​​​​The FRESH framework, an intersectoral partnership to Focus Resources on Effective School Health, provides the context for effective implementation of skills based health education programs.  Skills based health education, delivered through schools, is most effective where it is supported by other reinforcing strategies such as policies to provide a non-discriminatory safe and secure environment, provision of safe water and sanitation, provision of health and other services, effective referral to external health service providers and links with the community.  The FRESH framework provides this context by positioning skills based health education among its four core components, which should be made available together for all schools:

Skills based health education

The challenges facing children growing up in the 21st century, especially the poorest and most disadvantaged children living in low income countries are greater than ever.  Millions of children are affected by problems of poor nutrition, infectious diseases, inadequate access to clean water and sanitation, violence, substance abuse and the increasing threat and burden of living with HIV/AIDS.  Children and young people need to be equipped with the knowledge, attitudes, values and skills that will help them face these challenges and assist them in making healthy life-style choices as they grow.  Skills based health education delivered through schools is one of the ways through which children can be helped to face these challenges and make such choices.

1. Why skills based health education?

The application of skills based health education, in particular life skills, to areas such as HIV/AIDS prevention, reproductive health, early pregnancy, violence, tobacco and substance abuse is becoming increasingly widespread.  In areas such as these, individual behavior, social and peer pressure, cultural norms and abusive relationships may all contribute to the health and lifestyle problems of children and adolescents.  There is now increasing evidence that in tackling these issues and health problems, a skills based approach to health education works, and is more effective than teaching knowledge alone.

There are numerous studies indicating that providing information about issues such as sex, STDs and HIV (transmission, risk factors, how to avoid infection) is necessary, but not sufficient, to lead to healthy behavioral change (Hubley, 2000).  Programs that provide accurate information, to counteract the myths and misinformation, frequently report improvements in knowledge and attitudes, but this is poorly correlated with behavioral change related to risk taking and desirable behavioral outcomes (Gatawa 1995, UNAIDS 1997a).  Skills-based health education can be effective in the more difficult task of achieving and sustaining behavior change.

Skills based health education is widely applicable

Although the areas outlined above are seen to be problems largely affecting older children and adolescents, both this age group and younger children also face a wider range of health, hygiene and nutrition problems where skills based health education can play a vital role in sustainable prevention and management.  Examples of this include water and sanitation related diseases such as helminth infections. (Helminth infections include soil borne intestinal nematodes such as roundworm (Ascaris lumbricoides), whipworm (Trichuris trichiura) and hookworm, and water borne species such as Schistosoma haematobium and S. mansoni.)

Globally, millions of children are infected with parasitic helminths, with greatest burden in the poorest countries (an estimated 320 million with roundworm, 233 million with whipworm and 239 million with hookworm – PCD, 1997). School-age children are the most heavily infected group both in terms of prevalence and intensity of infection. Helminth infections are estimated to account for over 12% of the total disease burden in girls aged 5 to 14 years and over 11% of the burden in boys making this the single largest contributor to the disease burden of this group. Helminth infections have been shown to cause iron deficiency anemia (particularly hookworm), reduce growth and may negatively affect cognition (Drake et al., 2000; Stoltzfus et al. 1998).

Skills based health and hygiene education programs play a vital role in combating diseases such as helminth infections.  This is done through promoting Knowledge of areas such as symptoms, transmission, and behaviors that are specifically relevant to helminth infection in each community; Attitudes such as responsibility for personal, family and community health, confidence to change unhealthy habits; Skills such as avoiding behaviors that are likely to cause infection, encourage others to change unhealthy habits, communicate messages about worm infection to families, peers and members of the community (WHO, 1996). 

Skills based health education can also be seen as widely applicable to a range of other areas where knowledge, attitudes and skills play a critical role as part of a comprehensive strategy for combating disease and promoting healthy life styles.  This includes a wide range of diseases and conditions that affect the health of children and adolescents, including: vector borne diseases such as malaria; water and sanitation related diseases such as diarrheal diseases, trachoma and schistosomiasis; nutrition related conditions such as micronutrient deficiencies and other forms of malnutrition.

The skills based approach extends traditional methods of teaching about health, which tend to be knowledge based and didactic in approach.  In contrast, skills based health education focuses upon the development of Knowledge, Attitudes, Values, and Skills (including life skills such as inter-personal skills, critical and creative thinking, decision making and self awareness) needed to make and act on the most appropriate and positive health-related decisions.  Health in this context extends beyond physical health to include psycho-social and environmental health issues.  This approach utilizes student centered and participatory methodologies, giving participants the opportunity to explore and acquire health promoting knowledge, attitudes and values and to practice the skills they need to avoid risky and unhealthy situations and adopt and sustain healthier life styles.

HIV/AIDS – a critical need for skills based health education

HIV/AIDS is an area where the scale and impact of the problem is such that the urgency of implementing preventative measures, including skills based health education, is critical.  Skills based health education programs are being increasingly adopted as means of reaching children and young people to help halt the spread of this crippling epidemic.  Studies from African countries show that children between the ages of 5 and 14 have the lowest prevalence of HIV infection.  Below the age of 5 they are susceptible to mother to child transmission, and after they become sexually active, the rate of infection increases rapidly – especially for girls (Kelly, 2000).  Children aged 5-14 need to be reached at this critical stage in their lives and offer the ‘window of hope’ in stopping the spread of HIV/AIDS.

2. Skills Based Health Education Does Change Behavior

There is now strong evidence from an increasing number of studies that skills based health education, applied in an appropriate context, changes behavior – including behavior in sensitive and difficult areas where knowledge based health education has failed.

USA – Sexuality and HIV education:  This study was implemented in 4 schools in New York City with 9th and 11th grade students (867 students), in intervention (AIDS prevention program) and control classes (no AIDS prevention program).  The program focused on correcting facts about AIDS, teaching cognitive skills to appraise risk of transmission, increasing knowledge of AIDS-prevention resources, changing perceptions of risk-taking behavior, clarifying personal values, understanding external influences and teaching skills to delay intercourse and/or consistently use condoms.  An evaluation carried out three months after the end of the program found that the intervention group showed the following positive behavioral outcomes when compared with the control group:  decrease in intercourse with high risk partners, increase in monogamous relationships and an increase in consistent condom use.  (Walter & Vaughan, 1993).
Nigeria - HIV/AIDS prevention:  Health education programs are being implemented in many schools in Nigeria to increase levels of knowledge, influence attitudes and encourage safe sexual practices among secondary school students.  A study to evaluate one such program was conducted comparing 223 students who received comprehensive sexual health education with 217 controls.  Students in the intervention group received 6 weekly sessions lasting 2-6 hours, with activities including lectures, film shows, role-play stories, songs, debates, essays and a demonstration of the correct use of condoms.  Following the intervention, students in the intervention group showed a greater knowledge and increased tolerance of people with AIDS compared to the control.  The mean number of sexual partners also decreased in the intervention group, while the control group showed a slight increase.  The program was also successful in increasing condom use  (Fawole et al., 1999).  
USA - A cognitive-behavioral approach to substance abuse prevention:  The effectiveness of a 20 session cognitive-behavioral approach to substance abuse prevention was tested on seventh grade students (n=1,311) from 10 suburban New York junior high schools.  The prevention strategy attempted to reduce interpersonal pressure to smoke, drink excessively, or use marijuana by fostering the development of general life skills as well as teaching students tactics for resisting direct interpersonal pressure to use these substances.  Additionally, this study was designed to compare the relative effectiveness of this type of prevention program when implemented by either older peer leaders or regular classroom teachers.  Results indicated that the prevention program had a significant impact on cigarette smoking, excessive drinking, and marijuana use when implemented by peer leaders.  Furthermore, significant changes were also evident with respect to selected cognitive, attitudinal, and personality predisposing variables in a direction consistent with non-substance use.  These results provide further support for the efficacy of broad-spectrum smoking prevention strategy and tentative support for its applicability to the prevention of other forms of substance abuse. (Botvin et al., 1984).

USA – School based drug abuse prevention program: A randomized control trial involving over 3,000 students in 56 public schools, implemented a drug abuse prevention program, teaching general life skills and skills for resisting social influences to use drugs.  Follow-up data were collected 6 years after the initial baseline survey.  Significant reductions were found for both drug and polydrug  (tobacco, alcohol and marijuana) use in the groups that received the prevention program, compared to the control groups.  The conclusion from this study was that drug abuse prevention programs conducted during junior high school, can produce significant and durable reductions in tobacco, alcohol and marijuana use if they 1) teach a combination of social resistance and general life skills, 2) are properly implemented, and 3) include at least 2 years of booster sessions.  (Botvin et al., 1995).

3. Context for implementing Skills Based Health Education with HIV/AIDS prevention

Although there is strong evidence that skills based HIV/AIDS prevention is effective when properly applied and supported, implementing this approach and achieving this success on a larger, countywide scale is one of the greatest challenges to be faced.  To be effective, HIV/AIDS prevention programs must address the following areas:

Reassure stakeholders that these messages are beneficial: Talking and teaching about reproductive health and HIV/AIDS issues does not result in earlier initiation of sex or promiscuity. The evidence suggests that well implemented skills-based programs, conducted in an atmosphere of free discussion of all the issues, is likely to lead to young people delaying the initiation of intercourse and reducing the frequency of intercourse and number of sexual partners (Kirby et al. 1994, UNAIDS 1997a).

Provide support to teachers: The lack of support for implementation of new programs is one of the most important factors affecting success.  For most teachers both the content and methods of HIV/AIDS prevention programs are new and perhaps sensitive, and yet the approach has great potential to assist teachers both in their work and also their personal lives since HIV/AIDS is, of course, also affecting teachers.  Sufficient support, training, practice and time needs to be available to teachers, in both pre- and in-service training sessions and workshops, to facilitate reflection and development of their own attitudes, and to motivate them to apply their new knowledge and skills, rather than continue with the more didactic, traditional teaching methods, which are often focused on information alone (Gatawa 1995, Gachuhi 1999).  In addition, sufficient time and an appropriate place must also be given in the curriculum so that all students have access to HIV/AIDS prevention.

Start early: As well as targeting adolescents, programs need to be targeted at children at an early age, with developmentally appropriate messages, before they leave school (Gachuhi 1999, Partnership for Child Development 1998).  Because younger children are generally not sexually active, these programs will address the building blocks for healthy living and avoiding risk, rather than the very specific issues related to sexual relationships and HIV/AIDS which are progressively introduced to programs for older ages.  However, the large number and diverse age range of children within primary schools is an enduring challenge, especially when addressing sensitive issues (Partnership for Child Development 1998).  Active and self-directed learning methods which are commonly used in skills-based health education can be helpful in overcoming these classroom management issues to some extent.

Provide a supportive environment: Schools need to have strong policies and a healthy supportive environment in terms of behavior of students towards each other, teachers and school personnel.  Sexual abuse can occur in schools, with both boys and girls reporting abuse by school staff (Kinsman et al. 1999, Lowensen et al. 1996).  Programs need to address this potential problem by training and supporting teachers, so that they can become role models rather than neutral or adverse figures in relation to sexual behavior.

Respond to local needs: Many of the models for HIV/AIDS prevention have been developed in western, developed countries.  The available evidence from developing countries, although more limited in scope than the studies from non-developing countries, supports skills-based health education for HIV/AIDS and reproductive health (Hubley, 2000).  The main issue is that wherever programs are to be implemented they must be shaped to meet the local sociocultural norms, values and religious beliefs, and need to include ongoing monitoring (Kirby et al 1994, UNAIDS 1999, Kinsman et al. 1999)

4. Elements of a Skills Based Health Education for HIV/AIDS prevention

Reviews of school-based HIV/AIDS prevention programs (23 studies in the USA (Kirby et al. 1994), 37 other countries (reported in UNAIDS 1999) and 53 studies in USA, Europe and elsewhere (UNAIDS 1997a) have identified the following common characteristics of successful programs:

  • Focus on a few specific behavioral goals, (such as delaying initiation of intercourse or using protection), which requires knowledge, attitude and skill objectives.
  • Provision of basic, accurate information that is relevant to behavior change, especially the risks of unprotected intercourse and methods of avoiding unprotected intercourse.
  • Reinforcement of clear and appropriate values to strengthen individual values and group norms against unprotected sex.
  • Modelling and practice in communication and negotiation skills particularly, as well as other related “life skills”.
  • Use of Social Learning theories as a foundation for program development.
  • Addressing social influences on sexual behaviors, including the important role of media and peers.
  • Use of participatory activities (games, role playing, group discussions etc.) to achieve the objectives of personalising information, exploring attitudes and values, and practising skills.
  • Extensive training for teachers/implementers to allow them to master the basic information about HIV/AIDS and to practice and become confident with life skills training methods.
  • Support for reproductive health and HIV/STD prevention programs by school authorities, decision and policy makers, as well as the wider community.
  • Evaluation (e.g. of outcomes, design, implementation, sustainability, school, student and community support) so that programs can be improved and successful practices encouraged.
  • Age-appropriateness, targeting students in different age groups and developmental stages with appropriate messages that are relevant to young people.  For example one goal of targeting younger students, who are not yet sexually active, might be to delay the initiation of intercourse, whereas for sexually active students the emphasis might be to reduce the number of sexual partners and use condoms. 
  • Gender sensitive, for both boys and girls.

5. Additional Case Studies

Follow these links for additional case studies of Skills Based Health Education in Zimbabwe, Peru, Colombia, Vietnam and Tanzania.

6. The way forward

Skills based health education, promoted in a supportive framework such as that offered by the FRESH schools initiative, offers an effective approach to equipping children and young people with the knowledge, attitudes and skills that they need to help them avoid risk taking behavior and adopt healthier life styles.  The scope of skills based health education means that it can be applied to a wide range of areas, especially STD and HIV/AIDS prevention, but also including violence, substance abuse, unwanted situations such as early pregnancy, water and sanitation related diseases, and all areas where knowledge attitudes and skills play a critical role in combating disease and promoting a healthy lifestyle for children and young people growing up in the 21st century.

1.    Botvin, G.J., Baker, E., Renick, N., Filazzola, A.D. & Botvin, E.M. (1984). A cognitive-behavioral approach to substance abuse prevention. Addictive Behaviors, 9:137-147.​
2.    Botvin, G.J., Baker, E., Dusenbry, L., Botvin, E.M. & Diaz, T. (1995). Long-term follow-up results of a randomized drug abuse prevention trial in a White middle-class population.  Journal of the American Medical Association. 273(14): 1106-1112.
3.    Caceres, C.F., Rosasco, A.M., Mandel, J.S. & Hearst, N. (1994). Evaluating a school-based intervention for STD/AIDS prevention in Peru.  Journal of Adolescent Health. 15: 582-591.
4.    Drake, L.J., Jukes, M.C.H., Sternberg, R.J. and Bundy, D.A.P. (2000) Geohelminth infections (Ascariasis, Trichuriasis and Hookworm): cognitive and developmental impacts. Seminars in Pediatric Infectious Diseases 11, 245-251.
5.    Fawole, I.O., Asuzu, M.C., Oduntan, S.O., Brieger, W.R. (1999). A school-based AIDS education program for secondary school students in Nigeria: a review of effectiveness. Health Education Research – Theory & Practice, 14: 675-683.
6.    Gachuhi, D. (1999). The impact of HIV/AIDS on education systems in the Eastern and Southern Africa region and the response of education systems to HIV/AIDS: Life Skills Programs.
7.    Gatawa, B.G. (1995). Zimbabwe: AIDS Education for schools. Case Study. UNICEF Harare Zimbabwe.
8.    Hubley, J. (2000). Interventions targeted at youth aimed at influencing sexual behavior and AIDS/STDs. Leeds Health Education Database, April 2000.
9.    Kelly, M.J. (2000). Standing education on its head: Aspects of schooling in a world with HIV/AIDS. Current Issues in Comparative Education. 3(1).
10.  Kinsman, J., Harrison, S., Kengeya-Kayondo, J., Kanyesigye, E., Musoke, S. & Whitworth, J. (1999). Implementation of a comprehensive AIDS education program for schools in Masaka District, Uganda.  AIDS CARE, 11(5): 591-601.
11.  Kirby, D., Short, L., Collins, J., Rugg, D. et al. (1994).  School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Reports, 109(3): 339-361.
12.  Lansdown et al. (2001) Schistosomiasis, helminth infection and health education in Tanzania: achieving behavior change in primary schools.  Health Education Research (in press)
13.  Lowensen, R., Edwards, L. & Ndlovu-Hove, P. (1996). Reproductive health rights in Zimbabwe.  Training and Research Support Centre (TARSC).
14.  Meresman, S., Bundy, D. & Cerqueira, M.T. (2000). DRAFT paper on school health programming in Latin America
15.  Ndlovu, R. & Kaim, B. (1999). Adolescent reproductive health education project: lessons from ‘Auntie Stella’ – reproductive health education in Zimbabwe’s secondary schools. Part One. (report, May 1999).
16.  Partnership for Child Development (1997). Better health, nutrition and education for the school-aged child. Transactions of the Royal Society of Tropical Medicine and Hygiene 91: 1-2.
17.  Partnership for Child Development (1998). Implications for school-based health programs of age and gender patterns in the Tanzanian primary school. Tropical Medicine and International Health, 3(10): 850-853.
18.  Stoltzfus, R.J., Albonico, M., Tielsch, J.M., Chwaya, H.M. and Savioli, L. (1998) School-based deworming yields small improvement in growth of Zanzibari school children after one year. Journal of Nutrition 128, 2187-2193.
19.  UNAIDS (1997a). Impact of HIV and sexual health education on the sexual behavior of young people: a review update.
20.  UNAIDS (1997b). Learning and teaching about AIDS at school. UNAIDS technical update, October 1997.
21.  UNAIDS (1999). Sexual behavioral change for HIV: Where have all the theories taken us?
22.  UNAIDS (2000). Innovative approaches to HIV prevention.
23.  UNAIDS/WHO (1999). AIDS epidemic update: December 1999.
24.  Walter, H. & Vaughan, R. (1993). AIDS risk reduction among a multiethnic sample of urban high school students.  JAMA, 270(6): 725-730.
25.  WHO (1996)  Strengthening Interventions to reduce helminth Infections: An entry point for the development of Health-Promoting Schools.  WHO/HPR/HEP/96.1.
26.  WHO (1999). Preventing HIV/AIDS/STI and related discrimination: an important responsibility of health promoting schools.  WHO series on school health, document six.
27.  WHO (2000). Local Action: creating health promoting schools.  WHO series on school health.