Awareness and knowledge of National School Health Policy and School Health Programme among public secondary school teachers in Ibadan metropolis.

BACKGROUND: The awareness, knowledge, and involvement of teachers in the implementation of School Health Programme (SHP) in secondary schools are essential in ensuring the effectiveness and overall success of the School Health Policy. This study assessed the awareness and knowledge of teachers on SHP in Ibadan metropolis.
METHODS: A descriptive cross-sectional study was carried out using a two-stage sampling technique to select 426 secondary school teachers across all the five Urban Local Government Areas (LGAs) in Ibadan metropolis by balloting. Pretested semi-structured questionnaires were used to collect data from 426 teachers. Quantitative data were analyzed using descriptive statistics, Chi-square, and logistics regression tests at 5% level of significance.
RESULTS: About one-third of the respondents had heard of National School Health Policy (NSHP); however, few had seen the document. About half of the respondents were aware of the SHP in their schools. Many of the respondents had a good knowledge of SHP. Age and level of education of participants significantly influenced the knowledge of SHP. Above 50 years of age and postgraduate qualification were the significant predictors for the good knowledge of SHP.
CONCLUSIONS: Awareness of the NSHP was low despite the good knowledge of SHP. This could be due to the tertiary education that most of the respondents had. Concerted efforts of stakeholders are required to intensify the health education awareness campaign to improve teachers' knowledge based on NSHP.

INTRODUCTION

School Health Programme (SHP) is a health programme directed to meet the health needs of students at the present time and laying a good foundation for their future with the support of the home, community, and government.1 It is defined as the totality of projects and activities in a school environment, which are designed to protect and promote the health and development of the school community.2 The objectives of the SHP are to obtain a rapid and sustained improvement in the health of school children, to ensure that children from preschool age to adolescence are in optimum health at all times so that they can attain their physical and intellectual potential, as well as to receive maximal moral and emotional benefits from health providers, teachers, and the school environment.3

Unfortunately, almost one-third of young people in primary and secondary schools are undernourished; 9% are over-nourished; a tenth have engaged in substance abuse; and only 37% of the junior school students and 45% of the teachers have heard of family life and HIV education before.4 Adolescents (10-19 years) who are mostly secondary school pupils account for a significant proportion of Nigeria's population of 140 million.5 In 2001, the findings from the Statistics of the National Study of the School Health System in Nigeria carried out by the Federal Ministry of Health and Federal Ministry of Education in collaboration with the WHO revealed that health-care services in schools have not been properly implemented, thus it was noted that there was a lack of standard guiding SHP in Nigeria, which established the need for the National School Health Policy (NSHP).6

The goals of the NSHP are to enhance the quality of health in the school community and to create an enabling environment for inter-sectoral partnership in the promotion of child friendly school environment for teaching, learning, and health development. This will involve the development of appropriate preventive and curative services for school children and school personnel, the improvement of environmental sanitation, and the promotion of health education in all schools.2

Teachers’ knowledge on SHP is critical in determining the success of the program, i.e., the availability of qualified, interested, and enthusiastic teachers.7 In fact, teachers play a strategic role in the implementation of any effective SHP that is largely determined by the adequacy of teachers’ knowledge of the programme.89 Effect and importance of teachers’ preconceptions with tackling some commonly misconceived diseases has been substantiated in several studies.1011 Nevertheless, the role of teachers,’ most particularly in sub-Saharan Africa where there is documented poor job satisfaction,12 poses several limitations to the effective implementation of school programs and as such should be taken seriously.

Studies that provide information on the knowledge of teachers in the selected public secondary schools on SHP in Southwestern Nigeria have been abjectly inadequate.13 This study, therefore, was aimed at documenting the knowledge of teachers in the selected public secondary schools on SHP and also to determine the facilitators and constraints affecting its implementation in Ibadan metropolis, Oyo State.

METHODS

This was a cross-sectional study conducted in Ibadan (the State Capital of Oyo State in Southwestern Nigeria) with a population of about 1835,300 inhabitants, after an Ethical approval by obtained from the University of Ibadan./University College Hospital Ethical Review Committee.

Sample size was determined using the Leslie Kish formula for determining single proportion for descriptive studies.16

A two-stage sampling technique was used to select the 426 public secondary school teachers from all the five urban LGAs.

Stage 1

Twenty-one schools were randomly selected by balloting based on the proportion allocated to each of the LGA.

Stage 2

All consenting teachers from the selected 21 public secondary schools were enrolled into the study.

Data were collected using a pretested, semi-structured self-administered questionnaire containing a 25-point knowledge item. The instrument was developed based on the minimum requirements for the implementation of the components of the SHP as stated in the NSHP document by the Federal Ministry of Education.2 Validity of the content was ensured through consultation of relevant literatures on SHP and policy; experts with a wealth of experience for content and structure validity reviewed the content and the questionnaire was finally pretested in Oba Akinyele Memorial Grammar School at Bashorun, Ibadan, in the month of June 2012. Results of pretest were used to improve and produce a revised guide for the field study. Cronbach's alpha model technique was employed to test how reliable the instrument was. Reliability co-efficient of 0.94 was obtained thus showing that the instrument was very reliable using SPSS computer software. The outcome of the pretest was used to correct and modify questions not adequately or appropriately answered by the respondents.

To determine teachers’ overall awareness of the NSHP and SHP, a scale of two response categories – (yes1 and no 2) was used to compute the following two questions, “Are you aware of NSHP?” and “Have you ever seen the document?” Proportions were used to report the awareness of the NSHP and SHP.

There were 5 questions with 25 obtainable points on the knowledge of teachers on SHP. Each correct answer was scored 5 marks and each wrong answer was scored 0 mark; giving a minimum and maximum obtainable scores of 0 and 25, respectively. Each respondent's aggregate score was classified as being poor knowledge if it was <50% of the maximum obtainable scores (<13) and good knowledge if it was equal or more than 50% of the maximum obtainable scores (≥13). The data from the questionnaires were entered into the computer and analyzed using the Statistical Package for Social Sciences version 15.0 should be replaced with Statistical Package for Social Sciences version 17.0 (SPSS,Inc., Chicago, IL). Frequencies and percentages were estimated for categorical variables while diagrams and summary indices such as means and standard deviations were generated for continuous variables. Inferential statistics (Chi-square test) was used to test for associations between selected categorical variables, and logistic regression analysis was carried out to identify the independent factors associated with teachers’ knowledge.

RESULTS

Sociodemographic characteristics of the respondents

Mean age of the respondents was 39.4 ± 9.0 years. One hundred and seventy-five (41.1%) respondents were aged 40-49 years while 108 (25.4%) and 81 (19%) respondents were aged 30-39 and 20-29 years, respectively. Sixty-two (14.6%) respondents were aged 50 years and above. There were more male respondents, i.e., 221 (51.9%) than female respondents, i.e., 205 (48.1%) [Table 1]. The respondents were predominantly university degree holders, i.e., 270 (64.9%), followed by higher degree holders, i.e., 80 (19.2%), Higher National Diploma (HND) holders, i.e., 34 (8.2%), National Certificate in Education (NCE) holders, i.e., 29 (7.0%), and those with Diploma in Education constituting the least group, i.e., 3 (0.7%). Mean length of time in teaching service was 12.2 ± 8.7 years with 107 (25.1%) respondents having spent 11-15 years in teaching service.

Table 1

Sociodemographic information (n=426)

Concerning the awareness of “NSHP” [Table 2], only a few of the respondents, i.e., 151 (35.5%) had ever heard of the term “NSHP” before. Out of the 151 (35.5%) respondents who had heard of the term “NSHP,” only 24 (15.9%) had seen the “NSHP document.”

Table 2

Awareness of National School Health Policy and Knowledge of components of School Health Programme

As shown in Table 2, 175 (41.5%) respondents were aware of the implementation of healthful school environment followed by 154 (36.6%) respondents who were aware of school health services. Few respondents, i.e., 121 (28.6%) were aware of skill-based health education while 120 (28.5%) and 117 (27.8%) respondents were aware of the implementation of school, home, and community relationship and school-feeding services, respectively.

The respondents’ overall mean knowledge score is 13.5 ± 5.8, with more than half of the respondents, i.e.,, 238 (55.9%) having a good knowledge of the SHP [Figure 1].

Figure 1

Teachers’ knowledge of School Health Program categorized into good and poor knowledge

Healthful school environment

As shown in Table 2, majority of the respondents, i.e., 306 (72.7%) had a good knowledge of “healthful school environment.” In addition, most of the respondents, i.e., 261 (64.1%) had a good knowledge of the “skill-based health education,” followed by 217 (53.1%) respondents with a good knowledge of “school health services.” Two hundred and twenty-three (53.1%) and 192 (45.5%) respondents had a good knowledge of “school, home, and community relationship” and “school-feeding services,” respectively.

Respondents were asked for the basic constituents of “healthful school environment;” majority of the respondents, i.e., 348 (81.9%) understood and attested that the availability of proper refuse disposal bins ought to be made available in schools. Most of the respondents, i.e., 329 (77.4%) also agreed that schools should possess proper means of sewage disposal; 288 (67.8%) of the respondents posited that there should be availability of safe and potable water supply in a healthful school environment, while only 166 (40.2%) respondents knew that a “healthful school environment” should not be at a close proximity to the road. More than half of the respondents, i.e., 288 (68.3%) possessed knowledge that schools ought not be close to market places.

Activities in school health services

Concerning the respondents’ knowledge on “school health services,” a sizable number of the respondents, i.e., 245 (57.8%) knew that there must be provision of special health services for students with special needs while 206 (48.7%) respondents possessed knowledge of the fact that pre-entry screening of students should be carried out in schools. One hundred and ninety-six (46.3%) respondents knew that there must be periodic medical examination of students. Few respondents, i.e., 126 (29.8) expected that serious health issues of students should be handled in schools.

Skill-based health education

Concerning the respondents’ knowledge on “skill-based health education” [Table 2], majority of the respondents, i.e., 282 (66.5%) knew that skill-based health education curriculum should include monitoring the progress of learners toward the development of healthy habits. Two hundred and sixty-eight (63.2%) respondents knew that the scope of the curriculum should cover providing information on health issues affecting the school community while 259 (60.9%) knew physical and health education curriculum should be designed in such a way it will be called skill-based health education for the training of learners and 174 (41.2%) respondents also knew that the teaching of health education should not be based on promotion of personal health only. Less than half of the respondents, i.e., 183 (43.1%) had knowledge of the fact that health education should be taught 3 periods per week in schools.

With respect to “school, home, and community relationship,” majority of the respondents, i.e., 340 (80%) agreed that parents should be informed of the health needs of their children and 286 (67.5%) respondents knew that there should be interpretation of health observation of students to their parents. Few respondents, i.e., 167 (39.3%) knew that parents must pay visits to schools not only on parent-teacher association meeting days alone, while slightly less than half of the respondents, i.e., 202 (48.2%) knew that there should be a good relationship between a school and the members of the community in which the school is situated to allow for effective utilization of community resources. Very few respondents, i.e., 90 (21.3%) knew that a good relationship between schools and homes involves home visits by teachers.

Concerning the knowledge of participants’ “school-feeding services,” majority of the respondents, i.e., 349 (81.9%) understood that there should be adequate sanitation and hygiene practices among food handlers, 268 (62.9%) participants knew that there should be periodic medical examination of food vendors or handlers, and 257 (60.3%) respondents knew that school-feeding services should involve students bringing well-cooked meals from their homes. More than half of the respondents, i.e., 241 (56.8%) knew that there ought to be provision of at least one adequate meal per day to school children and 162 (38.1%) respondents attested that the regular deworming of students for intestinal nematodes should be carried out in the implementation of school-feeding services.

Bivariate associations between sociodemographic variables and dependent variables

Awareness of National School Health Policy

Although all were statistically insignificant, more respondents aged 50 + years (43.3%) and aged 30-39 years (42.5%), more males (36.6%), more married participants (38.4%), more Yoruba respondents (37.4%), more participants with only Diploma in Education (38.1%), and over 20 years of experience (44.8%) were aware of NSHP compared to other groups [Table 3].

Table 3

Bivariate associations between sociodemographic variables and dependent variables

Awareness of School Health Programme

Increasing age contributed to the awareness of SHP. More respondents, i.e., 50 + years (59.7%) were most aware of the existence of the programme, more females (55.1%), more married participants (54.6%), more Yorubas (54.0%), more participants with higher degrees (61.3%), and participants with <1 year of teaching service (61.9%) were aware of the SHP. However, these findings were not statistically significant [Table 3].

Knowledge of School Health Programme

More males (57.9%), married respondents (58.1%), Yoruba (56.5%), and over 20 years of teaching experience (69.6%) demonstrated a good knowledge of the SHP compared to other corresponding subgroup counterparts. However, these findings were not significant [Table 3]. Age (P = 0.007) and level of education (0.036) of the participants were significantly associated with the knowledge of SHP.

Predictors of knowledge of School Health Programme

Respondents aged 50+ years were twice likely to have good knowledge than those aged 20-29 years (odds ratio [OR] =2.00; 95% confidence interval [CI] = 1.20-4.10). (Table 4). Similarly, respondents with higher degrees (Masters/PhD) were twice likely to possess good knowledge than those who are only with a Diploma in Education (HND/NCE) (OR=2.34; 95% CI = 1.20 – 4.60) [Table 4].

Table 4

Logistic regression model for predicting knowledge of School Health Programme

DISCUSSION

The SHP has been defined as “school procedures that contribute to the understanding, maintenance, and improvement of health of pupils and school personnel.”17 Majority of the respondents in this study were males and within the age group of 40-49 years, which is in agreement with a study conducted in Ogun State with similar findings.18 Majority of the working population falls within this age group and this could explain why majority of our participants fell within this category. Since the study was conducted in Southwestern Nigeria, this could explain why majority of our participants were predominantly Christians and Yoruba.19 Median age at marriage of 22.0 years in Nigeria19 is also a very tenable explanation for majority of our participants being married. Majority of our respondents having completed at least university degree holders suggest a well-educated teaching workforce. However, it could probably be the reason a higher proportion (55.9%) of the respondents had a good knowledge of SHP. This agrees with the findings from the study conducted by Bankole and Mabekoje (2008), in which 72.8% of the teachers were university graduates;18 however, it was in contrast to the study carried out by Ofovwe and Ofili in Edo State which showed that only 30% of the teachers were university graduates.7 A plausible explanation for this variance could be because our study interviewed secondary school teachers as opposed to this study, which interviewed predominantly primary school teachers.

Awareness among teachers in the existence of NSHP, previously documented as suboptimal in Nigeria13 and South Africa,20 is buttressed likewise in our study, which revealed only 36.8% of the teachers aware of the NSHP and just 15.9% of ever seeing the policy document before despite the various advantages and linkages of an effective school policy to health of the students.212223 Despite the commitment of Nigeria to improving school health through establishment of Universal Basic Education in 1999, the poor state of awareness of the NSHP (2006) as demonstrated in this study remains disturbing. Weak information communication technology, communication lapses (between principals and Ministry of Education), and poor embrace of technology in schools,24 fostering limited access to the policy document, may be the unforeseen underlying factors responsible for this poor awareness.

Lack of awareness and understanding observed in educators (key stakeholders in SHP) is a major area of concern in policy implementation process because the roles of educators are not only fundamental to the effective implementation of the programme but also linked to adoption of healthy lifestyles.252627 Ahmed et al. further reiterated that before a SHP is implemented, it is important to equip educators with appropriate skills including awareness and understanding of the policy.28 The findings from this study showed that many of the class teachers and majority of the head teachers were aware of the existence of SHP in their schools as demonstrated in similar studies.7 Nevertheless, awareness of the various components of the SHP showed that most of the teachers were more familiar with the implementation of healthful school environment, which is a major prerequisite for the protection and promotion of the health of learners and attainment of Millennium Development Goal 2.29 Demonstration of good knowledge by over half (55.9%) of the respondents might be due to the fact that most of the teachers had university education, since knowledge is synonymous to an individual's level of education. This finding was contradictory to the findings of Akani et al. (2001) in Port Harcourt or Lawrence (1998) in Australia.30 Worthy of note, however, is that the contrast observed between this study and that of Akani et al. (2001) might be due to the fact that knowledge in this study was tested based on the contents of SHP as stipulated in the NSHP, as opposed to Akani et al. (2001) whose study was conducted in 2000 before the advent of the NSHP.

Respondents aged 50 years and above were twice as likely to have a good knowledge of the SHP compared with their younger counterparts similar to the outcome of the study carried out by in Dharwad, India, which revealed that knowledge on the prevention of dental decay and oral cancer was significantly higher in older age groups compared to the younger.31 Participants with higher degrees (Masters and PhDs) were also twice likely to have a good knowledge of SHP than those who were holders of Diploma in Education, NCE, and OND certificates. This is plausible as older age and higher qualification are synonymous with wider exposure as regards several subjects. Despite several studies that have emphasized the importance of water and sanitation323334 and food and hygiene,3536 constraints reported by more than half of the teachers was lack of adequate environmental facilities (means of waste disposal, source of water supply, and toilet facilities); inadequate health education instructional materials (posters, textbook, and pamphlets); inadequate training and poor knowledge of teachers on SHP, health beliefs, values and attitude of teachers and students; inadequate fund for the implementation of the health programme; lack of health facilities such as presence of a sickbay or first aid box; and parents’ financial status and their level of education, consistent with the constraints reported by similar studies.2037 The existence of these constraints would continue to impede successful implementation of the SHP except government parastatals “grab the bull by the horn” with renewed political will.

Factors serving as facilitators recommended to promote the implementation of the SHP according to the teachers were quite similar to those revealed in the interviews conducted with the principals,13 and they include adequate training of teachers on SHP, dedicated budget for the implementation of the SHP by government, community involvement in the promotion of the SHP, calling the attention of parents, and enlightening them on the importance of the SHP,7 creating awareness through mass media, involvement of nongovernmental organizations (such as school-governing bodies saddled with monitoring and regulation of SHPs), availability of adequate environmental facilities, availability of health facilities such as sickbay and health personnel, and establishment for the implementation of school health services.20 Ultimately, regular and periodic on-the-spot checks for compliance with regulations by experienced government delegates (from Federal and State Ministries of Education) with the National School Policy is favorably recommended.1837

CONCLUSIONS

The research explored the awareness and knowledge of teachers on SHP in public secondary schools in Urban LGAs of Ibadan. Awareness in majority of the teachers was suboptimal as many were not aware of the 2006 NSHP. However, most of them were aware of their schools having SHP in place.

Slightly, over half of the teachers had a good knowledge of the SHP with increasing age and level of education being significantly associated with knowledge of the SHP. Policies in various sectors of the economy have failed to achieve considerable success as a result of implementation and bureaucratic lapses. This goes without saying the need for an increased focus in the implementation of policies in Nigeria (such as NSHP), if there is to be any meaningful execution after formulation and draft of these policies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.