BARRIERS TO EFFECTIVE SCHOOL HEALTH PROGRAM

CHAPTER TWO

LITERATURE REVIEW

SCHOOL HEALTHPOLICY

The school environment is one of the key settings for promoting children’s environmental health and safety as explained in the National Health sector strategic plan as well as the Nigeria education sector support programme. A national school health policy (2009) and national school health guidelines (2009) have been developed and disseminated.

This national school health strategic implementation plan aims to identify and mainstream key health interventions for improved school health and education. The strategy comprises eight thematic areas; these are: Gender issues, Values and life skills, Child rights, child protection and responsibilities, disability and rehabilitation, Special needs, sanitation and hygiene, Water, Nutrition, Disease prevention and control and School infrastructure and environmental safety. The strategy outlines critical issues on health and education linkages that are important towards the improvement of child health while in school.

1. CAPACITYBUILDING

CSHP contemplates a situation where a school has adequate and able human resource to deliver key objectives of the program among these is addressing life skills education and gender issues. World Education Forum in Senegal-Dakar in April 2000 resulted in a Dakar framework for action 2000 which refers to life skills in goal 3. Life Skills Education are abilities which allows an individual develop adaptive and positive behavior so as to effectively deal with demands of everyday and life challenges. The main goals of the Life Skills approach is to enhance young people’sabilitytotakeresponsibilityformakingchoices,resistingnegativepressureand avoiding risky behavior. Where life skills education is well developed and practiced, it enhances the wellbeing of a society and healthy behavior promote and positive outlook. Life skills are classified into three broad categories namely; skills of effective decision making, skills of knowing and living with oneself, skills of knowing and living with others,

Values are beliefs, principles and ideas that are of worth to individuals and their communities. They help to define who people are and the things that guide their behavior and lives. People obtain values from families, friends, traditional culture, political influences, school environment, life experiences, religious teaching and economic experiences. Our values shape our behavior and a world view. For this program, health and education is intended to ensure that children are taught and assisted to acquire positive values (National school health policy2009).

Ages 0-19 years are critical formative years for the development of behavior and skills in an individual. Learners in pre-school, secondary and secondary school, face varied challenges, which are compounded by various factors. These include intra & interpersonal conflicts, lack of positive role models, negative mass media influence and unreliable and inadequate sources of information especially on human sexuality. Traditional education addressed the holistic view of human personality through the informal education system. However, due to historical reasons, educational and traditional family ties have largely broken down thereby leaving young people vulnerable. Therefore, there is need for the youth to be enabled to develop positive attitudes, values, skills and healthy behavior in order to help them effectively deal with the challenges of everyday life (WHO, 2003 – Skills for Health; UNICEF, 2005- The voices & identities of Botswana’s school children). Skill based health education supports the basic human rights included in the Convention on the Rights of the Child (CRC ) especially those related to the highest attainable standards of health Life Skills Education enables learners to develop and acquire skills such as critical thinking, problem solving, decision-making, interpersonal relationships, stress and anxiety management, effective communication, self-esteem and assertiveness. KIE has developed Life skills Education Curriculum for Secondary and Secondary schools and disseminated for implemented on January2009.

On gender, UNICEF 2003 defines Gender as the socially constructed roles, behavior, attributes and activities that a particular society considers appropriate for men and women. The distinct roles and behavior may give rise to gender inequalities i.e. differences between women and men that systematically favors one group. In turn, such inequalities can lead to inequities between men and women in both health status and access to health care. There are several gender related issues that affects learning for both girls and boys. In the MDG’s, MDG 2 Achievement of universal secondary education by the year 2015 and Target 3( a )of MDG 3 emphasizes elimination of gender disparity in secondary and secondary school education preferably by 2005, and at all levels 2015. Globally 150 million children currently enrolled in school may drop out before completing secondary school- at least a 100 million of these are girls. Nigeria secondary and secondary schools have at least 1 million menstruating girls at least 3/5 or 872,000 of who miss 4-5 days of school per month, due to lack of underwear and sanitary pads combined with inadequate sanitary facilities in their schools(GCN and MOE,2006).

The daily routine of a school is structured by formal and informal rules and ways of behavior. A ‘gender regime’ is manifest as part of this routine. Ways of relating and the type of interaction between students and boys, are part of this gender regime and serve to normalize certain types of behavior. This regime under which boys and girls interact is so ‘naturalized’ in schools that people don’t see a need to intervene when this interaction may have negative effects. Some examples include; physical space that girls and boys have e.g. who gets to speak, roles that girls and boys play, how they contribute to the school, who cleans the classroom etc. These gender roles produce a gender hierarchy, which more often than not is one where the male hierarchy dominates. Boys tend to have more physical space such as in sport than girls. Peer pressure to tease, intimidate, hassle, exclude, and in some cases perpetrate physical violence, can become a part of the school environment. These gender roles within the school are reinforced by girls and boys themselves both of whom are protecting their space, but in a very gender stereotyped way. There are few if any alternatives put forward that suggest that gender roles could be otherwise.

Teachers themselves perpetuate gender inequalities. They are not trained on gender hence they do not see it as an issue. Instead they have internalized local norms and rarely question them. As a result, they do not intervene on gender, abuse issues in the classroom nor harassment. In addition discipline issues have been seen to be mainly male led, and boys are most often the subject of corporal punishment resulting in more school truancy and violence by boys. It has also been reported in media and some reports here in Nigeria that transactional sex for good exam resultsisrampant.Thissometimesleadstopregnanciesandinmostcasesthegirlsareblamed for becoming pregnant, leading to expulsion without option for re-entrance. This results in high drop out for girl, while the perpetrators are not punished. Sexual exploitation of both sexes is also rampant while there exists no mechanisms of addressingit.

The relationship between schools and community members in developing countries is often rife with power dimensions that transcend gender issues. In many contexts, many community members will not challenge a teacher or question their behavior and are not supported or listened to when they do e.g. in relation to impregnation of school children, and sexual harassment. However in Nigeria there are opportunities like the constitution 2010, Children’s Act (2001), and Sexual Offence Act (2006) which can be exploited in addressing this vice.

1. SUPPORTSUPERVISION

Schools require support from different stakeholders to enable them operate optimally considering the difficult circumstances that schools in Nigeria operate under. Children are the most vulnerable members of our society by virtue of their stage of growth and age, their rights especially to health and education amongst others should be protected and safeguarded. It is important to ensure that health services and conditions for maintaining optimum health are accessible to all children. The CRC (1989) specifically mentions the special needs of children with a disability. Child survival strategies in Nigeria endeavor to provide a comprehensive and integrated approach to address the needs of all children without discrimination. Vulnerable children constantly experience barriers to enjoyment of their basic human rights and to inclusion in society. The parents, communities, teachers and pupils should be sensitized on relevant laws regarding child protection (national school health policy & guidelines2009)

Nigeria Government has ratified several international and national conventions / treaties on the rights of the child. These include, the African charter on the rights of children (2000), the United Nations Convention on Rights of the Child (UNCRC) on July 30th 1990, and the disability act 2003 and welfare of the child, enactment of the Children’s Act 2001, and the sexual offences Act 2006. These laws have since enhanced effective child protection in Nigeria. Several other Acts with positive implication for protection of children were later passed. These include the Industrial Properties Act, Persons with Disabilities Act 2003 and Criminal law AmendmentAct.

The constitution 2010 addresses issues of affecting children and guarantees for the Right of Children in various sections that include those with disabilities and vulnerable children. In line with the Child Rights and Millennium Development Goals (MDGs) the Ministry of Public Health and Sanitation and the Ministry of Education in collaboration with partners developed a National School Health Policy and Guidelines 2009. The two Ministries essentially have come up with a comprehensive School Health Programme addressing child protection, child rights, responsibilities, special needs, disabilities and rehabilitation amongothers.

Children in Nigeria (0—18) years) constitute more than half of the 38million (Nigeria national Census 2009) total population while 20% of the population is under 5 years of age. Since the introduction of free secondary education in 2003, Secondary school enrolment has increased from 77% in 2002 to 92% in 2007 with near parity nationally between girls and boys (National plan of action for children 2008-2012). Children with disabilities and those with special needs find themselves in difficult circumstances in accessing quality education and health equitably (KNSPDS 2007). Although the needs of vulnerable children are largely similar to those of other children in various aspects, they differ in that these children require additional support in enjoying and maintaining their rights as children (Child survival and development strategy Nigeria2008).

The ministry of education has developed a national Special needs education policy framework which is intended to improve the access and quality to education provided to children with special needs. It also addresses issues of improvement and equity of learning environment in all schools (The national special needs education policy framework 2009). It is in this regard that the ministry of Public health and sanitation and ministry of education intends to improve access to education and health care for children with disabilities and special needs through the development of thisstrategy.

The Nigeria National disability survey 2007 reported that the disability prevalence in Nigeria is 5.7%. PWDs are often marginalized and face difficulty as a result of their disability. Most have no access to health, employment, education, or rehabilitation. The majority experience hardships as a result of widespread social economic and cultural prejudices which results to stigmatization. Amongst children 0-14 years of age and 15 to 25 years of age only 55% of this target group is able to access health services when in need (KNSPWDs2007). Averagely 41% of children with disabilities of school going age drop out due to various illnesses. On the other hand 39% of children with disabilities drop out due their disabilities (KNSPWDs).

The KNSPWDs also indicated that children aged 0-14 years those with hearing impairment were 22.9%, visual 14.8%, speech 9.5%, mental disability 12.4%, physical disability 20.4%, self-care 9.7% and others at 10.8%. For those aged between 15 – 24 years it was found that hearing impairment was 11.2%, speech 6.1% visual 29.2%, mental disability 14.4%, physical 23.9% and

self-care 6.6% and other at 9%.

It is evident that there is a growing number of children with special needs and disabilities whose requirements are not being met. The lack of awareness amongst community and school age going children is also a major barrier to the education and integration of children with special needs and disabilities. The interventions should include but not limited to; Screening and identification for disabilities and special needs, medical care, therapy and rehabilitation, provision of appropriate assistive and supportive devices / appliances, educational referrals and interventions, Vocational and skills training and social interventions andintegration.

1. SCHOOLINFRASTRUCTURE

The school infrastructure plays a crucial role not only in the health of students and those working in the school but also in terms of their wellbeing and enjoyment of conducive environment. For example, sanitation, water and hygiene are critical towards creating an improved learning environment. The government’s commitment towards Education for All (EFA) has resulted in the over stretching of already inadequate water and sanitation facilities due to the dramatically increased enrolment and lack of adequate resources. Improving sanitation, water and hygiene in our learning institutions generates considerable benefits in terms of improved child-health, attendance, retention, performance, and transition of all learners including girls, boys and children with special needs. The aim for improving school Sanitation, Water and Hygiene (WASH) is reducing water-born and sanitation-related diseases e.g. cholera and other diarrheal diseases, worm infestation, skin infections,etc.

Learners are positive change agents within their communities, and instilling habits early is the most effective way to change current practice. Therefore, the multiplier effect of appropriate and positive messages on hygiene promotion will influence the larger communities. This influence will translate in reduced ignorance and ill health and will ultimately result in a well-informed society. The MOE, within the Nigeria Education Sector Support Programme (KESSP), is currently taking measures to better equip school managers, teachers and learners in Sanitation, Water and Hygiene promotion, knowledge and practices. Funding for recurrent costs, infrastructure and improved practice in water, hygiene and sanitation has been increased, and the government and development partners intend to adequately support the sector. Given the need to harmonize and coordinate support from the various providers within the sector, CSHP provides the MOE with the framework to doso.

The rapid increase in the number of children in the secondary schools from 5.9 Million pupils in 2002 to 7.2 Million pupils in 2003 and currently at more than 8 Million pupils has resulted in straining hygiene and sanitation facilities in schools. Water, hygiene and sanitation are critical towards creating a child friendly environment in learning institutions. Improved water, hygiene, and sanitation in learning institutions generate considerable benefits in terms of improved child health, attendance, performance, retention and transition.

Provision of safe and adequate sanitation, water and hygiene services forms the basis of a sustainable solution to the threat of water, sanitation and hygiene related diseases among school children. The health benefits of safe and adequate water, improved hygiene and sanitation range from reduction in diarrhea, ecto-parasites, intestinal worms, infections and trachoma, to enhance psychosocial well-being afforded via such factors as the dignity that goes with using a clean toilet/latrine.

WHO estimates that between 25% and 33% of the global burden of disease can be attributed to by environmental risk factor. Globally causes of mortality, morbidity and disability for the age group 5-18 years conforms with this as it is shown that they are mainly due to cardiovascular disease, cancer, chronic lung diseases, violence, depression, substance abuse, nutritional deficiencies, injuries, HIV/AIDS/STI and helminthes infections and can be significantly reduced by preventing six interrelated categories of behavior, that are initiated during youth and fostered by social and political policies and conditions such as tobacco use, Behavior that results in injury and violence, dietary and hygienic practices that cause disease, Alcohol and substance use, Sedentary lifestyle and Sexual behavior that causes unintended pregnancy and disease

Worm infections are likely to affect children’s cognitive development differently according to their levels of poverty, general health status and psychosocial stimulation. (Donald A. P. Bundy et all 2009). Two billion people are infected with intestinal worms. In many areas, the majority of school children are infected and the World Health Organization (WHO) has called for school- based mass deworming. Existing evidence indicates that mass school-based deworming is extraordinarily cost-effective once health, economic and educational outcomes are all taken into account, and it is thus unsurprising that a series of studies from the 1993 World Development Report to the recent Copenhagen Consensus argue that treatment of the most prevalent worm infections is a very high returninvestment.

In Nigeria the documented causes of outpatient morbidity (Health facility service statistics-HMIS report, 2009) although different from above are also largely due to environmental factors. These are malaria, skin diseases, respiration system infections, diarrhea, accidents, rheumatism, pneumonia, urinary tract infections, eye infections, intestinal worms and dental disorders. However WHO has also shown that worm infestation is the greatest cause of morbidity in the age group 5-14 years. The resulting diseases give rise to much suffering and death. In addition, they contribute to perpetuation of poverty by impairing the cognitive growth and performance of children, and reducing the work capacity and productivity of adults and hence negatively impacting on nationaldevelopment.

The Nigeria vision 2030 goal for the health sector is to provide affordable and equitable quality health services to all Nigerians. The vision also aims at restructuring the health care delivery system to shift the emphasis from curative to promotive and preventive health care. In addition, measures are being taken to control environmental threats to health as part of the effort to lower the Nation’s disease burden. This is being implemented under the existing health legislations and policies.

Nutrition is the science that explains the role of food and nutrients in the human body during growth, maintenance and development of life. Good nutrition is essential to realize the learning potential of children and to maximize returns on education investments. Malnutrition affects a child’s attentiveness, aptitude, concentration and overall performance. For these reasons, schools should provide an ideal setting to promote good nutrition as they reach a high proportion of youth and children. Efforts should be made to promote good nutrition practices in schools by integrating nutrition interventions including micronutrient supplementation into school activities.

Poor diet and sedentary behaviors are among the major risk factors of chronic diseases which account for 59% of 56.5 million deaths annually and 46% of the global disease burden. There is clear evidence that high consumption of energy-sugar, fat-in and starch relation to physical inactivity is a fundamental determining factor of nutrition-related chronic diseases. Health diet and physical activity are key to good nutrition and necessary for a long and healthy life. Eating nutrients dense foods and balancing energy intake with the necessary physical activity to maintain health is essential at all stages of life. Consuming too much food high in energy and low in essential nutrients contributes to energy excess, obesity andoverweight.

In Nigeria, malnutrition continues to affect a significant proportion of children and women. The most recent countrywide study done in 2005/06 (KIHBS1, 2007) shows persistently poor nutrition outcomes with marginal increases in wasting (6.1%), stunting (33%) and underweight (20.2%) compared to 2003 data as shown below. The national micronutrient survey of 1999, found high levels of Vitamin A deficiency (VAD) among preschoolers, 61.2% moderate VAD, with 14.7% having acute and. Factors that were associated with this high prevalence include malaria infection, hookworm infestation and acute malnutrition. From the national micronutrient survey, Iron deficiency was also high with 43% of preschool children. Data on Iodine deficiency (ID) data from KEMRI (2004) indicate an improvement from 16% deficiency in 1994 to 6% in 2004, attributed to the consumption of iodized salt by a large proportion of Nigerian households 91% CBS/UNICEF Multi Indicator Cluster Survey or MICS 2000)

A healthy school environment should include the structures that protects pupils and staff but poorly designed school buildings and play areas may present serious health risks. Special construction techniques may be required to ensure safety particularly in areas prone to natural disasters. Schools should be designed to prevent temperature extremes inside classrooms. Poorly and cold damp ventilated classrooms provide an unhealthy environment for school children particularly poorly nourished and inadequately clothed pupils who are especially vulnerable to respiratory and other infections. Extremely warm conditions may reduce attention and concentration span and can lead to heart related illnesses, thermal stress, fatigue and heat stroke (WHO2003)

According to UN Convention on the rights of persons with disability (2007), appropriate measures should be put in place in schools to ensure an equal basis for children with disabilities to live independently and participate fully in all aspects of life. These measures shall include the elimination and identification of obstacles and barriers to accessibility to buildings, roads, transportation and other indoor and outdoor facilities including schools, housing, medical facilitiesworkplaces.

Since children spend much of their day within the school environments during their critical developmental stages a healthy school environment is required to improve their health and effective learning and this will contribute to the development of healthy adults who will be skilled and productive members of society. In addition pupils who learn about the link between the health and environment will be able to recognize and reduce health threats in their own homes. (WHO2003)

The Nigerian government’s commitment towards Education for All (EFA) and the MDGs has resulted in the free secondary education since 2003 and free day secondary education in 2007. This has resulted to increased enrollment from 5.9m in 2002 to 8.6m in 2010 of pupils in secondary and students in secondary schools. This has over stretched the already existing inadequate water and sanitation and infrastructural facilities.

Secondary education still continues to experience many challenges relating to access and equity, overcrowding, including overstretched facilities, and poor learning environments and lack of appropriate sanitation. Education opportunities for learners with special needs and disabilities are a major challenge to the education sector. There is need to link inclusive education with wider community based programs for persons with disabilities and special needs. Successful implementation of the CSHP’s strategic plan would improve efficiency in resource allocation, improve the quality of education provided to Nigerians while also addressing gender imbalance and equity, improve the learning environment for both girls and boys including those with disabilities and special (Ministry of education strategic plan 2006 –2011).

1. THEORETICALFRAMEWORK

This section reviews the theories guiding the study. The researcher identified the theory of planned behavior and resource dependent theory as the key theories guiding the study and discussed this theories in relation to how they affect the variables used in this study.

1. THE THEORY OF PLANNEDBEHAVIOR

The Theory of Planned Behavior (TPB) was formulated by Ajzen and Fishbein as the Theory of Reasoned Action in 1980 to predict an individual's intention to engage in a behavior at a specific place and time. The theory was intended to explain all behaviors over which people have the ability to exert self-control. The key component to this model is behavioral intent; behavioral intentions are influenced by the attitude about the likelihood that the behavior will have the expected outcome and the subjective evaluation of the risks and benefits of that outcome. The theory holds that intent is influenced not only by the attitude towards behavior but also the perception of social norms, the strength of others’ opinions on the behavior and a person’s own motivation to comply with those of significant others and the degree of perceived behavioral control.

This theory can be used to explain capacity building variable since a person’s behavior is highly influenced by their capacity to engage in a given behavior. If a teacher has little knowledge regarding CSHP, they are least likely to actively engage in its implementation. The same can also be used to explain support supervision variable since the perceived degree of behavior control instilled by support supervision influence compliance or non-compliance. Therefore if those charged with support supervision do not do it, it is likely that the implementation of CSHP may bederailed.

Attitudes of teachers and education official’s on CSHP can also be explained by this theory since attitudes are socially constructed and shaped by social norms, therefore depending on a person’s attitude towards CSHP, efficiency and effectiveness of implementation may be affected.

1. Resource dependence theory(RDT)

This theory was formally developed in 1970s, with the publication of The External Control of Organizations: A Resource Dependence Perspective (Pfeffer and Salancik 1978). It holds that procurement of external resources is an important tenet of both the strategic and tactical management of any organization. Resource dependence theory has implications regarding the optimal divisional structure of organizations, recruitment of board members and employees, production strategies, external organizational links, contract structure, and many other aspects of organizational strategy.

According to this theory, Organizations depend on multidimensional resources: labor, capital, raw material, etc. Organizations may not be able to come out with countervailing initiatives for all these multiple resources. Hence organization should move through the principle of criticality and principle of scarcity. Critical resources are those the organization must have to function. An organization may adopt various countervailing strategies—it may associate with more suppliers, or integrate vertically orhorizontally.

This theory can be used to explain school infrastructure variable in relation to how it influences implementation of CSHP. If a school is not able to earnest its own resources and those around it or within its reach, it may not be able to effectively implement CSHP. This therefore calls for partnership of purpose between schools’ BOM, PTA, students, NGOs, government etc.

1. ConceptualFramework

According to Peters et al. (2000), a conceptual model is a schematic presentation which identifies the variables that when put together explain the issue of concern. It is a set of broad ideas used to explain the relationship between independent and dependent variables. The researcher explains this study using the conceptual framework on Figure 1.

Figure 1: Conceptual Framework

Independentvariable Interveningvariable Dependentvariable

Capacity building

• Training onCSHP
• Training on lifeskills
• Training on gender issues

Government policies

Support supervision

• Disease prevention
• Child rights andprotection
• Nutrition
• SpecialNeeds

Implementation of CSHP

• Capacitybuilding
• Supportsupervision
• Schoolinfrastructure

School Infrastructure

• Water andsanitation
• Conduciveclassrooms
• Environmentalsafety

Attitudes of teachers and

B.O.M on CSHP

MODERATING VARIABLE

From the above conceptual model, the independent variables which include school infrastructure, support supervision and capacity building would affect the implementation of CSHP. Specifically human resource capacity of a given school has an influence on how such a school implements the health program. On support supervision, it is expected that if a school has access to adequate support, then it enhances the implementation of CSHP and if there adequate infrastructure, the school stands at a better position in ensuring the safety and health of the students. The researcher recognizes that the relationship between the independent variable may not be linear even in the best of conditions. Government policies and attitudes of teachers and education officials on CSHP comes in as the intervening and moderating variables respectfully since it may affect the relationship between the independent and the dependent variables.