The Health of Educators in Public Schools In South Africa 2015/2016 Prepared by Funded by The Global Fund to Fight AIDS, Tuberculosis and Malaria through NACOSA on Behalf of DBE and SANAC
Presentation outline Background of the study Research Design and Methods Results Summary Recommendations
HSRC project team Prof. Khangelani Zuma - Principal Investigator Prof Leickness Simbayi - Co-Principal Investigator Prof Thomas Rehle - Senior Technical Advisor Ms Ntombizodwa Mbelle - Project Director Dr. Nompumelelo Zungu - Project Director Dr Njeri Wabiri- Statistician/Data Manager Dr Sizulu Moyo- Epidemiologist/Laboratory coordinator Ms Alicia Davids- Project Manager Dr Jacqueline Mthembu- Project Manager MrJohan van Zyl Project Manager
Project Background In 2004 the ELRC commissioned the HSRC to undertake the first-ever comprehensive study on factors determining educator supply and demand in South African public schools for its stakeholders such as: Departments of Education at national and provincial levels The South African Council for Educators (SACE) Teacher unions (SADTU, NAPTOSA & SAOU) Study set the baseline for the impact of HIV/AIDS in the education sector.
Project Background (continued) In 2005 the HSRC published eight research reports from the study which including one which was titled The Health of Our Educators. Key findings of report: HIV prevalence was 12.7% (i.e., thus comparable to that found in the general population) High AIDS morbidity High levels of absenteeism due to HIV-related illnesses Hotspots (districts which had high HIV prevalence >20%) were mainly located in KZN, EC and MP provinces.
Project Background (continued) Based on the 2005 study, ELRC together with for teacher unions (SADTU, NAPTOSA, SAOU and NATU) started a pilot programme known as Prevention, Care and Treatment Access (PCTA) which delivered HIV/AIDS programming dedicated exclusively to educators living with and affected by HIV/AIDS in the three provinces that were most impacted by HIV/AIDS (viz., KZN, EC and MP). Due to its success the pilot was expanded nationally as PCTA II by ELRC together with four teacher unions except that SADTU was replaced by PEU supported by PEPFAR/CDC while the American Federation of Teachers (AFT) provided technical assistance.
Project Background (contd) SADTU also implemented a concurrent project called the HIV Prevention, Palliative Care for Teachers, Orphans and Vulnerable Children (PPCT-OVC) project which sought to address the effects of HIV on SADTU members and learners who are orphans or vulnerable in schools. Given this background, it is imperative to track the progress of the disease in the education sector since 2005 as well as evaluate the impact of new prevention efforts mounted by both the government (e.g. HIV and AIDS Life Skills Education and Peer Education Programmes) and the unions alike (such as PCTA, PCTA II and PPCT-OVC).
Project Goals Two main goals: To investigate the HIV related epidemiological profile of educators and school leadership (principal, vice principals and Heads of Departments) in the public education sector To assess the impact of HIV prevention, care and treatment programmes on HIV prevalence
Specific Study Objectives Estimate the prevalence of HIV Establish baseline data for HIV incidence Estimate the number of educators and school leadership on ARVs in SA Assess the relationship between behavioural factors and HIV infection Compare HIV prevalence, and risk behaviour among public educators and school leadership in SA over the period 2004 to 2015
Additional objectives Assess the self reported prevalence of TB, STIs and non-communicable diseases Evaluate mental health status including job-related stress Assess levels of substance abuse Establish environmental issues such as violence in schools Ascertain structural issues such as large class size and workload
Research Design and Methods
METHODOLOGY: Study population Population: all educators teaching from Grades R to 12, working full-time or part-time, employed by the state or by school governing bodies, in the public education schooling system in SA
Study design A cross-sectional survey employing second-generation surveillance methodology which combines both bio-medical and behavioural indicators in the same survey. Bio-medical indicators included testing for HIV status, HIV incidence (new infections) and ARV use Behavioural indicators included examining knowledge, attitudes and risk behaviour
Sampling design: In schools A multistage stratified cluster sample: The sample was stratified by province and educational districts. Schools were classified according to their districts and province. In each district/ metropolitan council and within each phase of the school (primary or high), a sample of schools was randomly selected probability proportional to size. The number of educators within each school were used as a measure of size.
Sampling: In schools 1. Define target population ( All Educators) 2.Define sampling frame EMIS (Master List of schools Circuit Offices) 3. Define Primary Sampling Unit PSU Schools 4. Define explicit strata (Provinces-municipal districts) 5. Define reporting domain (Municipal districts and race) 6. Define Measure of size (All educators) 7. Define Ultimate sampling unit (SSU ) (All educators present on the day of survey) 8. Allocation of sample proportions - MOS To drawing a sample
Questionnaire Modules Fieldwork was undertaken from August 2015 and concluded in February 2016 Questionnaire modules included among others: Demographic characteristics Teaching responsibilities and workload Morale and job satisfaction General health HIV/AIDS and TB knowledge Sexual behaviour Stigma against HIV and TB Violence within institutions Exposure to HIV communication
HIV Specimen Collection A finger prick was used to collect dried blood spots (DBS) Biomarkers were tested in SANAS-accredited laboratory for: HIV status and HIV incidence (DBS) Antiretroviral (ARV) drugs (DBS) Linked by barcode (no identifiers)
Laboratory Testing Dried Blood Spot HIV Antibody screening Antibody Positive HIV Incidence Testing Anti-retroviral exposure
Study Results
Response analysis Out of 1380 schools that were sampled 1365 were valid Of the valid schools 97.4% agreed to participate in the study 21495 educators completed interviews (85.5% of eligible educators) 16392 educators provided dried blood spots for testing(65.2% of eligible educators)
Age distribution, South African educators 2004 and 2015 2004 2015/16 50 45 40 35 44.5 40.8 Percentage (%) 30 25 20 15 25.4 15.7 25.1 23.9 15.1 10 5 0 5.0 3.3 1.1 18 to 24 25 to 34 35 to 44 45 to 54 55+ Age groups
HIV Prevalence New infections Prevalence Deaths
Overall HIV prevalence The overall estimate for HIV prevalence among educators in the 2015/16 survey was 15.3% translating to 58000 educators living with HIV (95%CI: 54550 61438) The overall 2004 estimate for HIV prevalence among educators was 12.7%.
Comparison of HIV prevalence 2004 and 2015 by sex
HIV prevalence among male educators 2004 and 2015 by age group
HIV prevalence among female educators 2004 and 2015 by age group
Comparison of HIV prevalence by province 2004 and 2015
HIV prevalence by school related characteristics Variable n HIV+% 95% CI Type of school Primary school 8714 15.9 14.6-17.3 Secondary/high school 5759 13.8 12.3-15.3 Combined/intermediate 1546 18.1 15.4-21.3 Position at the school Junior staff 12336 16.6 15.6-17.6 Senior Staff 3773 11.7 10.3-13.2
HIV INCIDENCE
HIV Incidence (number of new infections) Variable Incidence (%) (95% CI) Estimated number of new infections* 95% CI) Total 0.84(0.77-0.90) 2 900 (2,656-3,105) Sex Male 0.76(0.67-0.85) 800 (656-844) Female 0.99(0.90-1.07) 2 100(1,947-2,315)
HIV incidence by demographic characteristics Variable Incidence(%)(95% CI) Age(years) 18 to 34 1.92(1.73-2.11) 35+ 0.67(0.61-0.73) Locality type Urban 0.53(0.47-0.59) Rural 1.38(1.26-1.50)
HIV incidence by type of school and marital status Variable Incidence(%)(95% CI) Type of school Primary 0.92 (0.83-1.00) Secondary 1.14(1.03-1.26) Marital status Married 0.53 (0.47-0.58) Not married 1.44 (1.30-1.58)
Antiretroviral Treatment Exposure
ART exposure by sex and age Variable Estimated number of educators living with HIV (n) Estimated number of educators on ART (n) Proportion of educators living with HIV on ART(%) 95% CI Total 58 000 32 000 55.7(53.2-58.3) Sex Male 15 000 8 000 53.8(48.5-59.0) Female 43 000 24 000 56.4(53.5-59.3) Age(years) 18-34 10 000 4 000 39.9(34.2-46.0) 35+ 48 000 28 000 59.0(56.1-61.8)
ART exposure by race and locality Variable Estimated number of educators living with HIV (n) Estimated number of educators on ART (n) Proportion of educators living with HIV on ART(%) 95% CI Race African 57 000 30 000 55.7 (53.1,58.2) Other 500 300 60.5 (31.5-83.6) Locality type Urban formal 12 000 7 000 56.9 (51.9-61.7) Urban informal 7 000 4 000 58.7 (50.2-66.7) Rural formal 13 000 7 000 52.8 (47.4-58.1) Rural informal 23 000 13 000 56.5 (52.4-60.5)
Awareness of HIV and ART exposure : current gaps in meeting UNAIDS treatment targets HIV positive educators (%) 100 80 60 40 20 0 16.0% 74.0% Aware of HIV status Educator survey 2015 25.3% 55.7% On ART UNAIDS target
BehaviouralFindings
Multiple sexual partnerships
Male and female condoms accessibility Male condoms were more accessible than female condoms (68.8% vs 52.7%). A high proportion of educators (86.3%) knew of a place in the community where they could obtain a male condom for free compared to two thirds (66.9%) who said the same for female condoms. The majority did not know of a place in their school where they could obtain both male (83.7%) and female condoms (85.5%).
Condom use at last sexual act with non-regular partners Variable Percentage 95% CI Race African 76.8 73.5-79.8 White 32.7 18.3-51.2 Coloured 68.4 55.6-78.9 Indian/Asian 61.0 38.4-79.6 Age groups(in years) 18 to 24 80.3 69.6-87.9 25 to 34 79.6 74.9-83.5 35 to 44 77.9 72.4-82.5 45 to 54 72.9 67.1-78.0 55+ 50.7 38.0-63.3 Total 75.3 72.1-78.1
Male Circumcision Variable Percentage 95% CI Race African 68.4 66.5-70.3 White 20.0 15.4-25.5 Coloured 27.7 22.4-33.7 Indian/Asian 25.0 17.8-33.9 Age categories 18 to 24 59.0 49.6-67.7 25 to 34 54.4 50.1-58.6 35 to 44 61.8 58.5-64.9 45 to 54 64.9 62.3-67.5 55+ 54.3 49.5-58.9
Circumcision setting Circumcision setting varied considerably from home (2.9%) Hospital or clinic (50.5%) Mountain/Bush initiation school (46.6%) Majority of educators in Free State, KwaZulu-Natal and North West reported having been circumcised in hospital Limpopo and Eastern Cape indicated they underwent traditional circumcision.
HIV risk perception How likely is it that you will become infected with HIV? Total HIV prevalence 95%CI Will definitely get infected with HIV 3541 8.6 7.4-10.0 Will probably get infected with HIV 4507 12.3 11.0-13.8 13.8 Could possibly get infected with HIV 6147 18.5 17.2-20.0 20.0 Will probably not get infected with HIV 1216 22.7 19.3-26.6 Will definitely not get infected with HIV 605 28.7 22.7-35.6 Total 16016 15.3 14.4-16.2 16.2
Ever tested for HIV by age 100 73.4 86.4 91.3 86.5 77.1 85.9 Percentage (%) 50 0 18 to 24 25 to 34 35 to 44 45 to 54 55+ Total
Correct responses to HIV knowledge (1) High levels of knowledge (89.5%) about risk behaviour and HIV transmission Highest levels of knowledge found among: 18 to 24 year olds (94.1%) Whites (93.0%) Coloureds (92.9%) Teaching in urban formal areas (90.6%) Rural formal areas (90.1%) Those based in Northern Cape (94.8%)
Correct responses to HIV knowledge (2) Knowledge statement Percent 95% CI Having sex with a virgin can cure HIV and AIDS 94.7 94.2-95.2 Having sex with more than one partner can increase a person s chance of being infected with HIV 94.0 93.5-94.5 A person can be infected with HIV and still look healthy 96.9 96.6-97.2 ApersoncangetHIVbyusingacuporplatethathasbeenused byapersonwithhivandaids 97.0 96.6-97.3 A person can get HIV by sitting in a hot tub or a swimmingpool withapersonwhohashiv 96.5 96.1-96.8 You can get HIV through contact with infected blood 97.0 96.7-97.3 People can protect themselves from HIV by using a condom correctly every time they have sex 97.4 97.1-97.7
HIV stigma Educators reported reasonably low levels of HIV related stigma (10.5%). Many educators indicated that they feel comfortable talking to others about HIV/AIDS. The majority of educators across all provinces (55.5% to 62.9%) and of all ages (58.7% to 66.3%) showed some ambivalence about disclosure of their family members being infected by HIV to others.
Self-reported general health status
Self reported Prevalence of chronic illnesses Diagnosed with the disease in past 5 years Percentage 95 % CI High blood pressure 22.1 21.3-23.0 Stomach ulcer 9.1 8.5-9.8 Diabetes 9.0 8.4-9.5 Asthma 5.9 5.5-6.3 Lung or breathing problems 4.3 3.9-4.7 Anaemia 3.3 3.0-3.6 Heart disease 3.1 2.8-3.4 Tuberculosis 1.7 1.5-2.0 Cancer 1.3 1.1-1.5
STI prevalence and HIV infection HIV positive (%) 50 45 40 35 30 25 20 15 10 5 0 36.8 Diagnosed with STI in the last three months 33.0 Sores/ulcers on genital organs in the last three months STI syndrome 31.3 Abnormal penile discharge 25.0 Genital warts
TB transmission knowledge
Prevalence of TB symptoms by race and age Variable Percentage 95% CI Race African 11.2 10.4-12.0 White 6.0 4.5-8.1 Coloured 7.8 6.1-9.8 Indian/Asian 8.8 6.5-11.8 Age groups(in years) 18 to 24 9.4 6.7-12.9 25 to 34 8.3 7.1-9.6 35 to 44 9.7 8.6-10.9 45 to 54 11.5 10.4-12.7 55+ 10.5 9.0-12.2 Total 10.3 9.7-11.0
TB stigma TB statement Don t Yes (%) No(%) Know (%) Share meals with someone with TB 52.4 40.4 7.2 Work or study with someone who has TB 78.0 17.7 4.3 Hug a person with TB 74.9 20.8 4.3 Kiss someone with TB 21.7 67.0 11.3 Have sex with someone who has TB 33.2 57.0 9.9
Alcohol Use Percentage (%) 100 80 60 40 20 0 Males Females 82.5 56.1 34.4 16.3 9.6 1.2 Abstainers Low-risk drinkers High-risk drinkers (Audit)
Drug use 1.4% of educators reported that they had ever smoked dagga 1.7% indicated that they had used sedatives/sleeping pills.
RETENTION AND ATTRITION
Educators Workload Percentage (%) 50 45 40 35 30 25 20 15 10 5 0 46.8 Workload in the past three years has 31.2 13.8 7.3 Increased a lot Increased a little Remained the same Decreased
Job stress and job satisfaction 19.4 Stress 30.9 22.9 Statisfaction 25.2 49.7 51.9
Intention to leave the profession by type of school Intention to leave the education profession decreased from 55.0% in 2004 to 34.5% in 2015
Educator career choices and career changes 70 60 64.0 Percentage (%) 50 40 30 20 28.2 10 0 Teaching was first choice Had considered changing career
Reasons for considering career change 35 32.1 30 25 Percentage (%) 20 15 10 5 20.0 10.8 9.5 9.3 7.8 5.7 4.7 0 Salaries are poor Too many demands on educators Class size Educators feel depressed Many curriculum changes Status of profession has declined Educators have less time for preparation and marking Educators teach subjects for which they are not trained
Violence in the school Type of violence in schools % Students and/or educators have been found carrying weapons onto your school 20.3 Apersonwasassaultedatyourschooloronthewaytotheschool 19.8 A fight involving weapons took place on your schools premises 16.0 You are aware of gangs operating at your school 12.3 You/someone else was sexually harassed at your school 5.4 Apersonwasrapedatyourschool 3.0 Apersonwasshotatyourschooloronthewaytotheschool 2.3 A person was killed at your school 1.6
DBE policies and support Over half of educators (52.6%) reported that DBE addresses the problem of HIV/AIDS stigma adequately, compared to 42.4% reported in 2004. A high proportion (87.1%) of educators indicated that DBE supports educators who are ill/sick. Less than half (49.0%) were aware of DBE Integrated Strategy on HIV, STIs & TB. Overall, just over half of educators found the strategy to be very useful, whilst a low proportion (3.6%) found it to be of no use.
Union HIV/AIDS policy The majority of educators (86.2%) reported that they were members of teacher unions. There were no differences between males and females. Educators are generally unionized irrespective of race, locality type and province.
Training of educators A high proportion of educators attended life-skills education training (71.2%) and in-service training (67.2%). Attendance at these trainings consistently increased with age and experience of educators but it was lower among African educators compared to other races.
SUMMARY
HIV prevalence increased 1.2 times since the 2004 Although the HIV prevalence in the Western Cape remains the lowest, there was a 2.3% increase since the 2004 survey. KwaZulu-Natal and Eastern Cape have the highest HIV incidence, which was higher than the national average of 0.84% Majority of educators were sexually active in the 12 months prior to the survey with one sexual partner. High levels of knowledge about behavioural risk and HIV transmission. High levels of correct knowledge about behavioural risk, prevention and cure of TB transmission.
Most educators were physically, mentally and emotionally healthy. More educators reported being admitted to hospital in the previous 12 months compared to the 2004 survey. Main reasons for considering a career change or intention to leave were poor salaries, heavy workload, facing too many demands, and increased class sizes. Increased workload was due to increased class sizes, lack of parental involvement, learners ill-discipline, shortage of educators and educator absenteeism. A higher proportion of educators reported that DBE addresses the problem of HIV/AIDS stigma adequately in 2015, compared to that reported in 2004.
Recommendations
HIV Prevalence, incidence and antiretroviral treatment (1) The response to HIV in the education sector should be comprehensive and encompass biomedical, social, economic and behavioural interventions. DBE should implement an evidence-based comprehensive and multi-sectorial response to the HIV/AIDS epidemic in the education sector including: promotion of condom use, uptake of medical male circumcision, and uptake of ARVs especially among those who are not on medical aid.
HIV Prevalence, incidence and antiretroviral treatment (1) Tailor interventions for high risk groups, namely, females, younger educators, those living in rural areas, and those living in the high HIV burden provinces of KwaZulu-Natal and the Eastern Cape. Include interventions to reduce multiple sexual partners especially among high risk groups.
HIV Prevalence, incidence and antiretroviral treatment (3) Introduce social and behavior change communication campaigns (SBCC) to encourage consistent condom use among educators during any sexual contacts. Female condoms should be made widely available to educators. There is a need to continue promoting HIV Counselling and Testing through workplace wellness programmes
Stigma and substances There is a need for stigma mitigation programmes to address stigma and encourage disclosure of HIV status within the sector. It is recommended that DBE should implement a workplace substance use prevention programme which includes alcohol, tobacco and drugs use cessation/reduction programmes.
Potential Attrition from Public Education System It is recommended that DBE addresses the large class sizes at schools. DBE should implement workplace programmes that assist educators to manage high stress levels. DBE should emphasize strategies for educator career pathing and make educators aware of internal career opportunities, especially for younger educators who were more likely to want to leave the profession. DBE should implement programmes to improve awareness of the DBE Integrated Strategy on HIV, STIs and TB educators
Funders This research was supported by The Global Fund to Fight AIDS, Tuberculosis and Malaria through NACOSA on behalf of SANAC and DBE, and the HSRC
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