WHAT ARE THEY LEARNING: LESSONS ABOUT REPRODUCTIVE HEALTH IN INDONESIAN PRIMARY AND SECONDARY SCHOOL TEXTBOOKS
Iwu Dwisetyani Utomo, Peter McDonald, Terence Hull, Wienta Diarsvitri, Saparinah Sadli, Ida Rosyidah, Tati Hartimah, Nurul Ilmi Idrus, and Jamhari Makruf
First Asian Population Association Conference, 16-20 Nov. 2010 Wednesday, 17 November, 2010, 11.00-12.00, Hall 6, Second Floor, Main Building Correspondence and Inquiry: [email protected]
and [email protected]
Abstract After struggling to incorporate comprehensive reproductive health education in the Indonesian national school curricula, the Indonesian Government has added information on anatomical and normative aspects of reproduction and STDs/HIV/AIDS to the curricula of selected subjects. This paper assesses the content of primary and secondary school text books that reflect the new curriculum. Three hundred books were reviewed using a Reproductive Health Analysis Module developed by the authors to evaluate the depth of information given in Biology, Science, Sport and Health Education, Social Sciences and Islamic Religion text books. The assessment covered the type of information given, anatomical accuracy, gender depictions, and the social and religious values applied to issues of HIV/AIDS, reproductive health and sexuality. The most comprehensive book that provide detailed and progressive information on HIV/AIDS and reproductive health can be identified based on the scores provided by the authors. The study also considers the grade at which the information is provided and its appropriateness to children’s development stages. In explaining various ways to avoid transmission, many books reflect narrow conservative assumptions about behaviour and fail to mention safe sex strategies or the efficacy of condom use. Interestingly the gender depictions on HIV/AIDS information was minimal as compared with information on sexual harassment where women and girls were mostly described as causing such problem. Preliminary results revealed that starting in Year 5, understanding of sexual harassment has been introduced very briefly. In Year 6, in Science, genital hygiene, specifically how to clean the vagina is explained. Information on how the vagina should not be disturbed by the use of various products is also explained briefly. In Biology, anatomical aspects of reproduction and human development are outlined but no information is provided about sexuality and reproductive health. Drug use and information on HIV/AIDS are included in some of the text books, while others include information on STDs. Information and data about violence against women, child prostitution and child sexual abuse are
introduced in the later years in secondary school. Though found only in one book, gay marriage and the consequences of premarital pregnancy are explained very briefly. More comprehensive information and understanding should be included in the national curricula on sexuality and reproductive health as well as the emotional and social aspects of sexual relationships that include more gender progressive norms and values. In general some interesting information on sexuality and reproductive health is scattered across textbooks in various subjects but not as a topic on its own. Moral aspects and religious judgments on sexuality, menstruation, sex within marriage and adultery are given in Islamic Religion text books both in the later years of primary school and throughout secondary school. Anatomical aspects of reproduction are provided in Biology, some social consequences of premarital relationships in Social Sciences text books for secondary. It is notable that the HIV/AIDS and drug use chapter is often ‘appended’ as the last chapter (Chapter 12) in the Sport and Healthy Living text books after discussion of various sports and games activities in the previous chapters. Representation and content of reproductive health education in the Indonesian national curricula In Indonesia, the stereotypical gender roles enforced by the law, policies and programs on health in general and reproductive health specifically do not favor women to have control over their own body and sexual health. Abortion is illegal unless it is to save a women’s life. Nevertheless Utomo et al. (2001) revealed that 2 000 000 abortions occur annually and due to its illegality, many women try to self abort by drinking jamu (herbal medicine) and off the counter medicines. If they fail to abort this way then they approach traditional healers or traditional birth attendants. Many women in this case are risking their lives while other die due to the complications. Hospitals and private clinics are the last resort for women because of the stigma as well as the related cost (Sucahya, 2005). If a women wants to abort legally, she has to provide a medical certificate stating that her pregnancy is life threatening; a consent letter from her husband or family member; a positive pregnancy test result and a statement guaranteeing that she will directly use contraception. Women bear the burden of contraception as male participation in condom use and vasectomy is very low. Even though currently under amendment and in discussion with the parliament for the revision of law no. 10/1992 on Population and Family Welfare, it is stated in this law that only married couples can have access to family planning. The Indonesian government has also been slow in introducing reproductive health education in the school curricula. This is alarming as premarital pregnancy and abortion are increasing and education on the consequences of unsafe sex, negotiating sex and safe sex are not delivered either through the formal education or by parents. Parents are reluctant to discuss sexuality and reproductive health matters with their children because parents have little experience themselves on these issues (Utomo and McDonald, 2006). Parents might also think that talking about sexuality and reproductive health matters with their children is taboo and shameful.
In some countries, particularly Moslem and Asian countries, young people have little access to information and services related to their reproductive health. Young people are not identified as sexual beings with biological needs. Government officials in some of these countries are in a state of denial about the reproductive health problems of young people (Utomo 1998). Policies and programs related to young people should receive top priority, especially policies and programs related to young people’s reproductive health (Brandrup-Lukanow et al. 1991; Friedman 1992; Johnson 1995; De Silva 1997, 46; Mundigo 1997, 329). In an era of rapidly changing demographic, social and economic environments (Jones 1997, 1), with the emerging AIDS pandemic and other consequences of premarital sexual activity, investing in policies for young people, especially their reproductive health, will have wide-ranging consequences. Educating young people on sexuality and reproductive health will have long-term effects not just in saving young people from sexually transmitted diseases, unwanted pregnancy, maternal morbidity and mortality, unsafe abortion, and early marriages, but also in investing in the future so that young people will become knowledgeable parents who can educate their children on reproductive health issues. Living in a rapidly changing social environment with simultaneous exposure to conflicting values on sexual behaviour, young Indonesians are left alone to make decisions. This situation is made worse by the globalisation of information and the mass media images of sexuality, violence, and gender roles that influence young people’s values and material aspirations. With very limited knowledge of the nature of sex and no access to reproductive health counseling and services, young people are ‘trapped’ in ignorance if confronted with problems related to relationships with the opposite sex, sexual activity and sexual and reproductive health. Realistically, there are many years to come before Indonesia can develop and implement reproductive health education and services for young people who are still single. Strong political will is needed to deliver reproductive health education in schools and to develop friendly integrated reproductive health services for single young people. Ideally, this approach should be developed hand in hand with the willingness of parents to openly discuss sexuality related issues with their children. The government needs to develop policy and programs to develop parents’ capacity in communicating with their children and educating them on sexuality issues. It is important to open psychological and communication barriers between parents and children in discussing the risks and life threatening nature of not practicing safe sex and to stress the importance of consulting with parents if they are confronted with problems related to sexuality (Utomo, 2003). Diagram 1. described whether reproductive health education should be given as a subject or integrated in related subjects? With the politics of how the Indonesian government never want to acknowledged the importance of reproductive health education provided in the school curricula and always never state the word reproductive health education explicitly in all policies and program on this subject, the authors recommend that the second approach is used. In this case ideally reproductive health education should be
mainstreamed in all related subjects and introduced in all appropriate schools and extracurricular activities. With recent development of decentralization, some of the districts in West Java, South Sumatra, West Nusa Tenggara, East Nusa Tenggara, West Kalimantan, Papua and West Papua have developed reproductive health education as a subject and taught as the “local Subject” (Muatan Lokal) (Utomo, 2010; Diarvitri, Utomo and Neeman, Forthcomming). This approach should be rewarded as well as the authors think that all channels should be used to promote providing reproductive health education in schools. Thus various venue can be use to assure that reproductive health education is provided and accessible to students. Methodology As part of the 2007 AusAID-Australian Development Research Award funded project, the authors examined the content of Indonesian school textbooks from Year 1 to Year 12. The purpose is to evaluate these books in relation to the quality of the reproductive health education that they provide. Following a workshop in Jakarta in March 2008, the team determined the dimensions upon which texts should be evaluated. These dimensions were: the type of information given, anatomical accuracy and appropriateness, social values relating to reproductive health and sexuality, reproductive health rights, heterosexual relationship development, negotiation of sexual behaviour, harassment and sexual violence. The evaluation also considers the grade at which the information is provided and its appropriateness to the child’s development stage. In conducting the content analysis of the school textbooks from years 1–12, several stages were taken: 1. The national curriculum of 2006 was analysed. Any descriptions or related key words relating directly or indirectly to reproductive health was recorded (Table 1). 2. The team decided to analyse books on Islamic Religion; Sport and Healthy Living Education/PENJASKES; Biology; Social Sciences/IPS; and Sociology because these books might contain related information on reproductive health education. 3. The book selection was conducted in stages: first, all books accredited by the Department of National Education were sought. Then interviews were conducted by phone among teachers in the research areas. The teachers were asked what books on related subjects that the school used for the corresponding grades and subjects. Second, in choosing the text books used in the analysis, the popularity of the publishers used by schools was also taken into account. Then based on these data, books were selected and bought. The books were bought from various book stores in Senen wholesale book stores and Gramedia. Each researcher had access to the books. 4. Books corresponding to years and subjects from various publishers were purchased. The content of the books was checked individually, books that have reproductive health information were selected. On the other hand, books that were supposed to have reproductive health information and knowledge but did not include these topics were noted (Total number of books analyzed: 172 and number of books not containing any RH information: 59).
5. A module to evaluate the books was designed (Table 2). Thirteen reproductive health fields were evaluated against: Coverage (1/lowest level of coverage – 9/highest level of coverage), Accuracy (1/lowest level of accuracy – 9/highest level of accuracy), Normative (1/very conservative – 9/less conservative) and Gender Content (1/male dominated; 2/mostly male; 3/gender neutral; 4/mostly female; 5/female dominated). For this exercise, only coverage and accuracy of reproductive health information and knowledge were analysed. 6. Each author independently evaluates the books and provide a score for all of the content analysed. The score from each author was entered into a website that have been set up for this purpose. Each author has a pass word to enter the designated website and only Utomo can see the results. Utomo then down load the scores from each author, complied all the scores and conduct a simple calculation in a spread sheet. Based from these scores, graphs on accuracy and coverage were produced to understand what subject and in what grade provided descriptions on reproductive health issues. 7. An individual scientific content analysis was also conducted simultaneously by Diarsvitri who is a medical doctor and analysed whether the right terminology was used and whether the accuracy of the information was medically correct.
Table 1. Reproductive health key words used in the national curricula by level and subjects, 2008 Level of School
1* Washing for praying 1* good behaviour
2 3 4 5 6
1* Hadas, najis
Sport and Health Education
1* Human developme nt 1* Human growth
1* sexual hygiene 2* Resisting sexual harassment 2* STDs
1* Free sex
1*&2* Healthy living style
2* Good and bad behaviour 1* Big sin, homo, adultery 1* Family law, age at marriage and avoiding bad behaviour
2* Social problems
1* Human growth 1* Personality develop-ment 2* CSW
1* Human growth and development 1* Reproductive system
1* HIV, CSW 2* Towards Indonesian independence
1* Free sex
1* Conflict and social mobility 1* Social Institution 2 Research MethodHIV
Note: Analysed by Utomo et al., 2008. 1* stands for semester 1, and 2* stands for semester 2.
Table 2. Reproductive health analysis module for Indonesian primary and secondary school textbooks Name of reviewer: Grade/year of school: Type of school public/religious: Subject: Book title: No. Topic In cur Yes (1) No (2)
Yes (1) No (2)
2. 3. 4.
8. 9. 10.
11. 12. 13.
Give a score 1-9
Genital hygiene STDs HIV/AIDS Female reproductive problems Male reproductive problems Pregnancy and delivery Human growth and development Reproductive technology Social aspects of RH Moving towards liberal culture and its consequences Family Institution Violence and sexual crimes Religious aspects of reproductive health
Note: Developed by Utomo et al., 2008.
Findings: primary and secondary schools text books analysis For coverage and accuracy of reproductive health matters on genital hygiene, STDs, HIV/AIDS, reproductive technologies, pregnancy and delivery and growth and development covered in secondary schools text books, (please see Graphs). As noted from the graphs, reproductive health issues that are covered in text books include various information. For example, starting in Year 5, an understanding of sexual harassment is introduced and in Year 6, in science, genital hygiene, specifically how to clean the vagina is explained. In biology, anatomical aspects of reproduction and human development are outlined but no information is provided about sexuality and reproductive health. Drug use and information on HIV/AIDS are included in some of the Sport and Healthy Living text books, while others include information on other STDs. In the later years of secondary school, information and data about violence against women, child prostitution and child sexual abuse are introduced. Though found only in one book, gay marriage and the consequences of premarital pregnancy are explained very briefly. Gay relationships, specifically homosexual relationships are condemned in many books and are described as very sinful and one of the causes of HIV/AIDS. The reproductive health information taught in many of these subjects is a start, but more comprehensive information should be included in the national curricula on sexuality and reproductive health as well as the emotional and social aspects of sexual relationships that include more gender-progressive norms and values. Some interesting information on sexuality and reproductive health is scattered across textbooks in various subjects but not as a topic on its own. The biological and anatomical aspects of reproductive health are treated perhaps too comprehensively with a strong ‘scientific’ focus—especially that which has been written for elementary students and to a lesser extended to material written for secondary school students. Moral aspects and religious judgments on sexuality, menstruation, sex within marriage and adultery are given in Islamic Religion text books both in the later years of primary school and throughout secondary school. Anatomical aspects of reproduction are provided in Biology while some information on the social consequences of premarital relationships and abortion is provided in Social Science text books for secondary schools. Information on HIV/AIDS and drug use is found in Sport and Health Education text books. It is notable that the HIV/AIDS and drug use chapter is often ‘appended’ as the last chapter (Chapter 12) after discussion of various sports and games activities in the previous chapters. In general, information on HIV/AIDS is provided in a very comprehensive manner although the tone of the information is strongly associated with an HIV stigma. Students are taught that religiosity can be used as a means of self control to restrain oneself from promiscuous behaviour. Only a few books that have an HIV/AIDS chapter promote safe sex and condom use as the best way to avoid being infected with HIV. More progressive reproductive health and sexuality information needs to be developed.
The family, in both Islamic Religion and Social Science text books, is described as the only institution in which a man and a woman can have sexual intercourse and this is linked with the family being the proper institution for people intending to have children. The importance of building family relationships as a strong foundation for child development is stressed. A detailed explanation of the function of the family is provided. Another important point for discussion is whether reproductive health and sexuality education can be given as a holistic subject and not integrated in other subjects. As we have previously stressed, currently reproductive health and sexuality information is scattered across a range of subjects. Assessment of Science and Sport and Healthy Living Textbooks from Year 3-11: Medical Perspective The Science and Sport and Healthy Living school textbooks in both primary and secondary were evaluated, because they incorporate many anatomical and medical terminology and aspects of reproductive health. This is why this specific analysis was conducted specifically for these two types of books. As mentioned earlier, the Sport and Healthy Living books has an appended Chapter on HIV/AIDS and drug use. To pin point the mistakes or misconceptions of the materials used in these books is very crucial as students might have wrong understanding of reproductive health issues that might or can cause them their life. Science school text books In three of four Science books for Year 3 students, the difference between growth and development were not explained. Miss conception of menstruation labeled as dirty blood and baby is born by pushing the mother’s womb were found in one Year 6 text book. Pushing mother’s womb during delivery can be severely dangerous as it can cause uterine rupture (Prawiroharjo, 1989). There are some Year 8 books (N=6) that provide inaccuracy of explaining about the process of delivery. For example one book stated that the doctor or midwife should cut the umbilical cord and placenta during childbirth, while the correct procedure only cut the cord because cutting the placenta can trigger bleeding after giving birth (Wiknjosastro, 1991). Other inaccuracy were found in explaining about genital hygiene; the function of thymus gland and pituitary gland in relation with growth and reproduction; the definition of a baby was mistaken stating that a baby is a period between 2 weeks and 2 years. Three Year 8 books did not explain about puberty and four books did not explain about fertilization. In Year 9, there are six books examined. Some books gave inaccuracy explanation about male and female reproduction, pregnancy, STDs and ways to prevent STDs; uses inaccurate pictures of reproductive organs anatomy and STDs. In explaining about STDs, three books stated that genital hygiene can prevent from STDs but not stated the
importance of safe sex practice for example avoiding sexual contact, having multiple partners and condom use. In Year 11 (N=5), there is inaccuracy about male and female reproductive organs and functions, spermatogenesis and oogenesis, the cause of STDs and how to prevent them as well as about contraception. Too details explanation about embryology and in vitro fertilization technology. No books explained that STDs often do not show any symptoms, thus young people experiencing STDs might not know that they are infected. Overall, at times the explanation of reproductive issues and processes are too anatomical and more intended for medical students. On the other hand explanation on abstinence, condom use and pregnancy prevention that should be included and more related to young people’s lives are absent. Sport and Healthy Living Books In Year 5 (N=7), we found inaccuracy in explanation about reproductive organs and their function as well as ways to avoid sexual harassment. Information about genital hygiene included in some books can be dangerous and may have an impact on the genital health. For example some books suggested that in cleaning the genital area, soap should be used. Clinical study (Hilier (1999); Pray (2004), Tansupasiri et al, 2005; Murtiastutik, 2008) argued that the use of vaginal douching, drying, vaginal refinement and soap can increase the vaginal acidity above 4.5, a condition that will suppress the vaginal normal flora that protects vagina and assists the growth of anaerobic bacteria that induce bacterial vaginosis. Rippke (2004) and Tansupasiri et al. (2005) stated that the use of chemical agents can cause contact dermatitis and vulvitis. In Year 6 (N=7) some books could not explain about substance abuse and how to avoid using substance abuse. In Year 7 (N=5), the cause, transmission, complication, signs and how to prevent STDs and infertility were inaccurately explained. All books inaccurately explained about the symptom of STDs, transmission, complication, signs and how to prevent STDs. Test to detect HIV was also inaccurately explained. For example, one book explained that STDs were caused by viral infection, AIDS was transmitted through sexual contact but did not explain of other ways of transmission such as by skin contact for STDs (in herpes simplex) and for HIV through placenta, sharing injecting needle and through blood transfusion. In Year 8 (N=5), inaccuracy about how to avoid sexual harassment were found in some books. In Year 11 (N=3), the importance of how HIV transmission and prevention and as well as the history of HIV were inaccurately explained. Conclusion Due to the political and moralistic standing of the government, the government do not want to explicitly provide reproductive health education to primary and secondary schools. Such subject is highly needed for students as information on reproductive health issues can safe many lives from unintended pregnancy, unsafe abortion, STDs/HIV/AIDS
and drug use. From the content book analysis that the authors conducted, we found 13 field of reproductive health issues covered in Science, Social Sciences, Sport and Healthy Living and Islamic Religion text books used both in primary and secondary schools. These include: genital hygiene, STDs, HIV/AIDS, female reproductive problems, male reproductive problem, pregnancy and delivery, human growth and development, reproductive technology, social aspects of reproductive health, liberal cultural and its consequences, family institution, violence and sexual crimes and religious aspect of reproductive health. Though from the curriculum analysis, at time reproductive health issues were not explicitly stated, explanation of reproductive health matters were found scatter in Science, Social Sciences, Sport and Healthy Living and Islamic Religious school text books in both primary and secondary level. If the Indonesian government still wants to demonstrates that the nation, especially the students do not face a great thread in facing and combating the increasing numbers of premarital sex, premarital abortions, substance abuse, sexual harassment and sexual violence, STDs and HIV/AIDS, then using the existing curricula and delivering reproductive health education mainstreamed into related subjects would be ideal. This strategy can accommodate materials already written in the text books and provide addition information from other sources that is more current development on such matters. Also this content analysis can be used to identified books that provide misleading and incorrect information on reproductive health matters. The other option would be to provide reproductive health education in a subject under the Muatan Lokal (Local curricula subject) which have been developed in some districts in West Java, South Sumatra, Nusa Tenggara Barat, East Nusa Tenggarra, West Kalimantan, Papua and West Papua. The disadvantage of providing reproductive health education as a subject would be the additional time and cost related to this both for students and the teachers who will be teaching this subject. Another disadvantage would be the related cost that the government has to put aside for writing a book on reproductive health issue, testing whether the written book is useful, and training of reproductive health education teachers. This of course would be an ideal approach but would take many years to develop and implement. The third option would be integrating the idea of mainstreaming reproductive education in related subjects, teaching it as well as a subject in its own and discussing the issues on various schools activities and ceremony. This multiple venue to accommodate reproductive health education as well as providing reproductive health education online would make students knowledgeable on reproductive health issues so they would not be trapped in a situation and make a wrong decision when engaging in sexual relationship. The Indonesian government actually already included partial and scattered reproductive health education in the national curricula. The existing materials should be corrected and used in addition to various information on reproductive health education that is available from published books, online information, and booklet and leaflet produced by NGOs and other institutions.
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Figure 1. Text books used in primary and secondary schools related to reproductive health by publisher, Indonesia, 2009.
Source: Utomo and McDonald, The 2009 Gender and Reproductive Health in the Indonesian National Curricula Study. Total books analyses=172.
Figure 2. Coverage and accuracy on genital hygiene and STDs in Sport and Healthy Living textbooks, 2009
Figure 3. Coverage and accuracy on genital hygiene and STDs in Sport and Healthy Living textbooks, 2009
Figure 4. Coverage and accuracy on HIV/AIDS and reproductive technologies in Sport and Healthy Living textbooks, 2009
Figure 5. Coverage and accuracy on pregnancy and delivery and growth and development in Sport and Healthy Living textbooks, 2009
Figure 6. Coverage and accuracy on genital hygiene and STDs in Science textbooks, 2009
Coverage and accuracy on HIV/AIDS and reproductive technologies in Science textbooks, 2009
Figure 8. Coverage and accuracy on pregnancy and delivery and growth and development in Science textbooks, 2009
Figure 9. Coverage and accuracy on genital hygiene and STDs in Islamic Religion textbooks, 2009
Figure 10. Coverage and accuracy on pregnancy and delivery and growth and development in Islamic Religion textbooks, 2009
Figure 11. Coverage and accuracy on reproductive technologies in Islamic Religion textbooks, 2009
Figure 12. Coverage and accuracy on genital hygiene, STDs, HIV/AIDS, pregnancy and delivery, growth and development and reproductive technologies in Social Sciences textbooks, 2009
Figure 13. Should Reproductive health education be given as a subject or integrated in related subjects?
Figure 14. Allocation of UNFPA Jakarta’s Budget for Adolescent Reproductive Health in pilot provinces, 2009
Figure 15. UNFPA leading roles with related stakeholders and NGOs in the development of Adolescent Reproductive Health Education in Indonesia, 2009