Hunger and undernutrition, as well as obesity, plague schoolchildren around the world. Along with vitamin and mineral deficiencies, nutritional problems can obstruct a child’s ability to enroll, attend, and thrive in school. While the inextricable link between health and learning has long been recognized, the most effective way to improve health for students has been less apparent.

Recent findings from the nutrition initiative in Zhejiang Province, China, conducted with EDC, the World Health Organization (WHO), and the Health Education Institute of Zhejiang Province, reveal that the health of students, families, and teachers improves when they are introduced to the comprehensive health-promoting school (HPS) philosophy.

A health-promoting school “fosters health and learning with all the measures at its disposal,” according to the World Health Organization. Involving communities, families, and school staff, health-promoting schools create a healthy school environment, enact health-oriented policies, provide health education, and offer health and nutrition services.

The nutrition project, which has continued to expand throughout the province, also provides guidance on how schools can assume a more prominent role in health promotion.

The program showed such promise that government officials expanded its scope; it now reaches more than 90,000 students in 50 additional schools in 11 cities across the province. Research on the impact of the program, published in the November 2004 issue of Health Promotion International, featured both quantitative and qualitative elements, including baseline and postimplementation surveys. Extensive interviewing of students, parents, and school personnel came in later phases of the work.

The project began in 2000 with three primary and three secondary schools in the Zhejiang Province, located in the southeastern part of China. The initiative, which involved 7,500 students and their families along with 800 teachers and school staff, focused on nutrition, with every school planning its own intervention (such as training for staff, distribution of materials, or outreach to families), all within the HPS framework. School personnel and local health officials attended a training workshop conducted by WHO, the Food and Agriculture Organization of the United Nations (FAO), EDC, and Chinese universities. After site visits and “mobilization meetings” at the school, the project collected baseline data.

“Although the program focused on the specific area of nutrition, it became an entry point to address a broader range of health issues,” says Carmen Aldinger, project director for Global Programs in Health and Human Development (HHD), an EDC division.

Students in the program attended health education classes, and the schools integrated nutrition instruction into more traditional academic subjects. Schools offered a variety of supplemental activities, such as student training in the preparation of nutritious food, planning the school lunch menu, and creating Web sites on nutrition topics. Some schools participated in composition and drawing competitions on the theme of “Nutrition, Health and Me.”

Supplemental activities in the school environment included renovations to the schools’ kitchens and dining areas and broader use of uniforms (e.g., having cafeteria workers wear hats and gloves). In addition, restrooms were cleaned, health examinations were offered at school, and “no smoking” signs were posted at schools.

Some schools delayed the start of the school day to allow more time for families to eat breakfast. Parents were given leaflets about healthy nutrition and meal preparation, and parents and community members were invited to the schools for lectures and workshops.

In the control schools, routine health education activities continued, including classroom instruction and activities in physical education. Most Chinese schools blend health education into the physical education or science classes, says Aldinger.

Quantitative Research

Using a questionnaire designed by Chinese scientists and researchers from Zhejiang University’s Medical College, data was collected on student, family, and staff knowledge, attitudes, and behavior, both at baseline and 18 months post-program. Highlights of the findings include the following:

• Parents and guardians showed the largest gains in nutrition knowledge, increasing their knowledge about nutritional deficiencies from 35 to 66 percent.
• Primary school students made the greatest gains in knowledge about dietary guidelines.
• The number of secondary school students who reported liking school lunches rose from 17.9 to 45.2 percent.
• The number of school staff who ate lunch at school increased in pilot schools from 87.5 to 93.9 percent.

“Given the fairly short intervention period, we were very pleased with the increases. Still, the time frame makes it understandable that some of these changes in knowledge, attitudes, and behavior are still of moderate magnitudes. If the interventions are continued, even stronger effects are likely,” notes Aldinger.

Qualitative Research

When the team had completed its quantitative research, it wanted to learn more about how people were thinking about and reacting to the initiative.

“We wanted to add qualitative elements to WHO’s survey assessment,” says Aldinger. The qualitative work, which is currently underway, entails four one-hour interviews and/or focus groups with school administrators, teachers, students, and parents in three schools at three junctures, respectively. “The qualitative work complements quantitative surveys and allows us to get in-depth information,” says Aldinger.

The completed interviews gave the team a sense of how deeply students, families, and school personnel understood the concept of HPS and why they chose the entry point they did. “We found that schools’ efforts were more comprehensive than those that introduce a single program without receiving philosophical or actual support from the rest of the school program,” says Aldinger. The comprehensive approach of HPS, she says, tends to cultivate more widespread change.

The Chinese culture and its “one child” tradition also had an impact on the results, notes Aldinger. Children have significant power in their families to influence health behaviors. Students and parents reported in interviews that students talked with their parents and grandparents about their schools’ activities regarding smoking prevention and persuaded their family members to stop smoking.

The interviews also revealed what the schools are doing well and what can be improved. “For example, interviews revealed that schools have not fully explored all of the data they collected at the outset of the project, so that helped us refine our technical assistance,” says Aldinger.

In addition, some headmasters and teachers reported that they had given up smoking in front of students, to set a good example. Students then passed this information along to fathers and grandfathers, who then also stopped. One headmaster stated, “Only when the headmaster is healthy can students be healthy.”

Some interviewees also reported that they took better care of school plantings or littered less. This information about more farreaching impacts of the program not only bolstered the initiative but spurred the HHD team to consider tracking more people in more extensive ways in its formal surveys.

Since every school offered different interventions and faced various extenuating circumstances, it is hard to distill the results into a single “model” or “approach” that could be replicated elsewhere, notes Aldinger. Still, she says, some of the most promising health promotion successes are not due to single factors. The successes come when schools address a variety of health issues, when varying aspects of the school program reinforce one another, and when staff and students have support from the highest levels of school administration.

“For example, when students learn about healthy eating in the classroom, the cafeteria cooks healthy food, and parents receive information about menu planning and nutrition, you’ll see improvements,” Aldinger says. On the other hand, if a teacher offers nutrition education, but the cafeteria continues to serve unhealthy food, and exercise is not offered at school, the education will have minimal impact. “The important aspect is that schools conduct interconnected activities,” says Aldinger. “They do what’s feasible in their particular situations, with the infrastructure they have and the district’s priorities. If a community has a hospital and doctors who are willing to visit the school for education and services, that’s wonderful. Another school might not have that but would be able to take other actions.” She adds, “It’s harder to evaluate a holistic combination of components. But we see that, together, these initiatives make a difference.”

The Future

The researchers’ findings conclude that “nutrition can effectively serve as an entry point to establish health-promoting schools [HPS] in China. The HPS concept is feasible to improve the dietary knowledge attitudes and behavior of students, partners and school personnel.”

Aldinger hopes that the successes will be contagious. “The HPS model is to help other schools in the vicinity follow suit,” she says.

The researchers hope the initiative continues to expand and “further promote the health of the children and also improve the education for [Chinese] children,” says Yu Sen- Hai, project researcher. “The schools are increasing their focus on helping children and teachers to develop socially and emotionally as they focus on their academic goals,” says Jack Jones, former School Health Group Leader, Department of Chronic Diseases and Health Promotion, WHO Headquarters.