updated 25 March 2003
Dutch school-based SE programs play a prominent role in the country's successful efforts in health education and the prevention of unwanted pregnancies, HIV and STIs. SE became an obligatory part of schools' curricula in 1993 and sexuality related questions were added to national exams (Berne & Huberman, 1999). In almost all secondary schools and in around a half of the primary schools, SE topics are integrated into many subjects such as biology, health care, social sciences, and religion courses. The selection of a specific program to be implemented in a particular school environment is allocated to local authorities. This agrees with the current tendencies in Dutch education policy that underline individual choice, and the freedom of schools to develop their own policies. (Buijs et al, 2002).
The growth of SE practices in the Netherlands can be traced through three successive groups of educational approaches and programs developed to reduce adolescent's risk behavior that may lead to HIV infection, other STIs, and unwanted pregnancies. In the middle of the Eighties, school-based risk-reducing educational programs were founded on the assumption that the increase in young people's knowledge about HIV/AIDS will result in the lessening of their risk-taking sexual behavior. These programs were quite short (one or two one-class period lessons), designed without a formal conceptualization and needs assessment, and primarily focused on transferring information. The next generation of risk-reduction programs was developed to include - besides necessary, but insufficient transmitting of knowledge - clarifying of values and attitudes, raising awareness of social norms and influences, and improving assertiveness, as well as communication and decision-making skills. With regards to working methods, these educational interventions use group activities, exercises, role-plays, videotapes, games and other tools for facilitating interactive and participatory learning (Schaalma et al, 1996).
In the beginning of the Nineties, the third group of SE programs started to appear, characterized by a systematic developmental process. This kind of a planned approach to the elaboration of (sexual) health education programs initially entails a problem analysis and definition, followed by a needs assessment to identify determinants that underlie the specified problem-causing behavior. In the next phase, based on the research insights on behavioral determinants, educational goals need to be formulated, and then translated into concrete educational activities and materials. The articulation of learning objectives and teaching strategies employs multiple scientific theories related to changing behavior through education, such as social cognitive theory ('modeling'), and various theories on communication, attitudes and group process. A key element in the whole developmental process and the actual implementation of the program involves a close co-operation with members of a target group (adolescents and teachers), as well as with the representatives of the educational system (local school authorities). Another important aspect of this systematic approach is the appropriate evaluation of the implemented program, the assessment of the measures taken with regards to the effectiveness of the educational intervention on the identified behavioral determinants and the problem-producing behavior (Schaalma & Kok, 1995; Schaalma et al, 1996).
The excellent example of the teaching program developed, implemented, and evaluated according to the systematic approach described above is 'Long Live Love!' (LLL), an AIDS/STI education program for use in Dutch secondary schools. The first version of LLL was designed in 1993, and today it is the most commonly utilized methodology for SE in schools throughout the Netherlands. This interactive educational program, primarily focusing on the promotion of using condoms consistently, is the joint project of several organizations and institutions working in the fields of sexuality, education, and health. The Department of Health Education at the University of Maastricht conducted a preliminary research on the determinants of (risky) sexual behavior among Dutch adolescents, as well as the assessment of teachers' needs and abilities. The Dutch Center for Health Promotion and Health Education (DCH) translated the research findings into teaching methods and outlined the lesson plan. The Netherlands Foundation for STI Control and Prevention (SSB) developed the educational material, and implemented and evaluated the program. The overall objective of this school-based teacher-delivered prevention program is to support adolescents to develop healthy, safe, responsible and positive attitudes towards sexuality, and to strengthen their skills in communication and negotiation about safe sex. The LLL educational package consists of a manual for teachers, and a booklet (information presented as role-model stories in teen magazine) and a videotape (also based on the teaching principle of 'social modeling') for students (Garcia-Sanchez et al, 2002; Schaalma & Kok, 1995; Schaalma et al, 1996).
Based on the findings from the systematic evaluation of the 1993 version, as well as on the recent research knowledge and insights on sexuality and STI prevention, the new LLL material was designed, implemented, and evaluated again in the period from 1999 to 2002. The new LLL version additionally addresses pregnancy prevention, incorporates gender equality perspective, and focuses on multicultural diversity of the Dutch society. The revised program involves six one-class period lessons, worked-out and described in terms of objectives, methods, and materials, and included in the teacher's manual. The manual also provides background information on adolescent (risk) sexual behavior, (un)safe sex, and support services; discusses the rationale for the whole LLL program; and specifies the learning outcomes in the areas of knowledge, attitudes, risk perception, social norms and influences, and communication and negotiation skills (Garcia-Sanchez et al, 2002). The whole 3-year project combined the improvement of the revised LLL version with the development of an implementation strategy and the research on the effectiveness of the implementation procedure (at the municipal and teacher level) and the effectiveness of the educational program at the student level. The project's realization was facilitated by the inter-sectoral co-operation between the SSB, the NIGZ, the Rutgers-NISSO Group, the TNO-Prevention and Health, and the Netherlands Association for Community Health Services. The implementation process entailed the initial training of regional health workers/educators at municipal health services (GGDs) that have functioned as 'linking agencies'. The health educators, in turn, trained recruited teachers, and together with them worked on the implementation plan for a particular secondary school. The teachers' trainings focused on strengthening their motivation and skills, and addressed practical issues concerning educational activities and materials. A monitoring strategy was developed to provide possibilities for continuous meetings and check-ups between teachers and regional health workers. Preceded by a small-scale pretest, 180 teachers put the new version of LLL to practice in 90 secondary schools, in 46 regions throughout the Netherlands. The implementation was accompanied by 'GENESIS' (Gender, Ethnicity, and Sexuality in Sex Education), a systematic evaluation project with the objective of measuring the impact of LLL educational component on pupils' attitudes and practices towards sexuality and safer sex, and especially focusing on gender roles and identities, and intercultural relations (Garcia-Sanchez et al, 2002).
With regards to public health issues and health education, SE was identified as one of the pressing issues (together with bullying, social skills, smoking, alcohol and drugs) related to health promotion in Dutch schools. This is one of the findings from the assessment of 200 schools concerning their activities, needs, and priorities in the area of school health policy. The investigation was conducted as a part of the project 'Developing a national action plan for a school policy on health', started in 2000, aiming to co-ordinate current projects in schools' health promotion, strengthen a co-operation between the health and education sector, and generate prospects for new school-based health promotion initiatives and programs. The project's findings point to differences between health organizations and schools in their views, interests, and concerns in the field of health promotion and health education in schools. The project's recommendations include promoting collaboration between these two sectors at all levels, focusing on schools (tailoring support to each school's needs) and regional organizations that should assist them in health promotion (Buijs et al, 2002).
The development of life-skills programs is one of the current initiatives in Dutch schoolwork on health promotion. Life-skills approach in health education is based on various theoretical perspectives, which justify the development of crucial life skills that promote healthy development and minimize harm and risk. Skills development, informational content, and interactive teaching methodologies are the key-elements of any life-skills program. With reference to SE programs, research supports the development of social skills (communication, assertiveness, peer-refusal, and negotiation), as findings indicate that young people's shortage in these skills is significantly correlated to the negative outcomes of adolescent sexual activity, such as unwanted pregnancy and STIs (Cohen & Burger, 2000; Aldinger et al, 2001; Lottes, 2002). Moreover, in the educational area of sexual and reproductive health and interpersonal relationships, life-skills development can be applied to many informational contents, like friendship and dating, social influences (including the media), information on contraception, gender stereotypes, gender (in)equality, as well as to seeking help and locating services.
In conclusion, contemporary Dutch SE incorporates a positive, comprehensive approach to sexuality and health, and is successfully integrated in schoolwork. SE programs are pragmatic, systematically developed on the basis of research findings and needs assessments, and designed using scientific educational and behavioral theories. In teaching, this means focusing on the prevention of negative outcomes by supporting and empowering young people to develop and enjoy healthy and safe sexuality. Likewise, educators emphasize a personal responsibility in sexual decision-making that is based on individual and informed choices, as well as the respect for one's own and others' sexual and reproductive health and rights. In a classroom, educational practices are directed to the development and strengthening of social skills, especially communication and negotiation skills, and towards an open discussion about sexual issues that reflect adolescents' interests and needs. Moreover, a strong public support to sexual health education is reinforced by continuous mass media campaigns focused on promoting safe sex and condom use (Berne & Huberman, 1999; Lottes, 2002; Schaalma et al, 1991). The Dutch experience shows that the combination of qualitative and comprehensive SE and confidential, affordable, and accessible services provided by numerous government-funded centers for sexual and reproductive health, results in positive epidemiological facts, including the low rates of unplanned adolescent pregnancy and abortions, as well as the high frequency of contraception use.