Health-promoting school in India: Approaches and challenges.

Interventions early in life are the need of the hour when it comes to controlling the rising incidence of communicable and non-communicable diseases (NCDs) globally. WHO has issued guidelines towards health promotional initiatives at schools as a part of Global School Health Initiative, and the Government of India has directed many policies and programs to integrate health deep within the school activities. School Health Promotion is an international need with programmes implementing across continents due to numerous documented benefits, to not just the individuals but to the community and country as a whole. Simple teachings like hand hygiene have shown to reduce the incidence diarrhea by more than 50% amongst children (a major cause of mortality in India), thus raising an urgent need of developing a model for health promotion at schools that is replicable, sustainable, and can be modified to the local needs as well. Though the existent programmes have a few documented challenges, a multisectorial involvement of government agencies, educational boards, and health sector along with the school is the way forward to address those challenges and covert the theory of health promoting schools (HPS) into a well-established fact. It presents a scope for the various established and newly emerging Schools of Public Health in the country to come forward and collaborate with these multiple sectors. These collaborations can be the only way to ensure sustainability and incorporation of health promotion into the core academic structure of schools in a diverse and highly populous country like India. Copyright:

Introduction

In today's scenario where there is a global transition in the incidence of communicable as well as NCDs, creating awareness about the healthy aspects of day to day life amongst the school children might just prove to be the most needed intervention to break the wheel and restrict the morbidity due to such diseases. Students and parents invest a huge amount of time, money, and resources in schools, and if those schools start fostering a healthy attitude into the mindset of children, then the same might become the greatest investment that would not only benefit the families but the community and the nation as well.[1]

According to the recent directives issued by the Government of India, the Ministry of Health is focusing on promoting child health through appropriate interventions. The Integrated Child Development Scheme under WCD also addresses the issues of child health. There is, however, a need to synergize the multi-sectoral interventions taken by the relevant GoI Ministries to ensure greater focus on child health through improvements in existing schemes and suggest new holistic interventions.[2] Thus, there is a need for a sustainable health promotion model that can be embedded the school curriculum with the view of improving child health.

Besides the GoI, the World Health Organization has also been advocating the need for health promotion in schools since the early 1990s under the Global School Health Initiative.[1] It can also be viewed as a highly cost-effective tool for improving primary health care in the country, if periodic medical examination of students, in-service training programmes for the teachers, adequate water, and sanitation facilities are provided within the school itself.[3]

However, the challenges are needed to be addressed to improve the coverage of schools that promote health-related aspects in daily routine to their students. It is, thus, the focus of this article to discuss the various aspects of health promotion at school and its benefits.

What is a health-promoting school?

A health-promoting school is a school that constantly strengthens its capacity as a healthy setting for living, learning, and working. WHO describes a health-promoting school as one that fosters health and learning with all measures at its disposal and engages health and education officials, teachers, students, and parents in the efforts to make the school a healthy place.[4] It involves working together while giving everyone a chance to express ideas and opinions and then collaborating to develop policies, practices, and structures to include health promotion in every action done by the school and community in order to meet a common goal.

It is a place where the school community works together to promote and protect the students’ health through both formal and informal methods of teachings, thus creating a safe and healthy school environment. It also invites and appreciates families’ and communities’ efforts to promote health. The concept of Health Promotion at Schools is an international development, with many countries throughout the world are working on programmes that support schools and their communities in making better health decisions.

Following up from the Ottawa Charter for Health Promotion, workplace health promotion has been established as one of the priority settings for health promotion in the 21st century.[5] The health-promoting schools complement the Ottawa Charter and the WHO School Health Initiative, which motivates for mobilizing and strengthening the schools activities towards health promotion and education at the local, national, regional, and global levels. Health promotion at schools should also be set up in a sustainable manner for the students as well as for the staff, in which the commitments are constantly reinforced. Along with reinforcement, the concept should be widely acceptable, so that the future of the initiatives should not merely depend on the willingness and enthusiasm of a handful few. The proposed approach would be to incorporate the policies and structures into the core framework of the institutions promoting health, making them a fundamental part of the institution.

Need for health promotion

India has the largest number of adolescents in the school-going age group of 10-19 years in the world – 243 million out of 1.2 billion. In total, 56% of these girls and 30% of the boys in the age group of 15-19 years suffer from Anemia.[6]

NCDs contribute to around 5.87 million deaths globally that account for 60% of all deaths in India. These include the four major NCDs – cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes, that make the largest contribution to morbidity and mortality due to NCDs. Major metabolic risk factors are obesity, raised blood pressure, raised blood glucose, and raised blood total cholesterol levels.[7] Recent studies have shown that globally, approximately 2.8 million deaths are reported as a result of being overweight or obese.[8] It is of due consideration since India has the second-highest number of obese children in the world, with 14.4 million reported cases.[9]

The prevalence of current tobacco smoking has shown a slight decline in males but the prevalence (23.6%) is still higher than the global prevalence of current tobacco smoking (22%). Tobacco use has been identified as the single largest risk factor attributable to the development of NCDs.[7] Global Youth Tobacco Survey found that nearly one in ten students in India aged 13–15 years used some form of smokeless tobacco (SLT) (9.4% overall; 10.7% boys; 7.5% girls). Further, the Global Adult Tobacco Survey conducted in India in 2009–2010 among those aged 15 years or over revealed that SLT was the most common form of tobacco used. Prevalence of current SLT use was 26% (33% men; 18% women) and of daily use, 21%. The average age of initiation to SLT was 17.9 years, similar to that for smoking.[10]

Every fourth individual in India aged above 18 years has raised blood pressure (hypertension), and the prevalence has increased by 10% from 2010 to 2014. The per capita consumption of pure alcohol (age +15) in India is estimated to be 5.2 liters per year. In 2010, the corresponding figure was 4.3 liters per year, which was significantly higher than the average consumption in the SEAR (3.2 liters per year). More than two-thirds of the adolescents aged 11–17 years are physically inactive in India as per WHO standards. The level of physical inactivity among adults is around 13%.[7]

Furthermore, simple primary care interventions focusing on hygiene habits, such as lessons of hand hygiene, have a vital role in health education and promotion.[11] With constant reinforcements, such measures have proven to lower the incidence of pneumonia by 50% and diarrhea by 53%, which is the fourth common cause of death in India.[12] It has a herd effect on the community and reduces illness-related absenteeism by 26% amongst school children.[13]

The widespread occurrence of such diseases and the evidence that these diseases begin in childhood show the need to begin prevention early for virtually everybody. Unhealthy habits and lifestyles need to be addressed through a coordinated effort towards comprehensive health education of school children.[14]

While most of the common causes of the “Invisible NCD-Epidemic”[15] are preventable, a life-course approach focusing on the school-going age groups can prove to be a game changer in the fight against rising morbidity and mortality by the NCDs. Following a life-course approach during childhood and adolescence can prevent NCDs and should influence global health and socioeconomic development. Good nutrition aimed at preventing NCDs during childhood and adolescence may be more cost effective than managing established NCDs in later life with costly tests and drugs.[15]

Benefits of a health-promoting school

Everyone, right from the nation and society, down to the individual and families benefits when the schools start promoting health.[1] By incorporating a novel way of thinking into young minds, schools can make a substantial contribution to the health and wellbeing of students and their families. Children benefit from an enhanced environment of psychological, physical, and social well-being and gain from their parents’ participation in the school. Children who learn skills to maintain health when they are young are able to apply them in their adult lives and pass them along to their children.

Schools benefit from constant inputs and support from the parents and community. Schools can get the opportunity to collaborate with different sectors of the society and utilize the resources to reinforce classroom teachings, through message delivery from mass media, community organizations, families, and religious groups. School staff can do their jobs more effectively with their own health improved.

Parents and community members benefit by obtaining a better understanding of the local health problems and learning new skills to tackle those issues. Not just the students but the parents as well might have the opportunity for skill development through their children's education if they are assured that the schools are open to their ideas and participation.

Community groups and organizations benefit by having students and teachers involved in community activities. Educated and healthy people are an asset to the community as a whole. The nation, with healthier and better-educated men and women, has a stronger basis for economic development.

The world progresses if fundamental human rights as described in numerous international health conventions and declarations are guaranteed.

A study by Jatinder Kaur[16] et al. (2015) observed the good practices and gaps amongst the schools of Chandigarh, Punjab, and concluded that HPS 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 Health Promoting.

Langford[17] et al. (2014) provided evidence that education and health are interrelated; children who are healthy are likely to bring better results. Cochrane analysis of HPS framework showed effectiveness in some of the interventions like reduction in students’ body mass index (BMI), changes in physical activity, improvement in intake of fruits and vegetables, reduction in the use of cigarette, and reduced incidents of being bullied.

The study conducted by Suja Karkada[18] et al. (2016) concluded that if implemented properly, the HPS will enhance children to develop decision-making skills.

Vikram[19] et al. (2017) stated that prevention and health promotion are necessary to address the burden of diseases among children. Evidence explored that school, as a health-promoting setting can play a vital role to empower each member of the school and the community partners to increase control over, and to improve their health.

Lawrence St. Leger[20] et al. reviewed several publications and enumerated numerous studies conducted over time that showed the effectiveness of the health promotional strategies at schools in various arenas that are required to promote overall wellbeing such as Nutrition, Mental Health, Physical activity, and drug abuse.

A study by Rentala S[21] et al. provided research evidence highlighting that providing mind-body interventions on adolescents in school settings significantly reduces anxiety, depression, and stress, thus providing a wider scope for primary care providers to implement these kinds of interventions in school settings.

Existing approaches and challenges

The concept of school health promotion was proposed by the WHO in the early 1980s. In 1992, the European Regional Office of the WHO, the Council of Europe, and the Commission of the European Communities jointly set up the European Network for Health Promotion Schools.[1] Since then, the concept of health promotion at schools has been adopted throughout the world at different levels and with different approaches, slightly different to one another, such as the Australian Health Promoting Schools Association, 1996 and the Comprehensive School Health Programme (CSHP) in North America. The Western Pacific Region of the WHO developed “Guidelines for Health Promoting Schools” for its 32 member states in 1995 (WHO, 1996). Similar developments to these have fostered HPS and Coordinated School Health in Latin America, North America, South America, the Middle East, Asia, and Africa.[20]

The literature mainly describes the following three major components as the approach towards health promotion, namely: (i) incorporation of a formal health curriculum – to provide the school-aged children essential knowledge and social skills and allow them to make enlightened choices affecting their physical and psycho-social health; (ii) optimizing the school environment (including the quality of the physical environment, the school climate, health services provision, and the policies of the school); and (iii) community interactions (Booth and Samdal, 1997).[22]

In the US and Canada, the CSHP comprises of eight components including (i) health education from grades 1–12, (ii) school-based health services, (iii) school environment, (iv) physical education, (v) food services, (vi) student counselling, (vii) staff health promotion, and (viii) community integration. Both the HPS and the CSHP approaches indicate a shift from practices that rely solely on classroom teachings to a more integrated approach together with the community that focusses on children's attitudes, behaviors, and their environment, although the operationalization issues to establish links between school and community remained a challenge to this approach.[23]

The HPS in Australia use the following components to define and measure the characteristics of a health-promoting school: (i) formal curriculum, (ii) school ethos, (iii) physical environment, (iv) school policies and practices, (v) school health services, (vi) school-home-community interaction, and (vii) organizational structure. Thus, again the emphasis on the community involvement and environment denotes the importance of their incorporation to achieve the objective of school health promotion. However, the ability to monitor the implementations and assess their effects remain a challenge due to the absence of reliable valid instruments.[22]

Lawrence St. Leger[20] et al. expressed the uncertainty of the outcomes about school health promotion. According to them, health and education are not a level of attainment that can be valued by certain designated standards (such as BMI, not smoking, and high grades). They are dependent on the degree of importance to the people as they move through life. Thus, there is the need of an increased input from students, teachers, and parents, in addition to assessing the standard outcomes for school health promotional interventions to give a more holistic appreciation and understanding of all the effects of school-based health promotions.[24]

In India, there is a lack of studies based on the concept of health promotion in schools,[21] though initiatives such as the “framing criteria for healthy schools – seal of approval”[25] established by the PHFI, AROGYA World, and HRIDAY are available in literature reviews, but no further information about such initiatives and their implementations is available. Thus, it opens up a wide avenue to work on this concept in a highly populous country like India and document as well as overcome the challenges that are apparent but not yet documented.

Approach to building a health-promoting school in India

While talking about health promotion in the schools, it should be considered that the schools themselves only have a limited set of resources that might not be adequate to meet all the requisites needed to promote health. The role and contributions from the healthcare professionals, health sector, and public health institutions are, thus, of essence in order to achieve this objective. Though there have been ongoing efforts from the government and the schools to take up the various aspects of health promotion such as routine health checkup (dental, eye, etc.) for the students and staff, physical education being made part of the curriculum and government initiatives such as deworming, there remains a lack of organization and discreteness in these efforts. A need to organize such discrete efforts under a comprehensive head of School Health Promotion exists that can be modifiable and replicable in the various parts of the country, in accordance with the distinct state and local health issues.

Health promotion at schools is a multi-sectorial approach that involves not merely the schools and community but also the contributions from the health officials and health professionals. According to the Ottawa Charter,[5] the successful mediation of health promotional efforts depend on the collaboration of all sectors of government (social, economic, etc.) as well as independent organizations. Drawing support from the guidelines issued by WHO on health-promoting schools,[4] the initiative can be taken up by considering the six components, shown in Table 1, essential for schools to promote health.

Table 1

Components and checkpoints for School Health Promotion Framework (adopted from Regional guidelines - Development of health-promoting schools: A framework for action, Series 5; Western Pacific office of WHO)[4]

Components	Checkpoints
School health policies	Healthy food habits
	Tobacco, alcohol, and illicit drug abuse
	Gender equity
	First aid
	Health screening
	Deworming
	Preparedness in case of an emergency and disaster.
Physical environment of the school	Safety for the school community (sporting equipment, building, traffic)
	Adequate water and sanitation Sustainable environment
	Light and ventilation Student participation
School’s social environment	School ethos supportive of mental health
	Environment of care, trust, and friendliness
	Support to disadvantaged
	Inclusive environment
	Attention to the educational needs of parents
Community relationships	Family and community involvement Proactivity in addressing local community needs
Personal health skills	Theoretical and practical understanding of health issues in curriculum
	Skill development of stakeholders
Health services	Basic health service availability (relating to local needs) Contribution by health personnel

These six components provide a broad view of areas essential to be introduced or worked upon and improved in order to make any school a health-promoting one.

Another step that needs to be addressed is the sensitization of the stakeholders before the initiation of any such program. The stakeholders’ motivation and participation would ensure the sustainability of any model directed towards achieving long-term goals as expected by such initiatives.

Conclusion and Discussion

It is noteworthy that despite the concept of school health promotion being proposed for more than three decades, an organized effort towards such an objective is yet to be initiated in a country like India. Various sectors of the government, educational institution, educational boards, health sectors, and healthcare professionals are required to be brought together to convert the discrete ongoing efforts to a structured comprehensive one.

The government can contribute to policies and programmes, including law and legislations such as the sale of tobacco near school premises. Education boards should be advocated to issue directives to incorporate the health promotion into the school curriculum. Volunteerism forms the Health sector and Healthcare professionals need to be sought to routinely conduct screening and checkup camps at schools along with trainings/workshops for the teachers. Primary healthcare providers can view health promotion at schools as a tool to introduce the concepts of timely prevention and health maintenance in young minds. However, amongst these, most importantly, the willingness of the School management and the School staff to participate in the school health promotional activities along with their routine work must be reinforced, thus ensuring sustainability and make them a part of everyday school activities.

Looking at the way forward, the newly emerging schools of public health in the country might be the apt solution for the collaborations needed to create the models of school health promotions. There is a dire need to develop such models and frameworks that can be replicable to different diverse areas of the country and can be adjusted or modified based on various state health needs.

Financial support and sponsorship

Nil.

Conflicts of interest

There is no conflicts of interest.