Abstract
The Kenyan government established the Kenyan Comprehensive School Health Program (KCSHP) on the basis of Kenyan National School Health Policy. A KCSHP pilot project was carried out in eight primary schools in Mbita Sub-County of Homa Bay County in the Nyanza Region from 2012 to 2017. This pilot project provided health facilities and support for evaluation with a school health checklist, and organized teacher training on health education, a child health club, and school-based health check-ups. The present study aimed to examine the appropriateness and reliability of the strategy of the second KCSHP pilot project in Kenya. We analyzed data from self-administered questionnaires targeted at pupils in seventh-grade in the eight primary schools. The questionnaire consisted of questions on health-related knowledge, attitudes and practices, self-evaluated physical and mental health status, self-awareness of health control, subjective happiness, recognition on the importance of learning about health in school, absenteeism, and sense of school belongingness. The project contributed to improving health-related knowledge, attitudes and practices, self-evaluated health status, sense of school belongingness, recognition on the importance of learning about health in school, self-awareness of health control, and absenteeism. On the contrary, subjective happiness did not improve significantly.
Keywords
Introduction
Cost-effectiveness of school health activities has become a widely recognized concern worldwide. The effectiveness of school health activities is measurable in terms of not only improved health and nutritional status but also improved educational outcomes, reduced wastage, less repetition, and enhanced returns on education investments (1). For example, several researchers reported school-based health education had positive effects on health-related knowledge, attitudes, and practices (2,3). A study in Kenya reported school-based hand hygiene instruction and hand-washing promotion decreased student absenteeism (4). However, such individual interventions that handle a single issue may not be very effective (5). Apart from that, school health in low-income countries has often been realized through vertical programs focusing on only one or a few specific issues and has otherwise run into limitations (6).
Amid these circumstances, the World Health Organization (WHO) introduced health-promoting schools (HPS) as an approach to promoting health in pupils, school personnel, families, and entire communities through schools (7). The Focusing Resources on Effective School Health (FRESH) framework was then launched in 2000 (1). After the spread of FRESH, several developing countries formulated national school health policies (NSHPs) and aimed at achieving comprehensive school health (8–10). Evidence accumulated thus far supports the effectiveness of a comprehensive school health approach and suggests its prospects for improving a variety of indicators (11). Furthermore, a WHO technical report (12) emphasized the importance of promoting a comprehensive approach as an essential factor for striving to achieve school health nationwide.
In Kenya, the government launched a comprehensive school health policy in 2009 (8), and then established the Kenyan Comprehensive School Health Program (KCSHP). Additionally, both the Ministry of Education (MOE) (formerly Ministry of Education, Science and Technology) and Ministry of Health (MOH) (formerly Ministry of Public Health and Sanitation) adopted the National School Health Guidelines (13) and Kenya Comprehensive School Health Handbook (14) in 2009. The handbook describes the components of the KCSHP, such as situation analysis, making an action plan, monitoring and evaluation, and giving awards to schools with good performance in school health activities. The MOE and MOH additionally developed a school health checklist to evaluate the status of school health activities (14). Following this, a KCSHP pilot project was implemented in 30 schools in the Kilifi and Msambweni districts in 2012 (15), though it was not implemented at a national scale following the pilot. Against this backdrop, the Nagasaki University Institute of Tropical Medicine, MOE, and MOH decided to carry out another KCSHP pilot project in the Mbita Sub-County of Homa Bay County in the Nyanza Region.
As mentioned, school health promotion has become widespread and gained recognition as an effective practice worldwide. However, less attention has been paid to evaluation of the influence of NSHP implementations, particularly to evaluation in terms of children’s health-related knowledge, attitudes and practices, absenteeism, and other psychosocial aspects.
Objective
The present study aimed to examine appropriateness and reliability of the strategy of the second KCSHP pilot project, focusing on health-related knowledge, attitudes and practices, self-evaluated physical and mental health status, self-awareness of health control, subjective happiness, recognition of the importance of learning about health in school, absenteeism, and sense of school belongingness.
Methods
Target areas and pupils
The project targeted four areas of Mbita Sub-County in Homa Bay County: Rusinga West, Rusinga East, Gembe West, and Gembe East. Only 48 primary schools in these areas had classrooms for enrollees in grades 1–8 in 2013. Among these 48, the project selected two in each area as target schools, for a total of eight, and targeted all seventh-grade pupils in these schools. Whereas the official languages of Kenya are English and Kiswahili, the study area was mainly the Luo settlement area, and the daily used language in the area is Luo. When creating a questionnaire, it is preferable to use the language of the target region, but Luo (Dholuo) is a spoken language and there is no uniform rule in the alphabet notation of Luo. Therefore, we decided to create a self-administered questionnaire for evaluation in English, and, consequently, we selected the pupils who could fully understand and answer the questionnaire in English as target pupils. In addition, the eighth grade is the highest grade, and, thus, students in eighth grade are the most familiar with English in the school. However, they have to prepare themselves for the national uniform examination to be held at the time of graduation. Therefore, we decided to target seventh-grade students so as not to place an additional burden on eighth-grade students. We conducted a one-year intervention with seventh graders repeatedly during the project period – namely, four consecutive years. The subjects of this study were all Luo. The number of pupils was 268 in 2013, 277 in 2014, 295 in 2015, and 304 in 2016. The average age of subjects was 14.0 ± 1.0 years in 2013, 14.0 ± 1.0 years in 2014, 13.9 ± 1.0 years in 2015, and 13.7 ± 1.0 years in 2016. Furthermore, the percentage of girls selected in each year was 51.9% in 2013, 49.8% in 2014, 49.8% in 2015, and 49.3% in 2016.
Project overview
The project was implemented from September 2012 to August 2017. Table 1 shows an overview of activities for each year. In its activities, the project involved a variety of stakeholders, including parents, local government offices, sub-county hospitals, and community health volunteers (CHVs). During the project, assessment of the status, prioritizing required activities, making an annual action plan, implementing the action plan, evaluation, and presenting awards were repeated each year.
Activities in the pilot project.
SNS: social networking service; CHC: child health club; SHC: school health checklist; CHW: community health worker.
Provision of health-related facilities
The project conducted an annual survey each year to collect information about health-related facilities in schools, and based on the survey results it provided the schools with facilities and materials, including equipment for building toilets and rainwater harvesting tanks, and cleaning equipment.
Assessment and evaluation with a school health checklist
The school health checklist, which had been developed by the MOE and the MOH, was used in status assessment before the start of the pilot project in 2013, and in the school-year-end evaluations of implementation status from 2014 to 2016. It consisted of the following eight components: 1) value and life skills; 2) gender issues; 3) child rights, child protection, and responsibilities; 4) water, sanitation, and hygiene; 5) nutrition; 6) disease prevention and control; 7) special needs, disability, and rehabilitation; and 8) school infrastructure and environment safety (13). An evaluation team comprising staff from the district offices of the MOE and the MOH visited each school to collect information by observing the schools and interviewing children, teachers, head teachers, and chairs of the school health committees. At the end of each year, schools received feedback from the project about the annual evaluation, and an awards ceremony was held to recognize schools based on the checklist scores.
Training for government officers, teachers, school committee chairs, and CHVs
The project provided four types of training, with different scopes and trainees as follows.
1. Training on introducing evaluation using the school health checklist for principal stakeholders
Education and health government officers, school committee chairs, head teachers, and teachers in charge of health-related issues were the target participants. The main components were methods for evaluating the status of school health implementation and means of making an action plan by referring to evaluation results. For the latter topic, teachers learned how to classify activities in order of priority, and what elements to include.
2. Training to improve health education quality for head teachers and relevant teachers
The main topics were teaching methods on health and nutrition education. Participants learned how to create teaching materials and the importance of such education for raising health awareness among children and community members.
3. Training to reactivate child health club (CHC) activities for head teachers and relevant teachers
At the start, the project confirmed the CHC activities’ concept and objectives. It then provided information on how to organize CHCs and the importance of children’s participation in the activities.
4. Training to introduce school-based health check-ups for relevant teachers and CHVs
The project provided training on health check-ups in 2013 and 2015. In the first training in 2013, the project explained the objectives and methodology of school-based health check-ups to the participants (head teachers, relevant teachers, and CHVs). After that training, trained teachers began to measure the children’s weight and height at least three times a year. In the 2015 training, teachers learned how to use health check-up data for health education.
Conducting questionnaires
Questionnaire development
The project developed an English self-administered questionnaire by referring to Kenyan Science textbooks (16) and exercise books (17,18). In the process of developing the questionnaire, we conducted a pretest and modified questions to better adapt them to the Kenyan context. The developed questionnaire consisted of questions inquiring on general information as well as closed-ended questions on health-related knowledge, attitudes and practices, health status (somatic symptoms) by self-evaluation, subjective happiness, sense of school belongingness, frequency of school absence, self-awareness of health control, and self-evaluated effectiveness of health education. We used questions asking accuracy regarding the health-related knowledge and questions asking frequency or degree regarding health-related attitude, practice, and other items.
Data collection and analysis
We used the data collected via questionnaires the project conducted each year from 2013 to 2016. Ordinal data were analyzed using a Mann–Whitney U test, and nominal data were analyzed using a chi-squared test to examine for significant differences among years. The level of significance was set at 0.05. Data analyses were conducted using IBM SPSS Statistics for Windows, version 21.0.
Ethical approval
The Kenya Medical Research Institute approved the present study (registration number: SSC PROTOCOL NO. 2916). The data used in this study were collected in the second KCSHP pilot project.
Results
Improvement of health knowledge
Table 2 shows percentages of correct answers for the questions on health knowledge, by school and by health topic, for 2013–2016. Regarding the results by school, there were no significant differences between the results in 2013 and 2016 for any school. However, percentages of correct answers of the eight schools in total were 62.9% in 2013 and 65.4% in 2016, a significant improvement (p = 0.029). Regarding the results by health topic, irrespective of the year, over 80% of pupils answered correctly for the questions on basic hygiene – namely, washing hands, using toilets, and oral health. Moreover, knowledge on HIV/AIDS testing and free treatment was significantly improved.
Percentages of correct answers for the questions on health knowledge, by school and health topic, for 2013–2016.
Improvement of attitudes, practices, somatic symptoms, self–awareness of health control, effectiveness of health education, and sense of school belongingness
Supplemental Table 1 shows improvements of attitudes toward health, health practices and somatic symptoms, self-awareness of health control, effectiveness of health education, and sense of school belongingness for 2013–2016. Averages of 14 items on attitudes in 2013 and in 2016 were 71.2% and 86.4%, respectively, marking a significant improvement (p < 0.001). Regarding practices, the average of the 12 items in 2016 was significantly improved compared with that in 2013. Regarding somatic symptoms, responses for all items in 2016 except menstrual irregularity were significantly improved compared with those in 2013. Responses for questions on effectiveness of health education and self-awareness of health control improved significantly after the implementation. The total score of school belongingness in 2016 was significantly increased compared with that in 2013.
Improvement of subjective happiness and frequency of school absence
Regarding subjective happiness, percentages of pupils who answered very happy were 74.3% in 2013, 80.5% in 2014, 74.6% in 2015, and 78.0% in 2016, marking no significant change among any of the implementation periods. Regarding frequency of school absence, percentages of pupils who responded that they had never been absent were 50.0% in 2013, 64.3% in 2014, 62.7% in 2015, and 67.1% in 2016. Significant improvement was thus between 2013 and 2016 (p = 0.001).
Discussion
This study examined the appropriateness and reliability of the strategy of the second KCSHP pilot project. The results showed the project contributed to improving not only knowledge, attitudes and practices, and self-evaluated physical and mental health status, but also sense of self-awareness of health control, school belongingness, recognition of the effectiveness of health education in school, and absenteeism.
Teacher training is an essential component of HPS (9,10,19). In this project, teachers received several training sessions. This may spur improvement of health education in school, and this improvement may also contribute to improving children’s health knowledge, attitude, self-awareness of health control, and recognition of the importance of learning about health in school.
With the support of the project, some schools built toilets and water tanks for washing hands in school. As FRESH emphasized the importance of environmental support for promoting school health practices (1), activities for creating a hygienic environment may have contributed to improving children’s health practices in this project.
Several studies have reported the effectiveness and importance of using a school health checklist and award system for promoting comprehensive school health (10,20). The importance of monitoring and evaluation was also reported in several studies (9,10,20). Assessment and evaluation with a school health checklist helps in recognizing essential and required minimum health and environmental conditions for promoting children’s health (10). Award systems can also motivate teachers and communities to implement the activities (10,20). This project organized periodical evaluations using a checklist and feedback meetings, and an award system to motivate schools. The present study thus reinforces the effectiveness of the checklist and award system. Other studies have indicated that children’s participation in health-related activities in school contributes to improving their health-related knowledge, attitudes, and practices (2,3). A WHO technical report on school health also reported the importance of children’s, teachers’, and communities’ participation as an essential factor for disseminating school health (12).
Regarding health-related activities, a study reported the importance of promoting daily activities in school (21). In the Kenyan pilot project, schools conducted daily cleaning of toilets, classrooms, and promoted washing hands (22). Such daily activities may help improve children’s attitudes and practices related to health. Generally, acquiring appropriate health-related knowledge, attitudes, and practices is an essential factor for improving one’s health. Improvement in these areas may have impelled positive changes in children’s health status in the present project as well. This Kenyan project promoted child-driven health activities through the CHC in school, where children took responsibility for certain activities, such as cleaning of toilets, classrooms, and treatment of drinking water. Schools additionally conducted cleaning activities in the community, and organized campaigns to raise awareness about health in both schools and communities (22). Some teachers reported children’s socialization had been fostered through CHC activities (22). A report on HPS pointed out that child participation is not only a right of children and young people, but also beneficial to children’s health and social and psychological development, as well as to society as a whole (23). This report highlighted the importance of decision-making by children in health-promotion activities in school (23). However, we could not evaluate whether children had participated in the decision-making of the CHC in this study. In future studies, it will be necessary to examine how children would be involved in CHC activities and the effect of the involvement on children’s education and health outcomes.
Moreover, the questionnaire results indicated possible improvement in children’s health-related knowledge, attitudes, and practices, and in their sense of school belonging. In fact, this project involved not only schoolteachers and children, but also chairs of school committees and the CHV. The project also organized activities by having education and health government officers work cooperatively (22). As several studies pointed out the importance of multiple stakeholders’ involvement (10,19) and of joint efforts by both the education and health sectors for successful NSHP implementation (19), such cooperation may be the essential factor for successful implementation of the KCSHP.
Regarding academic performance, a study has reported children’s health status influences their motivation and ability to learn (24). Sense of school belonging also predicts academic outcomes, including motivation, effort, and absenteeism (25). Generally, absenteeism is strongly related to children’s poor academic achievement and dropping out. In this study, improvements in absenteeism and sense of school belonging were confirmed. Therefore, we have concluded that HPS activities of the project contributed to both health and educational improvements, although we could not directly examine the relationships between these factors in this project.
Meanwhile, we could not find significant change in children’s subjective happiness. A previous study found family was the most influential factor on high school pupils’ subjective happiness (26). Another study on primary school children reported confidential family relationships were one of the most influential factors (27).
Limitations
This study had several limitations. First, we were unable to set control groups. Second, we used only quantitative data for evaluation. Evaluation of a school health program generally needs not only quantitative data but also a synthesis of analysis of outcome, process, and data collected by mixed methods (28,29). Moreover, a previous study pointed out the importance of evaluating both health and educational outcomes in HPS activities (29). In a future study, it may be necessary to analyze qualitative data and conduct a process evaluation, considering both health and educational outcomes. Third, we could not evaluate how teachers implemented what they had learned from the project in their teaching or improvement of teachers’ health-related knowledge, perception, and motivation toward health education. Related to that, one previous study reported that teachers’ perception, motivation, and commitment were the essential factors for successful school health promotion (30). We therefore need to conduct further studies for evaluating changes in teachers’ health-related knowledge, perception, motivation, and commitment toward health education, as well as how such changes influence the outcomes. Fourth, we could not evaluate children’s participation in decision-making and its influence on the outcomes. A report emphasized the importance of keeping a balance between teacher’s guidance and children’s independence, teacher’s professional development for facilitating children, and teacher’s support for developing children’s voluntary activities to promote child participation and increase the influence of children in decision-making (23). In further studies, we will need to examine children’s participation considering these points. Fifth, a comprehensive school health approach should positively influence not only pupils and teachers, but also the entire community. This study, however, did not examine the project’s effect on communities.
Despite those limitations, this study demonstrates the potential of a Kenyan school health program. The information obtained would be useful for nationwide dissemination of school health activities in Kenya. Confirming the broad effectiveness of a comprehensive school health program is an important finding for the future promotion of school health in many developing countries.
Conclusion
The results of this study indicate that a comprehensive school health project in Kenya contributed to improving not only health-related knowledge, attitudes and practices, and self-evaluated physical and mental health status, but also a sense of school belongingness, self-awareness of health control, recognition of the importance of learning about health in school, and absenteeism. Subjective happiness, however, did not improve significantly.
Supplemental Material
Supp_mat_new – Supplemental material for Examining the appropriateness and reliability of the strategy of the Kenyan Comprehensive School Health Program
Supplemental material, Supp_mat_new for Examining the appropriateness and reliability of the strategy of the Kenyan Comprehensive School Health Program by Sachi Tomokawa, Takashi Asakura, Sammy M. Njenga, Doris Wairimu Njomo, Rie Takeuch, Takeshi Akiyama, Haruki Kazama, Alex Mutua, Walema Barnett, Hanae Henzan, Masaaki Shimada, Yoshio Ichinose, Yasuhiko Kamiya, Satoshi Kaneko, Kimihiro Miyake and Jun Kobayashi in Global Health Promotion
Footnotes
Acknowledgements
The authors would like to thank the MOH and the MOE in Kenya, pupils, teachers, parents, and all those who were involved in this project and study. This paper has been published with the permission of the Director General, KEMRI.
Declaration of conflicting interests
The author(s) declared no conflict of interest with regards to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Ministry of Health, Labor and Welfare of Japan (Kosei Kagaku Research Grant, International Cooperation Research Grant 24S2, 27S1). The study sponsor did not have any specific role in any procedure of this study.
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References
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