Health Education Research Advance Access originally published online on June 1, 2006
Health Education Research 2006 21(5):621-632; doi:10.1093/her/cyl031
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Process evaluation of the teacher training for an AIDS prevention programme
1 Department of Psychiatry and Mental Health, University of Cape Town, E36A Groote Schuur Hospital, Observatory, 7925, South Africa
2 Adolescent Health Research Institute, University of Cape Town, E36A Groote Schuur Hospital, Observatory, 7925, South Africa
3 Health Systems Research Unit, South African Medical Research Council, PO Box 19070, Tygerberg, 7505, South Africa
4 School of Public Health, University of Cape Town, Observatory, 7925, South Africa
5 Department of Health Education and Health Promotion, Maastricht University, PO Box 616, 6200 MD, Maastricht, the Netherlands
*Correspondence to: N. Ahmed. E-mail: ahmnaz002{at}yahoo.com
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Abstract |
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This paper provides a process evaluation of a 6-day teacher training programme which forms part of a sexuality education project. The training aimed at providing teachers with the necessary knowledge and skills to effectively teach a 16-lesson Grade 8 (14 year olds) life skills curriculum consisting of participatory exercises on sexual reproductive health, human immunodeficiency virus (HIV), sexual decision-making, abstinence, consequences of sexual activity, safe sex practices, substance abuse and sexual violence. Questionnaires administered prior to the training, on completion of the training and at two follow-up time periods were analysed as well as participant observation notes. Findings indicate that teachers reported increased confidence and comfort in teaching the sexuality curriculum. However, many struggled with the transfer of sexual reproductive knowledge and facilitative teaching methods into the classroom context. This highlights the need for HIV education to form part of teacher trainee programmes. Ongoing support and engagement with teachers is needed to encourage alternative teaching practices.
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Introduction |
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The role of the education system in sexual health promotion and human immunodeficiency virus (HIV) prevention has been widely acknowledged [1–4], with evidence that adolescents who receive HIV and sex education are less likely to engage in sexual activity and more likely to engage in safer sexual activity [5]. Teachers are key to the success of school-based sex education programmes [6, 7]. Equipping them with knowledge and skills to effectively teach a sensitive range of topics necessitates emphasis on specialized and effective training [1, 8–10].
There has been increasing interest in teachers' comfort teaching sex education and the impact of this on what is actually implemented in the classroom [6, 11–13]. Determining the resistances and establishing a deep understanding of teachers' values and ideologies are important to the success of a project [14].
The success of reproductive health programmes for adolescents depends on the quality of the implementation of the programme and on the quality of the programme itself. Hence, for school-based programmes, equipping teachers with appropriate skills prior to programme implementation is important. The provision of pre-implementation training has been found to increase the integrity with which teachers implement a curriculum [15–17]. The success of HIV programmes depends upon the extent to which teachers are provided with suitable training and support in the participatory teaching methods required for this type of education [18, 19]. Training should aim to specifically meet the skill-related problems of teachers who implement HIV programmes [18].
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Aim |
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The present study describes the results of a qualitative process evaluation of a teacher training programme which forms part of a larger HIV/acquired immunodeficiency syndrome (AIDS) intervention project. It provides a description of the knowledge, skills and confidence with which teachers equipped themselves during the training. This paper reports on the teacher training component and does not include data on the evaluation of actual programme implementation.
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Context of sex education within the South African school system
In South Africa, HIV education in schools under the banner of life orientation has been mandated in all public schools. However, teachers are faced with a myriad of contextual factors which impact on their ability to effectively teach sex education. The legacy of apartheid has resulted in historical racial disparities continuing within the education sector. During the apartheid years, schools were segregated along racial lines, resulting in inequalities within the education sector such as access to resources and teacher training. The quality of education varied as a result with black students being exposed to the poorly resourced schools, unqualified teachers and poor school management. The medium of instruction was primarily didactical teaching and rote learning [20].
Attempts at addressing the inequalities in the education system took the form of outcome-based education (OBE) through a government policy document called ‘Curriculum 2005’. Introduced in 1997, this new method of education focuses on student participation and free discussion as opposed to didactic methods of teaching, student-centered and activity-based education as well as encouraging critical thinking. The reality however is that the majority of teachers is not trained in this new form of educating. A Review Committee appointed in 2000 concluded that while there is overwhelming support for the principles of OBE and Curriculum 2005, implementation was hampered by among other factors, inadequate training and development of teachers, unavailable or insufficiently used material, staff shortage and resources to implement and support the new curriculum [21]. Presently, teachers are challenged with embracing a new method of engaging students and adopting a more facilitative approach to learning. Despite the changes in government policy, little has changed in the black township schools since the apartheid regime [20].
In addition to a new system of education, came the introduction of life orientation which many teachers found challenging given the lack of training in this area. Within the revised national curriculum, life orientation was made compulsory but is not yet an examinable subject. It aims to develop skills, knowledge, values and attitudes which empower students to make informed decisions and take appropriate actions regarding their health, social and personal development. Students are expected to be knowledgeable about strategies for living with HIV/AIDS and to familiarize themselves with discussing personal feelings, community norms, values and social pressures associated with sexuality [22]. Historically, life orientation was perceived as a soft subject not requiring much preparation or skill. Often time allocated for life orientation was used for more formal subjects deemed more important since these involved assessment. Thus, the introduction of life orientation and more specifically HIV education were received with mixed feelings by teachers [23] where the newly revised curriculum is taught by teachers with little or no background or interest in HIV education.
Description of the SATZ curriculum
The teacher training programme that is the subject of this article is part of a multinational research collaboration aimed at developing sexual and reproductive health curricula for schools in South African and Tanzania (SATZ), evaluated through a randomized controlled trial. The broad aim is to encourage school-going adolescents to postpone the onset of sexual activity with those not yet sexually active and to increase the use of safer sex practices in those who are sexually active. This paper reports only on the training of teachers for the SATZ curriculum developed in Cape Town, and does not include the curricula developed at the two other sites in Mankweng in South Africa and in Tanzania. The Cape Town curriculum was developed for Grade 8 students (14 year olds). A fuller description of the project can be found in Aarø et al. [24].
Prior to the development of the curriculum, a situation analysis was conducted which highlighted teachers' and principals' feelings and attitudes towards sex education in the education system, as well as students' perspectives on sexuality [23] (Ahmed et al., in preparation). Data obtained from the situation analysis informed the development of the curriculum. The development of the curriculum was based on a systematic approach to theory- and evidence-based health promotion programme design based upon collaborative planning, entitled Intervention Mapping [25]. This method informed the development of a 16-lesson curriculum comprising skills-based lessons aimed at influencing sexual behaviours. It covers sexual value clarification, the reproductive system, dimensions of sexuality, gender and sexuality (social and cultural aspects), sexual risks, sexual decision-making (self-esteem, assertiveness, communication and negotiation skills), sexual coercion and violence in relationships, abstinence from sexual intercourse, condom use and contraception, sexual risk-taking and substance abuse.
The curriculum focuses on factual knowledge and skills development. In line with the steps of the intervention mapping method, the two broad aims of the SATZ programme were operationalized with more specific behaviours identified within each lesson. For example, the condom-use lesson explored students' ability to purchase condoms and store condoms. Delaying the onset of sex involved lessons identifying risky sexual situations. It is designed for interactive, participatory teaching methods including small and large group discussions, role-plays and homework assignments. It comprises a student workbook and teacher manual, available in English, Afrikaans and Xhosa, the three dominant language groups in the Western Cape. Ancillary materials used in the curriculum include a condom demonstrator (dildo), condoms, sexual and reproductive anatomy charts and brochures.
An experienced curriculum advisor assisted in ensuring that the curriculum was culturally sensitive and age appropriate. She is an experienced teacher who was integrally involved in the development of the government education's primary school life orientation programme and was hence very familiar with the OBE system requirements. A panel of diverse teachers provided feedback on the curriculum by piloting the lessons in their classrooms. It was also reviewed by government education department representatives and by the HIV trainer who conducted the teacher training. A revised version included modifications to the content and sequencing of lessons in the curriculum. These efforts ensured that the SATZ curriculum was delivered as part of the life orientation programme of the Department of Education, rather than being considered an additional burden for teachers. The lessons were delivered during regular teaching periods allocated to life orientation. The periods are 
40 min in duration. Teachers were requested to complete the 16-lesson curriculum within 6 months. On average, teachers spent between 2 and 4 hours per lesson. A fuller description of the implementation process of the curriculum is currently in progress (Mukoma et al., in preparation).
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Methods |
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Sample
Participating schools and teachers
In Cape Town, the randomized controlled trial was conducted among Grade 8 students in 26 high schools (13 control schools and 13 intervention schools), selected to be representative of all public, mixed gendered high schools in the Western Cape, ensuring diversity in terms of the demographics of the Western Cape with respect to language, gender and race. The Grade 8 teachers responsible for life orientation at the 13 intervention schools were invited to the SATZ training programme. The initial training programme was attended by 24 teachers, 14 of whom were female and 3 were white. Teachers reflected the ethnicity of the schools in which they taught. The age range was 20–59 years, the majority being in the 30- to 49-year age group. All the teachers were local to the school community and culture. Teachers' teaching experience varied from 2 to 20 years. Nine out of the 24 teachers did not previously receive any other form of HIV/AIDS or sexuality training. Only four teachers were not actively involved in teaching Grade 8 life orientation. The majority of teachers expressed a preference for teaching abstinence and was reticent to teach about safe sex practices.
With the introduction of the revised national curriculum, many teachers felt inadequately prepared to teach a subject for which they received little training, resources and support. This was perhaps one of the most important motivating factors for their participation in the SATZ programme. They were not only offered free training by experienced HIV specialists but also provided with a student manual and teacher workbook which clearly presented lessons in accordance with the OBE system. The training and SATZ curriculum were therefore perceived as an opportunity to obtain teaching material and be trained in effectively implementing it. The involvement of the Department of Education's senior representatives added credence to the programme. In addition, all the principals encouraged teachers to attend since the new education system requires that teachers receive ongoing training and development. Participation was voluntary and teachers were generally keen to participate in the training, although there was doubt among more experienced teachers whether there would be any new gains from yet another training programme.
Ethical approval
The SATZ project was approved by the Ethics Committee of the Faculty of Health Sciences, University of Cape Town, the Western Cape Education Department, as well as the ethics committee of the University of Bergen, Norway, where the principal investigator resides. Principals and Grade 8 life orientation teachers of the intervention schools met with the SATZ researchers and provided their consent to participating.
Description of the teacher training
The initial training was conducted during February 2004 and spanned four full days, two consecutive Fridays and Saturdays, at a mountain resort an hour's drive outside of Cape Town. Two 1-day refresher trainings were held in April and July 2004. An experienced HIV trainer who was familiar with the curriculum conducted the training. The trainer was a white, female who was fluent in two of the three dominant languages and had 10 years experience in the field of HIV training. She previously conducted HIV training for the national government education department.
The objectives of the training programme were first, to equip teachers with the necessary knowledge to confidently and effectively implement the curriculum. Emphasis was placed on enabling the transfer of acquired knowledge and skills into the classroom context. The training focused on factual information since teachers within the South African education system are not trained in sexual health education. Second, the training programmes aimed to equip teachers with facilitative skills to teach the curriculum. The training was experiential in nature with teachers actively engaged in all the lessons of the curriculum as participants, thereby demonstrating participatory and facilitative learning. Reports demonstrate that this type of active training leads to more faithful implementation of programmes rather than removed methods such as video training [16, 26]. The third objective was to create self-awareness of factors which may influence the teaching of sexuality education. This was done by facilitating discussions on teachers' feelings, beliefs and attitudes towards sexuality education, and exploring underlying personal and social morals and values. The last objective was to facilitate ownership of the curriculum through teachers' active engagement and feedback on the curriculum.
The refresher training, which took place during the implementation phase, aimed to facilitate discussion on teachers' experience of implementing the curriculum, revise lessons where appropriate and ensure completion of the curriculum within the 6-month period. On average, teachers had completed two lessons by the first refresher training and eight by the second. Twenty teachers attended the first refresher training and 16 the second.
Data collection methods
Anonymous evaluation questionnaires comprising open-ended statements and questions were administered to the participating teachers at four time periods over the 6-month period, eliciting the following information: (i) prior to the training: brief demographic data, expectations of the training, beliefs and values about teenage sexuality, comfort teaching sex education to youth, areas of discomfort, skills required to teach sex education; (ii) on completion of the training: understanding of, and feelings about the curriculum, extent to which underlying messages in the curriculum matched personal beliefs and values, level of comfort and confidence teaching the curriculum, foreseeable challenges, appropriateness of teaching condom use to Grade 8 students, aspects of the training which were useful, enjoyable and personally challenging and (iii) on completion of each of the two refresher trainings: experience of the curriculum, engagement of students, skills and knowledge applied from training or lacking from training, confidence and comfort teaching the curriculum, avoidance of lessons, support needs.
Another source of data was participant observation notes. One member of the SATZ team (Nazeema Ahmed), a clinical psychologist, took the role of participant observer, paying attention to the content and process of the SATZ teacher training. Observation notes included details such as content areas covered during the training, the varying levels of engagement of the teachers in the training, areas of discomfort, silences and anxieties with particular topics and the dynamics of the group. Observations of each training session were discussed with the trainer and second member of the SATZ research team attending the training.
Analysis
Questionnaires were analysed by means of thematic analysis involving reading and rereading of the responses a few weeks later. Common themes in the responses to questions and statements were noted. These findings were compared with the observation and discussion notes of the participant observer which provided a deeper qualitative and contextual understanding of the responses.
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Results and discussion |
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This evaluation of the teacher training process differs from the evaluation of programme implementation which is the subject of another manuscript currently in progress (Mukoma et al., in preparation). The findings of the process evaluation are presented by first outlining some of the expectations of teachers at the onset of the training. This is followed by a discussion of the four objectives of the teacher training programme and concludes with some of the challenges faced by teachers.
Teachers' expectations at the onset of the training
Prior to the training, teachers expressed hopes of increasing their knowledge of sexuality and HIV, and gaining dynamic approaches to effectively and confidently teach sex education to Grade 8 students. They hoped the curriculum would be teacher and student friendly, practical to implement and be compliant with the existing life skills curricula guidelines as set out by the provincial education department. Some expressed a need for teaching materials, detailed guidelines on lessons, resources for students and ongoing support.
Knowledge gains
Before the training, the majority of teachers felt anxious about their lack of knowledge and exposure to HIV issues. On completion of the initial training, 16 of the teachers believed that they had acquired sexual reproductive health knowledge. However, at the final refresher training it was clear that the majority of teachers attending still had inadequate knowledge. For example, teachers were divided into three groups and asked to complete a task which tested their knowledge of the presentation and cure of sexually transmitted illnesses (STIs). All three groups achieved only slightly over 50% on this group effort test. Teachers clearly struggled to internalize much of the factual knowledge provided during the training. Some had called in biology teachers since they continued to feel ill-equipped to teach students about the sexual reproductive system and effectively answer questions without an adequate knowledge of human biology. This suggests that the information provided during the intensive period of training was not easily retained. While the failure of the training to improve teachers' knowledge is of concern, it can be understood in light of the numerous historical factors highlighted earlier, their poor training, the adverse conditions in which teaching takes place, the lack of priority which life orientation receives and the professional development of teachers not being prioritized. The inadequate initial teacher training in the area of health education has been referred to elsewhere with teachers being found to lack confidence when the foundation training is poor [27, 28]. Many of these factors need to be remedied at a broader level.
Instructional strategies
At the end of the initial 4-day training, 16 teachers noted that they gained an experiential understanding of group facilitation skills and group-work experience. The knowledgeable and skillful facilitation of the HIV trainer was valued and provided an experience of a student-centered approach to teaching. However, they remained cautious about their ability to transfer these skills. Once implementation of the curriculum began, many struggled to move beyond didactic methods to implement this new facilitative, participative approach.
The teachers found that small group work was not effective with large class sizes (upto 60 students in a class) and facilitation of group work was challenging. The lack of confidence and experience of teachers contributed to difficulties facilitating small groups. More systematic inhibiting factors included poor resources (for example, limited space, no teacher assistant to manage large classes). Teachers found that the students were reluctant to discuss their personal values and beliefs in the presence of their peers. Research in other settings confirms the difficulty of small group discussion, with teachers and students giving preference to large group discussions when the social and emotional aspects of sexuality are discussed [29, 30]. Gender differences were also evident: the teachers reported that girls were more cognitively mature, being more able than boys to assess new knowledge, engage in discussions and respond to arguments. Similar findings were noted elsewhere [13, 30] where classroom management concerned teachers who had to deal with diversity of maturity within a class, making age appropriate sexuality education challenging.
From the outset of the training, teachers expressed concerns about role-play activities. Many believed that students would find difficulty with role-plays since it was unfamiliar to them. Furthermore, the teachers did not have confidence that they possessed the good facilitation skills required for managing role-plays in large class sizes. During the implementation of the curriculum, students cautiously engaged with role-plays, perhaps as a result of their anxiety about attempting it. Only four teachers attempted role-play activities with students and reported that it was difficult for students. Three of these teachers provided students with dialogues with which to role-play:
The roleplay will be difficult. Most of the students will not be comfortable to roleplay in front of the class and they will not know how. They do not have the frame of reference for this.
Discomforts with role-play methods are well supported in the literature [11, 13, 18, 31–33]. Role-plays were found to be problematic for teachers despite it being given special attention in the training [34]. Kinsman et al. [31] recommend additional training and support for teachers unfamiliar with these participatory teaching methods.
Self-awareness
Some teachers indicated their appreciation of the opportunity to openly voice their opinions, and reflect on their personal and community values and norms. They valued the contributions of teachers from diverse communities, for example, ways of better managing large class sizes, and an increased appreciation of the huge disparities within the education system reflected in the structure, management and functioning of schools.
Prior to the training, the responses to the questionnaires revealed that 15 of the 24 teachers held strong beliefs around abstaining from sex until marriage. On completion of the initial training, 17 teachers felt that the underlying messages of the curriculum matched their personal beliefs and values. Others were more ambivalent, since they were not in agreement with the safe sex message in the latter part of the curriculum. When asked which values they were likely to transfer when teaching the curriculum, the majority stated that it is the belief that abstinence is best and that no sex before marriage should be upheld.
Considerable difficulties were reported with the first lesson in the curriculum which entails discussing personal and societal values and norms. This was surprising given the intensive training on these issues. Students were reported to have difficulty in understanding the terminology (for example, norms and values) and teachers struggled to clarify it for them. At refresher trainings, some teachers expressed their need to uphold and express personal values despite being perceived as conservative, while others found difficulties when their norms and values differed with those of the students. Reflecting on the personal challenge of the SATZ curriculum, several articulated internal conflict particularly with the safe sex lessons:
... the personal challenge is trying to get a balance between my own beliefs and the idea that I must teach certain material that I believe should not be taught to Grade 8 students.
During the training, teachers continually reflected on broader social contexts of their students, for example, poor boundaries at home due to poor socio-economic conditions, sexual activity among adults being witnessed by students, poor parental supervision, intoxicated students at school and increasing teenage pregnancy.
Throughout the training, teachers were anxious about the safe sex lessons which several felt went against their personal values. This was addressed at each training, but more particularly at the final refresher training since these lessons are in the latter part of the curriculum. On completion of the training, 18 teachers felt that it was appropriate to teach Grade 8 students about condom use, but 16 reported the condom demonstration lesson to be personally challenging for them. There were concerns that students would take things literally and interpret messages of safe sex as teachers condoning sex as a norm for their age group. Teachers who felt it was not appropriate to teach Grade 8 students about condom use expressed the following concern:
At this age the students take things literally or you cannot be sure of how they would interpret the lesson; how would this affect your (teacher) image to them as a parent/teacher and what negative messages can it bring to their minds, thus making them miss the point you wanted to drive home.
I suspect that the students at this age would see me as somebody who promotes sex in their immature reasoning minds.
Most of them (i.e. SATZ curriculum objectives) match my personal beliefs and values—eg abstinence. But there are those which challenge my values such as demonstration with dildos to the young 13 and 14 year olds.
Others feared losing respect of students who may consider them promoting or condoning sexual activity among youth by communicating that there is a safe way to have sex. The feeling was that if the aim is to reduce sexual activity, then the message of safe sex is a contradictory one. There were also fears that students might be unable to reconcile the religious affiliation of the teacher with the content of what is being taught.
In a way you are encouraging students to have sex. You are telling them here is a way to have safe sex by using a condom. My focus will be to encourage them to abstain from sex.
Concerns about teaching safe sex are universal. Teachers' moral views about teenage sexuality may make it difficult for them to discuss condom use and to facilitate safe sex negotiation skills [10, 31], despite successful teacher training [34]. Teachers' own feelings play a role in their comfort with safe sex lessons and failure to discuss condoms arises when teachers personally disapprove of them for young people [31]. Reasons for limited discussion of condoms are a result of teachers' belief that condoms promote and encourage promiscuity [5, 35]. It is likely that the training did not sufficiently address teachers' concerns that teaching about condom use encourages promiscuity. At the end of the refresher trainings, many teachers strongly felt that 14-year-old youths should not be sexually active and that providing messages of safe sex would encourage promiscuity. Since teachers will only adopt new values and ideas if they are closely aligned with their own belief systems [36–38], it is important that training programmes be equipped to deal with the reluctance to include condom lessons in the curriculum [39]. Whether or not the safe sex lessons were taught will be determined by the process evaluation phase of the project. What is evident is the dilemma within teachers with these lessons, despite considerable training and support being provided.
Facilitate ownership of the curriculum
The teacher training was used as a means of further developing the curriculum and educators' comments and criticisms of it contributed to its development. During the course of the training, considerable feedback was provided on various aspects of the lessons in the curriculum, for example, language, appropriateness of activities and layout, resulting in a revised version at the end of the initial 4-day training. A teacher advisory board comprising five teachers from schools not included in the SATZ sample piloted the curriculum prior to the teacher training. Further adaptations to the curriculum arose from the 4-day training. During implementation, there was an overwhelmingly positive response from teachers about the overall coherence of the curriculum and the well-planned workbook and manual. Many enjoyed teaching the curriculum and expressed awareness of their contribution towards the final version. Nine teachers commented on the enthusiasm and enjoyment of students towards the curriculum. They also noted that students varied in their participation with some being shy and others actively engaging. These outcomes are in line with the work of Paulussen et al. [18] who found that teachers' adoption and implementation of HIV programmes is dependent on their beliefs about the interest and enthusiasm of students, the feasibility of the classroom procedures and their ability to deliver the curriculum. Provision of clearly documented lessons which are effective in the classroom has been found to impact on the confidence and skills of teachers to deliver the lessons as planned [32].
Ongoing engagement and support of teachers played an important role in their ownership of the curriculum. Teachers commented on their appreciation of the ongoing support from the outset of the project. Some required more support than others. Paulussen et al. [40] highlight the importance of engaging personally prior to and during the implementation of a curriculum by way of training and technical assistance to ensure success. Staff development is important in light of staff turn over and commitment issues and necessitates follow-up staff development programs [41]. While ownership of the curriculum was achieved through the ongoing participation of teachers in the curriculum development process, this should not be confused with the fidelity of programme implementation. The latter is dependent on a range of more challenging factors such as experience, knowledge and skill of teachers, resources, support of the school and other contextual factors. Since the programme was continually edited based on input from teachers, they felt a sense of ownership and better equipped to implement the programme.
Challenges
Impediments to the implementation of the curriculum included insufficient time in the curriculum dedicated to life orientation, and teachers' limited experience in implementing the lessons. Teachers required time to adjust to a new curriculum and method of teaching. The time constraints placed on teachers was largely a result of the time line of the research which was a hindrance to the majority of teachers who felt pressured to complete the lessons in a stipulated time period. Time concerns are perhaps specific to life orientation classes where the education is not limited to the classroom and requires more time [9]. Similar to the work of Kinsman et al. [31], it is likely that incorporation of the curriculum into the mainstream curriculum over the course of the school year would alleviate time constraints felt by the teachers.
Another challenge was the emotional language for this developmental stage and the language in the curriculum being too academic and advanced given the poor literacy in some schools. Allied to the latter is the vast age range of students at times which implied developmental differences within the classroom. Concerns were raised about the poor literacy level among Grade 8 students. As a result, teachers found it easier to engage students in discussions than request completion of written tasks. Students were reluctant to complete homework tasks and activities involving reading and writing. All these factors had implications for teaching the curriculum within a specified time period.
Teachers were singled out as the facilitators of sex education in our research and there are obvious difficulties with this, which could not be addressed but needs mention. The first concerns reports of sexual harassment of students by teachers in South Africa [42]. Human Rights Watch [43] found sexual abuse and harassment of girls in particular by teachers and other students widespread in South Africa. This is of concern since teachers have been mandated to teach sex education within the life orientation curriculum.
Another concern in our research was the turnover of teachers where some left for personal reasons (maternity, illness) or were allocated to teach elsewhere. Nine teachers defaulted from the programme at various points but were replaced with teachers who were provided with the same training as the original cohort. This became apparent during the implementation phase and at refresher trainings where new teachers replaced previously trained ones. Teacher attrition is of great concern where large numbers of teachers (55%) report intending to leave the education profession in South Africa [44]. Furthermore, the HIV epidemic has been found to seriously affect South African teachers [44], with 12% of teachers found to be HIV positive [4, 45].
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Conclusion |
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The findings of this process evaluation suggest that the participating teachers benefited from the training programme, by acquiring the sexual reproductive knowledge and an experiential understanding of the skills required to teach sex education to Grade 8 students. However, the objective of enabling the transfer of knowledge and skills to the classroom was not successfully achieved. After the initial training, teachers had inadequate and inaccurate knowledge of sexual reproductive health and HIV. This highlights the need for HIV education to form part of both continuing professional development of teachers as well as teacher trainee programmes. Bursts of sex education training will not be sufficient for teachers to internalize the factual information.
A great deal of support and ongoing engagement with teachers is needed to encourage the adoption of alternative teaching practices. Despite the lack of knowledge and difficulties with facilitative skills, teachers reported feeling considerably more comfortable and confident teaching sex education to their students than prior to the training. Honest discussions and reflections in questionnaires suggested increasing self-awareness. However, the conflicting norms and values which some teachers experienced with the curriculum continued to impact on their comfort teaching. Paulussen et al. [18] are of the opinion that support should be provided to teachers, focusing on the dilemma faced where it is incompatible with HIV instruction and particularly sexual morality. Teachers who have good rapport with students may be the best candidates for training since HIV/AIDS prevention programmes are found to be more effective where relationships between teacher and students are open and trusting [46]. Rohrbach et al. [47] highlight the importance of recruiting and training teachers or other providers who are committed, enthusiastic and skilled in the use of non-didactic methods. Gyarmathy et al. [33] found that the most successful teachers implementing the curriculum were young, engaging and were ‘outsiders’ to the students. They encourage research focusing on identifying teacher characteristics associated with good outcomes such as knowledge, age and personality factors. While this is ideal and high quality training of teachers at both the undergraduate and postgraduate level is vital for appropriate sexual health promotion in classrooms, there are of course budgetary [10] and practical considerations.
The present research highlighted the importance of investing in extensive and ongoing liaisons with various levels of the education system. This enabled commitment to the programme. The importance of developing rapport with teachers and research staff is discussed by Kealey et al. [48]. The piloting of the teaching materials during the course of the training programme provided an opportunity for teachers to take ownership of the curriculum. The excellent facilitation of the HIV trainer provided for real engagement and debates within the training. Furthermore, considerable efforts were made to ensure that the trainer's agenda and underlying thinking around HIV prevention was in strict accordance with the objectives of the SATZ programme and curriculum.
The fidelity with which programmes are implemented is important. The SATZ project's evaluation arm includes classroom observations in all the intervention schools as well as teachers' keeping diaries of each lesson completed. This, together with individual interviews with each teacher who implemented the curriculum will provide an indication of the extent to which the programme was implemented and the effectiveness of the teacher training. Details of the process evaluation of the implementation of the programme is reported elsewhere (Mukoma et al., in preparation). Ultimately, evaluating the effectiveness of the teacher training should be based on classroom performance as well as long-term evaluations of the knowledge, skills and teaching methods used by teachers.
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Acknowledgements |
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The authors would like to thank the education department, principals and teachers who participated in the research, who cannot be named for reasons of anonymity. This paper forms part of a larger project titled: ‘Promoting sexual and reproductive health. School-based HIV/AIDS prevention in sub-Saharan Africa’. The acronym for this larger project is ‘SATZ’, which stands for South Africa Tanzania. Financial support for this research was provided by the European Union Commission Health Systems Research programme, the SATZ study is funded by the EC-INCO research programme (Fifth Framework Programme-Contract number ICA4-CT-2002-10038). The partners and principal investigators include: University of Cape Town (A.J.F.), Muhimbili University College of Health Sciences, (Sylvia Kaaya), University of the North (Hans Onya), Karolinska Institute (Minou Fuglesang), University of Maastricht (H.S.), University of Oslo (Knut-Inge Klepp), World Population Foundation and Youth Incentives (Jo Reinders), University of Bergen (Leif Edvard Aarø—coordinator). http://www.uib.no/psyfa/hemil/satz.
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References |
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Received on July 11, 2005; accepted on March 23, 2006
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