M Taylor 1 , SB Dlamini 1 , N Nyawo 1 , R Sathiparsad 2 , CC Jinabhai 1 , H de Vries 3

1. Practical Challenges to the Implementation of Cognitive Theory-Based Lifeskills Programmes in South African Public Schools M Taylor1, SB Dlamini1, N Nyawo1, R Sathiparsad2, CC Jinabhai1, H de Vries3 1. Dept Public Health Medicine, UKZN; 2. School of Social Work, UKZN, 3. Dept of Health Promotion, Maastricht University

2. Background (1) • High prevalence of HIV /AIDS in SA • Youth 15-24 years at risk of infection • Young women at increased risk • Most SA children attend School – Not all complete high school (DED) • Strategy to reach large numbers of learners to prevent HIV infection • Dept of Education Policies include: HIV/AIDS Policy,1999; Guide for Educators, 1999; Inclusive Education Policy, 2003

3. Background (2) • Sexual transmission of HIV: known by most South Africans • Despite awareness campaigns by Govt, no decrease in HIV prevalence • Effective school-based programmes required • Life Skills: part of Life Orientation,OBE • Taught by the Life Orientation Educator • Includes information on HIV prevention and has a skills’ component • Every school due to implement by 2003

4. Health Education • Theory based interventions more successful: identify risk factors and target determinants • Most behaviour change theories originate in developed world • Effective in South African context? • Need comprehensive approach – address personal & ecological factors • Transtheoretical Model (Stages of Change)! “Precontemplation, Contemplation, Preparation, Action, Maintenance” 1 Prochaska (?/)

5. Planning Health EducationThe Precede / Proceed Model* PRECEED • Needs’ assessment to target and tailor the health education provided • Ecological perspective - Identify behavioural risk factors and psycho-social & physical environmental causes • Identify predisposing, reinforcing & enabling determinants PROCEED • Intervention to address the determinants that influence the risk factors to improve health *Green & Kreuter, 1999

6. Predisposing Factors MotivationFactors Ability Factors Behavioral factors Plans Psychological factors Attitude: Pros & Cons Rational & Emotional Performance Skills Biological factors Social Cultural factors Social Influences: Norms Modelling Pressure Intention State Behavior State Awareness Factors Precontemplation Trial Efficacy: Routine Social Situational Stress Knowledge Contemplation Cues to Action Maintenance Preparation Risk Perception Information Factors Message Barriers The I-CHANGE Model De Vries et al., 2004; 2005 Channel Source I-Change Model (Combination of Theories)

7. Intervention Mapping -Designing Evidence Based Health Promotion Programmes • Problem –eg. Lack of consistent condom use amongst sexually active learners • Use appropriate theories as conceptual framework to guide intervention. What are the best theories for condom use? • Methods to influence determinants of condom use? • Strategies? Develop Intervention Programmes: promote use of condoms? • Targeting learners at stage of change

8. Health Promoting Schools • School policy re Condoms??? - SGBs, Educators & Learners • Supportive environment: Schools not judged on quality of lifeskills’ programme; Stigma • Community support - Messages promoted in schools re condoms should be reinforced by parents, community, religious & political leaders • Skills: Educator training to assist learners; Counsellors in schools • Intersectoral links to reinforce health messages about prevention & treatment (health workers, CHWs etc)

10. Constraints to Effective Programme Implementation: School Facilities & Programme • Overcrowded Classrooms: grades 8-12, 40-90 learners in classroom • Insufficient time for in-depth focus • Small group discussions & role-plays difficult • Lack of teaching aids eg Videos • Lack of attractive, informative materials • Tailored messages required to address learner’s needs • School time-table

11. Constraints to Effective Programme Implementation – Educator Training • Lack of adequately trained Educators comfortable in discussing sexuality • Cultural constraints • Variable quality of Educator Training • Lack of provision of adequate resource material • Little monitoring of implementation and evaluation of training • Provision of regular updates, eg information on ARV roll-out • Address learners’ needs? Questions?? • Stigma?

12. LifeSkills Classroom Programme • Adolescents at vulnerable stage of development • Youth: wide age range at different stages of development • Both sexes: different needs • Lack of gender equity • Address Verbal abuse, Physical abuse, Sexual Abuse in Schools • Address Stigma around HIV/AIDS • Develop, Implement & Evaluate Programmes

13. Constraints to Effective Programme Implementation: Classroom Culture • Wide age differences amongst learners (13 to >20 years of age) • Lack of Gender Equity despite Bill of Rights • Boys scoff at girls’ opinions and denigrate their contribution • Girls lack self-efficacy to challenge • Classroom microcosm of community • High unemployment; sex perceived as resource to meet felt needs.

14. Health education to prevent HIV/AIDS • HIV prevention messages that promote abstinence or consistent condom use need to be positioned, targeted and re-inforced • Reach learners early to delay sexual initiation, and promote the use of condoms • Attitudes: Association of condom use with lack of trust, Males decide • Address determinants such as partner communication (James et al, 2003, Self-efficacy to use condoms, Know someone with HIV/AIDS (Taylor et al, 2006),

15. Recommendations • Improve Educator training • Health Promoting School: multiple approaches, delay sexual initiation, target stigma, condom policy • Use Theory based approaches to identify determinants / factors influencing behaviour • Targeted interventions eg. Inter -vention Mapping – Comprehensive to develop, implement & evaluate • Clear messages about HIV epidemic, prevention and treatment but no cure

16. Acknowledgments • Department of Education • Schools, Parents, Learners • Research Team • Funders: SANPAD, World AIDS Forum