Health Education Research, Vol. 17, No. 1, 59-72,
February 2002
© 2002 Oxford University Press
Implementation of a teacher-delivered sex education programme: obstacles and facilitating factors
MRC Social and Public Health Sciences Unit, University of Glasgow, Glasgow G12 8RZ and
1 Department of Sociology and Social Policy, University of Durham, Durham DH1 3JT, UK
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Abstract |
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Interventions are unlikely to achieve their desired aims unless they are implemented as intended. This paper focuses on factors that impeded or facilitated the implementation of a specially designed sex education programme, SHARE, which 13 Scottish schools were allocated to deliver in a randomized trial. Drawing on qualitative and quantitative data provided by teachers, we describe how this intervention was not fully implemented by all teachers or in all schools. Fidelity to the programme was aided by intensive teacher training, compatibility with existing Personal and Social Education (PSE) provision, and senior management support. It was hindered by competition for curriculum time, brevity of lessons, low priority accorded to PSE by senior management, particularly in relation to timetabling, and teachers' limited experience and ability in use of role-play. The nature of the adoption process, staff absence and turnover, theoretical understanding of the package, and commitment to the research were also factors influencing the extent of implementation across and within schools. The lessons learned may be useful for those involved in designing and/or implementing other teacher-delivered school-based health promotion initiatives.
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Introduction |
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TopAbstractIntroductionThe programmeMethodResultsDiscussionAppendix 1: The SHARE...References |
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Interventions are unlikely to achieve their desired aims unless they are implemented as intended (Basch, 1984
; Pentz et al., 1990; Resnicow and Botvin, 1993). It should not be assumed that once organizations, and/or individuals within them, decide to adopt an innovation, full implementation will follow (Basch et al., 1985; Parcel et al., 1990; Brink et al., 1991; Resnicow et al., 1992). In general, interventions are more likely to be implemented successfully if they are relatively simple to understand and deliver (Tornatzky and Klein, 1982; van Assema et al., 1998); have prompt, observable benefits (Rogers and Shoemaker, 1971); are regarded as an improvement on previous practice without additional unacceptable costs (Rogers and Shoemaker, 1971); are pre-specified (Scheirer, 1981); and do not require high levels of resources. There is, however, no simple recipe for success. Crucially, the intervention must `fit' with the routine procedures of its site (Goodman and Steckler, 1989), and with the skills, beliefs and practices of those responsible for its implementation (Peterson and Bickman, 1988). Moreover, the socio-political context of the host society frames the implementation process and incompatibility at this level will hinder progress (Roberts-Gray and Scheirer, 1988; Reid et al., 1995). This paper focuses on a specially designed 2-year sex education programme, SHARE, evaluated through a randomized controlled trial (RCT). Twenty-five schools in the east of Scotland were recruited to the study, agreeing to be allocated either to deliver the new programme in full to two successive year groups (13 schools) or to continue with their existing sex education (12 schools). Using qualitative and quantitative data provided by teachers we outline the degree (or fidelity) of implementation during this research period (how much of the programme was delivered and/or how closely did delivery adhere to the programme as laid out in the pack), focusing particularly on the nature of non-implementation and we identify those factors that constrained or facilitated full implementation. There are few published accounts of the process of implementation of interventions once they have been formally adopted by schools, particularly in the British context, and this is the first of which we are aware in relation to sex education.
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The programme |
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TopAbstractIntroductionThe programmeMethodResultsDiscussionAppendix 1: The SHARE...References |
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Development
In the mid-1990s a group of social scientists teamed up with a sex education consultant and trainer to develop a teacher-delivered sex education programme which incorporated insights from recent social science research on young people's sexual behaviour and `best practice' from behavioural interventions (Wight and Abraham, 2000
). Funded by the Health Education Board for Scotland (HEBS), the programme aimed to improve the quality of sexual relationships, reduce exposure to sexually transmitted diseases (STDs) and reduce unintended pregnancies. To translate psycho-social theory into acceptable classroom lessons it was necessary to meet the needs of policy makers, address school and classroom cultures, and acknowledge the requirements and skills of teachers whilst retaining core elements which research suggested encouraged behavioural change (Wight and Abraham, 2000). In order to facilitate this, it was designed in consultation with representatives of the educational establishment and health promotion practitioners. The involvement of a sex education consultant and teacher trainer—who was the first author of the SHARE pack (Dixon et al., 1996)—gave credibility to the project in the eyes of educationalists. The training and pack were piloted in four schools, substantially modified and piloted again in four schools, following which final changes were made (Wight and Scott, 1996).
Aims
The resulting programme was called SHARE (Sexual Health and Relationships: Safe, Happy and Responsible) (Dixon et al., 1996). It is a 20-session package (see Appendix 1 for a brief description of each session) for 13–15 year olds designed for delivery in Personal and Social Education (PSE) lessons over 2 years (Secondary 3 and 4, 10 sessions in each year). The pack seeks to present clear values; provide practical sexual health information; encourage a better understanding of relationships; improve negotiation skills for sexual encounters; and teach that to avoid sexual risk entirely one should abstain from sexual intercourse, but if one does have sex then one should use condoms effectively (Dixon et al., 1996). The core of the intervention is comprised of a number of skills-based sessions which aim to influence behaviour, i.e. three sessions which use an interactive video to develop pupils' sexual negotiation skills, a role-play session developing skills to say `no' in potentially sexual situations, and a `condom skills' session with information on obtaining condoms and an exercise in which pupils practice correct handling. In both years practical information about local sexual health services is provided and in the penultimate session pupils either visit a local service, have someone from a local service visit the class or watch a video scenario in which a couple access their local family planning clinic. Mixed sex groupwork is central to many of the sessions, encouraging the exchange of viewpoints between boys and girls. An integral part of the intervention is a 5-day teacher training course, intended for every teacher delivering the pack.
Recruitment
Schools were recruited into the trial through meetings with Head Teachers and senior managers. SHARE was presented as having been very carefully developed, incorporating the most recent evidence on effective programmes, and endorsed by HEBS. The main meetings were attended by teachers who had piloted the programme and who enthusiastically recommended it. It was explained that participating schools would be randomly allocated to the intervention or control arm of the trial. In intervention schools all costs (including teacher cover) would be met for third and fourth year teachers to receive the 5-day training course. In return they were asked to deliver the intervention as specified in the teacher pack, to two successive year groups (cohort 1 and cohort 2) in Secondary 3 (age 13–14) and 4 (age 14–15), thus taking 3 years to complete. In control schools a sum equivalent to teacher-training costs would be paid to the Guidance Team (staff members who have a remit for pastoral care, in addition to their taught subject, and who normally deliver sex education) to use on anything other than sex education materials. In return they were asked to agree that their sex education programme would not be altered because of participation in the study. Twenty-six of the 47 schools approached agreed to participate in the study, two of which were soon merged. Thirteen schools were randomly allocated to deliver the intervention.
Training
Training was delivered by the pack's first author: 4 days at the start of the course and a `top-up' day a year later prior to the second half of the programme, at which point teachers could reflect on their initial experiences delivering SHARE. The training consisted primarily of experiential exercises to develop skills and confidence to deliver the programme, but it also discussed broader issues in sex education and the theoretical basis of the programme. The teacher's pack contained SHARE's rationale, detailed lesson plans explaining the aim of each lesson and optional extras.
The need for standardization
Throughout the trial the second author (D. W.) maintained contact with teachers and emphasized the need to deliver SHARE as specified in the pack, were it to be rigorously evaluated. It is recognized that, ordinarily, it is desirable to adapt materials to class needs and such modifications have the further advantage of developing the teacher's sense of ownership of materials. However, as the purpose of this study was to rigorously evaluate the SHARE pack, standardization, and thus close adherence to the pack, was required. A SHARE Bulletin was sent to schools periodically, to encourage a sustained group effort to cooperate with the evaluation, as well as to keep teachers informed of preliminary research findings.
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Method |
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TopAbstractIntroductionThe programmeMethodResultsDiscussionAppendix 1: The SHARE...References |
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The study
The RCT to assess the effectiveness of SHARE was complemented by a process evaluation, designed to investigate the extent and quality of sex education delivery (thus guarding against Type III evaluation error), the mechanisms by which it was intended to work, pupils' response and contextual factors facilitating or impeding the programme. This analysis is concerned purely with process, rather than outcome, data from the trial and focuses on the implementation of the intervention. Outcome data are being reported elsewhere (Wight et al., 2000
, in preparation) as are other of the process data (Buston and Hart, 2001; Buston et al., 2001).
Table I presents an overview of the timing of various components of the process evaluation. We monitored the delivery of SHARE through in-depth interviews with teachers and senior managers (n = 26), teacher self-complete lesson monitoring forms (n = 103), teacher questionnaires (n = 83, at three time points for the majority), direct observation of sex education (29 lessons), and interviews (n = 36) and group discussions (n = 8) with pupils. In addition, a great deal of time was spent in the schools or phoning them, and many informal conversations with teachers and pupils were documented to supplement this more systematic data collection. Apart from the teacher questionnaires, all these methods provided information on the fidelity of delivery of SHARE and factors facilitating or impeding this.
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For the sake of brevity and clarity this paper draws only on the data from lesson forms and teacher interviews. The lesson form data is used to outline fidelity of implementation and the nature of modifications made by teachers. We then draw on the teacher interview data to identify factors which constrained or facilitated full implementation.
Lesson forms
In the first 2 years of the evaluation all of the teachers delivering SHARE to the first cohort of pupils were asked to complete a form detailing each session delivered. If teachers were delivering SHARE to more than one class in each year group, a form was sent for each class. The form contained a section for each of the 10 sessions, asking about how closely each session as presented in the pack was followed (`very closely', making `slight modifications' or making `considerable modifications'), the appropriateness of its timing (`time to spare', `timing about right', `timing very tight' or `could not complete'), its effectiveness, the methods used and any comments on particular successes or problems. All but the last question required teachers to tick a box with the final question inviting written comments with space provided for a short open-ended response. Non-respondents were followed-up by letter or phone call on at least two occasions.
Of the 69 teachers who were delivering SHARE in one or both of these years, to 104 classes in Year 1 and 103 classes in Year 2 (as in one school two classes were merged), 53 returned a form for at least one of their classes (with all forms returned fully completed, i.e. noting delivery details relating to each of the 10 sessions). Table II details the response rate for each school, showing the proportion of teachers who returned a form and the proportion of classes for whom information was received in each year, as well as the total number of forms returned as a percentage of those sent out over the two years. In Year 1, 75% of teachers delivering SHARE (sessions 1–10) returned at least one form, covering 63% of classes, and in Year 2, 40% of teachers delivering SHARE (sessions 11–20) returned at least one form, covering 37% of classes. Of the 2070 sessions that should have been delivered to the 104 classes which we aimed to track over third year and fourth year, we received information about 1030 (just under 50%).
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Teacher interviews
In each school we aimed to interview at least two teachers: the Assistant Head Teacher (AHT) or the teacher with responsibility for PSE and a teacher who was actually delivering SHARE. The former group (n = 11) was interviewed about the organizational context and resource implications for the programme, how PSE is regarded and organized within the school, and relationships within the Guidance Team. These interviews were not available from two schools due to rapid staff turnover and poor tape-recording quality. The classroom teachers (n = 15) were interviewed about the experience of delivering SHARE, modifications they made to the pack, their experience of the training and general motivation to deliver sex education. In two schools extra teachers were interviewed to explore particular process-related issues. Interviews were tape-recorded and transcribed in full. With the exception of a replacement senior manager who thought she had nothing to contribute to the study all of those teachers approached for interview agreed.
Analyses
The quantitative lesson form data were analysed using SPSS; data were first double entered and cleaned. Simple descriptive statistics are reported. Comparative analysis (between schools) has not been undertaken due to the partial nature of these data (see Table II
). The teacher interview transcripts were entered into NUDIST and were then coded according to a coding frame developed from the researchers' prior conceptual categories plus themes emerging from initial readings of the texts. Relevant data segments were then retrieved and, along with the qualitative lesson form data, further sorted according to factors which appeared to be working to constrain or facilitate implementation. Having identified these factors, the data from each school were analysed to see which obstacles or facilitating factors applied where and to understand why this was so.
Limitations
There are limitations to the data presented here. We relied on teacher self-reports, which may under-estimate the number and scope of modifications, including instances of non-delivery, particularly as one of the investigators (D. W.) was closely associated with the pack's development and provision of training. We tried to overcome this limitation in several ways. First, we explained to teachers that we needed to take modifications into account in interpreting the outcomes from the trial and encouraged them to be open about variations in delivery. Interviews and lesson forms focused specifically on such modifications and reasons for not delivering particular sessions or exercises. Second, any data (in the form of informal comments, teachers' description of their colleagues, dates that did not tally when arranging observations, information from pupils) that suggested that the pack was not being fully implemented were followed-up. Finally, the first author (K. B.), who was one of the three interviewers, had no involvement with the development of the pack and made this clear to teachers.
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Results |
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Fidelity of implementation
Amongst those teachers who returned lesson forms (see Table I
) in Year 1 all but two teachers (4% of Year 1 respondents) reported delivering all 10 sessions; in Year 2, all but four teachers (17% of Year 2 respondents). These six teachers failed to teach between one and six of the 10 yearly sessions. For 71% of sessions teachers reported having followed the pack `very closely', for 23% of sessions teachers reported modifying the session as set out in the pack `slightly' and for 6% of sessions they reported making `considerable' modifications.
There were very different rates of reported modification across lessons. Figure 1 shows that the percentage of reports that the pack was followed `very closely' range from 93% for Session 5, a primarily discussion-based session which explores and challenges myths and misunderstandings around male and female sexuality, to 35% for Session 19, a session about accessing local sexual health services, with the lesson plan recommending that pupils visit a local family planning clinic. Fidelity to the pack was better in Year 1 (sessions 1–10) than in Year 2 (sessions 11–20).
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Figure 2
shows rates of `considerable' modifications vary from 25% for session 10, a key session which aims to develop skills to `say no' and which is the only session in which role-play is used, to zero (discussion-based sessions 3, 5, 13 and information-based session 14).
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Figure 3
indicates considerable variation between schools in reports of following the pack closely: from 38% in School 3 to 88% in School 13 (see Table II for a detailed break-down of differential response rates between schools). It should be noted that within each school fidelity varied from teacher to teacher.
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What did teachers mean when they reported making `slight' or `considerable' changes? Their responses to the open-ended lesson form question provide information on this. Some modifications judged to be `slight' by teachers would not be judged as compromising the essence of the intervention by its developers. For example, teachers in two schools removed cartoon pictures of naked people from a hand-out in case these encouraged disruptive behaviour through pupils making unflattering comparisons with their teachers. In contrast, reports of `considerable' modifications included: missing out sessions and/or key exercises, amalgamating sessions, abandoning exercises when pupil resistance was experienced, and modifying teaching methods. Of 53 teachers, 25 (47%), from 11 schools (1–11), reported making `considerable' modifications. However, 10 more teachers made what they reported to be `slight' modifications but which (according to the qualitative information provided on the form) the pack's authors would judge to have compromised the essence of the intervention, e.g. missing out or not completing key exercises.
Fidelity: constraining and facilitating factors
Adoption or imposition of programme
In the majority of schools the teachers who delivered sex education were fully involved in discussions about whether to participate in the study. In most of these schools the prime motivation to participate was the potential to be allocated to the intervention arm, and receive the training and deliver the new materials, rather than receive the equivalent resources in money (approximately £2500). In one school (School 7), however, the prime motivation of the Head of Guidance had been to receive the money and teachers reported that he had not communicated to his team the consequences of being an intervention school in terms of the demands on teacher time, the current PSE programme and the timetabling of PSE. The Guidance Team themselves were not happy about delivering the intervention and delivery was limited. In another school one teacher dissented from the majority decision of the Guidance Team to participate in the study, having pedagogic and moral objections to the programme. He was open about his intention not to deliver the programme in its entirety, although he did make some use of it. With few other exceptions, the teachers in participating schools were receptive to the programme, although there were individuals who had misgivings about elements of the pack.
Time
For all schools, adopting the 20-session pack meant allocating more time to sex education, particularly in Secondary 4, but this did not deter them from agreeing to participate. In practice, however, schools found it more difficult as the study progressed to set aside 20 lessons. There were few schools that did not raise this as a problem and as a result in many the programme was `pruned to suit' [Teacher, School 6], with the final two sessions of the programme (Sessions 19 and 20) most often abbreviated, often drastically.
However important teachers felt sex education to be, they were cognisant that other topics also had to be addressed as well. At the end of Year 1 one of the most conscientious SHARE teachers told us:
I don't think I could usually fit in more than 6 weeks. I mean this has really distorted my whole programme...I've not done any study skills, I've not done anything on drugs or alcohol, I've hardly done any work experience. And next year [Secondary 4] I've blocked in 10 weeks and really, once I've done that, there isn't, like then they're all into exam leave and I've still got to get study skills and still to get in things from Skills Seekers' college visit, so it's blocked up a lot of my programme. [Teacher, School 11]
Even where there had previously been gaps in the PSE programme the realities of the school calendar caused problems:
it fills up a huge slot in our programme for 2 years which is great for us...because sometimes finding material, well relevant materials, for social education isn't always easy...I haven't got as much time as I thought I had...two Wednesdays ago we had a job skill day so the whole third year timetable was suspended so I missed a class. Yesterday, Wednesday, was activities day so the same class I've missed again, so with that I find I had to try and put [sessions] 7 and 8 together and 9 and 10 together [in a 40 min period]. [Teacher, School 3]
Teachers' enthusiasm to deliver SHARE was dampened by the difficulties of fitting it in with the many other topics that also had to be covered. Exigencies such as study leave, exams, special holidays or sports days, staff sickness, or disruptions due to various crises meant 10 sessions in each year became difficult to accommodate. Full implementation was compromised as a result in a majority of schools.
Lack of time was an important barrier to full implementation in another sense. During the 2 years of development sessions had been pared down to fit into 40-min lessons. However, this timing was over-optimistic, and perhaps achieved in the pilot stage because of the high motivation of teachers and/or the cooperative behaviour of pupils, due to their status as `special' implementers or receivers of a brand new programme. In five of the 13 schools (3,4,7,11 and 13), sessions were taught in periods of 40 min or slightly less. The remaining schools all allocated between 55 and 80 min sessions to SHARE (in theory if not always in practice). Overall, the timing of just over half of sessions was reported in lesson forms to be `about right', while around a third of sessions either `could not be completed' or `time was tight'. Unsurprisingly these problems were more likely to be reported when time available was relatively short and in these cases sessions were more likely to be `slightly modified' though there is no difference in rates of `considerable' modifications between these and longer lessons.
Timetabling
Schools differed as to how they prioritized PSE within the general timetable which had implications for the delivery of SHARE since this had to be done by specially trained teachers. In those schools where PSE was fitted in around higher priority subjects it was sometimes difficult to match SHARE trained staff to third and fourth year PSE classes. This problem was worst in School 5 where even in Year 1 not all classes received trained teachers and by the third year only one trained teacher had a PSE class. The Head Teacher's inflexibility over the timetable meant that, despite attempts by some of the trained teachers to re-allocate classes, the situation could not be rectified. In contrast, in School 13, a very large school, there were problems matching trained staff to classes but arrangements were made, with the help of a very supportive Head Teacher and AHT, for a small number of trained teachers to `travel round' PSE classes delivering the programme to all pupils.
Schools found it easier to accommodate the intervention if they had a system of teachers following their own case-loads through the school. Where such a system was not established, and allocation of teachers to classes was more ad hoc, PSE was generally taken less seriously and difficulties such as those described above were more likely to arise.
Staff absence and turnover
Training was provided to all teachers identified as necessary to deliver the programme over the 3-year research period, though schools were discouraged from putting forward large numbers for training. In most schools staff absences occurred or staff left the school after training. The impact of this on the delivery of SHARE varied according to the school's flexibility to allocate teachers which (as seen above) was shaped by senior management but also the cooperativeness of the Guidance Team. In some schools lessons were missed, in others untrained teachers delivered the lesson, classes were doubled up (not ideal given the participatory nature of sessions) or, more appropriately, other trained teachers were allocated to deliver the pack.
Training and skills
Teachers' evaluation of the SHARE training was overwhelmingly positive. It was seen as particularly successful in boosting the confidence of those teachers with poor self-confidence at the outset and with respect to delivering those elements of sex education teachers considered most challenging. However, in practice, role-play (used in Session 10) was particularly problematic for many teachers, despite this being an area given special consideration in the training. For example:
I turned round to 3A on Tuesday...I said `you're not going to do this [role-play] are you now?' in a way that let them opt out because they went `no', but I knew they weren't going to do it and I didn't have a strategy really for thinking `right, I've hit the wall, what do I do with them?'. [Teacher, School 3]
The poor use of role-play by some teachers was probably linked to it being an area in which teachers had least experience (based on self-reports in the teacher questionnaire).
Theoretical understanding
Where decisions were made to adapt the programme, the theoretical understanding of individual teachers became salient. While some teachers made changes that retained the core of the programme, others made modifications in more fundamental ways, not realizing, one must assume, the impact this would have on the programme as a behavioural intervention. For example, this teacher told us he felt that the condom skills lesson had gone well, adding:
None of them did the condom demonstration. They watched me quite happily and, you know, made comments and so on when asked. They didn't particularly want to get involved hands-on as it were. [Teacher, School 6]
The importance of pupils themselves practising the skill in order to boost self-efficacy was overlooked. Another teacher talked about dropping the final two sessions of the first year, which, crucially, develop pupils' skills in `saying no', because the pupils `really don't like it'.
Commitment to research
Although the intervention was generally regarded as very worthwhile, some teachers were more committed to the research project than others. In some schools teachers took their agreement to deliver an unmodified programme very seriously and a few sex education coordinators who appeared to be particularly committed to the study consulted D. W. on whether or not modifications would be acceptable. Other teachers felt their professional autonomy should allow them to adapt the programme without such consultation.
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Discussion |
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TopAbstractIntroductionThe programmeMethodResultsDiscussionAppendix 1: The SHARE...References |
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There were several reasons to suggest that the SHARE programme would be thoroughly implemented during the trial. It was widely regarded as an improvement on previous practice, was clearly specified, did not require extra financial resources, broadly fitted into the existing delivery of PSE, and was endorsed by the schools' senior management and the national health promotion agency. However, SHARE was not fully implemented. Here we have presented the main barriers evident from teachers' reports.
The SHARE programme required extra resources in terms of time and in several schools it imposed new arrangements in the delivery of PSE, particularly through the allocation of teachers to classes. Furthermore, the role-play lesson, in particular, did not fit with the skills and practices of all teachers (despite training), and current analysis of observational data suggests this may also be the case with video-based Session 9. While the benefits of delivering SHARE were observable for many lessons, in terms of pupils' positive response, for other lessons the benefits were not immediate but, potentially, long term (in modifying behaviour). For the SHARE intervention, failure to meet a few of the criteria summarized in the Introduction resulted in less than full implementation.
This analysis also investigated factors that facilitated implementation. The full involvement of Guidance staff in the decision to participate in the trial, Guidance systems that allowed teachers to take their own case load for PSE and very high quality teacher training were all important. The support and priorities of senior management; the coherence of the Guidance Team; the motivation of the sex education coordinator and the values and confidence of individual teachers are overarching factors which shape the delivery of sex education in Scottish schools (Buston et al., 2001) and are important in understanding why SHARE was more readily implemented in some cases than in others.
The factors impeding the full implementation of SHARE during the research phase are also likely to undermine its subsequent sustainability. Indeed, even during the evaluation period the extent of implementation eroded as time went on [see also (Rohrbach et al., 1993)]. What can be done to facilitate the sustainability and diffusion of SHARE and of school-based behavioural interventions more generally?
The research findings from the process evaluation will be used to make the SHARE pack easier for teachers to use. It will be rearranged to have a core of 16 sessions, individual lessons will be shortened, the role-play session and video will be revised, and flexibility will be introduced to allow it to be delivered over 2 or 3 years. While addressing problematic elements of the original package should help improve adherence, the lack of monitoring after the research phase means losing the `fidelity boost' due to being researched (Reid, 1999). In addition, the use of role-play may remain problematic. The developers of SHARE are committed to such a methodology as being of central importance in modelling skills and securing behavioural change. However, this and other studies have shown that teachers do not feel at ease with this active method (Levenson-Gingiss and Hamilton, 1989a,b; Csincsak et al., 1994) which leads to them adapting exercises and reducing students' opportunities for practising specific skills. Training continues to have a role in addressing this. What cannot be addressed by the authors, however, are those barriers existing at the level of the school and educational policy.
Time is vital and increasingly scarce for two different reasons [see also (Connell et al., 1985; Fors and Doster, 1985; Resnicow et al., 1989)]. First, more than ever before, schools appeal to interventionists and policy makers as a forum in which virtually all young people can be `captured' during their formative years (Hargreaves, 1993; Easthope and Easthope, 2000). Concurrently, greater demands on schools and teachers—increased accountability, administrative work and innovations throughout the curriculum—have been made (Hargreaves, 1993). The result, according to many educational theorists, is chronic work overload [see, e.g. (Hargreaves, 1993, 1994; Easthope and Easthope, 2000)]. Not only are teachers increasingly expected to teach outside their area of expertise, as in many aspects of PSE (with little time to develop this expertise or prepare for lessons) (Easthope and Easthope, 2000), but there is more and more to pack into those curricula that have not been prescriptively regulated.
In the Scottish context PSE is usually taught by Guidance staff, but they have two other major roles. Typically they have a case-load of pupils for whom they have pastoral responsibility, involving administrative tasks such as completing course-choice forms, and they also teach a mainstream subject. Of these three roles for Guidance teachers PSE is usually of lowest priority, and their pastoral care role often involves urgent problems and crises which must be dealt with immediately. In terms of the PSE curriculum itself, an increasing number of topics are seen as worth addressing: drugs education, study skills, bullying and work experience are just some. PSE's non-examinable status means it is available to tackle new areas, but the school year is finite and there is a limit to how many topics can be covered. Hargreaves writes: `time compounds the problem of innovation and confounds the implementation of change' [(Hargreaves, 1993), p. 95]. For programmes such as SHARE, widespread implementation means that the challenge of time needs to be confronted (Reid, 1999).
A realistic amount of time needs to be allocated to sex education if the calls for `improved' school sex education are to be met [(Social Exclusion Unit, 1999); see also (Scottish Department of Health, 1999; Department for Education and Employment, 2000; Scottish Executive, 2000)]. There needs to be ring-fenced time for course development, teacher training and on-going development, and preparation. One way forward may be for Guidance teachers to have no subject commitments, although this is not favoured by Scottish Guidance teachers themselves (Scottish Office Education and Industry Department, 1996). Certainly, PSE should be seen as a specialism in itself, for which particular skills and expertise are required (Fors and Doster, 1985; Resnicow et al., 1989). The importance of high-quality training in improving confidence and in facilitating implementation has been highlighted here and elsewhere (Connell et al., 1985; Anderson et al., 1987; Flay et al., 1987; Parcel et al., 1989; Tortu and Botvin, 1989; Perry et al., 1990; Parcel et al., 1991; Ross et al., 1991), and the notion that anything can be taught by PSE teachers whether or not special training is provided must be dispelled.
The status of PSE should also be considered. Unless PSE is regarded highly by senior management, teachers are unlikely to be released for training, and their PSE development time and the PSE lessons themselves may be encroached upon (Rohrbach, 1993). One way forward might be to subject PSE to examinations (as is now the case for Higher Still—the upper school examination—in Scotland). Potential benefits would be the higher status of an examined subject, greater clarity in relation to what is to be covered and improved pupil motivation. However, to have maximum impact PSE would have to become a compulsory Standard Grade (the equivalent to the GCSE in English schools); a possible disadvantage might be that some people could regard themselves as failures in general life skills.
In the meantime, interventions such as SHARE will continue to be implemented inconsistently [see also (Botvin et al., 1989, 1990a,b; Taggart et al., 1990; Rohrbach et al., 1993)]. We hope that the SHARE case study will alert others involved in school-based, teacher-delivered health promotion innovations in the UK to some of the key issues which may affect implementation success or failure.
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Appendix 1: The SHARE programme, brief description of content and methods used in each session |
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References |
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TopAbstractIntroductionThe programmeMethodResultsDiscussionAppendix 1: The SHARE...References |
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Anderson, B., Odden, A., Farrar, E., Fuhrman, S., Davis, A., Huddle, E., Armstrong, J. and Flakus-Mosqueda, P. (1987) State strategies to support local school improvement. Knowledge Creation Diffusion Utilization, 9, 42–86.
Basch, C. (1984) Research on disseminating and implementing health education programs in schools. Journal of School Health, 54, 57–66.
Basch, C. E., Sliepcevich, E. M., Gold, R. S., Duncan, D. and Kolbe, L. (1985) Avoiding type III errors in health education program evaluation: a case study. Health Education Quarterly, 12, 315–331.[Web of Science][Medline]
Botvin, G. J., Dusenbury, L., Baker E., James-Ortiz, S. and Kerner, J. (1989) A skills training approach to smoking prevention among Hispanic youth. Journal of Behavioral Medicine, 12, 279–296.[Web of Science][Medline]
Botvin, G. J., Baker, E., Dusenbury, L., Tortu, S. and Botvin, E. M. (1990a) Preventing adolescent drug abuse through a multimodel cognitive-behavioural approach: results of a 3-year study. Journal of Consultative Clinical Psychology, 58, 437–446.[Web of Science][Medline]
Botvin, G. J., Baker, E., Filazzola, A. D. and Botvin, E. M. (1990b) A cognitive-behavioral approach to substance abuse prevention: one-year follow-up. Addictive Behavior, 15, 47–63.[Web of Science][Medline]
Brink, S. G., Levenson-Gingiss, P. and Gottlieb, N. H. (1991) An evaluation of the effectiveness of a planned diffusion process: the Smoke-Free Class of 2000 project in Texas. Health Education Research, 6, 353–362.
Buston, K. and Hart, G. (2001) Heterosexism and homophobia in Scottish school sex education: exploring the nature of the problem. Journal of Adolescence, 24, 95–109.[Web of Science][Medline]
Buston, K., Wight, D. and Scott, S. (2001) Difficulty and diversity: the context and practice of sex education. British Journal of Sociology of Education, 22, 353–368.
Connell, D. B., Turner, R. R. and Mason, E. F. (1985) Summary of findings of the School Health Education Evaluation: health promotion effectiveness, implementation and costs. Journal of School Health, 55, 316–334.
Csincsak, M., De Bourdeaudhuij, I. and Van Oost, P. (1994) School-based sex education in Flanders: problems, barriers and perceived needs for future practice. Health Education Research, 9, 473–483.
Department for Education and Employment (2000) Sex and Relationship Education Guidance. DfEE Publications, Nottingham.
Dixon, H., Wight, D., Abraham, C. and Scott, S. (1996) SHARE: Sexual Health and Relationships, Safe, Happy and Responsible. MRC Medical Sociology Unit, Glasgow.
Easthope, C. and Easthope, G. (2000) Intensification, extension and complexity of teachers' workload. British Journal of Sociology of Education, 21, 43–58.
Flay, B. R., Hansen, W. B., Johnson, C. A., Collins, L. M., Dent, C. W., Dwyer, K. M., Grossman, L., Hockstein, G., Rauch, J., Sobol, D. F., Sussman, S. and Ulene, A. (1987) Implementation effectiveness trial of a social influences smoking prevention program using schools and television. Health Education Research, 2, 385–400.
Fors, S. W. and Doster, M. E. (1985) Implications of results: factors for success. Journal of School Health, 55, 332–334.
Goodman, R. M. and Steckler, A. (1989) A model for the institutionalization of health promotion programs. Family Community Health, 11, 63–78.
Hargreaves, A. (1993) Time and teachers' work: an analysis of the intensification thesis. In Gomm, R. and Woods, P. (eds), Educational Research in Action. The Open University, London, pp. 75–95.
Hargreaves, A. (1994) Time. Quality or quantity? The Faustian bargain. In Hargreaves, A. (ed.), Changing Teachers, Changing Time: Teachers' Work and Culture in the Postmodern Age. Cassell, London, pp. 95–116.
Levenson-Gingiss, P. and Hamilton, R. (1989a) Teacher perspectives after implementing a human sexuality education program. Journal of School Health, 59, 427–431.
Levenson-Gingiss, P. and Hamilton, R. (1989b) Evaluation of training effects on teacher attitudes and concerns prior to implementing a human sexuality program. Journal of School Health, 59, 156–160.
Parcel, G. S., Eriksen, M. P., Lovato, C. Y., Gottlieb, N. H., Brink, S. G. and Green, L. W. (1989) The diffusion of school-based tobacco-use prevention programs: project description and baseline data. Health Education Research, 4, 111–124.
Parcel, G. S., Perry, C. L. and Taylor, W. C. (1990) Beyond demonstration. In Bracht, N. (ed.), Health Promotion at the Community Level. Sage, Newbury Park, CA, pp. 229–251.
Parcel, G. S., Ross, J. G., Lavin, A. T., Portnay, B., Nelson, G. D. and Winters, F. (1991) Enhancing implementation of the Teenage Health Teaching Modules. Journal of School Health, 61, 35–38.
Peterson, K. A. and Bickman, L. (1988) Program personnel: the missing ingredient in describing the program environment. In Conrad, K. J. and Roberts-Gray, C. (eds), Evaluating Program Environments. Jossey-Bass, San Francisco, CA, pp. 83–92.
Pentz, M. A., Trebow, E. A., Hansen, W. B., MacKinnon, D. P., Dwyer, J. H., Johnson, C. A., Flay, B. R., Daniels, S. and Cormack, C. (1990) Effects of program implementation on adolescent drug use behavior: the Midwestern Prevention Project (MPP). Evaluation Review, 14, 264–289.
Perry, C. L., Murray, D. M. and Griffin, G. (1990) Evaluating the statewide dissemination of smoking prevention curricula: factors in teacher compliance. Journal of School Health, 60, 501–504.
Reid, D. (1999) Failure of an intervention to stop teenagers smoking. British Medical Journal, 319, 934–935.
Reid, D., McNeill, A. D. and Glynn, T. J. (1995) Reducing the prevalence of smoking in youth in Western Countries: an international review. Tobacco Control, 4, 266–277.
Resnicow, K. A. and Botvin, G. (1993) School-based substance use prevention programs: why do effects decay? Preventive Medicine, 22, 484–490.[Web of Science][Medline]
Resnicow, K. A., Orlandi, M. A. and Wynder, E. L. (1989) Toward an effective school health education policy: a call for legislative and education reform. Preventative Medicine, 18, 147–155.[Web of Science][Medline]
Resnicow, K. A., Cohn, L., Reinhardt, L., Cross, D., Futterman, R., Kirschner, E., Wynder, E. L. and Allegrante, J. P. (1992) A three-year evaluation of the Know Your Own Body program in inner-city schoolchildren. Health Education Quarterly, 19, 463–480.[Web of Science][Medline]
Roberts-Gray, C. and Scheirer, M. A. (1988) Checking the congruence between a program and its organizational environment. In Conrad, K. J. and Roberts-Gray, C. (eds), Evaluating Program Environments. Jossey-Bass, San Francisco, CA, pp. 63–81.
Rogers, E. M. and Shoemaker, F. F. (1971) Communication of Innovations: A Cross-Cultural Approach, 2nd edn. Free Press, New York.
Rohrbach, L. A., Graham, J. W. and Hansen, W. B. (1993) Diffusion of a school-based substance abuse prevention program: predictors of program implementation. Preventive Medicine, 22, 237–260.[Web of Science][Medline]
Ross, J. G., Luepker, R. V., Nelson, G. D., Saavedra, P. and Hubbard, B. M. (1991) Teenage health teaching modules: impact of teacher training on implementation and student outcomes. Journal of School Health, 61, 31–34.
Scheirer, M. A. (1981) Program Implementation: The Organizational Context. Sage, Beverly Hills, CA.
Scottish Executive (2000) Report on the Working Group on Sex Education in Scottish Schools. Stationery Office, Edinburgh.
Scottish Office Education and Industry Department (1996) Guidance in Secondary Schools. Scottish Office, Edinburgh.
Social Exclusion Unit (1999) Teenage Pregnancy. Stationery Office, London.
Taggart, V. S., Bush, P. J., Zuckerman, A. E. and Theiss, P. K. (1990) A process evaluation of the District of Columbia `Know Your Own Body' project. Journal of School Health, 60, 60–66.
Tornatzky, L. G. and Klein, K. J. (1982) Innovation characteristics and innovation adoption—implementation: a meta-analysis of findings. IEEE Transactions on Engineering Management, 29, 28–45.
Tortu, S. and Botvin, G. J. (1989) School-based smoking prevention: the teacher training process. Preventive Medicine, 18, 280–289.[Web of Science][Medline]
van Assema, P., Brug, J., Glanz, K., Dolders, M. and Mudde, A. (1998) Nationwide implementation of guided supermarket tours in the Netherlands: a dissemination study. Health Education Research, 13, 557–566.
Wight, D. and Abraham, C. (2000) From psycho-social theory to sustainable classroom practice: developing a research-based teacher-delivered sex education programme. Health Education Research, 15, 25–38.
Wight, D. and Scott, S. (1996) Mandates and Constraints on Sex Education in the East of Scotland. Health Education Board for Scotland, Edinburgh.
Wight, D., Henderson, M., Raab, G., Abraham, C., Buston, K., Hart, G. and Scott, S. (2000) Preliminary reported behavioural outcomes from a randomised controlled trial of a specially-designed teacher-delivered sex education programme in Scotland: intention to treat analysis. Presented at the 13th International AIDS Conference, Durban.
Received on December 24, 2000; accepted on May 24, 2001
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