SUMMARY
Most efforts to limit the spread of human-immunodeficiency virus (HIV) infection stress education as the primary vehicle for producing preventive behavior. More than most diseases, the acquired immunedeficiency syndrome (AIDS) appears to elicit highly negative, prejudicial and fearful attitudes towards patients with AIDS. Biological education carried out in Portuguese schools can educate children and young adolescents concerning the characteristics of AIDS and its transmission and prevention, and promote greater sensivity towards AIDS patients. However, this requires teachers to use a cross-sectional approach to teaching some biology themes.
This paper describes a leading program to assist compulsory education children and young adolescents (7 to 14 years old) in reducing risk behaviors of HIV infection and to eliminate negative behaviors and attitudes towards patients with AIDS. Finally, issues relevant to the implementation of such interventions in Portuguese schools are discussed.
Key-Words: Human-Immunodeficiency Virus (HIV); Acquired Immunedeficiency Syndrome (AIDS); risk behaviors; primary prevention; stigmatization; cross-sectional curricular matter; practical work
RÉSUMÉ
La plupart des efforts qui visent limiter le diffusion du virus de l’immuno-déficience humain (VIH) accentuent le rôle de l`éducation comme véhicule primaire de production d’une conduite préventive. Plus que la plupart des maladies, le syndrome de l’immuno-déficience acquise (SIDA)semble produire des attitudes hautement négatives face aux malades atteints de SIDA. L’éducation biologique développée dans les écoles portugaises peut former les enfants et les jeunes en ce qui concerne les caractéristiques du SIDA, ses conditions de transmission et de prévention et peut aussi promouvoir la sensibilité face aux malades atteints de SIDA. Pourtant ceci implique que les professeurs traitent certains thèmes de biologie de façon transversale.
Cet article décrit un programme capable de conduire les enfants et les jeunes (de 7 à 14 ans) à la réduction des conduites de risque et à l’élimination des attitudes négatives face à l’infection par HIV et face aux gens qui en sont atteints. Finalement, on discute certains aspects que l’on croit importants pour l’implémentation de ces interventions dans les écoles portugaises.
Mots-clés : Virus d’immuno-déficience humain (VIH); Syndrome de l`immuno-déficience acquise (SIDA); comportements de risque; prévention primaire; stigmatisation; traitement transversal du curriculum; travail pratique.
1. Introduction
Even at the turn of the millennium, and after two decades of an epidemic, Human-Immunodeficiency Virus (HIV) infection and Acquired Immunodeficiency Syndrome (AIDS) still have a greater impact on science and society than chronic diseases with a much higher morbidity and mortality rate such as cancer, diabetes mellitus and cirrhosis.
What distinguishes AIDS from other contemporary diseases, is the fact that it threatens the significance of millions of deaths caused by other epidemics because of its specific characteristics. First of all, although it kills fewer people than most diseases which are common in our society, it is quite new and, contrary to many others which are also lethal, it is "transmissible". Secondly, HIV infection consists of a continuing, slow, incurable immunological disorder and, therefore, it is uniformly lethal after a long incubation period through which the virus is insidiously contagious. Thirdly, most people infected show no symptoms and are healthy for a long time, however being able to pass the virus to others without even knowing. Finally, contrary to other epidemics caused by viruses, which last for months or years, the AIDS epidemic is reaching its third decade, is not very contagious and can be disseminated through behaviors that can be altered.
Therefore, since most common ways of transmission (sexual and blood-related) involve risk behaviors, the only effective way of preventing the infection is to change the behavior patterns related to HIV transmission, through educational interventions.
Since the onset of the epidemic, it is clear that AIDS is looked at in a very different way from other contemporary diseases. It is seen as a lethal disease that can be transmitted through specific behaviors, and that it is more common between male homosexuals and intravenous drugs abusers. This conceptualization of the syndrome, results in a double stigma: the identification of AIDS as a serious and incurable transmissible disease, and its identification with people and groups who had been stigmatized even before the appearance of the epidemic (Herek & Glunt, 1988(4); Kelly et al., 1987a(5); 1987b(6); 1988(7); Kelly, 1989(8)).
Stigmatization related to AIDS, as a lethal disease, makes healthy individuals, in an attempt to keep a distance from death, to define AIDS as a risk only to others. As with other serious illnesses, the attempt to maintain this attitude drives people to form imperfect characteristics of patients, for example, those with cancer are pictured as being subjugated by emotions or as lacking the will-power to get better (Herek & Glunt, 1988). Other aspects to be considered regarding the AIDS stigma as a disease, is the fear of HIV casual contamination, which is probably due to misconceptions about the ways of transmission of AIDS (Herek & Glunt, 1988; Kelly et al., 1987ª; 1987b; 1988; Kelly, 1989; Morin, 1988(9); Schuster, 1988(10); Levine, 1992(11); Marková, Power, 1992(12); Vilaça, 1994(13); Cruz et al., 1997(14)). It has been convincingly demonstrated that HIV infection is not transmitted through closed social or family contact. Also there are no risks of transmission at school or at work places and risks involving the health professions are almost non-existent when all necessary precautions are taken.
In spite of these facts, there are still persistent and often irrational fears which make the individual with HIV positive susceptible to discrimination in what concerns work, housing and education (Kelly, 1989). This includes restrictions at work or dismissal, refusal of life assurance by insurance companies, refusal of public services (including police, cleaning services and burial homes), refusal or delays at some health care services or excessive precautions by health workers when dealing with the infection by health workers. These are typical examples of discriminatory effects of unfavorable legislation and of the existence of compulsory tests to detect HIV antibodies (Tross & Hirsch, 1988(15)). In a less formal way, but possibly in a more damaging way, a broader social support group, such as friends and family may feel frightened and reject or avoid these individuals (Kelly, 1989).
A study developed on Portuguese adolescents and young adults shows that, although they seem well-informed about the ways of transmitting HIV (Vilaça, 1994; Vilaça, Cruz, 1996(16)), they also show attitudes of stigmatization towards patients with AIDS (Vilaça, 1998(17)), though, on a smaller scale than in similar studies (e.g. Kelly et al., 1987a; 1987b; 1988).
In this sense a pilot intervention program in compulsory education, which I will later describe, has two goals: the prevention of infection by HIV, and preparing children and young adolescents to avoid negative biases and to encourage them to interact with people infected by HIV/AIDS.
2. A leading intervention program
Educational and preventive campaigns regarding HIV/AIDS infection has shown that there has been some resistance from adolescents, partly because of values and attitudes typical of the developmental stage they are going through, which may inhibit or make a change of behavior difficult (Cruz, 1999 (18).
Adolescence is a period marked by a search for autonomy and confrontation with new changes. Independence may often be followed by resolutions concerning friends, future education and work. This is also the time for many of them to establish intimate relationships and commence risk behaviors related to drugs and alcohol, which may increase the chance of infection by HIV. Young adolescents often base their evaluation of risk, present in these or other decisions, on their immediate consequences. They find it difficult to understand long term personal negative effects, because they lack a cognitive skill to carefully consider all significant risk behaviors. In what concerns adolescents, risk behaviors may occur because they are going through a developmental stage where their cognitive and social skills are limited, just as their ability to weigh future consequences and decisions and to include specific knowledge into coherent systems which usually increase during adolescence (Brooks — Gunn, Boyer, Hein, 1988(19)).
Mason, Olson and Parish (1988(20)), in their first efforts regarding AIDS prevention, stress the fact that adolescent attitudes towards risk behaviors are often the denial of any chance of contamination and to adopt the belief that they are invulnerable to any possible risk. For them, in accepting this risk as some kind of value, almost like a social norm, they do not desire to look less adventurous than their peers (Fisher, Misovich and Fisher, 1992(21)). Some authors suppose that adolescent tendency to take risks in what concerns sex, is related with other variables such as a strong and intense emotional pre-adult relationship. Whenever any adolescent has a sexual experience, he or she lacks any previous experience or skill necessary to cope with strong feelings which promote taking a sexual risk (Bowser & Wingood, 1992(22)).
The idea that adolescent norms may influence much of the levels of risk or of safe behavior is being supported in others studies outside the AIDS prevention domain such as contraception, smoking, alcohol and drugs. Social norms, influence many of their risk behaviors (Fisher et al., 1992). That is why adolescents have been described as being susceptible both to pressures, in order to participate in activities that involve sexual risk or drug abuse, and to prevention behaviors.
According to this, prevention of HIV/AIDS infection should commence at the onset of Primary School Education through a cross-sectional approach on health issues included in the program set by the Department of Education. We should value the development of children’s personal and social skills which allow them, as adolescents and adults, to adopt safe sex and to avoid using drugs. Information based on facts about HIV infection and AIDS should be based on a global perspective, taking into consideration the students’ ideas and stressing the implementation of basic individual and collective hygiene rules, so that the possibility of risk infection by HIV/AIDS or by any other pathogenic agents is minimized.
In the higher levels of Compulsory Education, both inter and transdisciplinary prevention projects should reinforce training in the development of social skills and the promotion of the significant gathering of more specific knowledge on the etiology and epidemiology of the virus and about HIV transmission and infection.
2.1. Characteristics of the intervention model
The first characteristic of the intervention model is to consider the primary prevention of AIDS as a cross-sectional curricular matter. A true cross-sectional approach implies that all or most school subjects take part in its development. The traditional disciplinary structure is maintained, but health themes are incorporated in the goals and contents of different subjects. According to Gavidia and Rodes (1996(23)) this does not mean an increase of the material studied, but a methodological change in which health themes are absorbed in the teaching process and where knowledge from school and everyday life become one. In order to begin this program of Primary Prevention of AIDS in Compulsory Education, we have encouraged the participation of teachers from the same school and from different subjects to participate in a Workshop about in-service Teachers Training, which took place at the University of Minho.
The second characteristic is an active participation of the student as a methodological strategy. Primary prevention of HIV infection is not only about giving information about the scientific grounds related to this health issue or about the danger of some kind of behaviors, but it is also about promoting critical attitudes which may allow us to analyze the problems, search for proper information, think about the values which determine behavior, the taking of responsibilities and learning how to make a decision. In this perspective, the student’s participation is important for the mobilization of affective and emotional aspects. The educational process should, then, essentially make use of practical work.
Information about the scientific grounds that support the primary prevention of AIDS (etiology, epidemiology, transmission and prevention) should make use of non-laboratory practical work such as "role-playing", a didactic approach of pamphlets, debates about films or slides, data research, and so on, of non experimental practical laboratory work such as observing blood cells, dissecting the heart, learning how to use condoms and how to sterilize needles, and so on and of an experimental practical work which would mainly focus on the construction or reconstruction of conceptual knowledge in activities such as Foresee- Observe- Explain- Think, for example, solving the following problem: What does the conception of the Mussel consists of, when seen under the microscope?. It would also be preferable if the reports on laboratory studies were Vee Maps, made to demonstrate the conceptual and methodological elements which interact in the process of building knowledge (Novak, Gowin, 1996(24)). Besides, these reports promote the construction of values based on the results of the research, not only in what concerns the area which is being approached, but also the area outside it.
The third characteristic of the model under discussion is to use Cognitive-Social Learning Theory as a guide-line for its development. This theory, described by Bandura (1989), for the prevention of HIV/AIDS infection, is based on two main specific principles: modeled strategies and self-efficacy. The pre-condition for a change of risk behaviors is that information should be planned and developed in order to increase people’s perception and knowledge of the risks of illnesses. For that to happen, it is necessary to supply a large quantity of fact-based information about the nature of the disease, the risk and preventive behaviors, "which should be communicated to society in an understandable, believable and persuasive way" (Bandura, 1989, p.131(25)). Therefore by using modeled strategies to develop the necessary social and self-regulatory skills in order to apply the information, we can bring about an effective preventive action.
Modeled strategies should influence the construction of a sense of self-assurance and the transmission of rules that help us deal with problems in an effective way. A strong belief in self-efficacy should probably make one achieve and maintain the necessary effort to change health damaging habits. The goal of the third element of this model is to increase skills and develop the ability to recover the perception of self-efficacy. The ability to quickly recover perception of self-efficacy is necessary to maintain a change in health habits. The last element aims at the acquisition of social supports for the expected changes. These changes depend on social factors, which can delay, weaken or help efforts for personal change.
The conceptualization of this prevention model is reinforced by Hodson and Bencze (1998(26)) when he stresses the following fact:
Recent research concerning students’ alternative frameworks of understanding and the concomitant development of constructivist pedagogy, the incorporation of more sophisticated understanding of issues in the history, philosophy and sociology of science into the curriculum, and the increasing emphasis on the social, cultural and affective dimensions of learning, have led to a series of proposals for a radical reappraisal of the role practical work and a substantial reorientation of its practice, including much more extensive use of practical work in non-laboratory contexts (p. 683).
Therefore, the "Leading Intervention Program of Primary Prevention of HIV Infection and AIDS in Compulsory Education" is defined in four stages.
The first one is the identification and analysis of behavior and attitudes of individuals at school and within the local community which facilitate HIV transmission. Some of the behavior patterns reported by the epidemiological studies which contribute significantly to an educational project adapted to the reality of the community where the school is included are: alcohol, illicit drugs abuse (predicting factors of risk behaviors), early unsafe sexual intercourse and sexual promiscuity.
The second is the selection of negative behavior patterns which we mean to change and the identification at school and within the local community of high-risk situations for the occurrence of the selected behaviors and the pressures endured by the child and adolescents that may lead him to behave in such a way and maintain his negative behavior.
The third stage is the planning of the intervention program in which, according to the use of the Cognitive-Social Learning Theory, combine four major elements:
(A). Information, whose goal is to increase people’s awareness and knowledge about what kind of health risks are related to selected negative behavior.
(B). The training of social and self-regulatory skills of behavior, are necessary to apply information-related contents into preventive behaviors. The development of abilities for the acquisition of these skills may be reached by using modeled strategies. Modeled strategies ought to influence the increase of self-efficacy and the acquisition of rules necessary to deal with problematic situations in an effective way. In order to increase the impact of modeled strategies, characteristics of role models, such as age, sex, status, the sort of problems they have to face and the situations which require the application of their skills, should be similar to the ones of the group which are in training. Therefore, role playing should be real and describe accurately, high-risk situations and the kind of pressures young people must endure.
(C). The training for the improvement of social skills and the development of the ability to quickly recover the perception of self-efficacy. Since children and young adolescents have already developed new abilities and social strategies, it will be necessary to follow guide-lines and to create opportunities to improve them. Bandura (1989) stresses the fact that they should, initially, practice them through simulated situations in which they are not afraid to make mistakes or to feel inadequate. This could easily be achieved through role play games. Role playing should continue until the abilities are performed in a useful and spontaneous way; such as children and young adolescents being allowed to describe their own past situations where they have participated in risk activities in which they did not wish to get involved also, they may refer to their state of mind at the time and the context in which it took place. After that, there should be a discussion on the possible changes they should make in order to, in similar situations in the future, reduce the chance of assuming that particular risk behavior. They should further be taught to make environmental changes in order to facilitate safe behavior.
(D). The development of environmental and social support favorable to a change in the advised behavior. This may be achieved by educating parents, teachers and community leaders through school-community interaction.
At the last stage, a reappraisal of the program should be made through a research of knowledge, attitudes and behaviors of the intervening parts in the program.
2.2. The goals of the program
There are two main kinds of goals for the development of the intervention strategies: goals related to educational development and learning, and goals related to intervention strategies.
In what concerns educational development and learning during the project, we essentially aim: 1. to include primary prevention of AIDS in schools in order to achieve, from all participants in the educational community, positive attitudes and behavior concerning HIV infection and towards patients with AIDS; 2. to increase knowledge and promote healthy attitudes and habits in children and young adolescents concerning the following issues: "Affective and sexual education and primary prevention of AIDS" and "The circulatory/ immune system and primary prevention of AIDS"; 3. to introduce health education contents at school throughout the curricular development of the different issues related to AIDS; 4. to provide the necessary conditions for the hidden curriculum, with its underlying values, to be able to consolidate and complete what is learned in class; 5. to promote relationships between the school, the family and the community in order to build social and environmental support favorable to the advised changes of behavior.
The goals related to the intervention strategies are as follows: 1. to introduce contents (concerning concepts, procedures and attitudes) related to the primary prevention of AIDS into teacher in-service training; 2. to plan and promote the organization of educational material necessary to achieve the goals mentioned above; 3. to create instruments for evaluation of school projects.
2.3. Methodology
The organizing structure of the program has been defined in a way in which to allow a significant fluidity of information and work between the various schools, teachers involved and the University, during the development of the projects.
There are fifteen compulsory education teachers, from different learning areas, being trained. The in-service training consists of a Workshop which involves practical training, in which some kind of socialization contexts are created, where each one of the participants talks about his/her affective practices, shares this knowledge with colleagues, questions oneself about them, and, after that questions the application of new ways — either methodological or technical. For that reason, simple regulatory mechanisms have been built, both for the work done at the Workshop, and the practical application of the materials produced there. Among these mechanisms, there have been some percentile joint sessions (a total of 25 hours), in which together, teachers at the Workshop produce a reflective and practical kind of work. In what concerns conceptualization, these sessions are separated in time, in order to enable the use of the educational projects and material in schools.
As a previous activity in teacher training, a set of basic materials have been elaborated through which the chosen criteria and guide-lines of work are presented, along with suggestions and examples of activities and programs.
According to this, a file called "Primary Prevention on AIDS in Compulsory Education" has been set up. The first part of the file includes material for the teacher, in which all scientific concepts related to AIDS is made clear, the introduction intervention models in health education and the underlying model of the program which will be developed, and a description of the method to be followed concerning the implementation of the various activities. The second part is permanently being elaborated, because it includes all the material for the student, which will be evaluated by teachers in a training-action-research process.
Some videotapes and games on Primary Prevention of AIDS published in Portugal (Gonçalves, 1997a(27), 1997b(28), 1998(29); Silva, Santinha, Alão, Alves, Sampaio, Carvalho, 1997(30); Sanders, Swinden,1995(31)) have also been made available.
2.4. Evaluation models and techniques
In the last school year (1998/1999), an instrument of measurement for gathering data was elaborated on within the educational community that should enable us: (1). To evaluate knowledge of HIV/AIDS infection; (2). to analyze personal vulnerability towards the virus at school; (3). to evaluate the awareness of personal discrimination in social interaction if you were a patient with AIDS; (4). to analyze social interaction between peers when one of them is infected with AIDS; (5). to analyze children’s behaviors and attitudes towards someone infected with AIDS; (6). to investigate differences among the distribution of dependent variables according to demographic variables; (7). to analyze existing associations between the dependent variables (Vilaça, 1999(32)). Based on that study, a Questionnaire called "Stigmatization of patients with AIDS" was validated. It was elaborated according to a previous study on Portuguese students in Compulsory Education and Secondary Schools (Vilaça, 1994; 1998; Vilaça & Cruz, 1996(33); Cruz et al., 1997), which, in its turn, was elaborated according to studies by Kelly and his collaborators (Kelly et al., 1987a; 1987b; 1988). The answers were classified according to Likert scale (Vilaça, 1999).
The questionnaire teachers are using, in compulsory school, as a pre and post-test, has been based on this study.
3. Conclusions and implications
The epidemiological paths of HIV infection and AIDS characteristics as a recent and transmissible and lethal disease, the possibility of being transmitted by asymptomatic indiviuals during HIV’s long incubation period and its reduced infectiousness level, controlled by changeable behaviors, make the virus’ primary prevention a great challenge for all professionals involved in Health Education. The number of elementary schools with HIV positive students and with students who live day by day with patients infected with HIV/AIDS or with someone who knows those patients will, unfortunately, increase. These students often know, but do not apply the basic individual and collective hygiene rules which allow them now, and in the future, to avoid running the risk of being infected with HIV or other pathogenic agents.
Risk reducing programs concerning HIV infection, based on a model whose main guide-lines consist of a cross-sectional approach of the health issues related to AIDS included in the curriculum of Sciences, the active participation of students as a methodological strategy (making use, mainly, of practical work) and the use of the Social Cognitive Learning Theory as a psychosocial model for a change in behavior, seem to be quite interesting and effective in what concerns interventions in compulsory education.
Teachers lack training in that area since Health Education teacher training in Portugal usually consists of three to four days updating courses, short modules included in curricular subjects in in-service training (except for some Schools of Education and Universities that teach Health Education) or support texts, information pamphlets or the participation in meetings on scientific issues, during pre-service training. In this country, the appearance of in-service training courses and post-graduation in Health Education is quite new.
Therefore, this research aims to reduce some existing difficulties and/or needs of both researchers and, mainly, teachers who are trying to implement projects related to primary prevention of HIV/AIDS infection in the educational community, before students leave compulsory education, namely (Vilaça, 1999): (1). the acquisition and elaboration of properly tested and evaluated didactic material, for the organization of projects in elementary school; (2). the elaboration of educational projects adjusted to the specific reality of each school, with a theoretical corpus of references that allows us to evaluate the level of achievement of the intended goals; (3). the validation of evaluation instruments that may allow us to analyze the efficacy level of the projects which have been developed; and (4). teachers in pre-service and in-service training in order to develop skills for the elaboration and implementation of projects concerning primary prevention of HIV/AIDS infection, adjusted to the different education realities.
FOOTNOTES
1. This research was partially supported by Instituto de Inovação Educacional (P nº 88/99- Primary Prevention of HIV/AIDS in School Community: A Leading Intervention Program in Compulsory Education) and Programa FOCO, medida 2.
2. Maria Teresa Machado Vilaça, Instituto de Educação e Psicologia, Universidade do Minho, Campus de Gualtar, 4700-320 Braga, Portugal. E-mail tvilaca@iep.uminho.pt
3. Manuel Sequeira, Instituto de Educação e Psicologia, Universidade do Minho, Campus de Gualtar, 4700-320 Braga, Portugal. E-mail msequeira@iep.uminho.pt
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