CHAPTER TWO

LITERATURE REVIEW
The chapter provides the literature review of the study. It will be discussed under the following
sub-headings:
1. Theoretical framework for the study
I. Theories of School Health Programme

The Health Belief Model

The Health Belief Model (HBM) is a model that attempts to explain and predict health behaviour

(Becker, Drachman, & Kirscht, 1999) by focusing on individual beliefs, perceptions and

attitudes. The HBM has been developed to encompass solutions to practical problems in public

health services, and was first developed in the 1950s by social psychologists Hochbaum,

Rosenstock and Kegels working in the U.S. Public Health Services (Rosenstock, 2001).

Broadly spoken, the model illustrates that there will be some predisposing factors that together

with certain enabling and supportive factors will lead people in different directions when they

make choices related to how they are to treat their illness. Predisposing factors involve health

beliefs and attitudes towards the illness, the related treatment, as well as the health services. The

health beliefs people hold include general health beliefs such as how “health” in general is

perceived and willingness to seek help based on a certain medical direction/treatment. It also

includes more specific health beliefs such as perceived susceptibility to the disease, belief in the

diagnosis, and perceived severity of the condition.

The other main constructs that constitute the HBM is “perceived barriers”, which is an

individual's assessment of the factors that discourage a certain health related behaviour, whereas

“perceived benefits” is an individual's assessment of the factors that are seen as a positive

consequence of adopting a certain behaviour. At a later stage the HBM included certain

modifying factors such as demographic variables (e.g. sex, age, ethnicity, occupation), socio-
psychological variables (e.g. socio-economic status, coping strategies), and “cues to action” (e.g.

information provided by powerful others, personal experiences) (Becker, 2000). This means that

perceptions and experiences of for example socio-cultural factors or direct or indirect economic

costs related to the behaviour are all influential. The combination of different factors will

continuously be interpreted and evaluated and subsequently the “sum” of perceived negative and

positive aspects of treatment lead people in different directions, making different choices related

to their health.

The PRECEDE model

Green et al (1980) Predisposing Reinforcing and Enabling Causes in Educational Diagnosis and

Evaluation (PRECEDE) model is one of the most popular and extensively used contemporary

health promotion planning models of recent years. The original PRECEDE model is a four-phase

model that draws from the fields of epidemiology, social-cognitive psychology (behavioural

diagnosis), education and management (administrative diagnosis). Its intention is to establish the

relationship between health-related programmes and their targets in such a way that its

`proximal, intermediate and distal outcomes' can be initially identified and then assessed to

ensure that the programme is internally consistent

(MacDonald, 1998). A demanding, complex, highly structured and linear `effect' model, it is

unlikely that it is used much, if at all, within nursing arenas for these reasons alone.

Naidoo and Wills (1994) state that where it is used, the reality and practice is that it is rarely used

as it is meant to be, usually being simplified by the user. It is worth noting that despite its

complexity, the popularity of Green et al.'s

PRECEDE model of planning has meant that it has been revised and emulated by others, such as

Bonaguro and Miaoulis (1983), who adapted it to incorporate a `social marketing' approach to

health promotion.

Wills (1994) identify that as a health education model and not a health promotion model, the

PRECEDE model of planning is primarily focused on behavioural change. Green and Kreuter

(1991) did go on to further develop the model and produced a cyclic add-on component called

PROCEED. This has produced an overall model that has, in essence, a preparatory effect

component and a stage component to follow. This makes the model more encompassing and

health promotional in its nature, yet more complex to use.

Sanderson et al. (1996) describe the two different approaches that are used in the

PRECEDE/PROCEED model as the two most common types of `diagrammatic' models. They

refer to the former sequence of activities or events as actual or hypothetico-causal relationship

`effect' (how-it-works) models and the latter as `stage' (how-to-do-it) models.

2. Conceptual Framework
History of School Health Programme

Prior to the mid-1800s, efforts to introduce health into public schools were isolated and sparse.

The “modern school health era” began in the mid-1800s 24 after the release of the Shattuck

report, which recognized the role schools could play in controlling communicable disease with

their “captive audience” of children and young people (Allensworth, Lawson, Nicholson and

Wyche, 1997). The era of “medical inspection” began at the end of the nineteenth century when

“medical visitors” went to schools and examined children thought to be “ailing.” (Means, 1975).

The role and advantages of school nurses began to be recognized around the turn of the century

after Lillian Wald, in 1902, demonstrated that nurses working in schools could reduce

absenteeism due to contagious diseases by 50 percent in a matter or weeks (Lynch, 1977). The
range of school-linked health services was broad in the early twentieth century, and school-based

medical and dental clinics were set up to provide services, especially to indigent students.

School health professionals often state that the ''modern school health era" began in 1850 (Pigg,

1992). In that year, the Sanitary Commission of Massachusetts, headed by Lemuel Shattuck,

produced a report that had a significant impact on school health and has become a classic in the

field of public health. Shattuck served as a teacher in Detroit and as a member of the school

committee in Concord, Massachusetts, where he helped reorganize the public school system. His

background led to school programs receiving major attention as a means to promote public

health and prevent disease (Means, 1975). The report states the following: “Every child should

be taught early in life, that, to preserve his own life and his own health and the lives and health of

others, is one of the most important and constantly abiding duties. By obeying certain laws or

performing certain acts, his life and health may be preserved; by disobedience, or performing

certain other acts, they will both be destroyed”. By knowing and avoiding the causes of disease,

disease itself will be avoided, and he may enjoy health and live; by ignorance of these causes and

exposure to them, he may contract disease, ruin his health, and die. Everything connected with

wealth, happiness and long life depends upon health; and even the great duties of morals and

religion are performed more acceptably in a healthy than a sickly condition.

Soon after the release of the Shattuck report, the medical and public health sectors began to

recognize the role that schools could play in controlling communicable disease with their

"captive audience" of children and young people. For example, even though a vaccine had been

developed years earlier, smallpox continued to strike well into the latter half of the nineteenth

century, due to the constant influx of new immigrants and the mobility of the population. When

New York City was faced with an outbreak of smallpox in the 1860s, no mechanism was in place
to provide free vaccinations to those who needed them, so the Board of Health turned to the

schools. Education officials agreed to permit inspection of school children to determine whether

or not they had been vaccinated, and in 1870, smallpox vaccination became a prerequisite to

school attendance (Duffy, 1974). Although the schools of this period had the potential to

confront and control communicable disease, no doubt they also contributed to the spread of

disease. In the late 1860s and early 1870s, the New York City Board of Health instituted a

program of sanitary inspections of all public school twice a year. These inspections revealed a

filthy environment and excessive crowding. Modern plumbing was nonexistent, and schools

were sometimes overrun by rats. Frequently, more than 100 students occupied a single small

classroom, with two or three children sitting at the same desk. Classrooms lacked ventilation and

fresh air, a problem exacerbated by using stoves for heating and gaslights for illumination. These

problems continued in New York City even into the early twentieth century, and no doubt the

situation was not unique to New York (Duffy, 1974).

The era of school "medical inspection" began in earnest at the end of the nineteenth century

(Means, 1975). In 1894, Boston appointed 50 "medical visitors" to visit schools and examine

children thought to be "ailing." By 1897, Chicago, Philadelphia, and New York had all started

comparable programs, and most of the participating medical personnel provided their services

without compensation. The success of these early programs developed into more formalized

medical inspection. In 1899, Connecticut made examination of school children for vision

problems compulsory. In 1902, New York City provided for the routine inspection of all students

to detect contagious eye and skin diseases, and employed school nurses to help the students'

families seek and follow through with treatment. In 1906, Massachusetts made medical

inspection compulsory in all public schools, a step that ushered in broad-based programs of
medical inspections in which school nurses and physicians participated. Legislative mandates

became the means of ensuring medical inspections, and legislation continues to this day to be the

basis for many elements of school health programs.

The most significant school health education initiative of the 1960s was the School Health

Education Study. This study defined health as a dynamic, multidimensional entity and outlined

10 conceptual areas of focus that over the years have often been translated into 10 instructional

content areas. These conceptual areas include such themes as human growth and development,

personal health practices, accidents and disease, food and nutrition, mood-altering substances,

and the role of the family in fulfilling health needs.

In Nigeria, an attempt was made in 1929 to introduce a medical service that could cater for

school children. A scheme was proposed that entrusted school inspection to medical officers with

special training in that field and a thrice-a-year examination of school children throughout their

school years (Oduntan, 1972). In 1944, the Christian Council of Nigeria called attention to the

high incidence of malnutrition among school children and hoped that government would

inaugurated the proposed school medical service. In 1952, the government of western Nigeria

published a policy white paper that contained a four-year plan to introduce a school medical

service which would be available and free to all children. The objectives of this policy were to

ensure that all school children received regular medical examinations, bring teaching of health

into children's homes and also provide a liaison between the homes and medical authorities. In

1971, a school health service headed by a medical officer and assisted by other professional

heads emerged at the Federal Government level in Lagos. Special clinics were set up to serve as

treatment points for school children with minor ailments, in some state capitals and large towns

such as Ibadan, Enugu, Kaduna, Benin City, Zaria and Jos.

In 1987, Nigeria adopted a comprehensive national health policy which accepted Primary Health

Care (PHC) as the foundation of this policy and the principal method of ensuring the provision of

health for all her citizens by the year 2000 and beyond (Bravema and Tarimo,1994). The

National Health Policy (1988) adopted the Alma‘s definition and declaration of primary health

care as:

Essential health care based on practical, scientifically sound and socially acceptable methods and

technology made universally accessible to individuals and families in the community and

through their full participation and at a cost that the community and country can afford to

maintain at every stage of their development in the spirit of self-reliance and self-determination

(National Health Policy, 1988). The idea of primary health care scheme is to ensure that both

rural and urban dwellers not only have access to meaningful health care but also that they

participate actively in the implementation of every facet of the prorgamme. The idea of equal

access and affordable health care for all the people could only be brought about by the education

of the public about how they could effectively carry out their own health care. For primary health

care programme to succeed in this country, Nigerians must be educated about primary health

care concepts. This involved a number of educational issues which are essentially dependent on

systematic health education.

Concept of Primary Health Care

Primary health care was described in the 1978 Declaration of Alma-Ata as: “essential health care

based on practical, scientifically sound and socially acceptable methods and technology made

universally accessible to individuals and families in the community through their full

participation and at a cost that the community and country can afford to maintain at every stage

of their development in the spirit of self-reliance and self determination. It forms an integral part
both of the country’s health system, of which it is the central function and main focus, and of the

overall social and economic development of the community. It is the first level of contact of

individuals, the family and community with the national health system bringing health care as

close as possible to where people live and work, and constitutes the first element of a continuing

health care process”(WHO, 1978).

Primary health care is the first point of contact with the health system and involves the provision

of integrated, accessible health care services by a variety of providers in the health sector. It

includes care given on first contact and in ambulatory settings. Primary care services encompass

preventative, promotive, curative, supportive and rehabilitation services. These services,

provided by professionals from different disciplines, attempt to enhance the individual’s

physical, mental, emotional and spiritual well-being, and address factors that influence their

health. The services are usually designed to deliver services in conjunction with community

service providers.

Primary health care services encompass the general health of a population. Most poor and middle

income nations’ disease burdens are managed by primary health care services (Ehiri et al, 2005)

Primary health care constitutes the foundation of the health care delivery system in these

countries and is accepted as the best model for delivering basic health care to their populations.

(Lewis et al, 2004)

Concept of Health Literacy

The World Health Organization (WHO, 1998) defined health literacy as the motivation and

ability of individuals to gain access to, understand and use information in ways which promote

and maintain good health. The National Consumer Council similarly suggested (Sihota and

Lennard, 2004):‘Health literacy is defined as: ‘the capacity of an individual to obtain, interpret
and understand basic health information and services in ways which are health-enhancing'. The

core elements in all these versions are capacity/skills to process information and to make

decisions in relation to health.

Promotion of health literacy in the school environment has been a longstanding activity, and

there is general agreement of the suitability of school as a vehicle for promoting health. Indeed, it

has been argued that health promoting schools also tend to be more effective in a range of non-

health related ways (St Leger, 2001; Public Health England 2014). The 1980s saw a wave of

interest in implementing health promoting schools across Europe and in North America, led in

part by the WHO’s (2012) programme in this area. An effective health promoting school will

lead to higher levels of health literacy among the pupils. This is likely to be as important both at

primary and secondary levels. Assessment of the effectiveness of the WHO Health Promoting

Schools framework identified health promoting school interventions as needing all of the

following three elements (Langford et al, 2014):

i. Input to the curriculum

ii. Changes to the school ethos

iii. Engagement with families and communities.

Simply having one or two elements was not sufficient. The Health Promoting Schools evaluation

noted limited success unless the approach was holistic. Issues tackled in health promoting

schools have included physical activity and nutrition, drugs and alcohol, bullying, mental health,

sexual health and multiple risk behaviours among others. In their Cochrane review assessing the

effectiveness of the health promoting schools programme on the basis of 67 trials, Langford et al

(2014) concluded that there were mixed effects. Positive effects were noted for reductions in

body mass index, physical activity, physical fitness, nutrition, tobacco use and bullying, but less
impact on alcohol and drug use, mental health or violence (Langford et al, 2014). As Benham

Deal and Hodges (2009) point out, the traditional health education curriculum has been focused

on specific health risk behaviours (substance use etc), rather than a skills-based approach.

Looking more specifically at attempts to promote health literacy in the secondary school setting

(Wei et al, 2013) provided an overview of 27 articles (including 5 Randomized Controlled Trials

(RCTs)) on mental health literacy programmes. They concluded that the overall quality of

evidence was very low, and that research in this area was still in its infancy, not allowing any

firm conclusions about efficacy. An earlier review of mental health promotion and problem

prevention in schools also concluded that there was mixed evidence for effects, and that the

characteristics of more effective interventions included a focus on teaching skills, on positive

mental health, on intervening early and throughout children’s time at school, and on embedding

work within a whole-school approach (Weare and Nind, 2011). One recent individual RCT of a

classroom based mental health literacy intervention demonstrated improved health literacy and

reduced stigma at 6-month follow-up (Perry et al, 2014).

Concept of School Health Programme

School Health Programme (SHP) refers to all aspects of the school programme which contribute

to the understanding, maintenance and improvement of the health of the school population

(Anderson and Cresswell, 1980). It consists of three main areas namely; school health services,

school health instruction and healthful school environment. School health services deal with

health appraisals, control of communicable diseases, record keeping, supervision of the health of

school children and personnel. School health instruction provides a formal classroom opportunity

for passing on information concerning knowledge, habits, attitudes, practices and conducts that

pertain to individual or group health. Healthful school environment deals with conditions within
the school that are most conducive to optimal physical, mental and emotional health, safety of

pupils, satisfactory relations among pupils, teachers, administrators, as well as for rest, relaxation

and recreation. The three areas are however, not rigidly demarcated as each supports the others

(Faluyi, 1987).

According to Adegbenro (2007), school health has been described as the neglected component of

Primary Health Care in Africa. Since almost every small community has a primary school, in

those communities without health centres, it should be possible to use the primary school as a

centre for primary health care delivery not just for the pupils but also for the community

(Akanni, 2001). A well organized and properly executed school health programme can be used to

create safe environment for school children (Adegbenro, 2007). School health programme can

become one of the strategies for promoting primary health care services. All efforts at addressing

the school health programme in Nigeria have remained largely at policy level, with minimal

implementation. Where implementation has been attempted the emphasis has been on outside

rather than within the schools (Adeniyi, 1993).

A comprehensive school health program is an integrated set of planned, sequential, school-

affiliated strategies, activities, and services designed to promote the optimal physical, emotional,

social, and educational development of students. The program involves and is supportive of

families and is determined by the local community, based on community needs, resources,

standards, and requirements. It is coordinated by multidisciplinary team and is accountable to the

community for program quality and effectiveness (Allensworth, Lawson, Nicholson and Wyche,

1997).

According to World Health Organization (WHO, 2005), a health promoting school is one that is

constantly strengthening its capacity as a healthy setting for living, learning and working.
School Health Programmes are primarily based on two pertinent premises. Firstly, the

relationship of quality of learning with the health conditions of students, and secondly,

responsibility of the state to facilitate smooth physical and mental growth of children for their

future role as productive members of the society. A third dimension emphasized in certain

situations is the potential contribution of students in dissemination of health and hygiene

education messages to their parents and community at large. This phenomenon is also termed as

child to child, and child to community transmission of information relating to health care and

disease control. While there is no one universally accepted definition and model of a school

health program, the following essential elements should be considered in designing a school

health program.

i. Services, which include health services (which depend on the needs and preference of the

community and include services for students with disabilities and special health care

needs and the traditional first aid, medication administration, and screening services),

counseling, psychological, and social services (which promote academic success and

address the emotional and mental health needs of students), and nutrition and food

services (which provide nutritious meals, nutrition education, and a nutrition-promoting

school environment).

ii. Education, which includes health education (which addresses the physical, mental,

emotional, and social dimensions of health), physical education (which teaches the

knowledge and skills necessary for lifelong physical fitness), and other curricular areas

(which promote healthful behavior and an awareness of health issues as part of their core

instruction).
 iii. School Environment, which includes the physical environment (involving proper building

design, lighting, ventilation, safety, cleanliness, freedom from environmental hazards that

foster infection and handicaps, safe transportation policies, and having emergency plans

in place), the policy and administrative environment (consisting of policies to promote

health and reduce stress, and regulations ensuring an environment free from tobacco,

drugs, weapons, and violence), the psychosocial environment (including a supportive and

nurturing atmosphere, a cooperative academic setting, respect for individual differences,

and involvement of families), and health promotion for staff (in order that staff members

can become positive role models and increase their commitment to student health).

iv. Community Participation, which includes parent and community involvement(which

consists of involving a wide range of community stakeholders—parents, students,

educators, health and social service personnel, insurers, and business and political

leaders—to develop and form the structure of the school health program tailored to meet

each local community’s needs, resources, perspectives and standards).

As part of measure of improving health programme in schools in Nigeria, the Federal

Government of Nigeria launched the Home-Grown School Feeding and Health program in

September 2005 under the coordination of the Federal Ministry of Education. The program aims

to provide a nutritionally-adequate meal during the school day (UNICEF, 2006). The pilot phase

(Sept, 2005-July, 2006) involved twelve (12) States in the six geopolitical zones; Bauchi, Edo,

Enugu, Federal Capital Territory (FCT), Imo, Kano, Kogi, Nassarawa, Niger, Ogun, Yobe and

Osun States. According to the Federal Government’s directive, the Federal, State and Local

Government were to fund the program with State and Local Government providing the bulk. Up

to February 2010, a total sum of N2, 881, 271, 987.00 was spent on feeding, de-worming,
equipment and materials; out of which the Federal Government released only N88, 788,460

(HGSFHP, 2010). The focus of the program in the state was:

i. To get every pupil fed with a quantitatively and qualitatively adequate meal each school

day.

ii. To ensure provision of healthy and inviting school environment.

iii. Provision of health facilities to take care of pupils’ health needs and problems.

The program was also aimed at boosting food production and farmers’ income since all food

were to be purchased from locality where schools are based.

According to Garram Children’s School (2010) school feeding contributes to the education and

well-being of children. A hungry child does not grow, cannot learn as well and faces many health

risks in the future. School feeding can bring children into school and out of hunger. School

feeding responds directly to the Millennium Development Goals (MDGs) related to hunger and

poverty, education and gender equality, and indirectly to child mortality and maternal health in

the following ways:

1. School feeding leads to outcomes that are mutually reinforcing, helping to lift households out

of poverty to end the inter-generational cycle of hunger. It also facilitates education and

particularly for girls, leads to improved food security, health and nutrition, the effects of which

all contribute to ending hunger.

2. Providing food for consumption at school can relieve immediate short-term hunger which is

very beneficial for learning. Alleviating short-term hunger among children at school helps to

improve performance on school tests and promote normal progression from grade to grade in

completing a basic education.

3. School feeding helps close the gender gap in schools and helps to empower women by

increasing their probability of employment.

4. When girls are educated they are more likely to have fewer and healthier children and to head

families that are food-secure.

5. Maternal and infant mortality rates will decrease and better- educated girls will make more

informed choices.

Importance of School Health Programme

The school health services is needed because children in the school form a large proportion of

the population and are targets for malnutrition, and some other diseases. If their health is taken

care of therefore, a large percentage of the population will be covered. School children at this age

undergo several physical, emotional and developmental changes. These changes may create

problem for the school so the school authorities should recognize these problems and give

adequate solution. School age child comes to school and faces many risks e.g. accidents,

emotional stress, and also communicable diseases. The school therefore is a centre of risk and so

the school authority should take action to solve the problem. The school should care for the

health of the child because teaching about health in school is usually more effective than

teaching elsewhere eg. the mass media. The school health service is made up of important

components such as health appraisal, health examination, referral services, health counselling,

emergency care for sicknesses and injuries, correction of remediable defects, ambulatory

services, health screening, prevention and control of communicable diseases, teachers

observation etc.. For these services to be effective, the school health services needs to be given

adequate attention by education policy makers, school administrators and the public in general.

In Nigeria unfortunately, school health programmes form part of the school curriculum but
seems not to have been acknowledged or accorded the attention and treatment it deserves,

particularly, the school health services(Nwimo, 2006).

School-based health services (SBHS) have the potential to impact on the health of secondary

schools students by providing accessible, comprehensive and intensive health services. However,

currently only limited evidence is available on the effectiveness of SBHS in improving student

health outcomes. Research looking at the effectiveness of school-based health services would

ideally randomise the provision or withholding of school-based health services to schools and

follow the health outcomes among their students.

Kisker and Brown (1996) suggested that students in schools with health centers had greater

access to health care compared with a national sample of students in New Zealand without

access to SBHS, but found few differences in health risk behaviors, mental health, or pregnancy

rates. Another study of African American adolescents from 7 Midwestern US high schools found

that students in schools with SBHS were less likely to smoke cigarettes and marijuana than

students in schools without SBHS, but there were few differences in other areas they examined,

such as alcohol use (Robinson et al. 2003).

Kirby et al. (1991) compared sexual and reproductive health outcomes among students at 4

schools with SBHS and 4 paired schools without SBHS, and also at 2 schools before and after

the establishment of school clinics. They found some evidence of improved contraceptive and

condom use in schools with SBHS, but no consistent effects on self-reported pregnancy rates. A

study of 12 urban California high schools, 6 with and 6 without SBHS, found higher rates of

contraception use in schools with SBHS, but only among female students (Ethier et al. 2011). A

study from New Zealand using data from the Youth’07 national survey of secondary school
students found that there were fewer pregnancies among students at schools with health services,

but only when they provided sufficient doctor and nursing time (Denny et al. 2012).

Improving adolescent health literacy can potentially bring benefits for individuals (better self-

care, improved wellbeing), for schools (better attendance, less burden of illness on classes and

teachers, better academic attainment) and for local areas (more efficient use of services, and

reduced rates of indicators such as teenage pregnancy).

As they make the transition into secondary school and become more autonomous young people

start to absorb information about how to recognise health issues and to learn about where to go

for health services.

The benefits of accessible, high quality primary health care are considerable. The health

outcomes of communities are improved and people feel better about the health care they receive

(Atun, 2004). Accessible and appropriate primary care services also have the potential to

enhance educational outcomes by improving students’ physical and mental health, thereby

removing barriers to learning (Shaffelburg, 1997). This means teachers have more time to spend

on education issues because they are confident their students’ health and social needs are being

attended to and students themselves are more ready to learn (Geierstanger and Amaral, 2005).

Appropriate primary care services can also promote long-term health by encouraging the

avoidance of behaviours that have serious health consequences in adulthood. For example,

cigarette smoking is often initiated during adolescence and is one of the main preventable causes

of mortality in adulthood. In addition, maturing adolescents can be seen as ‘new patients’ who

are learning how to navigate the health care system for themselves (Royal College of Paediatrics

and Child Health, 2003). This is an important step towards students taking long term

responsibility for their own health. School-based services, especially when working in
partnership with health curriculum teaching in the classroom, have significant potential to

facilitate lifelong healthy behaviours.

Objectives of School Health Programme

The World Health Organization’s program “Global School Health Initiative” is designed to

improve the health of students, school personnel, families and other members of the community

The objectives of School Health Programme are as follows:

i. To produce a well adjusted physically vigorous child who is free from disease.

ii. To produce individuals who know how to care for their health, the health of the family

and others.

iii. To bring about continuing appraisal of the child’s health status. To understand the child’s

health needs and offer supervision and guidance for the child.

iv. To prevent and control diseases.

v. To encourage the correction of remediable defects

vi. To make a child become aware of the importance of health and develop healthy practices,

health knowledge, attitude and appreciation towards health.

vii. To develop healthy physical and psychological environment for the child.

viii. To provide first aid care in accidents and emergency.

ix. To promote a state of health, treat minor ailments, prevent diseases and maintain the

health of school population

x. To promote growth and development of every child taking into consideration the child’s

health needs.

xi. To create awareness of the collaborative efforts of the school ,home and community in

health promotion.
 xii. To develop health consciousness among the learners.

xiii. To create awareness on the availability and utilization of various health related resources

in the community.

xiv. To promote collaboration in a world of interdependence ,social interaction and

technological exposure in addressing emergent health issue.

xv. To build the skills of learners and staff for health promotion in the school community.

xvi. Health personnel apply necessary measures in order to be able to prevent communicable

diseases like viral meningitis.

xvii. In case of an outbreak of a communicable disease the Health personnel apply the

necessary measures in order to prevent spreading of the disease.

xviii. The Health Visitor co-operates with other health professionals for the investigation of

certain communicable diseases such as viral meningitis and tuberculosis.

Also, Health personnels give to students the routine vaccinations according to the existing

vaccination program of the Ministry of Health. The students as well as the parents are informed

about a certain vaccine that will be given. In order to vaccinate a student at school it is necessary

that the Health Visitor takes the parents or guardians written consent.

Components of School Health Programme

Health education

Health education is a profession of educating people about health (McKenzie, Neiger,

Thackeray, 2009). Areas within this profession encompass environmental health, physical health,

social health, emotional health, intellectual health, and spiritual health (Donatelle, 2009). The

Joint Committee on Health Education and Promotion Terminology of 2001 defined Health

Education as "any combination of planned learning experiences based on sound theories that
provide individuals, groups, and communities the opportunity to acquire information and the

skills needed to make quality health decisions” (Joint Committee on Terminology, 2001). The

World Health Organization defined Health Education as "comprising of consciously constructed

opportunities for learning involving some form of communication designed to improve health

literacy, including improving knowledge, and developing life skills which are conducive to

individual and community health” (WHO, 1998). The WHO health promotion glossary describes

health education as not limited to the dissemination of health-related information but also

“fostering the motivation, skills and confidence (self-efficacy) necessary to take action to

improve health”, as well as “the communication of information concerning the underlying social,

economic and environmental conditions impacting on health, as well as individual risk factors

and risk behaviours, and use of the health care system”. A broad purpose of health education

therefore is not only to increase knowledge about personal health behaviour but also to develop

skills that “demonstrate the political feasibility and organizational possibilities of various forms

of action to address social, economic and environmental determinants of health. Udoh, Fawole,

Ajala, Okafor and Nwana (1987) defined health education as a process with intellectual,

psychological and social dimensions relating to activities which increase the abilities of people to

make informed decisions affecting their personal, family and community well being. According

to them, health education is an integral part of the school curriculum at all levels, and an integral

component of community based health programme. Mass health education and mobilization of

individuals and the community to create health awareness is an important tool in the realization

of health for all by the year 2000 and beyond. Adegoroye (1984) stated that health education

should run through, and be built into all sectors of the community. There should be family

health education, school health education and community health education.

Health education provides students with opportunities to acquire the knowledge, attitudes and

skills necessary for making health-promoting decisions, achieving health literacy, adopting

health-enhancing behaviors and promoting the health of others.

Physical education

Physical education (P.E.) is an educational course related to the physique of the human body. It

is taken during primary and secondary education and encourages psychomotor learning in a play

or movement exploration setting to promote health (Anderson, 1989). P.E. is very important to

students health and overall well-being. The Centers for Disease Control and Prevention stated

that over the past few years obesity in children (ages 2–5) and adolescents (ages 12–19) has

doubled because of lack of activity and diet. Quality Physical Education programs will benefit

the lifestyle of young people and in many cases already has. Good Physical Education programs

Provide Structure for students to improve students fitness, positive choices, and setting and

reaching goals (Pangrazi,2007).

A particular trend that has developed recently in P.E. is the incorporation of health and nutrition

to the physical education curriculum. The Child Nutrition and WIC Reauthorization Act of 2004

required that all school districts in US with a federally funded school meal program develop

wellness policies that address nutrition and physical activity (Reynolds, 2013). While teaching

students sports and movement skills, P.E. teachers are now incorporating short health and

nutrition lessons into the curriculum. This is more prevalent at the elementary school level,

where students do not have a specific Health class.

Health services

Health services are the most visible functions of any health system, both to users and the general

public. Service provision refers to the way inputs such as money, staff, equipment and drugs are
combined to allow the delivery of health interventions (WHO, 2001). Health services include all

services dealing with the diagnosis and treatment of disease, or the promotion, maintenance and

restoration of health. They include personal and non-personal health services. Health services,

depending on the needs and preference of the community, may include services for students and

special health care needs and the traditional first aid, medication administration, and screening

services for students. Health services are provided for students to appraise, protect, and promote

health. These services are designed to ensure access and/or referral to primary health care

services, foster appropriate use of primary health care services, prevent and control

communicable diseases and other health problems, provide emergency care for illness or injury,

promote and provide optimum sanitary conditions for a safe school facility and school

environment and provide educational and counseling opportunities for promoting and

maintaining individual, family, and community health. Qualified professionals such as

physicians, nurses, dentists, health educators and other allied health personnel provide these

services.

School Health Services refers to prevention services, education, emergency care, referral, and

management of acute and chronic health conditions designed to promote the health of students,

identify and prevent health problems and injuries, and ensure care for students ( Marx and

Wooley, 1998). School Health Services are preventive and curative services provided for the

promotion of the health status of learners and staff. The purpose of the School Health Services is

to help children at school to achieve the maximum health possible for them to obtain full benefit

from their education.

Nutrition services
Under, school health programme, there is access to a variety of nutritious and appealing meals

that accommodate the health and nutrition needs of all students. School nutrition programs

reflect the U.S. Dietary Guidelines for Americans and other criteria to achieve nutrition integrity.

The school nutrition services offer students a learning laboratory for classroom nutrition and

health education, and serve as a resource for linkages with nutrition-related community services.

Qualified child nutrition professionals provide these services.

Health promotion for staff

In the school health programme, there are opportunities for school staff to improve their health

status through activities such as health assessments, health education, and health-related fitness

activities. These opportunities encourage school staff to pursue a healthy lifestyle that

contributes to their improved health status, improved morale, and a greater personal commitment

to the school’s overall coordinated health program. This personal commitment often transfers

into greater commitment to the health of students and creates positive role modeling. Health

promotion activities have improved productivity, decreased absenteeism, and reduced health

insurance costs.

Counseling, psychological, and social services

In this section, services provided to improve students’ mental, emotional, and social health.

These services include individual and group assessments, interventions, and referrals.

Organizational assessment and consultation skills of counselors and psychologists contribute not

only to the health of students but also to the health of the school environment. Professionals such

as certified school counselors, psychologists, and social workers provide these services.

Healthy school environment

Healthful School Environment is one of the interrelated aspects of the Organization of School

Health Programme. The concept “Healthful School Environment” denotes all the consciously

organized, planned and executed efforts to ensure safety and healthy living conditions for all

members of the school community (Lucas and Gilles, 2003). A healthful school environment

(physical, biological and socio-cultural) serves as a major determinant of health and greatly

influences the individual’s level of intellectual growth and development. Provision of healthful

school environment must be guaranteed for efficient performance of staff and learners. All the

necessary services, facilities and tools needed for the physical, social and emotional well being

of the school population must be assured, provided, safeguarded and sustained.

The Objectives of a Healthful School Environment are to:

i. To create a healthy and safe learning environment in the school.

ii. To provide adequate safe water supply and sanitation facilities for use in schools.

The major conditions required for healthful school environment include:

i. Location of schools away from potential environmental hazards.

ii. Protection of the school community from excessive noise, heat, cold and dampness.

iii. Provision of adequate buildings, constructed in line with approved standards, with

particular emphasis on facilities for physically challenged learners.

iv. Provision of an appropriate and adequate amount of furniture for learners and staff.

v. Provision of an adequate number of gender-sensitive toilet facilities.

vi. Provision of adequate safe water supply and sanitation facilities for the school

community.

vii. Provision of proper drainage and waste disposal facilities.

viii. Provision of safe recreational and sport facilities.

 ix. Perimeter fencing of the school.

Parent and community involvement.

Partnership among schools, families, community groups and individuals should be designed to

share and maximize resources and expertise in addressing the healthy development of children,

youth, and their families (Carlyon, Carlyon and McCarthy, 1998). The family, the school and the

community each have valuable resources that may be called upon to support schools and

Organization of School Health Programme. Within the community, many organizations exist that

influence the health, safety and learning potentials of students. The essential functions of family

and community involvement in school health include:

i. Providing time, expertise, and resources;

ii. Supporting student involvement in activities that support health;

iii. Ensuring that students and their families receive needed health services;

iv. Planning jointly to develop relevant and appropriate messages and services;

v. Delivering clear, consistent messages that support health, including high but

attainable expectations and offering appropriate role modeling.

Parents involvement in their children’s education and health enhance the health, self-esteem, and

academic potentials of the children, as well as empower the parents to be more responsible for

the health and education of their children. Regular communication with parents is key to

soliciting their involvement. The following are ways parents can be involved in a coordinated

Organization of School Health Programme:

1. Health services.
Parents with training in universal precaution can be volunteers for school-based health services.

The health team with the assistance of the PTA can plan and implement seminar/workshops for

other parents on first aid, disease prevention and control, and injury prevention.

2. Health Education

Parents can volunteer to have a regular column on students and family health in the schools

newsletter. Parents can ask teachers to require their students to share articles on health with their

parents. Parents can hold health education workshops for other parents, and be involved in

planning and implementation of such workshops. Parents can teach or speak about health related

careers i.e career counseling. Parents and the community may also become involved in the

school health program through organization such as PTA. PTA is a non- profit organization of

parents, educators, students, and other community members.

Coordinated School Health Programme (CSHP)

A coordinated School Health Program (CSHP) is a planned and coordinated school-based

program designed to enhance child and adolescent health, which consists of eight components:

healthful school environment; health services; health education; physical education; counseling,

psychological, and social services; nutrition services; family and community involvement; and

health promotion for staff (CDC, 1997). Coordinated School Health (CSH) is an effective

system designed to connect health (physical, emotional

and social) with education. This coordinated approach improves students' health and their

capacity to learn through the support of families, communities and schools working together.

The Office of Coordinated School Health works with many partners to address school health

priorities.
Roles of the Ministry of Education in School Health Programme

The role of Ministry of Education is as follows:

i. Advocate for routine sanitary inspection of schools.

ii. Revise school curricular.

iii. Support orientation of teachers and learners on the significance of the healthful school

environment.

iv. Facilitate pre- and in- service teacher training on hygiene promotion and sanitation.

v. Ensure sustenance of school health clubs

vi. Conduct operational research into various factors affecting the school environment.

vii. In collaboration with the ministries of information create awareness on the importance of

healthful school environment.

viii. Monitor and evaluate the state of environmental sanitation in the schools.

ix. Coordinate the design, development and distribution of skill-based health education teaching-

learning materials in the country;

x. Give technical support and distribute skills based health education guidelines to all levels;

xi. Develop human resources for skill-based health education at all levels.

xii. Promote intra and inter-sectoral collaboration by establishing relevant for a for effective

skill-based health education.

xiii. Ensure that delivery of skill-based health education is in conformity with this policy, and the

National Health Policy.

Empirical review
Resources allocation and School Health Programme

A National study of the school health system in Nigeria by the Federal Ministries of Health and

Education revealed that only 14 % of head teachers indicated that pre-enrolment medical

examination was mandatory in their schools and 30 % of the students had low body mass index

(BMI). It further indicated that 30 % of students have low BMI and the common health

conditions that contribute to absenteeism include fever (56 %), headache (43 %), stomach ache

(29 %), cough/catarrh (38 %) and malaria (40 %) (FMOE, 2006 ). There is a dearth of school

health clinics in Nigeria and where they exist, the services are not comprehensive enough or not

organized to meet the needs of the pupils (UNICEF, 2007). Studies have shown that primary

school children in Nigeria were not provided with basic health examination services and pre-

entrance medical examinations thus baseline health information about them was absent. There is

also a lack of routine medical examination which would have picked up deviations from normal

which make early referrals impossible and children vulnerable to preventable diseases (Ojugo,

2005).

In another study, Fajewonyomi and Afolabi (1993) studied the status and health needs of nursery

school children in Ile-Ife, Nigeria, using 13 nursery schools. They observed that 12% of the

schools did not have any form of health care facility while 92.3% had no written health

guidelines and there was no any backup resources to which children could be referred for

treatment. 77% of the schools were in the practice of sending sick children home. They found out

that the most common medical condition among nursery school children include cough, diarrhea,
fever, malaria, stomach pain and vomiting. Again, they found out that 61.5% of schools reported

high incidence of absenteeism due to ill-health. They concluded that availability of health and

knowledge about health needs of children in nursery schools investigated were generally poor.

Akinbile and Adelusi (2010) posited that the school health services being part of health

education involving the services of nurses, physicians, health counselors, cleaners and grounds

men no longer exist in either Nigerian basic or secondary schools. This is blamed on the fact that

provisions are not made in terms of facilities, personnel and materials needed for its execution.

Udoh (1999) reported that Nigerian secondary schools have not lived up to the expectation in

terms of implementing some aspects of the health education curriculum. The inability of

Nigerian secondary schools to implement the health education curriculum may have been due to

certain constraints.

Lie (1998) stated that it is a general knowledge that basic health facilities are essential to the

development of a healthful school living. In developing countries like Nigeria its has been

observed that many schools exist where school health services of any kind have not been

considered, medical personnel are hardly found in schools. Students health are hardly appraised

counseled, protected from communicable disease; they are not carried out, in cases of sudden

illness and injuries such a child is ask to go home.

Oyinlade et al (2014) in their study reported dearth of health personnel in Nigeria schools which

also implies that there has not been any improvement in supply of health personnel to school

health care in various parts of Nigeria. Akpabio (2010) in his study reported absence of sick bays

and school ambulance or bus which reflected the poor state of school health services in the

schools with the private schools just slightly better.

Resources utilization and School Health Programme

In the research conducted by Nwimo (2006) on the status of preventive health services in Owerri

educational zone of Imo state, Nigeria. The results revealed that preventive health services were

provided for students in varying degrees. For example, the findings showed that those students

who have communicable diseases are sent to physicians for medical attention. This findings was

encouraging and gratifying. The results also revealed that very few teachers reported students

being isolated, sent to school clinics or excluded from school as measures adopted in cases of

communicable diseases. These results suggested that little attention was given by teachers to

ensure that students with communicable diseases did not come into contact with healthy students

until they are certified fit to join their colleagues. Nwimo (2006) reported that her research

findings showed that many secondary schools in Owerri, Imo state of Nigeria , had poor

ventilation and lighting, poor sanitation and lack health conveniences such as toilet facilities,

overcrowded classrooms, poor water supply or intermittent or inadequate supply ,poor quality

housing and poor health habits.

Onyeyemezi (1996) in Onwuka (1996:45) stated that every where teachers need the basic

knowledge and skills necessary to make the fullest use of resource materials. One of the reasons

why available materials are not used by many teachers in schools and colleges is that they lack

the necessary skills to operate them.

Nwimo (2001) in a survey carried out more recently indicated that there were significant

divergences among schools in most aspects of health appraisal service. He pointed out that

results showed that health appraisal services were provided in the schools albeit in varying

degrees, specially, in the areas of inspection of students, clothing, hair, screening tests for

behaviours; and emergency and hospital attendance records, but not in screening tests for ear and
teeth; and height and weight records as a result of lack of facilities and equipment to carry out

these appraisals. Ejifugha (1993), reported that the only health examination which was provided

to school children in Enugu State, Nigeria were those for measurement of height and weight.

Sofola, Agbelusi and Jeboda (2002) in their study on oral health knowledge, attitude and

practices of primary school teachers reported that teachers had poor knowledge of oral health and

practices.

Ofovwe and Ofili (2007) reported in their study among public primary school teachers that

43.3% of teachers had poor knowledge of School Health Programme. Also, Alikor and Essien

(2005) in a study to assess the knowledge and attitude of primary school teachers regarding

childhood epilepsy in Port Harcourt, Nigeria reported that the overall knowledge of epilepsy and

first aid management of epileptic episode was poor among school teachers. Rotimi et al.(1986) in

their study on students' attitudes towards University health services suggested that time spent in

waiting room by students will lead to implication for future utilization of health care services

such as losing a patient in case of emergency situation. Also in their submission, Cole and

Mackey (1996) emphasized that experts had noted that the amount of time a student waits to be

seen is one factor that affects utilization of health care services. This situation needs to be given

attention because long waiting time could be an impediment to attending lectures. Therefore, the

need to provide urgent attention to students is imperative for effective utilization. Katende (1992)

also stated that accessibility to health facilities affected personal illness control by influencing

both choice and timing of the use of curative facilities or taking no action at all. He therefore

suggested that health facilities should be readily accessible to the students.

Adekunle et al. (2006) also reported that cost of health services and quality of care were

contributory to the non-utilization of health facilities.

In a study in Northern Nigeria by Toma, Oyebode, Toma, and Agaba (2014), it was reported that

school health service activities in private school were significantly better executed than in public

schools. They attributed this finding to better commitment of proprietors and greater provision of

funds to running of their schools.

Appraisal of literature review

Several works were reviewed in this study. The study of (FMOE, 2006) showed that primary

school children in Nigeria are not provided with basic health examination services and pre-

entrance medical examinations thus baseline health information about them was absent. Ojugo

(2005) also noted that there is also a lack of routine medical examination which would have

picked up deviations from normal which make early referrals impossible and children vulnerable

to preventable diseases. Fajewonyomi and Afolabi (1993) showed that the most common

medical condition among nursery school children include cough, diarrhea, fever, malaria,

stomach pain and vomiting. Again, they found out that 61.5% of schools reported high incidence

of absenteeism due to ill-health. They concluded that availability of health and knowledge about

health needs of children in nursery schools investigated were generally poor. Similarly, Nwimo

(2006) in his study revealed that preventive health services were provided for students in varying

degrees.
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