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ORIGINAL ARTICLE
Year : 2019  |  Volume : 63  |  Issue : 2  |  Page : 133-138  

Effectiveness of multi-strategic health screening cum educational intervention model in promoting health of school children in rural Coimbatore


1 Associate Professor, Department of Community Medicine, PSGIMSR, Coimbatore, Tamil Nadu, India
2 Assistant Professor, Department of Community Medicine, PSGIMSR, Coimbatore, Tamil Nadu, India
3 Professor, Department of Community Medicine, Believers Church Medical College and Hospital, Thiruvalla, Kerala, India

Date of Web Publication18-Jun-2019

Correspondence Address:
Subhashini Ganesan
Department of Community Medicine, PSGIMSR, Coimbatore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_226_18

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   Abstract 


Background: Schools are the best setting for health promotion activities, and in India, for many, the schools are in fact the only nurturing and supportive place where they learn health information and have positive behavior consistently reinforced. Therefore, health promotion addressing the nutrition and personal hygiene habits among school children would improve health of school children and mold them into healthy productive citizens of tomorrow. Objectives: The objective of the study is to find the effectiveness of multi-strategic health screening cum educational intervention model in promoting the health of school children. Methods: A school-based intervention was designed using multi-strategic approach to promote the health of 2500 school children in 13 schools in rural Coimbatore. Logic model was used to plan the intervention, and the approach included health screening, nutrition and personal hygiene assessment and educational intervention in three phases over a period of 1 year. The multi-strategic approach comprised of approach through doctors, teachers, and through peer educators. The effectiveness of the intervention was assessed with improved nutrition and personal hygiene habits, improved body mass index status, and reduction in sickness absenteeism. Results: There was a significant improvement in nutrition and personal hygiene habits among school children. There was also significant reduction in the proportion of underweight category. Furthermore, a slight increase in sickness absenteeism was observed. Conclusion: Our study shows evidently that a multi-strategic health screening cum educational intervention model can be implemented and can be effective in bringing changes in the nutrition and personal hygiene habits thereby promoting the health of school children.

Keywords: Educational intervention, health promotion, school children


How to cite this article:
Muhammad G M, Ganesan S, Chacko TV. Effectiveness of multi-strategic health screening cum educational intervention model in promoting health of school children in rural Coimbatore. Indian J Public Health 2019;63:133-8

How to cite this URL:
Muhammad G M, Ganesan S, Chacko TV. Effectiveness of multi-strategic health screening cum educational intervention model in promoting health of school children in rural Coimbatore. Indian J Public Health [serial online] 2019 [cited 2019 Sep 19];63:133-8. Available from: http://www.ijph.in/text.asp?2019/63/2/133/260600

Authors G. M. Muhammad and Subhashini Ganesan contributed equally to this paper.





   Introduction Top


Schools have been a popular setting for health promotion activities for many years and served as the major institution in providing education and experiences that mold the young children into responsible and productive citizens.[1] School health programs and interventions are one of the most effective ways in reaching the children of that age. Well-designed educational interventions in schools can bring about awareness leading to change in attitudes and behaviors and thus promotion of healthy practices.

In India, the major health problems of school-going children are undernutrition and added to that, micronutrient deficiency, and overweight/obesity are increasing.[2] In addition, another major reason for poor health and infections among school children is the lack of awareness of the health benefits of personal hygiene. Diarrheal diseases, skin diseases, worm infestations, and dental diseases are most commonly associated with poor personal hygiene. It is also an established fact that infection and malnutrition form a vicious circle and retard children's physical development. Studies also show that repeated attacks of infections often compound the existing poor health of children, compromising children's attendance, and performance at school.[3]

Hence, from a school health perspective, the major components to be addressed to improve the health of school children are improving their nutrition and personal hygiene. By doing this, we can target the major health problems of school children namely malnutrition and infections which are the major contributors to poor health and poor academic school performance, particularly in rural areas. Literature also shows that healthy eating habits in young children may prevent various chronic health disorders in childhood and adult life, including obesity, diabetes, hypertension, cardiovascular disease, cancer, and dental caries.[4],[5] School environment also provides an easily accessible setting for interventions targeting the children to promote healthy lifestyles.[6],[7]

There are many studies on interventions to promote healthy behaviors among school children, and systematic reviews have shown that interventions to promote healthy eating and physical activity were the most likely to be effective.[8],[9] A lot of studies have evaluated school-based interventions on a diet of which a few are from low- and middle-income countries. Review shows that the interventions that were effective are high-intensity school-based interventions which were comprehensive and multicomponent.[10]

A study done in India has shown that school-based child-to-child personal hygiene education resulted in behavior change among children.[11] Another study done among adolescent school students in North India included intervention components like nutrition education lectures, promotion of physical activity, individual counselling by a trained nutritionist, increased availability of healthier food choices in the school canteen and involvement of teachers and parents, showed effectiveness in improving the diet of school children.[12]

Studies have also shown that while it appears that parental involvement is crucial in school interventions, challenges exist for recruiting and sustaining parent involvement in school-based programs.[13]

Studies have revealed that reaching the children through peer leaders were more effective than when done through adults,[14] especially when targeting behavioral changes and draws on the credibility that young people have a rapport with their peers and provides flexibility in meeting the needs of their peers.[15],[16]

Similarly, the WHO also recommends that a variety of activities promoting a healthy diet and a strong educational component are likely to be more successful among school students.[17]

Hence, this study was conducted to find out the effectiveness of a multi-strategic health screening cum educational intervention model in promoting the health of school children.


   Materials and Methods Top


Based on the extensive review of various interventions and recommendations of the WHO as well as keeping in mind, the cultural settings and resources available, a custom-made intervention was designed to promote the health of school children, and this included the following components:

Morbidity screening and dietary and hygiene gap identification

The school children were screened for general morbidities including eye and dental examination. The morbidities were documented in the health card. The body mass index (BMI) was measured, and the WHO charts were used to grade the BMI status. Then, they were also assessed for personal hygiene habits and nutritional habits using a checklist developed based on standard recommendations. The gaps in the recommended diet and personal hygiene habits were identified. Those who needed referral were also given a referral slip.

Individual counseling of students based on individual gaps identified

The students at the end of the screening were given individual counseling by doctors on their morbidities, about the gaps in their diet and personal hygiene practices and how they can be rectified.

Modification of teaching curriculum

The heads of the schools, along with the teachers were approached, and efforts were taken to include the nutrition and personal hygiene education as a part of their routine classes in which definite hours were allotted for educating students on nutrition and personal hygiene using the tailor-made module designed using standard recommendations of the National Health Agencies.

Designing modules for dietary and personal hygiene education

The teaching module on good nutritive diet and personal hygiene was prepared based on standard recommendations and the one regarding diet-based on the Indian Council of Medical Research/National Institute of Nutrition (ICMR/NIN) recommendations for a balanced diet. We designed the module in such a way that the student's interest, i.e., their future aspirations and career choices were linked to nutrition and personal hygiene practices. How a proper nutrition and personal hygiene practices could bring them close to their aspirations. Further, the module developed was a flip chart with pictures for easy understanding and the key points to be told during the session were printed on the back side of the flip for ease of using it. Studies showed that flipchart was an effective tool in poor resource setting for health education.[18] This could capture the student's interest and be a motivation for the positive behavior changes expected in them. Based on the evidence of the impact of using posters on imparting knowledge, a poster was also given for each school that had the key points of the module.[19]

Training of teachers for communicating the health promotion messages

The teachers were given training on how effectively the tailor-made modules could be used to educate the children on nutrition and personal hygiene habits.

After the training, their sessions were observed by doctors and feedback on the same was given to the teachers to increase their effectiveness in the communication of key messages.

Selection and supervision of peer educators

The peer educators were chosen from each class with the help of teachers. The selected peer educators were motivated to teach their peers and use of the modules that would aid the diet and hygienic behavior change. The peer education sessions were supervised and feedback was given to the peer educators to improve their communication skills.

Reinforcing, cascading, and buttressing approach

The students were approached using three different approaches – through doctors, teachers, and peers.

  • First was through teachers, who have good face value and rapport with the students. We involved the teachers by training them to take sessions using our module designed
  • Second was through doctors and health team, the doctors did the nutrition and personal hygiene assessment and counseling. Doctors had good credibility among the students and were always looked on by the students, in this way, it motivated the students to a positive change in behavior
  • Third, we also used peer approach by selecting peer leaders in school in their same class and trained peers in using the module among their peers. It gave them recognition and motivation to deliver the modules to their peers.


Assessment tools and program evaluation

The assessment tools were designed based on standard recommendations (ICMR/NIN) and were developed as a checklist in quickly identifying the gaps in the recommendations. The same was piloted, and face validation was done among the experts of community medicine. The checklist developed assessed the nutrition and personal hygiene habits of children and based on this counseling was given. The tool designed was kept simple, user-friendly and effective in quickly identifying gaps and faulty habits in nutrition and personal hygiene. We also incorporated an evaluation component in the tool by giving a scoring for the assessment done.

The intervention was designed to promote the health of school children in 13 schools in rural Coimbatore. The study was done over a period of 1 year from 2014 to 2015. The preparatory work of planning the intervention, getting approval from authorities, acquiring funding, and designing the tailor-made modules were done during March–May 2015. When the schools reopened baseline assessments were done in all 13 schools and Phase 1 extended from June to August 2014, Phase 2 visits were done during September–November 2014 and final assessments were done during Phase 3 which extended from December 2014 to February 2015. The study population included all 2500 students from the age of 6–18 years of both sexes studying in these schools. The health team consisted of doctors, postgraduate students, interns, nurses, social worker, and health assistant who participated in the intervention.

Logic model was used to plan the intervention process leading to a desired result. It also helped to set out the evaluation priorities right from the beginning of the process.

[Figure 1] shows the inputs needed for the project, the various activities planned, the output expected from these activities, and finally, the impact of the project, a desired outcome of the planned intervention.
Figure 1: Logic model used in planning the intervention.

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The health education intervention was done in three phases. There was an interval of 3 months in-between these three visits. The final visit and assessment were done at an interval of almost 6 months from the baseline assessment. The Institution Human Ethics Committee approval was obtained for using the data for the study.

Phase 1

During the first visit, health screening was done, and the student was also assessed for the nutrition and personal hygiene habits and based on the assessment were given individual counseling. During the same visit, the teachers were given training by the health team member on how to use the tailor-made module on nutrition and personal hygiene to deliver the health education to students.

Phase 2

During the second visit, the students were again subjected to health screening and assessment of the nutrition and personal hygiene using the checklist. Based on which individual counseling and reinforcement of corrective measures were done. In this visit, the teachers were asked to deliver the health education session to the students with the help of the module, which was supervised and feedback was given. Child peer educators were selected from their own peers in each class.

Phase 3

During the third visit, again the students were screened and assessed for nutrition and personal hygiene and counseled individually. In this visit, peer educators delivered the health education which was supervised.

The module on nutrition and personal hygiene was given to each school, and a poster of the same was also placed on prominent areas of the school premises.

Measuring the effectiveness of the intervention

The outcome assessment indicators were chosen such that they would reflect the changes that we aimed doing this intervention. As our aim was to improve the health of school children by improving nutrition and personal hygiene practices, we chose the following indicators.

Change in the dietary and personal hygiene assessment score

The students were assessed for good nutritional intake and personal hygiene on the first visit following which a score was assigned against a maximum score of 10 each. The same was assessed at the end of the year; an improvement in score was considered improved practices of nutrition and personal hygiene.

Change in body mass index status

The BMI of school children was computed as a part of health screening so that the baseline BMI distribution could be compared with the change in the BMI distribution of the school population at the end of the intervention. Reduction in the underweight category was considered as a positive change indicating the effectiveness of the intervention.

Decreased absenteeism

This was another indicator that we chose. The days of absenteeism were noted down for each quarter; this was a proxy indicator indicating the health of school students. The mean days of absenteeism were compared using baseline and the mean days at the last quarter of the intervention. This indicator was chosen with the assumption that improved practices of good nutrition and personal hygiene would prevent most of the common communicable diseases thereby reducing sickness absenteeism.


   Results Top


The total number of students was 2500 of which 2204 were assessed at the baseline assessment and 1836 were assessed during the final visit. The baseline (preintervention assessment) score and the postintervention score for a total score of 10, at the end of 1 year were documented.

[Table 1] shows the basic characteristics of the study population; the participants belonged to the age group of 6–18 years.
Table 1: Gender distribution of the study population at baseline and postintervention

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[Table 2] shows the pre- and post-intervention mean scores. Scoring was given on a total score of 10 each for both the nutrition and personal hygiene assessment. The difference between pre- and post-mean scores was found to be statistically significant. However, the increased figures for absenteeism shows we need to further ascertain whether the absenteeism is because of sickness or due to other extraneous reasons.
Table 2: Indicators showing the effectiveness of the intervention

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[Table 3] shows the mean BMI distribution of the students, pre- and post-intervention. The BMI was calculated using the WHO standards,[20] and it was found that the difference in the distribution of BMI pre- and post-intervention was statistically significant. There was a significant reduction in the underweight category and improvement in the normal BMI category, though in the overweight and obese category there was a slight increase.
Table 3: Body mass index distribution before and after intervention

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   Discussion Top


Our study aimed to show and share multipronged model of promoting the health of school children. The intervention was school-based in which we targeted the school children by individual counseling by doctors, health education by teachers, and also peer-led health education. The intervention had led to the improvement in the total mean score of diet and personal hygiene assessment among the students at the end of 6 months.

Our study highlights that students when individually screened for gaps in diet and hygiene and counseled for the same, the acceptance and understanding are better and when doctors themselves give the counseling, it increases the credibility of the information given. Second, we involved the teachers also who already had the confidence of the students, and so information from them would reinforce the key messages to the students even more. Third, we also chose peer educators among the same class since they would be easily accessible to their classmates and they had greater influence on their peers through peer pressure.

We also used tailor-made health education material which linked the academic performance and the career aspiration of students to their dietary and personal hygiene habits which was a motivation for the students to adapt better dietary and personal hygiene practices.

Our intervention showed that by involving the stakeholders during the planning and implementation stages, even a multipronged intervention can be implemented and can be effective in bringing changes in the diet and personal hygiene habits of school children, which was evident from the increase in postintervention behavior change scores as well as its positive health outcome reflected by the change in BMI distribution and particularly so reduction in underweight category at the end of 1 year.

Similar studies done in other places have shown that school based and peer-led programs have been successful in bringing out changes in regard to nutrition among school children. A study done in Canada also shows that peer educators models have been successful in bringing changes in elementary children also.[21] A study done in China among school adolescents have also proven to be effective in reducing sedentary behaviors in school children.[22] Systematic reviews have been done which discusses the success and failures of these models and need for further studies.[9]

Although BMI status and mean days of sickness absenteeism was taken as proxy measures, BMI status change reflected the status change of the whole study population and not necessarily the change in the individual status. In addition, mean days of absenteeism observed does not necessarily represent actual sickness since we did not insist on production of the sickness certificate. Furthermore, the increased absenteeism seen as a finding during the final impact assessment may be a confounder arising due to it being done in the festive season.

Our study also found out the practical difficulties in bringing changes in the habits of school children. Nutrition and personal hygiene habits cannot be inculcated in school children unless the resources and opportunities are provided. Parents and schools should be able to provide them with the proper nutrition, and environmental facilities and resources have to be provided for personal hygiene practices. The major drawback identified was the lack of parental involvement in the intervention, effectiveness of this intervention cannot be completely assessed unless the parents are involved.

Limitations

Our study focused on finding the effectiveness of an innovative intervention in which change in the nutrition and personal hygiene scores were taken as a main indicator. Since we could not find any existing tool that was user-friendly in assessing a large number of children in a short duration of time, we developed our own tool in the form of a checklist to assess nutrition and personal hygiene habits. The reliability and validity of this tool need to be tested. The other limitation was though our tool assessed the habits of recommended nutrition intake and personal hygiene practices the scores were self-reported, so increase in score had definitely shown knowledge increase but how far it was transformed into change in practices could not be evaluated. Another limitation of our study was due to resource constraint the individual-level data could not be compared preintervention and postintervention, we had to use aggregate data to compare scores.


   Conclusion Top


Our study has shown evidently that this innovative model of health education where school children are intervened by individual counseling by doctors, teachers, and peer educators based health education sessions is effective in increasing the knowledge and practices of school children regarding nutrition and personal hygiene. Our evidence also showed a positive influence on the BMI of school children. Thus, this model of individual counseling involving health team, teachers, peer educators, and custom-made modules on relating nutrition and hygiene to their academic performances, aided by flipcharts and posters had created a positive impact on the ethos of the schools. Further studies with the involvement of parents and providing proper resources for aiding nutrition and personal hygiene practices are needed to study the real impact of the intervention.

Acknowledgments

We would like to acknowledge the work of the entire school health project team and L & T Coimbatore for its funding and support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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