Family Life, Reproductive Health, and Population Education:: Information Series On School Health

The World Health Organization’s
INFORMATION SERIES ON SCHOOL HEALTH DOCUMENT 8
Family Life,
Reproductive Health,
and Population
Education:
Key Elements of a Health-Promoting School
WHO gratefully acknowledges the generous financial contributions to

support the layout and printing of this document from: the Division of
Adolescent and School Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia, USA.
WHO UNICEF
The principles and policies of each of the above agencies are governed by the relevant decisions of its
governing body and each agency implements the interventions described in this document in accordance
with these principles and policies and within the scope of its mandate.
ii
This document is part of the WHO Information Series on School Health. Each document
in this series provides arguments that can be used to gain support for addressing impor-
tant health issues in schools. Each document illustrates how selected health issues can
serve as entry points in planning, implementing, and evaluating health interventions as
part of the development of a Health-Promoting School.
Other documents in this series include the following:
• Local Action: Creating Health-Promoting Schools (WHO/NMH/HPS/00.4)

• Strengthening Interventions to Reduce Helminth Infections: An Entry Point for the
Development of Health-Promoting Schools (WHO/HPR/HEP/96.10)
• Violence Prevention: An Important Element of a Health-Promoting School
(WHO/HPR/HEP/98.2)
• Healthy Nutrition: An Essential Element of a Health-Promoting School
(WHO/HPR/HEP/98.3)
• Tobacco Use Prevention: An Important Entry Point for the Development of a Health-
Promoting School (WHO/HPR/HEP/98.5)
• Preventing HIV/AIDS/STI and Related Discrimination: An Important Responsibility of
Health-Promoting Schools (WHO/HPR/HEP/98.6)
• Sun Protection: An Important Element of a Health-Promoting School (WHO/FHE and
WHO/NPH/02.6)
• Creating an Environment for Emotional and Social Well-Being: An Important
Responsibility for a Health-Promoting and Child-Friendly School (WHO/MNH and
WHO/NPH, 2003)
• Skills for Health, Skills-Based Health Education including Life Skills: An important
component of a Child Friendly/Health-Promoting School (WHO/NPH and UNICEF, 2003)
• Creating a Safe and Healthy Physical Environment: A Key Component of a Health-
Promoting School, (WHO/NPH and WHO/PHE, 2003)
Documents can be downloaded from the Internet site of the WHO Global School Health
Initiative (http://www.who.int/school-youth-health) or they can be requested in print by
contacting the Department of Noncommunicable Disease Prevention and Health
Promotion, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland,
Fax (+41 22) 791-4186.
In an effort to provide you with the most useful and user-friendly material, we would
appreciate your comments.
From where did you receive this document, and how did you hear about it?
Did you find this document useful for your work? Why or why not?
What do you like about this document? What would you change?
Do you have any other comments related to content, design, user-friendliness, or other
issues related to this document?
Please send your feedback to:

School Health/Youth Health Promotion Unit
Department of Noncommunicable Disease Prevention and Health Promotion
World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
You may also fax your feedback to +41 22 791 4186.
Thank you. We look forward to hearing from you.
WHO INFORMATION SERIES ON SCHOOL HEALTH

ACKNOWLEDGEMENTS iii
This document was prepared for WHO by Carmen Aldinger of Health and Human Development
Programs (HHD) at Education Development Center, Inc. (EDC), USA. Cheryl Vince Whitman and
Phyllis Scattergood of HHD/EDC provided technical guidance and expertise to the preparation
of this document, Frances Kaplan of HHD/EDC summarized reviewers’ comments, and Daphne
Northrop and Jennifer Davis-Kay of EDC assisted as editors. HHD/EDC is the WHO
Collaborating Centre to Promote Health through Schools and Communities.
Jack T. Jones, Department of Noncommunicable Disease Prevention and Health Promotion,

WHO/HQ, served as project officer for the overall development and finalization of this document.
WHO and HHD/EDC would like to thank the following individuals, who offered substantial
comments and suggestions during the document’s preparation and finalization:
Andrew Ball World Health Organization (WHO)/Headquarters, Geneva, Switzerland

Isolde Birdthistle World Health Organization (WHO)/Headquarters, Geneva, Switzerland
Paul Bloem World Health Organization (WHO)/Headquarters, Geneva, Switzerland
Venkatraman Chandra-Mouli World Health Organization (WHO)/Headquarters, Geneva, Switzerland
Ingrid Cox World Health Organization (WHO)/Headquarters, Geneva, Switzerland
Amaya Gillespie United Nations Children’s Fund (UNICEF)/Education Cluster, New York, USA
Mouna Hashem Consultant, New York, USA
Jamaludin Ministry of Religious Affairs of the Republic of Indonesia, Jakarta, Indonesia
Shireen Jejeebhoy World Health Organization (WHO)/Headquarters, Geneva, Switzerland
John Moore Centers for Disease Control and Prevention (CDC), Atlanta, USA
Paula Morgan Centers for Disease Control and Prevention (CDC), Atlanta, USA
Naomi Nhiwatiwa World Health Organization (WHO)/Regional Office for Africa, Harare, Zimbabwe
Shanti Noriega-Minichiello World Health Organization (WHO)/Headquarters, Geneva, Switzerland
Hisashi Ogawa World Health Organization (WHO)/Regional Office for Western Pacific, Manila, Philippines
Stella Ogbuagu Food and Agriculture Organization of the United Nations (FAO), Rome, Italy
Peju Olukoya World Health Organization (WHO)/Headquarters, Geneva, Switzerland
Bola Oyeledun Federal Ministry of Health, Department of Primary Health Care and Disease Control, Nigeria
Vivian Rasmussen World Health Organization (WHO)/Regional Office for Europe, Copenhagen, Denmark
Priscilla Reddy Medical Research Council, Tygerberg, South Africa
David Rivett World Health Organization (WHO)/Regional Office for Europe, Copenhagen, Denmark
Marilyn Rice World Health Organization (WHO)/Headquarters, Geneva, Switzerland
Lucero Rodriguez-Cabrera Ministry of Health, Mexico City, Mexico
Sheldon Shaeffer Formerly: United Nations Children’s Fund (UNICEF)/Education Cluster, New York, USA
O.J. Sikes United Nations Population Fund (UNFPA), New York, USA
Ieke Irdjiati Syahbuddin Ministry of Health, Jakarta, Indonesia
Robert Thomson World Health Organization (WHO)/Headquarters, Geneva, Switzerland
Catharine Watson Straight Talk Foundation, Kampala, Uganda
FAMILY LIFE, REPRODUCTIVE HEALTH, AND POPULATION EDUCATION: KEY ELEMENTS OF A HEALTH-PROMOTING SCHOOL
iv CONTENTS
ABBREVIATIONS ..........................................................................................................vii
FOREWORD..................................................................................................................viii
1. INTRODUCTION ......................................................................................................1
1.1 Cultural sensitivity................................................................................................2

1.2 Why did WHO prepare this document? ..............................................................2
1.3 Who should read this document?........................................................................2
1.4 What is meant by family life, reproductive health and population education? ......3
1.5 Why should schools address family life, reproductive health and
population education? ..........................................................................................3
1.6 How will this document help people promote family life, reproductive
health, and population education? ......................................................................4
1.7 How should this document be used?..................................................................4
2. CONVINCING OTHERS THAT FAMILY LIFE, REPRODUCTIVE HEALTH,

AND POPULATION EDUCATION THROUGH SCHOOLS ARE IMPORTANT
AND EFFECTIVE FOR PUBLIC HEALTH AND PERSONAL DEVELOPMENT ........5
2.1 BENEFITS TO PUBLIC HEALTH AND PERSONAL DEVELOPMENT ................6
2.1.1 Argument: Adolescence is a critical period of development

with dramatic physical and emotional changes that affect
young people’s health ................................................................................6
2.1.2 Argument: Adolescents need reliable information as they deal
with new experiences and developments ................................................6
2.1.3 Argument: Many young people are sexually active, not always
by their own choice ..................................................................................7
2.1.4 Argument: Too-early sexual relationships can have profound
effects on adolescent health ....................................................................7
2.1.5 Argument: Early sexual relationships and pregnancy negatively
affect educational and job opportunities and the social
development of young people ..................................................................8
2.1.6 Argument: Adolescents have limited knowledge of and access
to contraception ........................................................................................9
2.1.7 Argument: Education about family life, reproductive health,
and population issues can support the concepts of human
rights and gender equity............................................................................9
2.1.8 Argument: There is a demand from both students and parents
for education about family life,reproductive health, and
population issues ....................................................................................10
2.2 SCHOOLS AS APPROPRIATE SITES FOR FAMILY LIFE,

REPRODUCTIVE HEALTH, AND POPULATION EDUCATION ........................10
2.2.1 Argument: Schools are strategic entry points for addressing

family life, reproductive health, and population education ......................10

CONTENTS v
2.2.2 Argument: Schooling is a cost-effective means of improving

the health of the current and next generation of young people ..............11
2.2.3 Argument: Schools can encourage and support parents and
families to communicate with their children about family life,
reproductive health, and population issues..............................................11
2.2.4 Argument: Schools can provide an avenue for facilitating change
in thinking about harmful traditional practices........................................12
2.2.5 Argument: For better or worse, schools play a significant role
in family life, reproductive health, and population education ..................12
2.3 KNOWN EFFECTIVENESS OF SCHOOL-BASED EFFORTS............................14
2.3.1 Argument: Research has repeatedly shown that reproductive

health education does not lead to earlier or increased sexual
activity among young people and can in fact reduce sexual
risk behaviour ..........................................................................................14
2.3.2 Argument: Openness about family life, reproductive health,
and population education reduces risk factors............................................15
2.3.3 Argument: Education about family life and population issues can
prepare young men and women for responsible parenthood ................16
3. PLANNING EFFORTS TO ADDRESS FAMILY LIFE, REPRODUCTIVE

HEALTH, AND POPULATION EDUCATION AS PART OF A
HEALTH-PROMOTING SCHOOL............................................................................17
Who will make this happen?....................................................................................18

3.1 Establishing core teams ....................................................................................18
3.1.1 School Health Team..................................................................................18
3.1.2 Community Advisory Committee ............................................................18
Whose support is needed? ......................................................................................19

3.2 Gaining/accessing commitment from various stakeholders ..............................19
3.2.1 Political support........................................................................................19
3.2.2 Family and community support ..............................................................19
3.2.3 Support of teachers and school staff ......................................................19
3.2.4 Youth involvement and participation ........................................................20
Where should we begin? ........................................................................................21

3.3 Conducting a situation analysis..........................................................................21
3.3.1 Needs assessment ..................................................................................21
3.3.2 Resource assessment ............................................................................22
What should we do? ................................................................................................25

3.4 Action planning ..................................................................................................25
3.4.1 Goals........................................................................................................25
3.4.2 Objectives ................................................................................................26
3.4.3 Activities ..................................................................................................27
3.4.4 Evaluation design and monitoring............................................................27
vi CONTENTS
4. INTEGRATING FAMILY LIFE, REPRODUCTIVE HEALTH, AND

POPULATION EDUCATION INTO VARIOUS COMPONENTS OF A
4.1 Supportive school policies ................................................................................29

4.2 Skills-based health education ............................................................................30
4.2.1 Content and objectives ............................................................................30
4.2.2 Teaching and learning methods ..............................................................35
4.2.3 Characteristics of effective curricula........................................................38
4.2.4 Placement of skills-based health education ............................................38
4.2.5 Curriculum selection/development ..........................................................39
4.3 Healthy school environment ..............................................................................40
4.3.1 Physical environment ..............................................................................40
4.3.2 Psychosocial environment ......................................................................41
4.4 School health services ......................................................................................42
4.5 Cooperation with communities and families ....................................................45
4.5.1 Reaching out-of-school youth ..................................................................46
4.5.2 Involving mass media ..............................................................................47
4.6 Mental health promotion, counselling, and social support ................................48
4.7 Physical exercise, sport, recreation, and extra-curricular activities....................49
4.8 Nutrition and food programmes ........................................................................50
4.9 Health promotion for school staff ......................................................................50
5. TRAINING TEACHERS, SCHOOL PERSONNEL, PEER EDUCATORS,

AND OTHERS TO ADDRESS FAMILY LIFE, REPRODUCTIVE HEALTH,
AND POPULATION EDUCATION AS PART OF A
How can we prepare teachers, staff, and peer educators for these tasks? ............53
5.1 Teacher training ..................................................................................................53
5.2 Peer educator training........................................................................................54
6. EVALUATION OF PROCESS AND OUTCOME......................................................55
How do we know if our efforts have been successful? ..........................................55

6.1 Process evaluation or monitoring ......................................................................55
6.2 Outcome evaluation ..........................................................................................56
6.3 Sample evaluation questions for various components ......................................57
7. CONCLUDING REMARKS......................................................................................61
ANNEX 1 Useful Resources for Implementing the Various Sections ....................62
ANNEX 2 Sample Action Plan for School-Based Efforts Related to

Family Life, Reproductive Health, and Population Issues ......................66
ANNEX 3 Sample Evaluation Plan for School-Based Efforts Related

to Family Life, Reproductive Health, and Population Issues ................70
REFERENCES ................................................................................................................72

ABBREVIATIONS vii
AIDS Acquired Immune Deficiency Syndrome

EFA Education for All
FLE Family Life Education
FRESH Focusing Resources on Effective School Health
HIV Human Immunodeficiency Virus
IPPF International Planned Parenthood Federation
NGO Non-Governmental Organization
PopEd Population Education
SRH Sexual and Reproductive Health
STI/STD Sexually Transmitted Infections/Sexually Transmitted Diseases
UNAIDS Joint United Nations Programme on HIV/AIDS
UNESCO United Nations Educational, Scientific and Cultural Organization
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
WHO World Health Organization
viii FOREWORD
This document is part of the WHO Information Series on School Health prepared for
WHO’s Global School Health Initiative. Its purpose is to strengthen efforts to educate
young people about family life, reproductive health, and population issues and to prevent
related health problems, such as unintended and early pregnancies, HIV/STI, and sexual
violence. In school, young people learn about sexuality in informal as well as formal ways.
Therefore, we must ensure that our formal sources of learning provide accurate information
that can enable young people to care for themselves, both now and in the future.
WHO’s Global School Health Initiative is a concerted effort by international organisations

to help schools improve the health of students, staff, parents, and community members.
Education and health agencies are encouraged to use this document to take important
steps that can help their schools become “Health-Promoting Schools.” Although
definitions will vary, depending on need and circumstance, a Health-Promoting School
can be characterized as a school ”constantly strengthening its capacity as a healthy
setting for living, learning and working” (see the Health-Promoting School box on the
following page).
At the World Education Forum in Dakar, Senegal, April 2000, held on occasion of the tenth
anniversary of the Education for All (EFA) movement and after a global EFA assessment,
WHO, UNICEF, UNESCO, and the World Bank launched an initiative to work together to
Focus Resources on Effective School Health (the FRESH Initiative). In doing so, they are
helping schools become both “Child-Friendly Schools” – schools that provide a learning
environment that is friendly and welcoming to children, healthy for children, effective with
children, and protective of children – and “Health-Promoting Schools”. Education and
health agencies are encouraged to use this document to strengthen family life,
reproductive health, and population education in support of the FRESH Initiative and
Education for All.
The extent to which each nation’s schools become Health-Promoting Schools will play a
significant role in determining whether the next generation is educated and healthy.
Education and health support and enhance each other. Neither is possible alone.
Pekka Puska Cream Wright Hans Troedsson

Director, Noncommunicable Disease Chief, Education Section Director, Department of Child and
Prevention and Health Promotion UNICEF, New York, USA Adolescent Health and Development
WHO/HQ, Geneva, SWITZERLAND WHO/HQ, Geneva, SWITZERLAND
Paul Van Look Cheryl Vince-Whitman

Director, Reproductive Health and Director, WHO Collaborating Center to
Research Promote Health through Schools and
Communities
WHO/HQ, Geneva, SWITZERLAND
Education Development Center Inc.
Newton, Massachusets, USA

ix
A HEALTH-PROMOTING SCHOOL:
• Fosters health and learning with all measures at its disposal
• Engages health and education officials, teachers, students, parents, and

community leaders in efforts to promote health
• Strives to provide a healthy environment, skills-based health education, and

school health services along with school/community projects and outreach, health
promotion for staff, nutrition and food safety programmes, opportunities for
physical education and recreation, and programmes for counselling, social
support, and mental health promotion
• Implements policies, practices, and other measures that respect an individual’s

self-esteem, provide multiple opportunities for success, and acknowledge good
efforts and intentions as well as personal achievements
• Strives to improve the health of school personnel, families, and community

members as well as students, and works with community leaders to help them
understand how the community contributes to health and education.
In addition to these general characteristics of Health-Promoting Schools, WHO

Regional Offices have engaged their member states in developing regional
guidelines and criteria for Health-Promoting Schools and other school health efforts.
Please contact your WHO Regional Office to obtain these. For contact information
of Regional Offices, you may consult the WHO Internet site (http://www.who.int) or
communicate with any of these Regional Offices:
WHO Regional Office for Africa (WHO/AFRO), Brazzaville, Republic of Congo:

Tel: +47 241 38244; Fax: +47 241 39501
Regional Office for the Americas/Pan American Health Organization
(WHO/AMRO/PAHO), Washington, DC, USA:
Tel: +1 202 974 3000; Fax: +1 202 974 3663
Regional Office for the Eastern Mediterranean (WHO/EMRO), Cairo, Egypt:
Tel: +202 670 25 35; Fax: +202 670 24 92 or 202 670 24 94
Regional Office for Europe (WHO/EURO), Copenhagen, Denmark:
Tel: +45 39 17 17 17; Fax: +45 39 17 18 18
Regional Office for Southeast Asia (WHO/SEARO), New Delhi, India:
Tel: +91 11 337 0804 or 11.337 8805; Fax: +91 11 337 9507 or 11 337 0972
Regional Office for the Western Pacific (WHO/WPRO), Manila, Philippines:
Tel: +632 528 80 01; Fax: +632 521 10 36 or 536 02 79
1 1. INTRODUCTION
FACTS
• Most young people start sexual activity before age 20. Studies from Africa indicate that
sexual initiation of girls sometimes occurs before menarche.
• Fifteen million adolescents around the world give birth each year, accounting for
one-fifth of all births.
• Contraceptive use among adolescents is very low; for example, the rate in India is 7%,
and in Pakistan it is 5%.
• Children and young people around the world are victims of sexual exploitation for
commercial gain.
• Girls continue to be subjected to genital mutilation; in some sub-Saharan African
countries, as many as 98% of girls experience this trauma.
• In some societies, social pressures and norms about boys’ sexual initiation involves
contact with prostitutes.
• Sixty percent of all new HIV infections in developing countries occur among 10–24 year
olds–(UNESCO/UNFPA. 1998a).
Young people all over the world have common needs in order to achieve full and healthy
development: a positive and stable family life; an understanding about their bodies,
including the emotional and physical capacities that enable them to have sexual relations
and reproduce; an awareness of population issues and how these issues will affect them;
and the knowledge and skills to deal with these matters responsibly, now and in the
future. With these assets, young people are more likely to succeed in school, have
quality of life and relationships, and contribute to the economy and productivity of their
countries. Without them, they face interrupted schooling, personal insecurities, ill health,
and diminished economic opportunity.
This document focuses on a range of family life, reproductive health, and population
issues, and how they can be integrated into the components of a Health-Promoting
School to improve the overall health, education, and development of children, families,
and community members.
This document makes the assumption that in almost every school there are boys and
girls who:
• have inadequate understanding of the emotions and physiology of the human body and
would benefit from preparation for social and emotional relationships, marriage,
parenthood and adulthood
• have not engaged in sexual intercourse
• are currently engaging in sexual relations
• have engaged in sexual relations but have stopped
• are forced to engage in sexual relations (e.g., have been raped or forced by adults or
peers to engage in sex in exchange for money or other favours)
School personnel need to provide a range of information, skills, and support for all of
these students, enabling them to deal with concerns and issues they may face now or in
the future.

1. INTRODUCTION 2
1.1. CULTURAL SENSITIVITY
Any discussion of family life, reproductive health, and population issues must begin with
the acknowledgement that cultural norms and religion, social structures, school
environments, and economic factors vary widely around the world and will affect the way
that a school and community address these issues. Rural schools may face additional
challenges such as limited resources and access to information. The strategies
determined appropriate for use in a Health-Promoting School are likely to reflect the
beliefs, capacities, and setting of the local population and will vary from community to
community.
This document attempts to provide comprehensive information to be used across

cultures. School staff in various communities can adapt strategies that recognize religious
beliefs, social norms, cultural values, and behavioural practices. When translating this
document and its concepts into other languages, it is therefore important to find terms
and examples that take into account a particular culture and its religious beliefs. We
understand that one document cannot fully address the different cultural needs and
issues of all of its readers. However, the examples in this document address a variety of
cultural values and practices. They can trigger discussion in addition to providing
theoretical concepts and practical technical information. While the concepts introduced in
this document apply to all countries, some of the examples might be more relevant to
some countries and cultures than others.
1.2 WHY DID WHO PREPARE THIS DOCUMENT?
The World Health Organization (WHO) has prepared this document to help people make
a case for school-based efforts to address and improve family life, reproductive health,
and population education, and to plan, implement, and evaluate school-based efforts as
part of the development of a Health-Promoting School.
1.3 WHO SHOULD READ THIS DOCUMENT?
This document is for people who are interested in advocating for and initiating
school-based efforts related to family life, reproductive health, population issues, and
health promotion, including:
• Governmental policy- and decision-makers, programme planners, and coordinators at

local, district, provincial, and national levels, especially those from agencies in
the areas of health, education, population, religion, women, youth, community, and
social welfare
• Members of non-governmental institutions and other organisations responsible for

planning and implementing programs described in this document, including programme
staff and consultants of national and international health, education, and development
agencies who are interested in promoting health through schools
3 1. INTRODUCTION
• Community leaders and other community members, such as local residents,

religious leaders, media representatives, health care providers, social workers,
development assistants, and members of organised groups, including youth groups
and women’s groups interested in improving health, education, and well-being in the
school and community
• Members of the school community, including teachers, parents and students and
their representative organisations, administrators, staff, and school-based service
workers
1.4 WHAT IS MEANT BY FAMILY LIFE, REPRODUCTIVE HEALTH, AND

POPULATION EDUCATION?
Family life, reproductive health, and population education are interrelated. While each one
has a specific focus, they also overlap.
Family life education is defined by the International Planned Parenthood Federation

(IPPF) as “an educational process designed to assist young people in their physical, emo-
tional and moral development as they prepare for adulthood, marriage, parenthood, [and]
ageing, as well as their social relationships in the socio-cultural context of the family and
society” (IPPF, 1985).
Reproductive health education is described by UNESCO/UNFPA as educational

experiences“ aimed at developing capacity of adolescents to understand their sexuality
in the context of biological, psychological, socio-cultural and reproductive dimensions and
to acquire skills in managing responsible decisions and actions with regard to sexual and
reproductive health behaviour” (UNESCO/UNFPA, 1998b).
Population education is defined by UNFPA as “the process of helping people under-

stand the nature, causes and implications of population processes as they affect, and are
affected by, individuals, families, communities and nations. It focuses on family and
individual decisions influencing population change at the micro level, as well as on broad
demographic changes” (Sikes, 1993). Population education addresses such issues as
rapid population growth and scarce resources as well as population decline in light of
increasingly elderly populations.
1.5 WHY SHOULD SCHOOLS ADDRESS FAMILY LIFE, REPRODUCTIVE

HEALTH, AND POPULATION EDUCATION?
The number of young people today is the largest ever: 1.7 billion people are between ages
10 and 24 years (UN, 1998)—most of them living in Asia, Africa, or Latin America, and the
majority of them attending schools. In some countries, the age at first intercourse is
decreasing. The health and reproductive health behaviour of young people will have both
immediate and long-term consequences. Most societies share a vision for their children:
that they will reach adulthood without early pregnancy, finish their education, delay
initiation of sexual activity until they are physically, socially and emotionally mature, and
avoid HIV infection and other STI.
1. INTRODUCTION 4
When schools do not address family life, reproductive health, and population issues, they
miss an opportunity to positively affect students’ education, quality of life and
relationships, and ultimately the economy and productivity of nations. For example,
pregnant girls often drop out of school to care for and support their babies. Without a
school diploma, adolescent parents are often not qualified for jobs—or can get only
low-paying jobs, which do not adequately support the family.
1.6 HOW WILL THIS DOCUMENT HELP PEOPLE PROMOTE FAMILY

LIFE, REPRODUCTIVE HEALTH, AND POPULATION EDUCATION?
Family life, reproductive health, and population education can be addressed within the
context of Health-Promoting Schools, based on principles and actions that were identified
in the Ottawa Charter for Health Promotion (WHO, 1986). That charter recommended
actions in five key realms (which are detailed in this document):
1. Create Healthy Public Policy at the local, district, and national levels.
2. Develop Supportive Environments, including the physical and psychosocial school

environment.
3. Reorient Health Services to address issues of family life, reproductive health,

population issues, and other school health promotion efforts.
4. Develop Personal Skills needed for creating a healthy family life, developing and
maintaining reproductive health, and understanding population issues that affect
communities and nations.
5. Mobilize Community Action to engage the school and community in efforts that call
attention to current challenges related to family life, reproductive health, and
population issues.
1.7 HOW SHOULD THIS DOCUMENT BE USED?
This document can be used for advocacy efforts to make a strong case for addressing
family life, reproductive health, and population issues through schools. The content of
Section 2 in particular is relevant to creating arguments for such interventions in schools.
Subsequent Sections 3 through 6 give an overview of how these interventions and
training can be planned, implemented, and evaluated while at the same time creating or
expanding a Health-Promoting School.
This document can be used in conjunction with the WHO document Local Action:
Creating Health-Promoting Schools, a practical “how to” guide for work at the local level.
It includes tools and tips from Health-Promoting Schools around the world and can help
tailor efforts to the needs of specific communities. Other pertinent references are listed
in Annex 1.
5 2. CONVINCING OTHERS THAT FAMILY LIFE, REPRODUCTIVE HEALTH,
AND EFFECTIVE FOR PUBLIC HEALTH AND PERSONAL DEVELOPMENT
Policy-makers need good reasons to increase support for any health or education effort.
They must be able to justify their decisions. Advocacy is the art of influencing others to
support an idea, principle, or programme. An advocate for family life, reproductive health,
and population issues must convince school policy- and decision-makers and communi-
ties that school-based efforts are appropriate and doable and that these efforts can help
reach the goals we all share for young people. Annex 1 includes references to handbooks
that offer guidance on advocacy efforts.
The practical benefits of greater investment in family life, reproductive health, and
population education include a variety of individual and public health benefits:
• Delayed initiation of sex
• Reduced unplanned and too-early pregnancies and their complications
• Fewer unwanted children
• Reduced risk of sexual abuse
• Greater completion of education and later marriages
• Reduced recourse to abortion and the consequences of unsafe abortion
• Slower spread of sexually transmitted diseases, including HIV/AIDS.
Social development benefits:

• Progress towards gender equity, social participation and grassroots partnerships
for development
• Better preparation of young people for responsibility now and as adults, and skills
development to facilitate response to social change and opportunity
• Stronger primary health care systems with emphasis on health promotion
• Stronger, more relevant education systems
(Adapted from UN, 2000)
Though the needs for family life, reproductive health, and population education are many
and the benefits are great, advocates may still have to explain the background and
advantage of these programs. For example:
• Government officials may need to convince their supervisors or ministers that these
programs are cost-effective and will work (see Arguments 2.2.2, 2.3.1, 2.3.2 and 2.3.3).
• NGOs and professional organisations may need to persuade elected officials that these
are pressing issues that need to be addressed (see Arguments 2.1.2, 2.1.3, 2.1.4., 2.1.5,
2.1.6, and 2.1.8).
• School administrators and teachers may need to convince parents, families, community
members, and religious leaders that schools can address these issues in an appropriate
and effective way that does not lead to promiscuity (see Arguments 2.1.1, 2.2.1, 2.2.3,
2.2.4, 2.2.5, 2.3.1, and 2.3.2).
Explanations are often most effective when they include examples that are culturally
appropriate and relevant to specific local situations; thus, the arguments below may need
to be modified to suit local needs.

2. CONVINCING OTHERS THAT FAMILY LIFE, REPRODUCTIVE HEALTH, 6
It is also important to consider the inter-relatedness of behaviour: individuals that engage

in one kind of risk behaviour such as early sexual activity are also more likely to engage
in other risk behaviour such as tobacco and drug use or violence. Thus, addressing one
risk behaviour may also have positive influence on other risk behaviours. Providing a safe
and supportive environment can also help prevent or decrease the chance of young
people engaging in behaviours that are not conducive to health.
2.1 BENEFITS TO PUBLIC HEALTH AND PERSONAL DEVELOPMENT
2.1.1 Argument: Adolescence is a critical period of development with dramatic

physical and emotional changes that affect young people’s health
All adolescents1 (youth ages 10–19) experience profound physical changes, rapid
growth and development, and sexual maturation—often about the same time as
they begin developing new relationships and intimacy. For many young people,
adolescence is the time when they have their first sexual experience. In addition,
young people experience psychological and social changes as they develop
attitudes; abstract and critical thinking skills; a heightened sense of self-awareness;
responsibility and emotional independence; communication patterns; and behaviours
related to interpersonal relationships (Weiss et al., 1996; WHO, 1998b).
2.1.2 Argument: Adolescents need reliable information as they deal with new
experiences and developments
Adolescents need to know what is happening to their bodies, for instance, when
they experience menstruation or wet dreams. Many girls may have questions
about how to manage their period or concerns about losing their virginity (Mensch
et al., 1998). Boys may be concerned about consequences of masturbation, body
image and size of their genitals, sexually transmitted infections, and sexual
orientation (Kamil).
Limited knowledge about sexuality and relationships and their implications leave
adolescents vulnerable to increased risks from pregnancy, sexual exploitation,
and violence (UN, 2000). For instance, in Mexico, most 12 to19-year-old females
did not know about the menstrual cycle or how one becomes pregnant (Pick de
Weiss et al., 1991).
Media influences may sometimes convey a distorted view of sexual activity. In a

variety of media, the “prevailing images imply that sex is risk-free [and]
widespread and that planning interferes with romance” (Strasburger, 1993). Such
media influences may lead adolescents to overestimate the extent to which other
adolescents engage in sexual activities.
1
Adolescence is a cultural construct that varies across settings and contexts. In some languages and societies,
especially in traditional societies, this concept is non-existent (Villarreal, 1998).
2.1.3 Argument: Many young people are sexually active, not always by their
own choice
About one-fifth of the world’s population, more than one billion, are adolescents
(JHU/CCP, 1999). Millions of these young people are sexually active. World-wide, the
age of menarche, and in some countries the age of first intercourse, is declining, and
the proportion of adolescents having sex is increasing (Baldo, 1995; McCauley et
al., 1995). Studies suggest that the age of sexual debut is as low as 9–13 years
for boys and 11–14 years for girls in a number of developing countries (WHO,
1999b). While much of this sexual activity is pre-marital, large numbers of
adolescents in developing countries are married or in similar forms of unions and
also face the consequences of early sexual activity.
Both boys and girls are increasingly victims of sexual exploitation, and much
sexual activity during adolescence is coerced, not consensual. This includes
physical and psychological abuse, sexual harassment, sexual assault, rape, forced
prostitution, and the threat of violence if contraceptive use is suggested (Kirby,
1994). Sexual exploitation may occur with family members or adults in privileged
positions (UN, 2000). A study of 128 adolescents in Peru and 108 in Colombia
found that 60% had been sexually abused in the previous year. Thirty-nine of the
adolescent girls were pregnant as a result (Stewart et al., 1996). Studies in Africa,
Asia and the Pacific, Latin America, and the Caribbean indicate that adolescent
sexual experiences may be driven by economic gain for paid sex (Weiss et al.,
1996). A study in the Philippines found that 3% of all students, and 10% of those
who were currently sexually active, were involved in prostitution. The main reason
given for this was the high cost of college education (UNDP/UNFPA/WHO/World
Bank, 1997). Among girls, the early initiation of sexual activity is more likely to be
associated with coercion, exploitation, and violence than among boys (Mahler,
1997). A survey of six countries showed that 36–62% of victims of sex crimes
were adolescent girls under the age of 15 (WHO, 1997b).
Across cultures, a defining trait of masculinity is sexual activity. Adolescent boys

in Costa Rica, for example, were likely to be motivated by peer pressure to be
sexually active, while adolescent girls tended to give in to their boyfriend’s
insistence for fear of losing him (Villarreal, 1998). In addition, gender based
double standards and perceptions of normative behaviour make adolescents
vulnerable and influence their behaviour. For instance, sexual activity by boys may
be condoned (UN, 2000) while girls might be restricted in their mobility to protect
them from sexual encounters (Mensch et al., 1998).
2.1.4 Argument: Too-early sexual relationships can have profound effects on

adolescent health
Serious medical hazards may occur if pregnancy takes place before age 17 or 18
(WHO, 1995; WHO, 1998b) and if the girl is not healthy. For instance, girls under
age 18 are two to five times more likely to die in childbirth as women in their
twenties; their children are also more likely to die during infancy (WHO, 1998b).
Even in an industrialized country such as the United States, the maternal death
rate among mothers under 15 years of age is 2.5 times higher than the rate
among mothers aged 20–24 (WHO, 1989). Complications of childbirth before age

20 include obstructed labour, iron-deficiency anaemia, and pre-term delivery

(Scholl, 1994). Delaying first births until women are at least 18 years old would
reduce the risk of death for first-born children by up to 20% (Hobcraft, 1991).
When girls have children early, the gap between the generations decreases,
which can have a large impact on a country’s population growth rate (Kirby, 1994).
There is substantial evidence that young people (aged 15–19) are at particular risk
of contracting STI (UNICEF/WHO, 1995; WHO, 1997a). STI such as gonorrhoea
and chlamydia can lead to pelvic inflammatory disease, which in turn can lead to
infertility (Elias, 1991). Women under age 20 are also likely to have unsafe
abortions, especially in resource-poor countries. Complications from abortion can
result in life-long disability, infertility, or death (McCauley et al., 1995). In Nigeria,
for example, complications from abortion accounted for 72% of deaths among
women under the age of 19 (Unuigbe et al., 1988). Treating complications from
unsafe abortions also places a heavy strain on limited community and health
system resources (WHO, 1993).
Boys are also at risk of infection and causing unwanted pregnancy. Studies in
Africa, Asia, and Latin America showed that 25–27% of young men had multiple
partners in the past year, thus putting themselves at increased risk
(UNDP/UNFPA/WHO/World Bank, 2000a).
2.1.5 Argument: Early sexual relationships and pregnancy negatively affect

educational and job opportunities and the social development of young people
Early pregnancy can cause adolescents, especially girls, to drop out of school
(UNESCO/UNFPA, 1998a). “If pregnancy occurs prior to the completion of
education, then education is likely to be interrupted or terminated, either because
the mother is expelled from school or because the additional responsibilities and
costs of motherhood make it prohibitively difficult for the mother to continue her
education” (Kirby, 1994). Studies in Latin America have shown that adolescent
mothers are more likely to remain poor throughout their lifetime and that their
children have a higher probability of being poor (Buvinic et al, 1992). Lack of
education and skills limit job opportunities and may force young women to enter
the sex trade (UNESCO/UNFPA, 1998a). Thus, adolescent pregnancy is an
important factor in the intergenerational transmission of poverty (Villarreal, 1998).
Besides being cut short on educational and job opportunities, young pregnant
women are subject to discrimination, social tensions, difficulties, and pressures,
especially if they are unmarried (UNESCO/UNPFA, 1998a). In some countries,
unmarried pregnant girls face severe ostracism (Kirby, 1994). Unwanted and
unplanned pregnancies may also result in neglected or abandoned children or
family violence (Rice, 1995). Finally, children born to adolescent mothers are
usually at a disadvantage, due to adverse socio-economic conditions and low birth
weight (UNFPA, 2000).
2.1.6 Argument: Adolescents have limited knowledge of and access to contraception
A survey of more than 600 young people in 54 countries revealed that almost all
of the respondents said they needed more information on all aspects of their
sexual and reproductive health (Senanayake & Marshall, 1997). Adolescents’
knowledge of contraception and pregnancy varies considerably from country to
country and region to region (Kirby, 1994). In Africa, less than two-thirds of
adolescents in countries studied knew about at least one method of modern
contraception, but this varied from about 30% in Mali to more than 90% in
Botswana (Senderowitz, 1994). Data from various countries in Latin America, Asia,
and sub-Saharan Africa indicate that in none of the surveyed countries could at least
half of 15–19 year olds identify the time of the menstrual cycle when ovulation is
most likely to occur and pregnancy risk is highest (Mensch et al., 1998).
The main sources of information on sexuality, conception, pregnancy, and

contraception for young people are friends and the media (UNDP/UNFPA/
WHO/World Bank, 2000). Numerous myths persist among young people about
how to avoid conception, e.g., one cannot get pregnant at first intercourse or if
standing up during intercourse, if a girl has not started menses, or if a boy is
younger than the girl (Watson, 1999). Adolescents may believe that abstinence
will cause infertility, poor sexual performance, or painful childbirth at a later date
(Watson, 1998). Such myths can lead adolescents to engage in behaviours that
put their health and development at risk.
Case studies in various countries have shown that contraceptive use is as low as
1% among female and 9% among male 17–24-year-old college students in
Vietnam. Only 10% of female and 20% of male secondary school students in
urban areas of Nairobi, Kenya, and 12% of females and males under the age of
20 from Chile practice contraception regularly (UNDP/UNFPA/WHO/World Bank,
2000b). Lack of access to contraceptive methods is related to a variety of issues:
poverty that leaves people unable to afford contraceptives, policies and practices
that make it difficult for adolescents to obtain reproductive health services, and
reluctance to provide information and access to young people. And even when
services are available, adolescents may face hostility and disapproval from health
workers, or fail to use the services because they fear disclosure of their sexual
activity (Watson, 1999; Senderowitz, 1997b).
2.1.7 Argument: Education about family life, reproductive health, and population
issues supports the concepts of human rights and gender equity
The Universal Declaration of Human Rights proclaims that “men and women of
full age....have the right to marry and to found a family.” Likewise, the Declaration
grants everybody a right to “a standard of living adequate for the health and
well-being of himself and his family” (UN, 1948). Human rights that support
founding a family and reproduction include rights relating to life, liberty, and
security of the person; rights relating to the foundation of families and of family
life; rights relating to the highest attainable standard of health and the benefits of
scientific progress, including health information and education; and rights relating
to equality and non-discrimination on such grounds as sex, marital status, race,
age, and class (Starrs, 1997; UN, 1948). Most of these rights are also contained
in the International Convention on Children’s Rights (CRC). In addition, the CRC

contains a pledge of all states to specifically protect children from “all forms of
sexual exploitation and sexual abuse” (UN, 1989).
2.1.8 Argument: There is a demand from both students and parents for education
about family life, reproductive health, and population issues
In a UNFPA essay contest, adolescents from all over the world expressed their
support for responsible reproductive health programs. They highlighted the lack of
equality between the sexes and argued the need for the following: better
information regarding the joys and dangers of sexual relationships, accurate
information about AIDS and other STI, access to advice relating to early marriage,
greater male involvement in family responsibility, and support and guidance as
they make their transition to adulthood (Popnews, 1996). Students in Ugandan
schools listed the following topics as priorities for learning about sexual
development: girl-boy relationships, bodily changes during puberty, dealing with
parents, and HIV and STI (Watson, 1998). A Youth Counselling Centre in Asmara,
Eritrea, funded jointly by UNFPA and Norway’s Save the Children Fund, was
packed with children and young adults only six weeks after it opened in early
November 1996. The Centre provided adolescent counselling on sexual health and
STI/AIDS, and advice on reproductive health and family planning (UNFPA, 1999a).
A national poll in the United States found that 89% of public school parents feel
that public high schools should include education about family life and reproductive
health in their curriculum (Rose & Gallup, 1998). A study in Germany showed that,
although some parents discussed sexuality with their children, 90% of the
parents would like the schools to provide such instruction (Rehman & Lehmann,
1998). Data from 34 case studies in developing countries revealed that young
people wanted much more explicit focus on sexuality in the school curriculum,
preferably provided by health providers (Brown et al., 2000).
2.2. SCHOOLS AS APPROPRIATE SITES FOR FAMILY LIFE,

REPRODUCTIVE HEALTH, AND POPULATION EDUCATION
2.2.1 Argument: Schools are strategic entry points for addressing family life,
reproductive health, and population education
Schools have the potential to reach a large portion of the world’s children and
adolescents. More children than ever attend school. In the developing world,
where the last 30 years have seen an impressive improvement in enrolment
rates, more than 70% of children currently complete at least four years of school
(UNICEF, 1996a). Between 1985 and 1995, the global gap in school enrolment
between boys and girls narrowed in developing countries because of efforts to
enrol more girls (Cooper, 1999). Those gains are now threatened by the
devastating effects of the HIV/AIDS pandemic and by attrition, especially among
girls. Still, with more children than ever in schools, schools are an efficient way to
reach school-aged youth as well as teachers and staff. Children who attend school
can also be involved in school-based activities that include outreach to
family and community members and out-of-school children. Since schools are part
of the communities where they are located, they are in a good position to have
insights into how best to address these issues in a culturally appropriate and
acceptable way (Rice, 1999).
During the critical developmental period of adolescence, schools have the

opportunity to improve children’s health, self-esteem, life skills, and behaviour
with interventions to promote health and prevent diseases (WHO, 1996). Many
young people initiate sexual intercourse while they are enrolled in school (Weiss
et al., 1996). Schools have the opportunity to address young people before they
initiate sexual and other risk behaviours. Educating adolescents at this key
juncture in their lives can lay the groundwork for a lifetime of healthy habits since
it is often more difficult to change established habits than it is to create good
habits initially (Kirby, 1994). How reproductive health is addressed in childhood will
set the stage for how the population will deal with many health issues in years to
come (Rice, 1995).
Teachers can play an important role in influencing health. The president of

Education International, a world trade union for the education sector representing
more than 23 million teachers in 148 countries and territories, points out that
“teachers are absolutely critical, not only to the development of individuals but to
the development of nations as well. Teaching, more than any other profession,
influences who we are and influences societies in which we live” (Education
International, 1997).
2.2.2 Argument: Schooling is a cost-effective means of improving the health of

the current and next generation of young people
Research has shown that “women with more education stay healthier and raise
better-nourished, healthier and better-educated children” (Cooper, 1999).
Education has been found to expand choices for men and especially women
(Jejeebhoy, 1995). In most areas, women who attain more formal education are
more likely to delay childbearing and marriage than their peers with little or no
schooling (McCauley et al., 1995). Cross-country studies have shown that an extra
year of schooling for girls reduces fertility rates by 5–10% (UNICEF, 1996b).
Compared with various public health approaches, school health approaches that
provide safe and low-cost health interventions, such as screening and health
education, have been identified by the World Bank as one of the most cost-
effective investments a nation can make to improve health (World Bank, 1993).
2.2.3 Argument: Schools can encourage and support parents and families to
communicate with their children about family life, reproductive health, and
population issues
Many parents either lack knowledge about sexual matters or are afraid to discuss
them with their children (DeBouck & Rees, 2001; Oikeh, 1981). Intergenerational
studies have found that when there is communication between parents and
children regarding reproductive health issues, it is often limited to threats and
warnings without explanations (Wilson, Mparadzi & Lavelle, 1992). A study in
Germany found that among parents, 90% of mothers and 80% of fathers believed

that they knew the most favourable time for conception; however, only 78% of
mothers and 67% of fathers actually knew the correct information (Kluge, 1994).
Schools may offer classes or brochures directly to parents to help them become
more effective in addressing reproductive health and population issues with their
children, including questions related to sexual orientation and related depression.
Schools may also give homework assignments that students have to complete
with their parents and that may lead to increased family communication about
family life and reproductive health issues (UNESCO/UNFPA, 1998b).
2.2.4 Argument: Schools can provide an avenue for facilitating change in thinking
about harmful traditional practices
Some traditional practices, such as female genital mutilation, norms that favour
early marriage, and fewer reproductive health options for women than for men,
have been harmful to young people’s health. Female genital mutilation, the most
serious of these, is deeply entrenched by strong cultural dictates, but it can cause
severe physical and psychological damage (UNFPA, 2000).
Female genital mutilation is considered “violence against women and even more
so against children on whom it is practised without their consent”(UNESCO/
UNFPA, 1998a, p. 27). Immediate complications are very common and include
violent pain, shock, haemorrhage, injury to adjacent organs, infection (including
HIV and tetanus), and even death. Later problems include scarring, painful and
prolonged menses, recurrent urinary tract infections, sexual complications,
psychological trauma, and difficult childbirth (UNFPA, 2000).
Between 85 and 114 million females in the world have been subjected to female
genital mutilation, most of them when they were young girls or just before
puberty––a time when they might still be in school. Thus, the school may provide
a timely and effective avenue for intervening in an effort to facilitate a change in
thinking about this practice, as well as considering its role and function in
society. It is important for the younger generation to be included, together with
their parents, in open and challenging discussions of the practice. Family life,
reproductive health, and population education enhances women’s and men’s
autonomy and ability to make informed choices about this and other practices
(Jejeebhoy, 1995).
2.2.5 Argument: For better or worse, schools play a significant role in family life,
reproductive health, and population education
Intentionally or unintentionally and for better or for worse schools play a

significant role in contributing to or hindering efforts to address family life,
reproductive health, and population education. Examples of the roles schools can
play are listed below.
UNDER GOOD CONDITIONS, SCHOOLS... UNDER DIFFICULT CONDITIONS, SCHOOLS...
• ...provide access to education and opportunities to • ...may be limited by national or provincial policies and
reach students, staff, parents, and community traditions in the extent to which they can address
members with information and services about family sexual development and reproductive health
life, reproductive health, and population education • ...do not believe they have the responsibility or right to
• ...enhance gender equality by being responsive to the address reproductive health and population education
needs of young men and women in addressing • ...have policies that restrict clear and accurate
reproductive health information about reproductive health, resulting in
• ...involve young people in promoting healthy lifestyles unanswered questions, concerns, and suspicion
by engaging them in planning efforts, peer education, among students and staff
and a variety of other learning experiences addressing • ...offer poor-quality family life, reproductive health, and
family life, reproductive health, and population issues population education that is not clear, complete, or
• ...reinforce family life, reproductive health, and accurate, creating disillusionment and misinformation
population education through other relevant subject • ...ask or require individuals without proper training to
areas, such as social studies, home economics, teach about family life, reproductive health, and
science, health, and life skills population issues or provide related counselling and
• ...foster healthy sexual development by practices that health services
foster caring, respect, self-esteem, and decision- • ...sustain gender inequality by not teaching young
making, and through both physical and social men and women how to interact respectfully with
conditions that support the health of students, one another
teachers, and staff • ...do not have policies in place that clearly allow
• ...encourage adults to follow an ethics code and teachers to communicate information about sexual
model healthy behaviours development and reproductive health
• ...take part in national and community initiatives to • ...fail to recognise and address concerns and
promote healthy sexual development and prevent demands of community leaders who oppose
HIV, STI, and other negative consequences of interventions addressing family life, reproductive
sexual activity health, and population education
• ...involve teachers and education leaders in creating a • ...fail to implement policies and procedures that are
momentum to promote health and rights through designed to protect students from sexual exploitation
schools by teachers
• ...have a code of conduct for staff and have a
responsible adult designated to whom students can
turn in confidentiality to report any suspicious or
inappropriate behaviour or abuse, who can alert law
enforcement officials, if appropriate, and who can
refer students to appropriate counselling and health
care services, as required

2.3. KNOWN EFFECTIVENESS OF SCHOOL-BASED EFFORTS
“The content and goals of school-based reproductive health curricula are often a source
of great controversy. One major concern frequently voiced by parents, teachers and
school officials is that sex education and the availability of family planning services will
increase young people’s interest and involvement in sexual behaviour. Research
overwhelmingly points to the contrary” (Birdthistle & Vince-Whitman, 1997).
2.3.1 Argument: Research has repeatedly shown that reproductive health education
does not lead to earlier or increased sexual activity among young people and
can in fact reduce sexual risk behaviour
A study that analysed 1,000 reports on reproductive health programs (Grunseit &
Kippax, 1993), and a review of 19 published evaluations of sex education (Baldo,
et al., 1993), both primarily from developed countries, found no evidence that the
provision of sex education, including the provision of contraceptive services,
encourages the initiation of sexual activity. On the contrary, in some cases, sex
education delayed the initiation of sexual intercourse, decreased sexual activity,
and increased the adoption of safer sexual practices among sexually active young
people. These findings have recently been confirmed again by a study in the
United States (Kirby, 2001).
In 1997, UNAIDS conducted a comprehensive literature review of more than 60

articles from 13 literature databases and international experts in the field to
assess the effects of sexual health education on young people’s sexual behaviour.
The major findings confirmed the following:
• Education on sexual health and/or HIV does not encourage increased
sexual activity.
• Good-quality interventions can help delay first intercourse and/or reduce the
frequency of sexual activity, pregnancy, abortion, or birth-rates
• Good programmes can increase the condom use of sexually active youth and
thus protect them from STI, including HIV, and pregnancy.
• Responsible and safe behaviour can be learned (UNAIDS, 1997).
Education about family life, reproductive health, and population issues has been
found effective in countries and regions throughout the world. Here are some
specific examples:
• Latin America: In five Latin American cities, researchers found that young
women who took a sex education course were more likely than their
counterparts to delay having sex (Blaney, 1993). A study that examined data
from five Mexican cities found that use of contraception at first intercourse
was greater for those who had previously had some sex education than for
those who had not (Population Communication Services, 1992).
• Africa: Research in the Gambia showed that family life education in school had
a significant positive impact on knowledge and use of contraceptives when
students became sexually active (Kane et al., 1993). A population/family life
education curriculum in secondary schools in Nigeria significantly increased
health-supportive attitudes related to monogamy, family planning, and family

size. Among the group that received the curriculum, the percentage of
students that agreed that they would decide with their partners how many
children they would have and that a couple has the right to limit the number of
children they have increased significantly (Centre for Development and
Population Activities et al., 1993).
• The Netherlands: In schools in The Netherlands, where sexuality education is

integrated into many school courses and starts with pre-school children (Berne
& Huberman, 1999), data demonstrate no lowering in the age of sexual
initiation (Gianotten, 1995).
• United States: A review of 23 U.S. school-based interventions to reduce

adolescent sexual risk behaviours showed that good-quality programs did
delay the initiation of intercourse, reduce the frequency of intercourse, reduce
the number of sexual partners, or increase the use of condoms or other
contraceptives (Kirby et al., 1994). The Centers for Disease Control and
Prevention in the United States identified several school-based interventions
that effectively reduced sexual risk behaviours that contribute to unintended
pregnancies and STI/HIV infections. In “Reducing the Risk,” after 18 months
students in the intervention classes who had not had sexual intercourse
before the intervention reported significantly less initiation of intercourse than
students in the comparison group. Also, those students in the intervention
classes who did initiate sexual intercourse reported more frequent use of
contraception than students in the comparison group. Finally, students who
received the intervention reported increased communication with their
partners about abstinence and contraception (CDC, 2000). Characteristics of
effective programs and curricula are included in section 4.2.
2.3.2 Argument: Openness about family life, reproductive health, and population
education reduces risk factors
In a comprehensive UNAIDS review of sexual health education, five comparison

studies indicated that “when and where there was an open and liberal policy as
well as the provision of sexual health education and related services (e.g., family
planning), there were lower pregnancy, birth, abortion, and STI rates” (UNAIDS,
1997, p. 17). A 37-country comparison study found that countries that address
young people’s sexual health in a frank, open, and supportive manner experienced
fewer of the negative consequences of sexual activity, yet did not see greater
sexual involvement. The study concluded that “increasing the legitimacy and
availability of contraception and sexual health education (in its broadest sense) is
likely to result in declining adolescent pregnancy rates” (Jones et al., 1985, p. 61).
In Uganda, the Straight Talk Foundation has produced and distributed nation-wide
a newspaper that addresses adolescent concerns about sexual and reproductive
health. Counsellors and clinicians visiting schools allow students to ask them
questions directly. Recent studies in Uganda indicate that young people are
adopting safer sex practices and waiting longer to initiate sexual activity than they
did a decade ago (Gender-Aids, 1999). There has been little or no backlash to the
Straight Talk newspaper, despite its matter-of-fact approach to sexual health.

Straight Talk has used research from elsewhere in the world to reassure adults
that reproductive health education does not increase adolescent sexual activity
(Watson, 1999).
The youth in France, Germany, and the Netherlands experience an open,

matter-of-fact approach to sexuality education. When compared to youth in the
United States, who experience a more restricted approach to sexuality education,
the former initiate sexual intercourse later, report more use of effective
contraception methods, and have significantly lower rates of births, abortions, and
sexually transmitted diseases than do their American counterparts (Berne &
Huberman, 1999).
2.3.3 Argument: Education about family life and population issues can prepare
young men and women for responsible parenthood
Before a couple can make decisions about family size, they must first understand
that it is possible to make such a decision; they must have the means to
implement their decisions (e.g., family planning methods); and they must be
motivated to take action (UNFPA, 1993). In India, an unpublished UNFPA study
found in 1994 a number of newly married couples practising family planning, and
in some cases significantly postponing first pregnancy, in areas where this
practice would be against the norm. When asked what led them to their decision
to go against tradition, the couples responded that they had learned in school
about the risks associated with adolescent pregnancy (Sikes, 1999). Evaluations
of UNFPA’s population education projects indicate that “in China, pilot school
projects reported that following exposure to population education, students who
had agreed to postpone marriage were sticking to their agreement.... In rural
Bangladesh, health officials started to notice a sudden and steady influx of young
couples coming to health centres to ask for family planning. The timing of this
event coincided with the graduation from school of the first cohort of young
people who had been exposed to several years of population education in the
classroom” (Sikes, 2000, p. 43).
17 3. PLANNING EFFORTS TO ADDRESS FAMILY LIFE, REPRODUCTIVE
HEALTH, AND POPULATION EDUCATION AS PART OF A HEALTH-
PROMOTING SCHOOL
Once the importance and feasibility of addressing family life, reproductive health, and
population issues are understood by citizens, school officials, and policy- and decision-
makers, the next step is to plan the interventions. This involves determining specific local
needs and conditions and planning activities that will address the identified needs.
Planning for family life, reproductive health, and population education involves a number
of important steps (which are outlined in Figure 1). These steps are also relevant in
planning and implementing efforts that address other health issues and in developing an
effective school health programme, such as a Health-Promoting School. One particular
document in the WHO Information Series on School Health, Local Action: Creating
Health-Promoting Schools, describes in more detail how to implement each step; other
resources are listed in Annex 1. This chapter will discuss the particular issues related to
each step that tend to surface in planning and implementing family life, reproductive
health and population education.
Figure 1: Planning Overview
Planning Overview
Who will make this happen?

3.1 Establishing core teams:
- School Health Team
- Community Advisory Committee
Whose support is needed?

3.2 Gaining/Accessing commitment from
various stakeholders:
- Political support
- Family and community support
- Support of teachers and staff
- Youth involvement and participation
Where should we begin?

3.3 Conducting situation analysis:
- Needs assessment
- Resource assessment
What should we do?

3.4 Action planning:
- Goals
- Objectives
- Activities
- Evaluation design and monitoring

3. PLANNING EFFORTS TO ADDRESS FAMILY LIFE, REPRODUCTIVE 18
PROMOTING SCHOOL
Who will make this happen?
3.1 ESTABLISHING CORE TEAMS
School and community involvement is important. Health-Promoting Schools involve

members of the school and community in planning interventions that respond to their
needs and that can be maintained with available resources and commitments.
A Health-Promoting School should have a designated School Health Team to co-ordinate

and monitor health promotion policies and activities. The School Health Team receives
input from a Community Advisory Committee, which represents groups and individuals
outside of the school. The “School Health Team” and “Community Advisory Committee”
may be called by different names but should be designated with the responsibilities
described below.
3.1.1 School Health Team
A School Health Team is a group of various individuals within the school working
together to maintain and promote the health of all people who are working and
learning at school. Ideally, the team co-ordinates and monitors health promotion
policies and activities.
• If your school is a Health-Promoting School and a School Health Team already
exists, you might consider establishing a task force to integrate family life,
reproductive health, and population education into the various components of
your Health-Promoting School.
• If your school does not have a team organised to address health promotion,
the effort to address family life, reproductive health, and population education
could provide an opportunity to form one. A School Health Team can lead and
oversee all health promotion efforts in the school, and if given the
responsibility, time, and authority to do so, can be responsible for planning,
designing, and evaluating family life, reproductive health, and population
education interventions; clearly defining roles and responsibilities; and
facilitating communication about plans, progress, and challenges.
3.1.2 Community Advisory Committee
A Community Advisory Committee represents a wide spectrum of local groups,

organisations, and individuals. It can provide ongoing advice and support,
information, and resources to the School Health Team.
• If your school or school district has community advisors, it is essential to find
out whether they address health promotion, family life, reproductive health,
and population issues. In some settings it may be useful to collaborate with
existing community groups, such as councils, youth groups, and women’s groups.
• If your school does not have community advisors, the effort to implement a process
that addresses family life, reproductive health, and population issues provides an
opportunity to initiate partnerships with advisors from outside the school.
For more detailed information on establishing these teams, see Local Action: Creating
Health-Promoting Schools, WHO/NMH/HPS/00.4 (available online at http://www.who.int/school-youth-
health; select “WHO Information Series on School Health”).
PROMOTING SCHOOL
Whose support is needed?
3.2 GAINING/ACCESSING COMMITMENT FROM VARIOUS STAKE-

HOLDERS
Gaining commitment from political stakeholders, communities, families, teachers, school

staff, and youth will be important to support family life, reproductive health, and
population education in your school.
3.2.1 Political support
Political support, such as national policies, guidelines, and support from ministries
of education, health, and population, can be of immense help to local schools.
Political commitment can be evidenced in many ways, for example:
• Public acknowledgement by ministries and local officials of the importance of
the issues and efforts to address family life, reproductive health, and
population education
• Favourable policies and national/local plans, e.g., strengthening family life,
reproductive health, and population education, ensuring retention in school
after pregnancy, and confidentiality of health services
• Designation of someone with responsibility and authority to ensure
implementation of these policies and plans
• Provision of financial support, technical equipment, services, and materials for
such programmes
• A clear code of conduct and ethical standards to prevent sexual abuse and
harassment, bullying, and discrimination related to sexual orientation
3.2.2 Family and community support
Family and community members can play an integral part in discussions and
sensitisation about family life, reproductive health, and population topics.
Parent-teacher associations, adult education activities, formal and informal
presentations, open houses, civic clubs, religious centres, and community group
meetings can be appropriate venues for communicating with families and
community members around these topics.
Success is the best advocate. Local interventions that prove to be successful can
help gain support from individuals and groups that were initially not supportive. It
may not be necessary to achieve full support from all groups before beginning.
Resources may be better spent on building evidence of need, interventions that
meet the needs, and allies that do support it.
3.2.3 Support of teachers and school staff
Teachers and school staff play a key role in carrying out efforts to address family
life, reproductive health, and population education. A staff meeting is one useful
forum for developing teacher and school staff’s support and commitment.
Important ideas to discuss include:
PROMOTING SCHOOL
• Information and data that support the need for family life, reproductive health,
and population education, such as rates of adolescent pregnancy, STI and HIV
infection
• The roles teachers play as role models, facilitators, and partners of parents and
students
• Plans for teacher training and support to address their needs and concerns
about family life, reproductive health, and population education
• How teachers and staff members will be affected by efforts to address these issues
3.2.4 Youth involvement and participation
Young people – boys and girls representing all sectors of society – should be
involved in all stages of programme design, provision, and evaluation. In doing so,
they become part of the solution rather than the problem (UN, 2000). They often
can identify issues and ideas that others have not considered or find difficult to
consider. Young people’s participation can also build their sense of ownership.
They have tremendous potential to contribute to efforts within and outside of the
school. “Programme planners and international agencies, such as WHO, UNESCO
and UNICEF, recommend that the energy and creativity of young people be
involved on many levels: needs assessments; identification of problem areas;
design and planning; promotion of programmes; implementation; teaching;
counselling; organising activities; distributing information and over-the-counter
contraceptives; assessing materials; and evaluation” (Birdthistle & Vince-
Whitman, 1997, p. 23).
There are numerous ways in which young people can be involved:

• As members of the School Health Team
• As peer educators and counsellors
• As planners and participants in school and community projects
• As writers, speakers, mobilizers, parent educators, and distributors of resources
• With various other tasks in planning, implementing, and evaluating needs and
progress related to programming
In any of these roles, students could identify reproductive health and gender-
related issues, such as male involvement in family life education, or inadequate
and limited services and programmes for males or females, and then take a lead
in developing and carrying out actions that address these issues.
Case Study
In 11 African countries, approximately 13,000 young people were involved in

developing a questionnaire based on role playing and discussion of prototypical
behaviour of their own peer groups. Young people then administered the ques-
tionnaire to representative samples of youth in their target areas.The information
generated about sexual and contraceptive behaviour was used for programme
planning as well as broader policy discussion (Senderowitz, 1998;
WHO/ADH/ROA, 1993).
PROMOTING SCHOOL
Where should we begin?
Once commitment is assured to the extent possible, and the School Health Team and
Community Advisory Committee are established, members can start the planning
process by conducting a situation analysis. It is important to make the analysis
manageable and practical so that activities can proceed quickly to the action planning and
implementation stage. Too many projects never proceed beyond the assessment.
3.3 CONDUCTING A SITUATION ANALYSIS
A situation analysis can ensure that interventions are relevant to the local
situation. It consists of needs and resource assessments, conducted prior to
planning and implementing the interventions. The results of the analysis also serve as
baseline data for subsequent evaluations.
Situation analysis on the national, district, and/or local level is important for
several reasons:
• Policy- and decision-makers need a strong basis for their support, especially
when their policies and decisions involve the allocation of resources.
• Accurate and up-to-date information provides a basis for setting priorities for
action and for identifying groups in special need of interventions.
• Data obtained through the situation analysis are essential for planning to be
relevant to the local situation and actual health needs, perceptions,
experience, motivation, strengths, and resources of the target population.
• Data obtained in the situation analysis serve as baseline data for future
evaluation of interventions.
• Information from the situation analysis can be used for advocacy purposes to
more specifically tailor advocacy to the context of the target audience.
The situation analysis may involve gathering qualitative data including anecdotal informa-
tion, and quantitative (numeric) data on needs and resources inside and outside of school
that will be used for planning interventions and as a baseline to which changes can be
compared later. Qualitative information includes perceptions and feelings from individu-
als, which might be gathered through observations, focus groups, and in-depth inter-
views. Quantitative information includes statistical information on health status, knowl-
edge, attitudes, and skills related to the issues in question; it might be gathered through
surveys and reviews of existing data. It is important to be able to break down the data by
gender, urban/rural settings, migration status, etc. A situation analysis should include
assessments of needs and resources, as described below.
3.3.1 Needs assessment
A needs assessment helps to gain an understanding of the family life, reproductive

health, and population issues in your community. Accurate and up-to-date data can
help ensure that efforts focus on the health and developmental needs of the target
population. Concerns and perceptions vary by age and gender and by
demographic and socio-economic characteristics. Thus, a range of stakeholders

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and types of information need to be considered; e.g., when assessing the needs
of teachers and other school staff or students, quite different but related issues
may arise. Policy- and decision-makers will be more likely to support activities that
are based on documented needs.
The following types of information might be considered in a needs assessment:
• Health status: Data from health statistics and interviews with knowledgeable
professionals and community members will assist in gaining an understanding
of family life, reproductive health, and population issues in the target population.
Information may include the extent and consequences of pregnancy,
parenthood, and coerced sexual relationships during adolescence; morbidity,
and mortality; and rates of abortion, STI, and HIV/AIDS. For more specific
examples, see Figure 2.
• Knowledge, attitudes, beliefs, values, practices, behaviours, and skills

related to family life, reproductive health, and population education:
Information from focus groups, interviews, and surveys with young people
and community members can reveal what they know and believe about
sexuality, how relationships among youth are formed and how they get risky,
which cultural and religious practices influence sexual expression or health-
seeking behaviour, and how sex-related roles are defined. This information is
crucial for designing effective learning experiences. For instance, students
might not have the knowledge of when in the menstrual cycle ovulation and
pregnancy are most likely to occur; social norms and attitudes may not
support family life, reproductive health, and population education through
schools; religious beliefs might deter unmarried adolescents from engaging in
sexual relationships or prevent a pregnant adolescent from seeking prenatal
care; social values might encourage early pregnancy and large numbers of
children; cultural practices might introduce adolescent girls to genital
mutilation; youth risk behaviours might include high school students
engaging in unprotected sexual intercourse; and students may not have
sufficient skills to feel confident in their ability to negotiate contraceptive use
in a sexual encounter.
Without information about these helping or hindering forces, efforts are not
likely to target the most relevant factors that contribute to health and healthy
sexual development.
3.3.2 Resource assessment
A resource assessment helps planners gain an understanding of the school’s and

community’s capacity to provide services and resources that support family life,
reproductive health, and population education. A resource assessment should
examine the following:
• Relevant policies: A review of the school’s and community’s policies is
needed to determine the extent to which they support family life, reproductive
health, and population education — and, if supportive policies are in place, the
review must determine the extent to which they are enforced.
• Available resources and existing programmes: This includes determining
the nature and extent of current resources (e.g., staff, time, funding, services,
programmes, materials) in the school and community that are available to
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address the issues, understanding why prior attempts to address them might
have been unsuccessful, and determining the availability of specific resources
and services that might help in implementing new interventions. The amount
and nature of resources will affect the scope and amount of services that can
be provided, the availability of trained staff, and the capacity to plan and
evaluate efforts. Knowing this information allows the team to draw on available
personnel and financial resources and set reachable goals and objectives.
Figure 2 below provides sample topics from which specific questions can be
devised to assess needs and resources for specific audiences and localities.
Figure 2: Sample Basic Questions and Data Sources
SAMPLE QUESTION TOPICS SAMPLE DATA SOURCES / METHODS
Needs Assessment
What are the rates of adolescent fertility, pregnancy-related Existing data from health authorities
mortality and morbidity, unintended pregnancy, STI, HIV and health care providers
infection, and abortion among young people?
How prevelant is sexual behaviour that can result in unintended Existing data from health authorities and
pregnancy, STI and/or HIV infection, and contraception use among health care providers, possibly supple-
school-age children and youth in the community or nation? mented by interviews and/or surveys
Which conditions related to family life, reproductive health, and Interviews, focus groups sample
population issues are causes of concern in the community? surveys, and review of existing data
What are the important behaviours, behaviour determinants, Same as above

and conditions that place young people at risk for early sexual
relationships, unintended pregnancies, abortions, and STI in the
nation or community?
What basic knowledge about physical and psychological Same as above

development during puberty, the menstrual cycle, and
contraception do teachers, parents, and young people have?
What knowledge, attitudes, values, and skills might young Same as above
people need to enable them, to deal positively with family life,
reproductive health, and population issues?
What are parents’ and teachers’ attitudes toward sexual rela- Same as above
tionships, abstinence, and contraception?

PROMOTING SCHOOL
Figure 2: Sample Basic Questions and Data Sources (continued)
SAMPLE QUESTION TOPICS SAMPLE DATA SOURCES / METHODS
Resource Assessment
What policies exist in the community for allocating resources Interviews with school and community
to address reproductive health and population issues with leaders and representatives from health
young people? What do these policies call for? and education authorities, review of
documents
In this community, what programmes are in place that Same as above

addresses issues related to family life, reproductive health,
and population education, or what programmes exist that
these issues could be integrated into?
What kind of human, financial, and physical resources exist in Same as above
the school and community to provide family life, reproductive
health, and population education? To what extent do these
resources reach and serve young people?
For guidance on how to collect, manage, and analyze data related to adolescent reproductive health, see
Coming of Age and A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programmes
(references included in Annex 1) or other relevant publications.
PROMOTING SCHOOL
What should we do?
3.4 ACTION PLANNING
Using the information gathered in the situation analysis and the support from various
individuals and groups, the School Health Team –– in collaboration with the Community
Advisory Committee –– can develop a vision for change and an action plan.
Action planning involves the development of goals, objectives, activities, and a means of
monitoring and evaluation to determine whether the activities are being implemented as
planned and achieving the stated objectives and goals. Annex 2 includes a sample
worksheet that can be used or adapted to develop goals, objectives and an action plan.
Experience gained from reproductive health programmes for adolescents around

the globe has led to the following important programming principles that can help
ensure success for this population (UN, 2000):
• Plan a holistic and comprehensive approach: Develop policy and deliver the
various interventions, such as information, skills development, counselling, and
clinical services, in a co-ordinated and collaborative approach in a variety of settings.
• Take diversity into account: Recognise that concerns vary by demographic and
socio-economic characteristics, age, gender, etc.
• Focus on prevention and health promotion: Foster self-esteem and resistance
skills before adolescents become sexually active.
• Integrate health promotion into reproductive health services: Combine information
with provision of or referral to health services (for prevention and treatment).
• Strengthen the gender component of programmes: Consider the distinct
gender differences in behaviour patterns, socialisation processes, and expected
roles within the family, the community and society.
• Ensure youth participation in programmes: Involve adolescents in the design,
planning, implementation, monitoring, and evaluation of activities that concern them.
• Involve parents, teachers, and community leaders: Seek support from
community leaders, social workers, NGOs, and members of civil society.
• Establish multi-sectoral partnerships: Strive for concerted action from all
sectors, e.g., education, health, and finance, as well as various stakeholders:
governments, UN agencies, donor agencies, NGOs, private sector, and civil society.
3.4.1 Goals
Goals describe in broad terms what the interventions hope to achieve. The School
Health Team can generate overall goals related to family life, reproductive health,
and population education, in collaboration with school policy-makers and the
Community Advisory Committee. Goals should be related to the findings of the
situation analysis. For instance, if the needs assessment revealed that myths
related to sexual activity and contraception are very prevalent, a goal might be to

PROMOTING SCHOOL
decrease or eliminate the existence of sexual myths by providing accurate

information about sexual development and contraception to all students. If the
resource assessment showed that few or no reproductive health-related health
services exist for adolescents, one of the goals could be to establish such
services in schools or linked to schools through referrals.
Examples of goals:
• Family Life Education: To help young people have meaningful social
relationships in the context of family and society and to prepare them for
adulthood, marriage, parenthood, and ageing (IPPF, 1985, adapted)
• Reproductive Health Education: To explore a broad range of reproductive
health issues that are the reality of today’s adolescents and to stress the
development of skills and making informed choices through participatory
approaches (UNESCO/UNFPA, 1998b, adapted)
• Population Education: To help shape students’ knowledge and attitudes so that
they will make responsible population-related decisions (UNFPA, 1996, adapted)
3.4.2 Objectives
Objectives are steps that lead to the achievement of the overall goals. Outcome
objectives define in specific, measurable, and achievable terms what is to be
accomplished through the interventions, such as changes in the health-related
behaviours, knowledge, attitudes, beliefs, skills, or conditions associated with
health status. Process objectives describe what will be changed or implemented
in order to achieve the outcome objectives.
Specific short-term and long-term objectives or steps make clear what needs to
be done and when. The clearer and more specific the objectives, the easier it will
be to select appropriate activities to achieve them and to monitor and evaluate
how successfully objectives are being met. Thus, the objectives serve as
standards against which to measure progress.
Here are two examples of specific, measurable objectives:

• Outcome objective: By the end of this academic year, at least 80% of the
students in grade 8 will be able to describe correctly three different methods
of contraception. (Knowledge)
• Process objective: By the end of this calendar year, our school will have
provided one workshop for teachers and parents, respectively, discussing how
to talk to young people about at least three different methods of contraception.
For examples of health, behavioural, and KABS (knowledge, attitudes, beliefs,

skills) objectives for family life, reproductive health, and population education,
please see Section 4.2: Skills-based health education.
PROMOTING SCHOOL
3.4.3 Activities
Once the goals and objectives are delineated, the School Health Team can
develop activities, or, preferably, a combination of activities that are feasible for
the school and community to implement and that will most likely help achieve the
goals and objectives. Section 4 introduces numerous approaches that schools can
take to promote health and address family life, reproductive health, and
population education, and can provide guidance on developing activities to reach
the identified goals.
3.4.4 Evaluation design and monitoring
Evaluation—a review of what has been done and how well it worked—is
important for many reasons and should be considered from the outset. An
evaluation plan and mechanism for monitoring will help track a school’s progress
in implementing activities and achieving objectives. The groundwork for evaluation
is laid at the very beginning with the situation analysis, when needs are assessed,
objectives set, and activities planned. Specific recommendations for process and
outcome evaluation are discussed in Section 6 of this document.

4. INTEGRATING FAMILY LIFE, REPRODUCTIVE HEALTH, AND POPULATION 28
EDUCATION INTO VARIOUS COMPONENTS OF A HEALTH-PROMOTING
SCHOOL
A Health-Promoting School strives to help the total school population achieve healthy
lifestyles and to integrate health promotion into all aspects of the school’s daily routines.
This section describes numerous actions that schools can take to promote family life,
reproductive health, and population education, as well as health in general. Not all schools
will have the resources to integrate important aspects of family life, reproductive health,
and population issues into all components at one time. However, this need not
discourage any school from addressing these issues; even small steps can make a
difference. Each school should choose activities that are the most important and most
feasible to address first. A Health-Promoting School enables students, parents, teachers,
and community members to work together to make such decisions.
International Consensus
Health-Promoting Schools share the philosophy and approach of a major international

initiative called FRESH (Focusing Resources on Effective School Health), fostered by
WHO, UNESCO, UNICEF, the World Bank Education International, EDC, and
Partnerships for Child Development. FRESH was initiated at the World Education
Forum in Dakar, Senegal, in April 2000. This initiative focuses on four basic compo-
nents of an effective school health programme:
• Health-related school policies (see Section 4.1)

• Provision of safe water and sanitation as essential first steps towards a healthy
school environment (see Section 4.3)
• Skills-based health education (see Section 4.2)
• Access to or linkages with school-based health and nutrition services (see
Sections 4.4 and 4.8)
The agencies noted that these four components should be made available together
in all schools. They are a framework for the development of effective interventions
in broader efforts to develop child-friendly and Health-Promoting Schools
(UNESCO/UNICEF/WHO/World Bank, 2000).
The effectiveness of these components, and all the components of a Health-

Promoting School, is influenced by the extent to which they are co-ordinated to com-
plement and reinforce one another. For instance, school policies can ensure that
pregnant and HIV-positive students are not excluded from school. This can be
coupled with providing school-based or -linked health and nutrition services that
offer HIV and STI testing, counselling to pregnant (and non-pregnant) students, and
offer nutritious food which is especially important for the healthy physical
development of girls. Skills-based health education can teach about developmental
changes during puberty and communication and refusal skills that students can use
to negotiate limits of expressions of affection with their partners. This can be
reinforced by ensuring single-sex toilets where girls have privacy to wash and care
for themselves.
29 4. INTEGRATING FAMILY LIFE, REPRODUCTIVE HEALTH, AND POPULATION
SCHOOL
4.1 SUPPORTIVE SCHOOL POLICIES
School policies provide an essential framework to guide schools in planning, implementing,

and evaluating efforts to promote health. School policies and practices should promote a
clear set of school norms and be developed through participatory policy-making, with
careful consideration paid to gender equity.
Case Study
In Europe, students have been actively involved in developing and implementing

school health policies. In the United Kingdom, schools set up working parties,
consisting of pupils, teachers, school governors, the school nurse, the school
education social worker, the school’s police liaison officer, and a local health
promotion officer to revise the sex education policy. Regular meetings
immediately after school examined principles on which school policy should be
based, objectives in terms of education, and the structure of the existing
curriculum. A list of curriculum subjects, developed with the help of pupils, was
sent to parents. Pupils who were team members provided valuable insights and
advised on the suitability of resources. The school did not receive any requests to
exclude children from the curriculum. The success of the development strategy for
this sex education policy encouraged the school to use the same approach to
develop a policy on drug education (Bowker & Flint, 1997).
Written policies are developed by the School Health Team in collaboration with the
Community Advisory Committee. They should guarantee health interventions for all
levels of schooling, starting in the earliest grade and continuing through the last grade.
Policies ideally address all components of a Health-Promoting School that will be modified.
Examples of supportive policies include:

• A code of conduct for teachers ensuring that students and staff of all sexual orientations
are treated with respect and not discriminated against, harassed or abused
• Policies that ensure that pregnant and HIV-positive students are not excluded from
school
• Policies that support developmentally appropriate education about family life,
reproductive health, and population issues
• Policies that require co-ordination between health and education authorities at local
and district levels in planning and implementing family life, reproductive health, and
population education
• Rules about extra-curricular activities for males and females and criteria for allowing
outside groups to take part in school-based interventions
• Requirements for appropriate training of teachers who will teach about family life,
reproductive issues, and population education

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4.2 SKILLS-BASED HEALTH EDUCATION
Young people learn about family life, reproductive health, and population issues in a
variety of ways, for instance, from their parents, siblings, peers, and the media. These
sources may support cultural myths about sexuality and related issues, and where they
do, some adolescents may not have accurate information about the physical and
emotional changes they are encountering, nor how they can manage these changes safely.
Thus, it is important that schools provide accurate information, opportunities to develop
healthy attitudes, and skills-based learning experiences, using active teaching methods,
to help students make informed decisions and to reduce risk behaviours.
4.2.1 Content and objectives
Skills-based health education is designed to help students acquire the knowledge,

attitudes, beliefs, and skills that are needed to make informed decisions,
understand the consequences of a particular behaviour, adopt healthy behaviours
to avoid risks, and create conditions that are conducive to health. Thus, the clear
and precise delineation of behaviours and conditions that are to be influenced to
positively affect family life, reproductive health, and population goals and
objectives is essential for the development of effective skills-based health
education efforts. When delineating behaviours and conditions, it is important to
keep in mind that efforts need to address two types of audiences: those who
have not begun sexual activity and those who are already sexually active.
Examples of health, behavioural, and KABS (knowledge, attitudes, beliefs, skills)

objectives for family life, reproductive health, and population education are listed
below. Each grouping addresses slightly different aspects of these related issues
and provides a range of content that can be considered when developing
skills-based health education to address these issues. The decision to address
particular objectives should be based on the results from the situation analysis.
Examples of health objectives:

• Family life education helps students to minimize or avoid domestic violence
and sexual coercion.
• Reproductive health education helps students minimise their risk of or avoid
unwanted pregnancies, abortions, STI, and HIV/AIDS.
• Population education helps students to have their desired number of children,
with fewer pre- and postnatal complications, when they are ready to start a
family of their own.
Examples of behavioural objectives:

• Family life education helps students assume responsibility according to their
expected roles within the family and their friendships.
• Reproductive health education helps students negotiate abstinence or the use
of contraceptives.
• Population education helps students to delay marriage and space their children.
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Continued from previous page.
Examples of KABS objectives:
Family life education enables students to:

• explain how relationships, such as friendship, love, dating, marriage, and
raising children, play a central role throughout our lives (SIECUS, 1999) (K)
• appreciate the similarities and differences among families and family
members (UNESCO/UNFPA, 1998b) (A)
• practice important skills for developing and maintaining friendships
(UNESCO/UNFPA, 1998b) (S)
• develop skills to deal with the conflicts and changes that occur in families
over time (UNESCO/UNFPA, 1998b) (S)
Reproductive health education enables students to:

• describe what information and attitudes are needed to avoid unwanted
consequences of sexual behaviour, such as abortions, STI and HIV infection,
and sexual abuse (SIECUS, 1999) (K+A)
• explain how human development in the areas of reproductive anatomy and
physiology, reproduction, puberty, body image, and sexual identity and
orientation is characterised by the interrelationship between physical,
emotional, social, and intellectual growth (SIECUS, 1999) (K)
• describe how social and cultural environments such as gender roles, the law,
religion, the arts and the media, shape the way individuals learn about and
express their sexuality (SIECUS, 1999) (K+A)
• dispel myths related to sexuality and reproduction (UNESCO/UNFPA, 1998b)
(A+B)
• demonstrate life skills, such as decision-making, communication, assertiveness,
negotiation, and looking for help in practising skills specific to reproductive
health, for example, deciding when to try to become pregnant (SIECUS, 1999). (S)
Population education enables students to:

• explain the relationships between population and environment, population
and resources, population and economic development, and population and
socio cultural factors (UNFPA, 1996) (K)
• show concern about implications and consequences of rapid population
growth (UNFPA, 1996) (A)
• feel confident that they will have the desired number of children with a
minimum amount of complications when they are ready to have a family (A)
• get involved in extra-curricular activities related to such issues as population
growth or environmental protection (UNFPA, 1996) (B)
The curriculum should be age-appropriate in both content and teaching

methods, focusing on the established goals and objectives and on different
aspects, questions, fears, and challenges of youth at different ages. To assure age-
appropriateness, a person trained in child development could be asked to be part
of the curriculum development team. It is also important to consider that some
students may drop out of school early, especially students at high risk. This means

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that careful consideration must be given to the selection of content, as this may
be a young person’s only opportunity for formal learning about family life,
reproductive health, and population issues before needing to apply this learning
in practice. In addition, some repeaters or drop-outs may be older than their
classmates when they return to class and will require separate, age-appropriate
counselling (Sikes, 1999).
Folade, a 20 year old from Nigeria, says a family life education programme
taught him a lot about life: “Even boys can now understand why a girl has
to say ‘no’....I have learned so many things I didn’t pay attention to in my
biology class” (UNFPA, 1999b, p. 9).
Sample Curriculum Content
Figure 3 provides a small sample of curriculum content and objectives related to family life,
reproductive health, and population education, including suggested age levels, to give a
sense of the range of topics that could be considered in developing such interventions.
Core areas and objectives have to be adapted to make them age-appropriate and culturally
relevant to the implementation. Not all listed examples are relevant to all countries. (Most
of the information comes from UNESCO/UNFPA [1998b] and UNFPA [1993].)
Figure 3. Sample Curriculum Content
CORE AREAS (CONTENT) OBJECTIVES
Family life, including Young children:

relationships • To clarify the definition of family
• To better understand family relationships and responsibilities
Pre-adolescents:
• To identify the components of positive friendships and relationships
Adolescents:
• To clarify what level of intimacy might be appropriate for which kind of
relationships and to reinforce one’s right to set limits
• To understand what enhances and what damages a relationship
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Figure 3. Sample Curriculum Content (continued)
CORE AREAS (CONTENT) OBJECTIVES
Reproductive health, Young children:

including human and sexual • To develop self-awareness and self-esteem
development and family • To identify positive health habits
planning • To introduce correct sexual terms and to increase comfort with them
Pre-adolescents:
• To identify basic structures of the male and femal reproductive systems
• To identify physiological and emotional changes taking place during
puberty
• To understand the process of conception
• To define what human sexuality is and how it affects our behaviour
• To dispel myths related to sexuality and reproduction
Adolescents:
• To recognise and articulate some of the emotions that accompany
adolescent sexual development
• To describe how human reproduction occurs
• To discuss personal concerns and questions about puberty in a group
of same-sex peers
• To identify what is safe and unsafe sexual behaviour and how to
reduce sexual risk
• To describe how selected factors influence a pregnancy
• To identify different kinds of contraceptive methods
• To learn where to go for and how to avail oneself of family planning
services
Population education, Young children:

including responsible • To understand the concept of parenthood
parenthood Pre-adolescents:
• To understand that pregnancies can be planned
• To understand that parenthood can be an option rather than an obligation
Adolescents:
• To evaluate the readiness of adolescents for parenthood
• To explain how delaying first pregnancy and spacing births can be
beneficial
• To understand the impact of growing population sizes on our planet
For information on curriculum content related to HIV/AIDS and STI, please refer
to a WHO document in the same series, Preventing HIV/AIDS/STI and Related
Discrimination: An Important Responsibility of Health-Promoting Schools
(WHO/HPR/HEP/98.6).

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Skills-based health education is an important means of enabling students to

acquire knowledge and understanding about family life, reproductive health,
and population issues, including gender relations, social and emotional relation-
ships, and other related factors. A wide range of information on these topics can
be taught in schools; however, relevant and appropriate content areas should be
determined by local concerns and objectives agreed upon in the planning stage
(Birdthistle & Vince-Whitman, 1997; SIECUS, 1991). In a 1997 survey of more than
600 young people in 54 countries, some young people, particularly from Africa
and South Asia, believed that sex education should incorporate moral and
religious teachings in relation to sexual relationships, and a number of respon-
dents felt that sex education should also include positive aspects of sex, such as
the role of sex within a relationship (Senanayake & Marshall, 1997).
Case Study
In Zimbabwe, a randomized study was undertaken on reproductive health

knowledge and behaviour among adolescent pupils. It showed a significant
increase in correct knowledge about aspects of menstruation as compared to
control schools. Pupils from intervention schools were more likely to know that
a boy experiencing wet dreams was physically mature enough to make a girl
pregnant and that a girl could get pregnant at her first sexual intercourse.
Knowledge of family planning had increased significantly in the intervention
group after five months. The findings point to the value of early school-based
reproductive health education in helping young people acquire correct
information on reproductive biology and in preventing ill health related to
sexual activity (Mbizvo et al., 1997; Rusakaniko et al., 1997).
In regard to attitudes and beliefs, authors and programmers increasingly

recommend the inclusion of gender sensitisation in reproductive health curricula
(Consensus Panel, 1997). Gender sensitisation aims to facilitate self-respect
among young women and men and sensitise young people to the notion that they
have no rights over another person’s body. Gender issues and power differentials
can be taught in the context of human rights, along with explanations of rights
violations and respect for the rights of others (Birdthistle & Vince-Whitman, 1997).
Experts convening at the Netherlands Institute for Health Promotion and Disease
Prevention also recommended that activities include building self-esteem, respect,
and awareness of gender stereotypes among both boys and girls (UNFPA, 1994).
Information alone rarely equips young people with skills that lead to a healthy life
or the adoption of behaviours that prevent reproductive health problems (Tones,
1981). Students need to learn about and practice skills to protect themselves.
Education in life skills, such as decision-making, negotiation, conflict resolution,
and resistance to peer pressure, can enable children and adolescents to make
healthy choices and adopt healthy behaviour throughout their lives (Birdthistle &
Vince-Whitman, 1997).
Research has highlighted the value of addressing multiple learning domains,

specifically intellectual, emotional, social, and physical, in health education
curricula (EDC, 1990; SIECUS, 1991), as well as multiple family planning
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options. Approaches that have had success in delaying intercourse and reducing
risky sexual behaviour have also promoted a variety of family planning options,
including monogamy, abstinence, and condom and spermicide use (Birdthistle &
Vince-Whitman, 1997).
4.2.2 Teaching and learning methods
Skills-based health education has been shown to reduce the chances of young
people engaging in high-risk sexual activity that can result in pregnancy, STI, or
HIV infection (Kirby, 2001 & 1997; UNAIDS, 1997; WHO/GPA, 1994; Postrado &
Nicholson, 1992; Scripture Union, n.d.; Zabin et al., 1986). To implement effective
skills-based health education, teaching methods need to correspond to the
content to be taught. A lecture, for instance, can be an effective way to increase
students’ knowledge, but there are other methods that are more effective in
influencing skills, attitudes, and beliefs. For instance, a classroom debate on
gender stereotypes in which the teams change sides and thereby force them-
selves to think from different perspectives can influence attitudes.
Active, informal, personalised, and participatory learning methods, that are

culturally sensitive and age-appropriate are most effective in changing health-
related behaviour and skills (Birdthistle & Vince-Whitman, 1997) and in improving
the relationship between teachers and pupils (Parsons, Hunter, & Warne, 1988).
Some programmers and researchers found that testing students on reproductive
health information encourages them to take the class more seriously (Consensus
Panel, 1997). Examples of participatory teaching and learning methods for skills
building include:
• Class discussions
• Brainstorming
• Role plays
• Small group activities
• Educational games and simulations
• Case studies
• Story telling
• Debates
• Audio and visual activities such as arts, music, theatre, dance
• Practising life skills specific to a particular context with others, with verbal
feedback and coaching
• Visits or telephone calls to relevant health and social support programmes,
such as family planning clinics

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Case Study
In Kingston, Jamaica, high school students performed a skit about two sex
education tutors and a class of curious boys. Reflects one of the 17-year-old
student actors, “The people who saw the skit were awed by its boldness.
But the real beneficiaries were the performers—the boys. We learned that
having sexual feelings is normal, and in instances where we get sexual
urges it is important that we exercise self-control.” This student understands
the importance of sharing the lessons he learned from participating in this
creative exercise. He writes, “Obviously, we cannot prevent boys from
having sexual intercourse. What we can do is what the sexually explicit
movies don’t do, and that is to teach boys how to practice safe sex”
(Network, 1993).
[Note: This quote shows a particular student’s belief on this issue.]
Models that are based on theories of behaviour change and social learning have
been shown to help youth who have not initiated sex continue to delay onset
(Kirby, 1997 & 2001). If students in the target group are sexually active, the
reasons why they have sex should be considered in determining what strategies
are most appropriate for them to protect themselves (Consensus Panel, 1997). For
instance, efforts to build refusal skills are not likely to be effective interventions if
students are engaging in sexual activity for financial gain. Young people themselves
can be an excellent source of the information needed to create effective learning
experiences. They can also be involved in selecting and implementing the methods
to help them acquire information or skills.
Case Study
In Bogota, Colombia, the Colombia Human and Social Development

Foundation brought together a group of 15 youth volunteers who identified,
designed, and tested the following strategies to bring the subject of
preventing risky sexual behaviour into their peers’ daily lives: suggestion
boxes to collect the questions and opinions of adolescents; radio
programmes with brief, upbeat messages on prevention; word murals,
posters, flyers, bulletin boards, and pamphlets to share the project’s work;
sexuality education workshops hosted in schools; and community involve-
ment (Saavedra, 1996).
Peer counselling and peer education are two ways of involving students in family
life, reproductive health, and population education. As peer counsellors, young
people may counsel, inform, make referrals, and in some cases distribute
contraceptives to their peers. As peer educators, they may lead workshops for
their peers, focusing on skill building through interactive and experimental
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activities, with the twin goals of reducing high-risk behaviour and promoting
healthy behavioural choices (Advocates for Youth, 1997). In some cases, peer
educators, or “child to child” educators, have been involved in developing
teaching plans and selecting topics and teaching approaches (Jensen, 1997).
Qualitative information indicates that peer education and peer counselling are
valuable assets to school-based health promotion in countries all over the world
(Birdthistle & Vince-Whitman, 1997).
Case Study
In the Marshall Islands, young people are organisers, educators, and counsellors
for a programme designed to help their peers take charge of their reproductive
health. Run mainly by young people themselves, “Youth to Youth in Health” is
credited with reducing the number of births to adolescent mothers from 21% of
all births to 14% over recent years. In 1996, the group became an NGO. Health
education is the main focus of the initiative, which has trained more than 340 peer
educators and counsellors to convey information on contraceptives, sexuality,
and staying healthy. By the end of 1996, 50,000 “contacts” had been made with
young people, families, and communities—providing health education through
person-to-person counselling, small-group discussions and large outreach meet-
ings. Topics range from how to avoid STI and HIV/AIDS to good nutrition. The
young educators use music, dance, drama, and video to combine local cultural
elements with their health messages (UNFPA, 1999b, p. 20).
Peer educators have several advantages: they are with young people whenever
the topic comes up, they know how to talk to their peers and what motivates
them, and they themselves can benefit from participation (McCauley & Salter,
1995). For instance, in the Gambia, 90% of respondents in a peer education
programme responded that they applied the health information to their own lives
(Wong & Travers, 1997). Peer educators can also act as agents of change in their
families and communities. Since peer education experiences high turnover
(Senderowitz, 1997a), it is important to continually train new peer educators.
Case Study
Peer educators for reproductive health issues often become respected by

students as a source of credible information. Researchers in Chiang Mai,
Thailand, found that being a peer educator gave girls social legitimacy to talk
about sex without the risk of being stigmatised as someone who is sexually
promiscuous. The peer educators were successful in facilitating group
discussions about sex, educating their peers about their bodies, helping
them to develop communication and assertiveness skills, and changing
social norms (Cash & Anasuchatkul, 1995).

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4.2.3 Characteristics of effective curricula
Based on extensive reviews of effective curricula with positive behavioural results,

a panel of experts identified nine characteristics that effective curricula share:
1. A narrow focus on a small number of specific behavioural goals and a clear
message that continually reinforces the curriculum’s stance on these behaviours
2. Appropriate to the age, sexual experience, and culture of the students in
regard to behavioural goals, teaching methods, and materials
3. Based on social learning theories, such as social cognitive theory, social
influence theory, social inoculation theory, cognitive behavioural theory, or the
theory of reasoned action2
4. Last a sufficient length of time, that is 14 or more hours–or, if they last fewer
hours, they are implemented in small-group settings with a leader for each group
5. Employ a variety of active learning methods designed to involve the
participants and to have them personalize the information
6. Provide basic, accurate information, e.g., about the most relevant risks of
unprotected intercourse, methods of contraception, and population factors
7. Include activities that address social pressures on sexual behaviour, including
activities that address gender relations
8. Provide modelling and practice of communication, negotiation, and refusal
skills
9. Select teachers or peers who believe in the programme they are implementing
and then provide training for those individuals (adapted from Kirby, 1997)
A comprehensive literature review by UNAIDS identified the following principles

that underlie effective approaches:
• Education about sex is best started before the onset of sexual activity.
• Education has to be gender-sensitive for both boys and girls.
• Young people are a developmentally heterogeneous group, and not all can be
reached by the same technique.
• Learning materials and curricula should be based on frameworks with
foundations in research (UNAIDS, 1997).
4.2.4 Placement of skills-based health education
Skills-based health education, ideally, is provided as a planned sequential course

of instruction from the first grade through the last grade, addressing the physical,
mental, emotional, and social dimensions of health. A sequential series of
learning experiences is benefical so that learning can be reinforced at regular
intervals, and students are able to relate knowledge and skills to specific
situations encountered at different ages (OPS/PAHO, 1997).
2
Social learning theory teaches that children learn to behave both through instruction and through observation.
Social cognitive theory puts forward that teaching interpersonal cognitive problem-solving skills to children can
reduce and prevent negative behaviours. Social influence and social inoculation theories recognize that
children and adolescents will come under pressure from peers and others to engage in risk behaviours.
Cognitive behavioural theory views an individual’s cognition and thoughts as playing a vital role in that person’s
behaviour. Theory of reasoned action proposes that an intention to perform a behaviour is a function of a
person’s normative beliefs, i.e., what others will and do think about the behaviour.
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Family life, reproductive health, and population education - where culturally

appropriate - may be provided in a co-educational setting, where open and
realistic discussions with both boys and girls can take place, to give children
practice for a lifetime of healthy female-male communication (UNESCO/UNFPA,
1998b). Research has shown that providing opportunities to work in single-sex
groups can also be beneficial (Forrest & Vermeer, 1997, pp. 67–70).
There are different approaches to including family life, reproductive health, and
population education in a school curricula:
• Separate subject: Family life, reproductive health, and population education is
taught as part of a specific class on skills-based health education.
• Single “carrier” subject: Family life, reproductive health, and population
education is incorporated into an existing subject that is relevant to the issues,
such as biology, civics/social studies, or religion.
• Infusion across many subjects: Family life, reproductive health, and
population education is included in many existing subjects through regular
classroom teachers.
Each option has general pros and cons, although these may vary according to the
local situation. A separate subject can be an excellent long-term goal. It has
several advantages: Teachers are likely to be specifically trained and focused on
health, and a separate subject is most likely to have congruence between the
content and teaching methods, rather than the short-cutting that may occur
through infusion or “carrier” subjects. However, not all schools are able to have a
separate class on skills-based health education. A carrier subject can be a good
short-term solution. It is cheaper and faster to incorporate family life, reproductive
health and population education into materials of one subject than to infuse them
across all. Also, the training of teachers is faster and cheaper and teacher support
tends to be better than for infusion across all subjects. In the long term, the
carrier subject can be reinforced by infusion through other subjects. In general,
the infusion option in isolation risks losing the salience of the issue amid the
competing demands of the other subjects.
4.2.5 Curriculum selection/development
Curricula for family life, reproductive health, and population education and other
health-related issues may be available through governmental and non-
governmental agencies, universities, student groups, or teachers unions.
Supplemental materials specific to the local situation can also be generated by
teachers and students themselves. If new curricula are needed, it may be
feasible to collaborate with health personnel and specialists from universities in
curriculum development and creating learning and teaching materials. Teachers
should be involved in curriculum development, as they often are, so that they are
comfortable with the material they will present (Birdthistle & Vince-Whitman,
1997). For specific resources, please see Annex 1.

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4.3 HEALTHY SCHOOL ENVIRONMENT
A Health-Promoting School provides a safe and healthy environment that presents a

realistic and attractive range of choices that encourage a healthy lifestyle. It also provides
a supportive social structure that promotes self-esteem and helps students and others
develop their physical, psychosocial, and social potential. In a Health-Promoting School,
the physical and psychosocial school environment should be consistent with and
reinforce other health promotion efforts. The school environment must protect students
and staff from discrimination, harassment, abuse, and violence.
4.3.1 Physical environment
The physical environment includes the school building, classrooms, food service,
and health care facilities on school grounds; water and food provided at school;
and the surroundings in which the school is situated. The condition of the
physical environment can have a powerful effect on reinforcing or contradicting
education about family life, reproductive health, and population issues in the
school. The following aspects of a healthy physical environment can be integrated
into a Health-Promoting School, supported by related school health policies, to
complement skills-based health education:
• Physical facilities: Safe water and sanitary facilities; functional lighting,
heating, ventilation; and cleanliness are essential to good health. In relation to
reproductive health, adequate sanitation, water facilities, and single-sex toilets
are especially important to encourage the participation of girls, particularly
during the days when they are menstruating and need to wash and care for
themselves in privacy (UNICEF, 1996c).
• Healthy food choices: A Health-Promoting School promotes and provides
nutritional and high-quality foods to offer opportunities for healthy choices
(WHO, 1998). A school environment that reinforces education about healthy
nutrition is especially important for girls because nutritional status is closely
linked to achieving healthy pregnancies.
• Safe environment: A safe environment in a Health-Promoting School ensures
that students are protected from physical danger on school grounds and
provided with surroundings that are conducive to learning and comfortable for
socializing. For instance, a safe environment ensures that students are
protected from sexual assaults; e.g., by having chaperones at school activities,
guards for night events, and a trusted person in whom students can confide in.
• Resources/displays: A Health-Promoting School uses various occasions and
venues, such as meetings, assemblies, classrooms, libraries, hallways, and
blackboards, to provide messages and resources that promote family life,
reproductive health, and population education.
• Special facilities: A Health-Promoting School may have health care facilities to
provide services to students, teachers, and other school personnel, or may
maintain referral services. This may include, where locally acceptable,
providing products, services, or referrals for menstrual hygiene and birth
control. Some schools provide condoms or make them easily accessible to
students who need them.
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4.3.2 Psychosocial environment
The psychosocial environment relates to conditions that affect social and mental
health. Part of the psychosocial environment includes cultural norms and
expectations regarding sexual behaviour as expressed by friends, parents, and
school personnel. WHO and UNESCO (1992) recommend that school activities
take place in “an environment based on respect, trust, and acknowledgement of
similarities and differences so as to facilitate the growth of knowledge, the
development of skills, and the examination of values.” A Health-Promoting School
provides an ambience that respects the individual and fosters confidence in
healthy choices. The following aspects of a healthy psychosocial environment
should be integrated into a Health-Promoting School to support family life,
reproductive health, and population education:
• Respect/caring: A Health-Promoting School supports an environment that
fosters understanding, caring, and empathy for others and contributes to
positive values, beliefs, and attitudes among students, teachers, staff, and the
community. This includes values of mutual respect, gender equity, acceptance,
and a safe and trustful environment. Success in reproductive health initiatives
is most likely to occur when schools deliver education and services in an
environment where there is gender equity and respect, where social norms
favour the delay of sexual activity or faithful use of contraceptive methods, and
where pregnant girls are accepted at school (Birdthistle & Vince-Whitman, 1997).
• Non-discrimination: A Health-Promoting School advances relations between
girls and boys that are respectful, non-discriminatory, and non-abusive.
Instances of discrimination, double standards, harassment, and violence or
abuse between students and between staff and students should be openly
condemned in order to promote social and emotional well-being (WHO, 1996).
• Teacher role models: Teachers play an important role as adult role models and
as mentors. Teachers, and other school personnel, can encourage healthy
behaviours by demonstrating healthy practices themselves and by ensuring
that students are protected from sexual abuse and harassment.
• Peer reinforcement: Students can provide positive reinforcement to their
peers by discussing and reminding one another of healthy behaviours, such as
keeping their commitment to abstinence or safe sex. It is important to ensure
that peer influence is used in a positive way, because peer pressure can also
reinforce negative behaviours.
Additional psychosocial factors are addressed in Section 4.6 (Mental health

promotion, counselling and social support).

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4.4 SCHOOL HEALTH SERVICES
Health services should complement and be coordinated with health education and other
components of a Health-Promoting School. Sometimes it may be possible for schools to
link with clinics and health workers in the community.
Case Study
In Ethiopia, the Youth Counselling Services and Family Planning Education

Project of the Family Guidance Association provides clinical services to youth
through its four community clinics, and links with 35 area schools to promote
its services and expand the reproductive health knowledge of youth. The
programme has collaborated with area schools to develop a curriculum for
reproductive health education. The programme trains volunteers and peer
educators to deliver the educational sessions, provide counselling services,
and distribute condoms and non-prescriptive contraceptives in the school
setting. For additional services, the volunteers refer youth to the area clinics.
The programme encourages sustainability of this education by the school and
carefully evaluates each school’s progress in this direction (Hanson, 2000).
The following points may be useful to persons who are trying to increase support for
improved school health services, including those that correspond to family life, reproduc-
tive health, and population education:
• In many countries, young people have little or no regular access to primary health care
services. In some areas, the school is the only social institution with which young
people have contact.
• Despite evidence that school health services are viable and effective public health
interventions, and the growing evidence of their need, school health services are not
well developed, if available at all, in many countries. This is unfortunate, because
learning and academic achievement are strongly influenced by students’ physical and
emotional health.
• School health services can significantly contribute to the development of young people
and should be advocated as a means of community and economic development.
• As school health services are revised and new services proposed and developed,
they should be planned and implemented as an integral part of the existing school
health programme and available to all students, as appropriate and relevant. Services
that respond to reproductive health needs and related health issues are likely to be
most effective when integrated and coordinated with other school health and
support services (WHO, 1999a).
School-based or school-linked health services may offer treatment of minor injuries,

primary care, routine physical exams, immunizations (such as vaccines against tetanus
and German measles, which can be important for girls in promoting safe motherhood),
health promotion, and counselling. Services may include those specifically related to
reproductive health, such as gynaecological examinations, family planning counselling,
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and pregnancy detection, as well as services for males’ reproductive health concerns,
and screening and treatment of STI. In some countries, provision of such services to
adolescents or unmarried young people may be restricted or prohibited by the law. It has
been shown, though, that strengthening connections between sexuality education and
family planning services can both delay sexual intercourse among students who have not
had intercourse and increase contraceptive use among those who are sexually active
(Koo, Dunteman, George, Green & Vincent, 1994).
A paper delivered at a World Health Organization consultation called for females

to enter their reproductive years protected against tetanus so that
neither they nor their future babies get the disease. Tetanus can be prevented
easily through a highly effective, safe and inexpensive series of immunisations.
Countries which have a high enrolment rate of girls in the early grades of primary
school can take advantage of the long-lasting duration of immunity from each
successive dose and immunise both girls and boys in the early grades, before
the girls start to drop out of school. Several countries now offer tetanus
immunisation in early primary school, particularly in Asia and the Middle East.
(Steinglass, 1997).
The provision of reproductive health services needs to consider the social, cultural, and
economic environment and offer privacy, confidentiality, and, ideally, staff who are trained
to work with young adults - both males and females - on sensitive issues. Schools need
to make students aware of the availability of these services. Adolescent-friendly
reproductive health services should adopt some or all of the following key features
identified by young people (UNFPA, 1998):
• Confidentiality
• Comfortable and welcoming surroundings
• Non-judgmental attitude
• Provision of information and services that young people want
• Acceptance of youth as they are, without moralizing or demoralizing
• Asking about and respecting youths’ opinions about services
• Allowing young people to decide for themselves
• Provision of services within the timeframe available to young people
In addition, health services may be structured around the following key features (UN, 2000):
• Male and female staff trained in adolescent sexual and reproductive health and
development
• Adequate supply of accessible and affordable drugs and contraceptives (where
permitted by law and acceptable in the community)
• Multiple interventions that include information, counselling, telephone help lines and
referral mechanisms to community-based services
• Linkages to existing structures, such as recreational, educational, vocational, and
sports programmes

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To help prevent reproductive health problems and unintended pregnancies and to support
healthy development among students and school personnel, health workers could do the
following:
• Provide information and advice to students and school personnel.
• Provide opportunities for school personnel, students, and parents to ask questions
and clarify any doubts or concerns they have about development during puberty,
menstruation, pregnancy, and methods of menstrual care and pregnancy prevention.
• Serve as a confidant to whom students and school personnel can express fear and
anxiety about physical and emotional changes during puberty or pregnancy without
facing ridicule or judgement.
• Provide health products (such as contraceptives or condoms) when they are
permitted to do so by prevailing laws and practices, or refer students and school
personnel to an easily available source.
• Identify and collaborate with organisations that can provide appropriate non-health
services when required, such as legal or social support for children and adolescents
who are being abused or neglected (WHO, 1999a).
To help meet the needs of students and school personnel with reproductive health relat-
ed concerns, health workers could do the following:
• Be alert to the possibility and presence of health problems (such as STI) and/or
unhealthy practices (such as injected drug use) and detect them early, if and when
they arise.
• Appropriately manage health issues to the best of their abilities and based on the
facilities at their disposal. This could include providing medical treatment, responding
to childrens’/adolescents’ psychological needs, and helping them deal with the social
implications of their conditions.
• Refer students and school personnel to the next “level” of health service delivery
and/or to organisations that provide relevant support services.
To help strengthen the school’s/community’s response to reproductive health issues,

health workers could do the following:
• Advocate for supportive school policies and strong school programmes with
policy- and decision-makers and relevant community leaders.
• Engage and support education officials and representatives from other relevant
sectors in providing information, building skills, and providing counselling services in
the school setting (and be actively involved in these efforts themselves).
• Collaborate with school officials, students, and teachers to mobilize school and
community support for efforts that respond to reproductive health needs, for
example, developing peer networks among students that promote understanding
about and support for healthy sexual attitudes and behaviours, prevention
programmes, and care; and linking such networks to relevant programmes and
networks in the school and community.
(Adopted from WHO/UNAIDS/UNESCO, 1999, pp. 30–31.)
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4.5 COOPERATION WITH COMMUNITIES AND FAMILIES
A Health-Promoting School is an important part of the community that surrounds it, and
the community is a critical component of the school environment. Community members
should feel that their neighbourhood school is open and receptive to their ideas and
participation. Schools and students in turn should be supported by community members
through their participation in developing and supporting school-based initiatives and
providing social support (WHO, 1996).
It is essential that schools, parents, and communities work together. “Adults play a vital
role in the healthy development of young people and can contribute to a supportive
climate for behavioural choices through positive relationships” (UN, 2000). Students are
most likely to adopt healthy behaviour patterns if they receive consistent information and
support through multiple channels, such as teachers, parents, peers, community members,
and media. Thus, parents and other caregivers play an important role as nurturers, teachers,
disciplinarians, role models, and supervisors in providing an environment that is safe and
supportive with opportunities for full adolescent development. Far too often, however,
parents and other caregivers do not have the resources, skills, or community support to
carry out these roles as effectively as possible. As a result, the messages students receive
in the classroom may not be reinforced—or sometimes may even be contradicted—once
students go home.
A Health-Promoting School can provide parents and caregivers with information,

resources, and skills. Educating parents about their own and their children’s health and
development may be necessary. Parent involvement should begin early and be sustained
throughout school-based interventions (WHO, 1996). Parent education or training can
inform parents of the need for family life, reproductive health, and population education
and provide them with activities to enhance their skills in addressing these issues with
their adolescent children.
Case Study
School-based initiatives can help parents communicate with their adolescent

children. In one activity in the United States, parents were made more aware
of the social pressures on their children to become sexually active. Then
parents rehearsed ways to help their children resist these pressures (McCauley
& Salter, 1995, as cited by Rice, 1997).
A Health-Promoting school can also equip students with knowledge and skills that they
can share with their parents and other family members. Family and community members
can be involved in a Health-Promoting School in various ways:
• Taking part in planning and decision-making, for instance, by participating in the
School Health Team or Community Advisory Committee, and making decisions
through which components of the school family life, reproductive health and
population education will be addressed.
• Participating in activities and services offered through schools, for instance,
attending events to gain specific knowledge and skills about child, adolescent, and
sexual development or effective communication with adolescents; such events

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include health fairs, festivals, drama presentations, classroom discussions,

exhibitions, and special parental guidance programmes. Families may also be involved
in their children’s homework exercises related to topics in family life, reproductive
health, and population education.
• Providing support and resources, for instance, supplying financial or material
donations, being guest speakers, or providing specialist services related to health
promotion, family life, reproductive health, and population education. Midwives from
the community can offer informal discussion groups for students and parents, and
pharmacists can offer products for feminine hygiene and contraception.
• Advocating for health, for instance, knowledge and skills acquired in a school/
community project can be used by community and family members to take actions
that support healthy sexual development, such as freedom from sexual coercion and
access to family planning services.
Schools can be the centre for a number of community enhancement projects (WHO,
1996). For instance, when early marriage and childbearing is common, a major
educational effort could be mounted through the schools to help communities
understand the health risks and lifelong impact involved (Rice, 1995). Equally important,
if there are legal minimum ages at marriage that are overlooked, educational efforts could
apprise youth, parents, and communities of the existence of these laws and other legal
requirements, their rationale, and the consequences of disobeying them. Schools can
benefit greatly from partnerships with local businesses and representatives from various
agencies, such as health departments, youth-serving agencies, and non-governmental
organisations. Together, partners can discuss common problems, develop joint interventions,
and integrate services.
Case Study
In Thailand, more than 80% of secondary and vocational school students have
been reached with family life and sex education primarily because of the close
collaboration between the Planned Parenthood Association of Thailand (PPAT),
schools, and the government. PPAT helped to train teachers, while the
government supported the programme (Ford, D’Auriol, Ankomah, Davies, &
Mathie, 1992).
4.5.1 Reaching out-of-school youth
Involving the community can help affect young people who have dropped out of
school, are chronically truant, and who are at high risk of coerced sexual relations
and STI. Schools can co-ordinate activities with other sectors and plan joint
projects, for instance, with community health centres, health extension agents,
local entertainment centres, or law enforcement officials. Peer initiatives, which
can be based at schools, have been successfully used to identify and contact out-
of-school youth and street children (Senderowitz, 1997a). In some communities,
schools have organised health fairs that brought together parents, students, other
community members, and out-of-school youth to spend an enjoyable afternoon
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learning about health and the availability of preventive services and to screen for
important and treatable health conditions. These types of events are particularly
valuable in countries with a large proportion of out-of-school youth (Birdthistle &
Vince-Whitman, 1997). In some communities, religious services include
information about the importance of family planning. Schools may also use media,
such as radio broadcasts, to reach out-of-school children. The consequences of not
reaching out-of-school youth are likely to negatively affect in-school youth as well as
the community as a whole.
4.5.2 Involving mass media
Mass media can be a powerful influence in promoting and damaging the health
of young people. “In most parts of the world, young adults are exposed to media
that refer to sex and romance, often with little or no mention of responsible
sexual behaviour. Casual sex is depicted, but without references to sexually
transmitted disease or unintended pregnancy. Nevertheless, television, radio,
music, magazines and other media can also become powerful tools for giving
young adults perspectives on the consequences of sexual activity” (Keller, 1997).
When messages appear in different media simultaneously, their effect is
intensified. Various partners in the field of reproductive health, such as
governmental and non-governmental agencies, industry and trade, and women’s
and youth groups, can take a lead in mass media work. Schools can facilitate or
develop partnerships with mass media representatives to co-ordinate and
collaborate on efforts that address family life, reproductive health, and population
issues and to ensure consistent messages.
Examples how media outlets and schools can collaborate to promote family life,
reproductive health, and population education and to make it more acceptable to
discuss these topics:
• Providing free air time or space for messages to schools, especially for
messages created by youth that inform young people and encourage healthy
behaviour
• Enabling children and adolescents in schools to produce youth-oriented
newspapers or television and radio shows on family life, reproductive health,
and population education.
• Collaborating with schools in organising discussions or call-in radio or
television programmes that include accurate information about family life,
reproductive health, and population issues
• Collaborating with schools to address parents with accurate information and
guidance on talking with their adolescent children

SCHOOL
4.6 MENTAL HEALTH PROMOTION, COUNSELLING AND SOCIAL

SUPPORT
Case Study
A staff person at a school-linked health centre recounts how counsellors

helped her when she was a pregnant adolescent: “I was cushioned by
counsellors who made me realise that despite my unplanned pregnancy, my
dreams and aspirations could still be realised. They showed me where I had
made mistakes and helped teach me how to love and care for the unborn child
who was already mine” (Johnson, 1997).
Adolescents often feel like there is no one with whom they can privately discuss
questions, concerns, or crises related to reproductive health or sexual assault. Many
adolescents may also be concerned with developmental issues relating to changes
during puberty and relationships or how to protect themselves from HIV and STI.
Maintaining and supporting the mental health of students and staff is important to
complement and support education about family life, reproductive health, and population
issues. An individual’s psychosocial well-being, including self-esteem, self-confidence, or
self-efficacy, is critical in maintaining physical health and the ability to make healthy
decisions and avoid risk behaviours.
Counsellors and other health care providers can help adolescents improve their
self-esteem, make informed decisions, and feel more confident and in control of their
own lives. Counsellors can also help young people understand the other gender’s
expectations regarding sexuality and sexuality outcomes (FAO/WHO/ILO/UNESCO,
1998). Schools can serve as a credible venue for counselling services related to family life,
reproductive health, and population issues. In hiring counsellors to work with young
people, schools should only consider individuals who are:
• empathetic
• knowledgeable
• trustworthy
• clear about their own values regarding sexuality
• interested in and friendly towards adolescents
• able to develop respectful and caring relationships with adolescent clients
• able to address broader issues of physical and emotional development of
adolescents, including relationships, family conflict, and drugs
• used to working in a setting that ensures privacy and confidentiality
(Adapted from Senderowitz, 1997b.)
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Case Study
In the United States, girls enrolled in a school-linked pregnancy prevention

programme in Baltimore, Maryland, have been shown to postpone sexual
involvement seven months longer than girls not enrolled. Pregnancy rates were
reduced by 30% over two years among participating girls who received sexual
education complemented by individual and group counselling and medical and
contraceptive services. Pregnancy rates among other girls in a comparison
group increased by 58% in the same time period (Zabin et al., 1986).
Besides counselling, it is also important, especially for students, to have social support
that encourages healthy behaviours. Individuals from the school, community, family, and
religious affiliation can informally offer information and activities that provide adolescents
with answers to their questions and healthy options for their leisure. For instance,
religious and other organisations in the community can offer social activities that address
adolescent-related topics and provide opportunities for young people to talk informally
with adults and among themselves about sexuality, reproductive health, family life, and
population issues. Teachers and other school staff can help students in coping with
difficulties, adjustments, growth, and development.
4.7 PHYSICAL EXERCISE, SPORT, RECREATION, AND EXTRA-

CURRICULAR ACTIVITIES
Physical exercise, recreation, and sport help individuals acquire and maintain physical
fitness and serve as a healthy means of self-expression and social development.
Recreation activities can restore strength and spirits after school and work. Physical
education and recreation activities can provide opportunities for building self-confidence
and strengthening friendships between boys and girls in non-pressured group situations
(WHO, 1996). However, physical education and recreation activities can also turn into a
site of ridicule, physical compromise, and embarrassment if the activities are not
developed with consideration to the young person’s sensitivity to body image and
differences in physical development. Often, students learn about sexual and reproductive
health from the physical education teacher; thus such educators should be well-trained in
dealing with issues of puberty and sexual development.
Extra-curricular activities can include occasional events, organised either for the entire
school or for all students of a particular age, to address key social, cultural, and
environmental factors that relate to family life, reproductive health, and population issues
(Rice, 1995). These may include call-in media shows about relationships and love; hotlines
to discuss issues related to sexuality and reproduction; discussion groups among youth
to talk about friendships and expressions of sexuality; discussion groups with parents and
youth to talk about the transition to adulthood; youth camps that include discussions
about population issues—especially in highly populated countries—and their relevance to
young people; peer-education groups in schools about marriage and the family; or drama
presentations about a young couple that struggles with an unintended pregnancy
(adapted from UNESCO/UNFPA, 1998b). To design extra-curricular activities that appeal to

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youth, it is important to find out from young people where and how they spend their time
and what their current needs and health-seeking behaviours are (UNESCO/UNFPA,
1998b), and if schools have rules and limits to support the safety of and protect young
people from situations they may not be ready to handle.
4.8 NUTRITION AND FOOD PROGRAMMES
Children who are not adequately nourished are more likely to be absent from school, are
less likely to concentrate and perform well, and are thus less likely to benefit from
family life, reproductive health, and population education offered in schools. Adolescent
females who are not adequately nourished are also more likely to experience problems
with childbirth and have a greater risk of maternal death from obstructed labour (Kurz,
Peplinsky, & Johnson-Welch, 1994).
Health-Promoting Schools can implement nutrition interventions in various ways to

promote healthy development of students and staff:
• Micronutrient supplementation: Distributing micronutrients to children who have
nutritional deficiencies can contribute in the long term to reproductive health,
especially in girls. For example, promotion of medical (e.g., daily ferrous sulphate
tablets) and food-based (e.g., consumption of meat, legumes, or green leafy
vegetables) solutions can treat iron deficiency (where it has been identified as a
problem) and thus prepare young girls for less dangerous childbirth.
• School feeding: Providing free nutritious meals at school for children of low-income
families is of great importance to relieve short-term hunger and to ensure sufficient
nourishment for physical development, especially during the adolescent growth
spurt. School feeding programmes can also be an incentive for parents to send
children to school where they may consequently have the opportunity to learn about
health, including family life and reproductive health (WHO, 1996).
• School meals: The composition of school meals and their nutritive value plays an
important role in fostering educational achievement and health, both of which have an
important influence on reproductive behaviour. Also, if students become accustomed
to healthy food choices, they may develop and share habits of healthy eating with
other members in their family.
• Nutrition education: Teaching boys and girls about nutritional needs during
pregnancy and for new-born babies (e.g., the importance of breast milk) and the
importance of balanced meals for their future families can be taught by food service
staff as part of skills-based health education or in specially arranged sessions.
4.9 HEALTH PROMOTION FOR SCHOOL STAFF
A Health-Promoting School aims to promote healthy lifestyles for all who study and work
in and use the school, including teachers, administrators, and other school staff, some of
whom might be in their late adolescent years themselves and have sexual health needs
or be affected by HIV/AIDS or other STI. Strategies to promote family life, reproductive
health, and population education should become an integral part of health promotion for
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school staff. Health promotion for staff is intended to increase their interest in health, help
them acquire healthy lifestyles, help them model respect and gender equity, and prevent
sexual harassment or abuse. Addressing sexual and reproductive health in schools can
benefit teachers and other staff, rather than adding an additional burden (which some
staff may initially be concerned about).
School personnel need to be educated about, and to develop skills, in health promotion,
including healthy sexual development. There are several reasons why health promotion
for staff is important:
• Healthy employees are better able to fulfil their responsibilities.
• Teachers and school personnel are role models to students and others.
• School personnel can help identify policies and practices that are needed to support
health and well-being in schools.
Examples of staff development activities related to family life, reproductive health, and
population education include workshops, such as the one described below, and
distribution of printed materials, which might be available from national or local agencies.
Case Study
Education Development Center, Inc., a non-profit organization in the United

States, held workshops for its staff entitled “What’s Sex Got to Do with It?
Exploring Issues of Sexuality in the Workplace.” This workshop addressed the
complex interpersonal changes that staff must make in order to ensure that they
treat one another and their clients fairly and with respect. Participants were
presented with different and challenging case studies and asked to engage in a
lively discussion on the many grey areas of this important issue. Key topics and
learning points included the following: what legally constitutes sexual
harassment; what is appropriate behaviour in the workplace; relating one’s
perception of sexual harassment to case studies; how sexual harassment affects
morale, productivity and trust in the workplace; and one’s responsibility as a
trainer entering a school setting (adapted from Stier, 1999).

5. TRAINING TEACHERS, SCHOOL PERSONNEL, PEER EDUCATORS, AND 52
OTHERS TO ADDRESS FAMILY LIFE, REPRODUCTIVE HEALTH, AND
POPULATION EDUCATION AS PART OF A HEALTH-PROMOTING SCHOOL
Training of various individuals involved in school-based efforts related to family life,

reproductive health, and population issues is crucial in a successful approach to school
health. This document can only give a brief overview of some concepts and principles
related to training of teachers, school personnel, and peer educators. For information on
co-operating with families and training parents, please see Section 4.5 of this document.
Annex 1 includes references to training curricula.
Team training of teachers, school personnel, and others can help assure building a critical
mass of people who share the same educational objectives and who are trained to carry
out some new practice. A critical mass is needed for change to happen in schools
(Birdthistle & Vince-Whitman, 1997) and for a consistent application of health promotion
and reproductive health interventions in classrooms and other services at the school.
Team training for family life, reproductive health, and population education instructors,
administrators, and the School Health Team may include the following (adapted from
Birdthistle & Vince-Whitman, 1997):
• Review of relevant national and local policies
• Inspirational keynote address for the vision or “big idea”
• Understanding the concept of a Health-Promoting School, and how and where
family life, reproductive health, and population education can be supported across
components
• Review of leadership, management, and co-ordinating mechanisms for school-based
interventions, including the roles and responsibilities of teachers
• Information on when, how, and to what extent staff should be involved in the
prevention of and/or early intervention regarding pregnancy, STI, HIV/AIDS, sexual
abuse, and sexual harassment
• Overview of factors and techniques that influence family life, reproductive health, and
population issues
• Overview of policies and procedures for handling sensitive issues, e.g.:
• Informing teachers about what they can and cannot discuss with students in
regard to homosexuality and sexuality in general and when they can refer
students to outside resources
• Giving clear guidance about handling suspected cases of sexual abuse among
students or school personnel
• Factual information about human development, family life, reproductive health, and
population patterns that will facilitate an understanding of the way young people
develop physically, socially, and emotionally, with particular emphasis on gender roles
and various forms of relationships within the current cultural, social, and legal climate
of the country (Rice, 1995)
• Self-awareness about feelings about one’s own body and sexuality
• Awareness of available community-based services for student referral and how to link
with and use them (Majer, Santelli, & Coyle, 1992)
• Reassurance that classes will vary and presentation of the curriculum will not be
uniform among educators
• Addressing the concerns of parents or community leaders
• Instilling an understanding of the nature and type of local issues in regard to
addressing sexual development
• Providing counselling to teachers who are concerned about their own reproductive
health status
53 5. TRAINING TEACHERS, SCHOOL PERSONNEL, PEER EDUCATORS, AND
Training should sensitise the trainees for promoting family life, reproductive health, and
population education and the concept of a Health-Promoting School. It is important to
realize that this training may be the first time participants have openly discussed issues
of reproductive health (Birdthistle & Vince-Whitman, 1997). Training needs to “dispel the
myth that knowledge about reproductive health, including sexuality and contraception,
will increase promiscuity. [It] should also include participatory exercises” (Rice, 1995). In
addition, training may include techniques to monitor performance and evaluate learning
experiences and interventions.
Materials for training of teachers and others may be available through governmental and
non-governmental organisations and UN agencies, such as WHO Regional Offices,
UNESCO, UNICEF, UNAIDS, and UNFPA, as well as universities or teachers unions.
Supplemental training and learning materials specific to the local situation can also be
generated by schools within that country, community, or district. Guidelines are needed
for the creative training of current teachers as well as new teachers.
Case Study
In a UNESCO population education initiative on the island of Galapagos,

Ecuador, teachers, parents, and pupils from rural schools identified their own
learning needs and produced training materials to cover specific problems in
the community. The programme aimed to promote self-esteem and good
family relationships in order to help learners plan their futures and adopt
responsible parental attitudes. Teaching and learning aids, including a video
and newsletter that spread educational messages in clear, straightforward
language, were carefully designed (Beverley Kerr, UNFPA, as cited in
Birdthistle & Vince-Whitman, 1997).
How can we prepare teachers, staff, and peer educators for these
tasks?
5.1 TEACHER TRAINING
Teachers, especially those who are asked to teach family life, reproductive health, and
population education, need to receive training and accurate information to effectively
address these issues in their content areas. Health education research has found a
significant difference in student learning outcomes when teachers are trained. Research
has also shown that training teachers in the use of health curricula improves their
implementation of the programme (Ross, Nelson & Kolbe, 1991; Connell, Turner &
Mason, 1985). Education and training should inspire and equip teachers with knowledge
and skills to make a curriculum exciting in order to encourage students to establish
healthy behaviours. In addition, training should include exercises that address teachers’
self-awareness about sexuality and gender issues, help them assess their own practices,
and make them aware of the behavioural messages they give as role models.

5. TRAINING TEACHERS, SCHOOL PERSONNEL, PEER EDUCATORS, AND 54
Countries or individual schools may develop criteria for selecting educators to teach about
sexuality and reproductive health specifically. The Swedish Association for Sex Education,
for example, explains that a teacher of sexuality education needs to feel comfortable talk-
ing about sexuality and have a desire to educate. This person must also command trust
and give respect, and young people must have faith in this individual and feel comfortable
asking questions, discussing issues, listening and learning (Lindahl & Laack, 1996).
Teachers who are primarily responsible for family life, reproductive health, and population
education may receive specific relevant training in implementing a selected curriculum.
This training can address content and a variety of teaching strategies, including active
learning methods, such as discussions, debates, role plays, group activities, games, case
studies, and community education projects, that engage students and parents. Training
ideally provides a chance to practise some of these methods and demonstrates
strategies for integrating concepts and skills into various subject areas, such as social
studies, language arts, science, religious education, and/or math.
Ideally, teacher training is offered both pre-service and in-service. Both, approaches to
teacher education “should involve an understanding of the latest educational research,
relevant discipline studies, progressive pedagogical studies and classroom management
techniques” (Education International, 1998).
Non-governmental organisations or institutions of higher education that train professionals

and paraprofessionals in nursing or medicine may each provide training for teachers and
school health service providers. Teacher unions can also provide a leadership role in
training of school personnel. Continuing education should be offered to practising
professionals so that practitioners can acquire the skills they need to intervene early and
appropriately.
5.2 PEER EDUCATOR TRAINING
In countries where peer education is not common or even prohibited, peer education first
needs to be advocated for and accepted, and then proper guidelines need to be set up.
Peer educators need to receive training similar to that of teachers in family life,
reproductive health, and population education, as well as motivation and continued
support. “Training of peer educators to work with other students in educational and coun-
selling activities should focus on providing accurate reproductive health information and
practising techniques of problem solving, listening, non-judgmental communication,
giving feedback, conflict resolution, decision making, counselling, and basic education.
Peer educators should also be aware of sources of support for students who need
information, counselling or health services. Training methods and resources that are
practical, interactive, and can be replicated in the classroom should be used. As there is
often a high turnover of peer educators, some recommend regular retraining of peer
educators each year” (Ford et al., 1992, cited in Birdthistle & Vince-Whitman, 1997).
55 6. EVALUATION OF PROCESS AND OUTCOME
How do we know if our efforts have been successful?
Evaluation is a powerful tool that can be used to inform and strengthen Health-Promoting
School activities. It has the potential to provide solid evidence of effectiveness and
information on which interventions work best, which do not work, and how to advance
efforts in the future.
The primary intention of most evaluations is to provide information about the extent to
which interventions are being implemented as planned (i.e., process evaluation).
Evaluation is also used to provide evidence of the effectiveness of the interventions in
achieving the intended objectives at the school level (i.e., outcome evaluation) and more
broadly to convince communities and governments of the interventions’ importance.
Data collected through carefully designed evaluations can be used to improve
programmes and provide information to national, state, and local institutions as they set
goals and objectives for current and future efforts.
The value of evaluation includes:

• providing feedback to those involved in project planning
• making improvements or adjustments in the programme
• demonstrating the value of efforts of schools, parents, and communities
• documenting experience so that it can be shared with others
Evaluation as an important element of a school-based approach must be considered from

the outset and remain ongoing. The basis for evaluation is established at the very
beginning of the planning process when needs are assessed, objectives set, and
activities planned. At the same time, a monitoring and evaluation plan should be
established to track process in accomplishing objectives and carrying out activities. During
the implementation, evaluation is necessary to monitor the process in order to make
adjustments or corrections where needed. At the end of the interventions, or after a
pre-determined period, evaluation activities assess the results and impact of the
interventions and determine if the programme achieved its objectives or if it needs to be
improved. The cycle will then start again with the question of what further change is
desirable.
During evaluation, as well as during all other stages of planning and implementing school
health interventions, it is recommended to involve youth in a meaningful way. Engaging
young people in actual delivery and evaluation efforts fosters active involvement, ensures
that activities are relevant to young people’s needs, and provides continuing feedback for
improvement of the approaches (Senderowitz, 1998).
6.1 PROCESS EVALUATION OR MONITORING
Process evaluation measures the achievement of the process objectives: It provides

information about the extent to which activities were implemented as planned. It is an
ongoing process of monitoring those objectives to record what has been done, with
whom, and when to see if the programme is being carried out as planned. This
documentation can help others understand what led to success and avoid any

6. EVALUATION OF PROCESS AND OUTCOME 56
problems that occurred in their future programmes. Methods for process evaluation
include teacher or student diaries, tallies, school records, and interviews with teachers,
school administrators, parents, and others.
Process evaluation is necessary to answer such questions as these:

• To what extent are the interventions being implemented the way they are intended?
For example, how many class sessions were held on family life, reproductive health,
and population education; which materials were produced and distributed; how many
parents and community members were counselled; and what other activities are
being implemented?
• To what extent are the interventions reaching the individuals who may need them
e.g., children and adolescents, parents, teachers, counsellors, and/or community
members?
Case Study
The West African Youth Initiative, a collaborative adolescent reproductive

health project for in-and out-of-school youth, organised by Advocates for Youth
in Washington, D.C., USA, and the Association for Reproductive Health and
Family Health in Ibadan, Nigeria, has successfully engaged its peer educators
in evaluation, using their management information system (MIS) services. Peer
educators use special MIS forms and quarterly reporting forms to monitor
services provided, such as number of clients counselled and referred, and
number of contraceptives distributed. Currently, peer educators are involved in
monitoring of services by taking a basic count; however, as peer educators
become more comfortable and skilled, they will also document the types of
counselling encounters, types of referrals made, etc. (SIECUS, 1998).
6.2 OUTCOME EVALUATION
Outcome evaluation provides information about whether what has been done has made
a difference and to what extent the outcome objectives have been achieved. Outcome
evaluation is conducted to determine any changes that have occurred over the time
period from before an intervention is implemented to after implementation, and to
demonstrate that the identified changes are the result of the intervention itself, not some
other factors. Data items that have been assessed during the situation analysis, and that
are directly related to intervention objectives, should be relatively easy to collect again for
outcome evaluation.
Assessments may include quantitative and qualitative information of reproductive

health-related health status, practices, knowledge, behaviour, and attitudes. Quantitative
information includes objective numerical measures, such as prevalence of students
practising abstinence, or level of knowledge about how to avoid unwanted pregnancies.
Qualitative information contains subjective perceptions and feelings, such as feeling in
control about choosing how many children a couple wants.
Outcome evaluation is necessary to answer such questions as these:

• Are the activities accomplishing what we expected (e.g., to what extent did the
programme achieve increases in students’ knowledge, attitudes, and skills related to
family life, reproductive health, and population issues)?
• Which specific interventions or components of our efforts work best? With whom?
Under what circumstances?
• Are programme planners and participants satisfied with the outcomes?
• What components did not work? What went wrong?
• Where should we place more of our efforts in the future?
• What can be improved?
Where resources such as time, personnel, and budget for evaluation may be scarce, it
may be sufficient and more feasible to conduct a process rather than an outcome
evaluation. Too often, programmes rush to study their impact on youth without fully
understanding whether or how well implementation of the interventions occurred.
To conduct an evaluation, it is necessary to have the following:

• A good understanding of interventions, including goals and objectives
• A commitment to learning more about the strengths and weaknesses of the efforts
and to improving their delivery
• At least one person who is willing to be responsible for the evaluation and who may
receive some training in design and analysis of an evaluation
• Preferably, a trained researcher or social scientist as consultant, e.g., from the
department of health or education or a local college or university, who has experience
and can help lay out baseline analysis and outcome evaluation
Annex 3 provides tools for process and outcome evaluation, based on the action plan
developed in Annex 2. Annex 1 refers to resources that can be utilised to plan evaluation
efforts.
6.3 SAMPLE EVALUATION QUESTIONS FOR VARIOUS COMPONENTS
The following table provides an overview of various components that can be evaluated
and examples of quantitative and qualitative questions for process and outcome
evaluation. It might not always be possible to evaluate outcomes for each component
separately. This table is not all-inclusive and needs to be adapted to different settings and
fields of work, as approaches and objectives vary with local conditions. Evaluation should
be based on the objectives established in the planning phase and should be conducted
in collaboration with the School Health Team and Community Advisory Committee.

EXAMPLES OF PROCESS EXAMPLES OF OUTCOME

COMPONENTS
EVALUATION QUESTIONS EVALUATION QUESTIONS
Supportive School • Does the school have a • What impact did the school policy
Policies comprehensive policy on health have on any of the components of a
promotion and family life, Health Promoting School? (Use
reproductive health, and population specific questions tailored to a
education? particular school, e.g. enrolment
• Does the school enforce a policy on rates for girls; increase in
sexual harassment? knowledge, attitudes, and skills; and
• What do administrators, teachers, service utilization rates related
students, and parents think of the related to reproductive health.)
policies? • Has the incidence of sexual
harassment declined?
Skills-Based Health • Is there a curriculum for family life, • To what extent have knowledge
Education reproductive health, and population attitudes, skills, and practices of
education? students and staff changed? (Use
• Are interactive educational methods specific questions tailored to the
applied? objectives and activities of family
• Are gender-sensitive, age-appropriate life, reproductive health, and
materials utilized? population education conducted at
• Is training for peer educators and in- school.)
service training for teachers provided?
• Do teachers and peer educators feel
comfortable implementing the
various parts of the curriculum?
Healthy School • Are separate sanitary facilities • To what extent has attendance
Environment provided for girls and boys? changed since sanitary facilities
• To what extent are resources and have been improved?
displays provided that promote • What impact do students and staff
family life, reproductive health, report that resources and displays
and population education? had on them?
School Health • To what extent have school health • To what extent have unintended
Services services provided screening, pregnancies, STI, and HIV infection
diagnosis, and treatment of rates changed among students and
conditions related to teachers?
reproductive health? • To what extent has the rate of
• If appropriate: To what extent are contraceptive use changed?
contraceptives available? • To what extent has the number of
• Are students, teachers, and parents visits to reproductive health-related
satisfied with the confidentiality and services changed?
privacy provided?
EXAMPLES OF PROCESS EXAMPLES OF OUTCOME

COMPONENTS
EVALUATION QUESTIONS EVALUATION QUESTIONS
Cooperation with • How have community members • Which changes in knowledge,

Communities and and parents been involved in school- attitudes, skills, and practices
Families based interventions that address occurred in community members
family life, reproductive health, and who participated in school-based
population education? interventions that addressed family
life, reproductive health, and
population education?
• What changes in conditions have
occurred in the community?
Mental Health • How many youth have been • For those who participated in
Promotion, counselled by qualified staff on mental health counselling, what
Counselling, and family life, reproductive health, and changes were observed in
Social Support population issues? knowledge, attitudes, and behaviour?
Physical Exercise, • Which events in sports and extra- • What effect in individuals’ lives did
Sport, Recreation, and curricular activities include participation in sports and extra-
Extra-Curricular components that address healthy curricular activities have?
Activities family life, reproductive health, and
population education?
Nutrition and Food • Which healthy food choices are • Do nutrition and food interventions
Programmes offered on school grounds? demonstrate any perceptible results?
• To what extent are feeding
programmes and micronutrient
supplementation taking place?
Health Promotion for • Are reproductive health-related • To what extent do health promotion
School Staff services offered for school staff? initiatives for school staff help staff
• How many staff members to adopt healthy behaviours or create
participate in these activities? conditions that foster family life,
reproductive health, and population
issues?

Any evaluation is useful and complete only when its results are reported and communicated
to those who need and can use them, including those involved in planning and managing the
interventions. The value of evaluations is increased if the results are reported using
repeatedly the same objective criteria to ensure continuity and comparability. Evaluation
reports should contain interesting and easily understandable material for many
individuals and groups, including school staff, students, community members, and
families. Evaluation results can be used to initiate discussion, debate, and proposals that
can contribute to the development and support of family life, reproductive health, and
population education in schools and communities.
Annex 1 includes helpful resources and tools that can be used to conduct monitoring and
evaluation of young adult reproductive health initiatives.
61 7. CONCLUDING REMARKS
This document provided an overview of how to advocate and plan for school-based efforts
to address family life, reproductive health, and population issues. Since these issues are so
crucial for the life of all individuals, schools—with the support of the appropriate ministries—
should make every effort to address these topics in a culturally relevant matter.
Addressing these issues provides a good opportunity to establish or improve Health-

Promoting Schools and to support the FRESH (Focusing Resources on Effective School
Health) initiative (UNESCO/UNICEF/WHO/WorldBank, 2000).
Documents listed in Annex 1 can be utilised to implement these efforts. In addition, other
documents in the WHO Information Series on School Health (listed on the inside of the
front cover) may also be helpful, especially Preventing HIV/AIDS/STI and Related
Discrimination: An Important Responsibility of Health-Promoting Schools (WHO/HPR
/HEP/98.6) and Local Action: Creating Health-Promoting Schools (WHO/NMH/HPS/00.X).
“Young people are the partners of today, the leaders of tomorrow, and the
parents of the future. Much can be done today to enable them to succeed
and help prepare them for future roles” (UN, 2000, p. 8).

ANNEX 1 62
USEFUL RESOURCES FOR IMPLEMENTING THE VARIOUS SECTIONS
Section 2: Convincing others that Family Life, Reproductive Health, and Population
Education through Schools are Important and Effective for Public Health and
Personal Development
• Communication and Advocacy Strategies: Adolescent Reproductive and Sexual

Health. Booklet 2: Advocacy and IEC Programmes and Strategies. Booklet 3: Lessons
Learned and Guidelines, (2001), co-published by UNESCO and UNFPA, available from
UNESCO Principal Regional Office for Asia and the Pacific, P.O. Box 967, Prakanong
Post Office, Bangkok 10110, Thailand.
Booklet 2 includes advocacy strategies, such as generating the interest and
commitment of decision-makers, winning support by various sectors, and developing
recommendations and other documents. Booklet 3 summarises lessons learned for
advocacy and communications as well as a discussion of factors that may help or
hinder advocacy.
• After Cairo: A Handbook on Advocacy for Women Leaders, (1994), available from the
Centre for Development and Population Activities (CEDPA), 1717 Massachusetts
Avenue NW, Suite 200, Washington, DC 20036, USA.
Several chapters in this handbook describe how to plan and implement strategies for
advocacy: Planning for advocacy, Taking your message to the public, Forging alliances,
Advocating for resources, and Advocacy profiles.
• TB Advocacy: A Practical Guide, WHO/TB/98.239, (1998), available from the Global

Tuberculosis Programme at the World Health Organization, Geneva, Switzerland.
Even though on a different topic, this practical handbook contains useful step-by-step
information for planning advocacy efforts: documenting the situation, packaging the
message, working with the media, and mobilising others.
• Communications Briefings: 101 Ways to Influence People on the Job, (1998),

published by Briefings Publishing Group, 1101 King Street, Suite 110, Alexandria, VA
22314, USA.
This practical guide on how to influence people gives guidance on the role of the
influencer, the messages, and the audience, and includes tactics on how to persuade
others, especially in workplace settings.
• Influence: The Psychology of Persuasion by Robert B. Cialdini, (1993), published by

William Morrow, New York.
This book explains the six psychological principles that drive our powerful impulse to
comply to the pressures of others and shows how we can put the principles to work
in our own interest or defend ourselves against manipulation.
63 ANNEX 1
Section 3: Planning efforts to address Family Life, Reproductive Health, and

Population Education as part of a Health-Promoting School
• Coming of Age: From Facts to Action for Adolescent Sexual & Reproductive Health,
WHO/FRH/ADH/97.18, (1997), available from Adolescent Health & Development
Programme, Family & Reproductive Health, World Health Organization, Geneva,
Switzerland.
This manual includes steps for planning, doing, and using a situation analysis specifically
for adolescent sexual and reproductive health. Steps for doing a situation analysis
include collecting existing information, collecting new information, managing collected-
information, analysing collected information and data, and drawing conclusions.
• Local Action: Creating Health-Promoting Schools, WHO/NMH/HPS/00.4, (2000),

available from Department of Noncommunicable Disease Prevention and Health
Promotion, World Health Organization, Geneva, Switzerland, or online at
http://www.who.int/school-youth-health.
This implementation manual for Health-Promoting Schools at the local level includes
tools to assess resources, local health problems, and opportunities; involve members
of the school and community; define objectives and goals and develop an action plan;
and document progress and plan for the future.
• Strategic Assessment Tool for Planning Young Adult Reproductive Health Programmes
at Country Level, (2000), available from Pathfinder International, 9 Galen Street, Suite
217, Watertown, MA02472, USA, Phone. 1-617-924-7200. Fax: 1-617-924-3833 or
online at http://www.pathfind.org/.
This resource includes tools for conducting a situation analysis.
Section 4: Integrating Family Life, Reproductive Health, and Population Education

into various components of a Health-Promoting School
• Annotated Bibliography of Training Curricula for Young Adult Reproductive Health

Programmes, (1998), available from Pathfinder International, 9 Galen Street, Suite 217,
Watertown, MA02472, USA, Phone. 1-617-924-7200. Fax: 1-617-924-3833; also
available online at http://www.pathfind.org/guides-tools.htm.
This document includes information about curricula from countries all over the world.
Sections include Family Life Education Programmes; Prevention of STI/HIV/AIDS
Programmes; Pregnancy Prevention, Reproductive Health, or Sex Education
Programmes; Programmes Working to Reduce the Incidence of Female Genital
Mutilation; Programmes Dealing with Violence Prevention, Negotiation Skills or
Substance Abuse; Programmes Promoting Empowerment of Adolescent Girls; and
Adapting Curricula.
• Developmentally Based Interventions and Strategies: Promoting Reproductive Health

and Reducing Risk Among Adolescents, (2001), available from Pathfinder
International, 9 Galen Street, Suite 217, Watertown, MA02472, USA, Phone. 1-617-
924-7200. Fax: 1-617-924-3833; also available online at http://www.pathfind.org/.
This user-friendly tool has been prepared for those who design and deliver
programmes and who formulate policies and programme objectives concerned with
the well-being of young people, especially in the developing world and in regard to

ANNEX 1 64
reproductive health. It helps the reader understand adolescent developmental needs

during pre-puberty, early adolescence, middle adolescence, and young adulthood,
which helps them design more practical, age-appropriate programmes.
• Handbook for Educating on Adolescent Reproductive and Sexual Health. Book Two:
Strategies and Materials on Adolescent Reproductive and Sexual Health Education,
(1998), developed jointly by UNESCO and UNFPA, and published by the UNESCO
Principal Regional Office for Asia and the Pacific, P.O. Box 967, Prakanong Post Office,
Bangkok 10110, Thailand, under UNFPA Project RAS/96/P02.
This book addresses problems, responses, and gaps related to adolescent reproductive
and sexual health; requirements and strategies for introducing an effective adolescent
reproductive and sexual health education programme; and suggestions for incorporating
reproductive and sexual health into an existing curriculum. Selected strategies include
grounding programmes in social learning theory and social constructions; highlighting
gender equity issues and male participation; using life skills approaches and strategies to
ensure responsible behaviour development; and balancing cognitive and affective
behavioural components.
• Growing Into Healthy Sexuality (for grades 6–8)

• Respecting Healthy Sexuality (for grades 9–12)
These are part of the Teenage Health Teaching Modules (THTM), developed by
Education Development Center, Inc. (EDC), 55 Chapel Street, Newton, MA 02458,
USA; Phone 1-617-969-7100; to order materials, please contact EDC, P.O. Box 1020,
Sewickley, PA 15143, USA, or order online: http://www2.edc.org/THTM/.
THTM is a comprehensive school health education curriculum for adolescents. The
modules have been designed primarily for the use in the United States but they have
also been adapted for use in other countries. The overall goal of THTM is to provide
students with the knowledge, skills, and understanding necessary to act in ways that
enhance their immediate and long-term health and that of the families, schools, and
communities to which they belong. The essential health skills of risk assessment,
self-assessment, communication, decision-making, goal setting, health advocacy, and
healthy self-management are highlighted in all of the modules.
Section 5: Training teachers, school personnel, peer educators, and others to

address Family Life, Reproductive Health, and Population Education as part of a
Health-Promoting School
• Counselling Skills Training in Adolescent Sexuality and Reproductive Health: A

Facilitator’s Guide, (1993), WHO/ADH/93.3; published by the World Health
Organization; available on request from the Adolescent Health Programme, Division
of Family Health, World Health Organization, 1211 Geneva 27, Switzerland.
• Annotated Bibliography of Training Curricula for Young Adult Reproductive Health

Programmes, (1998), available from Pathfinder International, 9 Galen Street, Suite
217, Watertown, MA02472, USA, Phone. 1-617-924-7200. Fax: 1-617-924-3833, also
available online at http://www.pathfind.org/guides-tools.htm.
This document includes sections with summaries of curricula and references for
working with parents and for training counsellors, along with listings of numerous
other reproductive health curricula.
65 ANNEX 1
• EI/WHO Training and Resource Manual on School Health and HIV/AIDS Prevention,
(2001), published jointly by Education International and WHO; available online at
http://www.ei-ie.org/educ/aids/eepublication.htm or available from Education
International, 5 Bd du Roi Albert II (8th), 1210 Brussels, Belgium; Phone: + 32 (2) 224
0611; Fax: + 32 (2) 224 0606.
This manual provides teachers and other staff with useful activities and resources to
strengthen their advocacy skills and use of participatory teaching methods to prevent
HIV/STI and related discrimination. Included are materials that help teachers address
their own risks and concerns as well as resources that teachers can use to conduct
interactive learning experiences to help young people acquire the skills to avoid risky
behaviours. Most of this HIV/STI-specific material might be easily adaptable to family
life, reproductive health, and population education.
Section 6: Evaluation of Process and Outcome
• A Guide to Monitoring and Evaluating Adolescent Reproductive Health Programmes,

(2000), published by FOCUS on Young Adults, 1201 Connecticut Avenue, NW, Suite
501, Washington, DC 20036, USA. Phone: 1-202-835-0818; Fax 1-202-835-0282;
Website: http://www.pathfind.org/focus.htm.
This 450-page document guides readers through the how-to’s of monitoring and
evaluation, including developing a monitoring and evaluation plan, indicators,
evaluation design and sampling, data collection, and analysis. It also contains 15
different instruments and questionnaires that can be adapted to particular monitoring
and evaluation needs.
• Evaluating Family Planning Programmes—with Adaptations for Reproductive Health

by Bertrand, Magnani, and Rutenberg
• Handbook of Indicators for Family Planning Programme Evaluation by Bertrand,
Magnani, and Knowles (1996), published by The Evaluation Project, Carolina
Population Centre, University of North Carolina at Chapel Hill, CB 8120 University
Square, Chapel Hill, NC 27516-3997, USA.
These documents were written for programme administrators and managers,
in-country evaluation specialists, family planning researchers, and donor agency
personnel. The manuals prepare readers to differentiate between the main types of
programme evaluation, evaluate alternative methods for impact assessment, select
the most appropriate method for a given setting, and design an evaluation plan. The
handbook compiles and defines those indicators most useful in family planning
programme evaluation in an effort to make indicators better known and easier to use.
• Guidebook: Evaluating Teen Pregnancy Prevention Programmes, (2001), available

from Sociometrics, 170 State Street, Suite 260, Los Altos, CA 94022-2812, USA;
Phone: 1-650-949-3282; Fax 1-650-949-3299; also available online at
http://www.socio.com.
This how-to book is a comprehensive evaluation resource for pregnancy prevention
among adolescents. A field-tested resource for those who manage evaluations and
those who carry them out, it guides the integration of evaluation methods into all
aspects of adolescent pregnancy prevention programmes.

ANNEX 2 66
SAMPLE ACTION PLAN FOR SCHOOL-BASED EFFORTS RELATED TO

FAMILY LIFE, REPRODUCTIVE HEALTH, AND POPULATION ISSUES
For more information, please refer to

Local Action: Creating Health-Promoting Schools (WHO/NMH/HPS/00.4), Geneva: WHO, 2000.
I. GOAL STATEMENT
Based on your situation analysis, discuss in your planning team (e.g., School Health
Team) what you want to accomplish in regard to family life, reproductive health, and
population education.
Five Year Goal
Example: To ensure that all students are provided with relevant education and services
related to family life, reproductive health, and population issues to prepare them for a
safe and healthy life now and in the future.
What would you like to accomplish during the next year to meet this goal?
Year One Goals
Examples:
1. To provide skills-based health education to all students with accurate information
about sexual development, pregnancy and pregnancy prevention, and STI.
2. To provide confidential school health services to all students that offer diagnosis,
treatment, and counselling in reproductive health issues.
II. MEASURABLE OBJECTIVES
Measurable objectives describe specific outcomes that will help you determine whether
you are reaching your goals. Objectives should be set for each goal individually.
Year One Objectives for Each Goal
Examples
Objectives for Goal 1

I. Those responsible for creating and changing school policies will establish a policy
for the school to address family life, reproductive health, and population issues in
the curriculum.
II. Locate or develop age-appropriate reproductive health curricula for each grade.
III. Train teachers to implement family life, reproductive health, and population
education.
Objectives for Goal 2
I. Hire or train staff to address reproductive health issues confidentially.
II. Outreach to students to invite them to participate in family life and reproductive
health-related school health services, as needed.
67 ANNEX 2
III. HELPING AND HINDERING FORCES
Identify below the forces that will help or hinder the achievement of your goals and
objectives. Helping forces are anything that will assist in the completion of your goal.
Hindering forces are whatever makes reaching your goal difficult.
HELPING FORCES HINDERING FORCES
Examples: Examples:
• Community support • Lack of funding
• Supportive teachers and student volunteers • Lack of available trainers
• Political climate
IV. STRATEGIES
Activities related to strategies that have evidence of being effective need to be

chosen to address each of your objectives. To be realistic, the helping and hindering
forces that you identified need to be taken into account when making decisions about
which strategy to use in a particular situation. Multiple strategies may be chosen to
address a single objective.
YEAR ONE OBJECTIVES STRATEGIES ACTIVITIES
I. Those responsible for creating Supportive School Policies Ia. At a meeting, present
and changing school policies will arguments to convince policy-
establish a policy for the school to Skills-Based Health Education makers of the importance and
address family life, reproductive (e.g., skill training, participatory effectiveness of family life,
health, and population issues in learning, peer education) reproductive health, and
the curriculum. population education.
Healthy School Environment Ib. Draft sample supportive
II. Locate or develop age- (e.g., physical environment, school policy.
appropriate reproductive health psychological environment)
curricula for each grade.
II. Contact local, regional, and
School Health Services
III. Train teachers to implement international agencies to identify
(e.g., screening, diagnosis,
family life, reproductive health, effective skills-based health
referral availability of contraceptives)
and population education. education curricula that address
family life, reproductive health,
Cooperation with Communities
and population education.
and Families
(e.g., parent education, reaching
out-of-school youth, involving
mass media)

ANNEX 2 68
YEAR ONE OBJECTIVES STRATEGIES ACTIVITIES
Mental Health Promotion, IIIa. Identify suitable trainers of

Counselling and Social Support teachers, with the help of local,
regional, and international
Physical Exercise, Recreation, agencies.
and Extra-Curricular Activities IIIb. Identify funding source(s).
IIIc. Develop training schedule
Nutrition and arrange logistics.
(e.g., micronutrient
IIId. Conduct participatory teacher
supplementation, school feeding,
training.
nutritious school meals)
Health Promotion for School

Staff
Other:
V. ACTION PLAN
From the information you gathered, you can develop an action plan. On the form
below, list an objective. Use a separate page for each goal or objective. Identify the
activities needed to achieve each objective, who will take responsibility for the
completion of the activity, when the activity will be completed, what resources will
be required, and how effectiveness will be measured.
Goal # 1
I. Those responsible for creating and changing school policies will establish a policy
for the school to address family life, reproductive health, and population issues.
II. Locate or develop age-appropriate reproductive health curricula for each grade.
III. Train teachers to implement family life, reproductive health, and population
education.
69 ANNEX 2
Examples:
PERSON(S) COMPLETED BY RESOURCES EVALUATION

ACTIVITY WHEN REQUIRED PLAN
RESPONSIBLE
Ia. Present Headmaster March 2004 Arguments on the Positive decision

arguments at a evidence of effec- to establish school
meeting of those tive family life and policy to require
responsible for reproductive health family life
school health interventions education in each
policies. grade
II. Contact local, Health education May 2004 Contact Availability of skills-
regional and teachers, information of based health edu-
international administrator agencies, cation curricula for
agencies to resources family life,
identify effective reproductive
skills-based health health, and
education population
curricula. education
IIIa. Identify Vice headmaster May 2004 Contact Availability of

suitable trainers of information of trainers
teachers, with the agencies,
help of local, resources
regional and
international
agencies

ANNEX 3 70
SAMPLE EVALUATION PLAN FOR SCHOOL-BASED EFFORTS RELATED

TO FAMILY LIFE, REPRODUCTIVE HEALTH, AND POPULATION ISSUES
I. PROCESS EVALUATION
List the activity for each objective from the Action Plan (Annex 1). To create an
ongoing record of the actions that have been conducted to implement each activity,
record in the table below all dates of implementation, the number and description of
people who participated (e.g., 30 eight-grade students; 12 teachers), and the number
and description of resources used (e.g., 30 handouts depicting male and female
sexual anatomy, and 3 newspaper clip-outs with reports on current sexual violence
and harassment cases in the community).
Objective # 1 - III
Example
Train teachers to implement family life, reproductive health, and population education.
DATE(S) NUMBER AND DESCRIPTION OF NUMBER AND DESCRIPTION

ACTIVITY
IMPLEMENTED PEOPLE WHO PARTICIPATED OF RESOURCES USED
Teacher September 20, Five first grade teachers, three Training material adopted
training 2004 second grade teachers, four fourth from EI/WHO Training and
workshop grade teachers, two administrators Resource Manual on School
Health and HIV/AIDS
Prevention
71 ANNEX 3
II. OUTCOME EVALUATION
For each activity, list the data sources/indicator(s) that you plan to examine, according
to the Evaluation Plan you identified on your Action Plan, to determine if the activity
has achieved its goal. Record in the next columns the date when you examined each
data source and the measurement taken of the data source. In the last column,
record the result, i.e., to what extent the goal has been achieved.
Goal # 1
Example
Train teachers to implement family life, reproductive health, and population education.
DATA SOURCES(S)
ACTIVITY DATE MEASUREMENT RESULT
EXAMINED/INDICATOR
Teacher training Teachers completed an September 12 out of 14 Training was

workshop evaluation form; practice 2004 participants successful;
of interactive teaching answered a short booster training
methods quiz on content session
with at least 90% recommended in
accuracy; all 1-2 years
participants
checked off that
they felt
comfortable
implementing
interactive
methods after
practice

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NOTES 80
81 NOTES

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The World Health Organization’s

INFORMATION SERIES ON SCHOOL HEALTH DOCUMENT 8

WHO gratefully acknowledges the generous financial contributions to

Other documents in this series include the following:

• Local Action: Creating Health-Promoting Schools (WHO/NMH/HPS/00.4)

Please send your feedback to:

WHO INFORMATION SERIES ON SCHOOL HEALTH

Jack T. Jones, Department of Noncommunicable Disease Prevention and Health Promotion,

Andrew Ball World Health Organization (WHO)/Headquarters, Geneva, Switzerland

1.1 Cultural sensitivity................................................................................................2

2. CONVINCING OTHERS THAT FAMILY LIFE, REPRODUCTIVE HEALTH,

2.1 BENEFITS TO PUBLIC HEALTH AND PERSONAL DEVELOPMENT ................6

2.1.1 Argument: Adolescence is a critical period of development

2.2 SCHOOLS AS APPROPRIATE SITES FOR FAMILY LIFE,

2.2.1 Argument: Schools are strategic entry points for addressing

WHO INFORMATION SERIES ON SCHOOL HEALTH

2.2.2 Argument: Schooling is a cost-effective means of improving

2.3 KNOWN EFFECTIVENESS OF SCHOOL-BASED EFFORTS............................14

2.3.1 Argument: Research has repeatedly shown that reproductive

3. PLANNING EFFORTS TO ADDRESS FAMILY LIFE, REPRODUCTIVE

Who will make this happen?....................................................................................18

Whose support is needed? ......................................................................................19

Where should we begin? ........................................................................................21

What should we do? ................................................................................................25

4. INTEGRATING FAMILY LIFE, REPRODUCTIVE HEALTH, AND

4.1 Supportive school policies ................................................................................29

5. TRAINING TEACHERS, SCHOOL PERSONNEL, PEER EDUCATORS,

6. EVALUATION OF PROCESS AND OUTCOME......................................................55

How do we know if our efforts have been successful? ..........................................55

ANNEX 1 Useful Resources for Implementing the Various Sections ....................62

ANNEX 2 Sample Action Plan for School-Based Efforts Related to

ANNEX 3 Sample Evaluation Plan for School-Based Efforts Related

WHO INFORMATION SERIES ON SCHOOL HEALTH

AIDS Acquired Immune Deficiency Syndrome

WHO’s Global School Health Initiative is a concerted effort by international organisations

Pekka Puska Cream Wright Hans Troedsson

Paul Van Look Cheryl Vince-Whitman

WHO INFORMATION SERIES ON SCHOOL HEALTH

• Fosters health and learning with all measures at its disposal

• Engages health and education officials, teachers, students, parents, and

• Strives to provide a healthy environment, skills-based health education, and

• Implements policies, practices, and other measures that respect an individual’s

• Strives to improve the health of school personnel, families, and community

In addition to these general characteristics of Health-Promoting Schools, WHO

WHO Regional Office for Africa (WHO/AFRO), Brazzaville, Republic of Congo:

WHO INFORMATION SERIES ON SCHOOL HEALTH

1.1. CULTURAL SENSITIVITY

This document attempts to provide comprehensive information to be used across

1.2 WHY DID WHO PREPARE THIS DOCUMENT?

1.3 WHO SHOULD READ THIS DOCUMENT?

• Governmental policy- and decision-makers, programme planners, and coordinators at

• Members of non-governmental institutions and other organisations responsible for

• Community leaders and other community members, such as local residents,

1.4 WHAT IS MEANT BY FAMILY LIFE, REPRODUCTIVE HEALTH, AND

Family life education is defined by the International Planned Parenthood Federation

Reproductive health education is described by UNESCO/UNFPA as educational

Population education is defined by UNFPA as “the process of helping people under-

1.5 WHY SHOULD SCHOOLS ADDRESS FAMILY LIFE, REPRODUCTIVE