Health Promoting Schools in Kerala, India.

INTRODUCTION: Health promoting school (HPS) is a holistic concept where health and learning coexist. The objective of this study was to assess the health promoting standards of schools in Kerala.
METHODOLOGY: A cross-sectional study was designed in Kerala, India, with schools in Kerala as a study unit. A questionnaire which consisted of 37 items across eight domains of the HPS concept was developed and validated. The schools were then graded into compliant and not compliant categories based on scores obtained. Bivariate and multivariate analysis was also done.
RESULTS: Of 120 schools, 90.8% were compliant toward health education domain and only 8.3% were compliant with nutrition services. Majority of schools showed compliance with the other six domains. Average overall scores were 153 (58.8%) with the equal number of schools in both compliant and not compliant categories. There was a significant association between health education and physical education domain with respect to the type of school, i.e., privately managed had six times more chances of being compliant toward health education domain compared to government schools (odds ratio [OR] 6.05; 95% confidence interval [CI] 1.10-33.29). Hence, also private schools had two times more chance of being compliant toward physical education compared to government schools (OR 2.52; 95% CI 1.0 - 4.32). Physical education domain showed a significant association with respect to geographic region, i.e., the schools in North Kerala were found to be three times more compliant compared to South Kerala (OR 3.48; 95% CI 1.05-11.53).
CONCLUSIONS: Despite the good health and social indicators in Kerala, there is a deficiency in schools promoting health of children. A coordinated effort by the government and the education system can convert existing schools into health promoting. Copyright:

INTRODUCTION

Health promoting school (HPS) is a holistic approach,[1] wherein the concept of health and learning coexist.[2] Promoting health through schools is a life course approach to promote healthy behavior among children. The concept of school health programs has undergone a transition from the traditional three-component model[3] to the eight-component coordinated school health program model of the Centers for Disease Control and Prevention (CDC) and to the HPSs concept promulgated by the WHO. The HPS concept has been implemented in various countries worldwide[4] and has shown to be a promising approach.[456] In India, school health programs have been in conjunction with national health programs, namely School Health Scheme of 1996–97 and as a part of National Rural Health Mission.[7] These programs were not strictly “health promoting” as it did not fulfill all necessary criteria for a school to be considered as health promoting.

Kerala is a state known for its good health indicators and health delivery system compared to other states in India.[8] With a literacy rate of 93.91%[9] and a high enrolment rate into schools, this state is expected to have a learning environment that is “healthy.” Although previous studies had attempted to analyze health promoting status of schools,[10] a comprehensive assessment using a validated instrument was lacking. Hence, this study was conducted to assess the health promoting standards of schools in Kerala.

METHODOLOGY

A cross-sectional study was designed in Kerala State, India, from June 2017 to February 2018. The study unit was schools with first-to-tenth grades following curriculum prescribed by the State government.[11]

The sample size was calculated based on a similar previous study,[10] which estimated the proportion of the schools satisfying the HPS. With 80% power and α error of 5%, the final sample size was estimated to be 120. From a sampling frame of 905 schools, proportionality sampling with computer-generated randomization was used to select 120 schools from the three geographical regions viz. North, Central and South Kerala.

Development of questionnaire of health promoting school criteria

A literature search was done to identify the presence of similar criterion to assess HPS. CDC, USA in 1987 proposed an eight component “Coordinated School Health Program” model. With this framework, indicators relevant to Indian school settings were developed. Previous studies which had attempted a similar scoring system for each HPS criteria were found to have ambiguity in scores and the absence of weighted scoring system.[1012] Hence, the authors decided to develop a questionnaire which gave higher scoring (weightage) for “absolutely necessary” criteria and a lower score for criteria which were “desirable to have.” Here, we adopted the broad domains proposed by CDC and modified the criteria proposed by the Public Health Foundation of India[12] and Thakur et al.[10] The final questionnaire consisted of 37 items under eight domains. The maximum score that could be obtained was 260 with weightage of 5, 10, −10, and the schools were graded as compliant and not compliant categories. The prepared questionnaire was content validated by four experts in the field of education and public health using the Content Validity Index of Martuza.[13] A content validity score 0.95 was obtained.

Data collection

Each selected school was personally visited by the principal investigator, and permission with written informed consent was obtained from the school authorities. Five schools were resampled as it failed to meet the inclusion criteria.

Statistical analysis

The obtained data were coded, tabulated, and analyzed using the IBM SPSS Statistics for Windows, Version 20.0. (Armonk, NY: IBM Corp). Descriptive statistics (individual domain scores and overall scores) were expressed as frequency and percentages. The Chi-square test was used to assess the association between geographic region (north/central/south), type of school (government/private), area (urban/rural), and number of students (more than 578/< 578) in the school with the eight domains and overall scores. Multivariate analysis was performed for each domain against four independent variables.

RESULTS

The study was conducted in 120 schools in Kerala, and the response rate was 100%. The questionnaires were answered by the headmistress/principal in 57.5% (n = 69) of schools and by a teacher or school administrator in 42.5% (n = 51) of schools.

Domains of health promoting school concept

HPS concept domains were categorized to “compliant” and “not compliant” based on the median score obtained in each domain. Average overall score was 153 (58.8%) with the majority of the schools compliant toward health education domain 109 (90.8%) and least compliant toward nutrition services 10 (8.3%). For the remaining six domains, more than 50% of schools were compliant. [Figure 1] However, the overall scores showed the equal number of schools in both the categories.

Figure 1

Percentage of compliant responses obtained for each domain

Multivariate analysis

The multivariate analysis model was used to ascertain the association of each domain with the four independent variables, i.e., geographic region, type of school, area, and the number of students. The schools which were privately managed had six times more chances of being compliant toward health education domain compared to government schools (odds ratio [OR] 6.05; 95% confidence interval [CI] 1.10–33.29). For physical education, the schools in North Kerala were found to be three times more compliant compared to South Kerala (OR 3.48, 95% CI 1.05–11.53). Hence, also private schools had two times more chance of being compliant compared to government schools (OR 2.52, 95% CI 1–6.32). Assessment of other domains is given in Table 1.

Table 1

Multivariate analysis

Domain	Covariates	Variable	Reference	OR	LCI	UCI
Health education	Geographic region	Central Kerala	South Kerala	4.42	0.71	27.64
		North Kerala		4.37	0.73	26.31
	Type of school	Private	Government	6.05	1.10	33.29
	Area	Rural	Urban	0.41	0.07	2.47
	Number of students	<579	<578	0.28	0.06	1.42
Physical education	Geographic region	Central Kerala	South Kerala	1.73	0.63	4.71
		North Kerala		3.48	1.05	11.53
	Type of school	Private	Government	2.52	1.00	6.32
	Area	Rural	Urban	0.79	0.28	2.23
	Number of students	<579	<578	1.09	0.41	2.87
Health services	Geographic region	Central Kerala	South Kerala	1.79	0.70	4.55
		North Kerala		0.67	0.24	1.83
	Type of school	Private	Government	1.29	0.59	2.81
	Area	Rural	Urban	0.42	0.17	1.01
	Number of students	<579	<578	1.62	0.68	3.83
Nutrition Services	Geographic region	Central Kerala	South Kerala	0.63	0.09	4.21
		North Kerala		1.61	0.30	8.63
	Type of school	Private	Government	2.50	0.58	10.87
	Area	Rural	Urban	0.45	0.12	1.77
	Number of students	<579	<578	1.53	0.31	7.55
Healthy school environment	Geographic region	Central Kerala	South Kerala	1.37	0.43	4.38
		North Kerala		0.45	0.15	1.37
	Type of school	Private	Government	0.97	0.39	2.40
	Area	Rural	Urban	1.36	0.51	3.62
	Number of students	<579	<578	1.49	0.54	4.07
Family and community involvement	Geographic region	Central Kerala	South Kerala	1.83	0.71	4.76
		North Kerala		1.25	0.47	3.38
	Type of school	Private	Government	0.56	0.26	1.23
	Area	Rural	Urban	0.73	0.31	1.73
	Number of students	<579	<578	0.58	0.25	1.35
Community, psychological, and social services	Geographic region	Central Kerala	South Kerala	0.93	0.37	2.36
		North Kerala		1.17	0.42	3.21
	Type of school	Private	Government	0.49	0.22	1.09
	Area	Rural	Urban	1.68	0.71	3.97
	Number of students	<579	<578	1.39	0.58	3.28
Health promotion for staff	Geographic region	Central Kerala	South Kerala	4.10	1.56	10.72
		North Kerala		3.43	1.23	9.57
	Type of school	Private	Government	0.81	0.37	1.77
	Area	Rural	Urban	1.08	0.45	2.58
	Number of students	<579	<578	0.58	0.24	1.39
Overall scores	Geographic region	Central Kerala	South Kerala	3.10	1.22	7.89
		North Kerala		1.59	0.60	4.26
	Type of school	Private	Government	1.17	0.54	2.55
	Area	Rural	Urban	0.77	0.32	1.82
	Number of students	<579	<578	1.46	0.63	3.39

Dependent variable: Domains of HPS concept, OR, Independent variable: Geographic region, type of school, area, and number of students. OR: Odds ratio, LCI: Lower confidence interval, UCI: Upper confidence interval, HPS: Health promoting school

DISCUSSION

The WHO's HPS framework, developed in the late 1980s, underpins the reciprocal relationship between health and education. A systematic review[5] conducted in 1999 and 2015 suggested that there were “limited but promising” data that this approach could benefit student health. To the best of our knowledge, this study was first of its kind in India to report the presence of the HPS concept among the schools in Kerala. The strengths of this study included a representative sample design and use of a validated questionnaire to suit local needs.

Only one school present in South Kerala satisfied all the criteria for being HPS, which calls for an introspection given the health indicators of Kerala. The health education domain was more compliant in privately managed schools compared to government schools. The government schools depend on the nearby government health machinery for health education sessions, whereas private schools could afford health education at their discretion.

Although most of the schools satisfied the physical education domain, 28.3% of schools lack trained physical educator and most of the physical activities were inconsistent and more pronounced only during sports weeks of an academic year.

The School health advisory committee (SHAC) is an important component of the HPS. SHAC offers recommendations and advice to the schools administration on issues that relate to the health of children and their families.[14] It was interesting to note that the SHAC was present only in one school in South Kerala. However, 40% of schools had health clubs which could be viewed as an alternative to SHAC.

Nutrition programs such as the Midday Meal Program and Nutrition Programmes for Adolescent Girls were present in almost all schools managed by the government. However, 40% of school children in Kerala still show low nutritional status.[15]

Rural schools fared better in healthy school environment due to large infrastructure and eco-friendly activities, and teachers from urban schools mentioned that engaging students in cleaning, gardening, etc., was considered as “child labor” by most of the parents.

Health promotion for staff was found to be better in Central Kerala and North Kerala schools compared to South Kerala. Few schools had given health promotion for the entire staff. These teachers were provided with health-related classes by district administration or local governing bodies such as panchayat.

Overall, it was observed that schools were only partially compliant with HPS criteria. Encouraging schools to adopt different components of HPS in their activities would be beneficial to the overall development of the child. During the course of the study, it was felt that the assessment of HPS also required qualitative dimensions, and hence, we recommend this for future studies.

CONCLUSIONS

Nearly all the schools examined were not wholly compliant for all the criteria for being HPS. However, few components or domains of the HPS were satisfied, namely health education, physical education, and health promotion for staff. Further research for a more robust accreditation of HPS concept is the need of the hour.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.