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Chapter
II: Research Highlights from the Past Decade: What Strategies
Are Effective?
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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. |
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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. |
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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.
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Each finding is discussed below. |
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| 1. School-based
nutrition and health interventions can improve academic performance |
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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). |
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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). |
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| 2. Students'
health and nutrition status affects their enrollment, retention,
and absenteeism. |
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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). |
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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). |
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| 3. Education
benefits health. |
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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). |
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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).
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| 4. Education
can reduce social and gender inequities. |
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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). |
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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. |
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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). |
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| 5. Health
promotion for teachers benefits their health, morale, and quality
of instruction. |
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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. |
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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). |
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| 6. Health
promotion and disease prevention programs are cost-effective. |
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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). |
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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). |
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| 7. Treating
youngsters in school can reduce disease in the community. |
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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). |
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| 8. Multiple
coordinated strategies produce a greater effect than individual
strategies, but multiple strategies for any one audience must
be targeted carefully. |
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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). |
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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). |
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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. |
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| 9. Health
education is most effective when it uses interactive methods
in a skills-based approach. |
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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). |
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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). |
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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). |
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| 10.
Trained teachers delivering health education produce more significant
outcomes in student health knowledge and skills than untrained
teachers. |
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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). |
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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). |
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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. |
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| Moving
from Research to Action |
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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. |
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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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| Return
to contents |
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