Introduction

“More children than ever before are attending school, and for longer periods in their lives. Therefore schools in virtually every nation could do more than any other single institution to improve the well-being and competence of children and youth. Yet the evidence suggests that schools around the world have difficulty meeting critical physical, mental, and social health needs of children and youth”.⁽¹⁾

“Schools could provide the most cost-effective means to improve the health of children and thus to advance social and economic development”.⁽¹⁾

The health and well-being of children is a fundamental issue in education. Indeed, active promotion of health is now seen as a priority for schools. The level of concern is illustrated by the fact that WHO has set up a Global School Health Initiative. In countries around the world, the issue is being addressed through school health services, health education and school meal programmes. Although the physical environment in schools is now seen as one of the major elements of health promotion, relatively little work has so far been done on the relationship between this physical environment and the health of schoolchildren, particularly with relevance to schools in low-income communities. This document attempts to fill that gap.

It must be stressed, however, that this is not a manual. There have been numerous attempts to write manuals on school construction and furnishing. In reality, however, the underlying problems often persist irrespective of the designs used. The problems and the solutions, on the whole, are not to be found on the architect’s drawing-board. Nor is this an epidemiological study. Most of the health problems of children - and their causes - are well understood, not only by doctors but also by teachers and the children themselves. The real issues relate to the attitudes of teachers, children and communities to the shared resource that is their school.

In this document, rather, we attempt to highlight some key issues and give pointers to some simple achievable measures which can be taken by communities and local governments themselves.

A large number of schools in numerous countries was visited for the purpose of preparing this report. All the examples mentioned in the text, unless otherwise stated, were visited by the authors. The visits revealed that the health problems of school-age children are governed by a wide range of factors, some of which are specific to particular locations. In one school in Costa Rica, for example, health problems were reported to be overwhelmingly respiratory and eye infections. The school was for the children of workers in a banana plantation and located in the heart of the plantation. Consequently, the school and the children were regularly sprayed with insecticide from the plantation’s aircraft. Another school visited, in Thailand, was next to a rice-processing plant. During the four months of the milling season the school buildings and grounds were permanently covered in fine dust. Not surprisingly, the prevalent health problems were respiratory and skin ailments. Cases such as these demonstrate that there is a limit to what can be achieved for children’s health by improving school design per se. Most importantly, healthy children require a society which is committed to creating a generally healthy environment.

Beyond the problems particular to specific locations, certain trends are discernible which relate to general levels of prosperity. In the poorest communities the most prevalent health problems include helminth infections, gastrointestinal diseases, trachoma and acute respiratory infections. In some places, almost all children suffer from helminth infections. In more prosperous communities, health problems among children increasingly relate to inappropriate diet, particularly dental caries but also obesity. In some emergent economies there also seems to be an abnormal number of eyesight problems. (It may be that the poor lighting conditions found in so many schools in developing countries are contributing to this problem.) In wealthy countries, asthma and other ailments related to allergies are a growing problem and may be associated with building construction and operation. The focus of this document, however, is on the problems faced by schools in poor communities.

This document sets out not to prescribe solutions but to identify the key objectives for achieving a healthier school environment. To do this it aims to:

· raise awareness and understanding of the health impact on children of the physical environment of primary schools;

· increase the priority given to developing environments in primary schools that promote health;

· define areas where interventions are feasible and suggest what can be done and how, particularly under difficult conditions and within severe budgetary constraints.

Chapter 1 provides an overview of the current situation. It points out that, up till now, programmes of school construction and recommendations for school design have generally focused on developing standard designs. It concludes, however, that experience has taught us some key lessons: that good design is not enough; that standard designs assume standard conditions; that schools are more than just classrooms, and that the greatest need is to improve existing schools.

Chapter 2 reviews the main correlations between the physical environment in schools and the health of school-children. It concludes that, for most schools in low-income communities, the biggest scope for health-related improvements lies in the areas of water and sanitation.

Chapter 3 identifies eight key objectives which if met will go a long way towards achieving a healthier school: committed and informed people; a faecal-free environment; safer drinking-water; convenient handwashing facilities; well-lit learning spaces; protection from the elements; structural safety, and adequate cleaning and maintenance.

In particular, it is emphasized that decisions on the design and use of schools must be made locally. The key is to provide local decision-makers such as teachers, parents and local politicians with the information necessary to make those decisions. The decision-makers need to develop a commitment both to bringing about change and to sustaining that change. In addition, they need knowledge about the technical options available for solving the problems they face.

The concluding chapter recommends a shift in focus in four principal and strategic areas:

· away from buildings and towards adequate services, particularly water and sanitation;
· away from classrooms and towards total school environments;
· away from design and construction and towards operation and maintenance;
· away from central regulation and towards local motivation and ownership.

The case studies in Appendix A illustrate some of the low-cost and innovative techniques which can be employed to improve health in schools. Appendices B and C contain practical information about available technology and about planning for change.