Discussion of Results

10 Discussion of Results

This section of the report reviews the significant results of this study from two perspectives. We compare the results from this study to other, similar studies. We also compare the findings of the surveys with the results of the focus groups.

We have also applied research-based understandings of the nature of the two systems that are the subject of this status report.

For the education system, we have examined the results using the work of researchers such as Michael Fullan (1991), an expert on educational change and the work of Shannon & McCall Consulting (1993) which analyzed the role of school systems in preventing infertility for the Royal Commission on New Reproductive Technologies. For the public health system, we have used a recent work of the World Health Organization (1997) on the role of the local and district health centres as well as earlier work of the Canadian Public Health Association (1990) and the Canadian Association for School Health (Shea, 1991; Smith, 1991) to understand the potential role of the public health system and how it operates.

We have also called upon sources such as Green & Johnson (1996) research on diffusion that provides advice on the processes that are necessary to implement changes in public service systems. This research is consistent with the base of knowledge on educational change. We have also reviewed some of the specific research on AIDS and sexuality. For example, de Mauro has reviewed the impact of the US mandating sexuality education. Leithwood (Leithwood et al 1991; Leithwood et al, 1995) and Weick (1982) have explained the bureaucratic nature of school systems and how they are both open to outside influences at all levels as well as loosely-coupled, thereby making it difficult to unilaterally decide on their directions. These sources will be our basis for discussing the processes of diffusion and implementation of policy, moving from realistic policy to effective programs to sustained practices.

The format for the presentation of this section of our report is as follows; summary and findings, comparisons and lastly implications and conclusions.

We first summarize the findings of the interviews and questionnaires with education and public health personnel. The format for organizing the findings is the same as the sequence in the body of the report. We begin with some general observations and then discuss policy-making, curriculum and instruction, preventive sexual health services, social support and a safe, healthy physical environment in the school.

We next compare the relevant findings from the focus group discussions with students and parents. Once again a summary of these data is provided and discussed in relation to the other findings. A discussion of how these findings relate to the criteria for effectiveness that we presented in sections of this report is then presented. The overall findings are then compared with findings from other studies or related research.

We end our discussion of these summarized findings by identifying significant implications and by drawing some general conclusions. Some general suggestions for future policy directions are also presented in the conclusion of the report.

First, we have found that the previous levels of activity in both systems relative to the prevention of HIV and STD and promotion of sexual health has waned. Second, the two systems are in a period of significant transition and there are gaps within the two systems and between the two systems that are appearing. Third, governments at all levels and in all jurisdictions in Canada had been moving to roles more related to policy and evaluation. However, we have found that insufficient levels of monitoring and evaluation are occurring. Further, we find that policy is not being linked to resources and implementation.

1. The previous level of activity in school systems and in public health systems has declined. There are few examples of sustained public awareness campaigns. The curriculum time available for sexuality education in schools has been reduced as jurisdictions have combined health education with either career education or physical education. There has been a withdrawal of direct public health nurse services to schools thereby reducing the quantity and quality of the preventive sexual health services provided to adolescents in the location most convenient to them; schools.

The focus groups with students and parents indicate that both adults and adolescents realize that, although the parent is the primary sexuality educator, family-based discussions cannot always deal effectively with all sexual health topics. Students realize they can get sexuality, including HIV/AIDS and STD information from a variety of sources but feel that the school is the most reliable and objective source for such information.

The parents who participated in the focus groups for this study believe that sexuality education and preventive sexual health services for adolescents to be very important. Parents want sexuality education to begin earlier, last longer into the senior grades and be more comprehensive in scope. Parents also felt that sexual health services for teenagers were not readily accessible, nor convenient to teens, even if those teenagers were to become aware of them.

Caspar (1990) found that parental influence alone on teenagers is insufficient to delay intercourse or to guarantee a healthy birth or conception. However, his research and other studies show that parents and school-based programs can have an impact on the use of contraceptives and on the nature of the relationships formed by youth as they grow older and become sexually active.

A recent study sponsored by the DUREX company (Mallet, 1998) found that young Canadians begin to have sexual intercourse earlier than teenagers in most other countries. The global average was 17.6 years. Canadians, on average, begin to have sexual intercourse at 16.6 years. It is not surprising, perhaps, that this study reported that over half of Canadians support sexuality education programs beginning as early as age 10.

The research on educational change (Fullan, 1991: Hord et al, 1988) and diffusion of health promoting programs and practices (Ferrence, 1996: Green & Johnson, 1996) strongly suggests that sustained, ongoing efforts are necessary to ensure that programs and innovations such as sexuality education or adolescent sexual health services are maintained and remain effective. This is particularly true for a controversial topic such as HIV prevention where there are many influences that will affect implementation (Shannon McCall, 1993) and where the innovation must go through several levels in the system (Leithwood et al, 1991).

Beazley et al (1996), in their focus groups with teachers in Nova Scotia found that sexuality education is often supported in theory, but much less so in practice, by school district and school level administrators.

Implications

• Without continuous, sustained support for programs such as sexuality education and preventive services such as adolescent sexual health services, there is little likelihood that such programs and services will survive the constant competition for scarce resources within both public systems.

• Further, policy-makers need to be conscious of the fact that, although excellent efforts were made in the past within schools and public health systems, there is a new generation or groups of young people each year that reach the age of experimenting with and then beginning sexual activity.

Consequently, we conclude that sustained support for the implementation and maintenance of sexuality education and adolescent preventive sexual health services is required if policy goals are to be met continually through ongoing programs and professional practices.

2. The school systems and public health systems in Canada are in a time of significant transition. Gaps are emerging within the two systems and in the coordination between the two systems in regard to promoting sexual health and preventing HIV and STD. There have been a dramatic number of amalgamations in both the school systems and the public health systems. For example, in the past few years, the number of school districts in Canada has dropped from about 1100 to slightly over 600. Similar reductions in the number of public health units have occurred in several jurisdictions. As well, in both systems, there has been a government policy to decentralize the decision-making to the local community level. This decentralization appears to be happening without a clear understanding or consensus on the long-term policy goals for sexual health promotion, without adequate mechanisms to promote communication and coordination and without an ongoing commitment to staff development. One-third of the respondents at the ministry and school district/public health unit level reported that their positions are under review. Further financial and human resources in both systems are being reduced without ensuring that local agencies and professionals have better links to community-based resources.

School systems and public health systems can be characterized as loosely coupled and bureaucratic systems. In other words, governments and decision-makers are not able to simply direct or control front-line professionals and local agencies.

In the introduction of this paper, we outlined the many steps and processes that must happen in both systems in order for a sexuality education policy to be implemented in school systems (Shannon & McCall, 1993). These steps also apply to public health systems.

• system leaders need to create and maintain consensus on the policy goals of the systems

• support for cooperation and communication needs to be provided at all levels

• staff development needs to be ongoing so that personnel can assume multiple functions.

The findings in this study are consistent with other studies and research on the devolution and restructuring underway in school and public health systems in other jurisdictions.

Ajzenstat and Gentiles (1988), in their review of sex education policies and programs in four Canadian provinces, found that, except for Saskatchewan, sexuality education programs evolved locally in the '70s and '80s. However, in the late eighties, this process began to change as education ministries improved, upgraded and mandated sexuality education in response to the threat of HIV. Currently, all Canadian provinces and territories mandate or require sexuality education and/or HIV education.

The World Health Organization (1997), in a review of the role of local community health centers in countries around the world, noted that health authorities were decentralizing responsibility to these local centers and requiring them to play more of a community development role. The Quebec CLSC model was cited as an example of this shift in role and responsibility. However, the authors of that report called for a significant increase in the staff development programs for public health so that they could play this decentralized, community development role more effectively.

Muller and Pollard (1994) have showed how the linkages among education, health and other systems need to be strengthened if policy-making is to be effective in today's decentralized environment. Their report on the Arkansas Family First initiative highlights the use of family and youth service centers as a hub of service delivery and program coordination. Similar to the WHO (1997) report, these researchers suggest that the local health centre (clinic) should be the hub of intersectorial activity and cooperation. However, in the past and in the results of this study, the local clinic has been viewed primarily as the front-line delivery mechanism for clinical services.

Implications

The delivery of sexuality education and adolescent sexual health services needs to be coordinated if they are to jointly have an greater impact on the sexual behaviours of Canadian youth.

Consequently, we suggest that the public health system be given the role, resources and staff training required to coordinate the delivery of adolescent sexual health programs. Further, we suggest that the ties between schools and the local health centres be strengthened.

3. Education and health ministries have transformed their roles in the past few years, moving towards more emphasis on policy coordination and monitoring. However, the findings of this study indicate that there is little monitoring and ongoing evaluation of the programs and services in both systems relative to sexual health promotion and prevention of HIV and STDs. For example, student achievement in health/sexuality education is not being monitored by education authorities, the sexual knowledge, attitudes and behaviour of youth is not being tracked by health authorities, the levels of public awareness of sexual health issues is not being assessed regularly, and the programs and practices of school districts, health units and front-line professionals are not being regularly recorded.

If decision-makers are to be informed about the impact of their decisions, they need regular, reliable and comparable reports on the context, inputs, processes and outputs of their systems.

The results of this national study show that these reports are not being produced or reviewed by decision-makers, even when the data might be readily available.

Other systems, notably those in the United States, are moving towards regular systemic reporting on youth health and the performance of school systems and public health systems. For example, the Centers for Disease Control have developed a Youth Risk Behaviour System (Kann et al, 1995) that tracks sexuality as one of six health issues that challenge today’s youth. The education and health systems are now into their second round of data collection of the School Health Policies and Programs Study (SHPPS) (Kolbe et al, 1995), a policies and program review that collects data on HIV/sexuality. The performance of the public health systems in the US are being measured against national standards (Turnock et al, 1994). The National Education Goals Panels (NEGP, 1998), reports regularly on two national goals that relate to student health.

Implications

• The Council of Ministers of Education, Canada has developed two ongoing mechanisms for reporting on the performance of school systems in Canada; the School Achievement Indicators Program, that monitors and compares learning in literacy, numeracy and science, and the Pan-Canadian Education Indicators Program, that tracks several issues and factors related to learning and school system performance. The CMEC has expressed interest in expanding the scope of these monitoring systems to include student and school health.

• Health Canada is currently cooperating with health, social service, justice and education ministries to develop a system to monitor the healthy development of children and youth. Presumably, HIV and sexuality will be part of that framework.

• Further, the Advisory Committee on Population Health, a joint federal/territorial body of Health Canada and the health ministries, is developing a framework for adolescent health. Sexuality and HIV need to be an important part of that work.

Consequently, there is a significant need for better monitoring and reporting mechanisms in both the school systems and the public health systems relative to sexual health promotion and prevention of HIV and STD. We suggest that CMEC and Health Canada use this study as a prototype for the development of an ongoing cooperative strategy to monitor school health polices and programs in Canada. We further suggest that the development of this system be coordinated as much as possible with other countries such as the US and the members of the Organization for Economic Cooperation and Development (OECD) for the purposes of international dialogue.

Policy Making, Implementation and Evaluation

4. The results of the study indicate that an appropriate policy-making cycle is not being followed in the school systems or the public health systems in regard to sexual health promotion or the prevention of HIV and STDs. An appropriate policy-making cycle includes problem formulation/reformulation, consultation, policy adoption, implementation and evaluation. In the late eighties, there was considerable effort to develop AIDS/sexuality related policies. Our findings suggest that the implementation and impact of these policies and ensuing programs is not being regularly assessed.

Effective policy-making is cyclical in nature (Burnam, 1989; CASH, 1996; King & Muthen, nd; Wallatt & Piazza, 1991; Downey, 1979). There needs to be a reporting mechanism and implementation timetable built into the policy adoption process.

Implications

• Policy-making, implementation and evaluation is the central process by which education and public health decision-makers can influence the direction and performance of their respective systems. If the process is faulty, the outcomes will not be apparent to decision-makers or the general public.

Consequently, we suggest that school system and public health system policy-makers undertake a review of the content and processes related to their policies on HIV/STD prevention as well as sexual health promotion. This review should focus on how the HIV/sexuality problem(s) have changed since those policies were adopted, assess and consult on the impact and effectiveness of current policies and programs and establish mechanisms to report more regularly on progress.

5. Long term policy goals for sexual health promotion are not clearly understood by respondents in both systems. Less than one-half of education and health respondents at all three levels were aware of written policy goals for sexuality education. Long-term goals for HIV prevention appear to be more explicit and better understood by respondents in the public health systems. Education respondents often referred to the sexuality/health curriculum for their policy direction. However, according to these survey results sexuality curriculum documents may not answer the key policy expectations of how much? when? and how it will be evaluated?

The responses from the parents who participated in the focus groups reflect this lack of clarity in respect to the long-term policy goals of the systems. Those parents did not think that they were adequately informed of the content of sexuality education programs. They were also unaware of how and where adolescent sexual health services were delivered in their communities.

The first criteria for effective policy-making cited in this study is that policy expectations need to be clearly understood by the personnel and participants in any public service system (Health Canada, 1994; CASA, 1992; CPHA, 1993). These policy directions need to be linked to available resources, both human and financial. The National School Boards Association (NSBA, 1981) has defined good policy as creating a framework within which the system staff can discharge their duties. Effective policies tell what and why the decision-makers want it, how much of it the decision-makers want, by when it should be implemented and how it will be evaluated and reported.

A review by the Canadian School Board Association (1989) of education ministry policies show that most education ministry policies did not describe how much, by when or how the policies would be evaluated. A model AIDS policy for school boards developed by the Canadian Association of School Administrators (1990) had to be drawn from several examples from school districts because not all, or even many, of the policy expectations were clearly defined in any single example.

The SHPPS study (Small et al, 1995) found that 77.2% of junior high and senior high schools in the US had written policies on HIV/AIDS. This study found that 65.9% of school principals follow ministry guidelines. But only 54.5% of education ministries said they had a written policy on HIV/sexuality.

Although there are several case studies demonstrating the effectiveness of school-based sexuality education, peer helper programs, preventive school health services for adolescents, and parental involvement, there is no compiled body of knowledge about the minimum levels of service/programs, and the standards for delivery of such programs in schools. Health Canada has defined general standards for sexuality education (Health Canada, 1994) and for preventive sexual health services (Health Canada, 1998), but these standards have not been applied to the school setting or to youth specifically.

Implications

• School systems and public health systems personnel should be guided by clearly articulated policy expectations about sexual health promotion and HIV/STD prevention. These expectations should delineate why, how much, by when and how the programs and practices used to implement these policies will be evaluated.

• the knowledge, beliefs and skills for sexual health that can be taught;

• the minimum levels of preventive sexual health services for youth that should be delivered in or near schools;

• the social support that can be generated by working closely with student groups, parents and community organizations;

• the minimum standards for a safe healthy school environment including the use of hygienic precautions and the prevention of harassment or discrimination.

6. The majority of school systems and public health systems do not have long-term action plans for sexual health promotion or preventing STDs. Less than one-half of respondents at all levels in both systems said that they have such action plans. Three-quarters of health ministries said they have an action plan on HIV prevention but only 56% of public health units and 42.8% of public health nurses reported that they have HIV prevention action plans.

This finding is in direct contradiction to our second criteria for effective policy-making; that explicit action plans should guide staff efforts at all levels in systems (Crighton, 1987; Odden, 1991; Roper et al, 1992; WHO, 1992; Canadian Public Health Association, 1996).

The results from this study are similar to other studies about the implementation of sexuality education. As well, recent research about the role of the public health system in promoting health or preventing HIV indicates that these systems may be in disarray.

• the size and complexity of the curricula that included a skills/behavior "health action model"

• lack of support for implementation and maintenance

• deficiencies in teacher education

• low levels of teacher comfort with suggested teaching methods and student assessment strategies

• teachers encountering classroom management problems with sensitive issues

• lack of administrative support

• the difficulty in locating appropriate teaching/learning materials.

Research on how educational innovations succeed or fail (Fullan, 1991; Hord et al, 1988; Adams, 1988) reinforces these findings and the need for appropriate implementation/
diffusion plans.

In addition to these normal problems of implementation, there may be additional barriers to youth and school-based HIV/STD prevention and sexual health promotion; namely the current disarray and crisis in the role of public health systems.

In 1993, the Canadian Public Health Association (CPHA, 1993) issued a report on the role of public health in preventing HIV. One of the conclusions of that report was, "there is a need to clarify and promote the role of public health in HIV and AIDS". Similarly, Turnock et al (1994) have reported that there is a lack of consensus in the U.S. public health community as to the purposes and content of organizational public health practice. They also found that less than 40% of American public health departments were successfully addressing core functions derived from a research review. Newell (1989) found that public health districts were understaffed and underfunded to accomplish their functions.

At a provincial level, Chambers et al (1994) assessed the current roles of public health nurses in Ontario relative to a set of expectations published by the Canadian Public Health Association. They found that nurses were active as educators/consultants, social marketers and facilitators. However, nurses were not active as community developers, policy designers, researchers and resource planners. Our study suggests that public health nurses are now facing further reductions in their capacity to play roles as educators, social marketers and facilitators.

Implications

• The absence of diffusion/implementation/maintenance plans in about half of the school and public health systems should be a source of concern for decision-makers. Sustainable implementation and maintenance plans should exist at all levels if sexual health promotion and HIV/STD prevention is to be effective.

• The role of the public health system in preventing HIV and promoting sexual health needs to be clarified in policy. As part of this, the role that public health should play in working with school systems needs to be articulated. The withdrawal of direct public health nurse services to schools should be part of this review.

Consequently, we suggest that further research into the cost-effectiveness of delivering preventive health services in or near schools should be investigated. This investigation should include the many roles that public health can play in working with school systems including research into local health needs, educator/consultant on programs, facilitating student access to health services, working with parents, advocating for policy and monitoring outcomes.

8. Current policies do not clearly set minimum standards for sexuality education. Education ministries almost always stipulate that health education, sexuality education and HIV education are required, but school district and school responses indicate that these mandatory requirements are not always followed. For example all education ministries say that health education is required to the end of junior high. However, only about 75% of school districts and 60% of school principals report that it is mandatory in their schools. Similarly, about three-quarters of education ministries say that sexuality education is required in junior high grades. That proportion declines to about two-thirds at the school district level. Less than 40% of school principals say that sex education is required in grades 7, 8 and 9. Student achievement in health education is not being monitored by education ministries, although it is being reported like other subjects to ministries by schools.

As well, about one-half (54.5%) of education ministries say that they stipulate or recommend a minimum time for sexuality education in the timetable. The average time recommended or required is 8.3 hours for sex education, with about 45-50 hours required for health education. A majority of school districts and school principals say that they follow these minimum times but it is clear that most respondents did not know what they were. Teachers report that they teach between three and eight hours of sexuality education per year, depending upon the grade level.

These findings are echoed in the comments from students and parents in the focus groups. Parents and students thought that sexuality education should be more comprehensive, start in earlier grades and extend into senior high school when students are likely to be continuing to making the decisions about sexual activity. Parents in the Nova Scotia and British Columbia focus groups thought that more curriculum time should be allotted to sexuality education.

The research on policy development clearly shows that, to be effective, policy expectations should include minimum standards to guide delivery of programs and professional practice (CASA, 1992; NSBA, 1981; Crighton, 1981). While the research in sexuality education does not clearly indicate the minimum time to be spent in classrooms, case studies of effective sex education hours are usually over 10 hours per year.

A study done for the Council of Ministers of Education, Canada (Warren & King, 1996) found that an instructional program of 26 hours was successful in influencing sexual behavioral intentions of grade nine students. However, without maintenance in later grades, the behavioral impact of this program, Skills for Healthy Relationships, declined in respect to delaying the onset of sexual activity.

As well, the research on the specific impacts of sexuality education needs to be reviewed. Some studies suggest that young people will begin sexual activity in their teen years, regardless of sex education or parental influence. What needs to be studied is whether sexuality education influences the relative degree of risk they encounter in becoming sexually active and the nature of the relationship they have with their sexual partner.

This difficulty in securing compliance and adequate time in the school timetable is reflected in other studies. Friesen et al (1988), in a qualitative study of the implementation of a Family Life Education program in British Columbia found that the first problem identified by school administrators whenever a new program is implemented is finding the time to fit it in the school timetable.

Ajzensat & Gentiles (1988), in a survey of 245 school districts in four Canadian provinces, found that 57% of school districts had sexuality education guidelines, up from 21% in a similar survey done in 1977 by the Canadian Education Association. They found these average numbers of hours of sexuality instruction for health education/sex education.

Figure 223

Barrett (1994) reviewed education ministry curricula in Canada and found that sexuality education was required in all but one jurisdiction to the end of junior high grades. (The one province without mandatory sex education did require HIV education).

The evaluation of the Saskatchewan Health Education curricula (Saskatchewan Education, 1996) noted that 120 minutes/week were recommended for grade 7 and 100 minutes/week for grades 8 and 9. The study found that about 40% of teachers reported they taught less than 60 minutes/week.

From these Canadian studies, it would appear that the number of hours devoted to sexuality education has declined in recent years. This is likely due to the reduced time now available for health education, which is being combined with career education or physical education in most jurisdictions. It would also appear that Canadian schools also do not simply follow ministry curriculum mandates, as was noted in the Muraskin (1986) review of US school districts.

Other studies from the US indicate that the Canadian school systems are requiring about the same or less sexuality education than their American counterparts. Kenney et al (1989) in a survey of states and large school districts found that 80% of the states require or encourage sex education and 90% of these school districts support sex education. However, these results are skewed somewhat because larger school districts are often bolder than rural districts in offering sex education.

Holtzman et al (1992) surveyed U.S. school districts and found that two-thirds (66.9%) required HIV education. They also found that sex education was concentrated at the junior high school level and dropped off in senior grades.

Collins et al (1995) in an overview report of the SHPPS Study in the U.S. found that 90.2% of states and 90.8% of school districts require health education. They also found that 48.9% of states and 76% of school districts required that sex education be taught. Another analysis of that report (Centers for Disease Control, 1997) found that 78.7% of states, 83.0% of school districts and 85.6% of high schools required HIV prevention education. STD education was required in 65.1% of states, 80.9% of school districts and 84.1% of secondary schools.

The US data can be compared to a similar general question in our study. 100% of provinces/territories, 87.6% of school districts and 84.6% of schools told us that they require sexuality education at some grade level.

However, the SHPPS study found that 71.3% of schools said that they required students to repeat the health education course if they failed the course requirements. Our study asked a similar question and found that 23.6% of schools said that students took the health education course again.

Implications

• Policy-makers need to be more explicit about the minimum standards for the delivery of sexuality education.

• Decision-makers should assure themselves that the teaching time available in the school timetable is sufficient to meet required learning outcomes.

Consequently, we suggest that policy-makers review their policy expectations regarding sexuality education to ensure that the scope and sequence of sexuality education is appropriate. (Should we be concentrating as much time in junior high? Should we teach more about sexuality in earlier grades? Or should we require coverage in senior grades, when students are deciding about sexual activity? What knowledge and skills should be included? In what order should these be presented?

As well, we suggest that research be undertaken to determine the minimum participation in an effective sexuality education (and subsequent maintenance learning) that is required to influence adolescent sexual behaviors.

9. One-half of health ministries reported that they require that preventive sexual health services be delivered specifically to adolescents. Almost all health ministries reported that such services are offered to the entire community. Most (three-quarters) health ministries said that the role of the public health nurse in working with youth or with schools is not explicitly defined. About one-half of public health units said that they have done so. The average school receives about five hours per month of direct service from a public health nurse. About one hour, on average, would be devoted to sexual health issues. However, not all schools receive these services. Most health respondents said that they do not regularly monitor the sexual knowledge, attitudes and behaviors of youth. Only one-third said that they do so.

The parent focus group participants said that students should have access to condoms, pregnancy testing, STD testing and counseling as part of a package of preventive sexual health services. Parents also felt that students are not aware of these services if they are offered outside of schools. They also believed that most of their children would not use community-based clinic services because of transportation difficulties and a lack of comfort with the nature of these services as they are presently delivered.

Two of the criteria of effectiveness that were developed for this study can be applied in the discussion of this finding. First, policy expectations for the public health system, like the school system, should include minimum standards for delivery. Second, there should be regular assessments, studies or reports that monitor adolescent sexual health knowledge, attitudes and behaviors.

Research relevant to this finding of an uncertain role for public health nurses in school-related health promotion suggests that policy expectations for public health systems need to be made clearer and that the role of the public health nurse working in schools should be clarified.

Fisher (1990), Vincent et al (1987) and many other studies of school-based health promotion show that combining preventive sexual health services with sexuality education is more effective in influencing adolescent behavior.

US, European and Australian models of school-based health promotion place far more emphasis than Canadians on the direct delivery of preventive health services in schools. (Neyton, 1993; Bradley, 1997). Langille et al (nd), in a survey of selected parents in a rural community in Nova Scotia, found that 84% of these parents felt that the public health nurse should be actively involved in the school's sexuality programs.

• 73% coordinated with teachers about the sexuality education program

• less than 20% referred students to sexual health counseling or testing

• almost none reported that they played instructional roles in the school

• very few reported that they coordinated the use of school and community resources.

Chambers et al (1994) in a Canadian study of public health nurses found that nurses were active as educators/consultants, social marketers and facilitators. However, nurses needed inservice education if they were to play roles in community development, policy/advocacy, research and evaluation and resources coordinator/manager. Ten per cent of the nurses in this Ontario-based study said that they do not deliver direct preventive health services.

Hacker et al (1994) in a similar study of school nurses in 40 U.S. cities found that nurses played these roles: educator/consultant (79%), direct service (76%), screening for health problems (76%), help in special education (72%), prevention activities (72%), referral and follow-up (42%), high risk services (33%) and other activities (27%).

• 14% of U.S. states have defined a minimum nurse to student ratio

• 59.2% of states fund school-based or school linked health services

• more than half of schools (57.3%) reported that they have a registered nurse on staff.

They also noted that the roles, responsibilities and training of health services staff in schools are not well defined. A clear consensus of the role of these health professionals also does not exist according to this study.

Implications

• Policy expectations about the role that public health should play in working with schools needs to be clarified.

• Health authorities need to establish an ongoing process to monitor and report on the sexual health knowledge, attitudes and behaviors of adolescents.

Consequently, we suggest that research be undertaken on the roles that public health staff and nurses can play in working with schools. This research should investigate the cost-effectiveness and cost-benefits of such assignments to public health staff. As well, this research should examine the polices and practices of other developed countries in regard to the deployment of public health nursing staff.

10. Education respondents reported that, in almost all cases, a list of authorized teaching materials for sexuality education was published and made available to teachers and others.

This finding indicates that these lists of authorized or recommended materials are developed and disseminated in a consistent way.

The research relevant to this finding comes only from one study. Saskatchewan Education (1996), in their review of the implementation of the Junior High Health Education Program, found that teachers wanted more structure in the program. Teachers wanted to see materials listed by grade level and learning outcomes, so that they would be easy to find and use.

As well, teachers wanted to see sample and suggested lesson plans that had clear beginning and end points.

Implications

• It would appear that teachers do not have the time to locate, purchase, review and assess the many prevention and promotion programs and resources that can be used in sexuality and health education. Access and use of these teaching/learning materials would be enhanced if catalogues of lesson activities and learning resources related directly to the curriculum, were developed. This need will grow if the number of health education consultants at the school district and ministry level continues to decline.

Consequently, we suggest that Health Canada and education ministries work with commercial and nonprofit producers of sexuality education materials to catalogue teaching/learning health materials according to grade level, learning outcomes and potential classroom use.

11. Policies to protect the rights of HIV-infected students and staff are well established in most school systems. These policies guarantee the right for these individuals to continue their education and employment in 76.5% of school districts. About three-quarters of school districts and one-half of education ministries said that their policies protected confidentiality.

This finding is similar to other studies from the U.S. Holtzman et al (1992), in a survey of American school districts, found that 60.3% had policies such as guaranteeing the right of HIV-infected students to continue their education. 41.2% of school districts in their survey reported that their policies gave the right of HIV-infected employees to continue their employment.

Small et al (1995) analyzed this same policy question in the SHPPS Study. 71.7% of American school districts in their survey reported that they had policies to protect the rights of continuation to HIV-infected students or staff. 70.1% of school districts in this study said their policies protect confidentiality.

Implications

• It would appear that the basic rights of HIV-infected persons are protected in policy. However, this is not to say that harassment and discrimination based on sexual orientation or other sexual issues is not prevalent in Canadian school systems.

Consequently, we suggest that school and public health authorities now turn their policy attention to other factors that can limit or hinder the rights of HIV-infected people or other individuals to equal access to education, employment, health services and a supportive, safe environment.

12. A minority of education and health authorities have defined the minimum qualifications required to teach sexuality education or to work as a professional promoting the sexual health of adolescents. Less than one-quarter of education ministries and school districts have defined any minimum qualifications to teach sex education. One-third of sex education teachers have no pre-service training, another one-third only have had a seminar or workshop in university to prepare them. About one-half of health ministries and public health units said that they have defined minimum qualifications related to sexuality for public health staff. But few health respondents said that they had defined qualifications required to work with youth or schools. Most public health nurses reported that they have a degree in nursing. About one-third said that they have a major or minor in sexuality or child/youth health promotion.

This finding tends to reinforce the impression that students and parents presented in the focus groups. Both parents and students believed that teachers were uncomfortable in discussing some sexuality topics. The criteria for effectiveness related to this finding are self-evident. Teachers and public health nurses need to be qualified for their respective roles in adolescent sexual health promotion and HIV/STD prevention.

Previous studies and research reflect this finding that front-line staff in the education and public health sectors are not fully qualified for their roles.

Quinn et al (1990), in a needs survey of health professionals, found that there were gaps in the professional preparation of health professionals. Shannon & McCall (1994), in a survey of Canadian college and university health sciences programs found that 26.8% had introduced a new course or part of a course to prepare professionals about HIV/AIDS. Another 12.8% had introduced an annual seminar.

An earlier study of 245 Canadian school districts in four provinces (Ajzenstat & Gentiles, 1988) found that only five of the 245 school districts surveyed had required pre-service education of their sex education teachers. 65 of these 245 school districts required that these teachers undergo inservice education.

The Saskatchewan Education (1996) study found that 55% of health education teachers had not had a health education class while in university.

Collins et al (1995) have reported on the preparation of American teachers in the SHPPS study. 68.6% of the states in that study said that they require health education certification for secondary teachers. 5.9% of US states reported that they require health education certificates for elementary teachers who teach health. They also reported that, similar to this study of Canadian teachers, about one-third of health education teachers do not have any pre-service training in health education.

Registered Nurse                         6.7%

Diploma in Public health Nursing 11.3%

Bachelor’s Degree (Nursing)         70.2%

Masters (Nursing)                         3.1%

Master’s (Other)                         4.4%

Other Diploma, Degree                 4.1%

Small et al (1995) examined the data in the same SHPPS Study related to the preparation of nurses. 62% of states offer certification programs for school nurses. About two-thirds of these states (about one-half of all states) require such certification for school nurses to be employed in a school setting. They also reported that 31.4% of nurses working in schools were registered nurses and another 32% had a degree in a discipline other than nursing.

Implications

• Well-qualified staff are the backbone to any delivery system. There are important indications that teachers and nurses working in schools have not received adequate pre-service education.
  

• Public health nurses working with schools appear to have good qualifications in nursing, better than their American counterparts. However, unlike their US counterparts, they are not likely to have had any pre-service education in working with youth or schools.

Consequently, we suggest that as part of the research on the school role of the public health nurse, investigations be undertaken to define the specific qualifications and additional education required to prepare nurses to work with youth and sexuality in school settings.

13. About 30-40% of education ministries, health ministries, school districts and public health units have an explicit policy favoring a Comprehensive School Health (CSH) approach. Most health ministries said that they require an integrated school-community approach from public health units and staff to prevent HIV.

The finding on this related policy issue, school-community coordination to promote health, is an indication of progress in the use of this health promoting strategy. This strategy was first introduced in Canada in the late eighties. In 1990, only 3% of a sample of 2000 education and health leaders (Health Canada, 1991) had heard of the concept. A decade later over one-third of local school districts and public health units have explicitly adopted this approach.

Given that this study has been structured on the comprehensive school health approach and its application to HIV prevention and sexual health promotion, this finding is somewhat heartening. However, other researchers (Wiley et al, 1991) who have examined the implementation of the CSH approach in seven Texas school districts found that the coordination of programs and services was very difficult, despite the explicit stated support for the approach.

The SHPPS Study (Collins et al, 1995) did not ask if there was explicit policy favouring the comprehensive school health approach. However, 96.1% of the state level health education staff and 59.4% of school district health education staff said that they had worked with other groups and personnel in coordinating their collective, school-related efforts.

Collins et al (1995) also reported that about one-third of school districts said that they have a school health advisory council or committee.

The results of our study in regards to CSH committee activity can be compared to the US finding from the SHPPS Study. 36.4% of education ministry respondents in our study said that they participated in an active inter-ministry committee, led by health, on sexual health promotion. 35.8% of school districts said that they participated in an active interagency committee on sexual health at the local level.

Implications

• Comprehensive School Health (CSH) is an application of a population health approach to the school setting. This finding indicates that policy-makers in both systems have begun to recognize the value of this approach. However, implementation of this coordinated approach is difficult. Sustained efforts to implement, maintain and evaluate/monitor the approach are required, both in general health terms and for specific health issues such as HIV, STD and sexuality.

Consequently, we suggest that a selection of essential data sources from this study be incorporated into a broader ongoing monitoring system to track the implementation of school health policies and programs.

14. A minority of health respondents (16.7% of health ministries and 38.6% of public health units) reported that they have written policies on adolescent health. Most education respondents (76.8% of school districts and 80.2% of school principals) said that the mission of their schools includes the healthy, social development of the child.

This finding represents both a challenge and an opportunity. The low frequency of public health policies on adolescent health must be addressed if schools are to become a more important target or setting for health promotion programs. With regard to school systems, progress in persuading educators to promote health more vigorously can be made if policies are tied to the social and personal development and academic achievement of the child. Indeed, the very first public schools in Canada were founded by churches and charities for essentially social, not academic, reasons.

Implications

• The prominence of the school as a key setting to promote the health of youth should be raised when policies on adolescent health are developed. After the family, the school is the only social institution capable of influencing the health of 100% of the adolescent population.

Consequently, we suggest that public health authorities develop explicit, comprehensive policies and strategies on adolescent health. Further, we suggest that those policies address the settings that can best reach youth, including schools, youth-serving organizations and recreational programs.

15. Sexuality and health education is clearly not a high priority in school systems. Respondents ranked it below almost every other subject or discipline being taught in schools. Sexuality was considered to be a relatively high priority by health respondents when compared to other health issues. However, most health respondents said that adolescent health was less of a priority than children's health in their systems.

This finding clearly contradicts the opinions expressed by the parents/students in the focus groups. They felt that sexuality education should be considered to be a higher priority.

Our criteria for effective policy-making includes a provision that policy-makers should ensure that system priorities are explicit and well understood (Broadfoot et al, 1994; Crighton, 1987).

Our finding that HIV/sexuality is a relatively low priority may be in contradiction to an American survey (Palfrey et al, 1994) of school districts that ranked HIV prevention in relating to nine other issues including violence, drugs, general academic curriculum, special education, health education, sports, music and art. 37% of school district respondents ranked HIV in the top half of their concerns.

With regard to the finding that adolescent health is considered to be less of a priority than children's health, this is somewhat inconsistent with a population health approach. To be effective, a population health approach should address all age groups in the population. To quote from a Health Canada (1996) position paper, "The population health approach focuses on the entire range of individuals, collective factors and conditions .... that may apply across the entire population."

Implications

• Despite a relatively low priority within the school systems, sexuality and health education are both stipulated in all education policy frameworks to be an essential element of the school's mandate. This means that sexuality education must be done well, be monitored and be reported upon regularly.
  

• The immediate attention given to HIV and adolescent sexual health within health systems is obviously not as high as it was in the late eighties when the AIDS issue became a significant public concern. Nevertheless, no effective cure of HIV has been found. Our best strategy continues to be prevention and schools are the best means to reach all youth. And, each year, a new group of teenagers begin to experiment with sexual activity, thereby facing risks from HIV and STD.

Consequently, we suggest that school systems and public health systems review the consistency of their efforts to prevent HIV/STD and to promote sexual health. The issue may not be the highest priority in those systems, but they still deserve regular and meaningful attention.

16. Staff assignments related to adolescent sexual health promotion and sexuality education in education and health ministries, school districts and public health units are being eliminated or combined with other responsibilities. About half (58.3%) of health ministries report that they have a coordinator for youth sexual health HIV prevention. About half of public health units said they have a position related to sexuality in their team for youth health, three-quarters said they have a position within their HIV team. Three quarters of school districts (76.9%) said that they have a position responsible for sex education and health education. About two-thirds of school principals said that a coordinator has been designated in the school. About 30- 40 % of these coordinator staff assignments were being reviewed.

To be effective, staff assignments need to be clear and appropriate administrative or coordinating positions need to be staffed so that the policy goals can be achieved (Odden, 1991; Macbeth, 1990; World Health Organization, 1997; Health Canada, 1994).

In the past sexuality education was usually assigned to a health education curriculum consultant in education ministries and in school districts. Within health ministries, there was often a team of people assigned to HIV prevention, where at least one person was responsible for youth. In the down-sizing and restructuring that has occurred in both systems, these assignments now include many other responsibilities or the positions have been eliminated entirely.

The parent focus group from Quebec expressed the view that the public health nurse from the CLSC should ensure the coordination of efforts and programs.

Previous studies reflect the finding from this study. For example, Holtzman et al (1992), in a survey of American school districts, found that 23.0% of districts had a staff position that was responsible for coordinating the health education program. In Canada, the Saskatchewan Education (1996) study of their Junior High School Program found that only 28% of schools had access to a health education consultant at the school district level. Small et al (1995) analyzed the school health services from the SHPPS study in the US and found that 75.5% of US states have a person responsible for coordinating school health services, with about three-quarters of those having other duties. 74.6% of school districts said they have a person designated to coordinate school health services.

Collins et al (1995) also examined the data from the SHPPS study. They found that 100% of states and 55.1% of school districts have a health education coordinator. That person is also responsible for physical education, sex education (including HIV prevention) and other subjects. Their report expressed a concern that a lack of leadership (through not assigning an administrator or coordinator) may translate into less priority being placed on health at the school level.

• The reduced consultant/coordinator support available to teachers at the school district and ministry level will make it more difficult for teachers to participate in inservice activities and stay up to date about new resources, teaching/learning strategies, health related information and research.

• The reduced number of coordinators in the public health systems will make it more difficult for the efforts of the schools and communities to be coordinated. As well, public health nurses will be less aware of information and developments related to health.

Consequently, we suggest that schools and public health systems strengthen their partnerships with voluntary health organizations related to HIV, STD, and sexuality. These organizations should be encouraged to work more closely with teachers and public health nurses. We further suggest that efforts be made to facilitate electronic access to teaching materials and learning activities/lesson plans. A concerted effort should be made to identify, catalogue, publish and maintain these resources and lesson plans on the Internet in teacher friendly formats so that the impact of reduced staff support for front-line professionals can be alleviated.

17. A minority of health and education respondents at all levels reported that they regularly promote excellence and innovation in youth sexual health promotion and HIV/STD prevention. Less than 25% of health and education respondents said that they regularly provide incentive or innovation grants. Less that 30% of health ministries, education ministries, school districts and school principals said that they organize workshops to promote innovative programs. Half of health ministries and one third of public health units regularly disseminate research. 90% of education ministries said that they maintained networks with education and health professionals to support implementation. About half (54.5% of education ministries said that they organized electronic networks to help health/sexuality teachers to exchange ideas.

Research on effective policy implementation suggest that research including best practices should be disseminated regularly and that supportive networks should be maintained to support implementation (MacLean, 1996; World Health Organization, 1997; Saskatchewan Education, 1996).

Research from several sources provide examples of why this type of policy-oriented support is needed. Educational innovation can be initiated and supported from the policy-makers within systems if these types of levers which are available to policymakers are used (Jubb, 1989: Shannon & McCall, 1993).

The evaluation of the Saskatchewan health education curriculum (Saskatchewan Education, 1996) found that teachers highly valued their professional exchanges among colleagues as a source of support for implementation. Twenty per cent of teachers in this study said that they subscribe to a health education journal. That report suggested that teacher networks be established within and among school districts. Bell & Joly (1997), in a review of the Canadian Public health systems, expressed a concern that, as a result of restructuring and regionalization of public health systems, the ability to disseminate research knowledge and good public health practices would be reduced.

Implications.

• Continued and sustained support for innovation in promoting adolescent sexual health and preventing HIV/STD is needed. This knowledge aboout innovative practices needs to be disseminated appropriately to teachers and public health nurses.

Consequently, we suggest that the development of Health Canada Centers for Excellence on Children and Well-Being, as well as the Canadian Health Network, the Canadian HIV/AIDS Clearinghouse and other mechanisms, be asked to consider how they can best support the dissemination of research on best practices to those who work with and within school systems on sexual health promotion and HIV/STD prevention.

18. Few respondents to the survey reported that they require comprehensive policies or action plans from their subordinate agencies. 9.1% of education ministries said they require the school districts to have a comprehensive HIV policy. 27.3% said that they had published guidelines or model policies. No education ministry said that they monitored these policies of school districts. 9.1% of education ministries said that they require school districts to have an action plan on AIDS/ sexuality. Similarly, 41.7% of health ministries said they had published model policies and 58.3% said that they monitored the nature of those policies. 8.3% of health ministries said that they regularly require public health units to have an action plan on HIV/sexuality.

Research on effective policy-making that suggests that policy directions should be linked to resource allocations (Consortium for Policy Research in Education, 1996; Funk, 1991; Tymko, 1980; CPHA, 1993; Health Canada, 1994).

Research on educational change suggests that "top-down" implementation can be enhanced through the use of required action plans and policies. (Shannon & McCall, 1993) .

Once again, we can refer to the SHPPS study for comparable data from the United States. Small et al (1995) reported that 58.8% of US states require that school districts have an HIV policy. Many states recommend different elements be included in these policies; including confidentiality (90.2%) support for HIV education (80.4%) support for teacher inservice (78.4%) and protection of HIV-infected students (68.6%).

Implications

• This finding may be related directly to the perceived relationship between ministries and local school boards or public health units. Many decision-makers and professionals in those systems may not view the local agency as being directly accountable to education or health ministries. Consequently, provincial ministries do not often require action plans or stipulate required local policies. If this is true, then this finding underlines the loosely-coupled nature of these two systems. Consequently, more emphasis should be placed on developing consensus, staff development and facilitating cooperation and communications.

Consequently, we suggest that qualitative research studies be undertaken to examine the functioning of public health and school systems in relation to the implementation of prevention and health promotion polices.

19. Less than one-half of education and health ministries, school districts, public health units and school principals reported that they regularly fund, organize or support staff development for teachers. One-third of health ministries and two-thirds of pubic health units said that they regularly provide inservice for public health nurses.

Research on effective policy-making suggests that systematic and ongoing professional development is required if polices are to be implemented (Butler, 1993; Popham & Muethen, nd; Shannon & McCall, 1990; Health Canada, 1994; CPHA, 1993; MacKinnon et al, 1994).

A comparison of our results to those of the SHPPS study is relevant here. Collins et al (1995) reported that 98.0% of US states and 83.6% of school districts offered inservice in health education. 98% of U.S. states offered inservice in HIV prevention education. 84% of states offered inservice in STD prevention. 58.4% of school districts offered inservice in STD prevention. 58.4% of school districts offered inservice in HIV prevention education. An earlier survey of American school districts (Holtzman et al, 1992) found that 57.0% of school districts provided inservice on HIV.

Small et al (1995) reviewed the inservice provided to school health services personnel that participated in the SHPPS study. 82.4% of U.S. states and 18.7% of school districts offered school health services staff inservice training in pregnancy prevention.

Implications.

• Sustained, systematic staff development is essential to the success of sexuality education and preventive sexual health services delivery to adolescents.

Consequently, we suggest that school systems and public health systems explore different cost-effective ways to offer ongoing inservice to their front line employees in sexual health promotion and HIV/STD prevention. These ways could include distance education, pooling of inservice funds between the two systems, seeking corporate support and working more closely with voluntary health organizations.

20. Inter-ministry cooperation between the two systems is not often supported by written protocols, active inter-ministry committees, assigned staff time or policies supporting coordination. 36.4% of education ministries said there was a written protocol on HIV/sexuality. 33.3% of health ministries said they sponsor an active inter-ministry committee on prevention . 18.2% of education ministries said they have an inter-ministry committee on sexuality education that has regular meetings. 25% of health ministries reported that they regularly assign staff time to facilitate cooperation. 45.5% of education ministries said they encourage school districts to work with public health.

This finding is in conflict with one of the criteria for effective policy-making used in study. This criteria suggests that cooperation should be actively encouraged by both systems (Muller & Pollard, 1994; CASA, 1992; Capper et al, 1996; Odden, 1991; CASH, 1994; Fisher, 1990; Baldwin et al, 1990; Barret, 1990; Institute of Medicine, 1997).

A similar question was asked as part of the SHPPS study in the US. 96.1% of state health education coordinators said that worked in inter-ministry committees to promote health through schools.

The World Health Organization (1997) suggests that the local health center should be the hub of inter-sectorial activity within a community. A similar vision and inter-sectorial role is presented as a model for the district public health service (Southern Metropolitan Region, 1998).

Implications

• There is a need for improved, sustained and regular cooperation between the two systems to promote the sexual health of adolescents.

Consequently, we suggest that ministry decision-makers in the school and public health systems review and strengthen their capacity to work together in promoting sexual health and preventing HIV and STD.

21. Interagency cooperation between school districts and public health units is not regularly and consistently supported through written protocols or active committees. 34.6% of school districts reported that a written protocol on HIV/sexuality exists in their community. 32.8% of public health units said that they sponsor an active interagency committee on prevention. Only 7.4% of school districts reports that they invite public health to serve on a school health committee. 30.3% of nurses said they serve on such committees regularly or in part. 65.7% of public health units said they assign staff time to facilitate cooperation. 74.1% of school districts said that they encourage schools to cooperate with health agencies.

A review of other research studies indicate that these results may be similar or somewhat less positive than other jurisdictions.

An earlier study (CASA, 1992) of Canadian school districts found that 56.8% of school districts responding to a survey said that they have an active interagency committee on HIV/sexuality. Hacker et al (1994), in a survey of school districts from 40 American cities, found that 45.0% of school districts said that they have community advisory committee on health education. Holtzman et al (1992) surveyed all US school districts and reported that 71.2% had an advisory committee on their sex-education program.

Collins et al (1995) reported from the more recent SHPPS study to note that 33.5% of school districts said they have a school health advisory committee. Small et al (1995) examined the responses from health services personnel in the same study. They found that 61.4% of health service personnel said they had cooperated with other parties on activities and programs relating to schools.

Implications

• Effective collaboration at the local level is needed to ensure a coordinated delivery of sexuality education, preventive health services and relevant social support.

Consequently, we suggest that school district and public health unit decision-makers review and strengthen their capacity to work together to promote sexual health and prevent HIV and STD.

22. The performance and outcomes of both systems are not being regularly monitored. Regular monitoring is not done, nor is regular use made of student achievement records in health education. Neither are regular reports made on progress in preventing HIV. There are few regular assessments of health services delivery. Students are assessed using a variety of methods, but those data are not used in Indicators systems or in annual reports of education ministries. About one-half of health respondents said they must report regularly on prevention progress. Very few health or education respondents said that they survey students or parents on their satisfaction with programs and services delivered. 41.7% of health ministries and 4.8% of public health units said that they monitor the levels of public support for HIV prevention.

The findings of the focus groups in the study underline the urgency and on-going need to monitor the satisfaction of students and services with sexuality education programs and preventive health services. Generally speaking, students in all focus groups were not satisfied with the sexuality education they had received. Almost no students in the focus groups were aware of youth-friendly preventive sexual health services in their community.

Parents in the focus groups felt that the sex education provided to their children was too little, too late and too shallow. Parents were either unaware or not satisfied with the access that adolescents have to appropriate preventive sexual health services. Confidentially and accessibility were of concern to these parents.

These data are in conflict with three research-based criteria for effective policy-making. First, mechanisms need to exist to monitor progress (Granheim et al, 1998; Miller et al, 1995; Institute of Medicine, 1997). Second, regular reports on progress should be issued (Funk, 1991; Health Canada, 1994; Institute of Medicine, 1997). Third, there should be regular communication with the public and with clients about system performance (Canadian Association of School Administrators, 1992; Institute of Medicine, 1997).

The Saskatchewan Education (1996) evaluation of the grade 7-9 health education curriculum reported on students in that program. Their findings were similar to those in this study. Repetition of course content was the most common complaint of students. Beazley et al (1996) conducted focus groups with students in Nova Scotia about the sexuality education they had received. They found that teachers used a limited number of teaching methods, that classes were boring and that sex education was not taken seriously. They also reported that students had a wide variety of experiences with sex education classes; the coverage of topics and the teaching approaches were not consistent.

The Saskatchewan Education (1996) study found that teachers used a wide variety of assessment strategies to evaluate their students' achievement in health education. 73% used written tests, 87% evaluated student presentations to class and 68% asked students to assess their own progress.

The data from the American SHPPS study (Collins et al, 1995) is similar, with teachers using a variety of methods to evaluate student achievement. However, about three-quarters of schools require that students repeat the health education course if they fail, indicating a more serious attitude towards achievement than that in Canada.

Implications

There needs to be more rigour in both systems in tracking the performance of students and the progress being made in preventing HIV. Without these data and regular reports, it is difficult to see how decision-makers can be assured that their systems are accomplishing the stipulated policy expectations.

Consequently, we suggest that a number of Pan-Canadian baseline studies be done to help provinces and territories assess their progress in adolescent sexual health promotion. First, a baseline study of the knowledge, skills and attitudes/beliefs being transmitted by school-based sexuality education could be done. Based on this bench-mark, school systems could then assess the results of their respective curricula. Second, a baseline should be established for progress in preventing adolescent sexual health problems and risk behaviours. The studies would then inform health ministries about their progress. Third, a Pan-Canadian study could be done with students and parents to report on their satisfaction with sexuality education, adolescent sexual health services, their discussions of sexual health issues within their family, their perceptions of the social and physical environment in schools and other related factors that contribute to sexual health. Subsequent to these studies, the instruments and methods could be disseminated to school districts, public health units and schools for their use.

Curriculum and Instruction

23. Very few parents (1.4%) exercise the right to have their child opt out of sexuality education. Teachers are not overly concerned about the level of parental support for or opposition to sexuality education.

This finding may indicate that despite the occasional controversies reported in the media, most schools, most parents and most communities are not concerned about having sexuality education a required subject at school.

• lack of materials

• lack of time in the timetable

• difficulties in facilitating and managing an unstructured class discussion or process.

Implications.

• This research is an important entry into the next series of findings related to the comfort level, teaching methods, materials, and other teaching strategies used by teachers. Teachers are not often dealing with several sexual topics considered to be important by students, parents and research, nor are they using active learning/teaching methods. But why? Is it because they are uncomfortable with the content? Or is it because they are reluctant to lose control of the process? Or, is it because they do not have access to good materials on these sensitive topics that can give them confidence in loosening up the process but in a planned way? Or, given the limited time available for the curriculum, are they feeling pressure to cover the material and consequently, revert to lectures, videos and didactic strategies to save time?

Consequently, we suggest that further qualitative research be undertaken to explain the why teachers are not adequately covering all topics necessary for effective teaching of sexuality education., and why they appear to be reluctant to use active learning strategies.

24. Sexuality education is almost always delivered within a health education or personal/social development curricula. Usually these curricula are combined with career education or physical education curricula at the secondary level. Over 80 % of school districts said they have a written document describing their health education, sexuality education and HIV education programs at the junior high school grade levels. Three-quarters of teachers (71.5%) said that they followed the ministry curriculum. One-quarter of public health nurses said that they have worked with school staffs to go beyond the required curriculum/program.

The discussions with students in the focus groups of this study indicate that there may be problems in the scope and sequence of the sexuality education being delivered. The students found that the topics, activities and materials were often repeated, grade after grade. Also, students have a broad view of sexuality and want to understand all aspects; the physical, emotional, psychological and social. But students said that teachers tend to use a narrow approach, focusing on factual material, preventing disease, physical anatomy, and condom use.

Consequently, when we turn to research-based criteria for effective curriculum and instruction King et al, 1990; Popham & Hall, nd, Walsh & Bibace, 1990; Otis, 1996; CASH, 1996; Kerr, 1989; Neutins et al, 1991; Health Canada, 1994), we find some conflicts in regard to this finding. The required learning outcomes need to be clearly described: are we concentrating only on the knowledge and ignoring attitudes/beliefs, skills and social influences? The delivery of HIV and STD prevention messages should be part of a healthy sexuality program, which is part of a comprehensive health education curricula. Are we only focusing on the physical and negative aspects of sexuality?

The design of the instructional program needs to be sound. Are we truly taking student needs into account? Is the instructional time for sexuality education adequate to meet the minimum learning outcomes described in research?

Related research studies on the design of instruction in sexuality and health education tend to reflect the findings of this study.

The Ajzenstat & Gentiles (1988) survey of 245 school districts in four provinces of Canada also found that sex education was most often taught as part of a health education curriculum. Barrett (1994) found similar results in his provincial/territorial review. Holtzman et al (1992), in their survey of American school districts, found that 79.5% of school districts used a planned, sequential health education curriculum. Collins et al (1995) report that, in the SHPPS study, 92.2% of states and 93.7% of school districts have written guidelines or a framework for health education. HIV education is almost always part of those instructional programs.

The evaluation of the implementation of the Saskatchewan Education (1996) Health Education curriculum found that 70% of teachers followed the curriculum. However, when the researchers delved deeper, they found that 30% of teachers were not familiar with the curriculum document, only 50% had a personal copy, 58% said they used the curriculum frequently and 31 % said they used the document occasionally.

That same Saskatchewan study surveyed students on the health curriculum. They found that students most often complained about the repetition of the same learning activities. Similarly, the BC review of the Family Life Education program (Friesen et al, 1988) found that students were bored with the repetition of facts ( but still did not know the material).

Implications

• Several jurisdictions have eliminated a detailed scope and sequence from their health curriculum in favour of letting the school districts or teachers decide how to best achieve the learning outcomes. Will this decentralization cause further repetition of activities and use of the same materials?

Several jurisdictions have combined or are combining health and sexuality education with career education, physical education or moral/religious education. Will health and sexuality education knowledge, attitudes/beliefs and skills survive in these curriculum structures? Will there still be an adequate, planned scope and sequence to the required learning about sexuality, HIV and STD?

Consequently, we suggest that it is urgent that age-appropriate learning outcomes (that include knowledge, attitudes/beliefs and skills) be described from research. Further, these minimum learning outcomes should be used to guide future development of provincial/territorial sexuality education curricula and school instructional programs.

25. Few education ministries and school districts are actively supporting the development of cross-curriculum approaches or interdisciplinary teaching materials for HIV/sexuality. Less than one-third of education ministries or school districts said that they had supported the development of cross-curriculum lesson plans or cross-referenced learning materials to help teachers integrate HIV/sexuality content into other subjects.

Research on effective curriculum and instruction are in conflict with this finding. Students should have an opportunity to learn about HIV in other subjects and courses (Centers for Disease Control, 1997; Canadian Association for School Health, 1996c; Institute of Medicine, 1997). Interdisciplinary of project-based learning is increasingly seen as a meaningful way for students to learn and should be used in sexuality education (King & Muthen, nd; Health Canada, 1994).

Implications.

• The development of cross-curricular or interdisciplinary materials or learning activities is not as simple as it may first appear to be. First, there needs to be clearly defined sequences and scopes in the two curricula to be intertwined, so that learning materials or activities can be integrated in a planned way. Second, there needs to be coordination between grade levels so that these interdisciplinary activities are not repeated. Third, curriculum planners need to assess and plan for the time required for such interdisciplinary teaching/learning. Integrating interdisciplinary content into the middle of a program cannot end up extending the time required to complete the course.

Consequently, we suggest that research be done on how HIV/sexuality learning can be integrated effectively into other subjects and disciplines including science, social studies, math, moral/religious education, law, human rights, art, music and other courses.

26 Teacher responses to the questionnaire show that they are using traditional, teacher-centered methods in sexuality education classes. These methods include lectures, videos, whole class discussions, and other didactic methods. More active methods are used far less frequently. These include role plays, small group discussions, theatre, student journals, imaging and other interactive methods.

Research on effective curriculum and instruction suggests that active learning/teaching methods should be used frequently in sex education classes (Ogletree, 1995; Barnes, 1989; Shannon & McCall, 1990; Cinelli et al, 1994; Saskatchewan Education, 1991; Health Canada, 1994). The finding from this study is in conflict with that criteria.

The students and parents who participated in the focus groups for this study wanted more use of such interactive teaching methods. Participants in these groups reported that lectures, videos and whole class discussions were used too often. Nova Scotia students also reported that teachers rarely changed even the seating arrangements in class to facilitate discussions.

Other studies on the teaching methods used in sex education are consistent with our findings in this study. For example, the Friesen et al (1988) review of the BC Family Life Education programs found that all teachers in the program used a lecture-discussion approach. As well, the topics selected for discussion were often teacher directed.

Levenson-Gingiss & Basen-Enquist (1994), in a statewide survey of Texas teachers, found that most used teacher-centered methods, most felt uncomfortable in using role plays or peer leaders, most avoided coverage of condom use or homosexuality.

MacKinnon et al (1994), in their study of New Brunswick teachers, also found that the methods used most frequently were teacher presentations, whole class discussions and videos. These teachers rarely used theatre, peer teaching, computers or presentations by people living with AIDS. They also found little emphasis on student journal writing.

The Saskatchewan study of the health education curriculum (Saskatchewan Education, 1996) found that most teachers favoured the use of a decision-making (Health Action) model, but they were not educated in how to implement the model. This study also found that teachers did not often use field trips/community assignments, simulations or student journal writing.

Beazley et al (1996), in their focus groups with teachers in Nova Scotia, found that, collectively, teachers used a wide variety of methods. But, individually, most teachers used only a few methods. They also found that, although the interactive approaches were most appealing to students, teachers did not use them unless asked to do so by their students.

Collins et al (1995) found similar results from the SHPPS study in the US. They found that lectures, large group discussions, adult guest speakers and videos were used most often by teachers.

Munro et al (1994) found that a well-trained teacher can use various teaching strategies, videos and guest speakers to influence students’ knowledge, attitudes and behavioural intentions about sexuality. Consequently, more support for teachers’ professional development is warranted. Doherty-Poirier et al (1994) found that teacher inservice in sexuality education was able to influence student learning outcomes. Better prepared teachers resulted in more positive changes in student knowledge, attitudes and behavioural intentions.

Other studies have begun to tell us how teachers might be persuaded to modify their teaching strategies. Levinson-Gingiss & Basen-Enquist (1994) found that teachers were uncomfortable in using peer leaders and role plays. The study from Saskatchewan Education (1996) suggested that teachers be given more opportunities to develop their abilities to use these interactive, more complex teaching styles. Warren & King (1994), in their study of the implementation of the Skills for Healthy Relationships program in several Canadian jurisdictions, found that teachers liked to use peer leaders and video scenarios after they had gone through the inservice activities.

However, the finding from the MacKinnon et al (1994) study of the impact of two different types of teacher in service (self-directed and guided) did not find any effect on the teaching methods used by teachers, with the exception that the self-directed approach convinced teachers to do more assertiveness training in their classes.

Implications

• This difficulty in preparing teachers to use more active learning/teaching methods, as well as to vary their teaching styles, is not unique to sexuality education. The same difficulties are reported for example in regards to be teaching of science education. (Harvey & Rillero, 1994; Saskatchewan Education, 1991)

Consequently, we suggest that research based strategies for preparing teachers to use active learning/teaching strategies be developed for the teaching profession as a whole. As well, specific applications for sexuality education should be developed and disseminated.

27. Teachers report that good teaching and learning materials are less available on topics such as sexual orientation, masturbation, oral and anal sex and negotiations with sexual partners. Few education ministries for school districts said that they regularly purchase copyright or site licenses for electronic materials in sexuality education. A higher proportion of health ministries (50.0%), public health units (90.5%) and public health nurses (79.9%) reported that they regularly fund, support or purchase teaching/learning materials in sexuality education than education ministries (36.4%), school districts (63.3%) or school principals (73.8%).

These survey findings are consistent with the opinions expressed in the student and parent focus groups. Students in all focus groups said that the teaching materials that they had used were outdated. They wanted more recent, more relevant and more realistic videos. Parents in the BC group wanted to see more use of Internet-based resources and CD-ROMs.

This finding is consistent with other research studies. MacKinnon et al (1994), in the their study of New Brunswick teachers, found that the teacher ratings of the adequacy of materials dropped for these topics; sexual orientation, masturbation, oral sex, anal sex and information about people living with AIDS.

This research study also found that when teachers were given the time (in the self-directed group), they were able to locate teaching/learning materials on these topics. Beazley et al (1996), in their focus groups with teachers and counselors found that teachers needed files of materials and research about such topics. As well, frequent teacher inservice, specifically on these topics, was desired.

Small et al (1995), in their analysis of the SHPPS study, found that health services personnel offered teaching and learning materials to teachers in these proportions:

                                State School District

HIV Prevention    81.6%    66.6%

Pregnancy Prevention  44.9%    26.5%

Implications

• An important part of any strategy providing sustained support to teachers will be to improve access to teaching and learning materials on sensitive topics in sexuality education.

Consequently, we suggest that efforts be made to catalogue such sensitive materials in relation to age/grades as well as appropriate learning outcomes and make these available to teachers on the Internet. Any gaps in the coverage or approach to these sensitive issues should also be filled with new materials if they are required. This should be part of the overall strategy to focus on students who may be at higher risk of HIV or STD infection.

28. Less than 20% of respondents in both systems and at all levels said that they regularly fund or support the development of teaching/learning materials for gay, lesbian or bisexual students. As well, a minority of respondents in both systems reported that they have regularly adapted such materials for disabled, minority or