Medicine, Faculty of
Population and Public Health (SPPH), School of
DSpace
UBCV
Milligan, C. Dawne
Master of Science - MSc
University of British Columbia
This thesis seeks to answer the questions “What combination of knowledge, skills and action is necessary to facilitate protection against the human immunodeficiency virus (HIV) and other sexually transmitted diseases (STD) in adolescents?” and “How does current education for the prevention of HIV/STD in British Columbia schools compare with these requirements?” A literature review of contemporary school-based substance abuse, pregnancy and HIV/AIDS/STD prevention programs was undertaken, with specific attention paid to theories underlying the programs. Interviews based on the literature and theory review were then conducted in three school districts in British Columbia to obtain a picture of local school-based HIV/STID prevention education. Students need to understand their level of risk and methods of preventing disease and to feel motivated and capable of implementing these methods with support from their peers and families. Educators in British Columbia are engaged in a struggle to provide the needed information, skills and support within an extremely limited time framework. They lack ministerial direction, stated goals and objectives and standardized measurement and evaluation tools with regard to HIV/STD prevention, and are facing dwindling opportunities for in-service/ training. The final chapter offers a set of recommendations. These include a clear statement of acceptance of responsibility for HIV/STD education by the Ministry of Education; joint program planning and implementation by the Ministries of Education, Health and Social Services; the creation of local school-community health advisory boards (integrating health agencies, school personnel, parents, students and community leaders into school health program planning, implementation and evaluation); increased support for the implementation of “Learning for Living”, British Columbia’s comprehensive school health program; expansion of mandatory health education courses for Grades 5-12; provision of adequate training and in-service for educators; increased attention to the needs of out-of-the mainstream youth; implementation of curricula, standards/goals/objectives and measurement/evaluation tools for HIV/STD education; provision of condoms to students free of charge; and continued and increased attention to social problems such as poverty, substance abuse and the perceived lack of life opportunities that predispose youth to problem behaviour.
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SCHOOL-BASED EDUCATION FOR THE PREVENTIONOF THE HUMAN IMMUNODEFICIENCY VIRUS ANDOTHER SEXUALLY TRANSMITTED DISEASESIN ADOLESCENTSByC. DAWNE MILLIGANA.R.C.T., The University of Toronto, 1964BA., The University of British Columbia, 1967B.C. Professional Teaching Certificate,The University of British Columbia, 1977A THESIS SUBMITTED IN PARTIAL FULFILMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF SCIENCE(Health Services Planning and Administration)inTHE FACULTY OF GRADUATE STUDIESDepartment of Health Care and EpidemiologyWe accept this thesis as conforming.THE UNIVERSITY OF BRITISH COLUMBIAJuly 1994© C. Dawne Milligan, 1994In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.__________________________(aDepartment of_____________________The University of British ColumbiaVancouver, CanadaDate 4c1tDE-6 (2)88)ABSTRACTThis thesis seeks to answer the questions “Whatcombination of knowledge, skills and action is necessary tofacilitate protection against the human immunodeficiency virus(HIV) and other sexually transmitted diseases (STD) inadolescents?” and “How does current education for theprevention of HIV/STD in British Columbia schools compare withthese requirements?” A literature review of contemporaryschool-based substance abuse, pregnancy and HIV/AIDS/STDprevention programs was undertaken, with specific attentionpaid to theories underlying the programs. Interviews based onthe literature and theory review were then conducted in threeschool districts in British Columbia to obtain a picture oflocal school-based HIV/STID prevention education.Students need to understand their level of risk andmethods of preventing disease and to feel motivated andcapable of implementing these methods with support from theirpeers and families.Educators in British Columbia are engaged in a struggleto provide the needed information, skills and support withinan extremely limited time framework. They lack ministerialdirection, stated goals and objectives and standardizedmeasurement and evaluation tools with regard to HIV/STDprevention, and are facing dwindling opportunities for in-service/training.The final chapter offers a set of recommendations. Theseiiinclude a clear statement of acceptance of responsibility forHIV/STD education by the Ministry of Education; joint programplanning and implementation by the Ministries of Education,Health and Social Services; the creation of local school-community health advisory boards (integrating health agencies,school personnel, parents, students and community leaders intoschool health program planning, implementation andevaluation); increased support for the implementation of“Learning for Living”, British Columbia’s comprehensive schoolhealth program; expansion of mandatory health educationcourses for Grades 5-12; provision of adequate training andin-service for educators; increased attention to the needs ofout-of-the mainstream youth; implementation of curricula,standards/goals/obj ectives and measurement/evaluation toolsfor HIV/STD education; provision of condoms to students freeof charge; and continued and increased attention to socialproblems such as poverty, substance abuse and the perceivedlack of life opportunities that predispose youth to problembehaviour.iiiTABLE OF CONTENTSAbstract iiTable of Contents ivList of Tables xList of Figures xiiAcknowledgement xvDedication xviCHAPTER ONE: INTRODUCTION 1CHAPTER TWO: METHODS 52.1 Literature search and review 52.l.A Sources of literature 52.1.B Evaluation of study design 62.1.C Coding and Evaluation Reference Sheet 82.l.D Review of theory 102.2 School district interviewing and analysis . . 102.2.A Data collection 102.2..B Data analysis 162.2.B.1 Creation of the Framework using the ConstantComparative Method for Qualitative Data Analysis 162.2.B.2 Analysis of the Framework using the PRECEDE-PROCEEDModel 172.3 Introduction to Chapters 3, 4 and 5 20CHAPTER THREE: THEORY AND LITERATURE REVIEW 223.1 Epidemiology 223.1.A Behaviour 223.1.A.1 Sources of data 233.1.A.2 Rates of sexual intercourse 253.1.A.3 Number of sexual partners 293.1.A.4 Self-reported sexually transmitted disease rates 323.l.A.5 Condom use 323.1.B Rates of HIV and other STD infections 353.1.B.1 HIV seroprevalence (antibodies to the HlVirus) ratesin young people 353.1.B.2 Sexually transmitted disease rates in adolescents 383.2 Theory . . . 41ivwwwwwwwwj1n),J1U1WMHDC)I—CDCl))U)iC)ctH-’<rr-Q0CD—HH0<rtCDH-QF--HCD-0R’r1iW-)$HrtH0U)DW00Wrt0DtPj<-W)Cl2H-H--<C)H-DC)-CD(I)HOU)’-ii-ci0-(1--HH-Hci--‘.0<LOP)w.(I)-CDciSci•H--H---l.Q.Ct•-yHU)•‘.0-R’-CD‘.0•H-bC--t1-•-0--CD-•---CD•-H-•-0-H ‘.0 CD CDHHHHHHHHHHHHHHOH‘.0CDJH0‘.0HP)PiCD0P)U)U)CrHciCDCD0H-iiU)CDU)II-LJLJii‘H1cH.Q‘.0H-QqC)ciciP)HH-H-C)CDU)U)-HCtCtU)—0-dL0P)P)‘DHHIM‘.0rto)‘.0.CDCDHH<‘.0-ciMçi H ‘.0--‘.0P) ci CD U) 0 0 H Cr N S P) 0 U) U) I- ci.S P).C-). 0•H-H 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U]F-iFJF)F-iMMFJF’)FJFJMoo—j--jo-a,U)FJD0WWJI-DO—)U]U]U]BIBLIOGRAPHY 352APPENDICES 407Appendix 1 408Appendix 2 415Appendix 3.1 427Appendix 3.2 429Appendix 3.3 431Appendix 4.1 432Appendix 4.2 438Appendix 5 442Appendix 6447Appendix 7448Evaluation of study designTheoretical models (See List of Figures)Letter of Introduction to School DistrictsStudy DescriptionSample Consent FormInterview schedule -- First version .Interview schedule -- Last version . . .FrameworkSkills for Healthy Relationships: Aims andSpecific ObjectivesCriteria for Evaluating HIV/STD EducationProcess and 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C)I-10 C)Cf)H-CDOL’JiQpJxixlH-CDCldPiI<CDLYH‘-r1OCDCDCDPiPJçt(tDTJH-ftQOCQU1PiH-Hl‘dH-PJHh<PJiD•Pi-H-hçtcthQhiH-CDhrtW-.--HQ-t0CDCDH-P)hH-‘—‘J1OrtctU)0CnH-PJdCD0-H-CDH---CDPJ0-<CDhh-h0lr1<CI))-0lCDtti0hrt‘-<‘-LYCDClH-rt0H-dtoCl)H-<CDF—C)(DP)00iQk<QFJFJl---Cl)F—’Hrt--iL’JI-’OH-F--1c1CDk<çtClH-C)0dH-rO)’dU)HLxiCiCDPik<•0CiHzi0HCDCDiCi‘1Lxi—S0--d-dCDH-lx’h--5HOHCDXDU)I-F-l—.H-iH-P1P)iCiU)0dI1-to)CDU)Cl)U)O-0CDH-l-Qto)CDiU)IIC)CD0h)H--LiH-rtLxi3iP1P1F-(Q---<0CDi-Lxi—LiU)0ClrtdhHCl)-.-L’i-CDCDC)CD--10000rrP1rFZhCDS0LiH-DHCD-Cl)HLxi<CDCiCDHd0çt-0.oP)ClCDIiCDP)P)-CDHL’lCitI)çtrt---<.j-Jk<LxJClrtCFWOH-CDH--CD--CICiCD0H-C)0-0EH--rFH-dH-iWOH-L’JCl)<P)-tflH-CDHHat.QH-ftC)QJCflto)J’U1CDWCD0H-hH-0-P1co-<I00---<tO0H-FCiH-U)H-O-P1-Hi0F-001QQP1CiHtl)-.0WtflhU)k<l-tOO‘dP1rtJ?QctH(I)iP1Ci)05Ci0d-0Cl)-QctClkoCDI--CDP1‘-0Cl-CD-0-H-HHtO-I-Cl)P1C)toS-ACKNOWLEDGEMENTI would like to express my appreciation and gratitude to thefollowing faculty at the University of British Columbia fortheir kind assistance and support:Dr. Sam Sheps -- for chairing my committeeDr. L.W. GreenDr. S.A. MarionDr. W.R. BowieDr. G.D. GramsDr. J.H. MilsumDr. G.O. EniI would like to thank the school boards and health departmentsfor permission to interview their staff and the people whoagreed to complete interviews with me. These people mustremain unnamed to protect the confidentiality of the study.I would also like to acknowledge the assistance and learningopportunities that were provided to me as a student researchassistant at the Institute of Health Promotion Research at theUniversity of British Columbia, through contact with staff,students and visiting scholars.I would like to thank the staff of the Woodward BiomedicalLibrary at the University of British Columbia for the highquality of assistance I was afforded as a student researcher.I would like to express my appreciation to R. Barnett and B.Easton of the Vancouver Women & AIDS Project run through theVancouver Women’s Health Collective.I would also like to acknowledge the assistance I received inthe form of documents from the National AIDS Clearinghouse.xvTo Mom and DadKathleenBettyRe saJohnand all my friends at theAli Akbar College of Indian MusicxviCHAPTER ONE: INTRODUCTIONInfection with the human immunodeficiency virus (HIV)and/or other sexually transmitted diseases (STDs) is apotential negative health outcome of unprotected orinappropriate sexual behaviour in adolescents. Bacterialinfections such as gonorrhea and chlamydia, if left untreated,may progress, in women, to pelvic inflammatory disease (PID)Acute PID increases risk for recurrent PlO, infertility andectopic pregnancy (CDC, 1991:931) . Viral infections such asHIV and human papillomavirus (HPV) may lead to premature deathdue to immune system dysfunction (HIV) (Yarber & Parrillo,1992:332) and to cervical cancer (HPV) (Grant & Demetriou,1988:1276)Surveys of sexual activity among adolescents andincidence and prevalence data for STDs and HIV indicate thatmany adolescents in Canada and the United States are at riskfor contracting these infections. Behaviours which putadolescents at risk have been shown to cluster (Jessor, 1982)adolescents at risk for acquiring STDs are also at higher riskfor substance abuse, unplanned pregnancy, delinquency andschool dropout. As adolescents are almost universallyaccessible through schools, many school-based preventionprograms have been developed and implemented. These programsare based on a range of theories, from developmental tobehaviour-change theories to broader ecological modelsinclusive of parents and communities.1School educators are potentially a major component infacilitating the development of health-enhancing behaviours inadolescents. What combination of knowledge, skills and action(developmental, behavioural, environmental change) isassociated with protection against STD/HIV infection inadolescents? How do current education and efforts toward theprevention of HIV/STD in British Columbia schools compare withthese actions related to protection?Information from evaluations of school-based programs forsubstance abuse, pregnancy and HIV/STD prevention may be usedto further the development of effective theoretically-basedprograms. Programs in three school districts in BritishColumbia were examined and compared to those found in theliterature with regard to application of theory (goals,objectives, strategies and content) and measurement andevaluation (quantitative and qualitative).Findings from the literature and theory review and schoolinterviews are presented within a model delineating thecombination of knowledge, skills and action necessary tofacilitate adequate protective actions in adolescents. Forprograms to be successful, they must include (a) a componentgeared toward motivating students to want to practise healthprotective behaviours; (b) skill development and provision ofhealth enabling circumstances; and (c) reinforcement foreducators to continue teaching and for students to adopt andmaintain new behaviours (Green & Kreuter, 1991)2In British Columbia, educators work within the contextsof “Family Life Education” (10 hours per year Grades 7-10; 4hours per year Grades 11 & 12, mandated by the Ministry ofEducation in 1987), and “Learning for Living” (a comprehensiveschool health education program, Grades K-l2, mandated by theMinistry of Education in 1990) . The ability of educators inBritish Columbia to present an adequate program within theimplementation climate surrounding them, is discussed in termsof the essential components of a successful program.Chapter Two, “Methods”, outlines the methods used tocollect and analyze the literature and interviews with schooleducators. Chapter Three, “Theory and Literature Review”,consists of five sections. Section One, “Epidemiology”,reports on the incidence and prevalence of unprotected sexualactivity and HIV seroprevalence and STD infection rates inadolescents in Canada and the United States. Section Two,“Theory”, presents theories, models and frameworks that havebeen applied to the prevention of adolescent problembehaviours. Section Three, “Methodological Considerations”,presents potential problems that arise when conductingsexuality research with adolescents. Section Four, “Surveys”,presents results of school-based surveys of HIV-relatedknowledge, attitudes, beliefs, intentions and behaviours.Section Five, “Interventions”, presents the results of recentschool-based experimental programs aimed at reducing the riskof substance abuse, unplanned pregnancy and }-IIV/STD3acquisition among adolescents.Chapter Four, “Interview Findings”, presents the resultsof the interviews with educators in British Columbia. Contentis organized into predisposing, enabling and reinforcing(Green & Kreuter, 1991) factors for educators, followed by adescription of program components and strategies.Chapter Five, “Discussion and Recommendations”, reviewsthe findings of Chapters Three and Four and discusses theinterview findings in terms of the literature.Recommendations are made, based on these findings, for theimprovement of local school-based HIV/STD preventioneducation.It is hoped that this thesis will contribute toreflection and action that will benefit the children and youngadults served by the school systems in British Columbia andother areas of North America.4CHAPTER TWO: METHODSThe methodology for this study included a critical reviewof the theoretical and program evaluation literature in thefields of school-based substance abuse, unplanned pregnancyand HIV/AIDS/STD prevention and the conduct and analysis ofinterviews with “Family Life” educators in the BritishColumbia public school system.2.1 LITERATURE SEARCH AND REVIEW2.l.A Sources of literatureThe literature reviewed included journal articles andbooks, reports, newsletters, pamphlets, conference proceedingsand abstracts, newspaper articles, teaching materials andcurriculum guides, and verbal reports of work in progress.References to studies were retrieved on Medline,Psychlnfo and ERIC databases, using combinations of thefollowing keywords and identifiers: AIDS, HIV, STD, sexuallytransmitted disease(s), adolescent(s), program(s),intervention(s), prevention, control, school, theory,education, review, meta-analysis, pregnancy, substance use,substance abuse, smoking, alcohol, and drugs. Furtherreferences were gathered from reference lists in the collectedstudies. Literature was also found by browsing in journalsthat had been found to contain one or more important articlesand by periodically reviewing the book sections on HIV/AIDS,5sexually transmitted diseases, and adolescent health in theWoodward Biomedical Library at the University of BritishColumbia. Documents and unpublished (so-called “fugitive”)literature were acquired from various sources, including theCanadian Public Health Association’s National AIDS ClearingHouse, the Center for Disease Control in Atlanta and theGeneral Accounting Office in the United States. Approximately800-1000 documents were gathered in this manner.Several related conferences were attended. Theseincluded the “1991 Canadian AIDS Conference: EnhancingPartnerships in the 1990s” (Spring 1991), the “Second CanadianConference on AIDS and Related Issues in the AboriginalCommunity” (Spring 1991), “AIDS as a Disability” (Summer1991), the “Fifth Annual British Columbia AIDS Conference”(Fall, 1991), the “First National Pediatric AIDS Conference”(Fall, 1991), the “Second National Association of HIVResearchers Conference” (Spring 1992), the “Second NationalConference on Health Promotion Research” (Spring 1993) and the“Second National Pediatric AIDS Conference” (Spring 1993)Aspects of the research were discussed with other researchersand unpublished documents were gathered at the conferences.2.l.B Evaluation of study designStudies providing descriptions and evaluations of schoolbased interventions designed to reduce the risk of substanceabuse, unplanned pregnancy and/or HIV/STD transmission in6H-IIo(Doc-I-CDH(DDiCDcI-HU)H--Nf-I-CDI-Dih U)CDQf-I DiCDDioDiCDh c-r0CD•CD10I-CDCDCD U)C)f-I-U)CDCDDi0-—iU)CD CDCPU)f-ICDCDDl-C)H-0CD C)H CDHCD‘-<C)CD0pIHf-i-CD_U)DiCDC)CDU)CDOf-I-U) f-IC)D):1CDU)’-<f-I-<f-I-SHI-j0HCDHH-H,C)I-P‘tiDlDiDiLoC)CDH,‘-DHID0CD0CDCDDiCDHCD<—.1DiC)IDCDC)I-H5I-QU)H-H-H-ID005IDHCDH-H-0f-I-HCDII5—Di50—CD—‘DlDiIQH-CDH-H-.05f-I-—--•Q.U)U)10‘-C)U)C)f-I-C)NH-CDCDf-I-CDU)CDH-DlC)I—I‘-<0CDDiDlif-I-U)ZQCDHCDDiHHCDH-I-IQ.f-I-U)CDH-Dic-I-0I-CDQDiH-CD0f-I-C)U)C)CDQc-I-H-hf-I-CDhCDC)f-I-DlH,0H-f-I-H‘-<C)U)U)‘U)00DiH-H‘dCD0CDCDLii—U)H-10il-U)0HCDCDDlIQQ5<-0DiCD00CD‘-<I-<SCDCDDlI-H,CD5CDU)H-‘ti1DiDiHCDU)DiCDCl.‘-<0CD-f-I-U)f-I-CDCD3IIH-QH,hQ,I-’ICl)U)110-.U)DiDi0-.DiDiDlh-0CDH-H•5rtHQC)IHIQiiC)I—I<C)5H-U)I-C)0H-f-I-‘-<CDf-I-H-0-.0-.CDCDCDf-I-Di0H,QU)NU)H-C)i51U)H-CDDiCD5t’03f-I-CDf-I-f-I-DiCDf-I-CDH-f-I-H-CD3C)DiDiDiR’f-I-H-H-U)I-IH-HHI—’CDCD0.H-0-.CDH0H-H-f-I-Hf-I-C)U)(-QCDH,CO‘-<DiH-H,5U)U)CD0-.DiC1C)CDC)‘df-I-H--CDH-CDf-I-5H-QF-0-,—.‘d‘-<0N0C)LiU)H,5H,ClCD3CDH-H-CD—0XH-0Dlf-I-I-IH-C)S-f-I-H-f-I-HCDDl10t-I—ICD0C)HCDIQC)H-f-I-CDII00-.50-.‘-<hI510CDCDiDl‘ii0C))H-I-IH-H--U)U)-II0l-C0f-I-—U)0CDDiDiCDH-CDH-hIU)CD—0-.CDH-DlH,50‘-hIIQHDlH-<0f-I-0-.f-I-00-.CDIiCDCDDiH-Dlf-I-f-I-C)C)H-f-I-CDhIH-CDU)SU)hIf-I-0U)H-HU)0HCD01QCDf-I-—CDCD‘-<0-.CDCDH-U)DiCDSf-I-I-CDU)DiDi3CDU)H,Dlf-I-hf-If-I-Di0DlDlH-3C)5CDDi0HU)CD-C)0HDl<hIH00-.hI-DiI-DlCDhCDH-H-H-C)f-I-H-f-I-C)hIDlCDCDDlf-ID)H5H,f-I-Cl)H-0-.f-I-U)CDH-f-I-‘-<00CD50U)H-hIDiCDCDNCDLiiH,hIhIH-0-.‘dCD0CDCDHCDH-CDhI0<H-f-I-CDhIf-I-HC)‘-<U)U)H,)lf-I-C)DiQU)0U)00U)f-I-CDCDCDDiSDHH,H-COIhIH-H-5CDU)><H0H-CDDlH,R’10hI0CDClU)0CDC)f-I-U)0f-I-DiH,H,-CD-3f-IhICD<f-I-CIIC)U)hIC)U)5CDHClU)H-hIDiH-f-I-0H-DiCDU)C)I-<-0‘t33H0H-3H,Dif-I---I-CDDiClCDf-I-DlH-30Cl‘-<U)H,bC)H-3U)H0IiH-HU)3H-H-U)0Di0f-I-C)H-H-HCl0H--f-I-3CDhIU)0F-CDCDCl0H-Zf-I-f-I-H-10U)0-.H-hIQH-IQ>4“<00U)-C)CDCDH-U)cI05F-U)DiDik<-HH,DiU)CD-CDCD--CDClf-I-f-I-2.1.C Coding and Evaluation Reference SheetI. Sample Demographics:A. Date of data collection:B. Number (sample size)C. Male/female ratio:D. Mean age:E. Age range:F. Location: (city, nation)G. Setting: (school, STD clinic, family planningclinic, other)H. Sample selection method:I. Recruitment policy:J. Representative of what population?II. Study Design Characteristics:A. Pretest:B. Control group:C. Random assignment to experimental/control:D. Posttest:1. Matched or unmatched:E. Follow-up:1. Matched or unmatched:III. Intervention and Control/Comparison Treatment:A. The intervention:1. Objectives:2. Content:3. Duration:B. Treatment of control or comparison group(s)1. Content:2. Duration:C. Process evaluation:1. Diffusion of the intervention/program:2. Exposure of the target group to theintervention/program:3. Acceptability of the intervention/program tothe target group:IV. Data Measurement/Collection:A. Standardized Instrument? (Name:)B. Pilot tested?C. Dependent variables: (items/scales measured)1. Knowledge:a. HIV/STD transmission modes:b. HIV/STD prevention behaviour:2. Attitudes:8Q’iL’JC)WCl)‘xJiJ-CD••itU)itF-’HHUtWL’JQQU)U1W•Q.it...OU)CDitO•itCDJCDU)OPJH-iU)Cl)000CDfrCDit><Q0H,0IC)ititititIIH-0H-POrtH,OU)piittd•.U)OH-H-H-”-F-’QEclCDCDODOCDt3O(DOCDH-OCDU)10)CDICDJdODCDH-it)H-rtCl)U)P)E$C5CDPJPJTJCDDitF—’CDH-r1itOitit0itOIit00dCDF—’CDH-ciiititOitit0PJCDHI—’U)O0CD00C)PJ’QOP)PiP)C)it0rt<SCD0p)itP)itPJitPJ—‘F-’CDitF-’P)itPJitOQQH-itH,owP)I—’OP)F--’CD)F-’CDC-r(D—0-,‘-<PiPiH-CD<P)F-’H-(Djc-tOCDOO’OH-U)H,CCDW00-P)U)0PU)OClrtU)0Q-,(D‘CDO-•PiU)H-U)0U)0QCDQ,iU)O.••H’•3i•JCDOCDQH,CDI-H-0JF-’I-H-F-’OH-F-’H-F-’•-H-f--’Q-’FitU)U)H-F-’----H-H-F-’-—H-OOH-U)U)H-OCtPJitP)itPJitiCDCDH-ititPiU)Q.itPJU)PJH-S.siitF-’.çt•-Jit•‘iitF-’PJCDCD-ci-----H--Jit----H-CDCD)CDCDCD-‘U)HiCDCDCD)itCD•-JH-H-CDci0-,Cl0.,H-Q,CD,H-0-,k<ClI-’PiU)OfrhClOH-0‘1H-H-ciciCDCDH-0(-QU)H-CD<1PiU)——itH---°00-PJP)itCD‘-<OCDH,U)H,0H-dhiCDH-000I—’CDCUCDCDCDCDcib’U)it00H,0-CDF—’—H-itU)U)OU)CD-j-CDCDU)ciH-sitU)Cl)CQH-HU)CDN•-.•pi0QCDU)ititCU0•\)•-ciCDCDCDH,F-’H-CUF-’itCUit(QCD——U)H-ciH-CDCDCDU)—U))-<ititH-—CDH-C)NU)Jh-C)0CD—f--a0H-I—U)0itCUCDH,CUI—’0Cl)ciCUMitCDCDitU)H-CDCDit0Pi 0U)0 H,hypothesis:2. Direction of outcome(s)3. Generalizability (targeted sample, responserate, attrition rate)2.l.D Review of theoryAll studies were analyzed for the theoretical assumptionsor underpinnings of their methodology. Theory having beenapplied to school-based prevention programs was reviewed andthe review was used as a framework for classifying theory andassumptions underlying the school programs described in theinterviews.Theoretical constructs relevant to HIV/STD preventioneducation were organized in an adaptation of the PRECEDE-PROCEED Model for Health Promotion Planning and Evaluation(Green & Kreuter, 1991:24) (Please see Appendix 2, Figure 11)2.2 SCHOOL DISTRICT INTERVIEWING AND ANALYSIS2.2.A Data collectionTo become conversant with the TiLearning for LivinglTCurriculum, one of the components of a comprehensive schoolhealth program, the author attended various meetings andworkshops over a one and one-half year period, includingregular monthly meetings of the Directorate of Agencies forSchool Health (DASH), a provincial meeting on AIDS educationin the school system, two meetings of the Provincial AdvisoryCommittee for the Implementation of Learning for Living andthe teacher in-service Sexuality Education Series given in1991-1992 by the Vancouver School Board.10U)CuH-CDU)U)CuU)—F-’-Cl—SCn‘-‘dCu0CDC)U)CDH,CDCiC)3I-3H-i0C)CD-H,F-1HH,H-I-C)ClbCDftU)3F‘d0CDCu0ftdH-30C)0LJHCDftClCD0hCuCuH-ftQftJH-C)(CuCD05CDCu‘-‘CD0CDC)CDHCDCuC)U)HCuC)ft<H-I-CDI—’U)ftftClU)CDIQC)C)ftU)ftftCDH-C)H,U)H-CDCu“<0H-CD—CuCDU)ClCDftftH,WH-<ClhCDftI-U)3<Cl‘--U)CD0<CDCD<H-CDft0ClCDCuCu5H-ftU)CDC)CuCT)hH-CuH,H-CUCu0ftIIClCDftH-ClC)ftClHU)0CuH-ClCDH-H-CDU)0CDCuftU)H-U)U)CuciU)<-U)U)iU)U)CuftH,iCDC)0bU)-FlU)HU)CDU)ft<HCu‘-TftCll-CuftSClcifthCDH-U)U)Cl‘-<U)U)H-0hft‘dftSCDUH-U)-CD0C)I-CuCuftCu0tYClCDC)ftC)Cuft‘<Clk<H0H-ftI-H-iCDftci-ClftH-Cu0oIQ0ciCD0iCDH-(Q0ClH-H-C)CD—.5ft‘-Cu<ftClU)‘-0CD3Cu0Cufrh0CUU)SCD-HCDCuH-H-U)iftU)Cl)C)U)ft0hCUftC)HCDCDH-HftCDU)Cl—H-HH-l-U)H-ftCuftClHft0H-ftCDft3CuciLQft0CDci00ftCl-CD<<WI-hC(Q(QCl3ft0CDCDftCuCDH-CD0-ClCDCDCuCUh-CHCDU)0U)H-CuC)C)ClCuCu-CuftI—’CDCDftC)HftCDClftH-HU)CDCl‘-00-CuI-IU)Cu<CDyft0HH-CDH-fth<0H-hCDCD50Cu30H-U)C)HHCDH-U)CDCuCD001-H-H-iSCDft0U)0CDU)<ftICTF-3iU)H-II5tIftCD)-H-CuH-CDClftH-H-(QH-(QH-3I—IH-S-jOC)CuU)CDU)<SCD0Cu-jCDCD<CuCuC)CDCDH,ft0(U)ciftH-I—’CD0H-U)CD-j<ICDCDftftftCDCDI-j3CD3.—CuU)CDHCDH-ClH-CDH,Cu3‘-ciICTft—-ci-H-ftH-CD0ftCDH-03ftCD0CDC)CDH-C)U)ft3ClciClH,ClH-0Cu0C)HH-U)-i3CuH-U)CuCuU))-jCD0H,CD‘-ciH,ftH-——ftCDI—’ftftftC)3ClCuU)H-CDft•I—’dCu0CDH-CLiC)I-ICDI-j(-CTciSClCDftCD‘—1ft<ICDCDCD13C)CDCl00CDCD(-Q0U)0H-CuH,CuftCuC)-Ci)H--ICuH,CuU)ftI-j‘tIU)(-CT0fthj0U)piCDft—U)CHC)H-ftDCuH-1H-1ci-jCl•ftH-(-QftH,H-U)-CDftC)CD‘dCDCDCuftCDU)Q1ClSH-U)-‘IU)0tYC)(-jjU)HCDCuCuCDCuCDCu0C)CU)H,HZ00ft5CD5ftCuft1C)0(-CTH-CuCD0Cu‘-I350‘tIftClU)ft00iFjI-jU)CC)CDCuClCuCuH-H-ciH-i-CT<1ftCDCDCuftU)ftC)HCD5CDH-CDI—’H,0(-ft-jH-CDCDU)I-i0H-H-QCDC)H-S<10k<CDciCufthjU)C)I-j()H,j<CDH-U)H-3CDCuftH-L15Cl5CDftH-0H-H,(-QCDClCl(-QClHCDCDCD—ClciiCD‘ticiH-0CDci(-CTC)300CDftFft0CuC)CuU)H,ClU)CuCuftft05ftH,CDU)U)H-ftftftft0CuH-H,CDCDU)H-hjftftH-CDLi-<0ftCDftftftH-Cu0HCDCDH,‘-joftCDHftC)U)QCDHU)U)ft-ClCDCDCDagreed to do so, and four school districts where the programwas being run were contacted by the author to ask theirpermission to interview staff involved in HIV/STD preventionprograms within their schools. These four districts werechosen because they were within driving distance of theauthor’ s residence.An interview schedule was composed, based on theconstructs outlined above and on topics about which it wasthought information would be potentially attainable. Theoperationalization of the constructs was taken as closely aspossible from the document entitled “AIDS: Preparing YourSchool and Community” by the Canadian Association ofPrincipals (Canadian Association of Principals, 1990) . Itwas thought that this would enhance the credibility of theinterviewer and create a feeling of trust with theSuperintendents.The interview schedule and a request for approval wassent to the U.B.C. Ethics Committee. Approval was granted(Certificate # 392-356)A letter of introduction requesting permission to conductresearch, a description of the study and a sample consent form(Please see Appendix 3) and an interview schedule (SeeAppendix 4.1) were sent to each of the districtSuperintendents. All four school boards agreed to allowinterviewing in their districts. One district failed toprovide a list of contacts, however, after having been sent12confirmation of U.B.C. Ethics Committee approval and receivingtwo follow-up telephone calls. The three other districts eachsent letters of consent and the author decided to interview inall three districts to enhance the generalizability ofresults.Interviews were set up in the following ways. In onedistrict a letter had been sent by the Board with the name ofone person per secondary school that would be interviewed. Aletter of introduction, description of the study and sampleconsent form were sent to each of these people. They werecontacted approximately two weeks later and dates were set upfor interviews. In the second district, the Board had givenmy name and telephone number to those people who it waswilling to have interviewed. When they called me, I arrangedinterview times and sent them the introductory material sothat it arrived before the date of the interview. In thethird district, the School Board asked me who I would like tointerview and I chose to interview the person in charge ofTiFamily Life Educationu/TlLearning for LivingiT in eachsecondary school in the district. The Board sent each of thema letter introducing my study and informing them that it hadbeen approved by the U.B.C. Ethics Review Committee and by theBoard and assuring them that their participation would beentirely voluntary. I then sent them my introductorymaterial, waited two to three weeks, and phoned to requestinterviews. Some of these people turned me down, saying they13were too busy. Some of the interviews that had been scheduledwere not able to be completed due to interviewee absence. Ialso interviewed one person in a Municipal Health Departmentwho conducted liaison with school programs in the district.This interview was set up after contacting the Supervisor bymail and receiving approval to interview the employee, uponwhich the introductory package was given to the employee andthe protocol followed.The interviewees consisted of two nurses, one socialworker, seven heads of counselling departments in theirschools, one science teacher, three teachers of home economics(two of whom also taught Family Management), one district“Learning for Living” co-ordinator, one Municipal HealthDepartment Co-ordinator of School Programs and two counsellorsin an alternate school. The interviews were conducted fromJanuary through June, 1993. Most interviews were one hour orslightly longer in length; one was about 40 minutes, and onespanned a period of two hours, with interruptions. All butone were tape recorded. Two-thirds were subsequentlytranscribed; by then it was possible to work out the frameworkfor analysis and listen through the other interviews tocorrelate them with the framework. Notes of key points werewritten down during the interviews in case the tape recorderfailed. Some interviewees presented me with sample lessonplans and other documents and brochures.14HiU)I-H-ftftClClHIH-bft‘-ftiHftHiC)0C)CUCDCDH-CDCDCD0H-0H-CD0H1HU)CDCUCDU)ClftCUU)CDftU)I-CDftClClftft0H-CDftft1.dftH-U)U)U)0ClCUCDCDI-(-QCl00C)U)C)ftCD0U)CUOClftCDH-hi—i]0HIiI-CUU)CDH0HiH-HHCDft0(iC)CUH-U)0<bIIHC)CUCliCDCDII1.dH-ft0CDCDHDCDU)CDH-0CDClH-ftH-IQH-CUH-ft0CUU)CDCU<H-CUCUCD0U)C)F-’-U)HiClQIftU)ftF-’-3ftHH-3PJCDH-Cl0H-C)H-10CDCDI1U)CDU)C)ft3CUI-CUHIU)CDH-3CD0ClH-H-ClH-CDCUHiHitYCDH1QCDH-CUftftC)ii0ft—ClH-0hHI—aCUCUClftH0CD0ClIQftCDU)H30I-0CD.Q00HU)CD3ClCDCDHCDCDCDHiU)ftH-1.dClftCD0U)ClCUftH-CD0ft0ftCDCDNCUC)HiClCDCDCUftCl0C)Clft1CDU)0CUH-ftH-CDCDCUCDU)C)ClU)CUHiftC)CUC)CU0Cl)HftCDH‘<U)H-0H-ftU)1.dCDHCDF-CDU)3‘dCD<CU0<0CUCDU)-0H-—CDH-C)CDiCDIQHCDIQftCUC)ftftCUCDCDCUCUCDCDH-H-CC)I—CCUC)CUH-ftQIFlU)Cl0CDCUftU)U)ft0HH-H-C)i3CDCDU)HiClCD0ftHCD1QHU)iCDClftFlftHiCDtYftCDU)CDFl‘-<U)CDU)CU0ftH-H-0H-‘<FlCUI-CUH-U)ftFlH-CDH-HiftftI-0<1•—ftCUCD<CD‘-<CDftCDIQH-Cl‘—Cl‘<IQClCUH-10H-C)0CD3CD0H-ftCDCDC)CDftCD—0I—’1.00U)FlftU)<0ci<0HCUCUC)CD<HCDHCDCDU)CUftCUHFlCDH-CUHiU)MHU)CUHIftftU)U)U)U)CDCDH-Q(-Q0C)Hi0H-C)CDCD0HiftCDQI0HH1.dU)CD0HiFlHICU0H-H<CDHIftFlCDFlft-CDClFl0HHFlU)U)ftCl‘-3U)CDC)CDH-CDCDHiClH-CD•C)ftCDftCUCDHC)0CUU)3H-F-’-CUHCDft—000HI10CDCl0HU)HICDCUCUC)ClftHIft10HFlCUClCDU)HI0U)FlCDCl—i-CDClU)I-U)0HiCUClH-1QCDCUCDH-(QCDHU.CDCUUJftH-0ftC)CU“ClU)CDC)“ClClCDHIU)0HFlCDC)ftH-0ftftFlCUft0FlCDC)ftFlCUH-HiH-FlCUH-CDClFlFlCDC)ftftU)U)ftftftC)CDft<I-H-ftCDCUftC)CUU)ftFlft—Cl30CDCDCUU)CDHCDCDCDCDi-I-H-U)0U)H-(QCDCDH-CUCU<FlU)ClCD<i“Cl“ClCDHCUftClClftHU)CDCDftH--H-HiCDCDC)ftftH-HCD0CDH-0FlClhftCD0C)HCD‘-U)U)Cli-U)U)UftCUFlH-H-0CDCU—CD0CU<U)CDftH-C)ftCDCDCiHiCiU)U)H-ClCiH-H-CUHi0ftCDFlClClCUH-10CDCi0Hi1QCi0ftCl00CiH-1Q<CftC)FlHH-HiHi0CDIH-HiFlU)0H-H-FlH-CiCi0ClU)CDCiCiCDCD0H-0CUH-ft10CiftCD10ft—U)I-’3CiCift0ftClCi“ClftCU-.CDIQClCiCDCU0ftCUftCi’SftCD<CUCiCi”ftCiCDCUCUCiCUftClCD0ft“<CCD‘-3 Ci CD H Ci ft CD <C H- CD U) C) CD Cl H CD CU U) I--C CD <C H- U) CD Cl I--C CD 0 I--C 1Q CU Ci H-N CD Cl CU Ci Clft5rtbC)C)ftHCDPiH-hPiH-CDCDiCDCDQ.CD0fthCDI-hCDhftM1PiCDC)Cl-H5H51QP1t5CDIQCDt30WH-CD0H05C)ftP1CDH-1HQH-I-I-CDft0<C)H-H$1C)CDCDH-ftCD0CDCDI-hftCDPJHCDE-<<P1P1JPIH0p1QCDp1piI-TI-hZ0CD<ftftCDCDftCDftOftCDH1CDCDiHF-’-CDCDCDI-I-CDH-CDH-H-c0—C)CD1H-Q<00TiPiftC)hp1H1C)SCDH---CDCl10H-0P1ft0CDH-H-H-CDh--C)3ftCDCDP1ftCDCDCDSCDftH-CDCD0P1ftClCDCDH—I-I-T(QP1ft-I-TCDP1Hlp1dPIp1QbOF—IC1•iClP1CT)CDP1P1CDftSCD‘dHCDPiftftCD<CDftH-rt5ftC)‘—CDCDCDH-H-p1H-ftCD—Qiftft0-ftH-FftPlOH-CDP1C)H-QCDHCDC)CDCDI-h‘-<H-C)-Cl—P1CDftp11CD<OPIH0CDC)C)<I-hCD-ftFH-HH,CDCDP1ftHI-CD(-QCDSH-P10CDH-P1H-CD<0<ftCDQftCD<HOI—0ftil-’CDClCDH,CDHCH-H-CDCDHCUH-PlCDI-TCDCDCDCDCl0—CDP1HH-0CDP1H-CDftPICDhP1HF-’CD0pl(QH-‘ti‘tiHftCDftI-hft—C)ftCDCDftC)IICD0ftCDC)CDCDTiP1CDCDtiCDOftPJH-P1,C)0ftI-H-I-iH-H-F-ftCDP1HftCDC)P)CDI-SOcrOPICD05CD0H-0ftI-rP1ftft‘-<3SCDCDH-h3‘tiClI-CDH-C)ftH-CDC)hP1NO’iOP1‘tiCDOH-ClC)P1CDCDCD0JP1CDCl1jOH-ftPIPI‘tiCDCDI-CDbC)CD5ftC)‘Clp1HCDH-ClH-iO0CDCD‘-<0CDft00HCDH-5CDhjOSCDO’d<ftti-I-ftH-3—.ftClH-C)P1$iOCD-3CDH-P1CDLJftCD3C)C)ftH-—P1hP1CD3hHCDhftH-1ClCDCD(I0CDC)3CDCDCDH-‘-<H-0ftH-CDClOH--C)ClCDS‘tiCD‘-C)CDC)CDKD0‘tiCD-1CDP1ftftH-‘tift0CD0CDH-(QClfthftdClHpiP11P1CD5biCDC)HCDp1ClCDp1ftP1CDHH-<(Q‘-<CDI-—0CD‘ti—0I-CDftHrrPl•CDCDCDCDp1CDP1H-•CDC)H-I—’5CDH-H-CDCDCDrtCDftCDH-ClCD3ft03C)C)3—CDftH-HS‘-Q05ft0ftQP1ICDPlO—CDPIH-H-P1CDCD30ClCDI-=ftLQCDPIC)CDftClCDIiCDCDI-P10H-C)Qi-C)Cift—CDCD0H---Cl50<lrrC)H-ftCDCDftI-hftftH-CDCDCD‘ti-CDft::35F-iH-Hft—CD—CDCDCDhl—-OZCDCD‘tiP1CDft0P1CD‘-IH-ftTiCDOCDCDHHftC)CDk<P1-0P1Pifi(CC)ftftHP1ftft‘tiCDCDI—’CD-ftO0hICiOP1H-3CDC)0CDCDHCDCD-P1Tiftp1II-hPlOI-lI-h‘-ICDCD0I-hCD0CDHI-hC)—CDCDSOCDCDft’—<CDftP10-—CDftI-I-•0ftHCDftI-CD-ftI-hC)1IH-H-CD0ipiHQ—CDc-r’-<’tiH-F—’H—3bClCDSPli<H--CDi-CDft3P1p10p1CDCDI—’‘tiHft—.I-CD—FHftI-ICDH,3Cl3CDp1‘-<C)CDOFtik<CDP1Cl0ftCDI-IClftC)hiCDC)P1hI0ftCDF-’-CDCD00H-ftP1H-Tifthi0P1ft5-ft5CDH,CDftCDH-Cl1QP1CDiCDH-ftH-ClH-O—hiHCDftCl0CDP1-H-0CDClCD5iI-P1could be combined and abstracted being placed into the right-hand column. In this way, by constantly comparing each ideato the others, a framework was created composed of threesections; the most concrete or specific ideas, properties orclusters of those, and the most abstract ideas, comprising thecategories.When a particularly eloquent statement was found withregard to a topic, a note was made of its location for use asan illustrative quotation. Each time an explanatory ideaoccurred to the author during coding, a note was made of theidea with the page number, for future reference.Once the codes from the first interview had beencompletely assigned, the categories and properties were typedinto a liFrameworkil The second and third interviews wereanalyzed by assigning their parts to the Framework. Duringthis process some of the categories had to be subdivided, asthey were becoming too cumbersome, and the properties had tobe rearranged. By the end of analyzing the third interview,the framework had become fairly stable. The remaininginterviews were sorted by assigning their ideas and supportingquotations to the framework. Once completed, this filled-inFramework (Please see Appendix 5) served as a rough draft forfurther analysis.2.2.B.2 Analysis of the Framework using the PRECEDE-PROCEEDModelFrom the Framework, representing all the information17CDC)H-HiHc-f5CDH,***1C)H0Q1H-hHk<pjCDCD-10CDHiCDCDClI-ft0HClC)HiCDLxiCUc-f1C)CD5CDftH-ClC)ftHHçtH-0I-Cl)ftCD0H-LxiCDci-CDCl)II5<ftCDI-LiiCDlcrdCDCl)dxlIIdCDH-Cl)Cl)Cl)CldL’il)ftCDCD0CDftCDCDCDH-)CDH-PJCDCDCD0C)—..—dCDClCl)iCl)iCl)iHC))CDCDftlbCDftClLJCl)dftCDH-H-Cl)çtClClC)C)H-<CD<H,HH<H-‘-<H-ii0çt0Cl)HNC)H-Cl)HCDftH-H-’d0CDH-H-’dCD0l-l-Cl)SCD(-QCl)CDCD<d1Q0Qhh0C)Cl)CDCD0ft—ftCl)0ftCl0IIh0C)CDhQQh-LxiftCDftCl)ftH-—3t’JC)JH-Hi—CDIH-<Cl)CDLIIH-CDH-CD0—ftiCDQCDH-5HiH-H-CDCDl100CDH-CDH-I1çH-ClOCUClIiiHiH-iHiC))C))ftC))0CDI-ClH-Cl)CDClCDftC)CDC))HiHCDHHHiC))ihhiHiH-ftC))hiCl)CDijHiiHH-H-ClCl)CD—CDiftC)ftC))QftHiiHC))CD=HC))ftH-H-hi0H-bCl)0CDOC)C))hiC))ClH-5ClC))C)CDiCl)CDHC)HiiCDCl)fthiiCDftftCDCDC)iCDC)H-fthI-QCl)ftftH-hiHiC))ftOH-ft1CH-0<ftCDft0Cl)H-ftfthiC)hiOC))hiOhi0iH-hiHC))CDCDC)CDC))hi<1HHH-OCDhiC)JhiCDC))hi(QL—)iCDCDCD0hiftCDC)H-HHCDobiCDftCl)--ClCDHC))CDH-0Cl)CDDftCDftH-ftCl-CDftC)ftCl‘ii—C))hiHftH-hiOftOC))CDCDlC))l-’5hiCDCD•-CDiCDihihihi)JH-iCDCDC))0ihiftLiiHiftCDHCDCDCDCDCDC))l-QClH-CDH-ft0CD0C)HihiC))U]ftH-HiCDHC))H-iC))H—LiiC))CDC)‘ZHHOiC))C))CDftCDiClH-hiLiiI-ClC)HiC))HhiH-C)Qfthift(.QC)hiiHiH-0CD<10hiCDCDCDiLxift0CD-H-ftCDft00Hi0C)JfthiCDk<Hi<1ftI0H-hiCl0fthiOC))CDhiCD0hiH-hiU]HC)C)CDftH-CDhihiCDH-HiCDCDhiHC)CDHC)Cl—CDC))H-C))ftCDI-CldCDCDCDCDH-CD5HH-CD5C))ftiiCDhi0CDFd0dC))NClOC))0iClC))0ft‘iiCDI-C)ft50C))C)—0iCDhiCDCDCDftiIC)hiH-CD-HiCDftLxiCDC))CDHhiClCliH-ftCDH--0Lii0HiC)3CDLxi0H-<CD•ft<CDft3C)hiC))CD‘lClC)bCDiH-OCDCDC))C)ci-H-0Liik<C)ClH-ClH-HIC)0CDhiCDri-CD03.—ljftCDiIC)ftC))C))CDC)ftC)ftH-C)Lii0iCDift0Hi0—CDCDH-0OCDCDftC))‘dhiC)-IhiftCDhiCDC))ClCliCDiiCDiiCDC)hiCD‘dCDCDCDCDCDCDCDH-ft0C)C)iftCDhC)0CDdCDCl)HiH-I-C)HiCDCDftCDHiCDCD0IC)0Cl)HiftCDHC)3IC)i0C)CDhihiC)CD00l-HCl—.-—ftOftftCDhiftCDClCDR’LxiCDhiCD0Cl)00CDhiH-O<0ftftCD5LxiH-fthi0C)CDhiHiftC)CDH-ftCD<3LiIC)ftftCDH0CDcrH-0CDhiCDCD0iIC)dC)hiCD—CD0IC)CDCDhiCDCD0CDCDCDCDCDCDhiCDiiH3dHiOhiCD0ClCDftH-F-’H-ftCDOCDftCDH-ftClCDhiIC)0ft‘<fthiii<CDH-CDCDft0CDSiSifthiH-H-CDCDH-CDfthiH0HC)h’<1CDftftft0H-ftftCDhiCDCDH-YH-hiCDHi0C)CDCDCD—OCDOhift03k<CD0hiCDhiCDHiCDs:iH,H,U)I0H-I-I1)CDH-0CDCDU)i:jc•cQi<U)ftftCDiCDH-H-CD0hQhU)Q1rrHrU)QftftQk<H-CDftQ<U)CDHCDrjCDCDCD’1-•-‘-mCD-)P)xjCDCD<U)H-hHDftCDCDC)QhCD(D-H‘CDU)H,HCDpjçi0U)U)H-C)HftCDHH-ç-tU)pjH-U)U)ftr-rCDC)(QjFCDIQCDH-QQH,HC)rrHC)0H-H0HftftCDH,ftCDU)HCDH-HU)CDCDCDC)<C)ft’H,U)DU)HftjPh<CDU)HHU)ftHH:ii<QftH-U)HCDjI-i00PiCHiftHC)U)HQ-HU)CDftCDHHH,Q.<IJpJ°CDHH,H-CtftçHI-0Ift..I-I-I-1-QIrr_U)JftCDftjcP)CDCDCDCDI(ttII-lHQ--ftCDçth<1HçiCDHH-)0CDCDCDc-tjrJftI-H-CDH-CDCDiU)FC)r-lC)JC)cDiJ01ftCD0H-ft0U)PJciHQ0H-ftfrlCD•:1F—hiUCDhCD1ftU)-LQ•-CD1‘-Ui Lii C) Lii C) Ll ‘-Ui 0 (2 Lii Lii 0 CD H :1i cv I-I CD H- H H U) Ci t-I cv ft CD ft CD H cii U) CD C) CD wH-C)H-—cii0C)F-’i0ftH,ftftC)ictCDU)CDCD0ft‘-CDhftI-ftI—i<1h<H,‘-dCDCD<H-H-H-HI-IH-CDC)CDI-ICDftCDftU)ftU)U)ftCD0U)-H,HH,H-H0Hiciid0iCDiCDQ<CD<1CDftH-CDICDHftHH-hcii1C0U)C)CDI-IH-U)0IH,CDiH,00CDH-iifth’H-fticiiCD‘1CDCDC)CDC)ciiC)k<QHI—’0HHcii‘-<I-IC)ciiftQH-‘-U)F-Ih0CDftftH-CDCD1CDCDU)U)ftF-h‘TJtYcii0CDi-ICDft‘iiciiCDftC)0ClciiU)JciiI-ICClCDiCDCDCDI-IciiU)ftC)HftCDCD‘-<CDCDCDU)Clfth(JbHYCD0‘-CDU)ci)CDCDI-IftI-ICDCDClU)oU)CDciiH,ft0CDCDU)Cl0H-H,H-H,ftH,ftClU)oftciift0C)ftH-ftCDH-CDCDU)CDftCl0U)0ftH,CDU)H-I-IftClCDftiCD0ciiJC)0H,CDftCDfthCDI-IH3CDftCDW0CDft::y0CDiH-CDI-IH-C)U)C)U)ciiciiCH-HU)i0CDftft‘-dft‘-I-II-II-ICDCDCDCDCDH-U)ClU)jCDH-HCDH,U)H-:i0C)‘-ftftI-Ici)0CDCDC)ftU)I-IClH-CDH-cii ft0CQ0(.QI-I-H,H-CDftciiCDCD—SEC)U)ft0ft-cii:-0bCDHI-IU)H0CDU)‘-H-I-I<:CD‘<CDH-C)I—’iH-I-IU)H,H,ciiCDHH- C)ClH-CDCD-3H,I-j:-C)ciiCDCDH-C)H-ftCDftIC)oH,I-‘-10CDCDCDU)I-I0ClC)C)I-IH,H-ciiCDC)oftftcii(.QCDH-ft(C)C)0ClH,0ciiI-Ici)I-jHH-C)HiftNC)CD0CD0ftI-’ClciiU)U)<CD-bftHI-II-I0U)cii0iI-IC)ciiC)ClClftoHU)oEk<HH-H,ftH-0CD U)H-ftiCD0ClciiH-h’iCDCD Cl C) cii ft 0 I-I U)C) 0 H ‘-3 0 C) 0 U) H- U) ft U) 0 H, F-I CD Cl H- U) 0 U) H CD cii H H IC) cii ciPredisposing, enabling and reinforcing factors foreducators lead to Column Three: the program (mainly educatorbehaviour), consisting of program content (information,attitudes, skills, resources) and strategies (passive toactive, individual to group) . Specific factors in columns oneto three were derived wholly from the interviews. The programinfluences predisposing, enabling, and reinforcing factors forstudents (Column Four) .As no interviews were conducted with students,predisposing, enabling and reinforcing factors for studentswere derived from the literature and theory review. Factorsin Column Four influence student behaviour (Column Five)Student behaviours relevant to risk reduction for HIV/STDinfection were deduced from the large surveys of adolescentsexual behaviours and the school surveys and programs specificto HIv/STD prevention reviewed in Chapter Three.2.3 Introduction to Chapters 3, 4 and 5Chapter Three presents the findings from the theory andliterature review. It begins with epidemiological datarelevant to HIV/STD in adolescents, followed by theoriescommonly found in adolescent behavioural research and an4For a detailed delineation of predisposing, enabling andreinforcing factors for educators and for students and adiscussion of how theoretical constructs were subsumed into thePRECEDE-PROCEED model, see Chapter 5, Sections 5.6A and 5.EB.20ftHQftftH-SiYM:DU)CD”CDH-PJCDHU)f-rH,CDU)•.QH,hCDCDdftH°°0;-gSiSi0ftpjJçt‘CDH-H-U)ihCDU)CDt,i-jU)S3ftdCDHftCDCDft.)H,HH-°0CDCDCDCDC)ftCDHQSiC).CU) H-HCDftQ1CDCDCDCDCDCDSiQh-jCDCD‘dH,1—djCD‘FoH-CDç.U)CDwftCDH-JCJ)ftCDHCDctCDCDftU)jD)çQQCD0.H-U)°FrrJi.QftEftSift-rr..CDP-)H-CDU)WCDC)UiH-H5U!DoU)C)C)ftH-CD5D7çD.H,ft-CDH-CD10I-H-JrtQ,.00H-U)1--QCD•HQHCDI-H-H-HU)CDftU)ftCDU)CDC)CD$DCDI-‘-i5))CD5))1)C)ftftU)ftCDSiH-Si5))s:i‘-0‘15))CDCDtI-5))CDCD305))hH,:ioQ1xJH,:iftH-H,H-U)c-i-<CDU)CDCDCD‘—5C)ftCDCDSiH-0tdQU)0i‘--5‘--5•CDH,ft‘-<CDCDCDCDciI--5h5HCDCD<CD3C)H-<ftoCDH-U)t-xjCDH-CDH,5))H-Cl)U)HciiSiHgiicici“<ftH-H-iH-Cl)o‘--5U)3CDft-<SiCDCDH-‘--50<H,CDCl)H-U)U)ftCDftftCDCDH-ciU)CDo—i0U)U)53H,CD00CDH,ftH,HSio5jHH‘--5CDft0ft U)H,H,CDCDiH-ci0ftSiH,SiciH5H-<ftCD5i5))CDU) H U)b•H,U)Cl)Cl)ftU)C)SiCDftci510CD‘--5531)515CDft5:5HCl)<H,51—0CDft(I)‘--5CDCh5CD‘-Q51h5‘•xjCDSiCl)0ciC)SiSiCl)51‘--5C)ftH-Cl)0C)fth5Cl)‘--5H-CD—CDoU)535))dCD53‘--553H-ClCDft53iCDCl)H CDft‘--5(.QH-CD0CDftiU)H-CDH-HU)i—5535353-’H-QftC)-CDC) ociCD<HCD53H-SiU)5))CD$C)5J-’l--5HH-HH-H,5))‘tS53H-•ft‘-QSiH-ci0p)Hci)Si5i5iSici‘-Q0Ci)H,h’5oCDI--5CDH-ftC)5353-’H-53H,HSi00U)QCh5ftHC)0IH-I-iSik<—Cl)U)0‘-0ciSiSiCDCDCDSiob’ftft<5U)ftHU)C)53H-CDHCDft00CDCl)HU)5))ci‘53C)53CD0C)CDCDC)U)H053’53CD—0H,•0ftH,U)5))Q‘-<51-5•tY’H,-CDSiU)53U)U)5))SiCD0CDC)dHU)bdftCDHoHU)CDSi0H-H-53HC).—53U)I5))ftHbftH-l-Cl)5))Cl)H-ft05i5iCD051’515153CD53SiCDciCliC)HCl0ftftU)U)H,ft0U)SiCD‘1Si1-51-5ft53‘<CDCD<S51ftU)CDCDH-U)Si<00CDHCliU)‘-iSiC)5353ftC)CliftH-C)‘-<S53Cl)000ciSi5i535))U)U)ciSiftSici‘-5Si5))C)0CDCl‘ft515(.Q5))‘<CDH-H-5U)53<5)1Si51H,‘-CD0Cl)U)CDU)Hft51H-H510H-H-U)SiU)H-ftftCDSi53SiCli51ftH,5153CD1-5CDClC)CDSik<CDftcftH-5))5))01-5H,Si51H-ft530Si 0 ft CD U) Cl) ‘--5 CD H Si C) H Si Cl CD Cl H, 0 1-5 CD Cl) C) Si-’ H ci CD 5)) U,CHAPTER THREE: THEORY AND LITERATURE REVIEWChapter Three consists of several sections, each coveringa separate but related area regarding adolescent sexuality andHIV/STD infection. The first section, “EPIDEMIOLOGY”, isdivided into two parts; adolescent self-reported “BEHAVIOUR”and clinically-reported “RATES of INFECTION”. The nextsection covers “THEORY” used to understand adolescentbehaviour and to plan interventions aimed at reducing risk-taking and increasing health-promoting behaviours. Following“Theory”, “METHODOLOGICAL ISSUES” and considerations pertinentto sexuality research with adolescent populations arediscussed. Finally, “SURVEYS” and “INTERVENTIONS” using thetheories discussed above are examined. The surveys attempt todetermine the extent of adolescents’ knowledge; to measure andunderstand their beliefs, attitudes, and values; and toconstruct meaningful links between measures of theseconstructs and those of their self-reported behaviour. Theinterventions attempt to create conditions under whichadolescents’ risk-taking behaviour decreases and health-promoting behaviour increases, and to measure and understandputative related and interrelated changes in knowledge,attitudes, beliefs, values and behaviours.3.1 EPIDEMIOLOGY3.l.A BEHAVIOURWhat percentage of adolescents have had sexual22uç-1c-thDQPJCDCDiIjIhhQQSpJH-tQI-CDiCDH-Q’<CDCDH-ftftH-50I-U)CD0UH-U)—ftQ1HctctHCDH-CDCDU)C)1-f--pJU)flQ’s:1QU)jCDI-CDU)f1HCDCDC)U)PJQCDCDCDCDH-C)0(QCDFPH--,.F-JftCDCD<CDCDPCDHCDH CDftiftMH-QCD°HwCDSU),-H-QHU)zU),—C,CDiHCD0U)0H 0:<U)HftpjCDH<HII0.U)k<CD‘rjCDU)C)CDft-CDCDH-CDHCDCC)()ftC)iCDPiCDCDHftQft,-,H-H-H-hhH,C)0U)SOuftC)pJH35H)F-Cft)CD0H4ftH-CCDICDHhCD)0çtd[hiCDii00U)CDHft<CDHH-CDU)<iiH-C)IQftU)CDI-H-CDiCD00P)ftHH,U)U)JCDftpiH-CDi0:1U)Q0H-H5CrH-CDI-0)0HCli0C):CliHH•Hl-ftCD aU)C)HI(.CDdeiCDCr-C)CD0U)0SCD[h0CDft()HQIH-CDH-Cli0iCDCDft:iCrU)H,CliCDftU)—H-H0CliCrbH,iiCDCD0U)Q-,SQl-U)CliJ-b:iC)CliCDft 0QI-•CDCl)CD0dH-hCDH-CD00HC)i:10ol-H-ddSU)QI5HCDCDCDU)Cl)CD5H-CrCliCli0U)l-iH,CliCDçtLQ0o5H,Cli ftH-CrH-H00CDCrU)CliSW(1)C<CDCr0CDCr0)<Cr-CliCliH-CDNftftCl)CrHCD:3HCrCDU)HQ-,•H<CDCli-U)CrHHIICliWClijCliClij0)r—I-,()QU)0CDCliCDS0:ijIH-CD0-CliU)CrQC)CrClik<CliCl)CD<:0Cli—HClH-CD0CrCrClH-JU)H-l-iCDU)CliU)CD-C)CliH-CDCliCDU)CrQICD0CliU)U)Ht3ClHCDCliHClCDII-U)Mft<I-HU)0H-CD00C)h’CrçtIQç-rCD IQR’HCrCliC)kDChjCliC)ClCli-H-ClHCliIHiH,C)(Q0Ci)CliC)U)HftCl(IDCli•Cl):-—CriCDClClH-HClHIIDCr0C)CrC).—.CDCrpiCD0—H-CCDi-HU)H-CDC::—CrClI-CDH-ClCrCDCDCD-ClCD ClU) Cr Cli Cr CD U) Cr CD O H H- U) H 0 0 H, Cl 0 H CD U) C) CD Cr Cl) Cl U) C) 0 0 H CD Cli H Cr C) CD Cr CD U)wp15H•:iCli0HjCr•Cl)k<CDHIS‘-10•CliC)H•‘JCl)i0CD<:k<IiU)CDCrHU)H-U)bH-CD00Cl)CDH,iCftCDCDCl)U)zJçtCrC)HSL’JCDCr5HCDU)hCCDCDCliC)HCliU)0CDClU)U)I.IJCDfthftb><H-iCl)‘-<C:0jIQCl)(QHICD-IHC) CDCridU)Cl)CDCDhI-CliU)U)ftCDC)CDH,0CDCD1j0FCl)Cll-’U)I-0ftH-SCliHCliU)Cl)Sb<CDHl-CDU)CDCD“<—U)IQU)CrC::H-0HC)CDl-CliCliH-U)<l-Cl)CD0CDHi<b3ft0Cl)CDC::CDCliftIIjftCD QCl)ftU)CliHCDClCliCDI-<•.JI-Cl 0CliCliH,<0U)CDH-U) “3national school-based “Youth Risk Behavior Survey”2 (Kann,Nelson, Jones & Kolbe, 1989; Kann, Anderson, Holtzman, Ross,Truman, Collins & Kolbe, 1991; Kolbe, 1990)Data from three other American surveys are also reported.For males aged 17-19, data from 1979 and 1988 are comparedusing results of the (1979) “National Survey of Young Men” (N= 609) and the (1988) “National Survey of Adolescent Males” (N= 742, aged 17-19) (Sonenstein, Pleck and Ku, 1989) . Forfemales, retrospective data are reported for the time period1970-1988 for (N = 8450) women aged 15-44 using results of the“National Survey of Family Growth”, conducted by the NationalCenter for Health Statistics (CDC) in 1988 (CDC:MMWR 1991,39 (51&52)In British Columbia, the first administration of theAdolescent Health Survey (McCreary Centre Society, 1993) wascompleted in British Columbia schools in 1992. Thisinstrument included 73 core risk behaviour items from theCDC’s Youth Risk Behavior Surveillance System, permitting datacollected in British Columbia to be compared to thosecollected in the United States3.component of the CDC’s Youth Risk Behavior SurveillanceSystem, which utilizes a multistage design to obtainrepresentative samples of students in Grades 9-12 from U.S.public and private schools.3Students (N = 15,549) from 48 school districts (174schools; approximately 840 classrooms) , were surveyed withregard to their health status and health risk behaviour.24Ci)Q,C)0)Cl)H-00wSC)ft5H0CDCDCDh’H-k<CrftC)rrCD<H-ft—jft02P0) S ft H- 0 0 H,C)CI)Cl)ft0Piftp)I-HH-ciII0ci SCDCDHtY-ift‘•ljH-,-ftJC)0piCDC)ClciH-0H-CDCD0ft 0c2 P) Cr P)U,H,H CDLiCD)pic-rfrj 0)H,HhP)0ftSCD I-ft—CDI-i CDciCD0P)HHCD 0)CrC) CDDi ftftH,i-<oo ci Cr0 ciCl)ftciH-CD0 I-C)Di0ciHCDHCl)CD C)—3ft CDHCDwDiWH0<o\0Di Dl H Cl) H- 0)Di CD -ci CD Cl) H S H- H Di ft 0 ci Di ft Di H, 0 S C-) Di Di ci Di Di Cl) Di 0 H CD Cl) CD CD Di H CDH-LiH,Cr—30)tIJH-HCDwiiDiCDCD-<0ftC)H5CD\O><CrHCDdH,Dici0CDCDCDI-0Hd0lI-jh-I-hC)ci0CDCDH,HDiC)H-Wh’0ftH,0)I-Q0DlHCDk<MH-ciCl)C)H,H-CD0iCr-ftCDCDIiI-HI-C)DiH-0)—Di5ft‘-.DCi)CDCDHCl)CDciCD<CrDlCD-CDH,iHH-DlHhHCDC)i(-QCDC)WH,50)5C)0ft0(CD0)0H00)DiCDCDL’J0H,0HCl)o\OIH><DiCl)HCrHCDI-0CDci0)ciCDftCD<ECD0)00)0)Dici05CDt-CDH,CD02—‘Hh1xJCDCDCDI-LCD-•HCDH-—.F-jCD5CDCrDiH-0)Cl)DiDiCH-IIbDiC)C)L’i1CiCDCDCD-<HftCDh-LftciCDH-i<1‘ziCDCDC)CDDicDi<C)CDIIC)0)H,0)-Lft0CDCDiCD0h’CDC)UiIiDiH,-Lci0)HDi1CCD0ciCl)JCDHIi‘-i,QtQH,MH-H-H-CDCi0ciCDhL0)HftI-QCrIQciCDi0)Cr0k<ftCDCDL’Jd:iCiCDDiLxiSCDCDCi—.H0)C)CD-0)F--Co\°ftC)ftCDftC)-00)H-0ci0H-0H,0—H-DiCDCDici<H,H,ftHCDI-H-5CDC)DiDCl)C)Cl)ft0H,DiH‘rJLxiDiDiftCDCl)CDiCDCiI-l—I—Cl)IQH-5Di‘zlDi0DiftDi0)ftDiCi0H-ft1H-DiftLD-<HH-F-iCD0DiC)o\0CDCDDiftC)0)hH-HC)0)iCDftj<CD0CD—3CiCDCl)H-0DilDiH,DiH-0ciftCDCl)ftO\0Di00)Cl)5CfH-C)ft5iciCDH-HDCDDi020ft><H0(-QIi0HC)H,CDciI-QcvH,R’ftCDDiH-C)0)05—HCl)CD0DiCDHH-—0C)-DiHHh‘-Dft0)ciLiCi)CDH-CX)HftCl)CD0CiCi0)CD—3H->0IDiCCl)ciHH0)0DiC)0)ftDiSHdiCD0)CDftDiciH0o\°0-H<ci0)ci‘<CDft0ftH,0)Ci)F-’-H-C)SH-H-HP)Dift HDlCDC)‘—°1-1)O\’ft0)02CD020)H]0 H,ftDiCDftCDHCD0’C)’cCDH-0)Cl)ftftH-H.H-Di(TC)0)ftftooftcCDS‘-L—CDCDCD(Cl) CD ft Di ft H-0)0CDC)DJH-H-Jftft0)biDlCl)CDCDCQftCDI-CDCU0frhH\)H0H-iCDCDCUrtH-CDCD‘D0I—hCodCDCU<0frCUII-QCDHCUQ02H-HC)Cl)01CDct)CU0CDIICDCtcik<piCl)3CtH-I-QCUH-Cr30F-1Cl)CDCDiCUCl)CrCr0—iiCD•CDH-ii—CrH-CDCDCUCr02CU0F-1CD02Cl)IQC)CDCfC)II‘-<CDHCDCl)Qt3000DCl)H-HI-jiCUbhiC)—CUCDCUCDCl)CrCDCrC)C)UC)t.QCDH-CDCDHCr0C)0HCDCD0CUQ-=CUC)HC)01I-C))C))-C))Hfr-iHCUH-hiiCDH-3CDCDo\°$10CDC)3C))H--‘IC))C)CU—CDMk<C)3CD0H-CUI-QICrI—iCl)iCl)0CDQIQII-CrCDC))CD<0o\°CUCl)CD<HQIHHCfCDCr0i-<C)0CDQI0ClJrp.Ct0H-CD-i-iICIQ.I—hCUCrCvCDHC))C))C)CfC))HDbCrCrCUC)CCUCDHHfrCU-ClCf<Cl)Jk<-DCDHCDH-00Cl)C))-0CDWH-I—QiCDCl)tOCDCl)tOICl)0iCrC)I--iCD0tOjCDH-CrCD-0I-ICUC)tOCfCD=CDhH-C))I-Jo\0H-C)H-H-CDCDCD<O\0CfCU0CrCf0CrCfCD0CDhCrCDCDC))‘-<—CClClWHvCfH—CD0hhH-CrCUCDfr-hHH-CDH-00CDCl0HClQ-CD0Cl)CfI—hCfiC))Cl)‘-.0H-Cl)CfdH-CrC)•Cf1.0Cl)CUCUCDCDCDCl)CD3CDCl)WCD3HH-I-IC)CDClH-•-Cl)CUCDC)Cr=(Q,W1J1Cl)CU0C)•HCl)Cl)CDoC))WHCr0H-CDCf—Ho\oCDH10HQ><CUCr•—<Cl)CiH-H-H-CDI-CrC)C)jCDC))bCUr-rC)i0ClCDCr<biiHF-’H-CUCfHhCl)0H-Cl)CDC))HCDCUCDCUH-C))—H-HCDhCl)1C)ClH-CfCl)C)C))‘-CUCl)C))QICrdCf0CD0HtOCDC)30frCDhCDH-CUC)C)Qh0CrhCl)o\00CrCl)CD3CUC)‘tiCl)Cr030000CDCUI—hCCD0CfI--iCi)02ClI--h0CrI--iCrCDCUClCUCDCrH-Cl)H-CfCUCr0CD0Cl(_)CD 33H-0P) ctlip.10p.)Hlct00RIHJp.) 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CD CD C) 0 Cr 0 H H 1.0 1.0 H pi w CHCD1.OCDpico<bODciHPJCD U]H-•IiCICDCDU1C)CDCOhciHI-SC)CDPJCDCD-C) CD CrCDpipijCDCD CDPdCr0I-hCrH-HCDrQCt H-P.)ciHCDhUQC) 0J.cipiCD CD CD1.OPJoHICr P.) HCci 0 H CD CD C) CD Cr CD P.) H Ct (I) ci CD SI 0 I-h CD CD ci p.) H H ‘-< P.) C) Cr H CD CD Cr ci ci CD Cr CD P.) ciCD II C) CD Cr P.) CD P.) ci CD ci H P.) CD C) CD Cr p.) (Q CD P.) C) 0 CD CD CD H 0 CD I-h 0 Cr CDP.) Cr P.) I- 0 Ct CD C) P.) P.) ci p.) 0 ci 1- I-I C,) C!) Cr ci ci P.) ci Ct CDci 0 H CD CD C) CD Cr CD P.) H Ct CLI ci CD p.) I- CD C) 0 H CD ci H P.) H CD CD Cr 0 CD 0 Ct CD0HHHHP<1.0CD—JCDUiQCDCDI- P.) H HH 1.0 -S.)MWWM1.11C1.0CD1.0MCH 1.0 —1WCDWHHU]CD1.0-J1.0CH 1.0 CD4CDUiWMH0ciCDCD—J—JH 1.0 CD—JUiWMU]H(A.)MCCH 1.0 CDU]—]JUiWMMUiCHMCDTable 6. Number of lifetime partners for those Canadian(1987-88) and British Columbian (1992) youth who have hadsexual intercourse at least once(Percentage)# c/u c/u D/o 13/0 CAN BC BC BC BC BCp’t * + GR GR** GR GR GR GR 10- loll 11 7-9 7-9 12 12M F M F M F M F1 23 36 15 23 40 40 41 50 33 392312 17 9 1232 362-5 43 413-5 29 26 j 28 354-5 6 12 156- 17 14 22 176+ 17 19 18 9 20 1211+ 19 7 27 13*College/University students+Recent School Dropouts**Number of partnersCanada Youth and AIDS Study (1988:93).Canada Youth and AIDS Study: B.C. Report (1988:26).Adolescent Health Survey (1993:40)It can be seen that the majority of sexually active youth(with the exception of grade 7-9 females in B.C. in 1992)report having had more than one lifetime sexual partner. Thelast four rows are of particular concern; four to fivepartners for approximately 10% of high school youth; 6-10partners for approximately 15-20% of college/universitystudents and recent school dropouts; six or more partners fora significant number of secondary school youth (approaching31)JpJ1H-C)PiHCD(QtQHH-I-CDi-)HQPJC)OH,PpjHiH‘CDCD°dCrCDHiFJiU)CDCDCrCD-hCDHi0Pip)Sr.Hh1Q0ç-tP)U)H-CDCD hçt,ThCDU)CDP3Q-HU).wCDCD><Irt3H-JCDC)HHcrHiP)CrCD0CDI-hCr“‘HHPJr-j-:iWU) ICDCD CDCDCD3P3“oU)CDCDH-P3HrtQCtpic-rpitQU)iP)C)rto::3HCDHH-CDHCDHU)—.-P3ciCrU)CDH-0CrCDCDrCDU)H-H-U)Cr k<H-‘-3U)P3U) CtCflHiH-CDSCDH-—)H-çtp3U)hC) 0P3H-0Hi5-i-iH-CDciI-Q,.QU)ciCDCDU)p3C)C)S‘-<0o oP3t.QHS 0C) p3IIcQop3 cioHcip3Cr U)-CD 0 H CD H IiC-) 0 0 Cl) Lii0wHiHU) CD <HP3 HCrH k<CDCl) LiiP3()C)P3‘xjCtIH-p3<ClLiiCDP3‘d 0I-,-<CD0-3C)iLiiCDCrOCrCl)R’LiiU) C) J-I-HoLioCiI:-’HCl)ciCr1-3ciocioCl)ciP3CrHU)-3-3P30LiiH S P3HCrCl)CDLiiH‘k<Cl) LiiH d-3CDLiiI-C!)C) CD Cf1.DH‘-<‘-3CD0P3ciH01U)CrU)Cr•H-HU)H-P3 <0CDH-HiH13P3CrCr-013CfCDHciC)U)13CDH-H(QP3C)13oCDIiU)C)QCt0o:3S13C)U)ciCDS‘-o 13CD l-P3P3U)0hHiU)CDCf1Q cipiiHhHpiCrCD13U)CDP3U)P3U) H-CrCDU)CD 13U)ciCl)0P3Ctçt0IiC)CrCDCD1:3-SP3CrCr:3-HCDCrIØQWU) CDP3Hi‘J100CDho\0P3U)00HiCDS—CDS P3p3C)H0CDHU)I-HoCDP.)P.)).Q13C)CDClH-ci01313HCQH-i•CDtoCDI-oh-IIU)HitoH-CD1J1Ct5O\O<P3 HHiU)CDoçtU)‘--Ici ci—SCDPiIiP3HCt13CDU)ClU)P3CDP313H13ciCDClClCDHh-I13o0o\000‘--IHicioCr5I--IU)0 ‘--IHiCDCDP3S).Q‘dP3P3P3HH-‘--ICDIiCrU)-:3 CD•0hU,:3U)w H 01C)U)HU)C)oCr‘-oCD0ci1-0>HCrClHciHi-CDP3CDoH1-QHCr5HCD-U)CDk<HhH-çj‘-0CDC)-H‘-0‘tIP3P3<1tO0Ii13CDP3i--IU)I--ICrI-<:ISU)CD0H-H-cx’QCrCtcx-,CrCr‘-<CD•P3ClU)ZJCtH-H-Clci13U)H-ClI-QU)CDCD13CDWP3ct<CDU)U)CD13CDh-IP3—CD13HP30H-0ClI--I13‘-I CrP.)Cl)CD13ciCDCl-‘çtCi)<1‘—3CDP3P3d<H-•H 13C)HiCD0H13ci‘03CrhP3CDcx’i‘-P3U)CDP3‘-I1-0CrHiC)010CDH•CDCrp3 U)H-0HCrU)Hi13CD0P3P3CrIiU)HzCDCDHCDI-<CD0(1)C)—Hi1(1)C)0H-Hii<005CDIiCl)l-QH-hCDC)CD5ctl—H-1Cl)I<Cl-iHCl)CDCD0H-HI(DH-ct-<ctC)çt5Cl)CD-<ijCl)CD0<iCD0H-CDi-Cl)--.CDhCDCt00Crd0-Hid0HCDCl)0<Crp)øCr-0ftilCl)C)QCDH-Cr5çtWCl)CDftjCDCDCD•-H-iHit.QCl)l-ClCDl-t0ClCD<H-HH-CDHiiCrl-H-Cl)C)C)Cl)—HCl)HI0C)CDCl)Cl)5Cl)C)QHiCDI-hCrCl0CD-‘0CrCl)CD=CDCr0cliCl)‘-<CDClClCD—0—CDCD0CDCtCDHH<Cl)CrC)0P.1CrH.c-rCDt0Cr0CD<CD—SCDCDICD—CDCD1QCDH-C)CrH-CrCDM—]ClH115‘—‘H-—I£1)Cr0CDCDCl)-Dçtw(I)H-çtQHH-—p1wCDCDCD13CrHçtCDClCDCt\OO.H-)HCtCDI-p1CDl-I-0CD13IICr13’I-CD0O\O0(-TICDCDC)SCl)Cl)C)I-QHi50CDCD0H-00HCl)Hi05HiCrHi‘DlCDlH-13Cl)CD0IiCDCDHSCDC)0CDh5C)CD—CT)Cl)0-CDCDH13p1ClCrCD—CDClCl1313Cl)ZCDCl)CD00ClCl)CDCDC)d13H5CDC)0ClCl)CDCDHHHCl13CDDCDC)-oCDCtC))-DCD0—JCDCl)CD—]CD‘-<H13(0H-I—io\°O130Cr-<0Cl)130\O0Cl)S13H-C)CDHi13ClHiCDCD0CD13Cl)ClH-13HiHiCD-CDHC)Cr0CDH—(0CD(0Cl)I—Hi5Cro13CDCl)Cl)0CtCl)HctHCD‘-<CDCrClizHH-Q0CD5CD5CDCl)CDCtCDCDi.Q‘-<CDCtCDH-CDS13CDC)CDC) 0 HHHHL’J(00Wt’JL’J13 H < I- 0Ht’JM0ts)t’s)MWL LI]Cr CD C) 0txJHLI]HHU]t\)HL13LI]H l-frr]0LxJdH0(0(OJiCrL’JCDCD C) CD 13 Cr Cl) CDHlCDCDOHCDCr H--.J13.HiCDCtQ13CD=13 C)Cl) <0H-Hi13 )-QC) 0CD13CDClCl)CDH-CD13 CrL3CD’-<C)QOCl)Cl)CDClCl)H-Cl) 13H 00 Ct0Cl1QH-OII13OCl H-OdC)tCDCl) Cr13H-CDCD13C)çi(QCDC)CD13CrCD Cl)Cl)Cl)l-CDCrH-HHk<CDCl)=CDHHCl)CD0HClHiCDH-CDC)CDCrCl13=0C)l-C)Cl)SOCtCl)13H-HCl0HO l-CDCDCDCDCDCl-0 C)ftH-00 IClCDH-C)CDOft13H-O13SIQH-C)H-CDCD13Ct Cl)CrCr1- CDCDCD-CDCDHIHHHooOD-(-I H HC’)0 CD Cl) rt CD H CD rt H H U] U]C’) 0 CD Cl) CD H CD Ct H c H U]H CD Cr 0 H C) CD Cn H (Q CD rrwH]H I-. Cl) Cr H rr CD C) 0 Cl) CD Cr CD Cl) CDo0 H]CDC)C)0Crj::dH-CD0C)CDS0Cl)Cl)LQH]PiH-ouN HçtU C)CDCrCr0 i-’CDJCl)crH-H-H-Soii‘d 0H-,I—fCro<IIj(I)C)CrHICDCD0CrH]‘-<I-CDP)fJCl) IICl)CDSt’JH-Cl)oCl)CroCl)oH-Cl)0CDIi><H--Cl)C)CrHHCDCDCrCi)çto Cl) CD1:1 Cl) CDCD C) CD Cr CDC)SHI0CDP)jrt1I-H00CD0’-DCl)H.CrH-CrHCl)ZcUjCDCl)1<rrClCDH-CDI3Cl)SCrpCDSFC)HHOCDCD-Cl)Cl)CDLQCl)CDCDH ‘.DHCl)—J-JHDIHH’<Cl)LojSCl)1C)brH-<H.0 Cl)CDcoIQCD H-CC) Cl)Cl) CD Cl)‘HHHAI-’U]t’)HIIIHCDHHHL’JCl)‘—0‘—)CQ CD Cl)H 0 —:1‘.0MrHZ0U]ML’J0 H ‘.0U]—.1OWHU]H0,L’JU] —:1 ‘.0MH.JMHOMU]U]U]‘.11U]‘.0—J-.1CD C) CD Cr CDH ‘.0 S.) ‘.0 w H 1.0 OD z U] o wU]Cl)—1Cto\0CD—S C)CrCDCl)Cr-CDCl)I-I.QCl)CDH]0HI-,f 0H-I-Cl) CD‘-<Cl)0Cl) CDiC)CDohCr—oH-HiSC)HCD‘.0Cl)‘.0Cl)MCDo<S.)H•H o\0 H]0 S Cr 0H-H]5HIiH-CDCl)c-rhCrbCDCl)I-CtOCDC)d0H-0iHFCrHCl)CDCrCDCl)-C)CD0I Cl)CD‘.0I-h—)Cl)CDI1.DCDCl)SSCl)Cl)5hCl)hHH0CDCDHCl)1-Cl)Cl)OCD1.PCl)Q.CDCDc2Cl)HCl)C)-.JH0’HH<1’.oQ.f)SC)Cl.Ic-rCl)C)HCrC)<0CDH]hH-1hH-5Ct1I- HCrC)OCl)Cl) LQ CD Cl) Crof condoms. There is presently a large gap between thebaseline percentages (1988) of young women (26%) and young men(57%) (aged 15-19) who used, or whose partners used, a condomat last intercourse. The U.S. Department Health and HumanServices would like to see the percentage of females rise to60% and of males to 75% (U.S. Department of Health and HumanServices, 1992c:ll9)Given the above data, it is not difficult to understandwhy rates of sexually transmitted diseases (including HIVinfection) in the adolescent and young adult population are amatter of national and international concern. The nextsection presents incidence and prevalence informationregarding these rates.3.1.B RATES OF HIV AND OTHER STD INFECTIONS3.1.3.1 HIV SEROPREVALENCE (Antibodies to the HlVirus) RATESIN YOUNG PEOPLEHIV seroprevalence studies have been conducted inselected populations but there have been no general populationstudies. In Canada, Schechter, Ballem, Buskard, Le, Thompson,Marion & O’Shaughnessy (1990) found a crude overall HIVseroprevalence rate of 2.7 per 10,000 (.O27percent) amongpregnant women (N = 22,512) in British Columbia and the Yukonin 1989. All the positive samples were from women aged 20 to29 years (Schechter et al., 1990:1187).As of March 31, 1994, 32 cases of AIDS among youth aged15-19 have been reported in Canada. One thousand seven35dd‘-<piC)CD0CD0II-d)PdCD:IIHU)PiHftH-PCD0ft0dftFlH-HHH-CUCU0QH-0iHiCD•CDCDCUcn>(QHftctCDft0H-o U)CUCUHCU0ftFla)U)U)CDCDCDCUiftH,CD0rt00IIH,oHçuUiiCDHh’IH-H0‘dU)ftH,0CD:3-•h’D—jiH,H-CDftMH0a)CUFlwCDoftU)U)FlH-Zft0H-0HEH-H-ftCUH-iHftHH-CDk<H-U)H,FlCDCDaC)IQftUiCUHft)JQHHFlU)0Cl0CDiCDH,CU<ftLQH-oCUftCDftClFlCDCUftCDU)HU)d0CUa)CDoClClhjCDCftCDI-CaftH0<CDCDhftCDClH-UiHCDU)D0FlF CDHH,0 FlClU)CUCDftHCUCD C)H,ftHCDU)0ClSCUCU0‘dCUU)HHftFlCUCD<:ftFlCDH-i‘-<0CUjftC)U)H0CDCl iU)fto:0ftCUCDHC)ClH0H-Clftci-C)H0ft.DU)HCDioHH-CUU)ibCDCDFlWH0FlHH-CDFlc-fClCDCU H-CU HH-CD(QCDC) CDCDFl H-U)ciU)ftU)ciCDClClS—H-—CDftU)0HH<ftftftU)0CDJCDFlCUCDCDk<ftFlCDiCDiFlftciCU5H-<FdCDU)CDH-CDCUClCUIIU)FlH0U)k<U)05-0H,CDCUHH-ciU)CD0H,ftCD<CD><HCUciClCtCUCD‘-3ciHCU5HC)CDH<CDU)HCDCD-FCUH-C)iFl0ftClCU-3H,H-H-ft<C)CDCDCUCDCUU)ClftII0CUH-CUUHCliFlftCD0f-QCDCDU)HU)C)CDCUC)CDU)CUCUC)ciFlftCDH-U)CDU)CDftC)U)CUU)lH,ciftCD05H-CUh5FlU)U)CUH-CDCUFlU)H-HH-H-CUNC)CDH-h5ClU)CDC)CU0H-iU)i0H-Clft0H-35ftCUH,-:5_CUci0HHU)U)ciCDH0CDFQH-—(QU)CUdCUU)CUCDFl0FlCDU)FlCDCDhoci0ftciHCUFdCDFU)CU<FlHCDCDCDftCUCD<ClH-H-<CUCU0HCI)ftFQHftiCUHCDCD0U)CDCDFl•HU)C)CDC)CDH-CD01QHH,H-h‘I‘I‘1ftCUH0CUCD‘<ftH-ft5ftCl0CDFQCDciU)CDU)C!)iftCDH,ftH,CUH0)oftCDhftCI)ciU)C)CDCliCDCDCtCUU)ciClCDCl-HU)C)Cl0ftH-SCDHCUU)CUU)CDH’-HC)ftU)ftftHH,C)ClCD0CD5H-ciU)ci0CDfttQCDftIIU)U)CDU)0oH-1QiCU0(CDU)cij:ij0HH-CD0CUH,FlCDCDftH-CUFlCDFlH-C)HCDIiCUoCUH-‘dHiNHQ,HU)ftCUCDCDU)ftH,HCDCDCUhHCDiIIfto<ft5HSClCUH-0CUftH,ftH-CDCUH-CU<ClH—CD-CDCtClHftCU<oCDftU)CUCD.z::0CU::3-•H-H,ciFlCDiciftClU)FlCDMCD0Cl5ftICU0F’)U)ftWHCU H—fto:ik<H,C)CDFCUCU0ftU)HiCDftCDCDU)U) CDC)HCU—:1‘dWa-,CDCDCUHoC)ClCUCUHci-C)CDU)CUCDU)‘dCDCD0FlU)FlH,H-CDHftCUHH<H-CD-0CD‘0CDHHCU•-CDftUiCDCD—ft 0C)Fl CD‘-3CU0<CDH-FlCDFlU)ftH-CD0H-ClCDClU)CDHH,Hi0‘DH-FlCDH,CtCD0CD1:3Fl‘tiC)CDC)HftCDCDCD ClHftsexual behavior”, with the youngest being at highest risk(Campostrini & McQueen, 1993:1139).Table 10. HIV÷ Seroprevalence Rates in Selected AmericanAdolescent Populations, 1987-1989[1988-1989]91 STD clinics (throughout the U.S. and Puerto Rico)(age 15-24)70 clinics at <1%10 clinics at 1-2%11 clinics at >2%(Kann et al., 1991:397.)[October 1987 - November 1989] (N = 131,119)Job Corps: 16-year-olds: Males: .12%; Females: .25%19-year-olds: Males: .59%; Females: .33%(Kann et al., 1991:397.)[January 1988 - June 1989]26 Hospitals: Range from 0% to 3.8% (by hospital)(age 15-19)(Kann et al., 1991:397.)19 Colleges: Rate = .2%(Fennell, 1991:35.)[October 1987 - December 1989]Covenant House, N.Y. (a facility for homeless runaway youthaged 15-20)15-16-year-olds: 2.2%17-year-olds: 2.9%18-year-olds: 3.4%l9-year-olds: 6.5%20-year-olds: 8.6%Females (N = 1037) 4.2%Males (N = 1611) 6.0%Overall rate: 5.3%(Stricof, Kennedy, Nattell, Weisfuse & Novick, 1991.)37H---..H--1i—SI0Q0frhW0CDCDH-00-(.HHdtiWHh’pOCDrtPri-00ctCD000H-1I-0Wr)H-C)PirtCDU)HCuH-irt.0CDU)CDiU)HH-H-rrQCD)HQWF-’H-(j)U)CD1U)rtCDd-CDII$)Jçirt-‘-‘-<CDH’U)CD00•H-C00WU)F-CDF-JCD00HU)Cl)QwCDCDr10><QCDdCD)U)0<CDCDCDhhCD)<PJwHU)k<‘-0U)U)CDMCD-rLiCtpjH-HU)CD—OOH,CD0H0CDPJiP)CDCi)PJ•.H1iHQH-U))H-H•Q,0Q,0rt••(QHCD0CD‘-<H<H<Q0<0CfU)CDCD—JU)I-h0HCfU)H-U)PJH-U)d0U)b0U)U)CfWCDPi-D‘-<H-CfH-CDH-CDH-iCrH00CDr-fF—1hh‘-<d---’t—‘CDCD3HCD•Cf<•1CDU)CfI-h(DCDF00CDCfCDCD0Q0Cf0$hCDU)C1)HiCDU)CDCDQH-O0iI-pi0-0CDU)F-JCDdPJCDHOHU)I-3CfH3Cf0CD<JCDci0H-CfCD0H-JI0HU)HCDHU)H-HHH-U)U)0U)U)H-0JCl)U)‘-<QH-0-DU)CDCfhCD00U)-QCDOU)HH03H-‘.DCDH-CiCDCf0H’CfCDdH300CDCDCDCfCfF-U)Cl)0CfI-•-PJCD<iii0Ct-’-<CDC)H0CDbCDPiHCDCf-—CDCl)HCDCfH-Q0U)CDLiCDjpH0I-hCDQCf—Ji)JH-hCfU))fHU)d1JWI-h0hCDWOU)Hf<JCDCDCfCfCDHCfU)CfCfCf<1QU)CD0<HU)CDJHU)h30U)PJ)HCD0H--U)CDhWU)CfCDCDOCDLYCDHCDCD(tI-hC)CT)CDfHU)CDH)1Q<0CI)CDPi00CDU)CDCl)0CfCDCfHH-H-L’JCDH-00CD0I1I-I-hCfPi0H-tM,’--CfCfH-PiCf0l—I-hH-CDHCDU)0U)H-H0I-hOCfH-0CDNHC!)CfCDU)H-CDCDCfHP)CDPi3diCDHCl)H-LiCD0pCD00CfU)I-friUCf0fHCf-$0U)0JI-HU)CUCfiF—PJCtCDH-U)0f•IjHCDI-U)CfCUU)CDPJCfctpJCDCDU)U)HCfCDU)p)0CDCfU)Cf‘-<CfCDCUHI-iCDCDCD3W•PJk<<HfbF-:-<pi-U)CDCUQU)Cf-CDCfCDHCD-CUCDLiCDp,CfU)H<1CUI-TCfCfHO’-<CDhCDCDDOCotIpH-HCDCDCDHQP3CDCfCfU)J”JQ<CD0CDU)CiHCDp3U)H-HH-CfQCUI—i-CDH-0U)CDCf’OF-IHpiU)H0CfH‘-<H-iCDCfCDH-FH-hTCfU)Cf-CDH-3U)PCl)CfH-HHH-iU)Cl)PJCDf-CfH-CDf-i-(-ff-foh-iU)CDCfH-i—CfCfH-U)piCf0piH-H-CfU)p0HCIP3CDPI—00CIH-CfU)CDF-0i0U)CDCDCIU)HP30CUH,U)CDCD0-f0tCiU)ç130.I-0iJQCDU)CDCDHI-hPJ33CDCfpiQCDHCIH-H-CDU)CfH-PJCDCfCDCf00I-•‘CfOH-H-LiWhU)Cfh0-ctQU)Cl)H-CfH,CDdPJCfCDP)CDCDf-iHCDC)0O0CDCfH-—CDCf0CDCDfH--tYCD0CfCD0.Li0.CDCf0CD00CDCfbH0Z0iCDCD•CDCfU)fCf0HtjCfCfH-00CD0.H-OCD•0PJU)CDC!)H-C!)CD0HH,U)0•0U)P)H-CDC-0CD0Cf0HPJCDH-CD3U)U)R1H0.PiCDCD•U)wQ0HPi0H,0iI$1ba)HHk<HCD-Q-H-0H,I—ioH-FtH,a)0 I-ik<:zo) <CD0CD 1CDIQCDC)oC) I-jCDPiCDCDPiH:i)a)CD•a)CDa)CDQPiH,(QH,0CDo‘-Q‘1Hk<00oiHH,P)CDCDHH,t-CD0a)I-.FtP.)‘<(Q0PJCDCD(.QH 01H,CDICDP.)Hh’DPiHH CD C))P.)P.)Ft1QCDCDa)H Ii Hi P) H CD H H p) çt CD a) 0 H, (Q 0 0 CD Pi p.) 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The y tells us aboutthe processes by which changes occur in the targetvariables. The when tells us about the timing andsequencing of our interventions in order to achievemaximum effects. The j, tells us the methods or ways weshould focus our interventions; it includes the specificmeans of inducing changes in the explanatory variables(Glanz, Lewis & Rimer, 1990:21-22)Kaplan, Johnson, Bailey and Simon (1987) reviewed theextant literature on the prevention of HIV infection and thedelay of onset of AIDS. They concluded that researchers needto broaden their search to include all known or suspectedpredictors of risk for HIV, and that all these factors need tobe considered simultaneously within an overarching theoreticalframework (Kaplan et al., 1987:147).3 .2 . B INTRODUCTIONWhen concepts and constructs are related to each otherand purposely combined to form a unit, the resulting entitymay be labelled a “framework’T, a “model” or a “theory”. Thereis considerable controversy regarding the boundaries or limitsdefining and circumscribing each of these creations.Generally speaking, a framework is a planning tool. It canincorporate theories or models or parts thereof, and allowsfor organization of a large and unspecified number ofpotentially predictive or explanatory variables. 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QftCDP.)CDCDdP.)0CDH-C)P.)H-CDCDH,ftH-ftC)ti0P.)CDftIiH-CD0H,iHI CD C) ftHiftH CDCDuse/abuse, presenting and discussing research to which theyhave been applied.3.2.C TAXONOMIES OF THEORIESTheories may be grouped according to the scope of theirfocus (e.g., those addressing intrapersonal, interpersonal orgroup levels of interaction), with group-level theoriesincluding those of organizational change, diffusion ofinnovations, community organization, media advocacy and socialmarketing (Glanz, Lewis & Rimer, 1990) . Theories may also beorganized according to the content of their focus (e.g.,cognitive, behavioral, social, environmental)Leviton names five “families of theories.1. Cognitive and decision-making theories, including thetheory of risk communication, the Health Belief Model,and the theory of Reasoned Action.2. Learning theories, including the theory of operantconditioning, social learning theory, and sub-theories ofself-efficacy, relapse, and self-regulation.3. Theories of motivation and emotional arousal, includingtheories of fear and fear-arousing communications,helplessness, and coping strategies.4. Theories of interpersonal relations, including socialinfluence, reactance, and group processes.5. Theories of communication and persuasion (Leviton,1989:44)When planning research, an investigator may wonder how tochoose an appropriate theory on which to base the inquiry.Since theories and models are usually specifically oriented,it is necessary to ask what the parameters of the inquiry45FtH-CD0P)U)F1 CDH--QCD)hHFtC)0C)P)QFt 0T1HH-CDFlCDII CDFtFtQ-P)00HH,CD >piC)0P)pjF-1C)$F-’PiFtFH-F-1FtCD0CD—CDCDQ—CDFl-U)CDOHf-tCDFlCDg CDp)HLICDH-0CD oFtLI.rrftp)CDH-HP))a-FlP)H-•H-PJCDCDC)FtU)CDC)CDp)oCD‘<FlCDHFlHHU)°CDSftDi0p) HFtCDb°0H’CDU)CDFtU)H-HdNH-FtCD0FlFtH-H-FlOH,Q°H-iC)iC)C)H-CUCDHP)FtF-1 F-1H-0I-Q<k<FtFlCDCDU)U)0FtHC)0FtCUCih0i.DQQ‘DHhCDCDU)F.JFt‘-<H-0FtH-H•-Fl-QFlCDWU)0CDI—IWH-CI)0HLJH-FtFtU)H-Q,E.CDFtHH,QikDCiFtCiCD--CDC)FtH-CDCiU)LDU)U)CDCDdFtPJH--H0FtCDFtC)U)Ft—FtH-FtMFtCD00CDHC)FtDhH,LI.CU5CDD•CDi••H-HFlFl0Fl‘-D00CUCDFt0C)CDCDWH,<U)P)CDMSFliU)CD1FtFtHQ’<-CDC)H-0—0U)hCiQ,CDH-Fl0CD0‘oQ,H-Q,FtFt’-<FlH,U)—SH0CUFt—pJQU)H-H-U)CDCl0CDHCUU)CI)Ft•OCDFtCH-CDFtHH-HiU)QCDLJ-FlU)50FtFtU)CI)U)ldCoClCI)CDCDFlCi0U)FtU)CI)FlUi0Fl0ClFld0CDCDCI)CD(1FtCD—U)ClH,00FlJQ00CDFlH,HFl0Fl‘-<<H,LJCDCU5FtH-H-H,CDFtCiCDCDU)C)FtH-CDFtCDCDFtCI)iHCD0iC)FtH-C)H-1H-LIHFtU)CUClHFtSCDCDFtC)—FtFtCiCI)HCDOOFt00H-SU)0——CI)U)dFlSFt1Q0CUU)FlH-CiU)HFtOCDFtFlFtCUCDCD‘-<I-H,H-iH-H,FlH-H-CDC)U)H-CiCDC)FlCDCDH,FtClCDFtOH-00—NHU)0‘-<H,CU‘-<FtU)<U)H-H-5H,Cl)CDI-H,FlC)Ft01xJCDClCI)H-H-CDH-CUCDC)FtClH0U)CI)CD0U)C)CI)C)CI)CDCDCDCDFlFtFtdFtFlFttY5FtCDC)FlCl00FtFl0CI)<H-HH-U)HFtFlH,CDHCDHFlCI)CD0FtCD<CDFtCDU)P)U)Fl<FlH-><C)0CI)FtH-FlCD—0H--CD-5U)CUFtCI)HFtC)i‘-<iC)FlOSU)U)CI)H-Ft5HC)CDCD1QCDCI)k<FlpiihU)CD-U)iFtHH-CDHCDH0‘tIC)FlU)0H-H,CClFtCUCI)U)0CDC)U)JFlH00U)FtP)U)FlbH,-0—CDCI)CU—FtCDU)H-Ci-H-HP)•FtC)ClIH-FtCDHCI)U)CUCD3<H,FlH-—CD0HJHCiH--bU)CI)0H-0C)C)HCDH,FlCDH-0FlC)CD5FtCiHCD1Q•CDCiH-CD0HCI)U)U)CI)CD—CiU)CI)FtCI)ClU)H-CI)FtU)U)0F-ICI)CDCUCI)CiU)0CDFtC10HCiFtCl(-Q5Ft-C)CDClH5CDStCDClH-Dik<U)CI)HCDU)—CDFlCI)CD5CiFtFtFt‘.<0FtC)FtCDFtCUi0CDCl)CiCI)0H,U)H-CiU)CDCUFlP)H-CI)0U)C)CDFlCI)HSH-FlFtFlU)C)FlCDp)U)CI)HH-iFtFt-CDCDFtCD5Ft5NCDQU)FtCD30FtU)0FlCD-H-FtCDCU00U)H,LIU)CiiFdOOHFlH,0CDFtFtC)0t-QCUCUFlH,U)H-iCUU)0FtFlHFlk<Cl)U)-FtCUU)-U)HiC)çtCDoiHc-CCDi0I—iCDC)(QotQ 00çUCDFCDH-<c-COCDp)I-<pii‘tiC)CDH-$1JC)Hc-CJCDHI-IH0CDCDC)HiçtH-ort<)C!)k<di—i0CDC)JH-‘dHc-CC)0P-)H-PiHiCDHoHCDH-CDCDCD H-Cl)CHc-Cc-CCDH‘CDhCDHoCD(QHiC)Pi‘-0c-C--PiII0hp1CDc-C00P1C)PiCD‘1C)0CDHiCDIp1CDH-c-C0C)k<1QH-p1‘dIIHc-CH-P1H-H-C)c-CCD01P1Hc-CiH0H0hCDHi0CDHiP1CDCD00HiHCDhHiH-c-tCD<P1CDHC)CDhP1H-c-CCDC)iH-CDCD<1P1CDCDCDH0CDo<P)c-ChH-CDH-çtc-CiCDCDctH-Hi0OCDCD00P1bc-CCDHHiC)CDCDPIP)0C)QHc-CI-WCD(QOHCDH-PJSb—1<CD1QCD<HiH-11ic-CHiQtCD0CDP1I-ICDC)HiH-HHP1OCDc-CCDHhCDH-ic-C.—.H-O<LJ-c-Cc-tP1WCDOC)CDNCDOhF5-CDHctp1CDc-CCD<CDHQH-—0Q-0P1CDHHiiC)IHiUiQCDop110p1-QCI-c-Coc-CC)CDH-’ic-CHH-CDCD0H-P)LI.DP1CDICDc1CD‘.DHOOH-0CDWiP10Hi••‘dH-’dCDiPJCD’tH-d1 CDWCDQ.,c-C0-0-CDCDPI•qQC)c-Ct-HCD3YOHiCDCDP)CDPJCDH-CDCDHC)Hicc-1Yctc-CP1CDCD‘Z-I-c-C<H-ct‘diCDCDjc-CiP1P1CDHCD0cCOQP1H-dCDCDC)<0dH-c-tCDh’CDFCD0CDCDctHiCDc-CCDCDOPICDCDHiH1c-COHc-CJC)CDH P1CDHH P1 CD Hi0 C) CD CD c-C CD CD 0 CD H CD P1 H- C) c-C CD CD C) H- CD C) CD c-C CD P-I C) CD CDP1 0 P1 P1 C) 0 H 0 H- CD c-C CD P-I P1 CD Hi 0 H U.H 0 P-I CD CD H 0 Hc-CC)OH CDC)P1HF-PIHCDk<CD H-CDHik c-CPICDH-NCDOCDCDCDHHiCDHi0(Qhcc-CH-CDH-H c-CP1:JC)CDc-C PJI-Hi IQH CDCD<CDCDtic-Cc-CH-H-0CDHi-H-CDPIHTable 12. Battjes’ Program Classification TypologyI. OrientationA. RationalB. DevelopmentalC. Social NormsD. Social reinforcementII. ApproachA. InformationB. Affective educationC. AlternativesD. Social pressuresIII. FocusA. Provide factual information about drugs, theireffects and consequences.B. Increase self-esteem and self-reliance; decreasealienation; development of decision-making skillsand/or interpersonal skills; usually includesminimal or no focus on drugs per se.C. Reduce alienation; increase self-esteem and/orreduce boredom; usually includes minimal or nofocus on drugs.D. Develop abilities to recognize social pressures touse drugs; develop skills in resisting pressures;identify immediate social and physicalconsequences of drug use.IV. Typical MethodsA. Lecture; questions and answers; displays ofsubstances.B. Lecture; discussion; group problem solving;minimal role playing.C. Participation in community improvement projects;vocational training; tutoring, recreationalactivities.D. Discussion; behavior modeling; role playing;extended practice; public commitment not to use.Source: Adapted with permission from Battjes. Copyright1985 Marcel Dekker Inc. (Bruvold, 1993:875)school classrooms. The “Affective” education programs aretypically delivered by classroom teachers, preventionspecialists and/or mental health professionals, and are found48in elementary and secondary school classrooms. The“Alternatives” programs are typically delivered in communityimprovement projects, vocational training, tutoring andrecreational activities, and usually take place in thecommunity, although occasionally are to be found in a schoolsetting. The “Social pressures” programs are typically taughtby classroom teachers and prevention specialists with the helpof same-age or slightly older peers, and are found from about6th grade through senior high school. The “Social skills”programs are typically taught by the same type of personneland found in the same type of setting as the Social pressuresprograms (Battjes, 1985:1116)Theories and models most commonly applied in research andprogram trials focused on prevention of HIV infection inadolescents are Expectancy-Value or Value-Expectancy theories(e.g., The Health Belief Model, The Theory of ReasonedAction), Social Learning Theory (also known as SocialCognitive and/or Social Influences Theory, including Self-Efficacy, Social Norms, Social Reinforcement and ReferenceGroup-Based Social Influences Theory), BehaviouralEpidemiological Theory (based on Developmental and ProblemBehaviour Theory) and Stages of Change Theory, including theTranstheoretical Model of Behavior Change and the AIDS RiskReduction Model (ARRM). 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with regard to several characteristics of both dreadedand unknown risks. This may help to explain why people aresometimes very fearful in situations in which they areactually at very low or no risk of contracting HIV.3.2.C.4 THE THEORY OF REASONED ACTIONThe Theory of Reasoned Action (Ajzen & Fishbein, 1980) isa highly precise theory outlining attitudinal (based oncognitive analysis and evaluation) and normative13determinants of behaviour (See Figure 1, Appendix 2).According to this theory, attitudes and subjective normsdetermine a person’s intentions, which are predictive ofbehaviour. The shorter the time span between the measurementof ITintentionslt and of TlbehaviourTi, the more likely thatITbehaviourTi will show congruency with previously statedit intentions 14An overview of research based on the theory of reasonedaction indicates that correlations between behavioralintentions and behavior are usually between .6 and .9(Petosa & Jackson, 1991:466) 15‘3perceptions of other’s desires regarding the subject’spotential behaviour and motivation to comply with these desires.14it is important to measure both intentions and behaviourwith the same degree of specificity.‘5This means the percentage of variance (r-squared)accounted for would be between 36% and 81%.573.2.C.5 SOCIAL LEARNING THEORYThe three major constructs in Social Learning Theory(SLT)’6 are: (a) behavioral capability (having the skillsnecessary for the performance of the desired behaviour) ; (b)efficacy expectations (beliefs regarding one’s ability tocarry out a course of action successfully or to perform abehaviour, i.e., self-efficacy); and (c) outcome expectations(beliefs that the performance of a behaviour will have desiredeffects or consequences) (van Ryn & Heaney 1992:321) (SeeFigure 2, Appendix 2).The leading concept in Social Learning Theory is that of“reciprocal determinism”. This means that behaviour isdetermined by the interaction among three elements; theperson, the person’s behaviour, and the environment. Theperson’s actions contribute to creating the environment, andthe actions and environment contribute to the person’scognitions or “expectancies” Expectancies are of threetypes: beliefs about how events are connected; about theconsequences of one’s own actions (outcome expectations); andabout one’s competence to perform the behaviour needed toinfluence the outcomes (efficacy expectations) . “Incentives”also contribute to behaviour: incentive or reinforcement isthe value of a particular outcome to a person. 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There are two conflictingtheoretical rationalizations behind this approach. One isthat adolescents take up substance use due to the absence ofexplicit norms for behaviour. The other is that smoking andalcohol use behaviours are adopted by adolescents to conformto the norms (i.e., their presence) governing behaviour of asubcultural group with which the adolescent is associating.The choice of activities for the social norms approachvaries depending on the situation and the theoreticalorientation of the provider. Some programs attempt to modifysocial norms directly within the school environment. Othersattempt to facilitate increased self-esteem and a sense ofaccomplishment by providing opportunities for skill- and self-development. Still others organize activities to help reduceboredom and provide healthy social stimulation for adolescents(Rundall & Bruvold, 1988:320; Battjes, 1985:1114-1115) . Thesocial norms approach is related to the developmental approachbut is more oriented to developing influential (health-enhancing) group norms as opposed to facilitatingcrystallization of healthy individual identity.3.2.C.7 THE SOCIAL INFLUENCES OR SOCIAL REINFORCEMENT MODELIn the social influence model, the determining factors ofadolescents’ engagement in behaviours that lead to negativehealth outcomes are social and peer pressures. The modelviews initial substance use as primarily a learned 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 as psychological inoculation, are applications of SocialInfluences Theory.3.2.C.9 THE INFORMATION-MOTIVATION-BEHAVIORAL SKILLS MODEL(1MB) OF AIDS RISK-BEHAVIOR CHANGEFisher & Fisher (1992, 1993) have included reference-group based social influence theory in their recently-developed model, the “Information-Motivation-Behavioral Skills(1MB) Model of AIDS Risk-Behavior Change”.The 1MB Model contains three major components:information, motivation, and behavioral skills. Informationis a necessary ingredient and must be both relevant andaccessible. The Motivation component includes all of theHealth Belief Model and Theory of Reasoned Actionvariables.21 The Behavioral Skills component includes thefollowing specific AIDS-prevention behavioural skills, as wellas self-efficacy and perceived control:* Self-acceptance of sexuality with likelihood of futurepreventive needs* Information seeking, editing and updating* Creation of personal AIDS prevention agenda (based onacceptance of personal sexuality and risk)* Presex negotiation of AIDS prevention and ability to exitrisk situations* Public AIDS preventive acts* Self and partner reinforcement (maintenance)* Evaluating prevention and possibly shifting scripts ifdesirable (to decrease anxiety, increase safety, etc.)(W.A. Fisher & J.D. Fisher, 1993:134)21incorporating personal attitudes toward preventivebehaviour and perceived social support for its performance.683.2.C.lO THE DEVELOPMENTAL APPROACHThe developmental approach is broad-based, emphasizingthe development of self-esteem, self-reliance, socialintegration and life skills. Little or no emphasis is givento trying to tTpreventll substance abuse directly. Rather, itis assumed that children and adolescents who feel good aboutthemselves will not be drawn to abuse substances or act out inother ways that would be detrimental to their health. Withyoung children the focus is on creating an environmentresponsive to children’s emotional, social and cognitive needswithin the family and school environments: “The goal is topromote healthy maturation, positive self-esteem, andsuccessful interpersonal skills which hopefully insulatechildren from subsequent drug abuse (Battjes, 1985:1114)With adolescents the emphasis is often on developingcommunication, assertiveness and decision-making skills.22Prevention programs built around developmental theory aim toassist adolescents in overcoming identity confusion andforming positive self-images and identities (Jessor, 1982)They may be constructed around academic achievement, athleticachievement, volunteer service, peer leadership or other22Decision-making includes clarification of values,assessing the consequences of substance use in relation tovalues, and finding alternative behaviours that would be morecontributive to social integration and the attainment of lifegoals.69lU)C)‘—ClH-CDCDCDCD0PJciU)(Qct<<dU)IU)‘c0ciCDCDP3HicH-CDctl-HHhCU)iF-ftH-H-OOPJII(QHU)rtftftCDftftH-CD::3P3U)H-CDH-H-JCliU)C)(iHiH-ct00ftf-tHHiftftP3H-0YI-CDCDU)ClCDCDP3OHC)CDU)P3CtftP3CD<P3CDU)CDCDftCD<1H-CD-CDC)HH-fl-HU)CD00P3H-H,ft‘dciU)i-ftCDP30rrcP30OCDU)CDH-ClU)ftH-H-<CDCDftQClCD0<-><P3I-CDP3(QciftF—P3ftU)ftH,—P3CD0ICDCDci—L’Jf--ftfthjH-HW--P3Q,P3U)R’H-H-lCDClftCD-iCDciU)CDP3—1CD<CDHCDU)P3P3CDHftU)ftHH0CDftftH-H-00U)ftH-hCN0ftF-CDC)P3H-H-CDClH- 0ClftQ(ftU)CDciCDP3F-H-ci-<ftP3P3C)P3U)3jC)C)HCDP3P3CDCDCDC)SDCDQ1H-U)000ClP3C)Cl—U)0QF—1PJCDHHiHiCDH-Q--ciHHU)P3ftHHMU)C)—C)H-P3HU)—)CDCDHftC)k<o<i—‘ft’-<-CDicift<H-ClP3 HCDft::0HWP3•C)L\)P3ft•ftH()CD•ftH-HftftHH-H-—CD U)wI•:tJLXJcift P3 ftHI0oci U)CDCDHL’JciCiHHI0H ClL-1jU)P3HI0o—CDoP30HHI-<Dft0 0 UlU)0CDoi U)•CD 0 HiU) CD H Hi 0 U) 0P3HU)HiP3CDC)‘dHiCDClLC)0H-0Qi0CDdI—s‘dH-H-CD-DC)Hft-0C)d0P3H-U)C)MH-CDH0U)P3CD<ClC)-.P30l-P3CDC)<iH-CDCDH0)HU)P3HU)H-H-ClU)SU)ftMH-ftC)P300H-H-0H-HCD—P3<ciP3CDU)cici><0I-QH-CD•iCDI-QU)U)H<P3Cl-CD0ftCD=0CDCDU)-HU)U)0‘—HiHitQU)H-WH-CD-P3•00-<ftHCDCDP3U)P35‘-1-0hU)ClC)ciClCIHiCDP3U)ft0CDCDC)CDP3P30I-HHCD0ClC4U)U)H-ciCDftC)H-h’ft0CD0P3P30P35U)00tYH-ClHU)C)5iciHCDC)ClHiCDU)H-CDU)H-CDCl1CDCDU)iHiI-U)0P30U)Hift<C)P3P3HiH-C)hHHiciP3ftCDH-ClftftCDU)CDciCDHH00CDP3h—CliClC)I-CciHCDIftHCDC)H-ftP3H-U)CDftH-i‘-D<ftciC)H-iU)5U)iftP31-DCDH-0ClCD0C)h(CH-iH--)HC)HiHiCDH-P3ClU)—0iCD5U)1QftHftU)U)P30CD-ftftHCDCD05-U)<HiP3IU)I-ciCD0HP3CDbU)P30CDft:iftC)I-CDCD<bftJHft0ClH-C)I-jCDH-CDCDP3H-P3CD5P3H-0C)H-P30ftC)<Hk<Cl‘-ci0U)<H-ciftH-CDF-’QCDI-I-H-iFCDH-C)U)C)0HC)U)ClU)0I-Q=CD<ciU)P35CDftH-—ciiCDFP3<iH-U)CDP3il-•C)U)C)ClClYClP3HiCDCDCDH-—H-CDClP3CD0CDiP3ftI-HHi0C)H-HHiftiHi0CDCDH-HftC)CD0‘ciU)ClciC)CDiCD0I-I-QCDftftftftftH-U)P3<dci—U)C)CDiC)U)H-HHhjC-CDftCDClCDCDCDP3P3CDCDHH--5---C)C)C)U)<0h’ftHiftftWH0ClCDU)CDCD000CDciiClCD0P3U)hCDCDClC)Hl-H-HCDP35CDCDH—5-P3i-CDHH-jU)<IICl0I-jp3U)H-ftty0C)U)ftftQci0CDftciP3ftH-ftCDHP3CDCD(.QI-ftP3U)U)w CD P3 H 0 ci i-I P3 H CD H- Cl CD S H 0 H 0 H- U) P3 C) 0 CD CD C) CD 0 Hi ft CD1277)Jessor’s conceptual framework for adolescent riskbehaviour contains five interrelated conceptual domains ofrisk and protective factors. The five domains arebiology/genetics, social environment, perceived environment,personality and behaviour.The framework is in accord with Social Learning Theory’sconcept of “reciprocal determinism” wherein persons, theirbehaviour, and the environment interact to affect each other.Each of Jessor’s domains has a direct effect on risk andprotective behaviours, and each also has an indirect effect onbehaviour and environment by affecting the other domain(s)Behaviours, which, when habitual, can be characterized aslifestyles, have direct effects upon health and life-compromising outcomes. Jessor’s model is bi-directional;outcomes also have a direct effect on behaviours/lifestyles,which have direct and indirect effects on the five domains.3.2.C.lla Risk FactorsWhether people participate in risk-reducing behaviour orin modes of (mal)adaptive response is a function of numerousmutually influential contingencies such as their socialsupport network(s), their socialization experiences regardingnormative adaptive responses, their beliefs regarding theself, the mutability of their environment, and their valuationof health (Kaplan, 1987:146). Factors can be assigned 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academic problems lead to increased anxiety,insecurity, depression, and social isolation andrejection from more competent peers, and the beginning ofalienation from school.4 School problems lead to disillusionment with schooling,withdrawal of effort, and rebelliousness, whichcontribute to further academic failure. Lack of successat conventional pursuits leads to increased alienationfrom academically and socially competent peers andaffiliation with similarly alienated peers. Associationwith delinquents leads to increased delinquency, druguse, resistance to authority, alienation fromconventional society, and rejection of social norms andvalues, as well as continuing academic problems and ahigh probability of early school exit (Lewis et al.,1990:38-40)A variety of social institutions, agencies and groupshave an interest in influencing and shaping the growth,behaviour and values of adolescents.25 When faced withpressure from this widely varying (and often contradictory)array of sources, adolescents may avoid confrontation bydenying that there is a problem, may make one source thepsychologically dominant one and ignore the others, maycompartmentalize by acting one way when with one source ofinfluence and another way when with another (not being awareof doing this), or may learn to make decisions based on input25These include the educational system, churches andsynagogues, “leisure time” agencies - recreational and cultural,social control and legal protection agencies such as police andjuvenile court system, therapeutic and special corrective effortagencies such as counselors, the work world such as employmentand personnel offices and supervisors of youth on jobs,political leaders with an interest in political socialization orin activation of adolescent political action, parents, otherrelatives and adults in the neighbourhood, peers, and the media- TV, radio, music, newspapers and magazines (Atwood & Donnelly,1993:221)76and interaction with the various sources of influence (Atwood& Donnelly, 1993:221-222). Atwood and Donnelly feel that thelatter course of action is the only viable one, and suggestthat to assist adolescents, the various systems impacting onthem must become linked and interactive.Although schools cannot alone be responsible forpreventing adolescent problem behaviours, they play animportant and crucial role (Rutter, 1979). Based on theItsocializationil model of adolescent problem behavior, Lewis etal. (1990) outline desirable characteristics of school-basedprevention programs. They should be clearly derived fromtheoretical models that recognize the multiple determinants ofdrug use, unprotected sexual activity, and related problems,and should be directed at influencing the general socialmilieu of the school. Programs that promote positiveinfluences on social development may be more effective thanprograms that attempt to counteract negative influences. Theprograms should be integral to the school curriculum, becomprehensive and long-lasting, and should begin prior to theemergence of problem behaviour. Finally, implementation mustbe carefully monitored to ensure the programs are beingdelivered as intended (Lewis et al., 1990:41-43).3.2.C.12 THE PRECEDE-PROCEED PLANNING FRAMEWORKPRECEDE-PROCEED (Green & Kreuter, 1991) is a 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CD U) ft C)) (P CD U) II CD HiH CD C) ft S 0 ft H C)) ft H- 0 C)) H C) 0 (P H- ft H CDC))H-ftftHCDC)CDCDCDH-CDCDftC))tiC))H-C))ftH-CDhH-<H-hifttH-ZC)H-C)JCDftSCD0C))00C)HCDC)-)H-CDClH-’iIIftCDC))h’0U)H-C))JClfttXC)ftH-0C)C))HiU)CDCDU)OiftCiQC))3ftCi••H-H-HiftftHiC))C))CDft000Ci0]1(Pi1H-CDC)ftftU)CDC)CD0CDCDH-]C))Hi••CD0C)C))H0ftftI—HftH-(PC))‘-ElCDCD0CDU)C))CDi—C))CDCUHU)H-OCDClCDCDCDH-Sti0C)><OftSF-Elft0ft‘-CDHCiSCDCDH-ClCDCDSCD0C)U)H-U)C))C))ClFdCUCDHP)CDHCUU)ftCDClCDftCDCI)(PC))CDftCDC))CD(PHi00htCDC))CDtiH<ft-H-ftHU)U)H-H-CDU)CiCDC)00C))CDU)CDHiClSF-CDC)ftU)C))CDCDC))H-C))ftOH-HC))<Hi(P—Hi)tY’CDH-CDHCDftftCDClC)(OH-ftC))H-(P(OtH-H-CiSH‘dC))O5CDIC))C))HCUHCDCDH-<3CUCDH---•Cl‘-<C)U)3<U)HiCDftC))-C))tUft0WU)QCD<0ft—CDC)(PCD05U)CDH-C)CD—ciH-ftC)Cl•••CDU)ft(PtUtUMC1)ftj1C))I•HCDtUftCD(PiUi‘-<‘iCD(P—ftClCDCD•H-U)50H-C))5k<CD* Stimulus control (avoiding or countering stimuli thatelicit problem behaviours)* Reinforcement management (rewarding one’s self or beingrewarded by others for making changes)* Helping relationships (being open and trusting aboutproblems with someone who cares)* Dramatic relief (experiencing and expressing feelingsabout one’s problems and solutions)* Environmental reevaluation (assessing how one’s problemaffects physical environment)* Social liberation (increasing alternatives for nonproblembehaviours available in society) (Prochaska et al.,1992 :1108)(derived from a wide range of psychosocial theories.)A third aspect of the Transtheoretical Model is itsclassification of levels at which variables contributing tobehaviour may be functioning. These include situational,cognitive, interpersonal, systems, intrapersonal and other(e.g., biological) (Prochaska, DiClemente, Velicer & Rossi,1992:827)3.2.C.14 THE AIDS RISK-REDUCTION MODEL (ARRM)The recently-developed AIDS Risk-Reduction Model (ARRM)(See Figure 6, Appendix 2) (Catania, Coates, Kegeles,Ekstrand, Guydish & Bye, 1989; Catania, Kegeles & Coates,1990) is a social psychological problem solving stage’T modelthat characterizes people’s efforts to change sexualbehaviours related to HIV transmission. The ARRM builds onseveral related theories and models of behaviour change.2626the Health Belief Model, self-efficacy theory, diffusiontheory, help-seeking models, and decision-making models.81The ARRM organizes predictors of health behavior in general(e.g., susceptibility beliefs) and sexual behaviorspecifically (e.g., sexual enjoyment), and also incorporatesunique influences created by the AIDS epidemic (e.g., personalcontact with an AIDS victim) (Catania, Coates, Kegeles,Ekstrand, Guydish & Bye, 1989:247)The ARRM focuses on social and psychological factorshypothesized to influence:* PROBLEM PERCEPTION (“LABELING’T)* COMMITMENT TO CHANGE (“COMMITMENT”) and* TAKING ACTION (“ENACTMENT’)The theories discussed above represent current knowledgein the field of behaviour change. Applications of thesetheories are examined in Sections Four and Five of thischapter, in the context of school-based surveys andinterventions or programs.3.2.D CLASSIFICATION OF SCHOOL PROGRAMSSchool programs for assisting adolescents in theprevention of substance abuse have been classified by variousauthors. Two major headings are “traditional” and“contemporary” or “innovative” (Rundall & Bruvold, 1988) . Theearliest programs, information- or knowledge-based, were builton the assumption that once teens knew the risks and dangersassociated with substance use they would choose to foregosmoking, alcohol and other drug use. The theory behind these82programs was rational or cognitive theory, which held thatbehaviors were shaped and determined by attitudes and beliefs.These programs, therefore, attempted to form, and ifnecessary, to alter, attitudes and beliefs regarding healthrisks, assuming that appropriate behavior change would follow.The programs did not produce the desired behaviouralresults, however, and it became apparent that a combination offactors, including social, psychological and environmental,interact to influence substance use (Flay, 1987) . Out of thisawareness grew programs based on developmental and socialinfluences or social learning theories. The majority of thesenewer programs focus on developmental (broad-based life skillstraining), social norms (alternatives to substance use) orsocial reinforcement (resistance skills training) theory.Programs with a focus on one of these approaches usually alsoincorporate elements of the other social influences models, aswell as an informational component. A “pure” program based onone approach only is difficult to locate (Rundall & Bruvold,1988) . These social influences programs “go well beyondincreasing individuals’ awareness of health risks and attemptto modify the enabling and reinforcing factors acting onhealth risk behaviors... (Rundall & Bruvold, 1988:321) .“There are several levels on which programs can beclassified. The broadest classification scheme refers to theunderlying theory or combination of theories used to developthe program. 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Know: 18.5% (n=236)“I am less likely than most people to get AIDS”.True: 52.5% (n=662)False: 20.7% (n=26l);Don’t Know: 26.9% (n=339)(DiClemente, Zorn and Temoshok, 1986:1444)3.4.3 Strunin & Hingson, 1987Strunin and Hingson (1987) collected data by random-digitdialing anonymous telephone interviews from 829 teenagers,aged 16 to 19 years, from August to October 1986, in astatewide Massachusetts survey. In response to questionsrelating to perceived susceptibility or vulnerability:Eight percent of respondents said they worried a greatdeal about contracting AIDS, 14% somewhat, 24% a little,and 54% said they did not worry at all about it. Inresponding to how likely they thought it is that theywill get AIDS in their lifetime, 1% thought very likely,7% somewhat likely, 31% a little likely, and 61% did notthink it at all likely (Strunin and Hingson, 1987:827)3.4.4 Hingson, Strunin & Berlin, 1990A follow-up to this study was conducted two years laterusing the same type of design and format [N = 1762], butincorporating more questions specifically related to theHealth Belief Model and the use of condoms to prevent AIDS.The number of surveyed adolescents who reported having hadsexual intercourse during the previous year was 1050.From 1986 to 1988, the proportion who said they wereworried about AIDS increased from 46% to 74% (p < .001)The proportion who thought it was very or somewhat likelythey will get AIDS in their lifetime also increased from9% to 18% (p < .001) (Hingson, Strunin and Berlin,1990:25)93Although teens who used condoms to avoid AIDS and teenswho did not showed similar levels of knowledge and beliefsregarding the efficacy of condom use,those who adopted condom use were more likely to worry agreat deal about getting AIDS, 18% vs 15% (P < .0001),and more likely to know someone with the disease, 11% vs4% (P < .0004) . They were also less likely to stronglyagree that condoms reduce pleasure, 13% vs 20% (P <.0001), and that condoms are difficult and embarrassingto obtain, 6% vs 14% (P < .005). Persons who adoptedcondom use were more likely to ask their partners beforesexual relations whether they had ever engaged inbehavior that placed them at risk for HIV exposure, 32%vs 21% (P < .001). They also had had more sexualpartners in the previous year than those who did notadopt condom use. Of those who adopted condom use, 17%had five or more partners in the previous year comparedwith 9% who did not adopt condom use (P < .0001)(Hingson, Strunin and Berlin, 1990:26-27)This study also tried to assess the relationship betweenadolescents’ use of drugs and alcohol and condom use.Questions focussed on whether condom use is less likely afterdrinking and drug use and whether those who use condoms lessoften after drinking and drug use have differentcharacteristics and beliefs about HIV transmission (Hingson,Strunin, Berlin and Heeren, 1990:295)[Condom] use was less among heavy drinkers and frequentdrug users, suggesting the limits of rational cost-benefit beliefs in determining condom use when people areintoxicated. ... The array of educational, counseling,and legal approaches to reduce adolescent alcohol anddrug consumption may thus have a particularly importantinfluence on HIV transmission (Hingson, Strunin, Berlin &Heeren, 1990:298)Using chi-square analyses to test whether individualbeliefs were associated with condom use, the authors foundthat while perceived susceptibility, perceived effectiveness94H-C)HCDHCDci>cH><CD(DCDIQCD-ciCDciH-H-CDCDHIiC)H-C)CD<CDH-ClCDCl—.ci-Cl)Cl),—HLOHrtU)MU]Cl)c—r\ijr:’JOciCl0\0CDOCDCD-j,RICrH,U)LoCDU]Cr><.HjHH:cj)k<HH$)O\ODC)PiCD°CrC)CDHCrCr<H,HHCD< CDo\0CDH)U]o\0O\O-O U)0CDCDCDcci F-DcciCDHH<HH-H-oClH]CD U)cciHU)HICDH-iCrcQHo H]iCD-0CDciCrU)CrCrCDH-oC)H-CDU)cciCrH-CDcitElF-CDCDU)U)iH,<0H,H-cioociIid HciCl)U)U)ciCDCDcicci<U)H-CDCDH- HC)U)H0C)cci jçtoC)iioCD0HHccik< U)ClCt-CDCl)S-0-ci U)C)trCD0CDS(Qo‘dcciHOClU) CD Clcci1ClCDCDOc-rc—rI-’CrCDH-CDU)CDC)cQjCDCrCrHIU)CDCl)wcciCDSci0C) CDIQj CrCl)iCDcQ><CDci cci0HH,H I.<cci Clcci0C)HCtCDH-U)<C)CDCDccirr U)Cl U) CD0ci 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surveys continued to test Health Belief Modelconstructs, but in conjunction with constructs from SocialLearning Theory, and, in particular, Self-Efficacy Theory.Results showed that Health Belief Model constructs have morepredictive power with younger adolescents than with olderadolescents. This suggests that preteens and teens are moreintent on acting in health-enhancing ways when they areyounger and more influenceable by adults, but that when theyare older, they are more influenced by social relationshipswith their peers. At this age, Social Learning Theoryconstructs are more predictive of their attitudes, intentionsand behaviour. This affirms the importance of using ReferenceGroup-Based Social Influence Theory when planning healthpromotion programs and interventions for older teens.Self-efficacy was found to be the most reliable of thetested constructs for predicting intentions and behaviour and,in particular, for predicting condom use. This suggests thatenhancing self-efficacy with regard to condom use could be animportant part of an HIV/STD prevention intervention withadolescents.3.5 INTERVENTIONSSection Five begins by presenting results of schoolprograms aimed at preventing or ameliorating substance use inadolescents. It then goes on to discuss pregnancy preventionprograms, which, in many respects, are closely related to109HIV/STD prevention. Next, early interventions for HIV/AIDSprevention are discussed. Lastly, recent HIV/STD preventioninterventions/programs are examined.3.5.A ALCOHOL, TOBACCO AND DRUG USE PREVENTIONIn the field of substance abuse prevention foradolescents there are numerous meta-analyses and reviews ofprograms. Several have been chosen to be included here on thebasis of being reviews of Social Influences programs.43These include reviews by Rundall & Bruvold (1988), Bruvold(1993), Best, Thomson, Santi, Smith, & Brown (1988), Flay(1987), Schinke, Botvin and Orlandi (1991) and Bosworth andSailes (1993) . Following presentation of the reviews,examples of various types of social influences programs arepresented. These include a program utilizing a dual approach(social influences and life-skills development) (Botvin,Baker, Renick, Filazzola & Botvin, 1984); a socialreinforcement program (McAlister, Perry, Killen, Slinkard &Maccoby, 1980); PROJECT ALERT (social influence model)(Ellickson, Bell & Harrison, 1993; Bell, Ellickson & Harrison,1993); and PROJECT I-STAR (a school-community program using43Due to the large volume of potential studies, and asmore traditional programs based on information or affectivetheory have been shown to be ineffective in changing behaviour(Tobler, 1986, 1989; Bangert-Drowns, 1988; Schinke, Botvin &Orlandi, 1991), the scope of this review was limited to studiesexamining more recently-developed theoretical applicationsutilizing social influences theory.110social influences theory) (Pentz, Dwyer, MacKinnon, Flay,Hansen, Wang & Johnson, 1989.3.5.A.1 Rundall & Bruvold, 1988Rundall & Bruvold (1988) conducted a meta-analysis of 47smoking and 29 alcohol prevention programs published since1970. They were unable to find programs based solely upon oneof the newer “innovative” orientations (developmental, socialnorms, social reinforcement) . Rather, they found programsthat were either solely “traditional” (information or rationaloriented) or programs that were a combination of elements ofthe newer orientations. They therefore limited theircomparison to two categories: “traditional” and “innovative”.Studies were scored and weighted according to the extentof their theoretical orientation and the design of the study,validity checks, randomization of assignment and rate ofattrition.The authors concluded that, in general, both smoking andalcohol prevention interventions had modest effects onimmediate behavioral outcomes, and that smoking interventionshad more successful long-term outcomes regarding behaviour.All but one of the programs produced increased knowledge ofhealth risks; however, only 29 of 33 smoking and 19 of 31alcohol program outcomes (measured at less than three monthsand/or more than three months after intervention) showeddesired changes in attitudes. With regard to the relative111success of type of program, the authors found “the dataindicate that for immediate smoking outcomes and long-termalcohol outcomes innovative interventions relying upon socialreinforcement, social norms, and developmental behavioralmodels are more effective than traditional “awareness”programs designed to inform adolescents about the health risksassociated with tobacco and alcohol use (Rundall & Bruvold,1988:317)The authors comment on community and cultural socialsupport for non-smoking as being perhaps an importantingredient assisting the outcomes of these interventions.They support this idea by discussing broad-based socialsupport for non-smoking, including “consistent anti-smokingmessages in the general media and [to] the emergence of astrong anti-smoking social movement exemplified by changes insmoking regulations pertaining to restaurants, officebuildings, and airplanes. This line of argument emphasizesthe importance of influences external to a student’s schoolenvironment that may affect the long term outcomes of schoolbased interventions (Rundall & Bruvold, 1988:329-330) 1I3.5.A.2 Bruvold, 1993Bruvold (1993) analyzed a sample of 84 articlesevaluating adolescent smoking prevention programs usingquantitative meta-analytic techniques to produce measures ofeffect sizes. The studies were chosen based on three112criteria: (1) they were school based; (2) they evaluatedprograms designed to prevent adolescent smoking; and (3) theyemployed a control or comparison group that received noorganized program designed to prevent adolescent smoking(Bruvold, 1993:874)All types of studies analyzed showed a significant impacton knowledge. The more contemporary programs were moresuccessful in altering attitudes than the rationally-orientedprograms. They also had a greater impact on behaviour, andthis was measured, in many cases, with one or even two follow-up observations, giving the finding greater weight. Thismeta-analysis gives clear direction to program planners. Itrank orders types of programs with regards to behaviouroutcomes and discusses the relationships found betweenknowledge and behaviour and between attitudes and behaviour:Behavioral effect sizes for programs with socialreinforcement and social norms orientations wereconsistently positive and significant, those for programswith developmental orientations were mixed in sign butgenerally positive and significant, and those forprograms with rational orientations were mixed in signand usually not significant (Bruvold, 1993:875-876)On the basis of results from the better methodologystudies, the present analysis showed that the rationalorientation had very little if any impact on behavior,that the social norms and developmental orientations hadapproximately the same intermediate impact on behavior,and that the social reinforcement orientation had thegreatest impact on behavior. Further analysis of thebetter methodology studies of junior high interventionssuggested that attitude change was related to behaviorchange, whereas knowledge change was not (Bruvold,1993:877-878).113(0ftH-H-ftftH-U))ftU)iftU)U)PiH,C)5wF-I—i9103-10CDHOCDCD91ftCDCDftdCDCDtiC)PH-U)C)FftU]9)k<CDCD0CD9191ciJCD5U)H0h91ftH-h<SCD91hQU)ftH1U)ftHU)H-IH9191CDciC)59191d91U)H-CDC)Cu<ID91C)ftU)çuftCDftH91CDftU)H-0301ciCDWCD-hftH-U)3H-CD1H-H,C)91C)H9)U)91ftH-910ftClCDft033CDH091HftC)H<CDIQH-I-H-IQH,3ciH-ftci3—I-CDH-CDCDSU)0ftciH-53ciClU)W035=ftH5(0CDU)5CDU)H-CDU)IDHCD0U)U)5CDcuCDU)CD0010ZU)U)U)ftCUCDftI--CDCD91—U)C)QQftC)9)ftIDCU<C)ClC)H-CDH-U)05—ftftI-009)IQHCDciCUft9)ft0H,HCUftH,U)0H-3QICDH-H,ft5ftCD“<CDH0CDH,<H-U)CDftU)ftH,JH--QI9)CDH-5)H-3ftftH-0WCDC)CDCDH-CDUi—0(1)ftft(0SCDHC)hCi’CDoD0IQftH-H-—9)91HftCD9)U)ftU)H-H,U)ftHCD9)(f)U)ciSCDU)LJCDC)H-ft9)9)iftU)HCi’0ClCDU)059)H-<ft0ftC)IQftciU)cihH-b‘-CDftU)0CDciH-—.QI‘-<CUCDCDHftCDU)U)CDCD0ft3QICDH-C)H-U)H-H-U)CiIICDQIftftH,C)0CDIQCDCD5C)H-C)—Cl)CDC)CDH-30HCUHC)U)0CDCDU)CD9)H,0CD0ftH00H-CiHQU)ftft(IDftU)ftH,H,C)ft-H,H,<IU)0CUH-5ftH-9)ftJCDftCDH—CDI-(09)9)0H-H-Hft0U)ciCD‘-ftCDU)ciCDftU)I-H-0H-ftH,C)ft—HClCDCU91CD01HCD<C)C)H,CDU)CDHCDC)CD01‘-0CDU)ciCD9)H-CD—Cc)ftftI-9)C)0U)H-ODU)5HQIH5C)005H-ftftCDH-H-ci0ftH,CDC)H-CDcidfthH,R’H-CDCDftU)ft3ftC)H,--00ft591H,hH-H-ftH-CDftIDH-91CDH—CU0CDU)WH-3dIICDCD9)ftI—JftU)0C)<(00I-ci(0hU)fth50HCDIDI--QIH-H-ftH-ftC)0R’5ft0-<CD—0U)ftCl0U)CDH-bCDU)<CDCDftH-C)-Hft—U)CDIIQ5QI91WCD-C)H-CDCDJ0H-CDU)0—Hr-<i-Cl5ft0H,HU)IDCDU)C)‘IQ—0CDH-CDH-ClHCDI-0CUhCDH-U)H-H0ft0U)ciH-0H-CDCDIDH,ftftH-9)I-CDftCiC)C)IDHCDIDCDH,CDH-U)U)9)--cik<ftH-CDCD9)h—C)HU)0H,H-ClU)C)CDCDCDH,ft9)H-—HCDCU0U)H-=CDftCDh9)ciH-ft0CDHH,CDIDU)3hftftClCDC)U)ClC)ciH,QIH-C)U)<50H-DCDCDCD9)U)ftC)C)0CDH-9)CUi0CDCUk<H-ClClH<ft0CUCD30FI-ft3U)0CU910C)U)HU)QIH-0H-CU915CDH,ftfth’H-CDH(UCDH0C)HCD0CD09191H-9)<‘-<C)U)CD3ftClHI-<ftI-5CDHCDftH-9)H-H-H-CUIDCDftCD9)<13ci-ClCDU)CDftC))Cl3CDCl5CDCDU)U)ftCDHQIHCDCDH-9)0H-k<C)U)U)U)CDU)ranging from 3 to 20. The spacing of sessions, provision offollow-up or booster sessions, age of the recipients,participation by the whole school or only some of thestudents, and how rigidly the curriculum must be adhered toall vary among the studies. All these variables (intensity,duration and variability in delivery) are likely to influencethe outcomes of the programs; however, they have not beenstudied separately to ascertain the relative contribution ofeach (Best et al., 1988:180).What are we to conclude about the efficacy of socialinfluence approaches to smoking prevention? Briefly,some of the curricula work with some youth some of thetime. It is hard to be more specific. Given the contentand methodological diversity described in this section,that results are as consistently favorable as they are issurprising. We suggest that much of the variability infindings is attributable to program participant,provider, and setting factors, ... (Best et al.,1988:181)This conclusion is supported by that drawn by theCommittee on Diet and Health in their restatement of Hill’scriteria for assessing observational studies: one measure ofvalidity is the consistency with which similar associationsare found in a variety of evaluations (Coyle, Boruch & Turner,1991:188) It also expands the search for explanation ofprogram success and failure beyond the conceptual foundationsof the program to include the implementation factors. Thisallows a much fuller set of circumstances to be brought intothe range of focus of the investigation. The authors expandon their observations regarding participant, provider and115setting factors.Regarding participant characteristics as they mediateprogram impact:• . few studies have examined the interaction of programeffects and participant characteristics. There are toofew and inconsistent data to draw any conclusions. Thestriking absence of research on major participantcharacteristics involved in smoking onset should be noted-- ethnicity, socio-economic, and cultural factors havereceived no experimental attention (Best et al.,1988:183-184)Regarding program provider:Eight studies have tested experimentally the effects ofproviders implementing social influence curricula.All of these studies are flawed methodologically. Mostare characterized by the general shortcomings common toresearch in this area; for example, nonrandom assignment,small number of units per condition, and failure toanalyze by unit of randomization. In addition, nonedistinguishes between the effects of provider type andprovider training. ... Furthermore, the studiescomparing peer to adult providers typically monitor peerimplementation much more closely than adultimplementation (Best et al., 1988:184).And regarding environment factors:Smoking environment-- the smoking and quitting of peers,parents, and siblings -- interacts with program content:A social influence curriculum is most relevant(effective) for those more exposed to smoking models.Community context may moderate school-based interventioneffects, but the hypothesis remains to be tested. Youthmay be especially at risk when making the transition to anew school environment -- what Jessor has referred to as“transition-pronenes&’.A host of factors have been suggested to account forsetting variance, including: school size, urban/rurallocation, incidence of smoking and quitting by others,school mobility, school involvement and support,transition proneness, and sanctions for use. Aconceptual framework to organize these diverse influencesis much needed at this point -- the Waterloo workingframework has shown heuristic value but needs refinement116iJiH-I-jHiWCDH-CDiPiP3H-JCDPJ(DC)C)ftc-iD)U)P3O(1ctP)ftF—OOl-F-c-i’di-’dP3CDCD‘-<0HH-U)ift-CDNQP)d’ftP3(F-P3CDftCDCDftl--<H(DH-cP3U)1CDCDQ0H-P3H-U)ct1’TJft-ctC)HOH-F--’P30‘-0U)00ICDcDdft’<ZHiftctCDCDPJCDCDH-QrtPJ0HC)dfto0H-OPJ-U)WftjhhHU)H-0<’dU)HH-00DP3ftH-i0HCDP3QC)ri-‘IIHCDOP)H-H-CDFftU)C)1Q’dP3HhftF-P3Q’C)H-00H-HP30‘dP)HHCDP3ftQQrtU)fthC)CD-HftU)dCDH-H-HiCD’dCDCDCDftOI1i-U)<jI—c-tOCDCDP)JftcctftCDH-P3oP)CDU)CDHQft><P3p3FpJOCDS’<U)CDC)HiCDP)CDPJlipJH-0U)P,P3ft’drtHiU)PJC)oU)U)HOCDO‘-<CDc1-H-ftC)U)CDH-ftc-H-H--H-P)U)CDOftHi)QCDQU)C)CDHC)C)ftU)0C)hftCDp30ht-P3tQU)0CDHH-H3ftC)ft0-çtH 0C)ftU)H00oC)d•’U)‘‘1C)H-H-CDH-P3P3HP3HU)k<P3 HtQH-H-HCDP3‘<Hi‘-<-U)HHC)H-(1CDCD3P30iCDft0C)HP3HCDP3U)H-P3—C)(X)ftCDP3P3hHhP3ft‘<H-U)-U)C)CDH-ftU)0HCDC)P3HoU)dHc-iCD‘•dl-P3HP3P3‘-<‘-<CDftb0><CDU)bCDCDfthH-CDCDçtP3U)QhHHihCDH-il-CDU)ftCD0H-H-CDSHU)CDH-ftU)U)p3ftC)CD300HftH-,Qk<d0ftftCDHft00CD0 iH CDP3P3‘-<CDdCDHftP3fthp3ftU)ftC)H-H-3U)CDCD01P3P30p3<CDhft0l-5CDU)H-CD‘d5P3HLU)CDI-HU)P3U)h‘dCDCDHU)HQ0‘-<c-ih10U)itCDCDp33CD0H-c-iC)U)C)CDd5ftHi3CDCD1Q•IICDQ,‘<CD0H-ft-HP3CD3l-ftc-i0P3ftP3<c-ic-iU)U)HCDftH-hH-ciP3U)S-C)P3‘d‘dCD0c-iHCDC)C)i-CDH0c-iH-P3P30ciH‘dP3cil-U)0ciCDU)CD33H-F<j0CDi-P3><U)QU)ftCDHCDU)ftC)0C)CDS‘dCDP3H-H-HC)P33CDhHic-iC)0U)1QQciH-HU)ft3CDHiH-c-iU)P3HftU)CD0P3P3HH-H-ftCDU)H-CDC)3H-30CD3c-tU)p3c-i(Q$1IQ3Qft3ftH-HiH-0CDHciP3<QctQU)0‘-<CDU)itCDII(.Q0CDciftHiH-hH--—H-ciII-ctP3ftP3CD<Hift3U)HftCD3dp3HHCD3Cl)00p30<ft‘oCDH‘-<iCDCD5c-iU)P3ftH-c-iU)C)51ftçtCDCDft0fthH-U)0U)H--.CDCD00HiCDH-ftH—QQQ51C)Qk<U)H-H-CDcici•Hi-H-ft0Ui1QU)c-iH-P3H-i-5CDI-ftftHCDft3CD‘0<C)CDH]F-’ft-ftI—‘d051CDCDH-CDCDCDH-0H-H-0CD3hCDU)U)U)HiU)CDHiH-C)P3U)CDCDC)p3P3HU)C)•CD-51l-5P3ciP3ftU)ftft‘CIhCDP3iCDftU)ft‘CIHCDiP3cift0P3P30CDC)U)C)H-H-p351I—iI—h’C)CDciftftHCD51HiCDftU)C)0bCDU)3H-P3H-0tIU)IIft5ftCD5CIC)C)SC)I—iCDH-ft-CDU)U)H-0H-0‘CICD0ftU)ft•HfttI0l-1QftCDS‘-<P3C)U)iI-0H-0P3ftHH-U)P3HiC)U)P351k<5H-ciftU)ftft00051H-U)ftciHl-3CD0051P30CDCDP3CDHi‘-<II‘QH-ftl—CDHH-CDftC)P3P3ftCDH3.5.A.4 Flay, 1987Flay (1987) reviewed 26 school-based studies ofpsychosocial approaches to smoking prevention, eachrepresenting either the social influences or the broaderlife/social skills approach. He divided the studies into fourgroups called Tlgenerationshl, including the original work, thepilot studies, improved studies, and those most rigorous interms of study design to maximize internal validity. Findingsfrom generation to generation improve in terms ofinterpretability but even in the fourth generation findingsare mixed, with different studies reporting different types ofeffects. This confusion may be due to program differences (interms of all the variables previously mentioned) and/ormethodological differences between studies. The programstested in the two most rigorous studies had certain elementsin common; these may possibly be important, even necessary,elements of social influences programs:1 media material, with similar-age peers;2 information on immediate physiological effects ofsmoking;3 correction of misperceptions about the prevalence ofsmoking;4 discussion of family and media influences on smoking, andways of dealing with them;5 role playing and explicit learning of behavioral skills;6 a public commitment procedure; and7 extended duration.The author comments that:While this list of common elements is suggestive, wereally know very little at this time, either from thesestudies or others, about which of these programcomponents are necessary for program effectiveness, orhow other components (e.g., health information) or118methods (e.g., use of peer leaders) might or might notadd to program effectiveness (Flay, 1987:166)He concludes that the social influences approach tosmoking prevention can be effective, but raises many questionsthat need to be answered. Although the approach may beeffective, programs derived from competing theoreticalperspectives must be compared. These studies need to includecomprehensive measures of presumed mediating variables, ofprogram implementation, of involvement by the target audienceand of population characteristics.3.5.A.5 Schinke, Botvin & Orlandi, 1991Schinke, Botvin and Orlandi (1991), in their volume onsubstance abuse in children and adolescents (from theDevelopmental Clinical Psychology and Psychiatry Series),summarize results from studies of the various approaches tosubstance abuse prevention. They conclude that Iltraditionall?programs (i.e., informational, affective and alternativesapproaches) have been consistently found to be ineffective inpreventing smoking, alcohol and other drug abuse. Programswhich focus on providing factual information do show anincrease in knowledge and some succeed in changing attitudestowards substance abuse, but they do not achieve a behaviouralchange. Programs using fear arousal and moral appeals alsohave not shown a positive change in patterns of behaviour.Programs based on the developmental model have succeeded inincreasing self-esteem, decision-making skills, drug knowledge119C)50ft5piPi3ftft.)CDCDCDHCDCr‘rjpiH-H-CD00i0hI-HiCUCD—ftQ<pi0ft‘rJH-C)‘-D0CDQC)HiCDCDCDCDCDHCDC)HH-<CiCDCiC)CD0b(PQhH<CD33CD5i-I-0HPJCDECD‘1CDCI)1I1H-CDCDCD1\)C)CDCDCDCDCi‘D’<CiCD0H-HiCDC)3CDCD5FCDCD0fthftCDfti5F-1DQIOC)HiftHi)CDftCDft-HiCDI0CDHH-CUctCDHfttflCDYH-CI)CiH-H-CUCiH-(0CI)<-iH-••‘tJCDCtiC)I-’CD5CDCDI-CrpiCDI—aCDcCDCDCDC)piftC)WpipjrrI-hH-(PCDZft<(PpiH-Crft—CDCDCDCr0aiQC)0CDCDCiCi‘-iCiH-CI)-C)CDH-0i—LJ-C)CD(P(PCDftC)CUCDH-Qiii-CDCDP)iHiC)•CDCDCDftCUCrctC)hCDiH-C)CDCDCrCI)(PHC)FICiCI)FftCDCDCDH-5(PCDI-CDCI)f1CI)fti-CrCiCrCDCI)QI5—CD0I0CDCDICDHi<H-CDCrCl-tYH-Cl)CI)CDCD(PClCDCDIH-CrCDCDCDCiCD‘dCrC)CrCDHiH-IICiCD0CiC)CDCD—CrOCDCDI-QDbCDH-CI)0CUC)H-CDCDCiCl0H-CDCUHCDCDH-ftCDCDHCD<(P(P<H-HCiCri—sCDiI-CrHiClCDçt<HI-QhCDiHCDCDClHiCDCI)CDCDCI)CDCDCUCiI-)(PCDCDCDCiCDCI)CDCDCDHI-p15ClCI-5C)HihI-5CDCDft-dH-CI)CrF-1iCDCDCDftCI)H-HiH-CDCDd<1CDhI-0F-1h<0(P5SI-3CI)HCi<CDCI)HiSCDCDCDI-CDW0CI)HiH-C)00CI)C)iftCtCDC)0CDH0CIICI)H-5CI)H-CDClCD—ctHI-CDctO—piftClF-1CDi0fy(P3CDH-iftCDCDCDhH-Cr<H-hhft3H-CiCDiCU0—CD—CDF-0ICtH-H-bClCUCD0Hidh(PiCDCDCI)(PHCDICI)0<(PCU—P-(PCDHCrCI)H-Crft—CIICrCDCDCD5H--CDCl00CrHiH-H05CI)CDClSR’CDCI)05ClCDCI)—I<dCI)CDCI)C)CDCI)CI)CI)CDClH-hCiClHCIIC!)C)CD-F-1Cr(t<CtCiHi0iCI)CDCDCIIC)C)CDC)0CDCDH-CDCI-HiI-jCI)CDF-1C)3CD10CDftQSCl00-idCDHdCI)CDCDo\°H-HidCUCDH-ftdCDCD0C)CIIdCI)ClCiH-Cll-CU0CDiH-t-j<HiCDCDCD‘-<FCriF-I-0CD<ftCDftHCDCl0CDftHik<HCI)H-C)CDH-Cl0CDSCDCDCU0Cl3CDCD(PCI)CDCDCI)SS<H-CUCiCI)—‘-‘ift-CrCtWCD0I-CD—C)H-H-CrCU-C)iHiC)CI)QH-CDH-Q1HCDCD3I-UiCr0Cl0WCD5Cr0CD0ftCUCDOCDHCDCrCDCDl0o\0H-CI)Ci0-CDctCii<Q5C)0CD-DCDCDCII-0Cl5CrH-C)CI)H-CDCDH-l-’CD-DI-jp)ctC)ICI)ClC)HiCIIftH5F-CrCI)H-JCI)CDI-H-CiCI)C)-<IICDH-‘dftH--0--CUCDSCD3CI)H-ftift<I-0CDNRCDCDHiW-<HftCDCDCDClH-CDLJ0CDCDCl(PCI)CDClCI)UiCI)I•CDCiCI)H-I-CDft—CI)ftCDHH-ftClCI)b0CDHiCUClH-I-CDCI)C)CDH-CD03CDCDHi50HHHihIIftClCDftt’JCD(PCI)I-’CDCDCDH-CI)CDHi0H-CiCI)CDCD<CDCDHI-CI)CDCI)0CI)5HCDCD3CiCI)CDCI)C1IC)C)CiHftCD‘-<CD3CDCDCUCDH-CDftCDHH-IICDClCDJftCl-hH-CD<CDftft<F-’-H-0CDCDH-0CDC)--CDSCDHftCDCDCD‘-<0SI-ti 0 CD H CD H CD CD H 0 CD rtI-IrU)FCDCDH-C)H,I--1rtP0CDS><0H-IHC)H1TjrrH-tH-)CDCDU)CDhU)CD)r)CDCDrtHH-U)0H-UCDPJH-U)HCDH-CDCD0U)O)—U)DC)Hrr H-HC)I-dU)0PJU)1Q0P)rtU)iFCDIi-I-dI-dLQJH-HCDU)t)CD0-00-U))I-’-hCDC)U)H-HCDCD0f-1U)-YF-CDCDWH)U)C))0C)cl0H-H-CDoU)oU)QCDQ0F-H---0Q,0HCDCDCDCtH,CtU)H-ijLJh)HCDU)tCD-CDtrtP,H-C)iC)c1‘-i--t-tçtCDCDJH-H-HCD)rtiU)CDLQPCDçtH-O-—••CI)I—’CDi-U)I-dCDCDH-PJ-QhHtU)H0H0—1dOb—’-Ct0U)HHCDCDP.)D(.QCrH-U)SH-ODPJHP)iU)HCD•-U)C)U)HHQU)U)I-E’JCDCD-U)IJU)P)J.OH-0H-iIHCDPiLi<UCrCr<-HCDOH1CD—CDCDCDWU)r-rU)U1—U)Cr—QCDU)I-C)U)I-jCtoI-It.Qt-pi)QhH-çthP.)C)CDP.)5(-QSU)HH--P)CDH-U)Sc-IHCDHICDCD S CD3PiH-o:iIiçtCtCDpCDH-Q.ct HCrI0I-<)CDCrHHçt0U) U)HCDCDoU)0 ;‘s-iZP.)HP.)CrCtctH-0H opjCDH HP)11I.<I—I-QP)CrP)P.)0tH HCrU))-CDCDHI-CDHCD—Ct CDCDCl))çt-C)H-—Ct0H CDwCt•P)-<U] •CDCD U)•P.)0 H,H H,H,t-oCDCDU)F-U)CDCDoC)CrCrCDCD U)-Cl)0P.) 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Ellickson, Bell & Harrison, 1993; Bell, Ellickson &Harrison, 1993A project recently created to test the social influencesmodel (including information, resistance skills training andnorm setting) on adolescents’ alcohol, marijuana and tobaccouse is PROJECT ALERT (Ellickson, Bell & Harrison, 1993; Bell,Ellickson & Harrison, 1993) . Implemented and evaluated over atwo-year period with more than 4000 grade 7 and 8 students inCalifornia and Oregon schools, it has been shown to reducetobacco and marijuana use, and to mitigate a broad range ofbeliefs (measured using Health Belief Model, Theory ofReasoned Action and Social Learning Theory constructs)associated with the propensity to use drugs.”The program consisted of 8 classroom sessions in Grade 7and 3 booster classroom sessions during Grade 8. Thirtyschools were randomly assigned to: Condition A) 10 controlswho did not receive the program; Condition B) 10 experimentalswho received the program from trained teachers; and ConditionC) 10 experimentals who received the program from teachersassisted by older teens (peers)The program goals were to increase both motivation andskills to resist pro-drug pressures in the students. Resultswere positive for marijuana use and mixed for cigarette use.Project ALERT curbed marijuana initiation by one third46 It was not, however, able to influence beliefs aboutalcohol.128wopC) rt CDt00C)CD30CD0U)CDhrtHH-QC)CD[-hU)JU)0U)H-ctctH-1PJCDH----CD0CD<<(-QHiC)JCDCDC)CDHC)CDCDdc50U)CDCDCDctCDC)DC)F-CDC)ctHDJHiCD-<rtiOd—fliHCDHirtC)OHiH-—H-CDhh0bCDCDH-U)CDU)CDC)CDU)I—’HiC)JH--—Hi)C)P)-CDCD<-H,CDC)U))ciU)—CDF-’U)CH-O1JciC)0ciC)C)U)<0CDCDHU)J)QCtCDCDU)F-’C)HiF-’HiC)nH-ciCDH’CDCDCDHiF—’PJCtJC)ZCDbO00ciNH-H-iCDCDH’CDU)CDU)IQH-Q,CDF—’H-ciiQciC)CDCDcicitiC!)00H-C)0I-h0CDC)CD0<0U)H-1J U)OF—’hCD—Hicii-pJCDU)Jcici—‘0U)-.-.ciHciCD—cici00tj•0H-ci00C)HiCDciCD-‘QCDCD00P)C)C)HftH-CDDJO0))U)H-tIdCD<U)CUSHciC)0CDQhhPJciCDH-U)H-ci0CU0CDCUciU)(QQH--F—’Q‘-<0<0FciC)CUHiH-JCUCDCUPF5—CDC1SCDCD-SCDCDC)CDI—’CDHiQJ0CUWQ0(QU)CDci-JHCDFci1QQ0HciPU)-U)C)0bH-HH-0CF(QU)U)5U)ciCD1Q0bhCDci05H-cici<HiCUQci0U)H-ciciH-05ciciCDSCDC)t-hU)CDciCDCDCD00CDhC),Q,ciciCDU)CDHihCU(0CDC))U)‘-HiCDH-U)ciH-U)H-U)CDF-’U)ciciCD5OrrC)C))OHCDSHi0iciCr<CD(Q0000U)CD<U)H-—C))ciciH0ciU)H-CD0PH-U)CDCtLQCUFHiU)HiCUU)ciciCDOC))-DHiU)0CDQQciWCDU)CDH-CUU)CUciCDCDCDciMCDU)0ciH-’<Scici0H-CDCDcxDciCDCDCUU)H-ciC))C)-CD—ciciciS0QciC))0-CDU)0C)ciU)HiciciCDH-OI-C))Hi3H-C))H-H-h1QQCDHiC))ciCDCDciCQiciC))C))ci05ciC)C))(QHiFH-ci-H-ciCUH-H-0CDPciU)cid0ci”<0ciciU)cici—CrciciOHHrtOU)CDH0H-ici)ICtU)ciSciciiciU)CDhjC))cici5hC))ci5CDU)F-’U)CDOH-5C))CD0-—CDCUU)iciC)ci-ciCDU)C))CDU)ci0 Hit5C)00C))05U)d‘-‘ciF-’HC)ciU)C)LxJCDCDU)HC))H-d0CD0C))1ci0H-CD0ciCDciOHiU)F-’H0—U)WciCDU)H-ciICDH-CDiCD•.ciU)ci1QCDQCDU)HMciçiHHiciU)0‘-0U)MHiH-0HiCD0Hi‘..ociaci0CDH-CDwci—ciU)C)C)HiU)ci—ci-ciU)—ciC))CUCDHiCDQC)U)CDCDCD—ciCD<C)ciCD—OctHiCDU)F’..DHiU)CDH-frCDQC))U)IciOH-Q.,OciU)ciCDI—’ciyI-H-ciCrCDCDciC)ciCDQC)U)U)<U)Q3><0CDHiCDHiCDdciU)ci0C))CDU)CDHQ,ciC)CDH-00I-H—CDciCDci-ciHiCD0L’JCUHCDC)JH-CDF-’U)MPH-CDHOU)H-OCDCD3P0ciU)C)CDciCDSU)0ciciC))C))U)C))H-C))0U)ciQuiU)ciIiC))1CDOH-U)$1C)DFHi<CDW-CrciCDHiC))CDF-’U)HiC))‘-.0F-’ciC)ciC)ci—F-’CDciCDci-CDOciF-’O0cipOH-F-LJHF-’CDCDU)CD0F-’RCDCDU)HiF-’U)-ciU)---‘<<H-U)U)CDCDC)C))CDOH-CDCDCUC))I-SC)F-hU)I-ciU)CDC)U)0H-CUciU)CDC))U)ciCDH-H-HiC))OHH-CDhU)<ciHiR’ciU)CFCDCDci-H-C))Q,-iCDU)0U)ciciC)ciciCDCDciCDxj 0 CD H 0 ci U) CD CD H S CD ci CD U) H ci C) HQD(Q C)) ‘1 CD Cr ci CD U) 0 U) CD H-U)ciFciC))H-CDU)SU)H-ciH-0_U)ci C)(1(QtrCDf-I-’ciC)H00H-OciciQ‘ddC)CUIciC))ICDHtTiI-ciU)C))ciCDciU)CDCDciU)dF-’CDH-F-’00cicih(QCDU)hjciCDSC))SOC))5hiHiH-1tH-LJC))LJ55ciOC))C))ciC))HciH-C))C)CU--HPciC))’dcik<C))ciCUU) CDciCUciU)CUU)U)CDbU)C))F-’ciSUiH-0ci0CDU)Qci—CD0-ci CDQHOo\0ciH-C))C))CD(Q5PhOU)CDCDOU)ci0 ciWMHUH,)JhçtH-WCDH0)-iPJQCD0CDH,H-i-QCD01CD‘1CDUiH0H,H-hH-0UCDCDH-HHt-QHCDCDCDIIC)HCDIiCDQrtQ10dH-CDCDCDPi0H-Cl)ft<H‘jct<Cl)H-HCDftCD0H-C)C)CDCl)DJ—1)I-HCDH-C)CrCDH-I-CDCDCDCD-00ftCDH-CDCDCDOCDCDH-CDCDF-ct0H,CDC)QH-IQLi0H-CDPJ0dhH50H,0CDpiCDiCDCDCrr-rCDi0CDCDCD0CD1CDCr<CDHH-hiCDCDC)IC)H$iCI1—-d1H-H-0’<ftPi00Cl)ftOCDCDCl)‘-<ftCDCD•CrctCDPIFCD<CDC)‘-C)Cl)piCrPiiH-0iCli00ctH-H-CliHçtC)CDçt0—h0CD0CDCDiiCli0F-’ICDNCDC)hWCDCDCliCD0dCDCDCliçtCD0C)HhCDCDCL)-C)CD0CliCDCDHLJC)H-0CliCDCDH,ftHHdPC)0CliCDCD00‘1l-CrC)CDCDC)HF-l-CrCDCDH-0CDH,ft0‘-<OH1Q0CDCtC0C)CDH-H’-<Cli-3CDH,QC)CrH-CrrjH-hCDl-0Crçt10-‘OCDHCDC)CrIQhCDClJdNCDOhiI-HdCDCliCDH,I-(0o-‘-<10HfrCDCliHCD1QH-CDCDDHi0CDCDCr‘D-l-CDCDCDCDCtCli1CDI-SC)$CDC)-CrH,CD0HCDCD<H-H-IHCliCDH,iCDCDC)‘-CDQ0CDC)CD•CD0H,CD0P,C)0QHi0CDH-CDCliCDClih’H-‘-<H--CDCD0F—’CDPJCl-H-CrCDCrCDC)CDCliCr‘DClhI-hH-NCrClCD<H-CDCDH-ftHftC)HCDC)H-IOH-’-<OCrCDCD0H-IQ<CDH-0CliCli)HC)CDCD0H-’iH-Y0CDhHCl-H-CDCliH-Cl-‘DrH-HH-CDjjH,<CDCliH,H-ctHCD10C)WCDCDCJW-01QCtH-iCliCDCDCli0ICD10H,•.1QFHiCDCDH0C)HHH-Clil-Cl--H-HCliICl-C)iH--H,010-CDH-0iI-CDCDCtCliH-CDH-0Cl)0<0Clil-IQl-’C)(QCDHWQH,H,CDClJC)CDftC)C)CDH-0F-Q0‘—Cl-‘i0CD—HH,H,0CDCCD00CDHH-CliHC)•CDCDCDIICD<CliCDCDHH<CDIQCliCl-CDCDCDCDC)C)10C)H-H,CDCDH-H-H-ft‘-<CliH-HCDCliCDftftH-CDH-0CDCliCD0H-CliCrCliCDCDCDCli-H-H-l-CDCDI-CDIQ<CDhCDCliI—’010H-CDiftH-0ftCDl-ftCDCDH-CDCrCDH,H-H,00Cli••CliD‘-<HCliCDClCDCDiiCDCD’-<CDh0CrCD0ft0IQCDl-l-CliCliH-jCrçjH,l-CiCDCDCDCDClil-ft0ClibpftftCiCliH-10l-ft-Cl)CDCDCDCliH,0C)CDCl’tI‘-<HCDIQ0DCD0C)H-CliC)0ftHCDCDH-CDCl<I0CD-ftCDiC)Cli-CDCl-HftCiHOCDftHftH-iH,HCICICDCDHC)CDftOHCDCDl-Cl-CDHCliCli100CDC)0CiHH,H,CD0CllftIft<H-CDCDHHCliH,r-iCli10CDCDCiClH-CDCD<CDCD‘tiCli-C)C)IFfrCDCDhCDftCDCDF-’H-hCDHCD10dCD0CiftCDHC)ClirH-h1QCliH-iHl-0CDCD0CiC)CDCliPiO1QCDCDICD0ftILQ0H,H--‘CDCDhfthHCDC)C)•C)H-I-’C)HCDH-iClil-CD10WCDCllH-CDCD0iCliH-CiCrCrftIQbCDCD•Cii0CliCDCliH-CD0HCrCD0ClIH-Hii<HH-0HF-’C)C)CDCDCiCDftCDCDCDClCD4. Health policy change, which works with governmentofficials to promote antismoking policies, enforce drunkdriving laws, and create neighborhood watches for drugs.5. Mass media efforts, in which press kits, commercials,news features, and other television programs are utilizedto promote drug prevention (]Dryfoos, 1990:162).In addition to research, staff members from theUniversity of Southern California provide extensivetraining for teachers, parent groups, and communityleaders and pay particular attention to quality control(Dryfoos, 1990:162)I-STAR has been implemented in 50 schools in 15communities in Kansas and Missouri. The research design issophisticated, including a quasi-experimental design in KansasCity and a randomized experimental design in Indianapolis,Indiana. Statistical analysis includes adjustment forbaseline alcohol and drug-use levels and school demographiccharacteristics related to drug use, as well as use of theschool as the unit of analysis (to conform to use of theschool as the unit of measurement) . In 1984 and 1985, 22,500Grade 6 & 7 students received the program. Approximately one-third of the students were measured for baseline data, usingtwo different sampling techniques to minimize sampling bias.(In 16 schools, the entire Grade 6 and 7 cohort was measured;in the remaining 34 schools, 25 of the cohort was sampledrandomly by classroom.) Seventy percent of the sample wastracked by grade-cohort (including incoming students) and 30%was tracked individually (N = 1607). Attrition rates did notdiffer significantly between program and control schools,although, consistent with other prevention studies, users inboth experimental conditions were more likely to be absent for131H,d—‘dDiSSU)C)C)5U)C)CH,JH,QhH-I-i0CDCD0U)000Di000i00CDCliCDC)II0iHDiH10HftU)0ft-H-ClClH-U)I—’HHDih’CeH-—JH0H-H-—J-CD0U)0-<00d-HDi5o\0U)ftLiDi-JCDftftClH0U)C)5CDH-CDF-’—.o\°C)H-H-DiH-H-ICDCD0CDCD0i<--HClU)ClQQQftClDiU)U)‘10DiClDlCDUiCDCT)iDlDlHrjCDfttH-0CDhIHo\°)U)QDlft‘-<HDiD)PlI—’ClU)U)tH-f-f5C)ftCDU)-0—CI)fthH-$U)C)H-Cio\°—CDNMH-b0CDClCD‘diCDHCiC)I-ClU)ftfthC)05U)Cl)CDDiU)CDC)U)CDU)0CT)l<1CDCDCDU)o\0ftCDhCiCl0H-DiCDClftCDCDI-ftU)DiCDH-0wftZHtU)ftDiO\O<H-HH,ftIIDi<CfH,MNCfrtClCDDihClU)HCDDi00DiCDHDi—II0U)CDH-H-0H-H,—CiDiHo\0hftH-ClHH)[flftH-,H-ClHhIU)hftftCiftCD0to—u-il-rtH-H-CD0510H-—H,C)U)U)ft0CiCDU)0C)WIQC)SDi-DCD0CD0H--H-H-C)U)QU)—Di—I-ftto\°U)HhIQDlCtIQCT)CDC)CDUiCDI-ft0H-DiH-fth‘DDlDiICD-H,ftCDCi0U.-10CDSlClH-I-0-DlU)U)0HCDftCiCDF-‘-DDiCDClftH,DlU)0f-f-CDCD<’—’C)U)—DiDiH,00I-iftH-ftC)HCD0HH,CihWH-ftCiH-CDC)CDU)DlftftDidH,0IDiC)CDfttoLJCDl-ftDiU)0C)DiNHH-Ct0H,k<0C)-UiCiCl0—U)5H100DihCDCiftCIIU)Di0CDCt0HCDH-CDCDH0CDc510DDiU)0—CDl5CiHHH,U)H-HWClCtSCDOCDU)I-iCDHI-Di-Di0H-ftDi<10H-ftCD(Di1-5U)CtC)CiCl00U)DiDiftd0CDH,ClCiU)CiCDCiH-H-C)CDHU)CiftCDftCrHU)H-H-0l-0CiU)SU)U)ft0Cl0CD‘-Di-Ci0H-H-C)HFCD0CDIQk<HU)DiHCDHH-C)Di——ftH-CDH,C)‘xjjCiCDCtft100ClH-0ftCl:i‘-010HClU)CtHU)0U)-ft10CiCiHDi0CtI-0DiDi‘.oCDH,DiII-IQCt0I-Hf-fHCDH-Ct0‘<ZShH,to10CiCtH-I-H-o\0Hl-Ct3H-CDDH,C)U)0CDCl0CDCfH-<0CDU)TIHDi--OftI-dCD10CiH10<CDCtCDHWClCiCDCi)l‘<U)CDIQDiU)CDDiUitofrftCl5I-0CtH-10CDCfCrCDC)CfH-0U)hahCDDiC)H-0DihDiH0H,H-C)CiCtCl)0H-CD100I-CDiU)CDIQ0CDaii00H-0ClCDNCl—HftH-ftfto\oCD‘-Ii—<CDCDCi-Cl)U•ftU)DiCfH,fti--,DiU)C)U)ftCiDiSDi—S0I-H,‘-<‘--CDDiftftCDI-1DiIQCl0U)CDHCD0CDDiC)hHCDC)H,H-DiCDCDCDH-ftDiHC)l-TDiC)0<C)I-HDiH00—iDiftH,ftdU)0CDI-CDCD0H-0I‘d0H,SDiClDi-Cfi0U)1Q<U)H-hiCi0CDCD0U)toIH-HH,F’ft0ClCDCDClACtU)H-CDFS—CftoCiC)0100H-H—ClR’DiDiH-H-CDiCDftO\0100I—’hH0I-ft•CtIftHDi—iDi0Di010U)C)Di00Cl1UiCDCD—HCDCl-CDI-substance use. It is to be hoped that the combined school andcommunity approach will show longer lasting results thanschool-based programs that do not enjoy the broader activesupport of parents, community and media.3.5.A.11 SUNMARYA summary of these substance abuse prevention studiesreveals that IlinnovativelT programs are more successful inchanging attitudes and behaviours than TitraditionaliT programs;knowledge is a necessary but not sufficient component forinducing and supporting change. Little is known, however,about how or why programs work, and evaluation results areinconclusive with regard to whether narrowly-focusedresistance-skill development programs are superior to broad-based life-skills development ones, or whether a combination(e.g., Botvin’s Life Skills Approach) is better than intensiveapplication of a single approach. Also unclear is whether useof peer leaders consistently has more long-term impact thanuse of adults only. As presenter training and monitoringmethods in studies differ across these conditions, theirrelative impact cannot adequately be assessed. In addition,the level of implementation of programs is often notadequately measured or documented by the studies.Some tentative conclusions may be drawn, however. Allelse being equal, programs utilizing peer leaders seem to havegreater impact. Those incorporating Ttbooster sessions” (for133example, one or two follow-up classes a year later), seem toproduce longer-lasting changes in behaviour than those withoutprogram follow-up. Alcohol prevention programs generally havenot been as successful as smoking prevention programs. (Thismay relate to the lack of cultural reinforcement forabstinence from alcohol, and to the recent predominance ofcultural support for smoking cessation.)Flay’s list of possibly critical components suggestsdirections for future research on substance use preventionprograms. These elements include (a) use of similar-agepeers; (b) use of media material and discussion of media andfamily influences; (c) practise in resisting pressure; (d)pledging or commitment; and (e) extended duration of theprogram (Flay, 1987).Teacher training appears to be a significant variable.Teachers are likely to avoid using interactive teachingtechniques unless they confident and comfortable with them,and will not be able to facilitate intimate group discussionswithout a good grasp of the relevant information and issuessurrounding substance use behaviour.3.5.B PREVENTION OF ADOLESCENT PREGNANCYPrograms aimed at preventing unintended pregnancy inteens are presented next. Rather than being purely schoolbased, some of these programs are collaborative initiativesbetween community agencies (such as hospitals or family134planning agencies), and schools. The effect of collaboration,which may provide reinforcing support and produce morecohesive social norms, will be noted in reviewing thesestudies.3 .5. B. 1 INTRODUCTIONWhereas substance abuse prevention programs canjustifiably promote a universal abstinence message (that is,“to never use is best”), programs in the field of adolescentsexuality are conceptually more complex. As most people willbecome sexually intimate with other(s) at some point in theirlives, the task for educators therefore includes assistingadolescents (a) in sorting out when in their lives sexualintimacy would be in their best interest, (b) motivating themto want to do what is in their best interest, and (c) helpingthem, when they become sexually active, to do so in a way thatmeets their needs (including the need to avoid pregnancy anddisease) . Some say that promoting abstinence47 and teachingabout contraception within the same program gives a “mixedmessage”. Both can, however, successfully be part of acomprehensive program (Howard & McCabe, 1992)47Abstinence programs would probably be better called“postponement” programs. Abstinence until marriage is not areasonable goal for all people, depending on their sexualorientation and their cultural norms. At the very least, itdoes not recognize the needs of gay and Lesbian people, for whommarriage is not a legally—sanctioned possibility.135W)J5ftHiH-ft0PiftI-U)H-iI-i0-h-0U)-HiCDiCDCDH-CD0UiI-’00CDCD-jU)CDCDCD5QC)Cl)iCDftU)(Q<(-QSCD‘-<HHH-CDHQW0CDCDftCD•hHi)ftHf-IiCDU)d•HC)ftCDU)UC-4CDH-H$1C)1U)M<0<H-iftCD•(QC)<0CDH•HTCD5C)H-iC)1H-•5C)iiHiHCUtQCD<0CUCUCUCUCDCUtQ0HU)U)U)H-iHiIIH-t-HCDCUC)CDCDCDiC)—C)ftCDU)1iIiCDCU1Q‘-<0H-0(HC)CDCDU)CDI-U)CUSU)HidU)<hi0‘<U)hft<JhCDCUHU)0CDftICDCD13U)ftU)H-CUCDCDCD3‘-<13H‘1CDI-M13’0‘-‘1<1CDdHH-H-131313‘z3IQCUCD10CDIIU)CDHiCDCDQ-ftI-1x3C<1QC)ftI-13hCDft<C)0H13CDJCDH13CDCDH-CDCUCD13$1H-CDH-013CDtiCUftCD<11)ft0U)13CDH-1313C)Ii13>FftH-H-CDCU13CU13CDC)SHiU)(.QU)CDQCDft0CD0HiI-13HftCD13<0CD<CDH-0HCD130ftH0ftCUftI-H0CUHi<1ftS13‘tiH-0LQCDHU)hCUCDftHU)0CD0U)FdftCUQ0h0I-i5‘oCDCDfth-ICDI-jh5H-HiH-13CU‘tiH-CDHft5‘zift0ftU)U)5U)5ft0Cl<<CU0CDftC)I-CD151JCDU)CDCU‘-<U)U)U)I-IH-CDCDhh-I00CDCU0CUCUCDICTI-U)CDU)Ii(-Q0CU<I-Q13ftftftCDU)><Ii‘-<C)ftd<1C)‘tIftCDCDHi13CDh-IU)13CDCUCDCI)tL’l0CD13’CDh-IH-IU)hCUCDclI-IU)CU13HCDh-I(CDIiU)00U)ftftSCU5H-0CDHC)WCUCUCU13ftU)1Q13C)13’H-1QU)13CDQ—SHO‘rj5‘xjQIiH-CDhCUCDCDU)CDftCUI-Q‘rI‘-<13U)000ClCUftHU)CUft13’HIiftHCUHftCl13513CD5HH-0h-ICDCI)CU0U)ft-U)C)CD0-U)CU0H-0HiCDh13C)1313’I-CDH-CUtiU)CD13CDhftIi50C)ftCDCU<1U)13iC)H-<1CDCDftHU)CU1313I—I13CD••0CDCDftCD13’IiHiCUI—ICU13’H-13ftCD—U)130130hICD0H3CU13CD0hIU)5ftCDft5CDU)fthjhIftlCDHi)CUhjCDHH-H‘U)CUftCD1Y’CUCDH-HClC)CDI-Dft0ClX13HCDU)ftU)hIS13‘-<dClCD<ICUL)ft13H-U)CDCD0H-U)CDCDftI-IH-CD—10CD<0hICUIi0H--ftCDftCDftft13CD—‘Cl0H-ftCU0hI13Ii1JhI0<1H-H-ftCU0ClCDI-QCD0U)IQft0hICD0<1H-U)ClCDCD<ClhICUhICDClCDb’1313CD0H-hICldCDCU00CDU)HCDft-U)13CUU)Hh13ft50HiHi3CUH-hIID’CDCI)H-0ft0U)HiHCUftft5013’CU‘tiCDCDCU13—ft0CD0i0U)-U)ftH-0CUCUII13’CDClU)0ftC)CD0ClHiU)SCl0CDft0CDCUID0U)H-CD00U)hIH-Hi<1hICD13-ftfthIHI-CDCDU)CDCUhIC)1’U)HCDCDCU<1U)U)hISCDCDhIU)5CD-U)Hit1ftCDLiU)ftC)U)13CD0ftCD-13’CDftU)CUh’0CU13IiCDCUU)13ftClHCD1 delaying and reducing sexual activity;2 increasing the use of contraceptives; or3 life options/alternative opportunities (Hofferth &Miller, 1989:25)Programs can be classified as Iltraditionall? or“innovative’ along the same lines as substance abuseprevention programs. The traditional approach provides basicinformation on human sexuality and reproduction, decisionmaking, and sometimes values and ethics. Programs based onsocial learning theory are more interactive, providingopportunities for modeling and role playing while practisingand learning communication, negotiation and problem-solving,skills (Hofferth & Miller, 1989:25)3.5.3.2.1 Delaying and reducing sexual activityGoals of traditional sex education programs are11increased knowledgeH and informed decision making”. Theseprograms have generally been found to increase knowledge butto have little influence on sexual behavior (Kirby, 1984)Some programs have attempted to facilitate increasedcommunication between parents and children as a means ofdelaying intercourse; the outcome in many cases has beenincreased communication but the type of sexuality behavioroutcome has been dependent on the gender of the participantsand on the message that has been transmitted. For example, in137one program it was found that enhancing fathers’ communicationwith their sons with regard to sexual matters was found not todelay initiation of intercourse, while enhancing mothers’communication with their daughters on this topic was found todo so (Hofferth & Miller, 1989:26)3.5.B.2.la Howard, 1985; Howard & McCabe, 1990; Howard &McCabe, 1992A well-known large-scale program focused on delayingsexual intercourse, a social influence program usingbehavioral skills and assertiveness training, is “PostponingSexual Involvement: An Educational Series for Young Teens”(Howard, 1985; Howard & McCabe, 1990; Howard & McCabe, 1992)This program has been designed to help students in Grade 8resist pressures to become sexually active before they areready. The program is based on (1) developmental principles,(2) a clear value base that favors postponing sexualintercourse, (3) skill-building exercises and activities and(4) use of peer counsellors and parent support (Hofferth &Miller, 1989:26)The program consists of two five-class-period components;“Human Sexuality”, an information and skills oriented programincluding information on contraception, and “Postponing SexualInvolvement”, an experiential component based on the socialinfluence resistance training model. Evaluation in the early1980s revealed that the first component alone was noteffective in reducing the rate of sexual involvement or teen138pregnancy. The second component was created and added; itsgoals are to:(a) help youth identify where pressures to use drugs, smoke,drink, or have sex come from;(b) help them examine motivations behind those pressures;(c) assist them in developing ways to respond to thepressures; and(d) help them learn skills that they can use to say no topressure situations (Howard & McCabe, 1992:84)This hospital-based outreach educational program foreighth-grade students has been successful in helping youthfrom low-income American families postpone sexual involvementif they receive the program before beginning sexualintercourse. The first component, “Human Sexuality”, istaught by nurses and counselors from the hospital’s TeenServices Program. The second, the skill-building component,is taught by 11th- and 12th-grade youth under the supervisionof the nurses and counselors.The program has been evaluated using an extremelycomprehensive design involving schools and the hospital andcovering a two-year time period. One thousand one hundredfourteen (1114) youth were initially identified as eligible toparticipate in the evaluation (not the program), based onhaving been born at the hospital and having used its serviceswithin the past 10 years (ensuring that they had been born andremained in poverty) . The program was given to approximatelyhalf the schools (N = 24) within the district, selected on arandom basis, and the other schools (N = 29) were not giventhe program. Youth who participated in the evaluation were139C)ftHH0M]Cl)0Jft—TDJ(iTdftftCl)0CDCDCD000H,ft0Q-PiP.CDCD(I)(QII(I)H-I1CD<H-CDU0Cl)h-HCDI-QClTJCDft0C)3HCDCtftCDHCDCD‘-<CDftI-(ClCl)HHH-0CCQ(Q<Cl)hH-dC)H-1—CD<CiiCDCD“JH--iH-Nft(DCrCl)CiiQ.ft0H-II(DCl)CrI3H-0<1CDCjCl)Cl)0ftH-30Cl)Q(Db<CDft(Cl10—-H-f-i-Cii3Cl)(QiCiiH,(Cl(DH-(D(Cl(Cl(ClI-0H-CDC)(QCr0Cl)1Q(Q1Q0I-CiiCiiCCftii-CrCiftI-H-I-H-H-H,(ClCl)ft(Cl(Q00CDYCl)l-F-1l(ClftCl)H-Cl)ft(ClCl)I—’CDft-0Cl.CCftftH-HiCl)0ftCl)CiiHiCDCD‘dH-CDCD(PC)0ftftdCii(ClCii(P—i-h(PI-()i-o\O0<HH-(ClftH-IftI-‘-<Cii-•<0I-’(Q<LJ0(Cl0(Cl0CDCDCl)Cl)CiiH-(Q(IiH-H-CiftI-0ft-<CD(P(PI-ft3(Cli--TI0(ClJCiiHHUiCD0HJI--H-(PCl.CliCDH,ft(ClCD<CDftCiHC)CDftCliCiiH-(ClCl)Cl)(Clft<ft0Cii0ft—CDl-H-TIftCDCD0H-CDH0CDCl)3CiiH,H--HH-Ci(ClCl)<TIftCiiCiCii3CD(Clft0(P(ClH-CD0Cl)(ClftftECiiH(ClCDCDC)I-H-I-(ClC)Cl)CiiliHftHI-Cl)h’Cii0(ClftC)ft(ClTI(Cl0(ClH0(ClftCiH-0Cii(Clft(ClCl)ftCDHICl)H)i0H,I-H-H-CDTITI(ClC)ftH-‘-<ftH-Dft(P(Cl0iCDH,CD(P0CD(ClH-CDH-CDCii(P0H-Cl)CD(ClI-h0Cl)0CD0I-H-iftC)ftCiiI-H-0H-I-Cl)0CiCDH,30CiCiiTIftftDftCDftI-ftCDibH(PCDh0l-C)TIftH(iH-H-CDI-CD—CDHCOTICiiC)i--iftTICDC)CD0TI<-TICDTIH-0ftftCl)CDCl)H-H-0CD-ftIH-H,CiiC)CiCD0CD0I-hI-iCD-ftdCDH-H-0-<I-ft0TICDCDCl)3ftCl)CiiCiiTIftCD<Ci0H-CD(Q‘<TIiCDCl)-CD—<1iCDCD0Cl)CDftCiI-Cl)I-CCH-H-—CDCDft3-Cl)Ift(P<CDCiiftH-—TI0(P(PH-H-C)HCD•-H-H-H-QftH-C)CiiiF-TJCiitYft-0Cl)CDCD(iCDCDH‘-<Cl)0CliftCDftCii—CiiftCDhH-CiiCl)TITICDCD—C)CDCDftCiiCDCl)Cl)ftCl)CiiC)ftCDI-CDCDCiiHCiiI-Cl)iC)•0JCl)F—1•(QCiiiCiiH—JCl)<1CDH-CDCl)CiiCD00‘10H-C)ftiH\O0ftH-(PiCDd(PCDCl)CiiCl)0CDTICl)CDCl)H-(PI-0H-Cl)H-H-CDCDH-TIftCl)0Cl)CDft<Cl)CDH,ft(Cl3<CDft‘-<IWH,CDCiCDH-CiiI-ftCDft(PCDH-0o\00hH,TITI0TIftCl)HH-CDiH,0CiftI-CD0CiiCD‘-<h0CDi-0(PC/)dft0i-ft1I-TftI-T-CDCl)<H,hCDCDI—T(P0ftCDCDCDCiCiiH-<0CD0CiiH-I-’ft><0CDI-(PH,CiiCii0Cl)CiCl)0CD0H,Ci(PCiihCDC)CiC)ftTI(0C)HH,0CDCiihbCiiCiiCl)CDftCD—ft-Dk<Cl)cii--HCiiCDH-CDCiiI-I-fto\0CD0—QI—(PCiiH-HTIC)H-CDoI-CD0H-3H,TITIft3H-0HCDCDTI0TICD—CiiCiiCiiH-o\0ftH,CD0)HCiiilHftftCl)0H-3ftCl)H-CDCDCDH1i00TI0Cl)—CDl-3Cl)(PCCto control for test-retest bias, as students were not awarethat this was a separate evaluation. To control for possiblereading problems, questions were read to the youth, andarrangements were made to ensure confidentiality of responsesby wording questions so that answers could be given as uyesflor “no” or with a code so that others in the room would not beable to know what the questions had been. Confirmation ofself-report data was done using hospital records; only onepercent of responses were found to be questionable.There were no significant differences between thetreatment and comparison groups when baseline measures weretaken. The differences between program and no-program groups12-18 months later showed that the program did have an impacton the students with regard to postponement of sexualintercourse, for those who had not already begun intercourse.Group differences in sexual intercourse experience, dependingon how the data were organized, were in the range of 8 to l5with an average of 12 (Howard & McCabe, 1992:95).Questions to be answered by the evaluation were:How would youth react to the Postponing SexualInvolvement program?Would youth who had not had sexual intercourse beforethey were given the program postpone sexual involvementin the eighth grade?Would youth who had not had sexual intercourse beforethey were given the program continue to postpone sexualinvolvement in the ninth grade?Would both boys and girls who had not had sexualintercourse before they were given the program postponesexual involvement?Would youth who began sexual intercourse after having hadthe program report less sexual involvement?Would girls who had the program have fewer pregnancies?141Would youth who had sexual intercourse before the programchange behaviors as a result of the program? (Howard &McCabe, 1992:91-92)The major findings were as follows:1 The program helped youth postpone sexual involvement.2 The program was of assistance to both boys and girls.3 Youth who had sex were less likely to continue [Youth whobegan sexual activity after the program began engaged insex less frequently than those who had begun before theprogram.]4 Fewer pregnancies occurred.5 The program did not have an impact on those who had sexprior to being given the program (Howard & McCabe,1992:102-103)The Postponing Sexual Involvement Educational Series isnow being disseminated throughout the United States as anabstinence model for young teens (Howard & McCabe, 1992:83)3.5.B.2.2 Increasing the use of contraceptivesPregnancy prevention programs based on increasingknowledge were found, in a meta—analysis of 134 studies, toproduce a meta correlation coefficient between knowledge andcontraceptive use of only 0.17 (r-squared), supporting thefailure of greater knowledge to significantly reduceunprotected intercourse (Kirby, 1992:281) . Other studies,based on nationally representative samples of young women,found that those who had had a sex education course in school(details of the courses were not reported) appeared to be moreeffective users of contraception (Hofferth & Miller, 1989:28)Programs based on values clarification and/or facilitation ofdecision-making and communication skills have also produced142somewhat inconsistent results, perhaps due to the variablesmeasured. They did not, however,markedly hasten or delay onset of intercourse, reducesexual risk-taking behavior, or reduce teen-agepregnancy. However, they may have increased slightly theuse of birth control or had other positive effects thatcould not be measured by the evaluation methods employed.These results are similar to those found in evaluationsof smoking, alcohol, and drug abuse curricula based onsimilar theoretical models (Kirby, 1992:281)3.5.B.2.2a Schinke, Gilchrist & Small, 1979; Schinke,Blythe & Gilchrist, 1981; Gilchrist & Schinke,1983Schinke, Gilchrist & Small (1979), Schinke, Blythe &Gilchrist (1981) and Gilchrist and Schinke (1983) havedeveloped and utilized what they call a ‘TLife SkillsCounseling Approach48 with adolescents. They outline fournecessary components to the approach: access to accurateinformation about human reproduction and contraception;understanding and retention of the information;personalization of the information and use of it in decision-making exercises; and development of behavioral skills(ability to obtain contraception, regulate sexual encountersand negotiate the use of birth control) to enableimplementation of the decisions in social situations.The approach was pilot tested with 36 high school seniors(mean age 15.9 years) randomly assigned to a Solomon four48Also called U cognitive and behavioral training.143C)II0CDjw0ft-0H‘1t)0L’I00CDF-’-C)-C)o—CD-l-‘ziCl9)WAfQMCDCD—-ftCl0ftII0CDUiFl 9)ftwftUi9)ftCD-H-Clft-CDHClU)CDCDAU)U)HU)ft-ftU)0Fl0H0CD0HH9)Hi—‘H-Fl9)ClftC)HiCDCD9) S0H-H-H’F-’0Hct9)I—’ftCl9)CDCDU)I-QftH9) rtftCD-CDftH-—WftA 0 Ui Fl CD 9) ft CD Fl Fl 0 ft CD C) ft H 0ti: C)9) ftHF-’9)CDU) ftCD ctH9)ftHCD Fl C) 0HFl0U)HDUiftw-wClftftftH-0CDU)CDU)ftCDftH->4dU)jC)CDCDCDh$9)CiF-’0)Hi<H-Ci0CDU)H-F-’FlFlftS9)CDU)9)Cl9)CDF-’0C)CldH’HiCDCD ftftftft‘DCD—)CDFlCDU)WCDCDftCD-Hi00ftClU)Fl0ftCD5ftft9)CD(QH-0)CDFlftoU)U)HCi•U)ftU)CD•J0Fl0 F-’CDHI-IHClCD0ftftCDIU)I-iCiCDC)CDH-CDftiClftCDftCiH-U)CDF—’oftFlCDU)<U)CD9)j9)9)H’ftFlU)H-Clit00H-o‘0H-wFlF-’9)0 CiHift0U)U)FlttftU)ftH’CDCDCD9)U)tQH-U)ft0F—’ftiH-ftHH-H-U)19) ft—0SH-tt9)CD0FlI-’:i9)0CDClU)—ClCiHt.QC)Fl-CDCDoCDftSClCDI-ftU)U)9)Flft0b9)9)CDH0C)FlCl<CiCDftH-ft‘dH-H-ftC)1QFlH-H-—CD<dFlCDçIJ09)FlH’U)0f-iCDU)ClFlU)CDCi9)-FlC)C)F-’ftftft9)9)H-H-H-ft‘-<<0C)ftU)CDiCDH-—U)fi-•CD9)CiU)ClU)ClCD-dU)ftCDC)H-HftU)0FlH-0H-5ft9)>459)CiIH-FlSC)F-’Cl0H-0H-C)ftHif1-9)ft<9)ftFlSU)H-0HiH--0F-’0F-’Flk<Hi09)9)ftF-’:ijH’ClClCD0 CiFl CD H 0 Ci U) H’ Cl CD CD H’ 0 CD Cl F’ U) ft Fl Ci S CD ft U) CD Fl CD Fl CD H- U) CD Cl 9) Cl Ci U) CD Cl ft 0Fl 0 Ci Cl CD U) H Fl CD ft CD U) ft ft Fl 9) H H 9) Cl 0 U) ft ft CD U) ft ft Fl 9) H HCD9) Cl0 U) ft ft CD U) ft Fl CD ft CD U) ft 9) Cl 0 U) ft ft CD U) ft 9) Cl It 0 U) ft ft CD U) ft 0 H’ftd9)C)bftFl‘-<i0‘-<FlCD9)ClCDC)5ft9)9)U)ft0<Flf-iCDH-ClCD9)C)SSU)U)CDFlC)09)CDU)CDH’tYCDiH’H-H-9)ftCDftoH-I—’ftCD5H-9)C)U)‘•d-9)<1ft0I-’iCDCliCDFlCl9)U)5059)H-CDF-’iCDClU)iCD0ftHiftftU)CDCDH-d<0ftSCliF-’CDClFl9)9)FlU)9)I—’0‘-<-ftCDHiCD9)CDC)9)F-’d1-Q(QHFlH-FlCiClC)0CD9)H-0bU)ClUiFlFl5H’Ci0CDCD5CDH-9)ICl5ift5CDiC)CDH9)H-U)F-’FlC)0CiU)Ci0U)9)H’Clcft9)ft<CDC)CDI-’F-’H-H-ClH-CD•09)(QCl:i(FlH’FlCD0CD9)5CiCDCDFl09)CD9)ft0FliFlClU)ClU)CD0CiCDiClC)U)U)U)9)CDU)ftftU)t1U)H-CiH-H-FlU)9)<Cl0F-’CDCDCDiH’CDClU)U)ClH-ftH--C)ft3Fl00CD0F-’9)F-’ftH-C)0ClIQft(QCDDH-‘-<C)CDriU)ftCDCD9)CDCl—ClCliH-CD0iC))C)-HoCD ‘-ClU)bCDCD.)ClCl)H•CloCDoCi)Cr2C)Cr0H-Cl CDCDft HCrft0U)Ci) 0P)hH]jPiCloP)CrjH-d0Ci)I-ClCD0CDClP)HHC)HftU]-CD Ci)I—bCDCDk<H]CiftCDCi) P)CDP)HHH-)CD0iPi‘1ClClCi)CDI-1-’H-CDCi)Ic0U)CDH]SU)Pirr-F-1CDHP) H PJ ClH-ClC)H]CrSCDH-PiFdC)FC)CDHH-C)ftCDU)SH-SCDCD0Ci)PiftCFIP)Cl0PiSClCrpiC)C)siH-CDp.)C)oH-Ci)HCr•C)H <1oHCDH]Ci)tiP)CF)-ftP.)ftCD0H-jiClCDCi)HtcCDC)Cl‘dSFCDHIH-C)CiCi)Ci)ftH-Ci)0;s-Ci)HCi)P.)H-Cl<C)oCDH-H-CDIij:iFd-CDIQCrHHH0Ci)H-0CD(CDH-Ci) Ci)ftHH<100H]H-Ci)iH]0odCi)l-CDftSP.)C)H-P)HH-iCDCrH]C)HCI)H-HCi)0C)ftH-ClHdCDClHHClCD‘-<Ci)P.)ftfthftCi)Ci)CDCD-HPjH]p.)H-00fthCi)H-Hp.) 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Cl‘-ii H-H]ft CD CDI-Qft0CDd0U)0H-ftH—CDC)vi ftfr1’)H-H-CP.)U)HftU) ft0RH]ClCl]CDftC)ftCDH-U)HCDft CDHCDWft H-0CD 0CDft ftH SH-U)H CDftS11CDH P.)ftHCD ClH ftH ftH CH—3P.) CDH U) C) 0 0 H U) ft Cl CD ft U) S CD P.) P.) CD H —1 CD P.) U) Hi H ft ft CD CD 0 H]H CD U) ft H .) ft 0 U) C) 0 Cl C) ft CD Cl P.) H] ft CD II H- H 0 ft ft CD U) ft ft 0 H CD U) ft H P.) ft CDgroups, with leaders and other group members coaching andproviding feedback. Students were also guided throughrelaxation exercises and then asked to imagine scenes of asexual nature and to construct dialogues using their newskills. They were asked to write out these dialogues forhomework, and then role play them at the next meeting.Assignments to be carried out outside the classroomincluded requesting birth control information from someone inthe community, pricing contraceptive products in local drugstores, discussing birth control with dating partners, andobtaining opinions about sex from parents, counselors,ministers, or other significant adults, followed by submissionof written descriptions of the results of these activities,which were read to the group by the discussion leader and thenpraised and discussed in class.Analyses revealed no pretest differences betweentreatment and control groups. Intervention groups once againexcelled in all measures. Results suggest that cognitive andbehavioural treatment, even when conducted with relativelylarge groups, can help adolescents to acquire skills to avoidunplanned pregnancy. The investigators comment that as thetreatment was composed of multiple components, it wasimpossible within the study to evaluate the power of any onecomponent over others (Gilchrist & Schinke, 1983:383-386)These two studies report a rich series of outcomemeasures that might be usefully applied in future related146research. Scales included knowledge, attitudes andintentions, problem-solving ability, communication skill,social adequacy, self-efficacy and behaviour. Knowledgeincluded awareness of human reproduction and contraceptionthrough looking at facts, myths, probabilities and sequelae.Attitudes were subjects’ opinions regarding the desirabilityof using contraception and of communicating with a partnerabout it, and evaluation of their own ability to do so;intentions were their perceived likelihood of communicatingwith their partner about, and using, contraception at nextintercourse. Problem-solving ability was measured in thefirst study as being able to specify interpersonal problems,identify obstacles to solving them and generate potentialsolutions. In the second studya problem-solving performance score was computed for eachsubject by summing frequency counts of the followingvariables: the number of times subjects raised the issueof opportunity for intercourse or need for birth control,the number of plans they generated to resolve thediscussion, and the number of potential consequences theyverbalized (Gilchrist & Schinke, 1983:384)Communication skills in the first study were assessed on thebasis ofuse of eye contact with the opposite-sex interpersonalpartner, the declarative ‘No’ in response to socialpressure, statements expressing refusal to riskpregnancy, and requests that partners shareresponsibility for birth control and cognate sexualdecisions (Schinke, Blythe & Gilchrist, 1981:452-453)In the second studya composite score representing communication skill wascomputed for each subject by summing frequency counts ofrequests for information and feedback from partners,147Cl) CD CDrrI.(DDihCDhCD-020H-°QDiCDo2Dir-i-Di(.QC)CDo2C)<HCDk<c; CDiCD Di 02C)LQHCD02(QHH-j-(QCf2j—ItCD(Q: CD IIDiCDOCDQr(QDiCD-oCDDiD)DiH-DJr-CD02 CDCDCD02Q$1--02DioH-I—DiftrtD)oDi—t Cro 0) C)CDDib.Di F-’DiØ,CD 02CDHQDiCDjti Q-0)DiCDO0)frh-.02::;-CCrCDCD-,-‘CD-HDiDiCl-Di 02H-DiCD0) r-i-02H-DiCr CDCD CD I—’;HCO‘Di—0 C)H-CDCDI—,C) DiCDCDI—’Cl-H-I-’-C) CDDi0)rCD ‘IC) 002 C)oDiCDCD‘-°H-ICDCl- 02Di“CDD)I—’CD 0-.WDiQF-frhCOu-0•H-H-DiDiCDDiCDDie,CDCDDiCDDiCDH-02Di(Q02DiC)—a.G)CDH-a.DiF-’CDC)C)CDDi-. C)Cl-i-i- H CDCri02 CDr-roCDCD CD0Ci)Il3.5.B.2.2b Thomas, Mitchell, Devlin, Goldsmith, Singer &Watters, 1992In 1982, Thomas, Mitchell, Devlin, Goldsmith, Singer &Watters conducted a large-scale trial of the cognitive-behavioral model for preventing unwanted adolescent pregnancy(outlined by Schinke et al., 1981), in Hamilton, Ontario(Thomas, Mitchell, Devlin, Goldsmith, Singer & Watters, 1992)The evaluation was a prospective randomized controlledlongitudinal study involving 3290 Grade 7 & 8 students betweenthe ages of 11 and 17 (mean age at pretest 12.7 years(intervention group); 12.6 years (control group)) in 21schools. Schools were randomly assigned to treatment andcontrol conditions. Over the following five years, studentswere individually tracked until they had reached the age of17. Trainers (public health nurses and teachers), received 40hours of training. Training was composed of three parts:facts about human sexuality, techniques for facilitating smallgroups, and methods for teaching problem-based learning.The role of each tutor was:1. to establish a climate in which students are free toparticipate actively in inquiry;2. to demonstrate respect for the experience, creativity,personal values, and behaviors that students bring to thegroup;3. to facilitate the development of communication,negotiation, problem-solving, and decision-making skillswithin the group;4. to guide group process through clarification andprovision of resources as necessary, and;5. to be open and honest about his or her own biases andlimitations (Thomas et al., 1992:31).Each group of six to eight students received 10 1-hour149H H Cl ft CD Cl C) 0 H (Q CD CD H h CD 0 ft H ft CD C) Cl ft 3 Hi 0 St—ClCDCDH<H-CDPiHotY0H-tHCDC)H-CloftSk<H-CD CDCD ftS‘1CDPiP)IISCDftCDH-I-C)ftCDH-CDCld PiftCDf-fpihCDftCD—hIClCDH1Q•dp.)CDPiC)CDI-<jC)ftP)CDCDCD ctftC)CDCDp.)ClPiCDHiSHi00 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cognitive-behavioral model of skill acquisition andmaintenance. Training for group leaders involved about 60hours over a 2-week period. Interviewers were trained forapproximately 15 hours (Bisen et al., 1985:192-193).The percentage of sexually active participants whoreported “always using contraception” went from 28% atbaseline to 30% at posttest to 34% at follow-up. Thepercentage who reported “sometimes using contraception” wentfrom 51% at baseline to 47% at posttest to 45% at follow-up.The percentage who reported “never using contraception” wentfrom 21% at baseline to 23% at follow-up and dropped back to21% at follow-up. Thus the major accomplishment in terms ofuse of contraceptives was probably to move some of theparticipants from “sometimes” to “always”.5°Regarding the measurement of Health Belief Model (HBM)constructs, the investigators found that “changes in HBM-basedcontraceptive perceptions and sexual knowledge at immediatepost-testing were predictive of increases in contraceptiveusage at longer followup (Eisen, Zellman and McAlister,1985:185) .“Data on several other dependent variables indicated that:50We cannot be certain of this outcome because data arenot given with respect to individual changes. We can alsospeculate that without the intervention, it is possible thatthere would have been more movement in the “wrong” direction,but without data from a control group, particularly one to whichparticipants would have been randomly assigned, we cannot besure.154[Forty-nine] 49% of the participants talked with theirparent(s) about sexuality more frequently after theprogram; 41% sought out and received information fromsources other than parents; almost 14% got birth controldevices from a family planning agency or doctor, and 68%of those who were sexually active three to six monthsafter the program reported using contraception at lastintercourse (Elsen et al., 1985:207).As the investigators thought that this program showedpotential for success, it was further tested, using theinformation gained from the pilot study, in a large-scalefollow-up controlled field study (N = 1444; aged 13-19)Results of the large-scale study are reported in severalpublications, including Eisen, Zellman & McAlister (1990),Eisen, Zellman & McAlister (1992) and Eisen & Zellman (1992)The program had to be shortened to between 8-12 hours to beacceptable to implementers, and was evaluated against sevencommunity-based programs and one school-based intervention ofsimilar length.165’Recipients of the programs were from 13-19 years of age.They were randomly assigned individually or by classroom(depending on the agency) to the Health Belief Model-SocialLearning Theory (HBM-SLT) (experimental group) or to the51These “comparison programs” also covered reproduction,contraception, STD5 and dating, sexual values, norms anddecision-making. The main differences between these and theexperimental program were its use of Health Belief Modelconstructs and its greater emphasis on active studentinvolvement (e.g., role-playing).155agencies’ usual (comparison) program.52 Data were collectedprior to each intervention, immediately afterwards, and 12months later. No significant differences in baseline reportsof sexual behaviour or contraceptive use were found betweenexperimental and comparison group participants. At baseline,37% reported that they had had sexual intercourse; 49% ofthose had used contraception at their last intercourse; and74% of those using contraception had used a condom. Sixtypercent of the program participants completed the 12-monthfollow-up questionnaire.As no previous studies addressing adolescents’ healthperceptions of fertility control were found, items intended totap perceived “susceptibility”, “seriousness”, “benefits” and“barriers” were written (for the pilot study), were revisedafter “extensive” scaling and psychometric studies, and wereused for this study (Eisen, Zeliman & McAlister, l99O:264O.Information was also collected on students’ knowledge ofsexuality and birth control and STD prevention, and on52There were no “no-program” controls.53For the analysis, the 35 HBM items on the evaluationinstrument were first grouped by the four HBM constructs. Thenthe “seriousness” and “benefits” constructs were each dividedinto two dimensions. These were labelled “serious affectiveconsequences of pregnancy”, “serious pregnancy resolutionconsequences”, “benefits of effective birth control use” and“interpersonal benefits of birth control use”. The other twoconstructs were “susceptibility to pregnancy/VD” and “barriersto birth control use”.156behaviour.[W]hether adolescents had sexual intercourse; whetherthey used a contraceptive method(s) at first and mostrecent sexual intercourse; what specific methods wereused, if any; how consistently contraception was usedbefore and after the intervention; and whether they ortheir partner(s) had become pregnant since theintervention program concluded. Abstinence continuation,transition from virginity to coital activity, and use ofand changes in use of effective birth control methods atfirst and most recent postintervention intercourse wereassessed (Eisen, Zellman & McAlister (1992) :252)Using bivariate and multivariate methods, analyses showedno difference between experimental and comparison groups inpost-intervention health beliefs. Preintervention virginitystatus and gender were significant indicators of outcome. Forpreintervention virgins, the HBM-SLT and comparison programsled to an equal likelihood of maintenance of abstinence at theone-year follow-up. Comparison group female pre-interventionvirgins who became sexually active over the year were morelikely to have used an effective contraceptive method at mostrecent intercourse and to be more efficient contraceptors thanthose having attended the HBM-SLT program (a negativefinding) . For pre-intervention males who became sexuallyactive over the year, the programs were equally effective inencouraging effective use of contraceptives. Forpreintervention nonvirgins, both programs produced significantgains in contraceptive efficiency; however, the HBM-SLTprogram was superior to the Comparison program for males inthis category.These results suggest that programs need to be client157ftH-ftCDC)H-ftC)C)H-WHH,-Cl)ftH-U):3•Cl)0H-I—iiH-Cl)•CliCliCDCDCDiCDCl)CDLi.ftftCli0CDI—sU]HC)HClCliftC)10l-0CDCtU)C)0H-l-HCDClCliftl-H-CDC)CDhFCDU)l-‘-<H,H-CDU)HftIi0CDiH,H-H-<CDl-CDHCD0C)•0CDH-0ftQCliH-H,ftCDCl)U)CliftRCDt’.)H,U)0HU)U)H-C)H-CD‘<ftF-ftH-HCDCD-CDH-C)l-ftCl)0H-C)‘IjH-ciftH-t’J011U)IQCliCD0H-CDH,0Cl)CDCliCDCl0H-Cl)H-ftHH,C)F-1ftCl10H-H0i0UiiCr0U)-—SH-0CDCliC)C)CDH,H,0)ft•ftCl)0iCliftl-U)<H-F-1H-0CliF-’ciU)‘d—H-0H-Cl)cil-fti-CDCDk<Cl0dhHClCD0ftftH-iF-1Q,U)ClCs)CDC)hHwft0H-C)CDftU)ft0H-0LO‘-<CDHCDH-1ji0CliWftH,hftCliCliLO—<LOHhU)CDH,CDIQH-HCl0U)HC)JH-Cli0)ClidCDCD0CliU)CDICDClF-’CDCli—W10H0)CliIQCDI-ciH-ftU)Cl)CDHiC)HCDCliciICl—I-0H,C)iU)U)CDft0ftC)CDCDU)I-Cl)0)-CDftH-CliCDH-CDftl-U)ftU)0hCliftU)ftLOH-ftClCD<U)CDIICDh0C)CD‘1CllftCliCl(-Q0CD0H-H-ClCliH,ClU)H-ftCDftH,ftiCDH-Cl)H-CD0C)ftCDCD.QftftU]cil-U)iU)L0CliH-ci0CDC)ciH-CDCDftU]CDLQU)IQ0C)CI)H0-<hC)ClihCD0U)0F-ho\0H-C)ciHU)000HCD0iCDCD<CD—CliftftIQCliH-ICl.ftHRHCliQ,-CDHftCD0Cl)iH-CDCDft‘-<hH‘<00U)iU]ftU)CDClHH-CliCDk<“JHH-CDCDH,CDCDftIICDU)ftU)C)hCDCDCliH-CliU)U)CDU)U)<HCDI-iH-CDH-C)H-ciRIHCliftjCDC)CliH•CD‘d0CliCD><ClNft0HC)-iClH,CD‘-<0ftCDH,CDCliftCD010H,l--0U)di0H,C)HH-Cli-HCDU)CDR’ftl-U)CDCDH-HCliCDCDftH-ciftC)‘-0CliCl)H-CDH-ftiC)Clik<IrClH,l-ftCDH’J<H,ftCDftHftft0H-CDH-iCl)00CliIQLDCDClCDHHH-U)H-HCDCDCDCDF-ftCli<C)U)-0i1LoftCDCDCU<‘-<><CliIQH-CDftCDCDHC)0JhClCliC)0ciCDl-ft1C‘-Hci0CDftH,ftH-CDU)0CliHCDtICl)LOCl-U)CUCliciftiCliiCDU)U)LOH-H-H,-<UC)0H-ft10CDCl‘-ft0CDHU)h0HhC)CDU)QC)hjCliCD0l-CD10CliC)Cl-•ftCDH,.oCD0ciftU)ftU)iCliCliCDCDCli<H-hjL0U)jCliftH-l-U)C)jClH,l-iH-Cl)0WH-CDH-HQH<CDH-CDCl)ClCDftCl0HCliC)0CDftCD‘<C)U)Cl<-•0CD10t-l-ftft<U)CDftCDil-t-C)ftftU)H-CDLii-CliCDH-0H-CliClift00ftQU)CDftH-ftftiftb—-1ftDftciCDH-fthiU)hihiH-10CDU)ddCDH-ftCDCDft0CD0ftCDH-‘dCDU)Cli0Ii10HHU)fthhiCDCli-CliCD<1H-CDCDIQH-H-HftH-ftCDNCDftft0U)CDCl)0ftH-CD0CDH-0U)hi<CDU)CDU)CDClU)CDftftft10-•-ft0çtF-1F-1HCl)F-10C)C)F-0SoCDH-F’-CD0H-F-1<CDC)7cCD5ClCDCD0CDCDCrCDCDCDCDCDCDCD1Cl)hCl)IiF-1F-1F-1i-CDCDCDDCDCl)<‘-<dH-<—-C)C)F-’I-H-CD0H-CrCrHCDi-iCrCrto<CrCDCD0)0)00H-H-0CD‘-1‘-0CDCDCrI—’-H-CrCDCD><H-(PHH-Cl)CDCrCDCDH-CrCrH--lCD<1CDCD<(PH-H-Cl)HiCDCDC)I-CDC)C)CDCr)iCrCl)CDH-h0)0)02H-CrCl)1JH-CDH-0iCD<CriH-(PH-CDCDCDCD0ClCDCD(PCriCrCDF’CtCDH-C)I-H,(Po0)CrCr5H,F-’CrCDI-dCDJH-CDCDH-C-Cl0CrCrH‘<CD0C)ClCDSCDCD—Cr:içt0)CDCDH,CDCDCl)H-ClI-’Cr‘d0CrI-’0F-0)CD0CDCrCr(PHCD5CD5CrClCD0JF-’‘-<CDCrCr0H---I-CDCDH-CDCrCDiCD0)HCl)Cl)CrCDCod0(PCrCDCrJHiCDCDCDCrCDCOC)H-CDI-CD5H,0)Cr-CDH,C)CDCDh0-Cr0(PCDCD0II0—1CDH-Cr5CD5QICD(;‘F-’Hçt-CD‘-<H-0)ClCDCDCDI-H-HCr(PCl)Cl<p-iCrH-H-C)0)H-C)i0)0CDCr0CDCrCDCD0)hCD5H-HQ(PH,CDF-’CDCDCDH-Cr00Cr‘<H(PCOH-CtCi)ClCDCDCl)CD0Cr0)CrH-55HCD<iCDC)00H,0CDo‘-<---.IH,ClCD0CDCrCDCrH-C)0CDCDF-rrQhCDCDCDCDH5CD0)F-’CrH-H-5CDCDH-DCrCDCDH-CrCD(P(P0)bHCDSCD<C)-•CDCDCD00)CDHCD0550H-—-ClCDQ0‘-itoCl)CrCrl-l-CD(QbCl)02CrpihCDCD<H-CDCDo\°I-oH0H-i5H--CDH0CDC!)CD(Pl-(PCDh-ClCDCl)CDCDHCrC)0)hC)Q.)H,C)0CDC)P3t-0C)0P30CrHCrCD5C)H0)5CDC)0CDH,=HF-’0-CD0CDII05CDHHl-I-H)Q0J0)CDCDCrHCrCDiCDH-H,çt—<CDClCDCDClH-CD0)CDCD0CrC)0HCliC)CrHH,CDCr0CD00CDl-CDWH-Cr0)CDCDI-j(PwCDH-l-CrCrClCi)Cr<CrH-CDCDCDCDH•()0)0CDC)P3P3IICDCr1C)C)Ct0)0)CD‘•dCr-)HH-Cl)0I-iClC)H-5CrCDCDCDIICr5CtiCD0Cl)iCDH-(PCD(PCrl-H,<HCD—-Crl-H-0)CDIiCDCDCrF-’<<—-Cl)0)Cl)C)CDCDCDCDCDCDC)CrCDj1CD0Cl0CDl-’Clto—CoCrjCl-‘C)CrWCl)Cr0)H-0C)H-Cl)CD0CDCrC)h’<QIQjClH-F-CDCDSClCDl-Cri-F-’H-I-iH-‘<CDCD-CDC)CrHC)0)5CrIICDS0)Cl)CDCD0CDçtHUi-CrCr0IiH-CDCDCDH,Cr—C)Cl)CDW5QClClH-CDCD0Cr0)‘tI(PlCDH,CDCrCrhHP3t-Ci)CrCI)CD—3CrCD•ClCrCrCDCDHtoH-CDCDH-CrtoCr—.CrCD0)CD0CDH-H-CDCrCDC)(0C)CDçtICDCr0)CrUi(P0HCDCDSCDH-o\°5HCDCrHCDCDCD1<Cl)H-ClC)5H-0F-’CDCD-0CrH,ClCDCrH-CDCDCI)H-CrCDCrHCli-CrCDCrH-CDCD11‘-0H-(0CDCl)Cl)SClCD-0CD.opCDCDo\0HtoCl)H,CDHCr---CDCDCrCDD0(71CrCDCrClCD5CDCDCrCDoCD5CDCDF-—..Cl)IHCDCD(PC)CDCl)tI02k<ClCDCr000Cr<CDCDCD5-H-CDl-CrCDCl)-50)H-CDCD0=drink more frequently.The investigators created two groups for analysis; thesewere labelled “higher risk” and “lower risk” youth.Higher risk youth (n = 396) included all youth who didnot live with both parents, whose mother did not finishhigh school, who received grades in high school that weremostly D’s or lower, or who both drank alcohol one ormore times during the last month and normally drank fiveor more drinks on each occasion. Each of thesecharacteristics was significantly correlated with whetherthe respondent had ever had intercourse, frequency of useof birth control and/or use of birth control during thelast act of intercourse. Lower risk youth include allremaining youth (n = 362) (Barth et al., 1992:61).This program produced only one significant behaviouraloutcome for the whole sample; after 18 months 38% of thecomparison group pretest virgins but only 29% of the treatmentgroup pretest virgins had initiated intercourse. This findingis similar to that of Howard and McCabe (1992). There was nosignificant difference between groups for use of birth controlat first intercourse (for pretest virgins), in use of birthcontrol at last intercourse (in all sexually experiencedstudents) , or in the percentage of the treatment andcomparison groups who used contraception most of the time.Among the students sexually experienced at pretest, nosignificant differences were found between the treatment andcomparison groups at either 6 months or 18 months on either oftwo measures of unprotected intercourse. Thus the curriculumdid not have a significant impact on those who had initiatedintercourse prior to its beginning. The investigators foundsignificant differences between the high and low risk groups;160the curriculum was more beneficial to the low risk group.This finding, together with the high attrition rate of youthwith high risk characteristics, points to the limitedusefulness of this type of program for the student populationas a whole. The authors comment that more complete solutionsare needed which involve schools, parents and communitiesworking together, and issues such as life and careeropportunities need to be improved, particularly for high riskyouth.3.5.B.2.2e SUMMARYSummarizing school-based pregnancy prevention programs,one finds that pre-intervention status and gender are the mostsignificant indicators of post-program behaviour. Programswere generally successful in delaying intercourse for a smallpercentage of pre-intervention virgins. For males, theprograms succeeded in increasing the use of contraception.Even though these programs were state-of-the-art schoolprevention programs, incorporating active learning, skilldevelopment, values clarification, decision-making andcommitment/planning, their power to influence actions outsidethe school setting, possibly because in many or most instancesthey had not reached both sexual partners, was limited.The next program to be discussed addressed this issue,utilizing a community-wide base to change and adjust normsregarding teenage sexual activity. Although the report doesnot give measures of attitude change and skill development, it161reports how the program was evaluated in an epidemiologicalmanner, and according to the success criterion of reducedestimated pregnancy rates for girls aged 14-17, the programwas remarkably successful.3.5.B.2.2f Vincent, Clearie & Schluchter, 1987A school- and community-based pregnancy preventiondemonstration project combining the goals of delayal ofintercourse with use of contraceptives for those choosingintercourse was carried out between October 1982 and September1987 in a rural area of South Carolina (Vincent, Clearie &Schluchter, 1987) . The goal was to reduce the EstimatedPregnancy Rate (EPR) for females 14 to 17 years of age,measured using data collected by the Office of Vital Recordsand Public Health Statistics (live births plus fetal deathsplus induced abortions) [Numerator) and by National Censusdata for 1980 with population estimates for subsequent years[Denominator] . The intervention community was compared tothree demographically similar communities.54The intervention was based on a combination of Social54Lending validity to the study are the fact that all thepopulations were rural, low-income, and undereducated; there wasnegligible migration in or out of the communities; they hadagricultural economies and no public transportation; and theracial ratios (blacks to whites), population per square mile,annual per capita income and percentage of the adult populationwithout a high school diploma were all almost identical amongthe four communities.1620 H HiH H CD HiC) ft 0 U) p.) U) I- CD 0 I- ft CDHH CD U) CD p.) 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CD ftHCDHi0ClHiciHHiU)CD0HClh0CDH jHIP.)ft CDCDClh0U)CD-<H-ftHH-HOU)iCl ci HOftciH-U)HftClHHiftH-ftHCDftCDCD:3Cl0Oft CD U)ftH-OU)<H-U)00C)HiP.)ciC)fth-0ftCDCD0op.)H0ft1DH-U)U)LiiCDU)U)CDft0CDC)ftftP.)ciC)ftJHitHI0H-CDCDHiU)H-•CDClCDC)hCDk<U)0P.)SU)HIC)ECDHi5CD‘-<OciH-CD—11HCDftH-HC)P.)ftU)i-0dI-0‘-<H-<hIQftP.)5CD0CDU)pih<ft)-H-H-U)d-<ClIQCDp.)1QCDft)-IQCl0U)CD0U)ciP.)H-0ftH5H-HiU)H-ftHiHP.)P.)P.)0P.)U)ClIISciClH-C)Hft5HftP.)P.)H-CDU)U)CDftIU)CDC)l-CDI-i0<CD0H-ci-I-Hp.)p.)i-CDCDClHU)C)ciCDft5HP.)U)ci00ftU)ClU)-C)P.)CDftHiClHH-ClU)P.)0<HU)U)CDCDCDHiCDP.)ftU)0ftU)ClU)I-0I-QCDCDP.)H-U)HftCr<U)U)CDH-CD0P.)ftU)Cl0contribute to unintended pregnancy among adolescents:1 to increase decision-making skills;2 to improve interpersonal communication skills;3 to enhance self-esteem;4 to align personal values with those of the family,church, and community; and5 to increase knowledge of human reproductive anatomy,physiology, and contraception (Vincent et al.,1987:3383)Other interventions included use of the local newspaperand radio station to promote the program messages, provisionof speakers and organization of special events fororganizations, and celebration of National Family SexualityEducation Week with speakers, newspaper articles, andappearances by students on statewide television. Communityawareness activities focusing on other health issues such asalcohol and drug abuse, nutrition, weight control and tobaccouse were also participated in by the pregnancy preventionprogram staff; the generic message was an emphasis on problemsolving: considering alternatives, assessing risks andconsequences, making informed choices, and assuming personalresponsibility for the outcomes of one’s actions (Vincent etal., 1987:3383).Using the Estimated Pregnancy Rate as the outcomemeasurement, the program was very successful. While rates inthe three comparison communities continued to climb (frombaselines of 47.9, 37.9 and 32.5 per 1000 in 1981 to 60.2,53.7 and 54.9 per 1000, respectively, in 1985) they droppeddramatically from 54.1 per 1000 (1981), 67.1 (1982) and 61.7(1983) to 25.1 in 1984 and 1985 in the intervention community.164Due to the variety and number of intervention components,it is not possible to distinguish which of them would be mostcost-effective, which component or sequence of componentswould be superior, what level of implementation would benecessary, etc. What is clear, though, is that a community-wide intervention, targeting adults with resources foreducation, and supported by media, was successful in reducingestimated pregnancy rates in its adolescent female population.3 .5.B.2.3 Life options/alternative opportunitiesThe concept of ‘life options’ has been proposed in lightof the seeming intractability of teen pregnancy rates,despite prolonged efforts to expand sex education andcontraceptive services. The association between socialdisadvantage and teen parenthood (documented in Chapter5) gives evidence that changes in the social environmentare a necessary precondition to opening the opportunitystructure for deprived youngsters and giving them areason for wanting to prevent early childbearing(Dryfoos, 1990:176)Three programs using the life options approach arediscussed by Hofferth and Miller (1989). The Youth IncentiveEntitlement Pilot Projects program guaranteed jobs to 16- to19-year olds from low-income households who remained in schooland met specified attendance and performance standards. Fourprogram sites were matched with four comparison sites andmonthly employment rates in the communities were measured.Employment opportunity was found to deter childbearing in thiscommunity, although information on rates of sexual intercourseand use of contraception was not gathered.The Teen Outreach program, evaluated over a three-year165period (with a different group of participants each year),found pregnancy to be significantly lower for participantsthan for comparison students in all three years. This programseeks to reduce school suspension, course failure and schooldropout, pregnancies and births through a combination of smallgroup discussion and by providing volunteer service experiencein the community for its participants.The Summer Training and Education Program (STEP) providedschool remediation during the summer, instruction in decision-making regarding responsible social and sexual behaviour,part-time work during the summer, and support during theschool year to its participants (beginning in 1985 andcontinuing through 1988). Youth were randomly assigned to theprogram or to an alternate program (comparison group)consisting of full time summer jobs only. Treatment groupparticipants gained in reading and math scores and increasedtheir knowledge of birth control and of the consequences ofteen parenting. STEP participants who were sexually activereported an increase in their use of contraception.Preliminary results also suggest there was a delay ininitiation of sexual intercourse for program males (Hofferth &Miller, 1989:35)Although not much information was given regarding designand measurement in these programs, outcomes seem to bepositive in terms of reduction of pregnancy rates among theselow-income potential drop-out students, through the provision166of programs addressing alternatives and life options.3.5.C AIDS PREVENTION IN ADOLESCENTS3.5.C.l INTRODUCTION TO EARLY PROGRAMSFrom 1988 through 1992, a number of publicationsdescribed implementation and evaluation of relatively briefschool-based interventions for AIDS prevention. Severalreasons were given to justify the need for these studies.First, the epidemiology of AIDS being such that the longlatency period makes HIV infection invisible for aconsiderable length of time may contribute to teens’ lack ofattention to their potential risk and perhaps to feelings ofinvulnerability. Second, teens, because of theirdevelopmental needs, exhibit several types of behaviour thatput them at risk for HIV acquisition (experimentation withintravenous drugs; experimentation with sex; nonuse ofcondoms; homosexual behaviour, sometimes in the service ofclarification of sexual orientation; and unprotected sexualintercourse with a number of partners) . Third, school-basedprograms are important because they can reach a large numberof teens; it may be particularly important to reach thembefore they have begun to initiate risky behaviours. Not allteens are receiving AIDS education at school, and no programsspecific to AIDS prevention have been evaluated. Lastly,AIDS-specific curriculum is necessary as many people seeprevention of infection through behaviour change as the only167HI1)h‘-bI-FdCOCDQH-ft.—H-ftCDCD0H-CDCDCDH-C)HiCDCDt-CDCD-ftCDCQQHCO1CCQftPiHit-C)i<Hi<.)HiCDftU)CDP3H-0CDCDCUC)CDCDCDCDHiift<CDt-ii0C)ftF-’C)HCO<CiH-0i-CDCDC)C)H-HftCiCOLiiH-0ft0CDiH-CiIICDCDH-0COCD<1COH-H-ift(Q-CO03LQCOP3H-C)COCDC)CDCDHiCQCOP3COCift‘<03ftHCDtiCUCOCDCDh0CiCii<P3I—’-‘dCOHi0Ci(Qi—H-Q.<-F-COCOI-0H-F-0CiftCDCUft0ftCDP3ftCD<0‘-<HHI-CDH-ftCOPi3ftCDftC)Ci-CDC)CiOb-H-P30C)—0CDftH-0QI‘-<0I-ftCC)CDCQ0Hi00HiHiC)H-0CDPJCO0-CO30ft3CDftCiftPi0ift33ft0CDCDWCDftftt-’()jP3hftQ,CiCi0CiCOCDCD0CO0H-30CDCOH0COCDQCUC)ftHiCDHftftCDI--COCOH-00P)COftCUH-><CDCiCDPiCO0ftftftCOCDftH-CiPiftCi1Q.<1ft—CU0p3H-<C)><00COHP3PiCDCDCOCDHiftCD0ft‘-<HCD0CDCDHCOCDCDft300CUCiCDLYCDCOC)ftPiH-H-COI-CDCi3ftHCDQIH-HiCDCDftC)JC)0COHft0P3QH-H-HiCDCDCDCUCiCiH-COftIQCUH-QCOHiCDH-ftp3H-CiHHiCl)QIHC)H-Q.bCDH-CO0C)3P30ftftIICOCD0ftCDQCDCDHiCDi-iftft<H-CDClHCOft0CDCDQCOftHiCOCDH-P30H-(QHCD•00CiftftP3CDH-Pi‘-0IICD‘-0CD00CDHftdP3CiHIIft0<1CiClCD-iHiC)ftHftQCDCDP3H-HiCDFQI0P3P3COCOCDCDCDCD0ft0-Hift0CDCD0CO-I-ftCDCOftCDftH-HQIH<3P3CDCOH-ft0H-ClC)H-00ft0C)CDCO-COCO.QP3C)0iCflP3HCDH-QICOHft-ftCift0HCDP3ftftftCDCDP3CD‘-<P30COCDCDH-HP3ftHi0P3H-Ci<1F-’ClCOClHH-0HiH<0QICD<iCDH-ft(QH-HiClftIIHCDCiH-HCD0COIHiCDbCUH-0CDCift0HCDCO3H-CD0CDCOP3COftHiCUClp3p3p3ClCOftH><t-COHII0CDftIIt-0H-CDP3dQCDClCiCOECOH-CQCDP3Hi0ClCDCDCDCiClCDCDII0CDCiP3HCD3CQHF<ClH-CDHH-hftftftCDCOHI-COCDCDH-P3H-C)C)COCD00CO0CDH-HP3HCDCl)CDClH-<ft0tiH-P3CDCiHtiQ.ClCi1Z3P3COP3H-HiC)Cl)ftiP3P3k<Cl)CUHiC)F-I0b0ftft3iH-0CDCDClH3COCD1P3H-ClP3CDCDQIihCl<COCDp3COCDClCD03CDH0ClC)C)CDCDT<P3CiHCiftClCiCDftHP3ClHCi<C)p3Hft‘CICO‘-<C)CO0CiftHCDCDCUH-ftftQIH-HftP3ftP3COClCltiClCOH0CDCDftP3Ci3ftftp3P3CDCC)H-CiClClCUCiC)ClQICDH-hftftQftI--HClCDH-CD0‘-<Clft00Hi‘-<ICOCDCD0COftCOCD0w U, 2 H pi H- H H CD 0 CD H CD CDC)1)C)C)J0U)CDC)U(QftH-‘-c)43F-’-CU(-Q0CD0CiH,H,ft0tY0ftCDIIF’-IIiCiCDit—U)CDftCiC)50H-CUCD0rrC)—ftCDftU)CDCFCl0‘dHCDUU,ICrhCDCiCUCFCDCDCUftCDU)M0ftWftH-CDLxiIU)HU)jC)CU0<H-HF-’CDCD0ftF-’ftCUU)D’H-CD•ft05CDUo\°U)U)ftU)iH-H-U)1CH-HICDiCU‘ZjH-CictCDCriCDiC)CD0CDU)Ci0tiCDCrCDU)UCrH-Cl)U)H-I-‘-3iCFCUHCUCDCrHH-F-’CDft-0•F-’0k<U)QhCl)U)HI-CDI-CUH-CUCU“<0‘dClCDCrCDU)CrU)CrHU)CDhCfHU)U)CDH-Cl0U)H-CD01.0HWHl0CD‘Zl00IiH,LJCUCDCDH—.1CDCFCiH-0ftCiCUCDU)CDo\0Cl)CDCDH-CDiiH,CDHC)HCrk<CrCUII-’CU0hQ.,ClC)HC)CrH-pECDU)Cl5CDU)CDCiCDI-CFr‘-<CDCDCDCUCl)CU•U)C)I-CDCU0IQIQ‘-3i-’hCr5Cl)CrU)CUCDCr5H-H,CrCDCDU)CD0C)CUCDCUH-CrU)CDCliCr0CD5I-CFCFF-’Cl)I-0Cl)CDClClU)CFCD0CDCUC)HCFC)I—ICDCiI-l-H,H,0CiCrCDH-Cl)CDSCUHFH-CUHU)CD)ClH-U)C)tYCrC)H-CUiClCDftClU)CDI-CDCDftI-C)C/)HCDH-CUC)(Q-CrCUCD0H-CDCDftI-QCUCDQftCDCUftU)‘tIftCDCU—•CUU)<ftU)CDftI-CUCDH,ftftC)CUU)HCUCDftC)0CDftCUftCUH,HC)CDClU)tCU0Ct<H-H-.—HU)CD1.05CDCDHH-CDH-CUCU0U)0H-CD0CDo\oCDI-I-’Cl<I-’HftHIClCD(0hHU)IiCDftCDCDCiCDClCDH-CDH-CD0H-HH-HU)F’-C)U)iftH-<C)CD—-0CUCDI.Q5ftC)CD(LU,<iCDF-’CDU)CUhClClCDCDCD‘ZiCDI-0IQHCDCD<1—-ClSCUftCUClCDCDI0U)•UiH-CUftIU)Cl)00CD5‘<C)H,ft5o\0ftftftCDftH,ftCUH-0CDH-0CDCUH-C)CDI-0H-H0HftCiQftF-5HCD0CUCDCD0CDCUftCiCDCDU)CUClH,CiftH-ftCDftC)U)hCDCUtYClCUftCD.<<F-CU—-CDHHH,C)F-’-H-C)CDU)HCDU)CDH-0H-CUftft‘1ClHC)LiftLiCUCDHCDUi•HH-H5CiCDCiCDCDC/)ftftHCDl-0H-H0H-0ClCUC)U)0‘dCDH-O\OCDft0I-ftCDU)CUU)0ftH-CUk<U)H-CUHU)CDft0HftCDCiftftCUIftft13H-iHCDCl)(I)CiH0CDftCl)00—Cl03Cl)ftI-hCDClH,U)H,IH-H,C/)CDCDU)ClCD0--CUCD0Cl)U)CUHHiHCUifttIftU)0CUftHClCUF-1I-CiftH-H,U)U)0ClCDH-HHftClCUC)HCDHIH-ftftH-ICD0CDHC)LQCD‘-3 CD H,H U) ft Ci tJ H F’- C) CU ft H- 0 Cl CD U) C) I-. H H 1Q CU H 13 C/)I- CD ‘:1 CD ft H 0H 0Cr5‘ii10‘1HiI)’PibCl5U)CltYC)C)C)0P)CDl-CDl-3CDCDCDi-CDH-JPitYCr0‘-J-F-QCr0Cl0Cl530ftCD5U)U)PiH-0‘100C)CDSSJ0UC)SC)CDCDF’hMIICDIQCD0<Pil-Cl10U)CDCDo\°13CrftC)H-l-H-U)ClI-’-hU)C!)CD.QfrC)U)CrU)H-FH1300Pi0U)U)ClH-U)CDCr0piCrP10P1130CD‘-DP1CD13liIiCDNH-<t-pipift10Q13Io\°H‘<ClhhHi00I-’-0CDp113hIç-rhIhICD‘-<0—H-U)0Hi1313l-CrCrClCDCDC)H-0ftH-U)SC)-hIftI-QC)CD13U)0CD013Hi013H-CDP1U)liP1H-10CDU)ftU)HiIQC)U)II13—ftII‘dCrH-U)H-H-CDhI0Cr0‘dhICDClCDCDCD13CrCDCDftU)CD13tHiH-H00CD0CD<113CD<CD13U)U)C)13ctU)U)CD13UiftU)P1Hi13hItH-CD13CDCD—CrH-U)liCD(I)Hcto\0CrU)0CDJhIU)13HCrCDP1Hi0U)CrCDCDICDhIftCD0U)-CrdCD13plSHH-13•P1hIHCrCDClHHH-HU)CDC)CDU)Crh<CDIiCDH-U)HiCD0H-10H-U)<H1QP1hICD013CDU)0U)13P1HiH10Cl1313C)0liH-0hI13CDU)H-13U)ftH5H-li<CDCl-I-’-13hICl<0C)13ftHftftH-13Cl)-CrCDCDCDCDft13IQH-CD0U)HCDU)CD5HU)0CldU)0003ClHH-ClCl1350‘-<p1CDHCDP1130IQCDU)P1HH-0dClU)13ftH-l-CDClp-IHCD13hI13hIHi0U)13’CD‘liCrP113CDCrCD0U)HCDP10-00CDP1H0p1CDdU)CDH-CrClftCt)P113hIClP1C)U)CDhIHhICDftH13I-’-1QftCl13hIftCDU)0H-ClftU)U)—130ftCDCl10ClCDClftftCD<1NhI0—CD13HiftiCDCDU)P113CDCDCDP1iP1U)013ClH-H3P1tiftPiCDU)dhICl‘-<U)P1HCDhICDCDftliftp1ftHftfthICDhICDCD13U)CDCDCl)U)13ftftH-H-0ClftCDCl13ClHU)ftCD1H-5ClH-U)CrWCD1013PiftH-U)QP113CrU)C)ftio\°13hCDCDHhIp1Cl0C)P1CDCDH-H0ClCDCD‘liH-H-13CD13CD13HSP1IiftDClHiCDH-Hi13U)H-13U)U)0U)p1‘-<U)jCrH-o\0CDU)13H-CDU)ClCDftSC)-QU)-Cl13U)CrC)ftH-CDC)H-ICD0hICD13H-Hi10H——.l-05CDC)ftt-CDhICDU)ftl-CDCDCD0013H-U)P1CrU)CDH-U)1d130U)U)0P1HihI—0U)Cls’H-CDftftP1CD5C)U)H-HiftU)ClHH-CDH-ftCD3ftCDH-H13ft01JCDftU)U)0ftC)Ii13U)ft50l-rjW0ft13HP1IO‘-<H-(0U)P10-1313CDCD00HliH-0Hi‘-<U)CDP1ftCDClhIo\0HHft0I13U)H-CD-0H-P1-<H-C)CD13CD3—Hi0CDC)0CD1zjftCDP1P1l—CDP17Tft131313U)CDI13ftU)P1H13U)CD13U)I1-C)hftft13C)1d0fthIU)P15<1U)U”H-C)C)CDP1ftC)0CDC)P1HiP1H-CrHP1CDU)IQhI13CD5U)U)HCl0HiCD0‘liH13ftCDCDCD-CDCDCDH-ClP1P1C)ftU)ftH-pi0ACl13hI13hICDSIil10CDhIhI10ftU)1013liClHIQpJHiU)H-CD-CDU)CDP1ft13P1CD13ftU)ClC)13HftCl0HftClCDCD013—0ftClHiP1 H 5i P1 ft H- 0 13 C) 0 Ii U) H- U) ft CD Cl 0 Hi S CD P1 U) Ii H- 13 10 ft CD CD hI C) CD 13 ft P1 IQ CD 0 HiIn their literature review, Miller and Downer callattention to two important unresolved questions; the unknownnature of the links between health education and subsequentbehaviour, and of those between attitudes and behaviour. Theynote, as a positive referent for their intervention, that onecommunity with a program emphasizing communication anddecision-making skills was able to show a significantreduction in pregnancies compared to rates in three comparisoncounties that did not have comparable programs (i.e., Vincentet al, 1987)Implications drawn by the authors include the necessityfor elicitation research when designing school educationprograms for adolescents and the need to continue the shift ofrisk perception from risk groups to risk behaviours. Theyemphasize that explicit information is necessary for teens andthat goals of education must be expanded to include increasedmotivation for and translation of information into behaviouralskills. The authors also recognize, from their review of theliterature in related areas, that problems similar to thosealready occurring in school-based drug education programs maybeset more newly-developed school-based AIDS-preventionprograms, as AIDS-prevention programs must target some of thesame risk behaviours and may be planned and implemented withsimilar methods.An article on the failings of school-based drug educationprograms discussed four problems that also may apply to1710CrH-H-Cl)P1Cr3H,H-Cl)0CDCDCDC)Cr(QQ(j)CrH-CDJCrhp1i-IQCrI-CDIQH-CD<0hCD)I-HiCDP1H-0P1CDH0CrCDbbH-0HC)HCDH-CDCl)P1H-H-C)0CrFDihl-5CDCDCl)CDH-00CDHil-SCDCrC)Cl)H-Cri010H-CD0CDP1C)CDI-CDfrH-CDCD<1H-0hH-C)P1P1C)1001(DHCtC)QI-H-01b5thH-CrCDC)H-H-P1CrCDHH-Cl)‘-<PJPJCl)01CDHC)HiCtH-H-CDCl)H-5P1CDCDPJCt<0t-Ct0p1-CrHCrCDH-1HiH-0Q0CDSF-ClH-CDCDCDCDCl)5CDCDHP1(Q0Cl)oCDCD0F-it-0tCl)Cl)CDCl)ctCl)1CDP1CD00CrH<P10Ct-p1C)H-H,-CtQQ(DHI-HCtQC)p1F-P1•Cl)CtSC)C)1-1,5Cr10(QCDh-H-C)HH-tyiH-H-d0P)CDCDCrP1j03<H-H-CDU,H-iCl)C)CD01CDCD01CDCri-1H-CD‘dH-H-C)CrI-Cl)--15(Qh0hCDdCD0C)P1Cl)P1Cl)P1it(QCl)C)C)Ci010QIHCDCl)HtJHCtCr0C)(0-CDH-CDH-PlC)p1p1p1k<Cl)I-F-H-Cl)Ct‘-<0QCDH-0WCl)P1C)Cl)0C)CD0HCrHCD-—CtC)P1Cl)C)CD-<1CDH00H-PICl)5P1<H-Cl)C1H-CDH01iP1H0CDH-H-QI0H,Cl)tdCl)-Cl)0k<HP1CrHidCDP1Cl)hHh(Q(DO-H-CDC)’-<bCl)1-C)(0H-H-C)CDC)0iCtQIHiCl)I1HiOFP1<HCDCD1-PICrP1QCr0Cl)CDCl)CrCr$iCD0CDC)01C)P1CrCDO0CtU,H-jp1Cl)‘dH-Cl)QIC)P1CDOH-Q1QQh1QH-.5CDCrCtCrCDH-H5CrpDCl)H-OCr$QC)O0Cl)(0HH-H,0Cl)P10PJ0C)CDCtP1Q1OCD(QCrtJI—1CDH-Ct00CtH-CDCD(0CtP1HC)H-C)H-O<P1U-HCDH,0hCrCl)OCl)H-0CDCD0(QCtCDP1CCIP1i-0Cl)H-CDCl)S(Q<HiOHQI5Cl)(0t’J(0I-11HCtC)i-jCr1iCDCl)P1OQIH-CDP1CDCl)(DC)=CD1P1‘<H-(Q05--5t1QQCl)H-H0C)tP)l-CtCl)5Cl)CrP1CDPICD00—CDtH,CtOCrCDQ4YP1CD0CtCDCrSCDP1)P1CtCl)ClCDP100H-1jCtH-0><(0P1H-QICl)0HIQ—P1OCDCl)QQ1H1Q1iCl)0CDH-iCl)Cl)QIC)5OQHH-(QCDHIQp1p1-l-CD(QH-p1Cl)H-QCDHH,p1CrOCl)HCrp1CDHHl-Cl)l-bC)HP)QHiCDCl)<CrCDk<H-QICDCrCl)P)CrCDCDHP1Cl)H-ldQ1-P1JH-CDSP1CtI-fCl)0CDCrQH0tP1CtSHP1H-0H-0“<HHiCDH-QICl)P1P1H5HhjHH-0H-HCt(QP1H-P1-’dCDH-P1‘dHHCDCDCDp1I-HCrP1‘-0I-‘Crb00CtQICDHOC?I-CDQICD(QCl)Cl)QIH-0Cl)CDH0P1CrSCDtCr0—CrHhH-O--CDCDP1QICD01iCrP1CDCDSCrP1H-<00C)k<CDCl)HI-OCDQI-QHP1H-0t’CrCDP1HP1CDHP1Cl)CrCrCDCl)tCl)CDQ1CDH-Cr5CD(DCl)0IQ5P10P1<Cl)$iCrCDtQICrHCDCl)hH-CDCDQ1HCrH,P1CD0P1P1tHiCDCrH-0Cl)CD-H-FQiHP1tdH-CDCDCDCl)10CDCrH-CrCrCDC)CDH-P101-H-CrHH-P1QIC)01H,0C)(00H-Cl)H-HiOH-’-<p1Q(0tiCDp1CD0.QH-CrCl)‘-<iH-CDHiHCl)itiC)Cl)tQIHP1P1P1CDP1H-5(QC)(0H-C)CrH-P1Cl)CDp1HCl)I-H00CrP1p1Cl)CD-CrP1C)0H0(0C)CDiI-Crtt-i(0H-tPICtH-Cl)CDP1H-QeZ300<CrCrCrCrH-CrCrOH-Cl)HiH-<tY00CD(QC))U):-HHCU)ctQC-tS tIH-H-HPJcrCDCi)c F-’-CDH-ft02U)CDQiItJOCDCr0tfl‘1ClU)CrCDU)TiU)H-ClHOnOCDU)I—’“H-CDCrCDc1-QClHCD(-t.ClCDU)01CDCDU)c-rFU)PCrCD—C) IIClhCDj)CDr-rIl-H-U)I—IHCrCDQCuwCDClCDCDc:T))ClI-CDIQCuU)CD1)H H-O0’d0CuCDCtCl5CDH-CuClCDQ,rt:-CuHOr-rCDjCtCD-tCtQ,QJICDFiCuOU)hCloCrCDCtCDCDCI)U)H-I-U)CD1hCuU)F-IQCDCrOU)CDI-hI-U)WOO)0CD-ID--C)CDH-CuCrCrClCrOC))5U)C)WpiiU)0I-CDWiCuHICl)H-ciU)IICDCrCuC)CT)IDClCrTiHCrI-CrUiCDIII-CDciC))I-C)Cl)CDYhI-H-C)U)U)CDC)U)IQC)H-H-CDC)H-C)H-CuH-Cl5CI)CuQCri—iH-H-CrC)I-TiTiU)C)U)H-U)ci0ciCuiH-TiMiH-HCDHCT)CrLQ-U)CDU)CuClCl(CrH0C)TiU)H-U)CDHCDCDU)ciI-HQ5—CuH-S-U)i0CDCD5ClCDTiCDH-0H-çtI—’CrI-5dTiCDI-ClClU)Cr0U)CD<1H-U)H--CDTiHCI)CuCDHCudI—TMi-<CDH-><C)iHCrC)çtU)U)CDC)C)SCDCDCDhC)LI)ftH-CuCr0CDHCuCrHCDCt0U)CD(DCI)0(I0I-H-5CrC)Cr-‘C)CD0H-ID—H-C)[-hCD5CD-F-1CrCuH><—t-hCD<U)H-00CDCuhC)U)CI)CDCDCrI-ClCrC)U)CuU)CDH-H-1QCDCr—-H-Cri‘dU)H-CDCD<CDClCDI-Cu0I-I-TCDI-CDC)CuU)CD0CDCrC)CuCuI-CDU)H-U)I-’CF-’-iCDH-iU)iH-CDTiHdCQCDC)H-CrClClC)H-IQI-ClCuCi)‘-DHH-CtCuCuTiCuiCuClCuCrCrODCD<hiCQ—CrHU)CI)I-CD0‘-DU)CDI-U)H-00hClCrCDClU)‘-<HCDCuQSciCDS50H-HCDHciCDCDH-Cr<dCDH-5U)CuCDCI)CrCDCrhCD0HjC)ICr0C)CuU)U)C)C)CDU)U)Cuk<Cu-00i00I—CuCrI-CrCuI-Cr0HiClU)CliCDU)H-CDCr5—MiCD0C)Cl)H0U)TiU)U)CuTi0CDCDI-ClHHCrCDçtCD1QC)-U)CuiCrU)00U)CuI-jY’C)ICDF-’0CrU)I-5C))U)Cuci0U)H-0C)U)H-U)HQçtC))CrCrU)C)MiH-CliC))CrCl)I-H-U)IICr0Cu00CDU)Cr0<CuTi3’C)Cr0iIQH-Cl)CD-TiCDClClCr11ClCrHI-CuHH-CrC))CI)dH-CDCDHCDCuTiCDU)0iH-0H-U)ClU)C)C)Cl)CurTiCD0Hc-rCuC)H-H-CrCrU)CDbCDFd“JClH-U)TiU)CD0U)CuCDt-‘-<I-I—i-CDU)U)H-U)l--CuiCD<C)H-CuHI-h—U)0U)ClCrCDQHICu00H-H-CrC)k<5CrC)Ti-HII0HI0Cu000dCrCDH-Cl)H-CDH-5C)TiHiCrHCDH-HI—TU)CrC))HCs)CDHH0CD<C)CuH-Cr-h-TCDCDCD0CrCD0I-U)CuH-ClCuI-II-ClC)I-hH--CD-CDCr‘—EliCDCrP—Cr<HIXClC)Cs)CDCDC)IQH-CDCDCDU)CD-ElClF-’k<0C)CuI-TiCuCuCuiF-’CrR’U)0U)i-hU)CuHQCD-•0U)—U)0HI-THTi0bU)CuHCrCr5‘-<CD50U)started, the intervention posttest given immediately after theprogram and the nonintervention posttest given three daysafter the baseline questionnaire. The questionnaire consistedof two subscales measuring knowledge (alpha coefficients 0.83and 0.71) and an attitudinal section measuring tolerancetoward persons with AIDS.The intervention group (on average) demonstratedconsiderable gain in knowledge and tolerance compared to thenonintervention group (on average) . The authors conclude thatthe curriculum was successful in achieving its goals.Although the first study of its kind to include a designatedcontrol group, the study has limitations. These include thepotential for contamination between intervention andnonintervention groups (which would lead, nonetheless, to amore conservative estimated outcome); the extremely short timebetween pre-and posttests (which would overstate the gain bynot allowing time for the natural process of forgetting tooccur) ; and the lack of permission to measure behaviour. Thusthe study was not able to contribute information towardsalleviating uncertainty as to whether or not increasedinformation and more tolerant attitudes in students lead toincreased self-protective behaviour.3.5.C.lc Huszti, Clopton & Mason, 1989Huszti, Clopton & Mason (1989) developed a carefullycontrolled demonstration study that included a program similar174to those concurrently being presented in schools. Twotreatment groups (one receiving a film and the other alecture) and a control group (receiving nothing) were testedone week before, immediately after, and one month after theprogram. To control for similarity in information between thetwo treatment groups, the lecture was based on a transcript ofthe film.The intervention consisted of either the film (18minutes) or an 18-minute lecture, followed by another 8minutes of lecture information, and concluded with about 15minutes for students’ questions. Regular Science 10 classesin two suburban public schools in Oklahoma City were randomlyassigned to groups. Mean age of the students was 15.6 yearswith a range of 14-17 years. Names of students were notrecorded; however, some method of matching must have been usedas only data from students completing all three questionnaires(n = 448) were used for analysis.Goals of the program were to increase students’ knowledgeabout AIDS; to increase tolerance towards persons with AIDS(PWA5); and to increase positive attitudes towards practisingpreventive behaviours. Due to community and institutionalconcerns, the investigators were not able to assess students’actual behaviours.Two instruments were developed; one each for knowledgeand attitude assessment. The knowledge scale was anadaptation of an earlier instrument and was reviewed by175OHiftU)I-hOOHI-hH C)ftH-QPJJ(D()U)I-’U)H-CDy—(U0CDHOCDCDU)tI_pOU)cuH-’k<PJ<H-HC)H-ft(QCDQO0 HhOhH-CDç-iCDM,PHQCDCDHU)U)i.<H CDH-<U)(aftU)pJH-P.(DQCDH-<U)CD U)ft00CDCDU)U)Q-,b-U)HCDH-0:IJfrd0H- 1-hDH-H-U)CDI)CrIJJHt-1 Ctt-(DPi<U)U)CrCrC)0U)I)CrC)djQI-I-hC)I-CDI-0IIQCD10U)PiCDp1ftF-1ct),-i-iCDHHH-YCDbCDCrUH-H-CDH-U)U)U)PJYCDP1H-°‘U)C)iCDPiU)H-p1iftH-CDH-C)U)ftH-CD(QpJHCDPiCDbP1QP1PJMHU)pJp10H-CDP1p1CDCDHOiQU)HLJjU)F—JH-C)ctU)-U)P1<FCDCDCDQH-<>çtCrU)(QU)CrU)U)ftU)CrH-O.0P1HI-U)‘<H-C0I-H-CD-OCrIIH-CDH-WH-CrpiH,p1CDp1I-jU)(10U)10-U)CrU)-F-’CDIiCDCDft(-P1><0ftQU’U)CDCtCDU)U)t-hQ<CD0H-QP10H-CD--Ct<ftOCDP1CDCDCrH,WCrC)U)P1CD0ft0P10hH-H(DC)<P10-0CD‘<CrU)JH-0CDH----<1—CDCrftH,CDCrU)U)CDP1U)P1J’—])1U)CD0CtH0QHCDCft’<tQCrtCDtQftJCt<P1H-P11HCDCDCDH-AH-XCD1CDU)CDHC)iU)CtIU)000-CDPI-QhCDCDftQCD‘iQftCDO’-<0P1QH-HU)U)H(Iit-<U)U1-QQi-jCriCDH---H-Cr<CDCD<H,1Z5‘—U)CDOCrP1CrCr0H-PICDCtPIOCDH,CDI-CrCDp1Q(-QCDI-QHU)hOciC1ClP1P1H-I-iCD-H-CDH-H-IIH-frP1F-’-C)ftP1H-CDftCD0CDOPICtSI—hOU)ftI-1ftp10HI-U)QCDCrl-h0H-CDHH-Q,HClH,U)H-CD0CDCDCD0U)k<U)CDH-I-0U)Qft0U)—CDt-hH-CDftCDClCDU)H-C)H,U)I-ftU)0H-U)<P1CDI-HH-ft0HftHCDCU)0U)H-HhI-hftU)(0CDnCDftCD<CDU)H-P1CDPIOCD0CDOF-U)U)CDCDI-jCDI-NQH0P)CDH-P1H-CDP1CDU)P1-CDft0’QOU)U)0CDIIIIU)U)ift-H-H-CDQPICDCDHftCDQ,ftftft—C)C)H,tftH-H-U)Q--<1U)CDHCD0CDH-HCDQH-CDft0CDHH-H,H-H-ft0CDCDCDCrU)I-hhi‘tiC)C)oft‘-dH-U)OCDH-ft‘-<-°)-cft0H(UCD0000CDCDtU)H-D’0H-CDU)hHQH0OI-hI-hp)Q.1CDP1<U)ooP1‘-P11-CDCDPIU)U)CDH,HHft<-cU)-QU)U)ftP1U)ftp1ftftCD(1CD(1HHI-hCDCDhP1.Q0CDC)ftQU)CDH-H0CDHCDI.QCDCDH3(lU)CDP1H-ftftft‘ti‘D<ft0CDH-I‘-<CDHCDU)H-CDCDOCDP)U)-ClP1CDCDft0ClH-HCDtU)PJCDCDCDCD-hCDCDU)ft“U)ftU)QP1P1H-CH-CD‘DC)CD(lftCDU)H0-0C)P1(QP1H-PJO0dSU)H-CDftftU)H-ft(I-tftQI-hH,ClI-cI-WHH-(1IICDCDH-U)ftH-CDP1<CDCD()U)CDHCDHP1CD-OH-H-ZiU)H-Q,0p1U)U)HI-P1ftftOP1ClftJ0P1tU)HCDH-ftH•CDU)()ClC1<CDc3ClH-cjCDPJCDOCD0“JCD1-h-(Qftshowed more positive attitudes toward practising preventivebehaviours than boys, but this was lost by follow-up. Bothintervention groups showed significant gain on knowledgescores from pre- to posttest, with some attrition by follow-up, but not back to baseline lows. Similarly, bothintervention groups showed improvement in attitudes towardPWAs at posttest which diminished but did not disappear atfollow-up. Both intervention groups showed improvement inattitudes toward practising preventive behaviours at posttestbut these had fallen back to baseline levels at follow-up.The non-intervention group, however, showed a significantdecline in their intentions to practise preventive behaviourbetween baseline and follow-up. The authors suggest this mayhave been due to contamination as the nonintervention groupwas very disappointed upon not being chosen to receive theprogram. Regarding the comparison of film and lecturetechniques, the “lecture” group had a slightly higher gain inknowledge than the “film” group.In their discussion the authors caution that this type ofprogram may not be enough to encourage or enable students topractise preventive behaviours. They recommend the inclusionof skill-building (including communication and problemsolving) but also note that until that type of component hasbeen added and evaluated it will not be possible to knowwhether it is worth the cost of adding them. They advocatefor measurement of student behaviours, while explicating the177H-Jjjftp-CD ‘1 <CDCDftft0H-P-0U)—LIIC) 0 H,piftF- ftCDH C)çtHoi ftU)CDCDQ-U) U)H-H- 0 U)t- piLJH,CDftIQH (Q ftH-ftCDp.) H, H HH-C)j0H oC)p.)c-rftCDH-P-0 U) CDCDC)PH-HH,ftH- C)ftçtCD0P.) C)HCDtI1p.)F-QCDCDft<CDH-P.)CDC)CDCD U)p.) 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Results showed that at least 24percent of the students had engaged in each of the behavioursmeasured (i.e., 32% had engaged in sexual intercourse, 47% hadbeen drunk and 27% had smoked marijuana; 24% had engaged inall three risk behaviours) (Brown et al., 1991:200).The educational programs were an average of 4.7 (+/-1.27) hours in length. Most programs combined techniques suchas lectures, audiovisual presentations, discussion, handoutsand guest speakers. Each program was developed in conjunctionwith its community members. Topics included factualinformation about AIDS (transmission, prevention and symptoms)and community resources available. Emphasis was placed onsexual activity and intravenous drug use as the most riskybehaviours. Some programs also included concepts such ascondom use, personal responsibility, abstinence and monogamy.Teachers had a mean teaching experience of 14.7 (+/- 7.01)years, and were either state certified health teachers orphysical education teachers specially trained to present AIDSeducation.The authors found that age was a significant variable inknowledge change. The program did not produce significantchanges in attitudes on any of the attitude scales.Implications of the results were discussed by theauthors. This type of educational program does increaseknowledge but perhaps, being “value-free”, cannot be expected181to change attitudes. However, if attitude change is aprerequisite for behaviour change, more intensive or differentprograms, or programs with different goals and objectives willbe needed to accomplish the ultimate goal of behaviour changeor development of safe behaviour patterns. Perhaps all thatcan be expected from short-term programs such as these isincremental change; for long-term significant change to occur,prevention efforts need to occur over a long time span and tobe broadly focussed. Communities should not, therefore,become complacent knowing a brief educational program on AIDSprevention had been presented to their children; they mustensure that the programs are repeated regularly and reinforcedby parents, community and the media.3.5.C.lg Ashworth, DuRant, Newman & Gaillard, 1992In 1992, Ashworth, DuRant, Newman and Gaillard publishedresults of an evaluation of a one-hour school-based AIDS/HIVeducation program on the knowledge, attitudes and behavioursof grade 11 and 12 students (N = 535 intervention and N =659control) . Assignment was randomly by school; four schoolswere involved, one urban and one suburban in each category.The one-hour program was presented by the Red Cross andconsisted of a video and discussion with two trained AIDSeducators. Objectives were to increase knowledge, improveattitudes and lower risk-taking behaviours. The pretest wasten weeks before the lesson and the posttest was two weeks182after. The evaluators were not allowed to measure sexualrisk-taking behaviour, but had to simply ask, “Have youchanged your behavior to avoid getting AIDS/HIV infection?”Analysis was sophisticated; means and standard deviationsare presented and principal components analysis, ANOVA andmulti-variate ANOVA were performed. Results showed, notsurprisingly, that the one-hour program increased knowledgeabout AIDS but did not influence attitudes or risk-takingbehaviours.3.5.C.lh SUMMARY OF EARLY PROGRAMSThese short interventions aimed specifically at AIDSprevention tended to stress knowledge and tolerance towardspersons with AIDS (PWA5) as their goals. Researchers wereshocked and disappointed to find that increases in knowledgewere not sufficient to produce changes toward more health-protective behaviour. Although this had been shown in earlierevaluations of programs in related areas (substance use andpregnancy prevention), perhaps they thought that perceivedseverity and susceptibility would motivate students to changetheir behaviour. Whether students perceive theirsusceptibility is a point in question; as AIDS wascharacterized by the media as a disease of homosexuals andintravenous drug users (IVDU5) during the first several yearsof the epidemic, it is likely that most students saw no reasonto include themselves in the susceptible group.183Discrimination toward homosexuals probably encouraged younggay men or those experimenting with same sex partners to avoidopen examination of their own risk. Likewise, moralindignation and lack of services for IVDUs were likely to havemade it difficult for people using drugs intravenously toaddress their risk for HIV infection.One benefit of the early programs was the reduction ofanxiety centering around casual transmission of HIV. If thiswas generalized to a reduction of realistic anxiety aboutbehaviours putting young people at risk of contracting HIV orSTD, however, it was of mixed benefit.The programs were short and not generally interactive,except for the inclusion, at times, of a person with AIDS, whowould lead a discussion with a class. Overall, these programsserved to break the ice of bringing the topic of AIDS/HIV/STDout into the open in schools and to give students some generalbasic knowledge about the diseases, but did not show successin terms of a dramatic enhancement of protective or reductionof sexual risk-taking behaviour.3.5.C.2 RECENT PROGRAMS3.5.C.2a Walter & Vaughan, 1993Walter & Vaughan (1993) report the development,implementation and evaluation of a six-lesson school-basedAIDS-prevention curriculum (Grades 9 & 11), based, in part, onsurvey research described above (Gladis, Michela, Walter &184Vaughan, 1992; Kasen, Vaughan & Walter, 1992; Walter, Vaughan,Gladis, Ragin, Kasen & Cohall, 1992)Rationale for the curriculum, its content and proceduresof implementation were presented to and approved by the local(New York City) Board of Education and by the administrators,teachers and parents of the schools chosen to participate.The curriculum was developed collaboratively by the researchteam, the participating schools and the Board of Education.Theories of health behaviour change used were the HealthBelief Model, Social Cognitive Theory and the Reference-GroupBased model of Social Influence. A needs assessment, usingthe PRECEDE-PROCEED framework, was conducted in theparticipating schools to identify deficiencies and problemareas in each of the theoretically-defined areas (knowledge,beliefs, self-efficacy and behaviour). The information fromthe assessment was used to plan the curriculum.The intervention consisted of six consecutive classperiods. The first two lessons addressed AIDS facts(transmission and prevention), risk appraisal andsusceptibility, and preventive resources within the school andcommunity. The next two lessons covered students’ perceptionsof norms (and attempted to correct distorted norms aboutsexual behaviour), values clarification, and skill development(negotiation skills for delayal of intercourse) . The finaltwo lessons covered skill development (negotiation forconsistent condom use), and knowledge and skills for obtaining185U)ftQQC)OI-jCDCDi1)U)oftHoH-I-CDHOiU)ftH1CDU)0U)-Hi-CD’ftoICDCDCDftCD 0H-U)0QP)U)oHi0CD:oH-hf-tCDftSrt0U)-CDQCDU).CDCDO)H0cx30F—1 ftHU)t-tCDCD(D CDrtCDU)0CDftQCDCDCDCDI_ftottf-t--<0HCDCDH-F-HU)CD0H-CDc-toEft0CDCDCDHh><oCDCDfthiJ-DCD.-ft--CD0H-tCDOCDH-••rt•cftECD)H-CUoClU)HEU)CUCDCUCDU)HIIF-Hift0o‘H-CDoCD0HHiH-<U)HidCDftH-CUClI-0ftCUH-U)o0ft<(_QU)CD-0ClH-CDCUidHiiftoClHHtJlH-CDCDC/)HCUIH-o)ft‘1‘<H-CD—U)0<ftCD‘thiCDCl-f-fhCDH-0-CDftCDH-CDCDClH dCUCl)<CDIH-0CDCDSiHiYhHCU-ft U)H-0CUCUSiH SiClCD‘U)bH-—CUU)jF-’0H-H--CD5ClU)U)CD-ft 0Cl‘-U)CDCDtU)HSioH-ClI-CUCDH-H-ftCDHU)ClH ftECU‘-<CU U)oU) ft‘-‘SCDCUCDftftH-CDU)U)ftrtH-CDo0ClEU)H•ftCD0Cl (.0‘-CDCDCDU)‘-‘StS Hh’SH-ftCUft5iCD0U)SCI)SU)HH-0U)SSiU)CDHH-CUCI)oU)ftSiH‘-‘S0CI)CD ClCl0ftHi‘-‘SCDftCDCD.<U)CDCUftI-’SIftH-‘-‘SH-CliCDoftHCDCDU)-U)ftH-ftU)CDI-’SftHiftCUSioCD0Cl‘-‘S‘-‘SCDCD-H-CDftHft‘-0U)H5jftCDH-—U)0HiftH-(00SiSiClft-s<CDCDI‘-‘SxCDClU)<5U)H-ftCDU)IQSisiH-ClftCDftCDH-H‘-‘SoHH-U)ft—00U)‘-‘S—(00ft0CDCUE0H‘-‘SCDCDHCDiH-o;:;ClU)\OU)ClCDSi‘-‘SCUWft<5CUHiH-CDftSHik<ClCD0H-CDo‘-‘S0Cl5ftCUHftft‘-<5U)H-0CD00U)HiCD0HiH‘-‘SHH-CDCDHiCloft05CDftCDECTCDU)H-CDftClft‘-‘SH‘-0U))U)—H)H-ftHiHS-0‘-<5‘eCDCD‘-‘SH-CDH-oLi.ftHiSi U) ftH-U)000ft CD0Cl‘-‘S00<5H‘HISCl)U)U)CDftdCUH-CUU)o‘-‘SftClftSi-H-ClSiU,C)‘-<5U)°H-HftCI)010ft0H-CDftftClCDH-CI)H5-,CUCl00CD0oCD CUH-U)oH-o—U)HftU)U)CD-0CDfto0HHH0‘-D‘-<5HU)0U)‘—SICDCDHU)0%-0CDDH-HCD ‘-‘SCDU)CDCl0ift0CU ClCDH0CDF-’CI) ‘-‘SU)‘-‘S0CDCDHi‘-‘S0<5CDHCDH-WCl<5HCDo-CI)ClU)U) ftooSioClHi‘-<5ft0‘-‘S‘-‘SFoCI)HCI)‘-‘SU)Hft•H 0F-IH-O Cl)CI) SioftSiU)h’S-‘-‘S H- oC)Si0HSiSiftS‘-‘S 0ClHSi ‘-‘S0H-‘-‘S(0 0ftSCDCU ‘-‘SU)HCDU)50CDSiU) ftU)CDft‘-‘SSi ClftCD SiCDft‘-<5U)H-CI)SiU)ftU)CDHh’S‘-0<5SiCDCDSiClft H-ftooSi‘-‘SU)CDft0SiCDClH-CD<5SiCDft U)ftCI)CDSi ClH SiU]ft—ICD—:1-‘S <5oCDoi5ft HCI)0‘-‘SSiH--U) 0 Si0 <5U)CDft‘-‘SSiCI)ClHCDF-’Si ftftU):D—CD ‘-‘SHiCD0 ‘-‘SCDCU‘-‘S CDft o—;iftwCU‘-0HxJ 0 SiTeachers received 8 hours of training from the researchstaff and were admonished to adhere to the instructionalprotocols. Implementation was monitored in two ways. Eachteacher recorded the number of lessons taught and each wasobserved and rated on two separate occasions. A standardizedobservation form was used for rating, covering the followingareas:Interest in and mastery of curriculum content;level of preparation evidenced;fidelity with which the lessons were taught as planned;use of appropriate instructional materials;opportunity for student participation; andability to keep the attention of the classroom (Walter &Vaughan, 1993:726).At baseline measurement, one-half of the studentsperceived benefits to participating in AIDS-preventivebehaviours (i.e., sexual abstinence, consistent condom use,sexual monogamy, and avoidance of sexual intercourse withhigh-risk partners), while one-third perceived barriers (theremay have been overlap between these two groups) . Perceivednorms indicated that although two-thirds of the students feltthat involvement in preventive behaviours would be acceptableto peers, only one-third perceived this to be commonlyhappening. Two-thirds reported perceived self-efficacyregarding ability to perform preventive behaviours. One-thirdof the students reported having engaged in sexual intercourseduring the past three months; of these, two-thirds reportedinvolvement in higher risk behaviours (no or inconsistentcondom use (1/2 of students), multiple partners (1/5 of187fttClftC)HiC)(PPiHHftftU)H-iJtU)U)U)00CD-CDH-0PJ0F-CD0CDCDC)ih’CD0C)ftftftU)0U)CPi<(PpiCVftCDi-i0a‘ti‘dCtCr0HiHCDH-C)0CDP.’H-CDC)ClClCl-CD0CDP.’—H-‘<F-’U)—0hU)Hi0CDCDCDH-—JC)(iC)-CVClU)U)CtCDF-1<CDH-iU)Hi0CtCt<HiH-tYCDF’-H-.—.—CDCDP.’Crçt—CDCrftHi0)CDU)HCDU)0C)>4I-U)I--U)U)U)CDCt0ftjcrQ‘<C)t—H-,CV0CtC)QI-Cr0-CiCt—CDCD-H-‘-<H-CDI-P.’HU)H-—ClH-CDF’-0CDCr0CDiH-CtIICrCrCD0(P0H-CVtCi(PCDftU)ft(PClU)(PU)0H-CD‘H-HçtFFCDftftjftwCDp.’Cr—tJ0ftC)CDCVCD=CDiCiH-0ftiU)0CiftCD0CV0U)RIC)ClHi<U)0ClHiHiClCDCDUiU)P.’HIU)U)U)JCDHiCVU)F-CDH-H-I-CDCVHiCiCDftCDH-<CDCDHH-iC)ftP.’C)U)CDiClU)—-CVHi0P.’hftC)QU)ftp.’(P0CDt-’P.’ft1HH0CiU)ftCDi—U)CDiH-HCiCVH---Ci0(PCD-U)U)ftQi-—H-CVWClHU)Ui.—.HiP.)U)H-HiU)U)ftCl)iClH-CDft>HClH-P.’HiCVECDi(P0H-CDCDftCDH-H0iCDftftiCD(PCDHiP.’HP.’F—’U)hHiP.’o\°ftFH-0H-ft-C)CD0HHiftH-H<ClHiU)iHCDft.-CDI-‘-<Iyi00H-CDCDCDCDH—.RiClCDP.’HH-U)CDCDU)HiftCVCDC)CDftU)ft‘dH-‘.0<(PHiH-H-HiICrftCD0<>40F-C)‘-.0CDCD0iU)HiCVHiCiP.’H-U)ClHii0CVS=CDWCiftH-h000ftCift——J0U)ft--CDClCDU)C)CDI-iH-HCiH-HiI-hC)(P‘1ftCDft—1U)CDCl‘-P.’p.’ftCl)(PCDU)100CVCDCDCiU)MU)<0C)U)H-CDCDP)P.’0HiH5P.’i0ClftCDCD-ftCD‘-<U)j-50‘—‘d—HCDI——.0iCD—0ftftClCVH-HH—H-iHi0P.’0ftClHiCD-H-H-HHC)CDCDftft0CiU)h<H-P.’I-U)U)C)HClCD00ftHI-0CDU)t—ftCV0U)<DCD0P.’CD55CD‘.oCDH11C)H-ClCD0FSb>4P.’ICl‘.0U)‘<H-C0CVCV‘-<(PQC)HH-HWU)C)5U)ftC)U)iftCDCDP.’CVCDHiCDft--ft0—.ICDH-CDCDU)ftH-CDHH-ClIiI-1CDH-ft—-.1CiI-0ftCiCl--..H-CiHiCD0ftftH-Hi<1iCDCDMClCDCl(PCD(PClH-P.’Cl-P.’iU)0CD(PClCl‘..DCDClCDP.’bftCDC)-(PCi(PCD0I-HCi‘d—HU)C)I-‘d‘-<H-P.’H-CDU)U)CDU)CDCrft0H-0H-0HiCri0—ftH-Hi—-.ftCDU)t5P.’HftH-H-U)ftCiCiiU)(P0HCiftCDftCDP.’ftb‘-<C)C)-bCl(P0I-H-Cl0CDH-tftCDP.’HftCDH-P.’(PU)CDCDft0H0CDHiU)H-hICD0CrP.’•HCi0CDP.’0ft—0<H-5t‘-<ftH-H-ftCD(PH‘zftH—ftH--CDU)0CDH0Cl)U)ftH---.-.U)IC)U)U)H0CVCiU)U)dHi<)-CiC)CD0—.1CDCDHftiU)U)CD0CDCDU)C)C)CD0—5H-H-P.’iibH-U)0H-ftI--0U)k<0CiP.’5CV0ClP.’ftCDCiUi--CDC)HiHd-HiH-IlDCDo\°S:3-‘-<P.’ft0CV(PClCDH-0I.oCDftHU)CiIlCDH-ClU)IlUiIlHftCDU)5CDo\°P.’CD0ClHHis’H,ftH0Cl)C)PiC)HH-C)C)WbH-I-ti0DCDDhftQ0CDtn0CDSbI-I:ii-CDp30I-’QCl)ft5P)Cl)tQLJUiftHçtCDH$10NH-ftCDf-CDCl))-JCDCl)I—aH-ftCl)FlFs)CD)JF-’(QP)H0C)C)<FlCDCD30—-3i—’FlCl)CDH-Fl-ICrCDH-H•H-<1Cl)p,ft-CrCDH-C)53)iCDCDH-SD3t\)0CD(-QCDCDCl)51Cl)0CD—CDCl)CrCl)<iIiCt-CDI-ICDFlCV0CrCDCI)CDC)HI-ftCDHFlCD3H-‘dHftft51CUftCl)CI)Cl)H-CDCliCi)5151Hi—CI)FlDCl)CDftft5i‘DQ-0HCDCI)-•C)—•0-DH-0H-0H-3.Q5151CUCl)(0(.QW51H-FlCrH,0HF-’C)CDSctCDCl)‘-I••CDCl)Cr0H-CtHH,CD•C)HH-H,C5151CDCl)Cl)Cl)C)51ftCiiC)0Cl)30051IIH-<5MH-CrH-CDHCDRIFlCrHCl)dH-HCDH-Cl-CDH-HSCl)CDH-H-CDCl)HHH-—‘3<Cl))CDWftQH,Cl)51Cr0ftW0Cii-CDH-13CrCrFlCiiHCD13oCr--CDCl)Ci)013CDCl)ClCr(QCD0‘-10H1jU0FlCDFlI115Cl)Cl)H-H01QCrCl)NCl)013CrCDciFlCDftC)CDftCDCl)‘-<Ci)tQI-I1DHCDH,CrC)$1CDI-I13<10Cl)IQI-II-Cl)L’JCD13‘<CDC)H,CDCi)-CDFJ51Cli551<Cl)tCDCl)CDFlCi)FlH0Cl)5Cl)i—ct13-k<CrH-0CriiCI)ciI-IctCli0H,Cl)C)ciCDCiiC)<SS13Cl)013F‘dCl)00Cl)H51CrFlCDC)CrCDCDH51CrSFlCr5CDFlFlC)Cl-‘DCDCDft0FlH1D51H13W0CD0CDCl)H-0CDH-H--013H,H-13CDp.1‘-10Cl-U’551CrCD13Ci)0WCrH,HCrCl)CDCl)-HCD0ciHftI-ICr13Cl)HciCliCl)CDftCl-‘-<ci0I-ICrCD0Cl)H-C)51C)H-Fl‘d0HFlCl)H,CD510Cl)Cl)Cl)CD13H05Flt-JCDCl)H-Cl)YCl)H-CD1313ftC)-000CDH—JCi)Cl)13FlCDH-1351Cl)Cl)Cl-513ftWCrCl)t-QCD13CI)0ftC)cji51C)CDCrCDC)5H-13H-HH,1DFlCDH-0Ci)Ci)51CrIJCl)‘<0CDIXHCt-C)ftCDCli<1H,HHCDCl)ftCD51313CU1313C)J’P-I3CDCl)CD‘dCiiCi)--Cl)ftCDF-’HHCl)51F-1FlCDft13C)I-ICi)-51CDCi)CDCi)dCD0CDCl)13-Ci)51Cl)Cl)FlHH-Fl51Cl)CI)CD‘d13CrH-CD—•H-Hf-rCD13CDciCl)•CDCDCl)HFlFl13Cl)W05C)13Cl)51CnCl)CDCI)CD0-D00CD013CUft0CrUiH-Cl-Ct---Cl)CD13Cl-13H0Cl-H-ciCl)Cl)k<Ci)CDH-Cl--C)Flft5H-S13H5113HCl)I-IftCD—0CDCI)CDCD0CDCDCDCDClFlCDH-CDH0CDO\OCI)5CI)FlS13-Q0F-’H,51131CCl)ftft‘-<CD0-C)1Qft1C5H,0H-0Cl)FlftftCI)S13FlC)ciCDCl)ciI-IH,fthftCIiCDH-FlCDCl)ftP-ICi.IFl-p)‘-<Ci)FlS-FlftH-13C)1313FlP-IH5Hft13ciftCDciCl)ft13—51H-13H515Ci)51000C)ClCl)0Cl)CDCD130Ci)CD13CI)0H-CDci1H,ft13CltiCl)13HF-’HCDCDftCD—51Cl)HciClftCl)Cl)CDCl-SftCDH-RICiiCDCD‘cH1313ClCl)Hcoefficients (using Pearson’s r on data from the comparisongroup at pretest and posttest) were .74 for knowledge and .73for attitudes. Students ranged in age from 10 to 13 years.Results showed that treatment-group students scoredsignificantly higher on knowledge at posttest and follow-upthan did students in the comparison group; however, studentsin the comparison group scored significantly higher onknowledge at follow-up than at pre-test (compared tothemselves) . Neither gender nor parental assistance withhomework had an impact on students’ knowledge of HIV/AIDS.Treatment group students in Grade 5 scored significantlyhigher on knowledge at both post-test and follow-up than didGrade 6 students. This may indicate that the program is moreappropriate for Grade 5 students (Gill & Beazley,1993 :S25,S26)Students’ attitudes, comparable at baseline, had improvedsignificantly within the treatment group at posttest, and thegain was retained at follow-up. Attitudes in the comparisongroup also improved, but not as much. Especially interestingare the facts that those students who received little or noassistance from their parents on the homework component hadsignificantly large attitude gains, and that there was nosignificant gender difference in attitudes, as has been foundin many studies with older students.1903.5.C.2c Robertson, Petracek, Taylor, Larry, Wright & Wilson,1993Skills for Healthy Relationships (SHR) (Robertson,Petracek, Taylor, Larry, Wright & Wilson, 1993) is a new 15-hour theoretically-based multi-component HIV/AIDS/STDprevention curriculum for Grade 9 students, recently developedin Canada by the Social Program Evaluation Group. Developmentand preliminary evaluation were funded by the National HealthResearch and Development Program (NHRDP) of Health andWelfare, Canada (NHRDP) and supervised by the Council ofMinisters of Education, Canada. The preliminary evaluation ofthe program was conducted in the four Canadian provinces ofManitoba, Ontario, Nova Scotia and New Brunswick (Robertson etal., 1993:4).The conceptual model (See Figure 10, Appendix 2) for theprogram includes four components: knowledge, skills,attitudes and motivational supports. Specific aims (goals)and objectives are given for each of the components (SeeAppendix 6).The overall goals of the program are postponement ofintercourse for those not yet sexually active; cessation ofintercourse for those already sexually active; and engagementin AIDS- and other STD-protective behaviour during intercoursefor all students choosing to be sexually active.Parent involvement is sought through the use of fivetake-home assignments, as well as a parent manual and schoolparent meetings. Teaching strategies are interactional 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For example,“What kind of teacher in-service went with this program?”“What tracking procedures were used?” “Were students lost tofollow-up comparable at baseline measurement to those retainedin the study?”This curriculum has not (in its first edition) beenaccepted by the B.C. Ministry of Education as an approvedlearning resource. The federal government will pay half thecost of teacher in-service provided provincial governments paythe other half. At this time the British Columbia provincialgovernment is not willing to do so.As mentioned earlier, Skills for Healthy Relationshipshas been shown, in a preliminary evaluation, to have had somepositive outcomes. As the evaluation was conducted during itsfirst year of implementation, teachers were not experiencedwith delivering the program, and it could not have had time toaffect general social norms through diffusion. Techniques forinvolving parents were not well developed or executed. Theseaspects are likely to improve over time as teachers developexperience with the program and school populations become moreaccustomed to receiving it. It has been made available as aresource, free of charge, by Health Canada, to schools, schoolboards and Ministries of Education across Canada who wouldlike to copy it (Health Canada, 1994;32(2) :4).198H‘dHift-I-CD0 S)CDU)ftfttTH-CDCD0C)jSooS CDI-CD0oi-QU)i-0•cl3H-5oU)H U)U)U)ft—CDHCDC)SPioftc-I-CDCD0ClCDU)I-)—CDU)Cr-p)Pi3Crc-I-C) CDftHiDH-PiCDI-’dU)‘dftU)-CDCD U)p.)CDCD CDClft3p.) ft0IIH-<CDoCD(Hp.)ooHi0C) k<CD Cl0 I- p.) 5H-U)c-fHioftIICDp.) Cl o‘-HQCDCDU) C)ftCD ftCDU)CD-ClHftCD0U) U)I.QoH-U)C)ftH- p.) ftCl CDS H-CDIQH 0ft P.)HCD b‘1CDCDCDCDHftCDHp.) F’3CD ClLXIH Cl CD S H 0 H 0 LQ H-C) p.) H CD H Cl CD C) CD H Cl H- C) p.) ft CD U) Ct p.) ft p.) H p.) 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Coupled with developmental approachessuch as broad-based life skills training, alternativesprograms addressing life goals, employment programs andremediation for school problems, this approach seems to be themost promising.The major question arising from this review of studies,then, is what combination of subject-specific programming(including awareness and reinforcement or linoculationTl skilldevelopment and alteration of social norms) and broad-basedlong-term developmental focus would be optimal for increasingHIV/STD prevention behaviour in students at minimal cost tothe school system? To some extent this question would have tobe answered at a local level for each school or district,through assessment of students’ present situations and needsand community norms, values and resources.Combined school and community interventions seem bestpositioned to be able to affect community norms. Havingparents and teachers work together, as in Walter & Vaughan’s(1993) program (which began with elicitation research and wasplanned with the community), and targeting adults for changeand development (assuming change would diffuse to theadolescents), as in Vincent, Clearie & Schluchter’s (1987)study, both show considerable promise as approaches.200))0tftHCl)U)CDiU)iPJPiH-05H,H-CDH-C)ftC)<Q‘-0C)0t-QC)CDU)-0H,C)0d0ftII)JftI-U)QH-H,$))iCD0Q0H-Hh(Q-05H-H-CDCDI-F-H-0tYCD00U)i0CDiftçt-Hft‘-<CDHH-U)çtJ))HU)Cl)HU)HU)CDCDCDH-U)ftC)CD5U)PiftU)ft0N00ftH-CDC)U)-C)CUH,-ftftU)00ftftH-I-CDCtClCUH-ftCDCD0CDH,(QftCDft0CDftftHftU)U)ClftCDU)Cl0(.QCUCDCUiCD30CDftftftH0UhçtU)IJI-HH--CrCDCUH-CUCU0ftCDU)C)HCUIII-ftU)I-jpJfrj0‘-0‘10CUfttYCDU)CDC)SCDH-H-CDHCrC)CDQi-‘-<U)ftXI-P30U)CU0C):iiU)-h’-U)CDH0CUH-CDCiCi0ClCiCDCUCDftCDCiHftClCUty(.Q0‘-<HCDCrCDH-hCU05ftk<H-0CDHHCDHCUUQC)0iU)<H,ClCUU)0ftCDCDU)CDCtHH-CUH-H-0H-iftCUSCUCiCDHF-HftH-I-H,iH,U)CUU)C)ctU)H-CD<CDHCrC)t.QJHCDH,H-CD<ftftCDCUH,IH-H-0‘-<CDCUCUCDH-Ct0iiH-H-CDH-—HftCDftCU5ClI-H,CD0ftU)H-><H,CD0iU)HH-CDCDft[-hCi0H-CUCiH-0iH-CD0h-I-fhClCDCDftH-hft<ClCrI.QU)hhCU<—HCDftU)CUCDftU)CU‘<H-CDU)CrCDC)Cr—..H0<CUU)CDCrU)ft0U)H-CDCiCl)CDhCDU)U)H-CiCDCDH-CUCDCUCiP30U)rr5IIU)-iU)ClH<ihI-h0U)CiI0CDCDHH-CrCrH-H-CU10CDCUCDU)C)CDU)5C)CDCUCDCiCDHCr1Q-<CrHHdCUCDIIClU)CDCiH,CrcU)CD5tH-Cl<H-CUI-ftCiCDCD0CU0CUH,CDCrCD-CDCDCDCUClCr0CD0C)JF-U)Cil-0<H5H-CliU)hCUH5CDCUCDCDI-CD<CDCD0CrCDCr05<<H-CDiClCiH-CU0CUH-CDU)CtCr‘-<H0Ci-IIU)H-CrU)0I-Ci0CDCDH-C)CD0ClI—IU)HCDCrt.0Ci‘-<C)CrI-H-0ftCiU)U)ClCitH-<U)f-C)5jCUH-ftftCDCUftCDHCDC)Ci•ClCDCDU)LOCU0CiCDftCUH0CDH-U)HH-U)•ftCD1QCUCl0HHU)-ftftCiU)H,U)CUCiftClCDCDC)H<CDCUH-CDU)ftH,I-h-H-H-U)0Cl)k<ft0H‘1ftCUH-CD‘-0ftC)0Cift5ft-CUU)Ci<H-CDiC)CUCDCiCU-bU)CiftftHU)‘—iC)CiCDClClftSU)-0ClCiCDftCDH0iiCDH-C)CUftU)CD-ClI-0H-ftCDH,CDftU)00CUCD0H-CDU)0H,iCi0iU)‘-<ft1QIQCl0U)H,CDU)C)CUftftU)t-ft0thICD05CiCU0H-0CUCDU)CU0‘ft0HC)ClH,CUH,CU55CUftft0CDHftU)5ftU)U)CDH-CiftHh0-0ClC)‘<CDCDCDH-U)CUCiC1CU<H,CD<10U)ftftft0CU-HCDH-U)CDCi0hf-ftCDHH0HCDCl)ClH,0 CD CU H Ci CU ft H 0 U) 0 H, U) C) 0 0 H U) ft Ci Cl H- CD U) CU Cl Cl CD U) U) H C0oU)0‘dl-CDU)CDCDHCDQ0CDCDrtrtçtrt0H-CUU)U)ioC)(QjC)I—iCD1o00I-H,H1HIIH5H,5CU0H-rrrtC)rtCUCDCDCDSHiU)0U)HU)U)H,U)C)i-CUCD—H-•CU0H-CUU)CDNC)H,‘ZiCUI-rtQ-CDçtQiCDH-CDI-00çtCDrtCDU)IIU)-i,00U)rtH-U)CDCDCUCDh-r1xjCD0CrjC)<(C0H-H-H,CrCrCUPiCDCr0<iCUCD0HCDCDCDC)QH-CDCrhClU)CrU)CUNU)H-Cr0CtCDU)‘-CU-CD-<C))H-ClC)CDH-CUU)ClU)H,0JU)iH-I-CDCrH,H-0CDCDi<HSCD0ClC)CrCrCDCDC)ClCrHCrHC)U)U)iU)CrCD0U)H-H-CrCDH-HClClCU0H-:iH-CUH-CrH-U)0CDC-QU)H-iU)CrClCDSCrCDC))H-CDCDCU0hCr0H0C)ClC)ClCrClH--CDCr0CUH-CDC)CD-CD5CDCUCrC)HCrU)CUCUClH0CliQU)C)C)U)CD0F-CtH,HCrCDC)CU<1U)00H-CtH-CDCrC))ClCD-l-l—l-U)frjCr-U)CDCDU)H-CrCr-ClW000Cr0H-CDl-H,U)CU1QCrU)CUH-çtU)U)CDCUCDdHCrH-l-•Cri0CrH-CUCDHCUU)U)CrCrClCUCU<H-CDCDCDCDH,l-’H-il-QCD0CDH,1C0-C)<H-l-C)CrCDCD-00H-CD0CDC)5HCDU)HtYU)CrCD•CD0•CDCrU)CDr5piC))C))YCUCrCUH-ClH-hCUCD0H-CDHHCUH-lHH-CUCrCDH-•CrU)U)k<0-HCUCU(-QSFlHiH-CDCUHCUHHCDCUHClFlCHAPTER FOUR: INTERVIEW FINDINGS4 .1 INTRODUCTIONGiven the findings from previous research with respect tothe combination of knowledge, skills and action necessary tofacilitate protection against HIV/STD infection inadolescents, what does education in selected secondary schoolsin British Columbia consist of and how does it relate to thefindings in the literature? What are the goals, objectivesand content relating to prevention of HIV and STDs, and inwhat contexts is the education presented? How are studentoutcomes conceptualized and measured? What are some of thefacilitators and barriers for educators working in this area?What kinds of relationships do the schools have with healthcare providers and with parents? How much support is given tothe program by various provincial Ministries, school boardsand school administrative staff?Data gathered from interviews with educators in threeschool districts were organized using the constant comparativemethod of qualitative data analysis and presented in anadaptation of the PRECEDE-PROCEED model for health promotionplanning and evaluation (See Appendix 2, Figure 11). Prior toa consideration of the interview data, it is useful to have abrief overview of both the theoretical and the historicalcontexts in which the interviews took place.The review of school-based prevention programs in ChapterThree suggests that a comprehensive school health program203encompassing both broad-based life-skills development andarea-specific (e.g., resistance-social influences) skills andawareness training is likely to be both most effective andefficient, as many skills and protective factors are commonacross adolescent problem behaviours.The goal and subgoals of school health education toprevent AIDS and sexually transmitted diseases have beenoutlined by the World Health Organization in its AIDS Series(#10). The goal would be to promote behaviour that preventsthe transmission of HIV/STD. Subgoals suggest that studentscompleting the program should:* understand the nature and modes of transmission ofHIV/STD;* recognize the symptoms of HIV infection, AIDS and STD andknow where to find appropriate resources, counselling,and medical care;* be able to make informed decisions about personal andsocial behaviour that reduces the risk of HIV/STDtransmission;* be capable of rejecting biased information and mythsrelating to HIV infection, AIDS and STD; and* show solidarity towards people infected with HIV/STD,respecting their right to privacy and confidentiality andrecognizing the benefits of the continued participationof HIV-infected students and staff in the schoolcommunity (World Health Organization, 1992:10)Objectives would be developed within communities,focusing on knowledge, attitudes, skills and support conduciveto students’ avoiding HIV or STD infections. The followingtopics would need to be addressed:* the nature of AIDS/STD,* the transmission of HIV/STD,* sexual behaviour,* risk behaviour,* behaviour that reduces risk,204sJ::3-*******************CDjIHftU)ftI I-hftftftU)ftCDOOOH-U)OU)gHICDPU)DOH-DH-H-CDU)Q.,H-OCDOQOftQOHQCDOCDCDIMU)JftCDCDJPJrtH-0HCDPJQI))C)CD0CDH,F—CDCDCDo--u—IH,rU)0H•F-CDU)ftU)-h(QIO’’QP)PJJU)F—’ftU)ftJU)CD-•QU0H-Cr-SCD-ITTftftftH-H-OH-H-OtIH-<DNF-H-OH-CDU)JTJCD0ftH-QH-pJCDF-’CDH-H-U)QU)CD0H0OU)CD0H-HIftO<ftCD0hiftftPU)ftOQU)pJCDCDCDQH-QftCDOJU)‘..OftftCDH-(QftCDJF—OftU)H-CD)H--CDHQft0OhH-H-CDSjCDF’--U)H-ftftftU)CDi><H1’tIWCDftU)ftM,)CDH-Qfl1ftH0H-CD<QIQCDdH-QpdhJ•-U0dU)-<U)U)H-HQ-H-QUdOHI’-<C)CDiU)WOk<HHOU)CDCDU)CD0U)OftF-1F--PJHftU)H-0-hU)C)ft—ftU)CDO01)HCDhH-PJH-CDPJHH-PJPiH0ft’dOQ..OOCDH-00LOU)ftH-QHU))U)<CDO(QOHpiQOOCDCDH-hCDH-OH-QiH-iQCDU)ftH0CDH-PiPiL’JPIQH-1QIQCDC)CDHU)U)H-HH-H-CDH-.U)H-—Q0HftI-••tICDH-t5H,CJ)ooODU)CDQCDQOOU)U)QQftH-CDHQPiCDpiOU)ç)CDH-H-U)OU)ik<H-giftQPlCDPiQ0HPiftCDLQ-H]0CDOCDU)-h0Q0H-CDIU)H-0H-U)U)pH-1OCDH-SCDU)OiU)ftPi(CDU)PiiHCDØOPiftCDrtH0U)H-Hft0<iftiU)0oCDiI-hU)L’JIHH-(MPiH-ftU)CDCDH-HU)piSU)H-CDH-H-Pip)0HisQCD<PiCDiU)OCDQftp)PijftU)I-<-H-C)ftoCDOH-U)U)CDftCDCDO((Q‘CDCD0PiH-CDviCDCDU)CDHQftiCDCi’dftftPiH-CiH0U)CDCnCDft0U)C)H-U)frrtpi0CDHHCDpiftH---HC)Cl)U)Ø.,-piOHftCD0CiOU)ft1QQHU)hU)H0iP10CDH-Cl)H-Pi1<C)H-b’ft-U)U)CD‘cQI0HU)OHCDOCDH-H-ftQQCDU)CD0P1H-00-HHHU)OftQH-CDCDCDP1H-OftOU)CDH0Piftft0U)CD0ftftHU)H--hOH-H00CDCDOPJHOftQCDH-00CiftCDI-ftHCDH.OU)ftpJ0HCD(QU)P1.tCDHHPhD)0U)0Ci30PiCDU)H-ftOCDPhCD•U)FU)Oft<H-fttJp)H-0Q0HiHQH-HftY’P)QU)I-hOU)I—hftHftCi0-OCDO-CDOftCDU)H-U)ftU)0ftCDH<IftU)U)OH-ftCDH-QOCiHI-hPJU)PICDC))HH-HiZjpJpiU)U)U)CDHOI-CD3ftV=—‘U)U)CDU)U)PiU)ftCDOOft01U)0CDPhCi-ftH-CDCQ-<CD0CiI--hOOCDHCDph:::r—.0Ph-OH-flI-jCDCD<IU)U)C!)CDftH-CD•-U)CDHCi0HIPJU)CDMiHCDCi0PhHI-ftHP)<QPhQU)CiQ,HOH-•Li-ftphftC)),oCiQHiH(CDH-U)ftU)OOHCiU)IH-ftftCDPlOCD1U)H-tx’0H-Phft0H-U)0LQI-ftQ0HH--OCDCl)Hft<C))H-0CD0H-CDCDC1H-OH-CDHIQU)C)1Q-j0phH-Phft0‘<CDHCDftCiF-’U)<0HH-H-PhU)U)H-HH-0C)hHPhU)CD0C))PhH-0iU)H-CDI-ftCD0—-ftH-CDClU)U)I--h0Clas well as annual implementation plans for the schooldistrict and individual schools should be established(Canadian Association for School Health, 1993:2).To what extent do the school program aspects specific toHIV/STD prevention examined in this study reflect the abovephilosophy? What are their strengths, and where are the gapsor areas that need improving? Findings are presented in termsof a framework of categories created from the data using theconstant comparative method for qualitative data analysis.From these categories, the data are linked with theoriesdiscussed in Chapter Three, and presented within the frameworkof the PRECEDE-PROCEED model. Discussion in Chapter Fivelinks this presentation to the philosophy of comprehensiveschool health programs and to the research questions outlinedin Chapter One.4.2 HISTORYSince 1987, “Family Life Education” has been a BritishColumbia Ministry of Education-mandated curriculum for Grades7 to 12; ten hours are required in Grades 7-10 and four hoursin Grades 11 & 12. In 1987, a “Family Life Education” Binderwas made available to all teachers of Family Life Education;this binder included three lesson plans on the topic ofHIV/STD. Since 1990, “Learning for Living”, the BritishColumbia prototype of a Comprehensive Health Educationprogram, has been mandated by the Ministry of Education in206British Columbia. The comprehensive health program includesthree elements:classroom instruction based on the curriculum,services for students, and a healthful schoolenvironment. These three interdependent elements of acomprehensive program are of equal importance [Provinceof British Columbia, 1990:14]“Learning for Living” is a framework that underlies andpresents the integration of the spiritual, emotional, social,intellectual and physical goals of education. The “Learningfor Living” curriculum includes four main themes organizedaround seven content areas: careers, child abuse prevention,family life education, healthy living, mental well being,safety and injury prevention, and substance abuse prevention.The four themes are:1 “Individual awareness and responsibility” (to identifyand develop the physical, emotional and spiritual self ofthe child, and to promote behaviour which supports self-esteem);2 “Relationships” (to develop communication skills and anunderstanding of types of relationships, roles andchanges in relationships);3 “Social awareness and responsibility” (to increaseappreciation of the value of cooperation and individualinitiative); and4 “Life long development” (to focus on the responsibilityof the individual as a continual learner, developingskills in adapting to new circumstances and practisingattitudes that promote a healthy lifestyle) (RoyalCommission on Health Care and Costs, l992:C-82).It has not been clear whether, and if so, when and how“Learning for Living” is to replace “Family Life Education”.In fact, “Family Life Education” is a component of “Learningfor Living”, and there should be no replacement; rather, there207should be an integration of current “Family Life Education”content with the four themes of “Learning for Living”.However, many educators and administrators at the secondaryschool level do not understand this, and there has been atendency to stop presenting “Family Life Education” while“waiting” for the implementation of TLearning for Living”, theworst possible outcome being that little or nothing getstaught in this area. This chapter looks at the presentsituation with regard to the implementation of “Learning forLiving” and the continuation of “Family Life Education”, withrespect to education specific to HIV/STD prevention, withinselected secondary schools in three school districts inBritish Columbia.4.3 CONTEXT FOR. THE FINDINGSTo set the stage for presentation of the interviewfindings and analysis, demographics, including jobclassification of the interviewees, size of the studentpopulations, setting for delivery of education specific to HIVand STD prevention and number of hours per grade devoted torelated instruction are presented.The interviewees consisted of two nurses, one socialworker, seven teacher-counsellors who were heads ofcounselling departments in their schools, one science teacher,three teachers of home economics (two of whom also taughtFamily Management) , one district “Learning for Living” co208ordinator, one Municipal Health Department Co-ordinator ofSchool Programs and two teacher-counsellors in an alternateschool.The size of the student population in the large secondaryschools, where most of the interviews were conducted, rangedfrom approximately 1400 to 1800 students. The number ofcounsellors in each school to serve these populations rangedfrom approximately 4 to 6. The Provincial CounsellingAssociation is currently trying to get the student tocounsellor ratio down to, at most, 250:1; some schoolsrepresented in this study were at or below this ratio and somewere above it.Some of the schools are organized such that they utilize“developmentally taughtu counselling; a grade cohort isassigned to a counsellor when it arrives at secondary school(Grade 8) and stays with that counsellor (unless thecounsellor moves) until graduation (Grade 12) . Various anddifferent arrangements are made for “Special Needs” children,“English as a Second Language” students, and for “Alternate”classrooms or attached schools. The following summaries forGrade 8-12 students do not include these special groups unlessthe students are integrated into regular classes for thesubject that houses the “Family Life” curriculum at thatschool.Grade 8 students represented by this sample seem to bereceiving their mandated 10 hours of Family Life Education.209The setting varies by district; one district offers it withina comprehensive Guidance program, the time for which isgenerally taken from the Physical Education program; anotherwithin compulsory Home Economics or Life Skills programs; andthe third within the Physical Education program. The timespent specifically on HIV/STID prevention topics varies from11tangentiallyI to about five hours during the year.Grade 9 students are in a similar situation. Usually thetime is taken from Physical Education; sometimes it is taughtby the P.E. teachers and sometimes by counsellors or by otherpersonnel assigned to the task, such as school nurses and drugand alcohol Prevention Workers. The amount of time dedicatedto STD- and HIV- prevention topics seems to be slightly morethan in Grade 8, varying from a minimum of 1-2 hours per yearto a maximum of about 6 hours in the year.Grade 10 students are generally in a somewhat similarsituation as Grade 9 students, with some exceptions; in onedistrict some of the Grade lOs received only one half-day ofFamily Life Education during the year, and none of that wasspecific to HIV/STD. (These students may be receiving HIV/STDinformation or other health information in Science 10; thiscould not be ascertained from the interviews.) The number ofhours devoted specifically to HIV/STD prevention for Grade 10students seems to be slightly less than for Grade 9, rangingfrom one to three hours per year. 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as seemed necessary (within given time constraints)possibly doing more one year and less another according totheir perception of the students’ needs and circumstances.They would also be available for out-of-class follow upquestions and counselling. When presented in Science or HomeEconomics, the curriculum would be more structured; STD/HIVwas more certain to be included at that particular time.Although Home Economics and Science teachers tried to beavailable for follow-up and counselling, there would be littleformal opportunity for follow-up.Although much of the literature reviewed in Chapter Threediscusses interventions based on Tlbehaviour change11 theory,teachers prefer to view their task as the TTdevelopment” ofappropriate behaviour rather than ulchangingll behaviour:2I hate to say ‘behaviour change’ for young people,because I guess I like to think a lot of the kidsaren’t doing any of these behaviours yet, and evenif they are they’re at an early or experimentallevel. So it’s more making sure that the behaviourthat we would want to have happen is more likely tohappen [7:2 end]4.5.B.2 Decision-making skills lead to preventive action.Many programs are built around assisting students todevelop a conceptual framework for decision-making and topractise the skills through role plays and scenarios. Even2Behaviour changehl is, however, the generic term in thetheoretical literature for both htdevelopmentTl and ?changeu1 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conditions and circumstances surrounding assumptionsrelate to educators’ conceptualization of their own, parents’and students’ roles and responsibilities with respect toeducation for the prevention of HIV and STD infection. Theseassumptions influence educators’ subjective norms with respectto teaching the subject; they are influenced by thereinforcing factors of others’ attitudes toward AIDSpreventive interventions.4.5.C.1 Educators’ roles and responsibilities.Educators are careful to refrain from imposing their ownmoral views into the situation and to support parental andfamily values while, at the same time, encouraging students todefine and clarify their own values.If it doesn’t feel good, and you wouldn’t be proud of ittalking with a family member, don’t do it [8:P13]I’m not trying to instill any kind of values or make anyethical judgments and impose it on the students [6:P4]The concession the school makes to the community is thatthe school doesn’t moralize. It presents information inan objective way [9:P1]Educators think it is important to be clear abouttheir own values, and to be honest and non-judgmental withtheir students. For an educator to be effective in presentingsexuality education, he or she must feel that it is importantand must want to do it.It’s ABSOLUTELY vital that the counsellor, that theteacher-counsellor or whoever is doing the program be intouch with their own values and be clear about them withkids. If talking about penises makes you uncomfortable,220you need to sedate that, and find a way to deal with thatin a comfortable way for you, by bringing in someoneelse, or using talking heads, or something, but nottrying to fool kids [8:P36]Honesty is always correct, whether it’s ‘I don’t know’ or‘I don’t feel comfortable sharing that with you’ [8:P36]They need people who are competent, who are well-trained,to assist them. And I think a non-judgmental person totalk to, someone who’s not going to superimpose morals[14:P4]Sexuality education is really really important, and thatthe counsellor must want to DO it. But if they don’twant to do it, not only because they feel inadequate, butif they don’t share those assumptions then they shouldfind some other way of having that material get to kids,because kids know it. You’ve got to, as I said before,“Walk the walk”. If we don’t believe in what we’resaying, kids are so smart. One slip in the classroom,and they’ve got our number [8:P36]All the teacher-counsellors interviewed saw sexualityeducation as the responsibility of the counselling department.All the others involved in the direct delivery of the topicalso saw it as their responsibility. Most saw it as one ofmany topics or subject areas vying for space with many other,also pressing, issues.The Guidance programs are between 15 and 20 hours a year;during that time we are trying to prevent and givestudents information on a hundred topics [12:1:24]Everything we do in Guidance is prevention; we try toprevent just about everything [12:1:327]4.5.C.2 Parental role and responsibility.Teachers feel the ultimate responsibility in the area ofsexuality education and HIV/STD prevention education restswith parents, but think that some parents are not fulfilling221their role. Some teachers would like to see parents moreinvolved at the school, while others are satisfied to havethem at arms’ length. No teachers indicated that parents werevery involved with the school regarding this topic. Someparents have a language barrier which may mean that they donot know what the school is doing. Although some schools sendnotices home to parents in several languages, there is almostalways a question of whether the notices actually reached theparents. If they did get into the home, there may be asignificant number of parents who are not literate in theirown language. Even if parents do comprehend the messages,many parents, according to the interviewees, look uponteachers as professionals who are not to be questioned.Parents don’t often attend parent nights or respond to noticessent home. Although parents are entitled to withdraw theirchildren from Family Life classes and present the material athome, with the assistance of a binder prepared by the Ministryof Education, very few opt to pull their children from theclasses. One teacher expressed his feelings about parentalresponsibility in sexuality education in this manner:Speaking as a parent, I think it’s something that comesfrom the home, it should come from the home. I reallythink we do a pretty thorough job here of telling thekids what’s there, how to use it, how to get it, how muchit costs, what the results are going to be if you don’t,and so on. But I think a lot of it is just therelationship kids have with their parents and how theirparents approach it. If the parents don’t say anything,and avoid the issue, I really don’t think that helps thesituation, whereas if a parent sits down with a kid andsort of explains what they know and, not the science endof it, but what they think is right or wrong and develops222C)I-’Pi‘d0CDiHCl)UiI-1dC)Q01)Cl)CDbH-HF—{Cl)0CDI—I-rftOPiCDH-QtYCl)ctW•.•.CDftO3OH-HH-•.PJQCl)ftQPJPJCDH-Cl)H-H-SPJCDftc-tCDk<ctQftCDftICD——CQQctQQft-CDhCl)H-CDftQCl)-CD.PiHCl)H,YyH-hH-0H-Cl)CD-CDJP)Cl)rtCl)ftiCDCl)CDPJH-H-ftftH-HPiftift3OCDCl)ftOOOP)ftftftQH-><Cl)ftCl)3CDSftCl)Cl)<tT<1H-CDCl)C)ShhQPJHCDOt5--OftCD-<-H-CDH-H-WCDCl)I-ftH-pii-H,ftCQ5k<CDF—iftH-P)Cl)hCDH$1Cl)ftCDftiCDPiYftI-0Cl)H-hhCD—J’CH—HHH-ftHOH-QCD-CDCDftCDHiftCl)CDPJCl)H-ftCDH-Cl)Cl)Cl)CDftCDPWftCl)Cl)Cl):O:QH‘dOCQrtPJ-OOH-P)P)OCDftCDOCl)ftH-0PJ-W0‘dCD‘dSCD<O-hQftPiCDh-CDI--PiCDHH-5H-H,ft•CD•ftP)F—’CDP)3ct—ftCDHCDQ.ClH-CDWfriCDCl)ftOHOftftQftH-<ft0Cl)•HCDCDftCl)CQHCl)C)•CDCDftPJH-ftCDOCDOftP1PiQ.rt-ftCDPJftH-ftOCDHPJO5I-H-H,CDtftCD50Hfr33HftF—Qft<0HftQCDCDPJHQftCDi-1Pi5CD3HCDCDCDCD(VFI’-<H-’-<CDk<QHpHH-Cl)O<H-<-PJCDCDCl)CDCD3Cl)H-H-ti0H,CDQ<pipCl)HH-H-<H-Cl)Cl)3OH-Cl)ftH-ftCDY•iCDl-Cl)3dH-i-bft)QDCliCDftH-C)CD<CT)P1C)3ftC)ftP)OH-ftH-0CQPiCDPiCl)30H-P1C)Oft1QPiftH-0Cl)0ftH-OP)idPJftOH,Cl)<HCDH-S1H,Hft0HftftCD5ft5CD5CDCDHQOCD0CDH-I-5-H-CDPJCDCl)CDftH-CDCDH-PiftMCDCDCl)ftCDClCDCl)I-I-Cl)ftC.QPiCDQHH-0<ftH-ftF-Q.-.HbH-Cl)‘-<ftH-Cl)Cl)ClHCD<OCQ1I—H—H-0H-CDH•WHH-Cl)ftftHfriPiCl)<HCDCDCl)Cl)(C<CDPJCDOCD<ftl-QH-H,Cl)ftQPJCDOPJftftCDCQl-QP1H-000HCl)-IQH-H-PiCDII-—CDCDlftH,$H-H-ClPJI-ICDfti1QOCDCDH-CDCl)HH-’dHCDCDCDftI0ft0ClftQOQ0F—3CDPift0QCDftCDH-0<P1Cl•CDftdClft3OIIS<ftCD-<-CDCDO(flH,SClCDHCD0L1JhCl)bP1CDCD0CDCDftftftftH-CD<I-UQCDftOhHhs’P1CDCD•Hft—I-CDO00CDP1ft0Cl)Cl)Cl)H-ftCDH-‘-<H-ftH-ftClH0SCl)0-ftftftHCICDCDCDCD•50ClftP1OP1Cl)QP1‘-<OHftP1HftP1FWF—-Cl)H-3I-50OH-ftP)CDCDiftHH-CDftp1i-CDCDftCDftH-0-O<P1P)CDftCl‘db’Cl)CDH-WftHCDCDP1F-lli-H—<frHftH,CD<ftH-H-‘.DP1<Cl)F—’CDCD0Cl—ftH-<0HCl)CDCDP)hH-OH-—C)OCDH-0P1ftft‘-<OCl)cCQ-OCl)tYft<P)<Cl)0ftCQFP)ftCDH-••0-P1ftCDCDftCQCD(ftHCD0P1CDCDI-‘-<PiftH-P)ftH‘-<P1PiCDCDI-P1l-Cl)5ft0H1Cl)ftCl)ftftWftH-OdCDOCDCDP1CDP1Cl)0CD‘—CDCQClH-3’H-CDCDftH-P1ftOH-ftH-ClfrH-••P1OIQClftP)H-5ClCDCD0P1CDH-(1)0-ftftCDft1ft’dCliCDCl)CDCD-H-F-ftftOCDCD3P1ftH--CD0Cl)•iCl)ftftP1H-HftP1CDCDCl)OCDft‘CIClHP)Ol-0HCl)Cl)I-h’ftfrICQ<Cl)H,H-HH-H-—-(l)iH-YH-CD’-<ClftftCDCl)CDCD0HCDClP10H-P1II3-jCDftftH-ftP1QHP1CD-ftHCl)HCDCDCDOftftI-0•i’<•CDCD-Cl1H-hftCl)CDPICD-CDY’Cl-ClCl)CDCD-ftCDWCDft-S4.5.D Educators’ Attitudes“Educators’ attitudes” emerged as a third property of“Cognitive Content”. Attitudes included those involvingconceptualization of the topic and toward the promotion ofabstinence and of condom use.4.5.D.l Conceptualization of the Topic.Many of the interviewees had difficulty settling on aterm that could be applied in our conversations to name thetopic, which I presented as “Education for the prevention ofHIV and STD”. Although they had the lessons in the FamilyLife Education binder from the Ministry, the topic underdiscussion was variously called “Guidance”, ‘1Sex Ed”, “FamilyLife”, “Learning for Living” and “the problem”. While thequestions on the interview schedule were narrowlyconceptualized from a medical point of view, it became obviousthat within the school system HIV/STD education was notthought of as a separate topic but was usually embedded withina larger, more inclusive, “package”. When asked if it wastaught as a discrete topic or linked to other topics, arepresentative reply was:I could never teach about HIV or STDs alone, because Ithink that’s wrong. It has to be put into a context ofnormal, healthy sexuality [8:P35]I think it has changed over time. I think if I trackback to my own experience and the experience ofcolleagues sort of ten, twelve years ago, we saw it as adiscrete topic. There was a big mandate from the SchoolBoard, we got a binder with THE THREE LESSONS in it touse, and a real investment was made and a commitment224demanded from us to do AIDS education. Not so much STO5in general then, but AIDS. And I think that we’ve movedaway from that again. Not moved away from the importanceof doing HIV/STD/AIDS education, but back to a moreinclusive way of doing it. I see it now as a part of thewhole human sexuality package, which is in turn a part ofthe whole Family Life Education package [8:2-3]One person mentioned trying to separate the idea ofdisease from that of healthy sexuality in this way:We usually, the focus is to try to separate STD5 and AIDSinto a different time slot, so that the idea of, well ofcourse it’s a risk of intercourse, we try to separate itfrom, “good love”, we try to, we try not to make it aresult of intercourse, we try to separate the two[11:1:75]4.5.D.2 Promotion of sexual abstinence.Educators’ attitudes toward promoting abstinence varied,ranging from those who definitely would not promote it, tothose who might promote “postponement”, to those whodefinitely would promote abstinence. Others were moreneutral, concerned with promoting informed choice anddecision-making:We don’t have any school philosophy about promotinganything, really. We have condom machines in the school.Abstinence is certainly outlined when we’re talking tokids about sexual activity as the safest option; we don’tbeat it into them. We don’t tell them they’re bad ifthey don’t choose it. It’s presented as an option thesame way condom use is [12:1:388]I think that we do ourselves a disservice by aiming forany common denominator because it isn’t common enough,we’ll be leaving some kids out. ... Although the kidswho are gay or Lesbian or may become gay or Lesbian are aminority, so may the kids in the class who have chosen tobe sexually active, and I think we do them a disserviceby laying on a set of values [8:P22]225I do teach them, if there’s any doubt in their mind, topostpone making the next step, so I am teachingpostponement, where I’m not teaching abstinence [8:P35]The goal is to put every kid through a process so thathe/she has the best information available and is able tomake the right decision when he or she ... If we state,for example, that abstinence is a goal, in class, we knowwe lose a lot of kids right away. So we try not to bejudgmental in any way; we try to leave it open-ended andlet them go through the process and then make the wisedecision [11:1:223]At the senior level the nurse’s topic is ‘I-low to besexually healthy and happy for the rest of your life’,and that’s kind of the way it’s talked about; more likethat sexual activity is part of life, it’s not somethingyour parents say is bad, and you should never do it, it’ssomething that most normal people will probably engage inat some time in their life and these are the things youhave to watch out for. It comes across quite naturally[12:1:388]Others considered promotion of abstinence to be in thebest interests of all their students and did so openly:Q: For all the Grade Twelve students at______A: Urn, hrn.Q: I’d like to hear about that day.A: Actually, I think it was just a morning, threehours. I had Dr._____come in and talk about STD5and AIDS. I had a woman from the Red Cross, and Ihad the______Church,_____,you should talk tothose guys, and they did that play on, basically itwas, their bottom line message was monogamy, andwaiting, I guess, and saying “No”; abstinence [l:Pl2]4.5.D.3 Promotion of condom use.Educators were generally in agreement with respect topromoting condom use for sexually active youth.I would say we do have a philosophy about condoms. Ithink that every one of the counsellors would say, “Ifyour decision has already been to have intercourse,either orally or genitally, vaginally or rectally, thatyou must wear a condom. Period. Yes, we have aphilosophy about condoms [8:P9].226—tYCDH,Cl)ECl)Cl)H-ftQCl)Clil-><CDC)•H-H-ftCDi0iH-Cl)HCl)ctCl)1H,Cl)LJF1H-Iift0•C)<00CDHiCD(-Q0H-H-hl—C)C)HPiH-i-HftI—’‘—3Cl)H-HC)‘-<ft‘<xjjxJCDC)0•-Cl)CDCDCl)F1H-CDCli-H---iC)0ECDCD-CDLyCliCDF-CI-çtpii’ftCDH-0C)H-I-iCDC)bWH-1<(O’-dIICl)Cl)—00H-Cl)iI—’Cl)H-0CDftCl)F1C)F-lOOCD‘-cifthiCl)-t-H-F—IftCDI-C)-o-OQ1H-‘-ciQI-0CDIICli(-Q-0-Cl)-çl-•iFlCl)Cl)HF1CliCliH-(QCl)OCDh-hCl)•C)H-H-0CIClH,CDC)CDH-ftC)QCDftH-H-C)H-H-CliCliCliH,-sJCl)H-iDOFYFlC)CD‘-<•‘-ciNftC)Cl)HClictQC)ftH-F1CJCDC)L’JCDPiH-I-CDICliCDftC)()o0CI)<1’-<F--’‘-ciCl)CliQfthQl-ft‘-3C)—0C)CDCliHC)H,H-H-hCD—QQctQCrCl)—,iH,CDftFlH-HCl)H0CD0Cl)Cl)F-’dCl)YCliWFlH-Cl)H-<Cia)Cl)Cl)F—’CDCl)Cl)Cl)CDft0CD•-li-ft<‘-ft$Cl)Cl)Clic-IFlCD‘ciCiCDCDCO‘-ciCDH-——iftCliH,j‘rJQH,0siCtHHCD0i0C)Cl00CiFlft‘—1QC)-H,‘-ci’-dI-FlCDfti0‘-ciCliQ,I-JH-CDFlCiCDH-<FlO’-ciCDCrCDCl)Cl)ICDCl)iCl)Fl—ClCliCiCDO-HOH-H00ftClh’CDLiiC)Cl)CDC)OF-’Cl)H-FlCD<ClH,l—ClClIJH-H-0FlC)ctH-CDH-FlCliClFClCDCl)‘-dCiiHCDCiCI•lQk<HftCl)0H-CDCD<-C)QMCiHHHh’FlQIQ-<0ft$rriCiCiH-‘-<—.OCiCD0CDCDH,h-0CiFlftHCl)Cr‘-3HH,Cl)Cl--FlH-ftctCDCl)C)00CiMCDftCl)-.‘-d‘-‘1C)0H-Cl)—CiC)hciH-CDftCl)’-ciC)CiCl)Cl)CliftCD00ft0Cl)Cl)oi-‘-xjH‘-ciFlQCl)‘-<iciH-CiC)HCiCl)H-(QQCDCD‘-ciH-H---FlCD0HftC)Cl)H-Fl0-iH-‘-ciHCl)C)CIjftH-Cl)(.Q<lftHFlctCl)0‘-<CliftftCDCiCliC)CliH—.Cl)CDCDCl)FlH-CDLiH-Cl)<ftLYHftC)Fl‘-<ftftCll-C)H-0H--HCDCDFlOHCliH-H-<C)CDCli00HClHHCIOCJFlCD<H,ftH-I—’H-CDH-CiH-OFlC)CDCDCDCDClFlCl)ftiCl)ClClCl)CD0Cl)—k<ftftCli<ft0Lii‘<Cl)H,cift—-CD(-QiiCDk<ftOCiFlCl-CiFlCDCl)hCD0-0,—,QH,H,ftC)CiCliftCDftftH,’-ciHClC)CDCDH-C)00CDCDCl)CDFlFl’-ciW--CDCliHH-CDiC)Ci><HftCiH,CH-H‘—aCICIF-’Cl)CiH-CDHHHCl)CiCDftciCDCJ•l))CIH-I—’CDiiCl)CDCl)Cl)Cl)ClHCDC)CI-3Fl0ftClQCl)ClftCiftC)CDHftH-CiiJF-hCiCDH-0‘-ciClCDH-CDCDCiH-ftCDftHCDCi<CD-H-C)j0ClC)H-CDFl0CDHFlftI—CDftCDCI)H,-ftC00ftCDftCl)Ci‘-J0FlH,0HCl)l-0Cl)Cl)H,CDF-’-Cll-CI-leery to have that open up, I think.Q: So you can’t, you don’t show them condoms?A: No.Q: You don’t bring any condoms?A: I think you could, and I think you’d get a lot ofphone calls, and I’m not sure he’s willing to acceptthem [3:P2]Compare this with another school in the same district,where birth control information is taught and devices areshown in Science 10, with all of it tested as part of thecourse requirements:A: So we send the letter home, and the parents look atit. There’s a paragraph that says, “If you don’twant your kid to take the course, which they don’thave to, please give us a call and you can sign thestuff out.” Since it is mandated by the government,the child is SUPPOSED to get the material. So theparent can sign it out through the Resource Centre.And they’re told that. Because I do test them onit, and it does count for everybody. So if they’renot here to do it, they better be getting itsomewhere else. I mean, it would sure be nice ifthe parents actually sat down and taught it to theirkids, but it sure doesn’t happen that often.Q: Those parents who don’t want them to get it atschoolA: don’t want them to get it at home either. And I’venever had one, as a matter of fact. The six yearsI’ve done this, I’ve never had a parent pull theirkid. But anyway, the list goes home, andeverything’s on it. “We’re going to do birthcontrol, there’ll be samples”, and the whole bit,and the parents have to sign the bottom. And thenit’s a homework assignment; “The homework tonight isto go home and get your parents to read and sign it,with their phone number. If you don’t have it intomorrow, your homework’s incomplete”, and they getnailed like they do whenever they don’t have theirhomework done. So that’s usually enough to get themget it home and read it. And then you collect themall, file them, keep on record, in case a parentever does call you on it and say, “What’s this, mykid’s learning about birth control?” “Well, here’sthe sheet you signed.” Then they say “O.K.” or theysay, “I never signed it”, in which case the kid’stoast for forging a name. It’s just a way to makesure that the majority of the parents know about it.228And that generally is how we do it [6:P5-6]It is interesting to speculate from these exampleswhether placing sexuality education within a core curriculumsubject such as science makes it easier for parents andpossibly Principals and other staff to accept.Another angle from which to look at how much and whatkind of support is being given from an administrative (in thiscase, school board), level is given by the following person:I think that the other lack of support, from a schoolpoint of view, is that there hasn’t been a formalizedleadership from the school board in the last year or two;actually, for always, really, from the senior level, thatthis is extremely important, and for setting standardsand doing an evaluation. There certainly have beenindividual people in our school board who are very veryinterested and very supportive, but they weren’t at thesenior level. And it’s that senior level that counts[7:2:242]Teachers, especially counsellors, carry the load oftrying to ensure that there are adequate “Family Life”programs, and trying to get the “Learning for Living”curriculum off the ground.The people who have lobbied overtly the most are thecounsellors, where we have gone to Victoria, we havewritten briefs, we have written proposals, we havebegged, we have interviewed, we’ve done everything we canto keep these kinds of programs going [10:2:70]A: I came here in this district in ‘86, and I was toldwhen I first came, “Do not mention ANYTHING aboutsex”. There’d been a serious situation where ateacher had given information, parents hadcomplained. At that point they took every videothat existed in the school board out.Q: Due to one parent complaint?A: No, it was a few of them. And, mind you, theinformation that was given was a little bit in poortaste as well. And unfortunately that caused allthe students to have absolutely no Family Life229education. So I spoke to the Principal about it,and said I thought it was really important, and hesaid, “Well you can do it as long as you don’t dodirect sexual functioning. And that sort of thing”,which is a little bit hard to do. So, anyway, Itended to stay to the biological end of it, and ifthey asked questions I answered them honestly, but Ididn’t put it in print, and I didn’t give handoutsthat would be taken home. I explained to thestudents that if they were at all unsure of what wasbeing said to come and talk to me afterwards [2:P1JEven though “Family Life” was mandated in 1987, thisPrincipal was still reluctant and the teacher had to take thelead in getting permission to have the program in the school:So basically at that point [when the program was mandatedin 1987] I went to my Principal and said I felt it wasvery important that we actually give a portion of time tothis, and he was sceptical at first, but he had, I guessI’d gained some of his trust in the fact that I’d taughta lot of this and done it without having anyrepercussions, how the parents talk to us, so he said,“O.K. Go ahead, look after it for the school and planout where we can put it and how we’ll do it”. And I didthat [2:P1]Principals often are afraid to take a stand, relying onsupport in the form of a “mandate” from the Ministry, whichdoes not materialize.______and I put together a survey that we were going togive, but my Principal said, “No”. ... He thought theparents would strongly object [1:P12].I think what’s happening, as I tend to see everythingthat comes through the office from the government, is,there hasn’t been much from the government lately in allof this stuff. Like, when the “Family Life Education”came, everywhere you went you were getting bulletins andpamphlets and you could not escape the thing, it wasthere. And I’ve heard about “Learning for Living”, andI’ve seen a draft, but they’re not pushing it like theydid with the other stuff. And so I don’t know howseriously schools are considering it. Just because thegovernment’s really not saying. I know our Principal, ifhe received documentation from the Ministry, “You gotta230do this in your school, in 1994-95, or 93-94, and it’sgot to be done at the Grade 8, 9, 10 and 11 level”. Ifit’s mandated, then he’ll act on it, and he’ll come tothe department heads and say, “Guys, we’ve got to teachthis, how are we going to do it?” But he hasn’t done anyof that, because I don’t think he’s, it’s really beendrilled into the office, like, “Make sure you guys figureout how you’re going to get this into your curriculum”.I don’t think that push has started yet [6:P3-4]Schools lack a clear mandate from the Ministry ofEducation. The Ministry’s handling of the implementation of“Learning for Living” has been of little use, according tothis educator, with no lesson plans or direction having beensupplied.Q: Do you consider that you’re doing the “Learning forLiving” curriculum now or that you’re gearing up todo it?A: We’re waiting for the government to get their acttogether so that they actually present us with howthey intend it to be done. ... “Learning for Living”is still a very vague framework. It’s not useful tous at all. And when I’ve gone to the sessions forit, I find just more useless information. They justaren’t prepared to actually give us the nuts andbolts of mandating when they’re going to do it, howthey’re going to do it, how they’re going to fundit; they’re just saying, “This should happen.” Andunless they mandate it, it’s not going to happen[2:P7]4.6.B CurriculumIn the eleven large secondary schools in which interviewswere conducted, two teachers felt they were well on the way toimplementing “Learning for Living”, two teachers had notlooked at the “Learning for Living” guide yet, and the restwere aware of the curriculum but for various reasons were notattempting to implement it. The two people who were not231familiar with the guide, (one had not seen it, the other hadbut hadn’t had time to read it), conceived of “Learning forLiving” as a new version of “Family Life Education” andthought of it as a new course to be fit in to the students’timetable.Q: Have you looked at the “Learning for Living”curriculum yet?A: I saw a government draft of it about a year ago, twoyears ago, and all I know about it at this point isthat apparently it’s going to be replacing, nowcorrect me if I’m wrong, but my understanding of itwas that it was going to be replacing the “FamilyLife” program? But I haven’t seen, I know, the FL,when it came out, you got the big binder, you gotthe films, you got all the lessons in detail. Ihaven’t seen any, I don’t know if they’ve advancedit to that point. Just that I know it’s coming.Q: Have you seen the guide?A: No, I haven’t [6:P1]Those who felt they were part of the process ofimplementing it mentioned how they were meeting and workingwith other teachers and that it was a group process.A: The P.E. department head was really enthusiasticabout it, and this year as well, we have a healthcommittee that sits in the school, and I think theirsupport was important, because there’sadministration, P.E. department head, a teacher,parent, students sit on that. And in terms of thecontent, I mean it’s all factual content, but itworks right in conjunction with the whole “Learningfor Living” Program. So it’s just a natural. Itfits.Q: Are you trying to implement the “Learning forLiving” Program?A: It’s part of the implementation of it, definitely{4:P3]Q: . . . “Learning for Living” curriculum. Are you usingthat guide at all yet?A: Oh, in a big way. Very much. I’m involved in a bigprogram here at the school with that.Q: In what way?232A: “Teaching for Success” we call it. But we’re usinga lot of it. Integrating classrooms, I have theTeen Moms come in and speak with my girls on issuesoften, I also teach science classes, I have theirscience classes teaching my Grade 8’s the rockcycle, so we use a lot of the “Learning for Living”.Q: You’re starting to break down the barriers betweenthe subjects?A: Yes. I’m very much involved in that program.Q: Is there somebody in charge of that?A: There’s just a lot of people doing it. I supposesomebody who’s holding the purse strings here wouldbe______,she’s a counsellor. She’s the one we askfor sub time for doing things, and whatnot. Butwe’re all just sort of doing our own thing.Q: Do you have a group that gets together to discuss?A: Yes.Q: How often do you meet to discuss that?A: Every other month.4.6.C Standards and AccountabilityNo-one seems to be in a position of responsibility to seethat “Learning for Living” is implemented. There is concernin the schools that “Learning for Living” will be seen as yetanother program that teachers are responsible for offeringwithout adequate outside support.Q: Who do you think should do the health promotion andhealth education in the schools?A: I think it should be all the adults and the kidstogether. I don’t think that health educationshould be the domain of the teacher, the counsellor,the nurse, or anybody, and that’s been one of myproblems with all of this all along, particularlynow with “Learning for Living”, the message has comedown that it is the teacher who’s responsible forthis. And I don’t think that that’s fair to theteacher. What I would love to see happen is thatthere should be standards and all the things you’vetalked about. I think one PERSON in each schoolshould be responsible and accountable and I thinkthat should be the Principal. Then how he and histeam work it out at his school is up to them. ... Ithink one person needs to be accountable, there233needs to be this finger going and saying, “Tell uswhat you’ve done this year, what have youaccomplished? TI And that person then has to go andget these other; we’ve left it so loose that no onedoes anything or even the people who want to, try,but they can’t make anybody else co-operate withthem. So it’s based on well-meaning people [7:2end].There are no standardized objectives with regard toinformation or skill development for health promotion/diseaseprevention within the school system. Not surprisingly then,no-one is held responsible to see that “Family Life Education”does get taught or that it covers certain topics, even though,in 1987, AIDS education was mandated.Q: Is it up to each school, then, what they offer inthis way?A: Yes. The government has mandated that it’s taughtfor 10 hours at each grade. It’s up to the schoolhow it’s presented. And nobody checks. There’s alot of flexibility. Our Grade lOs have been sort oflost in the paperwork shuffle.4.6.D Goals and objectivesWhen asked the question, “What are your school’s goalsand objectives regarding prevention of HIV and STD?”,respondents had to grapple with the question of whether theirschool had goals and objectives in this area, with wonderingwho would represent “their school” (would it be theadministration? the Principal?); and whether they themselves,or their professional associations, hold goals and objectivesin this regard. 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Sometimes we’ll dopresentations. They’ll have an exam, of course; they’llkeep a notebook, they’ll do co-operative group-typethings. That’s just standard that we do with all ourcurriculum [6:P4]Other indicators of success include the use of condommachines in the schools (both by the level of use and therespect with which the machines are treated); the use ofnearby health clinics by the students (a criterion suggestedby a school nurse); the relationship between the students andthe school nurses (in part, whether students go to the nursesfor condoms); whether students use reading material and seeand take pamphlets that are on display; and whether theyremember the content of the previous years’ courses.The fact that our condom machines in our school, I don’thave the stats for you on how many condoms are used fromthem, but they are healthy, the machines. They’re notdamaged, they’re treated respectfully [8:P9)Our Community Health Nurse feels quite strongly that thenumber of kids who come to the clinic is directly relatedto, and it’s a way of measuring effectiveness of ourprogram [8:P9].That kids will come to the nurse and ask for condoms;that’s a measurement [8:P91I guess I could say this week I saw_____whip in andwhip out of here with our one reference text on drugs andpills and obviously she was needing some information andshe was literally taking it with her, and so I guessthat’s measurable. She came in, she got the book, andshe left with the book. Whether she reads the book,whether she looks up the information she wanted to lookup, whether she loses the book, whether she uses thatinformation FOR some particular reason, she took the book237(Have to get it back from her) [laughter]. Or I see kidslooking at pamphlets, and reading them. They take themand read them. So that would be “measurable”. Did theysee the pamphlet? Did they pick it up? Did they take ithome? Pretty innocuous ways of measuring [14:P4]I think that they get a lot from it, and, certainly, inGrade 9, they remember us from Grade 8, and in Grade 10they remember the stuff from Grade 9[4:P5]More qualitative measures are also used by all theteachers involved. These consist of monitoring things such asstudent involvement and participation, enjoyment, comfortlevel, attitude and effort:We’re seeing that they’re becoming more and more open,with their questions and with their discussions, thetrust is starting. And something I found this year, justfrom doing it last year, is that already I can reallynotice their comfort level increasing. Like, last yearwe talked about, you know, penises and vaginas, and putup the overheads, or started talking about, you know,reproductive systems. They’d be just hooting, and reallyuncomfortable, and a lot of just carrying on. Butthere’s much more of a comfort level this year that’sreally quite noticeable [4:P5]As far as whether they’re enjoying the curriculum andwhether they’re gaining something from it, that’s onething I don’t think the government put out an evaluationform for students to fill out. But I generally can tell,just from the way the students have approached the unit,and, amazingly enough, it’s one part of Biology wherethey actually like it! A few of them get grossed out byit, there’s some pretty explicit stuff in the moviesespecially, but they have a real unique interest in it.And quite often the number of questions that come up, thehands just start shooting up all over the place. “Whatabout this?” “What happens if she does this?” Andsometimes in other classes you’re just trying to, youcould kill your kids to get them to ask a question. Inthis particular end they’re usually quite involved. Sothat’s sort of a measure in itself to me, you know, it’skind of qualitative [6:P41The quality of discussion in class, whether students usethe vocabulary and terminology that has been taught, along238with the concepts (e.g., negotiation, decision-making),whether they are able to speak back or write back what theyhave been told, and their growing ability to communicate, todiscuss and negotiate within the contexts of role plays andscenarios, are all measures teachers use to evaluate thesuccess of their programs.I think you can tell by the quality of the discussion,with who’s saying what about what [15:P9]I’ve seen with the conferences I’ve done in the past, theamount of discussion that’s generated afterwards, and theindividual students who’ve come and spoken to me, and theconnections I’ve made between professionals in the fieldand kids that need the help, for instance, the Alcoholand Drug Family Systems, you just see little light bulbsgo on in a lot of kids’ minds, and they come up and speakto them, and make appointments, and then you know thatthe ball is rolling and these kids are actually dealingwith some of the problems they have [2:5-7]Some teachers encourage students to evaluate the course,asking for comments on how they enjoyed it and how it could beimproved.The students are asked to evaluate the program; tocomment on whether they enjoyed it, how it might beimproved, and to rate it from 1-10. The comments arethat it is timely and good, and that they enjoy it[9:P2]Others still measure the success of their program by thepregnancy rate in their student population:Q: How many girls here are mothers?A: Right now, not too many. A couple of years ago wehad a fair number, but I think maybe we have twopregnant girls in the school right now. Which isnot bad, not bad at all.Q: But when you had quite a few, would that be 10 or12?A: Eight, ten. In a year. That’s probably the worstwe ‘ yeQ: Those would be girls who carried their pregnancies?239A: Yes. And they’d be from Grade 8 to 12. Like, oneincest case, and the whole, a little bit ofeverything [5:P8]In the last two years I know of six students that I’vetaught that are pregnant. That have had kids. Didn’thave an abortion. They had their child. They’re now,average, about 18 years old, I guess. And they kepttheir babies, which I guess, in some people’s mind wouldbe a positive thing, but, and I still result that back tojust not planning. In all of those cases, they weren’tplanned, they didn’t want to have kids, it was just amistake. And it just goes to prove the point that theydon’t plan ahead of time [6:P7]Unfortunately, there is a fairly high level of consensusamong the teachers regarding the fact that many students,despite their education, are still not availing themselves ofadequate protection:I still think that younger ones are probably practicingwithout probably birth control, without condoms [l5:P12].A: I guess the area that needs work, somehow, and Idon’t know exactly how to do this, is in the actualuse of condoms, and using the information that theyhave, and using the information they have may simplymean abstinence. Information I’ve seen lately talksabout a large number of kids who don’t use condoms.It flies in the face of all the information thatthey have; they may know it in their heads, butsomehow, that invincibility sense they have, beingteenagers, I guess, risky behaviour seems to follow.Q: So you don’t feel that your program is able toinfluence them in these ways?A: No, it’s not, no, I guess not [11:1:201]A: And if you survey a lot of the kids, which Igenerally do on their sexual habits, we do a littlesurvey, it’s totally anonymous, and it’s reallyinteresting to see what they write down, but thenumber of people that actually think ahead of timeto have condoms and stuff at this age, sixteen, isnot too high [6:P7]Many measure success by whether students are willing to240come to them to talk.As far as measuring it, I don’t see any way, it’s prettyhard to measure. I don’t know how to do it except to goby your gut feeling. And I know myself that lots of kidscome in and talk on a one-to-one basis, on whether tohave pre-marital sex, pregnancy, that kind of issues. SoI think if you go through the process with them in a kindof open-ended way then you succeed if they’re willing tocome and talk. If you don’t succeed, they won’t come,you know, once you get to know them. There’s no realconcrete test [11:1:239]Teachers who are presenting within a course context otherthan Guidance sometimes have the same students return forother courses. In that case they are able to observe thestudents, although they may not be able to engage them inconversation regarding “Family Life” topics.Student evaluations are a concrete indication that thiseducation is relevant to students and that they want more ofit.The students talk after they have the classes, and thatthey really like the classes and want more of the classesand they really liked having the peer counsellors in andteaching them, and made the Phys Ed teacher aware thatthey want more of that to happen, that they don’t justwant a teacher in there: “Let’s have the older studentsback teaching us”. So that was important for them. Sothe students make the teachers aware [4:6]If you ask them, [students] , and we’ve done a survey,they say they need more [2:5]We do some on birth control, but my students tell me,“Not enough”. They’d like to have more [3:P2]Q: Do you feel, overall, in terms of STD and AIDS, thatthe program that you’re able to offer within theconstraints of what your Principal allows is more orless adequate for the kids?A: No. And it’s interesting that kids still say theywant more, even though they have more here than mostschools do [2:5-7]241Finally, a very important indicator to educators is thequality of rapport they have been able to establish with theirstudents. This is measured by whether students continue tocome to them with questions and for discussion after theclasses or the courses are over, whether students use them asresources for work in other courses, and, for some teachers,by questioning students who continue to return long aftergraduation to visit.4.6.F Educator knowledge4.6.F.1 Knowledge of theory, understanding of teenagers, andunderstanding of how and why programs workEducators voiced the opinion that there is a lack of asolid research base to tell us what works and how to do it inthe area of HIV and STD prevention, as well as a lack of linkbetween theory and practise. Where there is solid research,there is a time lag between the research, dissemination of itsresults and its application. One person interviewed felt thatadults generally do not know teenagers and young adults verywell; do not understand them and what their lives are reallylike.A: If we really truly believed our product were healthypeople who didn’t get lily, then we would be doingthis in a totally different way. Because we’d getto know our consumers. If you want to sell somebodysomething you go out and find out an awful lot aboutthose people and what kind of things they want andwhen they would use is and how they would use it,and then you design your product for them. And thenyou make sure that it’s what they want, and you keepchecking it out.Q: So do you think that we don’t really know yet who242needs what?A: Yeah, and I think that certainly researchers havebeen doing some interesting research around this,and some of those articles are available. But wedon’t replicate that research, and we don’t applythat research. So people do a lot of this kind ofwork from old habits and old methodologies and I’dhate to think, but you probably, as you’re analyzingwhat I’ve said today, you might find that I’m reallybehind the times as well. Because we just don’thave that link, I think, between theory and practicevery well in public health or in education. Wereally don’t do that very effectively. And the timelag between doing something, researching something,replicating it, and then looking at it in the reallab of life, is years [7:2 end]Some targeted programs have been ineffective due tocultural issues. Those within the system do not have theresources to understand and overcome this type failure.A: We have put on programs for Indo-Canadian girls; theresponse hasn’t been wonderful. The Indo-Canadiancommunity has tried to put on sessions for them, andthey just haven’t flown.Q: What kind of sessions?A: Well, problems of being female in the Indo-Canadiancommunity, and how to try to deal with it. AndMosaic’s tried to put shows on too. Right here, inthis room.Q: Shows with what? A small group of girls?A: Yes, and they just haven’t flown.Q: How do you know?A: Because you maybe get 8 or 9 girls the first time,and the next time you get 2 and then that’s it. Forwhatever reason, I don’t know [13:1]The conclusion of this teacher was that nothing could be donefor these girls; it would take a generation for circumstanceswithin their community of origin to favour greater equality ofthe sexes.4.6.F.2 Risk factorsEducators hope that addressing risk factors early enough243I-QQhHC)H-CDI-I—i$2)C)I—a$1F—’“I‘L’J$2)HH-rtttTC)02rtH-H-H-..C)0CDW0CDCD00WCDC)CDF-jCDCDH,<C)0S0CD-SW[-hF-CDCUCD$2JrCDH-020C<rtCDH-0F--I—’02Cl)liCrH0<CD02ftC)CDCUCtC)CD-‘-<CiHCUctJCrH-CUCtftH-<CUH-HCUCl)H-rQiH-CD0H-CDH,F-ui02rCU0H,CDooCtCDHctCD-CDQ,H-><Ci’-<H-C1-$2)F1Cl)H,F-’-<0)CUCiQjCDct-Ci1CUH,H-CitCi02CiYiF—CtCiHCtH,jCDI-iFCiQH-hrr0dhçt‘<f—4CDCU02CUCD02QCUH-H-rtC)C)dP)Cl)QCDCDCrCDFCUCtC10)CDCDCDl—1F-’Cif-’H-CDH-Cr0HQH-dr’<F-1h0c)toCUOttOCDtn—ctftCDH-CUCDH-CCUCDtdCDCDCiC)CUftC)çt020)l1YC)h3flCUctci$2)-<CDCU)3<-H,ctctCUCiCDH-CDCt•00CDH-CrH-CDCnCt<CrCUH-hr0CtH,H-H-CD—$DIQICi3CDFH-CrrrCiCUCUN1Q•CDrtCD33CDCtCiC1,<00)CDhH--QiQ1>CflCDf—’<1h0CDH,CDH,Q,P)CDCrIQCUW0H-Cl)H,CDF-FCiH-H-QiH-F-Cl030FCU3•CDçt-CtCDH,H-FH3PJCUCOD)3<CDQiC)CrH-H-hQi—CH-0Cl)CDD)CrCrCDF-H,0)(PCUH-H-CDC)-)ftCDH-CiCDCUtWCrTCDH-ClCUCiCUCD00iJCUCDCflQCDH,<HICi•tDH,F—13<CDCitDH-QiftC)CDClCiHift’-<CDCi)t0$2)0QhQiCDCfH-CDH-H-’<C)Cfu)<PJCiOCUCtCl)F-$WH,itoCD‘-<IIH-0000CDQiF-1CDCr—)Cl0)0CDH-CDCUH-0bCD0CiCDQH-tH-hQiC‘-0W’dQ•CDCfk<CU<CDCtOF-iCiCDHctCU—‘H-IH-0)<H-0CDCDCl)•.CDiCl)rt0CtCDF-DhHCDctH,Cl)$2)3•CDCiCl)CDt)C)-•-JQiH-CD‘<CrCUF-’QiH-OI02rt(.Q)02F-H-CDCl)OH-ftCDH-00H{H-CDiCU3CiCUCDCiClCDH-02CD023—‘H,CfH-H,H,CtCD(PC)Cr(QftWCD-QiiQCD•02Cr0•H-HI-ctiH-CDCfWQict02Q‘Q,0)CiCDH,C)CUCl)CDCtCDCff—1Cl)0H-CUftCDCUD)CDCU-CDCDCl<$2)CDCDD)H1C1Cl)Cfr-,C)CDCUiXCl)0)‘tiH-CDH-F-1hCrQiCfCD0H-HQCrQCD0H-CUCi0i-i3CfCrCDCD<k<H,CUH-ftUiCrOH-H,CDCiCl)CU-H-<CDH,CrC)CDCfCf-0ctQit.Q••-Cl)CiCl—’Cl)0CUCDCU0H-CijiCDCD02CDQWClFClH,-tCDF-CDCiCl)<CDH-P)Ci‘<••iCDQiCDCDCDF-hF-I03Cl)CUr,biCDH-(QH-3H-CUCrCDdCUCUCUhH-H-çt$2)l-hH-CUH-CDYH,J’Q,rtCl)Qi—2C)Cl)Cl)0H-CUSF1C)Ctl-H,Cl)HCfH-OCrl-$F—’ctCU020CUH-‘—CU<CD0C)CtftCD0H-(QH-CUt<CtH,QiCrCDHILQCrr00H-’-<çt30F-’CUI—’biMCDCDH-H-QCDH-0H,H-CDCDCU0CD3CrCDb<F-’QCU<CDCl)CDH-0k<ICl)CfCD0•culSCiCU•0CD‘—‘F-’(-Q’<Nil<tY03-CDC)F—1C)CfCiH,•F-’Cl-CDCDCDCr•Cl)CiCDCfH-CrF--’C)C)H-CtCDCU<CUW1CUCU0CfCl)ClCUH1C)CDCUCDCDCrCfCDCDC)H-CDCU-j-CDD)D)CUD)3CU0-hHOCrCl)F-1C)CD><Cr<<CD(nOCDCDQ1CfCfCiCl)-CDCfCDCrCU•CiH-<CfH-CU00)F—’Q,C)I—’OCUI—’<ctJl-0)<0h0I—’0<0çlH-CrQi1Q1CrF—’H-CiCDCDH-H-H-F-’CUCiI—’CrCUCDCFCDClH,WCUCDH-tHCriCr<‘-‘‘<H-CD02CUH.CiCUbi‘-CUCU‘-<‘-$CiCrQH-CDCDWCDFiCtCDOCDC)ctCDCUF-1F-CDCl-OCUQCJ)-H,Cl)Cr-hft<Cl)Cl)CDH,CDH-Cl)CUCl)0Cl)CDI-’-0-H-CrC)CrCU3Ci)H,‘-QOCUCl)3CD0<‘-csP1I-‘-ijHIP1i0P1P1C)HioCDH-Ci)0iCl)HI<Ci)k<P1CrftCDH-t:-Ci)I-0LCDP1-H-FlCtP1P1HiH‘dHICDP1P1HIF-1Fl1P1L’ICi)CDiCi)Q-0iCi)p10FlCD0C)HiQC)P1ftH-ftCD0dP1H-H-iQP1ftQQI-H-iCDC)Ci)CD0=1FlCi)CDP1ftCi)bP1I-H-P1çtCDoP1FlCDoiQCDCr11CD Fl(Cp1Ci)1<‘tiCD-.ftF-1QP1ctCDHIHiCDSU)ft--CDCDCD0CDXSCr1ftftCDP1CDHiHI0FlQIH-P1h0CDftI-5jk<<ftCi)ft5ftCi)Ci)HICD0C)CDCrCDHitCi)o—CDP1Fl-H-SFlSC)C))H-P1Hi0H-CD0tFlCr1F-1Ci)H-0Hift<o5CDFlCDP1Fl<Cl)CD-•P1HIiCl)dC)FlQICl)CD0Ci)F-1—CDC)CI)HiH-oC)Fl5JH-0HiS0Hi5000FlF—ft5H-Ci)5P1C)HIH-ftP1-<Ci)H-ftCD0H-FlI-QoCDI-IP1QFl CDP10P1H-FlP1QIiCDFlC)0LXIH-o—HiQIoojC)FlC)P1P1QCDP1ftQIH-ft0CDP1Fli.QP1(-QftCi)ftP1:3P1H-H-CDH-C)oiH-hItIft0•0C)HiH-0CDHII-HIftHISCDH-CDP1Ci)P1H-0‘-I(Q(QCDCCr1Flt0CDftC)Cr1I-ICDHIftCDCr1P1H-P1FlftSP1C)CDftCi)Cr1HIC)P1HICDCi)P100Cr1C)0ftCDHIHICi)ftCi)C)-0CD0HiFlHIiCDHIH-P1FlCDftCDC)CDH-fto<1CDi)CDH-Cl)iCD0ftC)ftCD0FliCi)QI0H-CDHiP10Ci)jh Cl)P1P1Ci)tQCDCDC) H-ooP1ft‘-IHIC)‘-ijLXIohIQIiCDQ:iC)C)P1C)-ftftH-CDHI0S S-:CDH-‘-IQIftCi)HH-Hi0HiCDHIFlftC)CDCDHIFlP1ftiCi)HIP1Ci)‘<ftCDICDCi)P1Cl)HIC)CDoCi)S0 F-’P1LXICi)—Cl)l-QCDHIFlH-H-Cr1CD Ci)P1oCi)HiP1Fl‘-<Cr15dHiP1LIICD0ftP10C)QCr1siC)FlHIC)0Cr1QIftHICDC)HiCD0Ci)P1hICDP1i00Ci)ftC)CDftHiHiH-H-CDHIFlCr10Ci)CDftftdI—’io‘-<FlCDQFlP1CDCDFlC)CDftCDft0Cr1ftFli.QSP1JCDCDCDCDFlSCr1P1IFlP1p1CD0H•.<1ftC)Cr1Cl)ftCDP1ft0ftl-QftftH-iCi)CDP1H-P1iCDC)<i(Q5H-Cr1C)CDP1HiC)0CDQH-ftHiCi)FlH-C))CD0Ci)CDCi)Fl0C)Cr1Cl)bH-P1HIP1ftCDP1P1ft005Ci)HIHIP11H-CDCi)H-H-QIP1Cr1ic:iCl)P1QCD1FlCDft0CDP1.QftH-FlCDFlCl)U’00CDCDH-HIP1C)ClCDLxiftftFlCi)CDCi)C)CD0CDCDClC)CDHiP1CDP1ftftiH-iCDH-HiH-Ci)QIP1P10P1C)ftC)Cl)HICDft0H-H-Fl0P1ftLy’HIi<P1HiClFlt.QH-HICDFlP1HiCDFlQCDFl05H-P1P1H-FlP1:idP1ClP15ft.QHidftH-iP1CDCl00CDHICi)ftFlCDFlFl‘-<H-H-Cr15ftH0P1ftP1Ci)P1HIH-ft0Ci)0H-H-bP1H0ftCDH-Ci)P1—C)HIHiP1P1F—’Q,ftClHICi)HICDCDCD0 C) C) CD Ci) Ci) ft 0 P1 ft CD Fl H- P1 HI Ci) P1 I—I Hi 0 Fl S P1 ft H- 0ft CD P1 C) H S P1 ft CD Fl H- P1 HI Ci) P1 Ci) P1 Cl CD Cl P1 ft CD Hi 0 Fl S P1 H Ci) ft Fl CD P1 S C) HI P1 Ci) Ci) CD Ci) Cl ftCD H ft CD Fl H-CD CD CD Ci) CD Fl CD P1 IQ Fl CD CD S CD ft ft P1 ft P1 C) C) CD Ci) Cr1 ft 0Cl)dCD 1<CDCl)1HpiC)PH-<jCDrnCl)-CDCD ftCDoC) 0C)CDft 1 C)C)Cl) •P CD Cl) UI H P P CD 17i H ft CD Cl) ft0 CD CD ft CD U) CD CD 0 P CD H p.) ft H C) P p.) 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In the washrooms.Q: Just in the washrooms?A: They could get them through the counsellors, too.But they’re in the washrooms, and I don’t know, butrumour has it that maybe three have been sold in thelast two years or something.Q: It could be embarrassing.A: Anybody could walk in while you’re using the condommachine, that’s embarrassing. Personally, I can’teven go to a drug store, I mean I don’t use them anymore anyway, but when I was younger, I wouldn’t evenwalk into a drug store and buy them, I was just tooparanoid about people seeing you and looking at youand stuff, so personally I don’t blame anyone whowould be embarrassed.Q: So you would say that their access to condoms is notreally very good then, because there’s no sort ofneutral, it’s not a neutral issue?A: No, they’re here, but I think, and you know, I teachall the guys in grade 9 and 10, and I think they’re,if they were going to get them, they’d get them froma friend, or from somebody else, or maybe even hopethat the girl has them, as opposed to having to goto the machine and buy them. And I know I’ve seenon TV where they’ve interviewed custodians fromother schools that are responding, and they say“Very few of them get sold”. It’s just anuncomfortable situation [6:P6-7]There was general agreement among the teachers that whenthe “Family Life” Program was first mandated by the Ministryof Education in 1987, adequate in-service and resources wereprovided. However, since then, no training for new teachersof “Family Life” education and little updating of resourceshas been provided by the Ministry. School districts havevaried in the amount of in-service and training made availableto new teachers, but it has been steadily declining. Duringthe past two or so years it has been considered inadequate by248the teachers.Because of cutbacks in counselling departments, in someschools counsellors have had to turn over the responsibilityof “Family Life Education” to regular classroom teachers.This means that students and counsellors do not have as muchopportunity to get to know each other, and paves the way formore students to “fall through the cracks”. When specialistssuch as the Red Cross come in to present programs (e.g., childabuse prevention) , they recommend that counsellors payattention to certain students, but this is not considered bycounsellors as good as being able to observe and get to knowthe students more closely themselves.Unfortunately, some new teachers have had to present theprogram without having received specific training. Oneteacher mentioned not knowing how to teach valuesclarification, which would be considered by many to be anintrinsic part of an effective HIV/STD and pregnancyprevention program.Q: Do you do values clarification with the kids at anypoint? Do you try and help them clarify what theirvalues are regardingA: I don’t think we do enough of that, no. In fact,even just thinking about it, I don’t know how Iwould try and do it. You know, you assume that theyhave their own sense of values and morals, but as toget them to share them... [6:9]Nurses receive training from the Centre for DiseaseControl and from their health units, and this is stillconsidered to be adequate. However, nurses have less time tospend in schools than they did formerly.249Others, like this science teacher, do not feel a need forspecific “Family Life Education” training.I relied mostly on two things: one, my biologicalbackground, because that’s what my degree’s in, and,secondly, just my experience as a grown-up, having been akid. I consider myself like the majority of these kids,you know, your parties on weekends, and so on, so I’vebeen through it all. So I rely a lot on, you know, justexperience {6:P8]The educational system is currently experiencing severecutbacks in professional development, teacher layoffs andcancellation of programs and extra-curricular activities.Within this atmosphere it would seem difficult to implement anew program and philosophy.4.6.J Organization Issues4.6.3.1 Co-ordinationFamily Life Education and Learning for Living aresuffering from lack of co-ordination within schools and withindistricts. When FLE was mandated in 1987, each district had aco-ordinator who was responsible for overseeing the program.Since then, funding has not continued for the position, andalthough there are many teachers with the necessary expertise,they are back in classrooms teaching and devoting extra hoursto trying to make “Family Life Education” or ITLearning forLiving” happen.A: If the government would actually provide funding sothat within the school there was a half-timeposition for that, then you could do a proper job.You could make sure it was integrated into yoursubjects; when Social Studies is studying Africa,for instance, you could have AIDS taken during that250time,Q: So you’d like to see a half-time position for aperson to co-ordinate the Family Life Program. Halftime for each school?A: Yes. And perhaps for the large school boardscertainly a position at the school board where allof these people would be brought together and coordinate programs [2:5-7]Planning and co-ordination between departments could bemuch tighter with benefits to all sides:What I would like to see, though, is a lot more cooperative effort between the health department and theschool board on a senior level of business, to say thatevery student should receive And then let’s look athow we’re doing that, and have a lot more supportive, butauthoritarian type of direction, so that you’ve got thesupport from the underneath with people who are keen andinterested, but you also have resources being given toit, and time for training being given to it. In otherwords, if we say teachers are going to teach “x11 numberof hours per year, then they have to have flXT number ofrelease hours, and we have to pay for the training. Andwe have to have a pre- and post-evaluation of what thekids learned. If those things were all in place, I thinkyou’d have a much better chance of the kids getting whatthey deserve to get [7:2:229]Counsellors who have to work with the Ministry of SocialServices find that catchment boundaries are a problem.Once the resource takes over there’s sometimesdifficulties because the MSSH model is all based on wherethe kid lives, and so if it was based on the school thekid went to, we’d have a closer working relationship[11:2:34]There is a lack of co-ordination within each largeschool, within school districts and between health units,social services and schools. For ‘Learning for L±vingTI thereis confusion as to who is going to present it. Problems withregard to who would teach it and how they would get theirtraining were mentioned.251A: If you can somehow integrate the skills across thecurriculum; assertiveness, decision-making, lifeskills; but in other subject areas. And I thinkthat’s the basic plan of Learning for Living, if itever does come full tilt, right across the province.Q: So you’re looking forward to the Learning for Livingprogram?A: I’m looking forward to it; I wonder about trainingthe people who are going to do it, and who’s goingto do it. If counsellors do it, then we’re going tobe Learning for Living Teachers, and then we’re notgoing to have time for counselling.Q: What would a Learning for Living Teacher do?A: There’s quite an enormous number of hours devoted toit. Originally they thought the Humanities; Englishteachers, Social Studies teachers would teach it;then there’s a contradiction as to their trainingand their comfort zones; traditionally thecounsellor’s been involved in presenting that kindof material; if you were doing it, the number ofhours is quite high. ... I can’t remember how manyhours; it’s a lot. ... I wonder who else would do itwith the counsellors. Counsellors seem thenatural For example, AIDS, you could do, youcould read a story in English, a novel, dealing withAIDS, homophobia, relationships, or whatever. Dosome things around values, decision-making, withEnglish. You could use Social Studies, the origin,studies, Statistics, Science, the study of thevirus, ... You’d need a co-ordinator. If you had aco-ordinator, and the other teachers were willing totake direction, then a co-ordinator could make sureall of it got covered [11:2:99]4.6.J.2 TimeA major enabling factor for teachers is having adequatetime. Teachers not only have to cope with trying to presentthe course in a very limited amount of time, but they oftenhave to fight with their colleagues for that time.Time within the school. When you do get them to give upthree hours, it sometimes takes some fighting to getthose three hours, even though it’s supposed to be tenfor each grade [2:P5]252I went to the Principal, and he said, “Well, what’s theminimum that you need for the year, the minimum number ofhours, and where can we pull it from? And the P.E.department gave us a certain number of hours, whichwasn’t quite enough, so we pulled some from the Englishclass, and they did it begrudgingly, really, but did it[4:P2-3]Virtually all those interviewed felt that not enough timewith the students was available to them. They need time touse more varied teaching techniques, to review, to assess andevaluate. As one person said, and this represents the feelingof many:I think that what we do in this IlFamily Life Education’program is critical. It’s so important, and to just giveten hours to it in one year is not good enough [l:P12]There is not time for values clarification or for roleplaying. There is really only time for informationdissemination in class, sometimes in small groups.Communication and negotiation skills are not taught aspart of Guidance [9:P3]Q: How are you able to model behaviour for thestudents?A: I don’t have a whole lot of time.Q: Are you able to allow for rehearsal or practicetime?A: No. We don’t have enough time [l:P91.They lack time for checking learning outcomes [8:P26-29]Teacher 1: I would really like to have some kind of amechanism for determining the success ofmy program.Teacher 2: We never have the time or the funding todo that.Teacher 1: No. We have no way to know, and that’sbeen right from the beginning, we have noway of knowing, unless, I don’t know,birth rates go down, sometime in thefuture [1:12-13]Nurses find the same kind of constraints as teachers whenthey attempt to deliver prevention programs in the schools.253A: Skills that are important? Assertiveness, learninghow to negotiate a relationship, learning how to getinto a store and buy condoms, learning how to put oncondoms, being able to anticipate events and talkabout what might happen. I really would like to seekids doing a lot more role-playing.Q: Is this happening when your nurses go in theclassrooms?A: I don’t think it’s happening very much. The timeavailable is one of the major factors. You don’tjust go into a classroom and do this the first hour.You need to do this in a really well-planned waywith kids. So you probably need to have at leastfive or six hours of classroom time to really startdeveloping that type of work. And I think ithappens extremely infrequently.Q: Are concepts and skills reinforced over time in anorganized manner?A: I would say, “No” [7:2 end]Teachers also need more time for professional developmentand for departmental meetings and communicating withcolleagues.Major concerns with regard to “Learning for Living”include where time for implementing it will come from andwhether it will be a separate course, and if so, how it willfit into students’ timetables.A typical comment was:Q: What about the “Learning for Living” curriculum?Have you been able to move into that at all?A: No. We haven’t moved into that much, no. Justhaven’t had time.Q: Do you think that the “Learning for Living” guide isgoing to be more helpful than the “Family Life”A: I’m not quite sure where they’re going to get allthe time to do it all. It’s so encompassing,there’s so much there, in all areas... [5:P11]And the concern we have right now in this school is,we’re having second guesses as to where we want to teachthe course. With “Family Life” right now, I don’t mindit in Science 10, but we’re finding, for example, in PhysEd., it’s taking up a whole block of Phys Ed time.2541U)CD0Q,5H-CDC).hU)pQ-DCDKD0QC)YrQF-H•H-CDCDH-CDC1CDWH-)CDH-CUH-H-CDI-CDctCDCtU)piU)CDCUH-PC)QC)Zi,hhrrrtrtC)CDCQCUCD0H-CD0H-D_CUCUCDH-U)CDCl)rOr1CDctC)ti.-hC)I-hH-c-rc-tCDU)rC)dH,hOHH-CD30U)H-•rtC)U)H-Q,CDCDCD—CDQCUH-0CUCDU)•OCDCDF-U)CUU)00C)0CUQC)rthC)I.<CDHFJk<5rt-U)hCDOU)HH-H-CDC)U)hU)CDCDt0CUrtrl--—QH-CDCUbH,rt$rH<CUCDrtHQQH-rtU)CDH-rtOH-QCU0H--JCUCDU)rrOCUOCUH,U)CD00U)OCD01H-hQ.CUPU)‘-0Q0CUO0CUU)U)$C)0CUCD5iCD0H,CUU)CDCDU)JI-5QH-rU)CDU)CDF-iC)-CUCUH-CD‘1CIHU)U)H-H-H---PJH-F-’U)OHU)CD00CDrriCDrt’-dQc1CDU)C)H-H-çtH-U)CD•rtCDOCDH-bCD---.r0QHP<50-F—5-OU)rtCD—CUOL’iQQCUH’-<CDCUQU)CDH-L’iciCUC)-CU(1H-rrf--H-H-CUCDH5OQ5CD&cirirtt1Q.‘dQJU)CUI—’rtHC)CDH-ctC)-hci—‘U)ciH,0CUr-I-OOCDH-CDCUOCUH,C)10Cl)CDC)U)OCDCDCUrI-Ok<f-I-i55OCUOCDH’.MCUiH-f-tCD“Jf-I-CU<IH-I--CUCDrtO(QPJ-Jrt<TH-CDPrI-CUrI-I-CUU)CUH-CUH-H-hCDO<rI-CDCDc-I-H-CD(D:C)OØH-ctdCDI-CUU)<PJSf-I-C)<f-I-C)U)I-<0QQCDU)CDS‘-<hiOH-C)t’1CD<I—H-CUCDOCDk<—U)CU0f-thjCDciQi.QrI-CDCDH-CDCUCUI—i—0HU)OOCDU)OCUH-HciSCUOC)CDHMCUf-I-C)f-I--<GCDF-OCDLxJ(-HO<CDctH,CUCDCDCUrI-H-CDrI-CUCDUiCD-Hf-I-f-rECD•.51—IU)0ClOCUCDH,F-5—,QQifriCUI-H-UiQ-<jCD‘dH-CDCD‘-<(QH-cicijH,H----CD•CDCUC)H-I-JC)H1-QCUC)<5H,ci(.0--rI-I-F1f-I-F—i0H,CDcicii(.QCDCUctCUftCD—-f-tOf-I-‘dJHCDrI-H-CDI--’U)CDU)QC)cl-CU-<jCDH-HFHOH-<U)I-OQ-l—CDH--<CDI—=C)ctNSf-I-rI-QCDCDH-rI-CDH-CUtl)-f-I-(.0CDOCDOf-I-U)Q.U)I-H-CDCDOS0SHiU)f-I-f-I--(.0-Q5C)k<j—IQU)QCDH-CDCUU)0CUH-U)H-(.0‘ti—OH-CDH-rI-U)CDCUi-U)rI-f-I-—U)CDCDOHCDU)H-F-1f-I-f-I-H,f-I-HTf-ICDH-CUCDOH-CD0CDCUQ.H-C)f-I-—H-H-Q.H0CUQHC)—HH-H-H-<—f-I-CDf-tHH-5H-OH,CDU)(.QCUHHH,HrI-OI-<H-HHOOctCDCUCUU)t’tiH,U)CDCDCDH-CUCUf-I-U)OQbrI-H’-<hH,-HHH-7c—H•CDCU0f-I-tYC)rI-h<CD0‘-<H-’tCUCD3U)U)f-I-HQCDU)H-rI-‘.<f-I-H(DQQCDIQU)I-C)H,Hf-I-<CUOCDC)C)OCUCDH-OCD(-QCDCU00CUci0CDiCDb0CU(-QSCUU)CDHCUCD•C)CDrI-f-I-H-YCU0C)H-CDH-H1rI-HCDCUf-I-rt0U)(.QhC)0HrI-frf-I-Of-I-HC)U)C1)CDCUHH,CDCDf-I-CU<CU00CDh0—CDCUCDC)U)HQQ.CU—SCDH-Q0CDf-t:CDFICflCDO-0U)SSQCUCDU)—-<U)H-CUhCUU)CUU)ECUU)I-ciU)SQCDb’C)CUCDrI-CDf-I-f-I-CUrI-CD(.Qf-I-0f-I-U)C-irfCUCDCDC)-CDCDH0U)F1SU)CDci-iCD-50I-U)U)0)H-CDHC)0H-CDCDCD-00U)0frU)H,CDtJ-CDf-I-0I-H-H-U)5HH-CUf-I-C)’—<C)H-0CD<OH-CDU)C)CDHrtCUf-I-C)CDCDf-I-k<OHCUCD(.0CDf-I-CUCU‘---H-OCDCUCDJhH-CUiH,1OH-C)0.0U)U)0CDHI-H-CDCDci00CDC)FOOCD-U)0-HCDCDCDU)OrI-CUCD--CD<QCDCUH’<CUCDCDrI-h(.f-I-Q)I--<HU)f-I-CDCDU)f-I-f-I-s‘-<-0f-I0CD0CU0and restraint and all these other things. So yeah, thatis, it couldn’t be worse. [What problems has it caused?]The students can’t hear, their focus is less, there’ll bestudy halls going on there at the same time, there’ll beworkmen wandering through, even teachers wanderingthrough, you get cooking odours, you’re using cafeteriatables that are designed to seat eight people, it’s justlousy [13:1:255].4.6.J.4 StabilityThere is a lack of stability within the school systemthat is making it very difficult to plan for theimplementation of ‘ Learning for Living II. One counsellormentioned that every year the counselling situation in theschool is reorganized, depending on staffing, finances and howthe Principal wants to use the resources [11:1:448] . A moreconsistent approach is needed as to how to get the time.We negotiate with the subject departments to get ourGuidance time, so some of it comes weekly, some of itcomes in workshop/mini-course format, some of it . .. Iguess maybe that’s an in-house concern [11:2:180]It is basically left up to each school to decide wherethe hours will come from and what will be presented.Q: So you just have to negotiate hours out of othercourses then?A: Yes. That’s the problem. Everyone’s curriculumsare full.Q: Don’t they have a certain number of hours that theyhave to teach, too?A: No, they have a certain amount of curriculum theyhave to cover. The school overall has a number ofminutes that have to be taught each year, but itdoesn’t say how they have to be taught, to be used.Q: So part of it is getting the other teachers to agreeit’s important that the kids have Family LifeEducation IT?A: Yes. Good luck, right? [3:P7-8]256A: To be honest, I’m on the timetabling committee, andthis hasn’t even come up. I wouldn’t be surprisedif Family LifeT’ just sort of slips by and mighteven fade out because everybody sort of forgetsabout it.Q: Do you have the power to mention something likethis?A: Oh yes. I hadn’t even thought about it until youmentioned it [6:P3]4.6.K Professional Autonomy (Positive outcomes:innovation, creativity, lack of interference,freedom to choose style, strategies, content;Negative outcomes: lack of accountability andstandardization)Teachers appreciate the sense of autonomy they have inthis area:There’s a high degree of professional autonomy in the wayour contract says it in terms of our curricularpresentation [8:P23]And:In Guidance we have almost total latitude to teachwhatever we want. There used to be a provincialcurriculum but I don’t think it’s been looked at sinceabout the late 60s, so in______with the school boardand the expertise of some of us who have been around along time, within our own schools we develop a programthat seems to meet the needs of our own unique students.That’s kind of an exciting way to go; it’s not kindof lock-step or rigid. It seems throughout the[district) that somewhere between 15 and 20 hours is allwe can squeeze out, as well as providing the counsellorstime to see the students and their parents and whatnot ina counselling role [12:1:198]An interviewee from a health department, however, doesn’tsee the latitude given teachers as necessarily positive. Thehealth department does not have control over the presentationof prevention for STD5 and HIV within the school system, itmerely works with the schools, and although it may have it’s257own standards, they cannot be applied within the schoolsystem.Our standards don’t relate to the education, because youcan’t set a standard if you can’t manage its outcome. Inother words, I would like us to say that all studentswill receive 26 hours of education on STDs, birthcontrol, AIDS, etc., and that they will demonstratelearned knowledge through those programs. But becausethat’s not our “responsibility”, and we are onlyparticipating in it, we can’t really set that standard.The school board hasn’t set that type of standard. [It’sup to the individual schools?] That’s right, and that’sunfortunate I think. The Ministry of Education, as youknow, has got the mandated Family Life Program and thestudents are supposed to receive a certain amount of timeand certain subjects, but it’s not ever followed throughon. No one ever finds out if they actually receive it,and worst of that, no one’s ever really finding out whatthey’re learning, and if they’re learning. I find itinteresting; we test kids around math and English andscience and socials; I think there are ways of assessingkids’ knowledge and ability and skills even on thesesensitive subjects, that people could adjust to andmanage, and then we could really have a better sense.The only way we can do it now is to do Youth HealthSurveys every five years, and find out the outcomes.Well I think we could do a lot better work ahead of time[7:1:375]4.7 REINFORCING FACTORS FOR EDUCATORSReinforcing factors for educators include social rewards,moral support and encouragement from students’ parents,immediate colleagues and other school staff, and studentsthemselves.4.7.A Parental involvementThe predominant message from educators concerningparental involvement was that parents are disinvolved.Although some teachers were happy to have parents at arms’258length, more felt discouraged or disappointed at the lack ofsupport from parents and at parents’ lack of involvement withthe school regarding sexuality education. Teachers felt thatif parents were to be more involved and supportive, more couldbe accomplished in terms of risk reduction or harmminimization for the adolescents. One person described the[lack of I community support in this way:I guess the community support has almost been like theschool board; it’s apathetic receptivity. Because againwe haven’t had a lot of resistance from the public . . . soyou can go and do whatever you want, but that’s notalways very supportive because no one’s ever demanding,or asking questions; I’m always amazed at what parentsare willing just to pretend happens. I would like to seea lot more lobbying from a parents’ point of view[7:2:314]Although at first glance, it may look as if parents aresupportive, they do not seem to follow through with supportand pressure where it is needed.A: Yes, parents are very supportive. We go out and doa parent night, and they say, “Lets get at it.”Q: But they’re not really exerting enough pressure,they’re not making their will known?A: No, they’re not showing up at school board meetingsand saying “We’ve got to get “Learning for Living”off the ground, into schools.” The people who aresaying that, are, again, the counsellors [10:2:70]In another circumstance, the teacher in charge of “Family LifeEducation” for the school was faced with controversy fromparents and from other staff within the school.Q: What do you see as potential barriers to the successof your program(s)?A: Attitudes. Attitudes that if I teach it, it willmake them sexually promiscuous; that if I say theword “condom”, they will go out and use them.Q: Whose attitudes? Community? Parents?A: Not community. Parents, other staff,2590 (-Q S0 0CtH-1:-iH-H5CrH,CDCDCDCDLii0U)1CrQICDC)PiCD01P)ji-Ct0CDCDH-CrQI00CDH-=H,Q ::j—F-’U)SDiC)CDCr5U)0CD0U)i0DiCrCrF-’(.QDiCDCDF-’Q,U)çtCfJDif-rJ-CDb0CD0C)CtH,CCtCDC)CfCfU)CrCDCDCDCrF-’DiF-’()pi0CrI-0CDQh‘-dHI—iU)DiDl-SCDC)U)CfjCDC1U)ICfDiDiCDCffr. 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It would be sort of nice if they had thatconcern or interest. My guess is, however, that many ofthose consent forms are signed [by the kids]. ... Theforms are written in different languages so language isnot the barrier. I think its, the kids are afraid theirparents won’t let them take part. There is an evengreater barrier between the school and those parents whodon’t speak English; they see it (the guidance program)as promoting western promiscuity. It’s not a barrier tothe kids being there; the kids are all there. But Iguess my own sense, of wanting to have improvedcommunication between kids and their parents, and honestyand trust and those kinds of things would be enhanced byit. From the kids’ point of view, probably not, so it’sprobably my sort of pie in the sky. The problem is thelack of integration of school and home. It is cultural,but it also is generational, typical parent-adolescent1l:l:end]Some schools send home consent forms, some describe theprogram in a newsletter or booklet sent home, and some do notask for consent. One teacher mentioned sending homework forparents and students to do together. This would take place inabout 4 out of the 10 Family Life Education classes (at theGrade 8 level).We don’t bring the parents into the school (I have inother schools that I’ve been at) for discussion of, youknow, another generation giving their opinion on loadedtopics. We just haven’t done it here. So theinvolvement is just basically to let them know what weare doing here although also we periodically show the4This is a school with a fairly high percentage of EnglishSecond Language (ESL) students. Because of family dynamics thatdevelop when the children learn to speak English before theparents do, it is even more important for the parents to havecontact with and input into the childrens’ education.261materials and the methods that we are using to ourparents’ advisory group. It’s part of the school boardpolicy that you do that. ... Regarding informed consent;we send a one-way letter, basically, saying what’s goingon. If the student doesn’t want to take it home I figurethat’s between them and their parent. But we don’trequire them to bring back a signed form [13:1:165]We do not ask the parents for permission. The parentsreally seem positive, maybe relieved, that this is beingtaught in school. In the first newsletter we write upwhat we will be covering in Guidance this year and invitethe parents to call if they would like to discuss it.They never call. I take that to mean they trust us[12:1:540]Most of the parents don’t think their children aresexually active [9:P1]Q: What about parents? Are they supportive?A: I’ve gone to parents’ meetings and sometimes talkedto them about the program, and the parents we seeare very positive about the fact that it’s beingdone. ... I think probably with some of the ethnicparents, they may not be all that aware of what we,in fact, are doing. But I would think most parentsin our community would find it a difficult topic toraise with their kids and I think probably most ofthem would feel quite comfortable knowing thatsomeone was doing it.Q: Do you get parent consent?A: We put it in our booklet that that’s what we’redoing, we’re doing “Family Life” and “HumanSexuality”. A couple of times parents have sentnotes saying they do not wish their children to takepart in it (for religious reasons) . That hasn’thappened in years [15:2:240]Q: Do you have anything that you send home? How arefamilies involved?A: Not with STDs, no.Q: It’s an elective so you don’t have to get consent oranything?A: No [3:P6]4.7.B The general publicThere seems to be a general lack of political will to put262Cy0cCcvCtC)<1c-C0ctCDCDCDCDcvU)))Hk<H,)JcvcvCDCl)CD-HCtcv—hCDC)HCCC)t-CrH-5H-ci3CCCDCC0çtCl)C)CD0-C)cvH5yH-H-C)5Cl)0C)U)Ht-iCCCtZQ.Qi0-<‘-<[-i000hOCt--ci)JCl)ci)CQCt000OCDH,Cl)H-CD3(P5CD-Cl)H-C)CCCDCDJC)H,CDCDC)-<CDCCH-))0H-CD)-CCU)CDH,CDCD0H-(Pc-tCtC)H,CDU)Cl)CDC)Cl)Q-••cv><C)i-CCI-)0U)0(PcCCDcvCDHHCCH-5CDcv)-C)0CDCDSH-cvU)CD5(PcCCl)cC‘<HCUcvCJ)U)CDCDCDH-iC)U5CCF-CDCU0H,H--0Cl)H,CD5cCCC50C)CD-Q1CD0hH-0Ii0CDhU)H,PJCUOCCCDCDCDHH,CDCCIICCQCl)CDflb(DCCCI)CDQiiHCDH-JJU)c1JH-y5Cl)Cl)CDOcvhhcv—CCCCCDF-C)C1-CDCDcv0CD-CDciCl)HCCC)H-cvU)ctC)CD(PCDCDctCDcv0C)(PCDC)CDCl)H,cv-<0CCI-C)H-H-3H,tCDCl)H-CflCUI-CCCl)cvcvcCCDO3iQCDCDH-C)CDCDH-U)<C)0H0HQ5(PCC(PCt1U)Q,0U)’-<QCCH-CD0cCHCCk<H-S‘-<cvCDCDCD-H0-CCC3CDCtipit—1CDCDC)HcvcnctCC(PCD(Pcvp1ttYHCUH0CD0CDCDCtPiC)IHQU)CCQH,Cl)H-OH-OH-H--‘CCcvC)CDH-Ct3CCiI-5rtcC0CCciQCDhCCCD(PCDOOH-0CDc-CCUH-H-CDC3ct(P<0U)CDCO0I-jCDh3CtI-Qp1U)CD(P0CtCDFH—iH5çocvdCDCDdH-pl01.h<CD0U)CDCD--(PHCUCCCCiJQ1CDICCSCUCDpi0CDCDtCrI-’CDH-JCtCCHt’CDCU5hC)cvci1t3CD—CDIICUWrtQCCCDCDU)CDU)QCUCCb—U)CUH-CD5—hOciH-0k<H-3PCCCCDH.1cvCCCUU)C)hCDU)H-H5CcvCDCCHH-CCCDH-HI-H-HHCDOPiQ-ciCDCCiU(PCC0tyH-01C)U)3CDSHH-0CUcv5HPiiCl)05CCCDH-—C)çCCUCD‘<5CU)HH-CDiC)CC0)-CD(PCtH,CDCU0U)HU)HCtCtC)C)iCDCCDH-H-H-0ClCD<OCDU)CUCD(P(PI-H-5CDU)I-j0Cl5i-U)H-’iCCCDCCI-cv0CtOiCD0H,CDHU)CC-—HC)C)JCtI-hCt(Ppicv0Ct0CUCCH-H-(CDHCCCCU)ClC)ClCDiI-U)l-C)5CU1F-PiHCUCDH-iF1<OCDpiCUc-tCDCDCDCCCCty’CDU)OU)CDCDCDH-i00P1rtCt5C)Jcv-CDH,U)U)ClU)(Pc-C0H-CD-C)DU)CCCDClC)C)CC—HiiU)dCD0iC)CC0C)HP1OU)H-00U)piCCCDCtCDU)H,<JCt0H-CD-.tU)CCH,FlCUU).—OCDOOU)CD05‘dU)C)iicvH,<iCC-cvH0CDH,CDC)C)CDdHU)U)H,----SClcv•-CCCC(PH<U)H-HIii0H1<hCl)CDCDH,CUCl)H,COOCDH-cviU)Cl)Fpi—CiO<U)HHCl)H-H,H-CDCtH-5CC-CCCUU)•PiH,CDH-HHCUjH,CDU)OhHcvCDHClcv<iU)HCD000‘dCCS—-.i‘dCDcv-<I-H-0bH-CDU)J1F)0U)ClCUCC)CCDCUC)HiU)U)CU-U)U)CDH0—OHJH-Cl)<-CD(P—cvH-ClCUCCt3—•ClbcvHH-HCDCCCDCCCCCH,CCFCDHi’-<U)H--0CDCDCD•CD01CCCCcvcvi-iHQS0CDHCCHexpertise and feel comfortable in this area and others do not.The depth of communication among teachers of “Family LifeEducation” varies according to their job classification andthe school setting in which it is taught. Where counsellorspresent “Family Life EducationiT in Guidance classes, there arecounselling department meetings and shared in-service andprofessional association goals which create opportunities forcommunication. Similarly, teachers of Home Economics shareideas and resources at workshops and through nationalnewsletters. However, some interviewees did not know whattheir colleagues were doing in the area, and none of theinterviewees were aware whether teachers of other subjects,such as English and Science, were presenting similar orcomplementary material. A comment by one intervieweeexpressed this desire for feedback and communication.A: I would really like to learn what you find outthrough your research here. I would really like toknow what some of the others are doing, and howthey’re finding it. The feedback on what we’ve beendoing for the last five years really interests me.Q: Feedback from whom?A: On anything. I guess on, are we doing a good job asFamily Life Educators in this province? Ever sincethis information came out and was put out by theMinistry. Is it working? [l:Pl3)4.7.D StudentsStudents were said by all educators to be very interestedin and supportive of the programs. They love the program andmake their desires for more known to teachers:264Oh boy, we’re getting it again! [15:2:230]In one school a student health committee has been formed andgives feedback and direction to the program:We have a student health committee. We’ve got them tobrainstorm things that they wanted addressed in theschool, and some of their concerns included drug andalcohol issues, eating disorders, STD, HIV. They wantedto hear more from peer type or younger people; theywanted guest people to come into their class; they wantedpeople who had personal experience to come and talk withthem. They wanted more in [Grade] 11 and 12, not juststopped at 10. [They were concerned about] smoking, selfesteem, and tolerance between cultures [4:P4]The next section is a generic description of the program,the outcome of the above predisposing, enabling andreinforcing factors influencing educators’ behaviour. Thisprogram is the educators’ attempts to influence and usestudents’ predisposing, enabling and reinforcing factorstoward the facilitation of protective behaviour on their part.4.8 THE PROGRAM (Educator Behaviour)The program consists of content (information,attitudes/values, skills and behaviour), and teaching methods,strategies and techniques used to implement the content areas.4.8.A CONTENT4.8.A.1 InformationTransfer of information is a part of all the programs.Types of information educators impart include knowledge of thebody and its functions (including puberty, body functioning,anatomy and biology); knowledge pertaining to STD5 and265HIV/AIDS, (including modes of transmission, methods ofprevention and high risk situations); and knowledge aboutcondoms:The goal would be such that they would have SOMEinformation. I never want them to think about it ashaving to have EXPERT information. I don’t want themjust to be able to do their own diagnosis without makingcontact, you know? So we talk about, for example,knowing your body, knowing how it functions and how itruns, so that if at some point you happen to have adischarge or a pain where it shouldn’t be or somethingthat is unusual, you want to make sure that, Number One,they know their bodies really well, and that they’reexploratory, in terms of that, so using mirrors orwhatever one might need to do [15:P5].From grade 9-12, STD5 and AIDS are covered at each levelwithin Family Life - dating, girl/boy relationships,intercourse, conception, childbirth, etc. When weactually study AIDS, there’s a slightly different focusat each grade; we basically have a three-hour package.For example, in Grade 10, I did a unit on prejudice andhomophobia [11:1:75]We do talk about things, in the STD class, like, “How doyou think you could prevent yourself from getting STD5?”and, “Where would you go if you had one?” And we getsort of talking about, “What do you think about talkingwith your partner beforehand?” or, you know, “other waysof expressing intimacy?” [4:P5]Teachers also feel a responsibility to mention ordistribute lists of places elsewhere that students can go forquestions or services.But to also be able to know how to access resources inthe community. So at the school it’s the nurse, it’smyself, it’s putting up posters around about the healthunit and the clinics that are around, and what thatexperience might be like, that is, that no-one’snecessarily going to call home, the anonymity of theexperience, that these are caring professionals who knowwhat they’re doing, and the nurse can very often talkabout that kind of stuff. So, having information about,specifically, STDs, and knowing community resources andaccess routes to those community resources. And theissue of being able to communicate with partners, in266terms of STDs and AIDS and transmission, and high risk.What would constitute high risk in situations [15:P5]4.8.A.2 AttitudesA common theme is that while it is important to teachinformation, attitudes and skills are other necessaryingredients of an effective program.The other thing was an attitude from the counsellors atall grade levels . . . that we have really changed ouremphasis from teaching the data to teaching theattitudes. And in talking about the kids having respectfor partner, having knowledge about partner, usingcondoms and stuff, care of body, asking questions ofphysicians or counsellors or nurses, but not attemptingto go into the detail of titre cells or, you know, allthat kind of stuff, which I think we tended to do, someof us, when the first burst of enthusiasm of thecurricular areas came out [8:P4]Educators’ attempts to assist in the formulation ofhealthy attitudes centre around reinforcing family values,encouraging comfort with sexuality, encouraging development ofself-respect and respect for others, and facilitating self-esteem, self-confidence, honesty and the ability andwillingness to express one’s own needs openly.I guess the bottom premise I use is that each person isan individual, and can’t be compared to everyone else.The genetic makeup is there, basically you can’t changeTHAT; the family background is there, there are a lot ofdifferent environmental situations that influence theindividual. And those things are all different ineverybody’s case. So therefore you are an individual,and that’s who you are. Your attitude about yourself iswhat can be changed. And you control that attitude. Andyou have the power in yourself to change that, to like itor not. So, I guess, “How is self-esteem is emphasized?”Because of that, then, any of the decisions that youmake, any of the things that you do, you’re in control[1:P9-1O]267In terms of specific knowledge and attitudes I would comeback to the willingness to ask questions, to admitignorance, to respect their own feelings. . . . And it’sreal, just, respect for ‘Tgut11. And so it we can buildaround with the self-concept to the specifics of that, Ithink we’ll have done our job, I really do. It’s allself-concept of strength [8:Pl4]We try to influence kids to make decisions ahead of time,not on the back seat of a car; to make decisions free ofmanipulation by other people; to make decisions thatwould be in congruence with the values that are importantto them in their religion or their family’s culture, butno, I do not say that abstinence is what kids SHOULDCHOOSE [8:P22][In discussing Family Management (all girls)] We deal agreat deal with attitudes. Again, going back to the DateRape conference, the attitude is that the girl must havebeen drunk, or she must have done this wrong, or, andthat attitude has to change. So we do deal a great dealwith changing your attitude, because being so narrowminded is not a good thing. So we talk about that inmany many many different topics. Homosexuality, sexuallytransmitted diseases, date rape, confrontations withparents, boyfriends; we talk about attitudes a lot[3:P3]4.8.A.3 SkillsBeyond the dissemination of information, the developmentof communication and decision-making skills is the mostwidely-shared objective among the educators interviewed.We want to give them skills and we want to give themaccurate information [12:1:327]It was also generally felt it was important to try to providea milieu for self-esteem development and enhancement, and forthe development of self-understanding, personal strength,assertiveness, self-control, and respect for self and others.As one educator, citing the need for skill developmentfrom Kindergarten on, stated:268Decision making, conflict resolution, sexuality stuff,self-esteem, the right to say ‘No!’, acceptance of otherpeople’s differences, but the right for myself also to bedifferent, and how to read the media. Because kids arebombarded with so many messages that, you know, drinkingand sex is cool, and I mean that’s used to selleverything from soup to nuts, and they see it morning,noon and night. And how to teach them that this isn’treality, this isn’t the way it is. How to make healthychoices and how to see through all that crap [4:P9-lO]4.8 .A. 3a CommunicationCommunication is an important aspect of all of theprograms.Our goal would be to form and to have a meaningfuldiscussion and to really KNOW that that personunderstands the dangers, the revocations, theimplications, how to help a friend who’s suffering fromAIDS, all those kinds of things [l4:P4]And the issue of being able to communicate with partners,in terms of STD5 and AIDS and transmission, and highrisk. What would constitute high risk in situations{l5:P5]What was the video that we used, I guess it’s the Talkin’About AIDS one, where the young couple are up above, theupper part of a building, outside, and you can heartraffic below and whatnot, and they each have their owncondom, and afraid to say, afraid to raise it. So, he.And it gets very complicated, and that’s why I always saythe basis is communication, and if there can’t be thatdiscussion, it’s almost worth looking at why be intimateat this time with this person if you can’t talk about themost intimate of things? [15:Pll]I hope I’m training them up to be really demanding ofthemselves and of their partners, scrupulously honest,and scrupulously clear about what their needs are,whether it’s a case of sexuality in general, not beingmanipulated by partner, and devalued in terms of theirown orgasm, for instance. Or the use of condoms. Thatthings become clear and that they can learn to talk aboutit [8:P34]Many of the educators consider building rapport to be thesingle most important over-all focus of their teaching, so269CrCrI-o‘riftCrCD0ftU)CrCu5CrCr0ft0CDCDI-Cu0CDHift0H00ihCuCDCDH-I-pi0CDH---HI-CDCDJC)C)CDCrC)ftk<H0CDSCtH-C)CDHiF-1CuCl)CuU)F-ICDCu0HftCDCDCDC)C)-CrF-1CDQCiH-U)QI-U)ftICrCUQDCX)-<oCDCDQ,CiCDftftftU)CD0C)Ci‘dU)U)S0CD•-CDiCDLJCuECDI-Cut-CuC)S‘<‘dhbCuC)CDftU)CDCiCuPHH-Q0QCuh’0HiU)CiH-MH-CDCD00ftC)ftCDftH-Hi0HiHCD1QCD0CuU)i(Jr-tQCiCDH-CrH-hI—’0H-<1CD‘—U)CuU)0U)Hi0ftCrH,U)5CiCuftCDHC)CDQCD-CrtyCrH-CuH-0U)oCrCu0H-H-5H-U)CuQQij0CrCQCrCQU)Cuh05HHiCu-ftIi--ftU)H-CuCDCDJftH-5CDftH-‘-<Hi(QH-0CuH-0I-’ftHiH-H0CDCuH-CD05(QSftCDU)CiCuHII‘<CiF-I-Q0iCDU)C)CrCDftCuCDftHQCuCDHCuCDCDC)ftCiH-CrCDifri‘-ICuQF—1U)CuCDQ-odU)C)CDCrftlQ-H1CDbCuCDF-’“<CiC)00lCD<H-H-‘dOCDH-CD0H-CDClF-’U)CDCDI-5CDCDCrCuftOCrSfrII-ICu-SCDft<HiCDU)U)CDiH-friDFCufr1OCDCDC)U)‘-<HCDCuU)Cift-0CrU)CDCrCDHH-C)U)I-QCDbHiCrCDCDCl)CDCDClHoftCuC)CDiH-CuftU)CuCiU)CuCu0Ci‘-1CrClCDU)0<ftft‘—3U)Cu0lCDCuk<<C)iClU)CuCiC)H-CDH-i-IS<CD‘-dH-SCDU)CDCl0CuU)ftCuCl0H-0CD0U)‘dU)CDiCuftCrC)CDCi50CDfti5U)I-IF-1friCrH-CDCuCuft0iH0Hi°ClH—CDftCD<ftCDCuH-U)0i5CDU)0CiftCuCiCDCuH-CDCDC)I-ICiCr•C)ClU)CQHC)‘-<<1ft0ClCDH-CDftH-ftCD0ftU)H-ftCrC)oCDHiCuHiCu-friCuCuCDU)I-I5C)H-0CDCDH--CDCi‘-ICD0HU)CDftF-IH-CD’--3Hi0ClI-IHt.Q0U)CDCrU)CD<CuftU)0iU)C)CDHHiU)U)CDHCrJCu0ClH-HftCD‘-ift00CuU)I-IClH-ft0CD5CuCDU)‘-<CrH-5I-HftftjftoCiC)CDU)0H0HH-CD0HCiCDCiC)‘QCDCrU)0Cr‘-1CrCDHCiF-3ftCuc-rCDHCuH-iH-CuCDCD•-CDCDCDL’Jft0CDC)SClftftCDftU)SCu0U)‘-dftCD<10C)CDHiH-H-CiC)CDCrCiC)Q1CDft0iCrH-U)HU)0Cu0U)CuH-U)CD1QHi0‘—‘CDH0ftCiftU)CuCDftHftft0FlHDCDCi-SU)ift(-QCrCDCDCiH-CiClC)CDHF-I0CuCudCDU)CDCrCuCDH-ft-Cl0U)CiCDCuSCrCu5U)Cfl5CDCD0Cr‘-<hftCDiCDU)0LQU)CDCl-H‘-<U)HCDU)CDCrCrU)ftCD0HiHC)C)5ftH-CDft‘-<0ft—HiCrH-ftCl0Cl,.Q00Hi0CDHi00CuftCl0CiF-IF-IF-ICD05CDHH-CD—CD0iCD0ft3’-<CDU)CD0CDCu‘<CuCuU)CD<CD><I-IHHi‘-<CuftU)HHHCi‘-ICD-C)ftCuftCDCr-3ftCuCD‘t5U)CuHCu0(.QCuCDF-I‘-QCDCr0CuCuH-HCDfti0CrI-i--dCrI-QCuftftLxiCrOftF-ICuClCrftCDU)CDft0CiftCDCDCDI-IftCDICuftH-CuCiCiCDL’iU)ftH-U)CDCD5ftI-1-Cr5HiCDiCuCl‘d0CDCDF-ICDCDU)ftICuCDSCD‘sCrHI-ICl0get. I’ll just say in passing ‘Wouldn’t it be nice ifyou could sit down with your mom or dad, and just talkabout this? And just say you’re sexually active and’And the looks on their faces, it’s like ‘You gotta bekidding’. You can tell just by looking at them that itdoesn’t happen [6:P8]Communication with peers is an integral part of most ofthe programs. There were instances, however, where theteacher did not feel he or she had time to teach communicationand other peer-interactive skills. Relationship skills areconsidered to be the Number One priority held by students:What the kids said when they talked to us, when theyspoke out to us, was that the single biggest thing theyneeded was relationship skills. How do you negotiate,how do you talk to a partner, how do you deal withsexuality on that level? And they said right from squareone, kindergarten kids need stuff on relationships; weneed to give kids relationship skills [10:2:90]We don’t know how to communicate. ... We have to TEACHkids communication skills. ... Communication reallyconcerns listening. Not listening so that you can getthe next WORD in, as soon as that person finishes, butreally listening to the nuances of what somebody issaying. Communication means having respect for what thatperson says, even if you disagree with what the person issaying; communication is enabling you to sit down andtalk about differences, you know, talk about differenceswithout getting angry. ... I guess it really startsbeyond that, or before that, with teaching kids how tothink. We give LIP SERVICE in the schools to teachingthinking skills. ... So thinking and communicating. Andafter we think and communicate, then we act. But weDON’T. All we do is we DON’T think and we DON’Tcommunicate and we ACT. Well, no wonder we’re in such abloody mess [l4:P10-1l]Part of the facilitation of communication is to teachexplicit sexual language and encourage students’ comfort inusing it.271The way they react with vocabulary. We will model usingwhat we call ‘formal language’, we talk ‘penises andvaginas’ and we’re clear about what we’re talking about,and the way in which kids respond to that and can usecomfortably that language tells us something about whatwe’re doing, normalizing and making it concrete and real[8:P6]And I think we’re very explicit. We talk about anal sexand oral sex and vaginal sex, and we sort of use whateverwords we, you know, really, that the kids use [4:P4]4 .8 .A. 3b Decision-makingDecision-making skills are considered a top priority inthe area of sexuality and HIV/STD prevention.I think they need good decision-making skills; and mostof our guidance program is kind of built around that, ingiving them the skills they need to make good decisions[12:1:98]Just looking at all the things we’re trying to prevent,the information we want the kids to have, the tricks, theskills, we want them to have in their bag, I just thinkit all seems to come back to decision-making over andover again [12:1:180]The biggest issue, I think, is around the whole area ofsexual decision-making [11:1:174]4.8.A.3c AssertivenessImplicit within all the relationship training isdevelopment of assertiveness, particularly for girls.I do a lot of assertiveness training with girls, forexample. To me it’s very important. I have a couple ofmessages that I try to get through to girls, that I findare, to me, very important. Any girl that comes to seeme, one of the messages that I always give them is, “Whatyou want to get out of high school is, in your trainingis, independence, self-awareness, and the ability to beable to say ‘Bugger off’ to whoever you need to in thefuture, and you can afford to, and you have the strengthand the wherewithal to do that. And your training, andwhat you should be doing in the next year is, you shouldbe thinking of that. That whenever you get into a272relationship you’re doing it from an equal partner,strength position.’ And that’s a message that I push,push, push all the time with girls. That’s what I wantthem to have when they leave here [5:P5-6]Another school hires an outside person to come and give athree-hour training session in assertiveness to the Grade 10girls.4.8.A.3d Condom useAlthough all schools promoted condom use, there wasvariation in how specific teachers felt they could be, interms of what would be tolerated by their communities, inteaching about condoms. Some teachers did not feel able tobring condoms into the school. Others have incorporateddemonstrations and practise with models into the classroomcurriculum.The nurse brings in her big bag of wooden condoms andthey get in teams and they practise; it’s not quite reallife, but it’s as close as we can get. And all thecounsellors here and our terrific nurse are verycomfortable dealing with this; I mean we’ve been teachingthis, well, I have, for 25 years, and most of us for along long time. And so I think we’re quite comfortablewith it [12:1:388]4.8.A.4 BehaviourTiBehaviouril is something that is often targeted forchange in interventions. Often it is not defined, however, orit is narrowly defined, usually by implication, given theindicators used to measure it. Educators within these schooldistricts are not necessarily aiming for “behaviour change” somuch as for the development of health promoting habits,273including protecting oneself from HIV and STD infection. In acontext in which “behaviour” is often conceptualized asthinking, communicating or holding an attitude, however, itdoes become a target for change.I’m trying to change the WAY in which they make theirdecisions about behaviour, yes I am. I’m trying to movethem from their penis and vagina up to their brain, interms of how they’re making their decisions, thinkingabout it ahead of time. ... Change behaviour? Yes. Iwant them to be prouder of their decisions, to doreflective thought about that, and to be able to saythose to people who are important in their lives [8:P33-34]I try to keep them from being pregnant. To me it’s not agood option for kids. Some people think it’s a greatthing but I really don’t see it. I look at that childand think what kind of chance it’s got in the future.I’ve watched too many of them try to raise their childrenand very unsuccessfully [5:P4]4.8.3 METHODS, STRATEGIES, TECHNIQUESStrategies, methods and techniques range from non-interactive (e.g., lectures, presentations, films, videos), tosomewhat (e.g., large group discussion), and highly,interactive (e.g., scenario creation and role playing in smallgroups or between pairs of students, and one-on-one or couplescounselling) . Each of these techniques has a place in acomprehensive curriculum. Social cognitive/social learningtechniques such as modeling (by educators and/or peers),vicarious reinforcement (by seeing others succeed) andperformance accomplishment (by practising skills), are used tovarying degrees, according to situational (e.g., time) andpersonal/professional (e.g., capability and comfort of the274instructors) opportunities and constraints.I think we’re very strongly of a belief that we’remodelling when we’re teaching; not only givinginformation but demonstrating how information gets got.And so we’re modelling openness and willingness to share.I think that’s probably our biggest objective [8:P7]Within time constraints, teachers try to focus on thedevelopment of communication and decision-making skills intheir students. One teacher described her method of doingthis.you’d talk about things like listening skills,empathy, trying to understand another person’sperspective, conflict resolution, what happens ifyou disagree, those kinds of issues. So again, roleplays, giving them case studies, having them workout many different angles to .Q: How do you practise conflict resolution?A: You’d write up some sort of case study or scenario,where you were having a disagreement with a parentor with a child or two kids in a family, and so youcould just sort of set it, and not write thedialogue, and have them do it, freeze the action,have people come in, almost like a power play, tochange the direction of it: “How could, anyone herewant to take this person’s role and change it aroundin some particular way?” [15:P31Some districts are able to offer a consecutive programkeeping a teacher-counsellor with the same group of studentsover a number of years. Other districts have a differentteacher presenting the Family Life program to the studentseach year. This approach lends itself to more distinctivedivision of the Family Life curriculum into concrete sections.For example, in a district where Family Life is taught inScience class in Grade 10, the focus in Grade 10 is on thetechnicalities of pregnancy, birth, birth control, AIDS,bacteria and viruses, to the exclusion of “the psychological275and social part of that” [6:P3] . The reason for this focus isthat:The real push made at the grade 8 level is on decisionmaking and social responsibility. ... In grade 10 we tendto do all of the scientific part of the Family Lifecurriculum, but none of the social parts; those are justsort of done in passing, because I know that they’ve beendrilled into them in Grade 8 [6:P3]In contrast, in a district with a “developmental”approach (counsellors teach “Family Life Education” and moveup with the grade), the program is described in the followingmanner:It’s a spiral curriculum. We come back on the sametopics every year and do them in a different way. If Itake condoms for an example, one year I’ll use theHickory Dick and do a demonstration and pass them around.Another year I’ll give them each their own and they’llhave a pet condom and we’ll all do it together. (I’mthinking sequentially about this. At the beginningstages we’ll just talk about them and explain them whenthey’re littler kids.) And then I might give them casestudies to do. I’ll present a situation, they don’t havea hands-on condom at this point, but they’re going toTALK condoms with their hypothetical partner. So we’lldo it, it’s the same thing, it’s condoms, condomfamiliarity; but every year going at it from a differentangle. And like I said, if we had more time I would domore. The year that we do tactile I might also show avideo about it and they’d also do a paper and pencilthing with it, whatever. But I’ve only got time to doone, so I do something different each year. So theconcepts I would say are very basic and very repetitive.BORING. But we do different things [8:P31jAnonymous questions are a favourite activity and way ofknowing what students’ concerns are as well as answering themin a non-threatening way. Teachers also make use of humour.But mostly it’s real basic. Mostly it’s chatting andanswering questions and making it fun. I think humour issomething that is terrifically important. And sometimesI have to apologize to classes, where I’ll say, “Youknow, I DON’T want you going away thinking that I think276sex is just funny”, you know. “It’s sacred, it’swonderful, it’s special, it can be scary.” But I thinkit’s important to put it into a comfortable framework forkids [8:P33]and cognitive dissonance.I’ll use tricky devices. There’s always a question thatcomes in, “How old should you be before you have sex?”And I will always answer it, using something like anexample from a kid that I dealt with once. She was doingresumes in another class so I used that as an example.said, “Let’s pretend you’re writing your sexual resume.You’re older now, and you’re going to go back and writeyour sexual resume, your history. Do you want it tostart with this partner?” And she said, “God, no!”“Hey, you’ve just answered your question!” [8:P34]Facilitation of selfknowledge was described by one presenter.How to know when you’re not feeling O.K., what kind ofhappens to your body, and then how do you deal with thatsituation? We go through that, and then we take a lookat how to be more assertive, what does assertive looklike, what does it feel like, how do you do it? ... andthen how to take a look at the different areas of yourlife and go through those areas to see what’s working foryou and what isn’t working right f4:P6]One spoke of media analysis and the techniques s/he uses,I think also the influence of the media; it must be verydifficult for kids to filter out what’s normal, you know,if you watch M TV enough, if you watch the videos, theovert sexuality, and fashion television, or the lyrics,everything is built around sex and sexuality, and so it’shard to tell what’s normal; it must be confusing for thekids.For example, I do a unit on attraction. “What do youfind attractive in a girl?” We list them on the board.“O.K., let’s rank order them.” “What do you findattractive in a guy?” Rank order them, that kind ofthing. Then we put them in groups and discuss theirorder. Then you can, they’ll say, “Beautiful”. Well,“What’s ‘beautiful’?” Then you can talk about magazines,and Playboy magazine. “If that’s beauty, how many ofthese girls do you know? How many have you seen lately?”Like, if you’re waiting for this girl, you’ll wait a longtime. Is that what their vision of physicalattractiveness is? “Or does physical attraction grow thelonger you know the person? Or does being with somebody277who’s attractive, does that make YOU look better? Isthat why you do it?” These kinds of things that kidswill stop and think about. They’ll talk a lot aboutthose kinds of things. You kind of can build the mediainto it [11:2:180]while another spoke of condom familiarity.The nurse brings in her big bag of wooden penises andcondoms and they get in teams and they practise; it’s notquite real life, but it’s as close as we can get[12:1:388]Students are encouraged to become familiar with outsideresources.In Grade 10, one team will go into the local drug storeand check out products and costs and try to decide whatwould be the best form of birth control and prevention;another team goes to the health units, and another teamgoes and talks with their family doctors, and they bringit back and tell their findings. That was prettyinteresting. I was surprised how co-operative the peoplein the district were [13:1:58]Practise is an important element of an adequate program.It’s all self-concept of strength, and PRACTISE AHEAD OFTIME. I think that as teachers, that’s the other part.We’ve got to give kids an arena to PRACTISE theirdecision-making behaviour. We’ll play out, “How are yougoing to ASK the partner about their previous sexualexperience”? Or, how can you SAY, “I don’t like it whenyou hold my hands with your fingers between my fingers,it doesn’t feel good for me.”? You know? Andpractising. So that’s another venue that we can use tohelp kids rehearse for making good decisions [8:P14]Finally, one-to-one counselling is available and in somecases is necessary to get the point across or to establish arelationship.What we find generally I think is that when we puttogether a program, on sexual assault, on AIDS, orwhatever, it opens up the topic and kids can hear it inparticular ways. Then the next part is if they want to278have more detailed information they can come and talk tous individually, and then there’s other referral agenciesthat we can refer out to. Or you might just choose totake that kid for awhile and do some in-depth counsellingand spend some time [15:2:47]I think a one-to-one approach, [with high-risk students]first of all, is better. I think if we can look at theindividual as an individual and say, T11n your life, howis this behaviour going to be dangerous?11 Rather thansay, “Here is this lovely program that’s being prepared,and if you just follow the first ten steps, you know,you’ll be fine”, or whatever. I think individualizingit, which, of course, has enormous ramifications cost-wise [14:P2]4.9 SENSITIVITY ISSUES4.9.A HomophobiaAs has been discussed, schools are not able to offeradequate support or services to students who are differentfrom the “norm”. Nowhere is this more evident, posing aserious gap with respect to HIV/STD prevention, than withyoung gay males. For students exploring their sexualitywithin same-sex relationships, school climate, even if ateacher is non-prejudiced, can be very negative.Q: Does your course deal with sexual identity?A: Yeah.Q: Are there any sort of resources for kids who decidethey’re gay or Lesbian?A: I haven’t had one kid in this school, I think acouple of people have talked with the counsellorsover the years, but I haven’t had one boy, or girl,for that matter, and they use our servicesextensively, but I haven’t had anybody want to comeout of the closet, or whatever you want to call it.And they’re there. Kids have to be there. So youknow, we will talk about homosexuality and279ftCDM,ooooFt1)(ClDiF-’(.Q‘10CD(I)HH-<0CDk<I—aftDiCDDiH-Cl)H-0HOEH-ftWftQftCDftHDi0E0CDODiECDODiDiDiDiCDDiH-CDftDiCDCDHftHft-DiWH-ft0CDCDftW0CDHHHCDDiH-H-ftH-CDCDCDDiCDHH-CDDiCDftft-.H-Di0wCDDiHDiCD•H-WHDi00CD0H-QftftH.DiftCDCDCDDiCDftCDHftH.HDiCDDiHHQHCDDiOQCD--ftftDiH-ftH-CDHCD300-Di0DiCD0DiH•ftQftDi0oDi0ftH-CDCDCDH-DiCDCD0CDH-0H-DiDiHCDftHft0ftH-Hft.CDQHQftCDH-CDCDCD0°0DiCDftCDCDCDDiCDDiOH0CDOftCDCDft<0O•--FtH-CDCDQCDDiDiDiftDiDiWH--ODiftHDiDiDiH-HoDiCDHHftH.CDDiCDDiHCDH-CDDiCDwH-H-H-CDftDift<(H-H0-ftCDCDftftCDDiHCDDi.ftH-DiHftH-DiftCDHM•-Di0ftH-DiH-OOftH-.ftDiDiH-HCDftOCDCDoH-DiH-DiCD.H-ftWH-H-000CDCD0CDH-ftH-Di-ftQ<0W•OCDCD0HHWCDDiDi0o0CDCDWftDi0ftDiftQH-H-00ftDiH-ftftQftftft0QDi0DiHftft0-H-ftOCDH-CDCD0•HCDftCDftCDCDH-SDiH-H-H-WftDiftDiE0ftCD•CDOftDi00H-QH-CDQ--CDCDftftftftH-ftHDiCDftCDDiCD0ftDi0CDHftDi-0H--HCDftWCDH-DiH0H-CDCDCDODiCDft0DiftO0CDDiCDftftDiODiDift•H0HftDiH-HCDCDCD-CDHftDiHCDHftCD.HCDHHHCDQ-CDCDDi<00ftWH-ftCDCDt••CD0H-<rtftWDi0CDDi00DiDiftDi-Di-ftDiH-H-ftWftCDHH-0H-HH-CDH-DiCDOCDCDH-ftHCQCDQft<IH--QCD-ft-ft0CD.DiCD-H--used it in the last three years, because I know thatit’s been touched on in Grade 8. There’s a wholefilm, a whole hour-long lesson on sexualorientation, the underlying message, I think, beingthat sexual orientation should not be used as amethod of discrimination. And it’s actually prettygood, but you see, I don’t use that, because it justtakes too much time in the course, to get done witheverything else. So that’s one of the things I said“No, I guess we’ll chop this out”.Q: Do you think you have any problems for gay kids inthe school here? Are there any that?A: Good question. I’ve never thought about it. Youalways hear a rumour about, after they’ve gone youhear it, usually they’ve left. “And did you know soand so was gay?” The reason we chopped it in myopinion is I think it’s one area where most of thepeople don’t need to, other than the discrimination,where, you know, they’re just normal like everybodyelse, I don’t think there’s a great population ofhomosexuality in the school that therefore needs tohave some information provided. I mean it would benice to have, but I don’t think it’s, I don’t thinkthe kids are being deprived too much if we don’tpresent it to them [6:91Q: What about homosexuality. Do you have any kind ofmention of that in your classes?A: Yes. We’ve had to deal with it a few times. We’vehad a few students that are finding themselves,discovering that they are homosexual, we’ve dealtwith that a few times.Q: In class, or?A: No, in counselling. It’s a very ... most of themwill not deal with it publicly yet, but they will doit privately, and in some cases it’s come out as astudent is having emotional problems of some kind,and you find that there’s, something’s happening tothem, that they’re trying to come to terms with, andso on.Q: Do the classes, do the Family Life classes take upthe topic at all?A: Only in a very sort of brief way. It’s not in muchdetail, it’s just an explanation that it’s naturaland it’s O.K. and it happens and it’s a part ofsociety and that kind of outlook.Q: Do you find that the kids in the school arenonjudgmental, or are they fairly prejudiced?A: I think at the earlier ages they’re fairlyprejudiced along that line yet. I would say thatthey’re pretty narrow in their views yet. I don’t281think they’ve got beyond that, although a lot ofadults haven’t either, right? I mean it’s adifficult thing. It’s a question we all have todeal with, right?Q: And as they get older do you find that they’re moreaccepting, or?A: The more information they get the more open theybecome, and I think sometimes when they become awarethat there’s a fellow student that has a homosexualkind of an outlook, approach or whatever, theyrealize that that’s a, you know, that student’s beenwith them all along and they’re not that bad, andthat sort of awareness then becomes part of theirlife. We have a number of parents who arehomosexuals, so students come in and talk abouttheir relationships with their parents and so on,and need to deal with it. Are living it, and havelived it most of their lives, and so they’re muchmore aware. There’s more of it, I mean I thinkthere’s more of it. It’s, I think more accepted nowthan even ten years ago [5:P3]The inference can be made here that HIV and ST]D infectionis not being covered in a very thorough manner in theseclasses, in terms of risk behaviours and methods ofprevention, if homosexual behaviour is not or is barelymentioned, and that homosexual youth are not getting anyparticular support or targeting to inform them and encouragethem with regard to safe sexual behaviour.4.9.3 Other out-of-the mainstream groupsOther groups of students with different needs are alsonot having their needs for HIV/STD prevention education met.The other kids we need to be looking at are the ones Icall “the real high risk kidsTl, who don’t have muchchoice over their own behaviour, who are very veryvulnerable, and we’re throwing them all into thecommunity. These are the kids who are mentallyhandicapped and have mental illness, and can’t managetheir own behaviour, and yet we tend to pretend that theycan. 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Although condom use among young males has increasedsubstantially over the past decade (57% of males aged 15-19reported having used a condom at last intercourse: U.S.Department of Health & Human Services, 1992:19) (See Tables 8& 9, Chapter 3) , for young women, condom use by theirpartners remains low (26% of females aged 15-19 reported theirpartner having used a condom at last intercourse: U.S.Department of Health & Human Services, 1992:19) . Thishighlights an issue to be discussed below: young men andyoung women of similar ages tend to belong to different sexualgroups, females generally being sexually involved with maleswho are older than themselves.A report from the U.S. Centers for Disease Control andPrevention stated in 1991 that people under the age of 25years accounted for two-thirds of an estimated 12 millionpartners. It follows logically that those with more partnersare at increased risk. This is substantiated by our findingthat the reported rates of STD5 rose from 2.5% among those womenwho always or usually used condoms and had one or two partnersto 23.7% among women with five or more partners and inconsistentor no condom use (Bowie et al., 1990:714)”2”Biglan et al. found adolescents who most need to beusing condoms -- those who are sexual with multiple partners,with partners having many partners, or with partners not knownwell-- are the ones least likely to use them (Yarber &Parrillo, 1992:333).”3llReported use at last intercourse is two to three timeshigher than reported use in the 1970s (Yarber & Parrillo,1992:333).”286PiCD—H-H--H-U)C)C)H,)ibH-01C)C)U)CrCDCDH-H-Ci0CD)00CDCDCDCrCrçuH,5I-jQrrCrHt-CD)J0—..H-IQ1C)CD‘d0C)U)H-lCD)JC)I10Cr0I-•CUHhHI-HCiH-9)0Cl)Cl)CDHh0-9)h9)5Cl5iftH-<9)‘-3—310H-CUCDCDCl)CT)9)U)CD0CDCDCDCrC)5C)U)H-ft3CrhCDCDU)iClCDLXJCDU)<H,9)0CD0U)H-9)CD9)I-jlt00CUCDHC)IQCH,CrHCD0CrCH-H-HC)CD10ftftH-CDoC)013H,Cr0H‘-<‘-<—3CD9)CDCUH-9)CDQC)U)CDCT)l-CDCl13139)Cl)13CDU)H13HCrHCl—3I-HU)U)10CD9)U)13H-CDftC)QCriftH--C)••CD‘-<CDCDCU13Ct•13U)CD13CDH•-00H9)H9)ftH-CD130CDH-h5iTCrCDtiH-013II‘<01IQl--13—1H-H-9)CDH<‘-3IQU)9)9)O\OCt100—0CrQ13‘-<CDCDCrDCD13ft9)9)13139)CDI—13-1313H-9)l—U)CDH,H,HH-CD13013CUCrHl0CDH-130H00CDrrH,hCDH,1301310H-l-9)9)I-l-HCD0Cl)Cl)--CDCDCrHIH,0CDCrdCl‘-<HQH,‘-3U)‘-30<C)CDU)139)Cr10C)U)09)H,aCdCDCrU)ClClCr130I-130HCU130—.H13H-00H-13U)CUSCD13ClCr\.)—CDk<Cr<139)H,CD0Cr13CDH-U)()9)o\°i-<9)9)H-CD9)C)H-C)U)CrC)013Ct9)HC)H,C-HC)Cl5CDCD=‘-<13CDCD--9)CDH,-H013-0H0l5l-U)135CDIQU)0C)U)lCUCUU)9)HCtd9)CrCDCDIQCl3HCrF-—U)C)CDU)H-H-13CDH-13I-CUCDC5<HIH-13C)t)13HIC)H-I-U)ClC)CUCD9)CD013H-CrCD13F-CliCl)H-CrNR’Cr‘—‘I‘-<H101313H,H-H-H,C9)<ftC)H-H-WClH-H—010CDH,13U)CUIQU)H-9)1313CD13‘d<Hb—‘Cr0CDIQC)HI0HIHIQIQH,9)CD13ClCD50H,lC)ftCUU)H-H-U)rCDCT)Cl)HIH-ftftC)05HIU)CD013ftI-ift‘d1313ft9)CDH-13H-HI13H-H-SCDHIftCl135U)<CDI-U)‘dU)H-ft0ftClHCl)CD1309)—..CDCDCD0C)=HftH,ClC)CDCDHh9)H0H-5HI9)9)ft0CD0HH130H-H-Cl-HIHI09)H-CDS133ftHI135CDk<ft-C)1313HHI‘-<13ftU)Cl)13C)H-C)CDClU)Cl)H-IQ‘-<U)CrU)CrH-ft13CDCD13CUCDU)109)H13ft013C)U)CDC)CUClIQC)CDH-LOCD0C)CD0CDHIC))13U)CU10Cr0-.HI3LOft13Cl)H-H-C)HC)CrftCDH,CDMCDU)CUI-CD0CDCD133YH-HH-CUU)--CDCl)CrCDH,-13H,U)CDCDU)CT)U)H13U)CDW13ft13Cl-C)—13CDftHICDCDSH-ft0HWICUCD0CDCDH-CU-ClCrCD13CDH9)ftH-13-0059)lJH-U)I—iC)—10CDIift10HI13CDft13ft0Crft-CDU)CD-H-U)0Cl13ftHI0CDHIU)13CD0l-CDClU)C)CrU)HIH-09)ft9)0U)H,ftH-CD31313‘tiS9)ClCDCl)ftIQIII<1‘-<CHIHICD<1organizational level at which they are planned andimplemented4, the needs of the target population and theresources available to place in the service of accomplishingthe goals and objectives.During the past two decades, many school-based preventionprograms in the areas of substance abuse and pregnancyprevention have been launched. Some of these programs havebeen evaluated; study of the evaluations may contributeinformation and understanding useful for the creation ofeffective HIV and STD prevention programs.Early prevention programs (labelled ITtraditionall), werebased on rational or cognitive theory (in particular, usingconstructs of the Health Belief Model). The goal of theseprograms was information dissemination. They reflected theassumption that for students, knowledge would producemotivation for health-enhancing behaviour, and that motivation(predisposing factors) would be sufficient to stimulate thisprotective behaviour in adolescents. This type of program didproduce an increase in knowledge, but not in appropriateattitudes or behaviours. In time, it became evident thatinformation was a necessary but not sufficient basis for the“z’n intervention at the Ministerial level is broad whereasat the classroom level it can and should be more narrow infocus.288prevention of behavioural risk-taking.5Alternatively, “contemporary11 or “innovative” programs(based on developmental theory, social learning theory, or acombination of social and cognitive theory), were developedand implemented in schools. Rather than focusing on cognitivevariables such as perceived susceptibility and severity, theyturned to affective areas (such as values clarification andself-esteem enhancement) and to skill development andmodification of group norms. Developmentally-based programsstressed broad-based life skills training. Social influencesprograms focused either on changing social norms (alternativesprograms) or on the practising of resistance skills (socialreinforcement programs) . Thus “[these programs] go wellbeyond increasing individuals’ awareness of health risks andattempt to modify the enabling and reinforcing factors actingon health risk behaviors (Rundall & Bruvold, 1988:321).”The “contemporary” programs, as described above, do focuson enabling factors of skill development. To some extent theyalso focus on reinforcing factors, by attempting to changegroup norms. Reciprocal determinism, the key construct ofSocial Learning Theory, states that behaviour is influenced bythree variables; the person, the person’s behaviour, and the5jessor distinguishes between “risk behaviour” and “risktaking behaviour”, defining the latter as conscious ordeliberate thrill-seeking while the former encompasses much ofadolescent behaviour directed towards normal adolescentdevelopment (Jessor, 1992:22).289environment (or the environment’s response to the person andthe behaviour) (Perry, C.L.; Baranowski, T.; & Parcel, G.S.,1990:161) . The shaping done by the environment is seen as areinforcing or rewarding factor, which then goes on to becomea future predisposing factor (“Today’s reinforcement istomorrow’s predisposition” (Green, L.W., 1994b)).Through study of evaluations of these “contemporary” or“innovative” programs (see Chapter Three), it has becomeevident that although they show some behavioural effects, theyare not sufficient to protect all or even most adolescentsfrom negative outcomes generated by their exploratorybehaviour. As a response, the scope of programs has beenwidened; community-based programs, utilizing a school-basedcomponent among other interventions, have been developed andare in the process of being implemented and evaluated (e.g.,Project I-STAR).Jessor’s work on delineating clusters of “risk factors”predictive of the development of problem behaviour (Jessor,1980, 1992), and Rutter and Garmezy’s work on “resilience” or“protective factors” (Rutter, 1990) have provided newdirection for preventive program planning.6 Jessor’s workpresents evidence supporting the idea of the clustering ofcertain sets of risk behaviours in adolescents; in particular,68rown & Horowitz point out that “risk factor” researchand “protective factor” research are not the inverse of eachother; each evolved separately without reference to the other.290HCDC)C)CUI-hP)b00P10ClCUp)çtCD.DCDFt<Q1FtHtJC)iH-HH-CDCDiH-CDCDCDHiI(QWP)CDI-QCD’-<FtctOHHH-C)IH-HiOC)(tCDC)C)Q•CDH<OOCD’<FtO--C)H-hCDCDCDCDHCU<FtH-CDCD-’-CDClCDPJH-CDClH-C))CDP1Y<hP3WCDC)CDtCDCDCDSCDOCDH-H-HP1CDHihCDP)H-HH-I-iCDFtHHiCDFtH,CDH-Hi3hd-OPIHiP1CDH-PJPJP1CDCDHCDCDFtCDiFtFtHClOClCDtH-P1F--CD0Cl)Cl)0d<lCD-HiC)Cl—.CDP1FtHDCDP1JH-OtClHCDP1iHCDCDCDH-iH-ClP)P1CDP1H-CD--Cl1H(PJFt‘-<CDFtF-(OCDP1CDCDCl’-<d PIMCDCl)ClCDClhC)I-CDCDCDCDYFtC)HP1PJHClHH-CD—00CDHOHQUk<HiC)Cl)ClHi<C)H-P1CDop1HCDC)I-COP)ClC)P10H-0HC)ctl’TJp1CDCDH-CDQH---OCHCDHOHCl)CDCDH-HiCDfrh(QH-QClFtPJP1FtFt’-<FtC)H-CURiOCDH-H-ciOCD--HCDCDWHi<I-QP1 Cl) Cl)0 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individual tutoring;5 Organizational changes in schools, includinga) curriculum restructuring;b) increased opportunities for student involvement;c) greater school-faculty-community integration; andd) changes in school discipline procedures;6 Youth involvement in alternative activities; and7 Comprehensive risk-focused programs (Hawkins, Catalano &Miller, 1992:92-96)Lewis et al. (1990) suggest that programs should beclearly derived from theoretical models that recognize themultiple determinants of drug use, unprotected sexualactivity, and related problems. These programs should beintegral to the school curriculum, should promote positiveinfluences rather than trying to counter negative influences,should be comprehensive and long-lasting, and should beginprior to the emergence of problem behaviour (Lewis et al.,1990:41-43)Other theories, models and frameworks found to bepromising with respect to adolescent school-based preventionprograms are PRECEED-PROCEDE (Green & Kreuter, 1991), theTranstheoretical Model of Behavior Change (Stages of ChangeTheory) (Prochaska & DiClemente, 1983), the AIDS Risk-Reduction Model (ARRM) (based on Stages of Change Theory)(Catania, Coates, Kegeles et al., 1989, 1990), and theInformation-Motivation-Behavioral Skills (1MB) Model of AIDSRisk-Behavior Change (Fisher & Fisher, 1992, 1993) (SeeChapter Three).To the cognitive orientation of the value expectancymodels, including the Health Belief Model and parts of Social296CD C) hi CD CD rt H 0 hi 0 hi S CD Cl) H H S H CD Cl r1 0 CD Cl H- CD Cl) CD S H HH-rt5(iiC)CUCrH-hiClW5HCr5H-CDCrCOCl)C-1lD00CDCDCD0CDCU3J0C)0CD0CDI-IWClCDHiI—’<<<CDH-CrCUCDC)CrC)Uw0CDCr0CUCDCUCDCD0iCDH-H-H-hi—HhihCl)tI-ICrH<HhiCrhiHH-çU0PCD‘<Cr0CD5H-0H-MiCl)H-CD<1H-ClHHHi-I‘-ICiiiHH-CUCU0d0hiCDCDCD-CrCUCD0HHCr3H--100Cl)CUCUC)H-QDHCUClG)HCrH-Cl)5Mi3Cr0CD‘-rno<H-Crti0(Q5CUC)H-CUCrIQCDMiç-tCDCr0ClH-00-1ClCD0MiHCl)0iH-CDW-C)Cl3CDCl3ClCUH-CDCiCDC)—.b0Cr<CDCl)0CDCDCUhi0CrCrhiCD00CDJziCDHS—5HClCDMiCrhiH-CDI-IWCDCUCDLiiHH-0Cl)H-Cl)0CDCU<3C)‘-<CDCUH0CDCrCUCD0CrCl)Ly’H-CDC)CDI—’)HMiH-CDCrCiCUCDCDCDC)CDCl)CU0IQCDCULiiSCDCr1CCl)CrCiMi0CrIMiCDI-IhiCDCUHCDCDCUC)0500ClhI00(QC/)i0CrCDC)H-CD<C)hiCDI-IhiCrCrQCDCrClH-I—’CDCrH-CDC)I-Q0H-CrIihi—CD0I—’CD0H-H-0CDH-CDhiCiCDCDUCU<H3CUCl)CrCDCiCDiCDI-jç-r50HCU3CUCDhiMiIQCDCrI-00CDHCDCU—CDClCUH-CiCiUCUCDCiCU0CDC)HCDCruCr<3SClClC)H-CrH5H-CDH-CDH-CDCDCUCDH-H-0CDCU0Pi-<Ci<CDCD00CDCDCrC)<ClCDCiMiCDCDClihiHH-CD0I-QCDCDPJhiClpiCrTJDClMiCDhiH-CrCDClCDtJCr00CDCrH-H-CDH-CDCU•ClCDij3Mi0Mi0)Mi0030hi‘-ICDCrnCDMi-•Mii0t3C)t.QClCiC)1QCDLii0CrCDCDCrCDCD0CDhiCDCDCDhi0UhiCiZC)H-CDCD0hiCrCDCDCrCDCDMiLiik<CDCDCUCr33Hhi‘t3C)CDH-CDI-CUCDCrH-MiCrMi0CDCDCDF-ICU35hiMi‘dCDçtH-<0H-Ihi3CD0CDCUP30CU0CDhiCUCD0P33H-CiMiClCrCrCDC)0CD35HMiMiCrCD3CD0H-CUH-CDCrC)Cl0CDC)CUH-CUMiCDC)3hp-IIQ<0LiihiClCDHiCrCDH-CDCDCDC)5CDCrCDCUCrhiLiiC/)‘<H-CrC)CDCDCDCDCUCDCDCDCrCDCD0CUiC)0CiCUCUCrCD<CrH-hiH-ClC)0C)CDClC)CDCUCiH-CDC)0-MiH-MiCrCiCDP3H-<0CDhiP3CU0CCCDMiMihiCUH-CDCD0CD‘-<HhiH-i—0-1P3Hd0CDCUI-QI-ICDCUCD<1CrIiCrC)hiCD5CDtihiH--ClCUP3H-1CH-CDClCDCCU-CUC)CUClhihiC)00CUP3H-CDCDIQMip3H-CDCiCr‘d1313H-13CD0p30p3ClMi13C)p3p3HH-CDCDIQHhihi1313C)CDClCDCrCDCU<10CDH013CDCl0CDC)hiH-HhiCUCrCDCDH-ClCiZ3CrCUC)0CD0CrH0H-CUIiCr13CUH-CDCD13CDMiCrH-CDCU13ClC)<1<1H-00IiIQClCDH-H-CDCr<1—013CrCl—CD0H0CDMi0hiCiCDClhimore recently-developed theoretical applications utilizingsocial influences theory. All programs found to be targetingHIV/STD prevention were examined. The behaviours involved inthese subject areas are linked, with those adolescentsexhibiting problem behaviour in one area more likely to beparticipating in risk behaviours in the other areasconcomitantly.5.3.A SUBSTANCE ABUSE PREVENTIONRundall and Bruvold (1988) found modesthT effects onimmediate behavioural outcomes of smoking and alcoholprevention programs. Smoking prevention programs were moresuccessful than alcohol programs in long-term behaviouraloutcomes. Social reinforcement, social norms anddevelopmental behavioural models were found to be the mostsuccessful approaches. The authors suggest that community andcultural support (e.g., media, social movements) are importantinfluences external to the school environment.Bruvold (1993) studied smoking prevention programs. Hefound the largest positive significant behavioural effectsizes in programs utilizing social reinforcement theory.Smaller but still significant effects were found in programsusing social norms and developmental theory.Best et al., (1988) studied smoking prevention programs.They found social influences programs to be most effective forstudents who were exposed to smoking models in their close298Cl.0)C)0)H-::1)H-0IICD‘-<CD00H,CDCD0)0çH-0CDCiH-CDH-IICD00020-hhh0)ft(.Q)ftH-•H-’•ftCDCl00H-CDCD0WCl-.HHO0H-H,H,0S(.05SCuCDH-ftftEQ..CDCDH-H-CDrtCuCDH1H-CuCuC)SHrtCDS—CDCDf-I-Q5H,H-H-HI-s).pj0P.)ftID5jftH-Ci)CDHCDCuHb:3SH-0k<HCi)HH,ftH-CuH0I-ic-rHICD10CuCDIQ10C)H-CDCD‘dC)0)hCu‘dCDHCDo<CDCuCDF-HH,0)0)CDH,SiCDCuoC)C)0)CDftH-CD0IQH,0 H,Cu ClftCu0)0I-H0CD0)5ft<0CDCDCDi0ftCDH,5H-oo‘-ct0)CDçtHCD‘dCD0)1<Hi0CuSC)10i‘dC)lft0CDCuII0)5f-I-ft0)CD0p.1H,.CuftHCl 00oCDH‘-s:CDri-H,CD3C)0C)CDoCiCDC)SCDCDClftCl)0)0)ft0)P.)CDhCD><‘-<CiH,CuCDoHHHH-CDHft5o‘-<CDH-CDftiClCDIQCi C)p.)CuCD0)I-i‘-dH-H,CD00C) ft Cl)PjClftCloo CiHHCDClCu Cl0)ftftJCDCuCuH-CD<CDH0)ClCDCDHCDCDH0)‘xJH-I—’0)C)CDCuCuftH-CDCD‘-<CiCDiCl0)ClH-CuCuoHCD0)ftftP.)IDCDCiCuC)IQft--IS1-0C)CD—CuCDCD0CI)‘-<0)50)ftftftH-CuoCiCDft(.QI-ClH-0)H-.0CuCD0)5CDCifthQoClCD CC.)ftCDCl)H-0)ft0H-CDCl0)10C)0H-3(000CuCuCDH,HCDHCDftft<H-CD1iCDi.CuCD0H,HC!)ftHH-IICDH-CiNH-oCDCu0)•C)H-0CDHC)CDH-0HHftCDft))k<ftp.)H-<H-Cl0iCD0)H,CiHCiftHH-H,5H-H,H-CDCDCDClCDH0)H-ftk<0CiC)(0CDClftH-Ci)Cl)HD’CuCDCDCuHH,0)ft0ft50IA)E-’JHI-‘dP.)(0—.H-‘ziCDI-CDI—i0Clb<CDQ0ft00—C)0H-HCi(0HCiF-’(QClCuH-I-CDCiCDftl-Cu00)0)ClWCuH-CDSCDftC)CDH-CD5C)QCl0)C)CDCDCuft0)0)CD-.l-F-(0ft-CI)CiftftCDCDftft0H-H-1—CD0H:-0)ftCu‘-dC)CuftCiCDCD5H0J—ft0)Cl)h0)CDH‘dCuCuCuCiCD‘-<Ci3HI-ftH(QCl0•0P.)CDCDP.)H-0‘dh0)CuH,ftH-CuP.)CDCDH,H-(.0H,0)1)iftCuClCD0—-CDH-CDCDI-C)0)C)0)ftH-C)hftCD0CiCDCDft(QJCDH-H,HI-CDCDft<0ClP.)Ci)0)—CDCDIIhCDCDpih-i•—0<CuH,0)ft0ftC)ftCD0)H,H-ftH-——I-hH-bIH00CDCuftC)HH-CDi5C)iH0Cl)H-ftSClC)iH-0)ft0)CDCuCl)H-‘-<(0Q.00ftI-50Cl)C)CuH-‘-CI0CDH-CDC)0H,Cufrj‘-tIC)CuI-ftft‘-0p.)CuHCDCDftI—hClfthQftI-1iCuCDCDCD0H-H-CuCl)‘-CICDHiCD0)C)ftH-CDftIH,Iftft‘-<0)CDH-CuHCDH-I-ftI—iHp.)CiC)CDft.)CDCl)CDH-CDH-0)ftC)CD0)ftCDCDC)0Cl00Cu<CDCDCDCuH,CDCDCDftC)00)CD><CDft0h-jft‘-CI‘-CICiCDl-H-CDCiftCDt-CD,-0CD‘-<Cl0CD‘-CICi•H-H-H-(QCDftIICDftH,CD0)5I-ftCu00)CD0CDCDP.)(0ftClCi-350(0I--H-ft0)H,CDCu0ClCuCuft5iHCuftCD0)Cll- CDCDPi‘d I-içu0H-(.QHF-ipipjL:iiS0HU)CDH- 50d‘-IcHrr•CDCl)5•CDR’CrCl)p.piF-ICrH-CDH-fJ0CDCDU)CrH-H-U)HoU)-Dc:: CDWC)U)WhH-CDoi-j<oH-I))C)CrSCDH-Hi:i CD•jQCD:y•HCDCD)U)F-ICDF-ICDCro-CD F-IF-I p)FJCr5C’-‘-IU)H-i0H-Hiiio1:1)H-C)HIiH(-QU),-<oQ-CUCUdCDCr0CUhF-HiU)05<10Hi<1JCI)CD‘-I-J-CDC))H-0CDCDC)C)iCUCUC)Ct0C)U)C)HiCtH-U)00<0—CU0CDF-IU)CDC)CtU)U)CrHH-)H-CUCU‘<CUHCrCtHiHC)H-H-C)Hib0CD<Cr0CUCDSS0U)CDçtHCUH-U)H-5CD-ISb-CI)0CUCDCDCUCDC)CU))C)CtF-I3C)çitC)H-H-U)CDH-CtHi0•F-ICD0SH-U)U)ci-CD0C)0WCDI-IHiCD0CDF-IU)CDU)HF-CDU)CDQCDCl<1H-tIClCDF-ICDU)0F-ICUCitCrCI)0CUCUClHU)HiCDCl)C)CrCDH-CDCU‘—ICrU)CDU)0CrCtCDU)-CDF-IClCDCDF-ICUU)CD‘-<I-IH-HI-ICI)CDH-CD5H-CUHH-HiU)Cl)5HCI)CDCiIU)Ct(C—.HCUH0CDU)Ct1QCDClCU0U)CDSHiU)C)—CD0H-CiCDSCI)CtCDCr0HCDCDClCI)U)CDI-ICl<CrU)U)CrH-CI)CDoHH-CiCI).Q)CiH-HCriCrI-INHClCUCI)CDU)0HHH-IHU)Ct 0H-CI)U)dU)—ouiiHiCrF-CtCDHiCiCDCiHiCDClClHiC)H-CDH-CDci-CDCDCl)CDCUF-IC)H-U)ci-U)C)>Qft<H-CrdHH-CD0CUH-CDCiCDCriH-CDCI)•5CDCDCDCDH-HCl‘-<Cl-ClC)CUH-—.Cl)Cr0HiCiCUIDClC)H‘-I05Ct0Ci5CrF-I5(QI-ICI)CUU)<1CUSCDHClF-I5H-CrH-CUU)CtH-0H-CtdCDCrN0SClCDI-IH-H-R-CDC)iCI)CDftCI)c-t1Q1Q0OCt><CtI-IHiCrH-dF-IHHo<F-ICDCUCUCttHCD0U)HiOC)U)CiC)ClCDC)HF-hH0H-CDCroCUçt05U)0—SF-ICiHCiClU)HH0CDC)CDHi‘-DrQCDCUH-HF-ICI)‘OF-IF-IiU)CI)0HCI)iU)5ClSCUHCDbCDCl<0H—Cl1QCDI-ICUCt0‘-‘1CD0hI0H0CUiH-CDCUHi<C)0‘-1CD-<H-0H-CiCl0iU)ClCDCDCiU)HiF-ICUCrF-IH-C)CiCtU)hH-I-QCU<C)Ct5ihIHHCDCUClCiCD-0CIiCrU)U)U)-CtH-CDF-1CH00HHCI)CD<HiCI)CtIDH•-txU)0’Ci<IU)U)0•.CDHiHH H H U)U)‘ZiU)CF-CDCDH-0Ct00C)H1Q(-H-CDHI-IClF-U)HU)CUH-CI)CUH-0SCl50CtU)U)U)i5I-IH-ICDCU0I-Q5H-CDCrCDCUCtiI-IF-H-CI)H-CDI-ICDHiH-HiCDH-CUl))C)(QIiCI.I-IdHC)HU)0-ICDCDCDCt0H-F-CQCrU)ci-H-HCI)-10Ci0H5CUHiU)U)5‘-1U)H-HU)CDci-ClCI)C)CDCDCiiI-I‘—ICDC)C)CDC)0CDhICDCDCI)CDCDU)HCI)CDCiCD0CDCI)><U)ClHdCDU)1QCDHCD•CDbCDCD‘-IHCDCrH-HiYCU0Ct5QCU0CDCDCD<ClHiU)HClCtCDCr0CI)C)CDCUhICDCrhIC)HH-CDhiCrCDhiC)5-H-CI)CDU)CrU)CI)SU)CI)CiCDU)0ClCDH-ClHCDU)H-HCrU)CDCrHU)CDHI-QU)CDF-IHiCD•HCiICrHiCI)CrCDCiF-IICrU)U)ZICI)C)H-ClCrCDCDH-0<H-CDU)iCDClCD0H-H-HiU)SHiU)iH-CrCl0CI)CDCrC)C)CDCDusing interactive strategies to teach interpersonal andrelationship skills. The investigators found that mostteacher training sessions for these curricula averaged lessthan 2 days in length, and did not provide any follow-upsupport. The authors question whether this is sufficient andsuggest that most teachers who are in the position of tryingto implement these new types of programs may not havesufficient knowledge and skills to do so. The manuals orguides accompanying the curricula assume that teachers are“familiar with the prevention concepts and content and arecomfortable with ambiguities that may arise during classdiscussions (Bosworth & Sailes (1993:252)”. If they are not,it is likely they will fall back on more didactic teachingstyles, therefore negating the basic premise of the newprograms, which is the interactive teaching and learningstrategies.Botvin et al. (1984) combined social influences11 andlife-skills development theory in their “cognitive-behavioral”program aimed at reducing pressure to use substances. Thecurriculum included information, decision-making, coping,social and communication skills, assertiveness training andself-improvement (self-image) . The program was able to show asignificant reduction in new users of cigarettes, alcohol and11 . . .“with particular emphasis being placed on coping withpro-drug social influences (Botvin et al., 1984:139)”301U) 0 Mft-Qc-tI-W0Co0ftftP1dSP1H-H,CDCDCDCDCDH,I-ftH,P1CD3H,0CDfrCDP1CD(1)1QCDUIP1F-1P10Cl)Ci)0)1H,H-hCDHiH-hH-Cl)C)lQftH-ftCDC)UIiH-Crf-tCDCl)CD0hCDH,P1Cl)C)CtCD02H,L.J.0CDHftH-H,p1CDH-‘dftftCrCl)0l-Crf-rIICDP1CrCDft5Cr-HlP1CDCr‘i‘-C)P1CDp1ft5II-•IDCrCl)CD0H-P1CDC)CDp1F-HC)0H-CD0ftLJC)Cl)CDHP1Ib0CDCDCD1ftiHCrH-CrCDCDCD5H-<F-1P1IICDCr1Cr0C)C)P1CDCDCDCD101UICl)CDHQ10CD0çtCl)CDjc-F1CDCD0-CDHH-00)P1i0tCDI-ftIIHCl)0I-H-CDP1H-l-CD00C11P1H,‘-<Crp1CD-<0H1Q1QCDC)0)Cl)ICl)P1CDL’JHCDP1ftft‘-<CDCr5P10)CD—CDCDhP1i0)Cr0)frjCFHP1$15H,0Cl)tyftFP1P1H-051H-CD00H,CDtCl)hCl)C)<hP1CDH-P1‘<HH-CrJCDH-I-—.ftCDCi)h’C)HHCr‘oCDCDC)C)CD0)Qi.QCDCDWCDClCD•CDP1-P100CrCDQIQIHH,H5H-Cl)C)Sl-CiiCDCDCFCiF-10CD0P1Ci—CDiH-CDCi<CD<QICrC)C)H-Cl)l-HH,5HiH,C)H-Cl)CrH-ftçtC)5ctF-1OCFCrftH,C)P1CD0CD1QI-H-SCDC)CDCDCDCDi><H,ClH-Cl)P10CDC)Cl)CDftftP1P10QICDF-C)Cl)QId5I-IQi0l-0I-ftHCl)<ftCi)CDCi0CDhCDIQp1H-0HCDCDCI)H,H-C)CDCl)Cl)ftP1H,H-H-P1ftLJCDH-HiCiftP1H-H-H-ft5H,CDCl)hF-QI5ftP1ft0HftP1Ci)i5CDCDftftQIftP1CDftH-CDft0(QH-IQCl)C)ftH-Cl)DHft0H-iH-iHP1ft0P1C)CDP1CidCD0H-iP1ift0CDC)P1H5QICl)HP1Cl)C)l-5ftHH-iCl0FCD0P1H51.0CiCDP1CDP1CiCiHP100)l-P1ClC)—H0CDCi)C)ClClCl)H,-UIC)CDCDH-C)iCD0ftftCDH-H-ftH,Cl)C)ftH-HQI0HH-CDiH-CDCD—‘ft‘1ft0I-Ci)Ci)Cl3P1IQCDC)0H-CiC)0iP1H-10pl‘-<CDCDHft0C)CiP1P150U)ftHftClP1Cl)P1P1H-5ift5Cl)CDftQI—.--1fttYHIp1Cl)Cl)P10)0CI)CiCDCi0I-QftP1ftftP1H51J1ftCl)C)HH,CD0ClHH<ftHiH,P1H-P1P1CDCl)C)CDH-ftCDP1CD<QIl-IQH-1CCl)hHCDC)0Cl)H-H-iCDftI-CD0C)C)ftH-HI-0CD50)P1ftH,H<ftCl)5CDCDCDCDLJHCDHI-0ftHCl)CDP1H-CD0Cl)hH,CiciCDCDP1C)P1CDP1IIftCDC)ftH,P1ftP1ftC)CDH-H,QIH-iftI-H-P1ftCDCDftIICDHiC)H,CDP1ClH-C)P1CDftH,C)H-P1P1ClH-fttQCDCDhCD0CDHP10ftHHCD—5P1C)Ci)HCl)idiIICiClP1I-QftftCDftCDP1CD0ftCl)—P1ftCD‘-<0Cl)0Ci)CiH-P10)ftCDiCDCl)0HCDJftCDHH0HCiH-ftHP10..D0CD<‘<Cl)Ci)H-ftCDCD<‘-op1CDCDCD(.0-iCDU)CoOI-hCDClhProject I-STAR (Pentz et al., 1989) uses social influencetheory (developmental, social norms and social reinforcementparadigms) to teach resistance and competence skills as wellas providing environmental support to strengthen theconnections among youth, their families and the community.Elements of the program include school-based curricula, parentprograms, community organization, health policy change in thecommunity and mass media efforts. The study design addressesmethodological issues, including adjustment for baselinesubstance use levels and using the school as the unit ofanalysis (because it is the unit of randomization). At thetwo-year follow-up, differences of 9, 2 and 3 percentagepoints were found (in favour of the intervention group) withrespect to abstinence from tobacco, alcohol and marijuana userespectively.5.3.B PREGNANCY PREVENTIONHoward & McCabe (1992) focused on deferment of sexualintercourse (“postponement”) as the goal of their socialinfluences program. The program included information oncontraception as well as skills, assertiveness and resistancetraining (identification of pressures to participate in sexualintercourse, examination of the motivations behind thepressures, and development of ways to respond to thepressures) . Peer counsellors were used to teach part of theprogram and parent support was elicited. Results for those303not already sexually active were a 12 percentage point averageincrease in postponement, a reduction of frequency ofintercourse for those who began after the program and areduction of pregnancies in the same group. The program waseffective for both male and female preintervention virgins.The program had no measured effect, however, on students whohad already experienced intercourse before its start. Thisfinding supports the notion of the necessity of earlyintervention for successful prevention.Schinke, Gilchrist et al. (1979, 1981 & 1983), using the“cognitivebehavioraln life-skills counselling approach, wereable to show an increase in knowledge, attitudes and skills inexperimental groups. The program was geared toward increasingthe consistent use of contraceptives and involved access toaccurate information about human reproduction andcontraception, focusing on understanding, retention,personalization and use of the information in decision-makingexercises. Behavioral skills-training was geared towardobtaining contraception, regulating sexual encounters andnegotiating the use of contraceptives. Two somewhat uniqueaspects of the program were the inclusion of a component forthe development of a specific implementation plan forparticipants and the modeling of both verbal and nonverbalcomponents of approach, request and refusal responses by theprogram facilitators. The intervention also used guidedrelaxation/imagination exercises which included imagining304CDPict()H-It0CDHiItH-0dI-hI-JCDPiH-I-0000CD CDItçtH-CD-CDdMjCDItiCDo\Ohtl0I-HiCDr hhjHCDQ(-QCDU’CD.çtICDhCrCDHCDCl)tdiCD0OwCDCDCD(CDItCl0ItCtIdHi-Cl)<HiCDCDftCDCDCDMItCFCOCDCD(H-CrCl)0o\0.H1iCl)CDH-Crjh‘dtQClJ1l-000ctCD:D1tCDCl)CrCDCl)CrH-CDH0fr•Cl)i(QCl)00)H-0<0H-Cl)0H-dCDCDClCDCD00iCl)DiH-00HiF-10‘-Cl)ClCD00CtCl0CtCl1H-CDH-CDF-H0CtCDCDIICD-<I1iiCiCl)HiiH-0H-l-ClHQH-hjH-F—1CDH-CDH-<hCD0ClCl)H-ICD<CDCDCDH-H-H-CrH-0CDH-0Cl)bCrCDH-CrCDl.QCrCDCl)l—•CrCDCrCl)CDCDiCD0h0<00HCl)(CDCDCDCDCtCDCrHiCl)H-CDCDHiCl)CrCDCl)H-çtCl)yCl)IHi0CDCDH-ClCl)i0-CDH-Cl)0H1CDClCrIQCD0CDr<10QClItl-H00ICD0ClCDCl)CDCD0CDNH-CDCD-<I-HCD0CDCrClCrCt0I-QCrCDH-iCD<CDCrCD0CriiCD<0Hi.p<Cl)ItCD1d0ClYl-CDCDCrCr-CDHCl)Cl)0Cl)Hi—CDCD0Cl)CDF-hCliSCt0Cl)Cll-CDF-’0•H-1QCl)(CCDCl)CDClCl)F-11QQi-005l-l-CDCr0CDClCDCrCDCDCriC)CiCl)pCDCtl-Cr—Cr::jF-’“J05Cl)CDH-CDR’CrClCDCDH-HI-CrCD001QCrCDCr‘-<5CDCDCt0ClHih‘O0l-F-iCDl-H-ClCD><CDH-HiCDCOHCl)CCDCl)iHCD<HiCt0CtCl(—1CD0CDH-CDCl0CD0H-dClCDH<CDi—•CDCDhCDCDi‘tii0CDHClH-H-Cl)CDctS-1QI-‘d3IIH-Cl)Cl)Cl)CDCr0iClCr0H-CDC)CDCDCDCl0CD-<F-’CDi0CDH-HiiiCDiCl‘-0CDCt-0ClI-iCDk<CD0CtCrCrCDH-0ItHiCDCDtQ<‘-300CDFHi0CDItF0H-‘til-0IICDCD0ItCl)ItH-0CD00hCDI-H-Cl)CDHiHH-ItIt0P—HCDiCD00CD0ItCDCDHiCDH<H-CDHCl)CD1QI-CDIthiCDH-0CD00CDLOCDHiItCDF-‘<CDCl)It00t.Q0-.LOCD0hItCl)-Cl)Cl)0H-HiItI0CDCl)00•Cl)5ItHCD0H-H-Hi3CD—0Hi•-H-CDH0<HiCl)1QItHiItHi‘—30‘<It0CDH-•H-CDCDCl)00H—-0H-<0HClCD050)00Cl0H-ItHiClI00HCD(QCl)0tiCDCDl-h0iIICDH-HiItCD1QI-CD0Cl)l-ItCDCD‘-<It0ClCl010CDH-0‘-‘Cl)<0l-H-00I-QHiCDCl)CDH-CDJ10—Cl)0Hl-Cl)CDCD0iCDCDCl)CD0HHCl)HCD—ItClH-CDHCl)ItItCl)0CDItCD5CDH-<H-HF-ClCDiIQI-CDCDCl0Cl)<H-0ItH-ItCl)CDClCl1QCl.I00ItbCDl-Cl-I“‘0hCD‘-<0HiCD0CDCDIt‘0CD—Cl)hCDH-00Cl)Ct-H-0“13id‘-di0CDCl)i05HiH-iCDHCDCrCDH0t-’ClIQF-’‘-HiiCD‘-‘CDHH-hCDCDCDCl)CDCDSCrClH-00H—H-00H-LQCDiCDtIt0iCDIt0HHi0CDHi0CD0ClClCDCDCD‘—‘CrDH-ClCDCl)H-Cl)Cr-It0CDF-’0ci-ci-a)C)IIClU]ci-P3h’C)a)0I-’-H-Sa)dPia)HH0CD0CDCD-CDPiCrCDHCD0<3iiCDClCDCD0ti<310CrU)H-H-f1-Cl)3H-CDCra)0H-0Cl><Cl)a)Cl)CDa)P3CD1Q10F—1CD-Cl)Hl-tCDCrHI-iCDCl)l-CrI-lC)CDH-<0CDHP3(0H-HHHCDCl)CDH-H-H-l-tCl5111CrNH-H3.Ca)Ht-CrCDa)CDa)Hl-a)3iCrCiH-H-p30CDa)Da)HP3CiCla)Ha)CrC)(Q‘-<C)3iI-C)HiClH-CXH-CDCrCr(0c-ICih-CrIQCDH00—3C)HiH-CDCDa)5‘-<P3ClCD()a)-<F-’-CrH-C)00Cl-CD0CDp)0a)CrCra)0-U)HCDC)(0HClCDCliia)IHJCl)HI—a)U)H-a)a)CiP3HiCDH-ClCrCDCla)ICDCi<0CiP3Cr—H-a)H-a)HiCida)Cl0C)(IDH-l—-—--.HCDI-a)U)‘-<ClCrC)HiCDCDH-C)P35CDlj—.I—i<a)0—5CD0Cra)P3cvCra)dCDCDCDHP35—HiP3I-P3SCDCrH-bCtCDCrH‘-<ti—0CD-0H-a)H-dh-CDHH-0htH-H-Li(IDClCDCrHI-H-CrF-CDC)CD0Cr0bCD0H-—-.CDHIQP3rCDCr5Ha)i-Cii-3H-Hi(I)Cr10CrIQP3—CiHi-CD10Ha)CDH<0P3CDP3bCDClP3CDH-FCDCDLi-CDa)ClCDH-HCDH-H-<CDC)H-0CrP3CDCla)P3P3H-iCr50a)P3ClCr3I-Cr1d‘-<3(0Cr‘dC)P3Ha)P30HiCDdHH-(0H0Cr0CtCDClSCDH-C)HCr‘ti-Ci0fri0<CiC)I-ICDCrCDCD-1P3P3-IQt’i0C)CDCrI-IP3(0CDCiCD0a)ClC)H-P3<0P3H-C)5P3a)‘-<ia)SClHCDClCDCiCrLxiCi0CDCrH--a)H-5HiCD(QP3jI—HiH-a)0I-ICDC)SClH-a)CD<P3Ci0Cl‘-Ia)CrCr‘CIC)‘-<Cl0CDH01-1HCDa)<CDi-i0H-CDCI)CDCDCDH—5a)Cia)C)CD0C)Ci‘-IClH-Cr°3(0-1bi-Ia)0-P30Cla)iH-P3a)C)P3Q°(0HCDC)CrP3a)ZCrP3F-’-00-,CDHH-I-IP3Cla)LoCDH-a)Ct0ClH-Cr3HiH-(0H-CrCDci-0C)C)H-C)CDp3Hi0(0C)p3CDC)Cr‘-<‘tiH-HCD00Hi<1ClClia)0CDa)iCD‘-<I-I0CDHCDia)CDa)Cla)a)a)CDC)0a)I-ICl-a)Cl0H-C)Ci5CDCDCDCDhIP3CD0ClC)CD0Crhi10CDC)-.P3a)H-3ClCiCiP3CDCr5CiCD(00a)H-a)a)a)C)ClCihiC)0a)HClP3H0pja)P3FzjClH-C)a)CrClCrCDHiCrCDI-IP3CDP3HbP3HP3P3a)P3CDH-5HiI-ICrP3iCi(-QdC)P3(0h’0Cra)<ClCDCDCrH-H-HCl‘tia)CDCDCDCra)0C)F-’-—CDCDI—iHI—II-IP3a)CDiCr0CDa)<hiH-a)hibH-0C)CDCDCDCDa)-110h-CDa)0CiH-H)3CrP3H-(QP3Cla)H-CiP33-5a)CDHCDa)hiP3Hi0CrLia)HC)Cra)H-5‘tIP3ClH-Cl)C)S0I-IP30CDP3Ci-ia)i-ia)a)I—iC)(300CihiHICrCr0-p3—IQa)Cr0C)C)CiH-ClH-H-hia)Cl<P30Ci(QCD0I-<0I-I1QClCDCDCDCD0H-a)H-H-HClhihiSa)ClhiHiCrCD0CDCl<F-’-P3a)CrP3H-CDCrCrCDC)P3a)F-’-P3hiC)hiI-’-CD5hi3Cra)P33CDZ0CDP3CDa)a)P3H-0CDP3CDH-0H-Crii0QC)‘-<H-Cr0Hi<1Cl00—hiP3ClCrCD(005CiH-CDCDCi0HP3H‘dCi0CrCrClHhIP3a)CDHi-S-)Crhia)Cl0Cr—H-CDCDCDworried, indicating support for Health Belief Model constructsof perceived severity and susceptibility. It was also foundthat students with more partners reported using condoms moreconsistently, a different finding than that reported by other,more recent investigations. Condom use was, however, found tobe less likely after alcohol and/or drug ingestion, and to beless among heavy drinkers and frequent drug users. Perceivedbarriers (e.g., reduction of pleasure, embarrassment) werefound to be the most predictive of condom nonuse.Nevertheless, the Health Belief Model variables usuallyaccounted for only a small amount of the variance (e.g., 10%)in reported risk behaviours in these studies.Early school-based interventions aimed at preventing AIDSfocused mainly on increasing students’ knowledge about AIDSand their tolerance toward persons with AIDS. It was assumedor hoped, as with early programs in other problem behaviourareas, that perceived severity of the disease and knowledge ofhow to prevent acquisition would cause young people topostpone sexual intercourse, reduce the number of their sexualpartners and/or consistently use condoms to lower the risk ofinfection. However, as was found in substance abuse andpregnancy prevention programs, having knowledge is necessarybut not sufficient for young people to implement riskreduct ion methods.Realizing the limitations of the knowledge-basedapproach, several teams of researchers have recently307‘dH(D C)F-CDftH-C)OCDU)CD Hrrow1CD—H-CD HiCD hClHiHiHWC)a aC) Jo jhhCl:j CDU)rrOC)CDCDClCl CDC)rrftCl) 0Cl) 0I-C)H-HCflJpiQJH-H-U)3-<<U)U)H-CDCDfti--H-HCD)0Cl)CDHiCDCDCDClU)CDdHiHCDFdftHioHClC)CDC)0HiCDH-CDH-H-C)U)‘zJCliCDd0IClLQJH-0C)CDCDCDftl-CDU)HCl)5CDCDi-ftCl)0H-()C)H-fti-U)•3ClCl)HiCl)1I—sCDftH-C)<1H,0ftil)C)H-OCl0ftHibC)CDft—-0‘-<5CDl-CD05H-H-00U)U)0•-•—CDCl0U)ftCDH-QC)<5ftU)U)-•5ftQft<•CDPiCliCDftl)li—ftU)I-0CDU)U)IC)H-QC)-.ftCl)CDftH-Clt-ftCDU)‘<-CDR’ClHC)H0U)CD-Cl)iCDCDCDCDft<CD—U)tYCDCDftftCDCC)0C)h’U)—0CDCli3•CDCU)-H-U)Cli0C)H-ICl)U)I-ClXftH-0C)05C)‘dH-CDftCDH-HftI—CDC)Cl)ft0H-CliCDU)‘-<CliiCDH-H-l-Cl)Cli0QH-H-U)iH0-H<—.Q(CD—CDH3—Cli<0CliCD0I-ftftCD‘-PCliI-HHHCDHi3H‘<0U)HCDftU)C)HiClCDCDftl-H0ICliCDU)<H-hftHi0Cl)l-WH-Cl)0—tPCDI-Hl-U)CliCDH<HHiC)C)CD(QCliHiftU)CDCloHftCDHCliH-ftU)H-Hiio\0U)H-0H-DCDCDiH-H-H-ftftH-ftH-CDHi0C)CliHC)HCD0<CDCDH-0C)H-C)I-00l-CDtClftC)CliCDHiClU)ftHi<Cl)U)HiftdHCDH-CDU)—ClC)CDC)-ftCDI-I<HiCDU)0-.H-DClft‘<HiftClH-U)CD00b00CDCDC)QH-bU)I-CDCl)CDCl0U)CDh0I-CDftH-Hift0i-<Cl0CDftH-0CDCli0ftHI-HiClCDC)CDHH-U)CDH-0Cl—0H-HiCDCliCDCliftSCDU)1CliI-C)CliH-—U)ClCDftH-1PClH-Ift‘-<CliCD<‘-<ftHftCD0HH(QH-<HCDH--U)ftHiCli0H-U)CDHH-C)U)IICDCliCl0CDU)CDHH-—0C)I-U)CDCDCliCDftCDI-iH-•-ftCl0CliC)U)HiHI-‘-<C)U)C)C)CDCDCli0I-QCDF-C)U)HHftH-CDftlhU)il-ClH-<CDH,CDHftCliC)CliCDWC)5CliH-<CDiCli0I.<k<H-U)<CDH‘<CDCDU)ftftbCD<ftih3U]0H-H-ftH-CliClU)Cl0U)I-U)O\OH-<10H-H-H-<h’50CDftClClCDHiiCDH-<ftCDhU)0U)CliC)HH-0CliClftHiCliCiH-CiCl)dCDHH-Cl)ClU)HiftCDHiHClCDU)<CiCDCliftCDC)C)b3Z0CiCDhC)CDHCliU)HCDCiftCDCliCDft0I-CDU)CDU)CDpi<ClftU)f-H-ClSU)0H-ftH-ftU)U)U)CDCli‘-ft0CDCli-ftftH-0CiftH-HHft3<0H-C)0CiCli0—0<ClCDCDU)H-U)0H53Clil-000l-CliH-CiCl)0CDU)-H-C)5U)C)HClHi[-Cl)0H-H-IH-U)CDftH-CDH-0ft3HiCl)CDCli-HH-ftClftl-U)HHi0<C)I-CD-CD Cl) 0HCDHIft0Cl) CDft CiftDiCDftH- oHCI)lQ0 Hgft CDWDJ30ft<-H H S H- N CD 0 Di ft H 0 Di H H- N CD HCl)DiFFCiCi‘1CDCDftCDCl)fJCl)DQdDift0H-0ftDlI-C)CDCl)tCl)ft0H-H-C)F-bftDi0H-0H0HC)H,H-1IIHCrHIH-CiH-‘-<dCl)Cl)CDCrH,P.CD0 F-iftftQoH-Cr-Di01HCtiCDCDH-CiCrCrhCD0CDCD0ftF-C)0oCDDiCrH-ftCl)CD0CDCDDlH-Dii—1d‘CfCDCl)F-IC)CiCI-C)oCl)CD‘dCl)IH-H-CDh’Dl<ftCDCi)CDHoDiCrCl)H,c-fC)ftCDCD0I-<<aH05ftCDCi1Y0i-i—ftCDCl)0DftHDlDifrjDl<H-0CDftH-50dCDCi0ho ftftDlDliDijQHIftH CDCDDlDihICl)<C)CDftCDftdCi‘1Ci0a.DiDihICDHftCDHCDft Ci)DlHftCDCDCl)0hIHCl)C)0CD‘ZDiH-CDCD<IlhICDC)CD-ICDa.H-H-DiCl)< CDHCl)-a.0 H1DlCDCi1il:ji-ft0Cl)CDhI00HhftCiH-JftftCl)CDCDCD—hI H-‘-I0Cl)HHCl)H-CDHftCDCl):3ftDiCDCioClDift<ftH-Cl)CQ00H-hCl)CiCQ0CDhICiH-H-H,H-—0ClC)0CDDljCDfthCl)HCDC) Dl H CDH-C)Dli0iC)ft0i-QCDftCiZhIHH-ft0CDhIH-HH-0 i0CDLQCl)< CDDiI-C)HI0•ClDidiH-HClCDH,hICDDiCDCl)C)<Cl)ftftH-dk<H-ooH0CiCDhICl)--•H bIQhIH-CDCDHtIHCDH-ClDiCl)ftCDftCi‘<IIHH-ftH,Cl)0Cl)I-C)ftCl)ft0CDo0Cl)CDHCDCDHCl‘1Cl H-CDft0Cl)hIftC)DiF—CDftH-C)ft=CDftHhIDi—0CDHdftCl)hI::3CDCD—t-ftCl)C)0Cl)CD0HhICD ClDihI CDCDH DiHftUi0CDHClWDi Clft‘-<H-0CDCi)DiC)I-CD0Cl)ftClDi0H5CD hICiC)-.--Cl)CDHCDdDft‘DH,H-MI-io—CDCl)CDCi><CDoDljH,5C)H--<Di bCDCl)Cl0 H CiH-ft(QCD:yDiCl)jC)Cl0hI0CDHH DiCl)ftftH-Ci ClCDCDI-iftH-Cl)Cl)-05H,CD DiLi Di Cl) CDHILiCDiDiiQSCiH-H Cl)H-ft—HftoCDMCi S CD 0 H, Cl) CD Ci Di H Di ft CD hI Cl) Di Cl H, hI CD Ci CD C)H,CD S Di H CD C!) 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CD0Ok<H,H,U)<10bCt).lP.)ClP.)Cl)t3P.)IIH-ftP.)0CDCDH,h0H-ci-CDiU)CD30I-QCDIIH,CDH-ct0ft31CDHH,H-P.)U)CDP.)H-P.)0H-U)QCDP.)CDh.)ft3ft<0-CD<CDCDH,Crp.)ct0CDbDI-H-P.)HCDH-H-H-Cl0H.P.)0003U)ctctCDCtftCDQ0H-0CDft0ftP.)<H-U)U)U)H-30U)CDf-i-P.)<1CDftd-Q.p.Cl)U)-H-‘dCD0H-Cth5-P.)0HCDft00CD0CDH,U)0P.)NII0OP.)0Fpii-HfthCDC)HCDCDH-I-CDH-I-ftftCD0CDp.)I—’U)Hp.10CD0H-I--H-CDftH-U)CrCDCrHCDHH,Q,3H,CD0H,U)CDU)ciH0CD0(Q00h0ftH,H-CDhHCD0P.)ciH,P.)ciH-U)0CDU)HCDp.)ftQ?çp.)ftU)H3H,I-P.)ftQ.CDH1CDI-ftiHHU)H-0P.)CDHCDU)U)U)H-ci—P.)ftH0ftH,ftft01Q-CDHCDF-—I—’0HJU)0I0CDP.)H-ftCD3P.)ftCDCD<CDCDCDhHHciH0Q.5-ftQHH,P.)1HCDU’pjk<CD00I-QCD0P.)H,CDiH-U)HftU)HciH-CDU)ftH-<H-CDQi-H-H-ftCDHU)U)ciftCD03ciCD00ftU)P.)P.)H-IICDP.)ft0ftH,0I-U)i<U)CD0H-00U)U)CDCDH3CDH-3-<0CDCD<CDC)3‘-<QH-‘<NH-I-’U)H-i-HFftH,CDIQP.)ftCDft00I-CDH-ci‘-<U)U)CDCDH-0QP.)CDU)P.)U)P.)0CDCDH-P.)P.)CDP.)HftI-’P.)0Hl-ftH,H-U)ftihH-CDHU)H-H-QHCDftU)H-H,0CDtjHHH-Hd3ftHU)CDiCl)H,H-H-3U)Cl)Cl)ftt3ik<HU)IH,Hft)QH-0IP.)CDH,U)CD00H-<d30I-ftHP.)<CDICDftH0H-CDIIH-U)P.)ftCD><ciCD‘<ft‘ftQ.,P.)HCDCDU)HH,ci3<Hd-0CDCDCDCDHP.)CDH,0ciCDH,p.)CD0i-U)IftH-p.)0CDCDH-HP.)3CDH-QCD0HH-U)0ftU)H,CDP.)H,Q0Qftft0P.)P.)H-ftH-H-CD<1H-hp.)0$1ftP.)U)03CD<11313CD13CDF-’H-13hICDCD13CDftCDfthIftH,13H-CDU)0HHCDU)H-H-P.)cift13IIH,H-hIU)dCD13ftH-U)HH-P.)0H-<U)130CDCDHIQ<13P.)<H,CDP.)H-CDCD0><13H,HCDH-13hIftHH,ftciP.)P.)-00ftH-13H,H,hICvCI)H130ftciHCDP.)IH-H-U)I—’H-H,1301Dh11tY0U)CD0H,Cl)00CDU)CDHP.)ciH--ft-Q130-CD0P.)hI013P.)C)-’hIU)‘-<ftU)PCD0<0 k<interventions for this age group.The first school-based HIV-prevention program to show astatistically significant effect in reducing adolescents’sexual risk behaviour was a six-lesson curriculum developed(after conducting a needs assessment) by Walter & Vaughan,1993. The curriculum emphasized AIDS risk information, self-efficacy and sexual negotiation skills, beliefs aboutperceived susceptibility, barriers and benefits to engaging inAIDS-preventive behaviours, and perceptions of theacceptability and norms for involvement in AIDS-preventivebehaviour (DiClemente, 1993:760) . Teachers were specificallytrained to present the curriculum and implementation wasclosely monitored by the research team.Data collected at 3-month follow-up showed a small butsignificant decrease in the frequency of sexual intercoursewith high-risk partners, decreased number of sexual partnersand an increase in consistent condom use in the demonstrationgroup compared with the control group. This carefully-constructed brief curriculum, based on value-expectancy andsocial influences theories, could serve as a model for futureAIDS/STD school-based prevention programming.It has been easier to measure cognitive variables, suchas predisposing factors, than to develop and implement othertypes of measures (e.g., measurement of skills andcommunication ability). The Health Belief Model, being one ofthe older, more applied and tested models, has been more311thoroughly studied with respect to its predictive ability thanthe newer social influences models and theories. Weaknessesfound in relation to use of the Health Belief Model includepoorly demonstrated reliability and validity of measures ofvarious belief dimensions of the model and the lack ofempirically established relationships between the constructsof the model, making it impossible to predict the extent ofbehaviour change that will occur from influencing one of themodel’s variables. With respect to HIV research withadolescents:Limitations of the HBM regarding the prevention of HIVinfection in adolescents [also] include difficultyaccounting for change of habitual behaviors, relativeexclusion of emotional reactions and peer groupinfluence, and lack of maturational constructs (Brown,1991:53)5.4 SUMMARY OF PROGRAM FINDINGSThe review of substance use prevention programs showsthat a social reinforcement (‘learned resistance to peerpressur&’) component is necessary for behaviour change tooccur (relative to a control or comparison group) and thatthis approach is most effective when combined with genericlife/social skills training. Alternatives or developmentallybased programs are able to increase self-esteem, selfconfidence and decision-making skills but do not lead tosignificant behaviour change (avoidance of substance use)Program presentation by peers was able, in some instances, toachieve longer-lasting effects than presentation by adults,312but follow-up support is necessary for long-term maintenanceof behaviour change.As attrition rates were high in most of the studies, andthose students lost to follow-up were at high risk accordingto baseline data, there may be a group of students who needthem who are not benefitting from the programs. This might beaddressed by starting the programs at younger ages, beforeabsenteeism and dropping out occur. Aspects identified in themost successful programs included:1 use of media material, with similar-age peers aspresenters;2 information on the immediate physiological effects ofsmoking;3 correction of misperceptions about the prevalence ofsmoking;4 discussion of media and family influences on smoking andways of dealing with them;5 role playing and explicit learning of behavioural skills;6 a public commitment procedure; and7 extended duration of the program (Flay et al., 1987:166).The review of pregnancy prevention programs shows similarresults. Social influences training (skills, assertiveness,and resistance) was able to increase postponement and reducethe frequency of subsequent intercourse and pregnancy in preintervention virgins (Grade 8 level) but did not affect preintervention non-virgins. Again, this suggests the programsshould begin at an earlier age. A cognitive-behaviouralskills program was able to increase contraceptive use amongsexually active students. Another trial of this approach,which included many important components (e.g., adolescentdevelopment, peer pressure awareness, gender 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is taboo for discussion and remains ratherunconscious. Rapport and understanding are critical forknowing in the qualitative paradigm. Many questions remainwith respect to adolescent sexuality.2’Only a small percentage of the large number of school-based prevention programs have been evaluated, and thoseevaluations tend to have some methodological weaknesses.Nevertheless, the findings have been relatively consistent,suggesting that school-based or school and community programsmay produce a “significant” protective effect. However,usually the effect sizes are small, in the range of 8-15percentage points difference between groups in levels of use,and positive effects often do not survive longer than 6 monthsto one year without further intervention.5.6 Figure 11, (Appendix 2): How variables from othertheories fit into the PRECEDE-PROCEED model.5.6.A Predisposing, enabling and reinforcing factors foreducators.Theoretical constructs found in the literature/theory21For example, how do they define sexuality and what doesit mean to them? How do they interpret phrases such as“monogamy”, “bodily fluids” and “safer sex”? How do theyrespond to the media’s characterizations of AIDS andhomosexuality? How does the fact that researchers are askingthem questions about their sexuality (and, at the same time,possibly framing their experiences into language for the firsttime), affect them, and how does it colour their responses?318H-ftj0 ft CD CDH-j‘-2hMH-H-OpiCD‘-HU)C)iiCDU)H- CD CDjtP-,ftU)H-CDihCDCDiflçCDCu0W HCDCu(0FHi—3I-NCDCDU)0-CDCDCDiHftCDU) H,fti-U)CD H-U)0 C)‘I)()CuH1(PHHC)tY<CuCDZ<1H-f’CDH-U)C)MCu1HC1CDC))CDCDhC))ft>0C))C)0CDi0—CD0<CuCDI-ftClhH,ftftC)H-H,U)‘dClftC)CDC))C))U)ClH-H-CDCDH-HH-H-0HC)H-HDH-HY0H-C))ftC)H))0<1CiH,CiCDMCDCiC))H-H-C)bCiftS—CDC))hQCD(PCDU)H0H0CDftHClC))HiftCuFiftH-H,H-CiU)CDCDftC))CDC)<H-(PC)C)H-U)13U)ftI-H-U)U)CDC))0CDH-CDbftH,CD13CDU)H-H-H-ft01313H-‘-<800C))CDCD—-C)1313013•H-H-CD(PC))HHI-CD-HU)ftftH,U)CD13C))ft13ftHCDC)U)13H,CDH-CDHC))HfttY0ftH,ftftClH-C)H-—C))013Cii—HdCDHCuH-‘-<13CD1313CDU)H13ftCDClC/)CD13CDC)H,C)ftC))(Pft0(PH,7çft—‘H-130C))hft0hftCDH,H--0C)CuC)U)C)H-00ClH,(PftH-H13H-H-CD0H-‘1CDCDH-Cu0h13C)H13C))U)H-1313HU)C))130CDCDC))U)CDft(PCDHCi<U)H,k<H-ftHH,ftH-H-0C)—HCD0CDHU)0ftH0N13I-’<H-H-C))LJCl-CiCi1JCiCDH,k<CDC)13CDCDC))CDH-0C)C))CDCD0——C/)H,CDCDftH-CuC)H13ft13I-W13I-iC))0H-hCD0F-1ftCDHC)13ftClCDC)C)C)<H,13Ci13H-13CDC))C))HCDH-13ftH-0CD0ftI-H-<1CD013U)ftH-CD013H-H-C))ClClhIH-13CDH,3C))ftftJCDdCiCDCu(PC)0HCD0—(PH-CDftCDH,CDH1313H13C))13ft0CD013‘-C)HC))IC))ftU)130U)hICDhIftCDC)U)0‘-<13H-U)CDhI13013hIk<hIU)13CD0CDHCl13C))CuhICDftCD0U)—CDH13ClH-0CiH-H,CDI-hH-1D0U)H,00hICDC))CDCDHC)3CDCDbCDhIH,13U)<<HCD13ft13CiH-H-I-CDI-‘-<H-C))-H-CDH-Cl0C))CDH,13H-U)13ft—‘13C)zJU)U)ftH0<13H-(P13C))ftH,ftCD130CiC))U)CDHC)C)H,ft<1H-13HH-C))U)CD(P0hIi-CD0‘H-CDftH0H-ftCD13Ci0U)CiU)CDH,H-<CD-CD13U)U)13Ci0Ci0H-CD130ftH-C))CDU)Cl(PCDCDCDCiClhIC)1313L1—1JU)13hI“iH-H-H013CDhICD-<13C)—CDCDC))CDCiHH-H-U)H,13H,I-C)hCD11ClC)hIi.PCDftCiC))ftk<CDH,—ft0H-CDftdCiU)-<ClCi0C)CDC)—Cl00H,130C))H-J0CD-H-hIU)ft13Q-h13H,CiHC)<1CDH-hIU)-C))CDCDH-0ft131YCDC))HftftftCD0ftftft1313hH-H,<H-C)hICDCiC)H-hI13H-ClH(PU)0H-1313hIClC))CD003‘-<C))013H13ClH-13(P-<U)13W130ft1313H--H•CDC)CDC).I0C)CDCDh013ClC)0CDCD1313Cu013CDHH,CD13C))C)C))H,b’CDU)H-U)dC))Cl‘JCDH<1CDClCDH-H-—CDH-H,CDCuCDHH-13H-ft(PC))0C))C))Cl130CiClCi<1C)H-U)hhIH-ftC)CDH-(PCDftC))0H-130HCi0CDhI13ClWMHccLDCxD—]OUiWOHIt-H-UiCDHCDiCD0CD<H-CDHU)U)C)I-CDCD0(1)H,WHFHrtL’JCDU)H<I)U)P)OLx1’ei‘d0P)U)CDC)C)CD0C)DiC)DiiU)CDDiCDc-cC)CDCDC)hhCDCDCDt-‘bC)C)CDC)C)CDC)DiHCDHHU)ccQ.C)HHhF1CDC)c-cC)0DiH-CDCDDiH-CDbCDCDH-C)iF-OhhH,H-C)H-C)C)QH-H-CD0U)<F-WSU)C)HhU)Hc-ccCDCDOc-rC)$II00C)CDCDH-iiHHk<U)HU)c-tHU)H-C)U)DiC)U)H,(-QU)d0C)H-<’bH,HH-ct<U)QHH,CDC)c-cCDH-c-tbccH-ccQ---c-t(cH0H-CD--..H-CDc-cH-H,‘<CDCDH-0C)H,CDHOQQCDOU)H-OQ.CDbU)cU)H-DiCDQ,Q0U)ccDi-(IH,DiD)CD—I-hCDc-cH,U)•H-OC)QCD<CDiH-H-C)CDCDH-DiHU)U)d--piDiH-Di<DiU)U)LQF----HDiCDQP<U)c-10ccCDc-cU)C)CD—C)C)0OH-CDCDC)SH-CDCDDi(Q0-Qc-tc-cC)H-h-’CDQCDH,c-cDi‘—c-c-C)-cc-O<CDDiC)CD<1F1i•oI-U)O0Di<1<O0HCD0CDH-QH,c-c-tc-rC)CDCDCIH,U)cc-U)IIZIIQH-CDSC)hI-H-U)hC)-Di<--U)CDDic-cDlDiH-U)DiC)iOCD$U)c-cdU)OQF-i-CD-.Q.c-rDiH-c-cCDC)-HiDiCD-bU)CDc-cCIDi<CD-H$CDH-crc-c0c1Cl)0c-cH-CDU)H-(DDiclH,C)C)sQrJQQc-cOH--<OC)0CDI-c-c-Hh-<U)H-0c-c0H-ODiCDc-cH-H-Q—H,H-hCDDi1DH----.CDCI0l-c-cCDc-cIhH-C)DJhU)-•DiU)U)CDCDHc-cH-C)0c-cc-cQH-CIU)ODlc-c0U)H-H()c-cCD0C)‘<C)ODiH,H-Di0i-CDU)OH-QhCDH-0I-DlCDt-Q—CIH-C)-U)DiH-CIH,C)HCIc-c<—U)CDc-cC)c-c0c-cbc-tDiC)DIHOCDCDCD0C)CDHDlU)—CflhH-HDiCic-c0Hc-tIC)HiCDDiH-Ui--(DccDICICDCDc-cc-cH-H,H-DiU)CIC)C)c-cc-cCDH-HU)CDU)H-H-00hjI-H-CDCDH-H-CIU)bCICQ0HHU)iC)iiH-CD0CD0I-H-H-0c-cCDI]jI-HH-—C)DJCDI-QDiD)CDU)CiXCiH-0IICDU)DlCDU)C)H-CDc-cC)HDiD)bU)bC)CDCD<ICiCDCIC)C)CQ0U)c-cc-cc-c—Hct0DiCDtCICI—CDCDI-HH-CICDH-U)U)CD0H-c-cH-HDi-DiU)0U)CIH-DiCDDiOC)0U)—H-b0CDCDc-cHc-c0U)c-c0OctH-Hc-cDi—iH---CDCDCDH,hcc‘iH-0HCDDiccCDCDDlc-ch---3H,C)CDH-U)IHU)Cl)U)C)CDCD—-H-C)H,<CDH-CD0IQ1QH-H-c-1-DiCIHCDHCD0H-H,C)H-1WCiDlH,H-b—ciCDH-—C)H-Di<1<CDI-c-cQU)QH,CICIH-H-CIi0‘—c-cDic-cC)CDHCD0CDI-0H-CQH-CDc-c--<<piU)<Q.<H-CIC)-Dl$DiH-—CDH-DiCDHbCDH(QbCDdD)DiC)0DbU)I-H,HhU)-ccyc-cDiC)C)DlU)bCDCiiH,CiH--CDDic-c0hI-hc-CH-c-cCI0DiU)CIU)DiCiccH-CDDlOctH-C)HDiC)i—]‘CDHCIH,HiDiCQCIH-O0H-hC)CDHH-H-DiH,c-cU)C)H,CDbCDDictbCDCDtctCDC)DiOCl)CiDiU)c-cCDH-ctU)0CDH-1CU)ccccI-CDOHCIC)CliI-DiiOH-•00HDlH,DiH-cc0HU)IjH-tYCIDi0DiccI-U)H-H,CiCICD-H-H-CDU)c-cCII-i-CD0DlIIH0>0CI<-H-DiH-DiU)DiU)H-H,H,H-H,OU)U)H-CD0CICDH-0CIcc‘-<—U)0--CD-CIdecoding, decision-making, communication, assertiveness,negotiation, condom purchase and condom/contraceptiveuse);5 Personality factors (e.g., cognitive coping style, self-esteem, self-acceptance)6 Protective/resiliency factors such as abstinence fromdrugs, alcohol and sexual intercourse, practise of safersex, school bonding, school attendance, religiousattendance, extra-curricular activities and a meaningfulrelationship with at least one adult; and7 Promising life opportunities (educational andemployment);8 Understanding of media and peer influences.Reinforcing factors include:1 Social norms in favour of AIDS preventive behaviours; and2 Acceptance, approval and encouragement by peers, familyand school staff (including the right to self-determination with regard to sexual identity; approval ofhealth-enhancing attitudes and behaviours; andencouragement to develop into a responsible adult memberof society, with regard to self, intimate partners,family and society at large.How does the program presented in British Columbiaschools relate to these predisposing, enabling and reinforcingfactors for students?5.7 INTERVIEW FINDINGSThe philosophy and goals of comprehensive school healthprograms were outlined in Chapter 4. These include holisticapproaches and generic skills training, established outcomesbased on realistic standards, adequate time for students andfor teacher training, links with other agencies andministries, attention to psychological and social influences,healthy physical environments, publicly stated health goalsand annual implementation plans.321H-ClCJU)05CDJftU)ft<UFCJft0iiU)CDiftHiCDClC)U)ftH-CD-I-CDU)<ClftH-CDCDI-5hCD0t’iCDH-HCDCDClU)ftC)CDC)HH-CDCD‘-<5U)CDP)U)CDH0CDCDHCl)HiFU)Cl0L’JCDiftCDU)0ft0H0CtCDII-IU)ftH-CDCtftHftHi0IICl)IIC)HiH-t’l0CU0UoCDU)CD-1CDCl0H-Cl)ftH-CD0ICrIICDHiCDIICtClU)CDU)H-Ci33CDi3H-H-U)CD3U)DCtd<Cll-H-CtHC)0CtdCrCDF-t3‘10dCDH-U)H-CDCDft00HH-H-ou—.‘-<CDft‘-<CDCDC)ClCD<ClU)CDCDl-C)U)03CD<HHHl-’CfCiU)H-CiCtH50tTi0U)ctU)Cl5CDCUHiH-0Cl)CrCrCD•ClC)CD‘-<CDt‘1‘tiCD0H-CDhCUC)CDhU)Cr—HCiCDClU)l-ID<U)Cr‘-‘ICD0CDCDCD0Cl)CttiCl)H-Cl)Cl)U)H‘-<CDHtYU)HiI-H0H-Cl)05HiCDtI-0Cl00H0CDCrCDU)CDIIl-HiU)I-U)CDClC)CiHiCl)HiCl)CDU)Cl0CrCDU)CDU)Cr•jH-)U)SU)CiClH‘tiCl)SCl)CrHCl)HClH-I-0H-C)CtCDCDHi0ClCUCD0CDH-HCDCiSCl)J<II-HHiCl)ClCDHiCl)CDC)U)tCUHftCDCDClCDU)U)CDCl)0CDCl)Cl)CDCD‘ti‘<CDC)HCDU)H-0CrftCDI-ICUhCDCDhIH0<CtbC)Cl)H-0I-HCl)hIHH-C)3Cr0dCDCDH-H-0CDCDCl)00IICDH-CDCrCrCD0H-U)5HCDHCl)H3U)HiHIIiCDC)CrCl)U)CD05H-HCDU)U)U)0U)hII5CDftH-fttiCDC)—hICl)CDU)U)H-0dhI0Cr5‘-<hICrH-5ClU)U)HiWU)I-CDCrCDHiCl)CDCl)CD00hIU)CDU)0CDhIH0HI—’H-U)U)0CDHI<1Cl.’hICrCDClCl)CtClHU)CU0hICDCDC)HCD0U)Cr0C)Cl)C)0H-Cl)3CDHCl•Cl)‘-<0H-0HH0<0ClH-Ct050CD3U)CiU)CDClh3H-ClH-‘tih<CDtjctCDU)Cl)CDClH-0U)0CD5hICDH-H-ClClCDI0ftHCDCfI-QH-CDCDU)3•C)CDCDCthIhIf-hU)H-0hI1jc-fCDU)CDCfU)‘-<><0CihIIHCDCiCl)H-CDClCf0•0H-CrU)C)0C)H-5H5HiCD•0Ii50HiCDU)CDftCD0U)Cr•ClU)H-Cl<H-U)Cr‘tiHiCDi013U)C)13CD‘-<•ft13U)H-CDU)13HCDft5U)13HiHHCDHiH-hIoCD‘-<C)HCDCDHi•H-HiCl)H-<H-C)bH-CDC)Cl)00ClIU)13Cl)Cl)ft13H-HH-HCl)hICl)hIU)0C)CDClCDCDD13HCl)HH-CDCDCl)3H-ftHiCi03CDCDCDClCiH-‘tiH-ftHHh130HiCiU)13C)<CD5Cl)13ftftk<U)H-(CCi0ClHiCDCDCDCDSCl0U)hftftCD‘-<—0CD13fthICDCiClHCl)CihIftCDH-0l-hIhIftHi13ft0‘—‘-C)CDCiH13Cl)0l-0ftU)ftH-0CD0Cl)ClCl)-Qft“i13hIU)Cl)hI130U)H13U)Cl)ShIftC)CDft130ClCDH0‘tJCD5H-HCD0H13H-13CDCiU)CDC)CDU)5CDftftH13‘tihICl)ft0CDhICl)CD5H-hICDU)U)k<-<0ftCl)U)U)U)13Cl)1313U)Cl)U)HCDCD0l-U)U)HftftH0HiH13Cl)Hi-ftCl)IJft0CD13U)U)hIH-ClCl)CDCD0CD‘tiHU)HiU)DftftU)QU)Q.H,CDUift0tTftHU)DCl)IICDftCDCDJ1ftCD‘-<U)U)C)C)CDCDH-<f—s<1C)---1U)CDPJCD0ftH-F-CDCDH,CDftC)H-CDhftC)jI-H-U)CUCDHF-’I-IF-10CUI-CDCDCDC)H-CliU)0U)Cl0hft‘ti0H-CDH-Cl)0CD<105ft-CDdU)0ftU)F-’0F—1ClCDCU0H-5<SfrCDCD0I-QCDI-C)0CD5U)U)0CDCDCDH-U)ClCDCDC)ClH-H-CQClCUftU)H-I—’3iH-H-U)CUH-‘-<H-—ftCDftU)0ftClU)LJ‘dH-U)C))H-C)I—’C)<5—H-C)CUH-CDdIiClF-ftC))C))k<CDCD0‘-<H-5H1C)I-0CL’iCDH-’ftCDIIF-’CDU)U)‘dCDCDCUCDU)C)tlH-‘-<CU0U)CDftCUC))H-C))F-ftftH-I—IftftftFCl)U)C))C))CQftftft0IF-ftCDdiC!)C))H-U)3CDCD0U)ft—CDI—(QQC)Qft0Q,U)53CDClH-CU0ftCD—zJ0ftC)03CD0ftCDSC)ft‘1U)Cl)Cl)0CDU)U)U)U)CDC)3U)C))iJClCDC))CDCDHICDC!)C)H-dU)CD>H-0ftF-CDftftCDH-ftCUft0bH-ftC))H-U)ftC))H-CU‘<U)H-ftC))C)<CUU)5H-I-C))3U)H-i3I-CDC)ftCDtY-CDClSF-’H-ClC)Clft0ft1QF-’I-F-’C))ClF-’I—IdF-’ftCDF-’-ftCDC)CDiCDH-k<CDH,H-’CDH--CDCD3ft3IC))U)C))IH-iCDCDftH-‘-<C))fthCDC)5U)F-’C)F—’CUCD3I-QH-h-<U)C)I—’U)C))CDCDC))ftH-0H-CliU)CUCUH-—ftF-5N0CC)CU‘-<SCUftH,CD0H-IIH’5CD1—IC)I-IftU)0I-CD<C))C))WU)H,F-’-0U)F-’0C))C))ClClCD0C)U)tOQ,ftCDC))ft0CD0CDF-’ft0W00CUH-ClC)0ftH3HiHH-0<0H-ftC))—-I—IhIC)CDCQhICDCDI’H-CDCDhIftCl0U)ftCDC))CD-U)I-IH-ZIiC)1-h<CDU)U)hICDH-H-ftH--ftft000U)--hIftfthIC))-0U)H-5U)C))x1H,CD5t-F-fthCDIJCDIiCD0C))fthI00hICDS<F-CDC))H,C))•CDIi0hICDCihIt’JSftCD‘-<U)F-’CDCD—013hIClCDhIC)HIH-CDIi13ClCD13C)H,H,CUftU)0-H-CDH-CDCUCD0C)H-CDH,C))IiC))hIU)hIIi“J0C)5H-13C)IIftU)C)U)CD5ftU)Cl13CDH-H-II0U)H,C))U)13ClftF-’U)CD13U)C)C))IDC)U)13CD•ftCDClFCUftCDftClCDd1313H,C)F-H-F-H-0ftCUH,5hIH-CD13CDCDftCDC))F—IH-13<13d0<IC))k<<CDCDC)0C)U)CDC)H,IQCDftCDH-C)CD‘-<CDH-ClH-H,ftCDClft0CDU)CD13C))CD0U)H,13U)F-h0IC))hF1hI5ft13C))ftC)CDH-U)H,H,ftCDhI“IF-’13C))C))-<ClCD0C)hICDC))<00I0ClU)0Cl13C)-H-CDftftCDF-’ft13H-hICDH-C)13Clft01350<1F-0ftIF-’U)C))U)H,F-CQCDH-U)ftC))hICDH-h05HU)ft-d001<CD<1ftftCDU)13CU)C))CDCDCl0hIF-’‘dCUCDhICDH-H,ftCDF-CDU)C!)CDhIC)CDhI00H-—H-13—H-H,5ftH-CUCD1JU)U)IihIIiU)0ftCD13-13IihIU)U)Ii-I-QCUCD(013U)CDCU0C)13H-H-Cl13H,13-ClIi13ClCUSCQftplace.A few of the educators have moved into the area ofresistance skill development:How can you SAY, “I don’t like it when you hold my handswith your fingers between my fingers, it doesn’t feelgood for me.? [8:P14]The educators realize the interconnection betweenmultiple risk behaviours and focus as much as time permits onenhancing protective factors in and for their students. Atthe same time, they feel that parents are ultimatelyresponsible for the sexuality education of, and for settingstandards and morals with, their children, and that studentsare ultimately responsible for their own attitudes andbehaviour. For this reason educators strive to improvecommunication between students and their parents and tosupport family values.There is a broad range of relevant enabling factors foreducators, satisfaction of many of which is being frustrated.There is a lack of clear policy, of curriculum, standards,accountability, shared goals and objectives and measurementand evaluation tools and techniques. Current organizationalreality is also not particularly conducive to health programs.For example, educators have to continually lobby for thecontinuation of their programs and to fight for time, and insome cases, space, in which to present them. There is littleco-ordination within the schools, districts, or among outsideagencies or ministries with respect to the delivery of324(I)H-LXI1xJ5Clh;u SHC)H-H-CDCU•c:HSCrCD‘-<CDH 01:-ICfH-CDH,ClCUCD‘U)LXICUCrCli0ClC) CU0Cf0H-oC:=Ii =ClCD-CUCUçhCfCDiU)H-CD U) CDH rfH,0oCDIihU)HCU SCDH-U)C•)iCfCU hrfCD0H-U)U)CfrfCrhCD0QClQCDCDHHH-HQCDCf‘<00 H,S-’CrCUi0ClCD0CDHj.Q0 C)CUU)CUCfCDCUHCDClCfH1Cl)‘-<CrtioH-c-fU)CUoH-I-o‘-0dC)CDCDH-CfrfClCUCDCrc-f<1 H-C)CDCD0CDHjt-CUU)iHSCli CrCDCUCDht-t-CfCD<0H-<CDH,C)CUiHCrHCDHtiCUi0CDhC)jCDU)zU)CUCfCl CUC)ClCt-H-CDCUCD-CDU)1—fU)CUH-ClCUCl0CfCD0-H,CfCDCDCfH-CD(0CUCU<1U)(0ClCDCrH-0CUCl(0-C)CDCfC)H-CDCrU)U)U)tJC)U)CfCDHCrH-CDC:CDCUClH,I-CDCDo HCrCfCrCDC)U)H-CUC:jc-fU)CU(0H-CfUU)H,:3-JU)CUCDCDSCfC)k<k<CrCUCDoCUitiCUtiClSU)CD0CfU)H-<CDCf5CDCD0I-ClH-otiSCrCDH,H-00CD0it-jt-IH,CrCfCDCfCUCUçrIW3CDCDCrCDH-U)UijU)CfU)CDtiCDctCl0HCUk<‘tICU1H,CDCDCU0ClStij0U)C)oH,H-CDCriCD5><CDCU‘10‘tIiU)0HtiCr(Q<1CDoiiCDU)H,tYCUClU)0S-CDtiH-CloCUCDbClU)Cl‘-<•C)5CrCUCUCrCD0CDCDU)H-CDCfH-U)0C)CUCUCD‘tIF-1C)U)CDCDH-C) CDCUCUH-U)iClc-rC)U)CDCDH-U)CDC)U)Cf<h0(0CU0CUCDHCUtiH-ClCUCiU)C)ib-CUH-CDCt0CfjU)CUF-iH(0CDCr0H,H-oCUF-10I-IC)0S CDH-CD(0CUCfClSHU)HP)C)Cl)C)I-IiCUH-CfCDoCfCfCDoi00C)I-IC)H,H,H‘-I‘-<CDCfCDClCfCUF-IU)‘tICUF-ICU‘tICDCfCDH-CDF-IP)HCliC)H-F-IH-H-Cr0U)F-ICltICD(QCrCUI-IC)00‘-10çt)H,H-(0-iU)jF-IoClCfi(QCU SH-Cl<L:3U)H,iCDCDF-IIjH-ci-oU)CfjSCDH,CD‘-10CDCDCfCf<C)H-CfCfCDC)C)H-U)H-CD00C)c-fSH-CD-0CUU)0C)H-<1CrI—iU)CDU)‘-ICfCD‘-I‘-ICU‘-<CUCD‘.<HjjU)Cl)ClCf00‘-1H,CDCfC)‘tIU)CDCUHCDClCDiCUF-I‘tI(0U)U)‘tIC)U)C:U)00CULXIC)CUCDi-iCrCl(0U)CfH0CDCD0C)0HH-CUH-CD-CfU)LXII-IH,0Cl)CDCf0tiH-]CD‘-IU)U)j0‘-105CrQIC)U)ctCDU)0CrCDtiCUCD0iF-ICl<F-IH,‘tI0CDCDCU—CrH-CUCDCfCfH5C)<HU)CUCUC)CDCU‘-::—tICfCD<-HCDU)CfCDtICDF-IU)H-CDCUH-0CDH-CUCrjClH,H00(00U)0C::F-I5H,1-0U)CDH,CUCDCUCD0Cf<H>hiCDF-iH-CDCrp.it-<iF-I50H--H,CD‘tICfCUCl)0HC)HH-k<CUCDCDU)dSF-I-F-ICUC)CDiClictLXICrjH-Cr‘tICl‘-0CD(0CUitIhiHiCDCUU)H-ICDF-ICfC)0U)5CUCD0CUH•H-CftYCDCUiCUCDHU)U)U)CrC)CUCrCUF-ICUU)H-CDF-I0HSCl)CUCDSCDCDCD5CDC)CrH-00Clis a large gap between educators’ expectations of parents(roles and responsibilities) and what they see parentsaccomplishing (in terms of providing healthy social norms andreinforcement for their children)Lack of vocal public support and demand for appropriateprogramming is frustrating for the educators (one referred tothe public’s stance as “apathetic receptivity”) . Some of themread support “between the lines” in that although there islittle contact with parents, at least the parents don’trespond to messages sent home from the school in a negativefashion. Educators think that some parents feel incapable ofhandling sexuality education with their children and arerelieved that the school is addressing it. However, theschool cannot replace the parents in terms of things likesetting firm and consistent dating limits and providing familymodels and support for health-enhancing behaviours.Therefore, missing parental attention to this area is a weaklink.Some school colleagues offer support to “Family Life”educators, while others disapprove of various aspects of theprograms and/or begrudge the time taken from other subjects.When questioned about support from their Principals and schoolboards, most interviewees said they were TIpositivel. However,some Principals were less than forthcoming with support foraspects of the program, such as bringing condoms into theclassroom or running a small anonymous student behaviour326survey. Although they were targeted some years ago with adocument from the Canadian Association of School Principalsentitled AIDS: Preparing your School and Community23, schooladministrators seem to wait for requests rather than comingforward with proposals in support of Family Life Education°,TiLearning for LivingTl or goals/objectives or program planswith respect to HIV/STD education.5.7.B PROGRAI’V CONTENT AND STRATEGIESThe programs offered focus on:* Information (puberty, body functioning, anatomy, biology;STD5, AIDS, transmission modes, prevention, high risksituations; condom use);* Attitudes/values (reinforcement of family values, comfortwith sexuality, respect and pride, self-esteem, self-confidence, honesty, demanding of respect, expression ofown needs)* Skills (thinking -- reflective thought, clarity re:needs; communication -- including listening, use ofvocabulary, terminology; decision-making; assertiveness;negotiation);* Resources (counsellors -- modeling, rapport, individualcounselling; school nurses and physicians; outsideresources -- health clinics, Gay and Lesbian Centre, AIDSVancouver, Planned Parenthood, Red Cross)* Behaviour (self-control; use of condoms if sexuallyactive; communication with family and important others;abstinence/postponement; knowledge of partner; respect ofself and others.Measurement and evaluation of the programs consists ofvarious aspects, including:23A 67-page guide for school Principals, commissioned anddistributed by the Canadian Association of Principals and fundedby the Federal Centre for AIDS, Health Protection Branch, Healthand Welfare Canada.327* Outside (trend) information (Canada Youth and AIDS Study,McCreary Adolescent Health Survey; STD and AIDS reportsfrom health units);* Information (formal testing of content -- quizzes,worksheets, projects, assignments, labs, presentations,repeating back);* Attitudes (students’ affective reaction -- involvementand participation, attitude and effort, enjoyment andenthusiasm, comfort level, memory from year to year);* Skills (observed student skill development -- use of newvocabulary, use of new terminology, quality of discussionin role plays and scenarios, use of skills --assertiveness, negotiation, communication);* Resources (students’ use of resources -- counsellors(after class) , school nurses, health clinics, condommachines, pamphlets);* Student evaluation of courses (feedback via anonymousquestions, written at end of course)Strategies for delivery include:* In school (role play, scenarios; practise, reinforcement,feedback, developmental, behaviour change; classdiscussion, peer teaching, individual counselling)* Out of school (parents, community, health services)Sensitivity Issues:* Homophobia. Some educators are starting to try toaddress homophobia, but schools are not doing very wellin this respect. Many educators do not have anyhomosexual students openly coming to them forcounselling, do not make referrals to gay/lesbian outsideorganizations, and are not able to provide schoolenvironments free of sexual harassment.* High risk students: ESL, potential dropouts,differently-abled. These groups are not being adequatelyeducated re: HIV/STD risk.While a holistic approach is evident, there is not enoughtime to support its adequate implementation. Educators do nothave time to focus specifically on any one problem area indepth and rely on teaching generic decision-making skills tohelp students approach a multitude of problem areas on theirown.328The Guidance programs are between 15 and 20 hours a year;during that time we are trying to prevent and givestudents information on a hundred topics [12:1:24]They also do not believe in addressing HIV/STD infectionas a separate topic but enfold it within the presentation ofsexuality education. Finally, they feel to a large extentthat what is most important is the relationship between theteacher and the students, once again revealing the programfocus on the developmental approach.Some attention is paid to psychological and social forcesaffecting students’ health, but time does not permit enough.There are some inter-ministerial and inter-agency links, but,again, these are minimal compared to what would be trulyhealth-enhancing for students.Other aspects of the philosophy behind comprehensiveschool health programs are missing in the school programsstudied. Educational outcomes are not set, and there are nopolicies regarding realistic expectations or evaluation.Adequate time is not available in students’ timetables nor forteacher training. School boards’ health goals are notpublicized, and implementation plans are not created andreviewed annually.The question of direction from the Ministry of Educationis complex. The Ministry has mandated “Family Life Education”and, more recently, “Learning for Living”. However, theimplementation plan is vague, specifying only that schools maychoose whether and how to implement “Learning for Living”. In329some ways this may be beneficial, particularly to experiencededucators in schools or districts with a strong history of“Family Life Education” who appreciate the autonomy itprovides. On the other hand, to educators, schools ordistricts without as much experience or felt support, it is abarrier, as little happens while people wait for more specificdirection from the Ministry.It is agreed that co-operation, interest and motivationare needed for an educator to do justice to “Family Life”education, including presentation of HIV/STD prevention.Therefore, along with mandating the education, adequatetraining must be provided to ensure that the educators arecomfortable, competent and confident with the topic area, andeducators who believe it is an important topic and who want toteach it must be chosen to present it.5.7.B.l WHY ENABLING FACTORS ARE NEEDED BY EDUCATORSAs can be seen in Column 2, Figure 11 (Predisposing,Enabling and Reinforcing Factors for Educators), enablingfactors (skills) lead to behavioural capability which leads toa reduction in perceived barriers and to an increase in selfefficacy. This clears the way for increased intentions which,when combined with other predisposing factors such asperceived susceptibility of their students and severity of thediseases, and subjective norms toward presenting HIV/STDeducation, based on perceptions of what important others would330support (reinforcing factors), may lead to inspired teachingof the subject matter. It is obvious from this analysis thateducators need skills as an integral part of theimplementation chain.5.7.C. PREDISPOSING, ENABLING AND REINFORCING FACTORS FORSTUDENTSAs we have seen from the literature reviewed in ChapterThree, the developmental approach, although beneficial, is notsufficient to produce behaviour change for students involvedin risk-taking behaviours such as unprotected sexualintercourse. Self-esteem and decision-making skills, stressedby schools in British Columbia, are necessary but notsufficient in this regard. What would seem to be missing,according to the literature and theories, is broader socialsupport for students to engage in protective behaviours, andmore focus on practise of skills for specific assertion,negotiation, refusal and exiting from risky situations.Educators see HIV/STD education as part of a package ofhuman sexuality education. They do not want to focus on it insuch a way as to make students fearful of sexuality. They tryto focus on Tlhealthy sexuality”, and not to have students seea negative outcome as a result of intercourse. Their focus ison health promotion, not disease prevention. Will this beenough, however, to prevent disease? It might be if a fullscale health promotion program were in place, but this is notthe case. Schools are in a good position, with their focus on331health promotion and goals of empowerment of students, studentownership and student responsibility, to make a positiveimpact on student health. However, 3-4, or 10-15 hours peryear is not enough time. Studies have shown that 40-50 hoursper year devoted to health education are needed to produce asignificant effect on behaviour (Green et al., 1985;300) . Thebasis for a good program is there but it is not beingrealized.With regard to student sexual activity, a controversialtopic, a range of approaches existed in the schools. Threepoints on the continuum from abstinence to sexual intercoursecan be distinguished. First is long-term abstinence (waitingfor marriage, monogamy), “the safest, best option, the bottomline”. Next is postponement, ITwaiting until the student isabsolutely certain that intercourse is in his/her bestinterest”. (This implies that a sophisticated decision-makingframework is operant, which may not be the case for manystudents still operating in a concrete thinking mode.) Thenthere is advocacy for choice, presented without judgment bythe educator (but after the students’ having gone through aprocess of acquisition of relevant information and developedskills in decision-making) . “The counsellor is nonjudgmental, open-ended, the student makes the wise decision.”This is the inclusive approach, geared to not alienateminorities of any type, whether sexually active or not,differently-abled or belonging to a sexual minority. Sexual332activity is presented as normal and natural, with cautions asto what to be careful about. Very little discussion with theeducators centred on promoting alternatives to sexualintercourse (°safer sexTi or T1outercourse1 options)Schools definitely espouse a policy of condom use forsexually active students. Condoms are available in studentwashrooms in all the schools in which interviews wereconducted. However, the general opinion of the educators wasthat not many are sold.24 This may be due to studentembarrassment. Condoms are also available from some of theschool nurses, but some nurses require discussion when givingthem out, which may deter students from asking for them, andschool nurses’ time in schools is limited.Several of the predisposing factors mentioned in theliterature are being specifically addressed by the schoolprograms; notably, self-esteem, self-management, comfort withsexuality, and educational/career aspirations. Variablespertaining to the Health Belief Model do not seem to be beingaddressed in a definitive manner; however, as discussed above,these variables have not been shown to (at least on theirown), be particularly useful in the area of adolescent HIV/STD24The enabling factor has thus been taken care of, butpredisposing and reinforcing factors, Tiperceptions that friendsall/most use condomsiT are not yet in place, and none of theeducators interviewed seemed to be focused on bringing thisabout. This may be attributed to educators’ lack of access torecent theoretical findings showing perceptions of peers’ use ofcondoms to be highly predictive of condom use.333D:iH-‘1CDC)CDHOI-ftF-’CDCDdiH0ftFHft0)J0H-ft0CDCD J-JH-H-I- ftftCDCD0•H,ftCD00CDdS<H C)ftP)CDHCDH-0CrH,S oCDHICD<CDC)piJjC)ftQ-oH50Cl)CDH-CDCDiH 3LQH:(QCDCDCrCDoH:CDd)H-HçuC)—H Houi-<H, CD CDiJ H: CDH H-0CrCrHCrCDH-C)<0P-’Cf)CDH,dLQCDCD0<QPiH-30CD3PiHDF-1H:HiC)PiftCD<1PiC)3HCDH00PiCDCDH-C)CD0CDH:CD-<0H-C)S(-QCDftiHPidH:t-H:CDpjCDCDPiftQH:diCDC)0CDftPiCD0b0p1iCD0QH:ci0CDSCDI-HI-1QH:CDI-hjC)I-LQCDCfH0CDCDCDCDftpcrH-l-ftLi.pi0P1CDP10H,1H:CDHIH-CDC)(-QctftP1CD0(CfCrCrC)CD10C)H-C)CrI-0H-H-3CDC)D0H:C)QciC)CrH-ihH-ik<CDCf-IHCDCDCDSCDCfCD1çtCfCDCD00P1ci—CDCDCDCfbH-ft<CDCDCD515I-C)P1CDciCDH-CrCD-H-0CDCD<0P11CDC)1QCfQH:CrCrDH,H-fttciCD<0H-CDH,H-0CuCDC)C)ftCDCDP1CDpiQ3H-P1CD—CDP1F-1CDC)H-CDftH-ClCDftC)CDI-C)H:ciCD0CD.QCDHH-ci3CDP10H-HClH-CDClciCDH3HftH:ciCDCDCDH-—H-F-’CDCDk<P1ftCD0H-CDLCp1ftCDCDHH-Cl<1(CD-ciCDCl>H:0.QCD3P1C)P1CrftftCDCDciH-CDCDS(QHCDCDH-H,p1çuIC)H15CDftCD1plftCDCDHP1H,HI<0HHHIC)CD1C)H,H,CDH,CD0ftH-0CDCDH:p1<CDP1Cl0CfH---ICDH:3ftH:ftCDFH,ftH0ip1C)ftCDCD-<ftciCDCDP1ftCl0ft0CDIIWHP1-P1Cl0H,0CDCDW-oSCuP15CDH-00ClCDCDftCDCDHftP1Cf0HCDftH,><CD0H,C)CDP1CDH-LiftHCDHCl)P1<H-P1ci00•CDCf0HCD0H-<C)CDSC)P1P1ftH:ciCDH-H:H-H:CDH-HbH:3CDH-H,H-HC)CDP1HHCDCDCD(-QHIH:H-ftCD0C)CD00HP1H-1CD5ftCDH,P1H:k<ftP1H,CDftC)HP1ciClCDHH:CDC)P1P1ftftftClHCDHftd00CD3CDH:P1CrClftftH-0CD030H,<ftCDHCDH-5CD<H:H:H-H:H-H:CDH-H-P1ClSH-CDH-QftCDCDCDCDftCDHP1Clft0CDftCDCrH:CDHft0HCDH-0ftS‘-<0I-CP1ftP1H-cidH0HH-CDP1H-•ftH:ftP1H-CDCl5iC)I-<ClLJHCD0CDCDH-<ftCDCDCDCD0HC)ftH0-—ciCDftftH:ft3ftftftH-H-H-CDClHCDft0H:CDftp1P1CDp1ddCDCDCDftftCDftCDHI-CDft<pj<CDH-CDClClCDCDP10C)H:CD0CDC)CrftCl‘ti‘-<CDClC)ciHClH:H5QCDCrftCDCDP10WC)p1H-H-0CD0P1ftp105C)H:<CDIDCDClCD‘tCD0CDC)0H-ftCDCDH-CDCDI-CDCDH:5HHCDlftCrClCDClF-iCD0ClH:CD5<1H:H-P1CDCDH-CDH:00fti0CDHi‘-<5ft0P1Cl00ft0ftCDCD0(tp1d0uii5—rciftftCDClI-CD“Family Life Education” any more (are “out of theclassrooms”) , how will students get to know them to be able tofeel comfortable accessing them?Lack of co-ordination, planning and communication betweenschools and parents and between students and parents createsgaps in both enabling and reinforcing factors. As mentionedin the literature (Atwood & Donnelly, 1993), when adolescents’lives are fragmented, with different reference groups beingisolated from each other, they tend to think and act one waywith one group and another way with another group (i.e., theybecome “compartmentalized”) . Thus, although when at school,students may be planning to use their communication andnegotiation skills and to practise safer sex, when away fromschool, another reality may prevail. If they have littlesupport from parents (who often do not know or refuse tobelieve that their children are sexually active), peers, orthe media, it must be difficult for them to project goals andobjectives learned at school into their out-of-schoolenvironment. This reality would support the integration ofschools and the community as much as possible when planningand implementing health programs. School-community coordination would facilitate reinforcement of the same messagefrom multiple channels, an important component of acomprehensive health promotion program.School programs seem to be particularly deficient inrelation to serving students with special needs, whether they335be categorized as Differently-abled, English as a SecondLanguage, Potential Drop-outs, or gay, homosexual or bisexual.In many schools, students are free to make an appointmentwith a counsellor whenever they wish to, and it is tempting tothink that those who need counselling in the area of HIV/STDprevention will get it. However, according to one counsellor,when questioned about opportunities for targeting more HIV/STDprevention towards potential school drop-outs:The personal counselling you do with them is usuallycentred around dysfunction in the family, feelings aboutthemselves, self-esteem, and you’re not, you don’tusually cover sex education issues, because they’re notnumber one in what’s happening at that time with thestudent [11:1:337]Programs are not able to adequately reach students at highestrisk:The ones who have lifestyle things that can beproblematic. So things like if someone has a drug oralcohol problem or has a self-esteem problem or has beenabused or whatever. You know, some of those issues wouldmake them, I think, very high risk. And those kidssometimes need a lot more attention and time and sort ofa separate program, maybe, in some ways [15:P12]Even some of the school nurses were not comfortable withstudents in an alternate setting:The alternate school, I’m not quite sure. I can’t quiteget a sense whether I’m on the same wave length as themyet. I feel it’s harder in that setting to get arelationship going, whereas I feel like we’ve got thatgoing quite well in the classrooms [4:P5]With respect to students attending an alternate school, onecounsellor reflected on the situation as:A: It takes a long long long time for those kids tobuild up any kind of trust so that they will share.336It takes a long time. And you can’t push it.Q: So they’re really defensive?A: Yes. Very good reasons. For excellent, excellentreasons [14:5; 11]A number of school programs include bringing in a speakerwith HIV or AIDS to try to break down homophobia and increasestudents’ awareness of susceptibility and their tolerance andcompassion for people with AIDS. Schools have a long way togo, however, in providing support for young people who aregay:There is no gay and Lesbian club or support. It ismentioned, in passing, as an ‘alternate’ lifestyle, butnot dwelt upon [9:P2]5.7.D SURROUNDING CIRCUMSTANCESAlthough it is agreed that implementing “Learning forLiving” is a good idea, circumstances within the presenteducation system are making it very difficult forimplementation, with the concomitant training and in-servicesneeded, to occur:It’s so encompassing, there’s so much there, in allareas, it’s almost like they’re asking more than we’rereally capable of giving. ... Who has control over it?You know, it’s almost, you have to get your whole staffthinking differently. I find it really interesting thatthe whole curriculum and direction the province is movingis coming at a time when there’s less people available tomake it happen. The two things don’t fit. And it’sworthwhile doing. I have no problem with that. Butthey’re making it impossible to do. I met yesterday withour administrators to do planning for next year, andthey’re talking about further cuts. We’re at the bonesright now.... We were sitting here yesterday for twohours with the administrators, and it’s like two hours ofbeing depressed because they’re coming back from asuperintendent’s meeting and saying, TIWere going to haveto cut more teachers, we’re going to have to cut more337programs”, and at the same time, “We want to implementthis, and we want to implement that, we want to go to anew . . .“, and you’re thinking, “Wait a minute, things aregoing in opposite directions”. You can’t do it. Andstaff don’t want any change right now. They can’t handlewhat they’ve got, so they’re really resisting bringinganything in {5:Pll-l2]5.8 SUNMARYKnowledge, skills and actions necessary to facilitateprotection against STD/HIV infection in adolescents have beenstudied and presented. The current educational system inBritish Columbia secondary schools has been sampled withrespect to the circumstances surrounding HIV/STD education foradolescents.HIV/STD education is presented within the context of“healthy sexuality” programs, which may take place inGuidance, Science, Home Economics, Physical Education, FamilyManagement or other courses. Some educators are still usingthe 1987 lesson plans distributed by the Ministry ofEducation. Others have gathered new materials and strategiesfrom workshops or training sessions.Educators in a number of schools were waiting for cleardirection from the Ministry of Education as to plans forimplementing “Learning for Living”. Some educators felt thatimpetus for “Family Life” and “Learning for Living” weredisappearing amid hectic change, downsizing of staff, cutbacksin extracurricular programs and lack of direction from theMinistry of Education.Educators in two schools, nevertheless, said they were338very involved in implementing “Learning for Living”.All interviewees complained of lack of adequate time topresent information and nurture skills in their students. Anumber of other barriers were found, including a lack ofgoals, objectives, standards, accountability and measurementand evaluation tools specific to HIV/STD prevention. Parentinvolvement in the schools was largely missing.Predisposing, enabling and reinforcing factors foreducators were elicited from the school interviews, whilethose for students were organized from the literature andtheory review. These factors are presented in Figure 11, anadaptation of the PRECEDE-PROCEED framework for healthpromotion planning and evaluation.In light of theoretical and empirical evidence from theliterature and the present circumstances surrounding schooleducation for HIV/STD prevention in British Columbia, thefollowing recommendations are offered.5 .9 RECOMMENDATIONS1 That the Ministry of Education clearly articulate itscommitment to accept responsibility for a significantrole in the presentation of education for the preventionof HIV/STD infection in adolescents and that it manifestthis commitment by enactment of a mandate to this effectand by assignment of responsibility and accountabilityfor its implementation.Interviews with educators showed the importance theyplaced upon visible commitment via an enforced mandate fromthe Ministry of Education. Since 1987 there has been nofollow-up from the Ministry regarding HIV/STD education.339WL’JHCDCDftWiJCDCDUIftIiH-F-—<<10H-‘-<HH-J0P-.SC)CD<1CDftHC)I—iH-0ft.ftH-H:-flCD0HC!)CDCDH-0OdCDPiftH-CD-CUhCl)()CUHIctSCi0OH,Qr-ftH-CU3SCDCrhCUCUtiH=Cl)HCDftCDCU0(l)H-03CDICiCUC)C-QH-CDCUCD-CDftC)Hftftft(QH-03QhFH-C)ft0CDCDH0CUCrCDftOrCDrtCDOOCUSCDCUIII-0CDCUCUCiSCDCDCDCDCUH-H-ft<C1ftftCDftCDbHCDHH-ftC)(DCUCUSCDCDQ3CDCUH-H-H-CDC)H<‘<LJ•JftH-HftCDC)H-(QftCiC)-C)0CD0CDCDCDCDQPiH-C1CDSOtFCDCDC.QPJ003CDC)03C)OCUCDCDPJ0Ok<CDCDH1—J-H,0H,CDCrCrftH-O0HCUft3H-ftHOCDCDH0CUH-CUH-H-h00-JC1CDCiCDCrH0HCDi.Q0<QC)-H0Cr<p-i,trI-CDH,0hCiCDft0ftCDCDH-5H,-JCDC)PJCUCUCDCl)SCDCDH-CUCDHQCDCDCDCDCDbDCUDiCDI—’CDftdCDftCDHCU0CDftCD‘rJJCDHftH-1CJI-PJCiCDCDHC)0CUH,I-jCUH-JC)OCDCD$HCiH,0H-30CDQ0CDftCUCiO’<(QSC)CiQCUCUHCDC)0t-Q(.QCiCDH,ftHLQC)Cl-CD3H-0ftftiH-CUCUhQCUU0CUHC)OHCDCDftPJfti-CUCDftH-CDCDCUftCDH,CDftk<Cl)CDCUCDftH-HHClSClCDSHQQH-H-‘tiHCDftftCUH-CDClCD0‘rJ<CUH-CDCDCDCiCUN0CD<DiCUCltCU5hPJClCU—.C)N•H,CUH<1-C)‘dCUC)-.-.ClC)H-bCUCUHftCDCUCl5Cl)CDCDOCDCUCDCUftftH-CI2CiftH,HftH-CDCl’dCDH-H-ClCl5HftCUH-H,C)CD0CDHWCDCDiCU‘dCl3HOH,CDft00ft0CUH-LDPJClClH‘HQCUftH‘-<05ftCDhH-<C)ft.ijftH-CUClCDOHHCDCDftftftCD0CDCDH-Cl‘-<P)ftOCDCDCUCDDClCUCDCiPJ0C)3—-QClOCiHCDCihP)-0H-CiCDCDClftHftC!)d0CiCDC)CDftCiOiH-CH,C)<Ci‘dCDH-ftCD0CDCDCUC)H-CUHftC)CUCiH-CUi-CDCUCUl-CiQJCUCDCDHCU3ftftH-OftHftH-ftHCDftiCDhCiiCDftJ(QH-CDSCDClC-QCDDiH-CiS‘tICD-H-CDH-0H-ft0ftCDHCl0CUCD0-l-CDClCUOH-1OH-CD<bOftCift3CDft5H-CUCD3H,CD=CD•iCDCiOOCDC)H-ftCDC)‘tCDftCDCl•<H(-QC)ft-ftCiCDCUH-0CiCD0CUftftCDClCUCUHCDCDH-C)ftftCDft3CUOh’‘dCDCDI-CDHCDCD3IICUH,QC)H-3H,IIH-CiCiCD‘-<10CifthClClCDClHC)SCDOH-0C)QCD5HiCDCUCDCDCDCDHCD53PiH,CUCU0“JCDtQCD=ftl-lC)CiCDQCDC)=CDSftCUft0H,0Cl0Cl‘dIr’00ftCl-jCDHftCDC)H-HhH,CiCUCU0CDOHCDCDP)CiH-CDPJ0CDH-hCUHCUSCDftClClOClCDC)CUHClCD30C)CDClCDhCU3-)C)CDH,CDI-CiHCiH-CDOCDHftH--ClCDH-CD0ClCDHftCUClH,CDDCUH,HiSHft•-CUftlQCDCUCDH‘d0HH-CDCDI-H-ft-CDCiCDLQftCUCDCD-0CUb3b0(-QCUCDCDftCDCDH-CDCDHCUftH,ftCDHClCDH-H00CD00CDCDCDClCUCiCDCiCDHft‘.<HCDCDHClClCDCl)ZSC)ClftCl)C)ctC)Qf-fCDCDCDClC)H-H-0CUCU0CDI-CiftH-ClCDjj5t<CD0CUH-H-ft:ij<0H-H-5CDCDftC)ftNftClftC)(1)0Cl)Cl)51CDCDNCUCDCUF-HCtft-3H,5Cfli-CUCDCDCl0H-iCDHCl)iH-ft0“JCl)CDCDCUCDP)H-CDH-Cl)5CDiftiH-Cl)H-ftft0:hI-CUC)1FCUf-fCDCltC)QCU—CUCl)H--CD0-H-H-H-HH-H-fthCl)CDCDS—.-CD—-Cl)ClSCUCUftHCDH-CD(-QCUH,CUSCD‘-iiHH(H-ftC)ftCUHCDCUC)I-0Cl)ft-fthftCDCDHClh0-CDCDI—sCl)0ft0CUCUPJCl)CDCl•CD0CDH-0H-CUCD<h’LQQ,FftH-CUClQCUCDCD‘QH,H-JCl)Cl)H-0I-0H-CUCDCl)tY5il-HCli0HdClCDCDCDiftCDCUS0H><H-CUCDC)CUCl)f-f5IHF-H-CDClC)0CDiQ—ft‘-H-f-f50CUC)CD5H-0C)CD—CDC)5ftftH-CDH-CDCDH-CDCl)ftUjCUiC)CU0CDCUH-0Cl)H-Cl)ClH-f-ff-fH1CCDCt5H-Q0H(Q0H,ftClctftiCUCD00Cl)CD0CDCUH,CDf-fCDCDIICU(5H,I-CD--ClCDCl)hctClCl)CUftH-H0CD0CDCDCUCl)Cl)UIH,0H-iICD0f-fI-0-rtCD50CUh0CUH,iCUCDCDC)H,51H-ClH,hCUCD—ClhH-I-iH-(QH-0ClCUCDCDCl)0ftCUCDCDftCDf-fClftWCD0SCUCU<SCDLJC)0Cl)—Cl)H-f-fI1ftH,SClCUClC)dCDCUI—iCD0(-QCtCDDC)CDH-CDC)PJH-ClCl)HHftH,C)HC)CD0HCD0ftQk<fL1JftH-CDCU0CDIftH0CD—I-0C)H-FCl5f-fH-C)I-jCUCDCDSCDCD1WCDCUC)CDCDH-CDCDIICDCDH-CDC)CDH,5CD0IIdl-ft0CDC)0f-fft0—ClCUCDCUft-CDH,CD-HH0CDI-CDOSCUftHCDiH-ftCDCD0ft<l-CDQClCDft-CUH-CDH‘d—CDCl0051CD5H-CU0-CDiH-HiI-CDCDCl)—CDIQH-0dtCDftftHI-ftQ5I-CD5ft•:iClClCDH-H-H-C)CUiftH-CDICDS-CDC)CU0C)ft5OrfCU-CUCDCU00CDCDCDCDftHii-IH-HCDCDI-ClC)ftCDft5CD0CUH,CDH-00Clcih’CDH-dCDCDf-f051HH0.—CDCDH-CDCUC)dCD00iH,I-C)‘DH,CDClCDC)CUCDCDCDftClciClCUCD‘oCDb’0HH-CUftiij—tQCUCDftCDhCUS0Cl)CDH-ciCU<SftF-QCDClCUftCl)CU(-QClCD—cidft5rCDCDH-CUH--H-ftCD‘-<CUHH-CDH-CUCl><3Cl0CDClCDdHH-H-<ftCUCD0iCDCDClH--CDH-0H,H-ciCD0iC)CDCU5I-QCDC)—)iCD(QII-IIC)hf-fftC)CDClCDtCDCUftt—0f-f0CDftCDCDCDCUftCUIICD-H,05ciCD0i-1C)5ftC!)H-5iftCDCDftHCD0Cl)IIJCD0iCDCDCUCDH-ftC)H-H-CDC)HCD0ftC)(QCDH-CDFjCDCl)CDHCDft0I-OOftOH-ciClCDH-CDCDCU5H,ciHCUCUCDSC)IIftftCDCD0k<HCDH-CDC)CUH-HCD0CDCDCDiClCUC)f-fftci—ft5HCDClft0::yCDft‘-0—CUftCDftCDCUf-fCDCDH,0HCD0I-ftCDciftICDl-00CD(flH iCDH-ftCDciftClCD ftOCDH,CUL’iC)ClciHC)CDCUftCDH oft-CDHH1l)ftOCDHClCl H CD CU H 0 ci ft C) 0 S CD CDprograms should be placed under a joint mandate of theMinistries of Education, Health and Social Services. In linewith the Ministry of Health’s 11Closer to HomeT’ philosophy, allschool districts should be encouraged to develop local schoolhealth committees/school-community health advisory boards,with representation from health agencies, schooladministration, educators, parents, students and communityleaders, to be involved in planning, implementing andevaluating school health programs.Theory supports the integration of adolescents’ home,school and community environments to facilitate healthymaturation. Combined school-community programs were found inthe literature review to be more conducive to enhancement ofreinforcing factors for students (enabling parents andcommunities to provide more informed and committed support toadolescents) than programs that were solely school-based.Many agencies are already involved in the development andpresentation of health-related programs in schools. TheDirectorate of Agencies for School Health (DASH), an umbrellaorganization, could be engaged by an inter-ministerialdirective to work in an advisory capacity toward the settingup of integrated school-community health programs.5 That all Ministries support and facilitate theimplementation of “Learning for Living”, BritishColumbia’s comprehensive school health program, K-12.Current educational ideology holds that children’s342C)CDCDC)H-Q-=CDH-HctP)H-C)ft(0CDH,F-’ftCD-hCDH-Pi0CD0I-hCDH,l-ft-CD010CD00CDCDCDQHCD0CDHIIC)H-CDCDCD<<100HCtCDCDft1H-H-C)H-1HCDH-ftC)CDQHCDH-H-CDSCDftH-C)H,UC)H’0i01H-C)QSi-CDftH-C)I)0ftCDiJi—aH-CD(0H0CDH--)-CDF—1C)k(HftC)5H-CDCrPiH,JCDCDCUftQ,CUCDCI)CI)CUH-CD0H-CrH-CD0ftCD-CUHCUCU<CDft0H-C)CDh00CUC)C)0(flCD-I-CI)CDCr0Q,‘-<C)ftCD(0CDftC)CUCDCD0CU0CD3H,CDH-H-CDSH-C)ftC)MCD<CUp.,HH,CD0HCUCDoCrCD<ft0CD0CD0CDCDI-hCU5—C)H-H-H-iCD55CDC)CDCDCt5CU0H-H,Q.,<CDCrCD‘d0CDHCI)CDCDCDp.,0QCDHftCDCDCU0CDH,F-H,hCDUH0CDCDQ0ftH—.CDCDH,ft0CUCUCDCDPHh’C)CH-ftCDHCDCD0CD5CDH,C)—CD‘-JCDHCDCD030dQ=H,CDCt0CDCDCDCDCI)C)IQCDCDH,CI)C)H-H,‘z30<iCU3H-CD01CUCDCrC)H,‘<CDH-hH-CDCDS-i‘-CDCDHCD55‘-<CDCDhCrCI)CDCD-0CI)H-C)CUC)00CDH-CrH-0CDCDCUC)C)HC)IftCDCr<HçtCDCDCI)C)CtftftCI)H-H-CI)H3CDftCDCDCD-CDftH-CDHIJ’H-C)CDH-IiCI)CDH‘-<H-C)H-CI)0CD<0CD5H-<CI)C)HH-HftIQHCDCD3ftH-CDCDIICDI-HH-CDCI)(C)H-H-(C)0C)C)CDCU(1)HCU0CDH-H<CDCDCDIiJ0H0,iIC)ftI-01HH-H,C)CDCDCD00CD0—CDC)CDHCI)CDH-H’CD010DHft0CI)0CDWb’CD00H-CDiCDHCD0IIH-<H,HI-HHCDCDH,H,5(-C)CD(C)01CDHCI)ft<WHhCDIC)CDCDCDC)CDtiClftC)-3’H-0CDSQCD0ft3<CDH-H-I-t0ftCI)CDCDftCD<CI)H-CDCDH,CD0H,h’C)CDCD0ftCI)IC)CI)0H-CDCDQHC)H0H,CI)CDHCDHH-3‘dI-tHHC)QCDHH-H,HCI)$H-CD0CD—(-CDftH,ftCDCI)ftCDCDIH<CDCDIC)-(C)CD0CDCD0HH-H-CI)—H-CD0H-ftQH-—5IC)ClH,IC)0CD0<0CD0hH-I-CDCDHhtH-I-CI)CI)CDftCDCI)CU(C)CDCDCI)H-C)03CDI-itiI-I-ft-H-0ICDCl‘1ftH-ftftC)<CD53ft0H-0CDClDHC)5CDCDCDCI)H-CI)CDH-H-(C)<(C)CDCUH-CI)5H--IC)H,Hft0CDCDftiC)hH-I-C)HCI)H-Cl0CD-H-(C)CUCI)CUCCDHHH-CDIICUCDIC)CDH5IC)5H-ftCDftCDCD‘dCDC)htftCU=HCDH-CDIC)C)0CDCDCD0ftH-CDCDCI)CUClHftCDH,0CDH,CDH-SIC)C)H,CI)ftH-01I-HCD<0I-CD0ftQhCDCDI-t0CDCDH-i-iIIQCDClCDCDQCDht5d0ftCU5C)HOCl—C)htCDH-I-HCDHCI)ftSCUH-(C)H-WCD—ftCl)CI)-H0CDft5H-CDhtCDCUI-iCDCDftHI-H<(QH,C)0H-30ftCDCI)CDCDH-CDCI)CI)0CDCDH-CDCDHCDI-iCI)ft5ftCDD’HftCD—CDIC)ftH-CI)0CDH-CDCDCDHIHHH-H-CDCDCI)H-H,H,CDCI)3CD<CDH,0fth0C)Cl0C)CUHCD-.-..5IH-C)01H-CDI-’I-JHftCDCUCI)IC)CDftH--HCl0CD0CD<CD01H,-H,Canada, it would not be necessary to develop anothercurriculum. What would be more important would be to provideadequate educator training and follow-up assistance and tomonitor implementation of the curriculum for the purpose ofensuring its successful adaptation to local needs.6 That the Ministry of Education develop or adopt andimplement a distinct, examinable, compulsory corecurriculum health education course for students in eachof Grades 5-12.A health education course should be mandatory at eachgrade level in secondary school. At present not enough timeis set aside for “Family Life Education”. More time spentaddressing students’ social and emotional needs wouldfacilitate the enhancement of protective factors and theexpansion of students’ social and coping skills.Courses such as Family Management, offered in Grades 11and 12, should be expanded to the lower grades, be mademandatory, testable, and be renamed to be more inclusive.Presenting health education as a core course would be likelyto increase it’s acceptance by parents and communities.Students in Grades 5, 6 and 7, though still in elementaryschool, need expanded health education courses. Many studiesshow that a substantial number of students initiateinvolvement in problem behaviours prior to entering secondaryschool and that prevention is most effective when appliedprior to the emergence of these behaviours.344Cl02t’JH-Cl)—JCl)Ct02C)H1Cl)—JIICl)Cl)CDCl)H-Cr02WCtCDiiCDCDZCliClCDCtCl)Ci‘.D0ClCiCDCDCliCli-L0H-CiCDLJt-C)H1Cl<0)CliH-CiC)Ci00CDCliCl)CDH-CrH1HCD<Cl)Cl)Cl)Cl3<CtCiCl)ldCtH-H-Cl)HICl)<CtCtl-LiiH-I-H-i--H-(CDCtCDH-H-CldCt1H-0F-’Cl)0hjH-CDCl02(DC)Hl-Cl)0(20CDCl)CDHCtCiCD0CiCJ)Cl)frhCl)CD<H-H-H(2Cl)CDCDhCD02Cl)Cl)3(2C)Ci’dOCtCl)Cli(2-ClCDH-CD020I-Cl-ClCDCl)CDCDCrpl-l-CliCD0)Cl)iCtCrCtCl)Cl)0Ci)H.CrCl)C)CDoCQCDCDCl)-C)HCt0HhQh(2H-ctt.QH-QCtClClI-HCDCl)H-CtCl)HCi1Cl)hhhCtCiCliCD<Cl)H-3H-0H-CDCrCDCl)H--ClCl0ClC)Ci)CliCtH-C)I-CD0CDC)CDI-ICtCl)‘tiC)‘<CDClCt<CDCi<H-000Cl)ClClCl)CtCl)LQCiCDCDCliClH-Ct0<0Cl)CiH-H-C)CDCtCl)CDCDH-OCtCl)0Ct‘t50CD0CDCDCl)c-tCrC)CDCQhoCDClHH-Cl)Cl)H-CDCl)CrhCDClCl)CDC)ClCt02><CD0l-0Ci)CtCl0Cl)Cl)CDCDCl)CD(-QCDCl)oCtCiCQC)Ct0)I-h02iiH-C)<Cl)CDH-)CtCl)Cl)I-0CDCl)Cl)CtCiCl)CDHF-‘<Cl)CDCDCDCtHCl)Cl)Ct><C)Cl)0C)H-H-HCrCl)I—hC)F<CDClCiH-ClCrClii0CDCt0Cl)CtH-CiCl)H-Cl)ClH-Cl)3I--hCrI-LQCDCl)CDl-H-Clih’CliC)Cl)3CDCl)HLCDClCDCliCrCDClCtCl)QHQH3lQH02Cl)CDCDCl)CD0Cl)Cl3CDCDCl)CD0)<CDClH’CrH-C)iH’Ct0Cll-Cl)CrH-Cl)I-Ct0H-0)Cl)Cl)0CtIIl-Cl)-H-H-CDCtCJClCtCl)C)0—I-QI-‘-<CiCl)C)QCt0Cl)H’Cl)Cl0Cl)CDCDWCiCl)ClCDI-0HH-I-CtClCDI—’Cl)ClClCl02CDCl)Cl)CiCl)Cl)CliCDCtCDClCDCl)CtH-C)CDCDIl-Cl)CtCDCl)ifr-h-QCiCQCl(-Cl)Cl)CtCDQClCiH-CrClCDCl0H-H-CDI-hCDH-H-HCrCiI-NCri—iHCrH-CDCl)-‘d0CriCl)CtCl)Cl)H,<Cli0IiCtCtCli0CtCl)CtHtClCl)QH-CtI-CDCDCtH-CDH-0Cl)‘-<H-hCl)CDCl)Cr0CtH’<H-CtIQCl)Cl)H-HCDH-CrCil-CiCl)H-CliCDHCD0CDy’H’Cl)Cl)Ct,QCl)Cl)CDClCtC)I-CDfr-0ClCDH-CDCDCQC)CiH-CiCDQCDI-CQC)H-<H-I-Cl)C)H-Cl)CtCtCDClCl)Cl)-CDC)I-H-iClpiH’CDiCl)hCtCtCl)CDH-H,Cl)U)U)00H-3H-0ClClCtH-Cl)Cl02CD02CtCtH,Cl)H-0)ClCtCiCDH-CtC)CQC)‘H-hCi‘-0CDCtC)IC)Cl)HCtCl)0H-CtH-frCtCtCDCl0IICDH,CiCDLiCiCl)CtCl0CD0CDCtOHCi)CDCDH0ClCl)CiCl)C)CDCl)Cl)0Cl)HCD0)3I-QH-hCDClCl)CDCDCiCtC)02HH-C)CtHCtiCl)CQH-H-CDClClI—hCtH-HICl)CiCiHtI3Cl)<CCClCtCl)Ci0I-h<HH‘—i-iClCl)0)I-0)0CD1QI-CtC)bI0H-—.ClCl)H,oH-CDCl)CiH-CDCl)Cl)CDH,C)Cl):yH,0I-QI-QCtH-0‘-ClCtH0)HC)Cl)H-Ct0I-JHCl)Cl)CD0Cl)0)CtClit5k<H3C)Cl)CDCl)CliCtHCtC)h<CDDCDCD3Cl)CDHH-CtCl)H-CDCl-CtClH,CiCDCl)H-0H-IH-H-CtCt0)H-0)Cl)0CiiCllCtCDCt0CDl-CtCDIHH,CDCl)-CliCtCDU)U)ft-CtC)C)CDP-IQH-U)C)P(P0CDhC)H-CD00CDP-I00CD-D(PC)t-Q1CDQ10<t-ftCDLOIIH-CDft0QhU)I-CDftCD‘dF1U)CI)PCDCDU)CD0CDC)CDH-CDctHIH-0QU)PU)C)H’U)CDQCD—HiHIC)U)0C)IIiH-U)H-5çt—0iCDH-CDftiU)CDriiI-’-Ct50p.wH-NCDH-C)C)ftC)U)CDCDPQ.CDPCDCDfti—-.<CDiHICDH-CDH-H-C)C)rtftCI)ft0I-)HiCDClft(PH><CDPU)CtU)-HI0FCD0CDCI)=5CI)HI$1SH-(PftCDCDCDCD<H1IIQ,f-ICI)H-CDCDC)CtSCDO5ftU)H-‘-<-ClH’ftCDftCDH-I<Cl0C)‘-<H-QftH’CDI-F’CDiiQ.CDCDH-CDCDC)CD0HICDCl)0Cl0CDClP)C)CD0CDft-<QU)Hi0U)C)CD‘-<U)ftCDftftHiICDftU)tjU)CDU)HIftPJftHIftU)0I5U)CDCDU)Hihft(PH-H50CDCiH-CDCI)H-CDI-HiCDCDJCDH-H-JC)SI)C)U)Cl5(P><<0iCt0ft00I-ClU)‘<(P(P0CiHHIH-C)CD(PU)CD5H-ft0CiCDHiSCDCD‘c0CD5I-I—’CDCDCDiCD—CI)U)CDC)—ft0ClCi‘-<Ct0hp)U)F-’iftCtSCtCDCI))U)ftHiU)U)H-I-CtU)CDH-CDU)-ftU)U)0CDfti-0(PCDCDC)oi—itCDIICiH-C)CDU)5>0CDF-p)U)<05HiC)HiC)I-Ct03I-Ci0iH-5idF1H-CDF—’CDI-0U)CDCDI-CiF-O0CiU)CDH-bCDClF-piftt-’CDHI0CiC)H-0ClH-OCDCDF—’5H-I—I0HI5CiHIU)CD51‘-ft<CiCDC)F—’I-F—’0<H-i<(PH--‘-<-U)CDCDH-CDiU)H-H-F—CiftI-(P—.CDI-ctCtU)(PCli0ClClCDCI)0CtCI)<0Cl)U)CD<C!)HWCI)CDCDClH-CDU)0CtI-H-HI<H-Q5Q)F-’-ClCDCDCDH-<CDCDidH-tYH-U)ftClCi0U)(PClCDhCDCD‘-<ICDH-CDHIU)CDbHiH-ClC)0ClU)H-CI)i5C)F—’CDH-HiHIk<HIdCDQU)0ft5CiI—CD<U)dCDU)<5CDClHIF—HIC)5CDH-ftft0I-HiCD0CiH-CDCl)SCDdH-H-<CtCICD5ftF—’0Hi<CDU)U)HiU)•HICI)0U)C)5_—.U)C)CiH-H-CDH-C)U)CDU)CD0CtCDHIClHICD0CI)CtCli0CDH-CDU)C)ftCDU)H-h-U)U)CDH-)hi—IH-H-CiiU)CDH-><çtU)0C)U)ftH-CD0U)ftC)H-0HiHI]H-oCDftH-CDH-H’CDPC)<CI)Hi00‘z3i0CDCDCDftC)CI)CD•‘-<CDU)0I—ICiH-CiCDftI-CDU)CiCI)ft0U)ClII<CI)0—ftCI)HIC)H-CDI-CDSCDftOCDCI)HI(PCl)Z3ClCiftCI)(PCDCDClCOPI-U)C/)(PU)CDftCD(P0ftft),U)<HIftCD-CI)CD5H-H-CliHi<ClU)0H-0ftH-<CiSCDft0ClCl0ftC)ftOCDC)C)ClftC)ftCDCD<CDCDCD‘dCDJCOCDH-CDdU)ftH’U)CDI-CDU)C)dCDHICDU)U)IiCD0CDCI)CDHIU)ft0-0C)ft-U)ftCD50-CDHiCDHI0H-HClSCDH-CiU)<PCiftCD0CDft‘-<H-Hi0ftCDCDCl)0CDCDftCDHICDU)F-HIH-DCD(PiH-ftCiU)fti0Q,ClI-C)ft0CDCDH-U)H-CD-0ft(PClClCDCDCDU)0H-CDw00H-U)HICl1bftCD0CD—0ftyH-H-0-HIH-0U)CDClU)—U)encouragement to break out of these debilitating stereotypicalroles.9 That parent education be more highly profiled in theProvincial HIV/STD Prevention Strategy.Education of parents has been shown to be an effectivemethod of promoting health in their children. Parents mayneed assistance to “increase their monitoring andcommunication skills, develop appropriate expectations fortheir child [ren], and use fair and consistent discipline(Gilchrist, 1990:157).”Through participating as members of school healthcommittees, parents could identify their own needs withrespect to HIV/STD education and teenage parenting issues.Programs to increase protective factors for adolescents mightfocus on assisting parents with skills and support for settinglimits on dating times, places and partners.10 That new immigrants be taught about HIv/STD in theirnative language.It has been found that new immigrant students know lessthan their peers about the principal modes of HIV transmission(Hingson, Strunin & Grady et al., 1991:1640). They also haveinflated perceptions of the level of risk-taking activity oftheir peers, and may feel pressure, as new immigrants, toadopt risky behaviour in an attempt to fit in with their newculture (Hingson & Strunin, 1992:23) . For these reasons, it347is important to present them and their parents withinformation about HIV/STD risk and protection as soon aspossible, without waiting for them to be proficient inEnglish. This could be most effectively done using peereducators from their own cultures as informants anddistributing printed information to them in their nativelanguages. Appropriate templates for printed informationcould probably be acquired through government/health agenciesin their countries of origin or from the World HealthOrganization, decreasing the necessity for extensivetranslation activity to be undertaken.11 That health care providers, specially trained to interactwith adolescents, be available in the schools to provideeducation specific to STDs and HIV/AIDS, and health careproviders in private practice and in clinics beencouraged to take a sexual history and counseladolescents regarding STD/HIV prevention.Young people prefer to receive their information aboutSTDs and AIDS from health care providers (Bowie et al.,1990:714) . Health care providers, including school nurses,are seen as credible experts by adolescents, and in many casesmay have more relevant experience and feel more comfortablewith the topics of HIV/STD than regular classroom teachers.Cates (1991) found one of the determinants of consistentcondom use to be having talked with a physician about condoms(Cates, 1991:90). However, Hingson & Strunin found that only15 of students they surveyed had ever been counseled aboutAIDS by a physician (Hingson & Strunin, 1992:20). School348<1pH-M<(C)P1HU)H-I-IHP1C)U)U)ftP1P1-P1CDCiP1-P1HH-Cip150P1HU)P15P15<CDC)C)0Ci0bHCiN51H-F-1CD110CDLI-ftQI—iiCiU)U)P1p1P1H3ftC)HCD0hCDU)HftH-HftU)<CDH-0‘-<C)I-ftLI]ftC)ftP1-3U)CDQpiC)H—H-CDCDH-CD1ftHftU)P11C)HLQH-CDC)t]h5CDftCDCiCDCiCDQ.P1CDHC)P1HP1U)HH-53ip1QClbrfC)c1Jjp1ftiH-CDCDP1‘S.DHH-P10CiCiP1P1ftU)ftH-ftH-U)U)DHftClU)SClbft0ftSCDSdU)CDP1ft[\)‘-<H-0bCD0]ftH-CDF-’CDC)h3b3P1CD<H-.—0CDlC)0P1Ci3C)•H-CD0CDiiS10d0CDftH-ftCDQ)-0U)‘-<Clft‘P1Ci5QI-P1h0‘-‘CiCD0C)-0H-0‘<QCDk<F-P1P1QU)P1p1-Cii0I-C)P1.C)ftt-hU)U)P1P1H-CDSC)3P1CiHH-CD0H-0HH-H-5hQCDU)0LQ(QP1ClCDU)CD-3C)U)CDHiCDft5CDCDIU)p1P1U)I-hL5CDP1CDHP1P1CDC)P1ClJftCD5ClCDCDHCDH-Cl)IC)CD<ClClCDHU)OSHCDOCDP1CDU)HClDk<CiCiC)1C)iH-CDftH0k<ftCDLiLiC)P1ftC)ftP1U)CD1ftHpi0ftbftU)0-I<P1HOCDCDCD><3P1<CD<CDU)‘-<HQCDftU)GH-U)ClClH-C)XP1ClftCD0hC)H-H-C)I-P1CiU)0ftC)H-CiH-P1C)CiP10I-P1I-CitYP1H-00ftftI-HC)CDHHP1P1H5HCDHU)HI3H-P1P1P1CDSftI-ftCi—CDLOCDftI-ftP13CDCDC)ftp1U)tiD30H-U)ftU)C)ft(H-C)CDI-CitYLioC)CDSH-Lik<0CDfttYCDCiH-H-CDHH-C)H-dftCDftP13HI-CDH-I><CDC)H-HiH-H-ftCD0I-QP1U)C)ftHiCiCDH-IQftHU)I-Q0H-dCDft1-hftII•CfH-<P1P1<1C)C)’-<ClU)<U)iiClI-CDP1CDCD0HbP1CDP1PIOI-P1H-U)0CiP1ftII3HClCl3—S0U)ftOU)CDFP1ClCi<C)C)ClHCDCiU)CDP1<ftH-I--hMCD<‘-<CDCDH-CDH-CD0P1C)CDU)CDCD0H-><P1—U)CliU)P1ftU)H-CDCDP1CDCiCDCD3CDClClCiIIU)U)CD(QCDU)hH-ftiCl‘<U)P15CDFP1ClftC)U)ClP1CDU)HCiClQCDI-0-Li]CiH0H-CiftP1U)tYP1H-0CDP1CD<CDCDftftCDC)CDCDCDft0iftH1P1P1P1H-ClU)H-P10C)ClH-U)ClI-CD5iCDCDP1U)U)CiCDC)P1P10Ci0ft<CDCD><H-ftft-I-QC)><F—]ClftCiHftP10H-0ftC)H-CDC)ftdCDClCDU)H0C)U)ftHftft0I-P1I-’-P1CDCDU)U)CDftftCDJH-P1CDH-d033HiP1U)CDhU)I-IH-U)0ftC)I-P1I-P1UiHCDftiClH-<H’-<CDHP1CDP1HiH0C)1QC)HS—Cl0CDCDC)U)iU)<H<H-—-.3CiU)CD0‘tC)0ClIQftOH-ftP1ClCDCi3C)P10I-hCiCDHCDH•-CDC)C)HftP1HCl)P1H-ftClU)<CDI-HCDClU)OP1HftHftI-Q0CDCDhI-U)P1ciCDIIIP1ftF—’F--1H-H-H-1CLiH-bHHi-0CDU)P1HiH-C)ft0<CDH0IQIiCDF-ft<ClP1U)IQk<HiU)H-P1F-hlP1H-CD-..I-QU)RC)P113130‘1CDCiP1H-CDCQ0ftSCl1QH5H-P1U)13U)13Ii13U)0U)LiCDClftCDCDP11-1-ClP1U)CDinfection (Cates, 1989)13 That condoms be made universally accessible to studentsfree of charge.It was seen from the interviews that young students arenot yet in the habit of using condoms, and that there is stilla great deal of embarrassment around their acquisition.Condoms should be made freely available in an effort tonormalize their use.Condom use promotion programs should be especiallytargeted toward males across a range of ages, from preadolescent to adult. The majority of young sexually-activewomen become involved with males older than themselves. Thereis a power imbalance with regard to Tinegotiationhl of condomuse in these relationships. Studies have shown that young meneducated about condoms before they became sexually active weremore likely to use them than those educated after they hadinitiated sexual activity. If young men can be convinced toconsistently use condoms, over time this will improve thesituation for young women.14 That policies and actions conducive to the eradication ofpoverty/adverse life circumstances for young people beenacted by governments at all possible levels.Young people with low educational and career aspirationsand/or reduced life opportunities due to adverse lifesituations are more likely to abuse or not take care of theirbodies. Society should strive to provide all children and350young people with circumstances conducive to their developmentof a sense of responsibility, belonging and hope for 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U)—qrto.HhiCDCDDH-H—HCDHH1U]tiEDCIH HU]WL’iPJ—J0UiQOHU]OU)PJH-‘CDdrtrtU]0U]PJCD0MOH•(DI-h-PiP)hi(IDI-hiCDCDIlpiPJH(DO0rtrrcl_HH-H-CDowoiCUEDCD•P) <1(iD—0CDI---CDHPJctW..cAPPENDICES407APPENDIX 1: EVALUATION OF STUDY DES IGNCooper (1989) summarizes the most common categories ofresearch design as follows (valuable in ascending order)1. one-group pretest-posttest2. correlational3. nonequivalent control group (i.e., treatments aregiven to groups that existed before the research began)4. nonequivalent control group with matching orstatistical control (i.e., some procedure was used toenhance the equivalence of intact groups)5. random assignment to treatments(Cooper, 1989:31)Nutbeam et al. (1990) list the components of the idealdesign for efficacy evaluation, the randomized controlledtrial (maximum internal validity).Pretest studies to establish baseline measurements; theuse of a representative sample of the target population;random assignment of subjects to intervention and controlgroups; the use of a clearly defined intervention; andpost-test studies to identify change from the baselinemeasurements (Nutbeam et al., 1990:85).The Periodic Health Examination (1979) criteria’ forgrading the effectiveness of an intervention, according to thequality of the evidence obtained, are (from highest tolowest)I. Evidence obtained from at least one properlyrandomized controlled trial.1Criteria I and 11-1 are subsumed by the discussion below.Criterion 11-2 could include evidence on studies of mediainterventions, whether done deliberately to affect behaviour ornot. Criterion III is applicable to the interviews conducted inthe school system.40811.-i Evidence obtained from well designed cohort or case-control analytic studies, preferably from more thanone centre or research group.II.-2 Evidence obtained from comparisons between times orplaces with or without the intervention. Dramaticresults in uncontrolled experiments (such as theresults of the introduction of penicillin in the1940s) could also be regarded as this type ofevidence.III. Opinions of respected authorities, based on clinicalexperience, descriptive studies or reports of expertcommittees.(Canadian Task Force on the Periodic Health Examination:1979:1195)Green & Lewis (1986) list the elements of a trueexperimental design: 21 Representative sample of target population orprogram recipients;2 One or more pretests (measures preceding theeducational intervention);3 Unexposed group for comparison;4 Random assignment of the sample to experimental andcontrol groups; and5 One or more posttests to measure effects after theexperimental intervention (Green & Lewis, 1986:198)They rank-order combinations of these elements for thepurpose of maximizing internal validity (ability to attributethe effect to the intervention) and then re-order the elementsfor the purpose of maximizing external validity (ability togeneralize the results beyond the case studied)The hierarchy of options to maximize economy andminimize threats to internal validity is as follows:2°The first four elements of the true experimental designcan be compromised without a total loss of validity. The fifthelement-- the posttest or observation of educational effectsafter the experimental program-- is essential to any evaluationand cannot be eliminated (Green & Gordon, 1982:5) 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tQ,H-(CiCCHiCiflCr—Ci-CiCrCCC(CiCi)CC(DCi)—H-(Ci<çtOOH-5t.—0(Ci(1)Q-,COC)Ci)(U00C)(UI-C)1(Uk<P1Ci)(Cifrt(CiCrW(DOrtH(UCrHCrC)H-tCrH0)H-(DCCCC(D()(UCrH-0(Ci:::5•(Ci(CiCC(D-CrCl)Ci)HY(D0CCM-(Cic,CCPi(Ci0)CO0I-(CiCC(I)(UH-CCCCH-(Ci05P15H-Ci)(UC)H--.N(CidCi)Ci)HCr0Pi<H-(D1PJ0(Ci0P1—PP1COtYCi)0CrCO(CihsLJ-(UiCi)5(Ci1-h(U(DCCH‘-<5Ci)Cr(Ci0CCC)CC1(DOCrP1HHCrPJ00YH-0fr(DQsCC(DCrCi)HCi(DQ-In some cases it may not be possible to randomize groupsto treatment or control or to achieve comparable groups basedon known factors. Under these circumstances, statisticalmodelling may be used to eliminate selection bias and createcomparable groups. Possible methods include analysis ofcovariance, structural equation models and selection models.414Ihepemon’sbeliefthatthebehaviorletoztainahisorherevaluaticx)sofUetasAttitadetardthebehaviorH U]NRelativeinportanc*ofattit.djnalarzlrrmativecxziderationsIhepersc’sbeliefthatspecificüxlividualsorgrsthinkheorshesildorsxuldrx,tperformthebehavioraidhisorherzxctivationtooczplywiththespecificrefer*s—EEl/SubjectiverrmCLt--1’ -t- -m >BehavioralCapabilityDIr.ctRewardVicariousRewardSelf-managementEfficacyExpectationsTh vctAU”-nC[IICtExperienceModelingHP.rformanc.AccomplishmentsVicariousExperienceV.rbalPersuasionEmotionalArousalAcquisitionandMaintenanceofNewBehaviorsN[utcomeExPectatlonsjQJL(J\ 0-‘z 0L--b(p, - C.c1OC.0)0OD(_c-C ‘JJoHIGHExposuretoSupportiveInformationalSocialInfluence(e.g..favorableInformationaboutAPB)GroupExertsNormativeSocialInfluenceFacilitativeofAPB(e.g..supportforAPB;sanctionsfor lackofAPB)H —1RelativelyHighPracticeofAPBinNetworkMembersLOWGroupExertsNormativeSocialInfluenceInhibitiveofAPB(e.g..sanctionsforAPB;SupportforAPB-lnconsistentbehavior)/ExposuretoNonsupportiveInformational SocialInfluence(e.g..unfavorableinformationaboutAPB)InterrelatedConceptualDomainsofRiskFactorsandProtectiveFactors(I)____________________________________________________cc 0BIOt.[binary]-FriendsLow5.11-EsteemPoorSchoolWork>RacialInequalityConfictRiskTakingPropensityIllegitimateOProt.cdv.FsclorsOpportunityProtectIveFactorsLuHighIntelligenceProt.ctlv.FactorsProt.ctlv.FactorsChotchAilsndanceProtectlv.FactorsModelsforConventionalViii,.OnAchievmentlrWO.mOfllriSchoolarwloQualitySchoolsBehaviorValueonHalthVoIunLuyCIub%CCCohesiveFamilyHighControlsagainstDeviantIntoleranceofDevianceNeighborhoodResourcesBehaviorInterestedMulLsRISKBEHAVIORSADOLESCENTRISKBEHAVIORS/LIFESTYLES_-,-tj__Cç—L-__Probl.mBehaviorH.slth$i.Ist.dBehaviorSchoolBehaviorcIllicitDrugUs.UnhealthyEatingTruancy-‘lf\DelinquencyTobaccoUseDropout21—,Drunk-OnvingSedenlarinessDrugUseatSchoolC.NonuaeofSafetyBelt0QJ77_______________RISKOUTCOMES.HEALTHILIFE-COMPROMISINGOUTCOMES7PersonalPr.parstf onfor()H..lttiSocialRole.D.v.lopm.nlAdulthoodEDiseaselSchooll:ailu,eInadequateLimitedWorkIllnessSocialIsolationSell-ConceptSkillaloweredLegalTroubleDepressiorvUnemoyFitnessEarlyClildbeatingSwcideabilityPRECEDE—w a) —-4-C—0)Ino(ND0‘.-,0,c2QJ30Phase6ImplementationPhase5Phase4Phase3AdministrativeEducationalBehavioralandpolicyandanddiagnosisorganizationalenvironmentaldiagnosisdiagnosisPhase2Phase1)EpidemiologicalSocial—rjdiagnosisdiagnosis0 zH-n CEThPhase7Phase8Phase9ProcessImpactOutcomeevaluationevaluationevaluationPROCEEDi:- ACTION7.[REsIGNATIoJ.[RESIGNATIOJ.OvecvRecr [YâeADS!IIIIAepJD))(420HAmciôp toçcocictt(eaptôcbkiors\\)tcansmSs2 C c (t:MRômeXja0 in 0 cO.p<.rn#pc.025+pc.05aito cJJuc><‘p<.O1#p<.O25+p<.05C oce?OaQJAdii o(SDS / çT 02 Fjure.424C11CL)fYiSTACSF’ACTof?Sic’JFLUQ.i’.1CuDvC,‘i-TcSU-’-o Cr’ 0 -n C*re..4erto‘ctosLu4ratLaviinkptr4keetLe.factorstkPfECEOE-P?OCOFrarerkfikeatkp(ortO(Pu”YIA.eIa(uat’n((e.en4K(eütcr,tg1)FACTORSINILO€tJCI6T)D€,TSTHEPOCRArr’.• oAtt+’Jäes• •te5oucces•1’)TA-T&4IES•Pasv€1Actve•IndnLattroiçzNF8L)FAcTh1S•Ace’st€i-rvocgntcr1skrLcr• •Be-hah€Caca?abi1;b•Perscwi;t1factc(S• •o?()3(tUtl+5•6’&Aia/peercericesREio.cii.AcTS•oiflor4.4%-•AçroraA0peers,4.,kosta42c6TOOMTBEH’i\Jio’JR70Q16’ci&AcTs•PerejeckTkrt•Ec.çctt1aS•Occona)flS••At-t-;i-’es•Pfse..icSL‘‘- •+twtN(T1 -n C 0)•vne.vts-2se?wat,texcicsea-a5ec4eSS- —(cJSau5•%6€.Co•QrosecQyoer•,4SI,Itnec•Re.carkk-ckeorS/APPENDIX 3.1THE UNIVERSITY OF BRITISH COLUMBIADepartmeut of Health Care ad Epidemiology_________Faculty of MedicineMather Building, 5804 Fairview Avenue‘ Vancouver, B.C. Canada V6T lZ3Tel: (604) 822-2772Fax: (604) 822-4994DateDear___________________As part of the research for my Master’s Thesis at the University of BritishColumbia, I am looking at education for the prevention of HIV/STD (HumanImmunodeficiency Virus and Sexually Transmitted Diseases) infection inadolescents within the public school system in British Columbia. Your schooldistrict has agreed to allow me to interview consenting personnel, and I wouldappreciate the opportunity to talk with you about your work in this area.The purpose of the project is to ascertain what is available to students in the area ofHIV/STD prevention within the school system and through referrals from theschool. The objectives are to learn, from those associated with the program(s),what materials they are using; how it is presented; to what age groups; how muchtime they have; what their objectives are; what their outcome measures are; whatthey feel are the barriers, if any, to accomplishing their goals and objectives; andwhat support services,, beyond classroom teaching, are available to students, and towhat extent they are being used.I expect to be able to cover this within an hour of semi-structured interviewing,with possible telephone follow-up for further clarification or verification afterhaving written up the interview.All information gathered through the interviews will be kept confidential. Nonames of persons or schools, or identifying information, will be released to thethesis committee, the district board office, or anyone else. The data will bePaj, i427reported in the thesis in aggregate terms so that no instructor, person, classroom, orschool, will be identifiable. The district will not be named in the final report. Thedata will be destroyed at the allowable time after the thesis has been accepted.As well as talking to district personnel, I would appreciate being able to look atselected documents, such as teaching and reference materials.If you have any questions, please feel free to contact me, at-- or by writing,or my supervisor, Dr. Sam Sheps, at 822-4407, or at the above U.B.C. address.I will be calling you after you have received these explanatory papers, to find out ifyou are willing to participate. If so, we can then arrange a mutually agreeable timeto meet. At that meeting, I will ask you to sign a copy of the enclosed consentform for my records.I look forward to the opportunity to meet with and learn from you.Sincerely,Dawne Milligan,;_428APPEiJO;XTHE U NIVE RSITY OF BR[TISH COLUMBIA- Department of Health Care and EpidemiologyFFaculty of Medicine[ Mather Building, 5804 Fairview AvenueVancouver, B.C. Canada V6T lZ3Tel: (604) 822-2772Fa.x: (604) 822-4994STUDY DESCRIPTIONTITLE: PREVENTION OF HIV/STD INFECTION IN ADOLESCENTSbyDawne Milligan, Master of Science candidate, Health Care Planning andAdministration Program, Department of Health Care and Epidemiology, Faculty ofMedicine, University of British Columbia.PROBLEM STATEMENT AND RATIONALEHIV and Sexually-Transmitted Disease (STh) infection in adolescents is beingincreasingly recognized as a serious problem. As one major source of influence onyoung people’s knowledge, attitudes, beliefs, values and behaviour, the schoolsystem is a partner in developing and enacting strategies to assist in prevention ofthese infections and to help orient young people towards healthy living. Thepurpose of this study is to ascertain the prevalence, orientation and types ofHIV/STD education and support in a school district where the school board isencouraging and proactive in this area. The analysis will be framed within thecontext of the “Family Life” and “Learning for Living” curricula, and will attemptto elicit information regarding barriers to successful implementation of thesecurricula.The findings of this study will be of value to those who are planning andimplementing health education in British Columbia.c 3?429DATA COLLECTIONThe purpose is to collect detailed information about health education and supportservices for preventing HIV/STD infection in adolescents within the school district.This will include, for example, data on how many hours of instruction are offeredand at what grade levels, the form instruction takes, lesson plans that are provided,teacher in-service, school nurses and other health support personnel, and outsideservices to which children may be referred.The major data collecting method will be personal interviewing , with possibletelephone follow-up. As well, materials used for teaching, distributed lesson plans,curriculum guides and other relevant documents will be examined.Data will be collected from autumn 1992 through spring 1993.ETHICAL CONSIDERATIONSThe following conditions will be observed:1. Participation will be voluntary and participants must sign a consent formindicating they understand the purpose of the study and what their involvemententails;2. Participation may be withdrawn, partially or fully, at any time;3. The confidentiality of personal information will be protected, both during thestudy and after its completion;4. No data which may jeopardize a person’s position in the district will be used;5. The central office will be provided with a copy of the summary report of thestudy upon its completion.The University of British Columbia subscribes to the ethical conduct of researchand to the protection at all times of the interests, comfort and safety of theparticipants. This document and the accompanying consent form are given to youfor your protection, so that you may fully understand the procedures involved.Your signature on the form will ensure that you have received all the informationnecessary to give truly informed consent to your participation in this study.c430ppíioix 33THE UNIVERSITY OF BRITISH COLUMBIADepartment ot Health Care and EpidemiologyFaculty of MedicineMather Building, 5804 Fairview AvenueVancouver, B.C. Canada V6T 1Z3Tel: (604) 822.2772Fax: (604) 822-4994CONSENT FORMHaving been invited by Dawne Milligan of the Department of Health Care andEpidemiology at the University of British Columbia to participate in a researchproject, I have read her letter of introduction and document entitled “Prevention ofHIV/STD in Adolescents”.I understand the procedures to be used in this project and what my involvemententails.I understand that my participation is voluntary and that it may be withdrawn at anytime at my request, and that all personal information is confidential.I also understand that I may register any complaint that I might have about thestudy with Dawne Mifligan or with her Supervisor, Dr. Sam Sheps,Head of the Department of Health Care and Epidemiology at the University ofBritish Columbia (822-4407).I agree to participate in an interview, which may take up to an hour, and intelephone follow-up, as described in the above documents, during the time periodAutumn 1992 to Spring 1993.I acknowledge that I have received a copy of the study description and consentform for my records.NAME (please print)__________SIGNATURE__DATE431APPENDIX 4.1Interview Schedule (First Version) Interview # Date:The following questions are based on those contained in thedocument entitled “AIDS: Preparing Your School andCommunity”, developed for, and distributed by, the CanadianAssociation of Principals.I. Background. [First I would like to ask you somebackground questions .1A. How long have you been teaching?B. How long have you been teaching “Family Life” orAIDS/STD prevention?C. How many students do you teach the program to?D. At what grade level(s) are the students?E. In what context is the program taught (e.g., healtheducation, physical education, home economics,etc.)?F. In what ways is it integrated into other subjectareas?G. Approximately how many hours of instruction does theprogram consist of?H. Who developed the program you’re using?I. What do you assume is causing the behaviour you’retrying to change with your program?J. As far as you know, were any explicit assumptions ortheories used when designing the program? Pleaseexplain.432II. Concepts. [Now I would like to ask you about the topicsyou cover. I’m going to separate this into four areas:knowledge, attitudes, beliefs, and behaviour.A. Knowledge. [First, knowledge. What concepts do youwork with?] [What information do you present?]1. Infection2. Latency3. Immune system function4. Details of specific diseases5. Modes of transmission6. Sexual functioning7. Methods of “safer sexual activity”8. How to find out if you’re infected9. Condoms10. Other:B. Attitudes. [Now attitudes. What attitudes do youtry to influence?]1. Those towards infected persons2. Those towards homosexuality3. Values clarification4. Understanding of relationships5. Those towards abstinence6. Those towards use of condoms7. Those towards use of substances8. Other:C. Beliefs. [Now beliefs.]1. Susceptibility2. Severity3. Preventability4. Self-efficacy5. That you can tell by looking who is infected6. Other:433D. Behaviour. [Now behaviour. What behaviour do youtry to influence and which skills do you teach?]1. Abstinence2. Monogamy with an uninfected partner3. Safer sex activities4. Use of condoms5. HIV/STD testing6. Other:E. Skills.1. Resistance/refusal2. Assertiveness3. Peer pressure management4. Communication5. Esteem enhancement6. Proper use of condoms7. Other:III. Methods. [Now I would like to ask you about the methodsand materials you use. What teaching techniques do youuse when covering these topics?]A. Brainstorming/Listing exercisesB. Co-operative LearningC. Discussion/Discussion GroupsD. FilmsE. Guest SpeakersF. “I Learned” Statements/Incomplete SentencesG. Information Sharing/ProcessingH. LectureI. Question Cards/Anonymous QuestionsJ. Peer SupportK. Peer TeachingL. Role PlayM. Scenario WritingN. Simulation/Educational Games0. Student Reports/ProjectsP. “Trigger” VideosQ. Values ClarificationR. VideosS. Other:434HLii()WLQH,QWCDH-CD-3 ftCDH-CDCD IIftf9U)ftP3P)-CU1WJHU)HCDDOH-ftC00HH3CDCDH-P3HPinCDH-’-<.QH-1-QIQItU)CD1.Jk<(DPIH-0HLtI00U)CDOCDQi’L’JflQPIP)H0ftCDftCDU)U)ftU)CDpJctpIQftct(DOP1U)U)HU)U)CDrrU)ctCDH,pJCD(DPIH-U)H-CDH,CDH-P1ftCDCDU)ft0H0H-0CDH-QCDOpIftU)U)HH,U)CD•-HP1ftC)H-0HH,ICD0CDIU)cnik<P1p1U)P1P1CDftpltHi0H-‘<H-H0EftU)0PI0PJHhi101U)Hft‘<pipjQ(DOHCDCD‘<h0Q0QACDPJCD00<CD’<0QjIQFPIHftOrtortCDCDPIU)H0-)CD-CD0CDU)H-ftI-P10U)U)ft0rt[-hCDC,3H-U)CD0‘tI-‘tICDCDCDC-”CDH,HI-1CDCDH-OU)0CDp1CD’<0dH-HHU)PIHOHU)P1IQP10CDftHH-U)0ftftItH-hNCDP1(QCD0P1OCDCDCDH-CD(QCDCDC)P1U)C)PICD•CDP1CDftftP1H-It‘-<-QftftF-H-HU)U)U)0PIftP1P1CDPIftCDP1ftH-CtU)—,ftHH-CDH,0QftCD-CDH-CftCD0H,H-P1j-U)P10ItftP1CDU)HHP3U)It0‘<-U)frft1QC)QQ.CICDP1P1P1C)CDP1HH-ftU)H-CDC)0H-H-H,C)CDCDCDCDIiftCDft0H-CDH,H0WHQ•••CDfr’••UHI-CDrlQ.U)U)<HJtCDHH-H-U)rrCCCCCCUCUH-CUCUCDCftftLQC<ctQct(QCDk<ftCUCDftCOCUH-DCH-d‘-<CUH-U)U)dPJPiCrt(DU)OHF—CDri-CDCDft3(1)CDICDCUhU)h-C<CUCUU)ftCDU)‘Y<CDH-CctCU<ftU)U)ftCDU)HH-ri-H-hjU)H-CUCDCDCDCD0COCU’-<H-CDOCDI-’F-•sJCDCUU)U)ftCiCiH-H-<CPJU)U)CD<CD00H-HIh’U)ClOF-’O><U)CtJC‘dCUH-CD0CDCUClCUCOHF—’CD3CD(HrtiCDU)ftCH-CDCDftC)HF-CDH-(QccU)H-CDU)CDCCDOJCDH-)JftH-C‘-<Cl-iH-CUCCDSU)ClCUhiCiCCUCi-H-ctU)i-ti-II-hCD-CDH-CU•3CDU)U)hlH-CUCUH-CDI-QCDCDU)‘-<--“CDCDH-CH-H1-hH-0oCUCU)0)H-CDHU)U)l-h‘dri-U)CDCU0IiCUCUCHCDftl-QhiCHH-hii-tri-CCUhIl-IH-CDHftCCDH-CDCDU)H-CUCUU)CUCDCF—hiCUHHiOftCUCUF-IH‘<H-OCD•ftCDCUU)-ICUCDH,CCUCUCDH-<CUCCDCD‘<HCUCUftF-hHhU)3U)U)hiCDciCDCDH-<H-CUCUCD-CI—’CUC0‘-<H-H-ftHftCUCUH-CChiU)CUCD<HQH-ci-CCUhhCUH-F-’CU—ic-i-Ci-’OCCDCDci-U)hiHCUHU)CCiCDH-0OF—’hiH-hIftCDftCC)CUCDU)HCH-hhftClCDftCCDC•c-i-CD‘-<CH,h-U)‘-<CU•CU)CDCi-CCDfthiftC•CH-I-IClH-H’—ftCCft•,3-I‘-1ftCDClCCDHCUU)CDftD. Did it allow for practice/rehearsal time?E. Did the training include values clarification forthe instructors?F. Is follow-up support available to you?G. What or who do you have as an ongoing source of up-to-date information?VII. Climate. [Lastly, a few questions concerning the climatein which you are teaching.]A. What kind of community support exists for yourprogram?B. In what ways are the parents provided withopportunities to participate in and give support tothe program?C. In what ways do your Board/Trustees support theprogram?D. What do you see as potential barriers to the successof an AIDS/HIV/STD prevention program in a school?E. What do you see as barriers to the success of yourprogram?VIII. Thank you very much.437APPENDIX 4.2Interview Schedule: Last Version Interview 4* Date:The following questions are based on those contained in thedocument entitled RAIDS: Preparing Your School andCommunitylT, developed for, and distributed by, the CanadianAssociation of Principals.I. Background. [First I would like to ask you somebackground questions.]A. Approximately how many students are thereat your school?B. How does education for the prevention of HIV/AIDSand other sexually transmitted diseases fit in to thestudents’ curricula here?1. Is it a discrete topic? Is itlinked to other topics? How?C. Approximately how many hours during each grade wouldbe devoted to instruction and exercises relating to preventionof sexually transmitted diseases and HIV infection or AIDS?II. Conceptual: Goals and Objectives.A. What are the goals and objectives of your schoolregarding STD/HIV/AIDS education and prevention?1. Do these goals and objectives coincide withyour own?a. If not, how do they differ?B. How do you measure or know whether yours and yourschool’s goals and objectives are being met?1. Which of the goals andobjectives you mentioned arepresently being met, and to whatextent?438HI HI I-1c) CDC)tiDC)PJOOQjjCDftftHC1)HIWL’JHdMHCDftEH-ftH•i-CDH-CPJftiCDciCDftftPJJH-P.)CDPJ—ftftftCD—C)fthftftCDCDCDbJHIHCDH-HICDPiOiP.)Of)H-(QC)CDd••H,<hCDCH,CD0h’0PJPJOH-Cft:JO-CDliftC)CDCDftH-CCDCDCDCDftk<liCDtI<OO<0HICDCDO10C)P)‘JftQftCDCDftCCDCDPiCHO—d<><C-CC)HICC)HIftftftCDiCC&tSOH-H-H,CDCDftCDftCDH-0H-rtftCCDftCCDrtOCD1OH,H,ctfrhçti‘dpiCDPiiCDCDCCCCDYC)CDCCDIifrCDlirrCDH-CDCP.)CDP.)HH,H-‘dH-CDCl)CDCP.)CDH-CDC)CD-—i-HC)iI-CCDPIHHHI-<CDftHftftCDftCrt1CCDCDCDftdoftCDP.)CDC<CDH-hiCD1ft—.HPift:iop.)CH’<DC)P.)CDH‘C5CD‘<JCDftft1CDC)iHH-CC)C)H-CDCH-OCDHICDH-CDCDftC)CH-ftftICD<HftCDP.)CbH-P.)CDCD.)CC)CDiCDCDHH-’dCCD-‘dCD<CDHftF—CD)-C)CDOO1P.)CHCDH,0‘dCDCDftftC)iHWHIpJC)H-i‘dP.)p.)ft‘dI-ICH-ftCDC)CdCDC)ftCD<liCDiiC)CDCl)ftCDCDCP.)QP.)Cr)(.QftCDC)H-CDfrCliH-CDCCDC)PJCD[-hiOHP.)HhCftC<C)H——ftCDictftCDCCDH-hC)CDCDCDftH-H-ft‘dH-HliP.)CDH-‘-IHctP.)ClJl-CCDHIH,PJ•.)p.)CDHCDOftH-CDP.)iCDH-CD<ChiftCDCC)‘dpiCDftQP.)CDCDCCDc-rpiP.)Q.)CDCD‘.)CDCDCl)CDOCDLi.P.)CDCD—H-CD‘—P.)CDP.)H-IiCDiiiftft<CDftdQ.NfthiCDhiC)CDftCCDC)CDCDCOH-ftQhCDft‘.)CD.)H,CDiCIiP.)H-HHP.)CDCDH--.‘.)CD‘dCDHH-ftC)P.)ft<1ftCDH-‘d1-hCDCDCDH-CDl-CiQhiCDC)—p.)Q.ftHCDCDCDCDCC)CDCDH-CDH-•.)CDClCDH-CDp.)HCfth’)-C)HP.)CDC)H-ftCCDftHCDHCC)(CftOCDCDC)CDt.QP.)‘dCH-i‘-<H-31-hP.)CDhiCDCft•‘)ftCCQC)hiCDCDCDCOhiCC)ClhC)CD‘-<P.)CDCDftftPCHCDH-ClP.)CDCDftCP.)CD.)CCDH,CDHHHC)tftHW00QCDHCDCDPJPJP-ft1CDCDft<ftC)CDoCDCDCDI-ftEHpiOdCDHH-HctCDOCDO0C)0O*PJOCUCDH-CDHiJCDftHCDCUD)C)ftH,CDQrr0<‘ii(D<CDOH,IICUCUH-CUCUCU0•h1)CDftH--C)1c-tOOHQftiCDHH-HH-FC)H-OH-CDCD0CDjH,CDH,CUH,CD0CDCD.Qic-tHH,CDCUOftftH,H-CD1H-J3CDCDCDCDO--JF-JOCUftH-CU0CD0HCUD)0CDQO1i—hOOftftH-iftftPJH-tflk<JC)<CDCDCD0CCDCDH-—3CDOCDH-CDiftCDHCD0dQiCUc-tOftCDOQH-ft0HH-OCDftCD—CUH,3-iCDCDHClCUCUct’-<OCDCUCDCUiCDh-OH-OCDI-ftCDCDCDOCU3FtCDOOCUCDiC)CU0CDI-<iH-CUçt—CDft(QftCD•srI-CDCD0I-CDCDClCUCDftCDOH-CDpuC)‘<CDCl0C)CDhC)CD<CDCUCDCDftCUCDctH-OCUCD0CDC)HH-I-iH-CD‘dCUCUCU<<CD-‘)C)CU(-QCDC)ftCDCDCD—.CDH-3CUH-CDClCDCDH-CD3H-CUH$1OCDCU3—C)CDCDi:iCUftCDH,rtCUCDCDLQk<H-ft31ftC)ftCDCIJp.00CDCU0ftCDCDCDftCDCDH0(.QCDClCUCDH-CUH-ClCDft00HHCUClCDC)H-ftH-CDH-Ok<CDrtCDH-C)CDiFtCDftOH-O0ftCD(QCDCU(-QftH-H,H-‘)O3CDH-CDçtHH,H,00ftCDCUCU0ftH-CCDCDCUCDHftCDH-ft•CD0HClH,ftC)ftCDC)CDCDCDCDCDCDCDCU(-QCDCDCUCDC)CUftOC)0ftftftCD-H,OhH-H-ClCl0CDC)CU0H-(.Q10H-H3CDCC)CDPuHCDHCl30X. General questions about the program. [Now I’d like tofinish discussion of your program by asking you somegeneral questions about the environment or climate inwhich you are teaching the program.]A. In what way(s) do you feel the following person orgroups of people support or don’t support yourefforts to teach prevention of HIV/STD/AIDS?1. Principal2. Other staff at your school3. Board4. Parents5. Students6. Community AgenciesB. What services are available for you to referstudents to?C. What services do you feel are lacking orunavailable?D. What do you see as [actual and/or potential]facilitators of the success of an AIDS/HIV/STDeducation and prevention program in your school?E. What do you see as [actual and/orpotential] barriers to the success of anAIDS/HIV/STD education and preventionprogram in your school?441APPENDIX 5: FRAMEWORKFRAMEWORK: Categories (Roman numerals); Properties(capital letters) and Types, Circumstances andConditions (Arabic numerals) organized from theinterview data using the Constant ComparativeMethod of Qualitative Data AnalysisI. Cognitive ContentA. Theory/Philosophy1. Education should be developmentally appropriate2. Decision-making skills lead to preventivebehaviour3. Self-esteem is necessary for good decisions4. Students’ needs should be elicited; educationshould be responsive to students’ needs5. The Alternatives approach is good6. Practise ahead of time is necessary7. All problem areas are related and skills neededare the same (decision-making; self-confidence)8. Humour is a good strategyB. Assumptions1. Parental role and responsibility2. Teacher role and responsibility3. Necessary conditions for learning4. Student responsibility5. Risk factorsC. Teachers’ conceptualization of the topic (attitudes)1. Title or description of topic2. Importance of topic3. Context for teaching (discrete, inclusive,spiral)4. Clarity and honesty about own values5. Nonjudgmental and nondirective6. Use of languageII. Goals and ObjectivesA. Information1. Puberty, body functioning, anatomy, biology2. STDs, AIDS, transmission modes, prevention,high risk situations3. Condom useB. Attitudes/Values1. Reinforce family values4422. Comfort with sexuality3. Respect and pride, self-esteem, self-confidence4. Honesty5. Demanding of respect6. Expression of own needsC. Skills1. Thinking (reflective thought, clarity re needs)2. Communication (including listening), use ofvocabulary, terminology3. Decision-making4. Assertiveness5. NegotiationD. Resources1. Counsellors (modeling, rapport, individualcounselling)2. School nurses and physicians3. Outside resources (health clinics, Gay andLesbian Centre, AIDS Vancouver, PlannedParenthood, Red CrossB. Behaviour1. Self-control2. Use of condoms if sexually active3. Communication with family and important others4. Abstinence/postponement5. Knowledge of partners6. Respect of self and othersIII. Measurement and EvaluationA. Outside (trend) information1. Canada Youth and AIDS Study2. McCreary Youth Health Survey3. STD and AIDS reports from Health unitsB. Information: formal testing of content1. Quizzes2. Worksheets3. Projects4. Assignments5. Labs6. Presentations7. Repeat backC. Attitudes: students’ affective reaction1. Involvement and participation2. Attitude and effort3. Enjoyment and enthusiasm4. Comfort level443C’)C)xJ••CD U) 0rtF-HCDP-WMpC$DJPMHXIIt’)HCI)IWMHWMHCIDUi•F----0•CD--JC)--cl•CD•H-0ClCDU)HCoCDH-CDU)C)U)C)F-CDF1OH-‘dQqCDQU)dWdCD-H-EIdC)CflQOU)CU)-tjoh00H-U)CDCDF-CDrrP)OCD0000U)OCiU)U)•,CDrrodCQ‘dPJH-ICDCDdF—H-CD5JCDSCDCDPCDCDSCDF—1O.hF-FOU)CDrtQ1CDPIF-0U)50HCDCD)HiHi00flCDU)rtY’<D0rt0U)..OPJH-OOOi-U)JrtU)Jhcl-H-hCDP-F-’5HCDCr-h[-hbk<000CIU)CDH-’H-H5‘dctOrt010F—CDF1H-H-<U)CDFrrU)H-U)CDCDU)JU)CDiCr50FJU)0U)0iCDHCDH-H-CD00U)hti0—U)PJ1)U)P)-OclcU)0CDCDI-UctCD0ct1U)0rt<rr0H-ctH-Hi<0dCDH-<iU)-OJCDdclH-H-iU)U)QH-F-CD5H-F-1CDH-F-15OzCD—CD)0H-H-CDCDOF-1ct<1U)0JtjF-QPJrtH-0U)—iU)H-CD0U)<CDCrpit-U)CDCDU)S)irr—U)0U)CDCDH-U)CrQpi10U)-fU)05)c-tH-0CD005I0OOHi—Cl)H-I-SU))ZCDII-hHiCDU)U)iQ1H-F-1Crh0CDCD0<0U)U)OF-’CDCrCDU)Q0ctF—I-jII050U)CDH-F-Cli0F’-Cr—--F-’--U)00OCDI-QQhrrU)Cr-L’JF-1cli(<CD5U’C3Cl)U)U))QH-‘-<U)CDH-H-C1lCDU)CDU)Hi<H-Cl)U)S0CDCDU)U)CDiF-’-h1QH-H-I-hhcl0—hiF-1U)CDU)U)IICDCDCD‘-F-1CrH-U)---CDU)U)U)0I-U)U)U)Cr0U)F1‘-<CrH--H-F’--CDCD-hQI-h0ICl)dI-h0CDCDU)CDCDF-1F-1CDH-F--1<IIU)1-0Cli0U)CD0<-CliH-CrU)5Cr-U)0CrF-’-CDU)H-F-100CliCrCrCr0IHJ’H-U)Cli0CDCl-1-b’ F-1-H-dCD0SIU)2. Passive3. Practise4. Reinforcement5. Feedback6. Developmental7. Behaviour change8. Peer teachingB. Out of School:1. Parents2. Community3. Health ServicesVI. Professional AutonomyA. InnovationB. CreativityC. Lack of interferenceD. In counsellor contract (not in other teachers’contracts)B. Freedom to choose style, strategies, content (whatcomfortable with)VII. Lack of outside direction/policyA. Curriculum (none)1. Counselling in the 1960sB. Who teaches/should teach1. Decided at school level2. Have to fight for time3. Have to fight with principal over contentunless counsellorC. No health standards1. Re: HIV, STD, or skills, etc., content/outcomesD. Lack of accountability1. MOE does not check hours2. Principal is not accountable for hiFamily LifeEducationTi, TTLearning for LivingTl or HIV/STDeducationE. No written goals/objectivesF. Lack of outside evaluation or inside comparison445between schools etc.; lack of measurement andevaluation toolsG. Organization problems1. No co-ordinators2. Time3. Space4. Constant change5. Some kids missed if special circumstances,particularly ESLVIII. Professional relationships (lack of support)A. Colleagues1. Isolation2. Lack of understandingB. School Board/administration1. Neutral2. Principals not willing to mandate3. Principals not willing to stand up for teachersagainst parentsC. Ministry1. Adversarial2. Teachers have to fight and lobby for theprogramD. Parents1. Ignorant about the program2. Afraid of the teachers3. Lack of acknowledged and shared responsibility4. Neutral or non-existent (don’t lobby for itadequately)E. Media1. Teacher and school-bashing2. Hostile3. Values in questionIX. Sensitivity Issues1. Homophobia2. Racism3. Gender grouping4. Sexism5. Targeting6. Sexual Identity446•HIV/AIDSandotherSTD-NatureandImpact-TransmissionPrevention-Symptoms-Testing/Counselling-Sourcesof lnformationl•CooperativeSkills•InterpersonalSkills-Communication-Assertiveness•Condom-RelatedSkills•Self-Management•IndividualActivism•AdoptPositiveAttitudesTowardSelfandOthers-o C•Normative-Perceptionsof OthersBeliefsaboutResponsibleBehavioursreHIV!AIDSISTD•ProgramReinforcements-GroupProcess-Peers/PeerLeaders-Parent(s)/Guardian(s)-Reflection/LearningJournal-ActionPlans/Contracting-Student Evaluation•InformationProcessing!ThinkingATTITUDES.cHelp•PersonalRights!Assertiveness•SaferSex: Abstinence•SaferSex: Condoms•Attitudinal-Susceptibility-Self-Efficacy•PromotePositiveAttitudesToward:-Health-EnhancingBehaviours-ResponsiblePersonalRelationships-RespectingOthersRights-ResponsibleSexualRelationships-Society’sInitiativestoPreventAIDSISTD*******Hrt0HC)CD‘.oI<o:jIti(I)—C)C)-iC)ExC)HHQWHCDIOCl)iCD3<hCDCDF-IH-P)CDCDCDP.CDCDCDCDH00ODCDCDCDciCDPJCDQI—iH-HrWrtWiPCD0-irtrlI-c-i-O0)Q,rt0)PJCDiH,H-CD(X-rtJ<C)Wi-C0Cflrti3CD•-F-rrCDdCDj•.C)ICDHCDCDCfl0-CDCDrrCDPJC)hoH-CD0ciC)(DrfNCDCDC)00Mc-i-CDCOWHHiCDD)CiflH-H-1UD)Th<çn0)rtH‘—QWCiCDHQF,C))HCD’<HCDCDQCD<h<c1,QPJQCi-0c--i-1)p)fl0WCDOCDCDPJHJD)icnCl)-OdpjHci-:jF-CDH-1H--I—C)c--i-rV<CDHpç).C)-DH-iPJC)CDCDS0c-tH-M.QOc-icniQCDH-H,°CDH’dCD0)WCDrr<ct1JH-H-0)CDO0)C)H0)CDCDcncrç-tc--rCDct0cc-C)l-rrpiHh(DHJ<CDH-CDCDCDpjpjoI-’-HCDCDH-.H-IFHCOCO(c-c-iC)C)C)<OCDO)c-ic-iH-<0(OH-CDCc-00CDCDH-CD(C•0-hS0Fji-O<CDfr(ppJdH,H-<COc-iH-LiCrCD<rrH-C)wCflHI))C)C)c-CD(OW-NOOH--5CDcrOQCDCDCOQUP-’CDOOH-D-SH--SH,HCOc-i0)hQOCl)jfrf,rrCDCl)oCD:jH-0)0)CDH,.OH-0))idCDC)H <c-iH,c-<Ci)C)c--rrjH 02(l)50c--c-CuCDCDHCD0)Hj<CDHO’i-CDH-c-nc--c-CrCDCDpJHPJH-H-SQ-,QH-j:ic--I-F-fooCD<U1Hi(D02(0‘H-Cl)0)0)0oc-rc--I(OWHj--<OH-P-’I(_H-cc-H0‘-QPH-(0)HCD(l)UIWCD0)HCD(l)c-i0—CozIHI—hg0HI-I-QCDH-k<H--W<Cc-H-c--c-li0H-F--c-i-•oCDcc-(ClH-H-OiHCD(cJrtCDO0.D)IiCDH,O)Hl-HCDHopiCH-(OQ-CDCDc-CrC)N<c-sc-i-Cl)C)Q-0)CD><0)C)CD-CDFCDlic--rrtc-irOc--c-C)CD(DI11CIIH-dH-0)CD0C)0<C)CD<0)(1)CrPJPJPJI0F-cr0Cr(uCDP(OliH-Li0jc-t<I—i50)c-iH-Ci)Z(COOPiC)CQH-H-H-H-CDcc-H-0C)pCDc-iH-H-H-0)CDCD<OF0)crH-CDCD’3H0)H-WC)C)0)-3CDhCDC0I-Q0)(1)d-C-Cl)
Thesis/Dissertation
eng
Health Care and Epidemiology
Vancouver : University of British Columbia Library
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School-based education for the prevention of the human immunodeficiency virus and other sexually transmitted diseases in adolescents
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