| |
| |
|
Chapter
V: Conceptual Frameworks: The Principles that Drive Action
|
| |
|
|
| |
| A Historical
Perspective of the School Health Field |
| |
Since the World Conference on Education for All in Jomtien,
a major accomplishment has been the development of conceptual
frameworks or unifying principles for school health policies
and programs. These frameworks have also served as a catalyst
to mobilize partnerships across sectors at all levels. In addition
to the frameworks developed by U.N. agencies and a few other
international organizations, significant and noteworthy activity
was also conducted by frontline grassroot organizations in the
past decade (Chandra-Mouli, 2000). |
| |
| |
|
This chapter describes some of the major conceptual frameworks
that have influenced the school health and nutrition agenda
over the past decade. Frameworks developed in the 1990s include
the concept of the Health-Promoting School (stimulated by the
Ottawa Charter, 1986, and advanced by the Council of Europe,
the Commission of the European Communities, and WHO/European
office and WHO headquarters); the Child-Friendly School (UNICEF);
the Basic Cost-Effective Public Health Package (World Bank and
the Partnership for Child Development, University of Oxford);
and Active Learning Capacity (Levinger, EDC, for USAID and UNDP).
One framework, FRESH (Focusing Resources on Effective School
Health (WHO, UNICEF, UNESCO, World Bank), was launched jointly
at the EFA Conference in Senegal in April 2000. |
| |
| |
| The
Framework of the Health-Promoting School |
| |
|
The concept of the Health-Promoting School (HPS) started in
Europe. It is based on public health theory and builds on the
Ottawa Charter of Health Promotion (1986), which recognized
that "health is created and lived by people within the settings
of their everyday life; where they learn, work, play and love.
Health is created by caring for oneself and others, by being
able to make decisions, and have control over one's life and
circumstances, and by ensuring that the society one lives in
creates conditions that allow the attainment of health by all
its members" (WHO, 1986). The European Regional Office of WHO,
the Council of Europe, and the Commission of the European Communities
first widely promoted the concept of the Health Promoting School.
The aim was to achieve healthy lifestyles for the total school
population by developing environments conducive to the promotion
of health. The HPS concept extended beyond school health education
to a broader array of complementary interventions. |
| |
| |
|
|
The earliest descriptions of the HPS, then called "the Healthy
School," were developed during the first major conference
of all the European nations on school health promotion in
Scotland in 1986. The model, described in a report by Young
and Williams, featured an overarching policy and three essential
coordinated components: instruction, health services, and
a healthy school environment-both physical and psychosocial
(Young, 2000). A similar concept, the Eight Component Model,
was developed in the United States by Allensworth and Kolbe
in an effort to explore whether the concept of the school
health program should be expanded. If coordinated, the following
eight components of the model could have complementary if
not synergistic effects (Kolbe, 1986; Allensworth & Kolbe,
1987):
school
health services
school
health education
school
health environment
integrated
school and community health promotion efforts
school
physical education
school
food service · school counseling
school
health promotion programs for faculty and staff
|
| |
| |
|
In the 1990s both of these frameworks guided many policy decisions
and programmatic efforts throughout Europe and the former Soviet
Union and in the United States. As documents and program descriptions
were published, interest grew among international and national
health and education workers to apply them to the needs of a
broad range of countries. |
| |
| |
|
To gain a thorough understanding of the status of school health
worldwide and prepare recommendations for improving health through
schools, in 1994-95 WHO convened an Expert Committee. EDC synthesized
findings from hundreds of evaluation research and feeder papers
written by WHO's staff and experts around the world. This initiative
produced the following four documents, published by WHO: The
Status of School Health; Improving School Health Programs: Barriers
and Strategies; Research to Improve Implementation and Effectiveness
of School Health Programs; and Promoting Health through Schools.
|
| |
| |
|
The Expert Committee concluded that research in both developing
and developed countries demonstrates that school health programs
can simultaneously reduce common health problems, increase the
efficiency of the educational system, and further public health,
education, and social and economic development in all nations.
The committee made ten recommendations to improve health through
schools worldwide (see box). |
| |
|
Recommendations
of the WHO Expert Committee on
Comprehensive School Health Education and Promotion
(1995)
1. Investment in schooling must be improved and expanded.
2.
The full educational participation of girls must be
expanded.
3.
Every school must provide a safe learning environment
for students and a safe workplace for staff.
4.
Every school must enable children and adolescents at
all levels to learn critical health and life skills.
5.
Every school must more effectively serve as an entry
point for health promotion and a location for health
intervention.
6. Policies, legislation, and guidelines must be developed
to ensure the identification, allocation, mobilization,
and coordination of resources at the local, national,
and international levels to support school health.
7.
Teachers and school staff must be properly valued and
provided with the necessary support to enable them to
promote health.
8.
The community and the school must work together to support
health and education.
9. School health programs must be well designed, monitored,
and evaluated to ensure their successful implementation
and outcomes.
10.
International support must be further developed to enhance
the ability of Member States, local communities, and
schools to promote health and education.
|
|
| |
|
Following the Expert Committee's meeting and report in 1995,
WHO launched its Global School Health Initiative to support
schools to become Health-Promoting Schools. Although definitions
will vary among regions, countries, and schools according
to need and circumstance, a HPS can be characterized as a
school that is constantly strengthening its capacity as a
healthy setting for living, learning, and working.
|
| |
| A Health-Promoting
School: |
| |
|
WHO headquarters'
Global School Health Initiative uses four strategies to disseminate
this framework:
Consolidating
research and expert opinion to describe the nature and effectiveness
of school health programs (WHO, 1996a; WHO, 1996b; WHO,
1996c; WHO, 1996d; WHO, 1997a).
Building
capacity to advocate for the creation of Health-Promoting
Schools (HPS) and to apply the components of a HPS to priority
health issues, including helminth infections, violence,
nutrition, tobacco use, and HIV/STI (WHO, forthcoming; WHO,
1997c; WHO, 1998b; WHO, 1998c; WHO, 1998d; WHO, 1998 draft).
Strengthening
collaboration between the ministries of education and health
and other relevant organizations and national capacities
to assess, plan, and implement policies and programs to
improve health through schools (WHO, 1998e; Vince-Whitman
et al., 1997).
Creating
networks and alliances, including regional networks for
the development of Health-Promoting Schools and international
alliances, such as among WHO, EI, UNESCO, UNAIDS, CDC, and
EDC to strengthen the capacities of teachers' unions to
prevent HIV/STI (WHO, n.d.; WHO, n.d.; EI, 1998).
|
| |
|
|
These strategies have been implemented in collaboration with
other relevant programs and departments within WHO, including
the WHO Regional Offices, and with international agencies that
are interested in promoting the development of Health-Promoting
Schools, including Education International (EI), a trade organization
of about 25 million teachers worldwide, and Child-to-Child Trust.
The European Network of Health-Promoting Schools, for example,
has since 1990 enrolled more than 500 pilot schools with 400,000
students in 37 countries in Europe and the former Soviet Union
(European Commission et al., 1996). |
|
| |
| The
Framework of the Child-Friendly School |
| |
|
Based on the Jomtien documents and a number of other developments
in the field of children's rights, UNICEF has recently developed
a framework of rights-based, child-friendly educational systems
and schools that are characterized by being "healthy for children,
effective with children, protective of children, and involved
with families and communities-and children" (Shaeffer, 1999).
|
| |
| |
|
This framework builds on the Jomtien conference's proclamation
that "education is a fundamental right for all people, women
and men, of all ages, throughout our world." Relevant to health,
the declaration went on to say that "education can help ensure
a safer, healthier, more prosperous and environmentally sound
world" (Inter-Agency Commission, 1990a). |
|
| |
| UNICEF's
framework was also inspired by the Convention on the Rights
of the Child, held in 1989, which set the stage by acknowledging
that children's rights require special protection for the purpose
of the general improvement of their conditions and for their
development and education. |
| |
| |
|
UNICEF's framework broadly defines core components that characterize
a child-friendly school, each component incorporating factors
concerning education, health, and human rights. |
| |
|
|
In
a Child-Friendly School:
The
school is a significant personal and social environment
in the lives of its students. A child-friendly school ensures
every child an environment that is physically safe, emotionally
secure, and psychologically enabling.
Teachers
are the single most important factor in creating an effective
and inclusive classroom.Child-friendly
schools are teacher-friendly, supporting, encouraging, and
facilitating teachers toward being motivated, capable, self-confident,
and consistently available.
Children
are natural learners, but this capacity to learn can be
undermined and sometimes destroyed. A child-friendly school
recognizes, encourages, and supports children's growing
capacities as learners by providing a school culture, teaching
behaviors, and curriculum content that are focused on learning
and the learner.
The
ability of a school to be and to call itself child-friendly
is directly linked to the support, participation, and collaboration
it receives from families.
Child-friendly
schools have a key role to play in ensuring that children's
rights are reflected throughout the education system, just
as education systems must ensure that schools have the resources
to act on behalf of all children.
The
rights of children as articulated in the CRC are indivisible.
They all apply, all of the time, to all children. Schools
and educational systems have a role in ensuring that children's
rights are reflected throughout a country's governance community.
Child-friendliness is a broad public policy matter (Bernard,
1999 draft).
|
| |
|
|
|
Child-friendly schools aim to develop a learning environment
in which children are motivated and able to learn. Staff members
are friendly and welcoming to children and attend to all their
health and safety needs. WHO supports the framework of the Child-Friendly
School by helping schools become "health-promoting" as an essential
step toward becoming "child-friendly." |
| |
| |
| The
Framework of the Basic Cost-Effective Public Health Package
|
| |
|
|
The concept that schools are in a position to deliver a basic
package of health services to students has been widely acknowledged
during the 1990s. The appropriate level of services for the
schools to offer depends on each country's operational and financial
resources (Del Rosso & Marek, 1996). |
|
| |
|
A 1993 World Bank analysis concluded that most regions of the
world could greatly benefit by implementing a limited package
of five cost-effective public health elements. This package
could reduce 8% of the burden of disease in low-income countries
for $4 per capita and could reduce 4% of the burden in middle-income
countries for $7 per capita (World Bank, 1993). |
| |
|
The five
elements are:
An extended
program on immunization
School
health programs to treat worm infections and micronutrient
deficiencies and to provide health education
Programs
to increase public knowledge about family planning and nutrition,
self-care or indications for seeking care, and vector control
and disease surveillance activities
Programs
to reduce the consumption of tobacco, alcohol, and other
drugs ·
AIDS-prevention
programs with a strong component on other sexually transmitted
diseases (World Bank, 1993)
|
|
|
| |
|
|
The WHO Expert Committee on Comprehensive School Health Education
and Promotion commented on this basic package that "[al]though
school health programs are explicitly mentioned in only one
of the above elements, for a large portion of the world's population,
schools could efficiently provide all five elements of the recommended
package" (WHO, 1997a). |
|
| |
|
|
The Partnership for Child Development, UNICEF, the World Bank,
and other agencies have used this framework to guide program
development in countries around the world. In the state of São
Paulo, Brazil, a World Bank loan is helping to provide a broad
range of school-based services including feeding programs, health
and nutrition screening of schoolchildren, nutrition and health
education in the school curriculum, and school-based programs
for iron and vitamin A supplementation. A more limited package
of services with low-cost, easy to implement interventions is
applied in Guinea, where almost no prior nutrition and health
programs for school-age children existed. The elements of a
school-based health package in Guinea initially include a deworming
program and iron and iodine supplementation, accompanied by
education in health and hygiene (Del Rosso & Marek, 1996). Carefully
monitored school-based health and nutrition programs implemented
by the Partnership for Child Development in Ghana, Tanzania,
India, and Indonesia have now shown that the education sector
is capable of delivering a simple health package (health education,
anthelmintics, and micronutrients) to large numbers of schoolchildren
(50,000 to 3 million) without the creation of specific infrastructures.
These experiences suggest that the school system can contribute
to health delivery as long as the package is simple, demands
little school time, and is perceived as appropriate to local
needs (PCD, 1997). |
| |
|
| The
Framework of the Child's Active Learning Capacity |
| |
| |
|
In the early 1990s, in support of the mission to achieve Education
for All, Beryl Levinger of EDC wrote for USAID and UNDP about
the need to concentrate on improving a child's "active learning
capacity" (ALC). Consistent with theories in education and the
social sciences, she defined ALC as "the child's ability to
interact with and take optimal advantage of the full complement
of resources offered by any formal or informal learning environment"
(Levinger, 1994). The importance of this definition lies in
its belief that to maximize learning, a child must be psychologically,
emotionally, and physically well, able to concentrate on and
participate actively in the learning process, able to pay attention
and concentrate on tasks, and missing only a few days of school
for illness or other reasons. The ALC framework focuses on improving
the quality of the child as one of the most important factors
in achieving the goals of Education for All. |
| |
| |
|
This framework includes three primary variables: health and
nutrition status, hunger level, and psychosocial support. Health
and nutrition status refers to both current and prior physical
or mental conditions, such as height for age, sensory abilities,
nutritional status, and helminthic infections that influence
a child's ability to take optimal advantage of learning resources
and opportunities. Temporary hunger, especially if a child is
malnourished, contributes to a child's distractibility, inattentiveness
to environmental stimuli, and adaptive behaviors of passivity
and inactivity, all of which impinge on the development of a
child's ALC. Psychosocial support encompasses the degree to
which parents, caretakers, community leaders, and other significant
adults, community institutions, as well as values and norms
encourage a child's independence and inquisitiveness and support
expectations that favor overall learning as well as formal schooling.
|
| |
| |
|
Three variables are considered secondary in determining active
learning capacity: prior learning experience, a child's learning
receptiveness, and a child's aptitude for learning. Prior learning
experience refers to a child's exposure to formal and informal
situations conducive to acquiring new knowledge and skills,
such as preschool programs. Learning receptiveness refers to
a child's motivation and attention, which are influenced by
health status and hunger level, as well as by the quality of
the child-caretaker relationship. Aptitude relates to the time
a child needs to learn a particular task, attend to stimuli,
and concentrate. |
| |
| |
|
The ALC framework represents a dynamic portrayal of the complex
interplay among the determinants of educational outcomes, capturing
the high degree of influence that health, nutrition, sensory
impairment, and temporary hunger exert on the quality of the
child and hence on the child's learning outcomes (Levinger,
1994). |
|
|
| |
|
|
This framework was used widely by the South African Active Learning
Network, a group of NGOs, to develop materials, protocols, and
broker links between the health and education sectors. Among
the entities that participated were CIDA, WHO, UNICEF, the World
Bank, and USAID. Many of the Network's activities were designed
to promote the ALC model or to further its application. |
|
| |
|
| The
Importance of Frameworks in Collaboration |
| |
|
|
Some of the most important lessons learned in recent years are
the need for multisectoral collaboration and cooperation in
order to move toward the health and educational goals of Education
for All. "Indicators of a favorable policy setting include a
demonstrated ability to secure interministerial cooperation;
a coordinated, intersectoral approach to human development;
a history of support for community-based health and education
programs; and a commitment at the highest political levels to
programs that address questions of equity as well as growth"
(Levinger, 1994). |
|
|
| |
|
|
For instance, during the past decade, the World Bank coordinated
information to enhance the quality of school health and nutrition
programs through its International School Health Initiative.
Its experiences of good practice suggest that school-based health
and nutrition programs should be simple and locally relevant.
The following items have been suggested to contribute to such
programs: life skills training, health services, school snacks
fortified with micronutrients, an exemplary school environment,
equitable school health policies, and strategies beyond the
school (Dolan, 1999). |
|
| |
|
|
A shared framework and strategy for action often form the foundation
of successful collaboration. Even when there is no one unifying
framework, collaboration is more likely when the participants
at least understand and respect one another's language, methods,
and frameworks. In either case, the partners can identify their
unique strengths in the context of a framework and channel their
specific contributions to move a shared agenda forward. |
|
| |
|
|
As the decade draws to a close, some of the major leaders and
change agents at the world level are coming together to discuss
how they might build on the frameworks since Jomtien and collaborate
on a common framework for school health, such as FRESH. Such
collaboration may allow partners to harness their considerable
human and financial resources more effectively to address the
health needs of a greater number of children and adolescents
in schools around the world. |
|
|
| |
|
| The
FRESH Framework: A Concerted Effort to Focus Resources on Effective
School Health |
|
| |
| A framework
proposed jointly by WHO, UNICEF, UNESCO, and the World Bank
suggests that there is a core group of cost-effective components
that could form the basis for intensified and joint action.
These agencies are now developing a partnership to Focusing
Resources on Effective School Health (FRESH), launching it at
the Education for All Conference in Senegal in April 2000. |
|
| |
|
|
Each component of the framework stresses that a young person's
health is one of the many important factors that must be adequately
addressed to achieve any country's educational goals. As Bundy
comments, "Good health and good education are not ends in themselves,
but rather means which provide individuals with the chance to
lead productive and satisfying lives. School health is an investment
in a country's future and in the capacity of its people to thrive
economically and as a society" (Bundy, 1999). |
|
| |
|
|
Building on the frameworks developed in the past decade, this
shared view serves as a basis for an effective school health
and nutrition program. Its four components are intended to
be made available together in all schools.
Health-related
policies in schools: Health policies in schools, including
policies for skills-based health education and the provision
of some health services, can help promote the overall health,
hygiene, and nutrition of children. Good health policies
should also ensure a safe and secure physical environment
and a positive psychosocial environment and should address
issues such as the abuse of students, sexual harassment,
school violence, and bullying. By guaranteeing the continued
education of pregnant schoolgirls and young mothers, school
health policies will help promote inclusion and equity in
the school environment. Policies that help to prevent and
reduce harassment by other students, and even by teachers,
also combat the reasons that girls withdraw or are withdrawn
from schools. Policies regarding the health practices of
teachers and students can reinforce health education by
requiring that teachers do not smoke at school and thus
act as positive role models for their students. The process
of developing and agreeing on policies draws attention to
these issues. The policies are best developed by involving
many levels, including the national level and teachers,
children, and parents at the school level.
Safe
water and sanitation facilities: It is a realistic goal
in most countries to ensure that all schools have access
to clean water and sanitation. Without clean water and adequate
sanitation, hygiene education is meaningless. The school
environment may even damage the health and nutritional status
of its children if it increases their exposure to hazards
such as infectious diseases carried by the water supply.
By providing clean water and sanitation, schools can reinforce
the health and hygiene messages and act as an example to
both students and the wider community. This in turn can
lead to a demand from the community for similar facilities.
Sound construction policies will help ensure that facilities
address issues such as gender access and privacy. Separate
facilities for girls, particularly adolescents, are important
in reducing dropout at menses and even before. Sound maintenance
policies will help ensure the continuing safe use of these
facilities.
Skills-based
health education: This approach to health, hygiene,
and nutrition education focuses on the development of knowledge,
attitudes, values, and life skills needed to make and act
on the most appropriate and positive decisions concerning
health. Health in this context extends beyond the physical
to include psychosocial and environmental health issues.
The development of attitudes toward gender equity and respect
between girls and boys and the development of specific skills,
such as dealing with peer pressure, are central to both
an effective skills-based health education and positive
psychosocial environments. With these skills, individuals
are more likely to adopt and sustain a healthy lifestyle
during their schooling and for the rest of their lives.
School-based
health and nutrition services: Schools can effectively
deliver some health and nutritional services as long as
the services are simple, safe, and familiar and address
problems that are prevalent and recognized as important
in the community. If these criteria are met, then the community
sees the teacher and school more positively, and teachers
see themselves as playing important roles. For example,
micronutrient deficiencies and worm infections may be effectively
dealt with by infrequent (half yearly or annual) oral treatment;
changing the timing of meals or providing a snack to address
short-term hunger during the school day¾an important constraint
on learning¾can contribute to school performance; and providing
eyeglasses will allow some children to participate in class
fully for the first time.
|
| |
| |
|
Within this framework, these four components are intended to
be supported by effective partnerships between teachers and
health workers, effective community partnerships, and pupil
awareness and participation (WHO, UNESCO, UNICEF, World Bank,
to be presented at EFA 2000, Dakar). |
|
|
| |
|
|
---------------------------
|
|
| Return
to contents |
|
|
| |
|
