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The findings > Thematic Studies> School Health and Nutrition>Part 2 >cont. 1
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Chapter II: Research Highlights from the Past Decade: What Strategies Are Effective?
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.

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.

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 scores (Nokes et al., n.d.). Research by the Partnership for Child Development in Ghana recently showed that iron supplements¾which could be effectively administered by teachers¾lead 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 children¾especially those from rural areas and girls¾dropped 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 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 $18.80 in the cost of addressing problems 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 p-er 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 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).
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 successful 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.
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