In Partnership with Botswana: African Nation Revamps its Approach to HIV/AIDS Prevention in Schools

(July, 2003) Typically, messages about HIV/AIDS have been disjointed and disconnected from people’s lives, according to Scott Pulizzi, a project director in EDC’s Health and Human Development Programs (HHD/EDC). The messages tend to be negative and to blame individuals for their plight, rather than emphasizing positive

haven’t provided activities for young people to practice the skills that can protect them. For example, slogans such as “AIDS Kills” provoke fear and do not address the complexities of young people’s lives. “Many males believe they are invulnerable, that AIDS won’t strike them,” says Pulizzi.

In Botswana, a country with a high prevalence rate of HIV infection, the Ministry of Education is in the midst of making a significant shift in its approach to preventing the spread of HIV/AIDS infection. The Botswana government is launching a national

prevention program that will replace sexually explicit publicity campaigns and “just say no” programs with messages and courses emphasizing skill-building, decision making, self-respect, community ties, and personal and collective responsibility.

Researchers from HHD/EDC have been invited to join with colleagues in Botswana to develop prevention education and materials for three age groups, along with a national strategy to address HIV/AIDS through schools. The work is funded by the Global AIDS Program of the U.S. Centers for Disease Control and Prevention in partnership with the World Health Organization (WHO), Geneva, Switzerland. Teachers, educational administrators at the national and local levels, health workers, teacher unions, and representatives from the Ministry of Health in Botswana will co-develop the program to ensure its relevance.

The biggest challenge facing the team, according to Pulizzi, who is directing the project, is moving from a “fact-based, didactic, scare-tactic approach” to applying the behavior-change strategies that have been effective in many countries, such as Thailand and Uganda. A key part of the team’s work will be to figure out how to adapt these strategies to fit the cultural sensitivities, environment, and health challenges of Botswana in the classroom. According to Naomi Mnthali of the Botswana Ministry of Education, Curriculum Development Department, “The students have knowledge but lack the skills.

The Ministry is working hard to help teachers teach skills-based health education through several capacity-building projects.” “We know from research studies conducted in communities around the world that effective prevention messages have to be developed within a context,” says Pulizzi. “You can’t simply present facts and expect people to change longstanding practices and beliefs.”

Effective programs feature carefully crafted messages that honor young people’s culture and their day-to-day lives. They provide skill-building opportunities and knowledge for specific behavior changes, and they emphasize the need for supportive, safe environments that offer health services and address gender equity.

HHD/EDC’s Pulizzi summarizes it this way: “Botswana is now moving to provide a context for health messages and health related skills and to express them in language and a social context relevant to the culture that will connect with their young people in positive ways.”

For example, the Botswana prevention program will tap the strong cultural theme of community connection and shared responsibility, says Pulizzi. The new curriculum will offer activities that address HIV/AIDS prevention not only as a medical issue, but also as one of "stewardship,” which concerns individual integrity and national and local community and school pride. “Emphasizing the positive steps people can take, the campaign may, for example, tackle HIV prevention as the ultimate way to protect and strengthen families, relationships, and community life,” says Pulizzi.

Integrating this kind of cultural theme with research-based prevention strategies requires close collaboration between the Botswana team members, HHD/EDC, WHO, and CDC. In the fall, the HHD/EDC team traveled to Botswana for a 10-day site visit. During the visit, they worked with their Botswana colleagues to conduct a needs and assets assessment. Through intensive interviews, focus groups, and site visits, the HHD/EDC team came to understand the context more deeply, which will help them build support for the project among key stakeholders. The team met with teachers and administrators at more than a dozen schools on the Gaborone-Francistown corridor (the eastern border), and with education administrators representing national and local offices. “The goal of the Botswana team was to get the best thinking of the participants and to synthesize their ideas for HIV/AIDS prevention,” says Pulizzi.

In November 2002, a team of Botswana educators traveled to EDC’s headquarters in Massachusetts for a two-week professional development experience and study tour that focused on the rationale, theory, and research findings of behavior change strategies and the role of skills-based health education with young people—the approach successfully used in many HHD/EDC health curricula, trainings, and resource materials. The visit included trips to local high school health classes, seminars on several successful health education projects, and in-depth exchanges with HHD/EDC’s HIV researchers, curriculum developers, teacher trainers, and video producers drawn from several projects and centers.

In a number of working sessions, team members from both countries honed in on the challenges they share of using effective teaching strategies for HIV prevention in a school context. The team focused especially on how to prepare teachers to use participatory methods and prepare developmentally appropriate material on this sensitive topic. For example, in one of the sessions at EDC, Botswana members of the team tried out a role-playing activity from HHD/EDC’s Teenage Health Teaching Modules (THTM) that was designed to help students build “refusal skills”—the ability to say no and make it stick. “Beyond wanting to say no to a sexual advance, students need to understand the importance of saying no, how to say no, why it is hard to say no, and what to do when someone pressures you after you’ve already said no,” says Christine Blaber, a key developer of THTM, a comprehensive curriculum that has been proven effective in an independent evaluation.

In addition, the broader environmental and social norms of gender equity must be considered. What policies do schools have concerning teacher and student conduct? Do teachers uphold the standards they are teaching students? What are the respective rights of boys and girls, men and women, and how do these support the choice or make it difficult to remain abstinent or monogamous? Beyond classroom instruction, what types of preventive and screening services are available?

As they worked through the lesson, team members discovered the particular cultural context of using refusal skills in Botswana. In the role-playing lesson, the Botswanans acted out a situation in which one person wants sexual intimacy and the other has to improvise ways to refuse.

“The challenge was, How do you retain the relationship, yet say no assertively? While the HHD/EDC participants kept talking about the teachers’ role in taking a lesson like this successful, the educators from Botswana kept emphasizing to us the importance of relationships in their culture,” says Blaber. “It is important to say no in as courteous a way as possible.” As is the case in all countries, the HHD/EDC and Botswana team members agree that teacher training and the issues of broader school environment and services prove to be the most critical and challenging aspects of the project.

“Teacher professional development and curriculum resources go hand in hand,” says Blaber. “No matter how good the materials, if teachers are using a ‘stand and deliver’ didactic methodology, the impact on the students is nowhere near as positive.” Blaber cites research stating that the most effective health curricula are skills-based programs that use interactive teaching methods.

Similarly, consistent with WHO’s Global School Health Initiative, this project embraces the concept of “Health Promoting Schools,” which make the essential connection between skills-based health education, complementary school policies, a healthy psycho-social and physical school environment, and health services. Other elements include teacher, community, and parent involvement in designing and supporting programs. On a broader level, a global team—in this case from Botswana and the United States—can foster connections to tackle one of today’s most compelling public health challenges.