Changing lives:
AHI proposes delivering a simple, scalable and sustainable operational model for the WHO’s Health Promotion school initiative
Affordable Health Initiative Health Promoting School Operational Model
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 AHI HPS model. This procedure will be repeated at 6, 12, 24 and 36 months after introducing the AHI HPS intervention to monitor progress towards acquiring HPS status. An implementation study protocol was developed at the AHI Research Centre and is available in our web page “AHI Research Centre”.
Assessment of treatment needs and the impact of AHI HPS model
A qualified research team will be recruited to carrying 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. All measurements are carried out at baseline and repeated at 6 months, 12 months and 24 months to assess the impact of the AHI HPS model. In addition, the SAC will keep track of the AHI HPS model daily activities in a logbook throughout the study period. Data will be collected daily and includes recording sickness absence and reasons, time spent on carrying out school activities (physical activities and hygiene practices), episodes of bullying and violence, and monitoring referrals for vaccination and treatment. The SAC will also assess the general cleanness of the school once a day, and toilet cleanness before and after classes in the morning and afternoon. The data will be entered on a dedicated recording logbook. A health needs and impact study protocol was developed at the AHI Research Centre and is available in our web page “AHI Research Centre”.
Nominate a School Activities Coordinator (SAC)
The first step to implement the AHI HPS model is 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.
Equip the school to run the AHI HPS model
AHI supports equipping the school building environment. This includes building or improving condition of bathrooms and constructing sinks.
Run the AHI HPS model
The AHI HPS model includes a number of interlinked interventions as listed below.
Run life and health coaching
Coaching is different to teaching and takes more time. In addition to teaching, AHI coaches take on the role of a leader to guide, motivate, encourage and help the schoolchildren to set goals in their path through the life course. This pedagogical approach is flexible, engaging and centred on the learner. It encourages interaction (staff/staff, staff/student, student/student), collaboration and communication. AHI coaches use their knowledge to motivate schoolchildren in developing cognitive processes associated with health and life skills leading to health literacy and emotional evolvement and, which in turn motivates them to adopt a healthy lifestyle leading to wellbeing, better mental and physical health. The health coaching and the life coaching are delivered through the following activities: introduce a topic using e-learning (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 and a life skill topic 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 or the SAC following a coaching training exercise.
E-learning may be defined as any type of learning that takes place through or with a computer and is primarily facilitated through the Internet; but it can also be accomplished with CD-ROMs and DVDs, streaming audio or video and other media. Where it is not possible to access the internet, it can be accomplished with CD-ROMs and DVDs, streaming audio or video. AHI HPS e-learning model refers to electronically mediated learning in a digital format, using computers and/or the internet at school to enhance or facilitate teaching and learning. The coach will navigate the internet, filter through and identify up-to-date relevant material, construct a high-quality e-learning package appropriate to the local culture with appropriate content for children of school age and apply. The internet is a valuable source of information in all fields including animation material, learning games, simulations, virtual worlds and video clips. Also, AHI advocates using storytelling to deliver the coaching topic. This is a proficient pedagogical approach that can be delivered through E-learning or used as an alternative to E-learning. Storytelling is what connects schoolchildren to their humanity. It links human to our past and provides a glimpse into our future. Since humans evolved into Homo sapiens, they have told stories, far before the written word was developed. Children like to hear stories, and good story has a beginning, a middle, and an end. Stories should have characters that look like the local schoolchildren or at least share characteristics they can relate to. A story should build up to a thrilling climax, followed by a satisfying conclusion. It should be moving, either emotionally or viscerally, like in a good action film. AHI centre has also developed relevant material (animation and storytelling video clips) that can be used locally in all schools. In addition, AHI recommends creating dedicated message boards, social media and using various other means of online communication to allow learners to keep in touch and discuss couching-related matters, whilst providing a sense of community.
School quiz game is a form of game, in which 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. A quiz game is generally a frequent and short assessment that can gauge a student’s retention and comprehension of a small amount of information. AHI HPS model uses this game as an informative feedback device allowing both the instructor and the students to see where they are excelling or need more focus. A quiz can function throughout any training activity as an informative feedback device allowing both the instructor and the students to see whether they are excelling or needing more focus. Because this learning assessment takes the format of a game, the instructor will be able to assess learning without the pressure on school children of being assessed. Assessing the effectiveness of specific educational methods is essential to ensure the highest level of learning possible. Similarly, identification of knowledge deficits facilitates subsequent intervention to improve learning. Quiz game is a stress-free way to learn contrary to exams that is a stressful event focussed only on assessment. 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. When a child plays quiz games they keep their mind on what they are doing. Thus, it helps children to concentrate. Quiz games aid the learning process. It enhances the ability to retain information and builds confidence in addition to identifying gaps in knowledge. Playing quiz games make children feel good and so, makes them enthusiastic to play more. Quiz games can be played by individuals, pairs or in teams. The school quiz game is played individually. The coach will construct quiz games that include ten questions on the learning objectives of the life or health coaching topic addressed in the E-learning presentation. Questions are appropriate to the level of education of the children and pertinent to the topic covered on the quiz. A number of quiz questions are available on internet and the coach may obtain questions from reviewing available resources. AHI central have also developed relevant quiz questions that can be used locally in all schools. The quiz presentation may be made using PowerPoint (Microsoft Corporation) or calling the questions. Following, the instructor will give the answer to all question, one by one, and the children will mark their own answers. At the end the coach collects the answers and assess gaps in knowledge that need further attention, as well as, identifying skills that could be further developed.
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. It helps them developing attention, perception, memory, language, confident communication, assertiveness, higher reasoning, analytical and critical thinking, interpersonal skills, empathy and self-control. Also, it helps them to practise and gain experience in fitting their ideas into a time limit. This activity does not require special resources. A debating activity only needs a clear space where students can move around, some desks for writing notes, pens or pencils and paper. A ‘horseshoe’ or u-shaped set up is often best. This can easily be accommodated in a classroom. The coach will act as moderator of the debate. He/she will have a stopwatch to control the time of speeches. Phones can be used for this purpose. Debates can involve single-member teams or teams that include several students. AHI HPS model 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 in the previous week. The coach will welcome the school children to the debate and explain the rules. The moderator starts the debate briefly introducing a statement (e.g. ‘A diet rich in refined sugar keeps me healthy’). Then, the coach allocates one side of the room as the “agree” side and the other as the “disagree” side. The children may have a say in which side they want to be, and the moderator should quickly and diplomatically create two groups approximately the same size. Children who are neutral can be allocated to the smaller group to balance the size of groups. The moderator asks each group to identify a summary speaker. Next, the coacher allows time for each group prepares an argument for the summary speaker to voice. The moderator helps them to identify the major issue and asks them to focus their argument on it. Following, each summary speaker will present their group’s argument. The coach gives students an opportunity to discuss debate-statements from their own experience and also assures that their own experience meets evidence-based data. Finally, all children involved in the debate will act as judges. The moderator asks them to leave the room and, when they return, to choose again one or the other side of the room; “agree” side or “disagree” side. Then the coach closes the debate and thank you all for participating.
Topical 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. Participants bring up ideas, solve problems and give comments. This is a creative and dynamic activity which stimulates reflective thinking among the school children. Group discussion on health and life skills topics plays vital role in understanding these topics. Discussing a topic with classmates helps insightful and comprehensive learning the topic. 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. Whereas in a debate a set amount of time is given to two opposing groups of people to prepare an argument for a summary speaker to voice the views of the group. The former offers school children an opportunity to refine their own views in due course. In this activity school children exchange information, views and opinions about the topic presented in the E-learning session, as well as, an opportunity to identifying personal challenges and facilitators, environmental barriers and community level solutions and facilitators to behavioural change. The coach will act as moderator of the group discussion. The AHI HPS model topical group discussion format includes a whole school class (20-25 children). The topic of the group discussion will be related to the topic presented in the E-leaning and debate in previous weeks. The coach will welcome the students to the group discussion and explain the rules. The coach starts the group discussion briefly reintroducing the topic statement (e.g. ‘A diet rich in refined sugar keeps me healthy’). Next, he/she will ask participants to reasoning on their views on the statement and discuss among themselves. The coach should motivate all participants to share their views and opinions with other participants and work as a team to identify solutions to a challenge (e.g. how to reduce sugar consumption). The coach should encourage team approach, an approach that requires cooperative problem solving, effective communication skills, and the ability to influence others by presenting ideas in an open, approachable, and non-threatening way. The moderator 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 awings, 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. A goal is a desired result that a person or a group of people envision, plan and commit to achieve, an idea one or a group of people aspire to accomplish or wish to do. 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. Life is a journey similar to a road trip. One needs to identify a destination, plan the journey and be fit to travel. The process of setting goals helps schoolchildren to travel safely throughout the life course. By knowing precisely which behaviour a schoolchild needs to change, the child knows where to concentrate their efforts. Achieving a goal does not happen in a straight line, but setting a goal brings the benefits of awareness and personal responsibility and undeniably encourages achievement. Goal setting makes coaching work. The e-learning, quiz game, debate and group discussion provides schoolchildren with the initial thoughts. These sessions help the schoolchildren increase awareness of their behaviour, motivate them either to changing inappropriate behaviours or developing new behaviours that assist their life journey and start thinking and formulating ideas about their future desired behaviour and what they want to work on to achieve. The coach helps them to develop their own individual goals. This should not be done in an authoritarian way but through motivation. The AHI HPS model works with performance goals, which gives the schoolchildren the best opportunity for success and maximises ownership. With ownership comes motivation, underscored by choice and responsibility. It is important to establish the difference between end goals and performance goals. An end goal is the final objective and is usually something not completely in one's control. A performance goal is something at a measurable level that gives one a good chance of achieving the end goal and is largely in one's control. Good goals must be specific, measurable, achievable, realistic and time bound (SMART). The coach will support and help the schoolchildren to decide and articulate their own SMART goals. Goals should be positively stated. Goals would provide a stretch, if they are too challenging there is no motivation and it may take the schoolchildren into the "panic zone". Goals must be ethical. Goal setting is in the hands of the schoolchildren and they must set them. The coach may need to elicit the goal through questions such as "what will you do?" or "what would you like to get out of this topic?" By listening actively and asking clear questions the coach can help schoolchildren to identify a goal. A goal setting session considers individually what each schoolchild wants to achieve in relation to the topic addressed. Then, agree with the schoolchild that he/she will commit to it. Following, the coach will keep in touch with the schoolchildren and check their progress towards achieving their goals from time to time.
Run evening role model talks and community quiz game night
Role model talk is a lecture by an external speaker. Quiz game is a form of game, in which the players attempt to answer a series of questions correctly, to test their knowledge about specific subjects. This activity is run on Friday evenings to facilitate parents’ attendance. Therefore, there are four Friday evening activities a month of up to 90 minutes each. Quiz games are run a week after the role model talks and assess the learning objectives of the topic covered in the talk. Two topics are addressed monthly, a health topic and life skills topic. Role model talks and quiz games topics are associated the learning objectives of the topics addressed in the school health and life coaching. 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.
The organiser of the role model talk will identify external speakers and invite them to visit the school and give a talk. 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 topic. In the absence of a good role model available to be invited, the organiser may identify a talk on internet and show it on a screen as an alternative to inviting an external speaker. The school event usually starts with the visitor addressing an assembly. The organiser will agree the learning objectives with the speakers in advance. The guest speaker will use 30-45 minutes lecturing and the remaining time is for questions and discussion.
The organiser will also 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 and the health coaching, 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. Quiz games can be played by individuals, pairs or in teams. 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 2 rounds of 10 questions. At the end of each round there is a break. Questions may be obtained from reviewing available resources on internet. The quiz presentation may be made using PowerPoint (Microsoft Corporation). At the end of each round, the instructor will swap the answers between teams and give the answer to each question and a child will mark the answers. During the break the instructor will collects the answers and assess quickly the gaps in knowledge that need further attention, as well as, highlight skills that could be further developed.
Run the health detective game
The health detective game is a practical epidemiological exercise in the form of a game. 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. This activity may be run by a schoolteacher or the SAC on a Friday in the evening. 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. The instructor will use E-learning to deliver the exercise and provide a printed copy to all participating in the game. The form includes space to record information on the environment hazards and risk behaviour associated with the disease set in the exercise. Followed by, 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 home, school and/or 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).
Run ‘Classroom-based Physical Activity Breaks’
‘Classroom-based physical activity breaks’ includes all activity regardless of intensity performed in the classroom during normal classroom time. AHI HPS model 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. It includes play, which is a free activity that involves exploration, self-expression, dreaming, and pretending. Play has no firm rules and can take place in the classroom.
Run gardening
Gardening can be pretty simple if you boil it down to the basics. It involves growing vegetables and flowers. Easy-to grow vegetables include early potatoes (grow quickly and fun to dig); beetroot; pumpkins (lots of character); cherry tomatoes (the easiest type to grow and eat); peas (delicious straight from the pod); rainbow chard (very colourful); and fast-growing salad vegetables. Gardening tools are required for this activity. AHI advises to run gardening sessions twice a week. Gardening may be run by a local community gardener or a schoolteacher (45 minutes/week). Therefore, headteachers must allocate 90 minutes a week of school teaching time to run gardening.
Run sport training sessions and tournaments
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 in tournaments. It may include individual or team sports. This activity requires special resources including a physical educator coach and sport facilities. The selection of sports is based on school facilities, equipment availability and a proficient trainer. Ideally, a school should focus on a small number of sports, organise and run training sessions and participate in competitions. Parents are invited to attend the weekend competitions as spectators to support their children, improve community-school engagement and community and family ties.
Run active commuting
Active transport or active commuting refers to the use of brisk walking, biking, or other human-powered methods (e.g., skateboarding and rollerblading), and equates to moderate-intensity physical activity. This is an ideal low-cost strategy to increase physical activity and may account for the 30 minutes daily physical activities, representing 50% of a child’s recommended total 60 minutes minimum physical activities a day. In addition, active commuting addresses competition for time during the school hours because is run before and after classes.
Run basic hygiene practices
Hygiene may be defined as conditions or practices conducive to maintaining health and preventing 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). AHI HPS model implements the UNICEF Wash, Sanitation and Hygiene (WASH) in schools, a well-established health initiative designed to improve the effectiveness of hygiene behaviour change programmes, supported by UNICEF. Supervised tooth brushing with fluoridated toothpaste was added to WASH practices in the AHI HPS model, as recommended by the WHO. This activity requires supervising hand washing and tooth brushing. 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. In addition, the SAC checks the cleanness of the school, in particular toilet cleanness. School cleanness is checked in the morning and afternoon, and the data entered on a dedicated recording file. The total duration of this activity is 30 minutes, 15 minutes in the morning and 15 minutes in the afternoon.
Run 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.
Run and monitor health care
Health care includes dental, medical and mental health care services.
Dental health care includes screening for dental diseases and providing dental treatment at school. 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. Assuming that 600 school children will be enrolled in the programme it should take 30 hours in total to carry out this task. Taking as a module 400 school children enrolled in the programme it should take proximally 40 hours in total to carry out this task. 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.
Medical health care includes organising referrals for vaccination of school children missing recommended immunisation, and treatment of diseases identified in the health screening questionnaire and the stool sample analysis. AHI works in partnership with the local primary health care sector to run this activity. This activity is mainly computer based. Following the health screening and obtaining the results of the stool analysis, data is entered in a spreadsheet and analysed. A list of school children needing vaccination and treatment is produced. A computer programme will generate referral letters using a template form and the SAC will deliver the letters to a local public primary health care unit. The school activities coordinator organises and monitors the referrals for treatment and vaccination to ensure the school children receive the immunisation and/or the treatment needed. It is estimated to take approximately five hours a year to complete this task. The most timing consuming part of this task is to monitor the referrals. This activity does not interfere with school teaching hours.
Mental health care is provided in two stages. For children aged 6-12, the AHI HPS model promotes mental health and wellbeing mainly through life coaching and physical activities. At the second stage, AHI HPS model aims to introduce professional counselling to those experiencing mental health challenges. Life coaching addresses de-stigmatisation, bullying, violence, radicalisation, resilience, life coping strategies and social skills, which may reduce the level of stress, in particular anxiety among school children. Also, it is well known that physical activities promote well-being and mental health, in addition to physical health. Furthermore, improving hygiene, oral and general health may improve self-esteem. Clearly, a healthy appearance and clean body, as well as clean clothes are associated with higher self-esteem because they boost self-perception as attractive and promotes inclusion in society. There is good scientific evidence that poor oral health affects speech, smiling, mood, and psychosocial well-being. There is no need to allocate time to this activity. The first stage (Prevention of mental illness) is covered under other interventions described above. The second stage (professional counselling) is run outside school hours.