“Sexuality education helps pupils develop the social skills to avoid risk-taking.”
Dr Kai Haldre, M.D, a gynaecologist, directed the Estonian Family Planning Association (FPA) from its establishment in 1994 to 2001, then established the FPA Sexual Health Clinic where she works today. She is a founding member of the Estonian Academic Society for Sexology and co-author of the recent UNESCO study on the cost and cost-effectiveness of school-based sexuality éducation programmes.
How long has sexuality education been on the curriculum in Estonia?
I would say 1996 was an important year, when the human and civil studies curriculum, which integrated sexuality related topics, was introduced as a mandatory subject. Later, in 2002, the curriculum was renamed human studies, where sexuality-related topics take 18% of the programme today. The implementation is the responsibility of the Ministry of Education and Science, local governments and schools.
What topics are covered?
A great many! SE includes both specific topics (such as contraception and puberty) and more general topics (such as negotiation skills and conflict solving). It aims to develop a holistic personality, general human values and social competence.
Personal and social education is the basis for several other content areas (general health education, drug education), because it helps pupils develop the social skills necessary to avoid risk-taking in all these areas.
How is SE taught?
Human studies can be taught by teachers from various backgrounds. Pupils are expected to be active in the learning process. Varied teaching methods are encouraged: discussion, role play, group work, brainstorming, etc. Teachers help the pupils to integrate their knowledge in real-life situations. External specialists (chiefly from youth counselling centres) also play an important role: whenever possible students make a visit to a youth-counselling centre (there are 20 of them in Estonia) and have at least one lesson there. I must stress here that the SE programme is closely linked to youth-friendly, sexual health service delivery.
Could you describe the improvements in youth sexual health indicators in Estonia over the past two decades?
There have been unprecedented reductions in sexually transmitted infections (STIs) and HIV infection rates, but also sizeable downward trends in abortion and teenage birth rates, because of sharp increases in condom and contraceptive use among young people.
The abortion and fertility rates (ie the number of unintended pregnancies) among 15– to 19-year-olds declined by 61% and 59% respectively between 1992 and 2009. Further, the annual number of registered new HIV cases among 15- to 19-year-olds declined from 560 in 2001 to just 25 in 2009 (a more than 95% decrease).
Overall, we were able to calculate that between 2001 and 2009 (when the effect of school-based SE could have been expected), an estimated 13,490 adverse health events (unintended pregnancies, STIs and HIV) have been averted, including 1,970 HIV infections.
As seen in the recent UNESCO study on the cost and cost-effectiveness of school-based sexuality education, the Estonian SE programme is a great example of a fully scaled up, integrated programme with a relatively low cost. This may interest other countries. Why is SE in Estonia so cost-effective?
The cost per completed curriculum of US$32.90 is relatively low in comparison to that of SE programmes in other countries studied. The main reason is that it is an integrated, intra-curricular component of the Estonian basic school curriculum. This has several advantages. Firstly, it is implemented on a large scale, reaching 28,000 students in 2009.
Secondly, because of its integrated nature, the programme covers a high proportion of students per school, and as such reduces costs per student of school-level activities, such as teachers’ salaries.
Thirdly, cost per student may also be fairly low because of the relatively small number of lessons (some 24 hours over the course of three years) attributed to sexuality-related topics.
Since salary costs are already a regular expense of the Ministry of Education, the budgetary outlay for this programme equals US$8.39 per learner completing the curriculum. As a comparison, Estonia spent US$4,680 per learner on secondary education as a whole in 2009. SE thus represents only 0.2% of current expenditure per secondary-school student.
The Estonia SE programme can be considered cost saving if 4% or more of observed reductions in HIV infections are attributed to it. Both qualitative and quantitative analyses demonstrate that the impact is likely to be much higher. I can therefore confidently state that the SE programme in Estonia has been a cost-saving intervention.