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The findings > Thematic Studies> School Health and Nutrition>Part 1
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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 UNICEF/Central Asia & Kazakhstan Kunal Bagchi WHO/Eastern Mediterranean Donald Bundy World Bank/Headquarters L. Tomasso Cavalli-Sforza WHO/Western Pacific Maria Theresa Cerqueira WHO/Americas V. Chandra-Mouli WHO/Headquarters Vinayagum Chinapah UNESCO/Headquarters Lawalley Cole UNICEF/South & East Africa Frank Dall UNICEF/Middle East & North Africa Anna Lucia D'Emilio UNICEF/Cambodia Bruce Dick UNICEF/Headquarters Rosmarie Erben WHO/Western Pacific Haba Fassou WHO/Africa Robert Fuderich UNICEF/Central & Eastern Europe Lucille Gregorio UNESCO/Asia & Pacific Wadi Haddad Inter-Agency Commission, WCEFA Pamela Hartigan WHO/Headquarters Hugh Hawes Child-to-Child Trust Anna Maria Hoffmann-Barthes UNESCO/Headquarters John Hubley Consultant in Intl. Health Promotion, Leeds, UK Jim Irvine UNICEF/East Asia & Pacific V. Jensen UNESCO/Asia & Pacific Jiyono UNICEF/Indonesia Leo Kenny UNICEF/Central & Eastern Europe Ilona Kickbusch formerly WHO/Headquarters Jackie Knowles UNICEF/Central & Eastern Europe Lloyd Kolbe CDC/DASH Ute Meir UNESCO/Headquarters Sergio Meresman World Bank/Headquarters Elijah Beto Munetsi WHO/Africa Naomi Nhiwatiwa WHO/Africa Anna Obura UNICEF/South & East Africa Hisashi Ogawa WHO/Western Pacific Martha Osei WHO/South-East Asia Ulrika Peppler Barry UNESCO/Headquarters Philayrath Phongsavan UNICEF/East Asia & Pacific Vivian Barnekow Rasmussen WHO/Europe David Rivett WHO/Europe Alfredo Rojas UNESCO/Latin America Yu Sen-Hai WHO/Headquarters Sheldon Shaeffer UNICEF/Headquarters Anna Verster WHO/Eastern Mediterranean Ian Young Health Education Board for Scotland Howell Wechsler CDC/DASH Diane Widdus UNICEF/Central & Eastern Europe


AIDS Acquired Immune Deficiency Syndrome

ALC Active Learning Capacity

CDC Centers for Disease Control and Prevention

CIDA Canadian International Development Agency

CRC Convention on the Rights of the Child

CTL Conditions of Teaching and Learning

DALY Disability-adjusted Life Year

DASH Division of Adolescent and School Health (at CDC)

DFID Department for International Development DOH Department of Health

EDC Education Development Center

EFA Education for All EI Education Internationa

l ENHPS European Network of Health-Promoting Schools

FAO Food and Agriculture Organization of the United Nations

FRESH Focusing Resources on Effective School Health

HBSC Health Behavior in School-Aged Children

HHD Health and Human Development Programs (at EDC)

HIV Human Immunodeficiency Virus

HPS Health-Promoting School

IBE International Bureau of Education IQ Intelligence Quotient

MLA Monitoring Learning Achievement

MOH Ministry of Health

MOE Ministry of Education

NGO Non-Governmental Organization

PAHO Pan-American Health Organization

PCD Partnership for Child Development

RAAPP Rapid Assessment and Action Planning Process

RH Reproductive Health

STD Sexually Transmitted Disease

STI Sexually Transmitted Infection U.N. United Nations

UNAIDS Joint United Nations Program on HIV/AIDS

UNDP United Nations Development Program

UNESCO United Nations Educational, Scientific and Cultural Organization

UNFPA United Nations Population Fund

UNICEF United Nations Children's Fund

USAID United States Agency for International Development

WCEFA World Conference on Education for All

WFP World Food Program

WHO World Health Organization

WPRO World Health Organization Regional Office for the Western Pacific

WWW World Wide Web

YRBS Youth Risk Behavior Survey

Executive Summary
Chapter I: Introduction: The Link Between Health and Learning
I n 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 too-early 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 Effective?
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.

9) Health education is most effective when it uses interactive methods in a skills-based approach.

10) Trained teachers delivering health education produce more significant outcomes in student health knowledge and skills than untrained teachers.

Chapter III: 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.

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
Since the World Conference on Education for All, a major accomplishment has been the development of conceptual frameworks or unifying principles to guide school health policies and programs.
Several major frameworks have contributed to the advancement of school health and nutrition programs. 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 Development, University of Oxford); and Active Learning Capacity (Levinger, EDC, for USAID and UNDP).

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. WHO, UNICEF, UNESCO, and the World Bank are together developing "A FRESH Start: Focusing Resources on Effective School Health," launched at the Education for All Conference in Senegal in April 2000. 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.

4) School-based health and nutrition services.

These components are intended to be supported by effective partnerships between teachers and health workers, effective community partnerships, and pupil awareness and participation.
Chapter VI: Major Global Trends: Developments since Jomtien

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.

5) Skills-based methods for health education have gained recognition and greater use.

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.

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