In this issue:
Every Child Matters
Abstinence under fire
Who would have thought it?
THE OTHER 3 Rs Goes Live!
Every Child Matters
A proposal to appoint a children’s commissioner for England features among a number of new initiatives announced by the government in its Green Paper on children published in September. According to the consultation document, Every Child Matters, a statutory office is required in order ‘to ensure children’s and young people’s voices are effectively heard’. Using the language employed by children’s rights campaigners, the document refers to the commissioner as ‘a children’s champion’ independent of government, who will ‘develop effective ways to draw on children’s views, locally and nationally, and make sure they are fed into policy making’. Quite apart from the question of how a statutory office appointed and funded by the government to serve in an advisory capacity to the government can be truly ‘independent’, there are serious concerns that the appointment of an official empowered to ‘speak for all children’ will further undermine the role of parents who are far better placed and equipped to represent the interests of their children than any impersonal mechanism or bureaucratic machine (see Bulletin 111, Spring 2003).
Identity numbers
The consultation paper has been produced in response to the recommendations of Lord Laming’s Inquiry into the death of Victoria Climbié and emphasises the need to improve lines of communication between the various agencies concerned with the welfare of children. It proposes that all local authorities should have a list of children in their area and that each child should have a unique identity number so that his or her records will be electronically available to all agencies. This intrusive proposal has proved highly controversial. The civil rights group Liberty has expressed concern about the implications of such ‘information sharing’ for those falsely accused of abuse, while the NSPCC sees a potential infringement of ‘the right of the child to privacy’. There are also fears that the electronic availability of personal details of children to a number of agencies carries the risk of the system being accessed and abused by paedophiles. Quite apart from these considerations, it is difficult to see any justification for the inclusion of all children on such a database when the vast majority are not at risk of abuse.
The changing role of schools
One major proposal which has not received much publicity concerns the government’s plans to extend the remit of schools way beyond their educational function. The introduction of health clinics operating on school premises at which contraceptives and the morning-after pill are made available to pupils apparently only marks the beginning of a trend that is set to grow. In order to ‘integrate education, health and social care services around the needs of children’, the government wants to turn all schools into ‘extended schools – acting as the hub for services for children, families and other members of the community’. It is envisaged that, by 2006, each LEA will have at least one ‘full service extended school’ offering ‘a core of childcare, study support, family and lifelong learning, health and social care, parenting support, sports and arts facilities, and access to Information Technology’.
The plan to extend the role of schools is all part of the government’s commitment to protecting children at risk ‘within a framework of universal services’. Since most children are registered at a school, the government considers that the school is the ideal place to locate all the services which are deemed necessary for them. Therefore any child who is not registered at a school will not only be missing out on his or her educational provision, but also a whole host of ‘universal services’, providing additional justification for the Green Paper’s statement that ‘a child without a current educational record in the system should generate an alert’ and its desire to ‘help reintegrate children and young people who have been outside the school system’. This prospect has caused considerable alarm among the growing numbers of parents who legally home- educate their children under the provisions of the Education Act 1996. There is no basis for suggesting that home- educated children are more vulnerable to abuse than those registered at school. Indeed, since the Youth Justice Board’s Youth Survey 2002 found that 17 per cent of secondary school pupils reported having been bullied at school and 24 per cent reported having been the victim of a theft at school, there is a case for arguing that children at school are considerably more at risk than those educated at home.
Parents undermined
While the consultation document ‘seeks views from everyone…, it is addressed in particular to those vital groups of staff and professionals who are committed to meeting children’s needs’. The government is evidently more concerned to hear from the four million or so people in England who work with children in a professional capacity than from their parents who care for them in a personal capacity. In his introduction, the Prime Minister refers to the lives of some children which are ‘filled with risk, fear, and danger: and from what most of us would regard as the worst possible source – from the people closest to them.’ But nowhere in the Green Paper is there any recognition of the fact that the two-parent married family is by far the safest environment for children and that children brought up outside this setting are disproportionately at risk of being abused by ‘the people closest to them’. Mr Blair also comments: ‘Sadly, nothing can ever absolutely guarantee that no child will ever be at risk again from abuse and violence within their own family’, as if the family is the only place where abuse and violence take place. The Children and Young People’s version of the Green Paper barely mentions parents at all and gives the impression that the state has a more significant role in the lives of young people than the family.
Copies of Every Child Matters are available for purchase from The Stationery Office (Tel: 0870 600 5522). A summary version of the document (Ref: DfES/0672/2003) and the young people’s version (Ref: DfES/0673/2003) may be obtained from DfES Publications (Tel: 0845 6022260). Alternatively, all three documents together with response forms may be downloaded free of charge from: http://www.dfes.gov.uk/everychildmatters/ The closing date for responses is 1 December 2003.
Norman Wells
Abstinence under fire
Trevor Stammers
It will take more than condoms to reverse the tide of sexually transmitted infections engulfing Britain’s young people.
The Chief Medical Officer, Sir Liam Donaldson, unequivocally states in his first update for this year, that “Evidence does not exist to suggest that abstinence approaches are effective”1 in reducing teenage pregnancy. This is an extraordinary claim, since there is a wealth of evidence suggesting that abstinence approaches can be very effective in delaying the age of first intercourse, reducing unplanned pregnancy, and lowering rates of sexually transmitted infections.
However unjustified by the evidence, the Chief Medical Officer’s claim might at least be understandable if the “safer sex” approaches which have dominated sexual health education in the UK for decades had led to an overall improvement in sexual health, but this is clearly not the case. Under headlines such as “NHS clinics overwhelmed as promiscuity takes its toll on a whole generation”, David Hinchliffe, chair of the Commons Health Select Committee inquiry into sexual health stated, “Frankly the whole sexual health service is a shambles. . . . I do not use the word crisis lightly, but I think we have a crisis here”.2 The UK still has the highest teenage pregnancy rates in Western Europe (though, as in the USA, they are currently improving). Steep rises in cases of chlamydia (doubled in five years), gonorrhoea (up 86% in five years), and the resurgence of syphilis look set to continue unabated. Against this background, the Department of Health’s cursory dismissal of abstinence education is deeply regrettable.
WHAT ARE ABSTINENCE APPROACHES?
In the USA, where abstinence education is most widely established, there are two main types of approach: abstinence-only, where the focus is wholly on encouraging teenagers not to have sex, providing a rationale for this lifestyle choice, and equipping them with skills such as assertiveness and self esteem to fulfil this goal. Abstinence-plus programmes present the same message that abstinence is the safest form of protection against pregnancy and sexually transmitted infections but also provide information and advice on contraception. Abstinence components also play an important part in many contraceptive and safer sex focused programmes in the USA.3
There is ample evidence that abstinence approaches overall (whether only or plus) can be effective.
REVIEW EVIDENCE FROM USA SCHOOLS’ PROGRAMMES
In a recent review of six abstinence-only and two abstinence-plus programmes, Thomas notes significant knowledge or attitude changes in four of the abstinence-only programmes and delayed onset of intercourse at six month follow up in one of them.4 Both of the abstinence- plus programmes showed significant delay (up to 18 months) in onset of first intercourse among those who were not sexually active at the start of the programme (and, in the one study that looked at this, less likelihood of unprotected intercourse when sex was initiated).
A recent review of reviews by the Health Development Agency dismisses Thomas with the assertion that “no other review included here has identified abstinence-only approaches as successful”.5 In fact, the review by Card that was included identifies both abstinence-only as well as several abstinence-plus programmes among those that work successfully.
Card reviews 11 primary pregnancy prevention programmes with published evidence of their effectiveness.3 Of these, at least three are abstinence based approaches6-9 including two which appear to be abstinence-only. Even some of the more contraceptive based programmes included by Card contained a strong abstinence message (for example, Vincent et al10). Thus, one of Card’s conclusions is that, “Abstinence is the gold standard behaviour for teens in middle and high school because, among other reasons, it the only way to be 100% sure you will not get pregnant or cause a pregnancy to happen”.3 However, the Health Development Agency review oddly summarises Card on abstinence with the single statement, “Despite strong fiscal support being given to abstinence-only programmes, there is no firm evidence for their effectiveness”.5
EVIDENCE FROM USA SCHOOL/COMMUNITY PROGRAMMES
No school programme as a stand-alone project is likely to achieve the maximum impact in changing sexual behaviour and there is increasing evidence that community based abstinence education can be even more effective.
In the School/Community Program for Sexual Risk Reduction Among Teens in South Carolina, the primary objective was to “delay sexual intercourse among never-married teens and pre-teens”.11 The secondary objective was to encourage contraceptive use among those who did not comply with the primary objective. Courses to communicate these messages effectively were given not only to teachers but also to parents, clergy, and other church leaders and community agency professionals. Newspaper and radio advertising were also utilised extensively to try and achieve saturation coverage in the community of the programme messages. Two and three years into the intervention programme the pregnancy rates for 14-17 year olds in the intervention part of the county showed a “remarkable sustained decline”, not observed in the comparison counties.
A more recent paper also describes the highly significant effect of an abstinence programme in Monroe County, New York.12 This used a mass communications approach including TV, newspaper and radio broadcasting, billboards, and regular community events to promote the “Not Me, Not Now” abstinence education programme, which was used by all 9-14 year olds in the county schools. By the third year after the implementation of the programme, the percentage of students reporting intercourse by the age of 15 had fallen from 47% to 32%. The slope of the regression line for the fall in pregnancy rates of 15-17 year old girls in Monroe County following the programme was 2-3 times that for the surrounding areas of New York which did not run the programme.
Another community based programme to help adolescents avoid health risk behaviours was presented to children up to age 12 in Seattle.13 At nine year follow up after the end of the programme, when they reached age 21, those in the programme were less likely to have started having sex by age 21. They were also significantly older at first sexual experience (16.32 v 15.75 years), had fewer sexual partners (3.58 v 4.13), were less likely to become pregnant (38% v 56%), and were more likely to have used a condom at first intercourse. The striking feature of this programme is that it had no specific sex education component at all, though good decision making (including abstinence) in many fields was encouraged more generally. It is quite remarkable that, in the UK, sexual activity is one area in which encouraging abstinence in the under-16s is regarded as an unreasonable goal. We expect our children to abstain from stealing, bullying, and host of other activities but often imply that it is less important where sexual activity is concerned. This is quite bizarre in view of the fact that a large majority of 12 year olds readily accept abstinence as an appropriate method for them to avoid unplanned pregnancy.
Finally, the effectiveness of abstinence based community projects on changing teenage sexual behaviour is also shown by a comprehensive analysis14 of data from the 1994-96 National Longitudinal Study of Adolescent Health.15 This concludes that making a virginity pledge (one of the aims of some US abstinence programmes) delayed the onset of sexual intercourse by up to three years. Even though this strong effect was conditioned by both age and social context, it still constitutes powerful evidence for the effectiveness of abstinence education within that culture.
UGANDA AND ABSTINENCE
Evidence from the US is now further supported by results currently emerging from abstinence education projects in several other countries, particularly Uganda,16 where ABC programmes (Abstain, Be faithful, or wear a Condom) are widespread. Dr Anne Peterson, director of global health for the US Agency For International Development stated “Kids are willing and able to abstain from sex. Condoms play a part. They are better than nothing, but the core of Uganda’s success story is big A, big B and little C”.17
A recent four year study of safer sex interventions in one district of rural Uganda showed no reduction in the incidence of HIV infection.18 Another study from the Rakai district, reported no overall protective effect against HIV acquisition in women who reported condom use.19 Dr Norman Hearst, the epidemiologist who authored the USAID report on condom efficiency, concludes “There really is not any clear evidence that condom promotion by itself has been able to roll back the AIDS epidemic in any country where there is widespread transmission”.17 Indeed the rate of condom use in Uganda remains one of the lowest in Africa, yet several studies have shown the steep decline in rates of HIV infection since 1992.20 21 The prevalence of HIV among pregnant women in Kampala, for example, dropped from 25% in 1992 to 14% in 1998. This same time frame has also seen dramatic changes in sexual behaviour. The percentage of 13-16 year olds who reported having had sex fell from over 60% in 1994 to 5% in 2001 for boys and from 25% to 3% for girls.16 Among women aged 15 and above the number reporting multiple sexual partners fell from 18.4% in 1989 to 8.1% in 1995 to 2.5% in 2000.16
Evidence of the effectiveness of the HEART (Helping Each Other Act Responsibly) programme in encouraging sexual abstinence among teenagers in Zambia was recently presented at the 14th World AIDS Congress in 2002 by researchers from Johns Hopkins School of Public Health.22 A recent report from Harvard researchers on the stabilization of HIV rates in Jamaica included the recommendation that “the delay of sexual debut and abstinence messages promoted primarily through school and churches, should continue to be part of the national strategy”.23
At the UN child summit last year, Uganda’s First Lady Museveni was characteristically bold and blunt in stating, “The young person who is trained to be disciplined will, in the final analysis survive better than the one who has been instructed to wear a piece of rubber and continue with ‘business as usual'”.24 The Chief Medical Officer and our own government’s Sexual Health Inquiry would have done better to heed such advice, rather than making unhelpful statements ideologically opposed to abstinence education. It will certainly take more than condoms to reverse the tide of sexually transmitted infections currently engulfing young people in Britain.
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This article first appeared in the Postgraduate Medical Journal, July 2003, 79, 365-366, and is reproduced here by kind permission of the BMJ Publishing Group.
Authors’ affiliations: St George’s Hospital Medical School, London
REFERENCES
1 Donaldson L. Chief Medical Officer’s update 35. London: Depart-ment of Health, January 2003 (www.doh.gov.uk/cmo/cmo_35.htm#10).
2 Hartley-Brewer J. NHS clinics overwhelmed as promiscuity takes its toll on a whole generation. Sunday Express 8 June 2003.
3 Card J. Teen pregnancy: do any programs work? Annu Rev Public Health 1999;20:257-85.
4 Thomas M. Abstinence-based programs for prevention of adolescent pregnancies: a review. J Adolesc Health 2000;26:5-17.
5 Swann C, Bowe K, McCormick G, et al. Teenage pregnancy and parenthood; a review of reviews. Health Development Agency, 2003.
6 Donaghue MJ. Technical report of the national demonstration project field test of human sexuality: values and choices. Minneapolis, MN: Search Institute, 1987.
7 Howard M, McCabe JB. Helping teenagers postpone sexual involvement. Fam Plann Perpsect 1990;22:21-6.
8 Howard M, Mitchell M. Preventing teenage pregnancy: some questions to be answered and some answers to be questioned. Pediatr Ann 1993; 22:109-18.
9 Jorgenson SR, Potts V, Camp B. Project taking charge; six-month follow-up of a pregnancy prevention program for early adolescents. Fam Relat 1993;42:401-6.
10 Vincent ML, Dill H, Johnson C. School/community sexual risk reduction program for teens. Columbia, SC: University of South Carolina School of Public Health, 1987.
11 Vincent ML, Clearie AF, Schluchter MD. Reducing adolescent pregnancy through school and community-based education. JAMA 1987;257:3382-6.
12 Doniger AS, Adams E, Riley JS, et al. Impact evaluation of the “Not Me, Not Now” abstinence-oriented, adolescent pregnancy prevention communications program, Monroe County, New York. Journal of Health Communication 2001;6:45-60 (www.notmenotnow.org/research/ NMNNimpactevaluation.pdf).
13 Lonczak H, Abbott R, Hawkins D, et al. Effects of the Seattle Social Development Project on sexual behaviour, pregnancy, birth and sexually transmitted disease outcomes by age 21yrs. Arch Pediatr Adolesc Med 2002;156:438-47.
14 Bearman PS, Bruckner H. Promising the future; virginity pledges and first intercourse. Am J Sociology 2001;106:859-912.
15 Resneck MD, Bean PS, Blum RW, et al. Protecting adolescents from harm: findings from the national longitudinal study on adolescent health. JAMA 1997;278:823-32.
16 Hogle J, Green EC, Nantulya R, et al. Whatever happened in Uganda? Declining HIV prevalence, behaviours change and the national response. Washington, DC: USAIDWashington and The Synergy Project TvT Associates, 2002 (www.usaid.gov/pop_health/aids/Countries/africa/uganda_report.pdf).
17 Carter T. Uganda leads by example on AIDS. The Washington Times 13 March 2003 (www.washingtontimes.com/world/ 20030313).
18 Kamali A, Quigley M, Nakivingi J, et al. Syndromic management of sexually transmitted infections and behaviour change interventions on transmission of HIV-1 in rural Uganda: a community randomised trial. Lancet 2003;361:645-57.
19 Kiddugavu M, Makumbi F, Wawer M, et al. Hormonal contraceptive use and HIV-1 infection in a population-based cohort in Rakai, Uganda. AIDS 2003;17:233-40.
20 Mulder D, Nunn A, Kamali A, et al. Decreasing HIV-1 seroprevalence in young adults in a rural Ugandan cohort. BMJ 1995;311:833-6.
21 Mbulaiteye SM, Mahe C, Whitoworth JA, et al. Declining HIV-1 incidence and associated prevalence over 10 years in a rural population in SW Uganda: a cohort study. Lancet 2002;360:41-6.
22 Martin K. Zambia’s HEART programme evaluation shows youth respond positively to AIDS prevention plan promoting abstinence. Baltimore, MD: Johns Hopkins University Center for Communication Programs, 2002 (www.jhuccp.org/pressroom/2002/ 07-11.shtml).
23 Amara Singham S, Green E, Royes H. Final evaluation AIDS/STD prevention and control project; Jamaica. Washington, DC: USAID-Washington and The Synergy Project TvT Associates, 2002 (www.synergyaids.com/documents/ 744_Jamaica_Final_Report.pdf).
24 The Buzz. Available at: www.worldmag.com/world/issue/05-18- 02/opening_2.asp.
Who would have thought it?
“Mothers who stay at home and bring up their children, rather than going out to work, have been under-valued for too long by the government, Patricia Hewitt, the Trade and Industry Secretary, admitted yesterday. She told The Daily Telegraph that Labour ministers had created the per-ception since coming to power in 1997 that they believed that all women should get jobs. This had been a mistake.
“If I look back over the last six years I do think that we have given the impression that we think all mothers should be out to work, preferably full-time as soon as their children are a few months old’, she said. ‘We have got to move to a position where as a society and as a government we recognise and we value the unpaid work that people do within their families.”
The Daily Telegraph, 15 October 2003
THE OTHER 3Rs Goes Live!
Since the website for the Trust’s series of education modules, The Other 3Rs, went live last November, the site has received a total of 2,122 visitors and 23,311 pages have been viewed. Individual modules have been viewed or downloaded 1,325 times and the entire course has been viewed or downloaded on 466 occasions. Earlier in the summer, we mailed a flyer advertising the site to church primary schools in England and Wales with the result that September was one of the busiest months to date. You can visit the website yourself at: www.theother3rs.org