School Health Check-Ups In Kalahandi : A Study

Despite easily available treatment for Malaria, there has been abnormally high number of Malaria cases in the area covering the study. The population group most vulnerable to the disease are children and pregnant women. Lack of understanding on the disease, malnutrition and favorable environmental conditions for the malarial parasite to reproduce puts the population at even higher risk. There is a need for awareness on malaria and malnutrition among the population to reduce the number of cases and avoid deaths due to malaria. Educating school children is one of the ways to spread awareness in the community.

The government school system in the area has filed to engage the children from the community, inaccessibility, poor accountability, lack of qualified teachers are some of the reasons for the dysfunctional school system. Government of India recommends health education as part of every school curriculum.

Swasthya Swaraj is working with fifteen government schools in the area to promote health education among school aged children. School health checkup is an important component of the project and is conducted on yearly basis. There was a school health check-up conducted from February – March 2018 to mainly determine the total number of malaria and malnutrition cases. The paper suggests that awareness and education among the school aged children on malaria will not only help us reduce total number cases among the students but also among the community. This study will help field practitioners and social scientist to plan interventions on health awareness and education in school aged children.

Introduction

Schools are the most convenient setting for health education and health services for children. The concept of health promotion in school has been floating around for more than three decades now. Lot of countries in the west have successfully integrated health promotion as a part of their curriculum already. Focus on health promotion also stimulates the development of good learning climate and thus there is consistency between health promotion aims and school aims (Rowling and Jeffreys, 2000; Samdal, Viig and Wold, 2010; Tjomsland, Iverson & Wold, 2009; Viig and Wold, 2005). The first and official consideration of health promotion as part of the schools is considered to have taken place in 1986 with the publication of the Ottawa Charter for Health Promotion (WHO, 1986).

Health promotion within schools evolved in different manner in different countries as it was influenced by the national curriculum context. Australia and Scandinavian countries for example already mandated health promotion as part of the school curriculum, but in Netherlands health professionals mainly dealt with related issues.?Health promotion and health promoting schools is still very young field very much driven by the policy and practice development.?So far, there is very less evidence on the effectiveness of health promoting school approach (Lister-Sharp, Chapman, Stewart-Brown and Snowden, 1999, Stewart-Brown 2006).

Since most of the implementation and innovation on health promoting schools has taken place in western countries there is negligent amount of material available for its effectiveness in the South-East Asia. There are some initiatives, which focus on the urban settings, especially in India. One of the biggest challenges with the implementation is vague operationalization.

There are set guidelines given to schools but their operationalization and understanding has been mainly left to the schools and practitioners. Lack of specific implementation guidelines makes it difficult for the schools to identify concrete action steps to achieve health promotion in schools.

Classroom based health education essential part of health promoting schools. When we say whole school approach to health education it becomes essential to take into consideration all the stakeholders that are involved. Without involvement of the various stakeholders, the implementation strategies and approaches are bound to fail. In the past 30 years, there have been efforts to create a scientific base to school health promotion; in the process, people have been trying to achieve three major things.

First, linking health to education in various ways, secondly producing guidelines to outline the principles of health promoting schools and lastly looking for indicators to access if activity was meeting the guidelines or not. The most important thing to realize while implementing health promoting schools approach is that there are no universally acceptable concrete action steps, you can have guiding principles but every school has to in essence come up with their own ways of integrating heath as part of the curriculum. In addition, this can only happen with effective involvement of all the stakeholders. There has to be a system of accountability to make sure that various stakeholders are fulfilling their duties efficiently.

The government schools in India have mandated school health checkups every six months, but in many cases, even these mandatory health checkups do not happen.

Government of India launched a school health education project in 1989-1991 covering 10,000 primary schools, 20,000 teachers and 500 national social service volunteers in ten states that could be replicated across the country. Two NGOs that have made significant effort to promote health among students in India are HRIDAY and SHAN. They have covered 63 schools. Their program started off as school based health education and has expanded to mobilize students for community based health activism. Both of these NGOs are covering several metropolitan cities in India.

Project UDAAN in Jharkhand was an example of a successful school based health education in government schools in India. It was one of the largest health promotion project in India and over the years has scaled up. The biggest objective of the project is to provide sexual and reproductive health education to adolescent girls in government schools. High political commitment from the state government for sexual and reproductive health education resulted in formation of public-private partnership between Jharkhand State AIDS control Society (JSACS) and Centre for Development and Population Activities (CEDPA).

CEDPA was nominated as the nodal agency for providing technical assistance support for implementation of the project and it was supported by David & Lucile Packard Foundation. During the first phase of the project (2006-07) 48 master trainers from NGOs and private organizations and 757 nodal teachers were trained. The project was implemented in 444 schools covering 30,000 students. By the end of third and final phase of the project, a total of 87 master trainers from government sector and 2161 nodal teachers had received training and the reach of schools has increased from 444 to 1258.

The School Health Promotion and Empowerment (SHAPE) program is another example of school based health promotion intervention in Goa. The project was developed by Sangath and funded by John D. and Catherine T. MacArthur Foundation. The project was named ‘Manthan’, it was implemented in 324 government schools and 80 counsellors and 12 supervisors were appointed for the same. The project targeted male and female students studying from 5th-12th grades (9-17 years old) and was aligned with WHOs health promoting school guidelines. The project lasted from 2009-2014; the main objective of the project was to promote health and reduce health related impairments and disabilities among school going youth.

Current Status Of Schools

On conducting community meetings in seven villages, we found that not a single school has been functioning in those villages. We questioned the village members in detail regarding the reasons behind the school not functioning; surprisingly from all the villages we got a common response. They said that the teacher never comes to the school. The village members complained that the teacher visited school only two times a year. In order to understand the situation we contacted the teachers and asked them about the situation; the teachers said that the students never come to school; parents never send them.?

On visiting the school building, we felt that the school had been closed for a long time. This issue has existed here from the time when school buildings were constructed here. There are multiple reasons for schools not being functional here; absence of teacher alone cannot explain the issue. The teachers who teach in the schools here and they are all non-tribals, this is one of the reasons that explains the non-willingness of the children to go to the school. They are not able to connect to the teacher, if they have a teacher from their own community than it will easier for them to connect to that person. In addition, the teacher’s assigned teach in Odiya, which is different from the mother tongue of the tribal population. In the early years of school, it is difficult for the kids to learn in a language different from their mother tongue.

Outside one of the schools in the study area in Kerpai, Kalahandi, Odisha.

In some villages here, construction of school building has stopped because of various reasons, the authorities claim complain about the lack of funds. Because of the lack of buildings, the schools are half constructed. In some villages, the teachers have been assigned but there are no funds sanctioned for school buildings. In such situations, the tribal population requires role models who can spread the awareness about their rights.

The community needs the right kind of leaders who can take them in the right direction. The tribal population here requires leaders’ who can give them hope of a better life, they need someone who can make them dream big. Another problem encountered was the school calendar, which is not catered to the local reality. The tribal population has their own festivals that are not aligned with the regular calendar. Creating the right kind of awareness is of immense importance in the context of educational development among the tribal communities.

School Health Check-ups

Swasthya Swaraj is working with fifteen government primary schools in the two most backward gram panchayats - Kerpai and Silet to improve health, education and nutrition (H E N) of the children in an integrated way. The National Health Policy of Govt. of India (2017) lays greater emphasis on investment and action in school health - by incorporating health education as part of the curriculum, promoting hygiene and safe health practices within the school environs and by acting as a site of primary health care.

In Health Promoting School program, we explore how health can be taught across the school curriculum. Based on our understanding of various projects that have been carried out in the past in India and elsewhere we try to make health education an integral part of these fifteen government schools.

As per the recommendation of the government of India school going students need to undergo routine health check-up every six months. The interior villages of Kerpai and Silet cluster in Thuamul Rampur block are completely devoid of these due to logistical and operational challenges. For the past two years, Swasthya Swaraj has been conducting school health check-ups in the across fifteen government schools. The results of the health check-up conducted in February-March 2018 are presented below. Since there is high incidence of Malaria among the population and school aged children are particularly vulnerable to the disease, every kid was examined for Malaria. We conducted anthropometry of every kid as well in order to identify kids suffering from malnutrition.

Government of India has introduced the mid-day meal program in every government school to tackle malnutrition. We found that there is high irregularity in the implementation of mid-day meal programs in the schools we examined. This is mainly because no accountability system in place, headmaster of the school is the responsible for making sure that mid-day meal is served. There are several challenges associated with irregularity in delivery of mid-day meals. The inaccessibility of these villages makes it quite difficult get the required resources to the school. If somehow the resources are transported to the school then another challenge is to gather the students in the school. Despite the enrolment of students the attendance of students in the school is extremely low. There are various reasons for this as described previously.

Results Of School Health Check-ups

Under this HPS eleven school health camps were conducted covering a total of fourteen schools namely Danpadar, Silet, Sargipadar, Serkapai, Kachalekha, Melrofa, Podapai, Rupen, Taramundi, Kandulguda, Maltipadar, Bilamel, Kuturumali and Marguma. The number of school going children attended the camp were 450. In the camp, we found that 40.6% of children were having malaria who were then provided with required medicines and proper guidance as well. The findings of the health check are outlined as under. Out of the total student screened (n=450) majority were ST (87.1%) and 12.1% were SC and only 0.6% were from other castes.

Meeting With Parents

Villagers of Kaniguma (Kalahandi), parents, accumulated at the monthly ration distribution spot.

School health checkups conducted between 12th February 2018 and 14th March 2018 revealed some really interesting information for the HPS team. Apart from treating the kids, an integral part of the checkup was to conduct meetings with the parents in the village, talk to them and understand their perception. We believe that education of a kid has multiple stakeholders involved and all the stakeholders need to take the responsibility to make sure there is safe and efficient learning environment for the kids, which fosters their cognitive thinking ability at very young age. In order to achieve this school health meeting was carried out among four villages. Doing focus group discussions of parents in the villages carried out the health meeting. A standardized agenda was prepared in order to carry out the focus group discussions.

We found that in none of the villages the parents were aware of the school health committee, which had been formed during the school health checkups the previous year. Every time we tried to talk about the importance of education for the kids the topic of conversation got diverted to poor health among the people. The only demand from the parents was that the patients being treated at the clinic should be bought back to the clinic in the car.

This was really interesting to note, we have been stressing the importance of education but the basic need to enough food and proper health is still unmet. In a situation where you have to constantly think about where your next meal is going to come from, the need for education of kids ceases to exist, instead your kids become part of bringing the food at home. It was also interesting to note that some parents were in fact very much interested in sending their kids to school, but there was complete absence of teacher to teach.

This is precisely the reason why we also invited the teachers to be part of the meeting, there were cases when the parents blamed the teacher and the teacher blamed the parents for the kids not getting educated, it was a blame game. We also interacted with the teachers personally to fully understand the challenges they face in running the school. In most of the schools the building was dilapidated and not even rain proof.

There were two villages where the school building did not exist at all. And the teachers also complained about the lack support from the DEO and BEO to maintain the school. It clearly seemed that the mechanisms deployed by the government to drive the school system unaccountable is flawed and has lot of loopholes. Moreover the support system for the teachers is also non-existent, in such cases there is only so much a teacher can do.

To address this problem we decided to from sports club in every village that will be headed by one of the youth in the village who is relatively educated and motivated to teach the kids. The main role of this person would be to engage the kids every day at least for two hours so that the kids start developing an interest in education. The means of engagement would be playing different games and teaching mathematics for one hour.

The kids first need to gain a habit to come to the school only then you can make them sit inside the class. We also planned to get the members in the village decide a place to grow kitchen garden, the kids will be responsible for maintaining the kitchen garden and they will eat the vegetables that are grown in it.

This is a long-term project but it is impossible to achieve without help and support from the teachers. Help and support from the teachers will only come once the government system starts functioning more efficiently ad more importantly starts providing the right kind of support to the teachers. But we are making our efforts to do everything we can from our side so as the engage the children so that they can have a better future. Without educating them we can never expect them to have better health or even life expectancy for that matter. Average age of the people in the community wouldn’t exceed 50 years here, because poverty and negligence for years has left them in a terrible state. Hopefully with our efforts things will start taking shape soon.

Learnings And Suggestions

The status of schools in Kalahandi was alarming especially in the block that I was working in. It was horrifying to see school aged children being deprived of proper health and education. In such a situation it is often very difficult to find someone to blame, and it is not at all the approach to be taken. By investigating whom to blame you ever really find the solution, the best case scenario is you find the culprit, and then what? It becomes essential to look for solution to the cobweb of problems surrounding school health and education, i.e. every stake holder has to be dealt with. Health and education always go hand in hand, you cannot work on them separately, you can have different interventions but the interventions have to be interlinked.?

For school aged children we always focused on health, education and nutrition together, we used to call it the HEN project. Childhood is the most critical stage of mental and physical development for any person, considering the fact that immunity of kids is not as good as adults and they are vulnerable to variety of diseases, it is essential to include health education as part of their curriculum.

Mahir Bhatt (standing) in a training of Swasthya Swaraj animators for the survey.

Developed countries have successfully included health education and introduced healthy environments in their schools. The concept of health promotion in schools had emerged in the mid-1980s, it was evolution of health promotion as a distinct public health strategy. Many developed countries have made health promotion as an integral part of their school education and many countries in the west still struggle with this. The concept of health promotion in schools has still not gained enough momentum in the developing and least developed countries. There are various reasons for this, to give a bird’s eye view of the challenge, there are too many stakeholders that need to work in synergy to make it happen.

There is also political will required in order to do this. Government of India has recommended inclusion of health education as a part of the curriculum, many schools are yet to do this. It won’t take lot of time for the schools in the metropolitan area to implement this but the schools, especially government schools in tribal areas are far behind in this. There have been efforts to health education an inclusive part of school curriculum. The projects mentioned earlier give us a glimmer of hope but how can every school in the country adapt and implement health promotion as part of their curriculum is still a big question.

Reference: Fathi B, Allahverdipour H, Shaghaghi A, Kousha A, Jannati A. Challenges in Developing Health Promoting Schools’ Project: Application of Global Traits in Local Realm. Health Promot Perspect 2014; 4(1): 9-17

About the author: Mahir Bhatt completed his bachelor in engineering and went on to volunteer for a year with AIESEC in Nepal where he developed an interest in development project management. India Fellow gave him an opportunity to understand public health in Kalahandi, Odisha with Swasthya Swaraj. After this, he worked on health, hygiene and sanitation in rural Himachal Pradesh and urban slums of Delhi. He is now doing research to assess the relationship between Covid-19 spread and sentiments expressed by people on social media.