care, health and development Child: Original Article bs_bs_banner
doi:10.1111/cch.12231
Lessons learnt from school-based health promotion projects in low- and middle-income countries M. Skar,* E. Kirstein† and A. Kapur† *Department of Public Health, University of Copenhagen, Copenhagen, Denmark, and †World Diabetes Foundation, Gentofte, Denmark Accepted for publication 31 December 2014
Abstract
Keywords health promotion, lowand middle-income countries, school Correspondence: Mette Skar, Brogårdsvej 70, 2820 Gentofte, Denmark E-mail: [email protected]
Background Non-communicable diseases (NCD) are now the leading cause of death worldwide. As habits and lifestyle are established in childhood and adolescence, targeting school children before they develop unhealthy habits offers a window of opportunity to halt and reverse the emerging NCD epidemic. However, few experiences from school interventions in low- and middle-income countries have been collected. Therefore, the aim of this study was to review experiences of implementing school-based health promotion interventions to identify barriers and recommendations for future interventions. Methods A qualitative investigation of 17 school-based health promotion interventions in lowand middle-income countries was conducted. Data were collected through questionnaires (15 project leaders) and in-depth interviews with nine project leaders. The data from the questionnaires and interviews was triangulated and analysed using content analysis, where themes and categories emerging from the material were explored. Results Three key themes emerged from the data: 1) policy environment and stakeholder engagement, 2) health education sessions, and 3) practical health promotion activities. The themes explored the experiences and lessons learned from 17 school-based health promotion projects in low- and middle-income countries. Stakeholders at different administrative levels were important for the projects; however, stakeholders close to implementation were seen to be more engaged. Most projects conducted traditional health education lectures, which formed the basis of their intervention. Promotion of physical activity and healthy eating through participatory approaches were identified; however, barriers such as lack of areas suitable for physical activity and lack of healthy food alternatives in schools can obstruct the successful implementation of interventions. Conclusions This study has documented experiences with school-based health promotion in lowand middle-income countries, and has shown that schools can play an important role in facilitating NCD-related behavioural change in children. The study recommends increased emphasis on a whole-school approach where activities focusing on individual behavioural change are supported by interventions improving the structural environment.
Introduction According to the World Health Organization (WHO), over 60% (2008) of the global deaths are caused by non-communicable
© 2015 John Wiley & Sons Ltd
diseases (NCDs). Approximately 9 million of these deaths occur prematurely (before the age of 60), and over 80% in low- and middle-income countries (WHO 2010). Primary prevention should be the main approach to target this public health
1
2
M. Skar et al.
problem, as many risks are shared and modifiable (Nissinen et al. 2001; Dagogo-Jack 2006; Ramachandran et al. 2010). Such interventions are not only feasible and cost-effective particularly in the low- and middle-income countries, but also show that short-term interventions produce long-lasting effects (Pan et al. 1997; Ramachandran et al. 2006, 2007). By targeting populations before the onset of disease, costs of treatment can be considerably reduced (Dagogo-Jack 2006). Health-related (risk) behaviour is related to habits, which are shaped in childhood and last the lifetime. While still possible, interventions in adult life to prevent or delay onset of disease in people at risk are more difficult to implement (Hanson & Gluckman 2011); therefore, these efforts need to begin earlier in life. Targeting children before they develop unhealthy habits creates an opportunity to change their future prospects (Bhatia 2004; Lobstein et al. 2004). The idea of improving health through school-based intervention is widely accepted, promoted and documented (Pommier et al. 2010; Stewart-Brown 2006; WHO 2000). The concept of health-promoting schools stresses the importance of also including the social and physical environment in addition to health education (Stewart-Brown 2006). However, many of these interventions have taken place in Europe and other highincome countries (Veugelers & Fitzgerald 2005; DeBar et al. 2011). Large-scale interventions in low- and middle-income countries have primarily addressed obesity (Verstraeten et al. 2012). Nevertheless, few studies show that school-based interventions to address other NCD risks bring about desired changes in some behaviours in school children (Kain et al. 2004; Jiang et al. 2007; Mwanga et al. 2007; Sherman & Muehlhoff 2007; Shah et al. 2010; Singhal et al. 2010). Several school-based health promotion interventions target children in low- and middle-income countries, but little is known about the experiences from such interventions. Therefore, the aim of this study was to review experiences of implementing school-based NCDrelated health promotion interventions in low- and middleincome countries, with the objective of highlighting barriers and recommendations for future interventions.
Methods
teristics somewhat specific to projects funded by an external donor focusing on diabetes prevention. Thus, the experiences presented in this study may not be representative of other types of interventions. The projects were identified by screening the WDF project portfolio for the keywords ‘school’, ‘child*’ ‘adoles*’, ‘student’ and ‘primary prev*’. Inclusion criteria were projects initiated in the period 2002–2011, addressing health promotion as the main or one of the main activities, directed towards children in schools. Data collection was carried out from October to December 2011. Data were collected through questionnaires and interviews with the project leaders. First, a web-based questionnaire was developed and project leaders were invited to participate. The questionnaire served the purpose of mapping local stakeholders and their roles, currently existing national health policies in the country or target area, basic information on the selected approach, target groups, and specific activities conducted in each project related to physical exercise and healthy eating. Finally, the questionnaire explored barriers, successes and lessons learned from implementation. The questionnaire served as a guiding tool for the subsequent in-depth interviews. The in-depth interviews were conducted with project leaders, based on a semi-structured interview guide, which was developed to further explore individual experiences and perceptions. Questions were open-ended to facilitate and encourage exploratory information from the interviewees (Kvale 1996). Interviews were conducted via telephone or in-person. Depending on the complexity of the projects interviews varied in length from 35 min to 2 h. The ethical principles of voluntary participation, confidentiality and informed consent shaped the research. Written consent was obtained by all project leaders before arranging the interview and verbal consent along with permission to record all interviews where requested from and given by the nine project leaders that were interviewed face-to-face or via telephone. The study was approved by the WDF secretariat and according to the Danish Biomedical Research Ethics committee, this study was exempt from ethical approval as it was a questionnaire and interview study without the use of human biological material.
Data collection
Projects and participants
The study was a qualitative investigation of experiences of implementing school-based NCD-targeted interventions in low- and middle-income countries. The projects under investigation were all part of the World Diabetes Foundation (WDF) project portfolio. These school interventions may have charac-
The initial search of the WDF project portfolio identified 62 projects of which 16 unique partners were found eligible for the study. The projects included were from all regions of the world except Europe, and targeted schools located in urban, semiurban and rural areas. See Table 1 for the extensive list of
© 2015 John Wiley & Sons Ltd, Child: care, health and development
20
80
80
South Africa
Tanzania
Tanzania
Prevent obesity among young people through promotion of nutritional education Promote healthy lifestyle among children in secondary school through a school-based intervention in four Caribbean countries. Prevent children and parents from becoming obese and get diabetes
62
16
Caribbean, St. Kitts & Nevis, St. Vincent, Trinidad & Tobago and Grenada
Provide comprehensive diabetes care. Primary prevention component with school intervention focusing on healthy diet and exercise Implement a diabetes prevention project. Organize awareness and screening camps at schools to empower teachers, children and parents to spread knowledge in their social network Improve quality and delivery of diabetes care in Sri Lanka. Health promotion approach to empower communities (students, workers, poor) to develop healthy behaviours and thereby prevent the onset of diabetes Create a provincial diabetes and hypertension peer educator network. Awareness raising in schools, by educating teachers on healthy nutrition and physical activity Educate school children and their parents to improve general health and address diabetes prevention
Raise awareness at secondary school level on how to prevent diabetes. Conducting health education and yoga classes at schools
Develop and pilot a sustainable district level model to control diabetes through lifestyle changes and health promotion in school setting, that can be scaled up to a state level model
Expand and promote a holistic approach to diabetes care and prevention. Conducting ‘Healthy Living’ Campaign, including Wellness days for school children Create awareness about diabetes, obesity, lipid disorders and heart disease in children and adolescents through a school-based intervention programme
Improve access to diabetes care and prevention through the private health sector. Awareness raising through health education in schools and community Improve diabetes prevention and care by integrating school, community and health facility approaches to prevention and treatment. Train teachers to do anthropometric measurements of school children to screen for risk factors in school children School training programmes with health education focusing on obesity, healthy lifestyle and prevention of chronic diseases
Develop, implement and assess a school-based intervention programme aimed at promoting healthy lifestyle and preventing diabetes Promote healthy living in school children through information on healthy diet and physical activity
Strengthening the health care system to address diabetes. Raise awareness of NCDs in schools, through health clubs
Brazil, São Paulo
12
30
Sri Lanka
Marshall Islands
30
India, Ahmedabad
49
150
India, Karnataka
Cambodia
865
India, Kerala
92 India, Delhi, Uttarakhand, U Pradesh, Rajasthan, Maharashtra India, Andhra Pradesh 679
NCD, non-communicable diseases.
Region of the Americas
Western Pacific region
South-East Asian region
30
30
16
South Africa
West Bank & Gaza Eastern Mediterranean region West Bank & Gaza
50
Kenya (National Programme)
African region
Schools Objective
Country
Region
Table 1. Overview of the projects included in the review
Health education sessions for school children, and teachers, identification of high risk individuals in the community, screening of high risk individuals Health education sessions for school children, teachers and parents, health checks for teachers and parents, anthropometric measurements Health check for teachers, training of teachers, health sessions for school children Awareness sessions about NCDs, yoga classes, promotion of health food Physical activity, health education related to NCDs, stress management
School children, teachers, parents, community 11–14 years leaders, health workers, community members
School children, teachers, parents, community 11–15+ years leaders, health workers, policy makers School children, teachers, parent, community 11–14 years leaders, health workers, community members School children, teachers, community leaders & health care workers
11–15+ years
11–15+ years
School children, teachers, cooks and/or staff from school canteen, parents, food stalls in the surrounding environment, health workers
11–15+ years
11–14 years School children, teachers, cooks and/or staff from school canteens, food stalls in the surrounding environment, community leaders, health workers, community members School children 6–18 years
Teachers, community leaders
School children, teachers, parents, community leaders, health workers
Health education session, physical activities, anthropometric measurements of 10% of school children Training of teachers, health education sessions, promotional days
Increase risk factor awareness in teachers, increase risk factor awareness in community leaders, pre- and post test Health education sessions, daily exercise sessions, teacher training
Health education sessions, participatory activities for students, knowledge, attitudes and practise survey
10–17 years
School children, teachers, parent, community 6–15+ years leaders, health workers, community members School children, teachers, parents
Development of curriculum and training materials, training of school teachers, link schools to health care facilities Development of curriculum and training materials, training of school teachers, link schools to health care facilities
Screening, soccer tournament, healthy lunch demonstrations
Planning activities for implementation in schools, curriculum intervention, staff health check.
Training of teachers, sensitization of parents, creating materials for educational purposes
Training of students and teachers as trainers, health education sessions and development of materials Wellness days, health education sessions, school media
10–14 years
All age groups excluding kindergarten 10–14 years
All age groups excluding kindergarten 6–13 years
Age of targeted students Activities
School children, teachers, parent, community 6–15+ years leaders, health workers, community members
School children, teachers, cooks and/or staff from canteens, parents, community leaders, health care workers, community members School children, teachers, parents, community members, health care providers in health care facilities School children, teachers, parents, community members, health care providers in health care facilities
Teachers, parents, food stalls in the surrounding environment
Teachers, parents
Target Groups
School health promotion in low- and middle-income countries 3
© 2015 John Wiley & Sons Ltd, Child: care, health and development
4 M. Skar et al.
included projects. Fifteen of the 16 invited partners responded to the questionnaire (response rate 93.7%), and represented 17 projects. Nine projects leaders were selected and participated in an in-depth interview. Selection was based on the following criteria: completion of questionnaire, scope of the school health component and geographical representation.
Data analysis Content analysis was used to analyse the interviews, which were transcribed in full length to enable coding and to document validity of the analysis. Data were triangulated and the interviews and questionnaires were searched for meaning units and coded by developing categories, which emerged from the data (Hsieh & Shannon 2005). Two researchers then reviewed the categories separately in order to ensure that no overlapping categories described the same phenomena and to verify the identified categories. The coding was done continuously based on categories discovered throughout the period of the study. This ensured that the categories were exhaustive, and finally they were organized according to three meaningful key themes (Hsieh & Shannon 2005): political environment and stakeholder engagement, classroom-based health lectures, and practical health promotion activities.
Results
Number of projects reporting activity
The three key themes identified in the data analysis explored different aspects of the experiences and lessons learned from 17 school-based health promotion projects (led by 15 different
16
project leaders) in low- and middle-income countries. These themes structured the challenges and barriers faced at different administrative levels of the interventions and elaborated on the approaches selected by the projects to overcome these barriers. Furthermore, the themes explored the lessons learned from the projects. The first theme described the different political environments in which the projects operate and elaborated on the stakeholders identified to be included for a successful intervention. The two other themes concerned the different approaches and activities used to promote healthy behaviours in the schools (Fig. 1). The analysis showed that there were two main approaches, namely, the classroom-based health lectures and the practical health promotion activities. The theme evolving around the classroom-based lectures elaborated on how these classes were structured in the different projects and described the considerations the projects had regarding how to activate the children during the lectures, which formed the basis of 14 out of 17 projects. The third theme evolved around the existing barriers and challenges to promote behaviours relating to physical activity and healthy eating in schools and explained how the projects developed practical health promotion activities, where the students had an active role, to address these barriers.
Political environment and stakeholder engagement Despite large contextual differences in the countries where the projects operate, the project leaders identified similar stakeholders as being important for the implementation of the projects. All 15 project leaders reported school managements, students, teachers, parents and communities as being important
Activities
14 12 10 8 6 4 2 0
Figure 1. Activities conducted by the projects as part of the school health interventions.
© 2015 John Wiley & Sons Ltd, Child: care, health and development
School health promotion in low- and middle-income countries
stakeholders to include in the school interventions. On the national scene, the Ministry of Education was considered important for the nationwide projects, but their involvement and commitment varied widely between the projects; provincial and regional directorates being closer to the ground were perceived by nine project leaders to be more engaged. The majority of the project leaders interviewed (8 out of 9) reported that obtaining approval and inclusion of governmental bodies were paramount to gain access to (government-run) schools and to build a framework for action. However, it was recognized that this task was often time consuming and difficult. Project leaders described the approval process to enter the schools. We got the permission from the Permanent Secretary of the Ministry of Education first. (Project leader from the Caribbean) By getting the support from the district elected president we could enter the schools [and] . . . many barriers [from teachers and headmasters] were avoided. (Project leader from India) Before we went to the schools we went to the department of education. (Project leader from South Africa) We got the approval stage wise – first the state educational office, then the district educational officer, and then we went to the schools and got their permission. (Project leader from India) We got the approval from the government office first before we even meet the teachers – that’s substantial in order to convince them [the teachers]. (Project leader from India) First we got the clearance from the secretary of education . . ., then the [school] principal and then got the teachers on board. . . . They have to go out there and actually participate . . . they cannot be standing on the side lines directing the students to exercise. (Project leader from Marshall Islands) If you want your intervention to be successful the [school] principal needs to be the driving force. (Project leader from South Africa) All these statements from the majority of the project leaders interviewed emphasize the need to, firstly, get a locally relevant official permission to target the schools. After obtaining such an approval, it seems to be vital to convince the school principal and the teachers who would be involved in the activities. Only
5
one project leader described difficulties with getting the official permissions to enter the schools and hence had to use personal contacts to teachers instead. We tried the official channel first, but in the end we were not able to because of complications and paper work . . . so we started making contacts with teachers. (Project leader from Brazil) These experiences underscore that a large number of stakeholders, at different levels of decision making made it difficult to navigate and determine which administrative levels to address. Several project leaders interviewed (5 out of 9) experienced that there is still a huge discrepancy between the stated NCD emergency and the public health response to it. A project leader described the discrepancy. When considering the rate by which the NCDs are increasing in our country, the initiatives taken by both the public and private sector at present are grossly inadequate. (Project leader from India) The project leaders experienced a large gap between international declarations and actual implementation of effective policies at national, regional and provincial levels. Six of the 15 project leaders reported that there are either no policies or poor implementation of existing policies regarding health promotion in schools. School health policies, if present, are not integrated and target issues in a piece meal fashion making it difficult to gain attention for new initiatives. The study revealed a general lack of effective policies promoting and regulating physical activity in schools. Physical education is on the school curriculum in all countries surveyed, but only as a time slot on the timetable. Furthermore, across nine low- and middle-income countries the study found a general lack of, or poor implementation, of policies regulating nutrition in schools. Seven project leaders from South Africa, Brazil, Caribbean region and India reported free midday meals in schools subsidized by the governments. The execution and objective of such schemes is country specific, but ensuring a daily meal for school-attending children to improve school attendance is common to all. Four project leaders reported that the meal programmes lack focus on quality of nutrition and also particularly, fail to link the service with nutrition education.
Classroom-based health lectures For 14 projects, health education sessions were the cornerstone of their intervention. The project leaders described how such lectures were a prerequisite for other activities as this was where
© 2015 John Wiley & Sons Ltd, Child: care, health and development
6
M. Skar et al.
the students got the knowledge and understanding of the need for behavioural change in order to avoid disease. The duration and frequency ranged between a 40-min lecture, a 1-day session, a 10-week programme, and lastly a programme with 48 planned sessions. The classroom-based lectures informed on causes, prevention and consequences of NCDs and included key messages such as ‘prevention is possible through lifestyle changes’, ‘physical activity improves health’ and ‘there’s a link between lifestyle and NCDs’. Project leaders described the classroom-based health lectures: . . . the initial lecture in the schools was given by the project head and then project staff took up the responsibility of conducting educational lectures and activities with school children. (Project leader from India) We used an active participatory approach, meaning everyone was a teacher and educator in the session. Just to keep maximum participation. (Project leader from Tanzania) At the end of each class, we ask one of the children to give a summary to the rest of the class. The students are very eager to come forward to speak. (Project leader from India) They [the school children] don’t volunteer for the classes, so we teach in the science classes at the schools. (Project leader Marshall Island) We had 4 h of classes: introduction on lifestyle diseases and unhealthy lifestyle. Diabetes and cholesterol is covered because they are major issues. Then also other cardiovascular diseases. Nutrition will also be covered. All this will be covered and then there will be half an hour physical training. (Project leader from India) All 15 project leaders reported that they developed and distributed materials, such as pamphlets, water bottles and footballs. Such materials were used to support the messages conveyed in the health education classes in a culturally acceptable way. For example, eight projects developed pamphlets written in the local language and using locally available food choices and physical activities as examples, and four projects developed the materials in cooperation with teachers and students. The materials were prepared while the workshops for the teachers were going on. Thus it became a group effort. The content focused on the local realities like language, food available and the lifestyle of the people. (Project leader from India)
© 2015 John Wiley & Sons Ltd, Child: care, health and development
Practical health promotion activities In addition to the classroom-based lectures, a wide range of activities were implemented to promote healthy behaviour (Fig. 1). For example, nine projects used students as change agents, where selected students were responsible for measuring body mass index and other anthropometric measurements among peers and parents to identify people at risk. This approach was used to engage the students. The predominant focus of the practical health promotion activities was on physical activity and healthy eating. The project leaders identified several barriers to physical activity and the main barrier was related to the physical education sessions already in place in the schools. The physical time is mostly unstructured and children are usually sent to a playground to play. Many children just use the time to sit around and relax. (Project leader from India) There is one lecture per week dedicated for physical activities and sports, but usually schools tend to cancel this lecture and use the time for other lectures like science and math. (Project partner from West Bank and Gaza) Academically oriented teachers are a problem for physical activity. They [teachers] have very little focus on physical activity. (Project leader from Caribbean) Predominant focus on academic achievements was an important reason identified to explain why physical education has low priority in the schools. Such statements were common for 11 projects leaders who reported that the physical education sessions usually were under-prioritized, unstructured and un-graded. Because of poor execution of the physical education sessions, 14 projects promoted physical activity, and the main approach was to strengthen the status of the physical education sessions and to improve the quality of them. In addition to emphasizing the physical education classes, physical activity were promoted through e.g. sports tournaments, increase of physical activities during break time and arranging public walks. The other important barrier to physical activity identified in the data, was the physical environment, which did not facilitate physical activity. Several schools lacked suitable facilities such as playgrounds. Furthermore, ‘unsafe roads’, ‘lack of parks’ and ‘fear of crime in open public places’ were mentioned as other barriers for physical activity in the environment outside the schools. Consequently, eight projects targeted the physical environment to promote physical activity by providing equipment,
School health promotion in low- and middle-income countries
assessing the facilities with school management and suggesting improvements. The analysis also identified barriers to promoting healthy eating in the schools. Project leaders from India, South Africa and Brazil emphasized the need for approaching food habits cautiously as they were operating in areas where the economic status is not high. For example, it was difficult to advocate for expensive food choices such as fresh fruits and vegetables, as it would not be feasible for economically challenged families. Furthermore, some project leaders reported that implementing healthy food choices in school canteens was hindered by the short shelf life and high spoilage of fresh foods increasing their cost. This, combined with low purchasing power of school children, made it difficult for the canteens to make any profit on these items and they were therefore reluctant to sell healthy food. Children are not very into buying fruits, so before it is sold it gets spoiled. The school canteens want to make profits as well, and they were not able to make that on healthy foods. (Project leader from India) This was a common experience among the interviewed project leaders. Nevertheless, promotion of healthy food was targeted by 11 projects through locally adopted activities such as developing vegetable gardens, cooking competitions where parents were invited and provision of fruits and vegetables in the school canteens.
Discussion The findings and analysis provide insights into how multiple innovative strategies were applied to actively engage the school children and teachers. The study found that the common denominator for the successful activities is the participatory aspect, which is in line with other school-based interventions (Stewart-Brown 2006; Carlsson & Simovska 2012). Activities, which managed to actively involve the students and teachers, increased the sense of ownership and awareness of both students (Mwanga et al. 2007) and teachers. Activities such as establishment of food gardens, cooking competitions, sports tournaments, role plays and walks managed to engage children and teachers in various contexts. Besides the practical, participatory activities, the study revealed that traditional classroom-based lectures are still the predominant way of promoting health in schools. For many projects, health education sessions were seen as a prerequisite for other activities, as this is where the students get the knowledge and understanding of the importance of behavioural change.
7
The typical challenges for implementing school health interventions in low- and middle-income countries appear to be how to engage the students to be physically active in the natural course of everyday life and how to make food choices that are healthy. Such behaviour change face challenges by the structural barriers in urban planning and limited access to playgrounds and fields for exercising; high costs and poor access to healthy food and cultural views on body image (Stewart-Brown 2006). Based on the experiences of 15 project leaders in low- and middle-income countries, one could argue that a first step to promote physical activity among school children is to emphasize that the schools efficiently utilize time slots for physical activity already allocated and available in the school curriculum. An option in this connection could be to grade physical activity on similar lines as academic courses. As revealed in this study, physical activity is under-prioritized because of the lack of time in the school schedule; therefore, efforts should be placed on promoting physical activity in both formal and informal ways, such as physically active games during breaks and improving the physical environment of the school premises. One of the most sensitive and culturally dependent aspect of lifestyle is nutrition (Khare 1980). Many low- and middleincome countries are experiencing urbanization, acculturation and nutrition transition where traditional and locally produced foods are replaced with unhealthy processed food with high content of sugar and fat (Popkin 2006; Franks et al. 2007; Andreyeva et al. 2010; Misra et al. 2011). Growth in food processing and packaging has led to widespread availability of processed and packaged foods, and coupled with aggressive marketing, it is contributing to change in eating behaviour. The new emerging food habits are a major challenge for health promotion in schools (Lytle et al. 2006), and was also emphasized by the project leaders in this study. Therefore, it could be argued that availability and preferential pricing of healthy food in schools should be addressed to enhance school children’s ability to make healthy choices. In this study an opportunity to target school canteen staff as a means to improve healthy food availability and restrict sale of unhealthy food in and around the school premises was identified, pricing unhealthy snacks higher to cross subsidize fruits or other perishable healthy snacks could also be considered. A possible way to enhance learning and create ownership of the activities could be to include both interactive health educational activities that engage the primary targets and involve stakeholders in designing and implementation of activities. This study showed examples of participatory activities such as quizzes, poster making, debates, drama and role plays, cookery lessons, lunch box competitions, and sports competitions,
© 2015 John Wiley & Sons Ltd, Child: care, health and development
8
M. Skar et al.
which could improve lifestyle changes with active involvement of the students, teachers and parents. In addition, advocacy at local political level to create an enabling environment such as adjustment of curriculum, influencing quality of food (mid-day meal programmes) in schools and regulating the types of products sold in school canteens and by neighbourhood vendors could be considered for longer term impact.
Limitations This study has analysed only projects funded by the WDF. Hence, the approaches and experiences revealed in this study may be significant only to this type of projects. Nevertheless, the present study combined lessons learned from a wide range of projects in different countries, with different scope and targets of the projects. Hence we argue that these experiences could also be relevant for other types of school-based health promotion interventions in low- and middle-income countries. The study provides a snap shot of experiences with implementing health promotion activities in schools. Hence, the evaluation of the long-term impact of the students’ behaviours and the sustainability of the school interventions was beyond the scope of this paper, but could be followed up by future research.
Conclusion This research has documented that active participation and activities targeting multiple stakeholders are important for successful implementation of school-based health promotion interventions in low- and middle-income countries. The study has shown that schools can play a crucial role in educating teachers, children and parents in healthy living and thereby facilitate health behaviour change in children relevant for prevention of NCDs. Merely imparting theoretical knowledge to children regarding the importance of physical activity and eating habits is far from satisfactory. Increasing knowledge by health lectures in the classroom does not necessarily translate into behavioural change for the students as many factors influence how students move from knowledge, to motivation, to actual behavioural change (Carlsson & Simovska 2012). The study identified three main barriers to school health interventions including predominant focus on classroom-based health lectures instead of using participatory approaches, difficulties in engaging the students to do physical exercise and introducing healthy food choices in school canteens and premises. The study therefore recommends that applying a whole-school approach to school health projects in low- and
© 2015 John Wiley & Sons Ltd, Child: care, health and development
middle-income countries where behaviours and barriers are targeted simultaneously, and structural changes are put in place in the surrounding environment to support individual change.
Key messages • School-based health promotion in low- and middleincome countries can play an important role for facilitating behavioural change in children. • A participatory approach that engages and involves school children and other stakeholders in designing and implementing activities should be prioritized in addition to advocacy for structural changes that create an enabling environment for healthy living. • Adjustment of curriculum, with special emphasis on promoting the status of physical activity lessons, should be prioritized to increase the level of physical activity during the school day, but informal physical activity could also be promoted. • Influencing quality of food offered in schools and regulating the types of products sold in school canteens and by neighbourhood vendors is paramount for long-term impact on food habits. • To sustain behavioural change, school-based health promotion should be integrated into the formal school curriculum.
Funding The World Diabetes Foundation funded this research.
Conflict of interest All authors had financial support from WDF for the submitted work.
Acknowledgements Sincere thanks to the project leaders in the data collection process by sharing their experiences and perspectives through questionnaires and in-depth interviews. Furthermore, we wish to thank World Diabetes Foundation for allowing us access to the projects and for sponsoring a field trip to India.
References Andreyeva, T., Long, M. W. & Brownell, K. D. (2010) The impact of food prices on consumption: a systematic review of research on
School health promotion in low- and middle-income countries
the price elasticity of demand for food. [Research Support, Non-U.S. Gov’t Review]. American Journal of Public Health, 100, 216–222. Bhatia, V. (2004) IAP National Task Force for Childhood Prevention of Adult Diseases: insulin resistance and type 2 diabetes mellitus in childhood. Indian Pediatrics, 41, 443–457. Carlsson, M. & Simovska, V. (2012) Exploring learning outcomes of school-based health promotion-a multiple case study. Health Education Research, 27, 437–447. Dagogo-Jack, S. (2006) Primary prevention of type-2 diabetes in developing countries. Journal of the National Medical Association, 98, 415–419. DeBar, L. L., Schneider, M., Drews, K. L., Ford, E. G., Stadler, D. D., Moe, E. L. & Venditti, E. M. (2011) Student public commitment in a school-based diabetes prevention project: impact on physical health and health behavior. BMC Public Health, 11, 711–721. Franks, A., Kelder, S. H., Dino, G. A., Horn, K. A., Gortmaker, S. L., Wiecha, J. L. & Simoes, E. J. (2007) School-based programs: lessons learned from CATCH, Planet Health, and Not-On-Tobacco. Preventing Chronic Disease, 4, 1–9. Hanson, M. & Gluckman, P. (2011) Developmental origins of noncommunicable disease: population and public health implications. [Research Support, Non-U.S. Gov’t Review]. The American Journal of Clinical Nutrition, 94 (6 Suppl. ), 1754S–1758S. Hsieh, H. F. & Shannon, S. E. (2005) Three approaches to qualitative content analysis. Qualitative Health Research, 15, 1277–1288. Jiang, J., Xia, X., Greiner, T., Wu, G., Lian, G. & Rosenqvist, U. (2007) The effects of a 3-year obesity intervention in schoolchildren in Beijing. Child: Care, Health and Development, 33, 641–646. Kain, J., Uauy, R., Albala, Vio, F., Cerda, R. & Leyton, B. (2004) School-based obesity prevention in Chilean primary school children: methodology and evaluation of a controlled study. International Journal of Obesity and Related Metabolic Disorders: Journal of the International Association for the Study of Obesity, 28, 483–493. Khare, R. S. (1980) Food as nutrition and culture: Notes towards an anthropological methodology. Social Science Information, 19, 519–542. Kvale, S. (1996) InterViews: An Introduction to Qualitative Research Interviewing. Sage Publications, Thousand Oaks, CA. Lobstein, T., Baur, L. & Uauy, R. (2004) Obesity in children and young people: a crisis in public health. [Review]. Obesity Reviews, 5 (Suppl. 1), 4–104. Lytle, L. A., Kubik, M. Y., Perry, C., Story, M., Birnbaum, A. S. & Murray, D. M. (2006) Influencing healthful food choices in school and home environments: results from the TEENS study. [Randomized Controlled Trial Research Support, N.I.H., Extramural]. Preventive Medicine, 43, 8–13. Misra, A., Singhal, N., Sivakumar, B., Bhagat, N., Jaiswal, A. & Khurana, L. (2011) Nutrition transition in India: secular trends in dietary intake and their relationship to diet-related non-communicable diseases. Journal of Diabetes, 3, 278–292.
9
Mwanga, J. R., Jensen, B. B., Magnussen, P. & Aagaard-Hansen, J. (2007) School children as health change agents in Magu, Tanzania: a feasibility study. Health Promotion International, 23, 16–23. Nissinen, A., Berrios, X. & Puska, P. (2001) Community-based noncommunicable disease interventions: lessons from developed countries for developing ones. Bulletin of the World Health Organization, 79, 963–970. Pan, X. R., Li, G. W., Hu, Y. H., Wang, J. X., Yang, W. Y., An, Z. X. & Howard, B. V. (1997) Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care, 20, 537–544. Pommier, J., Guevel, M. R. & Jourdan, D. (2010) Evaluation of health promotion in schools: a realistic evaluation approach using mixed methods. [Evaluation Studies Research Support, Non-U.S. Gov’t]. BMC Public Health, 10, 43–54. Popkin, B. M. (2006) Global nutrition dynamics: the world is shifting rapidly toward a diet linked with noncommunicable diseases. The American Journal of Clinical Nutrition, 84, 289–298. Ramachandran, A., Snehalatha, C., Mary, S., Mukesh, B., Bhaskar, A. D. & Vijay, V. (2006) The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia, 49, 289–297. Ramachandran, A., Snehalatha, C., Yamuna, A., Mary, S. & Ping, Z. (2007) Cost-effectiveness of the interventions in the primary prevention of diabetes among Asian Indians: within-trial results of the Indian Diabetes Prevention Programme (IDPP). Diabetes Care, 30, 2548–2552. Ramachandran, A., Ma, R. C. & Snehalatha, C. (2010) Diabetes in Asia. Lancet, 375, 408–418. Shah, P., Misra, A., Gupta, N., Hazra, D. K., Gupta, R., Seth, P. & Goel, K. (2010) Improvement in nutrition-related knowledge and behaviour of urban Asian Indian school children: findings from the ‘Medical education for children/Adolescents for Realistic prevention of obesity and diabetes and for healthy aGeing’ (MARG) intervention study. The British Journal of Nutrition, 104, 427–436. Sherman, J. & Muehlhoff, E. (2007) Developing a nutrition and health education program for primary schools in Zambia. Journal of Nutrition Education and Behavior, 39, 335–342. Singhal, N., Misra, A., Shah, P. & Gulati, S. (2010) Effects of controlled school-based multi-component model of nutrition and lifestyle interventions on behavior modification, anthropometry and metabolic risk profile of urban Asian Indian adolescents in North India. European Journal of Clinical Nutrition, 64, 364–373. Stewart-Brown, S. (2006) What is the evidence on school health promotion in improving health or preventing disease and, specifically, what is the effectiveness of the health promoting schools approach? Copenhagen: WHO Regional Office for Europe. Verstraeten, R., Roberfroid, D., Lachat, C., Leroy, J. L., Holdsworth, M., Maes, L. & Kolsteren, P. W. (2012) Effectiveness of preventive
© 2015 John Wiley & Sons Ltd, Child: care, health and development
10
M. Skar et al.
school-based obesity interventions in low- and middle-income countries: a systematic review. [Review]. The American Journal of Clinical Nutrition, 96, 415–438. Veugelers, P. J. & Fitzgerald, A. L. (2005) Effectiveness of school programs in preventing childhood obesity: a multilevel comparison. American Journal of Public Health, 95, 432–435.
© 2015 John Wiley & Sons Ltd, Child: care, health and development
World Health Organization (WHO). (2000) Improving health through schools: national and international strategies/compiled and edited by Isolde Birdthistle. WHO Information Series on School Health. Geneva: World Health Organization. World Health Organization (WHO) (2010) Global status report on noncommunicable diseases 2010. Geneva: World Health Organization.
doi:10.1111/cch.12231
Lessons learnt from school-based health promotion projects in low- and middle-income countries M. Skar,* E. Kirstein† and A. Kapur† *Department of Public Health, University of Copenhagen, Copenhagen, Denmark, and †World Diabetes Foundation, Gentofte, Denmark Accepted for publication 31 December 2014
Abstract
Keywords health promotion, lowand middle-income countries, school Correspondence: Mette Skar, Brogårdsvej 70, 2820 Gentofte, Denmark E-mail: [email protected]
Background Non-communicable diseases (NCD) are now the leading cause of death worldwide. As habits and lifestyle are established in childhood and adolescence, targeting school children before they develop unhealthy habits offers a window of opportunity to halt and reverse the emerging NCD epidemic. However, few experiences from school interventions in low- and middle-income countries have been collected. Therefore, the aim of this study was to review experiences of implementing school-based health promotion interventions to identify barriers and recommendations for future interventions. Methods A qualitative investigation of 17 school-based health promotion interventions in lowand middle-income countries was conducted. Data were collected through questionnaires (15 project leaders) and in-depth interviews with nine project leaders. The data from the questionnaires and interviews was triangulated and analysed using content analysis, where themes and categories emerging from the material were explored. Results Three key themes emerged from the data: 1) policy environment and stakeholder engagement, 2) health education sessions, and 3) practical health promotion activities. The themes explored the experiences and lessons learned from 17 school-based health promotion projects in low- and middle-income countries. Stakeholders at different administrative levels were important for the projects; however, stakeholders close to implementation were seen to be more engaged. Most projects conducted traditional health education lectures, which formed the basis of their intervention. Promotion of physical activity and healthy eating through participatory approaches were identified; however, barriers such as lack of areas suitable for physical activity and lack of healthy food alternatives in schools can obstruct the successful implementation of interventions. Conclusions This study has documented experiences with school-based health promotion in lowand middle-income countries, and has shown that schools can play an important role in facilitating NCD-related behavioural change in children. The study recommends increased emphasis on a whole-school approach where activities focusing on individual behavioural change are supported by interventions improving the structural environment.
Introduction According to the World Health Organization (WHO), over 60% (2008) of the global deaths are caused by non-communicable
© 2015 John Wiley & Sons Ltd
diseases (NCDs). Approximately 9 million of these deaths occur prematurely (before the age of 60), and over 80% in low- and middle-income countries (WHO 2010). Primary prevention should be the main approach to target this public health
1
2
M. Skar et al.
problem, as many risks are shared and modifiable (Nissinen et al. 2001; Dagogo-Jack 2006; Ramachandran et al. 2010). Such interventions are not only feasible and cost-effective particularly in the low- and middle-income countries, but also show that short-term interventions produce long-lasting effects (Pan et al. 1997; Ramachandran et al. 2006, 2007). By targeting populations before the onset of disease, costs of treatment can be considerably reduced (Dagogo-Jack 2006). Health-related (risk) behaviour is related to habits, which are shaped in childhood and last the lifetime. While still possible, interventions in adult life to prevent or delay onset of disease in people at risk are more difficult to implement (Hanson & Gluckman 2011); therefore, these efforts need to begin earlier in life. Targeting children before they develop unhealthy habits creates an opportunity to change their future prospects (Bhatia 2004; Lobstein et al. 2004). The idea of improving health through school-based intervention is widely accepted, promoted and documented (Pommier et al. 2010; Stewart-Brown 2006; WHO 2000). The concept of health-promoting schools stresses the importance of also including the social and physical environment in addition to health education (Stewart-Brown 2006). However, many of these interventions have taken place in Europe and other highincome countries (Veugelers & Fitzgerald 2005; DeBar et al. 2011). Large-scale interventions in low- and middle-income countries have primarily addressed obesity (Verstraeten et al. 2012). Nevertheless, few studies show that school-based interventions to address other NCD risks bring about desired changes in some behaviours in school children (Kain et al. 2004; Jiang et al. 2007; Mwanga et al. 2007; Sherman & Muehlhoff 2007; Shah et al. 2010; Singhal et al. 2010). Several school-based health promotion interventions target children in low- and middle-income countries, but little is known about the experiences from such interventions. Therefore, the aim of this study was to review experiences of implementing school-based NCDrelated health promotion interventions in low- and middleincome countries, with the objective of highlighting barriers and recommendations for future interventions.
Methods
teristics somewhat specific to projects funded by an external donor focusing on diabetes prevention. Thus, the experiences presented in this study may not be representative of other types of interventions. The projects were identified by screening the WDF project portfolio for the keywords ‘school’, ‘child*’ ‘adoles*’, ‘student’ and ‘primary prev*’. Inclusion criteria were projects initiated in the period 2002–2011, addressing health promotion as the main or one of the main activities, directed towards children in schools. Data collection was carried out from October to December 2011. Data were collected through questionnaires and interviews with the project leaders. First, a web-based questionnaire was developed and project leaders were invited to participate. The questionnaire served the purpose of mapping local stakeholders and their roles, currently existing national health policies in the country or target area, basic information on the selected approach, target groups, and specific activities conducted in each project related to physical exercise and healthy eating. Finally, the questionnaire explored barriers, successes and lessons learned from implementation. The questionnaire served as a guiding tool for the subsequent in-depth interviews. The in-depth interviews were conducted with project leaders, based on a semi-structured interview guide, which was developed to further explore individual experiences and perceptions. Questions were open-ended to facilitate and encourage exploratory information from the interviewees (Kvale 1996). Interviews were conducted via telephone or in-person. Depending on the complexity of the projects interviews varied in length from 35 min to 2 h. The ethical principles of voluntary participation, confidentiality and informed consent shaped the research. Written consent was obtained by all project leaders before arranging the interview and verbal consent along with permission to record all interviews where requested from and given by the nine project leaders that were interviewed face-to-face or via telephone. The study was approved by the WDF secretariat and according to the Danish Biomedical Research Ethics committee, this study was exempt from ethical approval as it was a questionnaire and interview study without the use of human biological material.
Data collection
Projects and participants
The study was a qualitative investigation of experiences of implementing school-based NCD-targeted interventions in low- and middle-income countries. The projects under investigation were all part of the World Diabetes Foundation (WDF) project portfolio. These school interventions may have charac-
The initial search of the WDF project portfolio identified 62 projects of which 16 unique partners were found eligible for the study. The projects included were from all regions of the world except Europe, and targeted schools located in urban, semiurban and rural areas. See Table 1 for the extensive list of
© 2015 John Wiley & Sons Ltd, Child: care, health and development
20
80
80
South Africa
Tanzania
Tanzania
Prevent obesity among young people through promotion of nutritional education Promote healthy lifestyle among children in secondary school through a school-based intervention in four Caribbean countries. Prevent children and parents from becoming obese and get diabetes
62
16
Caribbean, St. Kitts & Nevis, St. Vincent, Trinidad & Tobago and Grenada
Provide comprehensive diabetes care. Primary prevention component with school intervention focusing on healthy diet and exercise Implement a diabetes prevention project. Organize awareness and screening camps at schools to empower teachers, children and parents to spread knowledge in their social network Improve quality and delivery of diabetes care in Sri Lanka. Health promotion approach to empower communities (students, workers, poor) to develop healthy behaviours and thereby prevent the onset of diabetes Create a provincial diabetes and hypertension peer educator network. Awareness raising in schools, by educating teachers on healthy nutrition and physical activity Educate school children and their parents to improve general health and address diabetes prevention
Raise awareness at secondary school level on how to prevent diabetes. Conducting health education and yoga classes at schools
Develop and pilot a sustainable district level model to control diabetes through lifestyle changes and health promotion in school setting, that can be scaled up to a state level model
Expand and promote a holistic approach to diabetes care and prevention. Conducting ‘Healthy Living’ Campaign, including Wellness days for school children Create awareness about diabetes, obesity, lipid disorders and heart disease in children and adolescents through a school-based intervention programme
Improve access to diabetes care and prevention through the private health sector. Awareness raising through health education in schools and community Improve diabetes prevention and care by integrating school, community and health facility approaches to prevention and treatment. Train teachers to do anthropometric measurements of school children to screen for risk factors in school children School training programmes with health education focusing on obesity, healthy lifestyle and prevention of chronic diseases
Develop, implement and assess a school-based intervention programme aimed at promoting healthy lifestyle and preventing diabetes Promote healthy living in school children through information on healthy diet and physical activity
Strengthening the health care system to address diabetes. Raise awareness of NCDs in schools, through health clubs
Brazil, São Paulo
12
30
Sri Lanka
Marshall Islands
30
India, Ahmedabad
49
150
India, Karnataka
Cambodia
865
India, Kerala
92 India, Delhi, Uttarakhand, U Pradesh, Rajasthan, Maharashtra India, Andhra Pradesh 679
NCD, non-communicable diseases.
Region of the Americas
Western Pacific region
South-East Asian region
30
30
16
South Africa
West Bank & Gaza Eastern Mediterranean region West Bank & Gaza
50
Kenya (National Programme)
African region
Schools Objective
Country
Region
Table 1. Overview of the projects included in the review
Health education sessions for school children, and teachers, identification of high risk individuals in the community, screening of high risk individuals Health education sessions for school children, teachers and parents, health checks for teachers and parents, anthropometric measurements Health check for teachers, training of teachers, health sessions for school children Awareness sessions about NCDs, yoga classes, promotion of health food Physical activity, health education related to NCDs, stress management
School children, teachers, parents, community 11–14 years leaders, health workers, community members
School children, teachers, parents, community 11–15+ years leaders, health workers, policy makers School children, teachers, parent, community 11–14 years leaders, health workers, community members School children, teachers, community leaders & health care workers
11–15+ years
11–15+ years
School children, teachers, cooks and/or staff from school canteen, parents, food stalls in the surrounding environment, health workers
11–15+ years
11–14 years School children, teachers, cooks and/or staff from school canteens, food stalls in the surrounding environment, community leaders, health workers, community members School children 6–18 years
Teachers, community leaders
School children, teachers, parents, community leaders, health workers
Health education session, physical activities, anthropometric measurements of 10% of school children Training of teachers, health education sessions, promotional days
Increase risk factor awareness in teachers, increase risk factor awareness in community leaders, pre- and post test Health education sessions, daily exercise sessions, teacher training
Health education sessions, participatory activities for students, knowledge, attitudes and practise survey
10–17 years
School children, teachers, parent, community 6–15+ years leaders, health workers, community members School children, teachers, parents
Development of curriculum and training materials, training of school teachers, link schools to health care facilities Development of curriculum and training materials, training of school teachers, link schools to health care facilities
Screening, soccer tournament, healthy lunch demonstrations
Planning activities for implementation in schools, curriculum intervention, staff health check.
Training of teachers, sensitization of parents, creating materials for educational purposes
Training of students and teachers as trainers, health education sessions and development of materials Wellness days, health education sessions, school media
10–14 years
All age groups excluding kindergarten 10–14 years
All age groups excluding kindergarten 6–13 years
Age of targeted students Activities
School children, teachers, parent, community 6–15+ years leaders, health workers, community members
School children, teachers, cooks and/or staff from canteens, parents, community leaders, health care workers, community members School children, teachers, parents, community members, health care providers in health care facilities School children, teachers, parents, community members, health care providers in health care facilities
Teachers, parents, food stalls in the surrounding environment
Teachers, parents
Target Groups
School health promotion in low- and middle-income countries 3
© 2015 John Wiley & Sons Ltd, Child: care, health and development
4 M. Skar et al.
included projects. Fifteen of the 16 invited partners responded to the questionnaire (response rate 93.7%), and represented 17 projects. Nine projects leaders were selected and participated in an in-depth interview. Selection was based on the following criteria: completion of questionnaire, scope of the school health component and geographical representation.
Data analysis Content analysis was used to analyse the interviews, which were transcribed in full length to enable coding and to document validity of the analysis. Data were triangulated and the interviews and questionnaires were searched for meaning units and coded by developing categories, which emerged from the data (Hsieh & Shannon 2005). Two researchers then reviewed the categories separately in order to ensure that no overlapping categories described the same phenomena and to verify the identified categories. The coding was done continuously based on categories discovered throughout the period of the study. This ensured that the categories were exhaustive, and finally they were organized according to three meaningful key themes (Hsieh & Shannon 2005): political environment and stakeholder engagement, classroom-based health lectures, and practical health promotion activities.
Results
Number of projects reporting activity
The three key themes identified in the data analysis explored different aspects of the experiences and lessons learned from 17 school-based health promotion projects (led by 15 different
16
project leaders) in low- and middle-income countries. These themes structured the challenges and barriers faced at different administrative levels of the interventions and elaborated on the approaches selected by the projects to overcome these barriers. Furthermore, the themes explored the lessons learned from the projects. The first theme described the different political environments in which the projects operate and elaborated on the stakeholders identified to be included for a successful intervention. The two other themes concerned the different approaches and activities used to promote healthy behaviours in the schools (Fig. 1). The analysis showed that there were two main approaches, namely, the classroom-based health lectures and the practical health promotion activities. The theme evolving around the classroom-based lectures elaborated on how these classes were structured in the different projects and described the considerations the projects had regarding how to activate the children during the lectures, which formed the basis of 14 out of 17 projects. The third theme evolved around the existing barriers and challenges to promote behaviours relating to physical activity and healthy eating in schools and explained how the projects developed practical health promotion activities, where the students had an active role, to address these barriers.
Political environment and stakeholder engagement Despite large contextual differences in the countries where the projects operate, the project leaders identified similar stakeholders as being important for the implementation of the projects. All 15 project leaders reported school managements, students, teachers, parents and communities as being important
Activities
14 12 10 8 6 4 2 0
Figure 1. Activities conducted by the projects as part of the school health interventions.
© 2015 John Wiley & Sons Ltd, Child: care, health and development
School health promotion in low- and middle-income countries
stakeholders to include in the school interventions. On the national scene, the Ministry of Education was considered important for the nationwide projects, but their involvement and commitment varied widely between the projects; provincial and regional directorates being closer to the ground were perceived by nine project leaders to be more engaged. The majority of the project leaders interviewed (8 out of 9) reported that obtaining approval and inclusion of governmental bodies were paramount to gain access to (government-run) schools and to build a framework for action. However, it was recognized that this task was often time consuming and difficult. Project leaders described the approval process to enter the schools. We got the permission from the Permanent Secretary of the Ministry of Education first. (Project leader from the Caribbean) By getting the support from the district elected president we could enter the schools [and] . . . many barriers [from teachers and headmasters] were avoided. (Project leader from India) Before we went to the schools we went to the department of education. (Project leader from South Africa) We got the approval stage wise – first the state educational office, then the district educational officer, and then we went to the schools and got their permission. (Project leader from India) We got the approval from the government office first before we even meet the teachers – that’s substantial in order to convince them [the teachers]. (Project leader from India) First we got the clearance from the secretary of education . . ., then the [school] principal and then got the teachers on board. . . . They have to go out there and actually participate . . . they cannot be standing on the side lines directing the students to exercise. (Project leader from Marshall Islands) If you want your intervention to be successful the [school] principal needs to be the driving force. (Project leader from South Africa) All these statements from the majority of the project leaders interviewed emphasize the need to, firstly, get a locally relevant official permission to target the schools. After obtaining such an approval, it seems to be vital to convince the school principal and the teachers who would be involved in the activities. Only
5
one project leader described difficulties with getting the official permissions to enter the schools and hence had to use personal contacts to teachers instead. We tried the official channel first, but in the end we were not able to because of complications and paper work . . . so we started making contacts with teachers. (Project leader from Brazil) These experiences underscore that a large number of stakeholders, at different levels of decision making made it difficult to navigate and determine which administrative levels to address. Several project leaders interviewed (5 out of 9) experienced that there is still a huge discrepancy between the stated NCD emergency and the public health response to it. A project leader described the discrepancy. When considering the rate by which the NCDs are increasing in our country, the initiatives taken by both the public and private sector at present are grossly inadequate. (Project leader from India) The project leaders experienced a large gap between international declarations and actual implementation of effective policies at national, regional and provincial levels. Six of the 15 project leaders reported that there are either no policies or poor implementation of existing policies regarding health promotion in schools. School health policies, if present, are not integrated and target issues in a piece meal fashion making it difficult to gain attention for new initiatives. The study revealed a general lack of effective policies promoting and regulating physical activity in schools. Physical education is on the school curriculum in all countries surveyed, but only as a time slot on the timetable. Furthermore, across nine low- and middle-income countries the study found a general lack of, or poor implementation, of policies regulating nutrition in schools. Seven project leaders from South Africa, Brazil, Caribbean region and India reported free midday meals in schools subsidized by the governments. The execution and objective of such schemes is country specific, but ensuring a daily meal for school-attending children to improve school attendance is common to all. Four project leaders reported that the meal programmes lack focus on quality of nutrition and also particularly, fail to link the service with nutrition education.
Classroom-based health lectures For 14 projects, health education sessions were the cornerstone of their intervention. The project leaders described how such lectures were a prerequisite for other activities as this was where
© 2015 John Wiley & Sons Ltd, Child: care, health and development
6
M. Skar et al.
the students got the knowledge and understanding of the need for behavioural change in order to avoid disease. The duration and frequency ranged between a 40-min lecture, a 1-day session, a 10-week programme, and lastly a programme with 48 planned sessions. The classroom-based lectures informed on causes, prevention and consequences of NCDs and included key messages such as ‘prevention is possible through lifestyle changes’, ‘physical activity improves health’ and ‘there’s a link between lifestyle and NCDs’. Project leaders described the classroom-based health lectures: . . . the initial lecture in the schools was given by the project head and then project staff took up the responsibility of conducting educational lectures and activities with school children. (Project leader from India) We used an active participatory approach, meaning everyone was a teacher and educator in the session. Just to keep maximum participation. (Project leader from Tanzania) At the end of each class, we ask one of the children to give a summary to the rest of the class. The students are very eager to come forward to speak. (Project leader from India) They [the school children] don’t volunteer for the classes, so we teach in the science classes at the schools. (Project leader Marshall Island) We had 4 h of classes: introduction on lifestyle diseases and unhealthy lifestyle. Diabetes and cholesterol is covered because they are major issues. Then also other cardiovascular diseases. Nutrition will also be covered. All this will be covered and then there will be half an hour physical training. (Project leader from India) All 15 project leaders reported that they developed and distributed materials, such as pamphlets, water bottles and footballs. Such materials were used to support the messages conveyed in the health education classes in a culturally acceptable way. For example, eight projects developed pamphlets written in the local language and using locally available food choices and physical activities as examples, and four projects developed the materials in cooperation with teachers and students. The materials were prepared while the workshops for the teachers were going on. Thus it became a group effort. The content focused on the local realities like language, food available and the lifestyle of the people. (Project leader from India)
© 2015 John Wiley & Sons Ltd, Child: care, health and development
Practical health promotion activities In addition to the classroom-based lectures, a wide range of activities were implemented to promote healthy behaviour (Fig. 1). For example, nine projects used students as change agents, where selected students were responsible for measuring body mass index and other anthropometric measurements among peers and parents to identify people at risk. This approach was used to engage the students. The predominant focus of the practical health promotion activities was on physical activity and healthy eating. The project leaders identified several barriers to physical activity and the main barrier was related to the physical education sessions already in place in the schools. The physical time is mostly unstructured and children are usually sent to a playground to play. Many children just use the time to sit around and relax. (Project leader from India) There is one lecture per week dedicated for physical activities and sports, but usually schools tend to cancel this lecture and use the time for other lectures like science and math. (Project partner from West Bank and Gaza) Academically oriented teachers are a problem for physical activity. They [teachers] have very little focus on physical activity. (Project leader from Caribbean) Predominant focus on academic achievements was an important reason identified to explain why physical education has low priority in the schools. Such statements were common for 11 projects leaders who reported that the physical education sessions usually were under-prioritized, unstructured and un-graded. Because of poor execution of the physical education sessions, 14 projects promoted physical activity, and the main approach was to strengthen the status of the physical education sessions and to improve the quality of them. In addition to emphasizing the physical education classes, physical activity were promoted through e.g. sports tournaments, increase of physical activities during break time and arranging public walks. The other important barrier to physical activity identified in the data, was the physical environment, which did not facilitate physical activity. Several schools lacked suitable facilities such as playgrounds. Furthermore, ‘unsafe roads’, ‘lack of parks’ and ‘fear of crime in open public places’ were mentioned as other barriers for physical activity in the environment outside the schools. Consequently, eight projects targeted the physical environment to promote physical activity by providing equipment,
School health promotion in low- and middle-income countries
assessing the facilities with school management and suggesting improvements. The analysis also identified barriers to promoting healthy eating in the schools. Project leaders from India, South Africa and Brazil emphasized the need for approaching food habits cautiously as they were operating in areas where the economic status is not high. For example, it was difficult to advocate for expensive food choices such as fresh fruits and vegetables, as it would not be feasible for economically challenged families. Furthermore, some project leaders reported that implementing healthy food choices in school canteens was hindered by the short shelf life and high spoilage of fresh foods increasing their cost. This, combined with low purchasing power of school children, made it difficult for the canteens to make any profit on these items and they were therefore reluctant to sell healthy food. Children are not very into buying fruits, so before it is sold it gets spoiled. The school canteens want to make profits as well, and they were not able to make that on healthy foods. (Project leader from India) This was a common experience among the interviewed project leaders. Nevertheless, promotion of healthy food was targeted by 11 projects through locally adopted activities such as developing vegetable gardens, cooking competitions where parents were invited and provision of fruits and vegetables in the school canteens.
Discussion The findings and analysis provide insights into how multiple innovative strategies were applied to actively engage the school children and teachers. The study found that the common denominator for the successful activities is the participatory aspect, which is in line with other school-based interventions (Stewart-Brown 2006; Carlsson & Simovska 2012). Activities, which managed to actively involve the students and teachers, increased the sense of ownership and awareness of both students (Mwanga et al. 2007) and teachers. Activities such as establishment of food gardens, cooking competitions, sports tournaments, role plays and walks managed to engage children and teachers in various contexts. Besides the practical, participatory activities, the study revealed that traditional classroom-based lectures are still the predominant way of promoting health in schools. For many projects, health education sessions were seen as a prerequisite for other activities, as this is where the students get the knowledge and understanding of the importance of behavioural change.
7
The typical challenges for implementing school health interventions in low- and middle-income countries appear to be how to engage the students to be physically active in the natural course of everyday life and how to make food choices that are healthy. Such behaviour change face challenges by the structural barriers in urban planning and limited access to playgrounds and fields for exercising; high costs and poor access to healthy food and cultural views on body image (Stewart-Brown 2006). Based on the experiences of 15 project leaders in low- and middle-income countries, one could argue that a first step to promote physical activity among school children is to emphasize that the schools efficiently utilize time slots for physical activity already allocated and available in the school curriculum. An option in this connection could be to grade physical activity on similar lines as academic courses. As revealed in this study, physical activity is under-prioritized because of the lack of time in the school schedule; therefore, efforts should be placed on promoting physical activity in both formal and informal ways, such as physically active games during breaks and improving the physical environment of the school premises. One of the most sensitive and culturally dependent aspect of lifestyle is nutrition (Khare 1980). Many low- and middleincome countries are experiencing urbanization, acculturation and nutrition transition where traditional and locally produced foods are replaced with unhealthy processed food with high content of sugar and fat (Popkin 2006; Franks et al. 2007; Andreyeva et al. 2010; Misra et al. 2011). Growth in food processing and packaging has led to widespread availability of processed and packaged foods, and coupled with aggressive marketing, it is contributing to change in eating behaviour. The new emerging food habits are a major challenge for health promotion in schools (Lytle et al. 2006), and was also emphasized by the project leaders in this study. Therefore, it could be argued that availability and preferential pricing of healthy food in schools should be addressed to enhance school children’s ability to make healthy choices. In this study an opportunity to target school canteen staff as a means to improve healthy food availability and restrict sale of unhealthy food in and around the school premises was identified, pricing unhealthy snacks higher to cross subsidize fruits or other perishable healthy snacks could also be considered. A possible way to enhance learning and create ownership of the activities could be to include both interactive health educational activities that engage the primary targets and involve stakeholders in designing and implementation of activities. This study showed examples of participatory activities such as quizzes, poster making, debates, drama and role plays, cookery lessons, lunch box competitions, and sports competitions,
© 2015 John Wiley & Sons Ltd, Child: care, health and development
8
M. Skar et al.
which could improve lifestyle changes with active involvement of the students, teachers and parents. In addition, advocacy at local political level to create an enabling environment such as adjustment of curriculum, influencing quality of food (mid-day meal programmes) in schools and regulating the types of products sold in school canteens and by neighbourhood vendors could be considered for longer term impact.
Limitations This study has analysed only projects funded by the WDF. Hence, the approaches and experiences revealed in this study may be significant only to this type of projects. Nevertheless, the present study combined lessons learned from a wide range of projects in different countries, with different scope and targets of the projects. Hence we argue that these experiences could also be relevant for other types of school-based health promotion interventions in low- and middle-income countries. The study provides a snap shot of experiences with implementing health promotion activities in schools. Hence, the evaluation of the long-term impact of the students’ behaviours and the sustainability of the school interventions was beyond the scope of this paper, but could be followed up by future research.
Conclusion This research has documented that active participation and activities targeting multiple stakeholders are important for successful implementation of school-based health promotion interventions in low- and middle-income countries. The study has shown that schools can play a crucial role in educating teachers, children and parents in healthy living and thereby facilitate health behaviour change in children relevant for prevention of NCDs. Merely imparting theoretical knowledge to children regarding the importance of physical activity and eating habits is far from satisfactory. Increasing knowledge by health lectures in the classroom does not necessarily translate into behavioural change for the students as many factors influence how students move from knowledge, to motivation, to actual behavioural change (Carlsson & Simovska 2012). The study identified three main barriers to school health interventions including predominant focus on classroom-based health lectures instead of using participatory approaches, difficulties in engaging the students to do physical exercise and introducing healthy food choices in school canteens and premises. The study therefore recommends that applying a whole-school approach to school health projects in low- and
© 2015 John Wiley & Sons Ltd, Child: care, health and development
middle-income countries where behaviours and barriers are targeted simultaneously, and structural changes are put in place in the surrounding environment to support individual change.
Key messages • School-based health promotion in low- and middleincome countries can play an important role for facilitating behavioural change in children. • A participatory approach that engages and involves school children and other stakeholders in designing and implementing activities should be prioritized in addition to advocacy for structural changes that create an enabling environment for healthy living. • Adjustment of curriculum, with special emphasis on promoting the status of physical activity lessons, should be prioritized to increase the level of physical activity during the school day, but informal physical activity could also be promoted. • Influencing quality of food offered in schools and regulating the types of products sold in school canteens and by neighbourhood vendors is paramount for long-term impact on food habits. • To sustain behavioural change, school-based health promotion should be integrated into the formal school curriculum.
Funding The World Diabetes Foundation funded this research.
Conflict of interest All authors had financial support from WDF for the submitted work.
Acknowledgements Sincere thanks to the project leaders in the data collection process by sharing their experiences and perspectives through questionnaires and in-depth interviews. Furthermore, we wish to thank World Diabetes Foundation for allowing us access to the projects and for sponsoring a field trip to India.
References Andreyeva, T., Long, M. W. & Brownell, K. D. (2010) The impact of food prices on consumption: a systematic review of research on
School health promotion in low- and middle-income countries
the price elasticity of demand for food. [Research Support, Non-U.S. Gov’t Review]. American Journal of Public Health, 100, 216–222. Bhatia, V. (2004) IAP National Task Force for Childhood Prevention of Adult Diseases: insulin resistance and type 2 diabetes mellitus in childhood. Indian Pediatrics, 41, 443–457. Carlsson, M. & Simovska, V. (2012) Exploring learning outcomes of school-based health promotion-a multiple case study. Health Education Research, 27, 437–447. Dagogo-Jack, S. (2006) Primary prevention of type-2 diabetes in developing countries. Journal of the National Medical Association, 98, 415–419. DeBar, L. L., Schneider, M., Drews, K. L., Ford, E. G., Stadler, D. D., Moe, E. L. & Venditti, E. M. (2011) Student public commitment in a school-based diabetes prevention project: impact on physical health and health behavior. BMC Public Health, 11, 711–721. Franks, A., Kelder, S. H., Dino, G. A., Horn, K. A., Gortmaker, S. L., Wiecha, J. L. & Simoes, E. J. (2007) School-based programs: lessons learned from CATCH, Planet Health, and Not-On-Tobacco. Preventing Chronic Disease, 4, 1–9. Hanson, M. & Gluckman, P. (2011) Developmental origins of noncommunicable disease: population and public health implications. [Research Support, Non-U.S. Gov’t Review]. The American Journal of Clinical Nutrition, 94 (6 Suppl. ), 1754S–1758S. Hsieh, H. F. & Shannon, S. E. (2005) Three approaches to qualitative content analysis. Qualitative Health Research, 15, 1277–1288. Jiang, J., Xia, X., Greiner, T., Wu, G., Lian, G. & Rosenqvist, U. (2007) The effects of a 3-year obesity intervention in schoolchildren in Beijing. Child: Care, Health and Development, 33, 641–646. Kain, J., Uauy, R., Albala, Vio, F., Cerda, R. & Leyton, B. (2004) School-based obesity prevention in Chilean primary school children: methodology and evaluation of a controlled study. International Journal of Obesity and Related Metabolic Disorders: Journal of the International Association for the Study of Obesity, 28, 483–493. Khare, R. S. (1980) Food as nutrition and culture: Notes towards an anthropological methodology. Social Science Information, 19, 519–542. Kvale, S. (1996) InterViews: An Introduction to Qualitative Research Interviewing. Sage Publications, Thousand Oaks, CA. Lobstein, T., Baur, L. & Uauy, R. (2004) Obesity in children and young people: a crisis in public health. [Review]. Obesity Reviews, 5 (Suppl. 1), 4–104. Lytle, L. A., Kubik, M. Y., Perry, C., Story, M., Birnbaum, A. S. & Murray, D. M. (2006) Influencing healthful food choices in school and home environments: results from the TEENS study. [Randomized Controlled Trial Research Support, N.I.H., Extramural]. Preventive Medicine, 43, 8–13. Misra, A., Singhal, N., Sivakumar, B., Bhagat, N., Jaiswal, A. & Khurana, L. (2011) Nutrition transition in India: secular trends in dietary intake and their relationship to diet-related non-communicable diseases. Journal of Diabetes, 3, 278–292.
9
Mwanga, J. R., Jensen, B. B., Magnussen, P. & Aagaard-Hansen, J. (2007) School children as health change agents in Magu, Tanzania: a feasibility study. Health Promotion International, 23, 16–23. Nissinen, A., Berrios, X. & Puska, P. (2001) Community-based noncommunicable disease interventions: lessons from developed countries for developing ones. Bulletin of the World Health Organization, 79, 963–970. Pan, X. R., Li, G. W., Hu, Y. H., Wang, J. X., Yang, W. Y., An, Z. X. & Howard, B. V. (1997) Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care, 20, 537–544. Pommier, J., Guevel, M. R. & Jourdan, D. (2010) Evaluation of health promotion in schools: a realistic evaluation approach using mixed methods. [Evaluation Studies Research Support, Non-U.S. Gov’t]. BMC Public Health, 10, 43–54. Popkin, B. M. (2006) Global nutrition dynamics: the world is shifting rapidly toward a diet linked with noncommunicable diseases. The American Journal of Clinical Nutrition, 84, 289–298. Ramachandran, A., Snehalatha, C., Mary, S., Mukesh, B., Bhaskar, A. D. & Vijay, V. (2006) The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia, 49, 289–297. Ramachandran, A., Snehalatha, C., Yamuna, A., Mary, S. & Ping, Z. (2007) Cost-effectiveness of the interventions in the primary prevention of diabetes among Asian Indians: within-trial results of the Indian Diabetes Prevention Programme (IDPP). Diabetes Care, 30, 2548–2552. Ramachandran, A., Ma, R. C. & Snehalatha, C. (2010) Diabetes in Asia. Lancet, 375, 408–418. Shah, P., Misra, A., Gupta, N., Hazra, D. K., Gupta, R., Seth, P. & Goel, K. (2010) Improvement in nutrition-related knowledge and behaviour of urban Asian Indian school children: findings from the ‘Medical education for children/Adolescents for Realistic prevention of obesity and diabetes and for healthy aGeing’ (MARG) intervention study. The British Journal of Nutrition, 104, 427–436. Sherman, J. & Muehlhoff, E. (2007) Developing a nutrition and health education program for primary schools in Zambia. Journal of Nutrition Education and Behavior, 39, 335–342. Singhal, N., Misra, A., Shah, P. & Gulati, S. (2010) Effects of controlled school-based multi-component model of nutrition and lifestyle interventions on behavior modification, anthropometry and metabolic risk profile of urban Asian Indian adolescents in North India. European Journal of Clinical Nutrition, 64, 364–373. Stewart-Brown, S. (2006) What is the evidence on school health promotion in improving health or preventing disease and, specifically, what is the effectiveness of the health promoting schools approach? Copenhagen: WHO Regional Office for Europe. Verstraeten, R., Roberfroid, D., Lachat, C., Leroy, J. L., Holdsworth, M., Maes, L. & Kolsteren, P. W. (2012) Effectiveness of preventive
© 2015 John Wiley & Sons Ltd, Child: care, health and development
10
M. Skar et al.
school-based obesity interventions in low- and middle-income countries: a systematic review. [Review]. The American Journal of Clinical Nutrition, 96, 415–438. Veugelers, P. J. & Fitzgerald, A. L. (2005) Effectiveness of school programs in preventing childhood obesity: a multilevel comparison. American Journal of Public Health, 95, 432–435.
© 2015 John Wiley & Sons Ltd, Child: care, health and development
World Health Organization (WHO). (2000) Improving health through schools: national and international strategies/compiled and edited by Isolde Birdthistle. WHO Information Series on School Health. Geneva: World Health Organization. World Health Organization (WHO) (2010) Global status report on noncommunicable diseases 2010. Geneva: World Health Organization.
