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The findings > Thematic Studies> School Health and Nutrition>Part 2
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Part II Findings
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 document¾Malnutrition and Infection in the Classroom¾which 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 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 well-being.

5. The teaching of school health education requires teacher preparation, guidelines, teacher 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.

6. The pivotal role of teachers in promoting health in the school and community needs to be 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.

8. School health education must be planned and implemented in the context of the pupils' 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 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 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:

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.
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