Relationships and Sex Education: exploring the process of quality assuring content, delivery and training

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Relationships and Sex Education: exploring the process of quality assuring content, delivery and training

Report September 2011

Developed by Brook Bristol On behalf of the RSE Hub South West Steering Group, supported by the South West Office for Sexual Health and

NHS South of England.

Written by Nicole da Costa, BSc, BScN Brook Bristol Sexual

Health Outreach Worker

Strengthening Relationships and Sex Education

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Sex and Relationships Education 2 Sept 2011

Foreword

Nicole Da Costa from Brook Bristol was commissioned to research this piece of work by the RSE Hub South West Steering group. Having read the report and heard Nicole present the rationale and content of the research I was impressed by the breadth and depth of the work and its tangible uses.

The research was undertaken due to concerns about the quality and

consistency of RSE. This was considered both in terms of content: what is being taught and delivery: how (and by whom) it is being taught. The need for quality assurance has been voiced across the South West by members of the steering group, by Ofsted (Time for change? Personal, social and health education, April 2007) and Young People (SRE: Are you getting it? A report by the UK Youth Parliament, June 2007)

PSHE, including RSE unfortunately remains non- statutory, it is still, however a subject that needs to be accountable, measured and considered at the same level as all subjects. In the Department for Educations The Importance of

Teaching - The Schools White Paper 2010 the Department has acknowledged that ‘Children need high-quality sex and relationships education so they can make wise and informed choices’ and recognises ‘that Children can benefit enormously from high-quality Personal Social Health and Economic (PSHE) education (DFE reference 4.29 & 4.30 page 45) please do as a footer

“PSHE (including RSE) is expected to meet the same high standards required by Ofsted of all subjects and teaching. Teachers must have consistently high

expectations of all pupils, draw on excellent knowledge, plan astutely, set challenging tasks based upon accurate assessment of pupils’ prior skills, knowledge and understanding and use well judged teaching strategies…”

(PSHE education and the new Ofsted Inspection Framework January 2012, PSHE Association briefing)

The comprehensive and robust research pulls together regional, national and international approaches and has some thought provoking options for assuring quality RSE.

We hope the outcomes will prove interesting and provide some evidence based methodology and ideology to inform practice locally and regionally, enabling the development of tools, to ensure children and young people receive high quality, coherent RSE, taught by well trained teachers and practitioners.

Zoe Baxter, SRE Advisor, and RSE Hub South West steering group member for Cornwall and Isles of Scilly.

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Executive summary

Introduction

Despite a growing body of evidence demonstrating that the delivery of comprehensive, high quality ‘relationships and sex education’ (RSE) has a positive impact on the sexual health and well-being of young people (Kirby 2007), RSE delivery in the UK is often fragmented, described as poor or very poor by young people, and inconsistent.

This report aims to explore the process of quality assuring RSE, both internationally and in the UK, and to identify approaches that might be appropriate for use in the South West, and potentially nationally.

What is quality RSE?

This report found that international bodies echo local guidance on what constitutes quality RSE and competent RSE educators.

Quality RSE can be identified as:

• comprehensive and representative of the needs of young people;

• free from judgment, prejudice, agenda and based on human rights;

• positive and holistic;

• established through partnerships;

• focused on knowledge, attitudes, values, beliefs and skills with the aim of empowering young people;

• based on effective learning principles (engaging, interactive, and participatory learning in a graduated and regularly taught programme) and evaluated frequently.

Competent RSE educators can be identified as:

• motivated and interested in the delivery of RSE within an agreed values framework;

• comfortable discussing sexuality;

• skilled in managing sex and relationships discussions and possessing a strong subject knowledge;

• having received comprehensive training that explored personal values and was taught by experienced trainers;

• having access to ongoing support and supervision.

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Perspectives of key stakeholders on quality assurance of RSE This report found that key stakeholders:

• support a quality assurance process that focuses on young people, includes partnerships, acknowledges levels of expertise, clearly identifies quality RSE, includes ongoing assessment of competency and is recognised nationally;

• identify time, funding, and capacity as barriers to implementation.

Recommendations

A range of approaches exist internationally and locally that aim to set standards for RSE delivery. Ideally, a quality assurance process would exist nationally.

However, several international and local approaches are worth considering in the context of the South West and the achievement of quality RSE.

This report recommends three progressive actions to assure quality RSE in the South West, and potentially nationally:

Identifying quality: checklists, informed by international and local guidance, can provide a clear definition of quality RSE and a matrix for developing practice and endorsing specific award systems, such as ASDAN, and educator training programmes such as those delivered by the FPA and Sheffield Centre for HIV and Sexual Health.

Recognising quality: quality assurance checklists can provide the basis for ↓ quality or kite-marks such as the Richmond kite-mark or the Kent quality mark.

Building capacity: educator confidence and competence could be ↓ improved by reinvesting in programmes locally, such as the CPD in PSHE, and expanding them to include a means of renewal or recertification, similar to the SHEC programme in Canada. A quality mark, similar to the SHine South Australia Focus Schools Programme, could enhance uptake by

schools by pairing participation with teacher training. The Christopher Winter Project and Brook Bristol’s teacher training pilot are examples of RSE delivery being paired with educator development in the UK.

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Background and introduction

What is Relationships and Sex Education ?

In the UK, RSE is described by the Sex Education Forum (SEF 2005 p.1) as

“learning about sex, sexuality, emotions, relationships, sexual health and ourselves”. Elsewhere in the world, terms such as ‘sexual health education’

or ‘sexuality education’ are used in a similar context. For example:

• ‘Sexuality education’ is defined by UNESCO (2009a) as being “an age- appropriate, culturally sensitive and comprehensive approach to sexuality education that includes programmes providing scientifically accurate, realistic, non-judgemental information. Comprehensive sexuality education provides opportunities to explore one’s own values and attitudes and to build decision-making, communication and risk reduction skills about all aspects of sexuality. Comprehensive sexuality education promotes critical thinking, self-actualisation, and

behavioural change through gaining knowledge about the body;

healthy sexuality; relationships; sex abuse, pregnancy, HIV and sexually transmitted infection prevention; and many other topics regarding human sexuality, and sexual and reproductive health and rights. A comprehensive sexuality programme will respect the diversity of values and beliefs represented in the community and will

complement and augment the sexuality education children receive from their families, religious and community groups, and health care professionals.”

• Sexual health is defined by the WHO (2011) as being “a state of physical, mental and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.”

For the purpose of this report both the terms ‘Relationships and Sex Education’

or ‘RSE’ and ‘Sex and Relationships Education’ or ‘SRE’ will be used

synonymously. This reflects the move to ‘RSE’ in many local areas to promote the relationships aspect whilst recognising national and international guidance, and academic reference to ‘SRE’.

The general aim of RSE is to “equip young children and young people with the information, skills and values they need to have safe, fulfilling and enjoyable relationships and to take responsibility for their sexual health and well-being”

(SEF 2005 p.1) and possess “the knowledge, skills and values to make responsible choices about their sexual and social relationships” (UNESCO 2009b p.2).

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Why is RSE important? Does it work?

RSE is a priority for the following reasons:

• sexuality is part of being human;

• people have a right to be informed;

• informal sexuality education is inadequate for modern society;

• young people are exposed to many new sources of information;

• there is a need for sexual health promotion (WHO Europe and BZgA 2010).

Not only does RSE provide young people with the opportunity to acquire information, explore attitudes, values and practise the skills needed to make informed decisions, it is also a critical part of preventative measures, such as stopping the spread of HIV (UNESCO 2009b).

A growing quantity of good quality evidence demonstrates that the delivery of comprehensive RSE brings forth positive behaviour change (Kirby 2007). The Sex Education Forum (2010a) reports the following:

• national and international research shows that young people who have had good RSE are more likely to have sex for the first time later and there is no evidence indicating that RSE hastens the first

experience of sex or increases the frequency of sex;

• research shows that young people who have taken part in a good quality RSE programme are more likely to use condoms and

contraception if they do have sex;

• research carried out in England has found that areas of the country which have achieved the greatest reductions in teenage conception rates in recent years have provided both good quality school RSE as well as accessible sexual health services for young people.

Brief overview of RSE delivery in the UK Context

The UK has one of the highest rates of teenage pregnancy in Western Europe (cited in SEF n.d.), although this rate is decreasing (Office for National Statistics 2011). Despite the knowledge that strong delivery of RSE is key to reducing conceptions and STI transmission (SEF 2010b) and the general agreement between education professionals and parents that young people need to be informed about safer sex (NCTA et al 2010), clauses that made RSE statutory were removed from the ‘Children, Schools, and Families Bill’ prior to its Royal Assent in April 2010. Therefore, RSE in England continues to be guided by:

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• the National Curriculum which includes some statutory SRE content within science teaching;

• the Department of Education’s ‘Sex and Relationship Education Guidance’ (2000) which considers the delivery of SRE within non- statutory Personal, Social, Health and Economic education.

Additionally, schools have a legal obligation to ensure the well-being of their pupils and RSE can contribute to this duty (SEF 2011a).

RSE in England is mainly delivered by school teachers who may or may not receive support from Personal Social Health and Economic education (PSHE) co-ordinators, school nurses, outside visitors or not-for-profit groups (IPPF

European Network 2006). Yet 80% of school leaders do not feel that they have been trained to talk confidently about RSE (NCTA et al 2010) and only 3% of teachers report that RSE is covered adequately in Initial Teacher Training (ITT) (SEF 2008a). Teachers report that insufficient time, confusion over what should be taught, too few teachers willing to teach the subject, and individual school RSE policies are barriers to RSE delivery in the UK (SEF 2008a).

Quantity and quality

There is significant variation in the quality and quantity of RSE provision across England (IPPF European Network 2006). The Office for Standards in Education (Ofsted) and numerous youth surveys give accounts of this variation and reveal significant gaps in learning.

Ofsted (2010), who assess the effectiveness of school policy and programmes, reviewed SRE delivery between 2006 and 2009 and found that:

• in just under a third of schools, SRE was fragmented and lacked

specialist teaching, resulting in weak skill development and superficial knowledge and understanding;

• out of 73 schools assessed, SRE delivery ‘was no better than satisfactory’ in 25 and ‘inadequate’ in three;

• the standard of teaching by form tutors was inconsistent

• a number of schools were delivering SRE through ‘drop-down’ days (rather than through a timetabled programme) which does not allow for progression in learning.

Youth surveys conducted in the UK provide a similar picture of school-based RSE:

• 40% of young people between the ages of 11 and 18 rated their RSE as poor or very poor, whilst a further 33% thought it was average (UK Youth Parliament 2007);

• more than half of the young people had not been informed of where their local sexual health service was (UK Youth Parliament 2007);

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• 57% of 16-17 year old females had not been taught how to use a condom (UK Youth Parliament 2007);

• 43% of young people reported that they had received no teaching on personal relationships (UK Youth Parliament 2007).

• a quarter of young people had learnt nothing about HIV and AIDS (SEF 2011b);

• of the RSE that is received, young people said that the information they receive is ‘too little too late and too biological’ (SEF 2008b).

Aim of the report

RSE becoming a statutory part of the curriculum is a significant step towards achieving effective delivery; however, this does not automatically lead to good quality education (WHO Europe and BZgA 2010). Good quality RSE is

dependent on a range of factors including bottom-up support, such as teacher training (WHO Europe and BZgA 2010), as well as top-down leadership, such as a cultural, moral and political context that supports its delivery (Schaalma et al 2004). Therefore, mandated or not, there is significant value in considering the implementation of methods and frameworks to ensure the highest quality RSE is being delivered to young people.

Questions around setting standards for the delivery of RSE may include:

• what is covered, at what age and how is the content delivered?

• who delivers it, how are they trained, and what qualifications do they have?

By exploring the process of quality assuring RSE content, delivery and training this report aims to answer the following questions:

• what guidance and approaches exist internationally and in the UK that provide a framework for the quality assurance of RSE?

• what recommendations can be made on the viability of quality assuring the content, delivery and training of RSE?

• which of these measures and approaches might be appropriate for use in the South West, and potentially nationally?

Methods

The following was conducted in the preparation of this report:

• a literature search was completed using the Ebsco database, CINHAL database and worldwide web. Published articles and a variety of government documents were reviewed;

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• international frameworks and methods were included after a review of information available on the worldwide web, with a focus

on International Planned Parenthood Federation (IPPF) affiliates of selected countries;

• key stakeholders in England delivering RSE education, to both young people and professionals, were interviewed to gather information on the programmes and training they deliver;

• key stakeholders in England were interviewed to gather information on their perspective on the viability of a quality assurance process.

Limits

The time allotted for this report was 18 days, which included:

• completing a search of the literature;

• reviewing pertinent journals and government documents;

• arranging and completing interviews;

• reviewing, compiling and editing gathered information;

• attending meetings with the commissioner and the South West Relationships and Sex Education Steering Committee.

Due to the time frame, the information contained in this report provides preliminary answers to the questions posed and further work is required to investigate the issue of quality assurance in greater depth. In particular,

additional time would be required to establish a more complete picture of the methods and frameworks used internationally as it is expected that, as in the UK, many innovative initiatives take place on a local level and may not have been identified in broader, nationwide searches.

Guidance from recognised international bodies

UNESCO, WHO Europe and the IPPF have been profiled for their contributions to the promotion of high quality RSE. As it relates to quality assurance, each organisation profile includes:

• a list of significant resources produced;

• a position on values;

• recommendations on educator¹ training and characteristics.

UNESCO

The United Nations Educational, Scientific and Cultural Organisation (UNESCO) is a specialised United Nations agency whose focus includes the attainment of quality education for all (UNESCO 2011).

1 Includes the various professional groups involved in the delivery of sex and relationships education (teachers, nurses, youth workers, and others)

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Resources

In relation to quality assurance of RSE, UNESCO provides:

• a summary of 18 characteristics of effective sexuality education programmes (see Appendix 1) (UNESCO 2009b);

• five recommendations based on identified good practice (see Appendix 2) (UNSESCO 2009b);

• a ‘basic minimum package’ of topics and learning objectives for a sexuality education programme for children and young people aged five to 18+ years of age (see overview Appendix 3) (UNESCO 2009c).

Values

Although it is not possible to remove values from the discussion of sexuality, UNESCO (2009b) supports a rights-based approach to sexuality education that links values such as respect, acceptance, tolerance, equality, empathy and reciprocity to universally accepted human rights.

Educator training

UNESCO (2009b) states that RSE educators should have an interest in teaching the curriculum, personal comfort discussing sexuality, an ability to

communicate with students, and be skilled in the use of participatory learning methodologies.

The training teachers receive should:

• have clear goals and objectives;

• teach and provide practise in participatory learning methods;

• provide a good balance between learning content and skills;

• be based on the curriculum that is to be implemented and provide opportunities to rehearse key lessons in the curriculum;

• help educators distinguish between their personal values and the health needs of learners;

• encourage educators to teach the curriculum in full, not selectively;

• address challenges that will occur in some communities;

• last long enough to cover the most important knowledge, content and skills and to allow participants time to personalise the training and raise questions and issues;

• be taught by experienced and knowledgeable trainers

• solicit participant feedback.

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WHO Europe and Federal Centre for Health

Launched by the WHO Regional Office for Europe in 2008 and developed by the Federal Centre for Health Education (BZgA), the ‘Standards for Sexuality Education in Europe’ provide standards for RSE that can be used to develop or upgrade curriculums. Unlike the UNESCO guidelines, this document is regionally specific to Europe.

Resources

In relation to quality assurance, WHO Europe and BZgA (2008) provide:

• a set of principles and outcomes of RSE (Appendix 4);

• seven characteristics of RSE (Appendix 5);

• a matrix of topics to included in SRE by age group that calls for RSE to start at birth.

Values

WHO Europe and BZgA (2008) endorse ‘holistic SRE’; defined by the following:

• gives children and young people unbiased, scientifically correct information on all aspects of sexuality;

• helps them develop the skills to act on the acquired information;

• contributes to the development of respectful, open-minded attitudes and helps build equitable societies;

• supports young people in becoming more empowered in order to live out their sexuality and their partnerships in an enjoyable, fulfilling and responsible manner;

• views sexuality as a positive human potential and a source of satisfaction and pleasure;

• based on internationally accepted human rights, in particular the right to know, which precedes prevention of ill health.

WHO Europe and BZgA list the following criteria for competent educators:

• training in RSE;

• openness to the subject and a high motivation for teaching it;

• firm belief in the principles of RSE;

• support and access to supervision;

• consistent use of neutral language;

• founding of RSE on human rights and the acceptance of diversity.

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International Planned Parenthood Federation (IPPF)

The IPPF is one of the largest non-governmental organisations working in the field of sexual health (Parker et al 2009).

Resources

In relation to quality assurance, the IPPF (2010) provides:

• a set of seven essential components of comprehensive RSE (Appendix 6);

• a set of principles of good practice in relation to planning, delivery, assessment and evaluation (Appendix 7).

Values

The IPPF approach to RSE links “safer sex with positive development, empowerment and choice, including sexual expression and fulfilment,

representing a shift away from the traditional approach that focuses exclusively on the reproductive aspects of adolescent sexuality and that associates sex with risk-taking and the prevention of pregnancy and infections” (Parker et al 2009 p.227). They endorse a rights-based approach to RSE and strongly

discourage education focusing solely on abstinence as young people’s right to informed decision making is embodied by comprehensive education (IPPF 2010).

The IPPF believes that, ideally, all professionals that support RSE delivery should (2010):

• have appropriate information, training, tools, skills and qualities;

• have an understanding of young people and their agenda;

• have the intention of enlightening, transforming and preparing others;

• be someone who young people trust and feel comfortable with and who creates an enabling environment;

• be someone who imparts knowledge and facilitates the development of skills;

• be accessible and non-judgmental, with no personal agenda that they want to impose;

• have access to ongoing support, supervision, materials and resources.

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Statutory and voluntary RSE guidance in the UK

In the UK, the delivery of RSE is directed by both statutory and voluntary sector guidance. Governmental bodies and other organisations that produce such guidance and are thus significant to a quality assurance process are profiled below.

National Curriculum and educational legislation Current legislation relating to SRE requires that:

• all maintained schools teach the statutory parts of the National

Curriculum science, which includes the biological aspects of puberty, human reproduction and the spread of viruses, with a separate

requirement for secondary schools to teach about HIV and AIDS (SEF 2011a);

• academies have varying academic requirements and do not have to follow the National Curriculum (SEF 2011a);

• additional SRE is contained within the non-statutory PSHE curriculum

• the Department of Education’s SRE Guidance (2000) strongly

recommends the delivery of SRE and it is expected by law that school governors, of both maintained schools and academies, give ‘due regard’ to such government guidance (SEF 2011a);

• the Education Act Section 405 (1996) gives parents the right to excuse their children from receiving SRE at school, with the exception of the education comprised in the National Curriculum.

In January 2011, The Department for Education (DfE) launched a review of the primary and secondary National Curriculum. Although components of SRE are included in the National Curriculum science, SRE is not included in the remit of the review. Instead, a separate internal review into PSHE was launched in July 2011. At present, both reviews are ongoing and the current curriculum is to be followed until a new curriculum is in place.

Department for Education

In 2000, the DfE published ‘Sex and Relationships Education Guidance.’

This document directs SRE by identifying the legal responsibilities of schools (including the development of SRE policy) and providing guidance on the delivery of SRE within PSHE.

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The DfE (2000) states the following:

• meeting the objectives of SRE requires a graduated, age- appropriate programme;

• teachers, and those contributing to SRE, are expected to work within an agreed values framework described in the school’s policy, which must be in line with current legislation.

Ofsted

Ofsted reviewed SRE delivery in maintained English schools between 2006 and 2009, and published a report on the status of PSHE in July 2010. The findings are significant as they demonstrate factors that have contributed to high quality SRE specific to the UK.

In relation to quality assurance of SRE, Ofsted (2010) reports:

• discrete, regularly taught PSHE lessons, supplemented with cross- curricular activities, is the most effective curriculum model;

• the best schools matched the content of their PSHE curriculum closely with the assessed needs and levels of maturity of their students;

• the use of methods such as open-ended questions, drama techniques, games and debate were seen in good PSHE;

• good PSHE was seen when feedback was used to revise content and approach before the material was used with the next group;

• the most effective schools took advantage of opportunities to formally accredit PSHE work (e.g. Trident Gold Award, GCSE-equivalent

courses);

• in good and outstanding teaching, discussion and debate about sensitive and controversial issues was skilfully managed and teacher’s approach to students’ responses was non-judgmental;

• in good and outstanding teaching, teachers’ subject knowledge was good, often because they were part of a specialist team and had access to training such as the national PSHE CPD programme.

Although the quality of teaching from form tutors was inconsistent, tutors who were given effective training and support often taught PSHE effectively;

• use of external presenters was most effective when they were well- briefed, students were actively engaged and teachers kept responsibility for the educational goals.

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To achieve high quality PSHE across all schools Ofsted (2010) recommends:

• the DfE, with its delivery partners, should:

o develop routes for initial teacher training education in PSHE education;

o promote the take-up of continuing professional development in PSHE education;

o support the development of good practice in assessing PSHE education.

• local authorities should provide access to high-quality continuing professional development and facilitate networking between teachers delivering PSHE;

• schools should ensure that teaching meets pupil needs, is engaging, and that systems are in place for assessing delivery.

Department for Health

In 2005, the Department for Health published recommended standards for the sexual health training of professionals and volunteers in clinical and non-clinical settings. They provide:

• best practice standards;

• recommended values and principles that underpin good quality sexual health training;

• standards for the preparation and delivery of sexual health training. (See Appendix 8).

NICE guidelines

The National Institute for Health and Clinical Excellence (NICE) guidance for PSHE, focusing on SRE and alcohol education, was drafted and put out for consultation. The draft guidance is available but currently there is no proposal to respond to the consultation or formally publish this guidance. For further information please visit:

http://www.nice.org.uk/nicemedia/live/11673/49240/49240.pdf

School RSE policy

It is mandatory that all schools have an up-to-date RSE policy (DfE 2000) that:

• defines RSE;

• describe how RSE is provided and who is responsible for providing it (including materials used and clear parameters on what will be taught);

• indicates how RSE is monitored and evaluated;

• includes information about parent’s right to withdraw.

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Sex Education Forum (SEF)

The SEF is a collaboration of diverse member organisations and practitioner networks and the leader in the UK for the achievement of quality SRE.

In relation to quality assurance of SRE, the SEF has published several excellent resources including:

• a set of principles and values that should underpin quality SRE (SEF 2011c) (Appendix 9);

• a set of principles of good practice (SEF 2005) (Appendix 10);

• a set of key elements of curriculum content (SEF 2005) (Appendix 11);

• a set of guidelines on what to include in an SRE curriculum by age (SEF 2011d) (Appendix 12);

• a checklist for the use of resources (SEF 2011d) (Appendix 13);

• guidance in the use of external visitors (SEF 2010c).

Education for Choice

Education for Choice is a member of the SEF and the only UK charity that specifically focuses on “supporting young people in making informed choices about pregnancy and abortion” (Education for Choice 2005).

In relation to quality assurance, Education for Choice (2005) has produced several significant publications including:

• eight aims and principles of best practice in abortion education which includes a checklist for assessing outside speakers (Appendix 14);

• a checklist for those delivering abortion education that considers resources and lesson planning (Appendix 15).

Viability of quality assurance and quality standards

In exploring the process of quality assuring RSE, is it imperative to elicit the perspectives of potential key stakeholders. As part of this report, several

organisations, school leaders and independent RSE educators were consulted.

Their perspectives of the benefits and challenges of a quality assurance process are highlighted.

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Methods

Four representatives from national and local organisations involved in RSE delivery, two school staff and three independent consultants participated in individual phone interviews which were structured around a set of interview questions. As this report does not include a structured analysis of the collected data, a brief summary of what appear to be common themes and key points is provided below.

Perspective of organisations

Organisations currently involved in the delivery of RSE appear to be supportive of a quality assurance process for RSE. Those interviewed stressed the

importance of partnerships and identified key components of the process.

However, they reported the absence of funding and capacity as significant barriers.

Across all four interviews, partnerships were identified as a key component to any quality assurance process. This included partnerships with organisations and agencies delivering RSE, schools, parents and, most importantly, young people.

Partnerships with regional and national organisations in developing the process would ensure that organisational needs are met and are reflected in the

standards. Involving young people would keep the process aligned with the needs of those receiving RSE. Parental support was seen as key to the success of the process.

Although the process should not be too complicated, interview data indicated that ideally the following components would be included:

• a mechanism for ongoing evaluation of practice and maintained competencies (which involves young people);

• a level of flexibility in RSE delivery that ensures the needs of young people are always given highest priority (both in delivery and content);

• a clear understanding of the outcomes expected with an acknowledgement that evaluating youth work is very difficult;

• a framework outlining how those delivering RSE can work together in a complementary way based on level of skills, training and expertise (for example on in a levels-based approach, where basic training can be identified as appropriate for some situations while higher level of competencies are required for more challenging work);

• a framework which would be transportable and recognised across the UK.

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All four representatives interviewed agreed that funding and capacity are significant factors in the viability of a quality assurance process. Having an education lead or coordinator was seen as important to viability though it was felt that this capacity does not currently exist at the local level. Additionally, the involvement of young people as well as a means of ensuring ongoing

competencies would also require significant ongoing investment.

Perspective of Schools

School staff appear to consider quality assurance as important to RSE. From the perspective of a head teacher, such a method would provide schools who want to deliver high quality RSE with a means to evaluate and develop their practice. From the perspective of a PSHE Coordinator, it would facilitate the evaluation of work being done, provide a means to demonstrate quality and be a tool with which to petition for continued RSE delivery.

Both interviewees agreed that RSE must be acknowledged as a priority by key stakeholders to move forward. For example, senior school management must support teacher training and development and parents must be supportive of progressive, age-appropriate RSE. From the perspective of the head teacher, school reputation and student well-being are considered when parents choose the schools their children attend. A quality assurance process could

demonstrate school commitment to well-being to the community while also improving RSE. The PSHE Coordinator noted that this commitment to student well-being has, in fact, been behind her school’s continued support of RSE, and her school administrators acknowledge that the skills young people develop through RSE contribute to student well-being.

Ideally, the quality assurance process would:

• assess for consistent emphasis on both relationships and sex;

• look beyond RSE delivery and include an assessment of the wider PSHE curriculum and ethos of the school;

• involve young people in the process (for example eliciting their feedback);

• remain focused on the needs of young people;

• include a mechanism for ongoing evaluation of practice (for example ongoing observation of session delivery by either an RSE specialist or by a peer using a set of guidelines);

• consist of various levels to identify differing levels of training and expertise;

• be a supportive process that focuses on strengths and building capacity.

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Perspective of independent consultants

Independent consultants appear to be very supportive of quality assuring RSE and would welcome a means of setting standards for its delivery. Those

interviewed identified personal benefits to quality assurance (for example, recognition of the quality of RSE delivered would make them more competitive with commissioners) as well as the benefit to young people who would receive better RSE. It would also provide a means of regulating terms such as ‘trained RSE educator’ and ‘specialist RSE teacher’, address the current gap in required qualifications and give a clear framework of what constitutes high quality RSE.

Those interviewed consistently identified time and funds as potential barriers to participation in a quality assurance process. The process would be best

received if it was thorough but not complex. Most importantly, those

commissioning or purchasing services would need to see value in the process in order to justify consultant participation.

Ideally, the quality assurance process would:

• be recognised nationally;

• take previous work and experience into consideration when assessing educator competencies;

• provide an agreed set of guidelines and definitions that inform RSE delivery;

• include a multi-level system to identify the range of knowledge and expertise among those delivering RSE education and training;

• require RSE educators to demonstrate assessment and reflection of personal values relating to RSE and to commit to an agreed values framework for RSE delivery;

• include a framework for quality assuring resources in RSE delivery.

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Quality assurance around the world: a snapshot

The Netherlands, Canada and Australia have been profiled to provide an international snapshot of quality assurance of RSE. These countries have been included for their individual contribution to quality assurance. A national curriculum is highlighted in the Netherlands, a set of national guidelines and a certification programme for RSE educators is highlighted in Canada, and a kite- marking scheme for RSE is highlighted in Australia.

The Netherlands

The Netherlands provides an important reference with regard to adolescent sexual health and related educational provisions (Ferguson et al 2008). Despite there being very little difference in the reported sexual experience (vaginal intercourse, oral sex and anal sex) of young people in the Netherlands

compared to those in the United States, for example, the Netherlands continue to report low rates of teenage pregnancy and high rates of contraceptive use (Ferguson et al 2008). Comprehensive RSE has been identified as a key

contributing component to such positive health outcomes (Ferguson et al 2008).

Nonetheless, it is valuable to consider RSE in the Netherlands within its wider context.

The national curriculum in the Netherlands provides schools with information on the subjects they are to teach and an indication of what students must learn.

The information, however, is general and vague, with schools free to decide how each target is met and how much time should be spent on the various subjects (NFER and INCA 2009). Within the national curriculum, it is only mandatory for Dutch schools to cover the biological aspects of RSE (IPPF

European Network 2006). Parents and schools themselves decide if further RSE is needed and how the school participates in its delivery (NFER and INCA 2009).

Despite this, 97% of secondary schools and half of primary schools include sexuality information in their curriculum (Weaver et al 2005). Key messages include responsibility and individual decision-making (Ferguson et al 2008).

There is also an understanding that RSE includes “not only transmission of knowledge but also of communication skills and attitudes” (IPPF European Network 2006 p.65).

National guidelines around RSE may be vague, but socio-cultural factors set the stage for positive sexual health outcomes. For example, principles of non-

discrimination and tolerance of different beliefs are enshrined in Dutch

constitution and society (NFER and INCA 2009). Additionally, the Netherlands has, for many decades, had a pragmatic approach to all aspects of sexuality, including a generally liberal attitude towards young people’s sexuality (NFER and INCA 2009; Weaver et al 2005). All of the above is reflected in the positive approach taken towards RSE, which often includes topics such as sexual

orientation and masturbation (Ferguson et al 2008).

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The media further reflects this prevailing attitude and actively contributes to these matters by disseminating information in relation to sexual health (NFER and INCA 2009). Overall, this “socio-cultural context has a strong influence on the types and content of health promotion activities” (Ferguson et al 2008 p.104).

The delivery of RSE in the Netherlands is well supported. Firstly, unlike the UK and the other countries featured in this report, teachers in the Netherlands are

trained in the delivery of RSE during their initial teacher training (Weaver et al 2005). Secondly, RSE is enhanced by the Rutgers Nisso Groep (the Dutch Expert Centre on Sexuality and the International Planned Parenthood member in the Netherlands), which provides a range of clinical and educational services (IPPF European Network 2006; Rutgers Nisso Groep 2011). Thirdly, the Netherlands has maintained a level of financial commitment to a national RSE programme

called ‘Long Live Love’ which is accessed by teachers and strongly supported by the Department of Health.

Long Live Love

Long Live Love is a national government-funded programme developed in the early 1990s through extensive collaboration with key stakeholders (Ferguson et al 2008). Although it has undergone significant evaluation and revision since its inception, the theoretical foundation is largely unchanged (Wiefferink et al 2005). The programme is aimed at students aged 13-15 years old with ‘safe sex’

as the central theme; the goal is to increase young people’s ability to engage in safe, mutual and pleasurable sexual experiences by developing

communication and negotiation skills (Ferguson et al 2008). The programme consists of 30 learning activities divided over six lessons, with nineteen activities indicated as core curriculum and the others providing teachers with alternatives that may better meet student needs (Wiefferink et al 2005). Teachers are

provided with a manual, student magazine and film and are trained to deliver the programme by Department of Health educators, who also encourage and support schools to deliver it (Ferguson et al 2008).

Canada

From 1996 to 2006, teenage pregnancy² rates declined by 36.9% in Canada and by only 4.75% in England and Wales (McKay and Barrett 2010). In

comparison to Sweden, England and Wales and the USA (countries similar to Canada with respect to economic development and political structure), Canada had the lowest teenage pregnancy rates in 2006 (McKay and Barrett 2010). McKay and Barrett (2010) suggest that this decline likely reflects

“increasing levels of effective contraceptive use, greater access to reproductive health services, exposure to higher quality sexual health

education, and/or shifting of social norms in a direction that provides greater support for young women’s capacity to exercise reproductive choice” (p.43).

2 Teenage pregnancy is defined here as teenage births and abortions

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Although RSE may be contributing to the decline of teenage pregnancy rates, it is important to note that there is no nationally mandated RSE curriculum in Canada. Instead, the Constitution Act gives each Canadian province the authority to regulate education (NFER and INCA 2009). As such, variation exists across the country, evidenced by comparing provincial curricula (British

Columbia Ministry of Education 2005, 2006; Ontario Ministry of Education 1999, 2010).

However, national guidelines for RSE delivery do exist. In 2008, the Public Health Agency of Canada published the 3^rd edition of the ‘Canadian Guidelines for Sexual Health Education’, a document which provides a framework to develop and evaluate RSE. The guidelines include the following:

• key definitions, including the working definition of sexual health presented by the World Health Organisation;

• a set of elements of effective RSE;

• a set of guiding principles;

• a set of easy to use checklists (see Appendix 16);

• endorsement of the Information, Motivation and Behavioural Skill Model with detailed guidance on how to integrate the model into assessment, planning, delivery and evaluation (see Appendix 17).

The Sex Information and Education Council of Canada (SIECCAN) is a registered charitable organisation which supports the delivery of high quality RSE through research, guidance, and up-to-date online resources (SIECCAN 2010a). For example, in 2010 SIECCAN published ‘Sexual health education in schools:

Questions & Answers, 3^rd Edition’ (2010b), a publication which specifically aims to support RSE. The publication highlights how the ‘Canadian Guidelines for Sexual Health Education’ can contribute to the “initiation and maintenance of high quality sexual health education programming in schools” through the use of the “clear, easy-to-apply, evidence-based guides” (p. 16).

Literature from across Canada indicates strong support for school-based RSE from the majority of students, parents, and teachers (Lokanc-Diluzio et al 2007).

Despite this support, many young people are dissatisfied with the quality of RSE, the lack of information on topics they consider important, and the lack of

comfort and knowledge of those delivering the curriculum (Lokanc-Diluzio et al 2007). More often than not, teachers are required to prepare themselves

through a combination of workshops, conferences, seminars or self-education;

this reflects the limited number of initial teacher training programmes that include any training in RSE (McKay and Barrett 1999).

Similarly to the UK, various education and training programmes exist across Canada that aim to improve the quality of RSE. For the purpose of this report, education and training provided by affiliates of the Canadian Federation for Sexual Health (the Canadian member of the IPPF) were reviewed.

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Most affiliates provide training, ranging from short topic specific workshops to more comprehensive training, often with an opportunity or requirement to do in-depth values clarification work based on the Sexual Attitudes

Reassessment (SAR) model.

Options for Sexual Health (OPT), a Canadian Federation for Sexual Health member in British Columbia, is unique in offering the only certification programme for RSE educators in Canada. Detailed information about the organisation, its work, and specifically its certification programme, is provided below.

Options for Sexual Health, British Columbia

OPT is the largest non-profit provider of sexual health services in Canada, including clinics, advocacy, education programmes, and an information and referral line. The organisation’s mission is “to provide comprehensive education, accurate information, support for sexual expression and reproductive choice, and confidential clinical services that help [residents] enjoy healthy sexuality throughout life” (OPT 2011a). The Executive Director of OPT reports that the organisation is funded through government contracts for delivered services (40%), earned revenue (such as contraceptive sales and education fees) (47%), and project-specific grants and individual donations (13%).

In addition to providing education to young people, parents, and professionals, OPT runs the ‘Sexual Health Educator Certification’ (SHEC) programme, which is a competency, knowledge and performance-based training programme designed to prepare educators to deliver comprehensive RSE (OPT 2011b).

It is aimed at, but not limited to, teachers and health professionals who deliver school or community based RSE. Although not formally accredited, OPT

acknowledges that SHEC graduates may later consider applying for certification through ASSECT. Initial certification and certification renewal (required two years after completion and then every five years) is awarded by the SHEC Advisory Committee.

What is SAR? SAR is a multi-day workshop that provides an opportunity for those working in the sexual health field to explore their values, beliefs and attitudes across the spectrum of sexuality. The aim is to increase

individual comfort with the wide variation of existing sexual attitudes, behaviours, practices and subcultures (ASPSH 2011). Some SAR

programmes are accredited by the American Association of Sexuality Educators, Counsellors and Therapists (AASECT), who certify sexual health professionals, including sexuality educators, through an in-depth and comprehensive review of education and experience (AASECT 2004).

Due to its complex nature, the AASECT certification has not been included in detail in this report as the feasibility of implementing such a programme in the UK is limited at this time. It has however been included for the purpose of completeness and future work.

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The SHEC programme is comprised of 3 elements (OPT 2011c):

1. A course component:

o Five three-day workshops (modules) on specific topics;

o Completion of OPT’s multi-day CAVE/SAR or equivalent SAR (Sexual Attitudes Reassessment).

2. A practicum component:

o Completion of 60 hours of RSE delivery to various audiences (10 of which are supervised and evaluated by a preceptor).

3. A continuing education component:

o Demonstration of ongoing knowledge, skills and competency

development through completion of approved courses, workshops, and ongoing RSE delivery is required for certification renewal.

Course fees, which are approximately £2300-£2600, are paid by the participant and cover all five modules and the practicum component (OPT 2011d).

Australia

In Australia, sexual and reproductive health continues to be a concern with increasing early rates of sexual activity in adolescents and young people, increasing sexual vulnerability associated with problematic substance use, significantly higher rates of teenage births than some other developed nations;

increasing rates of STIs, and overall, sexual and reproductive ill-health

disproportionately affecting certain populations such as young people (SH&FPA 2010). Despite young people in school identifying RSE as a main source of

sexual health information (Smith et al., 2009), variability in the delivery and quality of RSE exists across the country (Mitchell and Schlichthorst 2010; SH&FPA 2010; Smith et al 2011).

Education in Australia is governed by state or territory-specific curriculum frameworks (Department of Education Employment and Workplace Relations Australian Government 2011). Generally, states and territories place RSE within

‘Health and Physical Education’, a learning area which “focuses on the

significance of personal decisions and behaviour…including sexual health” (Ollis and Mitchell 1999 p.5). Health and Physical Education, however, is not

mandatory for all year groups and “demands on a crowded curriculum can mean that the mandated learning outcomes are met in only very limited ways”

(Smith et al 2011 p.51). Schools, however, are legally required to implement effective abuse prevention programmes, such as the child protection curriculum

‘Keeping Safe’; a majority of which can be covered through comprehensive RSE (SHine SA 2009).

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In addition to the curriculum, many government bodies endorse the Ollis and Mitchell’s (1999) ‘Talking Sexual Health: National Framework for Education on STIs, HIV/AIDS and Blood-borne Viruses in Secondary Schools’ (Department of Education and Early Childhood Development State Government of Victoria 2011; Department of Education and Training New South Wales New South Wales Government 2011; Department of Education Tasmania 2008). The framework addresses the complexity of issues surrounding sexual health, most specifically STIs, and recommends that successful RSE should:

• take a whole school approach;

• acknowledge young people as sexual beings;

• acknowledge and catering for the diversity of all students;

• provide an appropriate and comprehensive curriculum content;

• acknowledge the professional development needs of the school community.

In schools, most teachers deliver RSE without external support, though other school staff (school counsellor, school nurse, welfare staff and school chaplains) may be involved (Smith et al 2011). Unfortunately, it is likely that teachers have received either little or no initial or post qualification training, with any post- qualification training being short and fragmented (Mitchell and Schlichthorst 2010). In addition to a lack of training, teachers identify time constraints, exclusion from the curriculum, and lack of support from management and policies as further barriers to the delivery of RSE (Smith et al 2009). However, groups such as Sexual Health and Family Planning Australia (SH&FPA), the International Planned Parenthood member in Australia who represents sexual health and family planning organisations in Australia at a national and

international level (SH&FPA 2008), continue to push RSE forward. In their ‘Call for Action’ (n.d.), the SH&FPA have summoned the Australian Government to develop a national sexual and reproductive health strategy and complete seven key actions (Box 1). Independently, the SH&FPA continue to work towards several of the key actions, including researching core teaching competencies as standards to evaluate teacher training (SH&FPA 2010).

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Various education and training programmes exist throughout Australia that aim to improve the quality of RSE. For the purpose of this piece of work, education and training provided by affiliates of SH&FPA were reviewed. Although most affiliates provide some type of education or training, SHine SA (Sexual Health, Information, Networking and Education South Australia), developed and continue to run the Focus School Programme, a unique programme that provides a quality mark for the development of a whole school approach to RSE. Detailed information about the organisation, its work and, specifically, its approach to the improving RSE is provided below.

SHine SA (Sexual Health information, networking, and education South Australia) SHine SA is the lead sexual health agency in South Australia providing

prevention, promotion and education programmes, professional education programmes, clinical services and counselling, opportunities for partnerships, resources including a health educator network forum (SHine SA 2011a), and a set of best practice principles for RSE (Shine SA n.d.) (see Appendix 18). They also run the Focus Schools Programme, which was recently showcased at the 4^th Asian Conference on Sexuality education (SHine SA 2011b). Approximately 95%

of SHine SA’s funding is from the South Australian Government through the Department of Health and the Commonwealth Government via the Public Health Outcomes Funding Agreement, with the remainder being raised by the organisation through service provision (SHine SA 2009a).

Although RSE has been part of the curriculum for several decades, there has been reluctance to develop materials that support a comprehensive curriculum (Johnson 2006). To address this, SHine SA (in collaboration with the Department of Education and Children’s Services and the Department of Health)

Box 1: Time for a national sexual and reproductive health strategy for Australia: A call to action (SH&FPA n.d. p.2)

What are the key actions needed?

• core teaching competencies and minimum standards for relationships and sexual health education;

• consistent national minimum data collection of key sexual and reproductive health indicators;

• full burden of disease assessment and economic evaluation of a national strategy;

• a national research program and national clearinghouse on sexual and reproductive health;

• provision of a full range of contraception and community information strategies;

• sexual and reproductive health services and workforce development;

• legal, safe, accessible and affordable pregnancy termination services.

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researched, developed, piloted and externally evaluated the ‘Sexual Health and Relationships (share)’ Project between 2000 and 2005 (SHine SA 2009b). The project, when evaluated retrospectively, was found to be very effective

(Johnson 2006) and became the basis for the current Focus Schools Programme.

Uptake of the programme has been strong. In 2010 (SHine SA 2011b):

• over 80 schools were actively engaged in the Focus Schools Programme;

• 1723 students participated in the RSE course with 87% rating it overall as good to excellent;

• 294 teachers, counsellors, and other interested staff and community health workers participated in professional development.

The overall aim of the Focus Schools Programme is to “improve the sexual health, safety and well being of young South Australians” by supporting schools to develop a whole school approach to RSE (SHine SA 2011c). This includes specific objectives and outcomes for young people, parents and families, school staff, and the school environment, to which both SHine SA and the participating school contribute (see Appendix 19).

Schools that accept the offer to participate in the Focus Schools Programme are supported by SHine SA in the following ways (SHine SA 2011c; Australian Government 2011):

• assistance with all aspects of implementation and project management is provided by a SHine SA Schools Coordinator;

• a comprehensive curriculum for Years 8, 9 and 10, which is aligned with the required learning ideas and outcomes of South Australian Curriculum Standards and Accountability (SACSA) Framework, is provided along with a curriculum resource pack and $300 (~ £190) towards other resources;

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• free professional development is given for teachers and other members of the school community including:

o a 15 hour programme which covers the content and teaching methods of a comprehensive RSE programme, up-to-date sexual health and information statistics, and opportunities to review a range of resources, the curriculum, and a variety of classroom activities (SHine SA 2009b);

o additional training to cover specific topic areas, such as homophobia;

• access to an online network for teachers which provides:

o teacher resource manuals and supporting materials;

o information on professional development opportunities and conferences;

o latest statistics and relevant journal articles

o forums for teachers to debate on current issues and network (SHine SA 2009b);

• support for parent information sessions;

• additional support as negotiated with the school.

In turn, Focus Schools pledge to (SHine SA 2011c; Australian Government, 2011):

• implement the curriculum of 15 lessons, in at least two year levels, between Years 8-10 (schools can make individual decisions on how to best incorporate the lessons into the school curriculum);

• develop a Student Health and Wellbeing Team comprised of students, teachers, counsellors, parents and outside agencies who have the responsibility for looking at policy and practice, environment and ethos within the school, including:

• examples of what has been done in schools through this team include:

weekly outreach sessions, drop-in sessions, and short-term small group projects (Shine SA 2009b);

• identify a key teacher to coordinate the programme within the school;

• provide support for all relevant teaching staff, counsellors and other interested staff to attend 15 hours of professional development.

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The creation of the share Project

SHine SA began researching the share Project in 2000 through an extensive consultation process with key stakeholders, including young people, parents and teachers, to elicit their views on RSE and how SHine SA could support school communities. The consultation showed that the majority of parents supported RSE and wanted teachers who delivered it to be specially trained (SHine SA 2000). The consultation also provided the public approval to proceed with project

development that included a review of relevant literature to ensure the project, and specifically the curriculum resources, were evidence- based. Once this was complete, the programme was piloted in 15 secondary schools between 2003 and 2005. Some changes were carried out as the pilot was in progress, the most significant being a change from ‘passive consent’ from parents to ‘active consent’. This change occurred due to the significant backlash the programme received from conservative groups but had little impact on student participation with most parents consenting (Johnson 2009).

In his review of the pilot, Johnson (2009) notes that the factors that promoted the use of share included the quality and usability of

materials, the support at school and local levels, and the support from SHine SA School Coordinators. The factors that were noted to inhibit the teaching of share included reluctant teachers, cultural

differences, timetabling problems, curriculum arrangements, and public opposition to the programme. Overall, there was a strong impression that teachers and schools successfully coped with the demands of implementing the share project.

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Quality assurance in the UK: a snapshot

A variety of organisations in the UK have been profiled for their unique

contribution to quality assurance. First, organisations that specifically address the training of RSE educators are featured. Second, organisations that currently provide an array of frameworks for quality assurance are highlighted.

Training of RSE facilitators

In UK schools, RSE is taught by a mixture of teachers, outside visitors and school support staff (SEF 2008a). Various education and training programmes exist across the UK that aim to improve the quality of RSE. Although most training is in the form of short, topic-specific workshops, some organisations provide more in- depth, comprehensive support. As international and national guidance

emphasise the importance of having trained and competent educators delivering RSE, five training programmes are highlighted below.

PSHE CPD programme

Around 10,000 teachers, community nurses and other professionals have

completed the National PSHE Continuing Professional Development Programme (Ofsted 2010). There are several aims of the programme including: improving the competence and confidence of those delivering PSHE; raising the quality of teaching and learning in PSHE; and providing accredited recognition of

teaching competencies (VT Education and Skills 2009). During the 12-month programme, participants focus on two areas (VT Education and Skills 2009):

• core skills required to deliver PSHE;

• development of skills relating to ONE of the following areas: SRE, drug education, emotional health and well-being OR economic well being and financial capability.

The programme entitles participants to a minimum of 30 hours of guided learning and requires them to evidence meeting national and topic specific standards (VT Education and Skills 2009).

Overall, the completion of the PSHE CPD programme by teachers and

coordinators has a positive impact on the delivery of PSHE (Ofsted 2010). The majority of teachers who complete the SRE option, report improvement in their SRE delivery along with an improvement in the quality of SRE across the whole school (SEF 2008a). The evaluation of the original pilot identified that the scheme

“exemplified a number of features of effective professional development for teachers of SRE in schools” (Warrick et al 2005 p.235). However, since its

inception, coordinators of the programme in Bristol and Bath have reported that the programme has undergone several significant, negative changes:

Relationships and Sex Education: exploring the process of quality assuring content, delivery and training