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Life Skills-Based HIV Education: Some Virtues and Errors

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Title: Life Skills-Based HIV Education: Some Virtues and Errors
Language: English
Authors: Clarke, David, Yankah, Ekua, Aggleton, Peter
Source: Sex Education: Sexuality, Society and Learning. 2015 15(6):597-612.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 16
Publication Date: 2015
Document Type: Journal Articles
Information Analyses
Reports - Research
Descriptors: Acquired Immunodeficiency Syndrome (AIDS), Daily Living Skills, Sex Education, Instructional Effectiveness, Prevention, Literature Reviews
DOI: 10.1080/14681811.2015.1050090
ISSN: 1468-1811
Abstract: Since the early 1990s, life skills education has benefitted substantially from international agency advocacy and support, linked to its implementation in several countries as a key component of the education sector response to sexual health and HIV. The concept of life skills was first promoted by the World Health Organization through its programme on mental health as a means of promoting psychosocial competence. Since then, it has been extended to address a wider range of issues. Life skills-based HIV and sex education has proved to be a durable concept in education sector policy discourse on HIV and AIDS, despite a growing literature on the shortcomings in terms of its effectiveness in implementation in schools and delivering intended learning outcomes. Using a literature review, this paper aims to re-examine the adequacy of the life skills-based HIV education approach including empirical evidence for its effectiveness in educating about and preventing HIV infection among young people. Findings suggest that bureaucratic acceptance and advocacy for life skills-based HIV education has outstripped the theoretical adequacy and empirical evidence base for its effectiveness. Its current position among core indicators for the education sector response to HIV can be considered indicative of frozen thinking or inter-agency group-think.
Abstractor: As Provided
Number of References: 62
Entry Date: 2015
Accession Number: EJ1081188
Database: ERIC
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  Value: <anid>AN0110839154;bf401nov.15;2019Feb15.14:58;v2.2.500</anid> <title id="AN0110839154-1">Life skills-based HIV education: some virtues and errors. </title> <p>Since the early 1990s, life skills education has benefitted substantially from international agency advocacy and support, linked to its implementation in several countries as a key component of the education sector response to sexual health and HIV. The concept of life skills was first promoted by the World Health Organization through its programme on mental health as a means of promoting psychosocial competence. Since then, it has been extended to address a wider range of issues. Life skills-based HIV and sex education has proved to be a durable concept in education sector policy discourse on HIV and AIDS, despite a growing literature on the shortcomings in terms of its effectiveness in implementation in schools and delivering intended learning outcomes. Using a literature review, this paper aims to re-examine the adequacy of the life skills-based HIV education approach including empirical evidence for its effectiveness in educating about and preventing HIV infection among young people. Findings suggest that bureaucratic acceptance and advocacy for life skills-based HIV education has outstripped the theoretical adequacy and empirical evidence base for its effectiveness. Its current position among core indicators for the education sector response to HIV can be considered indicative of frozen thinking or inter-agency group-think.</p> <p>Keywords: life skills; HIV education; sex education; young people; effectiveness</p> <hd id="AN0110839154-2">Introduction</hd> <p>Life skills-based HIV education has proved a durable concept in education policy discourse on HIV and AIDS, despite a growing literature on the shortcomings of the approach in terms of effectiveness of implementation in schools and in delivering intended learning outcomes, especially in terms of behaviour and sexual risk reduction (Boler and Aggleton [<reflink idref="bib5" id="ref1">5</reflink>]; Yankah and Aggleton [<reflink idref="bib62" id="ref2">62</reflink>]; Clarke and Aggleton [<reflink idref="bib8" id="ref3">8</reflink>]; UNICEF [<reflink idref="bib54" id="ref4">54</reflink>]). This paper explores the genesis and evolution of the approach, offering an assessment of its strengths and limitations for HIV education in schools.</p> <p>From its initial origins in the field of mental health (Trower, Bryant, and Argyle [<reflink idref="bib35" id="ref5">35</reflink>]), life skills education developed as a popular field of theory and practice in the UK in the 1980s, achieving in the process something of a paradigm shift in the nature of health education. Hopson and Scally ([<reflink idref="bib13" id="ref6">13</reflink>], cited in Tones and Green [<reflink idref="bib34" id="ref7">34</reflink>], 236), who were vigorous proponents of such an approach, saw life skills teaching as providing a 'survival and growth kit for an age of future shock':</p> <p>... a school should provide a basic survival kit for young people ... they need to be taught skills like values clarification, decision making, how to cope with crises, intellectual and emotional problem solving, helping, assertiveness, relationship building, how to find appropriate information and use personal and physical resources which are available in the community. They need to be made aware of themselves, others and the world around them, in order to become more self-empowered people. (Tones and Green [<reflink idref="bib34" id="ref8">34</reflink>], 236)</p> <p>Implicit in a life skills approach for health promotion is the notion that it is not enough to have knowledge about health matters in order to adopt a healthy lifestyle. Learners need to develop a positive attitude to health and use a range of personal skills to become empowered and take responsibility for themselves. As James, Balding, and Iarris wrote in 1989, the fundamental objective of the life skills approach is to overcome constraints to change by developing self-empowerment (James, Balding, and Iarris [<reflink idref="bib19" id="ref9">19</reflink>]).</p> <p>The World Health Organization (WHO) was an early proponent of life skills education, initially from within its Division of Mental Health, but later across the organisation more generally. By 1994, life skills were defined as 'abilities for adaptive and positive behaviour that enable individuals to deal effectively with the demands and challenges of everyday life' (WHO [<reflink idref="bib57" id="ref10">57</reflink>], 1) and were seen as a means of promoting psychosocial competence.[<reflink idref="bib1" id="ref11">1</reflink>]</p> <p>In WHO's eyes and elsewhere, life skills have been viewed as having a key role to play in health promotion, in particular in areas where health problems could be tied to specific forms of behaviour. It was suggested that schools were not equipping young people with the life skills necessary to meet the increased demands of rapid social change. It was claimed that the psychosocial competence of children and young people could be enhanced by the teaching of life skills in a supportive learning environment. In retrospect, this conceptualisation was somewhat visionary, offering a new approach to education but one that would need to be tested in the classroom.</p> <p>By 1998, life skills education was being identified by WHO as an 'essential element' of a health-promoting school (WHO [<reflink idref="bib58" id="ref12">58</reflink>]). From here it seemed logical development to extend its application more fully within the emerging field of school-based HIV education. In this respect, life skills education benefited substantially from international agency advocacy and support, in particular from the United Nations Educational, Scientific and Cultural Organization (UNESCO), the United Nations Population Fund (UNFPA) and the United Nations Children's Fund (UNICEF), which led to its implementation in a substantial number of countries as a key component in the education sector response to HIV. A life skills approach was endorsed by the United Nations (UN) General Assembly Special Session on AIDS (UNGASS) in the Declaration of Commitment on HIV/AIDS in June 2001 (United Nations [<reflink idref="bib55" id="ref13">55</reflink>]) but was <emph>not</emph> re-endorsed by the follow-up UN General Assembly High-Level Meeting in the Political Commitment on HIV/AIDS in June 2011 (United Nations [<reflink idref="bib56" id="ref14">56</reflink>]).</p> <p>Despite this, the continuing influence of life skills education is attested to in the most recently published <emph>Measuring the Education Sector Response to HIV and AIDS: Guidelines for the Construction and Use of Indicators</emph> (UNESCO [<reflink idref="bib49" id="ref15">49</reflink>]). These guidelines include reference to life skills in no fewer than three of the eight core indicators prescribed for tracking and measuring the response.[<reflink idref="bib2" id="ref16">2</reflink>]</p> <p>It is against this background that the present review was conducted, seeking to examine why it is that life skills came to be so readily engaged with and advocated for by UN system agencies in their approach to HIV-related education, despite evidence of the serious limitations of such an approach (Boler and Aggleton [<reflink idref="bib5" id="ref17">5</reflink>]; Yankah and Aggleton [<reflink idref="bib62" id="ref18">62</reflink>]). Our focus here is not on offering an authoritative history of all developments relevant to life skills work in and out of school, but rather an account of the manner in which life skills came to be taken up as part of the UN system HIV-related education and prevention.</p> <hd id="AN0110839154-3">Methods</hd> <p>This paper has been developed following a robust review of the available public domain literature. This included the following types of materials:</p> <p></p> <ulist> <item> Technical guidelines on HIV education in schools published between 1990 and 2014;</item> <p></p> <item> Technical guidelines on life skills education published between 1990 and 2014;</item> <p></p> <item> Technical guidelines on school health education in schools published between 1990 and 2014;</item> <p></p> <item> Peer-reviewed and non-peer-reviewed papers, articles and research reports on life skills and HIV education, published between 2000 and 2014.</item> </ulist> <p>Databases searched included PubMed/Medline, ERIC and Google Scholar. The websites of key international organisations such as WHO, UNICEF, UNESCO and UNFPA were also hand searched. Citations referenced in identified papers were followed up. The key words used during the search were 'life skills'; 'life skills education'; 'life skills-based HIV education', 'HIV education'; 'life skills education guidelines'; and 'life skills-based sexuality education'.</p> <hd id="AN0110839154-4">The origins and evolution of life skills-based HIV education</hd> <p>Preventive education is the mainstay of many national HIV programmes in their drive to achieve zero new infections (UNAIDS [<reflink idref="bib38" id="ref19">38</reflink>]). The forms it takes include information, education and communication (IEC), behaviour change communication (BCC), life skills-based HIV education (LSBE), comprehensive sexuality education (CSE) and peer education approaches. The effectiveness of each of these different approaches is an ongoing focus of research and debate.</p> <p>Compared with the health sector, the education sector response to HIV was relatively slow to develop. In many countries, education ministries were reluctant to take ownership of the issue since HIV was perceived primarily as a health matter. Moreover, when schools did take action, moral, legal, cultural, religious and philosophical objections were often encountered, alongside institutional and bureaucratic barriers and community opposition to HIV-related education. HIV education has from the start been considered highly controversial (UNESCO and WHO [<reflink idref="bib51" id="ref20">51</reflink>]; Carr-Hill [<reflink idref="bib6" id="ref21">6</reflink>]).</p> <p>In schools in Africa and Asia, there has been a general reluctance to discuss condoms, contraceptives and the provision of services to young people. From the outset, teachers expressed a lack of adequate knowledge and self-confidence to teach sexuality to young people (UNESCO [<reflink idref="bib47" id="ref22">47</reflink>]; Clarke [<reflink idref="bib7" id="ref23">7</reflink>]). Accusations were made in some countries that the Ministry of Education was teaching school children how to have sex (UNESCO [<reflink idref="bib48" id="ref24">48</reflink>]). In order to obviate such political risks, a common approach has been to emphasise general health and physiological development instead (Nduati and Kiai [<reflink idref="bib27" id="ref25">27</reflink>]).</p> <p>The leadership role of UN agencies was critically important in kick-starting the education sector response to HIV. Independent of the HIV response, WHO identified a core set of 10 life skills that were considered to lie at the heart of skills-based health promotion interventions for children and adolescents (WHO [<reflink idref="bib57" id="ref26">57</reflink>]). These were further organised by pairing to arrive at five main life skill areas, which were considered to have relevance across cultures, although this has not been empirically tested (see Table 1). Together it was claimed that these constituted a vehicle for enhancing psychosocial competencies for better health outcomes.</p> <p>Table 1 Five main life skills areas.</p> <p> <ephtml> <table><thead><tr><td>Area 1</td><td>Area 2</td><td>Area 3</td><td>Area 4</td><td>Area 5</td></tr></thead><tbody><tr><td>Decision-making</td><td>Creative thinking</td><td>Communication</td><td>Self-awareness</td><td>Coping with emotions</td></tr><tr><td>Problem solving</td><td>Critical thinking</td><td>Interpersonal relationships</td><td>Empathy</td><td>Coping with stressors</td></tr></tbody></table> </ephtml> </p> <p>4 Source: WHO ([<reflink idref="bib57" id="ref27">57</reflink>]).</p> <p>WHO argued that these skills could be taught to young people. In the absence of any clear evidence, it was moreover suggested that <emph>generic</emph> life skills taught in relation to everyday life could lay the foundation for broader psychosocial competencies. This would include the practice of skills in relation to selected health and social problems and be combined with the provision of information about health. It soon became apparent, however, that the concept of generic life skills is problematic, since skills learned in the somewhat artificial context of the classroom may be less than generalisable to the real-world situations (e.g. being coerced into sex) in which HIV-related risks may be greatest. There is, moreover, little empirical evidential basis from the education sector for the foundational effects claimed for achieving better psychosocial competencies for health.</p> <p>It was UNICEF that subsequently took the theoretical concept of life skills and operationalised it, with a major, but not exclusive focus on HIV prevention. Life skills education was piloted in Ugandan schools in the mid-1990s as a way of addressing HIV prevention (Carr-Hill [<reflink idref="bib6" id="ref28">6</reflink>], 110–112). The aim was to bridge the gap between HIV knowledge and behaviour, which was considered to be lagging, through life skills education. This reflected WHO's claimed theory of change, which suggested that life skills development would lead to positive health behaviours and the prevention of health problems (WHO [<reflink idref="bib61" id="ref29">61</reflink>]).</p> <p>Life skills education was given a further boost by the establishment of UNAIDS and the approach's endorsement in a specific position paper (UNAIDS [<reflink idref="bib36" id="ref30">36</reflink>]). The large number of estimated HIV infections among young people (10–24 years), coupled with the accessibility of this group through national education systems, made for a strong argument in favour of HIV prevention in schools. It was argued that HIV prevention education should be integrated into the school curriculum in appropriate subjects in conjunction with materials development, teacher training, and the participation of parents and communities. It was also recommended that HIV prevention education begin at the earliest possible age, before the onset of sexual activity.</p> <p>Concomitant with this approach, UNAIDS began to advocate for a life skills approach to HIV prevention education. This, it was enthusiastically claimed, would enable young people to develop skills to manage situations of risk, e.g. how to refuse unprotected sex. There was little appreciation of the broader social context and the structural factors within it that might limit young people's access to preventive resources and prevent people from acting rationally and independently on the basis of what they have learned (Auerbach, Parkhurst, and Cáceres [<reflink idref="bib3" id="ref31">3</reflink>]).</p> <p>Technical guidance on school-based HIV prevention education was developed by WHO one year later (WHO [<reflink idref="bib58" id="ref32">58</reflink>]). This stated that education to prevent HIV and STIs should be combined with education about life skills, reproductive health and alcohol/substance abuse. Such an education, it was claimed, would help students to acquire the knowledge, skills and attitudes to make informed decisions, practise healthy behaviours and create conditions that are conducive to good health. A different mix of knowledge, attitudes and skills was identified as suitable for young children, pre-adolescents and adolescents (WHO [<reflink idref="bib59" id="ref33">59</reflink>]). A participatory approach to teaching and learning was advocated for, despite the fact that this form of education remains the exception rather than the norm in many medium- and lower-income countries (UNESCO [<reflink idref="bib41" id="ref34">41</reflink>]).</p> <p>Evidence of coalescing inter-agency consensus on the importance of life skills can be found in guidance on adolescent health programming developed by a WHO, UNFPA and UNICEF study group (WHO [<reflink idref="bib60" id="ref35">60</reflink>]), which applied the 10 life skills presented in Table 1 to a spectrum of adolescent health and development concerns.</p> <p>By 2000, therefore, HIV-related life skills work had gained widespread, if somewhat uncritical, acceptance. It made an important appearance in the Education for All (EFA) Framework for Action (UNESCO [<reflink idref="bib40" id="ref36">40</reflink>]) and was referred to across the diverse and emerging literature on HIV prevention education (Kelly [<reflink idref="bib20" id="ref37">20</reflink>]; UNESCO [<reflink idref="bib40" id="ref38">40</reflink>]; UNAIDS IATT on Education [<reflink idref="bib39" id="ref39">39</reflink>]; Carr-Hill et al. [<reflink idref="bib6" id="ref40">6</reflink>]; Kelly and Bain [<reflink idref="bib21" id="ref41">21</reflink>]), with life skills rapidly becoming the main paradigm for HIV prevention education in schools in Africa, the Caribbean and the Asia-Pacific region (Clarke [<reflink idref="bib7" id="ref42">7</reflink>]).</p> <p>Arguably the most significant boost to life skills education came with its inclusion in the Declaration of Commitment on HIV/AIDS, adopted by the United Nations General Assembly 26th Special Session (UNGASS) in August 2001. This asserted that young men and women should have access to information, education and services necessary for them to develop the life skills required to reduce their vulnerability to infection (United Nations [<reflink idref="bib55" id="ref43">55</reflink>]). It proposed that their education should include peer education and youth-specific HIV education. The programmatic importance of life skills was further enhanced by the inclusion of 'life skills-based HIV education in schools' as a core national indicator (Number 11) for all countries to report on biennially in the accompanying Framework for Action (UNAIDS [<reflink idref="bib37" id="ref44">37</reflink>]).</p> <p>It should be noted that an important conceptual shift had taken place by this stage. Life skills education had moved from simply being one component of HIV prevention education, to become <emph>the</emph> basis for such education, although how it would be developed programmatically through formal curriculum development was never addressed by the international agencies advocating the approach. Moreover, what actually constitutes a life skills-based approach had never been defined or exemplified in terms of any educationally relevant curriculum framework. All that remained available were learning outcomes specified in terms of the specific skills to be acquired, which is not the same thing at all.</p> <p>An important parallel development occurred when WHO further rationalised the types of life skills to be focused on in HIV-related education (WHO [<reflink idref="bib61" id="ref45">61</reflink>]). Three categories of life skills were delineated: (i) communication and interpersonal skills; (ii) decision-making and critical thinking skills; and (iii) coping and self-management skills (Table 2).</p> <p>Table 2 Life skills for skills-based health education.</p> <p> <ephtml> <table><thead><tr><td>Communication and interpersonal skills</td><td>Decision-making and critical thinking skills</td><td>Coping and self management skills</td></tr></thead><tbody><tr><td>Interpersonal and communication skillsNegotiation and refusal skillsEmpathy buildingCooperation and teamworkAdvocacy skills</td><td>Decision-making/problem solving skillsCritical thinking skills</td><td>Skills for increasing personal confidence and abilities to assume control, take responsibility, make a difference or bring about a changeSkills for managing feelingsSkills for managing stress</td></tr><tr><td /><td /><td /></tr></tbody></table> </ephtml> </p> <p>5 Source: WHO ([<reflink idref="bib61" id="ref46">61</reflink>]).</p> <p>This framework provided a template, which was later used to exemplify life skills in relation to HIV prevention (see Table 3). While this marked a move away from a focus on generic life skills, it is open to question on what basis these particular HIV-related life skills were selected, and whether they represented priority learning needs, including the prevention of high-risk sexual contact, which is the most common means of HIV transmission among young people. Few of the skills exemplified focused on the specific behaviours required to prevent HIV infection, an approach which has been documented as a key characteristic of effective sexuality education programmes (Kirby, Obasi, and Laris [<reflink idref="bib22" id="ref47">22</reflink>]). Exemplified skills do not include the practical or psychosocial skills required for the correct and consistent use of condoms, for example.</p> <p>Table 3 Life skills for sexual and reproductive health and HIV prevention.</p> <p> <ephtml> <table><thead><tr><td>Communication and interpersonal skills</td><td>Decision-making and critical thinking skills</td><td>Coping and self management skills</td></tr></thead><tbody><tr><td><italic>Communication skills</italic>Students can observe and practise ways to:• Effectively express a desire not to have sex;• Influence others to abstain from sex or practise safe sex using condoms if they cannot be influenced to abstain;• Demonstrate support for the prevention of discrimination related to HIV/AIDS</td><td><italic>Decision-making/problem solving skills</italic>Students can observe and practise ways to:• Seek and find reliable information about human anatomy, puberty, conception and pregnancy, STIs, HIV/AIDS, available methods of contraception• Analyse a variety of potential situations for sexual interaction and determine a variety of actions they may take and the consequences of such actions</td><td><italic>Skills for increasing personal confidence and abilities to assume control, take responsibility, make a difference or bring about a change</italic>Students can observe and practise ways to:• Assert personal values when encountering peer and other pressures</td></tr><tr><td><italic>Negotiation and refusal skills</italic></td><td><italic>Critical thinking skills</italic></td><td><italic>Skills for managing stress</italic></td></tr><tr><td>Students can observe and practise ways to:</td><td>Students can observe and practise ways to:</td><td>Students can observe and practise ways to:</td></tr><tr><td>• Refuse sexual intercourse or negotiate the use of condoms</td><td>• Analyse myths and misconceptions about HIV, contraceptives, gender roles and body image that are perpetuated by the media• Analyse social-cultural influences regarding behaviours</td><td>• Seek services for help with SRH issues e.g. contraception, condoms to prevent HIV or unplanned pregnancy, sexual abuse, discrimination, gender-based violence or other emotional trauma</td></tr><tr><td><italic>Advocacy skills</italic></td><td /><td /></tr><tr><td>Students can observe and practise ways to:</td><td /><td /></tr><tr><td>• Present arguments for access to sexual and reproductive health information, services and counselling for young people</td><td /><td /></tr><tr><td><italic>Interpersonal skills</italic></td><td /><td /></tr><tr><td>Students can observe and practise ways to:</td><td /><td /></tr><tr><td>• Show interest and listen actively to others</td><td /><td /></tr><tr><td>• Be caring and compassionate including when interacting with someone who is infected with HIV</td><td /><td /></tr></tbody></table> </ephtml> </p> <p>6 Source: WHO ([<reflink idref="bib61" id="ref48">61</reflink>]).</p> <p>One consequence of this UN-driven approach was that life skills education became legitimised as the standard paradigm for HIV education in the poorest countries (although not, paradoxically, in Europe, North America and Australia). As a result, the implementation of life skills education proceeded apace, primarily with UNICEF country-level funding and support. A UNICEF stocktake in 2007 reported that life skills-based education (LSBE) was being integrated into a large number of national school curricula. Out of the 156 countries that reported ongoing LSBE activities, 145 had initiated LSBE in their curricula for primary and secondary education. Moreover, in many countries, LSBE was driving the education sector response to HIV. By 2007, 57 countries reported having implemented LSBE for HIV prevention, and a majority of others were in the process of doing so: 111 out of the total of 156 (UNICEF [<reflink idref="bib52" id="ref49">52</reflink>]).</p> <p>Reflecting the UNGASS indicator on HIV education, national coverage of life skills HIV education curriculum in schools became a key issue. Data in UNGASS country reporting indicate substantial progress in many African countries towards providing life skills-based HIV education (Clarke and Aggleton [<reflink idref="bib8" id="ref50">8</reflink>]). By 2010, a significant number of countries reported coverage rates that were greater than 75%. However, some countries were still at an early stage of scale up, or were focusing their effort in specific regions of the country. Countries with coverage rates of < 25% included Nigeria and Uganda. A few countries reported 0% coverage, and some presented no data because they were not available. Among these were countries with very substantial HIV epidemics (Malawi, Mozambique and Zambia). The situation in the Asia-Pacific region was quite different, however. While a few countries there reported having achieved 100% coverage, the overwhelming majority reported a coverage rate of < 50% or many presented no data at all. Some countries reported that life skills-based HIV education was simply not relevant to them (Iyer, Clarke, and Aggleton [<reflink idref="bib18" id="ref51">18</reflink>]).</p> <p>The development of international technical guidance on sexuality education for schools (UNESCO [<reflink idref="bib46" id="ref52">46</reflink>]) initially appeared to herald a change in approach to HIV prevention education, drawing heavily on the pioneering work of Kirby, Obasi, and Laris ([<reflink idref="bib22" id="ref53">22</reflink>]) who made no explicit mention of life skills in their well-defined 'characteristics of effective HIV education programmes'. Instead, Kirby's multiple reviews of the efficacy and effectiveness literatures pointed to the importance of rigour in developing the curriculum, ensuring clear and appropriate curriculum goals and objectives, sound teaching methods that help learners personalise the information and which were designed to change risk factors and objectives, and a strong focus on curriculum implementation as designed.</p> <p>Since 2006, UNESCO ([<reflink idref="bib42" id="ref54">42</reflink>], [<reflink idref="bib43" id="ref55">43</reflink>], [<reflink idref="bib44" id="ref56">44</reflink>], [<reflink idref="bib45" id="ref57">45</reflink>]) has developed guidance on 'good policy and practice in HIV and Education' in the form of a series of booklets. In these, there is a notable retreat from a focus on life skills-based HIV education and a stress instead on an evidence-informed approach to teaching and learning concerning HIV. There is no substantive discussion on life skills education in these booklets in terms of either theory or practice, which is perhaps indicative of evidential issues.</p> <p>In 2010, UNICEF attempted to codify principles, concepts and standards for life skills-based education (UNICEF [<reflink idref="bib53" id="ref58">53</reflink>]). This was in part in response to a growing number of questions raised concerning the effectiveness of the approach (see for example Boler and Aggleton [<reflink idref="bib5" id="ref59">5</reflink>]; Yankah and Aggleton [<reflink idref="bib62" id="ref60">62</reflink>]). In 2011, the United Nations General Assembly met again to review progress on HIV and AIDS. The resolution adopted made no reference to life skills-based HIV education, talking instead of age-appropriate 'sex and HIV prevention education' (United Nations [<reflink idref="bib56" id="ref61">56</reflink>]). In 2011, UNAIDS accordingly removed Indicator 11 with its focus on life skills-based HIV education in schools from the core list of indicators for monitoring progress with respect to the 2011 UN Political Declaration on HIV and AIDS.</p> <p>UNESCO and the UNAIDS Interagency Task Team on Education were subsequently tasked with developing new indicators for the education sector. Bizarrely, and perhaps contrary to the wishes of the UN General Assembly, this process resulted in the development of three new indicators, and the phoenix-like re-emergence of a focus on 'life skills' once again in the form of new indicators for (i) life skills-based HIV and sexuality education, (ii) life skills-based orientation for parents and guardians and (iii) life skills-based HIV and sexuality education teacher training and teaching (UNESCO [<reflink idref="bib49" id="ref62">49</reflink>], 45–57).</p> <p>In 2012, UNICEF published the report of its long-awaited Global Evaluation of Life Skills Education (UNICEF [<reflink idref="bib54" id="ref63">54</reflink>]), which catalogued a long list of limitations associated with a life skills education approach. In particular, it highlighted multiple shortcomings in programme design and implementation. These included:</p> <p></p> <ulist> <item> Few instances of the participation of young people in programme design;</item> <p></p> <item> A lack of differentiation in programme design to adapt it to various social contexts;</item> <p></p> <item> A large gap between design and the realities of implementation, especially in terms of adoption of participatory methods in the classroom;</item> <p></p> <item> Life skills education tending to be squeezed out in contexts where the curriculum is already overcrowded and resources for teaching and learning are scarce;</item> <p></p> <item> Limited support and professional development for teachers;</item> <p></p> <item> A lack of attention to assessment of life skills learning outcomes in school examinations;</item> <p></p> <item> Delivery of life skills education is constrained in moving from knowledge acquisition to developing and practising skills, attitudes and behaviours.</item> </ulist> <p>On a more positive note, the evaluation noted the relevance of the life skills approach to some aspects of the lives of learners and its potential to support the use of participatory teaching and learning methods, but this would require more attention to adapting the approach to different social contexts and target groups.</p> <hd id="AN0110839154-5">Strengths of the life skills approach</hd> <p>So what then are the advantages of a life skills approach to HIV prevention and education? Opinions differ, but the following strengths can be identified.</p> <p>A life skills approach remains influential as part of HIV prevention. In some countries it has enabled ministries of education to overcome resistance to education about HIV in schools. The adoption of a life skills approach by UN system agencies has led to the emergence of a shared discourse about HIV education, which in turn has raised the international profile of school-based HIV education.</p> <p>A life skills approach has perhaps more modestly contributed to improving the quality of education. It has supported the development of education that includes a focus on skills in addition to knowledge. It has caused curriculum development in some countries to become more focused on skills acquisition and promoted their specification in terms of learning objectives.</p> <p>The participatory approach to learning promoted by life skills education has also made a contribution to educational reform, especially in contexts where didactic teaching and rote learning remain the norm. When well applied, the approach is activity-based, although the extent to which teachers trained in more didactic forms of pedagogy can adequately implement such an approach remains open to question.</p> <p>More generally, the concept of life skills has been attractive to non-specialists. It is now widely used in educational discourse beyond the field of health education, along with other terms such as functional skills, people skills and soft skills, which also engage with the area of psycho-social development. Although still poorly defined, and variously implemented, life skills approaches have in some contexts become part of mainstream education.</p> <hd id="AN0110839154-6">Some limitations</hd> <p>Against these strengths, however, must be set limitations – not only those that emerged from the 2012 review commissioned by UNICEF, but also the more general doubts voiced earlier. It is appropriate to synthesise these, before trying to identify the basis of a productive way forward.</p> <hd id="AN0110839154-7">Definitional (in)adequacy</hd> <p>Can life skills be distinguished from other skills important for life such as reading, numeracy and livelihood skills? WHO ([<reflink idref="bib57" id="ref64">57</reflink>]) acknowledged from the outset that definitional problems would be encountered in delineating life skills. In practice, almost any skill can be considered a life skill, which risks nullifying the utility of the concept and renders scientific measurement problematic.</p> <p>The issue of definitional adequacy was later returned to by Boler and Aggleton ([<reflink idref="bib5" id="ref65">5</reflink>]) as well as more recently in the Global Evaluation of Life Skills Education (UNICEF [<reflink idref="bib54" id="ref66">54</reflink>]). Given the apparent open-endedness of the term, ideas of life skills may have greater value in political advocacy than as the basis for evidence-informed HIV prevention programming. The term life skills is perhaps best considered a cover-all descriptor for a range of interpersonal and psychosocial skills, with all the strengths and weaknesses that these carry as individualistic frameworks for understanding risk reduction and behaviour change.</p> <hd id="AN0110839154-8">An unproven theory of change</hd> <p>How can life skills education help learners achieve intended learning outcomes? WHO set out the logic of life skills education as a simple theory of change illustrated in Table 4 (WHO [<reflink idref="bib61" id="ref67">61</reflink>]). According to this model, life skills are seen as enabling individuals to translate knowledge, attitudes and values into abilities, or <emph>what to do</emph>, and <emph>how to do it</emph>. The acquisition of these abilities is followed by behavioural reinforcement or change, leading to positive health behaviour, which further contributes to the primary prevention of health problems. Individual motivation to behave positively with regard to health is considered an important prerequisite for life skills development.</p> <p>Table 4 The logic of life skills education.</p> <p> <ephtml> <table><tbody><tr><td>KnowledgeAttitudesValues</td><td>+</td><td>Life skills</td><td>+</td><td>Behaviour reinforcement or change</td><td> → </td><td>Positive health behaviour</td><td> → </td><td>Prevention of health problems</td></tr></tbody></table> </ephtml> </p> <p>Significantly, this linear model, while based on empirical evidence, has not been scientifically tested. Failure to acknowledge broader contextual and structural factors affecting sexual behaviour augurs poorly for the adequacy of the approach. The meanings sexual behaviour carries for young people and the contexts in which it takes place are dynamic, being strongly influenced by factors such as time and place, and gender and sexual identity (Aggleton et al. [<reflink idref="bib2" id="ref68">2</reflink>]). Because of this, it is difficult if at all possible to apply a 'one-size-fits-all' model to the variety of young people's experiences.</p> <p>Moreover, as indicated earlier, evidence from systematic reviews of effective approaches to HIV education, such as those conducted by Kirby, Obasi, and Laris ([<reflink idref="bib22" id="ref69">22</reflink>]), indicates that success follows from engagement with a range of educational factors – including a focus on clearly defined health goals, the quality and duration of teaching, and the school environment, among others.</p> <p>In contrast, the approach detailed in Table 4 is largely consistent with an individualistic, deficit model in which young people are assumed to be ignorant and lacking in knowledge and skills. The recipients of life skills education are viewed as being in need of training and enlightenment, rather than having experiences and assets on which to build. The model conforms with a narrowly behaviourist approach to educational growth and development, in which specific behaviours are seen to flow 'naturally' from certain knowledge, attitude and skills-based antecedents: an empirically unjustifiable view of how health education in general (Tones [<reflink idref="bib33" id="ref70">33</reflink>]), and sexual health education (Ingham and van Zessen [<reflink idref="bib15" id="ref71">15</reflink>]; Ingham [<reflink idref="bib14" id="ref72">14</reflink>]) in particular, proceed.</p> <hd id="AN0110839154-9">Individualistic focus</hd> <p>Not unrelated to this, each of the life skills exemplified above focuses on individual-level factors and assumes that individuals have control over their actions. This largely neglects the contribution of structural, community contextual or societal factors determinant of HIV-related vulnerability and risk (Parker, Easton, and Klein [<reflink idref="bib28" id="ref73">28</reflink>]; Gupta et al. [<reflink idref="bib12" id="ref74">12</reflink>]).</p> <p>Poverty, together with gender roles, power relations and cultures of masculinity are important influences on young people's lives (Silverman [<reflink idref="bib32" id="ref75">32</reflink>]; Mane and Aggleton [<reflink idref="bib23" id="ref76">23</reflink>]; Melendez and Tolman [<reflink idref="bib25" id="ref77">25</reflink>]; Rivers, Aggleton, and Ball [<reflink idref="bib31" id="ref78">31</reflink>]; Aggleton, Ball, and Mane [<reflink idref="bib1" id="ref79">1</reflink>]). The ability of these factors to constrain 'choice', including whether or not young people are able to practise safer sex, is dramatically downplayed by an individualistic life skills paradigm. One consequence of this is that it is the individual, not the family, community or society, that is blamed when things go wrong.</p> <p>Contemporary thinking about the health of young people has shifted well beyond an individual-level perspective to focus in on the context within which young people live and the complex network of family, social relationships, peers and cultural factors that shapes HIV risk and protective behaviours (DiClemente, Salazar, and Crosby [<reflink idref="bib11" id="ref80">11</reflink>]; DiClemente et al. [<reflink idref="bib10" id="ref81">10</reflink>], [<reflink idref="bib9" id="ref82">9</reflink>]). HIV education needs to be developed using such a multi-factoral appreciation to engage with HIV-related issues in the context of the broader socio-contextual environment rather than seeking to correct and/or ameliorate individual deficiencies and deficits (Gupta et al. [<reflink idref="bib12" id="ref83">12</reflink>]; DiClemente et al. [<reflink idref="bib9" id="ref84">9</reflink>]). Put quite simply, all the individual skills development in the world can do little to compensate for the effects of a seriously constraining environment in which poverty, unequal gender relations and lack of access to HIV protective technology (such as condoms) place young people at risk.</p> <hd id="AN0110839154-10">Ad hoc implementation</hd> <p>Even when life skills education has been included in the formal and mandatory curriculum, it is unclear to what extent and with what consistency life skills education is implemented by teachers who have been adequately motivated and trained to ensure necessary learner participation and learning environments conducive to life skills learning (UNICEF [<reflink idref="bib53" id="ref85">53</reflink>]).</p> <p>Recent work by Iyer and Aggleton ([<reflink idref="bib16" id="ref86">16</reflink>], [<reflink idref="bib17" id="ref87">17</reflink>]), Boler ([<reflink idref="bib4" id="ref88">4</reflink>]) and others has pointed to the highly variable ways in which teachers engage with a skills-based curriculum, especially in settings where teacher education and school education traditionally take a didactic form. Other research highlights structural and environmental factors affecting what teachers can and cannot do when it comes to delivering good-quality sexuality education in contexts where conservative social norms and cultural values make it difficult for questions of sex, sexual relations and sexuality to be talked about and engaged with (Rijsdijk et al. [<reflink idref="bib30" id="ref89">30</reflink>]).</p> <p>All of these factors conspire to make the consistent implementation of life skills programmes and other similar forms of HIV-related education difficult to achieve.</p> <hd id="AN0110839154-11">Limited evidence of effectiveness in changing HIV-related risk practices</hd> <p>Evidence for the effectiveness of life skills approaches in changing HIV-related behaviours remains limited (Yankah and Aggleton [<reflink idref="bib62" id="ref90">62</reflink>]), and findings of the systematic review of reviews conducted by Mavedzenge, Luecke, and Ross ([<reflink idref="bib24" id="ref91">24</reflink>]) suggest that no one type of intervention is invariably effective.</p> <p>Kirby, Obasi, and Laris ([<reflink idref="bib22" id="ref92">22</reflink>]) report difficulty in formulating and measuring the outcomes of effective forms of sex and HIV education in terms of skills alone. Among the qualities that appear to yield more successful sexual health learning outcomes are curricula that employ a variety of skills and knowledge-building activities. That said, encouraging young people to develop skills of refusal, negotiation and condom-use requires teaching techniques and learning cultures that are often unfamiliar in school environments, especially those typical of middle- and low-income settings.</p> <p>There remain major gaps in research and the evidence base. Significantly, key systematic reviews of evidence of effectiveness in HIV, sex and sexuality education, such as those by Mavedzenge, Luecke, and Ross ([<reflink idref="bib24" id="ref93">24</reflink>]) and Kirby, Obasi, and Laris ([<reflink idref="bib22" id="ref94">22</reflink>]), fail to disaggregate life skills-based HIV education from other approaches. Beyond these, there exists no published research that has sought to control for the contribution of life skills education to HIV prevention in studies involving control groups that have participated in HIV-related education but <emph>without</emph> a life skills component. No reviews exist either that have focused on the effectiveness of life skills, either individually or collectively, as a means of bringing about sexual behaviour change.</p> <hd id="AN0110839154-12">Conclusions: some virtues and errors</hd> <p>On the basis of the available evidence, it seems clear that bureaucratic enthusiasm for life skills-based HIV education has far outstripped both conceptualisation and evidence of effectiveness in HIV prevention with young people. That life skills remain among the education sector core indicators for HIV education recommended by the UN, is perhaps best considered indicative of frozen thinking and a degree of inter-agency 'group-think'.</p> <hd id="AN0110839154-13">Virtues</hd> <p>In summary, the main virtues of a life skills approach to HIV education appear to derive from its capacity to offer:</p> <p></p> <ulist> <item> a common framework for HIV education in schools;</item> <p></p> <item> a politically acceptable approach to HIV prevention, especially in circumstances where more evidence-informed approaches may be difficult to advocate for, and implement;</item> <p></p> <item> a contribution to broader education reform through the emphasis given to participatory teaching and learning and skills development; and</item> <p></p> <item> a means of ensuring that HIV education with young people achieves an international profile.</item> </ulist> <hd id="AN0110839154-14">Errors</hd> <p>Throughout the history of the HIV epidemic, there has been a recurrent search for a 'magic bullet' to prevent HIV. Experience implementing HIV prevention programmes strongly suggests that instead, it is combination prevention that works best (Merson et al. [<reflink idref="bib26" id="ref95">26</reflink>]; Piot et al. [<reflink idref="bib29" id="ref96">29</reflink>]). Approaches to HIV prevention that address social and cultural vulnerability alongside individual risk are often the most effective. Unfortunately, not only is there little evidence to suggest that life skills work is effective in bringing about consistent forms of sexual behaviour change, but also it fails to address these important questions about social vulnerability and risk because of the emphasis placed on individual behaviour. Nearly 20 years' implementation experience reveals some of the main errors of the approach:</p> <p></p> <ulist> <item> Inadequate educational definition and conceptualisation – at best, the term 'life skills' operates as a shorthand for a participatory approach which includes some practical and psychosocial skills development, but there is far more to good-quality HIV-related education than this;</item> <p></p> <item> An undue emphasis on individual-level behaviour change at the expense of a more balanced and nuanced perspective on sexual risk reduction and HIV prevention;</item> <p></p> <item> The inappropriate adoption of a deficit model to work with young people, rather than recognising that learners have their own experiences, skills and assets to be drawn upon;</item> <p></p> <item> Overstretched advocacy – international agency endorsement of life skills has over-reached itself, well beyond what can be confidently asserted on the basis of empirical evidence;</item> <p></p> <item> Too anodyne an approach – life skills education has allowed national authorities and ministries of education to avoid dealing with sensitive but much-needed issues as a part of HIV education, including gender and sexual inequality, sexual and gender difference, gender violence, sexual coercion and abuse.</item> </ulist> <hd id="AN0110839154-15">Way forward</hd> <p>So what then is the way forward?</p> <p>In our view, there is an urgent need to rethink the position of life skills education in HIV and sexuality education. Psychosocial skills development may well be part of the combination approach to HIV prevention that is required to bring about better learning outcomes. What is urgently needed, however, is a better understanding of the individual skills that matter most when it comes to HIV prevention, the contribution they may make as part of a more comprehensive response, and how these can best be taught in school and out-of-school settings.</p> <p>The loss of Indicator 11 on life skills from the core list of UNGASS indicators provides both a challenge and an opportunity in this respect. The problem is that there may be reduced international pressure for countries to invest fully in education for HIV prevention. The opportunity is that a reduced emphasis on life skills may allow for greater experimentation, flexibility and adaptation to context. If comprehensive sexuality education is to become the new internationally endorsed paradigm (UNESCO [<reflink idref="bib46" id="ref97">46</reflink>], [<reflink idref="bib50" id="ref98">50</reflink>]) for HIV-related work with young people, then greater investment in research is required into the relevance and effectiveness of life skills as part of this new approach.</p> <p>Moving forward however involves a major shift from rhetoric to evidence in HIV education and the promotion of a more holistic approach with a focus on the structural and community, as well as the individual, aspects of transmission. In support of this, there is a need for more honest and robustly critical evaluations of HIV education as currently practised in the Global South, and a move to develop a new division of labour for addressing this field of education internationally. This will likely involve building on existing investments in life skills education for HIV, but refining these within the context of a broader, rights-informed, more inclusive framework for HIV and sexuality education better suited to the twenty-first century.</p> <hd id="AN0110839154-16">Disclosure statement</hd> <p>No potential conflict of interest was reported by the authors.</p> <ref id="AN0110839154-17"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref11" type="bt">1</bibl> <bibtext> <sups>1.</sups> Psychosocial competence is defined as a person's ability to maintain a state of mental well-being and to demonstrate this in adaptive and positive behaviour while interacting with others, his/her culture and environment (WHO [57], 1).</bibtext> </blist> <blist> <bibl id="bib2" idref="ref16" type="bt">2</bibl> <bibtext> <sups>2.</sups> These are life skills-based HIV and sexuality education (Indicator 4); life skills-based HIV and sexuality education orientation process for parents and guardians (Indicator 5); and life skills-based HIV and sexuality education teacher training and teaching (Indicator 6).</bibtext> </blist> </ref> <ref id="AN0110839154-18"> <title> References </title> <blist> <bibtext> Aggleton, P., A. Ball, and P. Mane. 2006. 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Items – Name: Title
  Label: Title
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  Data: Life Skills-Based HIV Education: Some Virtues and Errors
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  Data: English
– Name: Author
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  Data: <searchLink fieldCode="AR" term="%22Clarke%2C+David%22">Clarke, David</searchLink><br /><searchLink fieldCode="AR" term="%22Yankah%2C+Ekua%22">Yankah, Ekua</searchLink><br /><searchLink fieldCode="AR" term="%22Aggleton%2C+Peter%22">Aggleton, Peter</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Sex+Education%3A+Sexuality%2C+Society+and+Learning%22"><i>Sex Education: Sexuality, Society and Learning</i></searchLink>. 2015 15(6):597-612.
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  Data: Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals
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– Name: Pages
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  Data: 16
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  Label: Publication Date
  Group: Date
  Data: 2015
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  Data: Journal Articles<br />Information Analyses<br />Reports - Research
– Name: Subject
  Label: Descriptors
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  Data: <searchLink fieldCode="DE" term="%22Acquired+Immunodeficiency+Syndrome+%28AIDS%29%22">Acquired Immunodeficiency Syndrome (AIDS)</searchLink><br /><searchLink fieldCode="DE" term="%22Daily+Living+Skills%22">Daily Living Skills</searchLink><br /><searchLink fieldCode="DE" term="%22Sex+Education%22">Sex Education</searchLink><br /><searchLink fieldCode="DE" term="%22Instructional+Effectiveness%22">Instructional Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Prevention%22">Prevention</searchLink><br /><searchLink fieldCode="DE" term="%22Literature+Reviews%22">Literature Reviews</searchLink>
– Name: DOI
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  Data: 10.1080/14681811.2015.1050090
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1468-1811
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Since the early 1990s, life skills education has benefitted substantially from international agency advocacy and support, linked to its implementation in several countries as a key component of the education sector response to sexual health and HIV. The concept of life skills was first promoted by the World Health Organization through its programme on mental health as a means of promoting psychosocial competence. Since then, it has been extended to address a wider range of issues. Life skills-based HIV and sex education has proved to be a durable concept in education sector policy discourse on HIV and AIDS, despite a growing literature on the shortcomings in terms of its effectiveness in implementation in schools and delivering intended learning outcomes. Using a literature review, this paper aims to re-examine the adequacy of the life skills-based HIV education approach including empirical evidence for its effectiveness in educating about and preventing HIV infection among young people. Findings suggest that bureaucratic acceptance and advocacy for life skills-based HIV education has outstripped the theoretical adequacy and empirical evidence base for its effectiveness. Its current position among core indicators for the education sector response to HIV can be considered indicative of frozen thinking or inter-agency group-think.
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  Data: 2015
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  Data: EJ1081188
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        PageCount: 16
        StartPage: 597
    Subjects:
      – SubjectFull: Acquired Immunodeficiency Syndrome (AIDS)
        Type: general
      – SubjectFull: Daily Living Skills
        Type: general
      – SubjectFull: Sex Education
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      – SubjectFull: Instructional Effectiveness
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      – SubjectFull: Prevention
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      – TitleFull: Life Skills-Based HIV Education: Some Virtues and Errors
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            NameFull: Aggleton, Peter
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