Sexual and Reproductive Health educational intervention for school teachers in district of Kalutara, Sri Lanka

To plan and implement a Sexual and Reproductive Health (SRH) educational intervention for school teachers and evaluate the effectiveness of the intervention. Methods An educational intervention was designed based on a situational analysis of existing SRH education in Sri Lankan schools. Intervention was carried out as four days teacher training workshop on SRH teaching for school teachers (thirty one) in the intervention group. Teachers in the control group (thirty) exposed to the pre-existing educational seminars conducted by the ministry of education at zonal level. After the intervention teachers in both intervention and control groups taught SRH lessons to grade nine students acc-ording to the existing school curriculum. Teaching skills were assessed using standard checklists. A quasi-experimental, equivalent control group design with pretest-posttest components was used to evaluate the effectiveness of the intervention. Sixty one teachers and 914 grade nine students aged 15-16yrs completed anonymous self reported pre-and post intervention questionnaires. Scores for baseline, first and second posnests were compared between intervention and control groups. Results Results of the situational analysis showed that the ill prepared teacher is the main barrier for SRH education. Post intervention teaching skills were significantly improved in the intervention group (p-0.002). There was also a significant improvement in SRH knowledge and attitude among grade nine students (p < 0.05) in the intervention area after the intervention. Developing and conducting a· new educational intervention for SRH education based on situational analysis proved successful with regard to improved teaching skills as well as knowledge and attitudes among students.


Introduction
The global trend of an early onset of puberty combined with increased age at marriage, leading to increase in premarital sex is also observed in Sri Laoka where mean age of menarche is 11.4 and age of marriage is 24.6 years t . The period between men arche and marriage is seen as a risk period for re productive health of adolescents as they initiate and continue sexual activities 2 . These factors may lead to sexual abuse, unwanted pregnancies, unsafe abor tions, maternal deaths and contracting STls includ ing HIV/AlDS 3 .

Regardless of its form and emphasis, Sexual and
Reproductive Health (SRH) education has been controversia! 24 • Many have feared that it might en courage sexual activity among young people who are not yet sexually active, and increase levels of risk-taking behaviour among those who are sexually experienced 2 · 5 • Discussion points include: how much explicit e.ducational matetial there should be.how often sexual education should be given and at what age to initiate this education 6 • However, it has been shown that well-designed SRH education programmes can positively influence the delay in initiation of se. xual activity, reduce the number of sexual panners and reduce unplanned pregnancy and STis 7 . s. Although many interventions were carried out to improve Adolescent Sexual and Reproductive Health (ASRH), there is lack of effective school based interventions as a package in many developing countries including Sri Lanka. Scientific and valid information on e. ffe.cti ve interventions promoting ASRH would make a positive contribu tion towards making policy de.cisions and pro gramme planning for ASRH. By conducting scien tific intervencion programmes, researchers can iden tify effectiveness of the programme as well as defi ciencies of the implemented interventions. This will help to derermine better ways of conducting new programmes by overcoming the deficiencies in an effective and suscainable manner. Therefore, investment is needed in research that provides practical and sustainable solutions, which will be able to reduce SRH problems among adolescents.
Teaching SRH requires different skills and approaches compared to than teaching other less sensitive, more conventional subjects 9. Teaching the content alone is not sufficient in sexual health edu cation. St udents may be able to pass a paper-pencil test on health knowledge, but this does uot ensure that the student will put that knowledge imo practice. This is known as a "health behaviour gap", which refers to the discrepancy between personal health knowledge and general health behaviour' 0 .
The Ministry of Education io Sri Lanka introduced Sexual and Reproductive Health (SRH) component into the school cu1Ticulum io 1994 and revised it in 1999. During the past ten years, teacher-training programmes for SRH conducted in Sri Lanka have consisted mainly of knowledge-based seminars and were not focused to develop competency in SRH teaching". In addition. even though SRH had been included in the school curriculum, knowledge of and attitude to SRH was low among Sri Lankan adolescents 12 • 1 •. In an attempt to improve this we designed a new educational iniervention on SRH edu. cation for adolescents and assessed the feasibility and effect of implementing this in Sri Lankan schools.

S1udy site and population
Kalutara district is located in the western province of Sri Lanka. It has a population of about I million of which 20% are adolescents. For educational purposes Kalutara district is divided into three educational zones, namely Kalutara, Horana and Mathugama 15 . Grade nine students were considered as the most appropriate group for the intervention because in Sri Lanka SRH teaching is already part of the curriculum f or this age group. There are 218 schools with grade nine classes in the Kalutara district with 5.488 grade nine students 'S . . This study was conducted in two comparable Journal of the Community Physicia11s of Sri Lanka educational zones . Kalutara educational zone was selected as the intervention area and Horana educational zone as the control area.

Study design
A quasi-experimental, equivalent control group design with pretest-posuest components was used to evaluate the effectiveness of a new SRH educational package The study consisted of five phases {Figure I).

Situational analysis of existing SRH education (Phase I)
To identify the existing situation for SRH education, informal interviews (five) were caJTied out with experts in both health and educational sec tors in Sri Lanka who had experience in SRH edu cation. Focus group discussions were carried om with school principals (one), master teachers (one), health and physical education teachers (two), grade nine school children (two) and their parents {two) with 10-12 participants in each discussion. Documents relating to SRH education such as the school curriculum, school text books relating to SRH, teachers' guide books, previous re pons on school SRH education and 5-year work plans on school education were reviewed. The availability of basic facilities in schools such as whether there was a separate classroom for grade nine students, ade quate numbers of desks and chairs, blackboards and teaching-learning aids for SRH education were also assessed using a checklist.

Selection of study groups and pre-intervemion assessment ( Phase II)
Among 218 schools with grade nine classes only 61 schools had health and physical education teachers who teach SRH. All these 6 I schools were included in the study {31 schools in intervention area and 30 schools in control area). Sixty one health and physi cal education teachers (one health and physical edu cation teacher from each school) were included as primary target group in the study.
To evaluate effectiveness of the intervention grade nine students who are taught SRH lessons by health and physical education teachers in intervention and control groups were included as secondary target group for the study. In calculating the sample size for grade nine students, it was considered necessary to identify a difference in the stated outcome of at least 15% from a baseline value of 35% with power of 85%. A multi-stage sampling method was adopted. A grade nine class was considered as a cluster. Sixty one grade nine classes (one class from

Joumal of the Community Physicians cf Sri Lanka Volume 12 December 2007
each school) were randomly selected for the study.
To minimize the clustering effect, the obtained value was multiplied by a clustering effect of two 16 . Accordingly, from the 61 schools, 914 students (15 from each class) were selected ran domly with almost equal numbers of boys and girls were included into the study (483 girls and 431 boys).
The pre-intervention assessment was carried out in the respective schools one week before the educational intervention was introduced. Two separate self-reported pre-coded and pre-tested questionnaires (one for studentS, one for teachers) were used to gather information on knowledge and attitudes in relation to SRH. The questionnaire included three sections: (i) demographic characteristics, (ii) a section evaluating SRH related knowledge including anatomy and physiology of'1 the reproductive system; and knowledge about' pregnancy, abortion, sub fertility and STis and (iii) a section evaluating participants' attitude towards SRH education in schools, size of sexual organs, nocturnal emission, masturbation, menstruation, virginity and myths surrounding STis.
Data collectors were informed about the objectives of the study, random selection of students, and distribution of the questionnaires, problems that can occur during the data collection and how these can be tackled. G11idelines on data collection were prepared and given to the data collectors to facilitate and standardize the data collection.

Development of the new SRH educational interven tion package ( Phase III)
Information obtained in phase I and 11 was analyzed by using the SWOT model [Strengths, Weakness, Opportunities and Threats) (

Introductio11 of the SRH educational intervention (Phase IV)
Intervention was carried out as four-day reacher trainjng workshop for the teachers in the interven tion group. There were six-45 minutes sessions per day consisting of lecture discussions supported by visual techniques and participatory learning meth ods, smaU group activities, case studies, role playing exercises, demonstrations and micro teaching sessions. Topics discussed during the train ing workshop included: importance of teaching SRH in schools, physical and psychological changes that occ11r during adolescence, prevention of teen age pregnancy, sexual abuse, unsafe abortions and STJs/ AIDS, how to dispel myths about e.g. size of sexual organs and discuss topics such as nocturnal emission, masturbation, menstruation and virginity. During the workshop teachers were specially trained to prepare lesson plans for SRH teaching and to talk about sensitive issues openly with ado lescents. 1n the intervention area this workshop re placed the usual annual seminars on SRH as given by the Ministry of Education. Teachers in the con trol area continued with the annual seminars con sisting of non-participatory lectures on anatomy and physiology of the reproductive system ( 4-days of seminars).

Post intervention assessment (Phase V)
One month after the training workshops and annual seminars, teachers in both intervention and control groups were as.ked to teach SRH lessons according to the existing curriculum to grade nine school chil dren in their respective schools during the given period of time allocated to this in the curriculum (one and half months-one classroom session per week).
Teaching skills of all teachers in the intervention group and the control group were observed and as sessed by ma�ter teachers using a validated check list. Post intervention knowledge of and attitude to SRH among teachers in both study groups was as sessed one week after completion of SRH teaching in schools by using the same self-reported question naires used in the pre intervention assessment. Im pact of the intervention was evaluated from post intervention knowledge of and attitude to SRH among grade nine students in the intervention and control areas (one week and six weeks atier comple tion of SRH teaching) by administering the same self-reported questionnaires used in the pre intervention assessment.

Statistical analysis
For continuous variables, mean scores on SRH knowledge and teaching skills were calculated and tbe t-test was used to assess differences between the intervention and control groups. Scores of attimde were not nor mally distributed. Therefore, nonpara metric tests i.e. Man Whitney U-test (for unpaired data) and Wilcoxan signs rank test (for paired data) were applied to assess the difference between pre and post intervention attitudes and difference between intervention and control groups. Data were analyzed using SPSS version 12.0.

Ethical approval
Ethical clearance for this study was obtained from the Ethical Review Committee of the Faculty of Medicine, University of Colombo, Sri Lanka. Written informed consent from the parents or guardian was obtained for all children. Before the study commenced permission was also obtained from the State Ministries of Education and Health, ancl from the Provincial Directors of Education and Health -Western Province, Deputy Provincial Director of Health Services (DPDHS) Kalutara and school authorities. AU data collected at the pre and post intervention assessments was handled maintaining strict confidentialiry throughout the smdy.

Results
Socio -demographic information of teachers in the intervention and control groups were compared. The majority of teachers were in the 30-39 year age gro. up and there was no significant difference in mean age of teachers in the intervention (37. l) and control group (34.3) (p=0.176). Majority of teachers in both groups were female (intervention group -74.1 %, control group -80.0% ). More than ninety five percent of teachers were Sinhalese (intervention group -96.7% , control group -100.0%) and majority of them were Buddhists (intervention group -96.7% , control group -90.0%). When comparing their educational level only 25.0% of teachers in the intervention group and 20.0% in the control group had done the GCE (A/L) examination in science subjects. This in educational qualification was not statistically significant (p = 0.651).
The majority of teachers who were given the responsibiUty for teaching SRH were appointed as health and physical education teachers (90% ). Mean duration of service was 14 years and duration of teaching health and physical education subject is 10 years in both study groups. Mean number of years experience of teachfog SRH was 4.7 (SD 2.6) and

Joumal of the Community Physicians of Sri Lanka
6.2 (SD 3.2) years in the intervention and control group respectively. It is impor1ant to note that 80.0% of teachers in both groups had never received any in-service training in relation to SRH. attitude towards SRH education was not posi tive. 6. Grade nine school children's knowledge of and attitude to SRH was poor.

Volume 12 December 2007
Opportunities Several funding bodies in Sri Lanka were keen to promote adolescent reproductive health education and funds were available for SRH education ( UNFPA, UNICEF, Plan Sri Lanka) Most of the parents prefe1Ted it if the school took responsibility for SRH education.
Annual seminars on SRH for health and physical education teachers were conducted by the Ministry of Education regularly.

Threats
In Sri Lankan culture SRH issues are not discussed openly. There is an inadequate number of teachers to teach the "Health and Physical Education" subject. Only 61 out of 218 schools in this survey had a teacher for this. The time allocated in the school curriculum to teach SRH was not enough. The SRH lessons in the grade nine CUJTiculurn and text book are last but one; therefore these are sometimes not given due to time constraints in delivering the whole curriculum. According to teachers and parents the media give misleading messages about SRH. Majority of parents do not like to discuss SRH issues with their children. Some parents did not understand and appreciate the imp01tance of SRH education.
There was no statistically significant difference in Socio-demographic data (age, sex, ethnicity, relig ion, parent's education level, parent's occupation) between students in the intervention and control groups.
Information obtained in phase I and II was analyzed and is presented in Table l.

Assessment oJTeachers
All 61 teachers were assessed during the post intervention survey (Intervention group -31 and control group-30). The difference in teaching skills between two groups was tested using a t-cest for independent groups. Statistically significant higher mean scores were obtained in the intervention group compared to the control group for most of the components of the checklist ( Table 2).
The difference in pre-and post-intervention knowledge among teachers in the intervention group was compared to that of those in the control group. Significance of difference was tested by using a paired t-test. There was a Statistically significant improvement in knowledge for the section about pregnancy related issues (conception, pregnancy, abortion and sub fertility) (p=0.001) and Sexually Transmitted Infections (p=0.001) in the intervention group, with no statistically significant improvement in the control group (p>0.05). However,. when comparing the difference in mean scores for overall (all sections) knowledge of SRH,  Table 3).
Sigoificance of difference in pre-and post intervention attitude to SRH among teachers was tested using the Wilcoxan signs rank test. There was a statistically significant increase in mean scores for attitude for all the selected sub topics of SRH (all sections) among teachers in both intervention and control groups (p=0.01, p=0.001) ( Table 3).

Assessmem of studems
For students, significance of difference in pre-and post-intervention knowledge was tested using t-test for independent samples. For the first post intervention tests (after I week), a statistically significant improvement i11 mean score for knowledge 011 anatomy and physiology of reproductive systems (p=0.0001); pregnancy related issues (p=0.01); and Sexually Transmitted Infec tions (p=0.01) was noted in the intervention group.
In the control group there was no statistically sig nificant improvement (p>0.05). With regards to attitudes there was statistically significant improve ment in attitudes to SRH in the interveqtion group on most of the selected sub topics reflected in the difference in mean overall score (p 0.029) ( Table 3).
In the control group a statistically significant differ ence was noted in a negative direction (less good attitude score) for some of the topics such as mas turbation (mean score: pretest: -2. I posttest: -5.2) and size of sexual organs (mean score: pretest: -4.7 posuest: -6.5). A statistically significant improve ment in mean scores for knowledge on anatomy and physiology of reproductive system; pregnancy and related issues; and Sexually Transmitted Infecrions was exhibited in both intervention and control groups (p<0.01) in post test 2 (6 weeks later). How ever, !here was no sratisrical significant improve ment in SRH attitude in post test 2.

Discussion
The results of the FGDs and informal interviews revealed the importance of SRH education in schools and school is identified as the most appropriate place to educate children on Sexual and Reproductive Health. However, officials in education sector did not have a clear idea on age appropriate SRH education and current needs of adolescents. Moreover, school children and their parents expect good SRH education to be  established in schools. Furthermore, factors affecting SRH education and lraining needs of teachers were identified during the situational analysis of existing SRH education in schools. This revealed that although the importance of giving SRH education in schools was agreed by experts in both the health and educational sectors. as weU as by most parents, the existing training in teaching SRH to adolescents for teachers was not based on a needs assessment and was not directed to improving teaching skills to enable teachers to address sensitive issues with confidence. Lack of competency in teaching sensitive issues is a common problem faced by teachers during SRH teaching sessions 17 • Another main barrier for suc ce. ssful SRH teaching that was identified in this study was the inadequacy and lack of appropriate teaching/learning materials. Therefore, it was agreed that there was an urgent need to prepare user friendly teachers' guide on SRH teaching at least to cover the already existing curriculum. In this study, teachers in the intervention group obtained statistically significant higher mean scores for SRH teaching skills than in the control group showing improved competency after participating in the new training workshops. Except with regard to some specific areas of knowledge (about pregnancy related issues) teachers did not show a statistically significant improvement in SRH knowledge and attitude was not measurably changed after the educational intervention. However, there was a statistically significant improvement in knowledge of and attitude to SRH among students in the intervention group after introducing the new SRH educational package (with no statistically significant improvement in the control group). It is recommended that SRH teaching skills are assessed in an actual classroom setting rather than in micro-teaching sessions 18 • Master teachers in health and physical education assessed the teaching skills of the teachers in both study groups during their normal supervisory visits. All the teachers who were selected for the study were informed that this would happen. This may have led to bias as they may have performed better than during normal (unsupervised) classroom sessions (Hawthorn effect). However, teachers in the it1tervention group clearly exhibited a better performance in SRH teaching than in the control group (p=0.002).
We have shown that the new educational intervention can improve adolescents' knowledge of tbe anatomy and physiology of male and female reproductive systems; pregnancy and related issues; and Sexually Transmitted Infections. A non randomized controlled trial used to evaluate an

Joumal of the Community Physicians of Sri IAnka
AIDS Education Progamme among grade ten stu dents in two public schools in Oklahoma city also showed significant improvement in knowledge· among students 19 • Attitudes towards SRH among adolescents in the intervention group became more positive (mean scores: pre 4.7 post 8.4). An intervention on AIDS education for primary school children in Tanzania also revealed that pupils in the intervention group scored significantly higher marks for the knowledge, auitude and communication skills (P<0.001) related to AlDS 20 . Another study done in Nigerian secondary school students revealed that students can benefit from speci fie education programmes that ti·ansmit important information necessary to prevent risky behaviour, and improve knowledge and attitude towards HIV/AIDS 21 • Simi lar studies conducted to evaluate the effectiveness of reproductive health related interventions have shown positive infiuence on knowledge, attitudes and behaviour in relation to reproductive health 22 ' 2 \ The present study further observed that attitude to ward masturbation and size of sexual organs changed in a negative direction (less positive) among adolescents in the control group. This high lights the fact that SRH education because of its sensitive nature, if not handled carefully and if ac curate knowledge is not transmitted, may result in deterioration of existing status. It clearly showed that sensitive issues in SRH should be taught by well qualified trained teachers. We recommended collaboration between the education and health sec tors to determine content of the SRH curricul.um and incorporation of a learner-centered educational package such as the one used in this study, which is low in cost and has the advantage of a participatory approach. Training of teachers alone is not adequate to improve heHlth e. ducMion in schoo1� 25 . Supervi sion of the performance of SRH teaching by master teachers, providing relevant teaching/learning mate rials, allocation of adequate time for SRH teaching, sensitizing principals of the schools on the importance of SRH teaching should all be considered when introducing a comprehensive new SRH education package. This study was carried out ill one district of tbe country and the results may not be exactly the same in other settings. In addition due to limited resources and time constraints the present study was not able to enhance the validity of the quantitative data by complementing tbese with qualitative data (e.g. FGDs) to evaluate the effectivene.ss of the educational intervention on behaviour and attitude in more depth and/or in the longer tem1. However, we feel this educational package was welcomed by both teachers and ado lesceot.S, was easy to use and ·could be scaled up for usc in similar settings.