Current Issues and Controversies in School and Community Health, Sport and Physical Education [1 ed.] 9781621003724, 9781621003274

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Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved. Current Issues and Controversies in School and Community Health, Sport and Physical Education, Nova Science Publishers, Incorporated, 2012.

Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved. Current Issues and Controversies in School and Community Health, Sport and Physical Education, Nova Science Publishers, Incorporated, 2012.

EDUCATION IN A COMPETITIVE AND GLOBALIZING WORLD

Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved.

CURRENT ISSUES AND CONTROVERSIES IN SCHOOL AND COMMUNITY HEALTH, SPORT AND PHYSICAL EDUCATION

No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in rendering legal, medical or any other professional services.

Current Issues and Controversies in School and Community Health, Sport and Physical Education, Nova Science Publishers, Incorporated, 2012.

EDUCATION IN A COMPETITIVE AND GLOBALIZING WORLD Additional books in this series can be found on Nova‘s website under the Series tab. Additional E-books in this series can be found on Nova‘s website under the E-book tab.

SPORTS AND ATHLETICS PREPARATION, PERFORMANCE, AND PSYCHOLOGY

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Additional books in this series can be found on Nova‘s website under the Series tab. Additional E-books in this series can be found on Nova‘s website under the E-book tab.

Current Issues and Controversies in School and Community Health, Sport and Physical Education, Nova Science Publishers, Incorporated, 2012.

EDUCATION IN A COMPETITIVE AND GLOBALIZING WORLD

CURRENT ISSUES AND CONTROVERSIES IN SCHOOL AND COMMUNITY HEALTH, SPORT AND PHYSICAL EDUCATION

JENNIFER A. O'DEA

Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved.

EDITOR

Nova Science Publishers, Inc. New York

Current Issues and Controversies in School and Community Health, Sport and Physical Education, Nova Science Publishers, Incorporated, 2012.

Copyright © 2012 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers‘ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works.

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Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. Additional color graphics may be available in the e-book version of this book. LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA Current issues and controversies in school and community health, sport and physical education / editors, Jennifer A. O'Dea. p. cm. Includes index. ISBN 978-1-62100-372-4 (eBook) 1. School health services--United States. 2. Health education--United States. 3. Physical education and training--United States. I. O'Dea, Jennifer A. LB3409.U5C87 2011 371.7'10973--dc23 2011032593

Published by Nova Science Publishers, Inc.  New York Current Issues and Controversies in School and Community Health, Sport and Physical Education, Nova Science Publishers, Incorporated, 2012.

CONTENTS Preface

ix

Section 1: Issues in Health Education

1

Section 1.1: Issues in School Health Education

3

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Chapter 1

The Challenges of Conducting Research in Schools on Obesity, Weight, Diet and Health Wendy Wills, Mei-Li Roberts, Kathryn Backett-Milburn, and Julia Lawton

5

Chapter 2

Suicidal Behavior and Prevention in Adolescence Hatim A. Omar, and Joav Merrick

Chapter 3

Abstinence only Until Marriage Programs in the United States of America (USA): Science and Human Rights John S. Santelli, Mary A. Ott, Joanne Csete, Shama Samant and Dana Czuczka

23

Social and Emotional Training in School: A Contentious Matter in Sweden Birgitta Kimber

35

Producing the Self-managing Female-citizen in a Climate of ‗Healthy‘ Living Kellie Burns and Kate Russell

45

Chapter 4

Chapter 5

Chapter 6

Addressing Body Image Issues in Australia‘s Health Education Classroom: A Case for a Constructivist Approach to Media Literacy Interventions Michelle Gorzanelli

Section 1.2: Issues in Community Health Education Chapter 7

Reframing Pre-service Teachers‘ Perceptions of Sexuality Education: Challenges for Teacher Educators Margaret Sinkinson

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55 67 69

vi Chapter 8

Teacher Training for Child Protection Kate Russell

Chapter 9

Eating Disorder Prevention Programs on the University Campus Jennifer A. O‘Dea and Renata L. Cinelli

Chapter 10

Chapter 11

Chapter 12

Chapter 13

Chapter 14

Chapter 15 Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved.

Contents 81

91

Life Skills Education and Teacher Training Workshops in Japan Tetsuro Kawabata and Naomi Chisuwa

105

Youth Gambling: An Important Social Policy and Public Health Issue Jeffrey L. Derevensky

115

A Review of Undergraduate University Tobacco Control Policy Process in Canada Lynne Baillie, Doris Callaghan and Michelle Smith

131

Teachers‘ Detecting and Reporting Child Abuse and Neglect: Research into the Determinants of Complex Professional Behavior Kerryann Walsh, Adrienne Goebbels, and Jan Nicholson Smoke Free Environments for Children: The Relationship between Schools and Wider Smoke Free Environments Heather Gifford and George Thomson Internet-delivered Health Behavior Change Interventions Aimed at Adolescents Rik Crutzen

141

157

167

Section 2: Issues in Sport and Physical Education

181

Section 2.1: Issues in School Sport and Physical Education

183

Chapter 16

Chapter 17

Chapter 18

The Trial of Activity in Adolescent Girls (TAAG): From Theory to Implementation in Middle School Physical Activity Promotion John P. Elder,, Leslie A. Lytle, Deborah R. Young, Larry Webber, Russell Pate, June Stevens, Charlotte Pratt and Timothy Lohman Unstructured and Structured Environments for Physical Activity in Schools Jorge Mota, José Carlos Ribeiro and Maria Paula Santos Enhancing Educational, Health and Physical Activity Goals among Children and Adolescents: The Development of School Curriculum Areas Louisa Peralta

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185

197

211

Contents Chapter 19

An Overview of the Benefits, Issues and Challenges that Generalist Primary School Teachers Face when Teaching Physical Education Andrew Bennie and Ben Still

Section 2.2: Issues in Teacher Physical Education and Sport Eduation Chapter 20

Chapter 21

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Chapter 22

Approaches towards Health Promotion and Doping Prevention in Light of Determinant Factors of Substance Abuse in Sports among Adolescents Berit Wanjek, Jenny Rosendahl, Bernhard Strauss and Holger Gabriel Teaching Coaching Expertise: How to Educate for Coaching Excellence Paul G. Schempp, Bryan A. McCullick and Matthew A. Grant Knowledge of Performance Enhancing and Prohibited Substances in Elite and Recreational Athletes Rhonda Orr

vii

223 235

237

251

265

Section 2.3: Issues in Community Sport and Physical Education

281

Chapter 23

Challenges Facing Youth Coaches Donna O‘Connor

283

Chapter 24

The Integrative Power of Sport Myth or Reality: The Story of Two Vietnamese Families and their Involvement with Community Australian Rules Football Melanie Nash and James Morrissey

Chapter 25

Chapter 26

Chapter 27

295

Striving for Excellence: The Talent Identification and Development Pathway Donna O‘Connor and Balin Cupples

307

The Place of Laptops in Physical Education: Should they Stay in the Changing Rooms? Wayne Cotton

321

Using Performance Technology in Coaching: Is it Only for the Elite? Donna O‘Connor

329

About the Editor

341

Index

343

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Copyright © 2012. Nova Science Publishers, Incorporated. All rights reserved.

PREFACE The fields of health education and school-based health promotion are fundamental contributors to the overall health status of children, adolescents and young people worldwide. The delivery of health education messages, programs, interventions and evaluations not only produces more well informed citizens and communities, but also contributes to the health and health literacy of future generations. This new book provides unique and contemporary insights into the major current issues in school and community health education, including topics such as weight control, childhood obesity, body image, eating disorders, physical activity, suicide prevention and sex education. These topics are discussed in light of their application in school environments. Additionally, this new book deals with controversial and contentious issues in health education, including the decision to measure weight status; teach abstinence only sex education and whether schools should become involved in emotional training in schools. Authors in this particular section of the book provide thought-provoking insights into these topics from experiences in the United Kingdom (Will et al); Israel and the USA (Omar & Merrick); Sweden (Kimber); the USA (Santelli et al) and Australia (Burns & Russell; Gorzanelli). The significance and consequences for current and future developments in teacher education are then discussed with unique viewpoints from New Zealand (Sinkinson); Australia (Russell; Cinelli & O‘Dea) and Japan (Kawabata & Chisuwa). The issues in community health education that are dealt with in this new volume are similarly consequential and controversial with critical discussion of current topics such as youth gambling in Canada by Derevensky; university tobacco control policy processes in Canada by Baillie and her colleagues; teachers‘ detecting and reporting of child abuse and neglect in Australia by Walsh and her colleagues; the relationship between schools and wider smoke free environments in New Zealand by Gifford & Thomson and how we can best utilize Internet-delivered health behavior change interventions aimed at adolescents by Crutzen from the Netherlands. The international perspectives developed within this new book provide a truly global and comprehensive insight into these topical issues. The next section of the book covers an array of topics under issues in school sport and physical education with a very comprehensive overview of the successful trial of activity in adolescent girls (TAAG) by Elder and his group from the USA. This chapter provides insights from theoretical perspectives to issues of implementation in middle schools. Issues of

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Preface

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how best to promote school PE are also presented by Mota and his colleagues from Portugal; and Peralta, Bennie and Still from Australia. The very controversial topics of doping prevention in sports and how best to encourage sports excellence are expertly reported by international specialists in these fields - Wanjek and colleagues from Germany ; O‘Connor, Orr , Morrissey, Cupples, Nash and Cotton from Australia and Schempp, McCullick & Grant from the USA. The unique focus of this new volume is to describe current issues and controversies using international perspectives and subsequently be able to create practical strategies for health and sports promotion activities in schools, communities and teacher education. I hope you and your colleagues enjoy reading these exceptional new contributions from international leaders in this field.

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SECTION 1: ISSUES IN HEALTH EDUCATION

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SECTION 1.1: ISSUES IN SCHOOL HEALTH EDUCATION

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In: Current Issues and Controversies in School and Community ... ISBN 978-1-62100-327-4 Editor: Jennifer A. O‘Dea © 2012 Nova Science Publishers, Inc.

Chapter 1

THE CHALLENGES OF CONDUCTING RESEARCH IN SCHOOLS ON OBESITY, WEIGHT, DIET AND HEALTH

1

Wendy Wills1,*, Mei-Li Roberts2, Kathryn Backett-Milburn,3 and Julia Lawton 3

Centre for Research in Primary and Community Care (CRIPACC), University of Hertfordshire, England, 2Centre for Rural Childhood, UHI Perth College, Scotland, 3 Public Health Sciences, University of Edinburgh, Scotland

ABSTRACT

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Many young people are sensitive about what they eat and their weight and yet little attention has been given to the practical and ethical issues that emerge when designing or implementing a study relating to young teenagers‘ diets, weight or health. This chapter draws on two research studies, which involved recruiting young teenagers aged 13-15 years through schools in Scotland. The focus of the first study was young people with low socio-economic status (SES) whilst the second study was concerned with young people from higher SES families. Seven hundred participants completed a short screening questionnaire and had their height and weight measured and their Body Mass Index (BMI) calculated. A sub-sample was then selected to take part in individual in-depth interviews. Young people from higher SES groups were less interested and harder to engage with the research. Recruitment in schools was complicated by the didactic nature of these settings, in terms of adult expectations that young people will participate in research and teenagers perceiving researchers to be in positions of authority. It proved difficult to prevent young people being coerced into revealing their measurements to their peers. Recruitment for these studies raised the question of the multiple roles of researchers. Researchers must take account of the nuances of implementing health promotion research in schools. The paper concludes with recommendations for research involving weighing young teenagers and recruitment for research in schools.

*

Correspondence: Dr Wendy Wills RPHNutr, Senior Research Fellow, Adolescent & Child Health, Centre for Research in Primary and Community Care (CRIPACC), University of Hertfordshire, Hatfield, AL10 9AB, England. E-mail: [email protected].

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Wendy Wills, Mei-Li Roberts, Kathryn Backett-Milburn et al.

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INTRODUCTION Undertaking research with children and young people requires careful attention to ethics (Morrow, 1996). Many teenagers are sensitive about what they eat and their body size or shape, yet little coverage has been given to the practical and ethical issues researchers face when designing or implementing a study relating to young peoples‘ diet or weight. Schools are often considered an ideal setting for recruiting young people because the majority of young people attend them (David, Edwards, & Alldred, 2001; Testa & Coleman, 2006). Issues of passive versus active parental consent for school-based recruitment for research on weight has received some attention in the literature (Mellor, Rapoport & Maliniak, 2008), but there is a large ‗black hole‘ in relation to other factors which might influence recruitment for research on diet and weight conducted with a school-aged population. This chapter reflects on the practicalities and ethical issues, which arose when recruiting young teenagers (aged 13-15 years) in schools, for two qualitative studies on perceptions and experiences of diet, weight and health. Our substantive focus was the influence of social class, or socio-economic status (SES). Study one focused on young people from lower SES families whilst study two was concerned with young teenagers from higher SES backgrounds. This led us to reflect on our recruitment procedures and the way that SES impacted on the research process. We also reflect on our experiences of weighing and measuring young teenagers in school during the recruitment process and conclude by offering practical recommendations to researchers for similar work on diet, weight and health, involving a school-aged population of young people. Both studies aimed to explore the experiences and perceptions of young teenagers with regard to diet, weight and health (Wills, Backett-Milburn, Gregory, & Lawton, 2005, 2006, 2008). The focus of study one was on young people from lower SES families because of their poorer diet and greater risk of obesity. We wanted to explore the perceptions of young people who were defined by their (BMI) as being obese, overweight or a ‗healthy‘ weight for their age and gender. Whilst the main method of data collection for study one was qualitative in-depth interviews with teenagers from lower SES backgrounds and their parents (Backett-Milburn, Wills, Gregory, & Lawton, 2006), we needed to generate a pool of young people from which to draw our qualitative sample. We therefore developed a screening questionnaire designed to collect young people‘s socio-demographic information which included: parent/s‘ occupation; home postcode; access to a car; household composition; details of their physical activity; and favourite/regularly consumed foods. We wanted half the interview sample to be obese or overweight and half to be a ‘healthy‘ weight and this necessitated weighing and measuring young people so that their BMI could be calculated. (This is discussed in detail later in this paper). Over 300 young teenagers completed the screening questionnaire and had their height/weight measurements taken for study one. The second study mirrored the first in terms of design, but the focus was young teenagers from higher SES families to enable an analysis of classed practices and perceptions to be made across the datasets. Almost 400 young people completed the screening questionnaire and had their height/weight measurements taken for study two.

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RECRUITMENT FOR RESEARCH IN SCHOOLS A number of schools classified as being socio-economically disadvantaged were contacted in central and Eastern parts of Scotland for the first study. The percentage of students eligible for free school meals was used as a proxy indicator of socio-economic disadvantage, in each school catchment area. Whilst adult gate-keepers can sometimes determine whether young people in schools are given the opportunity to take part in research (David et al., 2001), as they have the capacity to block access, we did not encounter resistance from any of the schools with regard to allowing us to recruit participants. Using schools meant that large numbers of young people could be informed about the research and this strategy represented an efficient use of time and other resources. Local authority education departments were asked to approve the research protocol before the studies commenced and University ethics approval was also sought. Recruitment in schools was not unproblematic. Our initial contact for both studies was with head teachers and school-based nurses. They were informed that the research we wished to conduct focused on teenagers‘ experiences and perceptions in relation to diet, weight and health. We highlighted that we were interested in recruiting young people with a range of heights and weights. Teachers and school-based nurses were often quite vocal regarding the young people they thought needed intervention for their (over) weight which reflected the different agendas that schools had, compared with the research team (National Teacher Research Panel, 2008).

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OBTAINING „INFORMED CONSENT‟ TO PARTICIPATE Whilst it was appropriate to ask young people aged 13-15 years to give their own consent to participate in the research, we also wanted to inform parents that their children were being asked to take part. Passive parental consent methods are suggested as maximising the numbers of young people available to participate in research on weight, compared with using active parental consent procedures (Mellor et al., 2008). Schools were keen for us to adopt passive parental consent procedures, as this was their usual procedure for contacting parents. Letters and information sheets were therefore sent out on behalf of the research team asking parents to contact the school if they did not want their child to participate in the research. Very few parents ‗opted out‘ during either study. Educational settings are often didactic in terms of the provision/transfer of information in the classroom and unequal power relationships often exist between teachers and students (David et al., 2001). This often means that teachers expect young people to participate in all classroom activities without questioning their purpose. One head teacher commented that she encouraged young people to question what is being asked of them by adults and we would certainly concur with this sentiment (Wills, Appleton, Magnusson, & Brooks, 2008), although only a minority of young people did so during our school visits. We wanted to ensure that young people were provided with adequate information about the study to ensure they felt able to refuse to consent or to make their own decision to participate in whatever aspects of the research they felt comfortable taking part in. During the study involving two schools in socio-economically disadvantaged areas, two or three members of the research team visited schools during Personal and Social Education

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Wendy Wills, Mei-Li Roberts, Kathryn Backett-Milburn et al.

(PSE) lesson periods. Young people were informed what taking part would involve, including why we wanted to take their height and weight measurements. It was stressed that there were no ‗right or wrong‘ answers and that we wanted to know what they had to say about diet, weight and health because little is known about young people‘s thoughts and experiences regarding these issues. Written consent was then obtained before young people completed the screening questionnaire. However, in order to further ensure that young people had all the necessary information to inform their decision about whether to participate, a member of the research team stayed in the classroom to continue to answer questions whilst the other team member/s prepared to weigh and measure participants in a separate room. (Further details are given about these procedures later in the paper). We had no problems recruiting boys and girls with a range of BMI‘s for study one, with lower SES young people. When we commenced study two, involving schools in more socio-economically advantaged areas it became apparent, after initial pilot work, that these young people were generally less interested and harder to engage with the study, particularly with regard to giving consent to be interviewed. Our research subsequently highlighted that higher SES teenagers engaged in a wide variety of out of school activities, particularly physical activities, therefore being ‗busy‘, together with a reticence to talk about weight, could have contributed to our difficulties with recruiting higher SES teenagers. The procedures were modified in order to capture the interest of higher SES teenagers and to enable potential participants to give their informed consent to participate. The researcher started the classroom session by handing out leaflets which featured cartoons and media headlines about: ‗junk-food‘; the introduction of compulsory cookery lessons in schools; and the idea that young people should sit ‗exams‘ on healthy eating in order to combat obesity. The class were told we wanted to hear what they had to say about these issues and that this would help them to understand our research topic. This helped to build rapport (Swain, 2006). Although, during study two, higher SES overweight and obese teenagers, particularly boys, were still less likely to participate compared with their peers in the study involving lower SES groups. This meant we had to schedule in additional school visits in order to generate a large enough sample of overweight/obese teenagers, which incurred additional time and costs.

Withholding Consent The majority of young people consented to complete the screening questionnaire, although, in study two, with higher SES teenagers, there were several young people who did not want to give details about their parent/s occupations or their home postcodes. We are unsure whether this reticence reflected the current climate of fear about ‗identity theft‘, worries about the use of personal information by ‗officials‘ in the UK or if it is related to the values of higher SES teenagers. It was explained that we needed this personal information to ensure we included young people from a variety of backgrounds. This did not, however, always reassure those students who had refused to consent to answer these sections of the questionnaire. One young person wrote ‗nosey, nosey‘ in place of his postcode. Field notes written after one school visit stated that:

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― One girl in particular seemed to have a problem with most of the questions on the questionnaire. She said her parents wouldn‘t be happy if she did the interview because her mum wouldn‘t know what it was about. She also was asking why we wanted to know her parents‘ occupations and when I said we just wanted to interview a variety of people, she seemed ok with that at first and wrote down their occupations but then had second thoughts. She remained adamant that her parents wouldn‘t be happy and scored it all out.‖ (Field notes written December 2007)

Each class was informed that their height and weight would be measured, in private, in either the medical/school nurse office or an empty classroom. The whole class were reassured that they did not have to be measured and could change their mind at any point. A protocol (see Table 1) for taking measurements provided a useful framework for helping to reassure participants and we found that girls were more anxious about being weighed than boys. Participants who declined to have their weight/height measured (usually one or two per class) were asked if they wanted to write down their reason for this on the back of their questionnaire, to help us to understand why being weighed made them anxious. Many declined, but several did write comments, for example, ― It would make me skip my meals‖ and ― I would break the scales.‖

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PROTOCOL FOR TAKING YOUNG PEOPLE‟S HEIGHT AND WEIGHT MEASUREMENTS A protocol (Table 1) was developed following consultation with other researchers who had conducted research that involved weighing young people. Practical measures, such as using digital scales with a remote monitor and placing the scales away from walls, proved, with hindsight, to be essential aspects of the protocol as they ensured that all young people could be weighed with minimum embarrassment and that participants did not have to see their weight if they did not wish to do so. All personnel involved in taking measurements were given training and informed of the need to reassure participants that their personal measurements would not be disclosed outside the research team. They were also asked not to enter into a dialogue with young people about what is ‗normal‘ in terms of their weight. This arose because some participants came to be measured asking, for example, ― I‘m big, aren‘t I?‖ and therefore it was important to stress that teenagers can be all shapes and sizes. All members of the research team (including administrative staff) took measurements at some of the school-visits and during study two we recruited postgraduate students to assist the research team. All personnel had enhanced Criminal Records Bureau checks prior to assisting in schools. A male postgraduate student volunteered to help us in schools and we were unsure how female participants would feel about having a man present in the medical room (he measured their height). This concern was unfounded, however, as most participants found his ‗funky‘ hairstyle and piercings a talking point, rather than his gender off-putting. There were some occasions when we were unable to organise two research assistants to attend the school visits and school-based nurses offered to help take measurements on these occasions. It proved more difficult to use the research protocol at these times, and school-based nurses were more

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likely to comment on participants‘ weight or height and to enter into discussion when asked by participants if their weight or height was ‗normal‘. Table 1. Protocol for weighing and measuring young people in schools

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Young people were informed that weight and height measurements would not be disclosed to school-staff or parents. Digital scales with a remote monitor were used so that participants could not easily see their weight on the display. Scales were positioned away from walls so that bigger participants would not be impeded during the weighing process. Participants were asked to remove shoes and outdoor jackets/bulky sweaters. Young people were sent to the school nurse office or medical suite to be measured in pairs or small groups of 4-5; this was dependent on behavior and advice from teachers in each school. Participants entered the room one at a time Two members of the research team were present at all times - one to measure height and one to measure weight. Using research assistants who were experienced or sensitive to the needs of young people was crucial for reassuring anxious participants. Research assistants were instructed not to enter into dialogue with participants about their weight. Leaflets with details of local and national organisations (e.g. internet sites; drop in centres; telephone help lines) were given to all young people who participated.

ENSURING PARTICIPANTS‟ PRIVACY Despite the measures we took to ensure that young people gave informed consent to participate, and the unequal adult-child power relations evident in most classroom settings, we had not anticipated how much pressure young people would be under to reveal their height and weight measurements to their peers. In study one, we rather naively wrote height and weight measurements on each individual‘s questionnaire. This resulted in some young people having their questionnaires taken from them by classmates to compare measurements and little opportunity for young people to keep their weight and height private. In study two, participants‘ unique questionnaire identification numbers and height and weight measurements were written on a chart kept by the research team in the medical room. Despite this, and the fact that we did not openly reveal measurements unless young people asked for them, many still wanted to discuss their height and weight with their peers when they returned to the classroom. Some declined, or said they did not know, which meant they could maintain their privacy, but many young people engaged in comparing whether they were the ‗biggest‘ or ‗smallest‘ in the class. Whilst some happily engaged in this sharing exercise, others looked uncomfortable doing so. Teachers often joined in, offering their own height and weight as comparison measures. We were surprised to find that the majority of young people could not comprehend kilogram measurements (which is the metric used in the

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school curriculum in the UK) and therefore the comparisons they were offering were in terms of being the ‗highest‘ or ‗lowest‘ rather than their weight having any meaningful value. Young people often asked the research team how they could convert their weight into ‗stones‘ or how they could calculate their BMI. Determining a teenager‘s weight status requires consulting a chart which takes account of age (in months) and gender (Cole, Bellizzi, Flegal, & Dietz, 2000). We usually claimed we could not help participants calculate their BMI or convert their weight measurement, as we did not wish to enable young people to do this. This was a relatively uncontrolled setting, with little privacy and we were not in a position to counsel individual students on what their BMI ‗meant‘. Some teachers, however, did tell their class how to convert their weight measurements, and some saw this as an opportunity for a class mathematics activity. Our concerns about what young people would do with this information were not unfounded. On several occasions when the researcher arrived to interview a participant in their home, they said they had not realised before we weighed/measured them that they were the ‗biggest‘ in their class, or that their friend was ‗that big‘.

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THE MULTIPLE ROLES OF RESEARCHERS This raises questions about the multiple roles or positions of researchers conducting research on diet and weight (Swain, 2006). We introduced ourselves to young people as university researchers interested in teenager‘s views and experiences. The core research team are all social scientists though the first author is also a public health nutritionist. During classroom visits, despite our reassurances that we were interested in hearing young people‘s views, the researcher stood in front of the class perhaps instilling the idea that we were somehow ‗in charge‘ as this is where the teacher usually stands. Some young people, and their teachers and parents, assumed that the researcher with whom they had most contact was an expert in nutrition counselling, child behaviour or weight management. Whilst the research team were happy to engage with young people on the research topic and the research process as a whole, we felt unqualified and uncomfortable stepping beyond this role to one of ‗practitioner‘.

DISCUSSION Our experiences of recruiting young people on these two contemporary projects of perceptions of diet, weight and health have given us an insight into the practicalities of school-based recruitment. The school setting was found to be effective for the recruitment of a relatively large number of young teenagers, from different social groups and with a range of BMIs. Whilst Testa and Coleman (2006) found that using fieldworkers, rather than teachers, to administer questionnaires increased the number of young people willing to provide their personal socio-demographic details, this was not our experience, particularly with regard to middle class youth. In common with Testa and Coleman (2006) however, we found that using fieldworkers, rather than teachers, was an effective strategy for ensuring that research runs smoothly in schools.

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Whilst we took steps to ensure that young people had enough information in order to make their own decisions about participating in the research, and that they were weighed/measured in private, it is questionable whether we prepared participants for the ‗consequences‘ of being weighed and measured in school. Indeed, we were also underprepared for the way that young people ‗took‘ and used this information. Researchers need to consider our experiences, and further debate is needed, to discuss whether and how, such consequences should or could be avoided.

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RECOMMENDATIONS We have the following recommendations to make to other researchers recruiting for research in schools, particularly research, which involves weighing and measuring young people. All personnel involved in weighing and measuring young people need to be fully trained and supervised using a detailed research protocol. This includes training school-based nurses or other school-staff, if appropriate. The possible risk of using research assistants or practitioners untrained in the requirements of the research, in terms of potentially raising anxieties amongst young people about their weight, or leaving young people with questions about their bodies, which remain unanswered lead us to conclude that delaying school-visits is preferable to using untrained personnel. Conducting research in a school setting allows schools and their students to become an active part of a ‗live‘ research project (National Teacher Research Panel, 2008) but it can also be disruptive to class timetables and to teaching staff (David et al., 2001). We would suggest that researchers take the time to meet relevant teaching staff in advance of research being conducted, rather than engaging solely with senior or supervisory staff. This should help with the smooth running of research in the classroom. This would also give researchers an opportunity to explain the nuances of a particular project. For example, in our research it was important that school staff did not single out overweight young people. Additional assistance in helping to ensure young people could give their own informed consent in the classroom setting and were able to keep their weight and height measurements private would also have been hugely beneficial. We found that having one researcher remain in the classroom throughout the lesson period, to answer questions and reassure individuals about aspects of the project which they were concerned, helped young people to decide whether to participate in the research. This period, after the initial time when students were informed about the research, when other young people and teachers were either busy completing questionnaires, chatting with each other or being set other work by the teacher, meant that the researcher could talk in relative privacy to individual students.

CONCLUSION As levels of childhood obesity continue to rise in developed countries like the UK, it is essential that research be undertaken to explore young people‘s own experiences of diet,

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The Challenges of Conducting Research in Schools on Obesity ...

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weight and health. It is also imperative, however, that such research is of a robust design, which gives young people the opportunity to provide fully informed consent and that participation does not cause undue distress. Researchers must take account of the nuances of implementing research in schools and use the experience of others to develop a research protocol that is appropriate for the age of the sample and the setting in which the research is conducted. Researchers need to consider their own multiple positions as gendered, educated adults who are seen in positions of authority by young people. Their perceived role as ‗experts‘ in nutrition or obesity also needs consideration as countering such perceptions, if they are inaccurate, may shift the way that young people, parents and teachers interact with research and researchers.

ACKNOWLEDGEMENTS The first study, of young teenagers from lower socio-economic groups, was supported by the Research Unit in Health, Behaviour and Change at the University of Edinburgh and NHS Health Scotland. The second study, of higher socio-economic teenagers, was supported by the Economic and Social Research Council (Ref: RES-OOO-23-1504).We would like to acknowledge Susan Gregory and Donna MacKinnon who were co-investigators on the first and second studies respectively. We would like to thank all of the young people and schools who participated in the research and the doctoral students and colleagues who assisted during the fieldwork phases of the research.

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REFERENCES Backett-Milburn, K., Wills, W. J., Gregory, S. & Lawton, J. (2006). Making sense of eating, weight and risk in the early teenage years: views and concerns of parents in poorer socioeconomic circumstances. Social Science & Medicine, 63(3), 624-635. Cole, T., Bellizzi, M., Flegal, K., & Dietz, W. (2000). Establishing a standard definition for child overweight and obesity worldwide: international survey. British Medical Journal, 320, 1-6. David, M., Edwards, R., & Alldred, P. (2001). Children and school-based research: 'informed consent' or 'educated consent'? British Educational Research Journal, 27(3), 347-365. Mellor, J., Rapoport, R., & Maliniak, D. (2008). The impact of child obesity on active parental consent in school-based survey research on healthy eating and physical activity. Evaluation Review, 32(3), 298-312. Morrow, V. (1996). The ethics of social research with children: an overview. Children and Society, 10, 90-105. National Teacher Research Panel. (2008). Housing research in school: securing benefits for schools, teachers and researchers. Retrieved November 3, 2010, from http://www.standards.dfes.gov.uk/ntrp/ourwork/hostingresearch/ Swain, J. (2006). An ethnographic approach to researching children in junior school. International Journal of Social Research Methodology, 9(3), 199-213.

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Testa, A., & Coleman, L. (2006). Accessing research participants in schools: a case study of a UK adolescent sexual health survey. Health Education Research, 21(4), 518-526 Wills, W. J., Backett-Milburn, K., Gregory, S., & Lawton, J. (2005). The influence of the secondary school setting on the food practices of young teenagers from disadvantaged backgrounds in Scotland. Health Education Research, 20(4), 458-465. Wills, W. J., Backett-Milburn, K., Gregory, S., & Lawton, J. (2006). Young teenagers‘ perceptions of their own and others‘ bodies: A qualitative study of obese, overweight and ‗normal‘ weight young people in Scotland. Social Science & Medicine, 62(2), 396-406. Wills, W. J., Backett-Milburn, K., Gregory, S., & Lawton, J. (2008). ‗If the food looks dodgy I dinnae eat it‘: Teenagers‘ accounts of food and eating practices in socio-economically disadvantaged families. Sociological Research Online, 13(1). Wills, W. J., Appleton, J. V., Magnusson, J. E., & Brooks, F. (2008). Exploring the limitations of an adult-led agenda for understanding the health behaviors of young people. Health and Social Care in the Community, 16(3), 244-252.

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In: Current Issues and Controversies in School and Community ... ISBN 978-1-62100-327-4 Editor: Jennifer A. O‘Dea © 2012 Nova Science Publishers, Inc.

Chapter 2

SUICIDAL BEHAVIOR AND PREVENTION IN ADOLESCENCE 1

Hatim A. Omar,1,* and Joav Merrick1,2

Adolescent Medicine and Young Parent Programs, J422 Kentucky Clinic, Department of Pediatrics, Kentucky Children‘s Hospital, University of Kentucky College of Medicine, Lexington, Kentucky, United States of America 2 National Institute of Child Health and Human Development, Office of the Medical Director, Division for Mental Retardation, Ministry of Social Affairs, Jerusalem, Israel

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Suicidal behavior in youth is not uncommon and currently one of the leading causes of death in adolescence in many countries around the world. Individual risk factors for suicidality in youth include: psychiatric disorder; certain personality characteristics; genetics; gender; sexual orientation; and previous suicide attempts. Family psychopathology and environmental factors such as media contagion also contribute as risk factors. Developmental issues, including: the establishment of independence and intimate relationships; as well as the pursuit of personal and career goals; may also provide stressors leading to suicidality. Prevention and intervention strategies are considered and include: early detection and treatment of mental disorders that increase suicide risk; increasing mental health services; training non-mental health professionals to assess for suicidality in young people; and providing post-attempt assessment and treatment.

*

Correspondence: Professor Hatim A Omar, MD, FAAP, Director of Adolescent Medicine and Young Parent programs, J422 Kentucky Clinic, Department of Pediatrics, Kentucky Children‘s Hospital, University of Kentucky College of Medicine, Lexington, KY 40536 United States. E-mail: [email protected].

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Hatim A. Omar and Joav Merrick

INTRODUCTION Suicide is a leading cause of death across the lifespan in many countries, the third cause of death in 15-24 year-olds and fourth cause of death in 25-44 year-olds (Merrick & Zalsman, 2005; Minino et al., 2006). Suicide in youth has been estimated to reach its peak between the ages of 19 and 23 years (Shaffer et al., 2001) or between the ages of 18 and 24 years (World Health Organization, 1999). Some authors (Reynolds, 1991) have reported that the average level of suicidal ideation experienced by college students was higher than that experienced by same-age young adults in the community. College student surveys have shown that as many as 50% admit to past-year suicidal thinking with 8-15% acting on those thoughts (Brener, Hassan, & Barrios, 1999). Other studies challenge the claim of a higher suicide rate among college students compared to non-college peers when reported figures are scrutinized statistically (Lipschitz, 1990). In a comprehensive attempt to compare the incidence of suicide among college students to a matched national sample of non-college peers, Silverman et al., (1997) found that for the 10-year period studied, college students had half the suicides of the non-college sample, i.e., 7.5 suicides per 100,000 for college students compared with 15 suicides per 100,000 for the non-college sample. They concluded that their findings supported those of others who found a lower overall suicide rate in college students versus the general population (Schwartz, 1990; Schwartz & Whitaker, 1990).

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RISK FACTORS In a longitudinal study, 496 young people aged between 10-21 years, who had committed suicide during 1981-97 in Denmark, (Agerbo et al., 2002) were compared in terms of family and individual psychiatric and socio-economic factors with over 20,000 controls, matched for gender, age and time. Parental factors associated with an increased risk of suicide included: suicide or premature death; admission to hospital for a mental disorder; lack of employment; inferior education/schooling; low income; divorce; mental illness in siblings; and mental illness and short periods of schooling among the young people themselves. The strongest determinant or risk factor was mental illness in the young people. The effect of parents‘ socioeconomic status decreased, after adjustment for a family history of mental illness and a family history of suicide. Risk factors for suicide in the school setting include some of the issues listed here and some we will discuss in more detail: Previous suicide attempts; Close family member who has committed suicide; Past psychiatric hospitalization or mental illness; Recent losses: This may include the death of a relative, a family divorce or a break-up with a girl- or boyfriend; Social isolation; Drug or alcohol abuse; Exposure to violence in the home or the social environment; Handguns in the home.

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Suicidal Behavior and Prevention in Adolescence

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Mental Health as a Risk Factor Psychiatric disorders have been shown to play a major role in youth suicidal behavior (Beautrais, 2003) and up to 90% of completed suicides have at least one disorder at the time of death. Those with multiple or comorbid mental disorders have a elevated risk of suicidal behavior compared to those with no disorder (Shaffer et al,, 1996). Mood disorders, like major depression and bipolar disorder have been shown to produce significantly elevated risks of suicidal behavior in college students (Lester, 1999). Depression is the most common diagnosis among young adults who have attempted or completed suicide. Substance abuse has also been associated with suicidal behavior (Shaffer et al,, 2001), and studies have found evidence of alcohol/substance abuse in 38% to 54% of youth suicide victims (Miller & Glinski, 2000). Externalizing disorders, i.e., conduct disorder, oppositional defiant disorder, antisocial personality disorder, have significant correlations with suicidal behavior in young people. Shaffer et al. (1996) found that those with conduct disorder had three times the probability of suicide than those without such disorder. Anxiety disorders have also been shown to have a small, but significant association with suicidal behavior in youth (Beautrais, 2003) and those with psychotic disorders are at high-risk for suicidal behaviors. However, since these disorders affect relatively few young people, they make a small contribution to overall rates of suicidal behavior in this population (Beautrais, 2003).

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Personality A number of studies have looked at personality characteristics associated with suicidality in young adults. Among the characteristics found to be associated are dependency and selfcriticism (Fazaa & Page, 2003), high scores on measures of neuroticism (Chioqueta & Stiles, 2005) and hopelessness (Shaffer et al., 1996; Merrick & Zalsman, 2005) and positive attitudes toward suicide (Gibb et al., 2006).

Genetics A strong predictor of suicidal behavior in young people is the presence of a family history of suicidal behavior (Mann, Brent, & Arango, 2001), suggesting a genetic component to suicide. Twin studies have shown moderate levels of inheritability in which up to 45% of variance in suicidal behavior may be genetic (Statham et al., 1998). In recent years, researchers have attempted to identify marker genes with a particular focus on those involving the serotonergic system, but the results are so far inconclusive (Merrick & Zalsman, 2005).

Gender Being male places one at much higher risk for a completed suicide. While females attempt suicide much more frequently (Shaffer et al., 2001), among 20-24 year-olds, the ratio

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Hatim A. Omar and Joav Merrick

of male to female completed suicide is greater than 6:1 (National Center for Health Statistics, 2006). Method of suicide also varies between genders, with ingestions accounting for approximately 16% of 15-24 year-old female suicides, but for only 2% of suicides in males; males are much more likely to use firearms (Shaffer et al., 2001; Merrick & Zalsman, 2005). Kirkcaldy et al. (2006) explored the determinants of self-injury and attempted suicide among adolescents in psychiatric care. They were able to identify common and specific social and psychological factors of covert aggression. For example: age; disharmony within the family; and excessive parental demands, emerged as significant global determinants of suicidal behaviour for both male and female adolescents. The same variables, however, were unrelated to self-injurious or socially disruptive behaviour, the latter being more associated with parental under-involvement and feelings of hostile rejection. Gender specific predictors of self-injurious and suicidal intent were found. Intelligence and age were significant predictors of overt aggression among females only. Moreover, although intellectual functioning, number of siblings and disability among family members emerged as major determinants of suicidal behaviour among males, this was not the case for females.

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Sexual Orientation Research has shown that young people who identify as gay, lesbian, or bisexual (GLB) were twice as likely to have a history of suicidal behavior than their heterosexual peers (Russell & Joyner, 2001). Stressors associated with suicidal behavior in this population include interpersonal turmoil associated with publicly acknowledging one‘s sexual identity, especially to parents, discrimination and victimization related to sexual orientation (Cochran, 2001). Another study showed that primarily heterosexual college students did not respond empathically to GLB‘s suicidal behavior.Due to the negative attitude of parents to ‘coming out,‘. This was in contrast to their empathic response to suicidal behavior in someone informed about an incurable illness (Cato & Canetto, 2003). These results suggest that young heterosexual adults may not be accepting of gay lifestyles.

Prior Suicide Attempts Previous suicide attempts predict higher probability of future suicide attempts (Gould et al., 2003; Shaffer et al., 2001). Estimates have ranged from 18%-50% for those completed suicides with a past attempt (Rudd, Joiner, & Rajab, 1996), indicating wide variability in studies, regarding numbers of attempters completing suicide. Rudd, Joiner, & Rajab (1996) in an effort to bring clarity to the issue of which attempters become completers, divided their sample into ideators, attempters, and multiple attempters. They found that multiple attempters showed more severe symptoms and elevated suicide risk relative to both ideators and attempters. A more recent study (Joiner et al., 2005) looked at four different samples differing in age, clinical severity, and gender, and found that past to current suicidality was direct and not accounted for by covariates, indicating that past suicidiality may be a causal factor in future suicidality.

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Suicidal Behavior and Prevention in Adolescence

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Family Issues and Life Events Parental psychopathology, depression, and substance abuse all contribute as risk factors for youth suicide. Parental or family discord and/or parental separation or divorce have an impact as well (Gould et al., 1996; Merrick & Zalsman, 2005). Negative life events have been shown to be related to suicidality in youth (Joiner & Rudd, 2000). A history of physical and/or sexual abuse during childhood (Beautrais et al., 1996) has also been associated with sexual abuse being more significant. Brown et al. (1999) estimated that between 16.5% and 19.5% of suicide attempts in young adults may be due to child sexual abuse, but forms of childhood maltreatment have also been shown as risk factors (Gratz, 2006). Environmental factors that influence suicidality in youth include media-generated exposure. An increased rate in suicides and an increase in the depicted method of suicide has been seen, following suicides shown on television. Adolescents and young adults appear to be most easily affected by media influence, with only minimal effects after age 24 (Gould et al., 2003).

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PREVENTION AND INTERVENTION Whenever feasible, the best approach to school-based suicide prevention activities is teamwork that includes: teachers; school health professionals;school psychologists; and school social workers; working in close cooperation with community services. Studies indicate that the best way to prevent suicide is through early detection and treatment of depression and other psychiatric illnesses that increase suicide risk. Beautrais et al. (1996) found evidence that the elimination of mood disorders would result in reductions of up to 80%for those in risk of a serious suicide attempt. This is not to imply that factors other than mood disorders are unimportant in suicidal risk, but adequate recognition and treatment of mental disorders are good first steps toward suicide prevention. Prevention of suicide may often depend upon front-line professionals who see suicidal youth. These professionals will not likely be mental health professionals, so primary care physicians and others who have substantial contact with youth need to be aware of and screen for suicidal ideation.; Such assessment needs to occur before a suicide attempt as well as after an unsuccessful one. A number of studies have shown that deliberate self-harm patients who presented to emergency rooms and left without a psychosocial and/or psychiatric assessment were more likely to engage in subsequent self-harm (Kapur et al., 2002). Thus, prevention of suicide must include intervention, regarding the precursors of the ideation, intention, and behavior as well as continued assessment and treatment subsequent to a suicide attempt. Warning signs of suicide and identification of stress, with any sudden or dramatic change affecting performance, attendance or behaviour should be taken seriously. Warning signs may include: Suicidal talk; Preoccupation with death and dying; Signs of depression;

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Hatim A. Omar and Joav Merrick Behavioral changes; Giving away special possessions and making arrangements to take care of unfinished business; Difficulty with appetite and sleep; Taking excessive risks; Increased drug use; Loss of interest in usual activities; Lack of interest in usual activities; An overall decline in grades; Decrease in effort; Misconduct in the classroom; Unexplained or repeated absence or truancy; Excessive tobacco smoking or drinking, or drug (including cannabis) misuse; Incidents leading to police involvement and student violence.

These factors can help to identify students at risk and if any of these signs are identified by a teacher or school counselor, the school team should be alerted and arrangements made to carry out an evaluation of the student.

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REFERENCES Agerbo, E., Nordentoft, M., & Mortensen, P.B. (2002). Familial, psychiatric and socioeconomic risk factors for suicide in young people: Nested control group. British Medical Journal, 325,74. Beautrais, A. L., Joyce, P. R., Mulder, R. T., et al. (1996). Prevalence and comorbidity of mental disorders in persons in serious suicide attempts: A case-control study. American Journal of Psychiatry, 153, 1009-1014. Beautrais, A. L. (2003). Life course factors associated with suicidal behaviors in young people. American Behavioral Scientist, 46, 1137-1156. Brener, N. D., Hassan, S. S., & Barrios, L. C. (1999). Suicidal ideation among college students in the U.S. Journal of Consulting and Clinical Psychology, 67, 1004-1008. Brown, J., Cohen, P., Johnson, J.G. et al. (1999). Childhood abuse and neglect: Specificity of effects on adolescent and young adult depression and suicidality. Journal of the American Academy of Child Psychiatry, 38, 1490-1496. Cato, J. E., & Canetto, S. S. (2003). Young adults‘ reactions to gay and lesbian peers who became suicidal following ‘coming out‘ to their parents. Suicide and Life-Threatening Behavior, 33, 201-210. Chioqueta, A. P., & Stiles, T. C. (2005). Personality traits and the development of depression, hopelessness, and suicide ideation. Personality and Individual Differences, 38, 12831291. Cochran, S. D. (2001). Emerging issues in research on lesbians‘ and gay men‘s mental health: Does sexual orientation matter? American Psychologist, 56, 931-947. Fazaa, N., & Page, S. (2003). Dependency and self-criticism as predictors of suicidal behavior. Suicide and Life-Threatening Behavior, 33, 172-185.

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Gibb, B. E., Andover, M. S., & Beach, S. R. H. (2006). Suicidal ideation and attitudes toward suicide. Suicide and Life-Threatening Behavior, 36, 12-18. Gould, M. S., Fisher, P., Shaffer, D. et al. (1996) Psychosocial risk factors of child and adolescent completed suicide. Archives of General Psychiatry, 53, 1155-1162. Gould, M. S., Greenberg, T., Velting, D. M. et al. (2003). Youth suicide risk and preventive interventions: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 386-405. Gratz, K. L. (2006). Risk factors for deliberate self-harm among female college students: The role and interaction of childhood maltreatment, emotional inexpressivity, and affect intensity/reactivity. American Journal of Orthopsychiatry, 76, 238-250. Joiner, T. E., & Rudd, M.D. (2000). Intensity and duration of suicidal crises vary as a function of previous suicide attempts and negative life events. Journal of Consulting and Clinical Psychology, 68, 909-916. Joiner, T. E., Fitzpatrick, K. K., Marcelo, T. B. et al. (2005). Four studies of how past and current suicidality relate even when ―ev erything but the kitchen sink‖ is covaried. Journal of Abnormal Psychology, 114, 291-303. Kapur, N., House, A., Dodgson, K. et al. (2002). Effect of general hospital management on repeat episodes of deliberate self-poisoning: Cohort study. British Medical Journal, 325, 866-867. Kirkcaldy, B.D., Brown, J., & Siefen, R.G. (2006). Self-injury, suicidal ideation and intent and disruptive behavioural disorders: psychological and sociological determinants among German adolescents in psychiatric care. International Journal of Adolescent Medicine and Health, 18(4), 597-614. Lester, D. (1999) Locus of control and suicidality. Perceptual and Motor Skills, 89, 1042. Lipschitz, A. (1990). College suicide: A review monograph. New York: American Suicide Foundation. Mann, J. J., Brent, D. A., & Arango, V. (2001). The neurobiology and genetics of suicide and attempted suicide: A focus on the serotonergic system. Neuropsychopharmacology, 24, 467-477. Merrick, J., & Zalsman, G. (2005). Suicidal behavior in adolescence. An international perspective. London: Freund Publishing House. Miller, A. L., & Glinski, J. (2000). Youth suicidal behavior: Assessment and intervention. Journal of Clinical Psychology, 56, 1131-1152. Minino, A. M., Heron, M. P., & Smith, B. L. (2006). Deaths: Preliminary data for 2004. National Vital Statistics Report, 54 (19), National Center for Health Statistics. National Center for Health Statistics (Centers for Disease Control and Prevention) (2006). Death rates for 113 selected causes, by 5-year age groups, race, and sex: United States, 1999-2003. Worktable GMWK291R, pages 373-376. Web site:http://www.cdc.gov/ nchs/datawh/statab/Mortfinal2003_worktable291r.pdf. Retrieved November 13, 2006 Reynolds, W. M. (1991). Psychometric characteristics of the adult suicidal ideation questionnaire in college students. Journal of Personality Assessment, 56, 289-307. Rudd, M.D., Joiner, T., & Rajab, M. H. (1996). Relationships among suicide ideators, attempters, and multiple attempters in a young-adult sample. Journal of Abnormal Psychology, 105, 541-550. Russell, S. T., & Joyner, K. (2001). Adolescent sexual orientation and suicide risk: Evidence from a nation study. American Journal of Public Health, 91, 1276-1281.

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Schwartz, A. J. (1990). The epidemiology of suicide among students at colleges and university in the United States. Journal of College Student Psychotherapy, 4, 25-44. Schwartz, A. J., & Whitaker, L. C. (1990). Suicide among college students: Assessment, treatment and intervention. In S. J. Blumenthal & D. J. Kupfer (Eds.), Suicide over the life cycle: Risk factors, assessment, and treatment of suicidal patients (pp. 303-340). Washington, DC: American Psychiatric Press. Shaffer, D., Gould, M.S., Fisher, P. et al (1996). Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 53, 339-348. Shaffer, D., Pfeffer, C. R., Bernet, W. et al. (2001) Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 24S-51S. Silverman, M. M., Meyer, P. M., Sloane, F. et al. (1997) The Big Ten student suicide study: A 10-year study of suicide on Midwestern university campuses. Suicide and Life Threatening Behavior, 27, 285-303. Statham, D. J., Heath, A. C., Madden, P. A. F. et al. (1998) Suicide behaviour: An epidemiological and genetic study. Psychological Medicine, 28, 839-855. World Health Organization (1999) Figures and facts about suicide. Department of Mental Health, World Health Organization. Geneva, Switzerland

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In: Current Issues and Controversies in School and Community ... ISBN 978-1-62100-327-4 Editor: Jennifer A. O‘Dea © 2012 Nova Science Publishers, Inc.

Chapter 3

ABSTINENCE ONLY UNTIL MARRIAGE PROGRAMS IN THE UNITED STATES OF AMERICA (USA): SCIENCE AND HUMAN RIGHTS John S. Santelli1,*, Mary A. Ott2, Joanne Csete1, Shama Samant1 and Dana Czuczka 1

Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, US 2 Section of Adolescent Medicine, Department of Pediatrics, Indiana University School of Medicine, US

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ABSTRACT Promotion of abstinence only until marriage (AOUM) programs has been a failed social experiment in the United States of America (USA), one that dangerously influenced global health thinking about adolescent sexual and reproductive health. While implemented widely in the USA through public health systems and public schools after 1998 and community-based organizations after 2000, the consensus of medical and public health organizations rapidly turned against these programs in the 2000s. In a key policy paper, the Society for Adolescent Health and Medicine (SAHM) described abstinence from sexual intercourse as a potentially healthy choice particularly for younger adolescents and those deciding they were not ready for sexual involvement. SAHM pointed out that few Americans remain abstinent until marriage, abstinence intentions often fail, and that abstinence as a sole option for teens is problematic from the perspectives of both science and human rights. Scientific critiques of AOUM programs note a lack program efficacy, the poor design of such programs, and a lack of medical accuracy in commonly used curricula, particularly misinformation about condoms. Program expectations are commonly inconsistent with the sexual realities of young people‘s lives and inconsistent with parent preferences for comprehensive sexuality education (e.g., sexuality education that includes discussion about abstinence and birth control) (Albert, 2010). Rights-based critiques include: withholding life-saving *

Correspondence: Professor John S Santelli, Chair, Heilbrunn Dept of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY 10032, USA. Email: [email protected].

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John S. Santelli, Mary A. Ott, Joanne Csete et al. information; censoring of textbooks and teachers; promotion of sexist and racist stereotypes; and insensitivity and unresponsiveness to lesbian, gay, bisexual, transgendered, and questioning (LGBTQ) youth. As such, AOUM programs are counter to standards in medical ethics and international human rights that prioritize informed consent and right to health information. The waning of such programs in the USA reflects: these scientific and human rights concerns; the effective use of key scientific arguments; the rejection of programs by mainstream public health officials; and change in political leadership.

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INTRODUCTION : HISTORY OF AOUM PROGRAMS IN THE USA Promoting abstinence from sexual intercourse has been a popular strategy to prevent unintended pregnancy and infection from human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) among young people in the USA. Abstinence promotion has been particularly popular among social and religious conservatives, but abstinence is also recognized as a behavioral prevention strategy by the USA Public Health Service (Healthy People, 2010). Given high rates of unplanned pregnancy and STIs among adolescents and young adults, abstinence may be a healthy choice, particularly for younger adolescents and for people at any age who decide they are not ready for sexual involvement given their current life circumstances (Ott, 2006; Santelli, 2011). But abstinence intentions often fail (Bruckner, 2005; Rosenbaum, 2009) and government policies promoting abstinence as the sole response to adolescent pregnancy and STI prevention should not be conflated with abstinence as a personal choice, as the two have vastly different implications. Governments‘ exclusive promotion of abstinence raises serious ethical and human rights concerns (Ecker, 2009; National Guidelines, 2004). Over the 12 years between 1998 and 2009, the USA federal government invested almost $2.0 billion in AOUM, funding over 800 state and local programs. The USA government provided some support to AOUM programs as early as 1981 via the Adolescent Family Life Act. After 1996, major expansions occurred in federal support for abstinence programming, and the emphasis shifted to abstinence-only-until-marriage and abstinence as a singular objective. While enacted by a conservative Congress under President William Clinton, abstinence became the leading federal government strategy for dealing with adolescent sexuality under President George W. Bush (2001-08). The expansion of federal support for AOUM included Title V, a new program state governments enacted in 1996, and Community-Based Abstinence Education (CBAE) projects in 2000 (Dailard, 2002). The CBAE program was promoted by social conservatives in Congress who wanted a more rigorous focus on abstinence and who felt that state health departments were not vigorously enforcing programs‘ restrictions. The CBAE project redirected funding to faith-based organizations and by 2001 the majority of federal support for AOUM was flowing through the more restrictive CBAE program (Dailard, 2002). At the same time, social conservatives were leading many states in requiring the teaching of abstinence in public schools as either a primary or an exclusive focus (Kantor & Bacon, 2002). Restriction of health information (abstinence only) and espousing scientifically inaccurate health information have been key concerns of federal AOUM programs. By definition, the federal AOUM programs were required to have the promotion of abstinence outside of marriage (for people of any age) as their ‗exclusive purpose‘ (Dailard, 2002). They

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could in no way advocate contraceptive use or discuss contraceptive methods except to emphasize their failure rates. These federal programs also prohibited dissemination of information on sexual identity and other aspects of human sexuality (Dailard, 2002). The Passage of Title V in 1996 reflected the growing strength of religious conservatives (primarily evangelical Christians), both as a political movement and as power brokers in the USA Congress. The ‗Religious Right‘ (i.e., primarily Christian, religious conservatives) has been a key influence in the development and promotion of AOUM education in the USA. Specifically, conservative evangelicalism became a potent political force in public policy debates about human sexuality (Balmer, 2006). Evangelicals rejected the sexual revolution of the 1960s and their embrace of the anti-abortion movement in the late 1970s was a reaction to what they regarded as rampant and unchecked sexual license (Kantor et al., 2008). The AOUM movement was a logical consequence, including the emphasis on traditional gender roles and marriage as the only appropriate context for sexual behavior. The existence of both secular and religious versions of many AOUM curricula is further evidence of the religious roots of these programs (Balmer, 2006). The Obama Administration ended the majority of federal support for AOUM in 2009 and shifted funding to science-based approaches to teen pregnancy prevention. However, in budget deals needed to enact the Patient Protection and Affordable Care Act in 2010, social conservatives revived Title V AOUM funding for state governments. Many states in conservative areas, such as the South, continue to support AOUM policies. Efforts to defund AOUM programs involved a variety of advocacy efforts, both locally and nationally. These efforts relied on multiple science-based and rights-based critiques and a strong partnership between advocates and scientists. Particularly effective were scientific concerns about program efficacy and medical accuracy. Finally, efforts to defund AOUM policies involved widespread rejection by professional health and medical associations and the state public health establishment. The rest of this chapter explores a number of these scientific and rights critiques.

HARM TO COMPREHENSIVE SEXUALITY EDUCATION AND SCIENTIFIC DECISION MAKING The emphasis on abstinence-only programs coincided with restrictions on what teachers were allowed to cover in health education classes (Darroch, Landry, & Singh, 2000) and with fewer young people reporting that they received information about such health topics as contraception and STI prevention (Lindberg, Santelli, & Singh, 2006). National data from 2006-2008 found that while 81% of male and 87% of female 15-19 year olds reported receiving formal instruction about ‗how to say no to sex,‘ only 62% of male and 70% of female teenagers reported receipt of instructions about methods of birth control (Martinez, Abma, & Copen 2010). Conservative support for AOUM has been described as part of a broad rejection of science as a basis for public policy, specifically where scientific evidence conflicts with religious beliefs and political ideology. Likewise, similar political battles have occurred over global warming, USA government approval of emergency contraception, and implementation of human papillomavirus vaccine programs (Scientific Integrity, 2004; Specter, 2006;

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Mooney, 2005). Tampering with scientific decision-making has included: the suppression of data collection and analysis; the muzzling of federal scientists; the packing of scientific advisory committees with members based on political or ideological considerations; the equating of fringe science with mainstream science; and the manipulation of the concept of scientific uncertainty to cast doubt on scientific findings.

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REJECTION OF AOUM BY HEALTH PROFESSIONALS All mainstream health and medical organizations in the USA support comprehensive sexuality education and many explicitly oppose AOUM approaches. The Society for Adolescent Health and Medicine provided early leadership in opposition to AOUM sex education, focusing on a lack of program effectiveness, medical inaccuracy, and obligations of health professionals to provide potentially lifesaving sexual health information (Santelli, Ott, Lyon, Rogers, & Summers, 2006). The American Academy of Pediatrics (AAP), The American Medical Association (AMA), the American Congress of Obstetrics and Gynecologists (ACOG), and the American Psychological Association (APA) all support comprehensive sex education programs (AAP, 2001; AMA, 2004; ACOG, 2005; APA, 2005). In addition, the American Public Health Association has also raised scientific and human rights concerns in rejecting abstinence-only education (APHA, 2007). While many national and state public health officials were willing to give abstinence a chance in 1998, opposition to these programs grew rapidly with a rising chorus of concerns about the program, particularly the lack of program efficacy and medical inaccuracies in commonly used AOUM curricula (Raymond et al., 2008). In fact, California never agreed to accept federal funding for AOUM promotion and between 2004 and 2007, 16 more states withdrew from the program. Before AOUM program restrictions were liberalized in 2010, half of the states had withdrawn from the program.

INCONSISTENCY BETWEEN AOUM AND THE REALITIES OF ADOLESCENT SEXUAL LIVES While abstinence until marriage is the primary goal of AOUM programs, waiting until marriage to initiate sexual intercourse is rare. Data from the USA National Survey of Family Growth (NSFG) (Finer, 2007) demonstrates this reality. By age 44 years, 95% of Americans have had pre-marital intercourse and only 3.3% report first sex after marriage. The rarity of sexual initiation after marriage today is the result of two global demographic trends. Across developed nations, the age at initiation of sexual intercourse has declined since the mid-20th century, as the average age at first marriage has risen (Kantor et al., 2008). In 1960, the median age at first marriage in the USA was approximately 20 years among women and 23 among men. By 2000, the median ages among women and men had risen to 25 and 27 years, respectively. Over this same period, the age at first sexual intercourse declined. In 1960, the median age at first sexual intercourse among women in the USA was around 20 years and was just slightly lower among men. By 2001, the median age had fallen to 17 years. Similar trends in marriage and age at first sex are apparent throughout the developed world.

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Today, the median age at first sexual intercourse is close to 17 years in much of the developed world. Eliminating the seven- to ten-year gap between the age at first sexual intercourse and the age at first marriage that American youth currently experience seems rather unrealistic. Moreover, while sexual intercourse among teens has increased dramatically over the past 50 years, rates of teen pregnancy have declined dramatically across developed nations (Teitler, 2002). The coexistence of these two trends suggests that there is little relationship between the timing of first sexual intercourse and teenage pregnancy. Rather, declines in teen pregnancy are primarily the result of modern contraception.

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CONCERNS ABOUT THE MEDICAL ACCURACY OF COMMONLY USED AOUM CURRICULA Concern about the medical accuracy of AOUM curricula began in 2004 with the release of a Congressional report from Representative Henry Waxman. The report reviewed 13 commonly used abstinence-only curricula and found that 11 of the 13 curricula contained false, misleading, or distorted information about reproductive health, including inaccurate information about contraceptive effectiveness and the risks of abortion. Moreover, these curricula treated stereotypes about girls and boys as scientific fact and blurred religious and scientific viewpoints. (Committee on Government Reform, 2004). Subsequent reviews have found serious problems with the accuracy of information about condoms in AOUM curricula; lessons about condoms frequently state or imply that condoms are ineffective (Lin & Santelli, 2008). By 2006, 21 of the 50 USA states, implemented requirements for scientific or medical accuracy in sexuality education and HIV prevention programs (Santelli et al., 2007). Although seemingly uncontroversial, these requirements responded to the increasing injection of ideology into sexuality education.

LACK OF EFFICACY OF AOUM PROGRAMS An important critique of AOUM programs is their failure to change adolescent behaviors. Abstinence is potentially one of several behavioral strategies to prevent unintended pregnancy and STIs. In comprehensive sexuality approaches, abstinence is used in conjunction with other behavioral strategies such as contraceptive use, condom use, and decreasing the number of sexual partners. Increased abstinence accounted for approximately one fourth of the decline in pregnancy rates for 15-17 year-olds in the USA from 1994-2002 (Santelli, Lindberg, Finer, & Singh, 2007). While rates of sexual involvement among teens in the USA declined modestly between 1991 and 2001, most of the decline in teen pregnancy during this period was the result of improved condom and contraceptive use. This decline is commonly ascribed to HIV education efforts, which began in the 1980s and not with federal AOUM programs which began in 1998. As with other prevention behaviors, abstinence has a failure rate. If a young person uses abstinence perfectly, its failure rate is zero (i.e. there will be no pregnancies or STIs). However, abstinence is rarely used perfectly and, while exact data on failure rates has not

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been calculated, indirect evidence suggests that it is quite high. In a nationally representative USA survey, over half the adolescents who reported making abstinence pledges at baseline (grade 7-12) retracted that report a year later. These retractions were three times more common among those reporting sexual experience at baseline or initiating sexual experience in the subsequent year (Rosenbaum, 2006). In the same nationally representative study at wave three, six years later, 10% of 18-24 year- olds testing positive for an STI had reported abstinence in the previous 12 months (DiClemente, Sales, Danner, & Crosby, 2011). Together these data suggest abstinence often fails and that the promotion of other behavioral strategies is necessary. Multiple systematic reviews of program effectiveness show that abstinence is best taught in the context of comprehensive sexuality education. The weight of scientific evidence demonstrates that AOUM sexuality education programs are not effective. Using a rigorous analytic approach, a systematic review of AOUM programs in high-income countries found no effect of abstinence-only sex education on biologic (HIV acquisition, pregnancy) or behavioral (any sex, unprotected sex, condom use) outcomes (Underhill, 2007). The United Nations Educational, Scientific, and Cultural Organization (UNESCO) and the USA Centers for Disease Control and Prevention (CDC) had similar findings in their systematic reviews of sexuality education programs. For UNESCO, of the six identified abstinence-only programs with rigorous evaluations, none showed effects on behavior changes; delayed sexual onset was seen in 2/11 programs if methodologically weaker studies were included (Ecker & Kirby, 2009). The Task Force on Community Preventative Services for the CDC found insufficient evidence to support abstinence-only approaches for pregnancy and STI prevention for adolescents because of inconsistent findings across studies (Community Guide, 2010). A single, recent high profile evaluation demonstrated an abstinence curriculum to be effective; however, investigators distanced themselves from federal abstinence-only programs requirements. Importantly, the program provided participants who asked, with accurate and unbiased information on condoms and contraceptives (Jemmott, Jemmott, & Fong, 2010). In contrast, systematic reviews support the effectiveness of comprehensive approaches to sexuality education. In a rigorous systematic review of comprehensive sexuality education programs, 23 of 39 programs evaluated were found to change at least one sexual behavior, including abstinence, condom use, and unprotected sex (Underhill, 2008). Similarly, UNESCO found strong evidence that comprehensive programs (covering abstinence, contraceptive use and condom use) are effective: 38% of comprehensive programs in their systematic review delayed sexual initiation; 40% increased condom use; and 40% increased contraceptive use (Ecker & Kirby, 2009). The CDC‘s Guide to Community Preventive Services recommends comprehensive risk reduction programs for adolescent pregnancy and STI prevention. These interventions were found to delay the onset of sex, reduce other sexual risk behaviors, and increase condom and contraceptive use (Community Guide, 2010). An encouraging finding by both UNESCO and the CDC was that replications of successful programs had also been found to be successful (Ecker & Kirby, 2009; Community Guide, 2010). Surveys of USA parents show a high degree of support for comprehensive sexuality education (Albert, 2010; Bleakley, Hennessy, & Fishbein, 2006; Ito, et al., 2006). A 2010 survey by the National Campaign to Prevent Adolescent and Unintended Pregnancy showed that 84% of adults wished their teens would have access to more information on birth control and STI protection (Albert, 2010).

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HUMAN RIGHTS AND USA FOREIGN AID PROGRAMS Importantly, opposition to AOUM programs in the USA and in USA foreign aid programs also came from human rights and civil rights organizations. The USA-based international organization Human Rights Watch (HRW) investigated the abstinence-only program of the state of Texas and found it in violation of human rights norms. HRW‘s 2002 report entitled Ignorance Only charged that Texas‘ program violated students‘ right to information and discriminated against gay and lesbian students by its message that marriage is the only legitimate context for sex (HRW, 2002). (Gay marriage is illegal in Texas.) The Texas curriculum ‗informed‘ students that condoms do not prevent HIV transmission, thus also violating students‘ human right to benefit from scientific progress and ultimately to protect their own lives. These human rights arguments figured prominently in the statement on abstinence-only programs by the Society for Adolescent Medicine (Santelli et al., 2006). The American Civil Liberties Union (ACLU), an organization focused on rights guaranteed in the USA Constitution, condemned the violation of the constitutional separation of church and state through the inclusion of religious messages in abstinence-oriented public school curricula. The ACLU first litigated this issue against religiously-laden material on ‗chastity‘ in programs supported by the Adolescent Family Life Act (AFLA) of 1981. The case (Bowen versus Kendrick, 1988) eventually reached the Supreme Court, which reversed a lower court decision in finding no violation of the separation of church and state (LeClair, 2006). The Court returned the case to the lower court for settlement, where eventually conditions were placed on AFLA programs, including that public school curricula not include explicitly religious references or allow grantees to use church premises for their programs (LeClair, 2006). As AOUM programs grew under President George W. Bush, the ACLU continued to litigate against these programs, notably in the case of ACLU of Louisiana versus Foster of 2002 (ACLU, 2005). A July 2002 decision from the federal district court held for the ACLU, finding against the communication of religious messages in public schools. Human Rights Watch and the ACLU became leaders in a broader struggle to limit the human rights damage of the USA‘s exportation of ‗abstinence-only‘ through official foreign aid. The 2003 law (P.L.108-25) that created the President‘s Emergency Plan for AIDS Relief (PEPFAR), a five-year, $15 billion program, gave a boost to ‗abstinence-only‘ approaches. It specified that of the PEPFAR resources supporting HIV prevention activities, 33% had to be allocated to ―a bstinence-until-marriage‖ activities (USA Leadership Act, 2003). A slightly changed provision that still mandates abstinence programming as part of prevention activities appeared in the 2008 legislation, re-authorizing the program (USA Global Leadership Act, 2008). The impact of the 33% provision soon became apparent. In 2005, HRW investigated ‗abstinence-only‘ programs in Uganda, a country that had been widely praised for its prompt action to contain a fast-growing HIV epidemic in the 1980s and 1990s (HRW, 2005). HRW found that Uganda had jumped quickly to the perceived PEPFAR tune of removing information about condoms from school programs and sometimes also included false information alleging the ineffectiveness of condoms. The Ugandan president, who had vigorously promoted HIV prevention, began publicly denouncing condoms, particularly for young people (HRW, 2005). Some teachers told HRW that they had been instructed by USAsupported organizations to drop all mention of condoms from classroom teaching. The

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abstinence focus was a drastic turn away from open discussions about sexual transmission that had energized Uganda‘s earlier success and a loss for countries that had looked to Uganda as an example of good practice. The Governmental Accountability Office (GAO), the research arm of the USA Congress, noted that the 33% requirement impeded integration and coherence of HIV programs in some countries because ‗condom-free‘ education had to be isolated from other programs (GAO, 2006). Implementing partners in Africa were confused about whether it was completely forbidden to talk about condoms in schools or rather if only ‗promotion‘ of them was prohibited and where the line between the two was drawn. HIV educators reported that they were stymied about what to do when young people asked explicit questions about condoms (GAO, 2006). Wittingly or unwittingly, PEPFAR‘s focus on abstinence-based education had a chilling effect on programs that were striving to give young people the capacity to protect themselves from infection in highly AIDS-affected African countries. The ACLU boldly built on its domestic litigation by taking USA Agency for International Development (USAID) to court over the exportation of these abstinence-only programs through PEPFAR, continuing to argue the illegality of the use of taxpayer funds to promote religious ideas, whether in the USA or abroad (ACLU, 2010). A 2009 report of USAID‘s own Inspector General indirectly boosted the ACLU‘s argument, noting that the overtly religious content of ‗abstinence-only‘ programs supported by USAID raised constitutional questions (Office of the Inspector General, 2009). The Inspector General‘s report cited a USAIDsupported curriculum that included this ―keyconcept‖: ― God has a plan for sex, and this plan will help you and protect you from harm‖ (Office of the Inspector General, 2009). While human rights arguments did not win the day in all cases, their articulation became an important part of the international debate on AOUM programs, even as the idea of a human right to treatment was energizing other corners of a growing AIDS movement. These arguments also helped build bridges – still perhaps too weak and too few – between HIV and reproductive rights efforts, both in program design and in global and domestic advocacy.

CONCLUSIONS The promotion of abstinence only until marriage to youth in the USA has been a failure in public policy making, a failure that has engendered considerable opposition from both the scientific and human rights communities. Other nations should eschew AOUM approaches. Documentation of the scientific and rights-based problems was instrumental in reducing and eliminating federal support for AOUM programs in the USA. Partnerships between scientists and advocates and progressive political leadership were essential to changing public policy. In contrast to AOUM programs, comprehensive sexuality education has been successful in reducing adolescent sexual risk behaviors, which lead to unintended pregnancy and STIs. Ultimately, efforts to improve adolescent sexual health and health outcomes need to address the underlying social and cultural beliefs and ideologies that inhibit sexual health (Schalet, 2004).

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REFERENCES Albert, B. (2010). With One Voice 2010: America‘s adults and teens sound off about teen pregnancy. Washington, DC: The national campaign to prevent teen and unplanned pregnancy. American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health and Committee on Adolescence. (2001). Sexuality education for children and adolescents. Pediatrics, 108(2), 498-502. American Civil Liberties Union. (2005). ACLU asks court to stop Louisiana Governor‘s program on abstinence from continuing to preach with taxpayer dollars (press release). Retrieved March 24, 2005 from http://www.aclu.org/reproductive-freedom/aclu-askscourt-stop-louisiana-governors-program-abstinence-continuing-preach-t American Civil Liberties Union. (2007). ACLU of Louisiana calls on Governor‘s program on abstinence to fix medical inaccuracies in abstinence-only –until-marriage curriculum (press release). Retrieved on April 1, 2011 from http://www.aclu.org/reproductivefreedom/aclu-louisiana-calls-governors-program-abstinence-fix-medical-inaccuraciesabst. American Civil Liberties Union. (February 26, 2010). If ―God has a plan for sex,‖ does Obama have a plan for monitoring programs overseas? Message posted to http://www.aclu.org/blog/lgbt-rights-religion-belief-reproductive-freedom/if-god-hasplan-sex-does-obama-have-plan-monit. American College of Obstetricians & Gynecologists. (2005). Policies and materials on adolescent health of the American College of Obstetricians and Gynecologists, Washington, DC: ACOG. Retrieved on April 5, 2011 from http://www. acog.org/departments/dept_notice.cfm?recno=7&bulletin=3316. American Medical Association Council on Scientific Affairs. (2004). Sexuality education, abstinence, and distribution of condoms in schools. Chicago, IL: American Medical Association. American Psychological Association Committee on Psychology and AIDS. (2005). Based on the research, comprehensive sex education is more effective at stopping the spread of HIV infection, says APA Committee (Press Release). Washington, DC: American Psychological Association. American Public Health Association. (2006). Abstinence and U.S. abstinence-only education policies: Ethical and human rights concerns. Retrieved on April 5, 2011 from http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1334. Balmer, R. H. (2006). Thy kingdom come: How the religious right distorts the faith and threatens America: An evangelical‘s lament. New York: Basic Books. Bleakley, A., Hennessy, M., & Fishbein, M. (2006). Public opinion on sex education in US schools. Archives of Pediatric and Adolescent Medicine, 160(11), 1151-1156. Bowen v. Kendrick, 487 U.S. 589, (1988). Bruckner, H., & Bearman, P. (2005). After the promise: the STD consequences of adolescent virginity pledges. Journal Adolescent Health, 36(4), 271-278. Committee on Government Reform—Minority Staff, United States House of Representatives. (2004). The content of federally funded abstinence only education programs. Retrieved on April 1, 2011 from http://belowthewaist.org/podcast/2008/12/20041201102153-

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50247.pdf The Community Guide and Centers for Disease Control and Prevention. (2010). Prevention of HIV/AIDS, other STIs and pregnancy: Interventions for adolescents. Retrieved on April 5, 2011 from http://www.theco mmunityguide.org/hiv/adolescents.html. Dailard C. (2002). Abstinence promotion and teen family planning: the misguided drive for equal funding. The Guttmacher Report on Public Policy. 5(1), 1–3. Dailard, C. (2005). Administration tightens rules for abstinence education grants. The Guttmacher Report on Public Policy. 8(4), 13. Darroch, J. E., Landry, D. J., & Singh, S. (2000). Changing emphases in sexuality education in U.S. public secondary schools, 1988-1999. Family Planning Perspectives, 32(5), 204211, 265. DiClemente, R. J., Sales, J. M., Danner, F., & Crosby, R. A. (2011). Association between sexually transmitted diseases and young adults' self-reported abstinence. Pediatrics, 127(2), 208-213. Éclairs, D. (2006). Let‘s talk about sex honestly: why federal abstinence-only-until-marriage education programs discriminate against girls, are bad public policy, and should be overturned. Wisconsin Women‘s Law Journal, (21), 291-322. Ecker, N., & Kirby D. (2009). International guidelines of sexuality education: An evidence informed approach to effective sex, relationships and HIV/STI education. Paris, France: UNESCO; 2009. Finer, L. B. (2007). Trends in premarital sex in the United States, 1954–2003. Public Health Reports, 122(1), 73–78. Government Accountability Office. (2006). Global health: spending requirement presents challenges for allocating prevention funding under the President‘s Emergency Plan for AIDS Relief. GAO-06-395. Washington, DC. Retrieved on April 1, 2011 from http://www.gao.gov/new.items/d06395.pdf Healthy People.(2010) Retrieved on April 1, 2011 from http://healthypeople.gov/2020/ default.aspx. Human Rights Watch. (2002). Ignorance only: HIV/AIDS, human rights and federally funded abstinence-only programs in the United States – Texas: a case study. Retrieved on April 1, 2011 from http://www.hrw.org/legacy/reports/2002/usa0902/. Human Rights Watch. (2005). The less they know, the better: abstinence-only HIV/AIDS programs in Uganda. Retrieved on April 15, 2011 from http://www.hrw.org/en/ node/11803/section/1. Ito, K. E., Gizlice, Z., Owen-O'Dowd, J., Foust, E., Leone, P. A., & Miller, W. C. (2006). Parent opinion of sexuality education in a state with mandated abstinence education: does policy match parental preference? Journal of Adolescent Health, 39(5), 634-641. Jemmott, J. B., 3rd, Jemmott, L. S., & Fong, G. T. (2010). Efficacy of a theory-based abstinence-only intervention over 24 months: a randomized controlled trial with young adolescents. Archives of Pediatric Adolescent Medicine, 164(2), 152-159. Kantor, L. M., & Bacon, W. F. (2002). Abstinence-only programs implemented under welfare reform are incompatible with research on effective sexuality education. Journal of the American Medical Women‘s Association. 57(1), 38–40. Kantor, L., Santelli, J., Teitler, J., & Balmer, R. (2008). Abstinence-only policies and programs: An Overview. Sexuality Research & Social Policy. September 2008. 5(3), 617.

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Kittredge, D. (2006). Abstinence and abstinence-only education. Journal of Adolescent Health, 39(2), 150-151; discussion 152; author reply 152-154. LeClair, D. (2006). Let‘s talk about sex honestly: why federal abstinence-only-until-marriage education programs discriminate against girls, are bad public policy, and should be overturned. Wisconsin Women‘s Law Journal, (21), 291-322. Lin, A.J., Santelli, J.S. (2008). The accuracy of condom information in three selected abstinence only education curricula. Sexuality Research and Social Policy, 5(3), 56-69. Lindberg, L. D., Santelli, J. S., & Singh, S. (2006). Changes in formal sex education: 19952002. Perspectives on Sexual Reproductive Health, 38(4), 182-189. Martinez, G., Abma, J., & Copen, C. Educating teenagers about sex in the United States. NCHS Data Brief, (44), 1-8. Mooney, C. (2005) The Republican War on Science. New York, NY: Basic Books. Office of the Inspector General, US Agency for International Development, 2009. Audit of USAID‘s faith-based and community initiatives. Audit report no. 9-000-09-009-P, 17 July, Washington, DC. [http://www.usaid.gov/oig/public/fy09rpts/9-000-09-009-p.pdf] National Guidelines Task Force (2004). Guidelines for comprehensive sexuality education: Kindergarten through 12th grade (3rd Edition). Sexuality Information and Education Council of the United States. Office of the Inspector General, US Agency for International Development. (2009). Audit of USAID‘s faith-based and community initiatives. Audit report no. 9-000-09-009-P. Washington, DC. Retrieved on April, 2011 from http://www.usaid.gov/ oig/public/fy09rpts/9-000-09-009-p.pdf Ott, M. A., E. J. Pfeiffer, et al. (2006). Perceptions of sexual abstinence among high-risk early and middle adolescents. Journal of Adolescent Health, 39(2), 192-198. Ott, M. A., & Santelli, J. S. (2007). Abstinence and abstinence-only education. Current Opinions in Obstetrics Gynecology, 19(5), 446-452. Raymond, M., Bogdanovich, L., Brahmi, D., Cardinal, L.J., Fager, G.L., Frattarelli, L.A.C., Hecker, G., Jarpe, E.A., Viera, A., Kantor, L.M., & Santelli, J.S. (2008) State refusal of federal funding for abstinence-only programs. Sexuality Research and Social Policy, 5 (3), 44-55. Rosenbaum, J. E. (2009). Patient teenagers? A comparison of the sexual behavior of virginity pledgers and matched nonpledgers. Pediatrics, 123(1), e110-120. Santelli, J. S. (2008). Medical accuracy in sexuality education: Ideology and the scientific process. American Journal of Public Health, 98(10), 1786-1792. Santelli, J., Ott, M. A., Lyon, M., Rogers, J., & Summers, D. (2006). Abstinence-only education policies and programs: a position paper of the Society for Adolescent Medicine. Journal of Adolescent Health, 38(1), 83-87. Santelli, J. S., Lindberg, L. D., Finer, L. B., & Singh, S. (2007). Explaining recent declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use. American Journal of Public Health, 97(1), 150-156. Santelli, J. S., Kowal, D., Wheeler, E. (2011) Abstinence, noncoital sex, and nonsense: What every clinician needs to know. Contraceptive Technology (20th Edition). Atlanta, GA: Contraceptive Technology Communications, Inc. Schalet, A. (2004). Must we fear adolescent sexuality? Medscape General Medicine, 6(4), 44.

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John S. Santelli, Mary A. Ott, Joanne Csete et al.

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Scientific Integrity In Policymaking: An investigation into the Bush Administration‘s misuse of science. (2004) Retrieved on April 1, 2011 from http://www.ucsusa.org/ scientific_integrity/abuses_of_science/reports-scientific-integrity.html. Specter, M. (2006, March 13). Political science: the Bush administration‘s war on the laboratory. New Yorker, 82(4) 58-69. Teitler, J. (2002). Trends in youth sexual initiation and fertility in developed countries: 19601995. Annals of the American Academy of Political and Social Science, 580, 134-152. Underhill, K., Operario, D., & Montgomery, P. (2007). Systematic review of abstinence-plus HIV prevention programs in high-income countries. Public Library of Science Medicine, 4(9), e275. United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, Public Law No. 108-25 § 402(b) (2003). United States Global Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2008, Public Law No. 110-293 § 403(a) (2008).

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In: Current Issues and Controversies in School and Community ... ISBN 978-1-62100-327-4 Editor: Jennifer A. O‘Dea © 2012 Nova Science Publishers, Inc.

Chapter 4

SOCIAL AND EMOTIONAL TRAINING IN SCHOOL: A CONTENTIOUS MATTER IN SWEDEN Birgitta Kimber* Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden

ABSTRACT

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The chapter considers reactions to the now widespread implementation of social and emotional training (SET) programs in Swedish schools, designed to promote well-being, which raises issues relevant not only in Sweden but also internationally. SET, which has its background in the skills-for-life tradition, is examined from both researcher and practitioner perspectives. In general, SET was found to have moderate positive impacts on a range of emotional variables, reflecting aspects of mental health, but had little effect on various scales measuring social skills. Also, favorable trajectories were detected for some subgroups of SET students with regard to substance use. From a research perspective, the author argues for a nuanced approach to evidence-based practice, clarifies the role of effectiveness studies in performing evaluation, and points to the problem of attrition in real-life settings. The chapter continues with an account of some of the controversies to which the practice of SET has given rise. A distinction is made between the roles of teacher and psychotherapist, and possible harmful effects of SET are discussed with regard to bullying, confidentiality and enforced participation. While the author affirms her confidence in the capacity of teachers to handle social and emotional issues, she recognizes the needs for SET to be further developed, in particular through feedback, allocating a prominent role to school leaders, and evaluating training, fidelity and aspects of implementation. She points out that a balance is needed between the risks of harmful effects and of failing to achieve beneficial ones, and concludes by stating that the participation of stakeholders of all kinds would be welcomed in the development of SET.

*

Correspondence: Birgitta Kimber, registered psychotherapist, Department of Public Health Sciences, Karolinska Institute, SE-17177 Stockholm, Sweden. E-mail: [email protected].

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INTRODUCTION This is a discursive chapter, none of which is new, but it does apply some key concepts and distinctions to reactions to the implementation of social and emotional learning (SEL) programs in schools. SEL is an international phenomenon, where the bulk of activities have been conducted in the United States (USA). The case considered by the author is the now widespread implementation of what is called social and emotional training (SET) programs in Swedish schools, all commissioned by local municipalities or schools themselves. The issues are relevant not only in Sweden but also internationally. The author is the creator of the Swedish SET material, much of which was inspired by works published in English in the USA, in particular about the PATHS project (Greenberg, 1996). The author is also a member of the research team that performed an evaluation of the SET program. It is estimated that around 35% of Swedish schools have used SET. Matters surrounding SET have become contentious in Sweden, from both an evaluative (researcher) and a substantive (practitioner) perspective. The current chapter begins with a brief description of the background to the SET program and a summary of findings from its evaluation, which is followed by a discussion of some substantive program aspects.

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BACKGROUND TO SET Among people in many high-income countries, aged 1-44 years, mental ill-health is one of the greatest health problems; it includes depression, aggressive behavior, feeling down, and alcohol and drug abuse. Specifically, internalizing problems, such as depression, account for a larger proportion of mental ill-health than externalizing problems (Murray & Lopez, 1996). Since virtually all children go to school, the school is an obvious arena for mental-health promotion. It is stated in the UN Convention on the Rights of the Child (United Nations, 1989, Article 29, 1a) that ―educa tion of the child should be directed to … the development of the child‘s personality, talents and mental and physical abilities to their fullest potential‖. Diekstra and Gravesteijn (2008, p7) write: ―Thecentral tenet of [Article 29] is that education is not just a matter of fostering cognitive-academic development, but should be directed at the overall, i.e. physical, cognitive, social, emotional and moral, development of the child. Consequently, educational systems or institutions, such as schools, that exclusively or predominantly focus on academic development violate children‘s rights.‖ A set of educational techniques, named social and emotional learning (SEL), based on cognitive and behavioral methods, is available to teachers to train students to improve self-control, social competence, empathy, motivation and self-awareness, and has shown promising results in the US (for an early review, see Catalano et al., 2002). SEL and its derivative in Sweden (SET) form a subset of skills for life (SFL) programs (World Health Organization (WHO), 1999, 2004), henceforth referred to as life-skills programs. Life skills are defined by WHO (1996) as ―abi lities for adaptive and positive behavior that enable individuals to deal effectively with the demands and challenges of everyday life‖. SEL programs, which were formerly prevalent only in the USA, have now spread to some extent in Europe, e.g. to Germany (von Marées & Petermann, 2010) and Portugal (Moreira et al., 2010). They have their underpinning in many academic studies

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(Durlak & Weissberg, 2005; Durlak & Wells, 1997; Greenberg, Domitrovich & Bumbarger, 2001; Greenberg, 2004; Shocket et al., 2001). Also, they are recommended by international institutions, such as WHO (2004), United Nations Educational, Scientific & Cultural Organization (UNESCO) (2006) and the European Union (EU) (2005).

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SUMMARY OF THE EVALUATION OF SET IN SWEDEN Evaluation of the SET intervention in Sweden has been presented in three papers in which comparisons are made between outcomes for SET and No-SET students. There is one data set, but three analyses, covering different time periods and using different statistical techniques. The first study concerned all aspects of SET after two years among all students, except for substance use among juniors (Kimber, Sandell & Bremberg, January 2008; the second, emotional and social aspects after five years among senior students (Kimber, Sandell & Bremberg, August 2008; and the third, substance use among seniors, again after five years (Kimber & Sandell, 2009). The study populations, procedures, instruments, statistical methods and findings are presented and discussed in detail in these three papers. After two years, there were positive impacts, not always statistically significant: on 4 out of 5 of the scales, covering social and emotional aspects for the juniors, aged 7 to 10 (the exception being body image); and on 18 out of 20 of the scales for the seniors, aged 11 to 16 (the exceptions being mastery and cooperation). For the junior sample, there was a large effect size for psychological well-being, but this fell just short of statistical significance. For the senior sample, there were statistically significant medium effect sizes for: body image; relations with others; psychological well-being; aggressiveness; attention-seeking; and bullying. Surprisingly, given the program‘s focus on social as well as emotional aspects, there was virtually no recorded differential impact on the social skills scales (assertion, cooperation, empathy, and self-control). SET also appeared to have had no favorable impact on mastery, defined as the extent to which one regards one‘s life chances as being under personal control. It appeared that the program had had stronger effects on externalizing problems. After five years, the impact of SET on social and emotional variables was found to be generally favorable, and the effects detected were now greater for internalizing than for externalizing. This is in line with the view that the effects of early interventions appear later for internalizing problems (Mazza et al., 2010). The results of the intervention are important but not dramatic, as reflected in generally medium effect sizes. Also, there is considerable short-term variation in the No-SET group. There is no evidence of any gender effect. Social skills again appear as a special case, out of line in terms of outcome comparisons concerning the other variables, in that there is no difference between the SET and No-SET groups. With regard to substance use (smoking, drinking, sniffing and consuming alcohol), senior students were divided into latent classes. Statistically significant intervention-by-duration interactions, with medium to large effect sizes to the advantage of the SET students, were found for all substances in one or more, but not all, of the latent classes. Favorable trajectories were found for: non-users/light-users of drugs; moderate ‗sniffers‘; non-users/light users of alcohol; and occasional smokers. Only in the case of heavy smokers was there a possible detrimental effect of SET at a macro-level. Assuming that the degree of substance use is an

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indicator of mental ill-health, programs like SET, given a duration of two years or more, may lessen increases in use with grade/age and discourage early use, even though they are not specifically targeted at use itself.

SCIENTIFIC ISSUES Scientific issues in the current chapter are considered in order, from the general to the specific. The issues are: evidence-based practice; risk analysis; efficacy and effectiveness studies; and ‗dropout.‘

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Evidence-based Practice Although it has a long history, the concept of evidence-based medicine, or more broadly evidence-based practice, has been strongly advocated in recent years. In Sweden, for example, it is enshrined in current national guidelines for health promotion (Landstinget Västernorrland, 2004), and in many other health arenas. Despite this, the notion of evidencebased practice is rather more complicated than often supposed. In general terms, it is concerned with applying the best available evidence gained from scientific research in order to make clinical decisions, including consideration of risks and benefits of treatments or, indeed, lack of treatments. Cochrane (1972), one of its leading proponents, used the concept to argue for randomized controlled trials (RCT). Others have used it more broadly to suggest that anything that might bear upon a particular matter should be considered. Still others have tried to operationalize it more rigidly, in particular by ranking or grading evidence according to quality, stipulating replication rules, and so on. Clearly, evidence is not a dichotomous concept, since it runs on a scale, from a method that is tested according to low scientific criteria to one where very strict criteria are applied. Further, RCT evidence is not the only kind of evidence. Indeed in many effectiveness and quasi-experimental studies, it is not feasible to set up a randomized control group (Cook & Shadish, 1994). One thing is clear: the stricter the criterion for an evidence base, the lesser the risk of a harmful intervention, and the greater the risk of failing to adopt a beneficial one. In the case of SET, which has been criticized for being non evidence-based, it should be stated that, the family of life-skills programs, of which SEL forms a part, has a strong evidence base in the USA. For example, the Center for the Study and Prevention of Violence (2009) concludes that PATHS, which is one of the major influences on SET, is ―am ong 11 model programs certified by Blueprints, meaning that they have a high level of evidence supporting their effectiveness and should be replicated in other communities to prevent violence and drug abuse.‖ SET involved entering the key components of PATHS and Botvin Lifeskills training (Botvin et al., 1984; Botvin Lifeskills training, 2010) into a program suited to Swedish conditions, which raises the general question of the international generalizability of any country-specific study or instrument. For a recent international review of many, largely peer-reviewed, papers, see Diekstra (2008).

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Risk Analysis Of relevance to the current chapter is the distinction between basic and applied research, which relates to the schematized view of efficacy and effectiveness presented above. Normally, risk and protective factors are identified in basic research, or perhaps in an efficacy study, while whether they increase or decrease in importance are considered in applied research (within the tradition referred to as an effectiveness study by the author). Making some kind of formal risk assessment, which has been advocated by some, is seldom practiced in the psychosocial arena. The author‘s argument with regard to SET is that the general approach has a strong foundation in international life-skills research, and that this is supported by effectiveness studies, conducted by the author. These studies, whose specific weaknesses are explicitly reported, are not enough in themselves to place a seal of approval on SET, but in conjunction with previous research, they suggest that it is largely beneficial.

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Efficacy and Effectiveness Studies The concepts of efficacy and effectiveness, although employed in many ways in the literature, are used in the current chapter to mark the difference between studies conducted in an experimental context and those performed in a real-life setting. The SET study program was explicitly an effectiveness (real-life) study, given that it involved teachers as ‗program implementers‘ and ‗data-gatherers‘. The important point here is that, on the strict interpretation of an evidence-base, no effectiveness study can be evidence-based, nor, presumably, can it have any relevance to the assessment of risk. However, the author doubts that even the strictest advocates of evidence-based practice would assert, given the long tradition of effectiveness studies, that there is no place at all for them in a wider research setting. For example, in a recent prevention-related article, Welsh and colleagues (2010) presented a schematized, perhaps over-schematized account, of what they call ―t he implementation and evidentiary process in going to scale‖. The steps involved are called efficacy, effectiveness, and dissemination. The idea is that, given some basic research, an efficacy study is performed ―underoptimal conditions‖, followed by an effectiveness study, which is an ―i mplementation of intervention and effect replication study in secondary sites, target populations,‖ and then by dissemination, alternatively called ―goi ng to scale‖ or ―r olling out‖. The key point is that an effectiveness study cannot be considered in isolation from the body of basic research findings that precedes it.

ATTRITION One of the major criticisms directed at the SET program has been the high rate of reported attrition The distinction between effectiveness and efficacy studies is important in this context, for it is almost certain that attrition will be greater in real-life than experimental studies, as pointed out in the discussion from the author‘s previous work (Kimber, Sandell & Bremberg, January 2008). Approximately a third of junior students ‘drop-out‘ each year, as a matter of course, as they advance from junior to senior level. A strict analysis of possible

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biases showed, that our comparisons between the SET and No-SET groups were unlikely to have suffered from bias (Kimber, Sandell & Bremberg, August 2008). Although it was argued earlier in the current chapter that imputation of missing data was unsuitable, the author decided to further increase the statistical power of our analyses by employing a multiple imputation technique, and also M+ modeling to analyze the data at several levels, at least at individual and class levels. The results of these analyses should be available later in 2011.

SUBSTANTIVE ISSUES The SET program and life-skills programs in general received a lot of attention in the Swedish media during the autumn of 2010. The research issues discussed earlier in the current chapter were mentioned, but little serious attention was paid to them. The matters relevant to practitioners are as follows: SET as therapy; SET as a harmful intervention, particularly in relation to bullying; and, SET in need of development.

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SET AS THERAPY One criticism aimed at SET is that it is a form of group psychotherapy rather than an educational method and that most teachers do not have adequate training for its delivery. In the author‘s view, this criticism, which has been presented by some psychotherapists, reflects a distorted view of what psychotherapy is, and also implicitly denigrates the skills of teachers. There is an apparent consensus in Sweden that schools should have the breadth to address social and emotional aspects of life rather than simply to convey knowledge about traditional subjects on the curriculum (such as mathematics, Swedish, English, and so on). What is disputed, however, is whether social and emotional issues should be treated within a structured, manual-based program, such as SET, or left to the individual teacher. One way of approaching the issue is to consider paradigm cases of therapy and educational practice. Arguably, a therapist is a person who has committed to a specific approach to the treatment of a disorder, whether any such treatment be cognition-based, psychodynamic or something else, which requires specific training or skills. By contrast, an educationalist is a person who has entered into a learning arena, usually with a particular subject skill, who also has to address social and emotional issues within the setting in which she or he operates. Naturally, it might be argued that the domains of psychotherapy and education overlap, in particular with regard to the use of cognitive methods, which are not the exclusive property of psychotherapists in arguably the same way as psychodynamics. Since teachers have greater contact with the young than most, it might be presumed that they have, at the very least, a foundation to promote young people‘s welfare. The question in this regard is whether structured programs, like SET, have something to offer, or whether teachers should simply be left to their own devices.

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SET AS A HARMFUL INTERVENTION Some claims have been made concerning negative effects of SET, which go far beyond the assertion that SET, and life-skills programs in general, have no evidence-based effect. The most vehement criticisms have concerned bullying and secrecy. Neither of these criticisms is based on any empirical material, and such material is limited. The author found that, although there was no difference after five years in the intervention and non-intervention groups, in the SET schools bullying was at a continuously low level, whereas in the No-SET schools the level varied strongly from year to year (Kimber, Sandell & Bremberg, August 2008). This prompted us to speculate that SET may offer a means of providing greater continuity in this arena, in that peak incidences in the level of bullying are consistently avoided. The assertion that SET has negative effects is based on non-empirical speculation concerning the impacts of specific exercises and procedures. Three main themes are worth mentioning:

Reminder of Bullying Behavior It has been speculated that some exercises place bullied children at risk, in that the exercises are a reminder of exposure to bullying, or highlight the predicament of being bullied. Teachers as professionals would not, in the author‘s view, put a bullied child in a position, in a role-play, where he or she is bullied again.

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Confidentiality ‘What is said in the room, stays in the room‘ is a recommendation during SET lessons, and it has been said to impose ‗a duty of secrecy‘ on children. Pupils are encouraged to tell their parents and others what they talk about during SET lessons, but they are also encouraged not to tell others what their friends have talked about, so as to enhance their skill in maintaining confidentiality. In my view, this is an important social skill, and is far away from the imposition of secrecy.

Forced Participation It has also been argued that children cannot use their right to say ―pas s‖, which enables them to remain silent if they want to. The idea is that the teacher, in more or less subtle ways, will force a pupil to talk. While this may sometimes be the case, it is not a specific SET issue.

SET in Need of Development Naturally, all grounded criticisms of SET have to be considered, and in the long run, all discussion will be beneficial to SET and other life-skills programs. How to promote social and emotional skills is an important issue and can be addressed further. The exercises

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themselves are being constantly reviewed in light of feedback from teachers using the program. This is currently done on the SET website. It is very seldom that an exercise itself needs to be changed, but the instructions for teachers are changed. The teacher‘s manual can always be improved to make sure that the exercises are performed correctly. Training and fidelity are also important issues to follow-up, as is the implementation process. Teachers need training in this arena, just as they do in the other subjects they teach. This is the responsibility of the head-teacher; for life-skills teaching to be successful, head-teachers must not only be ‗on board,‘ but they must actively support the teachers, and also to follow-up teaching quality and fidelity. Committed school leaders are key to the successful implementation of the program.

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CONCLUSION In so many arenas the stricter the rules for permitting the adoption of an intervention strategy, the lesser the risks of harmful effects, but the greater the risks of failure to achieve beneficial ones. The stronger the barriers to intervening, as erected, for example, by the media or others, the greater is the likelihood of a non-optimal outcome in terms of well-being. As is demonstrably the case with regard to introducing new medications, there is a cost or risk in both intervening and not intervening. With regard to SET, whatever the limitations of the evaluations of SET, which are thoroughly reported in the published papers concerned, there is scientific assessment to an extent that is not reached in the cases of most school programs or activities. The extreme case, of course, is that schools themselves have a negative influence, constituting an arena where students are more harmed than benefited. The future of SET and similar programs lie, fairly obviously, in considered evaluation of effects and processes. Longer-term evaluations are needed, although these, by their nature were not possible in the effectiveness context of the SET studies, given that it was administered by teachers, and could not be pursued after students left school. The material and procedures used in SET, now that it has been running for some years, need to be reviewed, as does the implementation process. The participation of stakeholders of all kinds would be welcomed.

REFERENCES Botvin, G., Baker, E., Botvin, E., Filazzola, A. & Millman, R. (1984). Prevention of alcohol misuse through the development of personal and social competence: a pilot study. Journal of Studies on Alcohol and Drugs, 45(06). Botvin Lifeskills training (2010). Evidence-based prevention programs for schools, families and communities. Retrieved December 12, 2010, from http://www.lifeskillstraining.com Catalano, R., Berglund, M., Ryan, J., Lonczak, H. & Hawkins, J. (2002). Positive youth development in the United States: research findings on evaluations of positive youth development programs. University of Washington. Prevention and Treatment, 5, Article 15.

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Center for the Study and Prevention of Violence (2009). Blueprint model programs, Retrieved December 12, 2010, from http://www.colorado.edu/cspv/blueprints/ modelprograms.html Cochrane, A. L. (1972). Effectiveness and efficiency. Random reflections on health services. London: Nuffield Provincial Hospitals Trust. Commission of the European Communities (2005). Final Green Paper. Improving the mental health of the population. Towards a strategy on mental health for the European Union. Brussels Cook, T. D. & Shadish, W. R. (1994). Social experiments: some developments over the past fifteen years. Annual Reviews Psychology 45, 545-580. Diekstra, R. & Gravesteijn, C. (2008). Effectiveness of school-based social and emotional education programmes worldwide. In Social and emotional education: an international analysis. Santender, Spain, 255-312, Fundacion Marcelino Botin. Durlak, J. & Weissberg R. (2005). Meta-analysis of 655 school, family and community PYD interventions. Retrieved December 12, 2010, from http://www.casel.org Durlak J. & Wells A. (1997). Primary prevention mental health programs for children and adolescents: A meta-analytic review. American Journal of Community Psychology 25, 115-52. Greenberg, M. (1996). The PATHS Project: Preventive intervention for children. Final report to NIMH. Seattle: Department of Psychology, University of Seattle. Greenberg, M., Domitrovich C. & Bumbarger, B. (2001). The prevention of mental disorders in school-aged children: current state of the field. Prevention and Treatment 4, Article 1. Greenberg, M. (2004). Current and future challenges in school-based prevention: the researcher perspective. Prevention and Science 5, 5-13. Kimber, B., Sandell R. & Bremberg S. (January 2008). Social and emotional training in Swedish classrooms for the promotion of mental health: results from an effectiveness study in Sweden. Health Promotion International 23, 134-143. Kimber, B., Sandell R. & Bremberg S. (August 2008). Social and emotional training in Swedish schools for the promotion of mental health: an effectiveness study of five years of intervention. Health Education Research 23, 931-940. Kimber, B. & Sandell R. (2009). Prevention of substance use among adolescents through social and emotional training in school: A latent-class analysis of a five-year intervention in Sweden. Journal of Adolescence 32, 1403-1413. Landstinget Västernorrland (2004). En mer hälsofrämjande hälso- och sjukvård i Västernorrland [A More Health-Promoting Healthcare]. Västernorrland, Härnösand, Sweden. Landstinget Västernorrland. Mazza, J.J., Fleming, C.B., Abbott, R.D., Haggerty, K.P. & Catalano, R.F. (2010). Identifying trajectories of adolescents‘ depressive phenomena: an examination of early risk factors. Journal of Youth and Adolescence 39(6), 579-93. Moreira, P., Crusellas, I.S., Sá, I., Gomes, P. & Matias, C. (2010). Evaluation of a manualbased programme for the promotion of social and emotional skills in elementary school children: results from a 4-year study in Portugal. Health Promotion International 25, 309-317. Murray, C. J. L. & Lopez, A: D. (1996). Global Burden of Disease. Harvard. Harvard University Press.

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Shochet, I, Dadds M, Holland D, Whitefield K, Harnett P, Osgarby S. The efficacy of a universal school-based program to prevent adolescent depression. Journal of Clinical Child Psychology 30, 303-15. United Nations (1989). Convention on the Rights of the Child. Retrieved 12 December 2010, from http:// www.unicef.org UNESCO (2006), Life skills. Retrieved 4 February 2010, from www.unicef.org/ lifeskills/index.html. von Marées, N. & Petermann, F. (2010). Effectiveness of the "Verhaltenstraining in der Grundschule" for promoting social competence and reducing behavior problems [in German]. Prax Kinderpsychol Kinderpsychiatr 59(3), 224-41. Welsh, B. C., Sullivan C. J. & Olds, D. L. (2010). When early crime prevention goes to scale: a new look at the evidence. Prevention Science 11, 115-125. WHO (1996). Life skills education: planning for research. Geneva. WHO (1999). Partners in Life Skills Training: Conclusions from a United Nations InterAgency Meeting. Geneva. WHO (2004). Skills for health: An important entry-point for health, promoting/child-friendly schools. Geneva.

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In: Current Issues and Controversies in School and Community ... ISBN 978-1-62100-327-4 Editor: Jennifer A. O‘Dea © 2012 Nova Science Publishers, Inc.

Chapter 5

PRODUCING THE SELF-MANAGING FEMALE-CITIZEN IN A CLIMATE OF „HEALTHY‟ LIVING 1

Kellie Burns1* and Kate Russell1,†

Faculty of Education & Social Work, University of Sydney, Australia

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ABSTRACT This chapter offers a critical reading of the promotional culture around the Australian cervical cancer/HPV vaccination program. In analyzing print and television-based advertisements, the chapter works towards three key aims: 1) To locate the vaccination program within a New Public Health discourse that positions the individual as responsible for minimizing health risk and capitalizing on health rights and choices; 2) To consider how the ‗healthy‘, self-managing girl-citizen is produced and managed from within a promotional climate bound to discourses of risk and prevention; and, 3) to ask how schools, as the key administrative sites for the vaccination, are implicated in and through these discourses of risk and management. The paper argues that young women are being encouraged by the vaccination campaign to take control of their sexual and reproductive well-being, however, accessing better sexual health takes place within a broader climate of risk management underpinned by discourses of economic pragmatism. As such, the new health rights and sexual freedoms afforded to young women via the HPV/cervical cancer vaccination do not necessarily mark a significant shift in dominant discourses around women‘s sexual health or their sexuality more broadly. This vaccine, the chapter argues, is a useful case study for teaching media literacy in health education as it allows for critical conversations about emerging discourses of healthism and the gendering practices that underpin contemporary health policies and practices.

*

Correspondence: Dr Kellie Burns, Lecturer, Health Education and Professional Practice, Faculty of Education & Social Work, Education Building A35, The University of Sydney, NSW 2006, Australia. E mail: [email protected]. † Correspondence: Dr Kate Russell, Human Movement and Health Education, Faculty of Education & Social Work, Education Annex Building A36, The University of Sydney, NSW 2006, Australia. E mail: [email protected].

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INTRODUCTION From 2007 to 2009 the Australian government funded a new vaccine called Gardasil®, which protects against four strands of the human papillomavirus (HPV), a sexually transmitted infection which is linked to 70% of cervical cancer cases. The announcement of the free vaccine marked a particularly significant addition to the existing national immunization roll out for young people, as Gardasil® is in fact a ‗home grown‘ invention. In 2006 scientist Ian Frazer was awarded Australian of the Year for creating the vaccine. This chapter offers a critical reading of the promotional culture around the Australian vaccination roll out, specifically the print information produced for young women and their parents and the television-based advertisement. In analyzing these texts the discussion works towards three key aims. First, it locates the vaccination program within a new public health discourse that positions the individual citizen as responsible for minimizing the risks associated with her or his own health. Second, the chapter considers how the ‗healthy‘, self-managing girlcitizen is produced and managed from within a promotional climate bound to discourses of risk and prevention. Finally, it considers how schools, as the key administrative sites for the vaccination, were implicated in and through, these discourses of risk and management. We argue that schools are increasingly being asked to take up neo-liberal health reform under the banner of ‗whole-school health promotion schemes‘ and/or in the name of fostering healthy and productive models of citizenship.

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HEALTHY CITIZENSHIP IN A CLIMATE OF RISK MANAGEMENT Nicholas Rose (1999) argues that the promise of freedom offered by the current neoliberal governmental order also fosters the need to manage and minimize risk. One‘s freedom is always closely bound to one‘s capacity to foresee, reduce or control risk. On a daily basis citizens in western countries around the world are inundated with mediated messages that warn of new global threats. Everything from global warming to global terrorism to global epidemics pose new types of risks, that while macro-managed by global networks much bigger than an individual citizen, must also be micro-managed by the prudent and resourceful citizen. An entire micro-economy has emerged to minimize personal risk. Private insurance is perhaps the most obvious risk-reducing product on the market. Rose (1999) explains that with the introduction of liberalism in the twentieth century, the idea of insuring oneself and one‘s family as an act of solidarity, that is, to better the overall security of the national community, faded. The autonomous and individualistic subject of liberal government was to only worry about the safety and security of his/her own family. Privatized insurance purports to gratify those who take their personal security seriously as they no longer have to carry the burden of those less committed to issues of safety. Responsibility for life-long financial and medical security is given over to individuals who must act prudently to secure various facets of their personal life. In addition to various forms of private insurance – house, house contents, car, health, pet, life – there is a vast range of products that help reduce risk and provide a heightened sense of security. Everything from car alarms to weight-reduction programs, stress reducing vitamins and self-help books become ways of purchasing a heightened sense of personal safety and reducing everyday risks. Even fines for watering our garden during water

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restrictions in Australia, influenza immunization programs and ‗neighborhood watch‘ networks are peripherally linked to the political economy of risk-management. Individuals are provided with a number of consumer options with which they can minimize the risk posed to them, their family and their belongings. Reducing risk has been a prime directive of public health initiatives since the early sixteenth century. In Birth of the Clinic (Foucault, 1984) provides an archaeology of medical discourses, mapping the ways in which threats of spreading infection and disease have been wedded to practices of bodily discipline, surveillance and management. He uses the early confinement and quarantine of diseased or infectious bodies such as the plague, cholera and smallpox to illustrate how the management of ill bodies and/or populations became an imperative of government appointed experts. The nation was kept safe from disease outbreaks through state-sanctioned actions that minimized infection. Foucault suggests that the management of disease and illness changed in the eighteenth century with the birth of the clinic and its emphasis on the body as the site for close and careful pathology. The diseased or pathological body became marked under the ―cl inical gaze‖ (Foucault, 2003) as an economic and political problem. Maintaining good health became bound to national security and the stability of the work-force. At this time families became an important unit for the management of hygiene and good health via inoculation, food hygiene and by managing their children‘s behavior. This shift marked a move away from full government responsibility for health management toward a shared investment in the values of healthy citizenship between the state and the family unit. Public health movements in the late nineteenth-century were shaped by the introduction of epidemiology, which focused on measuring patterns of disease within certain populations. The growth of expert bodies of knowledge about health, helped target specific health issues and shape disease control programs for those groups or populations deemed more at risk than others. The growth of large-scale epidemiological surveys that focused on documenting patterns of disease within and across populations, marked another key shift, this time away from understanding disease as something that exists in an individual body, to instead seeing it as part of the social body. This shift, David Armstrong (1983) insists, led to the close surveillance of ‗― diseased populations‖‘ for the sake of the broader population and, by the early twentieth century, to the widespread idea that everyone was at risk of becoming a potential victim of disease. Deborah Lupton (2003) maintains that public health policies in the twenty-first century are characterized by the discourse of health rights and choices on the one hand, and the discourse of personal (health) care and responsibility on the other. Health is deemed a universal right and a fundamental good that the individual citizen should be personally responsible for optimizing. Individuals are exhorted to take responsibility for maintaining their health and preventing their ill-health in the future – and thus their burden of disease on the national economy (Lupton, 2003). An emphasis is placed on prevention and on identifying and managing ‗negative‘ or ‗risky‘ lifestyle behaviors. Lupton argues the discursive coupling of health as a right with the practice of self-management as the means to accessing this right, renders the values and ideals that underpin government agendas invisible. If an individual fails to adequately self-manage their own health, that is, to minimize risk and maximize good health, they are not making the most of the rights and freedoms afforded to them as a full citizen. This functions, in Foucault‘s terms as a ― dividing practice‖ (Foucault, 1995; 2001; 2003) that shapes the parameters of contemporary subjectivities. If one is selfmanaging, and thus healthy, he/she is deemed a responsible, exemplary citizen. In contrast, if one fails to actualise his or her ‗right to be healthy‘, he/she is rendered undisciplined,

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dangerous and a national burden. These dangerous and ‗unhealthy‘ bodies become the subjects of health research and campaigns aimed at lessening disease burden by changing the attitudes and behaviors of those ‗most at risk‘. Health promotion today focuses on prevention and minimizing risk especially amongst these ‗high risk‘ groups or populations. The prevalence of certain illnesses within these groups, is thought to be significantly reduced by devising ways for individuals to take (better) control of their own health. Health education, both in and outside of schools, reproduces this rhetoric in the form of ‗how to do‘ lists as follows: how to eat healthily; how to exercise adequately; how to reduce stress; how to stop smoking or drinking; how to prevent unwanted pregnancies; and so on (Burrows & Wright, 2007). The skills acquired to prevent ill-health are bound to discourses of lifelong learning and a commitment to ongoing management and care of the self (Rose, 1999). Giving individuals health knowledge and the specific skills needed to make healthy choices is directly linked to reducing dangerous or risky activities. Individuals are expected to be knowledgeable about their health and to view their health as a project to be worked on. The body becomes the primary site for managing these health projects. The onus placed on young women to work on their body functions as a form of biopower (Rabinow & Rose, 2003) that connects their sexual and reproductive health to state policy and power. Becoming ‗healthy‘ is bound to a person‘s will to do so and as such these pervading health discourses are central in shaping contemporary subjectivities. If an individual can be healthy or get healthier, she/he is an active and viable citizen. In contrast, if an individual remains unhealthy in the face of a range of new ways of becoming healthier, he or she falls outside the norms of the healthy citizenry and remains ‗at risk‘, open to scrutiny, regulation, and in some cases punishment by the state, by others, and by the self. In other words, healthy subjectivities and healthy citizenries are produced and governed against the bodies and lives of unhealthy subjects and unhealthy populations.

MAKING THE „HEALTHY‟ FEMALE CITIZEN Gender difference is a key organizing category of health-risk. Bryan Turner (1995) suggests that women have traditionally been defined as the ‗Other‘ to the male norm in medical discourse and that evidencing the ‗biological‘ differences between the sexes (male and female) was central in establishing women‘s ‗natural‘ role inside the home, away from the public sphere. Women‘s bodies were constructed as innately different in structure and composition and these differences made them naturally destined for domestic duty and childbirth. For centuries, scientific and medical discourses linked women‘s reproductive functions to innate fragility, weakness, emotional instability and irrationality, all of which made them unable to participate in the public and economic spheres (Lupton, 2003; Moscucci, 1990; Turner, 1995; Vertinsky, 1990). At the same time, women‘s bodies and sexuality were shrouded in discourses of mystery, danger and risk; they threatened the normal social and moral order and therefore needed to be controlled (Lupton, 2003; Turner, 1995). Women were, and continue to be, associated with the body and emotion, whereas men were linked to the mind and with logic and rationality. Women‘s attachment to biology and the body also meant that their sexuality was animalistic and dangerous (Moscucci, 1990) and something that needed to be managed and controlled. Managing and controlling women‘s

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sexuality rested on ensuring that their primary function as mothers was preserved, promoted and protected, and that any scope for risky behaviors was either prevented or ultimately punished. Any activity undertaken by women that undermined this role, such as engaging in hard thinking or excessive physical activity, would be challenged by males with moral (clergy), medical (doctors) and economic (husbands) influence. This experience mirrors more recent pathologising of women‘s bodies through the control and management of the reproductive space by gynaecological experts and its facilitators. For example, the ‗by prescription only‘ model for the allocation of the oral contraceptive pill perpetuated the highly paternalistic approach to the distribution and reproductive knowledge, indicating a clear message that ‗doctor knows best‘ and certainly knows all (Watkins, 1998). In this way the medical professional was positioned as the guardian of the creation of healthy and productive wombs. First and second wave feminist scholarship sought to challenge the dominant discourse of ‗biology as destiny‘ used to justify women‘s status as second-class citizens. In order to disrupt this myth of fragility, feminist writings as early as the 1920s attempted to reduce the differences between the sexes (male/female), free women from incessant childbirth and broaden women‘s roles outside the domestic sphere. These critiques, and those that followed well into the second wave feminist movement, insisted gender roles were socially constructed and thus artificially bound to biological sex. They highlighted how science and medical discourses reproduced these gender differences (or roles) in order to control and limit women‘s capacity to act as equal citizens and to uphold the sanctity of ‗men‘s domains‘. A great deal has been achieved for women in terms of shifting the dominant discourses governing scientific and medical research and practice, and also in terms of accessing greater control over the technologies used to manage their health and wellbeing. Oral contraception; the right to medical abortions; access to IVF technologies; and changing childbirth practices are just some examples of how women have shifted the assumed link between their body and reproduction. However, there is little doubt, as Lupton (2003) reminds us, that pathologies around women‘s reproductive capacities persist and that women‘s bodies and their sexual health continues to be defined against the normative masculine body. Likewise, discourses of risk and management still organize approaches to women‘s health, though a greater emphasis is placed on the freedom women have acquired to manage this themselves. In Lupton‘s words: ―W omen‘s experiences of the body cannot be separated from the discourses and practices which constitute them, [and] there is no authentic body waiting to be released from the bounds of medicine.‖ (Lupton, 2003, p. 172).

By inserting the HPV/cervical cancer vaccination program into these long standing narratives about reproductive and sexual risk, we argue that the discourses of risk and danger that young women (and their parents) must negotiate in deciding whether or not to have the HPV/cervical cancer vaccination is mediated alongside rhetoric around having achieved new freedoms and choices around their sexual health. Young women are being encouraged by the campaign to take control of their sexual and reproductive wellbeing, aspects of their health from which they have historically been detached. At the same time however, these new modes of accessing better sexual health are produced in a broader climate of risk management underpinned by discourses of economic pragmatism. As such, the new health rights and sexual freedoms afforded to young women by the HPV/cervical cancer vaccination, do not

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necessarily mark a significant shift in dominant discourses around women‘s sexual health or women‘s sexuality. We argue instead, that girls and young women are being asked in new and hitherto unimagined ways to manage their sexuality and sexual health such that they lower their collective burden of disease on the nation-state. This in fact upholds the ideals of dutiful female citizenship and continues to erase boys and men from public pedagogies of sexual and reproductive health.

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“I DID”: GARDASIL®, RESPONSIBILITY AND RISK REDUCTION Print advertisements in the form of pamphlets and posters, online and television advertisements (Australian Government, n.d) for the HPV/cervical cancer vaccination program mediate the discourses of health choice, risk reduction and personal responsibility through the advertising slogan ‗I did‘. Advertisements in all three mediums feature young, slim, well-dressed women brandishing band-aids on their arms that read ‗I did‖. This small, widely-recognized symbol of inoculation acts as proof of women‘s commitment to their health, to the project of making a healthy body and also serves as evidence that they are wise consumers who took advantage of the government‘s free two-year rollout. Here the discourses of health rights are produced alongside discourses of choice, responsibility and self-management. In each of the printed poster advertisements the model‘s name and profession are printed above the woman‘s smiling face. This information personalizes each young woman‘s healthy choice and suggests to other women-consumers that ordinary, everyday women ‗just like them‘ have made the choice to get the vaccine. Felicity the university student, Simone the public servant, Victoria the waitress, Candice the nurse, Emma the chef, Jessica the music journalist and Kate the client administrator invite young women to ‗join the fight against cervical cancer‘. These women are constructed as model young female citizens who are healthy, happy and wise consumers of state-subsidized health care. These modern young women are agentic and independent and are comfortable with and able to make good decisions around their sexual health. The military language used to urge women to ‗join the fight‘ against cervical cancer marks both a sense of urgency in combating the enemy (though as we‘ll suggest below, very little is said about what the vaccine actually ‗fights‘) and links women‘s personal choice to get vaccinated (or not) to national imperatives. To this end, women who choose to join in the fight become a cultural army of sorts, fighting the national disease burden and the ‗I did‘ band-aid functions as a war memento – proof of one‘s commitment to the values and welfare of the nation. This militaristic theme is carried through into the later advertisements designed to remind women that the government-funded vaccine catch up program expired in December 2009. In this poster campaign we meet blonde-haired Felicity again, no longer just a university student, but now a PR consultant. Felicity reminds us to ‗keep up the fight‘ and this time dons three ‗I did‘ band-aids to show that she has had her three doses, a complete (and working) vaccine. Felicity‘s shift from student to working woman alongside acquiring her three full doses of Gardasil® upholds the ideal of productive and progressive citizenship and validates her role as a modern self-made woman. Joining these ‗ordinary everyday‘ women in their fight against cervical cancer are a series of famous Australian female personalities, these include: Tania Major, 2007 Young Australian of the Year; Laura Andon, Professional Surfer; and Giaan Rooney, 2004 Australian Olympic relay

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swimming gold medallist. In contrast to the unknown faces, these women function as public role models whose bodies are already linked to virtuous, healthy models of citizenship. The female athletes in the campaign represent the low-risk female body, that is: fit; healthy; strong; and accustomed to making ‗good‘, ‗healthy‘ choices. This is perhaps best exemplified in the television advertisement which features Australian 2004 and 2008 Olympic gold medallist swimmer, Libby Trickett, who, smiling directly into the camera with pearly white teeth, tells us she‘s, ―j oined more than a million Australian girls aged 12-26 in the fight against cervical cancer.‖ At the end of the advertisement the camera pans out to reveal that, like her comrades, she too proudly wears three colorful ‗I did‘ band-aids on her arm. In the advertisement‘s closing shot, she proclaims ‗I did‘ and encourages other women to rethink their choice, asking them, ― so, what are you waiting for?‖ This suggests an outward impression of simplicity and a palpable expression of nationalism that presents Australia as a country with limitless possibilities waiting to be taken advantage of; where the phrase ‗she‘ll be right‘ espouses the belief that everything is doable and should be done. These are the ideal conditions for the neo-liberal citizen who is responsible for their own well-being and enterprise. Tania Major, as the only well-known indigenous woman in the campaign is not only a face of the responsible, ‗healthy‘ female citizenship, but one that operates slightly differently than these white iconic sporting bodies. Major‘s important work in her local Queensland community and her appeal to the former Howard government to ―l ift the blanket of shame‖ (Hill-Douglas, 2007) from sexual violence in Aboriginal communities has been profiled widely in the mainstream media (ABC TV, 2007). Major is positioned as a hopeful example for the direction of the ‗next‘ generation of young indigenous Australians. Major has vowed to make it her personal responsibility to shift the high levels of violence, suicide and incarceration in her community, a discourse which, in the hand of conservative and racist agendas becomes proof that those who are unable to make similar changes simply require a greater level of discipline, regulation and self-control. Cervical cancer happens to be the most common fatal cancer amongst Aboriginal women with morbidity rates linked to cervical cancer being five times greater than those of non-Aboriginal women. While this makes Major‘s participation in the vaccination‘s promotional campaign crucial, some critics (Cowan, 2008) have suggested the Gardasil® vaccine has not reached Aboriginal young women to the extent that it should because of a number of factors including the fact that the campaigns are run only in English and because of the longstanding shortage of primary healthcare services in remote areas. The question of access is important in asking how empowering the vaccine will be for all Australian girls and young women. The wholesome, glamorous cosmopolitan women used in the poster and television advertisements are hardly representative of most Australian women and it is important to question if ‗choice‘ and ‗risk‘ are produced equally across ethnic, racial, class or geographic lines. The health-related risks associated with HPV are only partially disclosed by the campaign materials. Very little is said about the link between HPV and cervical cancer such as: How does the former cause the latter?; What does Gardasil® guard against?; Can anyone and everyone be protected? It is only in the fine print of the larger pamphlets that this relationship is explained. The promotional brochure (Australian Government, n.d) moves through ‘some common questions‘ in an effort to help young women ‘understand more about vaccination and the disease, to enable [them] to have an informed discussion with [their] doctor‘ (sic). This is interesting given that nowhere in this brochure or in any of the promotional materials directly linked to the vaccination program are young women told that some strands of HPV are the

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cause of ano-genital warts. Young women are offered a sanitized understanding of the virus and its effects, and the models used throughout the campaign are allowed to remain healthy citizens, associated with notions of self-care, prevention and good health rather than with sexually transmitted infections and their less-than-glamorous side effects. This is no surprise, given the amount of controversy that was sparked by the vaccination program in other national contexts, for example in the United States (US), with parents concerned that the HPV vaccine would encourage their daughters to experiment with sex early and encourage promiscuity (Freed et al., 2010). So, herein lies the catch for young women today. On the one hand this vaccine is part of an important string of recent medical advances that have shifted women‘s relationship with their reproductive and sexual health most notably: the oral contraceptive pill; the orally administered RU486 (Abortion pill); pre-natal screening; and assisted conception technologies. If the virus responds to the vaccine as those engineering the drug intend, the rate of cervical cancer amongst women in the western world will drop dramatically. Likewise, greater choice for women is significant, given how gender differences have long organized power schema in most societies. However, on the other hand, women are being asked to take a heightened level of responsibility for an aspect of their sexual health, from an earlier age and without all the information needed to make an informed choice. While HPV is also carried and transmitted by men, very little is being said about men‘s role in ‗passing on the disease‘ or about the increasing rates of penile and anal/rectal cancers linked directly to HPV. In other words men are once again absent from discourses around sexual health and responsibility.

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IMPLICATIONS FOR SCHOOL HEALTH AND PHYSICAL EDUCATION CURRICULUM With secondary schools acting as the key clinical site for the delivery of the vaccination program to girls, we argue that health and physical education pedagogies need to respond to the gendered discourses of health, new public health policy and media representations of healthy citizenship. Elsewhere Burns (2005) has argued that addressing issues of gender and sexuality in the classroom requires a move away from pedagogies of the personal that focus on disclosures of personal narratives, toward pedagogies of the political that position ‗sexuality‘ and ‗gender‘ as socially produced categories that govern everyday living. In doing this, questions of gender and sexuality become relevant to all students in our class because they are being ‗made‘ and remade‘ by the social institutions, language, etc. that organize their lived realities. The same could be said about producing new health pedagogies that respond to the conditions of the present. As the sociology of health and medicine have illustrated, and indeed this paper has suggested, science and medicine function as a set of governmental technologies that produce and govern the bodies and lives it claims to merely represent. As such, studying health should include an understanding of how health has operated as a social, political and cultural institution over time. Health pedagogies have the potential to disrupt the dominant meanings and norms around health, but also of gender; often taken for granted as ‗real knowledge‘ and ‗absolute truths‘. Young people are also offered a space to understand the normalizing discourses of ‗risk‘ and ‗responsibility‘ that organize contemporary subjectivities. Media literacy is a useful way of demonstrating how knowledge and meanings

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about health are produced through culture and how sex/gender norms are reproduced in this ‗meaning-making‘ (Burns, 2005). Giving students the tools to think about how meanings around health or gender expectations and norms are produced and being able to situate them historically such that they ask, ‗what has changed?‘ is helpful in fostering critical media literacy in the classroom. More than 35 states in the USA now include media literacy as part of health education, and address issues such as: violence; sexuality; body image; nutrition; and substance abuse prevention (Kubey, 2001). The secondary school curriculum in the Australian state of New South Wales (NSWBOS, 2003) places a strong emphasis on understanding how media produces gender norms and shapes body ideals. Media literacy in health education often seeks to enhance the communication and decision making patterns of young people, and in doing so emphasizes the ‗control‘ young people have in managing their lives (Collins & Celluci, 1991). But of course, the project of critiquing the formation of media messages in the name of equipping young people with the knowledge and skills to take ‗personal responsibility‘ for their health and their relationship with mediated messages, reproduces the very discourse we are trying to unsettle in this paper. In an attempt to move away from the idea that media literacy is a ‗skill‘ or a mechanism with which young people can assert more control over the ‗meaning-making‘ that takes place around them, we suggest, following John Fiske (1989) that media literacy can act as a ―t actic‖ with which young people can ‘make do with‘ in a world that is highly saturated by media images that position them as mindless consumers. Following Fiske, media literacy enables consumers of media to find a multiplicity of creative tactics and strategies with which to subvert dominant discourses and to produce alternative meanings and practices. For young people, this means that they become active mediators of health discourses such that they know what it is they are taking responsibility for, how risks and responsibilities are produced differently for men and women and who it is that is driving calls to be responsible.

REFERENCES ABC TV (2007). Tania Major [Television series episode]. In Enough Rope with Andrew Denton. Australian Broadcasting Corporation. Armstrong, D. (1983). Political anatomy of the body: Medical knowledge in Britain in the Twentieth Century. Cambridge: Cambridge University Press. Australian Government (n.d.).The National HPV Vaccination Program, Guard against cervical cancer. Retrieved October 10, 2009, from http://www.cervicalcancer.com.au/ Balibar, E. (1991). Who comes after the subject? Cadava, E., Connor, P. & Nancy, J.L. (Eds.), (pp. 33-57). New York: Routledge. Burns, K. (2005). Practicing queer theories: Queer image-based texts in the tertiary classroom, Curriculum Perspectives, 25(3), 65-68. Butler, J. (2004). Undoing gender. New York: Routledge. Collins, D. & Cellucci, T. (1991). Effects of a school-based alcohol education program with a media prevention component. Psychological Reports, 69(1), 191-197. Cowan, (2008, March 18). PM Concerns raised over cervical cancer risk for indigenous girls. {Radio broadcast}. Sydney, NSW: Australian Broadcasting Corporation. Fiske, J. (1989). Understanding popular culture. Boston: Unwin Hyman.

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Freed, G.l., Clark, S. J., Butchart, A, T., Singer, D. C. & Davis, M. J. (2010, March 1). Parental vaccine safety concerns in 2009. Pediatrics, 125. Retrieved April 4, 2010, from http://pediatrics.aappublications.org/cgi/content/abstract/125/4/654 Foucault, M. (1995). Discipline and punish: The birth of the prison (A. Sheridan, Trans.). New York: Vintage Books. Foucault, M. (2001). Madness and civilization: A history of insanity in the age of reason. London: Routledge. Foucault, M. (2003). The birth of the clinic: An archaeology of medical perception (A. M. Sheridan, Trans.). London: Routledge. Hill-Douglas, O. (2007). ‗Young Australian: Tania Major‘. The Age, 26 January, Retrieved on October 6 2009 at http://www.theage.com.au/news/national/young-australian-taniamajor/2007/01/25/1169594432321.html Kubey, R. (Ed.) (2001). Media literacy in the Information Age: Current perspectives. Transaction: New Brunswick, NJ. Lupton, D. (Ed.). (1999). Risk and socio-cultural theory: New directions and perspectives. Cambridge: Cambridge University Press. Lupton, D. (2003). Medicine as culture. London: SAGE Publications. Moscucci, O. (1990). The science of woman: Gynaecology and Gender in England 18001929. Cambridge: Cambridge University Press. NSWBOS (2003). Personal Development, Health and Physical Education Years 7-10 Syallbus. Sydney: Board of Studies NSW. Rabinow, P., & Rose, N. (2003). Foucault today. In P. Rabinow & N. Rose (Eds.), The essential Foucault: Selections from the essential works of Foucault, 1954-1984 (pp. viixxxv). New York: New Press. Rose, N. (1999). Powers of freedom: Reframing political thought. Cambridge: Cambridge University Press. Vertinsky, P. (1988). ‘Of no use without health‘: Late nineteenth century medical prescriptions for female exercise through the life span. Women and Health, 14(1), 89115. Watkins, E. L. (1998). On the pill: A social history of oral contraceptives, 1950-1970. Baltimore: John‘s Hopkins University.

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In: Current Issues and Controversies in School and Community ... ISBN 978-1-62100-327-4 Editor: Jennifer A. O‘Dea © 2012 Nova Science Publishers, Inc.

Chapter 6

ADDRESSING BODY IMAGE ISSUES IN AUSTRALIA‟S HEALTH EDUCATION CLASSROOM: A CASE FOR A CONSTRUCTIVIST APPROACH TO MEDIA LITERACY INTERVENTIONS Michelle Gorzanelli* Faculty of Education & Social Work, University of Sydney, Australia

ABSTRACT

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Beauty ideals have been presented by the dominant communication modes of the time. Historically, icons in visual art were romanticized as unattainable epitomes of beauty; whereas, today it is the mass media that present images that reflect the cultural view of the ‗ideal‘ beauty. Adolescents are commonly pressured to emulate these images because the mass media has been widely acknowledged as a central resource for young people in the development of their identity. Although innumerable studies in physical education have looked at constructivist perspectives on learning, programs in health education have been slow to look at ways the same approach can address the well-being of students. This chapter rectifies some of this neglect and highlights critical thinking as an intervention that may educate students to challenge the media realities of what is termed ‗the ideal‘ body. By arguing that critical thinking can be taught through a social constructivist approach to health education, the chapter suggests that such teaching and learning practices will require students to exchange ideas, negotiate shared meanings and reflect on personal views. The exploration of a critical theoretical approach to teaching about body image issues will present constructivism as a useful pedagogy that could be incorporated into the Australian educational sector‘s ‗body image‘ programs.

*

Correspondence: Michelle Gorzanelli, Faculty of Education & Social Work, Building A35, University of Sydney, NSW 2006, Australia. Email: [email protected].

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INTRODUCTION Over the last 20 years there have been significant changes that have reformed the context of education in Australia. For instance, both globalization and technological advancements have placed environmental, social and economic pressures on education and skill development and changed the way individuals share and process information. Consequently, the National Declaration on Educational Goals for Young Australians (Ministerial Council on Education, Employment, Training and Youth Affairs, 2008) highlighted the need to encourage students to play an active role in their learning by thinking deeply, critically and logically when evaluating evidence. Students must therefore become problem-solvers who can adopt novel and creative ways of perceiving information (MCEETYA, 2008) presented in the media.

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MEDIA EXPOSURE AND BODY IMAGE IDEALS The technologically enhanced, unhealthy and unattainable images presented in the media contribute to what a culture considers ‗beautiful‘ (Australian Government, 2009, p.7). Young people are more likely to seek out external sources, such as the mass media, to help deal with concerns about the physiological, social and psychological changes they are going through (Ata, Ludden & Lally, 2007; Clay, Vignoles & Dittmar, 2005). Therefore, the characteristics adolescents deem ‗desirable‘ or ‗undesirable‘ as they form their own identity (Australian Government, 2009) can be influenced by images presented in the media. Kirk (1993) supported that the ―m edia culture is not merely consumed and discarded, but it is utilized to construct personal identities… [as the] material the media supplies is not passively absorbed but is actively appropriated as the stuff of people‘s sense of self, their place in the social world.‖ Studies also suggested that exposure to ‗ideal‘ images presented in the media may lead to body dissatisfaction, particularly when an individual‘s social environment (such as family members, peers and teachers) reiterates such ‗ideals‘ (Australian Government, 2009). The worrying assumption is that adolescents internalize media images from a complexity of sources in an uncritical manner. This consumption of ‗ideal‘ images may lead to increased body image concerns during young adulthood. it is important that critical literacy skills are taught through school intervention programs that strive to improve body satisfaction amongst adolescents (Freebody & Luke, 1990; Luke, O‘Brien & Comber, 1994; Kanasa, 2006, Australian Government, 2009). It is important to acknowledge that not all young consumers of the mass media develop body dissatisfaction. Although this suggests other factors affecting body image need to be considered, the casual relationship between media exposure and poor body image cannot be ignored. This chapter will explore how the teaching of critical media literacy skills in a social constructivist classroom could reduce the incidence of poor wellbeing and serious mental health conditions arising from body dissatisfaction (Australian Government, 2009).

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PREVALENCE OF BODY IMAGE CONCERNS There is ample evidence to suggest that body image concerns are prevalent within most western societies. In Australia, the National Survey of Young People (NSYP) reported that body image was one of the top three issues of personal concern for those aged 11 to 24 years old, across all states of the country (Mission Australia, 2010). Notably, the proportion of young people affected by body image concerns gradually increased with age, from 28% of 11-14 year olds to 33% of 15-19 year olds to 40% of 20-24 year olds (Mission Australia, 2010). Although much of the research on body image and eating disorders is focused on young females, boys and young men are not immune to the same preoccupation with their bodies (Wykes & Gunter, 2005). This has been a historic change as it is estimated that 45% of western men are unhappy with their body image (Dietitians Association of Australia, DAA, 2011). There are cultural differences in body image concerns and in the type of body shape that is idealized (Grogan, 1999). For females, the cultural ideal body shape popularly promoted is one of thinness whereas for males it is one of exaggerated muscularity (Cohane & Pope, 2001). To date, body image programs have tended to focus on the needs of females, as body dissatisfaction is believed to be higher in girls than boys. However, research has shown that young men who were dissatisfied with their body shape usually wanted to replicate the cultural trend to have a more muscular body (Lynch & Zellner, 1999), thus increasing the rates of steroid use and body dysmorphic disorder amongst males (Paxton, 2000). In Australia: 17% of men are on some sort of fad diet; about 3% of men have problems with binge eating; an increased number of men are undergoing cosmetic surgery; 4% of men are purging (vomiting or exercising compulsively); and about 3% of Australian teenage boys use muscle enhancing drugs such as steroids (Dietitians Association of Australia, 2011). These statistics suggest that boys are under increasing pressure to have an ideal body and one in 10 people with anorexia are now male. Most experts believe that the rates of eating and exercise disorders among males is under-reported as men are less likely to seek medical help for fear of looking weak, as concerns about weight and body shape has traditionally been perceived as a ‗female‘ problem.

SOCIO-CULTURAL CONSTRUCTS AND BODY IMAGE Ryan (2007) explained that there are intersecting and often competing discourses that influence the implementation of a critical schema. The enactment of a critical media literacy intervention to address body image issues is thus situated within socio-cultural constructs pertaining to: the nature of adolescence; school environments; society; and obesity prevention strategies in Australia.

ADOLESCENCE Adolescents are particularly vulnerable to body dissatisfaction. During this less predictable time of their lives, adolescents are continually making choices about what is

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salient (Clay et al., 2005). Body image interventions may prove difficult in encouraging adolescents to be critical of media practices in which they have a personal investment. Essentially, the consumption and replication of media images enable adolescents to be noticed, to be up to date with the latest trends and gain peer acceptance. Some researchers disputed the claims that adolescence is a time of major disruption. For instance, Ryan (2007) upheld that adolescence is a time when resistance to structural or dominant norms (i.e. the ‗ideal‘ body) in society is most readily achieved. The perception that adolescence is potentially the most relevant and suitable time to encourage individuals to question the widely accepted social expectations of the ideal body supports the need for development of critical literacy body image interventions within school programs.

SCHOOL SETTINGS Amidst a postmodern corporate culture, critical theorists argue that schools should initiate change and challenge hegemonic ways of seeing the world, rather than simply preparing students to cope with social change (Ryan, 2007). The unquestioning acceptance of ‗healthism‘ in the curriculum deems individuals responsible for making healthy choices that construct anxieties about their bodies‘ that may lead to unhealthy behaviors (Rich, Holroyd & Evans, 2004). However, it is widely accepted that schools can teach critical thinking skills in constructivist classrooms (Mimbs, 2005) to help students actively interpret and evaluate societal norms rather than passively accept their environment (Australian Government, 2009; O‘Dea, 2007).

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SOCIETY The Australian society values freedom of speech, business enterprise, creativity and diverse opinions. Consequently, there is a conflict between the financial drive of enterprises to attract consumers (through the use of particular images) and the ability to produce empowered young people. As the body has become an outward marker of ‗value‘ in a consumer culture, a social hierarchy based on body size, shape and weight has evolved in schools. For instance, a slim body is associated with particular psychological characteristics, self-control, status and ‗worth‘ (Rich et al., 2004, p.182-183). The (NSYP) urged media, fashion and advertising industries to promote positive body messages through initiatives that build critical literacy skills and self-esteem (Mission Australia, 2010).

OBESITY PREVENTION Obesity as a potential risk factor or consequence of eating disorders is often overlooked in most studies on body image (Wilksch & Wade, 2009). Overweight children are more likely to have lower self-esteem than their normal weight peers. As low self-esteem is also a risk factor for disordered eating, the effects of obesity on body image interventions need to be considered (O‘Dea, 2004). A ‗blame the victim‘ perspective underlies most obesity

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prevention programs. In such circumstances, being overweight is perceived as an outward sign of neglect for oneself (Rich et al., 2004, p.179), ‗shameful‘, ‗dirty‘ and ‗irresponsible‘. Obesity programs fail to address how such perceptions may reproduce and institutionalize an adolescent‘s moral beliefs about their body (Rich et al., 2004) and inherent levels of selfesteem.

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HEALTH EDUCATION PROGRAMS AND BODY IMAGE School-based nutrition and health promotion strategies have been shown to prevent body dissatisfaction. The most effective health education interventions are those that effectively promote self-acceptance and a positive body image by incorporating young people‘s perceptions, comments and suggestions (O‘Dea, 2002). Research highlighted that media literacy interventions based on an interactive, student-centered and self-esteem building framework may be a safe and effective way to reduce the risk factors for eating disorders (O‘Dea & Abraham, 2001; Wade, Davidson & O‘Dea, 2003). Paxton (2000) also found that media literacy interventions could teach critical appraisal strategies by supporting students in becoming active advocates on body image. This empowerment can be achieved by enabling students to identify, analyze, challenge and reject the thin ‗ideal‘ body images presented in the media (Wade et al., 2003). Tiggemann (2004) added that the development of cognitive-behavioral skills through body image interventions might ensure adolescents are resistant to media images. The skills would encourage students to identify distorted patterns of thinking and maladaptive behaviors (such as body checking, mirror gazing and social comparison) that previously initiated or maintained body image concerns (Reas & Grilo, 2004). Studies revealed that the majority of body image programs in schools used a didactic teaching approach rather than co-operative, interactive and participatory teaching and learning styles (Austin, 2000). In preference to programs that attack the media directly, it will be shown that a constructivist classroom could address these shortcomings and simultaneously enrich current media literacy programs.

CONSTRUCTIVISM AND CRITICAL THEORY There is extensive literature pertaining to the definition of critical theory and thinking. Grundy (1987) defined critical theory as ―afundamental interest in emancipation and empowerment to engage in autonomous action arising out of authentic, critical insights into the social constructions of human society.‖ Beyer (1989) added that critical thinking involves assessing the authenticity, accuracy and worth of knowledge. Thus, a critical pedagogical approach to teaching about body image in school could interrogate and content the ‗media realities‘ of the social world (McLaren, 2003). The benefits of critical theory in constructivist classrooms have been collectively agreed on, yet there are many perspectives on how students should learn critical thinking (McLaren, 2003). A selection of these constructivist strategies will be defined according to their perceived ability to address body image concerns.

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Approaches to Developing Critical Thinking A constructivist approach to teaching and learning views knowledge as a construction of cognitive processes, which are formed through interactions with the environment (von Glasersfeld, 1995). The teacher is required to, ―s et up conditions that encourage selfawareness and reflection, hoping to facilitate further growth‖ (Kincheloe & Steinberg, 1998) in a constructivist classroom. By placing the responsibility for learning on the students, they are encouraged to solve problems and develop critical thinking skills during this process. A critical constructivist teaching approach requires students to challenge the technical (objective facts and concepts) and practical (subjective and interpretative attitudes) views of knowledge by adopting an emancipatory perspective to learning – a view that knowledge is influenced by interaction of historical, cultural, political, economical and social contexts (Habermas, 1972). Teaching about body image issues through an emancipatory constructivist approach could: develop students‘ ability to re-conceptualize and integrate knowledge; and question students‘ construction of values, attitudes and beliefs (Kemmis, Cole and Suggett, 1983; Ward, 1996) on their body. Usher (1996) stated that, ― It is not sufficient for a teacher to teach students about thinking. Students must be taught how to think critically and to do this it is essential to use classroom techniques which actively engage students in thinking.‖ Brooks and Brooks‘ (1999) practices for a constructivist classroom promote deep understanding, by looking ―not for what students can repeat, but for what they can generate, demonstrate, and exhibit‖ (p.16). Body image interventions could adopt Brooks and Brooks‘ principles of constructivist pedagogy by posing problems to students based on the impact of the media on body image. By structuring learning around the primary concept (i.e. the application of critical thinking skills to the consumption of media images) the facilitation of group discussions would allow each student‘s point of view (on the intent of media images) to be valued. Adapting the curriculum to address students‘ suppositions (on the technological methods used to manipulate media images), teachers will be able to assess student learning by gauging their ability to transfer critical thinking skills to a variety of media sources. Perkins (1992) argued that the skill of critical thinking is often ‗disconnected knowledge‘ because it is taught through learning experiences that are separate from the content. For instance, adolescents may be unable to connect the importance of critical thinking skills to the improvement of self-esteem and body image. Bybee‘s (1997) model for constructivism involves a natural learning process that could link critical thinking with body image. Teachers could adhere to Bybee‘s (1997) approach by engaging students in the learning of critical thinking through posing questions, defining a problem or using group discussion to stimulate ideas. The students would then be encouraged to explore critical thinking through guided student inquiry. Following on from this, students would explain their own concept of critical thinking and clarify their understanding through class discussions. Students then elaborate on their ideas and apply their newfound knowledge of critical thinking to different situations. Finally, the teacher evaluates students‘ critical knowledge by assessing whether there has been changes in the way students think about body image.

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CASE STUDIES

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Home Economics Curriculum The Department of Education, Employment and Training in Western Australia reviewed its home economics curriculum and found that the content did not support changes to women‘s life patterns thus limiting their post-school opportunities (Maughan, 1996). Consequently, a socially critical orientation to the home economics curriculum was trialled at Kemslott High School to address gender issues and vocational outcomes by requiring students to understand how power is used to arrange everyday economic processes and social life (Kemmis et al., 1983). It was thought that critical theory could explore the relationship between gender and oppression in the family, workplace and schools (Maughan, 1996). This trial successfully trained students to critically analyze rather than simply participate in the given structures of society. Body image programs could adopt a similar critical orientation to empower students to become active consumers of the ideal body images presented in the media. Critical thinking shifts the role of the teacher from the ‗provider‘ of information to a ‗facilitator‘ of student interactions and discussions on concerning issues (Eyre, 1999). The Kemslott study found that the questions posed by teachers would stimulate critical thinking and thoughtful responses if they demand the collaborative challenging of facts and the status quo. Questions should also promote listening skills, the respect of individual views and the design of an action plan to enable students to learn their own feelings and see themselves and society in different ways (Maughan, 1996; Usher, 1996). The Kelmslott intervention lead to a ‗Stepping Out‘ literacy program focused on developing critical analytical skills. The use of three-level questioning effectively enabled students to analyze media messages by: identifying the main issues; reading into the inferences made; and evaluating the material based on individual opinions, values and feelings (Maughan, 1996). This approach could be applied to a body image program to enhance the critical consumption of media images of the body. Although this study did not specifically address body image, the socially critical approach at Kemslott developed an awareness of gender imbalances in society. The critical analysis of the media‘s intent prompted personal responsibility and independence. Students gained the skills to be reflective and critical (Maughan, 1996) in ways that would enable them to achieve the objectives of a critically orientated body image intervention.

Multimedia Supported Predict-observe-explain (POE) Tasks in Science The Science curriculum in Australia has frequently adopted a social constructive perspective to analyze and interpret the conceptions, clarification of and critical reflection on shared understandings. Kearny (2004) examined the use of multimedia-based POE tasks to elicit student ideas and promote student discussion on student‘s views and understandings of concepts in science. The POE strategy, initially promoted by White and Gunstone (1992), involved students predicting the result of a multimedia demonstration, discussing the reasons for their predictions, observing the explanations and then explaining any discrepancies

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between their predictions and observations. From a social constructivist perspective, the implementation of the POE strategy provided students with the opportunity to articulate, justify, debate and reflect on their own and peers‘ views while negotiating new and shared meanings (Kearney, 2004). Kearney‘s (2004) study revealed that computer-based POE tasks supported rich conversations between students based on the quality of peer learning that occurred. Although this study examined the use of POE tasks in science, it is evident that this social constructivist approach can ‗be used within rich social contexts that prompt students to interact with each other and the systems to create meaning‘ (Kozma, 2000). A health education classroom facilitating group discussions on how critical thinking can be applied to multimedia, demonstrates an image of the ‗ideal‘ body in the media. The use of POE tasks in a body image intervention may potentially facilitate collaborative ‗sense-making‘ among learners by prompting students to develop and refine ideas about a phenomena (such as the ‗ideal‘ body). The use of digital video media could provide students with unique opportunities to examine the viability of their own and their peer‘s conceptions on body image. In doing so, the multimedia images in the POE task would stimulate the analysis, linking, testing and reflection (Linn, 1998) of critical thinking skills to the consumption of media images. The POE approach effectively reinforces the social constructivist view of learning where learners construct (rather than acquire) knowledge. Students could learn about body image through the process of constructing, interpreting and modifying their own representations of reality based on their own experiences and those provided by the nature of POE tasks.

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CONCLUSION Australia is committed to supporting all young people in becoming: successful learners; confident and creative individuals; and active and informed citizens (MCEETYA, 2008). This chapter suggests that the subtleties of the National Education Goals can be achieved by developing students‘ critical thinking skills to enable them to make rational and informed decisions and accept responsibility for their body image. Although, critical theory may not immediately translate into improved body image, it may provide protection against external media pressures (Paxton, 2000). The implementation of a critical constructivist approach to teaching has been shown to complement the objectives of both body image interventions and the National Curriculum Goals of Australian schools. Further research could investigate the genuine transfer of the learning of critical thinking skills to the improvement of the body image among Australian adolescents.

ACKNOWLEDGEMENTS I wish to thank my PhD supervisor, Associate Professor Jenny O‘Dea from the Faculty of Education & Social Work at the University of Sydney for the opportunity to contribute a chapter to this edited book along with her support in its evolvement.

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REFERENCES Ata, R.N., Ludden, A., & Lally, M. (2007). The effects of gender and family, friend and media influences on eating behaviors and body image during adolescence. Journal of Youth Adolescence, 36, 1024-1037. Australian Government. (2009). Body image: Information paper. Commonwealth of Australia. Austin, S.B. (2000). Population prevention of eating disorders: An application of the Rose Prevention Model. Preventive Medicine. 1-32. Beyer, B.K. (1985). Critical thinking: What is it? Social Education, 49, 270-276. Brooks, J., & Brooks, M. (1999). The case for a constructivist classroom. Alexandria, VA: Association for Supervision and Curriculum Development Bybee, R. (1997). Achieving scientific literacy from purposes to practices. Portsmouth, NH: Heinemann. Clay, D., Vignoles, V.L., & Dittmar, H. (2005). Body image and self-esteem among adolescent girls: Testing the influence of socio-cultural factors. Journal of Research on Adolescence, 15(4), 451-477. Cohane, G.H., & Pope, H.G. (2001). Body image in boys: A review of the literature. International Journal of Eating Disorders, 29, 373-379. Dietitians Association of Australia. (2011). Eating disorders. Retrieved February 1, 2011 from http://www.daa.asn.au/ Eyre, L. (1989). Gender equity in home economics curriculum. Illinois Teacher,33(1), 22 – 25 Freebody, P. & Luke, A. (1990). Literacies programs: Debates and demands in cultural context. Australian Journal of TESOL, 5(7), 7-16. Grogan, S. (1999). Body image: Understanding body dissatisfaction in men, women and children. London: Routledge. Grundy, S. (1987). Curriculum: Product or praxis. Lewes: Falmer Habermas, J. (1972). Knowledge and human interests. London: Heinemann. Kanasa, H. (2006). Football, meat pies, kangaroos and Holden cars: The role of the media in the construction of male adolescent identity and its implications for middle schooling. Australian Journal of Middle Schooling, 6(2), 27-32. Kearney, M. (2004). Classroom use of multimedia-support predict-observe-explain tasks in a social constructivist learning environment. Research in Science Education, 34, 427-453. Kemmis, S., Cole, P., & Jugget, D. (1983). Orientations to curriculum and transition. Towards the socially-critical school. Melbourne: Victorian Institute of Secondary Education. Kincholoe, J. L. (1993). Towards a critical politics of teacher thinking: Mapping the postmodern. London: Bergin and Garvey. Kincheloe, J.L. & Steinberg, S.R. (eds.). (1998). Students as researchers: Creating classrooms that matter. London: Falmer Press. Kirk, D. (1993). The body, schooling and culture. Geelong, VIC: Deakin University Press. Kozma, R. (2000). The use of multimedia representations and the social construction of understanding in chemistry. In M. Jacobson & R. Kozma (Eds.), Innovations in science

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and mathematics education. Advanced designs for technologies of learning: A constructivism perspective. Mahwah, NJ: Lawrence Erlbaum. Linn, M. (1998). The impact of technology on science instruction: Historical trends and current opportunities. In B. Fraser & K. Tobin (Eds.), International handbook of science education. Dordrecht, The Netherlands: Kluwer. Luke, A., O‘Brien, J., & Comber, B. (1994). Making community text objects of study. Australian Journal of Language and Literacy, 12(2), 139-145. Lynch, S.M., & Zellner, D.A. (1999). Figure preferences in two generations of men: The use of figure drawings illustrating differences in muscle mass. Sex Roles, 40(9/10), 833-843. McLaren, P. (2003). Critical pedagogy: A look at the major concepts. In A. Darder and R.D. Torres. (Eds.). The critical reader. New York, NY: Routledge. Maughan, E. (1996). A critical approach in home economics: The Kelmscott experience. Journal of Home Economics Institute of Australia, 3(3), 37-43. Mimbs, C.A. (2005). Teaching from the critical thinking, problem-based curricular approach: Strategies, challenges and recommendations. Journal of Family and Consumer Sciences Education, 23(2), 7-18. Ministerial Council on Education, Employment, Training and Youth Affairs. (2008). National Declaration on Educational Goals for Young Australians. Commonwealth of Australia. Mission Australia. (2010). National survey of young Australians. Mission Australia. O'Dea, J. (2007). Are we OK or are we not? Journal of the Home Economics Institute of Australia, 14(3), 6–14. O‘Dea, J.A. (2004). Prevention of child obesity: First, do no harm. Health Education Research: Theory and Practice, 20(2), 259-265. O‘Dea, J. (2002). Can body image education be harmful to adolescent females? Eating Disorders The Journal of Treatment and Prevention, 10(1), 1-13. O‘Dea, J. & Abraham, S. (2001). Knowledge, beliefs, attitudes and behaviours related to weight control, eating disorders and body image in trainee home economics and physical education teachers. Journal of Nutrition Education, 33(6), 332-340. Paxton, S.J. (2000). Body image dissatisfaction, extreme weight loss behaviours: Suitable targets for public health concern? Health Promotion Journal of Australia, 10, 15-19. Perkins, D.N. (1992). Smart schools: From training memories to educating minds. New York: The Free Press. Reas, D., & Grilo, C. (2004). Cognitive- behavioural assessment of body image disturbance. Journal of Psychiatric Practice, 10(5), 314-322. Rich, E., Holroyd, R., & Evans, J. (2004): ‗Hungry to be noticed‘: Young women, anorexia and schooling. In J.Evans, B. Davies & J. Wright. (eds), Body knowledge and control: Studies in the sociology of physical education and sport. London: Routledge. Ryan, M. (2007). Critical pedagogy and youth: Negotiating complex discourse worlds. Pedagogy, Culture and Society, 15(2), 245-262. Tiggemann, M. (2004). Media influences on body image development. In T.F.Cash and T. Pruzinsky (eds.), Body image: A handbook of theory, research and clinical practice. New York, NY: Guilford Press. Usher, M. (1996). Critical thinking: Approaches to teaching and learning. Journal of Home Economics Institute of Australia, 3(3), 8-12.

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Von Glasersfeld, E. (1995). A constructivist approach to teaching. In J.Gale (Ed.), Constructivism in education. Hillsdale, New Jersey: Lawrence Erlbaum Associates Publishers. Wade, T.D., Davidson, S. and O‘Dea, J. (2003) A controlled evaluation of a school-based media literacy program and self-esteem program for reducing eating disorder risk factors: A preliminary investigation. International Journal of Eating Disorders, 33(4), 371-383. Ward, V. (1996). Searching for the perfect body: A critical theory workshop. Journal of the Home Economics Institute of Australia, 3(3), 29-36. White, R., & Gunstone, R. (1992). Probing understanding. London and New York: The Falmer Press. Wilksch, S. M., & Wade, T. D. (2009). Reduction of shape and weight concern in young adolescents: A 30-month controlled evaluation of a media literacy program. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 652-661. Wykes, M., & Gunter, B. (2005). The media and body image: If looks could kill. London: Sage Publications.

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SECTION 1.2: ISSUES IN COMMUNITY HEALTH EDUCATION

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In: Current Issues and Controversies in School and Community ... ISBN 978-1-62100-327-4 Editor: Jennifer A. O‘Dea © 2012 Nova Science Publishers, Inc.

Chapter 7

REFRAMING PRE-SERVICE TEACHERS‟ PERCEPTIONS OF SEXUALITY EDUCATION: CHALLENGES FOR TEACHER EDUCATORS Margaret Sinkinson* Faculty of Education, University of Auckland, New Zealand

ABSTRACT

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A three-year study into pre-service teachers‘ perceptions of and beliefs about health education in New Zealand schools, provided evidence of shifts in their understanding of sexuality education during their teacher education programs. Comparisons between their original beliefs about what constitutes ‗good‘ sexuality education and those they had developed after three years of teacher education showed notable changes in these studentteachers‘ discourses of sexuality education. Original views of sexual health education were typically expressed in the language of risk, moralising and fear. By the end of the study positive, inclusive and comprehensive approaches to teaching about sexuality were seen as desirable by most participants. Fewer however, demonstrated embedded understanding of sexuality as a social construction, or expressed critical or socioecological perspectives of sexuality education. In this chapter, participants‘ memories of their own school health education experiences are described and their prior learning experiences analyzed. Problematic situations for school health education, identified in initial data results are discussed, and dilemmas around the delivery of school-based sexuality are explored. Based on the outcomes of the study, recommendations for teacher educators of sexuality education are presented.

*

Correspondence: Margaret Sinkinson, Senior Lecturer, School of Critical Studies in Education, Faculty of Education, University of Auckland, Private Bag 92160, Symonds Street, Auckland 1150,New Zealand. E-mail: [email protected], [email protected].

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INTRODUCTION Since the early 1990s, the delivery of health education in New Zealand teacher education has been largely within the disciplines of psychology, sociology and physiology. Attention is given to the theories of resilience and motivation that will inform their own teaching of health education (Richardson, 2002), but pre-service teachers (student-teachers) are also taught to identify cultural, social and political contexts within which health education, and health status, exist (Alldred & David, 2007; Harrison, 2000). The aim of the teacher education curriculum is to: develop health education teachers who are able to conceptualize health holistically; who incorporate both personal dimensions and wider social and physical environments into notions of health; and who do not side step systematic analysis of social, political or cultural power relations (Luke, 2000). School-based health education does not, however, always reflect the pedagogy that is promoted in teacher education; despite health education‘s core curricular status to Year 10 level and despite a curriculum document that for over ten years has provided clear direction for philosophical and theoretical underpinnings, and content, for the delivery of health education in schools, a first challenge for teacher educators of newly enrolled studentteachers is to uproot often significantly confining perspectives of health and health education. Historic habits of treating health topics in clinical ways and ignoring social and cultural connections between power, privilege, discrimination and health status (Kenway, in Laskey & Beavis, 1996) continue to be exhibited by new enrollees each year.

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MEMORIES OF HEALTH EDUCATION In 2004, the author and four teacher education colleagues began a three-year four-stage study into student-teachers‘ experiences of secondary school health education, and shifts in their beliefs about and attitudes towards health education over the three years of their teacher education programs. The study involved both qualitative and quantitative methods and included questionnaires, surveys, focus-group interviews and individual interviews. During 2004 and 2006 participants were surveyed and interviewed several times before and after undertaking health education courses, with the purpose of exploring the development of their understanding of health education over that time (Sinkinson & Hughes, 2008). Initial data collected early in 2004, before participants had undertaken any health education courses in their teacher education programs, revealed interesting recollections of school health education, recollections that ranged from apparently well executed health programs to tales of bi-sectioned frogs, visits from outside providers, or in some cases, total silence. Although many of these student-teachers exhibited positive attitudes towards the subject, and clearly saw it as an important learning area of the school curriculum, a number of issues inherent in school health education emerged from these early data, all of which would benefit from future investigation. Participants‘ beliefs about ‗what is health education‘ proved to be rather impoverished and narrow. The discourses of health that they had been exposed to in their schooling seemed to have been mostly sermonising and deficit, peppered with warnings of undesirable but fully deserved health consequences for unwise choices. I use the word ‗discourse‘ in a Foucauldian

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sense as encompassing assumptions around knowledge, practices and power (Weedon, in Jackson & Weatherall, 2010) and implicit in these student-teachers‘ ‗health‘ language were what Ollis (2010) calls discourses of fear, illness, and individual morality. Overwhelmingly, personal responsibility for safety and risk avoidance was assumed. As a result, participants had come to view health education as a subject of safety ‗facts‘, safety rules and good behavior, although younger participants, influenced no doubt by the implementation of a new curriculum document Health and Physical Education in the New Zealand Curriculum in 1999 (NZ Ministry of Education [MoE], 1999), proved to have had greater exposure to education about emotional, mental and social elements of health. Participants‘ experiences of the delivery of health education revealed that health teachers in secondary schools were often not specialist health educators; only slightly more than half described being taught about health by a health teacher (51.9%), and / or a physical education teacher (49.8%). Others mentioned being taught by guest speakers (21.4%) or outside agencies (14.6%), science teachers (16.6%), or others, for example, counselors and religious educators (12.5%). Health education appeared to be an underdeveloped subject area taught by teachers sometimes randomly drawn from physical education, home economics, science disciplines or school counselors. It is likely that most of these teachers had had minimal teacher education or professional development in the field, and would be reluctant to teach what Ollis (2010) describes as the more sensitive issues in health. Pedagogies and teaching approaches were remembered by participants as traditional teacher-directed and teachercentred practices; health education was time-tabled less frequently than other subject areas, and teaching styles had preponderance towards using videos, worksheets, and written tasks, rather than the interactive and constructivist learning opportunities that typify a more engaging mode of health education (Sinkinson et al., 2008). The rather weak status of health education at senior school levels became obvious; overall 55% of participants had experienced no senior school health education, or taken nationally set exiting achievement standards in the subject. Particularly notable in early data were participants‘ lack of socio-ecological perspectives of health. For over a decade a socio-ecological perspective of health has been an underlying concept of the Health and Physical Education curriculum area (MoE, 2007; 1999), but little understanding of socio-political, historic, economic or cultural determinants of health was demonstrated. These new student-teachers exhibited a categorical belief that personal responsibility and inter-personal relationships determined health status, and health status was seen as something fully under the control of the individual. Few were able to analyze the politics of health education or the influences of broader factors that also determine the health of individuals, groups and society (MoE, 2007). Attitudes toward and beliefs about sexuality education were the most frequently reported, most detailed, and perhaps the most interesting results to emerge from initial data in 2004. Clearly sexuality and sexuality education were of high interest to these student-teachers. In this chapter the discussion is focussed on sexuality education, drawing also on results from the later stages of the study in 2006 to highlight potential issues for prospective teachers of sexuality education, and to make a few recommendations for teacher educators of health education.

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Margaret Sinkinson

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THE STATE OF SEXUALITY EDUCATION IN SCHOOLS When compared with other OECD nations, sexual health statistics amongst New Zealand youth consistently show higher incidences of unintended pregnancies, abortions and sexually transmitted infections (STIs) (NZ Ministry of Health [MoH], 1997; 2008; NZ Statistics, 2010). In 2001, mandating sexuality education in all state schools was an attempt by the New Zealand Ministries of Health and Education to reduce youth sexual health risks and establish positive sexual behaviors and attitudes amongst adolescents and young adults that might evolve into life-long health-enhancing habits. Undoubtedly there is an on-going call for comprehensive sexuality education in New Zealand schools. But indicators are that the delivery of education in this area continues to be haphazard and prone to idiosyncratic decision-making by school principals, Boards of Trustees and teachers. In their 2007 evaluations of Years 7 – 13 sexuality education programs in 100 New Zealand schools, the New Zealand Education Review Office (ERO) found that most schools had weaknesses in their delivery of sexuality education and many teachers were not well prepared to teach the subject (Sinkinson, 2009). It is clear from dialogue with student-teachers about their school-based teaching experiences, and from the author‘s own visits to schools to observe their teaching of health education, that for many schools sexuality education remains undefined and without educational justification. Programs still manifest as either cautionary warnings of undesirable outcomes – i.e. disease or unplanned pregnancies, or rather clinical descriptions of the reproductive systems. There is still little indication that programs go beyond educating about anatomy, physiology, pubertal changes, reproduction, contraception, and STIs – all of which are important components of effective sexuality education of course. Few schools however, extend the learning to include comprehensive examination of gender and sexual rights, relationships and love, desire and pleasure, or sexual identity and orientation. Commonly a ‗one size fits all‘ approach to teaching about sexuality typifies delivery as adequate, and appropriate resources are often not readily available (ERO, 2007).

PRIOR BELIEFS ABOUT, AND SHIFTS IN STUDENT-TEACHERS‟ CONSTRUCTS OF SEXUALITY EDUCATION Indicators from early data in 2004 were that the participants had experienced some degree of, and in a few instances rather bizarre, school-based sexuality education. Most (93.6%) recalled having ‗sex ed‘ at school. In this first stage of the study, sex education had higher reporting as a ‗remembered‘ feature of health education than any other health topic, which more likely reflects the topic‘s memorability than the frequency of its delivery. Younger student-teachers, those aged 20 years and under, had significantly greater exposure to virtually all health education topics than those aged 20 – 30 years, or those aged 30+ years, including topics such as drug and alcohol education (p