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Introduction

1. Education for health begins in the home where patterns of behaviour and attitudes influence health for good or ill throughout life and will be well established before the child is five. The tasks for the schools are to support and promote attitudes, practices and understanding conducive to good health. Insofar as they are able to counteract influences which are not conducive to good health, they should do so with sensitive regard to the relationship which exists between children and their families. While most children enjoy generally good health, some will be in poor health or suffer from specific disabilities, which will have consequences both for themselves and their families, as well as for those with whom they are educated. In addition, as children mature, sensitive questions related to their emerging sexuality or to social factors such as smoking and drinking feature strongly in the world about them and may arise at any time for any teacher. Schools need to recognise this and develop strategies to cope with it.

2. A school's regard for health education should be expressed not only through its normal academic and pastoral arrangements, but also through the whole school environment, the pattern of relationships established, the values transmitted by the personal example of teachers and other adults working in the school, and the self-esteem fostered among its pupils. These elements, which find expression in the life and work of schools and through, for example, assemblies, clubs and residential outings, contribute to a pupil's social and personal development. Help and reassurance can be given to individual pupils in a variety of formal and informal contexts. For these reasons schools cannot and should not seek to formalise each and every aspect of health education.

3. That said, planning is vital. The emphasis schools give to the general care and well-being of pupils in fostering their social skills, self-esteem and sense of responsibility is an essential context for the development of the more organised components of health education. Broadly speaking, these components should be concerned with the provision of the knowledge and skills that will enable pupils to understand their own bodies and how to keep them healthy, and to have regard for the health of the community. They should be

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helped to understand how to make the informed choices necessary to avoid life styles that increase the risk of disease, disability and accident and to encourage those which promote mental and physical health. Health education should, therefore, attempt to influence children's behaviour about, for example, choice of diet, smoking, road safety and personal relationships. Schools should avoid practices which appear to run counter to the principles of good health education, for instance, by allowing the sale in schools of foods with a high content of fats, sugar and salt. School meals, for those pupils who take them, should also encourage habits of healthy eating. The educational issues which arise should not be left to the catering and supervisory staff in isolation from what is taught and experienced about nutrition elsewhere in the schools.

The coordination and planning of health education

4. In the past two decades many LEAs have established working parties consisting of teachers, medical officers, health education officers and others to provide guidance in devising schemes of work in health education and in providing information about sources and resources. These and other developments over the past few years have led some schools to appoint a teacher whose duties include the coordination and planning of health education. Whether or not a school has a coordinator, written guidance about health education should be provided for the teachers.

5. Many schools have progressed from a rather tenuous and narrow view of health education, often synonymous with hygiene and sex education, to a broader concept; but if there is no explicit coordinated programme, health education is likely to have less than its due influence. Development of this kind requires links with appropriate external agencies, guidance from the LEA advisory service and in-service training for teachers.

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provision of a secure environment in which the children can develop confidence, grow and learn. Through play and a wide variety of activities such as physical education, drama, morning assemblies, visits, cooking, art, science and story writing, schools can do much to increase children's self-knowledge, self-esteem, ability to share and cooperate and can help to develop their respect for others and lead them to understand some of the many factors which affect their health.

7. By the end of the infant stage most children should have gained a wide vocabulary for naming parts of the body. By exploring sight, sounds, textures, tastes and aromas they should have learned how their senses help them to enjoy life and alert them to danger. They should have gained some awareness of growth, reproduction, birth and death. They should have started to develop a knowledge of the possible causes and effects of accidents on the road, in water, at school, during leisure activities and at home. They should have begun to understand the many ways in which children and adults are both similar and different in appearance, abilities, interests and temperament. They should have learned about the importance of personal care and cleanliness with regard to washing, dental care, clothing and keeping their living and working areas clean. They should be developing an awareness of their responsibilities in the family and elsewhere for the welfare of others and of other living things. They should have acquired sufficient social confidence and discipline to enable them to take turns, to take the lead, cooperate and become increasingly self-reliant.

The junior stage

8. With children between 8 and 12 years old there should be a steady progression towards more detailed knowledge and understanding of the working of their bodies and the ways in which they can take responsibility for their own health and well-being. Where they have opportunities to observe, measure, experiment, predict, debate and record their findings in many different ways, health education becomes a lively part of topic or thematic work. Because of its immediate relevance to the children themselves - their bodies, emotions, environment and families - health education is a valuable source of investigatory work. But effective work in topics and themes requires careful planning in which health education is of interest and value in its own right and

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integrated with the development of language, scientific method and mathematical skills.

9. Lessons about smoking, for instance, might usefully include, as part of a wider study of the human body, the study of the lungs and the adverse effects on them of smoking cigarettes. Illustrative experiments can be carried out; for example, the extraction of tar from cigarettes, the measurement of the capacity of pupils' lungs, the effect of exercise on the breathing rate and how the breathing rate correlates with the pulse rate. The results can be displayed in various forms and give rise to discussion and reflection. In addition to providing a simple knowledge and understanding of physiology, such activities should help to foster respect for the human body, and may influence children's attitudes towards the smoking habit. In embarking on teaching directed against smoking, schools will recognise that it may cause conflict between home and school. Such sensitivities should be taken into account but the risks to health associated with smoking, and the need for children to be informed about them, mean that schools cannot avoid the issue and should ensure that pupils are well informed in this matter.

10. Although the general focus of health education should be on good health, it is impossible to avoid some consideration of disease and of problems such as malnutrition and the misuse of medicines and other substances. In dealing with such matters what is taught about various health and social issues should be matched to the maturity and understanding of the pupils.

11. Many schools use television programmes to support their health education work. The best use of television programmes is where the ground to be covered is well prepared and appropriately and effectively followed up.

12. The toll of road accidents among school children is a matter of public concern and it is right that the road safety aspect of health education is strongly supported by outside agencies. The work of Road Safety Officers (RSOs) and the police is of particular importance in this. Though parents have the main responsibility for teaching their children about road safety, work in schools, and in infant schools in particular, should encourage the behaviour and skills necessary for safety on the roads. (1)

13. Work related to potential dangers in the home, from inflam-

(1) See Cycleway Royal Society for the Prevention of Accidents, 1983. This course includes all the practical content of the original National Cycling Proficiency Scheme but contains much more teaching material designed to occupy a more central place in the school curriculum.

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mable and hazardous materials such as cleaning fluids and medicines for instance, as well as in the local environment, should be a strong feature of health education in primary schools. For example, particularly in schools near coasts and rivers, water safety should be given almost as much emphasis as road safety. This work about safety can be linked significantly with work in science and environmental education.

Sex education

14. Most primary schools usually attempt, as a matter of policy, to deal with children's questions about the physical differences between the sexes and about human reproduction factually and honestly, as they arise. Some schools go further than this and develop specific programmes of sex education often involving TV programmes, filmstrips and accompanying tapes. However sex education is introduced, whether by simply answering pupils' questions as they arise or by more formal means, all schools have a statutory duty to include in their published information a statement of the manner and context in which education about sexual matters is given. (1) (Cooperation with parents about sex education is discussed in detail in paragraph 40 onwards.)

15. Whether sex education should be taught specifically, in addition to its arising naturally and incidentally as a result of other activities and in response to children's questions, is a matter for the head and staff to decide in cooperation with parents and governing bodies. If it is decided that sex education should go further than answering children's questions as they arise, its introduction should be carefully planned and the staff and parents should be fully consulted before it is implemented. Particular sensitivity should be shown to the views of those parents whose ethnic backgrounds and religious or other beliefs may cause them to hold strict reservations about such work. Schemes of work should provide for children gaining an elementary understanding of the working of their bodies, including human reproduction, with the introduction of the correct vocabulary. However it is dealt with, sex education should be

(1) Education Act 1980, S8(5) and the Education (School Information) Regulations 1981, SI 1981/630, Regulation 4 and Schedule 2, para 4 (c).

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presented in the context of family life, of loving relationships, and of respect for others: in short, in a moral framework. But teachers need to remember that many children come from backgrounds that do not correspond to this ideal and great sensitivity is needed to avoid causing personal hurt and giving unwitting offence.

16. While both boys and girls should know about the physical changes which affect both, schools which contain girls within the age and maturity ranges for menstruation to begin should make sure, in collaboration with parents, that such girls are adequately prepared for an eventuality which otherwise might cause them unnecessary distress. Talks to children about menstruation can be given by teachers, health visitors or school nurses. Practice varies in that these are sometimes given to single sex groups; but a promising arrangement is where the older pupils are given information about menstruation in mixed sex groups, while the girls alone are introduced to the importance of the correct use of pads or tampons and the importance of changing them frequently.

Progression in health education

17. In general, schools should plan, resource and carry out project or thematic work in ways that ensure development and within an overall curriculum plan that sets out the place of health education and its links with other areas of work. For example, a topic such as 'food' can be used to unify work in all curricular subjects and bring into school assemblies themes about feeding the people of the world; famine and plenty; harvest and thanksgiving; and food customs from other lands and cultures.

Organisation and learning and teaching approaches

18. Primary schools organise health education in various ways. The most common approaches are:

• an incidental approach which capitalises on current events, assemblies, school visits or visitors to the school;
• work which arises following a school television series associated with health-related studies;

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• health education built into other topics (eg 'Keeping Warm' or 'Food'), most frequently as a component within the topic;
• health education as a specifically planned project, topic or theme for a prescribed period of time, for example, half a term;
• health education as a component in another subject scheme, such as science;
• health education as a planned timetabled period, at least in some classes.

Objectives at the end of the primary phase

19. However health education is organised and practised, by the time they leave their primary schools the majority of children should have had experiences enabling them, at levels appropriate to their abilities, to have gained a simple knowledge and understanding of:

• the human body: the names and purposes of its main parts; human growth and development - to include the wide range of normality in physique, for example natural differences between individuals and groups such as eye, hair and skin colour;
• the conditions which promote healthy growth and development: such as fresh air; exercise; personal care (cleanliness, tidiness and dental hygiene); sleep; rest; a healthy diet, which should include consideration of varied foods prepared in different ways by a range of ethnic groups;
• health hazards: obesity; smoking; alcohol; unsuitable diets; dental caries;
• safety: safety on the roads, in the water, in the home and in the environment generally; the misuse of pills and medicines;
• some of the services provided to safeguard the health and safety of the community and their functions: such as the medical and nursing services; the fire service; the police; the public health services;
• social and environmental conditions that contribute to

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health and measures taken to improve them: such as sanitation; safe drinking water; food hygiene; clean air;
• the interdependence of man and other living things: as revealed by the study of food chains; the use and effects of pesticides and fertilisers; environmental pollution.

• choose a healthy diet, practise dental hygiene and road safety for example, and explain their reasons for doing so. This involves listening to differing views and putting one's own view; weighing evidence and reaching a conclusion;
• communicate knowledge and ideas about health education through speaking, writing and visual presentation, which may include simple graphical work;
• employ elements of the appropriate scientific vocabulary in talking about human growth and development;
• use the knowledge acquired, for instance in keeping themselves clean and tidy, and responding promptly and efficiently to emergencies.

21. The knowledge, understanding and skills acquired should give children:

• some appreciation of cause and effect: for example, that habits, life styles and patterns of behaviour can promote or detract from good health;
• a developing awareness of what is involved in making a decision about health-related matters (knowledge, expectations of others, personal feeling and an estimate both of the immediate and long term effects of a decision);
• the capacity to share and cooperate, to get things in perspective and to put them in order of importance;
• awareness of their own and others' emotions and feelings (as important aspects of mental health).

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for others, an understanding of different life styles, consideration for the handicapped and an abhorrence of both physical and mental cruelty. It should, more specifically, develop favourable attitudes to good health that predispose pupils towards sound diet and exercise, and against smoking and the misuses of alcohol, pills and medicines.

Continuity between the primary and secondary phase

23. In the majority of schools the pastoral arrangements for transfer are good, and considerable care is taken to cater for pupils' personal and social needs. Curricular liaison is generally less well developed, particularly for aspects such as health education. Record cards of individual pupils' progress are almost exclusively concerned with attainments in English and mathematics. Such records should contain information about the curriculum that has been followed and include health education.

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progress such as better housing, sanitation and clean water supplies;
• substantially increased knowledge about and understanding of the natural environment and a heightened understanding of man's place in it and his influence upon it;
• some understanding of the issues involved in controversial ethical questions such as developments in medicine and science related to human reproduction (eg test-tube babies) and social, political and economic issues such as the fluoridation of water and the labelling of foods;
• a knowledge and understanding of the health and welfare services and how to use them;
• an elementary knowledge of first aid: a pupil should know whether a particular injury needs more than simple attention and is therefore to be left alone; how to render such immediate help as will prevent aggravation of an injury or deterioration in the state of the injured person; and when and how to call for the help of a doctor and for the ambulance and emergency services.

26. Throughout the secondary phase the attitudes referred to in paragraph 22 should have been reinforced and begun to influence the behaviour and life styles of most if not all the pupils.

Organisation and learning and teaching approaches

27. Health education in secondary schools may be planned as part of courses such as personal and social education; it may figure in subjects such as biology, home economics, religious and

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physical education. It may also be a feature of tutorial time and, more rarely, may be taught as a subject in its own right. In all types of special schools there are substantial programmes of personal and social education, involving health education, which are regular features of senior classes, where the attainment of social competence before leaving school is rightly regarded as a particularly pressing need.

Health and personal and social education courses

28. Health education courses should cover health aspects such as physical fitness and hygiene; common infectious diseases, including those sexually transmitted; non-infectious diseases such as cancer, coronary heart disease and dental caries; the use and abuse of food, tobacco, alcohol and drugs; mental health including stress; sex education; and safety both in the home and on the road. Personal and social education courses are broader in scope and may include, besides health education, a wide range of studies including careers education. The trend in secondary schools appears to be towards developing personal and social education courses of this kind.

Tutorial time

29. In some schools programmes of tutorial work make valuable contributions to health education. In some instances the activities are left to the choice and discretion of individual tutors, while in others the work is based on commercially published schemes. While it is important that tutorial work should leave room for both tutors and pupils to decide how and when to deal with matters of mutual interest, it is also important that there should be an overall plan for the work. The purposes of tutorial activities should be understood by pupils, and this implies that aims need to be clearly set down and that the work done should relate to them. Many teachers require in-service education to equip them with the necessary knowledge and skills for successful individual and group work in tutorials.

Features of effective courses

30. Courses, whether specifically named health education or

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occurring in the wider context of personal and social education, should:

• be based on detailed schemes of work;
• move as the pupils mature from a concern with facts about the care and understanding of the body, its growth and development, and the effects on it of diet, smoking, drink, drugs, stress and exercise, to a growing awareness of personal development and relationships;
• be given status and importance in the eyes of other teachers and the pupils by making use of senior teachers;
• incorporate regular meetings of the staff involved in the course to discuss openly difficulties and doubts; to review and modify teaching approaches and materials; and to plan programmes of work;
• ensure the coordination of the health education elements of these two types of courses with those appearing in other subjects;
• offer practice, in relation to health matters, in the use of evidence and in questioning and arguing rationally;
• employ a wide variety of teaching methods including small group discussion work;
• develop ground rules for group discussion of sensitive health, social and personal issues, which seek to ensure that such subjects are introduced in ways which minimise embarrassment or distress to individual pupils, and which avoid situations which lead to unconsidered and unintended personal disclosure;
• be preceded by information to parents about the school's policy and practice for health education.

Health education across the curriculum

31. Important contributions to health education can be made by science (particularly biology), home economics and PE, and less directly by RE, history, geography and sociology. In the first three years most biology and general science courses lay the foundation of a simple knowledge and understanding of the human body, including reproduction and growth, though often the connection between these topics and health, and the wide range of normal growth and development, should receive greater emphasis. Similarly, the early years of secondary schooling

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should develop in pupils a simple knowledge and understanding of the basis of hygiene through the practical study of micro-organisms, clean water supply and other topics.

32. Home economics contains a substantial health education potential which goes beyond personal hygiene in its concern with handling food, safety, and nutrition education. Account should also be taken of current dietary views, such as the suggested importance to health for most people of reducing the amount of fat in their diet (1) and increasing their intake of dietary fibre by means of cereals and vegetables. The work of dress and textiles departments might include such topics as the use of flameproof materials and the appropriateness of different fabrics for differing purposes, including, for example, the inadvisability of dressing young babies in nylon on warm summer days. In addition, work in home economics can make an important contribution to pupils' knowledge and understanding of child development and of family life.

33. In physical education important health matters arise in a variety of ways, not least through its focus on body management and control. Some aspects of hygiene are suitably stressed, including changing into appropriate clothing and footwear for lessons. Showering should be the general expectation for all pupils after physical activity. Nevertheless teachers should be sensitive to the feelings of those pupils who find communal showering an embarrassment and be aware of groups which object to it on religious or cultural grounds. Many PE teachers stress the importance of looking after one's own body and the need for suppleness, stamina and strength, and in recent years there has been a growth in work explicitly concerned with keeping fit. This work can with benefit include discussion about fitness; discovering how muscles work; the possible relationship between exercise, health and physical fitness; and encouragement to pupils to continue some form of physical activity when they leave school.

34. The inclusion of health-related topics in schemes of work is not in itself an assurance that they will be taught, or that suitable emphasis will be given to them. On the other hand work in subjects less often thought to contribute to health education may make a substantial and unplanned addition to it. For example, a

(1) See Diet and cardiovascular disease HMSO (DHSS), 1984.

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historical study of hospital treatment through the ages, through a gradual and unobtrusive accumulation of factual information about medicine, can demonstrate the seriousness in the past of measles and smallpox and, by revealing the importance of modern vaccination programmes, can illuminate the health needs of today.

The coordination of health education

35. Since health education is an important cross-curricular subject it is particularly important that there should be adequate arrangements for its coordination in every school. The presence in a school of a coordinator for health education is not in itself a guarantee against unnecessary repetition and gaps. But good coordination should lessen their frequency and enable productive use to be made of overlapping concerns arising in different classes and subjects. Coordination can be facilitated by the compilation of charts which indicate aspects of health education and identify the subjects in which they should be taught, when, and to which pupils. However coordination is organised, the intention should be to ensure that a coherent programme exists which brings together the material contained in health or personal and social education courses, where they exist, and the contributions made by other subjects. Such coordination is most effective when health education is effectively planned and discussed and actively supported by the senior staff, including the head.

36. It cannot be assumed that the content of a health or personal and social education course will be underpinned by a sound base of knowledge gained through subjects such as biology. In any case many pupils give up biology after the third year, often having followed a course which has failed to provide them with a scientific basis for understanding health matters such as nutrition and dental care. Coordination of the work, whatever the pattern of curricular provision, is essential to prevent such omissions.

37. Special schools which tend to teach a great deal of health education need to ensure that there is not only a balance of content within health education courses themselves, but that health education does not take up too much of the total time. A reasonable balance is more likely to be achieved if schools are aware in some detail of where in the curriculum health education matters are taught.

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Cultural differences

38. Work in health education can be enriched by opportunities to study the ethnic and cultural variety of modern Britain, much of which in some schools can be contributed by pupils from their own experience. Positive influences on healthy living and attitudes to the habits and conventions of our multi-ethnic society might arise from comparative studies. For example, young children will be interested and gain much from studying the array and origins of foodstuffs available locally. Observations of market and shop displays and the examination of packages and labels show how much of our food originates outside Britain. Preparing different ethnic dishes will show how similar ingredients such as flour and water can produce an enormous range of foodstuffs: pasta, bread, chapatti; and how different staple diets can have similar nutritional values. Children will learn that the different ways of preparing food and eating habits all require similar attention to hygiene and to methods of storage and handling. Older pupils may be introduced to studies showing the good and bad trends in western diets compared with the simpler, often healthier diets of other countries. Other conventions, such as those concerned with the family, personal relationships and dress, can be seen to have their origins in useful ways of adapting to the common human situations and particular climatic conditions in other countries. These studies, including examples of significant cooperative endeavours often on a worldwide scale, such as those which led to the eradication of smallpox and the reduction of other diseases, will help children to understand aspects of health governing common human needs and the interdependence of human groups.

39. It is self-evident that work on the beliefs, values and culture of the home, whether related to ethnic minorities or children from the majority community, needs to be handled sensitively. Schools need to be aware not only of differing moral and social conventions about smoking, nutrition, alcohol, eating habits, hygiene and sexual relationships, but of the cultural heritage out of which these conventions arise. Teachers dealing with the subject of alcohol, for example, will need to remember that alcohol even in moderation is not accepted in some cultures, and that misunderstandings, personal hurt and embarrassment can result from lack of understanding by the teacher. There are other topics where similar misunderstanding can take place if patterns of behaviour are wrongly assumed to be common to all.

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Sex education: policy and teaching approaches

40. As indicated in paragraph 14 regulations made under Section 8(5) of the Education Act 1980 require local education authorities or school governors to inform parents of the manner and context in which education about sexual matters is to be given in schools. Because there are widely differing and very strongly held views about the subject, each secondary school needs to arrive at a carefully considered policy for sex education, developed through discussion between the head, the staff and the governors. As in the case of primary schools the policy should be set within a moral framework. Great care should be taken to inform parents of the policy in such a way that they have every opportunity to be aware not only of the general pattern of the programme and how it fits in with the personal and social standards which the school is aiming to encourage, but also of the teaching approaches and materials which are to be used.

41. Although responsibility for the curriculum does not rest with parents it is important for schools to seek and give weight to the views of parents and to keep their policy under continuous scrutiny in the light of those views. Consultations with parents should make it clear that a programme of sex education is part of the school's provision; the participation of pupils is as much a requirement for this as for other parts of the secular curriculum, and there is no statutory provision for the withdrawal of pupils. This makes it all the more important that schools should be ready to discuss fully and sensitively with parents any of their particular concerns, emphasising the complementary nature of the roles of parents and schools and stressing the importance of balance and objectivity in teaching children about sex and personal relations in a world where much in everyday conversation and the media trivialises and sensationalises these areas of life. Schools should also explain that in lessons such as biology, home economics or literature among others, as well as in less formal situations, issues related to personal relationships and sexual matters will inevitably arise, perhaps through questions from pupils, and need to be tackled. Parents should be reassured that in all these cases as well as in lessons specifically planned as sex education, the subject will be dealt with according to the spirit and practice of the school's policy.

42. The difficulty of the task faced by teachers in this area of

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personal and social education should be recognised. Teachers who are less than completely confident should not be expected to deal with certain topics, or to deal with them in particular ways. Confidence in these matters has only partly to do with knowledge; in some instances maturity, professional experience and an ability to convey a positive and unselfconscious attitude are equally important. Any uncertainty on the part of the teacher will make more difficult the situation of some pupils for whom discussion about sexual matters with an adult is a new and possibly embarrassing experience. Given the variation in how far parents educate their children in sexual matters, it is prudent for teachers to assume that they need to cover ground which may have been covered by parents. Some pupils, for example those whose parents have discussed these matters with them and have been receptive to their requests for information, may not only have gained a good deal of factual knowledge but may hold strong moral and religious views about sexual matters. It is no part of the school's job to undermine these. If pupils are asked about them, it should only be with the aim of helping all pupils to understand and respect other points of view.

43. In some mixed schools, sex education is given in single-sex groups in the belief that this reduces the likelihood of embarrassment. Some schools teach it to mixed groups on principle because, they argue, that is how society is and because it is essential for boys and girls to know about and respect one another. Some use a combination of single sex and mixed groups. Where separate single sex groups are used they often cover the same range of topics, so that each topic can be given appropriate emphasis according to the constitution of the group.

The scope of sex education

44. The importance of sexual relationships in all our lives is such that sex education is a crucial part of preparing children for their lives now and in the future as adults and parents. In sex education factual information about the physical aspects of sex, though important, is not more important than a consideration of the qualities of relationships in family life and of values, standards and the exercise of personal responsibility as they affect individuals and the community at large. It is therefore quite common to find sex education taught as part of a programme of personal and social education, sometimes in conjunction with

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religious education, as well as of a health education programme. Since, in addition, it can find a place in other subjects such as those mentioned in paragraph 31, there is some risk of either undue repetition or important omissions unless there is careful coordination to prevent this. The desire for neat coordination, however, should not undervalue or undermine the relationships which exist in many schools between individual teachers and pupils, and which enable certain pupils to seek from teachers, whether they have any formal responsibility for sex education or not, sound, balanced advice about personal relationships including sexual matters. In aided and special agreement schools, although the topics within a sex education programme might cover a range similar to that in other schools, the teaching will rest on the principles upon which the school is founded.

45. As pupils mature during the course of their secondary education it is important that they should regard sexual relationships as an element of their wider personal relationships. Many of the general principles appropriate to the teaching of young children will still be relevant, but pupils of secondary school age will inevitably become more directly aware of their own physical development and feelings of attraction towards another person, as well as of adult attitudes, sometimes conflicting, towards sexual behaviour. For this reason alone, schools need to deal sensitively and appropriately with such issues as contraception, sexually transmitted diseases, homosexuality and abortion. But such treatment is essential for other reasons also. All these issues involve not only knowledge, but moral and legal questions, are of concern to parents, and may prompt pupils to seek advice from the teacher, either in the classroom or more informally. How the school approaches these issues may also be affected by its legal status and the principles on which it was founded. Nevertheless it remains necessary to include all these issues as part of the secondary school's programme of sex education since they are brought to pupils' attention in a variety of contexts both inside and outside school. The discussion of these issues should be objective and attempt to explore all sides of the argument honestly. Some account of the law applying to sexual relationships involving children under 16, to homosexuality and to abortion should be given. It is recognised that individual teachers have views of their own about these matters and that often pupils will want to know, and seek to find out, where the teachers stand. Given that pupils are apt to place great weight upon what their teachers say in these matters, teachers have to set out their own

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views with the utmost care while pointing out that other people, including the pupils' own parents, might sincerely and properly hold quite different views.

46. Factual information about sexual relationships is manifestly incomplete without information about the nature of contraception and the various methods employed. It is therefore necessary to include such information. But it should also be explained that female contraceptive devices cannot be obtained or employed without medical advice or treatment and that under the October 1985 judgement of the House of Lords (Gillick) parental knowledge and consent are necessary before such advice and treatment can be given to a girl below the age of 16, save in certain rare circumstances defined in the judgement. Information about contraception should be offered on the basis that sexual relationships have a moral dimension which needs to be responsibly and honestly considered. Pupils should be encouraged to consider these matters not simply on grounds of what is expedient and possible, but with an understanding of the personal and moral dimensions involved in all sexual relationships, and in the light of their own religious and moral principles, taking appropriate account of parental guidance and the principles on which schools are based.

47. It is important to include in the teaching some reference to sexually transmitted diseases (STDs). In the course of years 1 to 3 of the secondary school, micro-organisms are commonly part of the biology syllabus, and this might be a suitable occasion for a first mention. In the fourth or fifth year they might be discussed again in the context of the health services and the special clinics provided for contact tracing, diagnosis and treatment of STD. Pupils should know that STDs are usually contracted through sexual intercourse and that, unlike the common cold, none of these diseases will go away if left untreated. Since most pupils have access to television, newspapers and magazines they will already be aware of the existence of STDs and the school's role is to provide clear information which will help to dispel any myths. In recent months there has been a great deal of publicity about AIDS (1) (Acquired Immune Deficiency Syndrome), for example, which will almost certainly cause some pupils to ask questions both about the condition itself and about the circumstances in which it can arise. Generally speaking, schools would be well

(1) Children at school and problems related to AIDS DES/Welsh Office, 1986.

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advised to separate information about STDs from the moral issue of promiscuity, whether heterosexual or homosexual. Both the moral and the medical aspects should be specifically addressed.

48. Given the openness with which homosexuality is treated in society now it is almost bound to arise as an issue in one area or another of a school's curriculum. Information about and discussion of homosexuality, whether it involves a whole class or an individual, needs to acknowledge that experiencing strong feelings of attraction to members of the same sex is a phase passed through by many young people, but that for a significant number of people these feelings persist into adult life. Therefore it needs to be dealt with objectively and seriously, bearing in mind that, while there has been a marked shift away from the general condemnation of homosexuality, many individuals and groups within society hold sincerely to the view that it is morally objectionable. This is difficult territory for teachers to traverse and for some schools to accept that homosexuality may be a normal feature of relationships would be a breach of the religious faith upon which they are founded. Consequently, LEAs, voluntary bodies, governors, heads and senior staff in schools have important responsibilities in devising guidance and supporting teachers dealing with this sensitive issue.

49. The arguments for and against abortion have been well rehearsed in the media, and various bodies have been active in promoting their different points of view. It is clearly impractical for schools to ignore the issue completely and, while some schools by their very nature are committed to a definite stance against abortion, others where this is not the case should do no more than explain what abortion is and set out objectively the main arguments. While it can be explained, for example, that one of the central issues in the public debate is a difference of opinion about when the foetus becomes an individual human being, it would be wrong for a teacher dealing with a class containing a variety of religious faiths and personal beliefs to attempt to make any kind of ruling on such a point. Yet, as said in paragraph 45, teachers may need to make clear their personal views or beliefs. On the other hand, facts to do with pregnancy, for example about the ailments or genetic factors which may affect the health of the mother or the unborn child, while they can have a bearing on the question of abortion, do not of themselves call personal conviction into question. In discussions of such matters as the freedom of choice of the individual, teachers should ensure that pupils

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recognise that such freedom extends only as far as the law and the creed of the individual allow.

Rubella

50. All schools should make reference in the early secondary years to the danger of rubella contact during pregnancy. It should be pointed out that the disease itself usually causes little trouble and may pass unnoticed, but that its effects on the child if it is contracted by a pregnant woman can be very serious. Some babies affected in this way face a lifetime of serious handicap. Pupils should be taught that immunisation provides a highly effective form of protection and particularly when given to girls in the 10-14 age group. It should also be stressed that previous exposure to, or a history of, rubella do not necessarily mean that immunity exists.

Smoking

51. Schools should attempt to show the association between smoking and disease in their teaching, whether through biology and child-care lessons or in special courses in which health education plays a part. This emphasis can be strengthened through curriculum projects in which smoking is considered. In all this work schools need to recognise the difficult but real problem, that teaching directed against smoking may cause conflict at home. For this reason and because it is the way good schools work, pupils should be encouraged to decide for themselves on the basis of evidence and advice rather than by exhortation. Consequently schools should set out to give a factual picture of smoking and its effects on the body, preferably using to good effect a variety of approaches and methods in their teaching; for example, by lessons on breathing which include pictures of healthy and diseased lungs, by the use of simple smoking machines to detect tar and nicotine yield from cigarettes, by small group discussions on the social consequences of smoking and, more rarely, by role play. The use of a variety of teaching methods is effective, not only in lessons about smoking but also in lessons about alcohol and drugs, partly because individuals vary and different methods and messages will affect them differently. In considering how to help pupils make their own informed decisions about these health-related matters, discussions of advertisements; the use and interpretation of evidence

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about smoking and disease; and critical inquiries into the evidence presented to the public should be undertaken to help pupils distinguish between fact, informed argument, opinion and polemic.

Alcohol

52. Work in health and personal and social education courses and in biology should aim to increase the knowledge and understanding of alcohol and its effects on the body. For some ethnic and religious groups in our society the consumption of alcohol for any purposes is totally prohibited. For those who do view it as socially acceptable it has particular consequences, not least for drivers, riders and pedestrians (1), which can be studied in various ways; for example older pupils can study the stopping distances of cars moving at different speeds, showing the extra distance travelled, when a small amount of alcohol has been consumed by the driver; and subsequent discussions of coordination and speed of reaction provide a basis for exploring the links between accidents and the consumption of alcohol.

Drugs and solvents

53. In recent years there has been widespread and increasing concern about the problems arising from the misuse of drugs or solvents and in particular with the threat this imposes to the health and well-being of young people (2). Work in schools aimed specifically at preventing drug or solvent misuse should be approached with caution because of the danger that it may promote experiment by pupils. However it is handled, it should form part of a broad health or personal and social education course which also includes teaching and discussion about socially acceptable drugs such as nicotine, alcohol and caffeine; the illegal drugs such as cannabis and heroin; life-saving drugs such as antibiotics; household drugs such as aspirin; and the misuse of medicines. Drug abuse should not be dramatically emphasised or highlighted by being treated as an isolated and separate topic (3, 4).

(1) See One for the road. Brewers' Society film in association with Royal Society for the Prevention of Accidents (1984).

(2) Drug misuse and the young DES/Welsh Office, 1985.

(3) Advisory Council on the Misuse of Drugs. Prevention HMSO, 1984.

(4) Health Education Council/inter-agency Drugs Education Project funded by DES, (in preparation).

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54. Suspected cases of solvent misuse should be dealt with at an individual level and the parents of pupils involved should be informed and consulted from the start. If, because of a considerable problem among the pupils or out of more general concern, the head, after due consultation with staff and parents, decides to include the matter of solvent abuse in a health education programme, several models are possible. (1) Even if no particular course exists which includes work on drugs and solvents, it is important for teachers to be well informed about the up-to-date facts of solvent (2) and drug misuse so that they may recognise the early symptoms of abuse amongst their pupils and be in a position to respond constructively to any discussions that arise spontaneously about these matters. As well as guidance about the signs and symptoms of drug misuse, information should be included about the agencies which provide help for misusers and their parents. This type of guidance is most effectively provided through in-service courses.

55. Youth workers in the neighbourhood of a school will often be aware of the nature and extent of drug misuse locally and regular contact between teachers and youth service personnel will help schools to become better informed about relevant local issues. In some areas youth workers are involved in education programmes for school pupils and their parents and such cooperation could with profit be more widely developed.

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because to make generalisations with any feeling of certainty about particular aspects of health education such as attitudes and personal relationships is difficult at any stage and particularly so at the primary level.

57. In the secondary schools however, some of these matters can be commented on and assessed in records of achievement that are more broadly based than examinations listing results alone. Devising, maintaining and coordinating them are difficult tasks and involve collaboration between those who specifically teach health education through personal and social and health education courses and those who deal with particular aspects in other subjects.

58. The broad aims and objectives for health education as outlined in paragraphs 19-22 and 24-26 should assist primary and secondary schools to develop schemes of work and to reappraise their policies for record keeping and assessment. Any assessment will need to take account of and coordinate judgements from many aspects of work some of which may previously have been unassessed. Schools already use a variety of forms of assessment to monitor progress in knowledge and understanding in the subjects of the curriculum which range from incidental day-to-day observations of pupils' progress and attitudes and unobtrusive questioning, to more formal procedures such as marks, grades and examinations, all of which could be applied to programmes of health education. Sometimes, at the secondary level, appraisal of a health or social education course is undertaken by the pupils themselves when they are asked to assess what they have learned and suggest improvements. When coordinated, any assessment should be used to determine the appropriateness of the levels of work provided and to identify any gaps and duplication.

59. In the secondary schools, whether taught through health or personal and social education courses, or across the curriculum in a variety of other subjects, health education cannot be examined as a single subject. Consequently, although much may be missed, it is best to approach the examination of health education at 16 not as a separate subject but through the examinations for related subject areas. For this to be possible it is necessary that important elements of health education are included as part of the core syllabuses of major subjects. For example, the new national criteria for General Certificate of Secondary Education (GCSE) in

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biology and home economics provide for this possibility. The knowledge and understanding of aspects of health outlined in paragraph 24 are implicit in many different syllabuses but their implications for health education need to be made explicit. Knowledge is an essential component of health education as a basis for decisions, opinions and attitudes, and for informed discussion of moral issues. Specific skills such as those outlined in paragraph 25 should be examined and their mastery assessed during the course of work carried out in classrooms and in more widely based projects.

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61. Comments and suggestions from individual readers of this document and from interested associations and institutions will be welcomed. They should be sent by December 31 1986 to:

HM Inspector (Health Education)
Department of Education and Science
Elizabeth House
York Road
London SE1 7PH

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Appendix 1

Supportive agencies for health education

A feature of health education in recent years has been the growth of resources produced both nationally and locally to support the teaching of health education. This development has coincided with the appointment by district health authorities or local education authorities of more health education officers (HEOs) many of whom regard as a key feature of their work the promotion and support of health education programmes in schools. In most areas HEOs have been active in making available to schools new health education materials including their translation into the Welsh language, publishing catalogues of resources, organising in-service training, and in a few instances joining with the LEA in writing health education schemes and reports. Some schools make direct contact with HEOs, or have benefited from the resources HEOs have made available to health visitors and school nurses whose assistance is generally valued by schools.

The Schools Council Health Education Project (SCHEP) 5-13 (1) is present in many primary and some secondary schools, although its spasmodic use typifies the unstructured approach often adopted in health education. Some schools have used successfully the Schools Council Science 5-13 material, (2) including units such as Ourselves, to introduce a more scientific approach to health education. The recently published SCHEP 13-18 (3) project and the slow learners project (4) are proving useful aids to structured programmes of health education in secondary schools and schools for pupils with moderate learning difficulties. Health Education Council and the Royal Society for the Prevention of Accidents (ROSPA) material, especially posters and pamphlets, feature in the work and display of many schools, particularly primary schools.

The school library service enriches school resources particularly in the primary phase with collections of books on a range of health topics for use by children in their project work. It has often served to augment schools' own modest provision of interest and reference books on health; and to isolated village

(1) Nelson, 1977.

(2) MacMillan, 1973.

(3) Forbes, 1982.

(4) Fit for life Health Education Council/Heinemann, 1984.

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schools the library and museum services have proved important life-lines to maintain the vitality of teaching.

Television programmes, films, filmstrips, video recordings and slides feature regularly in health education programmes and cover a wide variety of topics. Some are purchased by the school, most are borrowed from the local Health Education Office, some are video-recorded by the school staff. In social matters even more than most others, films and television programmes used in lessons should be up-to-date and of good quality; and as always preparation time needs to be given to previewing, editing, supplementing and if necessary rejecting material.

Sometimes published lists of resources fail to make the distinction between those for use by the teachers and material which can be shown to pupils. In sensitive aspects of the curriculum such as sex education this distinction is essential.

Work sheets are found in use in the majority of secondary schools. Many demand no more than the copying of appropriate information by pupils or the completion of questionnaires but there are others which require the use of resource material and a degree of independent thought. Few are seen which cater for the differing ability levels of individual pupils. Over-use of questionnaires and worksheets may lead to the lack of discussion and the meagre written work found in health education in the majority of secondary schools.

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tions. Health visitors speak, often to top junior classes, about a range of health topics linking aspects of human biology with healthy living but sometimes what is done has insufficient follow-up in related work such as science and physical education.

Youth workers, as a result of their contacts with young people in their leisure time and their social education skills, can make a two-fold contribution. They can assist with social education programmes and often provide information about patterns of drug misuse locally. Where youth and community workers are based on the school site they offer a natural resource for formal and informal health education programmes.

In secondary schools health visitors can make valuable contributions to health education programmes and child care courses while nurses may be part of a school staff. Besides routine duties, some health visitors and school nurses collaborate with a teacher to talk about, and show films on, for example, contraception and on the importance of vaccination against rubella. School nurses themselves sometimes become counsellor and friend to boys and girls presenting a variety of problems and thus provide invaluable help and support for individual pupils. As in primary schools community police are a notable and valued feature of the work. The main objective of their work is not seen to be disciplinary but to familiarise pupils with the police in a positive manner.

The school meals service is potentially an important resource, both through the staff attached to kitchens on school premises and dining centres serving schools, and through the authority's school meals organisers. One authority has developed a cross-curricular materials package in support of healthy eating as a result of close liaison between its Learning and Resources Branch, its school meals organisers and its home economics and health education advisers. Others have used the school meal to illustrate ethnic and cultural issues. In the schools of one authority members of the families of pupils are encouraged to take a school meal once a month and retired people in the community are also able to eat with the pupils.

Health visitors, police, road safety officer and dental health service are regular visitors to the majority of schools for pupils with moderate learning difficulties where they contribute to child development courses, cycling proficiency schemes, and road safety lessons.

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Although health education officers can help substantially with good and plentiful resources and practical help and advice on the planning of health education topics, impressions are that too few schools tap their knowledge and experience to help with the formulation of school policy and the planning of topics on health education.

The LEA advisory service has, in some areas, played a major role in the development of health education programmes and in providing in-service courses, more so for secondary than for primary schools. There is a growing emphasis on programmes related to Education for Personal Relationships, SCHEP 13-18, various forms of tutorial work and child care and development, but to support the good work already achieved in health education more in-service work is necessary.

Some particularly sensitive issues, for example child abuse, overlap with health education. In developing policies and approaches in such areas schools will wish to work closely with supportive outside agencies. The medical, educational welfare, social and educational psychology services, as well as various voluntary and other bodies, all have relevant expertise. In child abuse the major concern of schools must be to respond rapidly and effectively to any suspected cases. If any curricular initiatives are planned they should only take place where due emphasis is given to the attitudes discussed in paragraph 22, and where the criteria considered in the Conclusion, paragraph 60, are fully met.