issues should be in place at the very beginning of children's
education. Such building blocks include self esteem, positive values of cooperation and
teamwork, the protection and promotion of health, and pro-social behaviour. However, to
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5. PRIORITY ACTIONS FOR QUALITY AND SCALE
48
help young people develop positive behaviour and avoid risks, these topics must be
taught in a way that is increasingly specific to actual situations in their lives.
Figure 9 describes important knowledge, attitudes, and skills objectives for HIV/AIDS and
other health issues for three developmental stages: early childhood, preadolescence and
adolescence. This overview is only illustrative; local conditions and factors should always
be considered in designing a programme. For similar information regarding other health
and social issues, please refer to the WHO documents in Appendix 1.
Figure 9. Examples of Skills-Based Health Education Objectives
EARLY CHILDHOOD
KNOWLEDGE
ATTITUDES
SKILLS
Participants will know:
• second-hand smoke can be
harmful
• the benefits of eating a range
of nutritious foods (or balanced
diet), and where these foods
can be found locally
• violent behaviour is learned and
can be unlearned
• how HIV is transmitted and not
transmitted
Participants will demonstrate:
• respect for themselves and
others
• understanding of gender roles
and sexual differences
• belief in a positive future
• empathy with others
• understanding of duty in
regard to self and others
• willingness to explore
attitudes, values, and beliefs
• recognition of behaviour that is
deemed appropriate within the
context of social and cultural
norms
• support for equity, human
rights, and honesty
Participants will be able to:
• demonstrate practical and
positive methods for dealing
with emotions and stress
• demonstrate fundamental
skills for healthy interpersonal
communication
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5. PRIORITY ACTIONS FOR QUALITY AND SCALE
Figure 9. Examples of Skills-Based Health Education Objectives (continued)
PRE-ADOLESCENCE
KNOWLEDGE
ATTITUDES, VALUES, BELIEFS
SKILLS
Participants will learn:
• about bodily changes that
occur during puberty - and
that they are natural and
healthy events in the lives of
young persons
• about how Helminth and other
infections can be prevented by
using safe water and taking
other precautions
• the effects of tobacco, alcohol,
and other drugs on body
systems
• ways to identify nutritious
foods that are available locally
Participants will demonstrate:
• commitment to setting ethical,
moral, and behavioural
standards for themselves
• positive self-image by defining
positive personal qualities and
accepting positively the bodily
changes that occur during
puberty
• portrayal of human sexuality as
a healthy and normal part of
life
• confidence to change
unhealthy habits
• willingness to take responsibility
for their own behaviour
• an understanding of their own
values and standards
• concern for social issues and
their relevance to social,
cultural, familial, and personal
ideals
• a sense of care and social
support for those in their
community or nation who
need assistance
• respect for the knowledge,
attitudes, beliefs, and values of
their society, culture, family,
and peers
Participants will be able to:
• communicate messages
about HIV prevention, healthy
eating, and tobacco control to
families, peers, and members
of the community
• actively seek out information
and services related to
sexuality, substance use, or
other issues
• recognise and manage peer
and social influences on their
personal value system
• use critical thinking skills to
analyse complex situations
and a variety of alternatives
• use problem-solving skills to
identify a range of decisions
and their consequences in
relation to health issues that
are experienced by young
persons
• discuss sexual behaviour and
other personal issues with
confidence and positive
self-esteem, with responsible
adults and peers
• use negotiation skills to resist
peer pressure to use alcohol,
tobacco, or drugs or to get
involved sexually
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Figure 9. Examples of Skills-Based Health Education Objectives (continued)
ADOLESCENCE
KNOWLEDGE
ATTITUDES
SKILLS
Participants will know:
• which behaviours place
individuals at increased risk for
contracting HIV or malaria
infection
• what preventive measures can
reduce risk of HIV, STI, worm
and malaria infection, and unin
tended pregnancies
• how to obtain testing and
counselling to determine
HIV/STI status as well as
help with eating disorders and
drinking problems
• how to use contraceptives
appropriately
• how to prepare a balanced
meal
• what are the roles of
aggressor, victim, and
bystander
Participants will demonstrate:
• understanding of
discrepancies in moral codes
in their society
• a realistic risk perception
• positive attitude toward
alternatives to intercourse
• responsibility for personal,
familial, and community health
• support for school and
community resources that will
provide information and
services about risk prevention
interventions
• encouragement of peers,
siblings, and family members
to take part in prevention
activities
• encouragement of others to
change unhealthy habits
Participants will be able to:
• assess risk and negotiate for
less risky alternatives
• appropriately use health
products
• seek out and identify sources
of help with substance use
problems, including sources
of clean needles or needle
exchange
• advocate for tobacco- and
drug-free schools and
generate local support
(The preceding skills-based health-education objectives were adapted from documents in
the WHO Information Series on School Health.)
5.6. PROFESSIONAL DEVELOPMENT FOR TEACHERS AND SUPPORT
TEAMS33
Various individuals involved in skills-based health education must be trained to ensure
successful implementation of such programmes. Trained educators are more likely than those
who are not specifically trained in this learning area to implement programmes as intended, that
is, to teach all of the required content and to use effective, high-quality teaching and
learning methods (Kann et al., 1995). Skills-based health education teachers must possess a mix
of professional and personal qualities. Some individuals bring these qualities to the job;
others must receive training to acquire them. When properly trained, students themselves (peers),
community agency workers, guidance officers or counsellors, social workers, and psychologists
or other health care providers, as well as teachers, can facilitate skills-based health education.
What follows is an overview of the attitudes and attributes, professional skills, and
competencies teachers need to develop to teach skills-based health education, along with
some suggestions for training design of these requirements.
3:3Parts of this section are adapted form Chapter 3, "Programme Providers andTraining," in Mangrulkar, L., Vince Whitman, C., & Posner, M.
(2001). Life Skills Approach to Child and Adolescent Healthy Human Development. Washington, D.C.: Pan American Health Organization.
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5. PRIORITY ACTIONS FOR QUALITY AND SCALE
5.6.1 ATTITUDES AND ATTRIBUTES
The following descriptors identify the best programme facilitators.
• role models for healthy behaviours
• credible and respected
• skilled and competent
• able to access resources and leadership and institutional support
5.6.2. PROFESSIONAL SKILLS AND COMPETENCIES
Teachers and other facilitators of learning involved with skills-based health education
need to employ interactive teaching methods. For this reason, they need to possess or
develop the following characteristics:
• Ability to play different roles - to support, focus, or direct the group as required
(Tobler, 1992)
• Ability to act as a guide as opposed to dominating the group (Tobler, 1992)
• Respect for the adolescent and his or her freedom of choice and individual
self-determination (Tobler, 1992)
• Warmth, supportiveness, and enthusiasm (Ladd and Mize, 1983)
• Ability to deal with sensitive issues, such as hygiene, sexual and reproductive health,
HIV/AIDS prevention, dating, friendships, substance abuse, and difficult decisions
bout the future. These are topics that a teacher or facilitator needs to be prepared to
discuss, either by answering questions or knowing where to go for more
information. This requires training in content about adolescent stages of
development, body image, sexuality, and available community resources.
• Appropriate personal and professional attitudes and practices. Teachers and
facilitators are often expected to work with adolescents to develop skills that they
themselves may not possess, such as, assertiveness, stress management, and
problem-solving. Furthermore, teachers and facilitators may need help with their
own sexual health issues, HIV/AIDS coping strategies, substance abuse problems,
or violence in the home. Studies on health-promotion programmes for teachers
have shown that training can result in specific health benefits to providers as
well as improved attendance, morale, and quality of learning (Allegrante, J, 1998).
Some parent-focused interventions have addressed this concern by helping
parents (as programme providers) to develop skills in their children (Shure &
Spivack, 1979) while also helping parents improve their own problem-solving,
parenting, and stress-management skills.
• Practice what you preach. Teachers and other facilitators need extensive
opportunities to practise student participatory learning methods such as open
discussion, role-plays and cooperative group work. They should also model the
behaviours which their training advocates.
• Accurate knowledge of, and adequate personal comfort with, the range of issues
being addressed; and the ability to refer to other sources of expertise where
necessary.
Many adults will need to unlearn authoritarian approaches to learning in order to become
effective programme providers. The case study that follows the next section describes
the positive impact of skills-based health education training on teachers and students in
85 schools in the United States.
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5. PRIORITY ACTIONS FOR QUALITY AND SCALE
5.6.3.TRAINING DESIGN
Access to good-quality training and support is essential to the development of the
characteristics described in the preceding section.
Teachers and other facilitators ideally should receive quality training in both pre-service
and in-service contexts. Training needs to expose teachers to, and allow them to gain
experience in, participatory teaching and learning methods, with administrative support at
the school level, and ongoing support from experts to foster and sustain participatory
teaching and learning methods. Training for skills-based health education should mirror
the teaching and learning principles of the programmes that are to be implemented.
Training should incorporate active teaching and learning methodologies that take account
of what is known about adult learning styles. In reality, teachers in many countries receive
neither quality pre-service training nor ongoing in-service training, and there may be little
support for addressing sensitive and complex topics that require specific skills.
Whether or not teachers have had the benefit of quality preparation in the past, quality
training can support the development of positive attributes and substantially improve the
competencies required for skills-based teaching. The strategies utilised by skills-based
teaching are familiar within traditions of learning that have existed for generations in local
cultures. These traditions include learning in groups, from elders across generations,
through women's networks, through peers groups, and among girls and boys together;
information and culture have been passed down in these ways through history.
Key elements of effective training for teachers and other facilitators include the following:
• establishing an adequate knowledge base about the issues to be addressed and
networks of experts to draw on for further information
• establishing an effective, safe, and supportive training and programme environment
• inspiring broad participation and genuine interaction
• applying participatory teaching methods; for example, building competence in group
process, role plays, dramatisations, debates, small group work, and open discussions
• modelling the skills addressed in the curriculum
• focusing on the whole child and adolescent, not just, for instance, on the effect of
one particular health issue
• analysing adult perceptions of adolescents and adolescence, adult stereotypes and
myths, and clarification of adult values around issues relevant to young people
• building skills in conjunction with providing information
• addressing sensitive issues in adolescents
• providing constructive criticism and positive reinforcement and feedback
• accessing and assessing the quality of teaching and learning resources
• accessing and assessing referral and support networks and community liaisons,
and facilitating local participation
• fitting training to the skills level of the providers (Gingiss, 1992)
• providing ample opportunity for trainees to demonstrate and practise their new skills
and for ongoing coaching, including continued training and booster sessions
(Hansen, 1992; Botvin, 1986)
• allowing active participation of trainees in making decisions about programme
adoption
• pairing experienced skills-based health education providers with new trainees
(Dusenbury & Falco, 1995)
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5. PRIORITY ACTIONS FOR QUALITY AND SCALE
CASE STUDY
Developers of Teenage Health Teaching Modules (THTM), a skills-based health
education curriculum in the United States, effectively trained programme providers in
the following:
- establishing a programme environment in which open communication and positive
peer interaction are valued and constructive problem solving occurs
- using participatory teaching strategies
- modelling skills and applying them to particular behaviours, including how to give
encouragement and praise to reinforce positive social norms (O'Donnell, 1998)
- teaching complex social skills;
- providing resources for health information and referral
- dealing with sensitive issues (Blaber, 1999)
A study involving 85 schools found that pre-implementation training inTHTM positively
affected teachers' preparedness to teach THTM and student outcomes. Trained teachers
implemented the curriculum with a significantly higher degree of fidelity than untrained
teachers. Teacher training also had positive effects on student outcomes. Students'
knowledge and attitude scores were significantly higher for classes taught by trained
teachers than by untrained teachers. At the senior high school level, trained teachers also
accounted for curbing self-reported use of illegal drugs (Ross et al., 1991).
WHO INFORMATION SERIES ON SCHOOL HEALTH
6. PLANNING AND EVALUATING SKILLS-BASED HEALTH EDUCATION
Purpose: to identify key steps for effective planning and advocating for skills-based health
education, and to clarify elements of design and evaluation.
A document recently produced by the World Health Organization, called Local Action:
Creating Health-Promoting Schools, contains tools that can guide you or your school
health team through the planning steps described in this chapter.
6.1. SITUATION ANALYSIS
A situation analysis is conducted to ensure that interventions are relevant to local
conditions and cultures. It consists of needs and resource assessments and data
collection, conducted before interventions are planned and implemented. Needs
assessments involve the collection of accurate and current data that yield insight into the
health issues and behaviours in a community. Resource assessments yield knowledge
of the available capacities and resources in schools and communities.
The following types of information might be considered:
• health status, including local public health data on morbidity and mortality
• health priorities of children and adolescents
• behaviours and health conditions that are influencing priority health issues
• knowledge, attitudes, beliefs, values, skills, and services related to priority health
issues for young people and their associated behaviours and conditions
• relevant policies
• available human, financial, and material resources and existing programmes
that address health and social issues
Gathering evidence from credible sources can provide valuable information about what
young people know, think, feel, and do and what health conditions affect them. Many
sources of information can be utilised in this process, including the following:
• focus groups or in-depth interviews with the actual target audience or a similar
group of learners
• related literature and research
• survey results
• professional expertise
• parents, care givers, and community groups
• epidemiological data from health departments and local clinics
The points of view of different stakeholders need to be shared and considered together,
and ultimately agreement has to be reached. Where agreement proves elusive, it is the
needs of the learners that ultimately must be central to decisions about what to include.
For further information, please refer to Appendix 2.
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6. PLANNING AND EVALUATING SKILLS-BASED HEALTH EDUCATION
6.2. PARTICIPATION AND OWNERSHIP OF ALL STAKEHOLDERS
Schools may involve members of the school and community in planning goals and
objectives for interventions. Such involvement can help ensure that the interventions will
address the needs of learners and will be maintained over time.
School teams may include headmasters, teachers, students, school-based service
providers such as nurses or counsellors, parents, and support staff. Members of school
teams should represent a variety of backgrounds and viewpoints, be committed to the
idea of health promotion, be interested in skills-based health education, work well in a
team, and be able and willing to make a commitment of time. The team members work
together to maintain and promote the health of all people who are working and learning
at school, and to plan skills-based health education.
Community advisors can complement the school team and provide ongoing advice and
support from the community. Partners from the community sector may includes local
government officials, religious leaders, media and business representatives, community
residents and youth agency members, health and social service providers, and
representatives of non-governmental agencies.
Together, school teams and community advisors assess needs and develop programme
goals and objectives, and may work together in implementing and evaluating the
interventions.
6.3. PROGRAMME GOALS AND OBJECTIVES
With the results of the situation analysis in hand, especially the identified needs and
available resources, the school teams of students, teachers, and families, with support
from other community advisors, can play an active role in defining the goals and
objectives of the programme.
A goal describes in broad terms what it is hoped the intervention will achieve in the long
term. A goal is a fairly grand statement, targeting a change in health status, such as
reductions in teenage suicides or unwanted teen pregnancies. Many strategies are
required to achieve outcomes at this level.
Outcome objectives target risk behaviours or conditions related to the goal. For
example, if the goal is reduced teenage suicide or unwanted teen pregnancy, target
behaviours or conditions might include delaying the initiation of sexual intercourse and
increasing the number of teachers who serve as trusted adults to whom students can go
when feeling depressed.
Sub-Objectives (process objectives) define in specific, measurable, and attainable
terms what is to be accomplished to help achieve the outcome objectives. For skillsbased health education, this means describing the activities and interventions that are to
be implemented over a given period of time to influence knowledge, attitudes, skills, and
other factors associated with the outcome objectives and, ultimately, the goal. For
example, sub-objectives could include increasing knowledge about which factors
constitute depression, or developing skills for negotiating alternatives to sex.
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6. PLANNING AND EVALUATING SKILLS-BASED HEALTH EDUCATION
56
Figure 10. Outcome expectations for three levels of programing
LEVEL
TARGET
EXAMPLES OF STRATEGIES
REQUIREDTO ACHIEVETARGET
GOALS
GOAL
Many strategies are required to
achieve outcomes at this level.
Change in health outcome or
health status:
Reduction in HIV, STI, and teen
pregnancy rates, reduction in
teen suicide, reduction in drunk
driving car crashes, increase in
teens' eating according to
national nutrition guidelines; etc.
Skills-based health education
plus...
Public and school-level policy,
regulations and legal incentives,
mass media campaigns, access
to friendly services and needed
supplies, school-community
partnerships, etc.
______
OBJECTIVE
Several strategies are needed to
achieve these more complex and
broader outcomes.
A
Reduce risk behaviours:
Delay sex; increase contraceptive
use; decrease consumption of
alcohol, tobacco, and other drugs
by young people; increase eating
of balanced meals; decrease
bullying at school, etc.
Skills-based health education
plus...
School policies, links to health
and social services, a health
supporting school
environment, school-community
partnerships, etc.
Enhance knowledge, attitudes,
and skills:
Increased knowledge of
transmission and prevention of
HIV; peaceful solutions for
resolving conflicts; components
of a healthy diet; effects of
alcohol, tobacco, and other drugs
Enhanced attitudes regarding
self-image and reduction of
stigmatisation
Improved skills, demonstrated via
classroom activities, in abilities
related to assertion, negotiation,
decision-making, and values
clarification applied to a
specific issue such as HIV/AIDS,
violence, or alcohol, tobacco, and
drug use
Skills-based health education*,
by well prepared and supportive
teachers and facilitators.
A
SUB-OBJECTIVE
Educational strategies are
required to achieve these
relatively specific,
immediate outcomes.
•Although it is possible to achieve sub
objectives with skills-based health
education alone, it is always advisable to
reinforce it with other strategies to
maximize outcomes - such as supportive
school policies, school health services
and a supportive environment.
6.4. ADVOCATING FOR YOUR PROGRAMME
A first step in putting a programme into action is gathering support and resources. To gain
support, it may be necessary to advocate for the programme.
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6. PLANNING AND EVALUATING SKILLS-BASED HEALTH EDUCATION
Policymakers need good reasons to increase support for any health or education effort.
They must be able to justify their decisions. Advocacy is the art of influencing others to
support an idea, principle, or programme.
An advocate for skills-based health education must convince school policy and decision
makers and communities that school-based efforts in support of it are appropriate and
doable and that these efforts can help reach generally supported goals for young people.
The goal is to convince decision-makers to take actions that invest in and strengthen
school health programmes. Arguments about the importance and effectiveness of skillsbased health education can be used as part of this advocacy effort (see Chapter 4 and
this section, below).
Convincing people may be easier when the following two questions have been answered
first: What factors cause one person to say yes to another person? and What techniques
produce this result? While we cannot force people to think or act in a certain way, our
ideas and knowledge can shape the environment of their thinking.
For example, the following six principles of persuasion can make a person want
to say yes to another person:
• Commitment and consistency: Even small acts can gain commitment, and when
people commit, they tend to behave in ways that are consistent with that
commitment.
Social proof: People often use information about how others behave
to decide
what to do.
• Scarcity: People are more likely to act if the opportunity to do so is available only
once and there is a loss associated with not acting.
• Reciprocation: People usually try to repay, in kind, what another has given.
Authority: People with titles and significant knowledge can exert a lot of influence.
• Liking: People prefer to say yes to requests from those they know or like
(Cialdini, 1993)
Applying these principles to advocating for skills-based health education requires that a
presenter deliver a message to an audience. An effective presenter needs to be
trustworthy, confident, clear, and attentive to the needs of the audience. It is important to
find out whether, and at what level, the audience understands the issue, and whether they
can do something about it. Effective messages to audiences have certain common
qualities: They are simple, emphasising three key points and actions that the presenter
wants to get across. They balance facts with emotion and human stories. They avoid
jargon and complex data, and use specific examples, analogies, metaphors, one-liners, vivid
language, and images that the audience can easily identify with (Vince Whitman, 2001).
Appendix 2 provides references to handbooks that can be useful in planning advocacy
efforts.
In advocating for skills-based health education and life skills, it is not always obvious
which arguments or approaches work best with which audiences. What seems obvious
or appeals to health and education planners at first may not be the most persuasive
argument for others. For example, the chief of police for a college campus in the United
States reported that the college president and trustees were not persuaded to take action
when presented with statistics on high rates of student drinking, vandalism sexual
assaults, and related car crashes. What did make a difference was the chief's report that
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6. PLANNING AND EVALUATING SKILLS-BASED HEALTH EDUCATION
a very large number of students were dropping out on account of alcohol-related
problems,creating an economic loss for the university (Mangrulkar at al., 2001).
Experience from the Field
Existing skills-based health education and life skills programmes in Latin American and
Caribbean countries have yielded the following key lessons in advocacy, which can be
helpful in guiding new initiatives:
•
Strong advocacy requires clear arguments and a clear understanding of the life
skills approach, adapted to a particular audience and setting.
•
Data on local needs as well as the situation of children and adolescents (e.g., from
Demographic Health Surveys) can be a powerful basis for advocacy and critical for
determining programme objectives.
•
Buy-in and involvement of local programme providers, from the initial needs
assessment stage, is key to programme effectiveness and sustainability.
•
Programme providers themselves have health needs that should be taken into
account in programme implementation and can potentially be addressed through
life skills programmes.
•
Schools-based health education can serve as a unifying framework for the many
competing and duplicative adolescent health programmes in a given setting.
•
Support and technical assistance for curriculum development, which can involve
either adapting pieces of existing curricula or developing original curricula, are
needed at the regional or country level.
•
Planning for all stages, from needs assessment through programme institutional
sation, is a key to sustainability
6.5. EVALUATING SKILLS-BASED HEALTH EDUCATION
Evaluation is important to consider from the outset and throughout your programme.
When you assess needs at the very beginning (conduct a situation analysis), set
objectives, and plan activities (devise an action plan), you are laying the groundwork for
evaluation. At the same time, you need a formal evaluation plan to track progress, and you
need to be certain that your evaluation design is feasible to implement.
Comprehensive evaluation designs include both process evaluation and outcome
evaluation. During the course of the implementation, process evaluation monitors the
progress and provides feedback so that you can make adjustments or correct your
programme where needed. Outcome evaluation assesses the results and impact of the
interventions and determines if and to what extent the interventions were effective in
achieving the desired objectives. The cycle then starts again, with the question of what
further change or maintenance is desirable as a new goal.
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6. PLANNING AND EVALUATING SKILLS-BASED HEALTH EDUCATION
6.5.1. PROCESS EVALUATION
Process evaluation answers questions about how the programme was conducted rather
than what the programme achieved per se, and it monitors whether the programme has
been implemented as planned. Two important dimensions are coverage and quality of the
programme. Coverage assesses the extent to which the programme actually reaches the
intended audience. Quality refers to the adequacy of training and satisfaction of
stakeholders with training and delivery of the programme, but quality assurance should
go much further. Process evaluation may include formative evaluation about teaching and
training materials and sessions. This can provide insight for improving the programme and
its outcomes. Process evaluation may also monitor changes in intermediate factors such as
communication patterns, relationships, sources of information, social norms or norms
among peers, changes in programme providers, and changes in connection to community,
family, parent, or school.
Process evaluation is important for ensuring that the implementation is the same in all
programme sites, and importantly, for providing evidence that the outcomes observed
can truly be linked to the interventions, rather than to some other influence. Figure 11 pro
vides samples of process indicators at the programme level.
Figure 11. Sample areas of questioning for process evaluation
Coverage: Is the intended audience being reached? Who is not reached?
a) Is the programme being offered in all intended settings? E.g., schools?
- % of schools offering programmes, formal and non-formal
b) Is the programme reaching the intended audience of facilitators/teachers?
- % of all teachers/facilitators trained
c) Is the programme reaching the intended audience of children and young people?
- % girls/boys (rural/urban; ethnic groups, other...)
Quality: Are facilitators/teachers implementing the programme according to
quality standards?
Possible Programme Quality Standards
• Does the programme address relevant health and social issues?
• Are there objectives to influence behaviour?
• Is there a mix of knowledge, attitudes, and skills?
• Are participatory teaching and learning methods used?
• Is the programme participant-centred and gender-sensitive?
• Are policies in place to support the programme (e.g., teacher preparation,
in-service and ongoing support)?
• Are related support services accessible to the audience/participants?
• Are stakeholders consulted? Involved?
• Are facilitators/teachers trained for this purpose?
• Are facilitators/teachers supported in the implementation phase?
• Are facilitators/teachers satisfied with the implementation of the programme?
• Are participants satisfied with the implementation of the programme?
• Is the programme of sufficient duration to achieve the desired objectives?
• Are relevant educational materials utilised (accurate,
age-appropriate, accessible, language-appropriate, durable...)?
gender-sensitive,
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60
Figure 11. Sample areas of questioning for process evaluation (contnued)
• Is the programme based on relevant, current, accurate information and methods?
• Are programme impact and process monitoring and evaluation in place?
• How much does the programme cost?
It is advisable to continue some level of process evaluation or monitoring throughout the
life of a programme, even after it is mainstreamed, so that you can assess whether or not
it remains on track, whether changes are needed over time, and whether the programme
quality is maintained over time.
6.5.2. OUTCOME EVALUATION34
Outcome evaluation assesses whether or not the programme has reached its objectives
and whether what has been done has made a difference, especially in terms of affecting
targeted behaviours and conditions and the knowledge, attitudes, and skills that are
intended to influence them. Outcome evaluation is conducted to determine any impact
or changes that have occurred over the time of an intervention. The first steps begin well
before the intervention, including establishing some baseline or benchmark for
comparison, and should continue well after implementation.
This kind of evaluation needs to be quite detailed, rigorous, and scientific and seeks to
assess the size of the effect or change, often to "prove" that the strategies applied
really work. Programmes that have already proven to be effective in achieving the desired
skills or behaviour do not need a detailed outcome evaluation every time they are being
implemented. Where resources such as time, personnel, and budget for evaluation may
be scarce, it may be sufficient, and more feasible, to conduct a process rather than an
outcome evaluation. Too often, programmes rush to study their impact on youth without
fully understanding whether or how well implementation of the interventions occurred.
However, establishing effectiveness is essential before attempting to scale up, and
information from the process evaluation can be extremely useful in identifying possible
barriers to replicating the intervention elsewhere or at greater scale.
Outcome evaluation questions include the following:
• To what degree have objectives been accomplished?
• To what extent have knowledge, attitudes, skills, and behaviour of students
and staff been affected?
• Which specific interventions or components of our programmes work best? Which
elements did not work?
The outcome indicators selected for the programme depend on the desired goals of the pro
gramme. Skills-based health education that is well implemented should be expected to affect
changes in behaviours and conditions and related knowledge, attitudes, beliefs, and skills.
The impact of skills-based health education can be assessed at different levels, and it is
essential that expectations set for the programme are a reasonable match for the
strategies utilised. When implemented alone, skills-based health education is most likely
to achieve outcomes at the first level (immediate); however, when implemented with
indudeTboth meanings^ "OUtCOme" sometimes refer t0 the shorter - and long-term changes, respectively. In this document, "outcome"
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6. PLANNING AND EVALUATING SKILLS-BASED HEALTH EDUCATION
increasingly more coordinated strategies, outcomes at level 2 (medium term) and 3
(longer term) can be expected. The three levels are as follows:
1. Immediate outcomes: development of knowledge, attitudes, and skills. This level is
the main interest of facilitators or teachers in the classroom, although they will also
have an interest in medium-term outcomes related to behaviour and conditions that
are intended to be influenced.
2. Medium-term outcomes: changes or maintenance of targeted behaviour and
conditions that will impact on goals. This level is the main interest of the skills-based
health education coordinators or managers, although they will also have an interest
in immediate outcomes.
3. Longer-term outcomes: reaching the programme goals, changes in health status, or
social outcomes. This level is the main interest of policy- and decision-makers in
government, although they will also have an interest in medium-term and
immediate outcomes.
Figure 12 provides examples of questions at all three levels.
Figure 12. Sample areas of questioning for three levels of outcomes related to HIV/AIDS/STI prevention
LEVEL OF EVALUATION
Level 1.
Immediate Outcomes: Knowledge,
attitudes, and skills (session or
classroom level)
- Assessed by the facilitator/teacher
when the educational activities are
completed, or very soon after.
OUTCOMES
Learning Outcomes Knowledge:
Have students learned that ...
• HIV is a virus some people have acquired?
• HIV is difficult to contract and cannot be transmitted by
casual contact?
• people can be HIV-infected for years without showing
symptoms of this infection?
Have they learned ...
• how HIV is transmitted and not transmitted?
• the difference between HIV and AIDS?
• which behaviours place individuals at increased risk for
contracting HIV infection?
• what preventive measures can reduce risk of HIV, STI,
and unintended pregnancies?
• how to obtain testing and counselling to determine
HIV status?
*The term "attitudes" is used here to
encompass a wide range of beliefs;
feelings about self (e.g., confidence)
and others (e.g., discrimination);
values; thoughts; and social, religious,
and cultural tenets, morals, and
ethics.
Attitudes:*
Do students demonstrate ...
• acceptance, not fear, of people with HIV and AIDS?
• understanding of gender roles and sexual differences?
• empathy with others?
• understanding of duty in regard to self and others?
• commitment to setting ethical, moral, and behavioural
standards for themselves?
• a positive self-image by defining positive personal
qualities and accepting positively the bodily changes that
occur during puberty?
• willingness to take responsibility for their own behaviour?
WHO INFORMATION SERIES ON SCHOOL HEALTH
6. PLANNING AND EVALUATING SKILLS-BASED HEALTH EDUCATION
62
Figure 12 provides examples of questions at all three levels (continued)
LEVEL OF EVALUATION
OUTCOMES:
• an understanding of how their family values support
behaviours or beliefs that can prevent HIV infection?
• concern for social issues and their relevance to social,
cultural, familial, and personal ideals?
• understanding of discrepancies in moral codes in their
society?
• a realistic risk perception?
• encouragement of peers, siblings, and family members
to take part in HIV prevention activities?
•The term "skills" is used here to refer to life
skills, psychosocial and interpersonal skills that
can be applied to AIDS prevention and related
issues.These skills are important because they
can facilitate and may lead to behaviour change
when supported in comprehensive ways.
Skills*:
Are students confident they are able to ...
• acquire practical and positive methods for dealing with
emotions and stress?
• actively seek out information and services related to
reproductive and sexual health services, and substance
use that are relevant to their health and well-being,
including identifying a responsible adult or peer?
• use critical thinking skills to analyse complex situations
that require decisions from a variety of alternatives?
• use problem-solving skills to identify a range of decisions
and their consequences in relation to health issues that
are experienced by young people?
• discuss sexual behaviour and other personal issues with
confidence and positive self-esteem?
• communicate clearly and effectively a desire to delay
initiation of intercourse (e.g., negotiation, assertiveness)?
• assess risk and negotiate for less risky alternatives?
• appropriately use health products (e.g., condoms)?
(Examples in this section are adapted from WHO, 1999, pp. 19-21.)
Level 2
Medium-term Outcomes:
Behavioural Level
- Assessed a short time after
intervention.
- It is assumed that achievement of the
outcomes of Level 1 will lead to
achievements at this level.
SKILLS FOR HEALTH
Behavioural Outcomes
• Was a condom used at last sex?
• Has the number of sex partners decreased?
• Is age at first sex increasing? (Is the partner low risk?
What is the age difference between partners?)
• Is intravenous drug use decreasing?
• Are more intravenous drug users cleaning needles?
• Are fewer intravenous drug users sharing needles?
• Are participants (and others) affected by HIV/AIDS treated
as well as others are treated?
• Are more pregnant girls/young women who are at risk
receiving prenatal testing and treatment?
63
6. PLANNING AND EVALUATING SKILLS-BASED HEALTH EDUCATION
Figure 12 provides examples of questions at all three levels (continued)
LEVEL OF EVALUATION
OUTCOMES
Level 3.
Long-term Outcomes:
Social Health Epidemiology Level
Long-term health and social outcomes.
Health and Social Outcomes
• Are STIs decreasing? (Is the average duration of STI
decreasing? Are health services accessed more/earlier)?
• Is age of first pregnancy rising?
• Is age of first marriage rising?
• Are rates of HIV infection decreasing?
• Are those affected by HIV/AIDS healthier? Living longer
than before?
• Is mental health improved (e.g., self-esteem,
self-confidence, outlook, connectedness/sense of
community)?
• Is drug addiction decreasing?
• Are more children who are affected by HIV/AIDS staying
at school?
The following case study points to the common practices and shortcomings of
evaluation designs.
CASE STUDY
For twelve school health evaluation studies in Europe, the outcome evaluations included
measures of behaviour, knowledge, and attitudes. In recent years, more studies includ
ed measurement of normative beliefs (social influence), self-efficacy expectations, and
expectations regarding future performance (intention). Most evaluations used self
reported data (questionnaires). Physical examinations and biomedical measures were
used as a reliability check for self-reported data. Most of the interventions to which these
measures were applied targeted secondary school students, and all were in the form of
classroom-based activities, sometimes combined with parental involvement or
community interventions. The health issues addressed included smoking, drug use,
obesity, dental health, AIDS, and general health. Most programmes produced changes in
knowledge and some behavioural effects, but long-term effects were not assessed or
could not be found in most studies. Analysis across these studies suggests that
improvements could be made in evaluation by developing more rigorous evaluation
designs; increasing the number of subjects in the studies; including long-term outcome
assessment tools such as behavioural measures; establishing clear measurement
procedures; and ensuring the inclusion of process measures, such as the monitoring of
classroom factors and assessing whether the programme was implemented as
intended.
(From Peters, L. & Paulussen, T. (1994). School health - a review of the effectiveness of health
education and health promotion. Utrecht: Dutch Centre for Health Promotion and Health Education.
As cited by Hubley, J. (2000). School Health Promotion in Developing Countries: A literature review.
Leeds, UK: John Hubley.)
For further information on evaluation design, please refer to Appendix 2.
WHO INFORMATION SERIES ON SCHOOL HEALTH
6. PLANNING AND EVALUATING SKILLS-BASED HEALTH EDUCATION
6.5.3. ASSESSING SKILLS-BASED HEALTH EDUCATION AND LIFE SKILLS IN THE
CLASSROOM
This section illustrates that assessing skills-based health education can be a normal part
of what education systems do, and that life skills can be assessed in the classroom.
The preceding section focused on measuring behavioural outcomes as an outcome or result
of programmes over time. While large-scale surveys may be useful for measuring these
medium-term outcomes across schools, regions, or countries, other levels of evaluation can
offer more detail. In the school setting, assessment is a regular part of following student
progress through education systems, and many techniques implemented at the classroom
level can complement larger-scale surveys. Just as the skill of high jumping in a physical
education class or bandaging in a first aid class can be assessed against criteria, so too can
life skills such as assertion, negotiation, or cooperation be assessed. In addition, by
matching a detailed level of feedback on knowledge, attitudes, and skills with data on
behaviour patterns, it is possible to gain a better understanding of which aspects of the
programme are working well and which could be improved.
The classroom is an ideal setting for skills-based health education, including life skills. It
offers a relatively safe environment in which the application of information and the
development of attitudes and skills can be explored, observed, and assessed using role
plays, discussions, simulations, and other exercises.
PAPER-AND-PENCIL ASSESSMENTS
Knowledge, attitude, and skill levels can be self-assessed (by peers or students) or
assessed by teachers, other facilitators, parents, and other community members. Paperand-pencil assessments include worksheets, tests, quizzes, and homework assignments.
They may include forced-choice items like the following:
• multiple choice
• matching
• alternate choice
• true-false
• multiple responses
• fill-in-the-blanks
• scales
(From UNICEF/CARICOM, 2001.)
Ranked or forced-choice questions require the student to rank or choose statements
according to appeal or some other priority. An item could ask for a simple ranking from
high to low (e.g., How important do you think it is to have drug-free environments at
school?) Scales require students to choose from a point on a scale that corresponds to
the student's answer to a question. A student may be asked to answer yes or no to a
question (a two-point scale) or indicate the degree of agreement (a five-point scale).
(From Annette Wiltshire for the Trainer of Trainers Workshop Facilitators Programme,
CARICOM HFLE Project, May 2000.)
Formalised paper-and-pencil assessments include the Social Skills Rating System (SSRS)
(Gresham and Elliot, 1990), which is one of many different rating scales that have been
used to assess students' social skills, including cooperation, assertion, empathy, and self
control, by self-report as well as through teachers and parents. Social and emotional
adjustment can be measured through many different scales, including the Survey of
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6. PLANNING AND EVALUATING SKILLS-BASED HEALTH EDUCATION
Adaptational Tasks of Middle School (Elias et al., 1992). This survey asks teachers,
parents, and students about adjustment in middle school (generally ages 10 to 14 in the
United States). Another scale is the Self-Perception Profile for Children, which measures
children's perceptions of personal competency (Harter, 1985). In the area of violence
prevention, a number of self-report measures assess the attitudes and knowledge of
adolescents about violence. For example, the Beliefs Supporting Aggression Scale (Slaby
& Guerra, 1988) measures normative beliefs about aggression, and the Attitude Towards
Conflict scale (Lam, 1989) measures how young people feel about different methods for
resolving conflicts.
In addition to forced-choice assessments, paper-and-pencil assessment may include
essays or short written responses. Through essays students relate what they know about
content and demonstrate their ability to think and reason, by making an argument,
coming to conclusions, or problem-solving. Essays are also useful for assessing strength
and clarity of written communication skills. Short written responses are like mini-essays,
in which students respond to requests such as "In one or two sentences describe..." or
"Briefly respond to the following..." Responses are used to assess student understanding
of content, and to some degree provide insight about thinking and reasoning skills
(UNICEF/CARICOM, 2001).
ALTERNATIVE ASSESSMENT METHODS
Pen-and-paper methods are not always useful for assessing the affective domain, such as
feelings, attitudes, beliefs, and values or skills like assertiveness, refusal skills, locus of
control, decision making, and problem-solving. Creative ways of assessing skills include
a range of collaborative methods, such as peer feedback on a performance, group
assessment of a demonstration or of a role play against a set of predetermined criteria,
or community-based projects or internships.
In some cases a multifaceted assessment system, composed of a variety of assessment
methods, might be appropriate, especially for assessing skills, which by definition
are best understood by demonstration. A multi-faceted assessment may include the
following:
• Exhibitions
• Laboratory performance
• Essays
• Journals
• Short answer items
• Multiple choice items
• Projects
• Portfolios
• Interviews
• Papers
• Concept mapping
• Systematic observation
• Long-term investigation
• Manipulative skills
(From VISMT-Vermont Institute of Science, Mathematics and Technology, cited in
UNICEF/CARICOM, 2001.)
Some alternative methods of evaluating combined learning outcomes around knowledge,
attitudes, and skills are briefly described below.
WHO INFORMATION SERIES ON SCHOOL HEALTH
6. PLANNING AND EVALUATING SKILLS-BASED HEALTH EDUCATION
Observation - Teachers directly observe their students every day in a variety of settings,
under all types of conditions. Observation permits immediate, on-the-spot assessment of
behaviour, such as cooperation. Daily observation (e.g., a teacher log) over an extended
period permits more direct, more reliable references about patterns of behaviour than
data from a single administration of a written instrument; however, it is more time
consuming. Observations produce most consistent assessments where standards-based
or criterion-based checklists or feedback forms accompany the observations.
Interview - The informal interview is a variation of teacher observation. The teacher asks
the student a series of probing questions to assess what the student knows and
understands and how the student feels and behaves in regard to relevant health issues.
For this face-to-face encounter, the teacher needs to have carefully developed questions
in a structured or unstructured format. For dealing with sensitive content such as sexual
behaviour, drug taking, or other risk behaviour, experience shows that someone other
than the regular teacher, preferably someone from outside the school, can conduct a
more effective interview. The interviewer needs to ensure that the answers will be kept
confidential.
Peer observations - Students can learn to observe and give feedback to fellow students
as they make presentations or engage in role plays or discussions. Peer observers must
know what is expected of them as observers and what is expected of students they are
observing.
Student self-assessment - This assessment comes directly from the student. As
students carry out the self-assessment process, they reflect on their work and develop
new learning goals.
Oral presentations and reports - Through oral presentations, students can organise
what they know about content and demonstrate their ability to think and reason. This
format also enables students to demonstrate various aspects of their communication
skills. To some degree, plays, skits, role plays, speeches, and debates can be considered
variations of oral presentations and reports.
Portfolio - A portfolio is a collection or showcase of examples of a person's best work in
a particular field. Portfolios have the advantage of containing students' work (product)
over a period of time and their reflections (process) about doing the work. Portfolios can
provide evidence of students' increased knowledge and skills and can document their
progress as a learner.
Unobtrusive Technique - This is a related observational technique that may include a
review of school records, library checkouts, attendance records, student copybooks/
notebooks, and physical evidence such as voluntary seating arrangements. It requires
ingenuity and creativity on the part of the teacher.
(From UNICEF/CARICOM, 2001, and Annette Wiltshire for the Trainer of Trainers
Workshop Facilitators Programme, CARICOM HFLE Project, May 2000.)
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APPENDIX 1:
DOCUMENTS IN THE WHO INFORMATION SERIES ON
SCHOOL HEALTH
The following documents can be downloaded or ordered from the World Health
Organisation, Department of Noncommunicable Disease Prevention and Health
Promotion, 20 Avenue Appia, 1211 Geneve 27, Switzerland, ph. +41-22-791-2582 or 3581;
or on-line at http://www.who.int/school-youth-health/
Local Action: Creating Health-Promoting Schools, WHO/SCHOOL/98.7 published in
2000 jointly by WHO, UNESCO, and EDC, helps individuals working at the local level to
plan, implement, and evaluate efforts to improve health through schools. It provides
practical guidance, tools, and tips from schools around the world. It offers suggestions
about how school administrators, teachers, students, parents, and community members
can work together to implement the four components of an effective school health
programme. (1) school health policies; (2) safe water and sanitation as first steps in
creating a healthy school environment, (3) skills-based health education, and (4) school
health and nutrition services, as called for by WHO, UNICEF UNESCO, and the World
Bank in their joint initiative to Focus Resources on Effective School Health (FRESH).
Preventing HIV/AIDS/STI and Related Discrimination: An important responsibility of
a Health-Promoting School, WHO/SCHOOL/98.6, published in 1999 jointly by WHO,
UNESCO, UNAIDS, and Education International to help individuals advocate for and
implement HIV/AIDS/STI prevention through schools. It describes strong arguments for
addressing HIV/AIDS/STI prevention through schools; concepts and qualities of a
Health-Promoting School; and specific ways in which schools can use their full
organisational capacity to prevent HIV infection. The document describes how each of the
four components of FRESH can be used to prevent HIV/AIDS/STI.
Tobacco Use Prevention: An important responsibility of a Health-Promoting school,
WHO/SCHOOL798.5, published in 1999 jointly by WHO, UNESCO, and Education
International to help individuals advocate for and implement tobacco use prevention
efforts through schools. It describes strong arguments for addressing tobacco use
prevention through schools; concepts and qualities of a Health-Promoting School; and
specific ways in which schools can use their full organisational capacity to prevent
tobacco use. The document describes how each of the four components of FRESH can
be used to prevent tobacco use.
Violence Prevention: An important element of a Health-Promoting School,
WHO/School/98.3, published in 1999 jointly by WHO, UNESCO, and Education
International to help individuals advocate for and implement violence prevention efforts
through schools. It describes strong arguments for initiating efforts to address violence
prevention through schools; concepts and qualities of a Health-Promoting School; and
specific ways in which schools can begin to use their organisational capacity to prevent
violence.
Healthy Nutrition: An essential element of a Health-Promoting School,WHO
/SCHOOL/98.4, published in 1998 jointly by WHO, FAO, and Education International to
help individuals advocate for and implement efforts to promote healthy nutrition through
schools. It describes strong arguments for initiating efforts to address nutrition and
healthy eating behaviour; concepts and qualities of a Health-Promoting School; and
specific ways in which schools can use their organisational capacity to improve nutrition
among young people,school personnel, and families. The document describes how each
of the four components of FRESH can be used to improve dietary practices.
WHO INFORMATION SERIES ON SCHOOL HEALTH
APPENDIX 1:
DOCUMENTS IN THE WHO INFORMATION SERIES ON
SCHOOL HEALTH
Strengthening Interventions to Reduce Helminth Infections: An entry point for the
development of Health-Promoting Schools, WHO/SCHOOL/96.1, published in 1996 by
WHO to help ministries of health and education establish policies, provide skills-based
health education, create a healthy environment, and provide school health services that
reduce helminth infections among students, their families, and the community. The
document describes how each of the four components of FRESH can be used to prevent
helminth infections.
Creating an Environment for Emotional and Social Well-being: An important
responsibility of a Health-Promoting and Child Friendly School, to be published in
2003 jointly by WHO and UNICEF to help school personnel assess the extent to which
their school environment supports emotional and social well-being. The document
contains a checklist and scoring instructions to help school personnel identify
environmental qualities that support emotional and social well-being among students and
school personnel. The document helps school personnel to determine the extent to which
those qualities exist in their own school.
Sun Protection: An essential element of a Health-Promoting School, WHO/NPH/02.6,
published in 2002 jointly by WHO/PHE, WHO/NPH, and UNESCO to help school
personnel assess the extent to which their school environment informs students and staff
about the harmful effects of the sun and enables them to protect themselves from these
effects.
Alcohol Abuse Prevention: An important element of a Health-Promoting School, to
be published in 2003 jointly by WHO/MNH and WHO/NPH to help schools use the four
basic components of FRESH to prevent the abuse of alcohol by students.
Active Living: An essential element of a Health-Promoting School, to be published in
2003 by WHO to help individuals advocate for and implement efforts to promote active
living (physical activity, sports and recreation) through schools. It describes strong
arguments for addressing active living; concepts and qualities of a Health-Promoting
School; and specific ways in which schools can use their full organisational capacity to
promote active living among students and school personnel.
Model School Tobacco Control Intervention, to be published in 2004 jointly by
WHO/NPH and WHO/TFI to help schools implement school tobacco control programmes
that are sharply distinguished from tobacco industry programmes and that engage youth
in global, national, and local efforts to prevent tobacco use. The document places strong
emphasis on actions that students can take to support the WHO Framework Convention
on Tobacco Control.
Creating a Health Supportive School Environment: An important responsibility of a
Health-Promoting School, to be published in 2003 jointly by WHO/PHE and WHO/NPH
to help school officials create a safe and secure environment for students and school
personnel, and to engage students in efforts to create a safer and healthier environment
for all.
Family Life, Reproductive Health and Population Education: Important responsibilities
of a Health-Promoting School, to be published in 2003 jointly by WHO/NPH, WHO/RHR,
UNESCO, and EDC to help school officials address the controversies and problems
inherent in school-based efforts that deal with these issues. It will help officials work with
community members to decide on the most appropriate ways to educate students about
these issues.
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APPENDIX 2: RESOURCES
ADVOCACY
Communication and Advocacy Strategies: Adolescent Reproductive and Sexual
Health. Booklet 2: Advocacy and IEC Programmes and Strategies. Booklet 3:
Lessons Learned and Guidelines (2001), co-published by UNESCO and UNFPA,
available from UNESCO Principal Regional Office for Asia and the Pacific, P.O. Box
967, Prakanong Post Office, Bangkok 10110, Thailand. Booklet 2 includes advocacy
strategies such as generating interest and commitment of decision-makers, winning the
support of various sectors, and developing recommendations and other documents.
Booklet 3 summarises lessons learned for advocacy and communications as well as a
discussion of factors that help and hinder in advocacy.
After Cairo: A Handbook on Advocacy for Women Leaders (1994), available from the
Centre for Development and Population Activities (CEDPA), 1717 Massachusetts
Ave. NW, Suite 200,Washington, DC 20036, USA.This handbook describes howto plan
and implement strategies for advocacy in the following chapters: "Planning for Advocacy,"
Taking Your Message to the Public," "Forging Alliances, " "Advocating for Resources, "
and "Advocacy Profiles. "
TB Advocacy: A Practical Guide (1998), WHO/TB/98.239, available from the Global
Tuberculosis Programme at the World Health Organisation, Geneva, Switzerland.
Even though it is written from the perspective of a different topic, this practical handbook
contains useful step-by-step information for planning advocacy efforts: documenting the
conditions, packaging the message, working with the media, and mobilising others.
Why should we invest in adolescents, by Martha Burt (1996), published by the Pan
American Health Organisation (PAHO) (1998), Washington , DC. This document, which
focuses on Latin America and the Caribbean, makes a case for the importance of investing
health and other supportive resources in the lives of adolescents in order to strengthen
future health outcomes and productivity. It provides a framework for working with adults,
reviews the circumstances and needs of Latin American and Caribbean youth, discusses
expected payoffs from investing in activities that promote adolescent health, and offers
recommendations for shaping and targeting investments in adolescents.
Communications Briefings: 101 Ways to Influence People on the Job (1998),
published by Briefings Publishing Group, 1101 King Street, Suite 110, Alexandria, VA
22314, USA. This is a practical guide on how to influence people. It gives guidance on the
role of the influencer, messages, and audience, and includes tactics for how to
persuade others, especially in workplace settings.
Influence: The Psychology of Persuasion (1993), by Robert B. Cialdini, published by
William Morrow, New York City. This book explains the six psychological principles that
drive our powerful impulse to comply to the pressures of others and shows how we can
put the principles to work in our own interest and defend ourselves against manipulation.
PLANNING AND EVALUATION
Coming of Age: From Facts to Action for Adolescent Sexual & Reproductive Health,
WHO/FRH/ADH/97.18, WHO (1997), available from Adolescent Health & Development
Programme, Family & Reproductive Health, World Health Organisation, Geneva,
Switzerland. This manual includes steps for planning, conducting, and using a situation
WHO INFORMATION SERIES ON SCHOOL HEALTH
APPENDIX 2:
RESOURCES
analysis specifically for adolescent sexual and reproductive health. Steps for conducting
the analysis include collecting existing information; collecting new information; managing
collected information; analysing collected information and data; and drawing conclusions.
Tips for Developing Life Skills Curricula for HIV Prevention Among African Youth: A
Synthesis of Emerging Lessons. Technical Paper No. 115 (2002), published by the
U.S. Agency for International Development, Bureau for Africa, Office of Sustainable
Development. For information or copies, contact the Africa Bureau Information
Center, 1331 Pennsylvania Avenue NW, Suite 1425, Washington, DC 20004-1703; or
e-mail to abic@dis.csdie.org. This document offers practical guidance for people who are
planning, implementing, or strengthening skills-based health education and life skills
curricula for young people in sub-Saharan Africa. Section I provides background information
on the issues of adolescent sexuality and vulnerability as well as implementation of HIV
prevention with young people. Section II offers practical tips for implementing life skills
programmes for young people, divided into "Tips for Planners," "Tips for Curriculum
Designers," "Tips for Teacher Trainers and Head Teachers," and "Tips for Administrators."
Section III is a bibliography of the documents reviewed, and Annex A contains a list of
example life skills curricula and contact information.
Getting to Scale in Young Adult Reproductive Health Programmes (2000), published
by FOCUS on Young Adults, available through Pathfinder International, 9 Galen
Street, Watertown, MA 02472, phone: 1-617-924-7200; fax: 1-617-924-2833;
http://www.pathfind.org/focus.htm.This document describes four models of scaling up
and presents four specific examples from different countries as well as key ideas and
lessons learned. This is complemented by a section with practical tools that includes ten
worksheets to help managers scale up young adult reproductive health programmes.
Learning to Live: Monitoring and Evaluating HIV/AIDS Programmes for Young
People, by Webb, D. & Elliott, L. in collaboration with the UK Department for
International Development and UNAIDS, published by Save the Children Fund, UK
(2000). Available from: Save the Children UK, 17 Grove Lane, London SE5 8RD UK;
phone: 00 44 20 7703 5400; fax: 00 44 20 7793 7626. This is a practical guide to
developing, monitoring, and evaluating practise in HIV/AIDS-related programmes for
young people, based on the experiences of projects around the world. It focuses on
recent learning from work with young people in: peer education; school-based education;
and clinic-based service delivery working especially vulnerable children and children
affected by HIV/AIDS. Offers examples of good practise throughout.
A Guide to Monitoring and Evaluating Adolescent Reproductive Health
Programmes(2000), published by FOCUS on Young Adults, available through
Pathfinder International, 9 Galen Street, Watertown, MA 02472, phone: 1-617-9247200; fax 1-617-924-2833; http://www.pathfind.org/focus.htm. Also available in
Spanish: FOCUS on Young Adults/Pan American Health Organization (2002). Manual de
monitoreo y evaluacibn. Washington, DC. The document can be viewed at
http://www.paho.org/Spanish/HPP /HPF/ADOL/monitoreo.htm. This 450-page document
is a how-to of monitoring and evaluation. It explains how to develop and monitor an
evaluation plan and covers indicators, evaluation design and sampling, and data collection
and analysis. It also contains 15 different instruments and questionnaires that can be
adapted to particular monitoring and evaluation needs.
SKILLS FOR HEALTH
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APPENDIX 3: SELECTED SKILLS-BASED HEALTH EDUCATION
INTERVENTIONS
TARGET/COUNTRY/ i
REFERENCE
Adolescents attending ten
secondary schools in two
districts in Namibia
Fitzgerald, A. M., Stanton,
B. E.Terreri, N., Shipena,
H., Li, X., Kahihuata, J.,
Ricardo I.B., Galbraith, J. S.,
and DeJaeger, A. M. (1999).
Use of Western-based
HIV risk-reduction
interventions targeting
adolescents in an African
setting. Journal of
Adolescent Health 25,
52-61. Reference ID: 8586.
INTERVENTION
METHODOLOGY
EVALUATION
METHOD
IMPACT ACHIEVED
Content:
The programme consisted of
14 two-hour sessions over
seven weeks which focused
on basic facts about
reproduction and risk
behaviours such as alcohol,
drug abuse, and violence.
Pupils were asked to
volunteer for study. Eighty
percent agreed; 515 youth
(median age 17 years;
median grade 11) were
given a baseline self
completed questionnaireand randomly assigned to
the control or intervention
group. A follow-up
questionnaire was given
immediately after the
intervention. The
questionnaire measured
knowledge, attitudes,
intentions, and HIV risk
behaviours. Following the
post-intervention
questionnaire, controls
were given the
intervention.
Knowledge increased
significantly among
intervention compared to
control youth (88% versus
82%; correct responses,
p< 0001). At post-interven
tion follow-up, more interven
tion than control youth
believed that they could be
intimate without having sex
(p<0.05%), could have a girl
friend or boyfriend for a long
time without having sex
(p<0.01), could explain the
process of impregnation
(p<0.05), knew how to use a
condom (p<0.0001) and
could ask for condoms in a
clinic (p<0.05). Fewer
intervention than control
youth believed that if a girl
refused to have sex with her
boyfriend it was permissible
for him to strike her (p<0.01)
and that condoms took away
a boy's pleasure. More inter
vention than control youth
anticipated using a condom
when they did have sex
(p<0.05), and fewer expected
to drink alcohol (p<0.05).
Finally, after intervention, there
was a trend for increased con
dom use (but not significant).
There were significant gen
der-related differences at
baseline, although the inter
vention method had similar
impact on both sexes.
Skills:
The sessions were derived
from protective motivation
theory and emphasised
communication and
decision-making skills.
Participatory methods:
The sessions were
facilitated during after-school
hours by a volunteer teacher
and an out-of-school youth
(either a student teacher or a
youth who had completed
grade 12) in a classroom to
groups of 15 to 20
mixed-gender students.
WHO INFORMATION SERIES ON SCHOOL HEALTH
APPENDIX 3: SELECTED SKILLS-BASED HEALTH EDUCATION
INTERVENTIONS
TARGET/COUNTRY/
REFERENCE
80,000 pupils in 800
secondary schools in
KwaZulu, South Africa
Harvey, B., Stuart ,J„ &
Swan, T. (2000). Evaluation
of a drama-in-education
programme to increase
AIDS awareness in South
African high schools: A
randomised community
intervention trial.
Int. J. STD AIDS 11,
105-111. Reference ID: 8726.
SKILLS FOR HEALTH
INTERVENTION
METHODOLOGY
Content:
HIV/AIDS prevention
Skills:
Communication and
decision-making skills.
Participatory methods:
During the first phase,
teams composed of
qualified teachers/actors
and nurses presented a
play incorporating issues
surrounding HIV and AIDS.
The second stage
involved team members
running drama workshops
in the schools, with
teachers and students
using participatory
techniques such as role
play. The programme ended
with a "school open day"
focusing on HIV and AIDS
through drama, song,
dance, poetry, and posters
all prepared and presented
by the students.
EVALUATION
METHOD
Two schools separated by
more than 10 km in each of
five districts (four rural and
one urban) were selected
to be intervention (receiving
the drama programme)
and control schools
(receiving a 10 page booklet
on AIDS). A self-completed
questionnaire was given to
the same standard 8 class
pupils before (n=1080) and
6 months later after the
intervention (n=699) -mean
age 18,3 in range 13-25
years. The questionnaire
included sections on
knowledge about HIV/AIDS,
attitudes relating to
personal susceptibility,
immediacy of threat and
perceived severity, attitudes
toward people with AIDS,
self-efficacy and reported
behaviour, including
whether have had sex,
condom use, and number
of partners.
72
IMPACT ACHIEVED
There was a greater
increase (p<0.0002) in
mean percentage score on
attitudesrelating to
HIV/AIDS; increased from
38.1 (n=491) to 50.5
(n=305) in intervention
schools compared with the
control schools (50.0,
n=585 to 51.8, n=394).
There was also a greater
increase (pcO.0000) in
mean percentage score on
attitudes with the interven
tion schools (38.1, n=491
before and 50.5, n=305
afterwards) compared with
the control schools (40.5,
n=586 and 40.3, n=392).
There was a slightly higher
behaviour change among
the sexually active students
in the intervention group,
but the increase was signif
icant only for increased
condom use (p<0.01). There
was no evidence of an
increase in sexual activity
as a result of the education
al programme. The main
limitations in this study,
which the authors noted,
were the lack of linking of
pre- and post-test (because
the questionnaires were
anonymous), the use of
outcomes based on
self-reporting, and the loss
of pupils from the original
pre-test sample.
However, it is important to
note that the achievements
measured had been
sustained over the sixmonth period between
pre-and post-test, showing
that the intervention had
achieved more than merely
short-term improvements.
73
APPENDIX 3: SELECTED SKILLS-BASED HEALTH EDUCATION
INTERVENTIONS
TARGET/COUNTRY/
REFERENCE
INTERVENTION
METHODOLOGY
Primary schools in
Soroti district of Uganda
Content:
School health curriculum
with AIDS prevention.
Shuey, D. A., Babishangire,
B. B., Omiat, S., &
Bagarukayo, H. (1999).
Increased sexual
abstinence among in-school
adolescents as a result of
school health education in
Soroti district, Uganda.
Health Education Research:
Theory and Practice 14,
411-419. Reference
ID: 8437.
Egyptian primary school
children
Kotb, M., Al-Teheawy, M.,
El-Setouhy, M., &Hussein,
H. (1998). Evaluation of a
school-based health
education model in
schistosomiasis: A
randomized community
trial. Eastern Mediterranean
Health Journal 4, 265-275.
Reference ID: 8384.
Skills:
Decision-making skills.
Participatory methods:
Formation and meetings of
school health clubs,
application of child-to-child
health education techniques
(peer education), and
competitions in plays,
essays, poems, and songs
on health-related issues.
Content:
Health education consisted
of three modules presented
over three days, covering
the risks from contaminated
water, the life cycle of
schistosomiasis, and the
nature and importance of
preventive health behaviours.
Skills:
Skills for preventive health
behaviour, including
screening.
Participatory Methods:
The methods included
health talks, stories, case
histories, role-plays, and
drama.
EVALUATION
METHOD
IMPACT ACHIEVED
A cross-sectional sample of
ten students (five boys/five
girls) per school, average
age 14 years, in their final
year of primary school, was
drawn from 38 randomly
selected schools. They were
given a self-completed
questionnaire in English
(but questions were
explained in local language).
The questionnaire was
given to a similar sample of
children after two years of
interventions.
The percentage of students
who stated they had been
sexually active fell from
42.9% (123 of 287) to
11.1% (31 of 280) in the
intervention group
(p<0.001 %), while no
significant change was
recorded in a control group.
The changes remained
significant when segregat
ed by gender or rural and
urban location. Students in
the intervention group tended
to speak to peers and teach
ers more often about sexual
matters (p=0.34). Increases in
reasons given by students for
abstaining from sex over the
study period were associated
with a rational decision
making model rather than
fear of punishment. The
project had aimed to achieve
sustainability through working
through the existing structures
and only employed one
additional full-time person.
A randomized community trial
of three pairs of comparable
schools in rural areas was
implemented. One school in
each pair received screening,
treatment, and health educa
tion, whereas the other
received treatment and
screening only. A baseline
study was carried out on 422
and 378 children from three
intervention and three control
schools, respectively. The first
post-intervention survey was
carried out one month after
the health education pro
gramme on 212 children in
the intervention schools. A
second post-intervention
survey was carried one year
after the intervention with
394 and 360 children in the
intervention and control
schools.
The study revealed a
significant improvement in
knowledge and attitudes as
well as a reduction of
schistosomal infection one
year post-intervention in
the intervention schools of
pairs 1 and 2 (p<0.05%).
However, the
improvements in
knowledge in the
intervention school of pair 3
were not accompanied by
significant changes in
attitude or schistosomal
infection.
WHO INFORMATION SERIES ON SCHOOL HEALTH
APPENDIX 3: SELECTED SKILLS-BASED HEALTH EDUCATION
INTERVENTIONS
TARGET/COUNTRY/
REFERENCE
Schoolchildren in Brazil
Albandar, J. M„ Buischi, Y
A., Oliveira, L. B., &
Axelsson, R (1995). Lack of
effect of oral hygiene train
ing on periodontal disease
progression over 3 years
in adolescents. Journal of
Periodontology 66, 255-260.
Reference ID: 6135.
INTERVENTION
METHODOLOGY
EVALUATION
METHOD
IMPACT ACHIEVED
Content:
Two oral hygiene training
programmes for the control
of plaque and the prevention
of gingival inflammation in
adolescents were evaluated.
The first group received a
comprehensive programme
based on individual needs
that included information
sessions pertaining to the
etiology and prevention of
dental diseases.
A population of 227
Brazilian schoolchildren was
examined clinically at
baseline and annually over
the next three years (19841987) to assess plaque and
gingival bleeding. The data
were analysed by a multi
level variance component
analysis and divided into
three groups: controls
(n=76), test 1 (n=79), test 2
(n=72); 4% of the sample
left the programme.
All children showed a
perpetual improvement in
their oral hygiene and
gingival state during the
course of the study. The
improvements observed in
the comprehensive group
were significantly better than
those of the control group.
Results from the less
comprehensive group did not
differ significantly from
those of the control group.
Longer exposure to the
programmes appeared to
produce more improvement;
children with higher plaque
and gingivitis scores prior to
the programme showed less
favourable results; girls
exhibited better results than
boys. The impact at the end
of three years was greater
than after one year, showing
importance of duration.
More impact was obtained
with girls.
The impact of the sessions
was assessed in terms of
changes in the pupils' oral
health knowledge, attitudes,
and practices. Three random
samples, each with 300
pupils, including
conventional and modified
session groups and a
reference group not given
oral health education at
school, were interviewed
and examined
The group that received
modified oral health
education had better knowl
edge of oral health (pcO.OOl),
reported reduced consump
tion of sugary foods (p<0.01)
and increased self-reported
tooth brushing frequency
(p<0.001), and had better
"mswaki" (chewing stick)making skills (pcO.OOl) and
slightly improved oral
hygiene; in comparison with
the referents. The group with
conventional oral health
education had better oral
health knowledge, but their
practices were no better than
the referents'.
Skills:
Self-diagnosis and oral
hygiene skills.
Participatory methods:
Skills training.
In addition, an information
session was arranged for
parents and teachers of
these children.
Primary school children in
Tanzania
Nyandindi, U., Milen, A.,
Palin-Palokas,T, & Robison,
V. Impact of oral health
education on primary
school children before and
after teachers1 training in
Tanzania. Health Promotion
International 11 (3): 193-201,
1996. Reference ID:
4160.
SKILLS FOR HEALTH
74
Content:
Modified oral health educa
tion and teacher training
workshops were carried out
in one district by a dental
team in liaison with school
administrators.
Skills:
Tooth-brushing skills;
making dietary choices.
Participatory methods:
Pupils actively studied the
concepts and practical skills
for dietary choices
and tooth brushing.
75
APPENDIX 3: SELECTED SKILLS-BASED HEALTH EDUCATION
INTERVENTIONS
TARGET/CO UNTRY/
REFERENCE
INTERVENTION
METHODOLOGY
Female student teachers
in Zimbabwe
Skills-based AIDS
intervention
Wilson, D„ Mparadzi, A., &
Lavelle, E. (1992). An
experimental comparison of
two AIDS prevention
interventions among young
Zimbabweans. Journal of
Social Psychology, 132(3),
415-417.
Content:
HIV/AIDS and sexual
health.
EVALUATION
METHOD
IMPACT ACHIEVED
Comparison between
lecture and interactive
group on knowledge and
skills before and after the
interventions.
Female student teachers
who participated in skillsbased AIDS intervention
were more knowledgeable
about condoms and their
correct use, had a higher
sense of self-efficacy,
perceived fewer barriers,
and reported fewer sexual
partners four months after
the intervention than their
colleagues who participated
in a lecture. The researchers
concluded that interactive
teaching methods are "better
than lectures at increasing
condom use and confidence
in using condoms and at
reducing the number of
sexual partners."
Students were randomly
assigned either to receive
the Life Skills Training (LST)
programme (treatment
condition) or the control
condition. The study began
when the students were in
the seventh grade and
continued in the eighth and
ninth grades with LST
booster sessions. Tobacco,
alcohol, and other drug use,
as well as other factors
associated with substance
abuse risk, were assessed
by questionnaire at the
beginning of the semester,
before programme
implementation, and at the
end of the semester.
Breath samples were
collected to increase the
reliability of self-reports.
Programme implementation
was monitored by project
staff in randomly selected
classes taught by the
teachers in the intervention
group. In the third-year
intervention study, data
were analysed to determine
differences in cigarette,
The results of the third-year
intervention study showed
that LST had a significant
impact on reducing
cigarette, marijuana, and
alcohol use for those
students whose teachers
taught at least 60% of the
programme. Results of the
six-year follow-up indicated
that the effects of the
programme lasted until the
end of twelfth grade.
Specifically, there were
44% fewer LST students
than controls who used
tobacco, alcohol, and mari
juana one or more times
per month, and 66% fewer
LST students who reported
using all three substances
one or more times per
week. The strongest
prevention effects were
produced for the students
who received the most
complete implementation
of the LST programme,
including the two booster
sessions. Other significant
findings include the
following: LST reduced the
Skills:
Focus on relationship skills
and condom use.
Participatory methods:
One group experienced a
passive lecture on the
topic, and the other
experienced interactive
group work.
6,000 students from 56
schools in the United
States
Several studies by Botvin,
G. J.; See
http://www.lifeskillstraining.com/LST1.html and
http://www.cdc.gov/nccdphp/dash/rtc/eva I6.htm
Contact information:
National Health Promotion
Associates, Inc.,
141 S. Central Ave. Suite
208, Hartsdale, NY 10530;
USA
tel. +1-914-421-2525
or 1-800-293-4969;
fax +1-914-683-6998
Content:
Substance abuse prevention/competency enhance
ment programme designed
to focus primarily on the
major social and psychologi
cal factors promoting sub
stance abuse. It consists of
15 classes that can be
implemented in the first
year of middle school. It
also includes ten and five
booster sessions for the
following two consecutive
years, respectively.
Skills:
Skills include resisting
social (peer) pressure to
smoke, drink, and use
drugs; coping with social
anxiety and anger;
decision-making skills;
communication skills; and
social skills.
Participatory methods:
The curriculum is based on
a person-environment
interactionist model that
assumes there are multiple
pathways leading to
WHO INFORMATION SERIES ON SCHOOL HEALTH
APPENDIX 3: SELECTED SKILLS-BASED HEALTH EDUCATION
INTERVENTIONS
TARGET/COUNTRY/
REFERENCE
Students in grades K-6 in
the United States
http://www. ed. gov/p ubs/E P
TW/eptw9/eptw9d. html
Contact information:
The American Health
Foundation, 800 Second
Avenue,
New York, NY 10017; USA
tel. +1-212-551-2507 or 5512509.
INTERVENTION
METHODOLOGY
EVALUATION
METHOD
IMPACT ACHIEVED
tobacco, alcohol, and drug
use. The curriculum impacts
social risk factors, including
media influence and peer
pressure, as well as
personal risk factors such
as anxiety and low
self-esteem.
It includes skills training
and practise of the skills
mentioned above.
alcohol, and drug use preva
lence between treatment
and control groups. Later,
data were analysed to
determine the long-term
effectiveness of the
prevention
use of inhalants, narcotics
and hallucinogens.
LST increased levels of
assertiveness, self-mastery,
personal control,
self-confidence, and self
satisfaction
Content:
The Know Your Body (KYB)
School Health Promotion
Programme consists of five
basic components: (1) skilly
based health education
curriculum, (2) teacher/coordinator training, (3) biomedical
screening, (4) extracurricular
activities, and (5) programme
evaluation. Through its
substance abuse, healthy
relationship, and skills mod
ules, the programme can
help reduce drug use and
violence. As part of the
training, programme coordi
nators learn how to improve
their school food service as
well as how to achieve a
smoke-free campus, thereby
creating an environment con
ducive to learning.
Several longitudinal
evaluations have
demonstrated the effect of
the KYB programme. It was
also named as one of the
"Educational Programmes
That Work" by the U.S.
Department of Education
in 1995.
Evaluation results have
demonstrated that the KYB
programme has a
significant positive effect on
students' health-related
knowledge, behaviour, and
biomedical risk factors such
as serum cholesterol levels,
blood pressure,
cardiovascular endurance,
smoking, and diet.
Skills:
The programme stresses indi
vidual responsibility for health
and provides the basis for
making health-promoting and
disease-preventing decisions.
Skills are related to age-appro
priate outcomes, such as
making healthy breakfast and
snack choices and asking
adults not to smoke in the
presence of the young people.
Participatory methods:
Age-appropriate skill modules,
including student activity
books and puppet sets.
SKILLS FOR HEALTH
76
in
APPENDIX 3: SELECTED SKILLS-BASED HEALTH EDUCATION
INTERVENTIONS
TARGET/COUNTRY/
REFERENCE
INTERVENTION
METHODOLOGY
Students in grades 9 and
10 in the United States
Content:
The Stanford Heart Health
Curriculum is a multi-factor
cardiovascular disease
risk reduction/prevention
curriculum for adolescents.
Lifestyle factors such as
cigarette smoking, diet,
physical activity, stress, and
personal problem-solving
are targeted.
http://www.ed.gov/pubs/EP
TW/eptw9.eptw9g.html
Contact information:
Stanford Centre for
Research in Disease
Prevention Stanford
University School of
Medicine 1000 Welch Road
Palo Alto, CA 94304-1885;
USA tel. +1-415-723-1000
Skills:
The curriculum is guided by
social cognitive theory and
emphasises self-regulatory
skill development, building
perceptions of self-efficacy,
and social pressure
resistance training. Each
module provides students
with information on the
health effects, normative
information on the
prevalence of unhealthy
behaviours, and cognitive
and behavioural skills that
enable them to change
personal behaviour; specific
skills for resisting social
influences to adopt
unhealthful habits; and
practise in using skills to
improve performance.
V
I
EVALUATION
METHOD
IMPACT ACHIEVED
This programme was
named one of the
"Educational Programmes
That Work" by the U.S.
Department of Education in
1995.
Students participating in the
programme make
significantly greater gains in
knowledge of cardiovascular
disease risk factors on
programme-developed and
validated criterionreferenced tests; show
beneficial physiological/
anthropometric effects in
terms of resting heart rate,
triceps skinfold thickness,
and subscapular skinfold
thickness; and are more
likely to report that they
would choose heart-healthy
snack items than a
comparison group.
A higher proportion of
baseline "non-exercisers"
participating in the
programme were classified
as regular aerobic
exercisers two months after
completion of the
curriculum; more baseline
"experimental smokers"
participating in the
programme reported
quitting at follow-up; and
fewer reported graduating
to regular smoking than
their comparison group
counterparts.
Participatory methods:
The curriculum features
guided role-playing
simulations, an introductory
video-drama focused on
personal choices and
consequences, discussion
sessions, and personal
change student notebooks.
WHO INFORMATION SERIES ON SCHOOL HEALTH
APPENDIX 3: SELECTED SKILLS-BASED HEALTH EDUCATION
INTERVENTIONS
TARGET/COUNTRY/
REFERENCE
Students in grades 6-8 in
the United States
http://www.projectalert.best.org
Contact information:
BEST Foundation For a
Drug-Free Tomorrow
725 S Figueroa Street,
Suite 970
Los Angeles, CA 90017;
USA
tel. +1-213-623-0580; fax
+ 1-213-623-0585
INTERVENTION
METHODOLOGY
Content:
Two-year drug prevention
curriculum for students in
grades 6, 7, and 8, called
Project Alert. The 14
lessons are designed to
prevent or curb drug use
initiation and the transition
to regular use. The
curriculum focuses on the
substances that
adolescents use first and
most widely: alcohol,
tobacco, marijuana, and
inhalants.
Skills:
Skills include resistance
skills such as resistance to
pro-drug pressures and
communicating with
parents.
Participatory methods:
Project ALERT uses
participatory activities and
videos to help students
establish non-drug norms,
develop reasons not to use
drugs, and resist pressures
to use drugs. Skills-building
activities utilise the
modelling, practise, and
feedback strategy. Guided
classroom discussions and
small group activities
stimulate peer interaction
and challenge students,
while intensive role-playing
encourages students to
practise and master
resistance skills.
Parent-involved homework
assignments extend the
learning process.
SKILLS FOR HEALTH
78
EVALUATION
METHOD
IMPACT ACHIEVED
The original programme
was tested in 30 middle
schools from communities
in California and Oregon
that included different geo
graphic areas, income and
population density levels,
and racial/ethnic groups.
One of the leading U.S.
research institutes on drug
policy has longitudinally
field-tested the Project
ALERT curriculum, and
undertook a rigorous
scientific evaluation.
Longitudinal testing
included 6,000 students
from 30 junior high schools.
Project ALERT was
designated as an
"Exemplary Programme"
by the U.S. Department
of Education in 2001.
Project ALERT is highly
effective with middle-school
adolescents aged 11 to 14
from widely divergent back
grounds and communities.
It has been successful with
high- and low-risk youth
from urban, rural, and
suburban communities,
with youth from different
socioeconomic levels, and
with Caucasians, African
Americans, Latinos, and
Asian Americans. The longi
tudinal evaluation showed
that Project ALERT:
- reduces the initiation of
marijuana and tobacco use
by 30%
- reduces heavy smoking
among experimenters by
50 to 60%
- is effective for both highand low-risk students,
including minorities
- performs equally well in a
variety of socioeconomic
settings
79
APPENDIX 3: SELECTED SKILLS-BASED HEALTH EDUCATION
INTERVENTIONS
TARGET/COUNTRY/
REFERENCE
INTERVENTION
METHODOLOGY
EVALUATION
METHOD
IMPACT ACHIEVED
Preschool through junior
high school students in
the United States
Content:
Second Step is a school
based social skills
curriculum that teaches
children to change the
attitudes and behaviours
that contribute to violence.
It also includes school and
family members as part of
a comprehensive approach
to reducing violence.
A one-year evaluation
involved 12 schools that
were randomly assigned
either to an experimental
group or to a control group.
Investigators examined the
impact of the programme
on aggression and positive
social behaviour among
elementary school
students. Second Step was
designated as an
"Exemplary Programme"
by the U.S. Department of
Education in 2001.
Behavioural observation
indicated that physical
aggression decreased from
autumn to spring among
students who were in the
Second Step programme,
and increased in students
in the control classes.
Friendly behaviour,
including pro-social and
neutral interactions,
increased from autumn to
spring in the Second Step
classes but did not change
in the control classes. Six
months later, students who
had received the
programme maintained the
higher levels of positive
interaction.
The investigators concluded
that Second Step leads to
moderate decreases in
aggression and increases in
neutral and pro-social
behaviour in school.
Without the Second Step
curriculum, student
behaviour worsened,
becoming more physically
and verbally aggressive
over the course of the
school year.
Formative assessments on
Second Step have shown
positive changes in student
attitudes regarding
aggression in middle school
and junior high school as
well as improvements in
social skills and knowledge
in grades pre/K-9 students.
No formal evaluation has
been carried out as of this
writing, but interviews with
programme participants
revealed the following
indicators of success:
• positive changes in
student behaviour
• increased problem-solving
• increased coping with
emotions
Parents noticed positive
changes in their children
that in turn had a positive
influence on family
relationships. A child was
able to stop a fight between
his or her parents using the
expressions from the
workshop. The levels of
aggressiveness in class
decreased. The children
http://www.cfchildren.org/vi
olence.htm
Contact information:
Committee for Children
2203 Airport Way South,
Suite 500
Seattle, WA 98134, USA;
tel. +1-206-343-1223
or 1-800-634-4449
Fax +1-206-343-1445
Skills:
The curriculum teaches
social skills to reduce
impulsive and aggressive
behaviour in children and
increase their level of social
competence. The same
three skills are addressed
in an age-appropriate way
at each grade level:
empathy, impulse control,
and anger management.
Participatory methods:
The main lesson format is a
photo lesson card. Lesson
techniques include
discussion, teacher
modelling of the skills, and
role plays. Lessons are
divided into foundation
lessons and two levels of
skill building that include
discussions and live-action
video. These three levels
allow for a comprehensive,
multi-year training in
pro-social skills.
Students aged 10-15 in
Colombia
Maria Luisa Vazquez
Navarrete. (1999). Regional
Study on School Health and
Nutrition in Latin America
and the Caribbean. Life
Skills Training in Columbia:
A case study. Washington,
_________________
Content:
This programme, carried out
by the NGO Fe y Alegria on
behalf of the Ministry of
Health, focuses on the cul
tural roots of violence and
unhealthy behaviour.
Skills:
The life skills training
modules address such skills
as coping with emotions,
J
WHO INFORMATION SERIES ON SCHOOL HEALTH
APPENDIX 3: SELECTED SKILLS-BASED HEALTH EDUCATION
INTERVENTIONS
TARGET/COUNTRY/
REFERENCE
INTERVENTION
METHODOLOGY
DC: World Bank/
Pan-American Organization.
problem-solving, and
effective communication.
Participatory methods:
Participatory methodology
is employed at every level;
this includes workshops
with parents.
Primary and secondary
school students in
Myanmar
Report provided by UNICEF
Myanmar
Content:
SHAPE (School-based
Healthy Living and HIV/AIDS
Prevention Education) is a
school subject taught in
grades 2 through 9 using a
spiral curriculum that pro
vides continuity. The curricu
lum aims to equip people
with knowledge and skills to
promote healthy living and
prevent the transmission of
HIV/AIDS.
Skills:
Life skills such as communi
cation, 'cooperation, coping
with emotions and stress,
decision-making, and prob
lem-solving as well as coun
selling are promoted.
Participatory methods:
SHAPE uses student-centred
participatory teaching and
learning methods, which
encourage students to prac
tise what they have learned in
the classroom and at home.
Peer education, child-to-parent
dissemination of information,
and collaboration between
schools and communities are
important strategies in the
SHAPE programme. Review
meetings, presumably with
theinvolvement of teachers,
students, school principals,
education officials, parents,
and other community mem
bers (evaluation details were
not provided)
SKILLS FOR HEALTH
80
EVALUATION
METHOD
IMPACT ACHIEVED
• changes in teachers'
attitudes and behaviours
• spontaneous demand for
life skills training
• Increased coping with
difficult situations
involvement of teachers,
students, school principals,
education officials, parents,
and other community
members (evaluation
details were not provided)
have learned to speak in
public and to express their
emotions. Teachers
increased their capacity to
listen and became more
sensitive toward the
students. Students who did
not participate in the train
ing requested to be
trained in life skills. After a
massacre, life skills work
shops helped cope with
the difficult situation.
Review meetings,
presumably with the
involvement of teachers,
students, school principals,
education officials, parents,
and other community
members (evaluation
details were not provided)
The successes of SHAPE
affected whole
communities. In one case,
a whole community is now
consuming iodised salt as a
result of what students
learned from SHAPE and
shared with their parents,
who in turn got together
and convinced the shop
keeper to change the type
of salt he sold. In another
community, an AIDS
orphan was recognised as a
full-fledged member of the
village after students
learned and shared the
truth about AIDS. These
examples illustrate the
long-term impact that
SHAPE can have, and show
that one or two people
changing their behaviour as
a result of what they have
learned can affect the
behaviour of the greater
community over time. The
immediate challenge is to
understand what conditions
encourage "positive
deviance" and to replicate
these conditions.
81
REFERENCES
Allegrante, J. (1998). School-Site Health Promotion for Staff. In E. Marx, S. F Wooley, and
D. Northrop (Eds.), Health is academic: A guide to coordinated school health pro
grammes. New York: Teachers College Press.
Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice Hall.
Bernard, B. (1991). Fostering resilience in kids: Protective factors in the family school and
community. Portland, OR: Western Centre Drug-Free Schools and Communities.
Blaber, C. (1999). Teenage health teaching modules: Lessons learned and challenges.
Presented at a meeting of Life Skills Experts at the Pan-American Health Organization
(PAHO), Washington, DC.
Blum, R. M. & Rinehard, P M. (1997). Reducing the risk: Connections that make a
difference in the lives of youth. Bethesda, MD: Add Health Project. Originally published in
Journal of the American Medical Association, 10 Sept. 1997.
Botvin, G. J. (2001). Life skills training: fact sheet. Available on-line at
http://www.lifeskillstraining.com/facts.html
Botvin, G. J. (1986). Substance abuse prevention research recent developments and
future directions. Journal of School Health, 56(9). 369-373.
Botvin, G. J., Eng., A., & Williams, C. L. (1980). Preventing the onset of cigarette smoking
through Life Skills Training. Preventative Medicine, 9, 135-143.
Botvin, G. J., Baker, E., Botvin, E. M„ Filazzola, A. D., & Millman, R. B. (1984). Alcohol
abuse prevention through the development of personal and social competence: A pilot
study. Journal of Studies on Alcohol, 45, 550-552.
Botvin, G. J., Renick, N. E., Filazzola, A. D., & Botvin, E. M. (1984). A cognitive-behaviour
al approach to substance abuse prevention. Addictive Behaviors, 9, 137-147
Burt, M. R. (1998). Why Should l/Ve Invest in Adolescents? Washington, D.C.: Pan
American Health Organization (PAHO), W. K. Kellogg Foundation. Also available
on-line at http://www.paho.org/english/hpp/adol_burt.htm.
Caribbean Community (CARICOM). (2000). Multi-Agency HFLE programme manual for
facilitators of life skills based HFLE programmes in the formal and non-formalsectors.
Georgetown, Guyana: CARICOM. Cited in Health and Family Life Education (HFLE) Life
Skills Training, Barbados, March/April 2001, compiled by HHD/EDC, Newton, Mass.
CARICOM & UNICEF. (1999). Health and Family Life Education: Empowering Young
People with Skills for Healthy Living. An information package. Bridgetown, Barbados
Caplan, M., Weissberg, R_, Grober, J., Sivo, P, Grady, K., & Jacoby, C. (1992). Social com
petence promotion with linner-city and suburban young adolescents: Effects on social
adjustment and alcohol use. Journal of Consulting and Clinical Psychology, 60(1), 56-63.
Centers for Disease Control and Prevention (CDC). (1999). Adolescent and school
health. Available on-line: http://www.cdc.gov/nccdphp/dash/ .
WHO INFORMATION SERIES ON SCHOOL HEALTH
REFERENCES
Cialdini, R. (1993). Influence: The psychology of persuasion. New York: William Morrow.
Dakar Framework for Action. Education for all: Meeting our collective commitments
(2000). Text adopted by the World Education Forum, Dakar, Senegal, 26-28 April 2000.
Paris: UNESCO. Available on-line at:
http://www.unesco.org/education/efa/ed_for_all/dakfram_eng.shtml
Deffenbacher, J, Lynch, R., Getting, E., & Kemper, C. (1996). Anger reduction in early
adolescents. Journal of Counselling Psychology, 41(2) 149-157.
Deffenbacher, J., Getting, E., Huff, M., &Thwaites, G. (1995). Fifteen-month follow-up of
social skills and cognitive-relaxation approaches to general anger reduction. Journal of
Counseling Psychology, 42(3): 400-405.
Dusenbury, L. & Falco, M (1995). Eleven components of effective drug abuse prevention
curricula. Journal of School Health, 65(10): 420-425
Elias, M., Gara, M„ Schulyer,T, Brandon-Muller, L, and Sayette, M. (1991) The promotion
of social competence. American Journal of Orthopsychiatry, 6(13). 409-417.
Elias, M. J. (1991). An action research approach to evaluating the impact of a social deci
sion-making and problem-solving curriculum for preventing behaviour and academic dys
function in children. Evaluation and Programme Planning, 14(4).
Englander-Goldern, P, Jackson, J., Crane, K., Schwarzkopf, A., & Lyle, R (1989).
Communication skills and self-esteem in prevention of destructive behaviours.
Adolescence, 14, 481-501.
Errecart, M.T., Walberg, H.J., Ross, J.G., Gold, R.S., Fiedler, J.L., & Kolbe, L.J. (1991).
Effectiveness of teenage health teaching modules. Journal of School Health 61(1)
26-30.
Evans, R., et al. (1978). Deterring the onset of smoking in children: Knowledge of imme
diate physiological effects and coping with peer pressure, media pressure and parent
modelling. Journal of Applied Social Psychology. 8.
Evans, R.l. (1976). Smoking in children: Developing a social psychological strategy of
deterrence. Preventive Medicine, 5.
Feindler, E., Ecton, R., Kingsley, D., & Dubey, D. (1986). Group anger-control training for
institutional psychiatric male adolescents. Behaviour Therapy, 17, 109-123.
Fishbein, M. & Ajzen, I. (1975). Belief attitude, intention and behaviour: An introduction
to theory and research. Reading, MA: Addison-Wesley.
Gachuhi, D. (1999). The impact of HIV/AIDS on education systems in the Eastern and
Southern Africa Region and the response of education systems to HIV/AIDS: Life skills
programmes. Prepared for UNICEF ESARO.
Gardner, H. (1993). Frames of mind: The theory of multiple intelligences. New York: Basic
Books.
SKILLS FOR HEALTH
82
83
REFERENCES
Gingiss, P (1992). Enhancing programme implementation and maintenance through a
multiphase approach to peer-based staff development. Journal of School Health, 62(5):
161-176.
Green, L. W., Kreuter, M. W., Deeds, S. G., & Partridge, K. B. (1980). Health education
planning: A diagnostic approach. Palo Alto, CA: Mayfield Publishing.
Greene, W. H. & Simons-Morton, B. G. (1984). \ntroduction to Health Education. Prospect
Heights, IL: Waveland Press.
Gresham, F, & Elliott, S. (1990). Social skills deficits are a primary learning disability.
Journal of Learning Disabilities, 22, 120-124.
Griffin, T. & Svendsen, R. (1992). Promising prevention strategies for the 90s. Piscataway,
N.J: New Jersey Alcohol/Drug Abuse Resource Centre and Clearinghouse.
Hansen, W. (1992). School-based substance abuse prevention: A review of the state of
the art in curriculum, 1980-1990. Health Education Research, 7(3), 403-430.
Hansen, W., Johnson, C., Flay, B., Graham, J., & Sobel, J. (1988). Affective and social
influence approaches to the prevention of multiple substance abuse among seventh
grade students: Eesults from Project SMART Preventive Medicine, (17), 135-188.
Harter, S. (1985). Manual for the self-perception profile of children. Unpublished
manuscript, University of Denver.
Hubley, J. (2000). School health promotion in developing countries: A literature review.
Leeds, UK: J. Hubley. Also available on-line at http://www.hubley.co.Uk/#leeds.
Hunter, S..M., Steyn, K., Yach, D.., & Sipamla, N. (1991). Smoking prevention in black
schools: A feasibility study. South African Journal of Education, 11, 137-141. As cited in
Hubley, 1998.
Infante, E (2001). Five open questions to resilience: A review of recent literature.
Prepared for the Bernard van Leer Foundation.
Jessor, R. & Jessor, S. (1977). Problem behaviour and psychosocial development:
A longitudinal study of youth. New York: Academic Press.
Jemmott, J.B., Jemmott, L.S., & Fong, G.T (1992). Reductions in HIV risk-associated sex
ual behaviours among black make adolescents: Effects of an AIDS prevention interven
tion. American Journal of Public Health, 82(3), 372-7.
Jemmott, J., Jemmott, L., & Fong, G. (1998). Abstinence and safer sex HIV risk-reduction
interventions for African Amercian Adolescents: A randomized controlled trial. JAMA,
279(19), 1529-1536.
Kaim, B. (1997). Adolescent reproductive health project: Peport on initial findings from
four schools in Mashonaland East. A working document, April 1997 Training and Research
Support Centre.
WHO INFORMATION SERIES ON SCHOOL HEALTH
REFERENCES
Kann L, Collins, J. L., Paterman, B. C., Small, M. L., Ross, J. G., & Kolbe, L. J. (1995).The
School Health Policies and Programmes Study (SHPPS): Rationale for a nationwide status
report on school health. Journal of School Health, 65, 291-294.
Kass, J.D. (1998). The inventory of positive psychological attitudes. In: C. R Zalaquett & R.
J. Wood (Eds.), Evaluating stress. A book of resources. Vol. 2, pp. 153-184. Lanham, Md,
& London: Scarecrow Press.
Kirby, D., Short, L., Collins, J., Rugg, D., et al. (1994). School based programmes to reduce
sexual risk behaviours: A review of effectiveness. Public Health Reports, 109, 339-361.
Kirby, D. (1994). School-based programmes to reduce sexual risk-taking behaviours:
Sexuality and HIV/AIDS education, health clinics, and condom availability programmes.
Paper presented at the annual meeting of the American Public Health Association, San
Diego, Calif., 31 October 1994.
Kirby, D. (1997). No easy answers: Research findings on programmes to reduce teen preg
nancy. Washington, D.C.: National Campaign to Reduce Teen Pregnancy.
Kirby D. (1999). Looking for reasons why: The antecedents of adolescent sexual risk-tak
ing, pregnancy, and childbearing. Washington DC. National Campaign to Prevent Teen
Pregnancy.
Kirby, D. (2001). Emerging answers: New research findings on programmes to reduce
teen pregnancy Washington, DC: National Campaign to Prevent Teen Pregnancy.
Summary available on-line at:
http://www.teenpregnancy.org/resources/data/pdf/emeranswsum.pdf
Kirby, D. & DiClemente, R. J. (1994). School-based interventions to prevent unprotected
sex and HIV among adolescents. In R. J. DiClemente & J. L. Peterson (Eds.), Preventing
AIDS: Theories and methods of behavioural intentions, pp. 7-139. New York: Plenum
Press.
Ladd, G. & Mize, J. (1983). A cognitive-social learning model of social skill training.
Psychological Review 90, 127-157.
Lam, J. (1989). School mediation programme evaluation kit. Unpublished manual.
Luthar, S. (2000). The construct of resilience: A critical evaluation and guidelines for future
work. Journal of Child Development, 71(3), 543-558.
Luthar, S. & Zigler, E. (1991). Vulnerability and competence: A review of research on
resilience in childhood. American Journal of Orthopsychiatry, 61(1), 6-22.
Mangrulkar, L., Vince Whitman, C., & Posner, M. (2001). Life skills approach to child and
adolescent healthy human development. Washington, D.C.: Pan American Health
Organisation.
McConaughy, S. H., Kay, R J., & Fitzgerald, M. (1998). Preventing SED through
parent-teacher action research and social skills instruction: First-year outcomes. Journal
of Emotional and Behavioural Disorders, 6(2).
SKILLS FOR HEALTH
84
85
REFERENCES
McGuire, W (1964). Inducing resistance to persuasion: Some contemporary approaches.
In L. Berkowitz (Ed.), Advances in experiential social psychology. New York: Academic
Press.
McGuire, W. J. (1968). The Nature of Attitudes and Attitude Change. In: G. Lindzey & E.
Aronson (Eds.), Handbook of social psychology. Reading, MA: Addison-Wesley.
Meeks, L. & Heit, R (1992). Comprehensive school health education. Blacklick, OH:
Meeks Heit Publishing.
Mize, J. & Ladd, G. (1990). A cognitive-social learning approach to social skill training with
low-status preschool children. Developmental Psychology 26(3), 388-397.
Ndlovu, R. & Kaim, B. (1999). Adolescent Reproductive Health Education Project: Lessons
from "Auntie Stella" reproductive health education in Zimbabwe's secondary schools.
Part One. Ministry of Education, Sport and Culture and the Training and Research Support
Centre, Harare, with support from the Royal Danish Embassy (DANIDA).
0 Donnell, L., Stueve, A., San Doval, A., et al. (1998). Violence prevention and young ado
lescents' participation in community youth service. Journal of Adolescent Health 24(1)
28-37.
Oleweus, D. (1990). A national campaign in Norway to reduce the prevalence of bullying
behaviour. Paper presented at the biennial meeting of the Society for Research on
Adolescence, Atlanta, 10-12 December. As cited in WHO, 1994.
Perry, C.L. & Grant, M. (1991). A cross-cultural pilot study on alcohol education and young
people. World Health Statistics Quarterly - fiappo/t Trimestriel de Statistiques Sanitaires
Mondiales, 44, 70-73. As cited in Hubley, 2000.
Peters, L. & Paulussen, T. (1994). School health - A review of the effectiveness of health
education and health promotion. Utrecht: Dutch Centre for Health Promotion and Health
Education. As cited in Hubley, 2000.
Piaget, J. (1972). Intellectual evolution from adolescence to adulthood. Human
Development, 15: 1-12.
Postrado, L. T. & Nicholson, H. J. (1992). Effectiveness in delaying the initiation of sexual
intercourse of girls aged 12-14: Two Components of the Girls Incorporated Preventing
Adolescent Pregnancy Programme. Youth and Society, 23(3).
Prochaska, J. O. (1979). Systems of psychotherapy: A transtheoretical analysis.
Homewood, IL: Dorsey Press.
Prochaska, J. 0. & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more
integrative model of change. Psychotherapy: Theory Pesearch, and Practice, 19(3), 276-288.
Rosenstock, I. M. (1966). Why people use health services. Milbank Memorial Fund
Quarterly, 44, 94-124.
Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social learning theory and the
health belief model. Health Education Quarterly, 15(2), 175-183.
WHO INFORMATION SERIES ON SCHOOL HEALTH
REFERENCES
Ross, J. G„ Luepker, R. V., Nelson, G. D„ Saavedra, P, & Hubbard, B. M. (1991).Teenage
health teaching modules: Impact of teacher training on implementation and student
outcomes. Journal of School Health, 61(1), 31-34.
Rutter, M. (1987) . Psychosocial resilience and protective mechanisms. American Journal
of Orthopsychiatry 57 (3), 316-331.
Webb, D. & Elliott, L, in collaboration with UK Department for International Development
and UNAIDS. (2000). Learning to live: Monitoring and evaluating HIV/AIDS programmes
for young people. United Kingdom: Save the Children Fund.
Schinke, S., Blythe, B., & Gilchrest, L. D. (1981). Cognitive-behavioural prevention of
adolescent pregnancy. Journal of Counselling Psychology, 28, 451-454.
Scripture Union, (n.d.). All the right moves: Lifeskills for an Aids-free generation: Twelve
to fifteen year programme. Rondebosch, South Africa: Scripture Union. As cited in WHO
1994.
Sheeran, P & Abraham, C. (1996). The health belief model. In M. Connor & R Norman
(Eds.), Predicting health behaviour, pp.23-61. Bristol, PA: Open University Press.
Shuey, D. A., Babishangire, B. B., Omiat, S., & Bagarukayo, H. (1999). Increased sexual
abstinence among in-school adolescents as a result of school health education in Soroti
district, Uganda. Health Education Pesearch: Theory and Practice, 14, 411^419.
Shure & Spivack. (1979). Interpersonal cognitive problem-solving and primary prevention:
Programing for preschool and kindergarten children. Journal of Clinical Child Psychology
Summer 1979.
Slaby, R. & Guerra, N. (1988). Cognitive mediators of aggression in adolescent offenders.
Developmental Psychology, 24, 580-588.
Smith, J. & Colvin, C. (2000). Getting to scale in young adult reproductive health pro
grammes. Focus tool series 3. Washington, DC: FOCUS on Young Adults. Available on-line
at http://www.pathfind.org/guides-tools.htm.
South Africa Ministry of Health and Ministry of Education. (1998). Life skills programme
project report 1997/98.
Tobler, N. (1998). A meta-analysis of school-based prevention programmes. Draft, 28
August 1998. (Author deceased after completing draft.)
Tobler, N. (1992) Drug prevention programmes can work: Research findings. Journal of
Addictive Diseases. 11 (3).
Tolan, P & Guerra, N. (1994). what works in reducing adolescent violence: An empirical
review of the field. Boulder, Colo.: Center for the Study and Prevention of Violence.
UNAIDS Inter-agency Working Group on HIV/AIDS, Schools and Education. (2001).
HIV/AIDS, schools and education, global strategy framework. Draft, July 2001.
UNESCO/UNICEF/WHO/The World Bank. (2000). Focusing Resources on Effective School
Health: A FRESH start to enhancing the quality and equity of education. World Education
Forum 2000, Final Report. Dakar, Senegal.
SKILLS FOR HEALTH
86
87
REFERENCES
UNESCO PROAP Regional Clearinghouse on Population Education and Communication,
UNFPA. (2001). Communication and advocacy strategies: Adolescent reproductive and
sexual health. Booklet 3, lessons learned and guidelines. Bangkok, Thailand: UNESCO
UNFPA.
UNICEF (2000). McKee, N„ Manocontour, E„ Saik Yoon, C., & Carnegie, R (Eds).
Involving people, evolving behaviour. ISBN 983-9054. Penang, Malaysia: Southbound and
UNICEF
UNICEF/CARICOM. (2001). Alternative student assessment for HFLE. October 23-26,
2001. Jolly Beach Resort, Antigua. Workshop binder, UNICEF.
UNICEF/EAPRO. (1998). The Mekong Project. A pilot life skills approach for HIV/AIDS
prevention education in schools. Lifeskills Education: Collected materials on Lifeskills
Education and its application for promotion of healthy lifestyles and HIV/AIDS prevention.
Available from UNICEF/HQ
------.□ or in UNICEF East Asia and Pacific Regional Office, or at
http ://www. u n i cef. org.
UNICEF (2001). The Participation rights of adolescents: A strategic approach. Prepared by
R. Rajani. Commissioned paper for UNICEF Available from UNICEF, or at
http://www.unicef.org/programme/youth_day/assets/participation.pdf
Vince Whitman, C. (2001). Advocating for school health: Presenting an effective case to
decision makers. Workshop presented at the Mega Country Meeting: School Health
Component, at IUHPE, Paris, France, 15 July 2001.
Vince Whitman, C„ Aldinger, C., Levinger, B., & Birdthistle, I. (2001). Education For All
2000 assessment. Thematic studies: School health and nutrition. Paris: UNESCO.
Vygotsky, L S. (1978). Mind in society. Cambridge, MA: Harvard University Press.
Werner, M. (1991). Adolescent substance abuse: Fisk factors and prevention strategies.
Maternal & child health technical information bulletin. Washington, D.C: National Center
for Education in Maternal and Child Health.
Werner, D. & Bower, B. (1982). Helping health workers learn. Palo Alto, CA: Hesperian
Foundation.
Wilson, D., Mparadzi, A., & Lavelle, E. (1992). An experimental comparison of two AIDS
prevention interventions among young Zimbabweans. Journal of Social Psychology, 132
Wodarski, J. S. & Feit, M. D. (1997) Adolescent preventative health: A social and life group
skills paradigm. Family Therapy. 24(3), 191-208.
World Bank. (1993). World development report 1993. New York: Oxford University Press.
World Health Organization [WHO]. (1997) Coming of age: From facts to action for
adolescent sexual and reproductive health. Geneva: WHO.
World Health Organization (WHO). (1997). Life skills education in schools
WHO/MNH/PSF/93.7A.Rev.2. Geneva: WHO.
WHO INFORMATION SERIES ON SCHOOL HEALTH
REFERENCES
World Health Organisation [WHO]. (1998). WHO's Global School Health Initiative:
Health-Promoting Schools. WHO/HPR/HEP/98.4. Geneva: WHO.
World Health Organisation [WHO]. (1999). WHO Information Series on School Health.
Preventing HIV/AIDS/STI and related discrimination: An important responsibility of HealthPromoting Schools. WHO/HPR/HEP/98.6. Geneva: WHO.
WHO/GPA. (1994). School health education to prevent AIDS and STD: A resource pack
age for curriculum planners. World Health Organisation/Global Programme on AIDS,
Geneva. As cited in WHO, 1994.
WHO/UNFPA/UNICEE (1995). Programing fore adolescent health. Discussion paper pre
pared for the Study Group on Programing for Adolescent Health. Saillon, Switzerland, 29
November - 4 December, 1995.
Young, M., Kelley, R., & Denny, G. (1997). Evaluation of selected life-skills modules from
the contemporary health series with students in grade 6. Perceptual and Motor Skills 84
811-818.
Zabin, L. S., Hirsch, M. B., Smith, E. A., Streett, R„ & Hardy, J. B. (1986). Evaluation of a
pregnancy prevention programme for urban teenagers. Family Planning Perspectives 18
119-126.
SKILLS FOR HEALTH
88
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