Teaching life skills through arts; an option for adolescent health promotion in resource poor settings

Background Life skills education for adolescents has been incorporated to curriculums and health promotion programmes in several countries including Sri Lanka. However, a uniformly recognized evidence based method for teaching life skills is not available. A novel art based life skills teaching method that takes into account the vulnerabilities of and opportunities available for individual participants, was used for health promotion of adolescents in a resource poor setting.


Introduction
Life skills are abilities for adaptive and positive behavior that enable individuals to deal effectively with the demands and challenges of everyday life (1). World Health Organization (WHO) has outlined decision making, problem solving, creative thinking, critical thinking, effective communication, interpersonal relationship skills, self-awareness, empathy, coping with emotions and coping with stress as core life skills for adolescents (1). Life skills are being taught targeting to achieve different outcomes including those related to health, academic achievements, gender and sexuality (2)(3)(4).
In South Asia, Life skills are taught in schools as a stand-alone curriculum (Sri Lanka) or integrated to existing curriculum (Nepal's health curriculum) or as an extra-curricular activity (Pakistan) or as a combined approach (Indian adolescent education programme) (5). Active learning opportunities through games, role plays or brain storming sessions are key strategies used in life skills education (1). A universal method for evaluating success of life skills teaching programmes is not available. How to effectively deliver a life skill training programme, how to reach the hard to reach, socially disadvantaged populations, whether these programmes can relate to realistic situations and address the vulnerabilities and risks faced by a particular participant, whether there are practical opportunities to practice the new skills and what values should be taught through life skills education are key challenges that need to be evaluated and addressed when planning a life skills education programme (5).
Art can be used for helping people acquire positive skills (6). It is used for building resilience in children facing adversaries such as physical or mental disability or diseases, natural disasters and war (7)(8)(9)(10). It has been used in the cultural context of Sri Lankan children previously (8). This paper describes a novel programme where an art based life skills teaching method that takes into account the vulnerabilities of and opportunities available for individual participants, was used for health promotion of adolescents in a resource poor setting.

Study setting
This art based life skills training was conducted in a rural school in Anuradhapura district, Sri Lanka. Sri Lanka provides free education for all children and school enrolment in Sri Lanka in 2013 was 99.7%. (11). This particular school holds classes from grade 1 to grade 11 (6 to 17 years of age).
The researcher is an artist and has been trained in teaching-learning methods, life skills training and qualitative research methods. The programme was conducted as part of a routine school health programme.

Study participants
Adolescents between 13 to 16 years of age participated in the two hour programme. Most of the participants were not studying arts as a subject.

Intervention
A situation analysis was conducted by interviewing the key informants; teachers, social service officer and the primary health care staff involved with the school. The interviews were brief and aimed on identifying the common problems encountered in adolescents in the study setting. The session was planned to empower students to avoid or overcome the problems detected.
Alcohol usage, lack of interest in education, externalizing behaviors, leaving school for early marriages or occupations and poor parental guidance were identified as common health and social problems faced by adolescents in the area. Low education level, lack of parenting skills, alcoholism and being separated from children due to family problems or labor migration were identified as causes leading to poor parental guidance.
The programme consisted of two parts which consisted of a drawing activity each. (Table 01)

Data collection and analysis
Voluntary anonymous written feedback was obtained from the students at the end of the programme. The researcher documented observation memos. Contextual data were noted down regarding the process, outcomes and participation.
Drawings were analyzed to identify the themes represented by the students and to identify the meanings they tried to express through their art. Thematic analysis was conducted on the feedback data. Results from the analysis of feedback were compared with contextual data (behavior of students and their drawings) for triangulation.

Results
A total of 42 adolescents (22 girls and 20 boys) aging 13 to 16 years participated in the programme.

Observations
The first activity changed the formal attire of a routine health education session and enthusiastic participation in activities was noted in students of all ages. Students felt relaxed and comfortable. Only a few (n=4) managed to reproduce a drawing similar to the original. This led to a discussion about the importance of interactive communication. They identified that different people formulate different perceptions on a particular thing (for an example on instructions given to them) and discussing and asking for clarifications is important for effective communication.

Open Access
Anuradhapura Medical Journal 2018| Volume 12 | Issue 1 | Page 7 | To open a window to discuss the importance of interactive communication A game between two groups of students. A figure of an elephant drawn with geometric shapes was given to a volunteering student from each group.
He/she had to verbally guide his/ her group mates to reproduce the image. He/she was not to look at the drawings of group mates.
Other students were not allowed to ask for clarifications or look at the original or each other's drawings.
Ensuring that rules are followed

Discussion
Students were allowed to see the original drawing at the end.
They discussed the problems they faced during the activity.
Facilitating the discussion Drawing activity 2 "10 years into their future" To make students evaluate the strengths and weaknesses of their character.
To make students identify challenges and difficulties they face.
To make students evaluate skills and resources available in their environment which can be used to overcome the challenges they currently face.
Students sat in groups of their choice.
Each student was asked to reflects on their talents and preferences and draw what they wanted to achieve in 10 years. They were encouraged to have a holistic view of life including health, social and economic success.
Joining the groups, observing and discussing each student's drawing.

Discussion
Students reflected and discussed challenges and difficulties they are likely to face while perusing their goals.
Facilitating the discussion using clues gained during the activity and drawings Winding up Students were asked to include life skills needed to achieve their goals into their drawings. Feedback Anonymous, unstructured written feedback was asked for Several themes could be identified in the second drawings; preferred future occupation, personal appearance, assets, work place/work environment, vision for life and life events (Table 02). Occupations with better socioeconomic benefits and those having the ability to influence the society were preferred. Some of their choices seemed to have been influenced by what they noticed during the session, probably because they had not thought of their future goals until this activity ( Figure 01). Personal appearance was usually depicted as neat, fashionably and professionally dressed, usually carrying accessories that indicate their profession.
During discussions students themselves came up with almost all life skills as solutions for defeating obstacles.
Arguments and counter arguments about effectiveness of certain strategies to overcome specific problems were forwarded. Enthusiastic and open participation was noted in both male and female participants of all age groups.

Feedback
The response rate was 62%. Students' perception on themselves, perception on the programme, perception on the facilitator, perceived outcomes from the programme and their futuristic view were identified as main themes in the feedback.
Students' perception on themselves -Students felt that they lack opportunities and resources to improve their talents as their school was 'small' and 'poor'. One used the phrase 'like flowers blossomed in jungles' to explain this. Some had mentioned that they were not living with their parents.
Students' perception on the programme-The programme was described as 'fun', 'good', 'enjoyable', 'a novel experience' and 'clear'. They had expected to be bored but found it very interesting instead. Some described it as "the most entertaining programme they ever had in the school". They also described it as advisory and useful for the future. They wanted it to be conducted in their school again and in other schools as well.

Open Access
Anuradhapura Medical Journal 2018| Volume 12 | Issue 1 | Page 8 | Students' perception on the facilitator-According to the students the facilitator was a 'good teacher' and 'an asset to the country'. They were grateful for spending time to conduct a life skills training in their small school. Perceived outcomes of the programme-Programme answered many questions they had and filled the gaps in parental guidance. One student had stated "today you taught me many things my mother did not teach me". Many found it motivating to achieve their goals and some particularly stated that they were motivated towards education. Self-awareness, effective problem solving, importance of communication, building good interpersonal relationships, critical thinking about surroundings and situations, being creative, avoiding alcohol, understanding about life and an idea about a future occupation were mentioned as what was learnt at the session.
Futuristic view of students-Many stated that they felt determined to become productive people for the society and fulfill their duties as citizens.

Discussion
This paper report a novel life skills teaching method based on art creation that is designed for health promotion in socially disadvantaged rural adolescents. The intervention was designed in a way that goes beyond routine life skills education, creating room to address each individual participant's vulnerabilities, challenges he/she faces and opportunities they have to use life skills in their daily life.
Both the process and outcomes should be evaluated to determine the success of a life skills training programme (1). The strengths of this method are that it demands minimal resources including infrastructure, does not require lengthy prior preparation, can be accommodated within busy routines of health care providers and teachers, the discussions can be directed to suit the contextual factors and art is culturally well tolerated. It can reach the disadvantaged youth in rural settings well. According to observations and feedback the programme was perceived to be interesting and effective by the participants' through-out the age range.
Since the duration of a session is short, multiple sessions can be conducted sequentially.
In conventional games based approach used in Sri Lanka discussions are conducted by the trainer and incidences that are discussed are not direct experiences of the participants. New approach is more individualized allowing participants to reflect and recognize how life skills can improve their own lives. The trainer assumes a facilitator role only. Therefore, the training may directly address the vulnerability of a particular participant and take into account the

Open Access
Anuradhapura Medical Journal 2018| Volume 12 | Issue 1 | Page 9 | challenges for practicing life skills in their environment, empowering them to achieve health.
The success of an approach that heavily depended on the participation of the trainees was a concern expressed by the teachers during initial discussions as they claimed that the students in rural schools are accustomed to passive learning and are shy to participate in class discussions. However, informal and nonjudgmental attire created through drawing activities encouraged all the students to share their ideas and opinions freely.
Another concern about the new approach was whether the students' attention was directed only onto dreaming up a carrier rather than understanding the importance of life skills. However, it was evident from the feedback that this was not so.
An objective method to evaluate long-term outcomes like changes in health related behaviors, indicators of mental wellbeing and improved educational outcomes or to compare them with the conventional method is yet to be developed. Predominantly negative feedback was not available which may be due to those having negative ideas refraining from giving feedback. This reports the findings from only a single school.
Implementing the programme in several centers would produce more information and evidence.
The new art based programme for school based life skills education can provide an effective individualized active learning experience for participants. It requires minimal resources, infrastructure, time and prior preparation making it suitable for promoting health and wellbeing of adolescents in low resource settings. However, long-term outcomes need to be assessed objectively.