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Chapter
IV: Looking Back: The Status of School Health Leading Up to
Jomtien
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| A Historical
Perspective of the School Health Field |
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International collaboration in school health has a history of
more than 120 years. In the 1800s, school health became an issue
when compulsory education laws were enforced in Europe. In 1880,
the Third International Congress on Education in Brussels addressed
school hygiene as one of the plenary topics. Through each decade
of the 1900s, the agenda of international school health conferences
included such topics as school construction and furniture, medical
inspection in schools, individual health records, physical education
and training, the hygiene of dormitories, the prevention of
contagious diseases in schools, and hygiene for teachers, students,
and families (Mott, 1995 Draft). |
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Following a 1946 survey of ministries of education, the International
Bureau of Education of UNESCO prepared recommendations to improve
the teaching of health in primary schools, with the goal of
making it a genuine part of education. By 1967, all of the 94
countries replying to a second survey indicated that some form
of health education was compulsory in primary schools and was
often integrated into other subject areas, such as science education.
Nevertheless, the report recognized that not all schools were
effectively assisting children in adopting positive attitudes
and behaviors about safeguarding their own health and that of
others (IBE, 1946; IBE/UNESCO, 1967). |
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From the 1960s until the mid-1980s, international conferences
and publications in the field of school health were less evident
(Mott, 1995 Draft). This decline of attention at the international
level was consequential because international leadership and
advocacy can be catalytic for national and local efforts. |
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However, during this same period when school health was less
visible on the international stage, the developing world was
making considerable progress on another front: increasing the
survival rates of children from birth to five years of age.
In 1960, only 5 of every 6 children born (83%) lived to their
first birthday. By 1991, at least 12 of every 13 children born
(92%) were expected to reach that landmark. The success of the
Child Survival movement meant that more and more children were
going to enter school. An important question began to emerge:
how can we maintain and improve children's health to maximize
their learning? |
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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). |
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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. |
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For example, in 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). |
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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). |
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| The
Highlights of the Status of School Health in 1990 |
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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:
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.
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| A brief
discussion of each item follows. |
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| 1. Health
initiatives in schools focused primarily on disease prevention. |
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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. |
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| 2. There
was confusion about the concept and definition of school health.
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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). |
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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). |
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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). |
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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. |
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| 3. Single,
uncoordinated intervention strategies dominated. |
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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. |
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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). |
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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. |
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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, multistrategy, 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). |
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| 4. Few,
formal mechanisms for multi-sectoral collaboration were in place. |
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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 responsible
for water, sanitation, and the school's physical structure have
typically acted independently of the other sectors. |
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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. |
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| 5. Didactic,
topic-by-topic teaching was the typical approach to health education. |
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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). |
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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). |
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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). |
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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).
Child-to-Child placed young people in an active teaching role.
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| 6. Evidence
of the effectiveness of interventions was not well known or
disseminated. |
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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. |
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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. |
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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. |
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| 7. Few
tools to guide assessment and strategic planning were available. |
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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. |
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| 8. Few
donors earmarked school health programs as a priority for funding. |
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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. |
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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. |
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