TORIK BOUHAIRIE A N D PHILIP R. NADER
An Approach to School Health in a Developing Country
Introduction Children represent the richest resource of any country. They need an environment which prepares them for optimal growth and development and to understand and meet their own needs as well as those of the community. One important aspect of these needs is health. The responsibility of preparing children to meet health problems is shared by the home, the community and the school through medicine and education. School health is where medicine and education meet; yet today medicine and education tend to have little to do with each other.1 In most African countries little effort has been made to organize school health programs. This paper attempts to stimulate interest in these programs. It defines school health, traces particular aspects of its past history and current status in West and East Africa, and considers its needs. It proposes aims and objectives of a comprehensive school health program, recommendations for its establishment and a plan for its operation.
1
Definition A school health program is included in a system of curative and preventive ' health services in a community. School health is designed to cater to the health needs and problems of the school age child. Such needs and problems vary from one developing country to another and in urban and rural areas. Community and school health programs in West and East Africa Beginnings: In Ghana, West Africa, the first formal attempt to protect the health of children led to the appointment of a school medical officer by the Department of Health in the 1920s.2 In Kenya, East Africa, the Ministry of Health organized child health activities in Nairobi in the 1920s. It was not until the 1950s that determined efforts at organizing child health services on a countrywide basis were made with the introduction of the concept of a health center for developing countries as a nucleus for providing Environmental Child Health, August 1977
primary health care.3 Thus, in these two countries, the school health program began as an integral part of a community health program. Current Status: In Nigeria, West Africa, one model of a school health program instituted in Lagos is the most highly developed in the country and probably in most of West and East Africa. Beginning as a small school clinic the program has grown steadily and has established satellite centers. Special school health programs have also been organized and developed in other Nigerian cities and large towns. There is usually a school clinic which treats minor ailments and provides a periodic medical examination. These services are mostly administered by nurses or various health auxiliaries working under the supervision of medical officers of health.4 By contrast, in other countries, especially in the rural areas, school children receive medical care at dispensaries, hospitals and health centers, but there is usually no organized school health program. This is due partly to a general shortage of trained personnel. The doctors, consisting of general practitioners and very few specialists, are mostly employed in government services which are usually free of charge; and there is no organized supporting private practitioner service. The rest of the health team consists of: (1) physician/medical assistant who is the leader of the team working under the supervision of the doctor; (2) public and/or community health nurses, midwives; (3) sanitarians, health inspectors, etc. The need for a community and school health program in a developing country A program for the health of school children deserved special consideration for at least four reasons: population characteristics, growth and development, community health resources, and current morbidity. Population Characteristics The increasing proportion of school children and the high rate of morbidity: In Gliana, West Africa, the population, which is 8.5 million, is growing at the rate 189
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by TORIK BOUHAIRIE, M.D. (Paris), LMCC (Montreal) Fellow, Ambulatory Pediatrics and PHILIP R. NADER, M.D., FAAP Associate Professor of Pediatrics and Psychiatry Director, School Health Programs, Department of Pediatrics The University of Texas Medical Branch, Galveston, Texas 77550, U.SA. Supported in part by a grant No. 622, from The Robert Wood Johnson Foundation
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Growth and Development The necessity of obtaining optimum growth and development despite the problems inherent in the growth process and/or the school process: Children are constantly undergoing change in growth and development: physical, mental, emotional and social. The process of growth and development itself often causes problems, especially at adolescence and puberty. The educational institutions also influence growth and development by different processes: — Opportunities for health education along with learning — Learning disabilities (disorder in one or more of the basic psychological processes involved in understanding or in using language) and learning problems (resulting from visual, hearing or motor handicaps, mental retardation, emotional disturbance or environmental disadvantage). — Risk of communicable disease in group contacts. — Accidents sustained in sports, play and contact with traffic. The school represents .the optimal milieu for observation of the child's growth and development and for cooperation in a community health program.1 Preventive measures and health education undertaken during the period of growth and development while the child attends school may have a beneficial lifelong effect in many of the problems. 190
Community Health Resources The inadequacy of community health centers to meet the health needs of school children: Despite the difficulties inherent in the collection of reliable data, available estimates from hospitals and health centers indicate that children of school age constitute a high proportion of the patients. The health centers are not evenly distributed throughout the country. Even so, where they exist, distance, lack of adequate transportation and communication, the expense of travel, and traditional (superstitious) belief and attitudes limit their utilization. Some of the cases may be reported to the local "medicine man" and may never reach the health center or may only be reported to the health center at a later stage. In areas where health centers are utilized they are usually inadequately staffed and equipped and often overcrowded. The school represents the site for effective contact with the school child and for involvement of the child's family in a community and school health program.1 Current Morbidity Current specific health problems of school-age children: — Infections and parasitic disease and proteincalorie malnutrition: These are the principal causes of mortality and morbidity in children. In Ghana, West Africa, for example, about 30% of all registered deaths are caused by preventable communicable disease; about 10% of these are attributed to malaria alone.7 The high prevalence of communicable disease and malnutrition are due to factors associated with ignorance and poverty. — Psychological and psychiatric problems: There are little data on the incidence and types of mental health problems in African children. Recent studies in Uganda, East Africa,8 indicate a considerable and increasing proportion of psychiatric referrals mostly from the medical and allied health services with only a small proportion from the schools, despite the large number of school children with intellectual and emotional problems. The presenting complaints couched in simple terms relating to physical diseases could be categorized in the majority of cases as organic disorders associated with such conditions as mental subnormality and hyperkinesis. However, emotional disorders constitute the single largest category. Some of the psychological disorders9 are associated with identifiable factors in the environment, and a correlation with poor school performance has been demonstrated. The most important mental health problem now recognized in secondary schools and colleges in West and East Africa is the so-called "Brain Fag Syndrome." 610 This is a psychosomatic disorder -with manifestations which militate against the student's ability to Environmental Child Health, August 1977
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of 2.4% per annum. Children under 15 years of age account for 45% of the population, and 75% of the population lives in rural areas.3 In Kenya, East Africa, the population is about 13 million with a rate of rise of about 3.3% per annum. Nearly 50% of the population are children below 15 years of age, and 90% of the population lives in rural areas.3 In many areas in these two countries, as in many other countries, a high proportion of the children in the age group 5-15 years attend school. With the present rate of population growth and with plans to expand education, it is apparent that the population of school children will increase. In this age group the mortality drops, but the morbidity is still high. In countries where estimates of childhood morbidity can be obtained from the hospitals, clinics and health centers, the needs of the children of school age become apparent. While the elementary school children (5-12 years) usually present with communicable disease, malnutrition and accidents, the secondary school group (12-19 years) are seen, often only occasionally, when they present with gross conditions such as: pulmonary tuberculosis, veneral disease, septic incomplete abortion or a chronic disease. The gross conditions are part of the iceberg phenomenon now known as "the eyes of the crocodile or the ears of the hippo." The problem is bigger than it first appears. On analysis, some of the causative factors may be amenable to preventive measures and health education.6 Thus it seems logical that a fair share of the community health services should be organized in cooperation with the schools.
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Environmental Child Health, August 1977
little conservative dentistry. The loss of school time due to dental disease is not measurable. The problem of malocclusion that could accompany the premature loss of deciduous teeth is important in a country where orthodontic treatment is not readily available. The emphasis should be on preventive dentistry and this underlines the need for dental health education.15 Adequate data on visual and auditory defects are not available. — Smoking: In many countries there is a lack of data on smoking habits. The habit appears to be related to improving socioeconomic status. It is also observed among students, particularly those in boarding schools and colleges who escape parental supervision. The health service of Makerere University College in Kampala found . it necessary to bring to students' attention the health hazards of smoking as stated in the Report of the Royal College of Physicians (1962) and the U.S. Surgeon General's Report (1964).16 Aims and objectives of school health in a developing country The main aim of the school health program will be to cater to the health needs of all school children. The services provided to accomplish this should emphasize:17 — Medical examination including: (1) evaluation of health problems with referrals, routine physical examination and continuous observation: (2) screening for health problems; and (3) health supervision of school personnel. — Prevention with: (1) control of communicable disease; (2) sanitation; (3) safety control; and (4) improvement of nutrition. — Treatment providing: (1) on-site facilities for first aid and minor ailments; and (2) an integrated community and school treatment plan. — Education incorporating: (1) specific school health education for children, parents, and teachers and health professionals; and (2) school medical records. The problems likely to be encountered in the delivery of community health programs, such as a school health program, in a developing country are listed in Table I.18 Table I Problems in delivery of community/school health • programs in developing countries18 1. Limited resources, including money, trained personnel and working facilities (buildings, equipment, data). 2. Inadequate utilization of available resources. 3. Maldistribution, overuse and/or underuse of health services. 4. Obstructing factors in the chain,pf health care delivery inherent in professional personnel's reluctance to 191
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study. These include intellectual impairment, sensory disturbances, chiefly visual, and somatic complaints most commonly of pain or disagreeable sensations chiefly involving the head, neck and eyes, less frequently the abdomen, and of fatigue and sleepiness. It • appears to occur in students put under stress by high expectations from parents and relatives, the school and community, all of whom put disproportionate emphasis on academic education and achievement. It appears that awareness of such mental health problems and needs of children is lacking on the part of the school personnel, and that this is further complicated by the apparent scarcity of words or phrases in local dialects to describe the issues.8 Management of these mental health cases certainly needs guidance from doctors and psychiatrists but much can be done in the schools and perhaps at an earlier state to prevent some of them. There is, therefore, a need to emphasize mental health education; to devise methods (example: questionnaire in local language) whereby school personnel could be utilized to recognize mental health problems and deal with some of them (and eventually to develop special educational and psychological services).6 8 ' — Neurological disorders. Epilepsy is an important and common problem and recently there have been several reports published about it in Africa. In the Baganda tribe of Uganda, East Africa, for example," it is believed that epilepsy is "catching" and that it leads to the "spoiling of the brain." An epileptic is therefore an outcast. Epilepsy in children can lead to educational deprivation. The child may have to eat, play, and sleep separately from others. He may not be allowed to attend school or to continue to attend school. Even if he continues to attend school, he eventually falls behind the class appropriate for his age due to poor school attendance and performance besides various other reasons, often financial. Educational deprivation is only one of a number of the psycho-social consequences suffered by epileptics due largely to the environmental attitude of teachers, parents, and the public. Education of teachers and parents can help to reduce the rejection, deprivation, and retardation associated with epilepsy. — Physical defects: Studies on the dental health status of children in Nigeria, West Africa and in Zambia, East Africa12 " w " indicate a high incidence of dental caries, periodontal disease, and orthodontic abnormalities as well as the prevalence of poor oral hygiene. Dental care services in the communities are inadequate and cases are often seen at their disastrous phase. Treatment frequently consists of extractions with
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5. 6. 7. 8. 9. 10.
Recommendations In view of the magnitude of the problems (Table I) and the paucity of resources, recommendations will be proposed first for immediate (short-term) measures; then long-term program activities. Short-term
The recommendations for immediate (short-term) measures: should aim at utilizing available resources to improve existing community and school health services or to introduce new ones. These services should emphasisz"e:4 " " 1. Control of communicable disease: a. Mass immunizations: These are usually recommended, a.mong children of school age, for tuberculosis, tetanus and smallpox; • however, there are situations where other immunizations may be required: measles, typhoid.6 Since the development of the multiple jet injector guns and the portable foot operated model (Ped-O-Jet) provided technical assistance in the smallpox eradication and measles control program especially in those countries in West and East Africa, mass immunization campaigns against these diseases and tetanus have become more practicable and less expensive.20 b. Chemoprophylaxis: In West African countries where malaria is endemic, there is a high mortality and morbidity rate, especially from "malignant falciparum" during the first five years of life. Beyond this age those who survive acquire a "malaria immunity" which breaks down under stresses such as concomitant infection and/or malnutrition.21 The antimalarial chemotherapy is only one aspect of the malaria eradication program. Other communicable diseases such as intestinal worms .and even minor diseases such as pediculosis, scabies, and ringworm may in some areas be a serious problem affecting school attendance and performance. Provision should be made for adequate treatment which may need to be given in the school itself." 192
Sanitation: Rural communities may be handicapped in environmental hygiene. However, in a small community the population is usually sufficiently interdependent to make it relatively easy to get volunteer help and cooperation in the construction of simple adequate facilities; and it is also feasible to encourage good hygienic practices.17 Safety control: An important cause of death among children is accidents, especially in school children through the excitement of group play and competition without any precautions of the risks and the contact with traffic. Despite safety control measures at the school and its environs, accidents may occur. Consequently there should be a plan for handling emergencies with on site facilities for first aid, and call of medical aid when indicated. But of fundamental importance is health education in safety and accident prevention.17 Improvement of nutrition: Increasing growth and development demand an increasing supply of calories and proteins. In many countries these demands are not met by the usual diets which are readily available and cheap, but often deficient. Social and cultural factors may make it difficult to change food attitudes. However, during adolescence attitudes may be changed because there is often a sense of exploration beyond the confines of the culture in which the child was socialized.6 A school meal service should be introduced. In order to be effective as a nutritional measure to improve growth and an educational measure to improve eating habits, it should be carefully planned. Its organization requires data on food production and consumption; food attitudes, traditions and customs; and social and economic conditions related to educational activities. In most countries the data required are inadequate. In these circumstances a general idea of the food situation could be gained from the food balance sheets prepared annually by most countries which show on a per capita basis the estimated available supplies of food. This information can frequently be supplemented by knowledge of dietary habits possessed by local workers. The operation of the school meal service will vary from country to country. It requires the co-operation and collaboration of the administrative agencies (Ministries of Health, Agriculture), the school personnel and the parents. Parents should be carefully informed of the nutritional and educational benefits of the school meal so that they do not neglect the child's meal at home to offset the benefits.22 The meal itself should preferably be cooked and served at school. However, under certain conditions, it could be bought in the school canteen or even brought packaged from home.19 Environmental Child Health, August 1977
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delegate responsibility to auxiliaries and their social distance with the rural population. Inadequate systems of transportation and communication. Illiteracy, ignorance and conservatism. Malnutrition, communicable disease, inadequate sanitation including poor sewage system, contamination of food and water, poor, overcrowded living conditions. High birth rate and high morbidity and mortality, especially in children. Barrier of language, local customs, traditions and superstitions. Poor cooperation and collaboration among workers in various agencies of the public and government.
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5.
It is unrealistic to expect that health education alone can improve the environmental conditions of living. For example, in the urban areas, when schoolchildren without boarding accommodation are away from home, they may share lodgings with friends in the slum areas and may be exposed to smoking, drinking, violence, theft and prostitution. In the rural areas, Environmental Child Health, August 1977
when they share lodgings with parents or relatives, they may be exposed to excessive manual labor in fetching water, firewood and in cultivating. These and other unfavorable environmental conditions of living have unhealthy repercussions on school attendance and performance. Their improvement will depend on factors such as social and economic development. Long-term The recommendations for long-term program activities: Should aim at the establishment of the school health program as an integral part of the comprehensive community or child health program. The services should emphasize:17 1. Evaluation of health problems, incorporating: a. Referrals by nurse, teacher, parent or child: Referred cases could include: learning problems, behavior problems, neurologic disorders, physical, handicaps, drugs (smoking), venereal disease, unwanted pregnancies, etc. b. Routine physical examination by a nurse at least on admission and on discharge from both primary and secondary school. c. Continuous observation of the school child by the teacher trained to detect certain health problems. 2. Screening for health problems including: a. Visual and auditory defects, dental disease. b. Simple laboratory test with: Blood specimens for parasites, anemia, hemoglobinopathy; urine specimens for infection, protein; stool specimens for parasites. c. Chest X-ray in some cases. d. Skin test for tuberculosis. 3. Treatment procedures should be integrated with the community or child health program. 4. Health supervision of personnel in contact with school children (teachers, food servers, bus drivers, etc.): to ensure the maximum health of the school personnel and to protect the health of the school children. 5. School health records: Should be designed for easy coding and analysis. They should be carefully maintained, containing cumulative data relative to the health status of each child which should remain confidential. They could be of value not only in helping the school child to obtain and maintain maximum health, but also in guiding the school child into the vocation for which he is most suited. 6. School health education: Should be an important part, of the general education and a vital means of health promotion of school children. It should also be an integral part of general community health education so that parents may learn along with their children. A school health education conTmittee should be set • up to advise on school curriculum. 193
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Improvement of school health education should incorporate: a. Health instruction for school children: This should be woven into the teaching of all subjects, linked with their everyday living needs and experiences, and related to their economic social and cultural environment. The school's daily program should be planned taking into account the needs for optimal growth and development and in close co-operation with the home. The emotional climate of the class should be improved with wise administration of tests, grades and promotions, permissiveness of class procedures and personal warmth of the teacher.17 b. Health training for teachers: Teachers affect the health of the school child. They are partly responsible for the success or failure of the school health program. It is necessary that they understand the importance of the school health program as an integral part of the total educational program. Consequently, a preparation in health, including health education, must be a part of their training both in teacher's education institutes and during service.23 c. A handbook on school health practices and policies: should be prepared to suit the needs of the community for use by school teachers "and health workers. It should be subjected to constant revision as new information and ideas become available.17 d. Health guidance: The best health guidance is that given by the physician or nurse when they discuss with the school personnel and the schoolchild his type of health problem to help him understand it and what he can do to alleviate it. This is best carried out when the student himself, armed with awareness and understanding of his health problem, seeks help in a consultation with the physician or nurse.23 e. Establishment of association for teachers/ parents/household heads: This is important, not only to improve school health by advising on the health needs and their mode of delivery, but also to help to extend health education into the home by making them aware of its role in improving the health of the family and their environment at conditions of living.
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The responsibility of organizing should be assigned to a team working with an expert and involving: (Figure 1) 1. The schools of health including the medical school (departments of pediatrics, preventive and social medicine), the nursing school, the school of allied health sciences. 2. The community health services (hospitals, clinics). 3 The administrative agencies of the government including the ministries of health, education, social welfare, and agriculture. The team should work in. close co-operation to use the limited resources to provide adequate, effective health service. Objectives should be set to cover the whole program with priorities and targets and possible expansions in all regions with emphasis in the rural areas. The details of the model of the community and school health program should be based on the needs and resources of the community, and will therefore vary from one country to another. The successful implementation of the planning: will depend on the involvement and participation of the administrative agencies and the community itself from its inception and at all levels of its evolution.7 24 The administrative agencies should be implicated in the plan through consultation, collaboration and cooperation. The community itself should be involved with the plan through (1) education: propagation and discussion of the aims and objectives of the plan in local and public places including schools, local clubs, 194
voluntary organizations, party offices, parliament and in the newspapers, radio and television; and (2) example setting: organization and successful implementation of some other health project. The health services should be implemented through the training and utilization of health personnel and the delivery of health care.
Figure 1 Organization of Health Care
ADMINISTRATION OF THE GOVERNMENT Ministries of Heolth I Education
I
Social Welfare I
Agriculture
SCHOOL OF HEALTH Medicine
COMMUNITY Hospitals
I
I Nursing
I Allied Health Sciences
| . SCHOOL HEALTH SERVICES
Health Centers I
Clinics
I
Dispensaries
Training and utilization of health personnel: in view of the general. shortage of professional health personnel, reliance will have to be placed on large numbers of auxiliaries.5 The term applied to the health auxiliary has not been the same throughout the world, i.e., physician auxiliary, medical auxiliary, health center superintendent, etc. According to the definition accepted by all United Nations agencies, an auxiliary worker is: "a paid worker in a particular field with less than full professional qualifications in that field, who assists and is supervised by a professional worker."26 Although there is a need for health auxiliaries, their training and utilization will differ from one country to another, depending on the health problems, the health service, the influence of the professional organization, and the educational, economic, social and cultural development of the individual country. In developing countries there should be schemes for training and utilization of adequate numbers of health auxiliaries of all types — multidisciplinary and unidisciplinary — selected for training from areas where they will ultimately be posted to work.27 Delivery of health care. The ideal should be to provide each child of school age with adequate health service as close to his home as possible by the health team and referral Environmental Child Health, August 1977
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Long-term planning of the community and school health program in a developing country It is necessary when planning the overall economic development of a country to include adequate assignment of resources to the health sector. Planning should be a process of many co-ordinated parts and shoQld include: A preliminary survey of the health needs and the available resources including existing health services, and the administrative patterns:24 2S The needs of the population expressed by the experts may not be the same as the wants expressed by the people themselves. Neither should be ignored and a balance should be worked out. In most countries the needs are largely in preventive and social medicine and health education. However, the emphasis has largely been on curative medicine. This emphasis should be reoriented so that the health personnel could see themselves as part of a great effort which extends far beyond the confines of the hospital into the schools and the homes. The country can only have the health care it can afford to pay for. However, even under the most limited resources, a start can be made and the general principles guiding the program will continue to apply as resources improve. It is essential to know and accept the political philosophy in which the planning will be formulated and operated. In Ghana, for example, it is stated that the ultimate aim of the health service should be socialized medicine.
TORIK BOUHAIRIE AND PHILIP R. NADER
approach. In the urban area the service should be organized at four levels; the school dispensary; the school clinic serving a group of neighborhood schools, preferably in one of the big schools or outside the school; the special school clinic in the community health center; and the hospital. (Figure 2) Figure 2 Delivery of Health Care
Environmental Child Health, August 1977
Summary and conclusions The school health program operated as an integral part of the community health or child health program rather than a separate program offers great advantages, which are essentially money saving and continuity of care. • Cooperation and collaboration between the various administrative and community agencies should help to avoid the operation of separate individual health programs. The program based on the needs and resources of the community should make provision for alternate projects according to the costbenefit analysis. Successful implementation depends 195
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In the rural area trie service should also be organized at four levels: the school dispensary; the local dispensary serving a group of neighborhood schools, preferably in one big school; the special school clinic in the community health center in the nearest town; and the hospital in the nearest town or district. (Figure 2)" At the school dispensary the service should consist essentially of first aid administered by a trained teacher. At the urban school clinic and the rural local dispensary the service should be run by a trained (school) auxiliary aided by a trained teacher and under the supervision of a (school) nurse. At the special school clinic in the community health center the service should be run by a (school) nurse aided by •(school) auxiliary in close co-operation with public/community nurses and under the supervision of a (school) physician. Periodic evaluation, both formative and summative, should include: appraisal of the organization of the plan, its aims and objectives, its priorities and targets; appraisal of the evaluation procedure itself; appraisal of the developmental changes and research; and appraisal of the cost-benefit aspects. Although evaluation is a difficult process, perhaps one effective approach will be the preparation of periodic "Activity Reports". Development of the plan should be effected by adjustment and changes in the plan based on information resulting from the evaluations and research . in order to better meet the needs of the population.
Research should be selective and effective. It should primarily be applied research secondary to service, and the findings should be made available quickly for feedback. The schools of health should investigate the possibility of helping collect basic and reliable data designed for easy coding and analysis. There should be technical co-operation with an external advisory group, from both the developed countries and some relatively advanced developing countries with similar health problems. Their function should be that of assistance with the planning, its implementation and evaluation, and the development of training and research programs geared to the needs and resources of the community. There needs to be consideration of the health problems of children of school age who do not attend school. In many developing countries schooling is not compulsory nor is it free. School fees, though small by other standards, are a major cash demand on the meager resources of parents, -especially those with larger families. Though there is widespread eagerness to find the money for education, a significant proportion of children in many areas do not attend school or are unable to continue school. Besides this economic factor, there are also socio-cultural factors limiting school education, especially in children with certain health problems. Parents may not be prepared to "waste" money to educate such "problem" children. Teachers may be under pressure from parents of "healthy" children to remove "problem" children from class. Eventually "problem" children may drop out of class due to poor attendance and performance. Much improvement in health will be achieved by social and economic growth. However, investment in health is in the final analysis an improvement in the individual contribution to the economic growth, and the key factor is health education. What is needed, therefore, is a reorganization of the community health services existing in the.urban and rural areas, considering health in its broadest sense and the development of a comprehensive child health program with a school health program as its integral part. Then, having established the usefulness of such a program (and considering the cost-benefit ratio), it will be replicated in other parts of the country and eventually extended to children of school age who do not attend school.
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References 1. Nader, P. R. and Wright, G. F. 1973. Hosp. Practice, 8, 11 (editorial). 2. Ofosu-Amaah, S. 1967. Ghana Med.J., 6,51-52.
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3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27.
Oduori, M. L. 1973. E. Afr. Med. J., 50,546-550. Oduntan.S.O. 1973. Nigerian Med. J., 3,116-119. Boohene, A. G. 1971. Ghana Med. J., 3,295. Bennett, F. J. 1974. Trop. Geogr. Med., 26,96-98. Sai, F.T. 1972. Ghana Med.J. 11,11. Muhangi, J. and German, G. A. 1975. E. Afr. Med. J., 52,455-461. Minde, K. K. 1975.7. Child Psycho!. Psychiatry, 16,4959. Prince, R. 1962. IV. Afr. Med. J., 11,198-206. Tamale-Ssali, E. G. and Billinghurs, J. R. 1971. E.Afr. Med.J. 49,406-410. Sims, P. 1973. E. Afr. Med. J., 50,140-145. Henshaw.N. E. 1974. Nigerian Med. J., 4,185-196. Henshaw, N. E. and Adenubi, J. O. 1975. Nigerian Med.J., 5,152-159. Adenubi, J. O. 1974. Nigerian Med. J., 4,251-255. Arya, O. P. and Bennett, F. J. 1970. E. Afr. Med. J. 47, 18-28. Wld. HIth. Org. Techn. Rep. Ser. 1951.30,3-36. Bryant, J. H. 1969. Health and the Developing World. Rockefeller Foundation, Cornell University Press, Ithaca and London. Jellifle, D. B. 1967.7. Trop. Pediat. Emir. Child HIth., 13, 1-3. Oyediran, A. B. O. and Lucas, A. O. 1971. W. Afr. Med.J., 20,237-239. Lantun, D. N. 1971. W. Afr. Med. J., 20,286. Scott, M. L. 1958.7. Trop. Pediat., 3, 171-174. Johns, E. B. 1973. Wild Med.J., 20,87-90. Sai, F. T. 1965. Ghana Med. J., 4, 108-112. Sai, F. T. 1966. Ghana Med.J., 5,148-155. Wld. HIth. Org. Techn. Rep. Ser. 1968.385,6. Otoo, S. N. 1970. Ghana Med. J., 9,58-63.
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on the involvement and participation of the administrative agencies, the schools of health, community health services and community members. The emphasis should not be so much doing something for the community, as doing something with the community with the aim of inducing a behavioral change. Accordingly, in selecting pilot communities for the program, certain criteria should serve as guidelines; close proximity of the schools of health and the health centers; evidence of already existing local development groups and self-help projects supported by various government and private agencies, and other indications of adequate interest and motivation in the population; and existence of a common kinship, cultural and traditional bondage. And, as a useful adjunct to the schools of health and the health centers, the program could also serve to acquaint the health team with the population and its health problems and the resources available for selective and effective use, as well as the opportunity for them to appreciate the contribution which all members of the health team can make to total health care.
An Approach to School Health in a Developing Country
Introduction Children represent the richest resource of any country. They need an environment which prepares them for optimal growth and development and to understand and meet their own needs as well as those of the community. One important aspect of these needs is health. The responsibility of preparing children to meet health problems is shared by the home, the community and the school through medicine and education. School health is where medicine and education meet; yet today medicine and education tend to have little to do with each other.1 In most African countries little effort has been made to organize school health programs. This paper attempts to stimulate interest in these programs. It defines school health, traces particular aspects of its past history and current status in West and East Africa, and considers its needs. It proposes aims and objectives of a comprehensive school health program, recommendations for its establishment and a plan for its operation.
1
Definition A school health program is included in a system of curative and preventive ' health services in a community. School health is designed to cater to the health needs and problems of the school age child. Such needs and problems vary from one developing country to another and in urban and rural areas. Community and school health programs in West and East Africa Beginnings: In Ghana, West Africa, the first formal attempt to protect the health of children led to the appointment of a school medical officer by the Department of Health in the 1920s.2 In Kenya, East Africa, the Ministry of Health organized child health activities in Nairobi in the 1920s. It was not until the 1950s that determined efforts at organizing child health services on a countrywide basis were made with the introduction of the concept of a health center for developing countries as a nucleus for providing Environmental Child Health, August 1977
primary health care.3 Thus, in these two countries, the school health program began as an integral part of a community health program. Current Status: In Nigeria, West Africa, one model of a school health program instituted in Lagos is the most highly developed in the country and probably in most of West and East Africa. Beginning as a small school clinic the program has grown steadily and has established satellite centers. Special school health programs have also been organized and developed in other Nigerian cities and large towns. There is usually a school clinic which treats minor ailments and provides a periodic medical examination. These services are mostly administered by nurses or various health auxiliaries working under the supervision of medical officers of health.4 By contrast, in other countries, especially in the rural areas, school children receive medical care at dispensaries, hospitals and health centers, but there is usually no organized school health program. This is due partly to a general shortage of trained personnel. The doctors, consisting of general practitioners and very few specialists, are mostly employed in government services which are usually free of charge; and there is no organized supporting private practitioner service. The rest of the health team consists of: (1) physician/medical assistant who is the leader of the team working under the supervision of the doctor; (2) public and/or community health nurses, midwives; (3) sanitarians, health inspectors, etc. The need for a community and school health program in a developing country A program for the health of school children deserved special consideration for at least four reasons: population characteristics, growth and development, community health resources, and current morbidity. Population Characteristics The increasing proportion of school children and the high rate of morbidity: In Gliana, West Africa, the population, which is 8.5 million, is growing at the rate 189
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by TORIK BOUHAIRIE, M.D. (Paris), LMCC (Montreal) Fellow, Ambulatory Pediatrics and PHILIP R. NADER, M.D., FAAP Associate Professor of Pediatrics and Psychiatry Director, School Health Programs, Department of Pediatrics The University of Texas Medical Branch, Galveston, Texas 77550, U.SA. Supported in part by a grant No. 622, from The Robert Wood Johnson Foundation
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Growth and Development The necessity of obtaining optimum growth and development despite the problems inherent in the growth process and/or the school process: Children are constantly undergoing change in growth and development: physical, mental, emotional and social. The process of growth and development itself often causes problems, especially at adolescence and puberty. The educational institutions also influence growth and development by different processes: — Opportunities for health education along with learning — Learning disabilities (disorder in one or more of the basic psychological processes involved in understanding or in using language) and learning problems (resulting from visual, hearing or motor handicaps, mental retardation, emotional disturbance or environmental disadvantage). — Risk of communicable disease in group contacts. — Accidents sustained in sports, play and contact with traffic. The school represents .the optimal milieu for observation of the child's growth and development and for cooperation in a community health program.1 Preventive measures and health education undertaken during the period of growth and development while the child attends school may have a beneficial lifelong effect in many of the problems. 190
Community Health Resources The inadequacy of community health centers to meet the health needs of school children: Despite the difficulties inherent in the collection of reliable data, available estimates from hospitals and health centers indicate that children of school age constitute a high proportion of the patients. The health centers are not evenly distributed throughout the country. Even so, where they exist, distance, lack of adequate transportation and communication, the expense of travel, and traditional (superstitious) belief and attitudes limit their utilization. Some of the cases may be reported to the local "medicine man" and may never reach the health center or may only be reported to the health center at a later stage. In areas where health centers are utilized they are usually inadequately staffed and equipped and often overcrowded. The school represents the site for effective contact with the school child and for involvement of the child's family in a community and school health program.1 Current Morbidity Current specific health problems of school-age children: — Infections and parasitic disease and proteincalorie malnutrition: These are the principal causes of mortality and morbidity in children. In Ghana, West Africa, for example, about 30% of all registered deaths are caused by preventable communicable disease; about 10% of these are attributed to malaria alone.7 The high prevalence of communicable disease and malnutrition are due to factors associated with ignorance and poverty. — Psychological and psychiatric problems: There are little data on the incidence and types of mental health problems in African children. Recent studies in Uganda, East Africa,8 indicate a considerable and increasing proportion of psychiatric referrals mostly from the medical and allied health services with only a small proportion from the schools, despite the large number of school children with intellectual and emotional problems. The presenting complaints couched in simple terms relating to physical diseases could be categorized in the majority of cases as organic disorders associated with such conditions as mental subnormality and hyperkinesis. However, emotional disorders constitute the single largest category. Some of the psychological disorders9 are associated with identifiable factors in the environment, and a correlation with poor school performance has been demonstrated. The most important mental health problem now recognized in secondary schools and colleges in West and East Africa is the so-called "Brain Fag Syndrome." 610 This is a psychosomatic disorder -with manifestations which militate against the student's ability to Environmental Child Health, August 1977
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of 2.4% per annum. Children under 15 years of age account for 45% of the population, and 75% of the population lives in rural areas.3 In Kenya, East Africa, the population is about 13 million with a rate of rise of about 3.3% per annum. Nearly 50% of the population are children below 15 years of age, and 90% of the population lives in rural areas.3 In many areas in these two countries, as in many other countries, a high proportion of the children in the age group 5-15 years attend school. With the present rate of population growth and with plans to expand education, it is apparent that the population of school children will increase. In this age group the mortality drops, but the morbidity is still high. In countries where estimates of childhood morbidity can be obtained from the hospitals, clinics and health centers, the needs of the children of school age become apparent. While the elementary school children (5-12 years) usually present with communicable disease, malnutrition and accidents, the secondary school group (12-19 years) are seen, often only occasionally, when they present with gross conditions such as: pulmonary tuberculosis, veneral disease, septic incomplete abortion or a chronic disease. The gross conditions are part of the iceberg phenomenon now known as "the eyes of the crocodile or the ears of the hippo." The problem is bigger than it first appears. On analysis, some of the causative factors may be amenable to preventive measures and health education.6 Thus it seems logical that a fair share of the community health services should be organized in cooperation with the schools.
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little conservative dentistry. The loss of school time due to dental disease is not measurable. The problem of malocclusion that could accompany the premature loss of deciduous teeth is important in a country where orthodontic treatment is not readily available. The emphasis should be on preventive dentistry and this underlines the need for dental health education.15 Adequate data on visual and auditory defects are not available. — Smoking: In many countries there is a lack of data on smoking habits. The habit appears to be related to improving socioeconomic status. It is also observed among students, particularly those in boarding schools and colleges who escape parental supervision. The health service of Makerere University College in Kampala found . it necessary to bring to students' attention the health hazards of smoking as stated in the Report of the Royal College of Physicians (1962) and the U.S. Surgeon General's Report (1964).16 Aims and objectives of school health in a developing country The main aim of the school health program will be to cater to the health needs of all school children. The services provided to accomplish this should emphasize:17 — Medical examination including: (1) evaluation of health problems with referrals, routine physical examination and continuous observation: (2) screening for health problems; and (3) health supervision of school personnel. — Prevention with: (1) control of communicable disease; (2) sanitation; (3) safety control; and (4) improvement of nutrition. — Treatment providing: (1) on-site facilities for first aid and minor ailments; and (2) an integrated community and school treatment plan. — Education incorporating: (1) specific school health education for children, parents, and teachers and health professionals; and (2) school medical records. The problems likely to be encountered in the delivery of community health programs, such as a school health program, in a developing country are listed in Table I.18 Table I Problems in delivery of community/school health • programs in developing countries18 1. Limited resources, including money, trained personnel and working facilities (buildings, equipment, data). 2. Inadequate utilization of available resources. 3. Maldistribution, overuse and/or underuse of health services. 4. Obstructing factors in the chain,pf health care delivery inherent in professional personnel's reluctance to 191
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study. These include intellectual impairment, sensory disturbances, chiefly visual, and somatic complaints most commonly of pain or disagreeable sensations chiefly involving the head, neck and eyes, less frequently the abdomen, and of fatigue and sleepiness. It • appears to occur in students put under stress by high expectations from parents and relatives, the school and community, all of whom put disproportionate emphasis on academic education and achievement. It appears that awareness of such mental health problems and needs of children is lacking on the part of the school personnel, and that this is further complicated by the apparent scarcity of words or phrases in local dialects to describe the issues.8 Management of these mental health cases certainly needs guidance from doctors and psychiatrists but much can be done in the schools and perhaps at an earlier state to prevent some of them. There is, therefore, a need to emphasize mental health education; to devise methods (example: questionnaire in local language) whereby school personnel could be utilized to recognize mental health problems and deal with some of them (and eventually to develop special educational and psychological services).6 8 ' — Neurological disorders. Epilepsy is an important and common problem and recently there have been several reports published about it in Africa. In the Baganda tribe of Uganda, East Africa, for example," it is believed that epilepsy is "catching" and that it leads to the "spoiling of the brain." An epileptic is therefore an outcast. Epilepsy in children can lead to educational deprivation. The child may have to eat, play, and sleep separately from others. He may not be allowed to attend school or to continue to attend school. Even if he continues to attend school, he eventually falls behind the class appropriate for his age due to poor school attendance and performance besides various other reasons, often financial. Educational deprivation is only one of a number of the psycho-social consequences suffered by epileptics due largely to the environmental attitude of teachers, parents, and the public. Education of teachers and parents can help to reduce the rejection, deprivation, and retardation associated with epilepsy. — Physical defects: Studies on the dental health status of children in Nigeria, West Africa and in Zambia, East Africa12 " w " indicate a high incidence of dental caries, periodontal disease, and orthodontic abnormalities as well as the prevalence of poor oral hygiene. Dental care services in the communities are inadequate and cases are often seen at their disastrous phase. Treatment frequently consists of extractions with
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5. 6. 7. 8. 9. 10.
Recommendations In view of the magnitude of the problems (Table I) and the paucity of resources, recommendations will be proposed first for immediate (short-term) measures; then long-term program activities. Short-term
The recommendations for immediate (short-term) measures: should aim at utilizing available resources to improve existing community and school health services or to introduce new ones. These services should emphasisz"e:4 " " 1. Control of communicable disease: a. Mass immunizations: These are usually recommended, a.mong children of school age, for tuberculosis, tetanus and smallpox; • however, there are situations where other immunizations may be required: measles, typhoid.6 Since the development of the multiple jet injector guns and the portable foot operated model (Ped-O-Jet) provided technical assistance in the smallpox eradication and measles control program especially in those countries in West and East Africa, mass immunization campaigns against these diseases and tetanus have become more practicable and less expensive.20 b. Chemoprophylaxis: In West African countries where malaria is endemic, there is a high mortality and morbidity rate, especially from "malignant falciparum" during the first five years of life. Beyond this age those who survive acquire a "malaria immunity" which breaks down under stresses such as concomitant infection and/or malnutrition.21 The antimalarial chemotherapy is only one aspect of the malaria eradication program. Other communicable diseases such as intestinal worms .and even minor diseases such as pediculosis, scabies, and ringworm may in some areas be a serious problem affecting school attendance and performance. Provision should be made for adequate treatment which may need to be given in the school itself." 192
Sanitation: Rural communities may be handicapped in environmental hygiene. However, in a small community the population is usually sufficiently interdependent to make it relatively easy to get volunteer help and cooperation in the construction of simple adequate facilities; and it is also feasible to encourage good hygienic practices.17 Safety control: An important cause of death among children is accidents, especially in school children through the excitement of group play and competition without any precautions of the risks and the contact with traffic. Despite safety control measures at the school and its environs, accidents may occur. Consequently there should be a plan for handling emergencies with on site facilities for first aid, and call of medical aid when indicated. But of fundamental importance is health education in safety and accident prevention.17 Improvement of nutrition: Increasing growth and development demand an increasing supply of calories and proteins. In many countries these demands are not met by the usual diets which are readily available and cheap, but often deficient. Social and cultural factors may make it difficult to change food attitudes. However, during adolescence attitudes may be changed because there is often a sense of exploration beyond the confines of the culture in which the child was socialized.6 A school meal service should be introduced. In order to be effective as a nutritional measure to improve growth and an educational measure to improve eating habits, it should be carefully planned. Its organization requires data on food production and consumption; food attitudes, traditions and customs; and social and economic conditions related to educational activities. In most countries the data required are inadequate. In these circumstances a general idea of the food situation could be gained from the food balance sheets prepared annually by most countries which show on a per capita basis the estimated available supplies of food. This information can frequently be supplemented by knowledge of dietary habits possessed by local workers. The operation of the school meal service will vary from country to country. It requires the co-operation and collaboration of the administrative agencies (Ministries of Health, Agriculture), the school personnel and the parents. Parents should be carefully informed of the nutritional and educational benefits of the school meal so that they do not neglect the child's meal at home to offset the benefits.22 The meal itself should preferably be cooked and served at school. However, under certain conditions, it could be bought in the school canteen or even brought packaged from home.19 Environmental Child Health, August 1977
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delegate responsibility to auxiliaries and their social distance with the rural population. Inadequate systems of transportation and communication. Illiteracy, ignorance and conservatism. Malnutrition, communicable disease, inadequate sanitation including poor sewage system, contamination of food and water, poor, overcrowded living conditions. High birth rate and high morbidity and mortality, especially in children. Barrier of language, local customs, traditions and superstitions. Poor cooperation and collaboration among workers in various agencies of the public and government.
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5.
It is unrealistic to expect that health education alone can improve the environmental conditions of living. For example, in the urban areas, when schoolchildren without boarding accommodation are away from home, they may share lodgings with friends in the slum areas and may be exposed to smoking, drinking, violence, theft and prostitution. In the rural areas, Environmental Child Health, August 1977
when they share lodgings with parents or relatives, they may be exposed to excessive manual labor in fetching water, firewood and in cultivating. These and other unfavorable environmental conditions of living have unhealthy repercussions on school attendance and performance. Their improvement will depend on factors such as social and economic development. Long-term The recommendations for long-term program activities: Should aim at the establishment of the school health program as an integral part of the comprehensive community or child health program. The services should emphasize:17 1. Evaluation of health problems, incorporating: a. Referrals by nurse, teacher, parent or child: Referred cases could include: learning problems, behavior problems, neurologic disorders, physical, handicaps, drugs (smoking), venereal disease, unwanted pregnancies, etc. b. Routine physical examination by a nurse at least on admission and on discharge from both primary and secondary school. c. Continuous observation of the school child by the teacher trained to detect certain health problems. 2. Screening for health problems including: a. Visual and auditory defects, dental disease. b. Simple laboratory test with: Blood specimens for parasites, anemia, hemoglobinopathy; urine specimens for infection, protein; stool specimens for parasites. c. Chest X-ray in some cases. d. Skin test for tuberculosis. 3. Treatment procedures should be integrated with the community or child health program. 4. Health supervision of personnel in contact with school children (teachers, food servers, bus drivers, etc.): to ensure the maximum health of the school personnel and to protect the health of the school children. 5. School health records: Should be designed for easy coding and analysis. They should be carefully maintained, containing cumulative data relative to the health status of each child which should remain confidential. They could be of value not only in helping the school child to obtain and maintain maximum health, but also in guiding the school child into the vocation for which he is most suited. 6. School health education: Should be an important part, of the general education and a vital means of health promotion of school children. It should also be an integral part of general community health education so that parents may learn along with their children. A school health education conTmittee should be set • up to advise on school curriculum. 193
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Improvement of school health education should incorporate: a. Health instruction for school children: This should be woven into the teaching of all subjects, linked with their everyday living needs and experiences, and related to their economic social and cultural environment. The school's daily program should be planned taking into account the needs for optimal growth and development and in close co-operation with the home. The emotional climate of the class should be improved with wise administration of tests, grades and promotions, permissiveness of class procedures and personal warmth of the teacher.17 b. Health training for teachers: Teachers affect the health of the school child. They are partly responsible for the success or failure of the school health program. It is necessary that they understand the importance of the school health program as an integral part of the total educational program. Consequently, a preparation in health, including health education, must be a part of their training both in teacher's education institutes and during service.23 c. A handbook on school health practices and policies: should be prepared to suit the needs of the community for use by school teachers "and health workers. It should be subjected to constant revision as new information and ideas become available.17 d. Health guidance: The best health guidance is that given by the physician or nurse when they discuss with the school personnel and the schoolchild his type of health problem to help him understand it and what he can do to alleviate it. This is best carried out when the student himself, armed with awareness and understanding of his health problem, seeks help in a consultation with the physician or nurse.23 e. Establishment of association for teachers/ parents/household heads: This is important, not only to improve school health by advising on the health needs and their mode of delivery, but also to help to extend health education into the home by making them aware of its role in improving the health of the family and their environment at conditions of living.
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The responsibility of organizing should be assigned to a team working with an expert and involving: (Figure 1) 1. The schools of health including the medical school (departments of pediatrics, preventive and social medicine), the nursing school, the school of allied health sciences. 2. The community health services (hospitals, clinics). 3 The administrative agencies of the government including the ministries of health, education, social welfare, and agriculture. The team should work in. close co-operation to use the limited resources to provide adequate, effective health service. Objectives should be set to cover the whole program with priorities and targets and possible expansions in all regions with emphasis in the rural areas. The details of the model of the community and school health program should be based on the needs and resources of the community, and will therefore vary from one country to another. The successful implementation of the planning: will depend on the involvement and participation of the administrative agencies and the community itself from its inception and at all levels of its evolution.7 24 The administrative agencies should be implicated in the plan through consultation, collaboration and cooperation. The community itself should be involved with the plan through (1) education: propagation and discussion of the aims and objectives of the plan in local and public places including schools, local clubs, 194
voluntary organizations, party offices, parliament and in the newspapers, radio and television; and (2) example setting: organization and successful implementation of some other health project. The health services should be implemented through the training and utilization of health personnel and the delivery of health care.
Figure 1 Organization of Health Care
ADMINISTRATION OF THE GOVERNMENT Ministries of Heolth I Education
I
Social Welfare I
Agriculture
SCHOOL OF HEALTH Medicine
COMMUNITY Hospitals
I
I Nursing
I Allied Health Sciences
| . SCHOOL HEALTH SERVICES
Health Centers I
Clinics
I
Dispensaries
Training and utilization of health personnel: in view of the general. shortage of professional health personnel, reliance will have to be placed on large numbers of auxiliaries.5 The term applied to the health auxiliary has not been the same throughout the world, i.e., physician auxiliary, medical auxiliary, health center superintendent, etc. According to the definition accepted by all United Nations agencies, an auxiliary worker is: "a paid worker in a particular field with less than full professional qualifications in that field, who assists and is supervised by a professional worker."26 Although there is a need for health auxiliaries, their training and utilization will differ from one country to another, depending on the health problems, the health service, the influence of the professional organization, and the educational, economic, social and cultural development of the individual country. In developing countries there should be schemes for training and utilization of adequate numbers of health auxiliaries of all types — multidisciplinary and unidisciplinary — selected for training from areas where they will ultimately be posted to work.27 Delivery of health care. The ideal should be to provide each child of school age with adequate health service as close to his home as possible by the health team and referral Environmental Child Health, August 1977
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Long-term planning of the community and school health program in a developing country It is necessary when planning the overall economic development of a country to include adequate assignment of resources to the health sector. Planning should be a process of many co-ordinated parts and shoQld include: A preliminary survey of the health needs and the available resources including existing health services, and the administrative patterns:24 2S The needs of the population expressed by the experts may not be the same as the wants expressed by the people themselves. Neither should be ignored and a balance should be worked out. In most countries the needs are largely in preventive and social medicine and health education. However, the emphasis has largely been on curative medicine. This emphasis should be reoriented so that the health personnel could see themselves as part of a great effort which extends far beyond the confines of the hospital into the schools and the homes. The country can only have the health care it can afford to pay for. However, even under the most limited resources, a start can be made and the general principles guiding the program will continue to apply as resources improve. It is essential to know and accept the political philosophy in which the planning will be formulated and operated. In Ghana, for example, it is stated that the ultimate aim of the health service should be socialized medicine.
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approach. In the urban area the service should be organized at four levels; the school dispensary; the school clinic serving a group of neighborhood schools, preferably in one of the big schools or outside the school; the special school clinic in the community health center; and the hospital. (Figure 2) Figure 2 Delivery of Health Care
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Summary and conclusions The school health program operated as an integral part of the community health or child health program rather than a separate program offers great advantages, which are essentially money saving and continuity of care. • Cooperation and collaboration between the various administrative and community agencies should help to avoid the operation of separate individual health programs. The program based on the needs and resources of the community should make provision for alternate projects according to the costbenefit analysis. Successful implementation depends 195
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In the rural area trie service should also be organized at four levels: the school dispensary; the local dispensary serving a group of neighborhood schools, preferably in one big school; the special school clinic in the community health center in the nearest town; and the hospital in the nearest town or district. (Figure 2)" At the school dispensary the service should consist essentially of first aid administered by a trained teacher. At the urban school clinic and the rural local dispensary the service should be run by a trained (school) auxiliary aided by a trained teacher and under the supervision of a (school) nurse. At the special school clinic in the community health center the service should be run by a (school) nurse aided by •(school) auxiliary in close co-operation with public/community nurses and under the supervision of a (school) physician. Periodic evaluation, both formative and summative, should include: appraisal of the organization of the plan, its aims and objectives, its priorities and targets; appraisal of the evaluation procedure itself; appraisal of the developmental changes and research; and appraisal of the cost-benefit aspects. Although evaluation is a difficult process, perhaps one effective approach will be the preparation of periodic "Activity Reports". Development of the plan should be effected by adjustment and changes in the plan based on information resulting from the evaluations and research . in order to better meet the needs of the population.
Research should be selective and effective. It should primarily be applied research secondary to service, and the findings should be made available quickly for feedback. The schools of health should investigate the possibility of helping collect basic and reliable data designed for easy coding and analysis. There should be technical co-operation with an external advisory group, from both the developed countries and some relatively advanced developing countries with similar health problems. Their function should be that of assistance with the planning, its implementation and evaluation, and the development of training and research programs geared to the needs and resources of the community. There needs to be consideration of the health problems of children of school age who do not attend school. In many developing countries schooling is not compulsory nor is it free. School fees, though small by other standards, are a major cash demand on the meager resources of parents, -especially those with larger families. Though there is widespread eagerness to find the money for education, a significant proportion of children in many areas do not attend school or are unable to continue school. Besides this economic factor, there are also socio-cultural factors limiting school education, especially in children with certain health problems. Parents may not be prepared to "waste" money to educate such "problem" children. Teachers may be under pressure from parents of "healthy" children to remove "problem" children from class. Eventually "problem" children may drop out of class due to poor attendance and performance. Much improvement in health will be achieved by social and economic growth. However, investment in health is in the final analysis an improvement in the individual contribution to the economic growth, and the key factor is health education. What is needed, therefore, is a reorganization of the community health services existing in the.urban and rural areas, considering health in its broadest sense and the development of a comprehensive child health program with a school health program as its integral part. Then, having established the usefulness of such a program (and considering the cost-benefit ratio), it will be replicated in other parts of the country and eventually extended to children of school age who do not attend school.
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References 1. Nader, P. R. and Wright, G. F. 1973. Hosp. Practice, 8, 11 (editorial). 2. Ofosu-Amaah, S. 1967. Ghana Med.J., 6,51-52.
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3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27.
Oduori, M. L. 1973. E. Afr. Med. J., 50,546-550. Oduntan.S.O. 1973. Nigerian Med. J., 3,116-119. Boohene, A. G. 1971. Ghana Med. J., 3,295. Bennett, F. J. 1974. Trop. Geogr. Med., 26,96-98. Sai, F.T. 1972. Ghana Med.J. 11,11. Muhangi, J. and German, G. A. 1975. E. Afr. Med. J., 52,455-461. Minde, K. K. 1975.7. Child Psycho!. Psychiatry, 16,4959. Prince, R. 1962. IV. Afr. Med. J., 11,198-206. Tamale-Ssali, E. G. and Billinghurs, J. R. 1971. E.Afr. Med.J. 49,406-410. Sims, P. 1973. E. Afr. Med. J., 50,140-145. Henshaw.N. E. 1974. Nigerian Med. J., 4,185-196. Henshaw, N. E. and Adenubi, J. O. 1975. Nigerian Med.J., 5,152-159. Adenubi, J. O. 1974. Nigerian Med. J., 4,251-255. Arya, O. P. and Bennett, F. J. 1970. E. Afr. Med. J. 47, 18-28. Wld. HIth. Org. Techn. Rep. Ser. 1951.30,3-36. Bryant, J. H. 1969. Health and the Developing World. Rockefeller Foundation, Cornell University Press, Ithaca and London. Jellifle, D. B. 1967.7. Trop. Pediat. Emir. Child HIth., 13, 1-3. Oyediran, A. B. O. and Lucas, A. O. 1971. W. Afr. Med.J., 20,237-239. Lantun, D. N. 1971. W. Afr. Med. J., 20,286. Scott, M. L. 1958.7. Trop. Pediat., 3, 171-174. Johns, E. B. 1973. Wild Med.J., 20,87-90. Sai, F. T. 1965. Ghana Med. J., 4, 108-112. Sai, F. T. 1966. Ghana Med.J., 5,148-155. Wld. HIth. Org. Techn. Rep. Ser. 1968.385,6. Otoo, S. N. 1970. Ghana Med. J., 9,58-63.
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on the involvement and participation of the administrative agencies, the schools of health, community health services and community members. The emphasis should not be so much doing something for the community, as doing something with the community with the aim of inducing a behavioral change. Accordingly, in selecting pilot communities for the program, certain criteria should serve as guidelines; close proximity of the schools of health and the health centers; evidence of already existing local development groups and self-help projects supported by various government and private agencies, and other indications of adequate interest and motivation in the population; and existence of a common kinship, cultural and traditional bondage. And, as a useful adjunct to the schools of health and the health centers, the program could also serve to acquaint the health team with the population and its health problems and the resources available for selective and effective use, as well as the opportunity for them to appreciate the contribution which all members of the health team can make to total health care.
