CHAPTER TWO
2.5 Programmes and their effectiveness in promoting safer sexual behaviours
2.5.3 Effective sexuality education for people with intellectual disability
106 This would include but not limited to, addressing issues about how a particular disability may impact on sexual function, the suitability of particular contraceptive methods for people with different disabilities, and prevention of sexual exploitation and abuse.
Furthermore, Groce (2004b) proposes a general guideline for designing interventions for PWD as follows:
TYPE I: PWD being reached with HIV/AIDS messages as members of the general population with little or no additional adaptation or expense
TYPE II: Adapting HIV/AIDS outreach campaigns to ensure inclusion of PWD as members of the general population, with low to moderate additional expense
TYPE III: Making disability-specific adaptations to existing materials and developing new materials to reach individuals with disability outside the bounds of the general population, targeting harder-to-reach individuals and populations. This involves moderate to high cost
107 intellectual impairment are disproportionately at risk of sexual abuse, which can partially be traced to lack of sexuality education (Sobsey & Varnhagen, 1988).
Commitments on the part of stakeholders are therefore necessary to break the barriers and obstacles experienced by PWD in realising their rights to sexual health (Di Giulio, 2003).
Parents, teachers, caregivers and health professionals could advocate and assist persons with intellectual impairment to self-advocate their sexual rights. These stakeholders could also equip themselves with necessary knowledge and skills to provide sexuality education to this group of individuals.
Di Giulio (2003) emphasises the importance of the principles of access and comprehensiveness when planning sexuality education for young people with intellectual disability. She recommends that they must be provided with sexuality education in appropriate formats, as the standard sexuality education does not align with their learning styles or level of understanding.
Di Giulio (2003) clarifies further that in order to be comprehensive, sexuality education for youth with intellectual disability, besides incorporating the basic information and skills required by all young people, must emphasise social skills and relationship training. In addition, skills must be taught that ensure personal safety against sexual exploitation and abuse, including how to clearly distinguish between inappropriate and appropriate behaviour, how to clearly and effectively say no to unwanted sexual advances or activities and how to report abusive behaviours.
Conversely, traditional sexuality education has been criticised in that its primary aim is to increase knowledge related to sexual functioning and it does not provide evaluation and further support. Lumley and Scotti (2001) identify the failure to ensure that participants acquire and maintain the target information and minimal support for the sexuality of PWID as drawbacks of traditional sexuality education. They recommend tailoring instruction to address individual needs (e.g. deviant sexual behaviour) and to incorporate knowledge and skills into a person‘s life (e.g.
in addition to knowing that using condoms prevents pregnancy and STIs, knowing how and where to obtain them). The authors assert that adequate support, as recommended, is pertinent to fully supporting the sexual expression of persons with intellectual impairment.
108 In proposing the level of support described above, Lumley and Scotti (2001) acknowledge its impossibility without administrative approval with respect to clients in a supervised residential setting. They suggest that lack of administrative support for the promotion of healthy sexual expression has limited traditional support to educational programmes only. Thus, system-level changes will be needed so as to implement a meaningful form of sexuality education. Such changes will include the following:
Person-centred approach: The implementation of an individualised programme approach requires continuous long-term planning and support that involves a team of persons who are closely involved with the target individuals, including family and formal care providers (Lumley
& Scotti, 2001). The team should include a psychologist, nurse, social worker, sexuality educator, relevant staff, and a coordinating supervisor trained in sexuality (Ames, 1991). Lumley and Scotti (2001) suggest that where agencies lack the resources to hire a full-time sexuality educator, an alternative may be to mandate sexuality training for those wishing to become a qualified intellectual disability professional, and the trained individual would then take primary responsibility in leading the team. The team approach ensures that the different areas of expertise, both professionally and in terms of familiarity with the target individual, are represented, and active support is provided to the client to ensure the latter achieves specific objectives and goals that have been developed (Lumley & Scotti, 2001).
Lumley and Scotti (2001) outline the advantages of the person-centred approach as follows:
As it is tailored to an individual, it considers factors such as the degree of intellectual impairment, presence of physical disability, existing skills and deficits, and individual goals when conceptualising any programme
It increases the likelihood that the developed programmes will meet the person‘s needs by involving persons who work closely with the individual
With set goals, a team approach increases the chance that specific objectives will be achieved
Implementation of a person-centred, team approach is capable of remedying the limitations of the traditional approach
109 Individualised assessment process: Individualised assessment to provide baseline information for evaluation and to gather information necessary for developing an individualised programme should be undertaken before initiating a sexuality education programme (Huntley & Benner, 1993). According to Lumley and Scotti (2001):
Team members could provide information on relationship history and future goals, appropriate and inappropriate sexual behaviours, and behavioural excesses and deficits in relevant skill areas (e.g. social skills, assertion), all of which are important areas to address in a comprehensive programme.
Functional assessment is a process used to gather information regarding an individual‘s repertoire of behaviours, and it yields five primary outcomes: (a) a clear description of the focus behaviour; (b) identification of behaviour antecedents, including times and events that trigger behaviour or, otherwise, (c) the consequences that maintain a behaviour; (d) hypotheses that describe the relationship between a behaviour and antecedent and consequent events; and (e) empirical data to support hypotheses (O'Neill et al., 1997). This type of assessment can be conducted to determine variables that maintain the current behaviours and to plan for teaching skills that would help the individual achieve specific goals (Lumley & Scotti, 2001). To aid the assessment of individual behaviour and needs, Lumley and Scotti (2001) recommend having a framework that provides standards for sexual behaviour.
The authors suggest that, basically, areas of assessment must cover: sexuality knowledge;
behavioural skills; and areas of concern such as socially inappropriate (e.g. public masturbation) or deviant (e.g. exposing oneself to a child) behaviours. In addition, sexual orientation; birth control, especially for women; and prevention skills for sexual abuse and STIs, including HIV, need to be covered. It is only after establishing the needs that efforts geared towards increasing knowledge and training skills can start.
Group instruction has been proven to be effective in increasing knowledge of sexuality and STIs/HIV (Blanchett & Wolfe, 2002; Jacobs, Samowitz, Levy, & Levy, 1989; Lumley & Scotti, 2001). The use of audio-visual aids could enhance learning, as seen in Johns‘ manual (2007).
However, those with severe intellectual disability may not achieve the same gains with audio-
110 visual aids, and this stresses the importance of pre-post evaluation so that such individuals can be identified and given remedial instruction. Alternatively, persons of the same level of intellectual functioning could be grouped together for sexuality education (Newens & McEwan, 1995).
However, this does not undermine the importance of pre-post evaluation in that those who still do not gain from being part of same-level intellectual functioning groups, due to internal group heterogeneity, could be targeted for remedial instruction (Lumley & Scotti, 2001; Newens &
McEwan, 1995).
In addition, information should be as simple as possible, as pointed out by Hingsburger (1990) and E.J. Brown and Jemmot (2002), and excessively high standards and too much information could lead to sensory overload for PWD. They suggest that the focus should be on teaching the person what they need to know to function at a desired level of sexuality and without endangering themselves or others, or engaging in socially inappropriate behaviours. Moreover, participants must be made comfortable to discuss sexual matters, and educators must be non- judgemental (Blanchett & Wolfe, 2002; Jacobs et al., 1989).
The main goal of imparting knowledge is to inspire behaviour change, but behaviour change typically is not affected solely through acquiring knowledge (Jacobs et al., 1989). After assessing an individual‘s level of needs, behavioural skills training (BST) made up of instruction, modelling, rehearsal, praise, and corrective feedback can be used to teach specific skills (Lumley
& Scotti, 2001). Behavioural skills training (BST) has been effectively used with individuals with intellectual disability to teach a variety of skills, including assertion and social skills, in Africa and elsewhere (Bramston & Spence, 1985; Johns, 2007; Warzak & Page, 1990). Again, use of audio-visual training aids was very helpful (Johns, 2007; Samowitz et al., 1989).
Though it is important to adopt a person-centred approach to sexuality education for PWID, in many African countries lack of human resources and political will may hinder it. However, with or without political will, Africa could adapt programmes that work with available resources. The few researchers in the field, teachers, psychologists and health workers could play a great role if trained to provide such education.
111 Moreover, a systematic review of sexuality and HIV/AIDS education curricula by Blanchett and Wolfe (2002) identified the following as attributes of an effective intervention programme:
1. Measurable goals and objectives: must provide direction for implementation and evaluation, and are better stated in an effective domain if they are to measure behaviours or skills e.g. ‗learners will describe their feelings regarding rejection by the opposite sex‘
2. Scope and sequence: must ensure that information is logically introduced and in a cumulative manner, and is flexible enough to accommodate any necessary adaptations;
delineates prerequisite skills for learning; and assesses previous knowledge regarding misconceptions, fears and concerns
3. Content and concepts: must include biological and reproductive terms and concepts;
health and hygiene, including STIs and HIV/AIDS; relationships; and assertive and self- advocacy skills
4. Instructional methods: must comprise explicit and life-like instructional media to promote understanding and application to real-life situations; effective instructional strategies (e.g.
role-playing to teach skills, direct instruction and discussions); self-protection skills (e.g.
how to assess, recognise and avoid sexual exploitation and abuse); and an in-built evaluation process to monitor progress during each lesson
5. Curriculum development and evaluation: must include field testing and validation, user feedback and systematic revision based on such evaluation; teacher training and parental involvement/training; possible collaborations between stakeholders; appropriate presentation and format; recognition of diversity (e.g. sex roles, disability heterogeneity, culture and values); and reference aids specification (e.g. relevant organisations for support)
6. Adaptations: must allow flexibility in modifying instructions, materials and students‘
progress evaluation
112 2.5.4 School-based sexuality education for adolescents in Nigeria
In Nigeria, a national task force developed guidelines for comprehensive sexuality education based on the Sexuality Information and Education Council (SIECUS) model of starting early skills development for adolescents, teacher training and community involvement (Finger, 2000).
This was orchestrated through a collaborative effort involving the Action Health International (AHI), key non-governmental organisations working in the area of reproductive health, and the Nigerian government. Following the introduction of the guidelines to the Nigerian public in 1996, more than 100 organisations have endorsed and integrated them into their programmes (Brocato, 2005).
A non-governmental organisation (NGO), the Association for Reproductive and Family Health (ARFH), in Ibadan Oyo State, in collaboration with the state government, first developed a curriculum based on SIECUS guidelines that was implemented in 26 secondary schools and for ten – 18-year-olds. Between 1999 and 2003, the Department for International Development (DFID) also implemented Life Planning Education (LPE) in 131 secondary schools in Oyo State.
The project focused on human development, relationships, sexuality, family life and personal skills development.
Moreover, the Nigerian government approved a national comprehensive sexuality education curriculum, entitled the Family Life and HIV Education (FLHE), a few years after the SIECUS guidelines were introduced. This is to be integrated into all levels of education, from primary to tertiary (Brocato, 2005). While a few states have started to implement it, many cannot due to financial constraints. However, the former‘s implementation of FLHE is not always adequate, and the programmes are only active in those schools supported by NGOs.
However, in December 2007, the federal government announced the inclusion of FLHE into the curricula of two subjects – Social Studies and Integrated/Basic Science – being offered in Nigerian secondary schools (Isa, 2007, December 16). The Nigerian Educational Research and Development Council (NERDC) (2003) defines FLHE as:
113 A planned process of education that fosters the acquisition of factual information, formation of positive attitudes, beliefs and values as well as development of skills to cope with the biological, psychological, socio-cultural and spiritual aspects of human living.
From this definition, one sees that the scope extends beyond sexual intercourse and rather approaches sexuality as being an integral part of being human. This is in harmony with the WHO definition of sexuality. Its emphasis on socio-cultural and spiritual aspects of life makes it applicable to the Nigerian society‘s diverse cultures and religions. In addition, if well communicated to different stakeholders, its implementation may achieve great success.
The curriculum is organised around six themes, each of which covers age-appropriate knowledge, attitudes and necessary skills:
i. Human development ii. Personal skills iii. Sexual health iv. Relationships
v. Sexual behaviour vi. Society and culture
According to NERDC (2003), it is designed to be learner-oriented, with each theme‘s content building from the preceding one so that the content is rich. Its thematic approach makes it robust and avoids unnecessarily overloading the school curriculum. Its structure is expected to achieve intended learning outcomes through comprehensive coverage of the listed topics.
Though the curriculum is intended to cover from primary to tertiary levels of education, only the junior secondary part is currently being implemented across the country. Furthermore, the only prevention for STIs and HIV offered by the curriculum under its ‗sexual health‘ theme is sexual abstinence. Therefore, it lacks comprehensiveness because it offers minimal options for prevention of STIs/HIV and neglects the needs of learners who are already sexually active.
Available data (national and local) show that high proportions of adolescents are sexually experienced/active (National Population Commission (NPC) [Nigeria] & ORC Macro, 2003;
114 Nwaorgu et al., 2009; Orji & Esimai, 2005; Slap et al., 2003), while a sizeable proportion intend to initiate sex in the near future (Nwaorgu et al., 2009). The implication is that the curriculum does not cater for these groups of students.
Moreover, the curriculum does not cover students in primary and senior secondary schools.
Many of them, however, are adolescents. In addition, the fact that it does not cover primary schools excludes a lot of adolescents with disability (particularly those with intellectual disability), who may not achieve beyond a primary level of education. The curriculum also fails to offer any disability-specific coverage for adolescents with disability who are included in mainstream education.