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THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION
In this issue
Health-promoting schools Hiroshi Nokajimo A health-promoting school starts with imagination Ilona Kickbusch 8. Jack Jones WHO's Global School Health Initiative Desmond O'Byrne, Jack Jones, Yu Sen·Hai 8. Heather Macdonald Eastern Mediterranean:
an action-oriented curriculum Mohamed AI Khoteeb Innovation in a fast-changing Europe Vivian Barnekow Rasmussen, David Rivett 8. frio Ziglio New horizons in health 1 D
Rosmarie Erben Health-promoting schools in the Americas 12
Maria Teresa Cerqueiro School health education in South-East Asia and Africa 14 Health can be "contagious"! 15
Sergio G. Meresman Ten steps to school health 16-17 Classroom health in Belize 18
Roman Magana Children versus mosquitos 19
Verity Beckles In London's East End 20
Kevin (orr Helping schoolchildren to help themselves 21
Chantos Penthisarn Greater awareness - better health 22
Jyotika Singh No junk food in the school canteen 23
Roy Donato D. Santos A Shanghai school shows the way 2 4
Coi Hong·Ying A school in Papua New Guinea 25
Buri Veneo 8. Pauline Doonar Sexuality and population education 26
0. J. Sikes Education International: an alliance with WHO 27
Fred von Leeuwen Intestinal worms 28 l. Savioli, K. E. Molt 8. Yu Sen·Hai Mental health promotion in schools 29
Rhona Birrell Weisen 8. John Orley Learning about HIV 30
Mariella Baldo
World Health • 49th Year, No.4 July-August 1996 IX ISSN 0043-8502 Correspondence should be addressed to the Editor, World Heolth Mogozine, World Health Orgonizonon, CH-1211 Geneva 27, Switzerland, or directly to
outho~, whose addresses ore given ot the end of eoch article.
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HEALTH
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©World Heolth Orgonizotion 1996 All rights reserved. Articles and photographs thot ore not subject to seporote copyright moy be reproduced for non-commercial purposes, provided thot WHO's copyright is duly acknowledged. Signed articles do not necessarily reflect WHO's views. The designonons employed ond the presentonon of moteriol published in World Health do not imply the expression of ony opinion whatsoever on the port of the Orgdnizonon concerning the legol stotus of ony country, territory, city or oreo or of its outhorines, or concerning the delimitonon of its frontiers or boundaries.
World Health • 49th Year, No.4, July-August 1996 3
Editorial
Health-promoting schools
T
he school is an extraordinarily effective setting in which to improve the health of pupils, staff, families and members of the community. It is a means of support- ing the basic human rights of both education and health. It offers op- portunities to achieve significant health and education benefits with the limited resources available to education and health agencies. It also offers highly visible opportuni- ties to demonstrate commitment to equity and to raising the social status of women and girls.Given the number of young people who do not attend school, it might be asked whether the school is really significant as a setting in which to promote health. The an- swer is a resounding "yes". Schools, worldwide, reach about 1000 million young people and, through them, their families and their communities.
Primary school enrolments are in- creasing in nearly every part of the world. This is true in absolute num- bers as well as in enrolment rates.
The only major exception is in sub- Saharan Africa, where enrolments are stagnating or declining. But there too, the school is the developing world's broadest and deepest channel for putting information at the dis- posal of its citizens.
Even in countries which are struggling to provide the most basic education to their children, schools are doing more than most people ever imagine to bring about improve- ments in health. Schooling in itself has been shown to be a powerful way to influence health everywhere. Its impact is clearly seen in benefits to
Dr Hiroshi Naka;ima, Director-General of the World Health Organization.
More schools than ever before are considering whether their policies, practices and overall organization contribute positively or negatively to the health of students, teachers,
families and community members. Those that
continuously strive to maintai n and improve positive
contributions to health are what WHO calls "health- promoting schools ".
maternal and child health. Literate women tend to marry later and are more likely to use family planning methods. Mothers with even one year of schooling tend to take better care of their babies; they are also more likely to seek medical care for their children and to have them immunized.
This issue of World Health shows the wide range of activities that schools are undertaking to promote health, along with efforts to prevent and protect against death, disease and disability. The increased attention to health promotion represents a new strategy. More schools than ever before are considering whether their policies, practices and overall organi- zation contribute positively or nega- tively to the health of students, teachers, families and community members. Those that continuously strive to maintain and improve posi- tive contributions to health are what WHO calls "health-promoting schools".
This issue highlights some of the many ways in which schools are learning to promote health. We hope that these examples will inspire other schools to become health-promoting schools, too. •
Hiroshi Nokoiimo, M.D., Ph.D.
4 World Health • 49th Year, No.4, July-August 1996
A health-promoting school starts with imagination
Ilona Kickbusch & Jack Jones
Brushing Ieeth together is fun - and it is one way to keep healthy.
W
at are health-promoting chools? They are schools that do what they can to influence and promote health, even though their resources, support mechanisms and technical capacities may be extremely limited. This issue of World Health describes some of the imaginative ways in which schools are striving to improve the health of pupils, staff, families and communities.Administrators and programme managers think of school health in terms of infrastructure, systems, capacities and resources. Scientists, researchers and planners think of school health in terms of interven- tions, theories and technical factors.
These are important means of devel- oping and improving school health programmes, but they do not suffice.
Imagination is a universal re- source and can be found in abun- dance in each and every school throughout the world. So it makes an appropriate starting point in the quest to become a health-promoting school. Let us imagine a school in
which pupils, parents, teachers and administrators work together to ensure that school policies and prac- tices promote health and fulfil the broad educational and developmental purposes of the school.
Imagine a school in which the social environment is considered to be as important to health as the physical environment, and where pupils and staff work together to create policies and practices that reduce bullying, corporal punishment and other forms of violence, and increase equity, respect, caring, self- esteem and opportunities to experi- ence success in the classroom, the playground and the community.
Imagine a school in which teach- ers, pupils, community leaders and parents work together on sensitive issues such as sexuality and gender, taking local values fully into account, and enable young people to acquire the knowledge, attitudes, values, beliefs, skills and services that they need to prevent HIV infection, sexu- ally transmitted diseases, unintended pregnancy, sexual abuse and discrim-
ination.
Imagine a school whose staff work with representatives from a variety of sectors (health, recreation, social services, law enforcement, transport, food and commerce) to find ways of combining their re- sources and potential to maximize their ability to meet the health, edu- cation and development needs of young people.
To imagine what a school can do to become health-promoting is an excellent starting point. To share such ideas with others is to create a common vision, which in its turn can lead to effective collaborative action.
We invite all readers to write to us (at the address given below) about their health-promoting ideas and activities- especially those that can enable schools with very few re- sources to promote health on their own. Next year, we will issue a report called Health promoting schools: the results of imagination, so that schools throughout the world will be able to share each other's visions and successes. Please send your letters to Jack Jones at the address below and mark them
"Imagination". •
Dr Ilona Kickbusch is Director of the Division of Health Promotion, Education and
Communications, and Mr jack jones is a Health Education Specialist with the Health Education and Health Promotion Unit, World Health Organization, I 2 I I Geneva 27, Switzerland.
World Health • 49th Year, No.4, July-August 1996 5
WHO's Global School Health Initiative
Desmond O'Byrne, Jack Jones, Yu Sen·Hai & Heather Macdonald
I
n establishing the Division of Health Promotion, Education and Communication, the Director- General of WHO charged the Division with strengthening the Organization's capacities to promote health through schools. He recog- nized that many WHO programmes and Regional Offices support a wide range of health promotion, health education, and disease/injury preven- tion efforts in schools, but he also recognized that more needed to be done.To meet the Director-General's challenge, a School Health Team was established within the Health
Education and Health Promotion Unit of the Division. The team serves as a secretariat for an interdivisional Working Group on School Health.
Through the Team, the Working Group and its Regional Offices, WHO is committing its full organiza- tional capacity toward the develop- ment of a Global School Health Initiative.
This Initiative is built on experi- ence, research and partnerships. In
1995, a WHO Expert Committee on Comprehensive School Health Education and Promotion reviewed the status of school health pro- grammes, the strategies used to strengthen them, and research that can be used to improve them. WHO programmes, UN agencies, universi- ties, and education and health organi- zations worldwide contributed information, insight, case studies and research to the Committee. The Committee's report and its back- ground papers provide the founda- tion for the Global School Health Initiative.
The goal
The goal of the Global School Health Initiative is to increase the number of institutions that can truly be called health-promoting schools. Although definitions and their implementation will vary among regions, countries, and schools according to need and circumstance, a health- promoting school can be characterized as a
Working on the development of the Global School Health Initiative.
school that is constantly strengthen- ing its capacity as a healthy setting for living, learning and working. A
health-promoting school:
• engages health and education officials, teachers, students, parents and community leaders in efforts to make the school a healthy place.
• implements policies, practices and measures that encourage self- esteem, provide multiple opportu- nities for success, and acknowl- edge good efforts and intentions as well as personal achievement.
• strives to provide a healthy envi- ronment, school health education and school health services along with school/community health projects and outreach, health promotion programmes for staff, nutrition and food safety pro- grammes, opportunities for physi- cal education and recreation, and programmes for counselling, social support and mental health promotion.
• strives to improve the health of school personnel, families and
6
community members as well as pupils; and works with commu- nity leaders to help them under- stand how the community contributes to, or undermines, health and education.
Implementing the Initiative
WHO's efforts to achieve this goal are carried out through three broad health promotion strategies.
Building capacity to advocate for improved school health
programmes: The Initiative pre- pares technical documents, fact sheets and presentation kits that consolidate expert opinion about the nature, scope, effectiveness and potential of school health programmes. The materials are designed to help individuals in inter- national, national and local organiza- tions to argue effectively for
increased support of health promo- tion through schools. They are also designed to help policy-makers and decision-makers to justify decisions to increase support for such efforts.
Mobilizing public and private resources for developing "health- promoting" schools: WHO's Regional Networks of Health- Promoting Schools may represent the world's most comprehensive and successful international efforts to mobilize support for school health promotion. The first network was initiated by WHO's Regional Office for Europe, the Council of Europe and the Commission of the European Communities. This network has grown in five years to include 34 countries, 500 core schools, and 1600 affiliated schools together comprising some 400 000 students.
In 1995, additional Regional Networks of Health-Promoting Schools were started by the Regional Office for the Western Pacific. This year, the Global School Health Initiative will assist WHO Regional Offices to develop networks in the Eastern Mediterranean, Africa and Latin America. By 1997, it is hoped that every region of WHO will have established at least one network of public and private organizations
World Health • 49th Yeor, No.4, July-August 1996
Schoolchildren in India bringing health information to the community.
interested in working and learning together in collaborative interna- tional, national and local efforts to improve school health.
Strengthening national capaci- ties: WHO is working with China, the Russian Federation and the United States of America to help health and education representatives to collaborate in improving school health pro-grammes. In 1996, as part of the development of WHO's Mega-Countries Health Promotion Network, WHO and the Centers for Disease Control and Prevention (USA) brought together persons responsible for health promotion and school health from seven countries, which include over half of the world's school-age children. All are interested in improving school health programmes on a large scale.
The meeting enabled representatives to identify ways of improving their programmes by working and learn- ing from each other's experience.
Successful efforts will be diffused through the regional networks.
Partnerships and support
WHO recognizes that the success of the Global School Health Initiative rests on the extent to which partner- ships can be formed at local, national and international levels. This will require organizations interested in promoting health through schools to identify individuals with responsibil-
ity, time and authority to work in partnership with others. It will also require them to jointly develop mech- anisms which enable their organiza- tions to plan and work together, document their achievements and improve their programmes.
The extent to which each nation's schools become health-promoting schools will play a significant role in determining whether the next genera- tion is educated and healthy.
Education and health support, com- plement and enhance each other.
Neither is possible alone. Together, they serve as the foundation for a better world. •
Or Desmond O'Byrne is Chief of the Health Education and Health Promotion Unit, in which
Mr jack jones and Or Yu Sen-Hoi ore Health Education Specialists, Division of Health
Promotion, Education and Communication, World Health Organization, l 2 l I Geneva 27, Switzerland. Mrs Heather Macdonald,
formerly with the same Unit, is now Public Health Adviser to the Pacific Regional Team, AusAID's Centre for Pacific Development (ACPAC), I I l 0 Middle Head Road, Mosman NSW 2033, Australia. WHO wishes to acknowledge the following organizations which have contributed technical and/or financial support towards the development of the Initiative: the Division of Adolescent and School Health, National Center for Chronic
Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention
(USA); the Johann Jacobs Foundation (Germany); johnson and johnson European Philanthropy Committee (UK); Education International (Belgium); the Education Development Center (USA); UNESCO, and UNICEF
World Health • 49th Yem, No.4, July-August 1996 7
Eastern Mediterranean: an action-oriented curriculum
Mohamed AI Khateeb
Dentists and teachers promote oral health at the /sa Town primary school in Bahrain. Pupils at this school can become "oral health leaders" and communicate to other children what they have learned.
T
he importance of the health and well-being of children and youth is recognized by all countries in the Eastern Mediterranean Region, which consequently accord a high priority to school health education.Since globally there are close to 1000 million children in schools, the international community should see the school as a unique opportunity to promote Health for All. By reaching school-age children, health education can provide benefits to all dimen- sions of society: the individual, the family, the school, the community and the nation.
In this Region, there is a long tradition of school health education.
Ten years ago, WHO and UNICEF worked together on drawing up an action-oriented health curriculum for primary schools. By "action-ori- ented" the planners meant that the children should learn things that they could apply at school, at home and in the community.
In 1988, a meeting was held in Cairo to initiate the Action-oriented School Health Curriculum for pri- mary schools. Five countries were chosen for participation in the first
round of national implementation: Bahrain, Egypt, Jordan, Morocco and Sudan. In order to promote the programme and ensure effective interagency coordination, the Regional Directors of WHO, UNICEF and UNESCO visited each of those countries.
The following year, an intercoun- try and interagency meeting took place in Cairo in which the partici- pants discussed strategies for imple- mentation. The Ministers of Education in the five countries se- lected subsequently gave their ap- proval to adopt the programme in their countries. Today there are 12 Member States in the Region which use the Action-oriented School Health Curriculum to mobilize and equip teachers and pupils to provide the community with knowledge on preventive health care.
Many ministries and institutions are involved, such as the Ministry of the Interior, the Department of Traffic, the Ministry of Information, and municipalities. Health educators from the Ministry of Health partici- pate in the teaching, and parents are invited to attend. The schools also
arrange for pupils to visit health institutions, shopping centres (where they learn about available foods, food safety and hygiene) and facto- ries. These visits teach them a great deal about health in relation to socio- economic development.
In Bahrain, Jordan and Morocco, tests were developed to measure the knowledge and skills of students after the programme had been run- ning for some time. It was ciear that they had gained knowledge and skills regarding health, and knew how to practise what they had learnt about health-promoting behaviour.
The main questions now are not
so much about what to teach as how
to teach it, and how to train primary- school teachers to put the prototype Action-oriented School Health Curriculum into effect. We also need to find ways to integrate the various health subjects in the school pro- grammes, and to find the resources necessary to support schools finan- cially as they prepare educational packages for the programme.
The prototype Action-oriented School Health Curriculum (also the name of a publication available at the address below) is an innovative programme. It puts the school where it belongs, not in an "ivory tower", but at the heart of the community. It calls for parents, teachers and chil- dren to get together and take action.
This can take many forms, such as improving the school environment, creating school health clubs, or undertaking special projects.
Perhaps the most far-reaching signif- icance of this programme is that it outlines new roles for teachers and schoolchildren. •
Dr Mohamed AI Khateeb is Regional Adviser for Health Education at WHO's Regional Office for the Eastern Mediterranean, P. 0 Box 1517, Alexandria 2 151 1, Egypt.
8 World Health • 49th Year, No.4, July-August 1996
Innovation in a fast·
changing Europe
Vivian Barnekow Rasmussen, David Rivett & Erio Ziglio
A fast-changing Europe needs an innovative effort to create a climate of care and support in the schools. This network represents a sound investment for the future of Europe.
T
he European Network of Health- Promoting Schools is a concrete example of an activity that has successfully incorporated the ener- gies of three major European agen- cies in the joint pursuit of their goals in school health promotion.Launched in 1991, the project is a tripartite activity of the Commission of the European Communities, the Council of Europe and WHO's Regional Office for Europe. The joint planning and management of the Network was one of the recom- mendations of the three agencies' Conference on Health Education held in Strasbourg, France, in September 1990, and it builds on the collaborative work done in the 1980s in the pilot project "Education for Health".
Such pragmatic collaboration is essential to avoid duplication and provide a framework within which to foster and sustain innovation, dis- seminate models of good practice, and make opportunities for health promotion in schools more equitably available throughout Europe. The enthusiasm generated by this project is demonstrated by its rapid develop- ment, from a small pilot activity involving four countries in 1991, to the large complex of activities we see today, in which 37 countries partici- pate.
Countries committed to this pan- European initiative are directing their energies towards the final goal of creating supportive environments for health within schools. This goal is being pursued by promoting within the curriculum positive views on health and safety, which in tum influence teaching and learning styles. This is an ambitious goal, but a fast-changing Europe needs this innovative effort to create a climate of care and support in schools.
The health-promoting school seeks to achieve healthy lifestyles for the total school population by providing safe and health-enhancing social and physical environments in which to live, work and learn. Through its management structures, its internal and external relationships, the teach- ing and learning style it adopts and the methods it uses to interact with its social environment, the school will enable pupils and staff to control and improve their physical and emotional health. The health-pro- moting school should be seen by European countries as an investment.
Places in which to live and learn
Beginning as a small pilot project, the Network now includes over 500 project schools with 400 000 stu- dents in 37 countries. A further 2000 schools are linked through national or regional arrangements to the Network, which provides a unique platform for cross-country exchanges and partnerships.
The Network does not belong to the international organizations but is supported by them, morally and technically as well as financially. It belongs to the participating schools, with the primary objective of im- proving and protecting the physical and emotional health and welfare of pupils, teachers, non-teaching staff and the wider community.
The three sponsoring agencies have formed an international plan- ning committee, and a technical secretariat is hosted by WHO's Regional Office for Europe. Each country with pilot schools has a
"Improving and protecting the physical and emotional welfare of pupils, teachers and the community".
World Heolth • 49th Year, No.4, July-August 1996
national coordinator, and the coordi- nators meet at least once a year to discuss their experience, needs and challenges. The technical secretariat supports the coordinators with tech- nical guidance, and produces teach- ing and training resources and other material.
Thanks to the commitment and eagerness of the project schools, a considerable variety of programmes have already been initiated. These programmes have the following features in common: active collabo- ration between pupils, staff, parents and the community in making the health-promoting schools a reality;
environmental improvements which have affected the ethos of the school;
school policy development in spe- cific areas; and the creation of a supportive atmosphere for teaching and learning.
Twinning proiects
From the very beginning, the project has aimed at including a European dimension, where twinning projects at both national and local level are ways of sharing experience and gaining international understanding and mutual respect. Several twin- ning programmes have started already, involving the sharing of information and the development of parallel health promotion activities, with the help of such tools as elec- tronic communication and video recordings, together with the ex- change of teachers as well as stu- dents. These are monitored on a regular basis and the results are published in newsletters and other media.
Indeed the Network is now a large, complex, and truly European project and has been hailed as an exemplary model of collaboration between the three agencies that coordinate it. It is also beginning to gather real evidence of success.
Some examples:
• The project has from the very beginning focused strongly on collaboration between all the partners concerned. At the na- tional level, the formal agreement
on a joint commitment to the project from both ministries of health and ministries of education has opened the way to a more effective approach to health promotion and education.
• Several countries are already on the point of forming a national curriculum on health education based on the experience gained in the first phase of the project.
• The mobilization of resources to provide technical support through specific tools and training has proved increasingly successful.
• Exchanges and cooperation between countries and schools have strengthened the network and improved the quality of initiatives based on health- promoting schools.
• The project is reported to have an increasing impact on democrati- zation in schools as well as in pre- service and in-service teacher training.
• Some countries are reporting that the project has had an impact on policy development at national level.
• In several countries, networks are now expanding to include more schools and thus the original idea of the pilot phase moving into the phase of dissemination and coun- trywide development is increas- ingly being fulfilled.
The Technical Secretariat receives funding from WHO and the
Commission for the Coordination of Project Activities in European Union member states. The Commission also gives member states funding for country support. Other countries within the Network, in particular countries of central and eastern Europe, receive funding from WHO as well as voluntary donations from countries such as Austria, the Netherlands and Switzerland.
Particular problems are faced by some national coordinators, trainers and teachers in introducing new methodologies and practices into education and health systems. Many classroom teachers are not used to introducing new teaching methods and feel insecure about trying them
9
out. Many school administrators lack confidence in introducing change into school management structures. Trainers, although eager to learn new methods, require sub- stantial training themselves by competent group work experts. It is within this challenging context that the cooperation offered jointly by the sponsoring agencies is greatly appreciated by European countries.
The introduction of changes on the scale required by a health-promoting school needs skilful management if the new elements are to be finally established as a legitimate part of school life.
In the next phase of develop- ment, the Network will seek to reduce inequalities in health and education by introducing carefully targeted activities aimed at vulnera- ble groups, and at specific areas such as disadvantaged inner cities and rural districts.
At the International Planning Committee meeting held in
November 1995, a new development plan was endorsed by the three sponsoring bodies. It includes a working document setting out the strategy, aims and priorities for the future development of the Network.
Europe can look forward to a strengthened and expanding Network of Health-Promoting Schools; it represents a sound invest- ment for the future of Europe. •
Vivian Barnekow Rasmussen, David Rivett ond frio Ziglio are members of the Technical Secretariat, Health Promotion and Investment Unit, WHO Regional Office for Europe, 8 Scherfigsvej, DK-21 00 Copenhagen 0, Denmark.
10 World Health • 49th Year, No.4, July-August 1996
New horizons in health
Rosmarie Erben
Used on the cover of various school health reports of the WHO Western Pacific Region, this drawing fries to symbolize how schoolchildren can work together for better health and welfare.
T
o respond to the challenges of the 21st century, WHO in the Western Pacific Region has outlined in the document New hori- zons in health a coherent way of structuring plans and programmes in pursuit of the goal of health for all.This document identifies three themes for future work with Member States, namely, preparation for life, protection of life, and quality of life in later years. The central concepts in the document- health promotion and health protection - were taken up by the Ministers of Health of the Pacific island countries in March 1995 when they expressed their commitment to "healthy islands" in the Yanuca Island Declaration.
The concept of health-promoting schools reflects the directions set out in New horizons in health. It is in relation to the first of the three themes, preparation for life, which focuses on health promotion issues particularly relevant to infancy, childhood and youth, that these schools have their most immediate application. Schools are also fea- tured as a priority in the regional health promotion programme which was endorsed by the Member States in 1993.
In response to a proposal for the development of health-promoting schools, 27 countries and areas have expressed their interest in collaborat- ing with WHO in this project. In 1995, eight countries were actively involved: China, Lao People's Democratic Republic, Malaysia, Papua New Guinea, Republic of Korea, Singapore, Solomon Islands and VietNam. The concept was first discussed at a workshop on school health promotion for Pacific island nations and collaborating centres for health education and promotion, held in Australia in December 1994.
This approach was given further support at a workshop in Singapore in January 1995 for countries from the northern part of the Region.
These workshops were jointly orga- nized by WHO and the National Centre for Health Promotion, a WHO Collaborating Centre for Health Promotion in Sydney, Australia, and the Training and Health Education Department, Ministry of Health, a WHO Collaborating Centre for Health Education and Health Promotion in Singapore.
Practical steps
A WHO workshop for national coordinators of health-promoting schools from Pacific island coun- tries, jointly organized in October 1995 with the University of the South Pacific in Suva, Fiji, produced an outline for the practical steps involved (see box on next page). In the Pacific, the development of health-promoting schools is viewed as an important part of the Healthy Islands initiative. Later, a WHO working group on health-promoting schools was convened in Shanghai, China, in December 1995.
Regional guidelines, entitled Development of health-promoting
schools- a framework for action, have been prepared at the request of countries, as a basis for countries and areas in the Region to develop healthy lifestyles in the school setting in a comprehensive way.
They are as relevant for China, the largest country in the Region, as for small Pacific island countries such as Niue.
There are six major elements of a health-promoting school: school health policy, the physical environ- ment, the social environment, com- munity relationships, personal health skills and health services. A series of checkpoints shows whether action has occurred in relation to a particu- lar component and allows the school principal, teachers, students and parents to measure their progress. It also guides personnel at the local, regional and national level in the support and recognition of health- promoting schools.
China was the first country to translate the guidelines and discuss their local adaptation during a National Conference on School Health Promotion, held in Beijing in December 1995, sponsored by WHO. Some 100 participants repre- senting health and education authori- ties from all provinces participated in the Conference and agreed on the development of health-promoting schools.
Other issues in the series of booklets on health-promoting schools are the reports from the three workshops and the working group.
An issue on research relating to these schools is in preparation. The series is an important means of sharing experiences and activating networks
Working together
Building alliances is crucial for the development of health-promoting
World Health • 49th Year, No. 4, July-August 1996
schools. At country level, the collab- oration of the Department of Education and the Department of Health is a must. Within WHO an interdivisional theme group on preparation for life ensures that all relevant activities in programme areas such as nutrition, tobacco, and HIV I AIDS are considered. WHO has also made agreements to collabo- rate in developing health-promoting schools with organizations such as UNESCO, UNICEF, UNFPA, the South Pacific Commission and Education International.
Besides supporting the Australian Sports Commission in strengthening the physical activities programme in several Pacific island countries as part of the Australia South Pacific 2000 Sports Programme, WHO is also collaborating with Australia in a healthy islands project for five Pacific island countries, which fo- cuses on health-promoting schools.
The WHO Collaborating Centres for Health Education and Health Promotion have an important role.
The one at Sydney University, for example, will support eight Pacific island countries in carrying out a study on health behaviour in school- children. Several university depart- ments have also become strong allies. From 1996 onwards, the Queensland University is offering short training courses for staff on health-promoting school projects.
Other exciting developments are taking place in an increasing number of countries in the Region. Whether adopting the whole idea or using it in relation to specific health issues such as the control of helminth infections or substance abuse, countries and areas in the Region have responded enthusiastically to the concept of health-promoting schools. The biggest challenge, however, is to move from a given project to the nationwide establishment of health- promoting schools. It is encouraging to see that many countries have included the development of such schools in the activities funded through the WHO regular budget.
The regional activities also con- tribute to WHO's Global School Health Initiative, which provides
11
A school garden in the Philippines: a safe place to ploy, sing and learn.
valuable back-up for the countries in the Region, especially with regard to school health networking activities.
To obtain copies of the two documents referred to, please write to the author at the address given below.
•
A network for the Pacific
Cliff
BensonDr Rosmarie Erben is Regional Adviser in Health Promotion at WHO's Regional Office for the Western Pacific, United Notions Avenue, P.O.
Box 2932, I 099 Manila, Philippines.
A network of health-promoting schools in the Pacific was formally established at the WHO Workshop for National Coordinators of Health-Promoting Schools in the Pacific, held at the University of the South Pacific in Fiji from 2 to 6 October 1995. Attended by participants from 17 Pacific countries, as well as observers from Australia, this week-long gathering designated the Institute of Education at the University of the South Pacific as the focal point of the network, with its Fellow in Science Education, Sereana Tagivakallni, as Coordinator. The IOE is well placed to fulfil this role as it has regular contact with the Ministries of Education in the 12 member countries of the University. It also coordinates two other networks, one in teacher education and the other for women managers in higher education, which incorporate several non-member countries as well.
Regular satellite meetings are convened to ensure continuity of the network. The University's satellite system is used, although not all countries in the Network are connected to this system. However, the Coordinator maintains contact with those countries and incorporates news from them in records of meetings. The Institute of Education also produces a Pacific health-promoting schools manual for use by the national committees of health-promoting schools and in the schools themselves.
Mr Cliff Benson is Director of the Institute of Education, University of the South Pacific, P.O.
Box 1168, Suva, Fi;i.
12 World Health • 49th Year, No.4, July-August 1996
Health-promoting schools in the Americas
Maria Teresa Cerqueira
A teacher with her pupils in Argentina: the health-promoting team starts here.
T he Health-Promoting Schools human development.
initiative in the Region of the There are three principal areas of Americas stems from a proposal action for health-promoting schools.
by the 14 countries which were The first consists of health education, represented at a consultation on which includes reshaping and updat- Health Education and Promotion in ing the school curriculum, improving the School Setting, held at the the training and skills of the teachers, Heredia National University, Costa and preparing appropriate educa- Rica, in 1993. The initiative called tiona! material. The second involves for the development and strengthen- making the school environment ing of health education, environmen- healthy through such measures as tal health, and health and nutrition ensuring adequate sanitation and safe services at school. This entailed a water supply, improving the physical commitment to involving not just the infrastructure, preventing violence school but also the community and (including corporal punishment), and local and municipal health services. finding ways to improve mutual
The objective was to strengthen understanding between pupils, teach- the capacity of everyone concerned ers and parents. The third area is that to create an environment that would of health and nutrition services, and encourage better knowledge, atti- includes better coordination between tudes and health promotion practices, the health services, the parent- and would help to prevent risk fac- teacher associations, various non- tors for the younger generation. The governmental organizations and Healthy Cities and Municipalities community institutions.
movement helped to strengthen local capacity to identify and respond to
the requirements of this initiative. At
Regional strategy
the same time, the promotion of
school health also held out the The regional strategy for carrying out promise of reducing school truancy the initiative is to promote a variety and examination failures, both of of cooperative activities including:
which are risk factors for health and • disseminating the conceptual
Latin America and the
Caribbean have accumulated wide-ranging and fruitful experience in the field of school health, and ways are now being sought to apply the concept of school health promotion in a more integrated manner.
framework and action guidelines of the initiative, and supporting the formation of a Latin
American and Caribbean network of health-promoting schools to exchange knowledge and experi- ence about health promotion;
•
enabling the education and health sectors to formulate and put into effect joint policies;•
helping to consolidate the mecha- nisms of intersectoral coordina- tion, which will include mixed commissions to harmonize and evaluate health promotion activi- ties in the schools;•
strengthening the capacity of institutions to assess health needs;•
promoting environments that are healthy both physically and socially, and reinforcing the community's social support systems;•
coordinating the activities of local schools, health services and community organizations in the municipal context, and involving community leaders and local authorities so as to ensure that health promotion is incorporated in local development planning;•
encouraging health promotion atWorld Health • 49th Year, No.4, July-August 1996
the school level with the full participation of the community and parents' associations;
• strengthening the human resources needed for health promotion in schools, which includes training teachers and health personnel, and providing reference materials and technical support for teachers;
• finding ways to monitor practices that might endanger the health of schoolchildren;
• making institutions better able to evaluate the whole process of creating health-promoting schools, and the impact of health promotion and education on the knowledge, attitudes, practices and lifestyles of the school com- munity.
A range of experiences
Latin America and the Caribbean have accumulated wide-ranging and fruitful experiences in the field of school health. In Latin America, ministries of education are carrying out various programmes of school health, especially in health education at the primary-school level. Most countries in the region can rely on the health services to detect problems in areas such as hearing, sight, pos- ture, malnutrition, and caries. Many health education programmes are built into the curriculum on subjects such as hygiene, diet, accidents and waste disposal. However, many of these programmes tend to take a vertical approach in which the lessons are not related to other as- pects of life. There is no system of surveillance for risky practices at school, and this makes it difficult to design strategies, activities and teaching materials to promote health.
Certainly, environmental health is a priority area; others include im- proving human relations, preventing violence in the school and strength- ening the school's capacity for health monitoring and evaluation. Past experience has shown up a number of obstacles that prevent the concept of school health promotion from
manner. In 1994, a conceptual framework and guide were produced, with the aim of making the health- promoting schools initiative a reality.
The following year saw the launch of the Network of Health-Promoting Schools in the Region.
Here are some examples of what is being done. In Bolivia, educa- tional reform calls for close coordi- nation between the health and education sectors in order to bring about the full integration of health promotion and health education.
This reform is at present using the technique of "rapid diagnosis and analysis" to make a major evaluation of the country's institutional capacity to undertake health promotion and health education at the primary- school level. On the basis of this evaluation, a plan will be drawn up to integrate these two activities in accordance with the principles of the educational reform.
In Costa Rica, the process of strengthening institutional capacity to create health-promoting schools is making great strides. The Mixed Commission for Education and Health is already undertaking rapid diagnosis and analysis, has prepared a questionnaire to evaluate habits and practices that might endanger the health of schoolchildren and adoles- cents, and is coordinating the forma- tion of a national network of such
being applied in a more integrated Planting trees Foro healthier Future in Mexico City.
13
schools.
In Mexico, the national school health programme has the following aims: to promote a change in atti- tudes, habits and behaviour in order to inculcate a culture of health in the schoolchildren, their families and the community; to contribute to the early detection and prompt treatment of health problems; and to increase the effectiveness of health activities through the coordinated participa- tion of health-related and educa- tional institutions.
The Caribbean island states also have extensive experience in this field. One school health project, for example, aims at teaching life skills in the English-speaking Caribbean, with particular reference to
Dominica, Saint Kitts and Nevis, and the British Virgin Islands. It has been developed on the basis of the perceived need to improve the teach- ing of health education and sexuality in the schools. •
Or Mario Teresa Cerqueiro is Regional Adviser
For Community Participation and Health Education, Division of Health Promotion and Protection, World Health Organization Regional OHice For the Americas/Pan American Sanitary Bureau, 525 23rd Street N. W , Washington, DC 20037, USA.
14 World Health • 49th Year, No.4, July-August 1996
School health education in South·East Asia
T
he whole subject of health edu,cation in schools in WHO's South-East Asia Region is closely linked with the development of the Healthy Cities initiative in that Region. This link has enabled a number of supporting alliances to be established between schools and their immediate community, as well as creating a favourable environment for further joint activities to be undertaken in the future.A wide range of intercountry seminars and consultations have been arranged in recent years deal- ing with many aspects of school health and health education in the classroom. In particular, representa-
ti ves from the ministries of health and ministries of education have come together on a number of occa- sions to discuss methods of prevent- ing the spread of sexually transmit- ted diseases, especially HIV/AIDS.
As long ago as 1992, the Regional Office in New Delhi drew up and distributed a series of recom- mendations and guidelines for carry- ing out and strengthening compre- hensive school education in the Region. Since then, several coun- tries have made efforts to reorient their health services in such a way as to ensure that health aspects receive their due emphasis in school curric- ula at all levels.
India, Nepal and Sri Lanka, for instance, have been at pains to foster the development of school health education, not least through encour- aging "little doctor" programmes.
These seek to ensure that whatever the children learn in school about hygiene, good sanitation and healthy lifestyles is carried back to their families and their communities. In many parts of the world, school- children have proved to be very good teachers to their elders who have not had the benefit of instruc- tion in the basic lessons in healthy living. •
School health education in Africa
T
he African Region is collaborat- ing with WHO headquarters in Geneva and drawing on experi- ences of other Regional Offices in order to put together a regional plan for developing health-promoting schools. The Regional Office for Africa in Brazzaville has devised a plan that will result in the creation of three subregional networks of such schools. The first of these networks will be launched in an intercountry consultation in Gaborone, Botswana, in November 1996, jointly planned by the Regional Office and WHO headquarters.One project already under way involves working with the Finnish International Development Agency (FINNIDA) to assist Namibia in planning school health programmes and out-of-school health activities for young people. Support for simi- lar schemes is being sought from other organizations of this kind.
The spread of the AIDS pan- demic throughout the continent has served as a driving force, obliging governments to review the quality of school health curricula. Much more emphasis is now being placed on training teachers in health education
and health promotion methods. A general reorientation of health ser- vices is now taking place in Africa, as ministries of education and min- istries of health look for strategies to attract investment in school health programmes, and for ways of main- taining such programmes in the
future.
Among country-specific activi- ties, the Regional Office is working with Benin, Cameroon, Ghana and Namibia to bring about improve- ments in school health, particularly through community action •
In many African schools, more emphasis is now being placed on health education and health promotion.
World Health • 49th Year, No.4, July-August 1996 15
Health can be "contagious"!
Sergio G. Meresman
about in the classroom.
A
rgentina's"Health- Generating Schools" experiment stems from an investi- gation into health promotion in schools, undertaken by the Institute for Research in Education Sciences at Buenos Aires University. Last year we drew up a pilot
"Health is something wonderful", says the poster on healthy nutrition designed for the school by the children themselves.
The final step was to evaluate and synthe- size the process, with maximum input from pupils and parents, making the local com- munity a part of the process. This com- pleted a cycle which went from information (research, problem- plan for five schools in urban and
semi-urban areas of Buenos Aires and Quilmes. The programme was supported by the local office of the Pan American Health Organization and involved 25 teachers and auxil- iary teachers, more than 500 pupils in the 3rd to 6th grades of the San Cristobal, Villa Crespo, Ezpeleta and Berazategui schools, and a large group of parents, maintenance staff and school principals.
In order for each school-pupils, teachers and parents- to be truly involved in the programme on the basis of its own needs and dynamics, we carefully avoided the idea of
"outside assistance" which has char- acterized previous interventions in school health, because it tends to make the school a mere captive audience for the health professionals.
Outside assistance has also resulted in intermittent activity, focused on a single issue, which only served to reinforce misconceptions and under- line the passivity of the educational community.
Rather than being judgemental and pedagogical, we looked for an approach based on a positive concept of health. To do this, we used the formal and informal opportunities
which the school offers for promot- ing healthy behaviour. We tried to foster a culture of care, so that health-related themes would infil- trate daily school activities and not just be an adjunct to the curriculum.
Our objectives were as follows: to sensitize the educational community to its role in promoting healthy habits and health care; to improve the understanding of relations between health themes and other components of the school curriculum; to manage the school as a health-giving physical and social environment by making changes in the physical structure, the work pattern and the teaching- learning methods; and to optimize the links between school and health centre, thus encouraging joint initiatives.
We "diagnosed" the health situa- tion of each school and its commu- nity, looking not only at problems but also at opportunities for health. We then chose a particular health theme for in-depth study, such as diet, hygiene or accidents. The pro- gramme managers sought ways of making changes in the school's daily life which presented pupils with objective facts to discuss and learn
solving) through moti- vation (sensitization, involvement) to production (synthesis, communica- tion, change).
The success of this pilot project carried out in 1995 encouraged us to extend the programme so as to form a network of health-generating schools. The emphasis was placed not on "the absence of illness" but rather on "a culture of health and care". This gave every participant, whether child or adult, the opportu- nity to make an exciting discovery:
that health can be "contagious"! •
Dr Sergio G. Meresman, of the Institute for Research in Education Sciences at Buenos Aires University, Argentina, is at present working at the Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 50A, UK.
STEP ' TOS
GHEALTH-
Schools should be healthy places in which to work, help prevent and treat the common health problems of children and staff, and provide referral as needed to appropriate health institutions.
AN ENTRY POINT FOR HEALTH PROMOTION AND INTERVENTION
Skills-based health education can enable children to make healthy choices and adopt healthy behaviour throughout their lives.
CRITICAL HEALTH AND LIFE SKILLS
Schools must provide safe water and sanitary facilities and protection from diseases, violence and harmful substances.
A SAFE LEARNING AND WORKING ENVIRONMENT
Improving and expanding educational opportunities for girls is one of the best health and social investments a country can make.
FULLEDUCATIONALPARTICWATION OF GIRLS
Every Member State must provide education in school that meets the full range of children's learning and
developmental needs.
INVESTMENT IN SCHOOLING
WHO Expert Committee on Comprehensive School Health Education and Health Promotion.
HOOLHEALTH
~RO
International support must be further developed to enhance the ability of Member States, local communities and schools to
promote health and education.
ThiTERNATIONALSUPPORT
School health programmes must be well designed, monitored and evaluated to ensure successful implementation and
outcomes.
SUCCESSFUL SCHOOL HEALTH PROGRAMMES
The community and the school must work together to support health and education.
CO~ANDSCHOOLThiTERACTION
Teachers and school staff must be valued and provided with the support necessary to enable them to promote health.
TRAINING OF TEACHERS AND SCHOOL STAFF
Policies, legislation and guidelines must be developed to ensure the mobilization, allocation and coordination of
resources at all levels.
POLICIES, LEGISLATION AND GUIDELINES
Produced by the Division of Health Promotion, Education and Communication.
18 World Health • 49th Yem, No.4, July-August 1996
Classroom health in Belize
Roman Magana
Words of advice and
encouragement are valuable but they are simply not enough in the fight against diseases.
P
overty is probably the principal reason for some countries being ravaged by diseases. Belize, lying on the Caribbean coast of Central America, certainly suffers both from a poor economic situation and from widespread disease. At our school -Holy Redeemer Upper School in Belize City-the struggle to keep the children healthy is un- ceasing. We may lack the finance and technology needed to combat all the diseases that threaten our chil- dren, but our weapons of determina- tion, education and cooperation have helped us to make progress in this struggle.The school has received much help from international organizations like WHO, as well as from local
institutions such as the Health Department. We have been provided with the technical advice and infor- mation needed to equip us for pro- moting health in the classroom.
Occasionally, personnel from these organizations have visited our school to give lessons, stimulate discussion and encourage our children to take simple steps to prevent diseases.
Some of the classrooms have become like little art galleries displaying charts that depict the causes, effects and ways to prevent such illnesses as cholera, AIDS and malaria.
Over the years, we have set aside one day each year for nurses to come to the school to give our children lessons on sex education. We have seen how formerly timid students now want to learn more about them- selves and about the diseases that threaten their lives.
As teachers, we believe that words of advice and encouragement are valuable but they are simply not enough in the fight against diseases.
We do not have a particular time in the curriculum to teach health educa- tion, so this topic is included in the
Through discussions and practical work, children quickly learn haw to promote health in the community.
science lessons. Recently, one class was encouraged to do research on several tropical diseases and to make presentations in class. The results were astounding. The children produced charts and equipment to help them with their presentations.
One student, Giovanni Santos, brought a stethoscope to listen to the heartbeat of his classmates. Sharnir Polanco brought an instrument to test the blood for sugar content, while Jamie Rosado illustrated- with the help of a plastic heart- how cholesterol can be deadly to us.
These are only a few examples of what these children did themselves to acquire knowledge about sickness and good health.
Hygiene is accorded great impor- tance, and our classrooms, our yard and especially our toilets are kept clean and tidy. The cost of maintain- ing the toilets is quite high but the results are satisfactory. Our school has won several first prizes for being the cleanest school in the city, and only last year we won an essay competition on "Keeping Belize City clean and beautiful."
Holy Redeemer Upper School does not have all the resources necessary to provide comprehensive health to our children, but the tools we do have are time, motivation and dedication. Our ultimate goal is to see that our children eat well and have balanced diets. We are aware that a few children lack adequate nourishment; consequently one of our immediate aims is to generate the resources needed to ensure a healthier future for our school- children. •
Mr Raman Magana is an Assistant Teacher at Holy Redeemer Upper School, 14 New Road, Belize City, Belize.
World Health • 49th Year, No.4, July-August 1996 19
Children versus mosquitos
Verity Beckles
Pupils of the L. T. Gay Memorial School in Barbados separate garbage at the point of disposal.
W
e in our small island nation know how important it is to fight against all types of diseases and environmental hazards, and to work for a healthier world.There is no better way to succeed in this than to educate our children at an early age. That is why the L.T. Gay Memorial Primary School near Bridgetown, the capital of Barbados, was pleased to become one of the many pilot schools in the Caribbean to be involved in community-based dengue prevention and control.
Health education which leads to good health practices should be everyone's business. Despite the emphasis of primary school educa- tion on "the three Rs", with a concen- tration of effort on assisting pupils through the Common Entrance Examination at age eleven, our school has devoted much time to the Environmental Health and Vector Control Curriculum. We chose the integrated subject approach because weekly 45-minute sessions on health education proved inadequate. This
"infusion" approach was used in social studies, mathematics and agricultural science, and it helped
pupils to express themselves through art, poetry, composition and craft.
The theme chosen was REDUCE, RECYCLE and REUSE. Since the mosquitos that transmit dengue may thrive in rubbish tips, our goal was to reduce the amount of garbage that was being collected daily by the sanitation workers. We introduced garbage separation, setting apart plastics, paper and non-
combustibles. Combustible materi- als were incinerated and the ashes were applied to the garden beds as fertilizer.
In the craft programme we used plastic drinks bottles as vases, aquaria, candle-holders and a variety of other household items. To avoid wasteful use of water, they were also used in the school garden as funnels to channel irrigation water down to the roots of the crop plants.
Comments from parents revealed that their children had taught them many ways of controlling vectors and some important facts about dengue fever. Parents and teachers also said their children assumed the role of health inspectors, searching their surroundings and looking for
mosquito breeding places. They often collected larvae for study, informed the local authorities, and eliminated breeding sites.
District public health inspectors arranged visits to the local neigh- bourhood, and these gave the pupils first-hand knowledge of good and bad health practices in the commu- nity. The inspectors also gave in- struction to the janitors and school meals staff about vector control and safe food-handling methods.
Two exhibitions at the school and the wealth of knowledge shown by the pupils on various health topics were proof of the dedication and hard work of the teachers. The pupils' pictures, poems and compositions showed how strongly they felt about things that affect their health.
One of the difficulties which the school faced initially was the reser- vation expressed by teachers about adding a new topic to the already busy health programme. However, in time the project received the fullest support of the teachers. It is clear that, for maximum effect, health-promoting schools need to formulate long-term plans. •
Mrs Verity Beckles is a teacher at L. T. Gay Memorial School, St Michael, Barbados.
