Public Health

06/11/13

01:30-03:30 Lecture 6

YL7 Module#01 Principles and Perspectives | Public Health School Health Dr. Rey Baquiran

Group 8 ANTONIO.APELES.CABATAN.CAUSING.EUSTAQUIO.LIM.LLAMIDO.MALANYAON.QUIWA.TAN Page 1 of 7

OUTLINE I. School Health Defined II. Frameworks III. Adolescent: 6 Critical Health Behavior IV. School Health Examples

V. Life Skills VI. Summary VII. Review Questions VIII. Answers to Review Questions

SCHOOL HEALTH DEFINED

“...An integrated set of planned, sequential, and school-affiliated strategies, activities, and services designed to promote the optimal, physical, emotional, social and educational development of students.” Source: Committee on Comprehensive School Health Programs, Institute of Medicine… It aims to improve student outcomes in terms of two grounds:

1. Developmental outcome 2. Educational outcome

What is School Health?

No single definition. Loosely applies to anything on health that is done in the school

setting.

Appropriate setting/venue for: - (1) health of school-aged children and adolescents - (2) clinical work as well as public health work to be done.

Serves purpose for being able to achieve specific outcomes

In practice, “school health” can be anything. They call anything they do on health as “school health” - E.g. school health: feeding programs, eye examinations

(refraction errors), immunization campaigns, DOH capaigns done in the schools, etc.

Why School Health?

New opportunities, unfulfilled needs Builds on investments in early child development (ECD)

- Child Survival Children – 0 to 5 years old refer to statistics or figures on the health of children up to

the age of 5. - If you take a look at the data from way back, there has been

an improvement in the child survival program; a lot of children are surviving and reaching the age of 5.

- Now the challenge is what happens after the 5th

year. Once they start schooling (kindergarten). That’s where the gap is right now. The gap is in terms of various morbidities and problems (e.g. nutrition, oral health, helminthes infestation, etc).

- In the health centers, the children who are there are mostly infants, because they have to complete their vaccines.

- As a system, there is a mechanism in place for taking care of 0-5 yrs old children. But when you talk about morbity of nutrition, oral health, helminthes infestation, substance abuse, sexual health etc., the appropriate area where you can do promotive health and intervention is the school.

Better learning in school and better educational outcomes - Very important connection between health and education - Seminal publication: Health for All. This recognizes the role of

health in promoting education, and the need for education to promote health (education of life skills keep you healthy). You need a certain state of good health to be able to actually learn the metrics expected of you’re in grade school (e.g. when your

tooth is aching, when you cannot concentrate because your tummy is grumbling because you haven’t eaten or because parasites are lurching inside)

Enhanced equity - In the Philippines, there is not much gender issue between

Males & Females. There are a lot more females than males for students and

faculty, compared to other countries such as India and China. - Gender-gap issue has to be addressed by educating the girls.

Promotes youth development

A cost-effective investment in health and education - Cost issue of doing intervention in school health is much

cheaper. - The other reason experts are mentioning is there is a lot more

school health structures (schools) than there are health centers.

- It is a lot cheaper in the school setting as opposed to doing it community-wide

Interplay of Health and Education - Recognizes the role of health in promoting education and vice

versa. - You need to have a certain state of good health to be able to

learn the things expected of you when you’re in grade school. - When you’re hungry, when you’re tooth is aching, its hard to

study. But at the same time, you need education to provide the knowledge to keep yourself healthy.

Education for All (2000) - School health is approached both for the educational and

health outcomes for school-age children - Read salient points raised in executive summary

Schools as a platform for health and nutrition intervention

“Effective delivery relies on the school providing children with age-appropriate, actionable knowledge;

“Serving as a conduit for knowledge on health and nutrition for the community;

“Demystifying health and nutrition; and, “Reinforcing positive behavioral messages and addressing

stigma.”

At the end of the day, what really matters especially for the school-aged years are the life skills. That’s the one point that, hopefully, the whole education system is doing. Those are the skills that the children will carry with them until the adult life.

In our area of health, where we’re supposed to be experts, its something that we can relay so that they have the life skills on health that will help them when they become older. Source: Rethinking School- a key component from Education for All. Bundy D (ed) Washington DC: World Bank, 2011

World Bank Education Strategy

“Ensuring children are ready to learn and enroll on time (MCH, ECD);

“Keeping children in school and learning by enhancing attendance and reducing dropout rates (ECD, school health, school);

“Improving learning at school by enhancing cognition and educational achievement (school health, school feeding).”

More Audio: It is important for us to take a look at school health as an appropriate setting for the school-age child as well as the adolescence.

SCHOOL HEALTH PUBLIC HEALTH __________________________________________________________________________________________________________________________________________


FRAMEWORKS

The two international bodies that have done significant amount in school health:

Health-Promoting Schools

World Health Organization

www.who.int/school_youth_health/gshi/en/ Child-Friendly Schools

United Nations Children’s Fund (UNICEF)

www.unicef.org/lifeskills/index_7260.html FRESH

Focusing Resources on Effective School Health

An attempt internationally and nationally (by DOH and DepEd), to standardize and to make a little bit more comprehensive the different interventions that groups (governmental and non-governmental) are doing as far as school health is concerned.

Four Core Components 1. School Health Policies - In Africa and Muslim countries, the female school-aged

children are not in proportion in number than boys in school especially when they reach the age of puberty menstruation. There’s a drop in proportion of female students at Grade 5 & 6 (during girls’ puberty). Solution is to implement a policy to have separate restrooms for males and females.

- Bottom line is to create simple, rational and effective policies that we need to identify that can promote the attendance of children in school.

- Another example is feeding in school. In India, there is also a drop in attendance regardless of age. The intervention that they implemented is a mandatory lunch program. As a result, in addition to the health aspect, academically, they saw the correlation between the initiation of the lunch program and the increase of attendance of students in school. Its keeping the students in school.

- These are school health policies which will involve people in the school setting but may require a lot more from stakeholders outside the school setting. Opportunity to engage Grace Poe: supports children in school

along the lines of school health and nutrition. 2. Water, Sanitation & the Environment - Dirty and smelly wash rooms: No water supply in school - We are teaching the students how to apply skills on cleanliness

and handwashing, and yet they have an environment that doesn’t have water or facilities to model such behavior to them.

- Schools should be models of water systems or sanitation systems that children can learn and bring home to their families. Do not underestimate the power of the school. There is an authority structure to influence behavior of children. One outcome we want is children bringing new knowledge to

their homes (e.g. nutrition, variety of food, toothbrushing). The multiplier effect.

3. Skills-based health education - E.g. Toothbrushing, handwashing - Simply telling them or instructing them to do it doesn’t work, it

has to be skill-based now (e.g. handwashing, toothbrushing) 4. School-based health services - Most of the time, the school nurses are the teachers (teacher

nurses) - We ask ourselves, are there models we can actually consider

where we are able to provide primary health care services in

the school setting? --- we haven’t explored them but there are models we can use.

Also mentioned are some of the supporting policies UNESCO has identified: (1) community partnership, (2) student participation, (3) health and education. You know what we mean by stakeholder participation and

stakeholder analysis. Even looking at components, you see very well that it is not limited to the principal, to the parents or students alone. There are a lot of players involved in promoting the program

TARGET CLIENT

School-age child

Adolescent School Health as vantage point for greater community

involvement (Multiple / Multi-stakeholder involvement) - “to build a community, build a school home” - the school becomes a focal point in subsequent community

involvement School-age Child: School Health & Nutrition Initiatives

Can be handled or developed in the school setting

Mirror burden of diseases prevalent in a school aged child De-worming and prevention of worm infection;

Use of bed nets to prevent and control malaria;

Hand-washing and prevention of infections;

Tooth brushing and prevention of dental caries; Eye glasses and refractive error;

- Kala ng mga bata ganun na pala kalabo yung daigdig o pisara (blackboard).

- Given corrected lenses, they see the beauty of their surroundings.

- Something hopefully to be picked up in the school setting early on in order to promote learning and health care.

Physical exercise, healthy diet and weight concerns; - Dual burden of disease (Communicable and Lifestyle diseases). - How to nip that in the bud? Too late in adulthood (i.e. doctors

smoke, but they know that they should not be smoking) - Behavioral changes need to happen as early as the school age - If as early as now you can brainwash your child that smoking is

bad, you have a greater likelihood that your child will not try smoking regardless of the ads he receives from tobacco companies

Micronutrient supplementation and micronutrient deficiency; - Vit A and iodine

Food and hunger - Issues of nutrition (wasting, stunting) can be addressed in the

school setting

ADOLESCENTS: SIX CRITICAL HEALTH BEHAVIORS

Six critical health behaviors

Alcohol and drug use

Alcohol and other drug use among our nation’s youth remains a major public health problem. Substance use and abuse can increase the risk for injuries, violence, HIV infection, and other diseases.

http://www.who.int/school_youth_health/gshi/en/

http://www.unicef.org/lifeskills/index_7260.html



Injury and violence (including suicide)

Approximately 72% of all deaths among adolescents aged 10-24 years are attributed to injuries from only four causes: motor vehicle crashes (30%), all other unintentional injuries (15%), homicide (15%), and suicide (12%).

Tobacco use

Each day in the United States, approximately 4,000 adolescents aged 12-17 try their first cigarette. Each year cigarette smoking accounts for approximately 1 of every 5 deaths, or about 438,000 people. Cigarette smoking results in 5.5 million years of potential life lost in the United States annually.

Nutrition (i.e. obesity) Healthy eating is associated with reduced risk for many diseases, including several of the leading causes of death: heart disease, cancer, stroke, and diabetes.

Physical activity

Participation in physical activities declines as children get older. Overall, in 2005, 36% of 9-12 graders had participated in at least 60 minutes per day of physical activity

Sexual risk behaviors

Every year, there are over 19 million new STI infections in the United States, and almost half of them are among young people ages 15-24 years old

“These behaviors usually are established during childhood,

persist into adulthood, are inter-related, and are preventable. In addition to causing serious health problems, these behaviors also contribute to the educational and social problems that confront the nation, including failure to complete high school unemployment and crime”

School is still the setting to address all 6 issues and health concerns of the adolescent population

Why do we need to worry about them? People and science are recognizing that chronic diseases (both medical and psychoemotional, including mental health conditions), are rooted to conditions that happened as early as childhood (adverse childhood experiences)

Figure 1. [Pyramid of Contributing Factors] – Mechanisms by Which Adverse Childhood Experiences Influence Health and Well-being Throughout the Lifespan Adverse childhood experiences: physical abuse, emotional abuse, sexual, alcohol, household incarceration of family members, depression, violence, absentee parents, emotional or physical neglect.

There is hard data to support that what happens in childhood do have an impact on the disability, both on physical and mental health of individuals

See how the bottom of the pyramid, the adverse childhood experiences contribute as one gets older to conditions of disability, disease, social problem, the adoption of risky behaviors and eventually, early death.

These are in terms of actual data analysis (not concepts or theories) - Retrospective studies (those with such conditions and going

back, doing the associations and case controls) - Prospective studies (follow children or young pediatric age

group through adulthood and noting all of the things that happen)

Those experiences do have impact on the disability both on the physical health and the mental health of individuals.

This burden is going to increase. Previous focus is on intervening when it has already happened,

but is there some way for us to go down to the actual childhood experiences and do more promotive health there?

School is one arena where you can do them

Users of Primary Pediatric Care Clinics

Infants- 40% Toddlers- 30%

School-age- 20%

Adolescents- 10% - This is an informal survey of three private pediatric clinicians. - Seen in the breakdown, they hardly reach adolescents. - Talking about critical health areas that involve the

adolescents, the clinic of the pediatrician is not the venue for addressing those concerns of the adolescents.

- The survey means two things: [1] Pediatricians in practice (public or private), if they have an adolescent in their clinic, they have to exert extra effort to address issues. [2] We should start thinking of other venues where we can reach the adolescents, and the school setting is one (they are a captive audience, because out of the 365 days in a year, they spend as much as 200 days in school).

ENCOUNTER WITH ADOLESCENTS HEADSS

Home

Education/employment/eating patterns

Activities

Drugs Sex/sexuality

Suicide/depression - Guide questions and trivia questions for each area - Emphasize the need to do these tests with some seriousness;

you might just be able to make a difference in the life of that person.

GAPS

Guidelines for Adolescent Preventive Services - Tool published by American Medical Association - Handy screening tool used by pediatricians and practitioners

that can be handed out to students waiting in the clinic or given as a screening tool for the whole class

- There is a way for the respondent to identify the specific issue he/she may have



There is comprehensive listing of issues Consistent with health areas of concerns for adolescents (i.e.

eating, friends, family) Questions like: Are you satisfied with your eating habits? Do

you exercise or participate in sports that make you sweat and breathe hard for 20 minutes or more at that time, at least 3 times a week? (Definition of what appropriate exercise should be)

- If you have a lot of responses in a certain category column, that should raise a red flag. Easy to use for addressing the issue. This is an opportunity for them to open up and engage them (used in Loyola schools with good feedback). Sometimes the physicians are the ones who become

uncomfortable with it because the adolescents are actually talking. If adolescents open up and tell you they have these certain conditions, it is a good sign that means they are ready to talk about the certain topic (e.g. checked STD as a concern, marijuana)

- On an individual basis, it is a very useful test, but it can also be used as a group-screening test. For group, you have to respond immediately to the answers, because like any other screening test, when you see a positive result, you cannot dismiss that, you must explore that further. Like when you have screened positive to G6PD in newborn

screening, you don’t just say “Positive po kayo sa G6PD,” you have to validate and confirm that. Same thing as this screening test like this, if you have positive responses, need to explore that with the adolescent.

SCHOOL HEALTH: EXAMPLES

Bullying prevention program Latest in the Phil: already a Republic Act, awaiting signature of

the President. Sponsored by Antonio Trillianes in the Senate. Started in the US as school-based.

“Olweus Bullying Prevention Program” at www.olweus.org - Bullying 101 for Principals

Specific methods employed - (Localized) Assessment of problem - Setting school conference days - Providing better supervision at recess - Forming a bullying prevention coordination group In the Phil: slogans of schools saying “Bullying is not

allowed,” Chris Tiu: “Not in Our Schools” - Scheduling parent-teacher meetings - Establishing classroom rules about bullying - Convening classroom meetings about bullying - Requiring talks with bullies and victims - Inviting talks with parents of involved students

(Cyber bullying mentioned as new advent of bullying) - through facebook, twitter, text, etc

Outcomes/Evidence - (There are outcome measures) - Longitudinal cohort evaluation: 50% reduction in the number

of students bullying others as well as in the number of victimizations

- Validated by other studies School Health Interventions

School-based health centers (SBHC) - These are examples of models we can use to provide clinical

services to needy schools where [1] there are many children or

adolescents in school and [2] there are no professionals trained at providing primary health care. Like a system in New York, there is a close collaboration

between the public school system and private institutions (e.g. medical center with an established school-based program). What they do is that the medical center runs the clinics in the different public schools. They provide the primary care centers, and a huge variety of services (primary care, health assessment, intakes). The morbidity there is asthma, so they have asthma intervention and education. They provide laboratory services if necessary, blood can be drawn on site, and results can be discussed with parents. In addition, there are mental health providers, such as a psychologist and a social worker with training and clinical work. Reimbursement is in terms of insurance (Medicaid). Through the school health programs in the city, that’s the entry point where people are provided with insurance (Medicaid), and that’s how the medical center gets paid (reimbursement scheme). The schools provide the spaces where the clinics can be housed.

School health insurance (Vietnam) - Vietnam: use schools as an avenue to issue insurance Conditional Cast Trust Program (trans,2015)

- Similar to cash transfer code (CTC) that we have. Requires that you are in school before insurance is given to the family

- CTC requires that your child has attended school and received vaccinations before financial support to your family is released

Issue-specific intervention - Bullying Prevention - Physical Activity/Obesity - Alcohol, Tobacco, and Substance Abuse - Asthma Gather kids with asthma, find symptoms and what do they

do when they have symptoms. Their catch phrase is “I have asthma, but asthma doesn’t have me!”

Peer counseling - An example of an intervention for senior high school (grades 8-

12) - Initiated by the school-based center to address the issue on

drug use and risky sexual behaviors - Trained peer counselors Talk and identify students who require treatment On-site Also for follow-up Support and counseling (because they work in tandem with a

mental health professional) Uses the school setting to address burden that would not be

addressed otherwise if you use the community system that is outside.

Blue Plate for Better Learning- 4k Feeding Program It’s already the second year of Blue Plate Program in the 4

schools in Quezon City

Outcome measurement - Using baseline weight as controls for the study - Used the standardized growth chart of WHO (baseline weight

is compared to weight or BMI for age) - Percentile growth as endpoint - Study was also able to measure rate of growth

http://www.olweus.org/



The Blue Plate Program was not done primarily as a health intervention; rather it was done as an educational intervention and a social safety support as well.

The data collected is there to support a wider implementation of the program. - If we can get a portion of the pork barrel or money from our

legislators, we can establish or support a school-wide lunch program.

Essential Health Care Package

Interventions - Hand washing - Tooth brushing - Mass de-worming

Sustained by local stakeholders Mines Elementary School (YL-8 LEC Group)

Sample School Health program (www.fitforschool.ph)

Fit for School

“Fit for School Inc. is a Philippine Non-Governmental Organization that works closely with the health and education sectors, various development agencies and private partners on effective school health programs. It offers information, technical assistance and a high-level network to support the institutionalization of school health programs.”

Four Core Components 1. School Health Policies 2. Water, Sanitation, and the Environment 3. Skills-based Health education 4. School-based health services

Three Supporting Strategies 1. Health and Education 2. Community Partnership 3. Student Participation

Source: http://www.fitforschool.ph

Sustaining School Health

Not a one-time or limited intervention

Need for a systemic and systematic perspective and framework Video: Fit for School Started in schools in Cagayan de Oro “Fit for School” is the name of the program which is implemented

in a good number of sites. In the Misamis province, there is support coming from the

provincial governor. If you noticed the dispenser and how much toothpaste it contains,

that’s the only amount of toothpaste you need. You don’t have to follow the commercials where you put toothpaste across the whole length of the toothbrush.

If you notice how they brush their teeth, they just spit out the froth and don’t gargle after. That is what is taught now. You don’t need to. This is based on 2 grounds:

(1) The small amount of fluoride that you swallow is good because there is low fluoride supplementation in the Philippines – there is no fluoride in our water supply.

(2) The froth that remains help coat the enamel and prevent caries

You can tell that to the children that you will be meeting in your LEC

It’s a simple intervention. They recognized what the burdens are: Hand washing because of infection

Oral health

Parasitism They used the school as the medium to deliver interventions The outcome measures of these interventions (were already

taught by Dr. Monse according to Dr. Baquiran) are based on many studies where they have implemented the program.

Drop in the prevalence of dental carries was as much as 60% Sustainability is important

It cannot be a simple one-time intervention

You must think about providing interventions systematically

Fluoride patrols (student leaders) - Born from the deliberate effort to make sure that the program

will work - Student-driven: students are running the program

If you give the job to the teacher (instead of the fluoride patrols), it will not work because the teacher has a lot of responsibilities and work already. The teacher will simply supervise the student leaders.

Figure 2. Wagstaff’s Conceptual Framework for Understanding the Determinants of Health Outcomes

You can use this as a framework in developing a program Fit for School:

Who are the providers? The students, they’re the ones doing it.

Who’s going to finance it? This is where the private sector comes in. (For the public sector) package it in such a way that it can also benefit the politician (i.e. the toothpaste tube will have the picture of the governor).

This is taking all in a systemic perspective so you can be able to sustain the initiative.

The Wagstaff matrix talks about the need to identify and promote the resiliency factors.

The children bring those attitudes and practices at home multiplier effect younger kids who are not in school will also imbibe the habit brought home

Same effect is seen in Blue Plate: the parents who are not so involved ask their kids what they ate in school and the children would respond “mongo at malunggay”.

Choose interventions in the school setting and push it to the community improve resiliency factors

http://www.fitforschool.ph/



Functions and Objectives

Figure 3. Functions and Objectives of School Health-based Programs Taking a systemic perspective: not just the delivery of services but

creating resources to be able to deliver services (how do you finance?)

When a governor loses, how do you make sure that funds will still continue?

How do you engage people and stakeholders? How will you make sure that support for the program will

continue? **Audio note: The succeeding texts were not thoroughly discussed by Dr. Baquiran

LIFE SKILLS

“Skills for Health” Education for All

“Life skills as a basic learning need for young people” (UNESCO) Life Skills-based Education

“… an interactive process of teaching and learning which enables learners to acquire knowledge and to develop attitudes and skills which support the adoption of healthy behaviors” (UNICEF)

Skills-based Health Education (FRESH – Focusing Resources on Effective School Health – Framework)

COMMUNICATION & INTERPERSONAL SKILLS - Interpersonal communication skills Verbal/ nonverbal communication Active listening Expressing feelings, giving feedback (without blaming) and

receiving feedback - Negotiation/ refusal skills Negotiation and conflict management Assertiveness skills Refusal skills

- Empathy Ability to listen and understand another’s needs and

circumstances and express that understanding - Cooperation and Teamwork Expressing respect for other’s contribution and different

styles Assessing one’s own abilities and contributing to the group

- Advocacy Skills Influencing skills & persuasion Networking and motivation skills

DECISION-MAKING & CRITICAL THINKING SKILLS

- Decision making/ problem solving skills Information gathering skills Evaluating future consequences of present actions for self

and others Determining alternative solutions to problems Analyze skills regarding the influence of values and attitudes

of self and others on motivation - Critical thinking skills Analyzing peer and media influences Analyzing attitudes values, social norms and beliefs and

factors affecting these Identifying relevant information and information sources

COPING & SELF-MANAGEMENT SKILLS - Skills for increasing internal locus of control Self esteem/ confidence building skills Self awareness skills including awareness of rights,

influences, values, attitudes, rights, strengths and weaknesses Goal setting skills Self evaluation/ Self assessment/ Self-monitoring skills

- Skills for managing feelings Anger management Dealing with grief and anxiety Coping skills for dealing with loss, abuse trauma

- Skills for managing stress - Time management - Positive thinking - Relaxation techniques - Not a one time or limited intervention

How do you develop these skills while at the same time delivering basic education? Integration

i.e. Reading food labels - How can a grade school or high school student understand it?

Include it in mathematics or arithmetic class as a tool to introduce the subject.

SUMMARY

School Health is defined as an INTEGRATED set of planned, sequential, and school-affiliated strategies, activities, and services designed to promote the optimal, physical, emotional, social and educational DEVELOPMENT OF STUDENTS in two grounds: Developmental and Educational Outcome.

School health intervention can vary for the simplest of intervention to a more complex one.

Reasons why the school was chosen as an avenue for health

New opportunities, unfulfilled needs Builds on investment in early child development

Better learning and educational outcomes

Enhanced equity

Promotes youth development Cost-effective

Interplay of health and education

Education for all Frameworks used in creating the concept of School Health

Health-Promoting Schools Child-Friendly School

FRESH (w/c includes School health policy, water, sanitation, & environment, skill-based health education, and school-based health service



There are two international bodies responsible for these: WHO, UNICEF

School is also an avenue to address the six critical health behaviors identified, which includes alcohol and drug use, injury and violence, tobacco use, nutrition, physical activity, and sexual risk behavior

Examples of School Health

Bullying prevention program

School-based health centers

Blue plate for better learnin-4K feeding program EHCP

School is also an avenue to develop life skills particularly skills for health

Communication & interpersonal skills

Decision-making & critical thinking skills Coping & self-management skills

REVIEW QUESTIONS

1. All of the following are included in the Six critical health

behaviors for adolescents EXCEPT:

a. Alcohol and Drug use

b. Physical Activity

c. Getting Tattooed

d. Tobacco Use

2. Which of the “Life Skills” includes the ability to listen and

understand another’s needs and circumstances and

express that understanding?

a. Communication & Intrapersonal skills

b. Decision Making Skills

c. Coping Skills

d. Self-Management Skills

3. Which “Life Skill” includes information gathering skills?

a. Critical Thinking Skills

b. Decision making skills

c. Empathy

d. Cooperation and Teamwork

4. T/F - The World Bank Education Strategy aims to enhance

learning through feeding students.

5. T/F – For the School-aged child, school health programs

should include a de-worming program but not the

provision of corrective lenses.

ANSWERS TO REVIEW QUESTIONS

1. C

2. A

3. B

4. F – this strategy aims to enhance learning through keeping

children in school and reducing dropout rates

5. F – The ability to read (well), is important to the education

of the school-aged child, so it should include the provision

of corrective lenses to those that need them.

Public Health

Documents

health of school

health of children

school health examples

oral health

sexual health

promotive health

role of health

health centers