Executive Summary

3 Executive Summary

The purpose of this study is to report on the status of policies, programs and practices in the school systems and public health systems across Canada that seek to prevent the transmission of HIV/AIDS and to promote the sexual health of adolescents. In this study, HIV and STD prevention have been positioned within a healthy sexuality approach and connected to other health issues and to health promotion/education in general.

There have been no national Canadian studies of the status of policies, programs and practices. This study is the first of its kind in Canada. If decision-makers are to be informed on the progress being made in HIV/STD prevention, then accurate data on the performance and capacities of the two systems are required. This study provides a baseline for such policy and program monitoring.

The study was undertaken by a consortium of Canadian researchers for the Council of Ministers of Education, Canada (CMEC) with funding and support provided by the AIDS Prevention and Community Action Program of Health Canada. Education and health ministries in the provinces and territories were consulted and cooperated in the design and implementation of the study.

Recent HIV transmission data indicates that teens continue to be at high risk of HIV due to unsafe sexual behaviours and injection drug practices. School-based programs and preventive health services, delivered in schools or other youth friendly locations, can help to influence those health behaviours. Every year students need the benefit of well-delivered sexuality education, youth-friendly sexual health information and services, supportive school environments and school-parent cooperation to help them make healthy, responsible decisions. These programs and services influence the knowledge, coping skills, health beliefs, health services and social support available to adolescents.

The healthy social development of the child, health education, and sexuality education are a part of all core school mandates in Canada. Public health authorities are all mandated to promote school-based prevention as an effective means to reach all youth in the community. However, this study found that sexuality education competes with several other issues for attention within schools and that working in schools is a decreasing priority for public health systems. Yet HIV prevention and sexual health promotion for youth is an essential responsibility of public health and of schools. In short, both systems have a continuing job to do in HIV/AIDS prevention.

This study points out the need for clearer, achievable goals and objectives for HIV and for sexuality education for both systems. As well, this study could lead to enhanced accountability, better coordination within and between the two systems; more sustainable support for implementation through greater efficiency within the health and other curricula, more extracurricular program support, more involvement from parents and the community, students, improved adolescent preventive sexual health services and a framework for ongoing monitoring and reporting on progress.

Canadian Success Needs Maintenance

Earlier in the AIDS epidemic (1980s), schools and public health systems responded quickly and effectively to the AIDS crisis. Curricula were developed and implemented, policies developed and prevention campaigns were launched. Canadian systems were in the forefront of the worldwide response to AIDS. Education and health ministries and agencies worked together to develop policies and to organize awareness campaigns. However, the findings of this study indicate that many of these excellent, initial efforts are not being sustained.

Currently, schools and public health systems are challenged to meet increasing demands in the context of limited resources. As our knowledge explodes and as social or economic problems confront society, schools are under pressure from communities to teach more about technology, science, math, history, violence, the environment and many other issues. Health systems, including public health, are under pressure from increasing costs due to an aging population.

The Systems are in Transition

Faced with these pressures, governments have tried to decentralize the public service decision-making closer to the front-line. Provincial/territorial ministries are moving to policy coordination and monitoring roles. Local agencies and institutions are being given more flexibility to respond to local needs. This restructuring is evident in the responses to our surveys by personnel at all levels in both systems. More than one-third of all respondents reported that their employment status or roles were being, or had recently been, reviewed, restructured or changed.

At the same time, governments are trying to integrate and coordinate the delivery of programs and services more closely to reduce overlap and to increase synergy and impact. Several jurisdictions have introduced committees, agencies and even ministries to coordinate the delivery of programs and services to children and youth.

The findings of this study suggest that decentralization is proceeding in the absence of necessary linkages and connections between and within these two systems. The two systems are already based on a loosely coupled approach to public service delivery. As more decentralization is introduced, there is a greater need for both systems to articulate clear goals and priorities, to provide inter and intra-system communication, to encourage more cooperation with community resources and to support more staff development at all levels to enable personnel to play multiple roles.

These findings also suggest that gaps within and between the two systems are emerging. For example, at least two-thirds of respondents at all levels in both systems reported that there was not an active interagency committee helping to coordinate efforts. Research and other information is not being shared regularly. As well, the responses to several questions asking if data on student or systems performance were being collected or reported indicate that decision-makers are not being informed on a regular basis.

Major Findings

The survey component of the study is based on telephone interviews with randomly selected personnel at three levels in these two systems including:

As part of the overall study, several focus groups were held with students and parents in selected schools to help provide "voices" to accompany the survey data. A summary of their perceptions is reported here. Full reports on these focus groups are available. Some of the comments from the students and parents are used in this report to highlight some of the findings of the survey component of the study.

As well, a content analysis of ministry documents is provided separately. A full technical report is also available. Provincial/territorial reports will be provided to the ministries and their respective communities.

These findings present a status report on two systems, schools and public health, that have mandates to prevent HIV and STD and to promote sexual health. Data were collected during a period of rapid restructuring in both systems. The results are generally consistent with several smaller case studies in Canada and a comparable large scale study in the United States. Response rates were high, (over 80% in all cases) but difficulties had to be overcome in reaching adequate sample sizes in each jurisdiction. This study of two systems does not report on other prevention activities being undertaken by community groups, parents and other systems.

The data from the survey are presented here under five themes consistent with population health theory and its application to school programs (comprehensive school health):

Policy and Accountability

The findings suggest that the goals of the two systems with regard to sexual health are not clearly defined or understood. A minority (from 25% to 40%) of education and health respondents reported that they are following long-term policy goals for sexual health. Policy goals for HIV/AIDS were much clearer. As well, a minority of respondents reported that they were following explicit, long-term action plans for sexual health promotion. Again, HIV/AIDS action plans were much more explicit in both systems.

The standards expected within the two systems also appear to be unclear. Although all education ministries require sexuality education, only about half suggest or recommend a minimum time for that instruction. Ministry, school district, and school principal respondents report different results when asked if health education is mandatory. The actual classroom time reported by teachers (between three and eight hours per year) would appear to be insufficient according to research. As well, student achievement in health and sexuality education is not being monitored by education authorities.

About one-half of health ministries have described the nature of the preventive health services to be delivered to adolescents and a minority of public health respondents reported that they had a clear description of the role of public health in schools. Most health respondents reported that they are not conducting regular studies, nor receiving data, to monitor the sexual health behaviours of adolescents.

About one-quarter of respondents in both systems reported that they have defined the minimum standards or qualifications required of those who teach about sexuality or promote sexual health among youth.

Neither the school systems nor the public health systems are asking parents or students if they are satisfied with the programs and services being delivered.

Written policies that promote universal safety/hygienic precautions and enable students or employees with HIV to continue with their studies or employment are widespread. However, very few respondents reported that staff are being trained in the use of these guidelines. Compliance with these guidelines is also not being monitored.

In most jurisdictions, subordinate agencies are not being required by the level above them in the systems to prepare or implement comprehensive policies or action plans on HIV/sexuality .

Other related policies to support HIV prevention are also not in place in most jurisdictions. The role and education of guidance counselors in respect to sexual health problems is not clear. The role of the public health nurse working with schools is vague and being reduced. The majority of respondents at all levels and in both systems reported that they are not following an explicit policy to coordinate school, agency and community programs.

The respondents from both systems reported infrequent use of actions that facilitate or sustain implementation of education programs or services. These include administrative support, incentive grants, support for interdisciplinary cooperation, maintaining networks, promoting written interagency protocols and disseminating research.

Instruction

Instruction to prevent HIV is almost always delivered within a sexuality education unit that is part of a health curriculum. (Note: Several jurisdictions call their health curriculum a personal/social development program.) One-third of education respondents reported that they were actively supporting the integration of HIV/sexuality content in other curricula.

Teachers, on average, reported that they teach between three and eight hours on sexuality, including HIV, each year.

About two-thirds of teachers reported that they had received at least some minimal type of preservice education in sexuality education, usually in the form of a workshop or a lecture while attending university. One-half of school districts reported that they regularly offer inservice for sexuality education. One-third of teachers reported that they had participated in such inservice.

Most education respondents, at all levels, reported that they used the authorized list of teaching materials. One-third of education ministries, two-thirds of school districts and three-quarters of school principals reported that they purchased teaching materials about sexuality. About one-fifth of education ministries and school districts said that they were funding or developing electronic learning materials in HIV/sexuality. However, teacher responses indicate that high quality materials are not readily available on topics such as sexual orientation, sexual behaviours such as anal and oral sex, masturbation, coercive sex, and pleasure/fulfillment.

The teachers appear to be comfortable, feel competent and believe they cover most of the non-controversial sexuality issues. The teachers have taught for an average of 14.6 years and have taught, on average, a unit of sexuality education 20 times. However, many teachers reported that they do not cover topics such as sexual orientation, oral or anal sex, masturbation and pleasure/fulfilment. Also, most teachers use traditional teaching methods such as lectures, videos and large group discussions. Active learning strategies such as role-playing, student journals and small group discussions are used infrequently.

Seven out of ten public health nurses report that they are teaching about sexuality in classrooms, although the teacher responses indicate that they do not appear in the majority of classes. About 30% of education respondents at all levels reported that AIDS or sexuality organizations were helping them with instruction.

Preventive Health Services

Health respondents reported that sexual health services are mandated and delivered in all jurisdictions. Most health respondents reported that steps had been taken to adapt the delivery of these services to the needs of adolescents. About one-half of health respondents reported that they had adapted the sexual health services for gay and lesbian youth.

Adolescent access to the available services may be hindered by the fact that half of health ministry respondents reported that they advertised the availability of these services. Furthermore, only about one-half of health ministries and public health units reported that they coordinated delivery of these services with schools.

The nurses who work regularly in schools do so with about six schools, spending on average about 12 hours per month in those schools overall. However, not all schools benefit from nurse services. The average school in Canada receives about five hours of nurse presence in school per month, with about one hour per month, on average, spent on sexuality.

Nurses are qualified for their roles, with almost all reporting that they had a degree in nursing and with about one-third reporting that they had a major or minor in health promotion, sexuality or child/youth health. About half of the nurses reported that they had participated in at least three workshops related to HIV/sexuality. As well, the nurses, on average, had over 13 years of experience, over 10 years working with youth and over nine years working on sexual health.

Social Support

Most health respondents reported that they were no longer conducting or organizing youth-oriented media awareness campaigns about HIV/AIDS. The campaigns that were reported did not appear to be coordinated with school programs. As well, these campaigns did not appear to ensure that information and counseling resources were available to respond to inquiries generated from such media campaigns. There was little involvement of AIDS or sexuality organizations in government or health unit media campaigns.

Very few health respondents reported that they used media advocacy strategies to prevent HIV or promote sexual health. Less than 10% of health ministries and health units reported that they had aimed social marketing messages at the business community.

Less than half of health ministries and health units reported that they published or sent HIV or sexuality information to parents directly. Even fewer school districts and schools reported that they sent such information. About one-third of nurses reported that they coordinated their activities with HIV-related community events. A similar minority of teachers reported that they coordinated their teaching with community events. About two-thirds of nurses reported that they used AIDS Awareness Week materials.

Fewer than one-quarter of education and health respondents reported that they funded or worked with peer helper programs, student groups or youth groups in the community on sexual health issues and activities.

Healthy Physical Environment

Policies and procedures on universal safety and hygienic precautions have been written, but there has been little follow-up, monitoring, professional development or any other form of active support for these guidelines in either the public health or school systems.

Most school system respondents reported activity on harassment policies and the prevention of discrimination, but there may not be a specific focus on homophobia or preventing harassment of gays or lesbians. Public health respondents reported little activity in the prevention of any type of discrimination.

Major Findings of The Focus Groups

The views of the individuals selected to participate in the focus groups for this study cannot be interpreted as representing all students and parents. However, the results are generally consistent with other, similar small scale investigations.

Eight focus groups were held with students and parents in four communities across Canada. Students expressed frustration with the narrow scope of the sexuality education they received (anatomy, disease and condom use) and the repetition of certain activities or videos. Students wanted more coverage of topics such as sexual orientation, date rape, negotiation with sexual partners and sex behaviours. Hardly any students were aware of, or had ever used preventive sexual health services in their communities. Parents expressed concern about the readiness of teachers in sexuality education programs and whether sexual health services in their community were truly youth-friendly. Parents joined the students in calling for more in-depth sexuality education programs.

Suggested Policy Directions

The following general directions are suggested from an examination of the findings. These are included here for consideration by policy-makers and practitioners.

1. Focusing on Higher Risk Behaviours/Populations

Students who are at highest risk would benefit from greater protection and enhanced services. The higher risk behaviours associated with HIV transmission and populations who are at higher risk may be benefiting the least from the attention of school and public health programs. Teaching practices and materials about sexual orientation can be improved. The social climate in many schools discriminates against gay and lesbian students causing such students to deny their sexuality until their first sexual encounter. Current school programs against harassment could address homophobia. More involvement from public health professionals and agencies could help these students through information and other preventive sexual health services. As well, these health services could be adapted to meet their needs.

2.     Clearer Goals, Clarified Roles

Both systems would benefit from greater clarity about, and better monitoring of the outcomes being sought in school-based HIV prevention and sexual health promotion. Curricula could stipulate more specifically the minimum knowledge, skills, attitudes/beliefs and forms of social support that can be achieved through instruction and other school activities. These standards will not encompass all of the factors that influence sexual health behaviours, but the school’s contribution would be defined realistically.

These learning outcomes could then be pursued in cross-curricular learning, as well as earlier and later within the health curriculum. Further, the scope and sequence of the health curricula could be reviewed so that greater efficiency can be achieved by coordinating essential HIV/sexuality content with decision-making skills, media literacy and other generic skills that can be taught in the overall health curriculum. This will help avoid competition for time and/or duplication. These two curriculum strategies could help to increase the amount and quality of the instructional time available for HIV/sexuality.

Also, public health could articulate its objectives and minimum standards for preventive service delivery in adolescent sexual health promotion. Consequently, the role of the public health nurse in working with schools could be described, staffed and supported more effectively.

The education and qualifications required of teachers and public health staff could be defined and promoted in pre-service and inservice training programs.

3.     Sustained Support for Implementation

Teachers and their students would benefit significantly from enhanced electronic access to learning resources, more community and parent involvement and organized activities that engage students in health-promoting activities.

Teachers are either not aware of, or are not using, teaching materials on topics such as sexual orientation, oral and anal sex, pornography, masturbation and pleasure/fulfilment derived from caring, sexual relationships. These materials need to be developed or disseminated more effectively. The use of electronic means to deliver such materials could be utilized. This study indicates that technology is not being used extensively in health and sexuality education.

Both systems could seek more involvement of parents, AIDS/sexuality groups and students themselves. Parents should be supported in becoming involved in sexuality education. The implementation networks of teachers and others that have been established by many health and education ministries and agencies could be strengthened.

Research has shown that parents can be involved in health promotion in a variety of ways. More support, in the form of workshops and access to targeted information, could help parents in initiating dialogue with their children and in responding to specific situations.

Recent research on youth-led health promotion can be applied to HIV prevention and sexual health promotion. Youth could help their peers, create supportive social environments and advocate for programs and services.

4.     Better System Coordination

Public health and school systems would maximize the use of their limited resources if their policies and programs were coordinated more effectively.

The mechanisms for promoting cooperation between the two systems are not strong. More effective interministry/interagency communications, more use of active interagency committees, more dissemination of research and best practices as well as more staff support for coordination could all be used to improve coordination.

Support and more explicit policy direction for both systems could ensure that community-based resources are used effectively and efficiently. As well, personnel in both systems could receive training in collaboration and be assigned time for interdisciplinary and interagency cooperation.

5. Better Monitoring and Reporting

The public and decision-makers would be better informed and accountability would be improved if both systems enhanced their capability to monitor and report on progress and capacities within the two systems.

Data that are currently being collected on student knowledge in health and sexuality education could be used to monitor the effectiveness of programs and services. As well, regular client satisfaction surveys could be undertaken.

6.     Further Research

Knowledge about school-based health promotion and HIV prevention that should guide policy and program development would be greatly enhanced if this study led to further research on key questions.

Several directions for further policy-oriented research can be derived from this study. The section of this report that discusses the results of the surveys and focus groups includes 20 suggestions for future research. We highlight some of them here.

This research could answer important policy and program questions such as:

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