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The findings > Thematic Studies> School Health and Nutrition>Part 2 >cont. 3
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Chapter IV: Looking Back: The Status of School Health Leading Up to Jomtien
A Historical Perspective of the School Health Field
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).
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).
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.
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?
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).
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.
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).
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).
The Highlights of the Status of School Health in 1990

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.

A brief discussion of each item follows.
1. Health initiatives in schools focused primarily on disease prevention.
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.
2. There was confusion about the concept and definition of school health.
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).
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).
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).
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.
3. Single, uncoordinated intervention strategies dominated.
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.
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).
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.
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).
4. Few, formal mechanisms for multi-sectoral collaboration were in place.
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.
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.
5. Didactic, topic-by-topic teaching was the typical approach to health education.
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).
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).
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).
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.
6. Evidence of the effectiveness of interventions was not well known or disseminated.
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.
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.
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.
7. Few tools to guide assessment and strategic planning were available.
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.
8. Few donors earmarked school health programs as a priority for funding.
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.
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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