Health Promotion Facilities In Schools :WHO ‘’Health Promoting Schools Initiative

http://doi.org/10.33698/NRF0187  -Jatinder Kaur,Sushma K Saini, Bhavneet Bharti, Surinder Kapoor

Abstract : Schools can make a substantial contribution to a student’s health and well- being.Health Promoting Schools (HPSs) represent key settings through which health can be improved. Despite this, there is some considerable uncertainty about the facilities available in schools to call the schools as Health Promoting. Objective: An exploratory study was carried out with the aim to assess the availability of school based health promotion facilities under the Health Promoting Schools initiative of WHO in selected schools of Chandigarh in the year 2012-13. Method: Twenty five high and senior secondary schools (13 government and 12 private) were selected by stratified random sampling from the list of schools updated by Director Public Instructions for schools 2010.The data was collected through interviews as well as through observations of the parameters of the physical infrastructure of schools and recorded using an observation rating scale at each of the selected schools whereas principals were selected purposively for the interview. The tools utilized for data collection were rating scale to assess the availability of physical infrastructure, health, sanitation and nutrition facilities as well as interview schedule each for the principal which was developed after extensive review of literature on regional guidelines of the WHO on health promoting. Results: The study concluded that the most promising facilities which were available were student’s health checkups in schools, health cards being maintained in schools, inter sectoral coordination, health education and regular co-curricular activities in schools and areas which need addressing were insufficient toilet facilities, lack of drinking water facilities and not well maintained first-aid kits and poor transportation facilities.

Keywords

Health promoting schools, health promotion, HPSI.

Correspondence at

Dr. Sushma Kumari Saini

Lecturer

National Institute of Nursing Education PGIMER, Chandigarh

Introduction

The school is an important influencing agency in a person’s life. Almost all children attend school at some time during their lives and spend 6 to 7 hours of their time every day in that learning environment. Health is closely interlinked to education. The health promoting school’ has emerged in the last decade as a new framework to assist schools in addressing health issues. It has been strongly promoted by the WHO and is being implemented in many countries throughout the world. The role of the nurses was linked to assessment, policy development and assurance of the availability of health services to the community. The WHO has played a key role in shaping the directions of school health.The early genesis for the health promoting school can be traced back to 1950 when the WHO established an Expert Committee on School Health Services. Another influential stimulus for school health is to be found in the Declaration of Alma Ata. The focus of the Declaration of Alma Ata (Health for All by the Year 2000) prompted a closer examination by governments and health authorities about how this could be Charter for Health Promotion. It has six essential components:

Safe and Healthy Environment: The physical environment includes school buildings, interior structures, play grounds, eating facilities, water and food provided at school and the surroundings in which the school is situated. The psychosocial school environment involves relationships between teachers and students, among teachers, and between  parents  and  teachers.6     It  also includes adequate number of functioning toilets, safe water for drinking and hand washing, appropriate means of waste disposal and security facilities. achieved.1    The  Ottawa  Charter  for  Health School Nutrition and Food Services:

Promotion was another major milestone in shaping the direction of health promoting schools. WHO further increased the momentum for school health with its School Health Initiative. In another approach WHO, UNICEF, UNESCO and The World Bank have developed a partnership to Focus Resources on Effective School Health. ‘Focusing Resource on Effective School health’ (FRESH) was launched in 2000 at World Education Forum in Senegal to make ‘child friendly’ learning environment. ‘FRESH’

Poor nutritional status is associated with impaired growth, ill health and lower educational attainment. School feeding programmes increase food availability while increasing and promoting healthy eating.7

School Health Education (SHE): This involves curriculum-based educational activities, designed to help students acquire knowledge, attitudes, beliefs and skills needed to make informed healthy decisions and practice healthy behaviors.8 recommends following components in schools like health related policies, safe water and sanitation facilities, skill based health education and school based health and nutrition services.3

School health was also identified as an important health intervention by Bhore Committee in 1946, but these services and programmes remained in infancy for next two decades. Since independence a number of committees were set up on school health. In 1961 the ‘Renuka Ray School Health Committee’ laid the foundation for a comprehensive school health programme. A Health Promoting School (HPS) is based on the World Health Organization’s Ottawa

School Health Services (SHS): School

health services include preventive, curative, first- aid and referral services. It also includes health promotion services for staff. Designated personnel could include trained School nurses, designated teachers or a school health team who have had appropriate training.9

Physical Education and Recreation: Physical education and recreation help individuals acquire physical fitness and provide opportunities for building self- confidence. Encouraging sports as part of school activities, availability of qualified physical education instructor, minimum two periods per week for physical activity is required so as to improve health and wellness by doing physical activity at the level of school.10

Health promotion for school personnel: A Health Promoting Schools are concerned with the health of all its members, including the teachers. Teachers can also act as important role models for students and others. Pre-service and in-service training can aid teachers to acquire health promotion knowledge which they can then use to improve their own health and also disseminate to students.11

School and Community Collaboration: Families and communities can help students to understand, practice and share what they learn about health in the classroom and to co- operate in efforts to enhance the health promoting aspects of the environment. The role of nurse working in community covers a vast spectrum of roles in school health services which includes direct health care services to students, screening and referral, provision of healthy school environment, health promotion of students, leadership role in school health policies and programmes, acts as a leader for the provision of health services and as a liaison between school personnel, family, community and other health care providers. A considerable gap exists in terms of facilities available and the situation that currently prevails in most schools in India. So the present study was planned with the aim to explore the availability of school based health promotion facilities using WHO component indicators for Health Promoting Schools in Chandigarh.

Materials and Methods:

The study was conducted in the Government and Private Schools within the Union Territory of Chandigarh. Chandigarh is the first well planned modern city of India and serves as the joint capital of both, Punjab and Haryana States. Chandigarh is known for its high literacy rate of 86.43% (2011). The target population included all the High and Senior Secondary schools within Union Territory, Chandigarh. Twenty five schools were selected from the list of schools updated by DPI (schools) in the 2010 through stratified random sampling technique. The strata in case of government schools includes Govt. Model Senior Secondary schools, Government Senior Secondary schools, Govt. Model High Schools; Govt. High Schools while in case of private schools the strata consists of only high and senior secondary schools. The sample contains schools both from urban as well as rural area. From each selected school principal was interviewed. The data was collected through interviews and observation of the schools based on the indicators as suggested by WHO in HPSs guidelines.

Tools for the study were developed based on the extensive literature review, expert opinion of guides, experts in pediatrics medical and nursing and Regional guidelines of the WHO on health promoting schools. Tools developed for the collection of data were observational rating scale to assess the availability of physical infrastructure, health, sanitation and nutrition facilities and interview schedule to assess school health services, policies and intersectoral coordination, promotion of personal health and life- teaching skills. Validity of tools was established by seeking the opinion of experts from the field of pediatrics, nursing, public health and consultation with the guide and co-guides. After obtaining the ethical clearance from ethical review committee, PGIMER, Chandigarh and permission from DPI schools data was collected in the months from August to October. Observation of the school was carried out with the help of teachers or other school personnel by utilization of observation tool. Five classrooms were observed for collecting the details of the infrastructure and sanitation of classrooms. The selected classrooms included one section each from classes 6th to 10th in high schools and from 7th to 12th for senior secondary schools.

Results

Out of the total 25 schools, 13 were government and 12 private schools. Regarding the category of schools, 11(44%) were high schools and 16 (56%) were Senior Secondary schools. Out of the total 25 schools, only 8(32%) schools had health personnel and the availability being more in 7(58.3%) private schools. Dietician was available only in 1(4.0%) private school. Regarding availability of counselor, only 6 (24%) schools had counselor. Majority 23 (92%) of the schools had physical trainer in the school. Majority of the school buildings 22(88%) were having boundary wall greater than five feet which includes 12 (92%) government and 10 (83.3%) private schools, with only 12 (48%) schools enclosed by fencing on all the sides. Almost all 24 (96%) schools were having security guard at the main gate. In relation to the presence of fire extinguishers in schools, a good number of 20 (80%) schools reported the presence of fire extinguishers which were well within the expiry limits in the school corridors which included equal number both in government as well as in private schools.

Table 1 reveals the availability of sick room which was there in 6 (46.2%) Govt & 7 (58.3%) private schools. Examination table & chair were available in 5 (38.01) Govt. & half of private schools. First aid kits were available in 3 (23%) Govt. & 5 (41.7%) private schools. Though expiry date medicines were checked regularly still most of the schools (84%) had few expiry date medicines in their first aid kits. Recording of utilisation of sick room was maintained by 7 (28%) schools. Regular physician/school nurse was there only in 6 (50%) private schools.

Table 1: Availability of Medical/First-Aid Facilities in selected schools              N=25

Medical/ First-aid Facilities	Type of Schools		Total n (%)
	Government n1=13 n(%)	Private n1=12 n(%)
–      Availability of Sick Room	6 (46.2)	7 (58.3)	13 (52.0)
–      Availability of Examination Table and chair	5 (38.0)	6 (50.0)	11 (44.0)
–      Availability of First – Aid kit	3 (23.0)	5 (41.7)	8 (32.0)
–      Expiry dates of medicines	9 (69.2)	12 (100.0)	21 (84.0)
–      Record for Utilization of sick room	2 (15.4)	5 (41.7)	7 (28.0)
–      Regular presence of a physician or school nurse	—	6 (50.0)	6 (24.0)

 Table 3 describes the availability of nutrition facilities in schools. Out of the total 25 schools, the mid-day meal scheme was available in all 13 (100%) government schools and only in 2 (16.7%) private aided schools. Out of the total, 25 schools, canteen facility was present in 20 (80%) schools that included all government 13(100%) schools but only 7 (63.6%) private schools.

It was observed that out of 25 schools 15 (60%) schools had mopped corridors & there was no littering (92%), no spitting/spilling (100%) in corridors. Eighteen (72%) classes & 64% corridors had dustbins. Most of schools (88%) had natural light in classrooms. (Table 2 )

Table 2: Availability of Infrastructure and Sanitation Facilities

in selected schools.                                       N=25

Infrastructure & Sanitation	Type of schools		Total n (%)
	Government n1=13 n(%)	Private n1=12 n(%)
– Mopped Corridors	4 (30.8)	11 (91.0)	15 (60.0)
– Absence of littering in corridors	11 (84.6)	12 (100.0)	23 (92.0)
– Absence of spitting/spilling	13 (100.0)	12 (100.0)	25 (100.0)
– Floor area according to students (10 sq. feet space for each student)	3 (23.1)	9 (75.0)	12 (48.0)
– Mopped Classrooms	3 (23.1)	11 (91.7)	14 (56.0)
– Absence of littering in Classrooms	5 (38.5)	8 (66.0)	13 (52.0)
– Absence of cob webs	12 (92.3)	10 (83.3)	22 (88.0)
– Adequate space between rows (S 80cm space between rows)	5 (38.5)	8 (66.7)	13 (52.0)
– Walking Space around sides	1 (7.7)	2 (16.7)	3 (12.0)
– Chairs/desks according to student strength	6 (46.2)	11 (91.7)	17 (68.0)
– Natural Lighting	10 (76.9)	12 (100)	22 (88.0)
– Artificial Lighting	10 (76.9)	8 (66.7)	18 (72.0)
– Open able Windows (S5 m2 area)	1 (7.7)	1 (8.3)	2 (8.0)
– Cross Ventilation	1 (7.7)	1 (8.3)	2 (8.0)
– Presence of Dustbin in Classrooms	10 (76.9)	8 (66.7)	18 (72.0)
– Presence of Dustbin in Corridors	8 (61.5)	8 (66.7)	16 (64.0)
– Presence of Dustbin Near Eating Place	8 (61.5)	7 (77.8)	15 (68.2)
– Presence of Dustbins in Ground	3 (23.0)	5 (41.6)	8 (32.0)

Table 3 : Availability of Nutrition Facilities in selected schools.                 N=25

Nutrition Facilities	Type of schools		Total n (%)
	Government n1=13 n(%)	Private n1=12 n(%)
Mid-day Meal Programme –        Availability of mid- day meal in school   –        Availability of Utensils –        Separate place for distribution of food –        Separate staff for distribution of meal –        Cleanliness of the area	13 (100.0) n1=13 — — 10 (76.9) 6 (46.2)	2 (16.7) n2=2 1(50.0) 1(50.0) 2(100.0) 1 (50.0)	15 (60.0) n=15 1(6.7) 1 6.7) 12(48.0) 7 (46.7)
Canteen facilities –        Presence of Canteen   Ø Hygienic canteen facility Ø Seating arrangement in canteen Ø Availability of healthy food/ drinks only Ø Availability of eatables at subsidized rates Ø Availability of Clean Refrigeration facilities	13 (100.0) n1=13 4 (30.8) 2 (15.4) — 13 (100.0) 3 (23.1)	7 (63.6) n2=7 6 (85.7) 1 (14.2) 1 (14.2) 5 (71.0) 6 (85.7)	20 (80.0) n=20 10 (50.0) 3 (15.0) 1 (5.0) 18 (90.0) 9 (45.0)

Table 4 reveals the availability of drinking water and sanitary toilet facilities in schools. Another important aspect in relation to the healthy school environment was the availability of sufficient toilets as well as separate toilet facilities for girls and boys. Only 14 (56 %) schools had sufficient number of toilets for boys and 15 (60 %) schools had sufficient number of toilets for the girls and the proportion reported to be higher in 10(83.3%) private schools

Table 4: Availability of drinking water and sanitary toilet facilities in selected schools.

N=25

Drinking Water & Sanitary toilet facilities	Type of schools		Total n (%)
	Government n1=13 n(%)	Private n1=12 n(%)
–     Sufficient number of Boys toilets	6 (46.0)	8 (66.6)*	14 (56.0)
–     Sufficient number of Girls toilets	5 (38.4)	10 (83.3)	15 (60.0)
–    Sanitation of Toilets	9 (69.2)	12 (100.0)	21 (84.0)
–     Sufficient hand washing Facilities near Boys toilets	12 (92.0)	11 (91.0)*	23 (95.0)
–     Sufficient hand washing Facilities near Girls toilets	12 (92.0)	11 (91.0)	23 (92.0)
–     Availability of functional hand washing facilities	10 (83.3)	10 (90.0)	20 (87.0)
–     Presence of Dustbin in Boys toilets	3 (23.1)	3 (25.0)*	6 (25.0)
–     Presence of Dustbin in Girls toilets	6 (46.2)	9 (75.0)	15 (60.0)
–     Sufficient number of taps	3 (23.1)	4 (33.0)	7 (28.0)
–     Functional drinking water taps	11 (84.6)	12 (100.0)	23 (92.0)

*There was no facility of boy’s toilet in one of the private girl’s school. Two government schools had no hand washing facilities near girl’s toilets.

In relation to the educational qualification of principal, 18 (72%) principals were Post-graduate that included 7 (53.8%) in government schools and 11 (91.7%) in private schools.

Out of the total 25 school principals, only 12 (48 %) principals reported the presence of School Health Committee which included 7(63.3%) private and 5 (35.7%) government schools. Majority of the schools 24 (96%) reported the presence of school management committee. However, others reported the involvement of NGO’s in 8 (33.3%) schools, persons from social sector in 6 (25%) schools, MLA in 2 (8.3%) schools and in others Municipal counselor, Mayor, Panch, Sarpanch, ex-serviceman, retired teacher, advocate in 12 (50%) schools.

Most of the schools 22 (88%), had written document of school health policies that included 12(92.3%) government schools and 10 (83.3%) private schools, which mainly includes policies related to first- aid/ safety as reported by principals of 17 (77.3%) schools and prevention of drug abuse, equal treatment for children by 16 (72.7%) school principals, while tobacco control, prevention of corporal punishment policy by 15 (68.2%) principals of schools.

For the compliance of policies it was observed that in 20 (80%) schools tobacco products were not available within the distance of 100 yards from schools which included all 12 (100%) private schools and 8 (61%) government schools. Overall utilization of the government dispensary as referral centre by as many as 19 (76%) schools which included 12 (85%) government schools and 7 (63%) private schools, Government Multi -Specialty Hospital by 13(52%) schools, Post Graduate Institute of Medical Education and Research (PGIMER) 2(8%) schools followed by Government Medical College and Hospital (GMCH 32) by 3 (12%) schools.

Discussion

Promoting health through schools is a ‘life-course’ approach to promote healthy behavior among children. Schools therefore play an important role in learning, promoting health and development of students, their families and community. The present study was undertaken with the aim to assess the extent to which the health promoting facilities were available based on the recommendations of WHO health promoting schools.

The sample of 25 schools was chosen by stratified random sampling technique which comprised of both government and private schools representing different geographical areas like urban, sub-urban and rural so as to choose a representative sample for exploring the availability of facilities. In present study majority of the schools were located away from the market and all schools were away from factory area whereas a study done in Karnataka in 2010 found that out of 20 selected schools, one fourth of the schools were located at inappropriate place. Adequate space for the students (10 square feet/ student) in classrooms was found to be good in private schools as compared to government schools. In the present study, all schools had separate toilet facilities for girls and boys and the sanitary conditions of toilets was also found to be good however the facilities were still lacking in terms of availability of appropriate number of toilets both for girls and boys. The results of present study were comparable to the study done in Karnataka which had shown that latrines were grossly inadequate for boys as well as girls12.

Regarding availability of fire extinguishers installed in the premises of schools it was found that good number of schools had fire extinguishers which were all well within the expiry limits the findings of study were comparable to the study conducted in Hongkong where 99.3% schools had fire extinguishers in the schools.13 In present study, few schools had Medical personnel/ nursing personnel and out of those available, half of them were working on part-time basis. Similarly, a qualitative study conducted in European countries by Pommier J. et al found that nurses and doctors were working in schools on adhoc basis. It was found that all the schools were maintaining health records however the immunization sessions in schools were reported only in few of the schools.14

Regarding the nutrition services, all government schools were covered under the mid-day meal programme whereas only few private aided schools had the facility of midday meal. Similarly, a cross sectional study done in 30 schools of Mangalore city in 2010 by Joseph N et al. reported that mid day meal scheme was implemented only in government and aided schools. One (25%) government and 6 (50%) aided schools had no dining hall for serving mid-day meals.15 The findings of the present study revealed that few schools had hygienic canteen facilities and only one school promoted healthy foods/ drinks in school. Similarly the study by Villiers et al. (2012) in South Africa reported that the most common items sold at the tuck shops in schools were chips (100%), sweets (96%), cold drinks (41%), ice lollies (41%), and chocolates (28%).Regarding health and health-related priorities and programmes, majority of the principals reported of having school health policy which were mostly related to first aid/safety, prevention of drug –abuse, equal treatment for children and midday meal policy was reported by only government and private –aided schools. Similarly the study done in Uganda in four schools found that all the schools had policies related to prohibition on use of tobacco, alcohol and other substances and emergency policy.16

The component related to school and community involvement and inter-sectoral co-ordination was evaluated through School Health Committee and School Management Committee or Parent Teacher Association (PTA).Overall the parental involvement and other sectors involved in schools appeared to be good with 96% schools which had formulated the School Management Committee out of which majority had involved parents as members followed by involvement of community members such as Municipal Counselor, Mayor, Sarpanch, Panch and other community leaders as their members. This is in contrast to the findings of study by Villiers A de in which parental and community involvement appeared to be poor.17

The study concluded that the schools were lacking in terms of availability of facilities as recommended by WHO in its guidelines for ‘Health Promoting Schools’ so they cannot be called as ‘Health Promoting Schools’ truly. Importantly, most promising facilities which were available were students health checkups in schools, health cards being maintained in schools, inter sectoral coordination, health education and regular co-curricular activities in schools and areas which need addressing were insufficient toilet facilities, lack of drinking water facilities and not well maintained first-aid kits and poor transportation facilities.Thus the findings of the study revealed that the components as suggested by Health Promoting Schools had broaden the areas of work of nursing personnel as the different aspects are directly or indirectly under the scope of nursing personnel.

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