Introduction:
With the myriads of powerful theories and ideas surrounding the words school, health, and education; it is imperative first to understand the significance of school health education and effects of interventions, its targets and general practice. The understanding of school health initiatives has evolved much throughout the 21st century. However, little effort has been made in developing countries to provide preventive and promotive programs in rural areas, while in urban areas the focus is on curative approach for health problems.1 In general, it is regarded as classroom teaching on the subject of health/hygiene during the school going years. The major trend regarding changing definitions of school health education surrounds the ever increasing notion that school education influences adult behavior. It is imperative to make aware and educate a child to make informed decisions about matters affecting his/her personal health and the health of others. The health education in schools, which eventually led to a much more aggressive approach to educating the nation’s youth on matters of health including mental health. School Health services should address local health problems of the school child and culture of the community. Most children in the tribal areas have poor health and different health needs. In addition, there is a high prevalence of anemia and malnutrition among them.2
In Yelagiri Hills there are one government school and two hostels which was facing acute issues with performance and multiple student health issues. As one of the author residing in the Yelagiri Hills got exposed to the situation and felt the need for intervention. Hence the action research was undertaken to address the problem and simultaneously to empower the local community.
We believe empowering the community in addressing the health needs of the child will have far reaching effect and sustainability to become a powerful means in improving community health and future towards a healthy nation. In 1995, the WHO launched its global school health initiative to foster health promoting schools.3
Material and Methods
Study area
The present action research was done in Yelagiri hills, Tamilnadu, India which is 70 km from Vellore and about 220 km fromSri Manakula Vinayakar Medical College & Hospital, Puducherry. This hills have about 2000 permanent residents and a large number of floating population. Main occupation is agriculture, but lately shifting to real estate related business due to tourism development. Even then, majority of residents still continue to live in relatively poor conditions. Most of the adult population is illiterate and lives on daily wages. The present study was undertaken in Two Government Tribal Hostels (Government Tribal Residential School and Government Tribal Hostel) and one Government Higher Secondary School.
Study design
It was a mixed-method action research study comprising of quantitative surveys (before- after design) and qualitative approach (participatory intervention). It was a school based action research for the intervention through empowerment of the local community and health education of school children. The participatory approach was chosen to address primary health care issues among school children and ensure the future sustainability of the interventions. The process was facilitated by a team of four volunteer medical students, supported by post graduates and faculty in the Community Medicine department of Sri Manacula Vinayagar Medical College and Hospital.
Study duration
The present study was carried out for a period of 3 years from year 2012 to 2015.
Baseline survey (Before Study)
The school health checkup was done for the children in the above mentioned school and hostels. All children who were present on the day of the checkup in the school and hostel were interviewed using a predesigned and pretested questionnaire and examined by a team comprising of doctors, medical students and auxiliary nurse mid wife from the local PHC and social worker. Out of 179 children (6-18 years) enrolled in the school at time of survey, 177 children were examined. Two children were absent on day of examination. We adopted global school based student questionnaire for the purpose of present survey.4 The information on personal hygiene physical status, nutrition, environment, substance abuse, risk behavior, life skills and other areas were collected.
Hemoglobin levels were measured for children 12 -18 years using WHO hemoglobin color scale, a reliable and rapid method suitable for primary health care settings on developing countries.5,6 Based on their hemoglobin levels, anemia was classified as per WHO standards.5 The anthropometric measurements such as height and weight for each child were obtained by trained medical students. All children with mild ailments at the time of examination were given treatment. The school health survey was supervised by Faculty and Post Graduates in Community Medicine. The detailed treatment recommendations were given to the nearby PHC for further follow up and continuum of care. The data were entered and analyzed using Epi_infoTM (version 3.5.4) software package.
Participatory Interventions
The interventions were coordinated by the School Health Committee.
The intervention was done in two steps: (i) formation of the School Health Committee and development of a school health plan and (ii) activities of the School Health Committee.
Formation of the School Health Committee and development of the school health plan: First of all, efforts were made to understand local culture and dynamics by a living –in experience. Rapport building efforts were made through attending socials events like social functions, local festivals, marriages, panchayat meetings etc. with community members and acknowledging their roles in the community. Later the survey findings were shared and discussed with the committee members’ and their input was taken prior to prioritizing the identified areas of need to be addressed. Also weightage were given for members’ suggestion for the intervention and solutions. With this background work a School Health Committee was formed to coordinate the activities of all three premises. The committee had 10-14 members including local panchayat authorities, school headmasters and wardens, parent teacher association president, local council member, two representative from teachers and students, two local well-wishers, and social worker. The members were given orientation program and briefed about the children’s health needs and guidelines for the development of the school health plan during one of the visits. Our social worker acted as the facilitator of the school health committee, coordinated its regular monthly meetings, collective decision making and implementation of the decisions. The process of committee formation, allocation of responsibilities and decision making was flexible participatory approach to ensure sustainability of the program. Each study location were recommended to obtain a first aid box from PHC containing essential drugs and bandages.
Activities of School Health Committee: The monthly activities of the school committee were focused on personal hygiene environmental cleanliness, physical activity, better study environment, regular intake of iron supplementation and periodic deworming monitoring and recording, chlorination of the local water source, etc. The school health committee ensured better personal hygiene, hand washing with soap, nail trimming, wearing of clean washed clothes, appropriate physical activities, nutrition and also psychological and counseling support as needed. After deworming with albendazole (400mg, single oral dose), the school children were given iron folic acid tablets (100 mg elemental iron and 0.5mg folic acid) issued by the PHC once a week under the supervision of the trained school teacher and social worker. This was based on the guidelines of the local state government policy. Social worker kept a record of consumption of the tablet for each student. Students were advised to take tablets three hours after meals or with meals if they had intolerance. Apart from this, students, teachers and kitchen staff were educated about locally available iron rich foods like drumstick, green vegetables and citrus fruits. As a step towards improving the children’s immediate environment a vegetable garden was initiated at the hostels to provide supplemental organic vegetables for the students. Also plants with nutritional value such as lemon, guava, drumstick, and banana saplings were provided for planting in the garden. The school health committee identified the barriers in utilization of the sanitary latrine such as inadequate number of toilets, lack of water supply and electricity and addressed those in consultation with the students.
Follow up survey (After Study)
After one year, a follow up survey was done. 230 children were examined out of 235 enrolled in the school at the time of survey. We used the same questionnaire for data collection and followed similar procedures for anthropometric measurements and hemoglobin estimation.
Ethics
Permission from the district education department and the concerned school principals and wardens were obtained. Also clearance from the research committee and institutional ethics committee of Sri Manakula Vinayagar Medical College and Hospital was obtained prior to initiation of the study. Written informed consent was obtained from parents of the school children.
Results
At baseline, 177 children examined, 85 (48%) were boys and 92 (52%) were girls. In the follow up assessment of 230 children examined, 106 (46%) were boys and 124 (54%) were girls. 24 number of children were 6-12 years of age in the baseline assessment and 44 in the follow up assessment, and the rest were above 12 years. Majority of the children belongs to scheduled tribe. There is no significant age and caste differential among boys and girls examined at the baseline and at follow-up. There was significant improvement in the personal hygiene and the reduction in related morbidity.
As shown in the Table 2, the prevalence of worm infestation was significantly reduced and other variables – head lice, scabies, multiple boils and fungal infections showed reduction however this difference is not statistically significant.
At baseline, of 153 children examined above age 12 years, 69 (45%) were boys and 84 (55%) were girls. In the follow up assessment, of 186 examined, 77 (41.4%) were boys and 109 (58.6%) were girls. The number of students with hemoglobin level less than 12 gm% decreased from 48(31.4%) to 21 (11.3%). The number of students with hemoglobin level more than or equal to 12 gm% increased from 105 (68.6%) to 165 (88.7%). There was a significant decline in anemia from 31.4% at baseline to 11.3% at follow up survey (p=0.001). Refer to Table 3. There was significant improvement in the consumption of green leafy vegetables and fruits among students.
Also consistent intake of iron supplementation, decrease in the reported open field defecation and improved hygiene habits observed.
As seen in Table 4, after one year of intervention there was a significant decline in number of Thin children (<5th percentile) from 85(48%) to 75(32.6%) (p=0.001). Notably, there was significant increase in percentage of Normal children(5th to 85th percentile) from 86 (48.6%) to 149 (64.8%) (p=0.001).
Table 1: Age and sex distribution among school children |
Variable |
Boys |
Girls |
Total |
Age groups |
Baseline [n=85] |
Follow up [n=106] |
Baseline [n=92] |
Follow up [n=124] |
Baseline [N=177] |
Follow up [N=230] |
6-12 years |
16 (18.8) |
29 (27.4) |
8 (8.7) |
15 (12.1) |
24 (28.2) |
44 (19.1) |
12- 18 Years |
69 (81.2) |
77 (72.6) |
84(91.3) |
109 (87.9) |
153 (71.7) |
186 (80.9) |
| Values in parenthesis are percentages |
Table 2: Morbidities related to poor personal hygiene among school children. |
Variable |
Boys |
Girls |
Total |
p value |
Baseline [n=85] |
Follow up [n=106] |
Baseline [n=92] |
Follow up [n=124] |
Baseline [N=177] |
Follow up [N=230] |
Head lice |
16 (18.8) |
14 (13.2) |
44 (70.9) |
51 (41.1) |
60 (33.8) |
65 (28.2) |
0.221 |
Scabies |
5 (5.8) |
3 (2.8) |
2 (3.2) |
3 (2.4) |
7 (3.9) |
6 (2.6) |
0.443 |
Multiple boils |
2 (2.3) |
1 (0.9) |
4 (6.4) |
1 (0.8) |
6 (3.3) |
2 (0.8) |
0.145 |
Fungal Infection |
4 (4.7) |
4 (3.7) |
4 (6.4) |
2 (1.6) |
8 (4.5) |
6 (2.6) |
0.294 |
Dental caries |
34 (40) |
27 (25.4) |
21 (33.8) |
26 (20.9) |
55 (31) |
53 (23) |
0.068 |
Worm infestation |
28 (32.9) |
10 (9.4) |
18 (29) |
2 (1.6) |
46 (25.9) |
12 (5.2) |
0.001 |
| Values in parenthesis are percentages |
Table 3: Iron deficiency anemia among school children of age group 12 - 18 years. |
Variable |
Boys |
Girls |
Total |
p value |
Hemoglobin value(gms%) |
Baseline [n=69] |
Follow up [n=77] |
Baseline [n=84] |
Follow up [n=109] |
Baseline [N=153] |
Follow up [N=186] |
< 12 |
23 (33.3) |
07 (9.1) |
25 (29.8) |
14 (12.8) |
48 (31.4) |
21 (11.3) |
0.001 |
> 12 |
46 (66.7) |
70 (90.9) |
59 (70.2) |
95 (87.2) |
105 (68.6) |
165 (88.7) |
0.001 |
| Values in parenthesis are percentages |
Table 4: Malnutrition among school children |
Body mass index |
Boys |
Girls |
Total |
p value |
Baseline[n=85] |
Follow up [n=106] |
Baseline [n=85] |
Follow up [n=106] |
Baseline [N=177] |
Follow up [N=230] |
Thin (<5th percentile) |
48(56.5) |
44(41.5) |
48(56.5) |
44(41.5) |
85(48) |
75(32.6) |
0.001 |
Normal (5th to 85th percentile) |
33(38.8) |
60(56.6) |
33(38.8) |
60(56.6) |
86(48.6) |
149(64.8) |
0.001 |
Overweight (85th – 95th percentile) |
1(1.2) |
2(1.9) |
1(1.2) |
2(1.9) |
1(0.6) |
5(2.2) |
0.182 |
Obese (>95th percentile) |
3(3.5) |
0(0) |
3(3.5) |
0(0) |
5(2.8) |
1(0.4) |
0.047 |
| Values in parenthesis are percentages |
Discussion
Formation of the School Health Committee with the community stake holders has shown significant improvement in the school children’s health at the Government Tribal School and Hostel at Yelagiri Hills, Tamil Nadu. As a result of intervention by School Health Committee there was improvements in personal hygiene and reduction in morbidity related to poor personal hygiene. There was also significant improvement in the reduction of nutritional anemia and malnutrition among the school children. The strength of our study lies in the process of community mobilization, which was crucial to foster commitment and ownership among the school health committee.
Dongre et al.3 and Nayar et al.11 have reported a positive effect of a school based intervention through teachers on personal hygiene related conditions among school children. Our approach was participatory in nature and involved community leaders, local well-wishers, school teachers and other staff members and students. Weekly iron and folic acid supplementation, periodic deworming, student’s initiative in cultivating vegetables and rewards for personal hygiene and environmental cleanliness, promoting physical and recreational activities and counselling services for the needful children were the notable services provided by the school health committee.
The increase in number of students examined in the baseline (177) and the follow up (230) was due to the effective functioning of the school health committee which played a vital role in improving the reputation of the school. Thus the action research not only improved the health of the school children but also helped in trust building among parents and school.
Our study was based on the health promoting schools (HPS) by WHO which has emphasized on policy formulation, school environment, education and school health services and supportive partnership with teachers, education officials, parents and community leaders.1 It is continuing as a service model and sustaining effect seen even after 5 years. The success and sustainability largely accounts to active participation of community through formation of school health committee and appointment of motivated social worker from same community. Also the empowerment of the students through health education, awareness training and consistent feedback mechanism of follow-up aided with positive results. However the present study was carried out in only one tribal school and two hostels hence the generalization of the findings is not possible. Another limitation was lack of control group in our study.
In conclusion, the action research could bring positive improvements in health status of school children through active participation of students, parents, teachers and community members.
Acknowledgement
We are grateful to Sri Manakula Vinayagar Medical College and Hospital, Pondicherry for providing partial financial assistance to the study. The present study was selected for the student project for health forum which was sponsored by FAIMER and GEMx and the authors received a scholarship to attend The Network annual conference in South Africa in September 2015.
References
- School based health and Nutrition Programs. Washington DC: Disease Control Priorities Project. [Online]. [cited 2013 Oct 7]; Available from: URL: http://www.dcp2.org/pubs/DCP/58/Section/8747
- Dongre AR, Deshmukh PR, Garg BS. The impact of School Health Education Program on personal hygiene and related morbidities in tribal school children of Wardha district. Indian J Community Medicine 2006;31(2):81-82.
- World Health Organization. Global Health Initiative. [Online]. [cited 2013 Jan 6]; Available from: URL: http://www.who.int/school_youth_health/gshi/en/
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- World Health Organization. Iron Deficiency anemia: Assessment, prevention and control. A guide for programme managers. [Online]. [cited 2013 Aug 12]; Available from: URL: http://www.who.int/reproductive-health/docs/anemia.pdf
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- Ramachandran A, Snehalatha C, Baskar AD, Mary S Kumar CK, Selvam S et al. Temporal changes in prevalence of diabetes and impaired glucose tolerance associated with lifestyle transition occurring in the rural population in India. Diabetologia 2004 May;47(5):860-865.
- Stoltzfus RJ, Dreyfuss ML. Guidelines for the use of iron supplements to prevent and treat iron deficiency anemia. International Nutritional Anemia Consultative Group (INACG). World Health Organization (WHO), United Nations Children Fund (UNICEF). [Online]. [cited 2013 Jan 6]; Available from: URL: http://www.who.int/nutrition/publications/micronutrients/anemia_iron_deficiency/1-57881-020-5/en/index.html
- Nayar S, Singh D, Rao NP, Choudhury DR. Primary school teacher as a primary health care worker. Indian J Pediatr 1990;57(1):77-80.
- Tandon R (ed). Participatory research: Revisiting the roots. New Delhi: Mosaic Books; 2005.
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