Module 1: Delivering Medical Intervention at Schools in the Developing World

Due to the significant impact of illness and malnutrition on educational outcomes, the role of effective health promotion and simple school-based programs to deliver low-cost interventions becomes increasingly important. A variety of programs have been implemented by several organizations to address a range of health and social issues, including nematode infections, HIV/AIDS, sanitation, drug use, violence and bullying, and nutrition. There are many ways to deliver school health programs, but diverse experiences suggest common features. The government and nongovernmental agencies, as well as other partners and stakeholders, play a significant role in the delivery of these programs. The Ministry of Education is usually a lead implementing agency, and responsibility is frequently shared with the Ministry of Health. The success of a program is also highly dependent on civil society, especially the beneficiaries and their families. The partnership between each of these institutions is critical to the program’s success. Common strategies in effective programs include:(1)

• Focus on education outcomes

• Develop a formal multi-sectoral policy

• Utlize widespread dissemination and consultation

• Use existing infrastructure as much as possible

• Use simple, safe, and familiar health and nutrition interventions

• Provide primary support from public resources

• Utilize inclusive and innovative approaches to identify implementing partners

There are many examples of successful school-based health programs. Perhaps the largest campaigns implemented in many developing countries that utilize the school setting are the de-worming programs provided in schools. These programs have demonstrated a significant impact on the overall health of school children and other community members. Aside from de-worming programs, many other health and nutrition programs have been successfully implemented and will also be described below.

De-Worming Programs in Schools

A range of infectious diseases affects school children. Parasitic worms are a common symptom of poverty and disadvantage. The poorest populations are usually at highest risk, especially children living in remote, rural areas, urban slums or in conflict zones.(2) Parasitic worms, which can cause severe pain and life-long disabilities, are often less visible than other diseases. Schistosomes are a common worm found in lake-side communities, around water development centers like dams, and wherever people are in contact with infested water during their normal daily activities of hygiene, recreation, or irrigation farming. Children are especially at high risk because they often spend many hours swimming and playing in water. Women who care for children are therefore also at risk, and irrigation workers and fishermen are largely at risk due to their exposure to contaminated waters.(3) Helminths thrive in tropical soils where there is a lack of sanitation. Infection occurs when the eggs are ingested from unwashed food or hands, through penetration of the skin from walking barefoot, or due to any other direct contact with infested soil. Children, who often play outdoors and do not have footwear, are highly susceptible to these worms. Worldwide, approximately 2 billion people (25% of the world’s population) harbor these infections. Three hundred million people are severely ill due to worms, and 50% of these people are school children.(4)

In 1999, the World Health Organization (WHO) estimated that schistosomiasis and soil-transmitted helminthiases represented more than 40% of the disease burden due to all tropical diseases, excluding malaria, and that infectious and parasitic diseases are the primary causes of death worldwide.(5) The good news is that many of these diseases can be treated with simple, inexpensive drugs. De-worming requires no specialized training, no injections, and no complicated drug regimens. The drugs are single dose, safe and easy to administer.(6) The medicines can also be administered to young children. Thus, governments and international aid organizations in many endemic countries have recently scaled up treatment and prevention programs. The overall goals of preventing helminth infections and schistosomiasis are to improve children’s health, nutrition and learning capabilities and to improve women’s caring capacity, work efficiency and economic productivity.(7)

“The school system offers one of the most efficient means of reaching school-age children, a high-risk group, in de-worming programs. Non-medical personnel, such as school teachers, can be given basic training which allows them to distribute the drugs and make a large difference.” Using schools as a center for health education has many other advantages. Regular treatment means that children are healthier, leading to increased enrollment and attendance, reduction of class repetition, and higher educational attainment. It is a cost-effective way to regularly treat a key high-risk group.(8)

However, one major concern is that treatment will not reach a large number of school-aged children who are not enrolled in school, particularly older children and those living far away from schools.(9) In Africa in 1996, gross enrollment ratios in primary school were 85.3% (males) and 71.2% (females).(10) The children who were not enrolled would miss the opportunity for a school-based health initiative. Also, recent studies in Africa show that school-aged children who are not enrolled in school have a higher prevalence and intensity of nematode infections than those children who are enrolled.(11)(12)(13)(14) Treating non-enrolled children is an important consideration in maximizing the effectiveness of treatment programs.(15) Despite this, school-based programs can be used to reach non-enrolled children. Reaching out-of-school children could be achieved by community-based control or by encouraging children not enrolled to receive treatment from the school setting.(16) A recent study conducted in an area endemic for S. haematobium in Egypt has shown that it is effective to use advertisement strategies and recruitment of community leaders, teachers and enrolled children to encourage children out of school to attend the school setting for treatment. The study found that more than 85% of the out-of-school children could be treated. As suggested by Jamison & Leslie (1990), children in school could have an important role in encouraging their non-enrolled friends and siblings to attend the school setting when treatment is offered.(17) Overall, the results of many studies support the implementation of school-based approaches, where targeting treatment at children in school will also reduce infection and disease in the rest of the population.(18)

According to WHO, over 300 million children were treated with de-worming medicines in 2011. By 2020, WHO hopes to eliminate soil-transmitted helminthiases in children by regularly treating 75% of the children in high-risk areas. (19)

Other School-Based Health and Nutrition Interventions

Aside from nematode infections, many other diseases affect school-age children. Although school-aged children have the lowest prevalence of any age group, an estimated 3.8 million children under 15 years of age have been infected with HIV and more than two-thirds have died.(20) In areas of unstable transmission, malaria causes 10-20% of mortality among school-age children. Acute respiratory infection, the most common acute infection in school-age children globally, is a significant cause of absence from school.(21) Stunting (low height for age) and low weight are indicators of chronic malnutrition. Hunger reduces one’s ability to perform school tasks. Children age 11-13 years improved their scores on arithmetic tests after one semester of receiving breakfast at school because they attended more regularly and studied more effectively.(22) Micronutrient deficiencies may take different forms, each having a negative impact on the children’s ability to perform well in school.(23)

There are many services that can be offered through school-based programs that will dramatically reduce worm infections, the incidence and impact of malaria, anemia, malnutrition and hunger, and improve care to manage injuries, provide specific treatment and mental health care. Examples of services include:(24)

• De-worming for intestinal worms and schistosomiasis

• Prompt recognition and treatment of malaria

• Insecticide-treated nets

• Micronutrient supplements

• Breakfast, snacks, and meals

• First-aid kits

• Referral to youth-friendly clinics

• Counseling and psychosocial support

Many interventions exist that provide these types of services. A major step forward in school program development was achieved when the FRESH framework was launched at the World Education Forum in Dakar in April 2000.(25) This program partnered with the Education Development Center, Education International, the Partnership for Child Development, UNESCO, UNICEF, the World Food Program (WFP), WHO, and the World Bank. It was recognized that universal education could not be achieved while the health needs of children and adolescents remain unmet. The FRESH framework provides a consensus in designing and implementing effective school health and nutrition programs. These components were essential for equitable and cost-effective programs:

• Policy: health and nutrition-related school policies that are nondiscriminatory, protective, inclusive, and gender sensitive, promoting nutritional, physical and psychosocial health of staff, teachers, and children

• School environment: access to safe water and provision of separate sanitation facilities for girls, boys, and teachers

• Education: skills-based education that addresses health, nutrition, HIV/AIDS prevention, and hygiene issues and that promotes positive behaviors

• Services: simple, safe, and familiar health and nutrition services that can be delivered cost-effectively in schools (such as de-worming services, micronutrient supplements, and nutritious snacks) and increased access to youth-friendly clinics.

The FRESH framework can only be implemented effectively if it is supported by partnerships with health and education sectors, especially teachers and health workers; schools and the community; children and others responsible for implementation. Adopting these strategies would provide a strong initial basis for any pro-poor school health program.(26) Two other key efforts, outlined below, have been implemented to improve health and nutrition in schools.

The Multiagency Effort to Accelerate the Education Sector Response to HIV/AIDS in Africa promotes the FRESH framework specifically and helps education systems carry out policies that avoid HIV/AIDS discrimination and stigmatization. Over 36 countries and a similar number of agencies, bilateral donors, and nongovernmental organizations have collaborated in this effort since November 2002.(27)

The Global School Feeding Campaign of the WFP has provided food aid, and the program also developed a link between nutrition and education. Working with national governments, parent-teacher organizations, and other community organizations, the campaign has promoted policies that make food aid conditional on girls’ participation in education; school sanitation, water, and environmental improvement; nutritional education; HIV prevention education; and nutrition services that include food distribution, de-worming, and alleviation of short-term hunger. Approximately 70 countries have begun to adopt these principles.(28)

There are many benefits of school health interventions. Arguably, the most obvious are the economic returns of improved adult health, resulting in labor force participation, increased wages, and productivity.(29) By enhancing educational opportunities for children through improved health services, programs are creating livelihood opportunities for low-income children and their families.

Footnotes

(1) DA Bundy, S Shaeffer and M Jukes et al., School based health and nutrition programs. In: D Jamison, JG Breman and AR Measham et al., Editors, Disease control priorities in developing countries (2nd edn.), The World Bank and Oxford University Press, New York, USA (2006), pp. 1091–1108.

(2) WHO: With the right medicines and services comes success. (2010).

(3) WHO. Action against worms. PPC Newsletter, March, Issue 1.Geneva: World Health Organization; 2003.

(4) Ibid.

(5) The World Health Report 1999, Geneva, World Health Organization, 1999.

(6) WHO. Action against worms. PPC Newsletter, March, Issue 1.Geneva: World Health Organization; 2003.

(7) WHO. Prevention and control of schistosomiasis and soil transmitted helminthiasis. Geneva: World Health Organization;2002. Technical Report Series No. 912.

(8) WHO. Action against worms. PPC Newsletter, March, Issue 1.Geneva: World Health Organization; 2003.

(9) The effect of the community-directed treatment approach versus the school-based treatment approach on the prevalence and intensity of schistosomiasis and soil-transmitted helminthiasis among schoolchildren in Tanzania. Khalid M., Pascal M., Amir S., Robert N., Benedict N., and Annette O. Transactions of the Royal Society of Tropical Medicine and Hygiene. January 2009 (Vol. 103, Issue 1, Pages 31-37)

(10) United Nations Education, Scientific and Cultural Organization (1998). UNESCO Yearbook 1998.

(11) Hussein MH, Talaat M, El-Sayed MK, El-Badawi A, Evans DB. Who misses out with school based health programmes? A study of schistosomiasis control in Egypt. Trans R Soc Trop Med Hyg 1996;90:362—5.

(12) Hammad, T.A., Gabr, N.S., Husein, M.H., Orieby, A., Shawky, E. and Strickland, G.T. (1997). Determinants of infection with schistosomiasis haematobia using logistic regression. American Journal of Tropical Medicine and Hygiene 57, 454±458.

(13) Useh, M.F. and Ejezie, G.C. (1999). School-based schistosomiasis control programmes: a comparative study on the prevalence and intensity of urinary schistosomiasis among Nigerian school-aged children in and out of school. Transactions of the Royal Society of Tropical Medicine and Hygiene 93, 387-391.

(14) Gyorkos, T.W., Camara, B., Kokoskim, E., Carabim, H. and Prouty, r. (1995). Enquete de prevalence parasitaire chez les enfants d'age scolaire en Guinee-Comakry. Cahiers Sante. 6, 377-381.

(15) Carabin H, Chan MS, Guyatt HL. A population dynamic approach to evaluating impact of school attendance on the unit cost effectiveness of school-based schistosomiasis chemotherapy programme. Parasitology 2000; 121:171-83.

(16) Husein, M. H., Talaat, M., El-Sayed, M.K., El-Badawi, A. and Evans, D.B. (1996). Who misses out with school based health programmes? A study of schistosomiasis control in Egypt. Transactions of the Royal Society of Tropical Medicine and Hygiene 90, 362-365.

(17) Jamison, D.T. and Leslie, J. (1990). Health and nutrition considerations in education planning. 2. The cost and effectiveness of school-based interventions. Food and Nutrition Bulletin 12, 204-214.

(18) Ibid.

(19) DA Bundy, S Shaeffer and M Jukes et al., School based health and nutrition programs. In: D Jamison, JG Breman and AR Measham et al., Editors, Disease control priorities in developing countries (2nd edn.), The World Bank and Oxford University Press, New York, USA (2006), pp. 1091–1108

(20) UNAIDS (Joint United Nations Programme on HIV/AIDS). 2003. AIDS Epidemic Update: December 2003. Geneva: UNAIDS.

(21) Cohen, S., and A. Smith. 1996. “Psychology of Common Colds and Other Infections.” In Viral and Other Infections of the Human Respiratory Tract, ed. S. Myint and D. Taylor-Robinson. London: Chapman and Hall.

(22) Simeon, D. T. 1998. “School Feeding in Jamaica: A Review of Its Evaluation.” American Journal of Clinical Nutrition 67: 790S–94S.

(23) Ibid.

(24) World Bank 2000. The FRESH Framework: A Toolkit for Task Managers. Human Development Network, World Bank, Washington, DC.

(25) Ibid.

(26) DA Bundy, S Shaeffer and M Jukes et al., School based health and nutrition programs. In: D Jamison, JG Breman and AR Measham et al., Editors, Disease control priorities in developing countries (2nd edn.), The World Bank and Oxford University Press, New York, USA (2006), pp. 1091–1108

(27) Ibid.

(28) DA Bundy, S Shaeffer and M Jukes et al., School based health and nutrition programs. In: D Jamison, JG Breman and AR Measham et al., Editors, Disease control priorities in developing countries (2nd edn.), The World Bank and Oxford University Press, New York, USA (2006), pp. 1091–1108

(29) Strauss, J., and D. Thomas. 1995.“Human Resources: Empirical Modeling of Household and Family Decisions.” In Handbook of Development Economics, ed. J. Behrman and T. N. Srinivasan, vol. IIIA. Amsterdam: Elsevier.