Primary School Action for Better Health project in Kenya (PSABH)

This case study describes the Primary school Action for Better Health project in Kenya. The Project, developed and managed by the Centre for British Teachers (CfBT) in Kenya, is funded by the Department for International Development (DFID) and involves the participation of Steadman Research Services Inc. in data collection and Eleanor Maticka-Tyndale from the University of Windsor in Canada in research and evaluation.The projects overall purpose is to bring about positive behaviour changes in sexual relationships of Upper Primary pupils in targeted areas of Nyanza and Rift Valley Provinces, such that the risk of HIV/AIDS transmission will be reduced. It aims to provide accurate information on prevention, promote abstinence and delay the onset of sexual activity.

The problem/needs

The main problem recognised by the project in its goal and purpose is the high HIV risk of transmission in Kenya; with particular focus on upper primary school pupils. Addressing this problem, however, requires addressing other problems and needs.

First of all, there is little appropriate knowledge as well as inappropriate attitudes and behaviours about HIV/AIDS. These extend to confusion about sources of information, abstinence strategies, the use of condoms and the risks of HIV/AIDS. Multiple sources of information (e.g. teachers, tradition, religious leaders, family and friends, public health and education campaign, NGOs) and confusion among key influential adults help confuse the young even further.

There are also difficulties with the implementation of HIV/AIDS programmes in schools with require a stronger understanding of the issues and alternatives.

In third place, poverty in the community is translated into poverty in the schools and children's sexual behaviours. Low enrolment and high dropout rates suggest an increasing level of child labour that competes with schooling time. Poverty at home provides incentives for girls to engage with sex in exchange for gifts or money (for themselves or for their family).

The policy context

Although suggesting that the policy context is complex is an understatement, this is particularly true whenever HIV/AIDS is present. This complexity stems from the multiple contrasting opinions and messages that exist in the policy context regarding the risk of HI/AIDS and the best, and worst, strategies to face it. The following issues are worth highlighting:

• Tradition is not the same as religion, and often the advice offered by religious leaders are in direct conflict with the lessons shared within a tradition or culture. Nonetheless, Church leaders are clearly influential in the community.
  
• Taboos and myths still dominate the policy process even when a more open and modern debate is observed. This is particularly true in the case of condom use education.
  
• The Ministry of Education remains silent about the use of condoms and this confuses teachers who, already in doubt about the benefits of condoms, have problems addressing them and responding to pupil's concerns.
  
• Barriers exist at all levels: development and implementation of HIV/AIDS programmes in schools, and changes in pupils' and teachers' knowledge, attitudes and behaviours.
  
• The Ministry of Education recognises the need for an effective model of behaviour change intervention in primary schools in Nyanza with potential for replication nationally.

What was done?

The project aims to remove the barriers that prevent changes in pupils' and teachers' knowledge, attitudes and behaviours towards HIV/AIDS by engaging directly with the community and educators. The main activities of the project are:

• Training workshops for school/community representatives: One Headteacher, Resource Teacher and Parents/Community Representative from each school, as well as additional teachers, peers and Church leaders from the community. These workshops involved 5 variations to determine which was the optimal combination of participants;
  
• Development of School Action Plans for Better Health (within the School Development Plan) and teaching and learning activities to support behaviour change for adolescents;
  
• Selection, procurement, generation, and distribution of resource materials to teachers, schools and the wider community;
  
• Capacity building of teachers to incorporate HIV/AIDS knowledge and awareness within the normal curriculum through the use of:
  
  • Improved resource materials (much of it self-generated);
    
  • Innovative teaching methodologies;
    
  • Creative forms of student self-expression;
    
• Public activities such as inter-school and inter-zone competitions in areas of drama, music, art, public speaking, recitations, writings, sports and exhibitions etc;
  
• Active inclusion of different opportunities for discussion and participation such as Question Boxes, Information Corners and School Health Clubs;
  
• Training of Education Officers in the monitoring of HIV/AIDS education in schools;
  
• Training of Deans of Curriculum and Students from all Pre-service Teacher Training Colleges;
  
• Substantial research and evaluation plan providing integrated quantitative and qualitative information using control schools.

The research component provided a strong base for the evaluation of the project using information collected by surveys of pupils and teachers, focus groups, interviews and other monitoring techniques. The baseline and evaluation results have informed the project (e.g. determining the number and type of participants in the training workshops as well as their content).

What was the impact?

The impact of the initiative was positive (although some aspects of it need to be reinforced). In terms of the impact it has had on the education sector it is evident that the projects has institutionalised a new attitude towards HIV/AIDS education in primary schools.

Teachers' and pupils' knowledge, attitudes and behaviours have also changed.

Pupils
Qualitative and quantitative research confirmed that there has been a dramatic shift in the pupils' attitudes and behaviours. Fewer boys and girls reported having played sex and more girls reported condom use at last sex. Also, both boys and girls reported delaying sexual debut. More girls became aware that the sexual activity they were engaging in was not of their own choosing, but was the result of being pressured or forced into sexual activity. Interestingly, condom use did not increase among boys.

Teachers
Teachers' changes in knowledge, attitudes and behaviours are more complex than that of the pupils'; but still positive. Although their knowledge and confidence about HIV/AIDS and prevention strategies increased significantly, their beliefs about which were the best prevention strategies presented barriers toward change in some areas. Teachers and community and church leaders believed in and presented abstinence as the only truly effective way to prevent HIV transmission. As a result, they had difficulty developing a clear position on the use of condoms. This is not surprising since they are surrounded by ambivalence about the place of condoms in preventing HIV transmission. This is reflected in the Ministry of Education's own silence on the matter, as well as conflicting positions taken in social marketing campaigns compared to the positions of churches and that of other influential leaders. This led teachers to often repeat the negative and inaccurate messages on condoms that they heard from others. Pupils recognized the contradictions in what they heard from teachers and other adults in their communities and turned more towards peers with sexual experience and some teachers who were more comfortable with the subject.

Knowledge proved to be too interwoven with beliefs and concerns about day-to-day practicalities of taking up certain activities. These could not be fully measured in tests and questionnaires, but required discussions with teachers and pupils to fully capture the accuracy and breadth of knowledge about HIV/AIDS.

Schools
Also significant is the effect the project has had on participating schools. Target schools have developed more comprehensive HIV/AIDS programmes and these have become resilient to changes in the educational policy as well as to strikes. Similarly, non-target schools have started to adopt the project as a sign of the government's interest in the initiative.

Why it had such an impact?

The CfBT considered that three key non-transferable issues made the project work in Kenya:

• HIV/AIDS is a recognized crisis with enough concern to motivate and mobilize
  
• National leadership
  
• Schools hold a central and influential place in the community and community is involved with what goes on in schools

These are necessary conditions for success that cannot be overlooked in the desire to replicate the project. Other transferable characteristics of the projects that have contributed towards its success are that it:

• Incorporates and responds flexibly to research findings
  
• Is able to respond to local conditions by including local communities as partners, enablers and 'watchdogs'
  
• Recognizes and works with the limits of what schools and teachers can do
  
• Is designed to work 'at scale' and to be sustainable

What are the lessons?

The impact of the project has been mixed but mostly positive as it has promoted an open discussion about HIV/AIDS as well as changes in knowledge, attitudes and behaviours among pupils, teachers and other key family and community leaders. The subsequent success, or failure, of the project depends on the following social issues identified by Eleanor Maticka-Tyndale's evaluation:

• Poverty-gender-early sexual debut: Both girls and boys describe poverty as a strong impetus for girls to play sex. Hence the poorest girls are likely to initiate sex youngest. Breaking-up this triad is crucial for success.
  
• Community silence: Sexuality in general, and condoms in particular are not to be spoken of and the silence in the rest of the community does not provide back-up for what teachers are saying. Promoting changes in attitudes outside the school is crucial.
  
• Resistance to considering condoms is prevalent across South Saharan Africa and creates serious problems for positively addressing condoms in programmes.
  
• The needs of those affected by HIV/AIDS at times overshadow the needs for prevention education. Rather they should be tackled together.
  
• Numerous cultural beliefs and practices create situations of vulnerability to HIV risk for youth and adults. By working with the community it is possible to try to work within them and reconcile modern preventive strategies with traditional customs.
  
• Churches are strong and have considerable influence over the population. Aligning with them has the possibility of strengthening the effect of school-based programmes.

Specific recommendations for the project focus on a continuous engagement with the Ministries of Education and Health, continue to develop the capacity to monitor HIV/AIDS interventions and data collection and involve church representatives, more teachers and peers in the workshops.

Policy interaction

The scale and location of the project mean that policy influence is not a key objective. However, the CfBt, through this and other projects interact at the national level with various key policy actors and take part in consultation and advisory processes with the ministries of Education and Health as well as with the Provincial Director of Education and the National Aids Control Unit.

References

Maticka-Tyndale, Eleanor (2003) Six Month Evaluation -Primary School Action for Better Health: Kenya, Presentation, September 2003
Maticka-Tyndale, Eleanor (2004) Primary School Action for Better Health: Kenya, Presentation to the Trustees of cfBT, November 16, 2004
Wildish, Janet (2004) Primary School Action for Better health: summary Project costs and cost-Effectiveness of tested variations, CfBT
Wildish, Janet, Primary School Action for Better Health, Presentation
Wildish, Janet, Primary School Action for Better Health (PSABH II) Kenya, CfBT

For further information on the project visit their website at www.psabh.info