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Health and nutrition considerations in education planning. 1. Educational consequences of health problems among school-age children

Joanne Leslie and Dean T. Jamison

Abstract

This paper utilizes recent findings to address, from the perspective of an educational planner, the question of how educational systems can intervene to improve the health and nutritional status of school-age children. Evidence is reviewed on the linkages between health conditions and three of the most important educational problems in developing countries-children who are unprepared to begin school at the usual age, the failure of many students to learn adequately in school, and the unequal participation in schooling by girls. It is clear that although less attention has been paid to the health and nutrition status of school-age children than to that of children of pre-school age or of adults, existing data are adequate to identify several widespread problems among school-age children that have well established negative consequences for school participation and performance. These problems include chronic protein-energy malnutrition, iron-deficiency anaemia, iodine deficiency and intestinal helminth infection. It was also observed that a number of other infectious diseases, as well as disability, premature fertility, and substance abuse, are also likely to undermine the health and educational success of many school-age children.

Introduction

The past few decades have witnessed remarkable improvements both in the survival prospects of children in the developing countries and in the opportunities for them to attend school. For example, the percentage of children who die before their fifth birthday has been estimated to have declined from 14% to 11% in the developing world as a whole between 19701975 and 1985-1990; even in sub-Saharan Africa, where mortality rates are highest and the economic shock of the early 1980s was most telling, the under-five mortality rate declined from 23% to 17% in this period [2: 3]. Between 1965 and 1985 primary-school enrolment rates in developing countries a]so improved: while the school-age population increased by 42% in that period, enrolments increased by about 62%, providing substantially improved access to schooling [4, ch 2]

The authors are affiliated with the University of California at Los Angeles, Los Angeles, California, USA.

This paper and the following one, by the same authors [1], served as background documents for an ACC/SCN symposium on Nutrition and Schooling and a Unesco/Rockefeller Foundation workshop on School Health, both held at Unesco headquarters in Paris in February 1990.

Education planners have paid relatively little attention to children's health and nutritional status despite the everyday observations of many teachers and parents about the importance of ill health and malnutrition for absenteeism and inattention. Exceptions to this generalization have been published, however [48]. There are discussions of the early experiences with school feeding programmes and with school-based health and nutrition education efforts in the United States [9; 10], and a summary of studies from rural China in the 1930s that show a strong relation of absenteeism to infection and describe approaches to including health in school and adult education curricula [11].

The very success of efforts to reduce child mortality and increase school enrolments may, somewhat paradoxically, suggest that it is time for education planners to give greater consideration to the health and nutrition determinants of children's school participation and performance. In many countries, the technologies underlying success in reducing child mortality may have had little effect on the incidence of morbidity, on nutritional status, or on general development; hence there may have been little improvement in children's preparedness for school. Documentation of the recent experiences of Sri Lanka [12] and Zimbabwe [13] provides support for this interpretation. Both countries have achieved relatively low mortality levels in the face of continuing child malnutrition. Furthermore, as access to primary schooling expands, increasingly marginal populations are being included; these populations typically manifest more severe problems of malnutrition and illness. For these reasons, therefore, education systems may now be faced with more substantial health-related problems despite progress in reducing mortality and extending schooling.

These facts, combined with the recent growth of research literature quantifying some of the adverse educational consequences of ill health and malnutrition, have prompted increased international attention to the linkages among health, nutrition, and education [14] The objective is to advance understanding of these linkages, to assess the efficacy of interventions for addressing the problems, and to develop and implement action programmes based on cost-effective interventions. An important recent step in this effort was the completion of a major review of the literature on educational consequences of specific types of morbidity and malnutrition; a monograph based on this review is now available [15].

Our purpose here is to use findings of that review (and the literature more generally) to address, from the perspective of an education planner, the question of how education systems can intervene to improve the health and nutritional status of school-age children. Our concern is with the entire school-age cohort: health, nutrition, and family-planning interventions are at least as important for bringing children into school and keeping them there as for enhancing their rate of learning while attending; the subject, therefore, must be the age cohort rather than the current student population.

This paper begins with an overview of the most common health and nutrition problems of school-age children. It then reviews three important educational problems-unprepared children, failure to learn in school, and unequal participation by girls-and concludes with a discussion, drawing substantially on the monograph referred to above [15], of how these educational problems are affected by poor health, malnutrition, and premature fertility. The following paper [1] discusses intervention packages and their costs, and then briefly overviews the strength of the claim of health and nutrition interventions for school-age children on scarce resources from an economic perspective.

The health of school-age children

A major focus of health, nutrition, and family-planning programmes over the past IS years has been on reducing mortality in infants and very young children. The combination of very high mortality with a package of cost-effective interventions justified this emphasis; and, as noted, the results of child-survival programmes around the world have been substantial and well documented [16].

An adverse consequence of the concern focused on child survival, however has been the relative neglect of the health and nutrition needs of school-age children and adults in developing countries. Possible reasons for this include the high emotional salience of early childhood deaths, the potency of available interventions to prevent these deaths, and a widespread perception that individuals who survive early childhood in the developing world are at only slightly higher levels of risk than those in the industrialized countries. However, a major review of issues surrounding adult health in developing countries shows decisively that problems of mortality and morbidity are far more substantial than in industrialized countries [17]. The perception that adult health problems are of relatively limited scope is thus incorrect, and the questions become ones of the feasibility and desirability of directing resources toward cost-effective ways of dealing with relevant problems.

To our knowledge, no parallel analysis overviews conditions of school-age children. All that is possible to do here, therefore, is to outline the dimensions of the problem and to underline the central importance for schools of the problems that exist.

The school-age population: Size, mortality, and morbidity

Defining and labelling age groups is necessarily a somewhat arbitrary task. While those above the age of IS years have been grouped in various ways, children below 15 are quite commonly divided into the ranges birth through 4 years and S through 14 years, with the younger group further divided into "infants" (0-1) and others. We use these groupings and label the younger group "pre-school-age" and the older group "school-age." This definition of school age corresponds approximately to the period from kindergarten through lower secondary school; it begins after the period of high mortality risk in the preschool years and continues through most of the adolescent growth spurt and sexual maturation to young adulthood.

School-age children form a substantial fraction of the world's population, numbering about 24% of the population of the developing world and about 15% of that of the industrialized world. Table I shows their estimated numbers (and percentages of population totals) in various world regions in 1985 and projects those numbers forward to the year 2000. Not only are school-age children a much larger proportion of the total population in developing than industrialized countries (24% vs. 15%), but their numbers are growing at a substantial rate in the former (1.4% per year) and not at all in the latter. In consequence, by the year 2000 approximately 87% of the world's school-age children will live in developing countries

TABLE 1. School-age children^a by region. estimates for 1985 and projections for 2000

Source: Calculated from ref. 2. Annex table A2 1. 2.
a. Children 5-14 years old.

School-age children have the lowest annual risk of death of any age group. In developing countries in 1985, for example, their annual death rate per 100,000 was about 13% that of children 1-4 years old and 61% that of people 15-44. Nonetheless, the rate was higher by a factor of 14 than that of children of the same age in the industrialized market economies; in Africa it was 33 times higher. Consequently, the absolute risk of death during school age (10Q5 in demographers' parlance) is substantial: about 2% of children who reach school age in developing countries will die before completing it, and in sub-Saharan Africa the figure rises to over 4%.

School-age children suffer from almost the full range of human illnesses, but the pattern of the relative importance of conditions for them differs substantially from that for adults or for pre-school-age children. Schoolchildren in the developing world have been relatively neglected in epidemiological studies; so hard evidence on their patterns of morbidity, and on how those patterns vary by income level and across regions, is only erratically available. Thus the burden of their illnesses and how it differs from that of other age groups remain to be established. Many conditions known to be important in the school-age years, however, such as helminthic infection and malnutrition, generate high levels of morbidity relative to their limited consequences for mortality. It is thus reasonable to hypothesize that the ratio of mortality rates of school-age children to that of younger children or young adults substantially understates the relative burden of overall ill health in the school-age population.

To assess what health conditions are likely to be important for school-age children, particularly from the perspective of their potential impact on the child's educability, Unesco and the Swedish International Development Agency convened a panel of experts to review the available evidence [14]. (The focus of the Unesco effort, and the main focus of this paper, is on developing countries. However, many important health, nutrition and family-planning problems affect school outcomes in industrialized countries as well [see, e.g., refs. 18-20].) Drawing on the Unesco effort but modifying it somewhat, we use the following seven categories of health conditions:

• nutritional deficiencies,
• helminthic infections (including intestinal parasites and schistosomiasis),
• other infections (ranging from malaria to dental caries),
• disabilities,
• reproductive problems (including premature fertility, sexual violence, and exposure to sexually transmitted diseases),
• injury and poisoning,
• substance abuse.

Although, for most conditions, data limitations sharply limit the possibility of compiling country by country prevalence data for school-age children, this is to some extent possible for a number of the nutritional deficiencies and parasitic infections [21]. Valuable overviews of age differentials in the prevalence of anaemia [22] and schistosomiasis and intestinal helminthic infections [23] are available.

While it is useful to have a general sense of the conditions potentially important for school-age children, these conditions will vary enormously from region to region within a country and even more so across countries. It is thus essential, in a country-specific context, to extract as much relevant epidemiological data as possible from available sources and to identify where collection of further data is needed or desirable.

A Unesco case study for Zimbabwe provides a working assessment of the probable significance of a number of important conditions for school-age children and also assesses the nature and quality of available epidemiological data for these conditions and this age group [24]. The quality of information and the estimated importance of the problem are, of course, quite different: short-term hunger is judged important in Zimbabwe, even though only impressionistic data are available. On the other hand, rather good data exist on the prevalence of ascariasis (roundworm infection of the intestine), and they suggest that in Zimbabwe, somewhat surprisingly, the disease is generally unimportant. While the case study identifies important (and remediable) gaps in the knowledge base for Zimbabwe, it shows that even the limited data available can provide a solid starting point for designing interventions, including, for some conditions, sufficient information to allow geographical targeting.

Schools and the health of school-age children

In low-income countries, and in poorer regions of middle-income countries, some school-age children must spend substantial time contributing directly to the economic well-being of their households. Reasonably early in the course of modern development, however, it becomes essential for the majority of school-age children to spend their "work" time investing in the future through schooling rather than in current production. Thus, a major adverse consequence of children's ill health, beyond immediate welfare losses and the cost of care, is in lost learning opportunities [25]. An important potential instrument for affecting children's health and nutritional status is school-based policies, particularly since this age group and the conditions they face are often relatively neglected by the formal health services.

As schooling is (or should be) central to the lives of these children, it may seem somewhat surprising that the mutual (potential) influence of the school system on health and of health status on school outcomes has been so little addressed. Of these two directions of influence, more is known about the effect of malnutrition and ill health on school outcomes. Much of that literature is carefully evaluated and reviewed, by specific condition, in Pollitt [15].

TABLE 2. Health conditions and the schools

a. Conditions that are likely to affect school participation or learning and to occur relatively frequently in some environments.

b. Conditions for which school-based interventions are likely to offer significant help.

In the next section we organize the available information on linkages between health problems and poor school outcomes in terms of three specific education problems: unprepared children, failure to learn in school, and unequal participation by girls. This then provides the basis for the assessment in the following paper [1] of the extent to which and the ways in which interventions can address the health conditions contributing to those problems. It is important to note that such interventions must address the health problems of school-age children whether or not they are enrolled in school, and that an important objective should be to facilitate attendance by those not enrolled or frequently absent.

The available literature on both the cost and efficacy of school-based interventions is limited; nonetheless enough can be inferred from evaluations in other contexts to allow conclusions that are at least suggestive for broad directions of policy. It is worth clarifying at the outset, however, that not all forms of ill health and malnutrition are important for education and, also, that school-based interventions offer promise for dealing with only a limited (although important) class of conditions (table 2). The main concern of this paper is with conditions that are important for education, and for which school-based intervention can help.

Education problems related to poor health and nutrition

Satisfaction in the development community with the remarkable progress made over the past 25 years in expanding access to and participation in schooling throughout the developing world (although not to the same extent in all countries) must be tempered by recognition of the remaining problems of inadequate participation in many developing countries, and inadequate levels of achievement in most. A recent World Bank review of policy options to improve primary education in developing countries identified as the main problems too few children completing primary school and the undereducation of those who do [4]. Low levels of enrolment and poor achievement in secondary education, particularly among females, are equally serious problems in most developing countries.

Analyses of options to improve the accessibility and quality of schooling in developing countries have tended to focus on school-related factors such as location, the availability of teaching materials, teacher quality, and institutional management. Demographic and socio-economic characteristics of households are also frequently noted as important determinants of school participation and achievement. Except for age and gender, individual characteristics, such as health and nutritional status, are surprisingly rarely discussed, although attention has been drawn to the constraints on teachability imposed by certain nutritional deficiencies and health problems [4].

Three of the most significant continuing problems facing school officials and education planners in developing countries are children who are unprepared to begin school at the usual age, failure to learn adequately while at school, and unequal participation in schooling by girls. These problems are especially significant because they constitute major barriers to the achievement of the goal of education for all, they affect large population subgroups in all developing countries, and they are in large part consequences of poor child health and nutrition.

Although the age groups that are affected overlap considerably, these three problems can also be viewed to some extent chronologically. Unpreparedness is primarily an issue during the pre-school years and the first year of primary school; failure to learn in school has received most attention at the primary level, although it certainly continues to be a serious problem at the secondary level; and the gender differential in school enrolment, while far from negligible at the primary level, manifests itself most acutely at the secondary level, in part because of its relationship to sexual maturation.

Unprepared children

A child's readiness for school can be defined in terms of a number of characteristics, including physical capacity, cognitive ability, psychological well being, knowledge base, learning style, and social competence [26]. These are determined in part by the child's health and nutrition (beginning with maternal health and nutrition during pregnancy) and in part by his or her psycho-social development. Depending on the nature and severity of the unpreparedness, a child may be entirely incapable of attending school (other than a special school designed for severely handicapped children), may be on a slow development path and thus be unable to begin school at the standard age, or may be able to attend but be severely disadvantaged relative to more adequately prepared peers.

There are no global estimates of the number of unprepared children in the developing world, and clearly any such estimates would vary depending on the criteria used to define readiness. Nonetheless, an extremely conservative estimate is that 10% fail to enrol in school at all, and many are "over age" when they do enrol. Early childhood development programmes have been shown to have significantly positive effects on enrolment and age at enrolment, with those exposed to such programmes enrolling at younger ages [26]. Therefore, it seems reasonable to conclude that an important part of non-enrolment or late enrolment is due to children being unprepared. In addition, lack of readiness for school not only in cognitive and physical abilities but also in communication skills and social behaviours contributes to poor performance once a child does begin attending.

Failure to learn in school

Whether performance is judged against national or international standards, a significant proportion of school children in developing countries are failing to acquire the minimal literacy and numeracy skills that are central goals of the school system and, even more important, that are necessary for them to succeed in their later economic, social, and parental roles. Data from the International Association for the Evaluation of Educational Achievement and other sources indicate that, on tests of mathematics, reading, and science, students in developing countries answer correctly only about 40% of the questions they should be able to answer [4]. Not only does this represent an unacceptably low average achievement but it masks considerable within-country variations. Since all developing countries have some schools (public as well as private) in which students achieve much better than an average 40% success rate on tests, they must also have schools in which the average is much lower.

TABLE 3. Gender differences in enrolment ratios at the primary and secondary levels, by region, circa 1986

Source: Calculated from ref. 27, annex table 29.

a. For most countries includes children 6- 11 years old.
b. For most countries includes children 12-17 years old.
c. Values can exceed 100% due to the enrolment of pupils younger or older than the standard age for that level.

Many factors contribute to failure to learn; among them are poorly managed schools, inadequate teaching (due to poor teacher training, motivation, health, or attendance), inappropriate curricula, low-quality or insufficient teaching materials, sporadic attendance, and inability to pay attention or absorb information on the part of students. These factors vary in relative importance not only from country to country but also from school to school within a country. In addition, they interact in ways that can be either compensatory or compounding. Nonetheless, there is growing evidence that poor health and nutrition can be important determinants of both the attendance and the teachability of students and thus have a significant effect on learning.

Unequal participation by girls

An important part of disparities in school participation rates can be explained in terms of household characteristics such as residence, religion, ethnicity, and economic status. Other determinants include school location, policy, costs, and admission criteria. Some disparities, however, are determined by individual student characteristics, and among these the most significant is gender.

The differences in primary school enrolment between boys and girls have narrowed over the last 25 years in most developing countries, but they remain significant (table 3). At the primary level, the average gross enrolment is 112% for males and 94% for females. When considered in terms of the percentage of the appropriate age group (usually 6-11 years old) who are not enrolled, the gender disparity becomes even more striking: only about 10% of 6-11-year-old boys do not attend school, compared to 40% of girls [4].

While the data are only adequate to make a comparison between the primary and secondary levels in terms of gross enrolment ratios (which include over-age children in addition to the appropriate age cohort), for all regions except Latin America and the Caribbean the female enrolment ratio as a percentage of the male ratio declines from the primary to the secondary level. It is of particular concern that the decline is most dramatic in sub-Saharan Africa and in South Asia, the two regions where overall enrolment is already the lowest. It has been calculated, using a broader definition of school age than ours, that almost 60% of girls 5-19 years old are not in school [28].

As with failure to learn in school, many factors account for unequal participation in education by girls, including a lower perceived value of education for females, a greater demand for their household labour, greater nutritional deprivation among girls (in some regions), location and security of schools, distance to schools, type of transportation available, and number of female teachers [29; 30]. At the root of many of these barriers are concerns associated with girls' sexual maturation and a desire for their early marriage. Because puberty can begin as early as age 11 or 12, and many girls in school are over age due to late entry or repetition, not only secondary- but also primary-school participation can be affected by reproduction-related issues.

Health and nutrition conditions and their consequences

While the empirical basis for evaluating the impact of health conditions on education is still fragmentary and in some cases inconsistent, there is already sufficient evidence to conclude that, overall, illness, malnutrition, and other health-related problems are probably important determinants of both school participation and school achievement.

Table 4 summarizes much of the information available to date concerning the linkages between seven major categories of child health and nutrition problems-nutritional deficiencies, helminthic infections, other infections, disabilities, reproductive problems, injury and poisoning, and substance abuse- and the three education problems just discussed. (The references to literature describing the conditions in table 4 may be particularly useful to education planners, who are likely to be less familiar than health planners with the clinical symptoms and epidemiology of the main health and nutrition problems affecting school-age children. Most of the references are to chapters in one of four books [31-34]. It was felt that so limiting the references would help to keep the essential health-related library of the education planner reasonably small.)

On the basis of information from school and health officials in both developing and industrialized countries, we feel that these are the health and nutrition problems most likely to have a significant effect on school participation and achievement in developing countries (at least for certain age groups and in certain regions). For a few, however, such as dental caries and sexually transmitted diseases, no information could be found on which to base an estimate of the nature or strength of the effect.

The strongest case can be made for a negative effect of nutritional deficiencies on school outcomes. Research has consistently found protein-energy malnutrition and iron-deficiency anaemia to have significant negative effects on tests of cognitive function in both pre-school and school-age children, and on attendance and achievement among the latter. It is also well established that prenatal iodine deficiency causes permanent mental retardation, and there is growing evidence of less severe mental impairment due to chronic iodine deficiency among school-age children and adults [35].

Given the high prevalence of many infectious diseases, such as intestinal helminths, schistosomiasis, malaria, diarrhoea, and acute respiratory infection, among school-age children, it is surprising that there has been so little research on their effects on school participation and achievement. At the moment, the strongest linkages that have been established are negative effects of hookworm on cognitive function and of Guinea worm on attendance. Based on impressionistic evidence from teachers and parents, however, it is likely that further research will document a significant effect of many, if not all, of the infections listed in table 4 on school participation, and of at least some on school achievement.

While there is also a lack of research on the effects of disability and injury on educational outcomes in developing countries, common sense tells us that such consequences do exist. Because there are so few special schools for handicapped children in developing countries, a severe physical or mental disability effectively prevents participation in formal education for most such children. In addition, continuing progress in the effort to save children's lives and to expand the number of available school places makes it urgent to develop cost-effective transportation and classroom management techniques to compensate for milder levels of disability and allow such children to participate in regular schools [36].

Problems related to reproductive health and substance abuse probably affect significant numbers of higher-grade primary-school students in developing countries, in part because grade repetition results in many over-age students. It is likely that these problems are even more important at the middle or lower-secondary level. Even if they tend to become more prominent among children over age 15, early intervention is likely to be a major component of strategies for addressing them. While more research is needed to quantify their extent, the combined effects of early marriage, unwanted pregnancy, and concerns about sexual vulnerability are almost certainly important reasons for the decline in female compared with male enrolment ratios at the secondary-school level [37].

TABLE 4. Educational consequences of health and nutrition problems among school-age children

This table draws substantially on Pollitt [15], although other sources have also been used to include the problems of unprepared children and girls' participation as well as certain health and nutrition conditions not covered in Pollitt's review. Only where there are reasonably strong grounds to believe that a consequence occurs has it been noted: where no consequence is noted relating a specific condition with an education problem, this should not be interpreted to mean that none exists but rather that no evidence is currently available.

The kinds of problems that have arisen in the education systems of the industrialized countries are not necessarily indicative of future trends in developing countries. However, the epidemics of unwanted pregnancy and alcohol and drug abuse in junior high and high schools in the United States and some other higher-income countries are bases for considerable concern, particularly in urban parts of the developing world [19; 20].

Conclusion

In a recent nationwide radio interview, a prominent US educator, currently the dean of the Harvard Graduate School of Education, was asked what her priorities would be if she were to become the education president that George Bush has stated he wants to be for the United States. She responded:

The first concern I would have was that the federal government assure that all children are healthy, because children who are not healthy are not going to be able to learn in school. I would make sure that health programs, prenatal health programs, pro grams for infants and children, programs like Head Start, and so on, would become much more widespread than they are today. [65]

Several questions face education planners who share this concern. The first concern the main health and nutrition problems affecting the school-age population: What conditions are important, and which population subgroups are most affected? One clear conclusion that emerges is that, although less attention has been paid to the health and nutrition status of school-age children than to that of preschool-age children and adults, existing data are adequate to identify several widespread problems that have well-established negative consequences for school participation and performance. These include chronic protein-energy malnutrition, iron-deficiency anaemia, iodine deficiency, and intestinal helminth infection. Observation and discussion with parents, teachers, and health-care providers suggest that other infectious diseases, as well as disability, premature fertility, and substance abuse, are also likely to significantly undermine the health and educational success of many school-age children.

The next questions concern possible interventions to address these health and nutrition problems, how effective they are likely to be, and how much they might cost. While information to answer such questions is much less adequate than education and health planners would wish, accumulated experience from both developed and developing countries suggests the range of options available and something about their effectiveness and costs. These issues are addressed in the following paper.

Acknowledgements

The United Nations Administrative Committee on Co-ordination, Sub-committee on Nutrition (ACC/ SCN), provided financial support for the preparation of this paper.

The authors are indebted to Alan Berg, Marlaine Lockheed, John Nkinyangi, François Orivel, Ernesto Pollitt, and Susan Van der Vynckt for valuable discussions concerning the substance of this paper.

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