Rationale for this Study
7 Rationale for this Study
The rationale for this study begins with the data that demonstrate that youth are at risk for HIV infection using behaviour, knowledge, attitude and belief data from Canadian studies. A brief review of HIV prevention and sexuality education intervention approaches demonstrates the value of schools and public health making a contribution to HIV prevention and sexual health promotion. Finally, and most particularly, the gaps in our knowledge of the current status of HIV prevention and sexuality-related programs, policies and services are identified.
Young people are a key target group for AIDS prevention, more so with recent epidemiological evidence showing that the median age of HIV infection has dropped to age 23 from age 32 between 1985 to 1990, and corroborating Canadian evidence indicating that the age of HIV transmission has shifted to the teen years (Health Canada, 1996). Youth engage in several behaviours that place them at high risk for HIV infection.
The indicators of high-risk behaviours include the early age of onset for first intercourse, the rates of condom and contraceptive use, the high rate of unwanted pregnancies and STD infection, multiple partners, having unprotected sex while under the influence of alcohol or other drugs, as well as the rates of needle-sharing through crack-cocaine use, and engagement in other drug-using or risky behaviours.
Consistent with problem behaviour theory (Jessor & Jessor, 1977) several health compromising or at-risk behaviours co-occur among youth, increasing their effects. Of young people with two or more partners, 60% binge drink at least once a month, had sex before the age of 13 and did not use a condom the last time of intercourse (McCreary Centre, 1993).
Though the AIDS epidemic has created anxiety among youth, this has not resulted in a modification of risky sexual behaviour. An Alberta survey (Quality Control Research, 1988) found that only 35% of teens strongly agreed with the statement that the threat of AIDS has caused them to change their behaviour. The Canada Youth and AIDS Study (King et al, 1988) found that young people knew even less about how to prevent the transmission of sexually transmitted diseases, a finding consistent with other studies (Nagy et al, 1990).
A positive association was found between condom use and the belief that condoms can effectively prevent the transmission of HIV (Langille et al, 1994). Moreover, young people generally hold favourable attitudes towards sexual activity among themselves and their peers with three quarters of grade 11 students agreeing with premarital sex with a loving partner (King et al, 1988).
These findings suggest that interventions need to address knowledge deficiencies, incorrect beliefs and misconceptions about HIV/AIDS and STDs. While knowledge, attitudes and beliefs play an important role in motivating young people to change their behaviour, these pre-dispositional factors need to be complemented by skills and broader-based community and social support mechanisms (Otis, 1996).
Unfortunately, perceived ability and confidence of youth to engage in skills and practices related to positive sexual health behaviour (i.e. buying condoms, using condoms) have not been measured as frequently as behaviour, knowledge, attitudes and beliefs. As pointed out by King et al (1990a), many HIV/AIDS prevention curricula implemented in Canada did not address skill development, which may limit the ability of youth to either change their behaviour or to practise healthy behaviours.
In summary, a significant number of youth are at-risk for contracting AIDS and other STDs in the next decade.
Current Status of Sexual Health Programs, Policies and Services
Assessing the current status of HIV/AIDS/STD/sexuality programs, policies and services represents the first step in a logical sequence which would inform policy development and program planning for HIV and sexuality related program needs of youth. Despite research findings showing youth are at high risk for HIV infection, there have been no systematic studies at the national or provincial/territorial levels reporting on the status of school-related health promotion efforts to prevent AIDS/HIV.
A large body of research has focused on understanding the implementation of comprehensive school health promotion and of AIDS/ HIV/ STDs/sexuality education in this context. Policy and program implementation is important for several reasons. Many health education programs are viewed as failures, even when the failure is due to the fact that the program, service or policy was never fully implemented (Basch et al, 1985).
To date, a series of partial and informal studies have been conducted. The Barrett (1994) and Health Canada (1995) studies reflect the most recent attempts to provide overviews of school health promotion efforts. Barrett's (1994) study was commissioned by the Sex Information and Education Council of Canada to assess the extent and diversity of school-based sexuality education programming. This study relied on interviews with key informants in each province. The information was reported in an anecdotal fashion. Health Canada (1995) recently completed a study to assess the status of school-based and school-linked health programs and services across the country using surveys and telephone interviews with ministry officials. However, specific information regarding HIV prevention and sexuality was limited and the results are reported at only the provincial and territorial levels.
A 1988 survey (Canadian School Boards’ Association, 1989) of education ministry policies on AIDS reported on instructional mandates and requirements of hygiene and the management of HIV infected students or staff. This study was limited to analyzing the provincial policies and directives and reported primarily on precautions for HIV infected students and staff. Little attention was given to instruction.
A review of instructional programs (Canadian Public Health Association, 1989) described the programs available in each province or territory at that time. The review was based on telephone interviews with key informants. The results of the review led to the development of instructional resources as part of the National AIDS Strategy.
Ajzenstat & Gentilles (1988) reviewed the policies and programs of school boards in four provinces for the Human Life Research Institute. The study examined the content of the instructional programs as well as the policies of the school boards who responded to the survey. However, the sample was limited to the four provinces and sampling of the school districts was not random, nor was it stratified.
Munro et al (1994) found that effective instruction by classroom teachers had a positive impact on the knowledge, tolerant attitudes and behavioural intentions of grade nine and eleven students. The use of videos and guest speakers or alternative formats for teacher presentations (such as assemblies) influenced the attitudes of grade nine students. Presentations from public health nurses were successful in influencing the attitudes of grade nine students and the behavioural intentions of grade eleven students. Senior students attitudes and behavioural intentions were influenced by visits with a person from an AIDS organization.
King et al (1990b) reviewed the content of provincial/territorial curricula from an HIV/AIDS perspective. The study found the design of most curricula to focus upon medical facts rather as opposed to a skill-based, psychosocial approach. Gaps were also identified in the coverage of some issues and certain attitudes about AIDS/HIV. However, there have been significant changes in curricula since the previous study was conducted.
Previous research conducted in the United States has assessed the implementation of comprehensive school health education, including sexual health education. The School Health Policies and Program Studies (SHPPS), funded by the US Centers for Disease Control and Prevention, is the most comprehensive of these studies. SHPPS was designed to measure policies, services, and programs at the state, district, school and classroom level across multiple components of the school health program (Kolbe et al, 1995). Several other studies have assessed either the implementation of comprehensive school health or factors related to its implementation.
In summary, previous studies focused primarily on instructional programs provided by schools. The level of youth-focused public health programs, policies and services, and the level of school policies, services, and parental involvement is not currently documented.
To date in Canada, no national studies have systematically assessed the level of implementation of policies, programs and services at the school level, or integrated efforts with other ministries. Though the Health Canada (1995) study suggests that inter-ministerial collaboration is present in the provinces to varying degrees, the nature of this collaborative effort is not focused on HIV and school-related sexual health promotion. The degree to which health units collaborate with schools, and the degree of preparedness of teachers and nurses, as well as the availability of training resources and teaching materials is unknown.
Consequently, this study was initiated in consultation with education and health ministries across Canada. Relevant policy questions were identified in a federal/provincial consultation meeting and ministries were subsequently asked to participate.