Unplanned pregnancies, sexually transmitted infections (STIs), HIV infection, and complaints of sexual abuse are issues that many high school pupils have to grapple with.
But resistance from education officials and school governing bodies (SGBs) towards the provision of health services at schools, may be preventing these teens from getting the treatment or advice they need.
A pilot school nursing programme initiated by the Desmond Tutu HIV Centre at 44 secondary schools in the Western Cape has revealed that pupils found the school environment to be less intimidating than having to visit state clinics. School management, on the other hand, was so worried about potential disruption to the curriculum that some rejected the initiative.
“We go to the clinic and it’s already packed ... here it’s never packed. Clinic nurses are rude. Here, the nurse doesn’t shout, she just helps,” said a pupil taking part in the study.
Of 344 pupils in the pilot — mostly girls aged 16 — over half sought sexual reproductive health services, including treatment for STIs, contraception and menstruation issues. About 50% of them received an HIV test and 16% had contraceptives.
About 4% had genital symptoms requiring referral for further treatment, and 12 males enquired about medical male circumcision. About 61% of pupils had never used condoms, and most did not know their partners’ HIV status. About 17% of them reported a history of sexual or physical abuse, while 11% had depression and 57% needed referral to another health facility.
While many of the pupils involved in the fortnightly nurse visits to participating schools appreciated “not being shouted at by school health nurses”, Nadia Ahmed, lead investigator from the Desmond Tutu HIV Centre and Mortimer Market Centre in the UK, said “divergent views across schools and different opinions from district education officials ultimately led to early termination” of the pilot.
This was despite the programme being tailored according to school preference.
“The department of education has traditionally worried about activities that are not directly related to education and curricula,” noted Ahmed and colleagues in a report published in the African Journal of Primary Healthcare and Family Medicine.
“It is incumbent upon us to show that benefits outweigh any perceived risks, and that this can be performed efficiently, minimising time that pupils may take from school-related activities rather than increasing that time.”
Implementation challenges have been attributed to managerial variation in the value attached to health promotion, insufficient collaboration between the departments of health and education, and inadequate stakeholder integration.
— Nadia Ahmed, lead investigator from the Desmond Tutu HIV Centre
While recommended in national policy, Ahmed said, in practice, school nursing programmes were not delivered as a standard in the country’s secondary schools. “Implementation challenges have been attributed to managerial variation in the value attached to health promotion, insufficient collaboration between the departments of health and education, and inadequate stakeholder integration.”
Researchers noted that the country’s high rate of new HIV infections, STIs and unplanned pregnancies among adolescents indicated “unmet health needs by the current [health] facilities and interventions”.
Ahmed noted that the fortnightly visits by nurses might have negatively affected the uptake of school health services.
She believes an increased familiarity with the service over an extended period “could have increased uptake, especially among traditionally difficult-to-engage male users”.
Schools that declined to participate in the pilot gave reasons including “commitment to other programmes, local safety concerns and school governing body opposition”. While the pilot was scheduled for 12 months, “a communication change from district education officials led to early termination, limiting the delivery period to 20 weeks”.
“A key challenge to school-based health service delivery arose from inadequate stakeholder support and differential views of adolescent healthcare needs among government officials, parents, guardians, school staff and governing bodies.
“These findings motivate for ongoing multilevel stakeholder engagement around the reality of adolescent healthcare needs, and further opportunities to deliver school health services for longer time periods, such that their feasibility, acceptability and potential to impact healthcare outcomes can be assessed in this setting.”
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