the instruction (NARAL Foundation, 1995). For example, in Louisiana, schools are required to teach that abstinence is the expected norm for students, but the law makes no mention of instruction regarding STD prevention. In addition, 19 states prohibit or restrict school health and education programs from making contraceptives, or in some cases information regarding contraceptives, available to students. The number of restrictive laws enacted or considered by states increased in 1995 (NARAL Foundation, 1995). Another important limitation of current school-based education is the lack of consistent STD-related education at lower grade levels.

The majority of health education teachers recently surveyed reported that they taught about sexual abstinence (76 percent); how to prevent STDs (75 percent); signs and symptoms of STDs (70 percent); and other topics related to risk factors for STDs (Collins et al., 1995). In the CDC survey mentioned previously, among teachers who taught in health education classes, 78 percent taught about sexual behaviors that transmit HIV (and other STDs), but only 37 percent taught about correct use of condoms (CDC, 1996b). The preparation of teachers who provide instruction on these topics is inconsistent. For example, while 86 percent of states and 33 percent of school districts that required instruction in STDs reported providing training on the topic (CDC, 1996b), only 16 percent of teachers surveyed reported receiving training on teaching STD prevention during the two years prior to the survey.

A 1989 survey of more than 4,200 seventh- through twelfth-grade teachers in specialties most likely to be responsible for sex education found that most teachers believed that information regarding HIV infection, other STDs, and pregnancy should be covered by the seventh and eighth grades at the latest (Forrest and Silverman, 1989). There was a gap between what the teachers think should be taught and what actually occurs. For example, almost all teachers believed that sex education information for students should include sexual decision-making and abstinence and birth control methods, but only 82 to 84 percent of teachers reported being in schools that provided instruction in these areas. Teachers cited (a) pressure from parents, the community, and school administration; (b) lack of appropriate teaching materials; and (c) lack of student interest as potential barriers to teaching sex education.

An IOM committee4 that is preparing a report on the role of comprehensive school health programs in the United States has come to the conclusion that health education does not commence at a sufficiently early age; the period prior to high school appears to be the most crucial for shaping attitudes and behaviors. By the time students reach high school, many are already engaging in risky behaviors or at least have formed accepting attitudes toward these behaviors. For

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IOM Committee on Comprehensive School Health Programs in Grades K-12.



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