8.0 Introduction
This final chapter draws together the various aspects of the study. It includes a critical review of the research methods used and suggests subjects and methods for possible future research. It also seeks to draw conclusions, based on the combined findings of the literature search (Chapters 2, 3 and 4) and the teacher and student surveys (Chapters 5, 6 and 7). It is intended that these conclusions will prove useful in helping teachers and others concerned with the design, implementation and review of HIV/AIDS education programmes in particular and health promotion programmes more generally, to improve the quality of their provision.

      8.1 Critical Review of Research Methods
            8.1.1 Advantages of the Research Methods adopted
      Given the limitations on the current study, the main advantages in adopting the research methodology described in Chapter 5 (i.e. a survey of Science and PSE teachers in Hertfordshire secondary schools and a survey of first year college students, both conducted by use of questionnaire) were as follows.
      Two geographically separated and therefore non-interactive groups were surveyed, which increased the validity of the findings by triangulation (i.e. collecting two separate views of HIV/AIDS education in secondary schools increased the definition of the picture painted).
      The survey design was informed by the recent, more detailed work, on the broader subject of sex education, undertaken by Gascoigne in 1991/92, which ensured that appropriate subject specialisms were targeted. Her work also provided an information base, against which to check the findings of this study, and so allow more valid conclusions to be drawn.
      Use of a questionnaire allowed a relatively large sample to be surveyed in the case of both teachers and students and provided anonymity to respondents, which may have elicited more honest responses than would have been achievable through structured interviews, in this sensitive area.
The study covered relatively homogeneous groups:
      - mainly co-educational, non-denominational, LEA funded schools
      - PSE and Science teachers
      - first year FE students aged 16+
in terms of geography, demography, economic and political factors. This will have had some advantages (e.g. making the findings, conclusions and recommendations highly relevant to the context in which the study was set) and some disadvantages (e.g. making it difficult to relate the findings or apply the conclusions and recommendations to other settings).
      The act of conducting the research has helped to keep the issue of HIV/AIDS education on the agenda both within the College and at schools by engaging teaching/lecturing staff, students and County Advisers in reflection.

            8.1.2 Disadvantages of the Research Method adopted
The main disadvantages of the methods used were as follows.
      Not all schools responded and in some schools only one teacher responded. In a few cases, one individual responded as both a Science and a PSE teacher, which gave that individual's response additional weight, through double counting.
      Because the College catchment area extends beyond Hertfordshire and does not cover the whole County, the schools at which students had experienced HIV/AIDS education programmes did not entirely coincide with the schools included in the teacher survey. Moreover, it had been hoped to relate student and teacher feedback for particular schools. Because of incomplete teacher responses and the diversity of student schools of origin, this was not possible. The maximum number of students emanating from a responding school was 5. The problem was made worse by many students choosing not to divulge the name of their former school, presumably for reasons of loyalty, if they were expressing criticism.
      Another discrepancy between the two surveys was that student experiences related to the period up to July 1992, when they had left school, whereas the teachers were responding during the academic year 1992/93. Also, many students' College programmes, followed during 1992/93, included health related topics, which may have increased their knowledge base about HIV/AIDS, subsequent to leaving school. Of course, both teachers and students would also have been exposed to external influences (e.g. media coverage), which may have affected the results to an extent and in ways which cannot be ascertained.
      With the benefit of hind-sight, the questionnaire design for both surveys could have been improved to increase its efficiency in trapping the required data. (In particular, it is regrettable that questions about AZT and Africa were omitted from the student questionnaire.) The need for improvement would have been identified, had small pilot teacher and student surveys been conducted initially, but time constraints precluded this, since it was necessary to complete the surveys before students left College on completion of examinations in June and in time for the responses to be analysed during the Summer vacation, when pressure of work was reduced.
The fact that respondents were anonymous precluded the opportunity for follow up interviews, where responses were unclear or ambiguous.
Finally, the gender balance of the student survey was heavily skewed towards girls, by the nature of the courses available at the campus where I had contacts at the time of the study.

      8.2 Conclusions of the Teacher and Student Surveys
The results of the survey of teaching described in Chapter 6 show that although about 60% of schools in Hertfordshire have a policy for HIV/AIDS education, teachers are not always aware of its existence or content.
      Teachers consider information giving a vital part of their role. Yet those teachers have little access to valid information themselves, being largely out of touch with original scientific papers and having had only limited staff development, the lack of which they lament. They are largely female and come from a homogeneous socio-economic group (which is likely to be ill informed about homosexual practices and substance abuse) and themselves admit that their own values influence their teaching.
      Moreover, the bulk of educational material, on which teachers rely, comes from the monolithic Health Education Authority, whose standards have recently been questioned, in relation to the publication "Your pocket guide to Sex" (Times 28.3.94, p35 "The battle of the birds and the bees" by Francis Beckett) and which is financially backed by commercially biased institutions such as the Wellcome Foundation. Although claiming to be independent, the Foundation clearly has close links with Burroughs Wellcome, which has a financial interest in perpetuating and reinforcing the direct causal relationship between HIV and AIDS (sales of HIV test kits and AZT).
      There was no reference, in any of the educational literature reviewed in Chapter 4, to scientific debate over the nature of AIDS, its relationship with HIV, the efficacy of AZT, whether the test for HIV is reliable, the origin of HIV or its discovery, although these controversies have been discussed in the press and on TV.
      Teachers believed that they should cover controversial issues in their classes, yet the only two issues actually covered by significant numbers of teachers are the efficacy of AZT and the African AIDS epidemic, if such there be.
      The self-perception by teachers that they are failing in their responsibility to deliver information (for the reasons discussed above) is endorsed by their pupils, 59% of whom expressed dissatisfaction with the HIV/AIDS education they had received at school, the chief criticism being that it was not sufficiently informative and in particular that the teachers set the agenda and pupil's questions were not satisfactorily answered.
      This was confirmed by the questions designed to test students' understanding, which demonstrated little depth of knowledge about the scientific basis of the subject. Delivery style is likely to be part of the problem, with teacher led chalk and talk or discussion and presentation of videos predominating. Although pupils claim that their questions are not answered, teachers believe that they are. While teachers claim to teach about HIV/AIDS in the context of other STDs, pupils' knowledge about other common STDs is poor and they have little awareness of the prevalence and relative risks of contracting other diseases (e.g. Hepatitis B) through unprotected sex.
      Teachers and pupils share a belief that HIV/AIDS education should be delivered earlier in the secondary school curriculum.
      While only a minority of teachers perceive behaviour modification as part of the purpose of HIV/AIDS education programmes, 64% of students said that the HIV/AIDS education they had received at school had influenced the way they led their lives. Clearly teachers are more influential than they realise.

      8.3 Recommendations
            8.3.1 Recommendations for HIV/AIDS Education Programmes
The conclusions of the study suggest that a thorough review of HIV/AIDS education is required:
      - at Central Government level, to identify what knowledge base should be included in the Science National Curriculum at Key Stages 3 and 4 and to review the accountability of the Health Education Authority
      - at Local Education Authority level, to improve staff development opportunities and review Adviser roles and responsibilities and
      - at school level, to review policy and strategy for delivery of HIV/AIDS education programmes.
The most urgent needs are:
1       to define more clearly the aims of HIV/AIDS education programmes and to develop a curriculum which is truly educational and not training. Such a curriculum would enable students to explore the history of AIDS, including its origin and the discovery of HIV. It would include debate about the African situation and the use of AZT for AIDS patients and for HIV antibody positive individuals. It would consider public expenditure on AIDS carers in relation to the number and distribution of sufferers. It would consider the various theories of causality, including an awareness of the possible roles of drug abuse, homosexual practices and of other sexually transmitted diseases and their treatment with antibiotics. It would include up to date and reliable statistical information about the relative incidence of AIDS among the various risk groups and it would clarify the difficulties and uncertainties surrounding our ability to test for HIV and to define AIDS.
      By doing so, it would enable students, for the first time, to make well informed judgements concerning their own lifestyles and behaviour in the face of the threat to their health (e.g. avoidance of all recreational drugs, not just intravenous drug use, awareness of the greater risks from anal sex compared with vaginal sex, avoidance of promiscuity, that diet and lifestyle can affect immune function, that safe sex gives protection from a variety of STDs, which are more common than AIDS and which can also be a significant threat to health). It would also offer hope to individuals identified as being HIV antibody positive and potentially increase their longevity by adopting a healthy lifestyle and considering seriously whether they should accept AZT treatment.

2       to ensure that all teachers engaged in delivery of HIV/AIDS education are appropriately qualified (for example that they have received a minimum, defined amount of staff development, to include reading and discussing key scientific texts and rehearsing interactive teaching styles.) In view of the pace of scientific advance, they should receive regular updating opportunities.

3       to set HIV/AIDS education in context, re-evaluating which aspects of the subject should be part of the Science, PSE and other subject curricula, to ensure coherence and avoid repetition/overlap

4       to diversify and increase the sources of information available to teachers, so that they become better informed.

5       to involve a wider range of teachers in the delivery of HIV/AIDS education, particularly men and ethnic minorities, in order to provide better role models for young people in terms of the need for everyone to be concerned about health issues.

6       to consider reducing the age at which most education about HIV and AIDS is received by one year (i.e. years 8 and 9 rather than years 9 and 10)

7       to increase interactive delivery strategies, so that student questions can be dealt with more effectively.

8       to increase the extent to which student feedback informs the evaluation of educational programmes to ensure maximum effectiveness in meeting student needs.

            8.3.2 Recommendations for Future Research
The scope and scale of this study has necessarily been limited. It suffered from the limitations described above. The following avenues of further research could and should be explored:
      - an in depth study within one or a small group of secondary school(s), to establish the relationship between the School Policy on HIV/AIDS and its implementation as perceived by governors, staff, parents and pupils. By use of structured interviews, group discussion and similar less impersonal techniques than questionnaire, the barriers to effective education could be more thoroughly explored and recommendations made, regarding good practice. This would follow on from the work of Gascoigne, who began to investigate the roles of governors and parents.
      - as a counterpoint to such a detailed study, a broader-based study, covering a wider geographic region and embracing greater ethnic, political, economic and social diversity than was achievable in this study would be valuable, to establish whether the conclusions can be generalised.
      - it would also be interesting to conduct a longitudinal study of the progression of HIV/AIDS education throughout school, FE, HE and into adult life
      - a thorough investigation into the range, impartiality and effectiveness of staff development available, as perceived by providers and recipients, would be useful, to establish how it could be improved and whether it is feasible to design and implement a qualification which teachers of HIV and AIDS would have to possess.
      - a study of the attitudes of young people, identified as being HIV antibody positive or as suffering from AIDS, to the education they had or were receiving would be valuable, to establish how they could be offered more support.

      8.9 Summary
In his article "The Greenhouse defects", Times Educational Supplement, 1.4.94, pVIII, David Wright of the University of East Anglia, writes:
      "I will begin with a confession. As author of the pack "The Greenhouse Effect", I now realise that it has the wrong title: a very large question mark needs adding to the title, - - -"
      He laments the definitive tone of the pack, which is used in schools, and goes on to argue that in view of the subsequent re-evaluation by the science and geography communities of whether there is actually a greenhouse effect, students should be encouraged to consider the scientific evidence available and formulate opinions, rather than being informed of the conventional wisdom of the day.
      The conclusion of this dissertation is to make a similar plea for the subject of HIV/AIDS. Where there is rapid scientific advance, the issue needs to be introduced into the secondary curriculum, particularly if, as with AIDS there is a serious risk to health. However, students are entitled to full and substantiated evidence from which they may draw conclusions, rather than to politically correct dogma. In the public consciousness, HIV and AIDS have become inextricably interwoven. The term "HIV/AIDS" as the title for health education programmes precludes rational debate about the causality of AIDS. The whole area requires thorough re-evaluation. What we need is the introduction of a huge question mark into the heading HIV/AIDS.


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