EFA 2000 Assessment Thematic Study on School Health and Nutrition
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- Title
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EFA 2000 Assessment
Thematic Study on
School Health and Nutrition - extracted text
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EFA 2000 Assessment
Thematic Study on
School Healtli and Nutrition
This report was commissioned by the World Health Organization’s
(WHO) Department of Health Promotion, on behalf of Education for
All (EFA) 2000, and prepared by Health and Human Development
Programs (HHD) at Education Development Center, Inc. (EDC), the
WHO Collaborating Center to Promote Health Through Schools and
Communities
Authors:
Cheryl Vince Whitman, Director, HHD and Senior Vice President, EDC
Carmen Aldinger, Research Associate, HHD/EDC
Beryl Levinger, Senior Director, Global Learning Group, EDC
Isolde Birdthistle, Senior Research Associate, HHD/EDC, WHO
WHO Project Officer:
Jack Jones, School Health Education Specialist, WHO
Final Version - July 5, 2000
1
x
06805
Table of Contents
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-v
Acknowledgments
Abbreviations
Executive Summary
Findings
Introduction: The Link Between Health and Learning
I.
II.
Research Highlights from the Past Decade: What Strategies
Are Effective?
III.
Looking Forward: Suggestions for EFA 2015
Basis of Findings
Looking Back: The Status of School Health Leading up to
IV.
Jomtien
V.
Conceptual Frameworks: The Principles that Drive Action
VI.
Major Global Trends: Developments since Jomtien
Figures
Examples of the Evidence of Effectiveness
I
of School-Based Interventions
II
Illustrative Roles that Educators and their Collaborators Can
Play to Address selected Health Issues
III
Selected Online Resources for School Health
IV
Highlights of Major Regional Trends and Activities, Barriers,
and Future Actions for School Health and Nutrition
V
Selected International Conferences that Addressed
School Health and Nutrition
References
2
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-
Acknowledgments
We are deeply grateful to all the individuals who responded in writing or in interviews to our
questionnaire and other inquiries about this study. We are also deeply thankful for the
suggestions and efforts of our editors Daphne Northrop and Luise Erdman.
Eskendirova Almagul
Kunal Bagchi
Donald Bundy
L. Tomasso Cavalli-Sforza
Maria Theresa Cerqueira
V. Chandra-Mouli
Vinayagum Chinapah
Lawalley Cole
Frank Dall
Anna Lucia D'Emilio
Bruce Dick
Rosmarie Erben
Haba Fassou
Robert Fuderich
Lucille Gregorio
Wadi Haddad
Pamela Hartigan
Hugh Hawes
Anna Maria Hoffmann-Barthes
John Hubley
Jim Irvine
V. Jensen
Jiyono
Leo Kenny
Ilona Kickbusch
Jackie Knowles
Lloyd Kolbe
Ute Meir
Sergio Meresman
Elijah Beto Munetsi
Naomi Nhiwatiwa
Anna Obura
Hisashi Ogawa
Martha Osei
Ulrika Peppier Barry
Philayrath Phongsavan
Vivian Barnekow Rasmussen
David Rivett
Alfredo Rojas
Yu Sen-Hai
Sheldon Shaeffer
Anna Verster
Ian Young
Howell Wechsler
Diane Widdus
UNICEF/Central Asia & Kazakhstan
WHO/Eastem Mediterranean
World Bank/Headquarters
WHOAVestem Pacific
WHO/Americas
WHO/Headquarters
UNESCO/Headquarters
UNICEF/South & East Africa
UNICEF/Middle East & North Africa
UNICEF/Cambodia
UNICEF/Headquarters
WHOAVestem Pacific
WHO/Africa
UNICEF/Central & Eastern Europe
UNESCO/Asia & Pacific
Inter-Agency Commission, WCEFA
WHO/Headquarters
Child-to-Child Trust
UNESCO/Headquarters
Consultant in Inti. Health Promotion, Leeds, UK
UNICEF/East Asia & Pacific
UNESCO/Asia & Pacific
UNICEF/Indonesia
UNICEF/Central & Eastern Europe
formerly WHO/Headquarters
UNICEF/Central & Eastern Europe
CDC/DASH
UNESCO/Headquarters
World Bank/Headquarters
WHO/Africa
WHO/Africa
UNICEF/South & East Africa
WHO/Western Pacific
WHO/South-East Asia
UNESCO/Headquarters
UNICEF/East Asia & Pacific
WHO/Europe
WHO/Europe
UNESCO/Latin America
WHO/Headquarters
UNICEF/Headquarters
WHO/Eastem Mediterranean
Health Education Board for Scotland
CDC/DASH
UNICEF/Central & Eastern Europe
3
»
Abbreviations
AIDS
ALC
CDC
CIDA
CRC
CTL
DALY
DASH
DFID
DOH
EDC
EFA
El
ENHPS
FAO
FRESH
HBSC
HHD
HIV
HPS
EBE
IQ
MLA
MOH
MOE
NGO
PAHO
PCD
RAAPP
RH
STD
STI
U.N.
UNAIDS
UNDP
UNESCO
UNFPA
UNICEF
USAID
WCEFA
WFP
WHO
WPRO
WWW
YRBS
Acquired Immune Deficiency Syndrome
Active Learning Capacity
Centers for Disease Control and Prevention
Canadian International Development Agency
Convention on the Rights of the Child
Conditions of Teaching and Learning
Disability-adjusted Life Year
Division of Adolescent and School Health (at CDC)
Department for International Development
Department of Health
Education Development Center
Education for All
Education International
European Network of Health-Promoting Schools
Food and Agriculture Organization of the United Nations
Focusing Resources on Effective School Health
Health Behavior in School-Aged Children
Health and Human Development Programs (at EDC)
Human Immunodeficiency Virus
Health-Promoting School
International Bureau of Education
Intelligence Quotient
Monitoring Learning Achievement
Ministry of Health
Ministry of Education
Non-Governmental Organization
Pan-American Health Organization
Partnership for Child Development
Rapid Assessment and Action Planning Process
Reproductive Health
Sexually Transmitted Disease
Sexually Transmitted Infection
United Nations
Joint United Nations Program on HIV/AIDS
United Nations Development Program
United Nations Educational, Scientific and Cultural Organization
United Nations Population Fund
United Nations Children's Fund
United States Agency for International Development
World Conference on Education for All
World Food Program
World Health Organization
World Health Organization Regional Office for the Western Pacific
World Wide Web
Youth Risk Behavior Survey
4
/
Executive Summary
Chapter I: Introduction: The Link Between Health and Learning
In March 1990, world leaders gathered in Jomtien, Thailand, for the World Conference on
Education for All (EFA): Meeting Basic Learning Needs. Rather than focus on the traditional
issues of how to provide school buildings, textbooks, and teachers, they decided to address
the process of learning and the needs of learners. Health and nutrition were included as
important contributors to the success of the learner and the learning process. This study
reviews the major activities that have taken place in the field of school health and nutrition
around the world since Jomtien and suggests actions for the decade to come.
As many studies show, education and health are inseparable: Nutritional deficiencies,
helminth infections, and malaria affect school participation and learning. Violence,
unintentional injuries, suicidal tendencies, and related behaviors, such as the use of alcohol
and other drugs, interfere with the learning process. Sexual behaviors, especially unprotected
sex that results in HIV infection, other sexually transmitted diseases, and unwanted or tooearly pregnancies, affect the participation of students and teachers in education. Most
important, many of these issues can be addressed effectively through health, hygiene, and
nutrition policies and programs for students and staff.
The information presented in this study is essential to policy- and decision-makers who are
committed to achieving EFA because the link between learning and health clearly shows that
it is unlikely that EFA can achieve its goals without significant improvements in the health of
students and teachers.
Chapter II: Research Highlights from the Past Decade: What Strategies Are Elective?
Since Jomtien, a significant amount of research has addressed the effectiveness of school
health interventions, and the relationships among health, cognition, school participation, and
academic achievement. Experience has shown that if the quality and quantity of school health
programs are to increase, the education sector must take a lead role.
Ten major findings offer important guidance for the future.
1) School-based nutrition and health interventions can improve academic
performance.
2) Students’ health and nutrition status affects their enrollment, retention, and
absenteeism.
3) Education benefits health.
4) Education can reduce social and gender inequities.
5) Health promotion for teachers benefits their health, morale, and quality of
instruction.
.
6) Health promotion and disease prevention programs are cost-effective.
7) Treating youngsters in school can reduce disease in the community.
8) Multiple coordinated strategies produce a greater effect than individual strategies,
but multiple strategies for any one audience must be targeted carefully.
5
9) Health education is most effective when it uses interactive methods in a skillsbased approach.
10) Trained teachers delivering health education produce more significant outcomes
in student health knowledge and skills than untrained teachers.
Chapter HI: Looking Forward: Suggestions for EFA 2015
The decade ahead offers great promise for strengthening the links between health and
education. Major suggestions emphasize the development of a shared vision, a commitment
to act, a pledge to work collaboratively, and the importance of a global effort to acquire and
share information.
The suggestions are:
1) Major leaders and change agents in the field must come together around a common
framework, relevant to the education sector.
2) To be successful, school health, hygiene, and nutrition efforts must be led by
educators, supported and assisted by health professionals, and made an integral part
of the efforts to improve education through policies and goals.
3) We must continue to deepen and expand collaboration, especially between the
education and health sectors, with mechanisms that sustain and nurture joint
planning, action, and learning over time.
4) More investment is needed in health services for children and adolescents that they
can reach easily, without stigma.
5) Access to information as well as sustained support to use it (e.g., professional
development, technical cooperation, and mentoring) must be improved for
education and health workers.
6) Multiple targeted and coordinated strategies are needed to improve desired
behavior patterns and health outcomes.
7) Indicators that provide universal measures of progress are needed to focus efforts
and report changes that are possible to achieve by 2015.
8) Model programs should be developed for different levels of investment because
countries vary in what they can afford.
Chapter IV: Looking Back: The Status of School Health Leading up to Jomtien
International collaboration on school health has a history of more than 120 years. As the
1980s came to a close, researchers around the world were launching studies to evaluate the
effectiveness of specific health interventions to address nutritional deficiencies and the
treatment of intestinal worms, in particular, and, where possible to examine the effect of
health interventions on cognition, school attendance, and other factors related to learning.
School health efforts in 1990 can be characterized in the following ways:
1) Health initiatives in schools focused primarily on disease prevention.
2) There was confusion about the concept and definition of school health.
3) Single, uncoordinated intervention strategies dominated.
4) Few, formal mechanisms for multi-sectoral collaboration were in place.
5) Didactic, topic-by-topic teaching was the typical approach to health education.
6) Evidence of the effectiveness of interventions was not well known or disseminated.
6
7) Few tools to guide assessment and strategic planning were available.
8) Few donors earmarked school health programs as a priority for funding.
Chapter V: Conceptual Frameworks: The Principles that Drive Action
^ssSSSSSSand programs.
Several major frameworks: tavethe Heallh-Promoling
“oX aZ 19S6. and advanced b, the CounodofEnrope, the
Commission
SSXr™»g Capaehy (Levinger, EDC, for USAID and UNDP).
As the decade draws ,0 a Cose, some offrmmajorats "Xrks Cn^VX
level are coming together to discuss how y g ,
Q UNICEF UNESCO, and
and collaborate on a common framewor orFocusing Resources on Effective
SS
in sUi in ApHi POOO.
The four essential components of the FRESH framework are:
1) Health-related policies in schools.
2) Safe water and sanitation facilities.
3) Skills-based health education.
Chapter VI: Major Global Trends: Developments since Jomtien
I
Several major global trends over the past decade have dramatically influenced the scope and
direction ^^^^Xm^stimulated a new demand and urgency for school health.
1 XZs a gradualmove from individual to multiple strategies and to mtegrated
and coordinated approaches to school health programs.
3
U in
sustained school health and nutrition interventions.
7
Chapter I: Introduction; The Link Between Health and Learning
The Role of School Health and Nutrition at the Education For All
Conference
In March 1990, world leaders gathered in Jomtien, Thailand, for the World Conference on
Education for All: Meeting Basic Learning Needs. Its goal was to “launch a renewed
worldwide initiative to meet the basic learning needs of all children, youth and adults and to
reverse the serious decline in basic education”(Inter-Agency Commission, 1990a). The
conference organizers chose a different approach: Rather than focus on the traditional issues
of how to provide school buildings, textbooks, and teachers, they decided to address the
process of learning and the needs of the learners. Health and nutrition were included as
important contributors to the success of both the learner and the learning process.
In preparation for the roundtable “School Performance, Nutrition and Health” at the
Conference, UNESCO published a key document—-Malnutrition and Infection in the
Classroom—which presented the relationship between the status of children’s nutrition and
health and their performance in school. The paper argued that because nutrition and health
are so important in determining educational outcomes, they should figure prominently in any
efforts to improve the quality of education and the ability of children to learn. In the preface,
the Director-General of UNESCO stated, “It is no longer possible to ignore the fact that.
nutrition and health can severely affect the ability of children to learn. We are constructing
the future with the precious resource of the present—our children. It is essential that they be
given the opportunity to derive maximum benefit from the schooling they receive” (Pollitt,
1990).
Schools have unique access to this "precious resource." In 1998, UNICEF estimated that out
of 625 million children of primary school age, 79% were in school. The vast majority was
receiving some basic education. It is also estimated that 70% of children in the developing
world complete at least four years of schooling (UNICEF, 1999). Therefore, a school's
potential to affect the health status and learning ability of an enormous number of the world’s
children stands before us. There are far more teachers than nurses or health care workers in
most countries. The teaching corps around the world can deliver many health promotion and
health service interventions easily and effectively, with benefits to the teachers themselves as
well (Partnership for Child Development, 1999d).
At the Jomtien Conference, participants echoed the need to broaden the perception of what
contributes to basic education and to consider the many factors that affect human
development. They called for an expanded vision of basic education, one that recognized that
“education does not work in a vacuum or in isolation from other factors that have a bearing
on society” (Inter-Agency Commission, 1990a). Ultimately, the 1990 World Declaration of
EFA and its articles recognized the relationship among health, education, and health/nutrition
policies and programs, stating that “education can help ensure a safer, healthier, more
prosperous and environmentally sound world” and “learning does not take place in isolation.
Societies must ensure that all learners receive the nutrition, health care, and general physical
and emotional support they need in order to participate actively in and benefit from
8
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education ” To do so, “new and revitalized partnerships at all levels will be necessary
between education and social sectors” (Inter-Agency Commission, 1990a).
This study reviews the main activities that have taken place in the school health and nutrition
field around the world since Jomtien, identifies strategies and interventions that have proven
effective and suggests actions for the decade to come. The information presented in this
study is essential to policy- and decision-makers who are committed to achieving EFA
because the link between learning and health clearly shows that it is unlikely that EFA
can achieve its goals without significant improvements in the health of students and
teachers.
A Call for Action at Jomtien
Conference participants addressed the link between health and education. For example,
UNESCO and the World Food Program organized a roundtable School Performance,
Nutrition and Health.” The discussants concluded that to learn effectively, children need
good health Further, they asserted that malnutrition and poor health may be important
factors in low school enrollment, absenteeism, poor classroom performance, and early school
dropout (Hoffmann-Barthes, 1999).
The World Health Organization and other agencies presented another roundtable, “Health in
Education for All—Enabling School-Age Children and Adults for Healthy Living.” The
paper presented by WHO on this occasion contained a compelling call for action:
1 “Health education must be inseparably linked with the Education for All Initiative.
2. Countries must formulate and support clear policies on school health education and
ensure that the education and health sectors have a joint strategy for their implementation.
3. Curriculum development must be based on the health needs of the different age groups
and take into consideration the socio-cultural background of the schoolchildren.
Curriculum development committees must include parents and community leaders.
4 Personal and social development must, along with intellectual development, be given due
weight in schools in order to foster values, attitudes, and behavior conducive to health and
The teaching of school health education requires teacher preparation, guidelines, teacher
5.
I
I
I
I
learning material and curriculum support. Teacher training institutions must revise their
courses in the light of this need. Team training of all categories of school personnel,
including the health, administrative, and general staff, is recommended for a
comprehensive school health program.
The pivotal role of teachers in promoting health in the school and community needs to be
6.
given high priority. The support of teacher associations must be sought to increase the
health awareness of teachers and encourage them to assume responsibility for being role
models for health in the school and community.
7 Schools must be health-promoting institutions. In addition to emphasis on the
development and implementation of health education curricula, attention must be paid to
ensuring that teachers and other staff and the school environment support and facilitate
healthful living.
School
health education must be planned and implemented in the context of the pupils
8.
support families and the wider community to which they belong. It must relate to the life
of the child in and outside of school. Involving schoolchildren in community activities
9
I
and the community in school activities will bring about greater understanding and
encourage mutual support” (WHO, 1990).
Note that recommendations seven and eight present “school health” as a concern for
everyone in the school as well as members of the community.
Although the roundtables on school health and education gave strong and clear guidance for
improving school health programs as a means of achieving Education for All, those
recommendations were not given priority in the final report or in the Framework for Action
following Jomtien. Furthermore, no specific goals for school health and nutrition or
indicators were established for the decade 1990-2000.
A Growing Body of Evidence—The Link Between Learning and
Health
In the decade since EFA, many publications and studies have elaborated on the link between
learning and health status (e.g., WHO/UNESCO/UNICEF, 1992). A WHO report stated, “As
long ago as 1950 it has been noted that nutritional deficiencies and poor health in primary
school-age children are among the causes of low school enrollment, high absenteeism, early
dropout, and poor classroom performance. Health is thus a key factor in school entry as well
as continued participation and attainment in school. Moreover, education that provides
children with basic academic skills and specific knowledge, attitudes, and skills related to
health is vital to their physical, psychological, and social well being. This is not only true in
the short term; such education lays the foundation for a child’s healthy development through
adolescence and across the entire lifespan” (WHO, 1997a).
As numerous studies show, education and health are inseparable:
♦ Nutritional deficiencies (protein-energy malnutrition, iron, Vitamin A, and iodine
deficiency) and health problems such as helminth infections (especially schistosomiasis
and infections with roundworm and other intestinal parasites) and malaria affect school
participation and learning. A 1990 analysis of nine studies on the relationship between
nutritional anthropometric indicators (such as height-for-age and weight-for-height) and
school indicators (such as age at enrollment, absenteeism, achievement test scores, IQ,
and performance on selected cognitive tasks) showed that better nutritional status was
consistently linked to higher cognitive test scores or better school performance (Pollitt,
1990).
♦ Violence, unintentional injuries, suicidal tendencies, and related lifestyle behaviors, such
as the use of alcohol and other drugs, interfere with the learning process. Children
exposed to violence may become highly aggressive, use psychoactive substances, or
show other dysfunctional ways of dealing with anxiety (Singer et al., 1995). This
behavior, in turn, may reduce attendance at school, impair concentration, and
detrimentally affect cognitive development (WHO, 1998d).
♦ Sexual behaviors, especially unprotected sex that results in HIV infection, other sexually
transmitted diseases, and unwanted or too-early pregnancies, affect both students’ and
teachers’ participation in education. These behaviors place at risk students who have
successfully reached secondary school. Too-early pregnancies negatively affect the
education of young girls, who often must drop out of school. HIV/AIDS has already had
10
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a devastating impact on children in sub-Saharan Africa, where over 90% of all AIDS
orphans live, most of them will never complete a basic education (UNICEF, 1999).
It is important that most of these issues can be addressed effectively through health, hygiene,
and nutrition policies and programs for students and staff. Figure I in the appendix shows
examples of effective school-based interventions that prevent or reduce specific health
conditions.
The Purpose of This Thematic Study
The Thematic Study on School Health and Nutrition explores what has happened in the field
of school health and nutrition since 1990. Drawing on the contributions of researchers,
practitioners, and policy-makers around the world, this study aims to learn from the
promising developments of the last ten years, stimulate dialogue, and move those involved to
a shared vision and plan of action for the next decade. Specifically,
♦
♦
♦
♦
♦
Chapter II presents research highlights of strategies that have been found effective;
Chapter III suggests actions to guide EFA 2015;
Chapter IV reviews the status of the school health and nutrition field leading to Jomtien,
Chapter V describes conceptual frameworks that were developed through the 1990s;
Chapter VI reviews major global trends during the past decade.
The authors have written this study for a broad readership: those who work at different levels
and in a variety of roles in the education, health, and other sectors.
To prepare this paper, the authors drew on:
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♦
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♦
telephone interviews with and electronic questionnaires from approximately 40
respondents in agencies at the world, regional and national levels;
the collection and review of research articles, country reports, and publications from
many world, regional, and country offices,
Web searches of agencies of the United Nations and other organizations;
their own firsthand knowledge of the field.
Many talented and dedicated people have worked tirelessly to move school health and
nutrition policies and programs forward in the 1990s. The authors are deeply grateful to so
many who contributed ideas to this timely review and to the many more who have advanced
the field of school health and nutrition through their work since Jomtien.
11
Since Jomtien, a significant amount of research has been conducted on the effectiveness of
school health interventions and the relationships among health, cognition, school
participation, and academic achievement. This chapter presents highlights of the evidence to
guide future investments in school health and nutrition.
Since Jomtien, experience has shown that if the quality and quantity of school health
programs are to increase, the education sector must take a lead role. Therefore, research data
must be made easily available to the education sector, and those committed to achieving
EFA, to guide advocacy, policy development, and program planning.
Ten major findings offer important guidance for the future:
1. School-based nutrition and health interventions can improve academic
performance.
2. Students’ health and nutrition status affects their enrollment, retention, and
absenteeism.
Education
benefits health.
3.
4. Education can reduce social and gender inequities.
5. Health promotion for teachers benefits their health, morale, and quality of
instruction.
6. Health promotion and disease prevention programs are cost-effective.
7. Treating youngsters in school can reduce disease in the community.
8. Multiple coordinated strategies produce a greater effect than individual strategies,
but multiple strategies for any one audience must be targeted carefully.
9. Health education is most effective when it uses interactive methods in a skillsbased approach.
10. Trained teachers delivering health education produce more significant outcomes
in student health knowledge and skills than untrained teachers.
Each finding is discussed below.
1. School-based nutrition and health interventions can improve academic performance
Evidence from around the world shows that treating nutritional and health conditions in
school can improve academic performance. For instance, some school-food programs have
shown marked effects on attendance and school performance (Levinger, 1994). In Benin,
children in schools with food services scored significantly higher on second-grade tests than
did those in schools without food services (Jarousse & Mingat, 1991). In Jamaica, providing
breakfast to primary school students significantly increased attendance and arithmetic scores
(Simeon & Grantham-McGregor, 1989). In the United States, low-income children scored
significantly lower on achievement tests than higher-income children before they participated
in a school breakfast program. Once in the program, the scores of the children in the program
improved more than the scores of the non-participants (Meyers et al., 1989).
Nutritional interventions such as micronutrient supplements and the treatment of intestinal
worms have also proved to increase students' attention, cognitive problem solving, and test
12
A
scores (Nokes et al., n.d.). Research by the Partnership for Child Development in Ghana
recently showed that iron supplements—which could be effectively administered by
teachers—lead to a very significant improvement in school performance for a period of up to
six months (Berg, 1999). In Malawi, when the diets of primary schoolchildren were
supplemented with iron as well as iodine, the gain in IQ scores was greater than with iodine
supplements alone (Shrestha, 1994). Two studies reviewed by Pollitt (1990) concluded that
iron-deficient anemic children showed lower aptitude when they first enrolled in school.
However, this disadvantage disappeared once the children became iron-replete (e.g., through
school-based supplementation). In the West Indies, a single chemotherapy treatment for
whipworm infection given to children at school, without nutritional supplements or
improvements in education, improved the children's learning capacity to the point that their
test scores matched those of children who were not infected (Bundy et al., 1990).
2. Students’ health and nutrition status affects their enrollment, retention, and
absenteeism.
Height and weight for age are typical markers for entering school, and children not tall or
heavy enough might be denied access. Thus, children in good health are more likely to start
school at the developmentally appropriate age. “For example, in Nepal, a study found that the
probability of attending school was 5% for stunted children and 27% for children of normal
nutritional status” (Moock & Leslie, 1986). In Ghana, malnourished children entered school
at a later age and completed fewer years of school than better-nourished children (Glewwe &
Jacoby, 1994).
School feeding programs have been shown to lower absenteeism and dropout rates. A recent
evaluation of a school feeding program in Burkina Faso found that school food services were
associated with regular attendance, consistently lower repeat rates, lower dropout rates, and
higher success rates on national exams, especially for girls (Moore, 1994). In Malawi, a
small pilot school feeding program over a three-month period led to a 5% increase in
enrollment and up to a 35% improvement in attendance (WFP, 1996). In the Dominican
Republic, up to 25% of children—especially those from rural areas and girls—dropped out of
school during a period without a school feeding program (King, 1990).
3. Education benefits health.
Regular school attendance is one of the essential means of improving health. The school
itself—through its culture, organization, and management; the quality of its physical and
social environment; its curricula and teaching and learning methods; and the manner in which
students’ progress is assessed—has a direct effect on self-esteem, educational achievement,
and therefore the health of students and staff (Hopkins, 1987; Rutter et al., 1979; Sammons et
al., 1994).
Multiple years of schooling and the acquisition of literacy in several domains make it more
likely that a person will be able to safeguard his or her health through living circumstances,
earning power, access to health services, and general quality of life. Even a few years of
schooling, evidence suggests, are associated with important changes of economic value in
individual skills (Selowsky, 1981; UNICEF, 1999). Schooling pays off with higher incomes
and a healthier workforce (World Bank, 1993).
4. Education can reduce social and gender inequities.
Poor health at school age is often connected with poverty and gender (Bundy, 2000). School
health programs have the potential to reduce inequities in society and to begin to break the
13
cycle of poverty. “Poor children with the worst health have the most to gain from school
based health and nutrition programs and the most to gain educationally. They show the
greatest improvement in cognition as a result of health interventions” (World Bank, 1993;
PCD, 1997).
During the 20th century, "education, skills and other knowledge have become crucial
determinants of a person’s and a nation’s productivity. The primary determinant of a
country’s standard of living is how well it succeeds in developing and utilizing the skills,
knowledge, health, and habits of its population” (Becker, 1995). One major reason given for
the dramatic differences in economic development between East Asia and Africa, for
example, is the significantly higher level of investment that East Asia has made in the
education and health care of its citizens (Kristof, n.d.). Thus, investments in education can
have both short- and long-term benefits to an individual’s health and the productivity of
nations.
Girls, in particular, are likely to benefit: educated girls are likely to delay their first
pregnancy, and have fewer and healthier children. For example, data from 13 African
countries between 1975 and 1985 showed that a 10% increase in female literacy rates yielded
a 10% reduction in child death rates (WHO, 1997a). Schools are also places where girls’
nutritional and reproductive health can be addressed early, thereby preventing later problems.
In Tamil Nadur, “a school feeding program attracted more girls to attend school and
improved the attendance of those already in school. In addition to benefiting educationally,
these girls had the opportunity to learn about family planning. As a result they had fewer
children when they reached child-bearing age” (Devadas, 1983).
5. Health promotion for teachers benefits their health, morale, and quality of
instruction.
The health of teachers is an important factor in the learning process. Teachers are the key to
both education and health promotion in schools. They are caretakers of both the school and
the students. Their health is thus critical to the achievement of EFA. While teachers must be
trained about health matters affecting students, they also need training about taking care of
their own health. Inevitably, the physical and mental health of the staff affects students
directly through the quality of teaching and the attributes of the school’s psychosocial
environment (WHO, 1997a). Attending to teachers’ health interests can motivate them to
address students’ health needs as well.
Some studies of the effectiveness of health promotion programs for school staff have shown
that they decrease teachers’ absenteeism and improve both their morale and the quality of
classroom instruction. Teachers who have participated in school health programs reported
improved attitudes toward their personal health and increased perceptions of general well
being (Belcastro & Gold, 1983; Jamison, 1993; Falck & Kilcoyne, 1984). Other studies
found that the school personnel's knowledge of and behaviors concerning health were
positively affected (Sandal, 1995; Maysey et al., 1988). One staff program in the United
States demonstrated a reduction in body weight, resting pulse rate, serum cholesterol level,
and blood pressure (Bishop et al., 1988).
6. Health promotion and disease prevention programs are cost-effective.
Money invested in the prevention of health problems through the schools can save societal
costs of treating disease. A recent study in the U.S. estimated that every U.S. dollar invested
in schools on effective tobacco education saves SI 8.80 in the cost of addressing problems
14
caused by tobacco use; every U.S. dollar spent on education for preventing alcohol and other
drug abuse saves $5.69; and every U.S. dollar spent on education to prevent early and
unprotected sexual behavior saves $5.10 (Rothman & Collins, forthcoming).
A 1993 World Bank analysis determined that a basic public health package with five central
elements could reduce the burden of disease for a relatively modest per capita cost (World
Bank, 1993). Extensive analyses of disease control priorities have established that school
based treatments of children are exceptionally cost-effective. For instance, school nutrition
and health programs have been estimated to cost only U.S. $20-34 per disability-adjusted life
year (DALY) gained, and school-based tobacco and alcohol prevention programs cost U.S.
$35-55 per DALY gained (DelRosso & Marek, 1996).
7. Treating youngsters in school can reduce disease in the community.
A leading publication by the World Bank, Class Action: Improving School Performance in
the Developing World Through Better Health and Nutrition (Del Rosso & Marek, 1996),
offers evidence that treating diseases prevalent in the school-age population can help to
interrupt the transmission of disease to the surrounding community. For example, on the
Caribbean Island of Montserrat, more than 90% of schoolchildren, age 4-12, were treated at
four-month intervals for two and one-half months with an antiworm drug. Infection rates
declined to almost zero. While less than 4% of adults in the community received treatment
during the same time, their rate of infection declined an almost equal amount because of
reduced transmission from the school-age children (Bundy et al., 1990).
8. Multiple coordinated strategies produce a greater effect than individual strategies,
but multiple strategies for any one audience must be targeted carefully.
Strategies for school health programs at both the national and local level have, for the most
part, been singular in their approach. However, research continues to show the positive
impact of multiple and targeted coordinated strategies. For example, a curriculum combined
with youth community service is more effective in reducing risk behaviors such as fighting,
early sexual behavior, and substance use than a curriculum alone (O’Donnell et al., 1998).
Policies for tobacco-free schools, combined with a skills-based curriculum on tobacco
prevention, are more effective than the curriculum alone (Sussman et al., 1993).
In 1994 the Ghana Partnership for Child Development implemented a program to treat
parasitic infections in children through many schools in the Volta region. The program used a
combination of strategies, including clinical treatment, teacher and administrator training, and
classroom education. After six months, test results showed a reduction in the prevalence of
schistosomiasis from 15 to 5.7% and in hookworm from 52 to 2.4%. A re-survey in 1996
showed the prevalence of schistosomiasis to be 5.4% compared with 15.2% in 1994 and
hookworm at a rate of 28% compared with 51% in 1994. In addition, children who took part
in the program improved both their attendance and school performance records (PCD,
1999e).
Often there are not enough resources and time to accomplish all the goals of a health
promotion or disease prevention effort. Program planners then must choose between
providing a variety of strategies for a given population or focusing on a smaller number of
activities. The National Structured Evaluation of Alcohol and Drug Abuse Prevention in the
United States undertook an analysis of more than 300 community-based substance abuse
prevention initiatives. The researchers concluded that projects that attempted to offer more
than three or four types of activities to a single adolescent population were generally
15
I
ineffective. The study concluded that “comprehensive prevention depends more on selecting
appropriate activities and services for each population served than on trying to provide a wide
variety of activities and services. There may be an effective limit to the variety of prevention
activities that should be provided at a given time to a single population, beyond which the
addition of a greater variety of activities adds little to measured effects of the prevention
efforts” (Division of Knowledge Development and Education, 1997). The implication for
school-based prevention is that planners need to select and target a few strategies to promote
health and to address the most serious health threats.
9. Health education is most effective when it uses interactive methods in a skills-based
approach.
Health education aims not only to improve pupils’ interest in health, their ability to relate
what they learn to their own lives, and their understanding of basic ideas about health, but
also the application of what they learn to the lives of families and friends. To do so, health
learning must emphasize skill development over simple information sharing, and provide
opportunities for students to practice healthy behaviors or to address the conditions that
promote health both personally and collectively (Hoffmann-Barthes, 2000).
Skills-based health education, including life skills, and interactive teaching methods have
been shown to promote healthy lifestyles and reduce risk behaviors. A meta-analysis of 207
school-based drug prevention programs grouped approaches to prevention into nine
categories. The author found that “the most effective programs teach comprehensive life
skills.” Programs were also grouped according to whether they used interactive methods or
not. The study concluded that “the most successful of the interactive programs are the
comprehensive life skills programs that incorporate the refusal skills offered in the social
influences programs and add many general life skills such as assertiveness, coping,
communication skills, etc.” (Tobler, 1998 Draft).
Skills-based health education and life skills have been shown to reduce the chances of young
people engaging in delinquent behavior (Elias, 1991) and interpersonal violence (Tolan &
Guerra, 1994); the use of alcohol, tobacco, and other drugs (Griffin & Svendsen, 1992;
Caplan et al., 1992; Werner 1991; Errecart et al., 1991; Botvin et al., 1984, 1980); high risk
sexual activity that can result in pregnancy or STD or HIV infections (Kirby, 1997;
WHO/GPA, 1994; Postrado & Nicholson, 1992; Scripture Union, n.d., Zabin et al., 1986);
emotional disorders (McConaughy, et al., 1998); and bullying (Oleweus, 1990).
10. Trained teachers delivering health education produce more significant outcomes in
student health knowledge and skills than untrained teachers.
Training for school personnel is an important aspect of school health promotion programs
(WHO, 1997a). Studies show that training teachers how to use a health education curriculum
improves its implementation (Connell et al., 1985).
Similarly, an evaluation of the Teenage Health Teaching Modules (THTM) curriculum, using
skills-based approaches for health education in grades 7-12 in the United States, showed that
training teachers before using the curriculum positively affected teachers’ self-reported
feeling of preparedness and had positive effects on both curriculum implementation and
student outcomes. Students in health education classes taught by trained teachers scored
significantly higher on health knowledge and attitude scores, and, at the senior high school
level, also on curbing self-reported use of illegal drugs, than those covering the same material
with untrained teachers (Ross et al., 1991).
16
t
!
Training teachers has the added value of gaining their commitment and support as well as
understanding of a specific curriculum and its supporting policies and program—all
important factors for successful implementation.
Moving from Research to Action
Figure I in the appendix elaborates on the evidence just described as it applies to specific
health issues and interventions. This figure highlights the effect on education of health issues
such as safe water and sanitation, helminth infections, nutrition, and lifestyle behaviors
associated with STDs, HIV/AIDS, and alcohol, tobacco and other drugs and gives evidence
that schools can address these issues effectively. Figure II provides an overview of illustrative
roles that educators and their collaborators can play to address selected health issues.
To make greater strides in the next decade to improve the health and education of the world s
children, this research and the directions it suggests must be made more accessible to
educators. State-of-the-art knowledge must move from the pages of technical journals to
discussions and debates in ministries, school buildings, classrooms, and communities. Only
when these findings and ideas become part of daily conversations among administrators,
teachers, and health workers will more attention be given to these important aspects of
successfill learning. Improvements in education will not succeed if we do not simultaneously
pay attention to the healthy development of both students and staff in schools.
apter
Forwi
I
IS for EFA 2015
With the research findings of the past ten years as a guide, the forthcoming decade shows
great promise for strengthening the links between health and education. The record of the last
decade affirms that the world community can translate its highest aspirations for children into
effective programs. If the past is indeed a prelude to the future, we can say with confidence
that the pace in responding to the learning and health needs of children greatly accelerates
once consensus has been achieved on policies and programs that work. We hope that the
following suggestions will encourage consensus on what countries must do to meet the health
and learning needs of their school-age citizens. These suggestions emphasize the
development of a shared vision, a commitment to act, a pledge to work collaboratively, and
the importance of a global effort to acquire and share information.
1. Major leaders and change agents in the field must come together around a common
framework, relevant to the education sector.
Such a framework should be part of a larger effort to improve the general quality of the
schools and the education children receive. The creation of frameworks in the past decade
(see Chapter V) contributed enormously to driving the school health agenda forward.
Frameworks have increased creativity, generated experimentation, and inspired a broad
range of research and program activities. At this juncture, however, we run the risk of
allowing the proliferation of so many frameworks to diffuse human and financial
resources and to confuse those who are ready to take action. A shared framework should
drive an action agenda that:
17
1) promotes healthy development and focuses on the most serious and common health
threats through the coordinated implementation of core components of a school
health and nutrition program in schools everywhere;
2) sets specific, quantifiable goals for the agenda;
3) applies lessons learned from the past decade on how best to implement the core
components; and
4) establishes indicators to monitor the implementation and effectiveness of the core
components in countries and schools worldwide.
A shared framework must view the school as a dynamic system in which people can
effect change to promote health and learning and which focuses not only on children but
staff, teachers, parents and community members, and links to health services.
2. To be successful, school health, hygiene, and nutrition efforts must be led by
educators, supported and assisted by health professionals, and made an integral part
of the efforts to improve education through policies and goals.
School health and nutrition efforts can have a powerful effect on improving the status of
schools (through efforts by schools and communities) as well as education (through
policies and goals). Much of the power of school health programs lies in their ability to
mobilize schools and communities around the improvement in educational quality and
outcomes fortheir children. Educators must be convinced that such programs are
practical and doable, yield results, are beneficial to staff and students, and advance
learning. It is equally important that leaders relate the efforts to the social and economic
agenda in gaining support. Recruiting a small but highly influential group of well-known
and respected international educators to champion the school health agenda would be
valuable.
3. We must continue to deepen and expand collaboration, especially between the
education and health sectors, with mechanisms that sustain and nurture joint
planning, action, and learning over time.
Experiments have taken place at the world, regional, and national levels to bring the
education and health sectors together. Where successful, these collaborations have created
a common language, provided unique contributions for sharing and learning, and
leveraged resources (e.g., Short, Talley, & Kolbe, 1999). However, sustaining the
collaboration is difficult. It is also important to identify and use the unique roles of
various participants. Collaboration does not mean that everyone does the same thing, but
each sector makes it unique contribution to common goals. Successful collaboration must
identify the most relevant role for the educator, the health worker, and the parent and
community members. More must be done to sustain emerging networks for collaboration,
providing professional development, resources, and materials to increase their capacity
and learning and to sustain energy and commitment in the face of obstacles.
4. More investment is needed in health services for children and adolescents that they
can reach easily, without stigma.
More health services should be located in or near schools and staffed with people trained
to work with youth. Young people all over the world need health services, particularly
those that are “youth friendly.” Traditional health services must move beyond medical
treatment to preventive services and early intervention and accommodate the particular
needs of young people (e.g., for emotional support, confidentiality, and accessibility).
18
i
5
Access to information as well as sustained support to use it (e.g., professional
development, technical cooperation, and mentoring) must be improved for
education and health workers.
Much is known about the effectiveness of various school health and nutrition programs.
Research findings could have a much greater impact if they were accessible to more
people We must try to extract key findings from the many excellent technical documents
that exist and make them available in simple, clear formats and multiple languages for
practitioners. There is a need for ongoing professional development and technical know
how for education and health workers about how to identify, select, and implement the
most effective strategies for their needs. A creative use of the Internet and online training
must be applied to the field of school health and nutrition on a global scale.
6. Multiple targeted and coordinated strategies are needed to improve desired
behavior patterns and health outcomes.
Research in public health, the foundation of most approaches to school health, has
demonstrated that multiple strategies coordinated to address a few common goals are
more effective in producing desired behavior changes and health outcomes than singletrack approaches. Such strategies may include coordinated policy, supportive
environments, community action, personal skills, and health services targeted to a few
selected conditions (WHO/Ministry of Health Indonesia, 1997).
7
Indicators that provide universal measures of progress are needed to focus efforts
and report changes that are possible to achieve by 2015.
While there has been tremendous progress since Jomtien, it is impossible to tell the full
story of what has happened globally without common indicators of progress. Such
indicators could provide information about national capacities and infrastructure to
implement school health programs. Measures could include the availability of school
policies and budgets with line items dedicated to health, mechanisms for collaboration,
and the health-related training of teachers and health workers. Beyond measures of
capacity, indicators of children’s health status could include height and weight data, rates
of anemia and other micronutrient deficiency diseases, and number of meals or fruit and
vegetable servings per day. At the national and local level, too, more and better program
planning and evaluation tools are necessary.
8. Model programs should be developed for different levels of investment because
countries vary in what they can afford.
We should identify the best package of inputs and services at different investment levels
(e g $2 $5, and $10 per child). For each “model package,” we should also identify the
expected benefits as precisely as possible. Such an approach will enable countries to
launch school health initiatives that are both efficacious and affordable.
Another observation must inform our efforts in the future. In many countries, people who are
very poor and disenfranchised have reported that their participation in addressing health
issues in schools has made a difference in their lives. The opportunity to have a voice and
role in creating change to improve the quality of life for their children, themselves, and their
community has transformed their world. In his book Development as Freedom, the Nobel
Prize-winner for economics Dr. Amartya Sen argues that reductions in poverty and progress
in economic development are possible only when citizens have the freedom or opportunity to
receive basic education and health care. With the participation of all—the education and
19
health sectors, parents, teachers, and community membera-people everywhere can make
gradual improvements in their quality of lite.
As we consider the changes that policy makers
XpmXSack
the future, it is good to> reflect °n deve opm
P
con tual frameworks
^^S»ttm.or trends that took place in the held ot
school health and nutrition since Jomtien.
The Status of Schoo. Health Leading Up
to lomtien
■
A Historical Perspective of the School Health Field
Mentational coHaboration in schoo! health
1800s, school health became an issue when
Europe. In 1880, the
in Enlss(.ls addressed school
eacb decade of the 1900s, the agenda of
Sio^S^nf^
hygiene for teachers, students, and families (Mott, 1995 Dra ).
Following a >946 survey
UNESCO prepared recommendations to P
B 19|7 n ofthe 94 countries
with the goal of making it a genuine
of
^health Education was compulsory in
replying to a second survey indicated that som
such as science education.
primary schools and was often Integra e 1^
J
effectively assisting children in
X"™ X—X —g their own health and that of
others (IBE, 1946; IBE/UNESCO, 1967).
k
the 1960s until the mid-1980s, international conferences and publications in the field of
catalytic for national and local efforts.
However, during this same period when school hutlth was less ™XfrMt“^Tng
stage, the developing world was making cons'derab 99^
™
of
6
the^survival rates of children from
children born (83%) lived to their first birthdayTJthe Child Survival
bom (92%) were expected to reach a.
school. An impoitanl
JS—:^iTwem^mailiand8improve children’s health to maximize
their learning?
20
By the end of the 1980s, a number of international organizations renewed their interest in
school health and nutrition programs around the globe. UNESCO was one of the first U.N
agencies to address the area of school health and nutrition. In the 1980s, UNESCO initiated
the Nutrition Education Series and held various technical meetings on this topic (Dolan,
1999- Hoffmann-Barthes, 2000). Also, the Council on Europe, the European Commission,
and WHO’s Regional Office in Copenhagen, were beginning conversations about a broader
concept of school health. These groups looked at all aspects of the school as a system and a
setting in which health could be promoted by those in it (Kickbusch, 1999). In the United
States with the support of the Centers for Disease Control and Prevention and backed by the
evaluations of several major school health education programs, the concept of a
comprehensive school health program with eight components became more widely
understood (Allensworth & Kolbe, 1987) and implemented (Kolbe et al., 1997).
As the 1980s came to a close, researchers around the world were beginning to evaluate the
effectiveness of specific health interventions to address nutritional deficiencies and the
treatment of intestinal worms, in particular, and, where possible, to examine the relationship
of health interventions to cognition, school attendance, and other factors in learning.
For
example in
For example,
in 1989
1989 an examination of the global distribution of parasitic worm infections
revealed that large parasitic burdens, particularly severe hookworm infection, were associated
with impaired cognitive function as well as poor educational outcomes, such as absenteeism,
underenrollment, and attrition (Bundy & Guyatt, 1989).
With these realities in mind, the Background Document for the World Conference on
Education for All argued that “the education sector needs to attend to the health needs of
children or they may be rendered ‘unteachable.’” It went on to say that “the adverse effects of
malnutrition and poor health on education may indeed be jeopardizing children s readiness to
enter school, their ability to learn, and the duration of their schooling. Addressing children s,
nutrition and health could make a difference in terms of improving educational performance
(Inter-Agency Commission, WCEFA, 1990b).
The Highlights of the Status of School Health in ISSO
While there was growing recognition of the need to address the health status of young people
to maximize learning leading up to Jomtien, what was actually happening in school health
policy and practice? Based on a synthesis of experts’ reflections and published studies,
school health efforts in 1990 can be characterized in the following ways:
I
I
I
I
1. Health initiatives in schools focused primarily on disease prevention.
2. There was confusion about the concept and definition of school health.
X Single, uncoordinated intervention strategies dominated.
4 Few, formal mechanisms for multi-sectoral collaboration were in place.
5’ Didactic, topic-by-topic teaching was the typical approach to health education.
6. Evidence of the effectiveness of interventions was not well known or disseminated.
7 Few tools to guide assessment and strategic planning were available.
8* Few donors earmarked school health programs as a priority for funding.
A brief discussion of each item follows.
21
A
1. Health initiatives in schools focused primarily on disease prevention.
Many school health efforts aimed to improve hygiene, prevent the spread of infections, treat
specific health conditions, and provide screening or medical exams. Many countries also
expanded their efforts to incorporate health topics into national curricula. Both the services
and curricular work tended to emphasize specific disease prevention more than health
promotion.
For instance, in 1987 Pakistan initiated a School Health Services Program and recommended
in its five-year plan that all children have a complete medical checkup when they enter school
and a comprehensive quarterly checkup as long as they remain in school. Pakistan’s
subsequent five-year plan (1993-1998) recommended that the program be reoriented toward
developing healthy lifestyles among schoolchildren, thus recognizing the need for a more
comprehensive and lifestyle-oriented approach (Memon, 1999). In 1990 Namibian schools
provided immunization, physical examinations, and a limited amount of information on
“health matters.” There were no policy guidelines yet, no provision for family life education
either for teachers or pupils, and the use of life skills education was at its very beginning
(WHO/UNESCO/UNICEF, 1992).
2. There was confusion about the concept and definition of school health.
As Donald Bundy of the World Bank commented, “There was considerable confusion about
the definition of school health and nutrition in 1990. Was the aim to promote health
education? Was it to use schools to deliver a service, such as nutritional supplements? Was it
to look at the broader structure and processes and conditions of the school environment?
There was even more confusion over whether the goal was to improve health, or to improve
education through improved health” (Bundy, 1999). Maria Teresa Cerqueira of the Pan
American Health Organization said, thinking primarily of Latin America, “The concept in
1990 was still bound to issues like hygiene or preventing Dengue fever, primarily physical
health issues. There was little attention to emotional or mental health. Parental and
community participation was minimal” (Cerqueira, 1999).
The confusion also affected the teaching of school health. Anna-Maria Hoffmann-Barthes of
UNESCO commented, “Health education, unlike other subjects in the curriculum, is one with
a history of involvement by people from outside of the education system, frequently health
professionals. The risks of such ‘outside ownership’ and subsequent lack of cooperation
between the education and health sectors are numerous. Education professionals have often
shown a certain disinterest in health issues; health professionals invited to teach about the
subject typically lack understanding of the pedagogy necessary for skill development and
behavior change and the effective implementation of school health education programs”
(Hoffmann-Barthes, 1999).
In 1990 health and education professionals usually defined school health and nutrition as
either health curriculum or health services, but seldom as the integration of the two. While
the importance of linking health instruction to services and other components was often
discussed, there was no unifying concept to galvanize all the participants to work together for
a truly global effort. Experience has shown that a powerful concept can create enthusiasm
and motivate policy-makers and practitioners to implement new ideas (Vince-Whitman,
1995). And, as David Rivett of the European Network of Health Promoting Schools said, “It
has been critical for us in Europe to have a concept or framework in place first. We have seen
how the framework has driven the agenda and provided a map for action in countries and
with local schools” (Rivett, 1999).
22
In 1990, at the international level, there was no one clear definition or framework across all
the agencies to guide their direction and activity. In the early 1990s a few more integrated
concepts began to appear. However, no matter what concept was used, school health and
nutrition were often regarded as separate and apart from the mission of basic education.
School health advocates often found themselves frustrated and unable to convince educators
of the importance and interdependence of health and education.
3. Single, uncoordinated intervention strategies dominated.
In 1990, and in some cases to this day, the field of school health and nutrition depended
primarily on single, uncoordinated strategies, which alone have limited potential for success.
Many school health efforts involved curriculum efforts that were not complemented by
policies or a supportive school environment. For example, teaching about the dangers of
tobacco took place in schools in which students and faculty were allowed to smoke.
Similarly, health services treated such conditions as intestinal worms, but often without
complementary improvements in sanitation and safe water or educational messages to
prevent re-infection. Seldom were approaches comprehensive, uniting policy with instruction,
services, and the school environment to reinforce one another in targeting specific health and
education outcomes.
Sheldon Shaeffer of UNICEF, who worked extensively in East Asia, commented, “Most of
the activities which I saw were limited to putting water supply and latrines into schools.
There may also have been a health education program in the same school, but it was not
coordinated with any other component of a school health program. The water and sanitation
effort was not accompanied by any reinforcing education strategy and there was no
evaluation of academic outcomes. There was no look at whether the provision of these
services increased enrollment (especially of girls) or general use of the facilities by students
or community members” (Shaeffer, 1999).
Too often there has been a vertical approach to a problem such as malaria. For example,
medical personnel will arrive at a school with the view that “malaria is your problem and this
is what you must do to treat it.” There has been little attempt to gain community participation
and support for the intervention. Therefore its acceptance and success are limited.
On the other hand, multiple strategies that are coordinated to address a few common goals
have proved effective. In the United States, for instance, Project Northland is a school
community substance abuse prevention program that includes planned parental involvement,
peer-led skills-building sessions, community policy change, and enforcement, all designed to
test the efficacy of a multilevel, multi strategy, multiyear intervention program for youth.
After three years, an evaluation demonstrated that the percentage of students who reported
alcohol use in the previous month and week was significantly lower in the intervention group
at the end of eighth grade than in the reference group (Komro et al., 1996; Perry et al., 1993;
Perry et al., 1996).
4. Few, formal mechanisms for multi-sectoral collaboration were in place.
In 1990 there were few cross-sectoral mechanisms in place at the world, regional, national, or
local levels. These mechanisms provide a way for partners to unite around common goals,
coordinate and leverage valuable resources, provide a forum for learning, and exchange
technical expertise. However, the education sector typically handled health instruction and
the health sector addressed services, with few linkages between the two. Agencies
23
responsible for water, sanitation, and the school’s physical structure have typically acted
independently of the other sectors.
Given the effectiveness of targeting multiple strategies to improve children’s health and
learning, collaboration is necessary across sectors (education, public health, medicine,
environmental services) and between agencies with common goals and interests
(governmental and nongovernmental agencies, national and international organizations). The
lack of such important structural mechanisms to expedite policy development and program
implementation, combined with confusion about a unifying concept, was the most critical
obstacle to progress in the field. Without such structures, it is difficult at any level to harness
the multidisciplinary expertise and resources necessary to achieve school health goals.
5. Didactic, topic-by-topic teaching was the typical approach to health education.
Most school health education programs have been concerned with providing information on
specific topics, not building skills (Hubley, 1998). A review of curricula from the early 1990s
reveals that they typically provided information about ten topics, almost all about physical
health or specific diseases, rather than building skills to practice healthy behaviors overall
(Hubley, 1998). Sexuality was usually omitted, as was any attention to emotional or mental
health; violence and suicide were not regarded as public health issues (Cerqueira, 1999).
A review of school health education in Europe in 1991 reported, “There is general agreement
in Europe over the range of health issues which need to be addressed in schools. There has
been a tendency, however, for school health education to be dominated by single health
issues—particularly drugs and AIDS—which has inhibited the whole-hearted adoption of the
holistic healthy lifestyle approach necessary for a balanced and convincing program in
schools” (Draijer & Williams, 1991).
While several innovative skills-based or life skills curricula had been developed during the
1980s, the primary teaching method continued to be the didactic lecture. It has now been well
documented that the teaching methods with the strongest likelihood of producing change in
the health behavior of students are interactive learning strategies or experiential learning
(Tobler, 1998 Draft).
Many in the field recognized the Child-to-Child approach as an outstanding program in
health education at the time of EFA (Hubley, 1998). Begun in London, the Child-to-Child
approach focused on teaching older children to deliver health messages to their younger
siblings through interactive methods. Gradually, the approach expanded to prepare children
to promote good health among their peers, families, and communities (Hubley, 1998). Childto-Child placed young people in an active teaching role.
6. Evidence of the effectiveness of interventions was not well known or disseminated.
Few evaluations were written about the effectiveness of health education curricula or any
other school health initiative. Those that did exist were disseminated primarily to health
education professionals rather than to the mainstream education sector or to professionals in
the public health or medical arenas. Similarly, research about health service interventions was
published primarily in journals aimed at the medical, nutrition, or public health sectors. There
were few opportunities for the two important audiences of educators and health workers to
learn together about the important link between health and education.
24
By 1990 a new body of research was emerging about the impact of health interventions on
the status of health and on cognition and learning outcomes. But the findings were not widely
disseminated.
At the time, the Internet was in its infancy, and the dissemination of information, especially
for developing countries, still relied almost exclusively on expensive printed documents,
most often available only in English.
7. Few tools to guide assessment and strategic planning were available.
Planning in public health, educational, and organizational development often begins with the
collection of data to define the problem and the assets or strengths to address it. From there,
planners can set measurable goals and objectives, then define action steps and milestones to
measure progress. In 1990 few, if any, assessment and strategic planning tools were available
for education policy-makers and program planners to collect and use data to plan policies,
programs, and interventions in an integrated and complementary manner designed for the
health needs of children and adolescents in school. Thus, educators in particular had little
information about the strengths and limitations of the many parts of a school health program
that could have guided them in selecting and developing effective intervention strategies. In
addition, there was limited information about the costs associated with implementing specific
interventions.
8. Few donors earmarked school health programs as a priority for funding.
While it is difficult to document, many in the field share the general perception that it was
hard to find departments within U.N. agencies and international nongovernmental
organizations with a title that seemed to include school health programs. It was also difficult
to find donors who had made it a priority to fund international efforts to improve school
health programs.
The field of school health and nutrition progressed considerably over the past decade.
Improvements involved the development of conceptual frameworks as well as various other
major trends and activities discussed in the next two chapters.
er1
icei
Frai
Since the World Conference on Education for All in Jomtien, a major accomplishment has
been the development of conceptual frameworks or unifying principles for school health
policies and programs. These frameworks have also served as a catalyst to mobilize
partnerships across sectors at all levels. In addition to the frameworks developed by U.N.
agencies and a few other international organizations, significant and noteworthy activity was
also conducted by frontline grassroot organizations in the past decade (Chandra-Mouli,
2000).
This chapter describes some of the major conceptual frameworks that have influenced the
school health and nutrition agenda over the past decade. Frameworks developed in the 1990s
include the concept of the Health-Promoting School (stimulated by the Ottawa Charter, 1986,
and advanced by the Council of Europe, the Commission of the European Communities, and
WHO/European office and WHO headquarters); the Child-Friendly School (UNICEF); the
Basic Cost-Effective Public Health Package (World Bank and the Partnership for Child
25
Development, University of Oxford,); and Active Learning Capacity (Levinger, EDC, for
USAID and UNDP). One framework, FRESH (Focusing Resources on Effective School
Health (WHO, UNICEF, UNESCO, World Bank), was launched jointly at the EFA
Conference in Senegal in April 2000.
The Framework of the Health-Promoting School
The concept of the Health-Promoting School (HPS) started in Europe. It is based on public
health theory and builds on the Ottawa Charter of Health Promotion (1986), which
recognized that “health is created and lived by people within the settings of their everyday
life; where they learn, work, play and love. Health is created by caring for oneself and others,
by being able to make decisions, and have control over one’s life and circumstances, and by
ensuring that the society one lives in creates conditions that allow the attainment of health by
all its members” (WHO, 1986). The European Regional Office of WHO, the Council of
Europe, and the Commission of the European Communities first widely promoted the
concept of the Health Promoting School. The aim was to achieve healthy lifestyles for the
total school population by developing environments conducive to the promotion of health.
The HPS concept extended beyond school health education to a broader array of
complementary interventions.
The earliest descriptions of the HPS, then called “the Healthy School,” were developed
during the first major conference of all the European nations on school health promotion in
Scotland in 1986. The model, described in a report by Young and Williams, featured an
overarching policy and three essential coordinated components: instruction, health services,
and a healthy school environment—both physical and psychosocial (Young, 2000). A similar
concept, the Eight Component Model, was developed in the United States by Allensworth
and Kolbe in an effort to explore whether the concept of the school health program should be
expanded. If coordinated, the following eight components of the model could have
complementary if not synergistic effects (Kolbe, 1986; Allensworth & Kolbe, 1987):
•
•
•
•
•
•
•
•
school health services
school health education
school health environment
integrated school and community health promotion efforts
school physical education
school food service
school counseling
school health promotion programs for faculty and staff
In the 1990s both of these frameworks guided many policy decisions and programmatic
efforts throughout Europe and the former Soviet Union and in the United States. As
documents and program descriptions were published, interest grew among international and
national health and education workers to apply them to the needs of a broad range of
countries.
To gain a thorough understanding of the status of school health worldwide and prepare
recommendations for improving health through schools, in 1994-95 WHO convened an
Expert Committee. EDC synthesized findings from hundreds of evaluation research and
feeder papers written by WHO’s staff and experts around the world. This initiative produced
26
/
the following four documents, published by WHO: The Status of School Health} Improving
School Health Programs: Barriers and Strategies} Research to Improve Implementation and
Effectiveness of School Health Programs} and Promoting Health through Schools.
The Expert Committee concluded that research in both developing and developed countries
demonstrates that school health programs can simultaneously reduce common health
problems, increase the efficiency of the educational system, and further public health,
education, and social and economic development in all nations. The committee made ten
recommendations to improve health through schools worldwide (see box).
Recommendations of the WHO Expert Committee
on Comprehensive School Health Education and Promotion (1995)
1. Investment in schooling must be improved and expanded.
2. The full educational participation of girls must be expanded.
3. Every school must provide a safe learning environment for students and a safe workplace
for staff.
Every
school must enable children and adolescents at all levels to learn critical health and
4.
life skills.
Every
school must more effectively serve as an entry point for health promotion and a
5.
location for health intervention.
6. Policies, legislation, and guidelines must be developed to ensure the identification,
allocation, mobilization, and coordination of resources at the local, national, and
international levels to support school health.
7. Teachers and school staff must be properly valued and provided with the necessary
support to enable them to promote health.
The
community and the school must work together to support health and education.
8.
School
health programs must be well designed, monitored, and evaluated to ensure their
9.
successful implementation and outcomes.
10. International support must be further developed to enhance the ability of Member States,
local communities, and schools to promote health and education.
Following the Expert Committee’s meeting and report in 1995, WHO launched its Global
School Health Initiative to support schools to become Health-Promoting Schools. Although
definitions will vary among regions, countries, and schools according to need and
circumstance, a HPS can be characterized as a school that is constantly strengthening its
capacity as a healthy setting for living, learning, and working.
A Health-Promoting School:
• Strives to improve the health of school personnel, families, and community members as
well as students.
• Fosters health and learning with all the measures at its disposal.
• Engages health and education officials, teachers, teachers’ unions, students, parents,
health providers, and community leaders in efforts to make the school a healthy place.
• Strives to provide a healthy environment, school health education, and school health
services along with school/community projects and outreach, health promotion programs
27
•
for staff, nutrition and food safety programs, opportunities for physical education and
recreation, and programs for counseling, social support, and mental health promotion.
Implements policies and practices that respect an individual’s well-being and dignity,
provide multiple opportunities for success, and acknowledge good efforts and intentions
as well as personal achievements.
WHO headquarters’ Global School Health Initiative uses four strategies to disseminate this
framework:
Consolidating research and expert opinion to describe the nature and effectiveness of
school health programs (WHO, 1996a; WHO, 1996b; WHO, 1996c; WHO, 1996d; WHO,
1997a).
• Building capacity to advocate for the creation of Health-Promoting Schools (HPS) and to
apply the components of a HPS to priority health issues, including helminth infections,
violence, nutrition, tobacco use, and HIV/STI (WHO, forthcoming; WHO, 1997c; WHO,
1998b; WHO, 1998c; WHO, 1998d; WHO, 1998 draft).
• Strengthening collaboration between the ministries of education and health and other
relevant organizations and national capacities to assess, plan, and implement policies and
programs to improve health through schools (WHO, 1998e; Vince-Whitman et al., 1997).
• Creating networks and alliances, including regional networks for the development of
Health-Promoting Schools and international alliances, such as among WHO, El,
UNESCO, UNAIDS, CDC, and EDC to strengthen the capacities of teachers’ unions to
prevent HIV/STI (WHO, n.d.; WHO, n.d.; El, 1998).
•
These strategies have been implemented in collaboration with other relevant programs and
departments within WHO, including the WHO Regional Offices, and with international
agencies that are interested in promoting the development of Health-Promoting Schools,
including Education International (El), a trade organization of about 25 million teachers
worldwide, and Child-to-Child Trust. The European Network of Health-Promoting Schools,
for example, has since 1990 enrolled more than 500 pilot schools with 400,000 students in 37
countries in Europe and the former Soviet Union (European Commission et al., 1996).
The Framework of the Child-Friendly School
Based on the Jomtien documents and a number of other developments in the field of
children’s rights, UNICEF has recently developed a framework of rights-based, child-friendly
educational systems and schools that are characterized by being “healthy for children,
effective with children, protective of children, and involved with families and communities—
and children” (Shaeffer, 1999).
This framework builds on the Jomtien conference’s proclamation that “education is a
fundamental right for all people, women and men, of all ages, throughout our world.”
Relevant to health, the declaration went on to say that “education can help ensure a safer,
healthier, more prosperous and environmentally sound world” (Inter-Agency Commission,
1990a).
UNICEF’s framework was also inspired by the Convention on the Rights of the Child, held in
1989, which set the stage by acknowledging that children’s rights require special protection
for the purpose of the general improvement of their conditions and for their development and
education.
28
f
UNICEF’s framework broadly defines core components that characterize a child-friendly
school, each component incorporating factors concerning education, health, and human
rights.
In a Child-Friendly School:
• The school is a significant personal and social environment in the lives of its students. A
child-friendly school ensures every child an environment that is physically safe,
emotionally secure, and psychologically enabling.
• Teachers are the single most important factor in creating an effective and inclusive
classroom. Child-friendly schools are teacher-friendly, supporting, encouraging, and
facilitating teachers toward being motivated, capable, self-confident, and consistently
available.
• Children are natural learners, but this capacity to learn can be undermined and sometimes
destroyed. A child-friendly school recognizes, encourages, and supports children’s
growing capacities as learners by providing a school culture, teaching behaviors, and
curriculum content that are focused on learning and the learner.
• The ability of a school to be and to call itself child-friendly is directly linked to the
support, participation, and collaboration it receives from families.
• Child-friendly schools have a key role to play in ensuring that children’s rights are
reflected throughout the education system, just as education systems must ensure that
schools have the resources to act on behalf of all children.
• The rights of children as articulated in the CRC are indivisible. They all apply, all of the
time, to all children. Schools and educational systems have a role in ensuring that
children’s rights are reflected throughout a country’s governance community. Child
friendliness is a broad public policy matter (Bernard, 1999 draft).
Child-friendly schools aim to develop a learning environment in which children are
motivated and able to learn. Staff members are friendly and welcoming to children and attend
to all their health and safety needs. WHO supports the framework of the Child-Friendly
School by helping schools become “health-promoting” as an essential step toward becoming
“child-friendly.”
The Framework of the Basic Cost-Effective Public Health Package
The concept that schools are in a position to deliver a basic package of health services to
students has been widely acknowledged during the 1990s. The appropriate level of services
for the schools to offer depends on each country’s operational and financial resources (Del
Rosso & Marek, 1996).
A 1993 World Bank analysis concluded that most regions of the world could greatly benefit
by implementing a limited package of five cost-effective public health elements. This
package could reduce 8% of the burden of disease in low-income countries for $4 per capita
and could reduce 4% of the burden in middle-income countries for $7 per capita (World
Bank, 1993).
The five elements are:
•
An extended program on immunization
29
•
•
•
•
School health programs to treat worm infections and micronutrient deficiencies and to
provide health education
Programs to increase public knowledge about family planning and nutrition, self-care or
indications for seeking care, and vector control and disease surveillance activities
Programs to reduce the consumption of tobacco, alcohol, and other drugs
AIDS-prevention programs with a strong component on other sexually transmitted
diseases (World Bank, 1993)
The WHO Expert Committee on Comprehensive School Health Education and Promotion
commented on this basic package that “[aljthough school health programs are explicitly
mentioned in only one of the above elements, for a large portion of the world’s population,
schools could efficiently provide all five elements of the recommended package” (WHO,
1997a).
The Partnership for Child Development, UNICEF, the World Bank, and other agencies have
used this framework to guide program development in countries around the world. In the
state of Sao Paulo, Brazil, a World Bank loan is helping to provide a broad range of school
based services including feeding programs, health and nutrition screening of schoolchildren,
nutrition and health education in the school curriculum, and school-based programs for iron
and vitamin A supplementation. A more limited package of services with low-cost, easy to
implement interventions is applied in Guinea, where almost no prior nutrition and health
programs for school-age children existed. The elements of a school-based health package in
Guinea initially include a deworming program and iron and iodine supplementation,
accompanied by education in health and hygiene (Del Rosso & Marek, 1996). Carefully
monitored school-based health and nutrition programs implemented by the Partnership for
Child Development in Ghana, Tanzania, India, and Indonesia have now shown that the
education sector is capable of delivering a simple health package (health education,
anthelmintics, and micronutrients) to large numbers of schoolchildren (50,000 to 3 million)
without the creation of specific infrastructures. These experiences suggest that the school
system can contribute to health delivery as long as the package is simple, demands little
school time, and is perceived as appropriate to local needs (PCD, 1997).
The Framework of the Child’s Active Learning Capacity
In the early 1990s, in support of the mission to achieve Education for All, Beryl Levinger of
EDC wrote for USAID and UNDP about the need to concentrate on improving a child’s
“active learning capacity” (ALC). Consistent with theories in education and the social
sciences, she defined ALC as “the child’s ability to interact with and take optimal advantage
of the full complement of resources offered by any formal or informal learning environment”
(Levinger, 1994). The importance of this definition lies in its belief that to maximize
learning, a child must be psychologically, emotionally, and physically well, able to
concentrate on and participate actively in the learning process, able to pay attention and
concentrate on tasks, and missing only a few days of school for illness or other reasons. The
ALC framework focuses on improving the quality of the child as one of the most important
factors in achieving the goals of Education for All.
This framework includes three primary variables: health and nutrition status, hunger level,
and psychosocial support. Health and nutrition status refers to both current and prior physical
or mental conditions, such as height for age, sensory abilities, nutritional status, and
30
2
helminthic infections that influence a child’s ability to take optimal advantage of learning
resources and opportunities. Temporary hunger, especially if a child is malnourished,
contributes to a child’s distractibility, inattentiveness to environmental stimuli, and adaptive
behaviors of passivity and inactivity, all of which impinge on the development of a child’s
ALC. Psychosocial support encompasses the degree to which parents, caretakers, community
leaders, and other significant adults, community institutions, as well as values and norms
encourage a child’s independence and inquisitiveness and support expectations that favor
overall learning as well as formal schooling.
Three variables are considered secondary in determining active learning capacity: prior
learning experience, a child’s learning receptiveness, and a child’s aptitude for learning.
Prior learning experience refers to a child’s exposure to formal and informal situations
conducive to acquiring new knowledge and skills, such as preschool programs. Learning
receptiveness refers to a child’s motivation and attention, which are influenced by health
status and hunger level, as well as by the quality of the child-caretaker relationship. Aptitude
relates to the time a child needs to learn a particular task, attend to stimuli, and concentrate.
The ALC framework represents a dynamic portrayal of the complex interplay among the
determinants of educational outcomes, capturing the high degree of influence that health,
nutrition, sensory impairment, and temporary hunger exert on the quality of the child and
hence on the child’s learning outcomes (Levinger, 1994).
This framework was used widely by the South African Active Learning Network, a group of
NGOs, to develop materials, protocols, and broker links between the health and education
sectors. Among the entities that participated were CDDA, WHO, UNICEF, the World Bank,
and USAID. Many of the Network’s activities were designed to promote the ALC model or
to further its application.
Some of the most important lessons learned in recent years are the need for multisectoral
collaboration and cooperation in order to move toward the health and educational goals of
Education for All. “Indicators of a favorable policy setting include a demonstrated ability to
secure interministerial cooperation; a coordinated, intersectoral approach to human
development; a history of support for community-based health and education programs; and a
commitment at the highest political levels to programs that address questions of equity as
well as growth” (Levinger, 1994).
For instance, during the past decade, the World Bank coordinated information to enhance the
quality of school health and nutrition programs through its International School Health
Initiative. Its experiences of good practice suggest that school-based health and nutrition
programs should be simple and locally relevant. The following items have been suggested to
contribute to such programs: life skills training, health services, school snacks fortified with
micronutrients, an exemplary school environment, equitable school health policies, and
strategies beyond the school (Dolan, 1999).
A shared framework and strategy for action often form the foundation of successful
collaboration. Even when there is no one unifying framework, collaboration is more likely
when the participants at least understand and respect one another’s language.^ni^hed^and
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frameworks. In either case, the partners can identify their unique strengths in the context of a
framework and channel their specific contributions to move a shared agenda forward.
As the decade draws to a close, some of the major leaders and change agents at the world
level are coming together to discuss how they might build on the frameworks since Jomtien
and collaborate on a common framework for school health, such as FRESH. Such
collaboration may allow partners to harness their considerable human and financial resources
more effectively to address the health needs of a greater number of children and adolescents
in schools around the world.
The FRESH Framework: A Concerted Effort to Focus Resources on
Effective School Health
A framework proposed jointly by WHO, UNICEF, UNESCO, and the World Bank suggests
that there is a core group of cost-effective components that could form the basis for
intensified and joint action. These agencies are now developing a partnership to Focusing
Resources on Effective School Health (FRESH), launching it at the Education for All
Conference in Senegal in April 2000.
Each component of the framework stresses that a young person’s health is one of the many
important factors that must be adequately addressed to achieve any country’s educational
goals. As Bundy comments, “Good health and good education are not ends in themselves, but
rather means which provide individuals with the chance to lead productive and satisfying
lives. School health is an investment in a country’s future and in the capacity of its people to
thrive economically and as a society” (Bundy, 1999).
Building on the frameworks developed in the past decade, this shared view serves as a basis
for an effective school health and nutrition program. Its four components are intended to be
made available together in all schools.
•
Health-related policies in schools: Health policies in schools, including policies for
skills-based health education and the provision of some health services, can help promote
the overall health, hygiene, and nutrition of children. Good health policies should also
ensure a safe and secure physical environment and a positive psychosocial environment
and should address issues such as the abuse of students, sexual harassment, school
violence, and bullying. By guaranteeing the continued education of pregnant schoolgirls
and young mothers, school health policies will help promote inclusion and equity in the
school environment. Policies that help to prevent and reduce harassment by other
students, and even by teachers, also combat the reasons that girls withdraw or are
withdrawn from schools. Policies regarding the health practices of teachers and students
can reinforce health education by requiring that teachers do not smoke at school and thus
act as positive role models for their students. The process of developing and agreeing on
policies draws attention to these issues. The policies are best developed by involving
many levels, including the national level and teachers, children, and parents at the school
level.
•
Safe water and sanitation facilities: It is a realistic goal in most countries to ensure that
all schools have access to clean water and sanitation. Without clean water and adequate
sanitation, hygiene education is meaningless. The school environment may even damage
32
the health and nutritional status of its children if it increases their exposure to hazards
such as infectious diseases carried by the water supply. By providing clean water and
sanitation, schools can reinforce the health and hygiene messages and act as an example
to both students and the wider community. This in turn can lead to a demand from the
community for similar facilities. Sound construction policies will help ensure that
facilities address issues such as gender access and privacy. Separate facilities for girls,
particularly adolescents, are important in reducing dropout at menses and even before.
Sound maintenance policies will help ensure the continuing safe use of these facilities.
•
Skills-based health education: This approach to health, hygiene, and nutrition education
focuses on the development of knowledge, attitudes, values, and life skills needed to
make and act on the most appropriate and positive decisions concerning health. Health in
this context extends beyond the physical to include psychosocial and environmental
health issues. The development of attitudes toward gender equity and respect between
girls and boys and the development of specific skills, such as dealing with peer pressure,
are central to both an effective skills-based health education and positive psychosocial
environments. With these skills, individuals are more likely to adopt and sustain a healthy
lifestyle during their schooling and for the rest of their lives.
•
School-based health and nutrition services: Schools can effectively deliver some health
and nutritional services as long as the services are simple, safe, and familiar and address
problems that are prevalent and recognized as important in the community. If these
criteria are met, then the community sees the teacher and school more positively, and
teachers see themselves as playing important roles. For example, micronutrient
deficiencies and worm infections may be effectively dealt with by infrequent (half yearly
or annual) oral treatment; changing the timing of meals or providing a snack to address
short-term hunger during the school day—an important constraint on learning can
contribute to school performance; and providing eyeglasses will allow some children to
participate in class fully for the first time.
Within this framework, these four components are intended to be supported by effective
partnerships between teachers and health workers, effective community partnerships, and
pupil awareness and participation (WHO, UNESCO, UNICEF, World Bank, to be presented
at EFA 2000, Dakar).
Chapter VI; Major Global Trends; Developments since Jomtien
Chapter IV described the status of the school health field leading up to Jomtien. This chapter
shows some of the major trends, events, and activities that have happened over the last ten
years. With a scope as broad as a decade and a platform as enormous as the world, only
selected examples are given. Figure III, in the appendix, lists selected online resources for
school health and additional information. Figure IV provides examples of major trends and
activities, barriers, and future actions for the field of school health across regions and
countries.
33
Several major global trends over the past decade have dramatically influenced the scope and
direction of school health work:
1. The AIDS pandemic stimulated a new demand and urgency for school health.
2. There was a gradual move from individual to multiple strategies and to integrated
and coordinated approaches to school health programs.
3. New mechanisms for multi-sectoral collaboration have emerged.
4. Student and community participation has been an important factor in promoting
school health.
Skills-based
methods for health education have gained recognition and greater use.
5.
6. The documentation and dissemination of evidence of effectiveness have increased.
7. New tools for assessment, planning, and monitoring have been tested.
8. Both, donor recognition of the field and investment have increased.
9. International conferences have addressed school health.
10. Various barriers still exist that can hinder future progress toward effective and
sustained school health and nutrition interventions.
To explain more fully:
1. The AIDS pandemic stimulated a new demand and urgency for school health.
A defining characteristic of the 1990s has been the influence of the HIV/AIDS pandemic on
school health policies and programs. The tragedy of this disease left many children as
orphans and many teachers and students dying. While this pandemic closed the school door
to many children and teachers affected or infected by it, it also opened many doors to school
health programs (Dick, 1999).
Because education to increase protective behaviors is one of the few measures available to
prevent HIV, and because prevention ideally should begin before the onset of sexual activity
or alcohol and drug use, schools became a very important setting for delivering life-saving
interventions to children and adolescents worldwide.
As educators and health workers began to plan and implement school-based efforts to prevent
HIV infection, many in the field were asking what strategies were most likely to motivate
people to adopt protective behaviors. Such questioning, in the face of the threat of HIV
infection, led to reviews of lessons learned from health education, sex education, family life,
and reproductive health education; increased calls for the implementation and improvement
of such programs; the innovative use of skills-based methods; the cross-fertilization of ideas
and strategies among experts; and the involvement of young people in designing and
delivering programs. UNESCO, for example, launched a global Program of Education for the
Prevention of AIDS, which focuses on integrating HIV/AIDS education into school curricula.
Its main goal is to put in place large national programs that draw on the experiences of other
projects and programs. UNESCO’s resource centers disseminate numerous materials and
documents on HIV/AIDS education, along with seminars and training for ministerial staff
and teachers (Dolan, 1999).
Since Jomtien, the following types of activities illustrate how the complex and sensitive
issues surrounding HIV/AIDS served as an impetus for strengthening national, regional, and
global efforts to improve health through schools:
34
7
On a national level'. In Zimbabwe, which has one of the highest rates of AIDS cases on the
African continent, the Ministry of Education and Culture initiated an AIDS Action Program
targeting students and teachers in grades 4-7. More than 2,000 teachers have been trained to
use not only specified AIDS education materials, but also participatory life skills methods.
National programs fostered by UNICEF and focusing on life skills have strengthened school
health efforts by helping teachers: explore their own attitudes and values about health,
establish an open and positive classroom climate, place education about HIV AIDS in the
context of a general program on health, personal development, and living skills, and use
positive approaches that emphasize an awareness of values, assertiveness, and other
relationship skills (Gachuhi, 1999).
On a regional level: In 1993, participants in the Inter-Country Consultative Meeting on
Comprehensive School Health Education, convened by the South East Asia Regional Office
of WHO, recommended that in view of the physical, social, and psychological needs o
children,’adolescents, and youth and the emerging health problems such as AIDS/STD, drug
and alcohol and tobacco use, comprehensive school health education be given the status of a
separate subject in the school curriculum, in addition to being integrated into other relevant
subject areas. Furthermore, the participants recommended that because comprehensive school
health education cannot be implemented effectively by teachers without appropriate training,
every member country in the South East Asia Region should give priority to such training,
including adequate financial support for strengthening pre-service and in-service training in
health for teachers (WHO, 1993).
On a global level: In 1995, El, WHO, UNESCO, and UNAIDS, in collaboration with CDC
and EDC, created an alliance to increase the interest and involvement of teachers unions in
HIV/AIDS prevention and in strengthening school health programs. In July 1998, at El s
Second World Congress, teachers’ unions from around the world adopted a resolution on
Health Promotion and School Health. It calls on EFs member organizations to:
•
•
Play an active role in the elaboration of school health education policies in close
collaboration with the ministries of education and health.
Take more account of the crucial role that the school system and workers in
education can play through health education to prevent HIV/AIDS and STDS and
drug abuse.
...
.
A
Become more involved at every stage of the conception, implementation, ana
evaluation of school health programs.
. Take action to ensure that all educational workers receive initial and in-service
training, enabling them to promote health and health education.
• Combat all forms of discrimination and exclusion affecting students or workers in
because of their genetic
education affected by HIV/AIDS or <excluded
-------------characteristics.
• Establish or develop contacts with parents and health professionals at the local or
national level.
• Commit themselves, especially in the framework of the Health Promoting School,
to make the school a healthy place that offers a reliable infrastructure to guarantee
protection from diseases, violence, and harmful substances.
•
Such actions show an increased recognition of the need for and value of working
collaboratively to address HIV/AIDS while also improving school-based efforts that address
other issues affecting health and learning. For instance, the use of tobacco and other
I
l
35
I
psychoactive substances has also stimulated interest and action in the field of school health
during the past decade, especially in the Eastern Mediterranean and the Western Pacific
regions. Often, however, efforts were implemented as separate, vertical programs (ChandraMouli, 2000).
2. There was a gradual move from individual to mu Itiple strategies and to integrated
and coordinated approaches to health education.
During the 1990s, frameworks evolved that included multiple strategies—rather than
individual approaches—to promote health and nutrition through the schools. For instance,
WHO’s Health-Promoting School model and its supporting tools (such as Local Action:
Creating Health-Promoting Schools) involve various participants at the school level to foster
health and learning with all the measures at their disposal. In UNICEF s Child-Friendly
Schools Framework, the school culture, teaching behaviors, and curricula content are all
conducive to learning and learners.
In the United States, the book Health Is Academic outlines the concept and components of
coordinated school health programs (http://www.edc.org/HealthIsAcademic). It was
developed by EDC, with funding by CDC/DASH, and reviewed by more than 300
professionals before it was published in 1998. This book and other efforts have had a marked
effect on moving national school programs toward a coordinated approach to school health.
The tendency toward more integrated and coordinated approaches to school health is likely to
continue and will balance content from traditional disciplines. Health education can be
coordinated with or integrated into other subjects such as science, technology, physical
education, home economics, and social studies.
There are some notable examples of implementing coordinated school health initiatives with
multiple strategies, which can both inspire and guide the field in the decade to come. For
instance:
• The Ministry of Health in Guinea, in collaboration with other agencies, developed the
following components for their Equity and School Improvement Project (PASE), using
data from baseline studies and the World Bank’s International School Health Initiative s
planning framework: teacher development in the areas of helminth treatments, health
education, and referral for health services; and health services in the schools to include
antihelminth drugs, iodine, and iron supplementation. Central to this project is
community partnership and partnership across sectors. A 1997 process evaluation study
revealed that the program was viewed positively by 99.3% of children and 100% of
schools and had an impact on enrollment, re-enrollment, and increased participation by
parents. Expansions are planned to include antimalarials, vaccination, reproductive
health, and HIV/AIDS/STD education, campaigns to combat substance abuse, and
measures to reduce hunger (PCD, 1999g).
• The county of Lianjiang, China, launched a comprehensive approach to creating HealthPromoting Schools in rural China, starting with deworming. The project included guiding
policy, collecting baseline data, training staff, mobilizing the community, two intervals of
deworming services, improving the latrines and safe water supply, and related health
education activities. Evaluations of this approach showed reductions in helminthic
infections and egg contamination in school environments and positive changes in the
students’ knowledge and preventive behaviors (Xu et al., 2000).
• A U.S. high school set up integrated services that included individual and family
counseling, primary and preventive health services, drug and alcohol abuse counseling,
crisis intervention, employment counseling, training, and placement, summer and part-
36
time job development, recreational activities, and referrals to health and social services.
During the first two years of the program, the number of births among the students in this
school dropped from 20 to 1, dropouts were reduced from 73 to 24, and suspensions were
reduced from 322 to 78 (Knowlton & Tetelman, 1994).
3. New mechanisms for multi-sectoral collaboration have emerged.
During the 1990s it became increasingly apparent that in order for schools to improve health,
international, national, provincial, and local agencies, education and health professionals and
parents and communities will need to work together on behalf of young people (Kolbe et al.,
2000). A recent survey of donors and agencies found that “there is a move towards inter
agency school health planning, monitoring and evaluation, particularly in the U.N.. This
reflects a move by the U.N. system and bilaterals towards a sector-wide approach to funding,
and away from a project approach” (Dolan, 1999). For instance, a situation analysis that
includes assessments of adolescents’ needs and responses was developed as an interagency
activity by UNDP, UNESCO, UNFPA, WHO, and PCD and has been evaluated by WHO in
Ghana, Zimbabwe, Botswana, Uganda, and Kenya (Dolan, 1999). The World Bank’s
International School Health Initiative has helped to create global partnerships that focus on a
common school health agenda (Bundy, 2000). Agencies and donors have also expressed
interest in a school health Web site and mailing list, as is currently being developed by PCD
with the World Bank, which will provide a vehicle for greater collaboration (Dolan, 1999).
The Partnership for Child Development has established programs that emphasize the
development of national collaborations as a part of locally managed programs, the core of
which is the essential partnership between the health and education sectors. There are now
PCD research programs or activities in more than 14 countries around the world that are
supported by a broad range of international agencies (UNDP, WHO, UNICEF, World Bank),
bilateral agencies (USAID, UKDFID), and charities (Rockefeller Foundation, Edna
McConnell Clark Foundation, James S. McDonnell Foundation, Wellcome Trust, and Save
the Children Federation). The Partnership was set up to develop the intersectoral
collaborations necessary to establish or strengthen school health programs. This international
initiative helps to provide technical assistance and support so that low-income countries can
monitor and evaluate the costs, processes, and impact of these programs (PCD, 1999f).
A major new global partner is Education International. Established in 1993, El represents
more than 25 million teachers and workers in the education sector, and more than 250
teachers’ unions in 150 countries are affiliated with El. El has adopted resolutions to promote
health and nutrition for its membership and has also participated extensively with WHO,
UNAIDS, UNESCO, and HHD/EDC in providing professional development on health
promotion for members and HIV prevention initiatives.
Stimulated by WHO headquarters, WHO regional offices, and others, networks have emerged
as a means of communication and technical support. Regionally, networks of persons
responsible for school health from both the education and health sectors have been created to
share experience and foster collaboration across sectors. One of these networks is the
European Network of Health-Promoting Schools, a consolidating initiative between the
health and education.sectors (European Commission et al., 1996). WHO’s Mega Country
Health Promotion Network serves as a new mechanism to foster cooperation between the
ministries of education and health in the 11 most populous countries, which face the common
problem of size. In the E-9 Initiative, sponsored by UNESCO, UNICEF, and UNFPA, leaders
of the 9 most populous developing countries pledged to universalize primary education and
37
reduce illiteracy in their respective countries. However, such intra- and intercountry networks
do not yet involve every country.
On a national level, collaboration between the health and education sectors has been critical
to program development. National intersectoral coordinating committees have been formed in
a number of countries, including Samoa, Cambodia, Indonesia, and Laos (Lin, 1999). In Viet
Nam, the School Health Insurance was introduced in 1995 as a joint effort of the Ministry of
Health and the Ministry of Education and Training. This collaborative achievement enabled
the government to respond to two major concerns of Viet Namese parents: the protection of
their families against adverse consequences of their children’s ill health, and the creation of
school conditions and programs that are conducive to health and that help children and their
families stay healthy (Carrin et al., 1999).
4. Student and community participation has been an important factor in promoting
school health.
During the 1990s, many publications and actions have recognized and strongly supported
youth and community involvement as important for effective school health and nutrition
programs. WHO’s Adolescent Health Program concluded that youth involvement ensures
project relevance, acceptability, dedication to project objectives, long-term effectiveness, and
personal development for the young participants (WHO, 1997d; WHO/UNFPA/UNICEF,
1995). A paper prepared for the Conference on Comprehensive Health of Adolescents and
Youth in Latin America and the Caribbean in 1996 states that “involvement of youth is
critical at every step along the way” (Burt, 1998).
The European Network of Health-Promoting Schools (ENHPS) has published many case
studies that show how students have been involved in planning, implementing, and evaluating
various school projects. In Gandrup school in Denmark, students have been involved in
planning. The pupils, who claimed that they learn more when they are able to influence the
choice of subjects, discussed the WHO definition of health and then identified conditions
they wished to change in their school life, the community, or their own lives (Jensen, 1997a).
In another project at the same school, students were involved in implementing programs.
Fourth-grade pupils taught second-graders. This project showed that “pupil participation is a
key prerequisite of sustaining their involvement and motivation” (Jensen, 1997b). In a school
in Finland, students were actively involved in the evaluation of a school democracy project in
which they evaluate themselves, their actions, and their progress twice a year. “This is
important to the young people because they can compare themselves with the prevailing
norms and then decide themselves in which ways they want to improve or change.” Feedback
from teachers, pupils, and others has proved that this project is worth continuing (Poentinen,
1998).
Family and community involvement has also been strongly supported during the past decade.
A recent U.N. study included community and family involvement as a vital factor for
“programs that work.” Community members must be recognized as central actors rather than
passive beneficiaries. In Tanzania, for instance, severe malnutrition disappeared during a
program whose feature was growth monitoring in the community (UNICEF, 1998).
Active community participation has also played an increasingly prominent role in effective
collaboration. An extensive analysis of the progress in the development of education in
Africa found that “the role of communities as providers of education is becoming more
complex and more substantive. ... Communities are becoming involved in matters previously
38
regarded as within the domain of professionals and ministries. Communities are currently
involved in the recruitment of teachers, the negotiation of teacher salaries, teacher
management (Guinea, Cameroon, Senegal, and Tchad), school management (Cote d’Ivoire,
Zanzibar, and Tchad), the selection of school curricula (Zanzibar), school mapping (Cote
d’Ivoire, Gambia), financial management (Madagascar, Tanzania), and the establishment and
management of preschools (Zanzibar). There appears to be a partial shift of the locus of
action and control from the central ministries to the communities” (ADEA, 1999, p. 64).
Local expertise is also indispensable to effective programs and to identifying and solving
local problems. Africa, for example, has a wealth of community associations, including
parent-teacher associations, that can channel community participation and responsibility. The
early involvement of such organizations in developing a program maximizes the
community’s commitment and the program’s sustainability. In Ghana, communities
“revealed not only their interest in alleviating the health and nutrition problems of their
school-age children but also a willingness to help pay for these services” (Del Rosso &
Marek, 1996, p. 36).
5. Skills-based methods for health education have gained recognition and greater use.
Research has demonstrated the effectiveness of skills-based approaches in promoting healthy
choices and in preventing or delaying risk behaviors. Such skills include refusal,
communication, critical thinking, and other life skills. Interactive methods, which give young
people in the classroom the opportunities to practice these skills with regard to important
health issues, are the most critical factor in achieving success. Increasingly, schools are
giving priority to teaching life skills. Numerous products have emerged to support skillsbased approaches. Many countries (e.g., Zimbabwe, Cameroon, Colombia, Costa Rica) have
carried out skills-based health education projects. Uganda, for example, launched a very well
planned, comprehensive school health initiative. Along with creating a network of health
educators at the district level for health education activities, skills-based health education was
integrated into the basic science curriculum and also became part of the examination process
(Hubley, 1998). In September 1999, the Pan American Health Organization convened a
conference with Latin American and Caribbean countries to plan how to strengthen skillsbased health education in the region.
6. The documentation and dissemination of evidence of effectiveness have increased.
The past ten years have seen an explosion in the number of documents published by
international organizations to report on the effects of single interventions, such as treatments
for intestinal worms or nutritional deficits to reduce health problems and improve learning.
Others, such as Promoting Health Through Schools, Report of a WHO Expert Committee on
Comprehensive School Health Education and Promotion (WHO, 1997a) and Class Action:
Improving School Performance in the Developing World Through Better Health and
Nutrition (Del Rosso & Marek, 1996), have synthesized the findings of hundreds of studies to
inform and convince policy-makers and practitioners that the status of a child’s health is a
critical variable in achieving the goals of Education for All. One of the greatest innovations
of the past decade is the use of the World Wide Web for global knowledge sharing. The Web,
relatively untapped for school health in 1990, is broadly disseminating evidence of the best
practices worldwide in timely and cost-effective ways. For instance, the Partnership for Child
Development and the World Bank are currently developing a Web site and moderating an email discussion list for donors, agencies, and governments in order to share school healthrelated experiences, research, programming, and related issues:
http://www.ceid.ox.ac.uk/schoolhealth (Dolan, 1999).
39
Figure III in the appendix lists many of the agencies and organizations that have gone online
to promote school health among a larger and more diverse audience via the Web.
7. New tools for assessment, planning, and monitoring have been tested.
Several tools have been pilot tested, including those for:
(1) Situational Analysis, developed by the Partnership for Child Development in
collaboration with other agencies, including UNICEF, the Edna McConnel Clark
Foundation, WHO, USAID, PAHO, and the World Bank (http://www.ceid.ox.uk/
schoolhealth/download%20documents.htm). The goal of the situational analysis is to
guide the design and evaluation of school-based health and nutrition programs.
(2) Rapid Assessment and Action Planning Process (RAAPP), initiated by WHO, PAHO,
HHD/EDC, El, and national agencies in Indonesia, Bolivia, and Costa Rica. Consistent
with the HPS framework, RAAPP includes instruments, data collection, analysis
procedures, and strategic planning tools. Its purpose is to assess and strengthen a
country’s infrastructure to support school health programs (Vince-Whitman et al., 1997).
Rapid Assessment Tools have also been used by various other WHO programs recently
(e.g., WHO, n.d.).
(3) UNESCO/WHO Survey on National School Health Policies, administered by
UNESCO in December 1999, includes items to assess which ministries are responsible
for school health issues and the existence of national policies relating to the school
environment, school health services, and the teaching of health in primary and secondary
schools. Preliminary findings were presented at the World Education Forum 2000
(UNESCO, n.d.; Birdthistle, 2000)
(4) Health Behavior in School-Aged Children (HBSC), developed by WHO/EURO and
adopted by more than 25 countries to monitor health and health-related behaviors and
social influences on young people (Wold & Aar, 1990; Wold, 1993; http://www.unibielefeld.de/gesundhw/hbsc/intpub.html ).
(5) Youth Risk Behavior Survey (YRBS), developed by the Division of Adolescent and
School Health of the U.S. Centers for Disease Control and Prevention and piloted in more
than 10 countries, including China and the Russian Federation. The YRBS collects data
through schools that describes the prevalence of high-risk behaviors among young people
(http://www.cdc.gov/nccdphp/dash/yrbs/index.htm ). Its purpose is to monitor whether
these behaviors change over time (Kolbe et al., 1993).
(6) The joint UNESCO-UNICEF International Assessment Survey Project helps
countries to collect empirical data describing health-related learning outcomes and healthrelated teaching and learning conditions in schools. Two prototype instruments have been
developed: (1) Monitoring Learning Achievement (MLA), which has a specific section
labeled “life skills” containing questions about health-related knowledge; and (2)
Conditions of Teaching and Learning (CTL), which contains questions about school
facilities and health, safety, and security measures taken by schools. The surveys provide
nationally representative data obtained from fourth-grade students (stratified random
samples). They have been adapted and implemented in approximately 40 countries as part
of the EFA 2000 assessment (Chinapah, 1997).
40
(7) School Health Policies and Programs Study (SHPPS), developed by the U.S. Centers
for Disease Control and Prevention to monitor improvements in eight components of the
school health program throughout the United States
(http://www.cdc.gov/nccdphp/dash/shpps; Kolbe et al., 1995).
The use of each of these tools has been fairly limited. Still needed are instruments to monitor
progress worldwide, based on common and comparable data items and data collection
methods.
In the coming decade, FRESH partners plan to work collaboratively to strengthen the
monitoring and evaluation of school health efforts, using and adapting the tools mentioned
above.
8. Both, donor recognition of the field and investment have increased.
Donors and philanthropic agencies appear to have an increased commitment to providing
financial and technical support for improving health through the schools. A survey of donor
and agency support for school-based health and nutrition programs found that increased
donor interest and investment in the health and nutrition of the school-age child was most
apparent in the U.N. system but also appeared in some of the bilateral organizations and
increasingly among NGOs (Dolan, 1999). Some samples include:
•
•
•
•
UNICEF currently supports a range of school health programs in water, sanitation, and
hygiene; life skills/AIDS; child-to-child and extracurricular activities; and health and
nutrition, including the provision of micronutrients, anthelmintics, and malaria tablets.
The World Bank’s investment has primarily been through educational projects, but also
through health, nutrition, and social protection credits. The Bank has created a specific
school health thematic group and has a specific school health initiative for Africa. An
increased investment in school health is also expected through a partnership on this issue
with PAHO for Latin American countries (Bundy, 2000).
The Canadian International Development Agency is a leading donor in nutrition
programming. Since 1992, CIDA has contributed more than $87 million to nutrition
projects and an additional $120 million to integrated projects that combine nutrition with
health, basic education, and income generation activities.
CARE supports a range of school health and nutrition projects, including school health
education in Kenya using Child-to-Child approaches; a school nutrition project with
community-based activities in Laos; and a Children’s Health and Environment magazine
project in Thailand (Dolan, 1999).
For more detail about a broad range of school health and nutrition programs carried out and
financed by donor agencies, refer to the “School Based Health and Nutrition Programs:
Findings from a Survey of Donor and Agency Support, Carmel Dolan, 1999”
(http://www.ceid.ox.ac.uk/schoolhealth/download%20documents.htm ).
9. International conferences have addressed school health.
During the past decade, many major international conferences brought together important
leaders and change agents and gained international attention. School health issues were
addressed in various contexts as part of these conferences. Figure V gives an overview of
selected conferences and the school health issues they addressed.
41
10. Various barriers stil! exist that can hinder progress toward effective and sustained
school health and nutrition interventions.
Despite the encouraging global trends of the past decade, barriers, controversies, and missed
opportunities continue to impede the implementation and effectiveness of school programs at
the national and local level. Significant work is still needed to make the hope of a HealthPromoting and Child-Friendly School a reality for most schools.
Country and regional representatives around the world reported the following national
barriers:
• The absence of political concern and national legislation to support school health
programs.
• The lack of a well-defined national strategy and policies for the promotion, support,
coordination, and management of school health programs.
• Limited funds allocated for school health programs or the inequitable distribution of
existing resources.
• Weak links between the health, education, and other relevant sectors.
• The failure to escalate pilot projects to large programs.
• The lack of data, particularly relevant disaggregated data, helpful to program planning.
Obstacles to effective partnerships for school health were identified by participants in the
World Education Forum in Dakar, Senegal:
• Different mind-sets and ways of thinking about conceptual frameworks
• Cultural barriers
• Competition for funding
• Hostility toward partnerships
• A lack of clear guidance in creating effective partnerships
Obstacles repeatedly identified at the local and school levels include:
• A lack of awareness and support for school health programs.
• An inability to sustain the quality and even the existence of school health programs.
• The overcrowding of pupils in schools and of content in the curriculum.
• A scarcity of trained people (including teachers) to implement school health programs.
• The inadequate supply and production of teaching and learning materials and resources,
including supplies, books, and equipment.
• Limited or no funding to support health activities.
• A lack of monitoring and evaluation of current school health programs.
• The deterioration of the initial positive effects of many school health interventions due to
unsupportive conditions in the school and its surrounding environment (e.g., the
availability of drugs, tobacco, and alcohol; messages in the media that contradict
messages promoted at school).
Finally, many schools still exemplify unhealthy living, where teachers and sometimes
students smoke, where the only food choices are unhealthy, dirt is prevalent, and harassment
is unchecked. There is an urgency and opportunity to use the knowledge, momentum, and
international commitment gained since Jomtien to tackle the operational challenges that
impede progress within both countries and schools.
To overcome these barriers, strong and genuine partnerships at all levels—i.e., between
different sectors, between governmental and nongovernmental agencies, between teachers
42
and health workers, between school and parents and the larger community—are critical to
successful school programs. To make partnerships work, it is important to remember the
common denominator that connects the various sectors, disciplines, and specialists: the larger
social development agenda and the welfare of children.
The FRESH framework is a good example of how international agencies can work together.
To achieve similar cooperation at national and local levels, the following WHO publications
may provide useful guidance:
• Improving School Health Programs: Barriers and Strategies. WHO/HPR/HEP/96.2
• Local A ction: Creating Health-Promoting Schools.
(Both are available at: www.who.int/hpr/gshi/docs/index.html; or from WHO, Dept, of
Health Promotion and NCD Prevention and Surveillance, 20 Avenue Appia, CH-1211
Geneve 27, Switzerland.)
Regional Trends
Progress in school health and nutrition has varied dramatically across regions and nations.
Figure IV shows major regional trends and accomplishments in school health and nutrition in
Africa, the Americas, Europe, the Middle East, South and East Asia, and Australia during the
past decade. This figure also lists barriers to school health experienced in these regions and
activities planned for the future. For example:
•
•
•
In Central and Eastern Europe, many of the formal mechanisms that were in place in 1990
providing social services to young people, including those through the educational
system, have deteriorated. This change occurred when the communist system fell apart
and with it the numerous structures that were reaching out to young people.
In the Western Pacific, extensive accomplishments have taken place to create HealthPromoting Schools, supported by national policy frameworks and a regional technical
assistance network.
Countries like Guinea and Indonesia have systematically developed comprehensive
school health programs with incentives and awards for local schools, and countries in
Africa, such as Uganda and Zimbabwe, have made excellent progress with skills-based
health education.
During the past decade, we have seen the best thinking about education and health coalesce
into several frameworks that identify the core principles shared by professionals and
practitioners around the world. Definitive research results proliferated, and collaborative
efforts expanded. Even failures and the tragedies of HIV infection have taught us profound
lessons that can guide us in future efforts.
The access to and attainment of education and health must therefore drive all development
policies, and many countries may need to rethink their social and economic priorities.
Education for All should be seen as the foundation for access for each and every person to
each and every level and form of education, and the quality of education should be seen, not
only in terms of educational standards, but also of relevance. The direct links to health are
clear: education has a fundamental role to play in personal and social development, and it is
unlikely that the goals of education will be achieved without significant improvements in the
health of both students and teachers.
43
Region
Major Trends and Activities
in learners’ homes and in the community - as a result of the interventions for schoolchildren in the community.
Few programs seem to target health behavior in learners while they attend school.
- School health education and life skills education are the “fastest moving” programs in the region and likely to
overtake more traditional health programs — partly due to significant UNICEF attention and deliberate targeting
across the region. However, the education sector has to keep on proving and demonstrating that they are
relevant; e.g., that a life skills program can reduce HIV/AIDS risk behavior.
- Zimbabwe’s Life Skills program, supported by UNICEF, is an “inspiration” in the region. It uses two eloquent
videos and textbooks that show evidence of “incredible work” (Obura, 1999).
“Although no research has been conducted on life skills education in Africa, the HIV/AIDS pandemic has led
Uganda and Zimbabwe to put life skills training into their school programs” (Del Rosso & Marek, 1996, p. 30).
The School Health Education Project, launched in Uganda in 1987, is one of the most coherently planned and
comprehensive national school health initiatives in developing countries. It was initiated by the government of
Uganda with support from UNICEF and the involvement of the Child-to-Child Program. Health education was
integrated into the basic science curriculum along with a parallel program to develop a network of health
educators at the district level to support community and school health activities. Teaching materials include
resources on AIDS, water and sanitation, diarrheal diseases, and immunization. Health education was made
possible to examine and became part of the primary students’ examination (Hubley, 1998).
The Child-to-Child approach, an educational method that originated in Africa, has been tried in almost all
African countries. It does not depend on the didactic relation between teacher and student but rather involves
children in reaching siblings, parents, and communities. Some programs have been credited with raising
vaccination rates, improving children’s hygiene, and leading to an increased knowledge of anemia and
significant changes in dietary practices (Del Rosso & Marek, 1996).
The Child-to-Child approach in Zambia has proved to be effective in delivering health education to some but not
all children in primary schools. A successful, innovative classroom at Kabale School in Mpika was characterized
by: the majority of teachers are involved in moving toward a Child-to-Child school; there are schoolwide
initiatives to have clean drinking water in each class and water for handwashing; the twinning of pupils includes
older with younger, able with less able, normal with mentally disadvantaged; children take responsibility for
their own learning and for that of their group (Gibbs, 1997).
Barriers
- Many schools are examples of
unhealthy living (e.g., tolerance of
dirt and unhealthy habits in schools),
yet teach a health curriculum.
- Some donors do not provide basic
essentials (e.g., latrines), others
don’t encourage community
participation. Programs are often
sporadic and rarely sustained. They
should include income-generating
activities and make the gathered
information and learnings available
to local educators.
Future Actions
Every class should have plans for
the day, the week, the term. Targets
should be concrete, attainable and
monitorable (Obura, 1999).
Increased NGO involvement and
dedicated, visionary leaders,
focusing on facilitating action at
the community level (Obura, 1999)
- Broad gender dimensions need to
be addressed so that health
education becomes less stereotypical
and focuses less on the “feminine”
roles but also attracts “the movers
and shakers of the world.”
Currently, women remain solely
responsible for the health of the
children and the home (Obura,
1999).
- The education system needs to
adapt to the impact of HTV/AIDS by
altering the content — knowledge,
skills, values — of what it teaches
and the methods it uses (Cole,
1999).
Africa has a major advantage in the wealth of its community organizations, such as parent-teacher associations.
These associations can be a channel for community participation and responsibility (Del Rosso & Marek, 1996).
“In a recent primary education project in Nigeria, for example, communities were asked to evaluate their
schools, to cite their expectations of improved outcomes and to indicate how they, as parents, teachers and
education administrators could help make those improvements” (World Bank, n.d.).
Americas
North America:
In the United States, from the start of the 1970s, the Centers for Disease Control and Prevention (CDC) has
been the federal focal point for technical assistance related to health education in the schools. The U.S. Congress
asked CDC to provide support for the development of comprehensive health education programs in schools
(PAHO, 1999).
North America
Barriers to collaboration in the
United States for improving health
through schools include:
North America
The book Health Is Academic
identifies as a promise for the
future that coordinated school
health programs become an
51
Figure IV: Highlights of Major Regional Trends and Activities, Barriers, and Future Actions for School Health and Nutrition
Region
Africa
Major Trends and Activities
Barriers
Africa faces significant challenges in health and education. According to a World Bank report, “[Njowhere
else in the world are birth rates so high, maternal and child deaths so widespread, use of family planning less
developed ... and HIV and other sexually transmitted infections so endemic. Infectious and parasitic diseases...
are on the rise and continue to severely affect poverty stricken areas. Two-thirds of the world’s HIV/AIDS
epidemic is in Africa.” Sixteen African countries still enroll less than half of their children in primary school,
and enrollment rates are dropping (World Bank, nd.). In most African countries, the enrollment of girls lags
significantly behind that of boys. In addition, malnutrition exacerbates the detrimental effects of hunger on
learning (Del Rosso & Marek, 1996).
WHO/AFRO identified the
following barriers:
The Partnership for Child Development has developed a protocol for a comprehensive situation analysis of
school-based nutrition and health interventions, which has been tested in several African countries (Del Rosso
& Marek, 1996).
- Shortage of supplies, including
books, furniture, equipment
- Lack of national school health
policies
- Lack of material and financial
resources
- Lack of essential infrastructures
Regional school health initiatives began in 1996 after tire WHO Experts Committee on Comprehensive School
Health Promotion reconunendations were made. Regional efforts have assisted some states to develop and
distribute school health promotion materials. Some states have developed national school health guidelines and
designed long-term plans and strategies for Ute implementation of school health initiatives (WHO/AFRO, 1999).
WHO’s major regional events aimed at strengthening the exchange of information, experience, and expertise,
including:
- the development and distribution of guidelines on Health-Promoting Schools (HPS);
- the appointment of national school heal til focal points;
- the formation of anglophone, francophone/lusophone HPS networks;
- designing long-term plansand strategies for HPS initiatives throughout the region;
- the use of communication media to meet basic learning needs (WHO/AFRO, 1999).
WHO/AFRO reports some of the positive trends:
- Throughout the region, school health services have increased. Improvement has been evident in expanded
programs for inununization and basic health services.
- School feeding programs are now common in a number of African countries and include one meal each school
day.
- The provision of potable water and sanitary facilities was improved.
- School/community garden and brick molding projects are common in many countries of the region
(WHO/AFRO, 1999).
A UNICEF representative reports:
- Because of the HIV/AIDS scourge, especially in sub-Saharan Africa states, U.N. agencies, NGOs, and other
concerned partners have joined in concerted efforts to implement school health programs, with an emphasis on
changing behavior.
- Some school health programs have targeted learners’ health behavior and the modification of health behavior
- Lack of teachers trained in health
issues
- Bureaucracy, red tape, and
administrative inefficiencies
- Serious congestion of pupils
in most schools
- High percentage of children and
adolescents in the
populations(WHO/AFRO, 1999)
Future Actions
WHO/AFRO plans:
- Development of national school
health guidelines and policies
- Constitution of AFRO HPS
Network
- Mobilization of resources at local
and national levels to reinforce
school health initiatives
- Strengthening intersectorial
collaboration in favor of school
health programs
- Increasing parent, teacher, pupil,
and community participation in
school health initiatives
- Assisting states to recognize the
schools as a critical setting for
health education and promotion
(WHO/AFRO, 1999)
- Difficulties to get hold of relevant
school health literature
The Word Bank’s new SchoolBased Health & Nutrition Initiative
for Africa has as its primary goal to
improve iron status to reduce
lethargy and otherwise to improve
learning (Berg, 1999).
- Lack of relevant disaggregated
data, particularly at the community
level.
A UNICEF representative
mentioned:
- No focal point, no institution
leading the region, no open network
at present_____________________
“Every head must become a school
health manager and every teacher
must be the class health manager.”
A UNICEF representative reported:
%
Figure DI
Selected Online Resources for School Health
______________ Agency______________
American School Health Association
Australian Health Promoting Schools Association
Canadian International Development Agency
(CIDA)__________________ ________________
CARE
_______________________________
Child-to-Child Trust________________________
Education Development Center, Health and Human
Development Programs______________
Education for All
_________________ Web site_____
http://www.ashaweb.org/__________
http://www.hlth.qut.edu.au/ph/ahpss7
http://www.acdi-cida.gc.ca/index.htm
http://www.care.org/_______
http://www.child-to-child.org
http ://www. edc. org/HHD/
http://www2.unesco.org/efa/
Education International___________________
Food and Agriculture Organization of the U.N.
International Committee of the Red Cross
IRC: International Water and Sanitation Centre
Pan American Health Organization: HealthPromoting Schools in the Americas_________
Partnership for Child Development (PCD)
http://www.ei-ie.org/_____________________
http://www.fao.org _______________________
http://www.icrc.org______________________
http://w^vw.irc.nl/________________________
http://www.paho.org/english/hpp/hs home.htm
Resources for School Health Educators
http://www.indiana.edu/~aphs/hlthk12.html#school_________________
http://www.savethechildren.org
http://www.oneworld.org/scf ______
http://www.unaids.org
Save the Children, USA______________________
Save the Children, UK_______________________
United Nations Joined Program on HIV/AIDS
(UNAIDS)________________________________
United Nations Development Program (UNDP)
United Nations Educational, Scientific and Cultural
Organization (UNESCO)_____________________
United Nations Population Fund (UNFPA)
United Nations Children’s Fund (UNICEF)______
United States Agency for International
Development (USAID)_______________________
United States Centers for Disease Control and
Prevention, Division of Adolescent and School
Health,
___________________________
World Food Program (WFP)__________________
World Health Organization, Department of Health
Promotion, Global School Health Initiative
World Health Organization Regional Office for
Europe, European Network for Health-Promoting
Schools___________________________________
World Health Organization Western Pacific
Regional Office____________________________
World Bank (Resources for Schools)____________
http://www.ceid.ox.ac.uk/child/
http://www.undp.org
http://www.unesco.org
http://www.unfpa.org
http.7/www.unicef.org
http ://^vw. info.usaid.gov/
http://www.cdc.gov/nccdphp/dash/index.htm
http://www.wfp.org
http :/Avww, who, int/hpr/
http://www.who.dk/enhps/index.html
http://www.wpro.who.int/
http://www.worldbank.org/html/schools/
The above Web sites are current as of May 2000. Some of them work properly only in the Internet
Explorer or Netscape Navigator browser. Web site addresses are subject to change
Figure II: Illustrative Roles that Educators and their Collaborators can Play to Address selected Health Issues
Condition or
Problem
Shaping and
implementing policy
directions
Advocating
interventions and
strategies
Partnering for
effective service
delivery
Delivering
therapeutic
interventions
Delivering
educational
interventions
Delivering
environ-mental
interventions
Tracking and
monitoring
Helminths
Reporting data on
infection rates to
local authorities in
order to create an
awareness of this
problem among
responsible officials
Outreach to parents,
education sector
officials, and others
to demonstrate the
educational
consequences of
infection
On-site deworming
Maintaining health
cards for students that
indicate date of last
treatment; keeping
records that permit the
monitoring of
treatment efficacy
Testing of low-cost
teclinologies for
providing water and
sanitation;
demonstrating
promising
teclinologies to
encourage further
investment
Latrine
construction;
creation of potable
water source;
modeling use of
ladle
Monitoring per capita
water consumption
Micronutrient
deficiencies
and related
disorders
Experimentation with
alternative
approaches (health
education, nutrition,
supplementation) for
addressing
micronutrient
deficiency disorders
Outreach to health
and education sector
officials to help them
understand the
educational and
health consequences
of poor sanitation;
communication to
relate female
enrollment to proper
water and waste
facilities__________
Outreach to parents,
education sector
officials, and others
to demonstrate the
educational
consequences of
micronutrient
deficiencies,
particularly vitamin
A, iodine, and iron
Participatory health
education on such
topics as clean water,
environmental
sanitation,
handwashing,
sanitaiy food
prepartion and
handling, the use of
shoes____________
Participatory health
education on such
topics as the
maintenance of water
systems and latrines;
the disease cycle; the
use of waste products
to improve food
production
Latrine
construction;
creation of potable
water source
Unsafe water
and
inadequate
sanitation
Forging alliances
with local health
personnel and NGOs
to secure treatments;
working with
community members
to undertake effective
treatment and
prevention
campaigns________
Mobilizing
communities to
contribute labor and
other resources for
school facilities
improvement
Working with NGOs,
cooperatives, and
agricultural extension
services to help
members gain access
to low-cost sources
of critical
micronutrients
On-site micronutrient
supplementation
through tablets or
school feeding
activity
Participatory health
education on such
topics as adequate
diet; local and
affordable sources of
key micronutrients;
school gardening
The use of latrines
and low-cost
systems to deliver
potable water to
help break infection
transmission cycles
that contribute to a
high incidence of
micronutrient
deficiency disorders
Maintenance of basic
records to ensure that
children are treated at
appropriate intervals;
maintenance of
accurate attendance
records to track the
impact of intervention
on children’s
morbidity rates.
On-site deworming
48
How does this issue affect education?
•
•
childbirth (which may keep teenage mothers
away from school), dangerous abortions, and
sexually transmitted diseases (which may affect
their health and their ability to concentrate on
their studies) (WHO, 1999 draft).
Tobacco is a major killer and a known or
probable cause of about 25 diseases (WHO,
1998c). In the developing world, it poses a
major challenge not just to health but also to
social and economic development and to
environmental sustainability (Bellagio
Statement, 1995).
The use of alcohol and other drugs poses a
special tlireat to young people because of the
short- and long-term consequences associated
with such behavior. For instance, alcohol can
lead to cognitive impainnent, which can lead to
unsafe driving, violence, and injury in the short
term and cardiovascular disorders, memory
loss, and Fetal Alcohol Syndrome in babies
bom to alcoholic mothers in the long term.
Marijuana can lead to the inability to pay
attention continuously or to digest complex
infonnation in the short term and to respiratory
problems and a loss of energy and ambition in
the long term (Girdano & Dusek, 1988).
Alcohol/substance abuse is often associated
with violent behaviors, suicide attempts, car
crashes, and other injuries (Northeast CAPT,
1999)
Examples of evidence that schools can effectively address this issue
•
•
•
•
•
thus managed to determine the roots and problematic nature of addictive behaviour” (Hefei & Yonder Muehl,
1998).
In Denmark, in a class on drug abuse, activities included writing a play in their Danish class and then acting it out
for a ninth class, including a warming-up dance and question and discussion period. In connection with the project,
the class also held two theme days. Pupil and teacher evaluations concluded that the project was generally
successful “in that it managed to bring a sensitive subject up for debate without pointing any fingers and by adding
a humorous approach and at the same time by successfully making the pupils aware of the risks of drug and
alcohol abuse” (Birkman, 1995).
In the United States, multiethnic elementary schools received a package of interventions that included in-service
training for teachers, developmentally appropriate parenting classes for parents, and developmentally adjusted
social competence training for children. The evaluation showed that, compared to those in the control group, fewer
of the students who received the full intervention reported violent delinquent acts, heavy drinking, sexual
intercourse, multiple sex partners, or pregnancy or causing pregnancy by age 18. The students who received the
intervention reported more commitment and attachment to school, better academic achievement, and less school
misbehavior than the control students. (Hawkins et al., 1999)
In Uganda, a health education program in primary schools aimed at AIDS prevention, emphasizing improved
access to information, improved peer interaction and improved the quality of performance of tlie existing school
health education system. After two years of interventions, the percentage of students who stated they had been
sexually active fell from 42.9% to 11.1%. Social interaction methods were found to be effective, because students
in the intervention group tended to speak to peers and teachers more often about sexual matters. Reasons for
abstaining from sex were associated with the rational decision-making model rather than with the punishment
model (Shuey et al., 1999).
Kirby and DiClemente (1994) found that negotiation skills enhance students’ ability to delay sex or to use
condoms. Wilson and colleagues (1992) concluded that interactive teaching methods are “better than lectures at
increasing condom use and confidence in using condoms and at reducing the number of sexual partners.” Their
evaluation found that the female student teachers in Zimbabwe who participated in a skills-based AIDS
intervention were more knowledgeable about condoms and their correct use, had a higher sense of self-efficacy,
perceived fewer barriers, and reported fewer sexual partners four months after the intervention than their
colleagues who participated in a lecture.
Research has repeatedly shown that school-based efforts that provide information and services for sexual and
reproductive health do not lead to earlier or increased sexual activity in young people. On the contrary, in some
cases, sex education delayed the initiation of sexual intercourse (Grunseit & Kippax, 1993; Blaney, 1993; Kirby et
al., 1994),
47
How docs this issue affect education?
Examples of evidence that schools can effectively address this issue
blindness and permanent damage of the eye and
may increase susceptibility to infections. A diet
deficient in iodine can lead to goiter and
impaired intelligence and hearing and may
cause young women to give birth to cretinous
children (PCD, 1999b)
Iron supplements help prevent iron deficiency
anemia and mild growth retardation as well as
low-birth-weight babies of iron-deficient
women. (Levinger, 1994).
scores. The program was most effective for children who were wasted, stunted, or previously malnourished
(Simeon & Grantham-McGregor, 1989).
• In Burkina Faso, a school feeding program found that school canteens were associated with increased school
enrollment, regular attendance, consistently lower repeater rates, lower dropout rates, and higher success rates on
national exams, especially among girls (Moore, 1994).
• In the Dominican Republic, up to 25% of children dropped out of school during a period without a school feeding
program. The effect was greatest in rural areas and for girls (King, 1990).
• In Spain, an interdisciplinary school nutrition project has been run successfully since 1988. It involves teachers,
tire school council, cook, social worker, school health team, and community nutritionist. It aims to promote healthy
eating habits and to develop skills and self-empowerment. Interventions are conducted simultaneously in the
classroom, a practical workshop, and tlie school lunchroom, together with addressing the families. Various
participatory teaching methods are used in the classroom, integrated in different subjects and complemented by a
food preparation workshop. A 1990 evaluation showed that students’ knowledge and skills about food had
increased; children were willing to tiy a greater variety of fruit, vegetables, and pulses; and there were positive
changes in personal hygiene habits but poor results in dental hygiene practices. Three fifths of tire children cooked
some of the suggested recipes at home. Among the lessons learned were: interdisciplinary work is important for
school nutrition education and school meals should be part of the educational program (Dixey et al., 1999).
___________________________________________
Lifestyle behaviors associated with STDs, HIV/AIDS, and the use of alcohol, tobacco, and other drugs
•
•
•
Asa result of HIV/AIDS, many young children,
especially in sub-Saharan Africa, are orphaned
or otherwise affected by the socioeconomic
consequences of the epidemic, especially in
hard-hit communities. In many countries, 60%
of all new infections occur among 15- to 24year-olds who will likely develop AIDS
eventually (WHO, 1998 draft).
HIV, which can be transmitted from infected
mothers to their offspring, can affect a child’s
nervous system, resulting in nonspecific
developmental delays, including impaired brain
growth, and chronic impairment of cognitive
performance. These conditions can lead to poor
attention and concentration, cognitive slowing,
or decreased speed of information processing
(Sternberg et al., 1997).
Early sexual relationships can have profound
effects on adolescent health and development:
unwanted and too early pregnancies and______
•
•
•
•
In the United States, a study of nearly 6,000 students from 56 schools implemented a Life Skills Training (LST)
program, based on a person-environment interactive model that assumes that there are multiple pathways to
tobacco, alcohol, and drug use. The results of the three-year intervention study showed that LST had a significant
impact on reducing cigarette, marijuana, and alcohol use. Results of the six-year follow-up indicated that the
effects of the program lasted until the end of the twelfth grade (CDC, 1999).
Australia, Chile, Norway, and Swaziland collaborated in a pilot study on the efficacy of the social influences
approach in school-based alcohol education. The data converge on the finding that peer-led education appears to
be efficacious in reducing alcohol use across a variety of settings and cultures (Peny & Grant, 1991).
In South Africa, a smoking prevention program, derived from Social Cognitive Theory, was implemented in
schools in the Cape Town area. During tlie intervention, children increased their self-confidence and decreased the
use of tobacco compared to those in the control schools. This evaluation led to a recommendation tliat the
Department of Education and Training consider making the program part of tire formal school curriculum (Hunter
et al., 1991).
In Switzerland, “addiction prevention days” at a secondary school in Basel initially had to overcome students’
attitudes of not wanting a project about addiction, perceiving it as “childish.” The six stages of the program
included individual and group activities, such as shopping with a budget of a certain amount; visiting a community
sewage system, and a communal information office for adolescents in crises; making plaster masks; and preparing
for a parents’ evening at which the outcomes of the project were presented. Tire manager of the project was
“impressed how initial resistance developed into participation and even enthusiasm of the participants.... The
experiences made during the various stages resulted in profound discussions.... Towards the end of the project, we
46
How does this issue affect education?
Examples of evidence that schools can effectively address this issue
concentrate diminish (Del Rosso & Marek,
1996).
• These infections decrease the learning potential •
of millions of children. They affect tissues and
organs, compromising children’s attendance
and performance at school and contributing to
•
children being listless, inattentive, absent, and
falling behind. Research shows that even when
infections seem to produce no overt symptoms
(e.g., diarrhea, abdominal pain), they can
diminish growth and cognitive development
(Nokes et al., 1992).
• Intestinal helminths are stunting the growth and
development of children, especially in countries •
that must count on their development to achieve
progress. Roundworm usually leads to impaired
growth and development as well as
malnutrition and abdominal obstruction.
Whipworm is associated with growth
retardation, chronic colitis, and iron deficiency
anemia (Berkley & Jamison, 1991)._________
Nutrition
term memory. After nine weeks, there were no significant differences in cognitive function between treated
children and an uninfected comparison group (Nokes et al., n.d.).
In Zanzibar, where worm infections were virtually universal, three Mebendazole treatments were given to all
schoolchildren. This program reduced the incidence of severe anemia by almost 40% and the prevalence of iron
deficiency by 20%. The treated group showed marked nutritional improvements (WHO, 1998a).
In China, helminth interventions (including semi-annual deworming and single doses of Albenzole given to most
students and community members) were implemented, together with other interventions, as one approach in
creating Health Promoting Schools. The evaluation showed that students’ knowledge about health and “good
health” behavior improved; the prevalence of helminth infections in students declined; environmental egg
contamination in schools decreased; school health education was established; school physical environments
improved (addition of latrines; water supply for handwashing; improvement of kitchen facilities); health-related
school policies were established; the school psychosocial environment improved; the relationship between school
and community strengthened; and family health behavior was positively affected (Xu et al., 2000).
WHO recommends that the healtli education component that accompanies helminth treatments should be aimed at
influencing healthy behaviors and conditions. The success of helminth interventions depends substantially on
whether individuals are willing and able to practice behaviors that reduce the likelihood of infection such as
washing hands before eating, not walking in the field without sandals, not urinating in water with which others
come in contact, not battling or washing in infected water, and not eating unwashed raw vegetables. Essential to
effective school health education programs is therefore a clear and precise delineation of behaviors specifically
relevant to helminth infection as well as activities that address the knowledge, values, beliefs, skills, and attitudes
that influence behaviors associated with helminth infection (WHO, 1998b).
Adequate nutrition, or tire lack thereof, affects
children’s health and well-being in many ways,
which in turn affect their ability to learn and take
part in education:
• Malnutrition can cause death and lead to the
impaired growth and development of millions
of children. Impaired growth may cause
children to fall behind in weight and height
measures, and they may consequently not be
admitted to school in time (WHO, 1998b).
• Good nutrition strengthens the learning
potential and well-being of children. Children
with more adequate diets score higher on tests
of factual knowledge than those with less
adequate nutrition (WHO, 1998b).
• A diet deficient in vitamin A can lead to night
In China, iodine supplementation through iodized salt brought the average hearing capacity of iodine-deficient
schoolchildren close to that of children without iodine deficiencies (Berkley & Jamison, 1991).
In India, iron supplementation virtually eliminated the differences in school performance and IQ scores between
schoolchildren previously deficient in iron and those without iron deficiencies (Seshadri & Gopaldas, 1989).
In Thailand, diets of children up to 9 years were supplemented with vitamin A. As a result, their iron stores and
resistance to infection improved (Bloem etal., 1990).
In Ghana, a study by the Partnership for Child Development showed that taking iron supplements for six weeks led
to a very significant improvement in school performance, compared with that of a placebo group. Six months later,
there were again no differences between the two groups of students—signaling the need for periodic
supplementation. The study also showed that teachers could effectively administer the iron (Berg, 1999).
In India, a school health package consisting of biannual treatments with an anthelmintic, vitamin A, and iron was
integrated into the Mid Day Meal Program. The impact evaluation showed a decrease in the prevalence of
intestinal parasitic infections, an increase in average blood hemoglobin concentrations, and a decrease of signs of
vitamin A deficiency (PCD, 1999c).
In Jamaica, providing breakfast to primary school students significantly increased their attendance and arithmetic
•
•
•
•
•
•
45
Figure I: Examples of the Evidence of Effectiveness of School-Based Interventions
Examples of evidence that schools can effectively address this issue
How does this issue affect education?
Safe Water and Sanitation
•
A result of inadequate sanitation is diarrhea,
which kills 2.2 million children per year and
consumes valuable resources in health care,
preventing families and nations from
developing further. Diarrhea lias an impact on
children’s health in such a way that they are ill
equipped for learning: diarrhea episodes leave
millions of children underweight, mentally and
physically stunted, easily susceptible to deadly
diseases, and drained of energy (Khan, 1997).
•
•
•
•
•
Since “girls in particular are likely to be kept out of school if there are no sanitation facilities” (UNICEF, 1997),
especially after they start menstruating, adequate sanitation in schools is likely to encourage their attendance.
Education about water/sanitation/hygiene in schools can encourage the construction of facilities and their
subsequent use in school and in the community. Schools can, with community participation, provide the necessary
learning experiences to encourage children to practice good hygiene in school, in their community, and later in life.
Sanitation facilities in schools can also provide the community with an example of improved sanitation
technologies (Hubley, 1998).
In Tanzania’s Lushoto Enhanced Health Education Project, health education has been taught as an extracurricular
activity to the whole school for one hour three afternoons a week, and for 15 minutes every day during morning
parade and inspection time. After only a few months, changes in the school environment were already evident: all
the intervention schools boiled water for the children to drink and stored it in newly purchased covered buckets. In
most schools the latrines were cleaned more regularly, and the process of constructing extra latrines had either
been identified as a priority or was in process (PCD, 1999a).
In Bangladesh, the International Centre for Diarrheal Disease Research set up a program to involve high schools in
sanitation activities. The evaluation found that almost all (91%) of those individuals who had built latrines during
the program said that the need to do so had been communicated to them by the pupils (Bilqis et al., 1994).
In Canada a pilot program for first-grade students promoted handwashing. The evaluation showed that children in
the program made 25 fewer visits to the physician, used 86% fewer medications, and were absent 22% less often
than they had been the previous year (Monsma et al., 1992),
Helminth infections
Helminth infections have various adverse affects on
children:
• They decrease the health and well-being of
children. While they seldom lead to mortality,
they are associated with high levels of
morbidity (Jamison & Leslie, 1990) such as
anemia, intestinal obstruction, lesions,
blindness, diarrhea, and cough (WHO, 1997c).
• Children heavily infected with worms eat less,
and their absorption and retention of certain
nutrients are impaired. As a result of this
helminth-related malnutrition, their learning
capacity and their ability to pay attention and
•
•
•
•
Mass treatment of helminth infections, given to children in school, is considered a powerful tool for improving
health (UNDP, 1992). Four very effective, safe, and inexpensive anthelmintic drugs have been on the forefront of
satisfactory treatment over the last 15 years: Mebendazole, Albendazole, Levamisole, and Pyrantel. A single 500mg dose of Mebendazole, for example, given three times annually, significantly improves the nutritional status of
school-age children, despite intense transmission, reinfection or incomplete deworming (WHO, 1998a).
Helminth treatments can be very cost-effective. Broad-spectrum, single-dose drugs such as Albendazole (20 cents
per dose) and Mebenzadole (3 cents per dose) are effective against several species of worms. They are both nearly
100% effective in eradicating roundworm, and Albendazole is about 98% effective in reducing hookworm (Del
Rosso & Marek, 1996).
In the West Indies, a single treatment for whipworm infection, without nutritional supplements or improvements in
education, improved children’s learning capacity to the point that their test scores matched those of children who
were uninfected (Bundy et al., 1990).
In Jamaica, the removal of whipworms in school-age children led to significant improvement in long- and short44
Region
Major Trends and Activities
Barriers
Lack of awareness
Until the 1990s, little was known about the prevalence of behaviors practiced by young people that put their
health at risk The Youth Risk Behavior Surveillance System (YRBSS) now provides such information. In
1994, CDC also started the School Health Policy and Program Study (SHPPS), to monitor policies and to
provide information on five components of school health programs. Data are compiled and converted into
specific guidelines to improve the effectiveness of school health programs (CDC, 1999; PAHO, 1999).
Lack of specific data
Limited resources (time, personnel,
funding)
CDC has established a national framework to support coordinated health education programs. More than 30
professional and volunteer organizations work with CDC to develop model policies, guidelines, and training to
assist states in implementing high quality school health education. (CDC, 1999)
Competing priorities
CDC collaborates with scientists and education experts to identify curricula that have successfully reduced
health risk behaviors among young people (“Programs That Work”). CDC provides resources to ensure that
these curricula, including training for teachers, are available nationwide (CDC, 1999).
Staff turnover
During the 1990s, the first national standards in health education were developed and published, spearheaded
by the American Cancer Society, the American School Health Association, and the American Association for
Health Education (Wechsler, 2000).
Insufficient staff training
Future Actions
essential part of every curriculum
to help children maximize their
academic achievement and positive
health outcomes.
CDC is in the process of launching
a national initiative to enable
schools to prevent cardiovascular
disease, cancer, and diabetes
through programs designed to
promote physical activity and
healthy eating and to prevent
tobacco use (Wechsler, 2000).
Unclear lines of communication
and/or organizational structure
Fear of change
Lack of supportive policies
One of the major nationwide activities in school health promotion in the U.S. during the past decade was the
Safe and Drug-Free Schools program, in which the U.S. Department of Education played a leading role
(Wechsler, 2000).
CTP P
QC’
*
cn -
O '
Fear of losing resources
(Marx, 1998)
In the mid 1990s, the Healthy School Meals Initiative, started by the U.S. Department of Agriculture,
established strong standards to get school nutrition programs to comply with the recommendations of the U.S.
Dietary Guidelines. The nutrition initiative supported nutrition education programs in schools (Wechsler, 2000).
In 1998 the book Health Is Academic: A Guide to Coordinated School Health Programs was published. It
describes the importance of incorporating students’ health into school programs and policies as a prerequisite for
learning and discusses how the eight components of a coordinated school health program can work together to
support students and help them acquire the knowledge and skills to become healthy, productive adults. This
book was developed by EDC with support from CDC and in collaboration with more than 70 national
organizations (PAHO, 1999).
In Canada, the province of British Columbia has introduced the revolutionary “Healthy Schools” initiative,
which involves students in learning and practicing habits that enable them to make responsible health decisions.
The program teaches students to work cooperatively to find solutions to the health subjects that concern them.
For example, the goal of balanced food consumption is reached through school lunch programs, nutrition
education, the exhibition of positive nutritional values of food, cultural approaches to food preparation, the
distribution and management of wastes, and community gardens (PAHO, 1999).
Latin America and the Caribbean:
In 1988, the Caribbean Food and Nutrition Institute initiated a school-based Community Nutrition Education
Program, “Project Lifestyle,” which is still being implemented in various Caribbean countries. The project
52
Region
Major Trends and Activities
focuses on the adoption of healthy lifestyle behaviors among primary schoolchildren (PAHO, 1999; Bocage,
1999).
The Health-Promoting School initiative originated in a meeting on comprehensive school health education in
Costa Rica in 1993. While earlier school health efforts in Latin America focused on health education only, the
new initiative also included environmental health and health and nutrition services at school. The Networkfor
the Development ofHealth-Promoting Schools was launched in 1995 (Cerqueira, 1996).
Early in the decade, Bolivia and Costa Rica undertook a “rapid diagnosis and analysis” to evaluate fully their
countries institutional capacities to undertake health promotion and health education at the primary school level
(Cerqueira, 1996).
During the decade, countries started to adapt the Youth Risk Behavior Survey since causes of death had shifted
from infectious diseases to lifestyle-related illnesses (Cerqueira, 1999). The view of health education has
changed accordingly from preventive education only to “healthy life styles” education (Rojas, 1999).
At the end of the decade, sex education and HIV/AIDS prevention education are included in some countries, and
drug prevention education is included in almost all countries. School health education programs are designed on
the basis of interactive educational methods. Recently, the UNESCO Educational Regional Office has
developed computer simulation games to train teachers and school directors in preventive education (Rojas,
1999).
Barriers
Latin America and Caribbean
A UNESCO representative from
Latin America reported:
- Initially, there was a lack of
political concern.
- Second, some health education
issues such as sex education or
HIV/AIDS prevention were
controversial, especially to the
church.
- In addition, there was a lack of
funds (Rojas, 1999).
There is a lack of know-how (e.g.,
for needs assessment,
implementation, evaluation),
materials, and training (Cerqueira,
1999).
Future Actions
Latin America and Caribbean
A 1999 situational analysis of
existing school health and nutrition
needs and strategies in LAC
identified — preliminarily — the
following needs:
- A need to restructure policy to
include priority setting, improved
coordination, focusing resources,
monitoring, and evaluation;
- A need to strengthen skills-based
education and improve conditions
for healthier practices;
- A need for increased support and
resources for school health
projects, teacher development, and
life skills-oriented health
education and promotion.
(Meresman, 1999)
PAHO’s Goals for 2010 include:
- Teacher training will be in place
- Health sector people will receive
training in education
- YRBS will be in place and yield
more data (Cerqueira, 1999)
Preliminary results of a 1999 situational analysis of existing school health and nutrition needs and strategies in
Latin American countries show that new health and education scenarios are increasing the opportunities for
collaboration (e.g.. El Salvador has a successful multisector strategy for health and education with a powerful
strategic alliance that includes sectors such as social protection, water and sanitation, international agencies, and
private sponsors), and school health programs facilitate community alliances (Meresman, 1999).
Country-specific example:
In the Bahamas, the Healthy
Schools Program requires that easy
access to services be provided, as
well as the replacement of
equipment and the restoration of
facilities (PAHO, 1999).
Europe
In 1991, an alliance was created among the European Commission, the WHO Regional Office for Europe, and
the Council of Europe to establish a European Network of Health Promoting Schools. The goal was to create
an international consensus on the concept of a Health-Promoting School (a school that “builds a living and
working environment that creates and strengthens health”). The network has rapidly expanded from a small pilot
activity involving 4 countries in 1991 to more than 500 pilot schools with 400,000 students in 38 countries,
including all 15 members of the European Union.
The ENHPS helped to shift school health efforts from a focus on curriculum and single causes of ill health to an
Health-Promoting Schools still only
comprise 2%-5% of schools in
Europe.
Strategies must increase
partnerships and participation with
the education sector.
There has not been an extensive
evaluation of the Network’s impact
Evaluation was not set in place early
on.
_________
Increase the political will to move
things forward to ensure that the
people and financial resources are
available to countries.
53
Region
Major Trends and Activities
Barriers
Future Actions
The link between the health and
education sectors was not strongly
established early on. There is still a
need to get health on the education
agenda and for the two sectors to
work together.
Provide tools and services for
countries and schools to conduct
evaluations and achieve the results
they wish to see. Approaches to
measure impact, quality, and
effectiveness must be developed.
integration of health promotion into all aspects of the school setting.
Representatives of 43 countries, from various sectors and professions, attended the First Conference of the
European Network of Health Promoting Schools in May 1997.
A strong partnership among the EC, WHO, and the Council of Europe (made a formal entity through an
International Planning Committee) has given political attention, financial backing, and a positive reputation to
the ENHPS.
While cooperation at the European level is strong, implementation at the country and school level is varied and
innovative. The ENHPS provides a flexible framework within which countries and schools can determine their
needs and work toward them in their own ways.
More must be done to tackle the
underlying issues of self-esteem,
critical thinking, and action
competence.
More countries and schools realize the connection between good health and education; in many parts of Europe,
health has become part of school life. A databank of Health-Promoting School projects throughout Europe has
been established and is available on the Web.
Continue to push toward more
structural changes within the
school setting.
The Health Behaviour in School-Aged Children Study, a WHO collaborative cross-national study begun in
1982, has continued throughout this decade with 24 countries participating. The findings are used to develop
health promotion policy and programs across Europe.
Reduce inequalities in health and
education.
In 1999, the European Network of Health Promoting Schools has developed guidelines for school health and
nutrition: Healthy eatingfor young people in Europe: A school-based nutrition education guide.
Central and Eastern Europe:
Many of the formal mechanisms providing social services to the population in the communist era have fallen
away without any replacement. Support for maintaining one’s health and nutritional status through the
educational system was an important feature of the social function of schools in the communist period.
The transition to the free market saw drastic falls in the provision of textbooks, school supplies and basic
facilities (like heating, running water, and functioning toilets), and school health initiatives like school meals,
health checks, and physical education. Recreational and leisure activities, once organized by teachers or
communist youth organizations, have almost disappeared, and there are few centers or clubs where young people
can engage in activities. Previously the responsibility of education ministries, recreational and after-school
activities are increasingly organized by the private sector.
At the same time, there is a wealth of burgeoning health problems among young people, including HIV/AIDS
rates, STIs, and IV drug use. The use of alcohol and tobacco and glue sniffing are also increasing.
A number of key international and bilateral agencies are working together to rebuild the social support
mechanisms that have fallen away. There is consensus among the agencies and an emerging strategy to address
the psychosocial needs of young people in the region.
There are numerous models of excellence within countries, such as the establishment of health promotion
Central and Eastern Europe
There is not only a lack of resources
but a skewed distribution of the
existing resources. Access to
education is not equitable for all
children. Financial and political
problems have also resulted in many
teachers’ working without pay.
Since the transition, there have been
overall declines in kindergarten
enrollment, particularly in the
former Soviet Union and
Southeastern Europe, and
enrollment rates in primary schools
have also dropped. The closing of
preschools has limited immunization
and medical care to children. More
Central and Eastern Europe
Teaching methods must encourage
participation and individual
development. Life skills education
must be provided, both formally
and informally, to reach those
falling through the safety nets.
Reduce disparities in access and
achievement. Increase educational
opportunities and quality for
lessadvantaged children.
Restimulation of extracurricular
support by schools
Investigation of child labor and its
links to school attendance and
learning
Integration of disabled children
into normal schools
Attention to the needs of ethnic
54
Region
Major Trends and Activities
centers to reduce the medical and curative emphasis of previous health services.
“One small but groundbreaking initiative reported by the National Centre for Health Promotion was in eastern
Slovakia, where life skills and practical home economics are being provided to Roma youth. Teacher, pupil and
community satisfaction was expressed with this short-term summer program of classes making use of active
learning methods by motivated and prepared teachers. Activities included personal budgeting, healthy nutrition
and childcare” (Kenny, Reichenberg, et al., 1999, p. 22). However, these examples are not the norm and have
not typically been taken to scale.
Middle
East and
North
Africa
Following a situational analysis of the state of school health education in the region, WHO, UNICEF, UNESCO,
and ISESCO joined forces in 1985 to develop, promote, finance, and implement the Action-oriented School
Health Curriculum. A workshop in 1986 led to the development of national guidelines and a prototypical
curriculum and teachers’ guide with teachers’ resource books. The curriculum emphasizes activity-based
learning and was designed to involve the family and community in health-related activities. Bahrain, Egypt,
Jordan, Morocco, and the Sudan are in their fourth year of a pilot program to try the new curriculum.
While a rigorous, comprehensive evaluation of the program has not been conducted, a meeting of project
coordinators in 1996 indicated limited progress to date. This, plus growing concerns over tlie quality and
relevance of education, caused UNICEF to rethink its approach to school health and introduce the Global
Education Initiative — now part of ongoing basic education reform processes in 7 countries.
During a UNESCO conference of education ministers in 1994, participants expressed concern over the decline
in the quality of education in the region, evident from increased repetition and dropout rates.
The region is becoming younger. Within five years, approximately 60% of the population will be under 25
years of age.
The 1970s, 1980s, and early 1990s saw an unprecedented increase in basic education enrollment.
School health education is included in the national budgets of most countries in the region.
Asia and
Western
Pacific
In 1994, the first regional WHO workshop on school health promotion identified the key areas for intervention
as school health education, school health services, and school health environment. Regional guidelines were
established in 1996 to provide a framework and a reference point to develop healthy lifestyles in the school
setting in a comprehensive way (WHO/WPRO, 1999). Collaboration in the development of Health-Promoting
Schools with organizations such as UNESCO, UNICEF, UNFPA, South Pacific Commission, and Education
International has been initiated (Erben, 1997).______________________________________________________
Barriers
Future Actions
children are working to supplement
family income, either while
attending school or dropping out to
do so, and more are engaging in
truancy and juvenile criminality.
Minority ethnic groups and the
disabled are particularly affected.
minorities
Poor management of public and
private sector educational
institutions and systems.
Provide educational training to
health professionals and include
education experts in school health
efforts and strategies.
International school health
initiatives did not incorporate the
larger educational goals and
processes of schools. Health
professionals lacked educational
expertise.
Different school health initiatives
are sometimes being conducted in
parallel in the same countries,
coordinated and funded by separate
agencies with separate funding.
Increasing numbers of young people
are unemployed and out of school,
including nomadic groups, the
disabled, rurally isolated children,
and those marginalized in urban
areas, refugees, and war-displaced.
Growing numbers of young people
are affected by smoking, HTV/AIDS,
and a wide range of drugs (with
young people contributing to the
demand and the supply).
WHO/WPRO reports:
Progress has been hindered by a lack
of understanding within
govenunents about the need for
intersectoral involvement,
community involvement, and new
Encouragement of early childhood
development
Adequate financial transfers to
local governments with weak
resource bases (UNICEF, 1998b)
Explore ways to merge the
different school health concepts
and initiatives occurring in parallel
in the same countries. Perhaps the
notion of a “child-friendly school”
can unify the health and education
goals of schools and agencies.
Countries and agencies must
recognize and address the growing
problems of the region’s
adolescents. Similarly, early
childhood care and development,
including health, nutrition, and
stimulation, need to be part of an
integrated educational approach.
Reformation of formal and
academic learning environments
into more flexible processes able to
meet the Arab world’s need for
technically skilled and globally
infonned human resources
(UNICEF, n.d.)________________
Summary of the WHO meeting
Networking for Health-Promoting
Schools in Beijing, December
1997, includes:
- Ministries of health and education
in the northern part of the region
55
Region
Major Trends and Activities
Barriers
Future Actions
should be invited to nominate a
representative to serve as a
standing member on the Regional
Network and create national
networks and a national plan for
The key issues that impinge on the
the development of HPS.
effective implementation of healthy
- Networking should continually
settings appear to include:
seek collaboration in facilitating
- limited resources,
While Health-Promoting Schools remain at the pilot phase in some countries (such as China, Viet Nam, and
the Regional Network.
- lack of ownership,
Mongolia), they are moving toward a national policy framework in other countries, especially in the Pacific.
- Findings from the helminth
- overreliance on a small number of
About 80% of the Pacific countries have started at least one Health-Promoting Schools project In some
control project as an entry point for
people,
countries (e.g., Singapore, the Marshall Islands), the concept of healthy schools has been integrated into an
Health-Promoting Schools should
- lack of action orientation or
existing school health program rather than started as a separate initiative (WHO/WPRO, 1999)
be printed and distributed.
insufficient results achieved,
- The Regional Network could
- insufficient management
At the country level, collaboration between the health and education authorities has been critical. In a
strengthen the Global School
capabilities among public health
number of countries (such as Micronesia, Vanuatu, Kiribati, Singapore, and Malaysia), national coordinators
Health Initiative by providing case
professionals, and
have been appointed in the Ministry/Dept. of Education, with a counterpart in the Ministry/Dept. of Health.
- insufficient engagement with other studies and reports.
National Coordinating Committees are also being developed in a number of countries, including PNG, Samoa,
- The Global School Health
health programs and with other
Cambodia, and Lao (Lin, 1999).
Initiative, in collaboration with the
sectors.
Regional Network, should consider
UNESCO organizes regional training workshops on preventive education, e.g., against HTV/AIDS, with a
The above list suggests that strategic convening a global conference to
focus on the professional development of teachers and health education providers, curriculum development, and
facilitate linkages across regions
timing and engagement of
the development of teaching-learning materials (Gregorio, 1999).
appropriate people is a primary issue for the development of HPS.
(Lin, 1999).
Country-specific examples include:
UNESCO plans the following
future actions:
UNESCO
also
reports
low
levels
of
China
- Sustained government support to
community support and
- National Conference on School Health Promotion, Beijing, December 1995, with participants from Education
health education-related activities,
participation
as
a
major
and Health sectors from all provinces.
not only from the Ministries of
shortcoming. It is trying to
- WHO Regional guidelines on the development ofhealth promoting schools— A frameworkfor action,
Education and Health, but also
overcome
this
by
setting
up
translated into Chinese. Commitment made to adapt these guidelines in the provinces.
from other relevant ministries,
- National Health Education Institute established health-promoting schools in Chifeng (Inner Mongolia), Wuhan, Conununity Learning Centers to
including supporting mobilization
and Beijing’s west city in December 1995. Midterm evaluation meeting in October 1996 indicated the success of build the capacities of the
by Ministries of the Budget.
communities and to encourage
the projects.
- More sharing of information on
community ownership, which will
- Using deworming as an entry point to health-promoting schools, the county of Lianjiang, China, launched a
health education by providers
hopefully
provide
continuity
and
comprehensive school-based approach (Xu et al., 2000).
through the electronic media.
sustainability of the programs
- Individual provinces and cities are starting to identify health issues as entry points for the development of
- More coordinated activities of
(Gregorio,
1999).
Health-Promoting Schools (WHO/WPRO, 1999).
U.N. agencies and donors.
- Linking school health programs
Country-specific examples include:
Indonesia
#
with informal and nonformal
- Implemented a school milk program and a program that uses schoolchildren to reach parents to encourage their
infrastructures.
Maldives
use of health services.
- Building capacity through
-Scarcity
of
trained
people
to
- UNICEF assisted the Centre for Physical Fitness and Recreation, MOEC, in producing textbooks on health in
continuing education and lifelong
implement health programs in
primary schools with a relevant Teacher Guide. Currently, UNICEF assists the Centre for Physical Fitness and
learning.
schools
_________
Recreation in developing a guidebook and module on life skill education (Jiyono, 1999).
Since then, Health-Promoting Schools have been started in nearly all countries in the region, linked into
Healthy Cities in China, Malaysia, Viet Nam, Laos, and Mongolia and as a central feature of Healthy Islands
initiatives in the Pacific. Projects to improve the physical infrastructure have been undertaken to improve the
water and sanitation in schools. Schools have provided the entry points for such issues as helminth reduction,
leprosy education, and smoking control (WHO/WPRO, 1999).
partners to help create HealthPromting Schools (WHO/WPRO,
1999).
56
Region
Major Trends and Activities
Barriers
Future Actions
- The Indonesia Partnership for Child Development implemented a school health program that provided mass
treatment with anthelmintics and a child-to-child approach to health education. A school health insurance system
is being developed to sustain the program (PCD, 1999h).
- Inadequate supply and production
of teaching and learning materials
for health
- Inadequate coordination between
the health and education sectors and
other concerned departments
- Lack of funds to train health
personnel
- Rapid turnover of health and
education personnel and difficulty in
coping with the fast-growing school
populations
This will take commitment by all
supporters of the program,
including policy-makers, users, and
implementers, including NGOs and
IGOs, and all levels from policy to
grassroots (Gregorio, 1999).
Philippines
- In the Department of Education, Culture and Sports (DECS), the Health and Nutrition Centre (HNC) has the
mandate to develop and manage an Integrated School Health and Nutrition Program (SHNP). It is directed to all
schools at all levels, reaching out to the homes and communities to institutionalize the Teacher-Child-Parent
Approach.
- School health activities in 1996 included a search for the most outstanding school, implementing (a) the “Clean
and Green school and community program; (b) the national drug education program; and (c) the intensification
of the nationwide implementation of the DECS’s “War on Waste” and the School-inside-a-Garden programs.
- DOH and DECS launched a Healthy School Initiative in July 1995, involving senior government, municipal,
and NGO representatives, at an elementary school in Bulacan. MOH and municipal staff are providing technical
assistance.
- Conducted the 2nd National Health and Nutrition Congress for school heal tli and nutrition personnel in October
1996 (WHO/WPRO, 1999).
Viet Nam
- Viet Nam Health Insurance implemented a program that uses school health insurance as a vehicle for HealthPromoting Schools. It showed that such insurance can be an effective system, not only to cover costs for the
primary health care and hospital care required by schoolchildren, but also for prevention and health promotion
activities.
- The Partnership for Child Development (PCD) introduced health education alongside a deworming program in
primary schools in Ha Nam. Stage one focused on health education lessons in schools. Stage two focuses on
extracurricular activities, health education out of school, and the impact of health education in the family. The
emphasis is on integrating health education into the children’s real lives.
Australia
-Organized the first Sydney workshop on school health promotion in December 1994.
- Several states have instituted Health Promoting Schools initiatives.
- Ministers of Health and Education launched the publication Towards a health-promoting school in August
1996 (WHO/WPRO Web site).
-Twinning between schools has started as an initiative of the Australian Association of Health-Promoting
Schools. Twinning puts a new Health-Promoting Schools in touch with a more experienced “mentor” school,
both nationally and internationally. One “tripling” project includes a school in the Philippines and one in Kiribati
(Erben, 1997).
Country-specific example:
Nepal
Lack of research and infrastructure
in the school health program and
lack of well-defined national
strategies for the promotion,
support, coordination, and
management of school health
programs
Cambodia plans to revitalize its
School Health Task Force; develop
comprehensive national policies
with clear roles and
responsibilities; bring together and
coordinate school-based initiatives
from different MOH programs
such as deworming, immunization,
micronutrient supplementation; and
strengthen linkages between
schools, health centers, and
communities (D’Emilio, 1999).
Bhutan
Limited national resources in terms
of skilled labor and communication
materials. Inadequate academic
period allocation on health in the
school timetable.
Australia
Central government proceeds
working on a document on health
promoting schools to be considered
by the National Health and
Medical Research Council.
Sri Lanka
Lack of awareness of the importance
of health education among decision
makers at regional levels and lack of
monitoring, follow-up, and
evaluation of current programs
(WHO, 1996c)
Australian Association of HealthPromoting Schools continues with
a “twinning project”’ to put new
HPS in touch with more
experienced “mentor” schools,
both nationally and internationally
(WPRO Web site).
Australia
Extent to which education and
health sectors are willing to fund
strategies to integrate systems and
networks (WHO/WPRO Web site)
57
*
/
Figure V: Selected International Conferences That Addressed School Health and
Nutrition
Conference
Contribution to School Health and Nutrition
United Nations:
U.N. World Summit for
Children,
29-30 September 1990,
United Nations
The World Declaration on the Survival, Protection, and Development ofChildren
includes:
• Enhancement of children’s health and nutrition — a first duty
• Commitment to work for a solid effort of national and international action to
enhance children’s health
• Commitment to work for optimal growth and development in childhood through
measures to eradicate hunger and malnutrition
Rome:
FAO/WHO International
Conference on Nutrition,
5-11 December 1992,
Rome, Italy
The conference document Nutrition and development— A global assessment reports:
• Consequences of poor nutrition include a significant impact on child growth and
development, learning capacity, work performance, and overall quality of life (p.
25).
• Nutrition education’s goal is behavior modification with strategies from social
learning, social marketing, and entertainment-education strategies (p. 86).
• School health initiatives can also have positive effects on adult family members
(P- 87).
• Nutrition education should be part of a comprehensive school health education
program that includes relevant curricula, preparation of teachers, pertinent
educational materials, modification of the school environment, and cooperation
among school, parents, and the community (p. 87).
New Delhi:
World’s First Education
Summit
(sponsored by UNESCO,
UNICEF, UNFPA)
16 December 1993, New
Delhi, India
(“Pre-Summit” 13-15
December)
•
Cairo:
U.N. International
Conference on Population
and Development
5-13 September 1994,
Cairo, Egypt
•
•
•
•
•
Summit provided an opportunity to mobilize high-level political support and
financial and technical resources for primary education.
Gave birth to the E-9 Initiative (summit participants: Bangladesh, Brazil, China,
Egypt, India, Indonesia, Nigeria, Pakistan, plus Mexico), committed to “pursue
with utmost zeal and determination the goals set in 1990 by the World Conference
on Education for All, the Summit of the Nine High Population Countries in 1993,
and the first Ministerial Review Meeting of the E-9 countries.”
“The landmark agreement reached at the Conference makes the well-being of
human beings the focus of all national and international activities designed to
address the issues of population and development with a view to achieving
sustained economic growth in the context of sustainable development in full
recognition and proper management of the important relationships between
population, resources including food security, the environment and development”
(UNFPA, Proposal for key actions for the further implementation ...).
Built consensus for integrating family planning programs into a new,
comprehensive approach to reproductive health services and won international
recognition dial educating and empowering women is die most effective way to
reduce population growth rates and promote sustainable development (U.N. “What
have diey accomplished?”).
Conference follow-up: Reproductive health approach: policy changes in many
countries demonstrate a clear commitment to move from vertical (family
planning) programs to a comprehensive approach; many countries have adjusted
dieir policies, terminology, institutional structures, even paradigm shift by
integrating and linking sendees; tiiere has also been an increase in the number and
variety of partnerships.
While tliis conference was very focused on population and reproduction issues, it
also strongly supported partnerships and collaboration.
Contribution to School Health and Nutrition
Conference
Copenhagen:
U.N. World Summit for
Social Development,
6-12 March 1995,
Copenhagen, Denmark
•
Beijing:
U.N. Fourth World
Conference on Women,
September 1995, Beijing,
China
___________
Harare:
E.I.’s First World
Congress (International
Conference on School
Health and HIV/AIDS
Prevention),
1995, Harare, Zimbabwe
•
•
Commitments (to eradicate poverty) include promoting and attaining ... highest
attainable standard of physical and mental health; ensure that children, particularly
girls, enjoy their rights and promote the exercise of those rights by making
education, adequate nutrition, and health care accessible to them (p. 15).
Action plan includes “education, training and labor policies”: partnerships
between education and other government departments; the active participation of
youth and adult learners in design of... education and training materials; lifelong
learning (p. 50).
Agreed on 5year action plan to enhance the social, economic, and political
empowerment of women, improve their health, advance their education, and
promote their marital and sexual rights (U.N. “What have they accomplished?”).
Lessons from Harare and the regional seminars include:
• Ministers of Education and Heal th should look upon teachers and their trade
unions as partners.
• It is essential that teachers are properly trained, not only in HIV/AIDS, but also in
interactive ways of encouraging pupils to articulate their concerns and learn how
to protect themselves.
• The design of school programs should be adapted to the local culture and provide
social backup.
Jakarta:
WHO Fourth International
Conference on Health
Promotion,
21-25 July 1997, Jakarta,
Indonesia
The Jakarta Declaration describes
• “Health is a basic human right... essential for social and economic development.”
• . Clear evidence from research and case studies proves that health promotion is
effective, especially comprehensive approaches in particular settings, including
schools, where people participate in decision-making and health learning.
• Priorities for the 21st century: promote social responsibility for health; increase
investments for health development; consolidate and expand partnerships for
health; increase community capacity and empower the individual; secure an
infrastructure for health promotion.
Washington, D.C.:
E.I. Second World
Congress,
25-29 July 1998,
Washington, D.C., United
States
The Policy Resolution on Health Promotion and School Health includes:
• A call for governments to adopt and implement concerted global policies of health
development and to promote a global policy of heal th education; to strengthen
policies and resources to support the promotion of school health; to reinforce and
broaden the partnersliips for health.
• A call for member organizations to play an active role in the development of
school health education policies; to take more account of the crucial role that the
school system and workers in education can play through health education; to
commit themselves to make the school a healthy place.
Lisbon:
U.N. First World
Conference of Ministers
Responsible for Youth,
8-12 August 1998,
Lisbon, Portugal
The Lisbon Declaration on Youth Policies and Programs includes:
• Ensuring and encouraging the active participation of youth in all spheres of
society and in decision-making processes at the national, regional, and
international levels
• Encouraging the inclusion of family life education, reproductive health, and drug
and substance abuse prevention in school curricula and extracurricular activities
• Promoting equal health development for young women and young men and
preventing and responding to health problems by creating safe and supportive
environments, providing information, and building skills and access to health
services through schools and other partners
• Creating access to basic health care with adequate youth-friendly services that pay
particular attention to infonnation and prevention programs for malaria,
malnutrition, diarrheal diseases, and other conditions
59
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