Implementation
Assessment of the school
Prior to implementing the Affordable Health Initiative (AHI) Health Promoting School (HPS) a qualified researcher will assess schoolteachers’ behaviour towards transforming the school in a health promoting school and the acceptability, adoption, appropriateness and feasibility of the AHI HPS model, as well as the schoolteachers’ health related behaviour. Data on current school policies, curriculum, social environment and community relationship will also be collected using a validated health promoting status assessing tool. In addition, he or she will carry out a walkabout around the school to assess the built environment. The inventory will assess the school facilities and will identify aspects of the built environment that needs improvement (e.g. source of water, condition of bathrooms, number of sinks and showers) to implement the full AHI HPS intervention. This is the baseline data for future comparisons.
Assessment of treatment needs
A qualified person will carry out clinical examinations, collection of stool samples for laboratory analysis for parasites and applying questionnaires to assess health related behaviour, health state and treatment needs of schoolchildren enrolled in the programme. Clinical examination includes measuring height and weight and assessing dental health. The questionnaire includes validated questions on their demographic, socio-economic, and cultural factors, children’s risk health behaviours, manifestation of a number of diseases and vaccination status, and impact of children’s health on life at school and at home.
Nominate a School Activities Coordinator (SAC)
It is advisable to nominate a SAC. The SAC may be a member of the school staff or a person external to the school. This position is ideally for an educator or a health promotion professional.
School conditions to run the AHI HPS model
The school building must be a safe environment. Schools in urban areas tend to be equipped with safe water and sanitation facilities. A common limitation is a small number of sinks for running the wash hands and toothbrushing at school. This generates a longer quew but it feasiable with more than five sinks.
Run the AHI HPS intervention
The AHI HPS model includes a number of interlinked interventions as listed below.
School Education
The aim of the education component of the AHI HPS intervention is to developing cognitive processes associated with health literacy and life skills. The former lead to literacy and the latter to emotional evolvement, which in turn motivates them to adopt a healthy lifestyle leading to wellbeing, better mental and physical health.
The health promotion approach is a creative and dynamic activity which stimulates reflective thinking among the schoolchildren. This is different than the dominant one that focus on health education. The approach is flexible, engaging and centred on the learner. It encourages interaction (staff/staff, staff/student, student/student), collaboration and communication. It helps them developing attention, perception, memory, language, confident communication, assertiveness, higher reasoning, analytical and critical thinking, interpersonal skills, empathy and self-control to take ownership of their health. Teachers take on the role of a leader to guide, motivate, encourage and help the schoolchildren to set goals leading to good health.
Health literacy and Life skills are delivered through the following activities: introduce a topic using e-learning or storytelling (first session, 15 minutes), apply a quiz game (first session, 30 minutes); moderate a debate on the topic a week later (second session, 45 minutes), moderate a topical group discussion in the following week (third session, 45 minutes) and set a goal for each topic (last session, 45 minutes). A health topic (e.g. “You can take ownership of your health,”) and a life skill topic (e.g. “To be happy is an option”) will be addressed monthly (eight sessions/month). Therefore, headteachers should allocate 90 minutes a week of school teaching time to each class to run this activity. This activity may be run by schoolteachers following a training in the methodology.
The “e-learn” format use video presentation to introduce the topic. It requires audiovisual equipments. As an alternative, “storytelling” is what connects schoolchildren to their humanity. It links human to our past and provides a glimpse into our future. Children like to hear stories, and good story has a beginning, a middle, and an end. It gives them a sense of “nothing is permanent”, an strengths to confront adversity. Stories should be culture appropriate and have characters that the local schoolchildren can relate to.
“Quiz game” is a stress-free way to learn contrary to exams that is a stressful event focussed only on assessment. In the school quiz game the players attempt to answer a series of questions correctly, to test their knowledge about specific subjects. It is a form of assessment that measures schoolchildren’s knowledge, skills, and abilities and gauge a student’s retention and comprehension of a small amount of information. Most children find that quiz games are fun. This is because it feels like playing, contrary to being evaluated, which often generates anxiety in most children. Furthermore, Quiz it enhances the ability to retain information and builds confidence in addition to identifying gaps in knowledge. The teacher select ten questions to form the quiz.
“Debate” is a formal discussion on a particular topic, in which opposing arguments are put forward. In a debate, opposing arguments are put forward to argue for opposing viewpoints. Debating is an important part of children’s education, in particular to develop their cognitive processes. It helps schoolchildren to become persuasive speakers and more informed about determinants of health and life skills in a fun way.This activity does not require special resources. A debating activity can easily be accommodated in a classroom. A u-shaped set up is often best. The debate includes two teams of 10-15 children. The subject of the debate must be related to the learning objectives of the topic presented in the “E-learning” or “Storytelling” in the previous week. The teacher will welcome the schoolchildren to the debate and explain the rules. He or she starts the debate briefly introducing a statement (e.g. “You can take ownership of your health,” “To be happy is an option”). The teacher will act as moderator of the debate, set amount of time to two opposing groups to prepare an argument, make a summary, and choose a speaker to voice the views of the group. Phones can be used to prepare the arguments.
“Group discussion” may be defined as an activity in which a small number of people meet face to face and exchange and share ideas freely or attempt to reach a common-sense decision on a specific theme. Group discussion differs from a debate. In a group discussion there are many people collectively contributing their thoughts, people can interrupt in between to put forward their views, and the arguments may then take a different flow and spawn a consensus view or a range of alternative outcomes. Schoolchildren bring up ideas, solve problems and give comments. The teacher will act as moderator of the group discussion. The format includes a whole school class (20-25 children). The teacher will welcome the students to the group discussion and explain the rules, and starts the group discussion briefly introducing the topic statement. The teacher ends the session by asking the schoolchildren to develop a goal associated with the specific topic addressed (homework), and produce a written and illustrated (drawings, photos, diagrams, graphs) summary of their work awnings, and bring to the next and final concluding session a week later.
“Setting a goal” is a powerful process for schoolchildren thinking about their lives, behaviours, attitudes and values, as well as, motivating them to change their trajectory in the life course. Without life goals there is no plan, route and purpose in life. Many schoolchildren in low-income communities feel if they are adrift in the world and will not reach anywhere worthwhile. A key reason that they feel this way is that they have not been aware of their potential or set themselves formal goals. The e-learning, quiz game, debate and group discussion provides schoolchildren with insights, increases awareness of their behaviour, motivate them either to changing inappropriate behaviours or developing new positive behaviours that assist their life journey. The teacher helps them to develop their own individual goals. Goal setting is in the hands of the schoolchildren and they must set them. Following, the teacher will follow up, keep motivating the children and check their progress towards achieving their goals from time to time.
Agenda:
Delivering the educational activities
a. Identify and recruit school teachers to run this activity;
b. Agree topics with the head teacher and school teachers (health literacy and life skills teaching);
c. Agree aim of individual topics and train online school teachers to run this activity;
d. Plan with school teachers the delivery of the exercise (materials);
e. Agree with the head teacher the time tabling to run this activity.
Delivering of the basic hygiene practices activity
a. Identify and recruit school teachers to run this activity;
b. Plan with school teachers the delivery of this activity (materials);
c. Train school teachers to run this activity;
d. Agree with the head teacher the time tabling to run this activity.
Community education
Community education includes three interventions: community lectures, community quiz game and the health detective game. The same two topics on health literacy and life skills explored at school are introduced to parents in an evening or weekend activity. The lecture always is presented before the quiz game. Therefore, there are four community evening activities in a month of up to 90 minutes each. The whole school community is invited, in particular the school children enrolled in the AHI HPS model intervention and their parents should be motivated to attend these activities. This activity is run on an evenings to facilitate both parents’ attendance.
“Community lecture” takes the format of a talk by an external speaker. The organiser of the lecture will identify external speakers and invite them to give a talk at the school or community centre. An ideal speaker is one that serves as an example of the values, attitudes, and behaviours associated with a specific role. It may also be an expert on the health topic. The guest speaker will use 30-45 minutes lecturing and the remaining time is for questions and discussion.
Agenda:
a. Agree topics;
b. Identify and recruit speakers;
c. Agree aim of the talk with the speaker;
d. Identify and book a room for the talk;
e. Organise reasonable requirements, i.e.: PowerPoint presentation.
“Community quiz game” follows the same format as the school quiz described above. Quiz game assess the learning objectives of the topic covered in the community lecture in the previous week. The organiser will construct quiz games that include a single topic. The questions are in line with the learning objectives of the topic addressed in role model talk, life skills and health literacy, but not the same questions used in the school quiz games. The organiser should develop or select questions appropriate to the level of education of the audience. The community quiz game is played in teams of up to 10 people. Parents and their children play in the same team. They may invite friends, relatives and other school children families to compose a team of ten people. Each quiz game will consist of 20 questions split into two rounds of 10 questions each. At the end of each round there is a break.
Agenda:
a. Identify and recruit a coordinator;
b. Prepare a set of questions related to the talk topic in previous week to be used in the quiz game;
c. Identify and book a room to run the quiz game.
The “health detective game” is a practical epidemiological exercise in the form of a game. This activity may be run by a schoolteacher. The organiser will run two health detective games a year, and each game requires two sessions of 45 minutes each, a total of three hours a year. In the first section, the instructor will set the exercise and instruct the children and their parents on this activity. S/he will identify a common local disease (e.g. an infectious diseases) in the local area and offer clues on its cause. Then, s/he will instruct the children and their parents on where to search for the causes of the disease set in the exercise. An specific form includes space to record information on the environment hazards and risk behaviour associated with the disease set in the exercise. School children in partnership with their parents taking on the role of a detective and will search for environmental and behavioural clues of causes of the disease (investigating the crime) in their community environment. They will be given two months to complete this task and return the recording form filled. In the second session, all participants will assembly at school to work together under the coordination of the instructor to collate and analyse the information collected (solving the crime), and in identifying potential solutions to prevent the occurrence of new cases of the disease (crime prevention).
Physical activities
There are many ways to be active and surpass child’s recommended total 60 minutes minimum physical activities a day. The AHI HPS model advocate adopting low cost physical activities.
“Classroom-based physical activity breaks” offer another opportunity to embed physical activities within the school teaching. It benefits education, physical and mental health. It involves exploration, self-expression, dreaming, and pretending. The intervention includes three classroom-based physical activity breaks of 10 minutes every day, accounting for 50% of the 60 minutes minimum of vigorous- or moderate-intensity physical activity per day. Headteachers should allocate 30 minutes a day of school teaching time to each class to run this activity. This activity is run by schoolteachers.
Agenda
Delivering of the classroom-based physical activity breaks;
a. Agree with the head teacher the time tabling to run this activity.;
b. Agree a range of physical activities and train school teachers to run them;
d. Plan with school teachers the delivery of the activity.
“Activety game” refers to the use of brisk walking, biking, or other human-powered methods (e.g., skateboarding and rollerblading), which equates to moderate-intensity physical activity. This is an ideal low-cost strategy to increase physical activity and may account for 60 minutes daily physical activities alone, without taken time from delivering the school curriculum.“Sport,” including martial arts, is a physical activity with special characteristics. It involves physical movement and skill and is an institutionalised competition under formal rules. Therefore, an ideal physical activity for inclusion within the school physical education classes. It may include individual or team sports. This activity requires special resources including a physical educator coach and a patio, in the absence of sport facilities at school.
“Gardening” is a good …
Basic hygiene practices
Hygiene may be defined as conditions or practices conducive to maintaining health and preventing spread of disease, especially through cleanliness. It refers to personal acts that can lead to good health and cleanliness. Personal hygiene includes body hygiene (skin care), oral hygiene (oral care), hand washing (hand care), face hygiene, fingernail and toenail hygiene (nail care), ear hygiene, hair hygiene (hair care), foot hygiene (foot care), armpit and bottom hygiene, clothes hygiene, menstrual hygiene (personal hygiene for women).
Hygiene practice at school includes “supervising hand washing” and “tooth brushing” with fluoridate toothpaste. Assuming a maximum of 30 school children per class, 15 sinks available and six minutes for each child to wash their hands and brush their teeth, this activity will take 12 minutes per day per school class. Each child should wash their hand and brush their teeth at the school setting twice daily, which increases the total duration of this activity to 24 minutes per class of 30 school children daily. Schoolteachers instruct and supervise schoolchildren enrolled in their classes on hand washing with soap before school meals and tooth brushing with fluoridated toothpaste after school meals. School cleanness should be checked in the morning and afternoon.
Agenda
a. Agree with the head teacher the organisation of the activity. Time table to wash hands before school meals and brushing teeth after;
b. Plan with school teachers the delivery of the activity and identify the best strategy considering the number of sinks.
d. Train school teachers to demonstrate and monitor this activity, and plan the delivery of the activity to their pupils.
Healthy food distribution
A healthy diet is not complicated but expensive. Food distribution is delivered in collaboration with existing approaches, for example as adopted by members of the Global Foodbank Network (see: https://www.foodbanking.org/). This activity is run by the SAC. He/she will collect the food from producers or retailers, take it to a distribution point for collection by the families enrolled in the programme.
Agenda:
a. Identify and recruit donors;
b. Identify and recruit volunteers to collect and pack the food itens;
c. Plan food items storage;
d. Plan food items distribution (school meals and family households)
Health care
Health care includes Dental care and Medical care.
“Medical Health Care” approach is to liasse the local primary health care sector to run this activity. This activity is mainly computer based. This activity does not interfere with school teaching hours. The latter run a surveillance for common diseases and organising referrals to local PHC for vaccination of school children missing recommended immunisation, and treatment of diseases identified in the health screening questionnaire and the stool sample analysis.
Agenda:
a. Identify and recruit a coordinator and collaborators (assessors);
b. Agree the provision of treatment with local primary health care services;
c. Train assessors to carry out screening on schoolchildren for health-related behaviour, obesity, audition, vision, taste, and parasites diseases;
d. Train assessors to check the immunisation status of schoolchildren;
e. Organise a referral system in partnership with local primary health care services for the treatment of health problems identified in the health screening and for the immunisation of the children missing vaccination.
“Dental Health Care” is provided at school setting. It includes screening for dental diseases and providing minimally intervention dentistry. A dentist and a dental auxiliary are required to run dental health care. Treatment should be offered preferably during school hours and if necessary due to high demand during lesson time. In the latter scenario, the children are excused from attending class in pairs to have dental treatment, while the other children remain attending lessons. Taking as an example, a school with 400 6-9-schoolchildren enrolled in the programme, it would take proximally 40 hours (one week of dentist time) to eradicate untreated dental caries in all schoolchildren. This is assuming a high prevalence of untreated dental caries at 40%, thus 160 children needing dental treatment, and that it would take 15 minutes to provide the treatment to each child.
Formula
Task duration = N_schoolchildren x Prevalence of tooth decay x 15 minutes (constant).
Apart from the constant, the parameters may be changed according to size of the school and prevalence of tooth decay.
Agenda:
a. Identify and recruit a dentist and a dental nurse;
b. Identify a space in the school to carry out the oral health assessment and dental treatment;
c. Train dentist and dental nurse to run the AHI dental care protocol;
d. Organise referrals to the local primary dental health care;
e. Deliver the dental care intervention at the school setting.