Evaluation of the School Health Programme Among Primary Schools in Ilesa East Local Government Area of Osun State, Nigeria

EVALUATION OF THE SCHOOL HEALTH PROGRAMME AMONG PRIMARY SCHOOLS IN ILESA EAST LOCAL GOVERNMENT AREA OF OSUN STATE, NIGERIA

A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA, IN PART FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF THE FELLOWSHIP OF THE COLLEGE IN PAEDIATRICS.

OLATUNYA, Oladele Simeon

M.B.B.S. (UNILORIN 2000)

MAY 2011

DECLARATION

I hereby declare that this work is original unless otherwise acknowledged. The work has not been presented to any other college for Fellowship award nor, has it been published or submitted for publication elsewhere.

Sign Date

------

Olatunya Oladele Simeon

CERTIFICATION

We hereby certify that this study was done by Dr. OLATUNYA OLADELE SIMEON, of the Department of Paediatrics and Child Health Obafemi Awolowo University Teaching Hospital Complex Ile Ife and that the dissertation was written under our supervision.

Supervisor Signature------

Name- Dr. SBA Oseni

Status –Senior Lecturer/ Consultant

Department of Paediatrics and Child Health

OAUTHC Ile Ife

Co- supervisor Signature------

Name- Prof. O.A. Oyelami

Status- Professor/ Consultant

Department of Paediatrics and Child Health

OAUTHC Ile Ife

DEDICATION

This work is dedicated to the glory of God, my wife, my parents, Tijesunimi our child and all other children of the world.

ACKNOWLEDGEMENT

I hereby acknowledge with profound gratitude the efforts of my supervisors; Dr SBA Oseni and Prof. O.A. Oyelami for their supports during the study. I also appreciate the assistance rendered by Professors G.A. Oyedeji, J.A. Owa and E.A. Adejuyigbe as well as Drs. N.A Akani, T. A. Aladekomo, J.A. Okeniyi, S. A. Adegoke and other consultants in the Paediatric department of our institution.

I give special thanks to the secretary of Ilesa East Local Government Education Authority, Hon. Eniolabi Adeyeye, Mr Adeniyi, (Head of school services of the Local Government Education Authority), Pastor Ajijala (Chairman of Parents’ Teachers’ Association of primary schools in the Local Government Area), Pastor Akinyemi (the Chairman, Association of Private Schools Owners), all the primary school head teachers, pupils and their administrators for their patience and cooperation. I thank immensely Drs. Caleb Adegbenro, Kayode Olaleye and Olorunfemi Ogundele of the Department of Community Medicine OAUTHC Ile Ife, for their support especially in putting me through the data analysis.

I am grateful to my wife and fellow residents for their supports during the study.

Finally (and most importantly), I am grateful to God the Alpha and Omega.

LIST OF ABBREVIATIONS

B.Ed – Bachelors Degree in Education

CDC – Centre for Disease Control

COPSHON – Conference of Primary Schools Head Teachers of Nigeria

FRESH – Focusing Resources on Effective School Health

GRADE II– Grade II Teachers Training certificate

HND – Higher National Diploma

HSE – Healthful School Environment

IELGA – Ilesa East Local Government Area

IELGEA – Ilesa East Local Government Education Authority

LGA – Local Government Area

MDG – Millennium Development Goal

NCE – National Certificate in Education

NEEDS – National Economic Empowerment and Development Strategy

OAUTHC– Obafemi Awolowo University Teaching Hospital Complex

OND – Ordinary National Diploma

PTA – Parents’ Teachers’ Association

SHCR – School- Home- Community Relationship

SHI – School Health Instruction

SHS – School Health Services

SHP – School Health Programme

SPSS – Statistical Programme for Social Sciences

UBE – Universal Basic Education

UNESCO– United Nations Education, Scientific and Cultural Organisation

UNICEF– United Nations International Children’s Emergency Fund

USA – United State of America

USAID – United States Agency for International Development

WHO – World Health Organisation

TABLE OF CONTENTS

PAGE

Title page i

Declaration ii

Certification iii

Dedication iv

Acknowledgement v

List of Abbreviations vi

Table of contents viii

List of Tables ix

List of Appendices xi

Summary xii

Introduction 1

Literature Review 3

Relevance of the Study 25

Aims and Objectives 26

Methodology 27

Results 31

Discussion 60

Conclusions 76

Recommendations 77

Limitation 78

References 79

Appendices 89

LIST OF TABLES

TABLES PAGE

I The distribution of pupils and teachers in the schools 31

II Age distribution of schools 32

III Distribution of the qualifications of the teachers interviewed 32

IV Availability of trained first aiders, functional PTA,

Extracurricular activities and School health committee 33

Va An outline of Healthful School Environment scores

for each of the public schools 34

Vb An outline of Healthful School Environment scores

for each of the private schools 35

VI Methods of sewage disposal 36

VII Toilet to pupil ratio 37

VIII Quality of buildings/structures of the schools 39

IX Sitting comforts, food service area and maintenance 40

X Healthful living in the schools 42

XIa An outline of School Health Instruction scores

for each of the public schools 43

XIb An outline of School Health Instruction scores

for each of the private schools 44

XII Contents / scope of health teaching in the schools 45

XIII Methods of health instruction 46

XIV Preparation of teachers for teaching health education 47

XVa An outline of the public schools scores on School Health Services 48

XVb An outline of the private school scores on School Health Services 49

XVI School health personnel in the schools 50

XVII Health appraisal services in the schools 50

XVIII Treatment/Health facilities in the schools 51

XIX Contents of the First Aid box 52

XX Care of emergency illness in the schools 53

XXI The mean scores attained in the various components of SHP

by group 55

XXII Independent sample t – test to compare mean scores between the

private and public schools in the various components of SHP 56

XXIIIa Total scores of public schools in the various components of SHP 57

XXIIIb Total scores of private schools in the various components of SHP 58

XXIV Age distribution of the schools and their total mean scores on SHP 59

LIST OF APPENDICES

APPENDIX PAGE

I The School Health Programme Evaluation Scale 89

II Letter of consent from the Local Government Education

Authority 96

III List of primary schools in Ilesa East Local Government Area 97

IV Letter of appreciation from Ilesa East Local Government Education Authority 98

V Electronic copy of sensitization seminar on school health

Programme by the researcher to Ilesa East Local Government

primary school community 99

VI Hard copy of sensitization seminar on school health programme by

the researcher to Ilesa East Local Government primary school

community 100

VII Pictures 104

SUMMARY

School Health programme (SHP) is a group of coordinated activities which promote the health and development of the school community. It is a veritable tool for the achievement of education and health related Millennium Development Goals (MDG) as its effective implementation helps to prevent various illnesses that greatly impair learning among school children. Although there exist a National School Health Policy of the Federal Ministry of Education, Nigeria, the level of compliance by primary schools in Ilesa East Local Government Area has not been evaluated.

The overall aim of the study was to assess the status of School Health Programme as available in primary schools within Ilesa East Local Government in the aspects of School Health Instruction, School Health Services and Healthful School Environment.

A cross sectional descriptive study of the School Health Programme in all the 64 primary schools in Ilesa East local government area was done with the use of respondent interview and direct observation. Relevant data was obtained from each school’s head teacher, health teacher and first two pupils (a male and female) on the attendance register present on the day of data collection selected randomly from the most senior classes. The responses were scored using the School Health Programme Evaluation Scale.

The 64 primary schools studied were made up of 34 public and 30 private schools. Only three (4.7%) schools (all private) attained up to the minimum acceptable score of 19 in the aspects of School Health Services while only one (1.6%) private school attained up to the minimum acceptable score of 57 in the aspects of Healthful School Environment. None of the schools attained up to the minimum acceptable scores of 27 in the aspects of School Health Instruction nor the minimum total cumulative score of 103 in these three major aspects of SHP assessed. The total mean scores of 63.23 ± 14.57 and 57.50 ± 6.59 obtained

by private and public schools respectively, showed a statistical significant difference with the private schools performing better (t= 2.068, df= 62, p=0.043).

The overall status of School Health Programme among primary schools in Ilesa East Local Government Area was very poor especially in public schools. There is need for implementation of the National Guidelines on School Health Policy and Sanitation by the agents of the ministries of Education, Health and Environment in the study area.

INTRODUCTION

School health programme (SHP) is a group of coordinated activities which promotes the health and development of the school population.1,3,4 It uses a multidisciplinary approach and fosters inter sectorial collaboration to enhance sustainable human, economic, community and national development.1,3,4 It encompasses many procedures that are carried out by teachers, health workers, counsellors and school administrators in conjunction with the children’s families and communities to provide social and health services to the school community. A child spends quality time in school being exposed to a wide variety of influence such as environmental, physical, emotional and social. Supervision of the health of school children is important because, sound health as well as health care potentials acquired during school going periods are of great benefit to these children, their families, communities and the nation at large as the children grow to become adults.7 According to Nigeria’s National School Health Policy,3 SHP has been described to be a major tool for the achievement of education and health related millennium development goals (MDG), the national economic empowerment and development strategy (NEEDS), as well as education for all campaign of the Federal Government of Nigeria. In Nigeria, funds are allocated each year for various special health programmes like: National Programme on Immunization (NPI), National School Feeding Programme and National Health Insurance Scheme. The NPI is to combat deadly childhood communicable diseases, while the School Feeding Programme is to help in reducing malnutrition and hunger among school children. The focus on children is understandable because the children of today are the adults of tomorrow and a healthy citizenry is an asset to any nation.8 Today, 93% of school age children have unhindered access to primary schools in Osun State9 (where this study was conducted). It is believed by health professionals, educators and social workers that the provision of SHP is a cost effective way of meeting the health needs of children. However the content of SHP as practiced in various parts of Nigeria has been found to be very poor 8, 11, 12. While Ojugo8 found that health appraisal services were

not adequately provided for primary school children in Edo State, Ofovwe and Ofili12 expanded the scope of their work to include other aspects of SHP like healthy school environment, school vending programme and teachers’ knowledge of SHP, all of which were also found to be grossly deficient. These findings were similar to those of Idris, Aikhionbare, Ogala et al 11 in Zaria using the School Health Programme Evaluation Scale (Appendix I)1. These reports from Nigerian studies8,11,12 are at variance with that of Kann, Brener and Wechsler 14 from the United State of America who found an appreciable improvement in the implementation of SHP between 2000 and 2006. There seems to be no study that holistically evaluates SHP in Ilesa East Local Government Area. Hence, this study aims to generate data on the status of SHP as practiced in this locality.

LITERATURE REVIEW DEFINITIONS OF TERMS A school is an institution for educating learners.3 Examples include: child care centres, primary schools, secondary schools, tertiary institutions and all other non-formal education centres.3 The school community however, refers to all the people living or working within the school premises including pupils/ students, teaching and non teaching staff as well as members of their families.3 Health is defined by World Health Organization (WHO) as a complete state of physical, mental and social well being and not merely the absence of disease or infirmity.13 School health programme represents a series of harmonized projects or activities in the school environment for the promotion of the health and development of the school community.1,3,4

HISTORICAL BACKGROUND

The link between children’s physical condition and their ability to benefit maximally from education has been appreciated for close to two centuries.7 The earliest efforts to improve the health of school children came from Europe.2 For example, free school lunches were provided in Germany by Bavaria as early as 1790.2 This was later followed by the 1833 enactment of laws to improve school health in France.2 However the biggest stimulus for a more holistic approach to school health programme did nsot come until during the First World War. 2 At that time, it was discovered that one out of every three examined draftees into the army in America had adverse physical, mental or emotional conditions that were not in tandem with military work; thus raising the question about whether the school could have been used to prevent or correct many of these conditions.2 Great emphasis was subsequently placed on the health of the school child. This emphasis was however erroneously tilted in favour of physical education with attendant poor results.2,14 Hence, during the second world war many recruits were still not fit for military service.2 The existing School Health Programme was then reviewed and is still being subjected to constant review till date.5,14 The

first known attempt to introduce School Health Programme in Nigeria was made in 1929, through a policy that entails periodic school inspection by medical officers.3,15 In 1952, the Western Region Government introduced a more robust School Health Programme backed with a white paper which contained a four year plan introducing free and compulsory school medical services for all school children.2 This was followed by the 1971 launch of Federal School Health Services headed by a Medical Officer.2 There was allowance for collaboration with other health professionals. Later the states emulated this.16 In view of the gross deficiencies in the components of SHP as being implemented in different parts of the country, various authors8,11,12 have expressed doubt as to whether SHP is being properly implemented in Nigeria. The similarities in the recent findings by Ojugo,8 Idris, Aikhionbare, Ogala et al11 and Ofovwe and Ofili12 may be due to lack of repeated appraisals of SHP in Nigeria as against that obtainable in other developed countries.14

THE PHILOSOPHY AND OBJECTIVES OF SCHOOL HEALTH PROGRAMMES

A child spends quality time at school being exposed to various environmental, physical, emotional and social influences.1 School going periods are within children formative years during which they can readily imbibe good health habits, knowledge and culture which will invariably have great influence on them, their family and the nation at large as they grow to become adults.7 For children to benefit maximally from their education, they must be in a state of good health (stable mentally, physically, emotionally and socially) because health is fundamental to education and vice versa.15 School health programme helps to inculcate healthy habits into the child, which he or she will maintain throughout life. It teaches the child to be in harmony with himself or herself, the family, community and the nation at large and maintains the child in optimal state of health so that he or she can benefit maximally from the education in school.1,3 A well coordinated school health programme should be able to produce accurate and sufficient knowledge about matters concerning health and disease (especially among children) for the purpose of promoting the health of the school population.

COMPONENTS OF SCHOOL HEALTH PROGRAMME (SHP)

School Health Programme (SHP) has passed through many reforms to become an integrated programme with different areas. In the United State of America its scope was expanded in 1987 from the traditional three components of School Health Services, Health Instruction and Healthful School Environment to an eight components model with the addition of five other areas namely: School Nutrition Services, Counseling Services, Community and family involvement, Physical education and Staff health promotion.4,5,17,18 In Nigeria four components have been identified namely:1,3

 Healthful School Environment (HSE)  School Health Instruction(SHI)  School Health Services (SHS)  School- Home- Community relationship (SHCR) The fourth component (school-home- community relationship) was introduced as part of the continuous review process of SHP.

HEALTHFUL SCHOOL ENVIRONMENT

The National School Health Policy of the Federal Government of Nigeria defined School environment as all the consciously organized, planned and executed efforts to ensure safety and healthy living conditions for all members of the school community.3 This is one of the key interrelated aspects of school health programme. It comprises everything in the school that affect the physical, mental and psychological well- being of the school community including school children.1 Children spend about seven hours every day in the school environment except during weekends. With the introduction of extra lessons which is rampant in Nigeria today, they now spend close to nine hours per day in school. This translates to one-third of a child’s everyday life and two-third of the child’s active life during the day. Nwana and Ukatu19 described the school environment as the factory of school children. Hence, everything should be done to make this factory safe so that parents and 18

guardians can release their wards to benefit maximally from the Federal Government universal basic education thus helping them to meet the health and education related millennium development goals. Despite the 1975 appeal for a robust SHP in Nigeria,6 official reports by the Lagos Federal Health Education division 6 years later ( in 1981) noted that many schools in Lagos were having unhealthful school environment.21 Later reviews of the SHP by Adegbenro20 in Osun State (2002), Idris , Aikhionbare, Ogala et al11 in Zaria (2003), Ofovwe12 in Edo State (2004) and Nwachukwu22 in Imo State (2004), also found most of the schools in these localities to be operating within poor environments. This may indicate deficiency in follow up on SHP by the Federal and State Governments from the first All African Education Conference (Lagos) of 1981. This is totally different from the practise in the United State of America (USA) where implementation of SHP are being reviewed every six years.14 The components in healthy school environment can be broadly classified into three: the physical, biological and social.

Physical Environment

Physical environment of the school represents the readily visible infrastructural facilities present within or around the school premises. These include school location, buildings, premises, water supply, classrooms, waste management (refuse and sewage disposal), school safety, school play/ sporting facilities.

Location

Ideally, schools should be centrally located within the community, away from industrial zones, busy markets, theatres, railway tracks and high ways. The land must not be water logged or damp while the topography must readily support the life of minors so that school children can access not only the schools but also their classrooms and other facilities within the school premises.7

School buildings

It is recommended that school buildings should be neat, heat resistant and preferably of bungalows. The buildings should have no cracks or leaking roofs and if possible 19

constructed with fire resistant materials.1 There should be separate provision for staff rooms within the buildings. In his interventional study, Adegbenro20 found that 40% of primary school buildings in Ile Ife were in dilapidated conditions before his intervention in 2002. The situation was a shade better than 30% obtained in Zaria.11 The poor state of school buildings in Nigeria may be attributable to the fact that most buildings are constructed and maintained by government contractors who are usually politicians and see the contracts as their own political patronage. This is without the knowledge and participation of the school community20. In USA on the other hand, there are entrenched policies on constant maintenance, inspection and construction of school buildings.18 In fact, Jones, Axelrad and Wattigney17 reported in 2007 that the state of school buildings in USA had improved tremendously between 1998 and 2006. Reflecting on the 50% reduction in the number of dilapidated school buildings in Ile Ife between 2002 and 2005 following intervention by Adegbenro20, one can suggest that giving the right intervention, school environments in Nigeria can readily be tamed to support the health of school community members.

Classrooms

Classrooms are the primary places where most academic activities take place within the school. Each classroom must have capacity to comfortably accommodate 40 children with a per capital space not less than 10 sq. ft.10 The combined area of windows and doors must account for at least 25% of the floor space with the windows preferably at a height of 75cm from the floor and each having protective bars.7 The disposition of the windows should be such that is controllable and allow for cross ventilation.1,7 Each classroom should be well lit with natural light preferably from the sides rather than front.7 They should also provide sitting comfort for both children and teachers in form of appropriate furniture with back rest to engender maximum comfort needed for academic learning. However, since 1981, the Federal health educators in Lagos had found that 25% of classrooms in Lagos had no windows, 15% of them were half walled and 95% had bad ceilings.21 This gory state of our classrooms seems not to have changed as Nwachukwu22 found in 2004 that 78% of classrooms in Imo state were overcrowded while in 2007, only 1% of the classrooms selected across 51 local government areas (LGA) of the country had basic

instructional materials like wall charts, posters, teachers guide, pupils worksheet, textbooks, games, supplemental reading materials and other teaching aids which are the criteria a classroom must meet before being adjudged as equipped.23 Findings from these observational studies21-23 reflect a continuous deterioration in the status of Nigeria’s classrooms.

Water supply

Water is a basic need of man and of great importance to human health. World Health Organization (WHO) currently estimate that over 1 billion people worldwide lack access to potable water and on the average, a minimum of 20- 40 litres of water per person per day is needed for drinking, personal hygiene and cleaning.24 Potable water should be free from chemical or biological contaminants and must be acceptable in terms of colour, taste and smell.25 Water supply to schools should be safe, adequate and preferably from independent source and should run from the taps within the school premises.1,7 Adequate water supply will not only satisfy the thirst of the school children but also help in maintenance of general hygiene thus preventing diseases such as skin infections which have been found to be very common among school children.15 Oyedeji, Oyelami, Oyedeji et al26 found that 98% of primary school children in Ijesaland have unsatisfactory domestic water supply. Reports by various authors22,23 also showed that schools from other parts of the country have not fared better. While the USAID survey in 200723 indicated that 55% of schools in Nigeria have no adequate water supply, Nwachukwu22 and Adegbenro20 had earlier indicated that 72% and 50% of schools respectively from different parts of the country had similar problems. These findings contrast with the situation in USA where 90% of schools not only have adequate water supply but also carried out periodic inspection and testing of water supplied to schools for contaminants.17 The fact that Oyedeji, Oyelami, Oyedeji et al 26 found a high prevalence of skin diseases among children with poor domestic water supply, is bad enough. Hence, schools should therefore serve as the last hope of school children having access to potable water20,22 thereby complementing whatever deficiency existing at home.

Refuse and sewage disposal

Refuse are solid waste materials while sewage are liquid wastes. These waste materials constitute threat to human life wherever they exist.3 Primary schools have the propensity for generating wastes because they are largely populated by children who are yet to fully imbibe the healthy ways of handling waste.3 Ideally, after being collected in waste baskets refuse should be properly disposed by any of the following methods: incineration, controlled tipping or composting.7 Reports across Nigeria27,28 have highlighted the poor waste management habits of the citizenry. More worrisome is the revelations by Onuzulike,27 that this bad habits permeates those training to be teachers in our primary schools, thus suggesting that they are unlikely to input into the school children healthy ways of handling refuse. The major sewage being produced by the school communities include faecal matter and urine. Ideally these should be disposed off through well constructed toilets located away from the classrooms and maintained in good hygienic conditions. The ideal toilet types include: water closet, ventilated improved pit latrines and urinals.1,3,7 There should be separate toilet and urinal facilities for boys and girls,1,3,7 with not more than 40 pupils to one toilet or urinal.7 The inadequacies of these facilities in Nigerian schools have been noted for long21 and there is very little likelihood that the situation has changed. While Ofovwe12 in 2004 found that one- third of primary schools in Egor Local Government Area of Edo State had no toilet facilities, Nwachukwu22 documented 72% in Imo state in the same year while Adegbenro20 in South Western Nigeria recorded 60%. These reports indicate that the sewage disposal systems of our schools are in very bad shape. The higher proportion recorded by Nwachukwu22 in his study may be due to the larger coverage area of his work. He surveyed a whole state while the two other authors (Ofovwe12 and Adegbenro20) studied one local government area each. However, it is worrisome that the USAID 2007 survey23 found that only one out of every hundred primary schools selected across the country had adequate toilet facilities. The USAID study23 is likely to be representative of the true state of waste disposal in our schools, because of its wider coverage. It is also interesting to note that none of these studies was carried out in Ilesa East Local Government Area, leaving one to ponder about what the situation could be in this local government area.

School premises

This is the immediate surroundings of school buildings and environments.7 The school premises should be kept clean always with the school plot well fenced so that distractions from the neigbours will be minimal.3 The topography of the school environment should be children friendly.3 It should not be unduly hilly, have gullies or vallies prone to flooding during rainy season as these can constitute health hazards to children.29,30 According to the National Guideline on school sanitation, the green grass should be cut periodically. Appropriate government agents like school board officials and sanitary inspectors should do periodic visitation to schools to ensure that the school premises support the health of children.31 The Federal Government stated in 1981 that most schools in the country were not visited by any sanitary inspector in the preceding three years.21 This contrasts with the situation in developed countries like USA where 96% of the schools were inspected within a year (2005-2006).17 Other studies conducted across the country also lend credence to the deplorable state of school premises in Nigeria. Idris, Aikhionbare, Ogala et al11 found that most primary schools in Zaria have nuisance/ health hazards like animal grazing on the premises, flooding, identifiable pests and vectors. These findings are similar to those of Joseph and Nwajei29 in Delta State, Nwachukwu22 in Imo State and Adegbenro20 in Osun State. The deplorable state of school premises in Nigeria is disturbing bearing in mind the fact that children are at greater risk of exposure to environmental hazards with the attendant chronic diseases that may follow.30

Accident prevention / Safety measures

Accidents and risks are parts of human life. Accidents have been defined as an unplanned event resulting in injuries or death of persons or damage to property.32 When an accident occurs on a large scale it becomes a disaster. The various levels of activities children get involved in while at school, prompted by their assertive, curious nature and their willingness to experiment with new things, make them vulnerable to accidents.32 School accidents may occur on the playgrounds, sports fields, gymnasium, classrooms, laboratories, school farms, corridors, stair cases and workshops.33,34

Hazards that predispose to school accident include: slippery or polished floors, inappropriate and dilapidated furniture, inappropriate handling of laboratory chemicals, cracked/dilapidated walls, dilapidated toilet facilities and major roads around the vicinity of the school.32,33 Also, emotional instability and excitability in the children are contributory factors to occurrence of accidents within the school premises.32 According to Schifferrs,36 more accidents occur during physical education and agricultural practice lessons than during other activities. School accidents can sometimes have very devastating effects and majority of them are largely preventable through appropriate safety measures.37 Safety can be said to be the guide or arrangements made against the occurrence of accidents.37 In an hospital based study by Adegoke38 on childhood injuries, he found that injuries represent 12% of total admissions with 20% of the injured victims dying. Majority of the victims were school aged children and school premises were the third leading place where the accident occurred thereby, underscoring the need for school teachers to guide children against injuries within the school premises. It is therefore unfortunate that Agusiegbe39 found that teachers are insensitive to this obligation out of their poor knowledge of principles of accident prevention as an integral part of healthy school environment. This poor knowledge was also noticed by Joseph and Nwajei29 in Delta state. Ninety three percent of schools in USA have procedure to educate students and families about rules on school safety.40 This has helped in reducing the high rate of school injuries in USA,40 unlike the high prevalence rate in Nigeria as reported by Adegoke.38

Play and Sporting Facilities Men of the ancient days were aware of the value of physical exercise. Galen (131-201 AD),41 the great Greek philosopher, once said in his treatise on the values of exercise that “Exercise produces strength and hardening of the organs, increases respiration and intrinsic warmth, better nutrition, metabolism and elimination.” Children are noted for their high level of exercise either as play or sporting activities at school.38 This is probably due to their high energy and adventurous nature.

According to Jones, Fisher, Greene et al 40 and Blair42, play activities help to promote mental, emotional and physical well being thereby helping the school child to attain a state of complete good health as defined by WHO.13 This can be achieved through engaging children in social activities like sporting competitions, membership to social clubs like Girls’ Guild, Boys’ Brigade and Scouts or excursion to places. Primary schools in Nigeria should have playing grounds that have appropriate sporting facilities giving room for a varied choice by school children of their elect sports. They should be thoroughly guided and supervised during sporting activities as obtainable in developed countries.40 This is very important as schools have been identified as potential sites where accidents occur locally 29,32,37,38 and internationally.40,43 Food service area This should be located within the school premises in a hygienic and readily accessible area. Nwachukwu22 found that only 24% of schools serve food in Imo state and this is done majorly by food hawkers with majority of the served items not inspected. He also found that most schools have no designated food eating or serving area. This is against the tenets of the National Guidelines on food handling within school premises which clearly stipulates that an hygienic area should be designated as such within a school premises.44 Also, it contrast with the situation in USA where the percentage of schools that serve food increased from 54% to 69% between 2000 and 2006.45 Majority of the schools also have designated food serving areas.45 When school meals are not provided for school children they are left to buy food or snacks that may adversely affect their health. In 1985, Ketiku and Akinnawo46 found that 96% of school children in Ibadan bought snacks/ food from hawkers and vendors. The commonly bought foods were Fan-ice, Buns, Puff-puff, Cake and Beans with sauce. Fan-ice, (the least nutritive of the five) was ironically the most preferred by the pupils, while Beans with sauce (the most nutritive) was the least preferred. This finding underscores the need to guide school children in making healthy food choices. An easy way to do this is through provision of food service areas in the schools where health promoting foods will be served.

Biological environment This includes all living things in the school environment such as protozoans, fungi, bacteria, viruses, helminths, plants and animals, some of which may cause disease. Protozoans have plagued mankind for centuries. A good example of protozoan infection is malaria which has grown to become a global nemesis with over 270 millon cases and about 3 million deaths annually world-wide majority of whom are children.47 Nigeria has its huge share of the burden. Likewise, children have also been found to be more afflicted with respiratory tract infections, diarrhea diseases and helminthiasis which are disease entities associated with other infective agents highlighted above. Oyedeji, Onayemi, Oyedeji et al48 in 2003 found a high prevalence of skin infestations and infections like impetigo, dermatophytosis, pityriasis versicolor and scabies among primary school pupils in Ijesa land. Though Ilesa East LGA was included in their study, the authors selected only a few primary schools in the local government area for their research.

Social environment This represents the entire social milieu within which a child operates in the school. It encompasses child-teacher relationship, child – child relationship, head teacher-teacher – child relationship and relationship between the child and school clinic, kitchen, transportation and the school’s recreational facilities.1 A teacher must never show discrimination against any child with regard to religion, race, community or social status.7 In developed countries most schools have well stated violence- related rules and penalties that await school children who break such rules, thereby providing a relatively violence-free school environment that can engender optimum psychological and social well being of school children.40

SCHOOL HEALTH INSTRUCTION School Health Instruction can be defined as the education of the school community (particularly school children) about health matters through which they can achieve the maximum physical, mental and social state of well-being.49 Ogundele50 simply described it as the instructional aspects of school health programme. The main aim of school health instruction is to motivate school children so that they can not only put their health knowledge into practice but also promote other positive health attitudes.49,50 Other objectives of health instruction in schools include: provision of information on key health issues affecting the school community and encouraging participatory learning experience for the development of knowledge.3 School health instruction must be skill-based, have clear parameters with which its impact can readily be quantified and backed up with appropriate instructional materials.3,49,50 Education is a major tool of change in any community and education prepares a child to be self reliant, healthy and productive while developing the ability to act competently within the society and at personal levels.51 School health instructions are carried out through various methods which can be broadly classified into three. These are: personal methods, non personal methods and a combination of these two methods.52

Personal methods This involves the health instructor who is usually the teacher or health personnel from the primary health care system having direct interaction with the school children by instructing them on health related issues. This may be through discussion method, demonstration using instructional materials, dramatization or exhibition.50,51,52 Discussion allows the children to ask questions thereby making the health talk a two-way affair.50 Ogundele50 explained that dramatizations are ways of making the children to express their feelings and urges through imitations and imagination. It is generally believed that children understand and remember better when facts are portrayed and better still, when they participate in portraying them.50,51 Clint and Broes53 have also described exhibition as a viable tool for teaching school children about pedestrian rules. To a large extent, personal methods of health education have lots of advantages which include: allowing room to tailor

discussion to suit local needs, opportunity to interact with the children and clear areas of ambiguity. Its success is largely based on the skill of the instructor, in terms of the grasp of the lecture topic, communication skills and personal life styles because children like to copy adults.7,49-52

Impersonal methods These involve the use of mass media, posters and billboards to impact knowledge or information to the recipients.50 This method has the advantage of reaching a larger number of school children at the same time. However, it may not be as effective as the personal methods because of lack of personal contact with the instructor.52 In an attempt to keep abreast of current developments School Health Instruction has been modified to include the following areas now being taught in hierarchical form. These include: personal health, growth and development, social and emotional health including drug and sex education, HIV/AIDS, safety education, community health and environmental health.50,52 The Centre for Disease Control in Boston USA, has established that, for every one dollar spent on health instruction delivered in schools, the society saves more than thirteen dollars in direct cost.54 As good and cost effective as School Health Instruction is, it is very sad that schools in Nigeria cannot be said to adhere to the recommended guidelines for implementing school health instruction.55 Eke56 in 1988 found that the practice of school health instruction in Nigeria was greatly neglected. In 2004, Idehen and Oshodin 57 observed poor compliance with Health Instruction activities among secondary schools in Edo State. Although, the focus of their study was on secondary schools, none the less, their findings cannot be totally divulged from the situation in our primary schools. This is in contrast to the situation in USA where 92% of schools routinely carried out health instruction activities between 2000 and 2006.58 The poor performance of schools in Nigeria in carrying out health instructions may be linked to the identified poor preparedness and attitudes of the school teachers especially in developing countries.12, 39,59 Agusiegbe,39 in her review of Anambra state primary schools teachers preparation for health teaching found that, 70% of trainee teachers were taught on health once per week and that it was possible for trainee teachers to graduate without covering up to

50% of their health related curriculum. Ofovwe and Ofili12 corroborated this when they found that teachers’ knowledge of SHP was very poor though they found a favourable disposition of the teachers to improve their knowledge if appropriately supported. Also, recent USAID survey in Nigeria identified lack of instructional materials in primary schools as a major factor limiting health instruction delivery in them.23

SCHOOL HEALTH SERVICES (SHS)

These are preventive and curative services provided for the promotion of the health of the school community.3 School health services deal with the maintenance of the health of school children by working in collaboration with teachers, health personnel and psychologists to control the various health variables that contribute to educational deficiencies in a child.1 It helps school children to achieve the maximum health possible for them to obtain full benefit from their education. The health situation in Nigeria can be improved by making school children to acquire proper health related practices through appropriate school health services.60 The specific areas covered by the school health services include health appraisal services which are provided through health clinic, school medical examination and school health record keeping.1,3,7 Other vital components are: school nutrition services, control of communicable diseases, health support for children with handicaps and immunization services.1,3,7

School medical examination School medical examination is the process by which qualified health personnels conduct general medical examination on school children and also test their excrements and blood to identify any health defect(s) they may have for appropriate intervention.1,3,7 Otherwise, these illnesses may significantly affect the children’s acquisition of good education.1,3 Meta analysis of medical screening reports have identified up to 15% of children with untreated medical conditions inimical to their health.1 Also, teachers are to carry out

periodic inspection of school children looking for clues on any suspected ill health as well as general cleanliness.61 Studies involving ophthalmological examination in school children have revealed significant proportion of them having eye diseases. Vernal conjunctivitis was found in 16% of surveyed primary and secondary schools students in Ilesa East Local Government Area62 (the reference area for this research), and in 15% of those studied in Benin- City (Edo State),63 while refractive error was the leading eye disorder among school children in Jos.64 Although, these were hospital based studies, none the less, they reflect the presence of these medical conditions among our school children bearing in mind the fact that schools are miniature components of the larger society. Interestingly, these eye disorders are also common in developed countries.65 In Lagos, hearing loss was the major problem66 while in Kwara State,67 it was umbilical hernia, a major disfigurement of the black children which may engender taunt from peers and distract them from learning. Other medical problems routinely discovered by school medical examination include: anemia, skin infestation/ infections and sickle cell disease.15,48,68 While urban noise pollution may account for the higher prevalence of hearing loss among Lagos school children, the higher rate of umbilical hernia among school children of Yoruba ethnic group in Kwara State may be a mere coincidence as the condition is very common among blacks generally.

Health clinics These are special arrangements made to provide remedies to school children health problems identified during medical examination.1,3,7 It also serves to tackle any emergency health care needs of the school community.7 It basically operates at two levels namely: minor ailments level and specialist care level.1 Minor ailments include simple cuts and bruises, slight fever and minor skin infections.1 Treatments of these ailments are provided with the use of first aid kits or sick bays in bigger schools.29 Components of a first aid kit include: scissors, blade, bandages of various types, iodine, Tincture of benzoic compound (TBC), dettol/ salvon, izal, methylated spirit, cotton wool, gauze, antacids (mist magnesium trisilicates or gelusil), clean water, glucose, hand gloves, forceps etc.29 Provision of treatment for minor ailments will not only nip them in the bud but also prevent children from being

absent from school as a result of their medical conditions. Oduntan15 found that 95% of children who were absent from school did so for medical reasons. It is also disheartening to note that majority of school teachers who are usually the persons to administer these minor treatments cannot make proper use of first aid kit materials. A report by Joseph and Nwajei,29 found that though 63% of primary school teachers in Delta state know about first aid kits, only about one third of them could actually name 6 out of the identified 13 components mentioned above. Specialist clinics are meant to be provided for children who require special treatment. Examples include those with hearing, visual and dental problems.1 This service is however still elusive in most Nigeria schools.1 The school clinic should also have facilities for referral services so that serious or emergency health conditions are promptly taken to hospitals where the children can be properly treated. Though different authors8,11,12,29,69 have highlighted the gross deficiencies in health interventional measures being provided in our schools, the exact situation in Ilesa East Local Government Area remains unknown as no study has previously been carried out in this locality.

School nutrition services Good nutrition is central to the normal growth of school children.7 Research has indicated that nutritional deficiencies and poor health in primary school children are among the causes of low school enrolment, high absenteeism, early drop out and poor classroom performance.67,70 The scope of school nutritional services include school meals, food hygiene and food supplementation or fortification with micronutrients like iron, iodine, vitamin A and other vitamins.7,70,71 The main aim of nutritional services is to provide at least one nutritious meal a day to all school children thereby preventing some specific nutritional deficiency states especially in communities where such are very prevalent.7,70,71 It also eradicates hunger among school children so that they can concentrate on their school work. Other objectives of school nutrition services include increasing school enrolment, attendance, retention and completion rates. 3,67,70,71 A good school nutritional services scheme should ideally, not only meet the micronutrients need of school children but also provides at least half of the daily protein requirement and at least one-third of the caloric requirements of the school child at “ no

profit no loss basis.”7 If the meals are supplied by food vendors, the vendor’s kitchen should be inspected periodically without any prior notice and screened for infections like typhoid fever and tuberculosis.1,44 The poor nutritional state of Nigerian school children has been noted for long. Adefunke, Adedapo and Magret72 in 1981, found that most school children in Badeku village (a rural community in Oyo state) were short-statured and underweight while 30% of them have angular stomatitis. Several years later, reports from across Nigeria67,73,74 suggest that our school children have not fared better. However, similar scenario is playing itself out in other developing countries.75 While the launching of school feeding programme in Nigeria in 200576 might have ameliorated the situation in some parts of the country, what obtains in the proposed area of study however, remains unknown.

Control of communicable diseases Communicable diseases are entities with living infectious agents that can readily be transferred from one person to another especially within the school community. Examples of such diseases include diarrhea, infestations of the skin, scabies and head lice, meningitis out breaks, epidemic conjunctivitis, mumps and tuberculosis. These have been found to be common among school children in Nigeria.15,26,48,72,77 The control measures which include health education, immunization services, isolation and specific treatment, are important aspects of SHP that have been described to be poorly implemented in Nigeria.8,15,56 Most communicable diseases are also major childhood killers15,68,77 and so controlling them through proper implementation of SHP will help in reducing Nigerian childhood mortality and encourage child survival.

School health records School health record is important in the health appraisal services of school children. A good school health record should provide on each child the following information: name and date of birth, parents name and address with telephone number for easy contact and home visitation as the need may arise.7 It should also contain past health history, illnesses, major treatments and immunizations the child has had.7 The contact address or telephone number of the family doctor should also be documented for easy contact.7 A good school

health record is not complete without proper documentation of the physical examination and screening tests results.7 Though, inadequacies in school health record keeping have been recognized for long in Nigeria,78 it is doubtful if the situation has improved as Ojugo8 in 2005 found that health records were not adequately kept for 78% of primary school children in Edo state. This is in tandem with the 1993 findings by Ejifugha69 in Enugu. The findings by these Nigerian authors8,69,78 are different from the situation in United State where Brener, Wheeler, Wolfe et al79 found that all the schools surveyed in 2006 kept health records for their students even though one third of the students’ health care providers refused to disclose full health information on their clients (students) claiming non authorization by insurance companies. The 70% full health declaration and 100% health records keeping in USA is an enviable standard desirable for Nigerian schools to strive towards.

Health supports for handicapped children

The term handicap means inability to achieve full potential or fulfill a role that is normal for the individual (school children in this context) as a result of disease or defects, impairment or disability. These entities are closely interrelated and common among school children.1,15,65 In developing countries, handicapped children face an uphill task, they are discriminated against on many grounds namely: right to live and be catered for, right to education and quality health care. So the few ones that find their way to schools should not only be given appropriate support within the school health programme but also assisted to attain their utmost potential to live as independently as possible so as to emerge productive and supportive to the society.7

School immunisation services

Immunisation against childhood killer diseases like Measles, Tetanus, Pertusis, Polio and Tuberculosis normally takes place before school entry.3,7 That these conditions still occur in school aged children implies failure of the nations’ immunisation programme.

The school represents a good catchment place to reach school aged children that constitute about 23% of the Nigeria population.80 Hence, the importance of school

immunisation services to mop up those missed by the primary childhood immunisation programme. It is note worthy that in countries like Britain, MMR (Measles, Mumps and Rubella vaccine) is given to children in secondary schools to prevent and control these infections7 while all elementary schools in USA required evidence of vaccination against Diptheria, Measles and Polio as a condition for school entry.79 Similar practice may not be feasible in Nigeria because of the poor school enrolment statistics in some parts of the country.9 It is therefore desirable that school immunisation services be strengthened in Nigeria thus helping in protecting children that make it to our schools against childhood killer diseases.

SCHOOL, HOME AND COMMUNITY RELATIONSHIP

This is the fourth component of School Health Programme that has recently been recognised.1 It is concerned with the coordination of what the child learns and experiences in school and their equivalence in the home and community.1,3 The relevance of this component is premised on the fact that the first health educators of the child are the parents, who shape the child’s habits from infancy long before the child is due for school3 and the fact that the success of a school health programme depends on the extent to which community members are aware of it and willing to support its health promoting efforts.3,7 For a balanced development of the child, life at home should complement a healthy life-style provided in the school. The synergy between schools and homes is therefore very essential.3 Its scope include home visits, regular visit by parents to schools, communication of health status of school children to their parents, active participation of schools in community outreach services like health planning, implementation, monitoring and evaluation.3 Schools have been used for community development in the past, an example being the famous story of Kerala, a rural community in south India where the unacceptably poor health indices of the community was transformed within a short period solely by school involvement in the community health activities.83 Also, Russo and Raymond84 found that community health aides, used as family liaison officers (after training) were instrumental to increased parents participation in the assessment of health status of some students in the U.S.A. These

studies83,84 confirm the invaluable roles a good School- Home -Community relationship could play in implementing acceptable School health programme. However the parameters for evaluating this fourth component of SHP are yet to be incorporated into the SHP evaluation scale as stated by Akani and Nkanginieme (Appendix I).1

OTHER CONCEPTS IN SCHOOL HEALTH PROGRAMME

These are new measures introduced into the school health programme to make it more effective. Theoretically, over the years, the concept of school health programme has continued to advance whereas implementation and practice have continued to lag behind in many developing countries including Nigeria. At the World Health Education Forum held in Dakar, Senegal in April 2000, a joint committee of UNICEF, UNESCO, WHO and World Bank working in partnership under a frame work called “FRESH” (focusing resources on effective school health) identified four basic components which must be provided in school namely:85 Health related policies in schools that help to ensure a safe physical and psycho- social environment, Water, Skilled health education, School health services and nutrition. Of the four, the concept of providing safe psychosocial and physical environments tends to be least addressed by the present scope of school health programme, hence, the advocacy for three additional concepts i.e. health promoting school, child friendly school and healthy school psycho-social environments.3,44

Health promoting school

A school is designated health promoting if it constantly strengthens the capacity for healthy living, learning and working.3,44 It should not only foster friendly learning environments, it should also integrate the school community properly and build capacity for peace, shelter, education, stable ecosystem, social justice etc, thereby improving the health of school children, personnels and the community at large.3,44

Child friendly school

The idea of a child friendly school is based on the United Nations concept of education as a right of the child.86 Though education is one of the basic right of a child, the child’s freedom must not be tampered with while he or she is being educated.86 A child friendly school must ensure that the school milieu is not only emotionally and psychologically secured it should also be friendly, welcoming, safe and support the health needs of school children. It should also provide equal opportunities to boys and girls.1,3,44

Healthy psycho-social school environment

This is an environment that promotes healthy social and emotional development that is supportive and rewarding for school children.1 It also forbids violence, torture, harassment, bullying and discrimination in the school.3,44

ORGANIZATION AND ADMINISTRATION OF SCHOOL HEALTH PROGRAMME IN NIGERIA The approach to school health administration and organization in Nigeria is multi sectorial with intense intersectorial collaborations.3 Health and education are on the concurrent list of the constitution of Nigeria.3 The principles of organizational structures and administration of school health is such that roles are decentralized with each level of government having well defined roles and active participation as stakeholders. The supervision, monitoring and evaluation of School Health Programme, lies with the ministry of health, with the active collaboration with Ministries of Education, Agriculture, Youth and Social development.3 All tiers of government have their statutory roles. While the Federal Government is mainly concerned with policy development, the State Government deal with man power supply and development of infrastructures and the Local Government through primary health care are responsible for the day-to-day implementation and supervision of SHP in Nigeria.3 At school level, the head teacher is the anchor person for SHP implementation in primary schools, apart from being the administrative head of the schools.2 His disposition towards health matters is very important as this will affect the health of other members of the 36

school community. He also designates staff members who will be responsible for directing and supervising the programme and supports activities like in-service trainings for the purpose of improving the skills of school teachers in implementing and improving the quality of SHP.2 Other roles expected of school teachers include highlighting and bringing to parent’s attention any identified health problems in their children and counseling the parents on means of obtaining professional services for the defects so identified.87 The teachers also follow up the children to ensure that they receive the appropriate care.87 If any child is on any special orders from a health professional, the teacher or attached health worker sees to its implementation while the child is in school.87 From the above, it is obvious that teachers occupy a central role in implementing SHP and the enormous roles expected of them cannot be successfully played if half –baked, poorly motivated teachers are working in our various schools as found by some authors.8,12,39 Health professionals like doctors, nurses, physiotherapists, speech therapists and psychologists also have prominent roles to play in SHP.1-3,7,87 The positive values that health workers interaction bring to school was corroborated by Owojaiye and Sadiq88 in 2002 when they found that most school children in Egbe ( a rural town in Kwara state ) had high health knowledge. The high health knowledge of school children in Egbe was attributable to their increased contact with health personnels and not merely to the availability of first aid kit and materials.88 Since 1950 when WHO recognized the link between children education and good health89 and United Nations 1990 recognition of children’s right to education and health,86 the SHP has been proven to be a veritable tool in achieving qualitative health for school children who are survivors of the major childhood killer diseases.1-3,81,83 As part of efforts towards making SHP effective in Nigeria, surveying the schools for background information is of prime importance. From such results, appropriate recommendations can be followed by reasonable implementation activities.

RELEVANCE OF THE STUDY TO THE PRACTICE OF PAEDIATRICS IN NIGERIA

The primary goal of going to school is to be educated. However, education and health are interrelated. A well implemented School Health Programme helps in meeting the health and education related millennium development goals (MDG). There is paucity of information on the status of School Health Programme as implemented among primary schools in Ilesa East Local Government Area and there is no known previous study that holistically evaluates the components of School Health Programme in this Local Government Area. This study seeks to provide information on the content of School Health Programme as practiced among primary schools in Ilesa East Local Government Area of Osun state. The information obtained can be made available to appropriate authorities for use in formulating policies that will strengthen the deficient areas identified. This will go a long way in improving the health of school children in the local government area, thereby enhancing their survival. Since, school age children are the lucky survivors of the major killers of Nigeria’s under-fives any effort geared towards enhancing their health is therefore not misplaced.

AIMS AND OBJECTIVES GENERAL OBJECTIVE

The aim of this study is to determine the status of compliance with the School Health Programme among primary schools in Ilesa East Local Government Area of Osun State, Nigeria.

SPECIFIC OBJECTIVES

The specific objectives are to determine:

1. The content of school health services as practised among Ilesa East Local Government Area (LGA) primary schools.

2. The healthfulness of Ilesa East LGA primary schools environment.

3. The extent of health instruction activities among Ilesa East LGA primary schools.

4. Some factors that may be responsible for the current status of school health programme as practised among primary schools in Ilesa East Local Government Area.

METHODOLOGY (MATERIALS AND METHODS) STUDY AREA This study was conducted among primary schools (both public and private) in Ilesa East Local Government Area of Osun State (IELGA). The LGA is populated mainly by Yorubas of the south western part of Nigeria. It has a population of 105,416.90 The LGA has two higher institutions namely Osun State College of Education and School of Health Technology. It also has a tertiary health facility (The Wesley Guild Hospital- a unit of Obafemi Awolowo University Teaching Hospitals Complex).

STUDY DESIGN The study was a cross sectional descriptive type. It involved all primary schools (private and public) in Ilesa East Local Government Area of Osun State. A school health programme evaluation scale (Appendix I)1 was used. In order to enhance objectivity in the assessment, this was administered by the researcher through separate interviews with the pupils and teachers in each school.

APPROVAL FOR THE STUDY An approval was obtained by the researcher from the Local Government School Education Authority (Appendix II). The consent and cooperation of each school head was sought by explaining the benefits of the research work to them in clear terms.

STUDY INSTRUMENT

The School Health Programme Evaluation Scale (Appendix I)1 was used to record information and score each school visited. The scale is weighted and has five parts which include: sections for data on the school administration, the three components of SHP under evaluation (school health services, school health instruction and healthful school environment) as available in the schools and collation of scores. The scale was administered by the researcher following separate interviews with two teachers and two pupils.

According to the evaluation scale (Appendix I)1, the maximum obtainable score in each of the three components of SHP are as follows: school health services (45), school health instruction (41) and healthful school environment (66) while the minimum acceptable score in each of the components are: school health services (19), school health instruction (27), healthful school environment (57). The total maximum obtainable score is 152 and the total minimum acceptable score allowed is 103. Details of the scores for the various aspects of the three components of SHP under consideration (SHI, HSE, SHS) are as shown in the evaluation scale (Appendix I).1

PILOT STUDY

A pilot study was carried out using two primary schools (one private and the other public) in Ilesa West Local Government Area (a location outside but close to the study area). The information obtained from the pilot study was used to modify the questions to make them clearer.

DATA COLLECTION

Separate interviews of the Head teachers, school health teachers and two pupils selected randomly from final year classes (Primary 6 pupils) were conducted by the researcher. The first available male and female pupils on the attendance register were chosen. Their responses were filled out on the spot. The researcher also carried out direct observation of all the aspects of Healthful School Environment as well as aspects of School Health Instruction and School Health Services that can be observed directly, with clarifications sought from the respondents where applicable.

The toilet-pupils ratio in each school was obtained by dividing the total number of toilets by the pupils’ population. The dimensions of the floor of the classrooms, windows and doors were measured using a measuring tape and their areas determined through multiplication of their lengths by their widths. A classroom floor space was adjudged standard if the space was not less than 19.4 metres square31 while ventilation was adjudged

adequate if the windows and doors were disposed in a way that allowed cross ventilation and their combined areas accounted for at least a quarter of the floor space.7,10 The ventilation was adjudged controllable if there were doors and windows with hinges that allowed their closing and opening as desired. The emotional climate was assessed by asking questions about job satisfaction from the teachers interviewed while the pupils were asked questions about relationship with their peers and teachers. The lesson notes of the respondent health teachers as well as presence of supplementary teaching aids like: posters, illustration charts, audio visual materials, e.t.c. were checked to corroborate their claims on the delivery of health instruction, while the scope of inspection of pupils was determined by asking about the parts of the pupils` bodies inspected and how frequently this was done.

The information obtained and the researcher’s direct observation were recorded and used to award scores to each school visited using the school health programme evaluation scale (Appendix I).1 The scores on the SHI and SHS were awarded from the average of the four respondents for each school to the nearest whole number. The score on the school environment being that obtained by the researcher’s direct observation after seeking clarifications from the respondents where necessary.

The summation of the scores so obtained, was recorded as the total score of each school on the implementation of the three components of SHP under consideration.

Discussions were carried out with the secretary to the Ilesa East Local Government Education Authority, Head of school services Ilesa East Local Government Education Authority and the Primary Health Care Coordinator of Ilesa East LGA to find out if there were any existing collaboration between the Primary Health Care Unit and the Local Government Education Authority on the implementation of SHP within the LGA.

DATA ANALYSIS

The data obtained was entered into personal computer and analysed using the Statistical Programme for Social Science (SPSS) version 1492. Means, standard deviations, proportions and percentages were determined as applicable. The results obtained from the public schools were compared with those of the private schools using the independent sample t- test and the Pearson’s chi-squared (ϰ2) tests with Yate’s correction was used as applicable. P values of less than 0.05 were accepted as statistically significant.

RESULTS

SCHOOL ADMINISTRATIVE DATA

There were 64 primary schools consisting of 34 public and 30 private in Ilesa East Local Government Area. The administrative data obtained are summarized in tables (I-V). Table I shows the distribution of pupils and teachers in the schools. There were a total of 18,694 pupils and 912 teachers. The schools had 9,140 male pupils and 9,554 female pupils with a male pupil to female pupil ratio of 1: 1.04. The ratio of teachers to pupils was 1:21 in public schools and 1:20 in private schools. There were more pupils in the public schools which had a total of 11,894 pupils representing 63.6% of the total pupils population compared to private schools with 6,800 (36.4%) of the total pupils population.

Table I: The distribution of pupils and teachers in the schools Type of No of pupils No of No of females No of No of male No of female school males teachers teachers teachers Public 11894 5742 6152 568 86 482 Private 6800 3398 3402 344 117 227 Total 18694 9140 9554 912 203 709

The age distribution of the schools is shown in table II below. The youngest primary school in the LGA was established two years prior to this study while the oldest had been in existence for 128 years, giving a mean age of 28 years. The mean age of public primary schools in Ilesa East local government area was 43 ± 31.76yrs (range 8-128 years) while that of private primary schools was 11± 8.92yrs (range 2-40 years).

Table II: Age distribution of schools

Age group of schools Public school Private school Total in years 1-20 12 26 38 21-40 4 4 8 41-60 9 0 9 61-80 5 0 5 81-100 2 0 2 101-120 1 0 1 121-140 1 0 1 Total 34 30 64

As shown in Table III, the highest qualification of the 128 teachers interviewed (64 Headteachers and 64 School health instructors) was bachelor degree, while Grade II teachers’ certificate was the least qualification. The commonest qualification encountered was NCE 99 (77.8%). The public schools significantly had more teachers with teaching related qualifications NCE (p=0.000). The private schools significantly had more teachers with non- teaching related qualifications, HND (p=0.008), Other Bachelor degree (p=0.000).

Table III: Distribution of the qualifications of the teachers interviewed

Qualification Public Private Total ϰ2 P value N=68 N=60 N=128 n n n (%) Bachelor of 4 0 4(3.1) *1.959 0.162 Education Other Bachelor 0 14 14(10.9) 17.815 0.000 degree NCE 64 35 99(77.8) 33.481 0.000 HND 0 6 6(4.7) 7.134 0.008 OND 0 3 3(2.3) *1.640 0.200 Grade II 0 2 2(1.6) *0.645 0.422

*- Chi-square (ϰ2) with Yate’s correction applied

Fifty three (82.8%) of the 64 schools had functional PTA while 42(65.6%) of them regularly organize extracurricular activities such as inter- house sporting-competition and cultural dances. A majority of public schools 73.5% (25 of 34) participated in these activities. However, 8 (12.5%) of all the schools had a school health committee and 6 (9.49%) schools, all of them private had trained first aiders (Table IV). Significantly more private schools had trained first aiders (p=0.006) while a significant proportion of the public schools had functional PTA compared to their private counterparts (p=0.001)

Table IV: Availability of trained first aiders, functional PTA, extracurricular activities and school Health committee Criteria Public Private Total ϰ2 P value N=34 N=30 N=64 n (%) n (%) n (%) Functional PTA available 33 (97.0) 20 (66.7) 53 (82.8) 10.343 0.001 Extracurricular activities 25 (73.4) 17 (56.7) 42 (65.6) 2.009 0.156 School health committee available 5 (14.7) 3 (10.0) 8 (12.5) 0.323 0.570 First aid trainer available 0 (0.0) 6 (20.0) 6 (9.4) 7.503 0.006

HEALTHFUL SCHOOL ENVIRONMENT

The various scores attained in the different aspects of Healthful School Environment by the schools are shown in Tables Va and Vb.

Table Va: An outline of healthful school environment scores for each of the public schools s/n of Water Refuse Sewage School Evidence of Healthful Total schools supply disposal disposal plan maintenance living score (max =7) (max=4) (max=8) (max=35) (max=2) (max=10) (max=66) 1 0 1 3 25 0 3 32 2 5 1 3 25 0 3 37 3 5 1 0 21 0 1 28 4 5 1 3 20 0 4 33 5 0 1 3 18 0 2 24 6 5 1 4 21 0 6 37 7 5 1 3 20 2 5 36 8 0 1 3 19 2 2 27 9 0 1 7 23 0 3 34 10 5 1 0 19 0 1 26 11 5 1 3 25 2 1 37 12 3 1 3 20 2 4 33 13 5 1 3 21 0 3 33 14 3 1 3 24 0 4 35 15 5 1 3 19 0 3 31 16 0 1 0 17 2 1 21 17 0 1 0 21 2 3 27 18 5 1 3 23 2 3 37 19 0 1 0 17 0 2 20 20 0 1 0 20 0 2 23 21 5 1 3 16 0 3 28 22 5 1 3 21 0 5 35 23 5 1 0 19 2 3 30 24 5 1 4 20 0 5 35 25 5 1 3 22 0 3 34 26 0 1 0 25 0 1 28 27 5 1 3 23 2 2 36 28 6 1 3 21 0 2 33 29 0 1 0 16 0 0 17 30 0 1 0 21 2 2 26 31 5 1 3 22 0 4 35 32 5 1 3 19 0 3 31 33 5 1 3 21 2 2 34 34 0 1 6 23 2 3 35

Table Vb: An outline of healthful school environment scores for each of the private schools s/n of Water Refuse Sewage School Evidence of Healthful Total schools supply (max disposal disposal plan maintenance living score =7) (max=4) (max=8) (max=35) (max=2) (max=10) (max=66) 1 5 1 3 13 0 0 22 2 3 1 3 21 0 3 31 3 3 1 3 21 2 1 31 4 5 1 3 17 0 2 28 5 6 1 6 33 2 6 54 6 3 1 4 23 2 4 37 7 0 1 0 11 0 3 15 8 0 1 3 21 2 2 29 9 3 1 3 16 0 2 25 10 0 1 4 26 2 3 36 11 3 1 3 16 0 2 25 12 0 1 4 26 2 3 36 13 3 1 3 16 0 2 25 14 6 1 8 32 2 8 57 15 3 1 3 16 0 2 25 16 4 1 5 16 0 3 29 17 6 1 6 29 2 3 47 18 5 1 4 27 2 2 41 19 3 1 3 21 2 1 31 20 6 1 6 29 2 3 47 21 5 1 3 15 0 2 26 22 5 1 4 27 2 2 41 23 0 1 3 17 0 1 22 24 5 1 4 16 0 1 27 25 5 1 3 15 0 2 26 26 0 1 3 17 0 1 22 27 0 1 3 16 0 2 22 28 5 1 3 17 0 2 28 29 5 1 6 23 2 3 40 30 5 1 6 21 0 2 35

Water supply

Forty five (70.3%) of all the schools(comprising 22 public and 23 private schools) had water supply while 19 (29.7%) schools (comprising 12 public and 9 private) schools had none. Forty (62.5%) schools (made up of 21 public and 19 private) got their water from well and five (7.8%) schools (comprising 1 public and 4 private) had functional bore hole. None of the schools had pipe borne water.

Location of water sources

Thirty four (75.6%) of the schools with water supply had their water sources located within the school premises while only 11 (24.4%) had theirs outside the school premises. Comparing private and public schools in terms of location of water sources, significantly more private schools; 9 (30.0%) as against 2 (5.9%) of the public schools had their water sources located outside their premises ( p=0.011)

Sewage disposal Twelve (18.7%) of the 64 primary schools in IELGA had no toilet facilities as shown in Table VI below. This is especially so in the public schools 10 (29.4%) as against two (6.7%) in the private schools; p=0.045). Majority of the schools 44 (68.8%) used pit latrines to dispose their sewage materials. Eight (12.5%) private schools used water closet (p=0.001). Bucket method of sewage disposal was not practiced in any of the schools.

Table VI: Methods of sewage disposal Toilet type Public Private Total ϰ 2 P value N=34 N=30 N=64 n(%) n(%) n(%) Water closet 0(0) 8(12.5) 8 ( 12.5) 10.362 0.001 Pit latrine 24(70.6) 20(66.7) 44 (68.8) 0.114 0.736 Surface/ No toilet 10(29.4) 2(6.7) 12 (18.7) 4.022 0.045 Bucket 0(0) 0(0) 0(0) - -

Toilet to pupil ratio In the schools with toilet facilities, the recommended toilet to pupil ratio of 1:30, exists in only 3 (5.8%) of the primary schools, comprising 2 (8.3%) of public and 1 (3.6%) of the private primary schools. This is shown in Table VII below.

Table VII: Toilet to pupil ratio Ratio Public Private Total ϰ 2 P value N=24 N=28 N=52 n(%) n(%) n(%) 1:30 2(8.3) 1(3.6) 3 (5.8) *0.019 0.891 1:31/45 0(0) 0(0) 0(0) - - 1:45/60 0(0) 6(21.4) 6 (11.5) 5.814 0.016 1:61/90 2(8.3) 3(10.7) 5 (9.6) 0.084 0.772 1:>90 20(83.3) 18(64.3) 38 (73.1) 1.513 0.219 * - Chi-square (ϰ2) with Yate’s correction applied

Refuse disposal- All the 64 (100%) schools practised open dumping and burning method of refuse disposal.

Quality of school buildings As shown in Table VIII, 27 (42.2%) schools had dilapidated buildings and 15(23.4%) had minor cracks while 11(17.2%) each had old walls with leaking roofs or strong walls with good roofs respectively. Significantly more public schools had dilapidated buildings while the private schools significantly had minor cracked- walled buildings. (p=0.004 and 0.001 respectively)

Fire Resistance As shown in Table VIII, most school buildings, (62(96.8%)) were constructed with fire resistant materials while two (3.2%) schools (all private) had some prefabricated materials used as their buildings. No school was entirely made up of pre-fabricated materials.

Floor Space As shown in Table VIII, forty three (67.2%) schools, comprising 32 (94.1%) public

schools and 11 (36.7%) private schools, had standard floor space while 21 (32.8%) schools made up of 2 (5.9%) public schools and 19 (63.3%) private schools did not have standard floor space and were too small. While the public schools significantly had standard floor space, p=0.000, a significant proportion of the private schools did not p=0.000.

Floor finishing Of the 64 schools, 43 (67.2%) schools had floors which were worn off/broken or dusty with public schools relatively worse off. Eleven (17.2%) schools had flat non glossy floors. Nine (14%) schools had flat glossy floors with the majority being private schools. One private school had completely sandy floor.

Ventilation Fifty two (81.2%) schools comprising all 34 public schools and 18 private schools had adequate ventilation. Ventilation was controllable (windows and doors can be opened and shut) in 49 (76.6%) schools made up of 33 (97.0%) public and 16 (53.0%) private schools. The ventilation of 15 (23.4%) schools (1public and 14 private) was not controllable. Significantly more private schools had no adequate and controllable ventilation p=0.000. (Table VIII).

Lighting As shown in Table VIII, 57 (89.1%) schools made up of all 34 public schools and 23 private schools had good lighting while 7 schools (all private) had poor lighting. Significantly more public schools had good lighting p=0.003. Three (4.7%) schools (all private) had their lighting supplemented with artificial light.

Insulation from heat Of the 64 schools, 10(15.6%) had properly ceiled rooms, while 40(62.5%) had their rooms partially ceiled. Fourteen (21.9%) schools had no ceilings at all with more private schools belonging to this category. (Table VIII).

Table VIII: Quality of buildings /structures of the schools Facilities/ structures Public Private Total ϰ 2 P N=34 N=30 N=64 value n (%) n (%) n (%) (a) Classroom buildings Dilapidated 20 (58.8) 7 (23.3) 27 (42.2) 8.231 0.004 Old walls & leaking roofs 7 (20.6) 4 (13.3) 11 (17.2) 0.190 0.663 Strong and minor cracks 2 (5.9) 13 (43.3) 15 (23.4) 10.458 0.001 Strong & good roofs 5 (14.7) 6 (20.0) 11 (17.2) 0.314 0.575 (b) Fire Resistance All buildings with fire resistant materials 34 (100.0) 28 (93.3) 62 (96.8) 0.656 0.418 Some fabricated buildings 0 (0.0) 2 (6.7) 2 (3.2) *0.656 0.418 All prefabricated buildings 0 (0.0) 0 (0.0) 0 (0.0) - - (c) Floor Spacing Standard 32 (94.1) 11 (36.7) 43 (67.2) 9.331 0.000 Not standard 2 (5.9) 19 (63.3) 21 (32.8) 9.331 0.000 Finishing Flat non glossy 6 (17.6) 5 (16.7) 11 (17.2) 0.011 0.917 Flat glossy 3 (8.8) 6 (20.0) 9 (14.0) 0.852 0.356 Worn off/broken/dusty 25 (73.5) 18 (60.0) 43 (67.2) 1.323 0.250 Sandy 0 (0.0) 1 (3.3) 1 (1.6) *0.004 0.950 (d) Ventilation Adequate 34 (100.0) 18 (60.0) 52 (81.2) 16.738 0.000 Not adequate 0 (0.0) 12 (40.0) 12 (18.8) 16.738 0.000 Controllable 33 (97.1) 16 (53.3) 49 (76.6) 16.981 0.000 Not controllable 1 (2.94) 14 (46.7) 15 (23.4) 16.981 0.000 (e) Lighting Good 34 (100.0) 23 (76.7) 57 (89.1) 6.673 0.010 Poor 0 (0.0) 7 (23.3) 7 (10.9) 8.908 0.003 Artificial light 0 (0.0) 3 (10.0) 3 (4.7) *1.680 0.195 (f) Insulation from heat No ceilings 5 (14.7) 9 (30.6) 14 (21.9) 2.181 0.140 Partially ceiled 24 (70.6) 16 (53.3) 40 (62.5) 2.025 0.155 Properly ceiled 5 (14.7) 5 (16.7) 10 (15.6) 0.046 0.829 * - Chi-square (ϰ2) with Yate’s correction applied

Sitting comforts As shown in Table IX below, Forty (62.5%) schools (17 public and 23 private) had desks and chairs for all their pupils to sit while pupils in 24 (37.5%) schools (17 public and 7 private) did not have enough desks and chairs. Forty five (70.3%) schools comprising 18 public and 27 private schools had tables and chairs for all their teachers to sit while teachers in 19 (19.7%) schools comprising 16 public and 3 private schools did not have enough tables and chairs to sit. Significantly more private schools had better sitting comfort for both pupils (p=0.028) and teachers (p= 0.003). Table IX: Sitting comfort, Food service area and Evidence of maintenance Facilities/ structures Public Private Total ϰ 2 P value N=34 N=30 N=64 n ( %) n (%) n ( %) (a) Sitting comforts Pupils 100% seated 17 (50.0) 23 (76.7) 40 (62.5) 4.836 0.028 <100% seated 17 (50.0) 7 (23.3) 24 (37.5) 4.836 0.028 Teachers 100% seated 18 (52.9) 27 (90.0) 45 (70.3) 8.785 0.003 <100% seated 16 (47.1) 3 (10.0) 19 (29.7) 8.785 0.003 (b) Food service area Available 34 (100.0) 17 (56.7) 51 (79.7) 18.489 0.000 Not available 0 (0.0) 13(43.3) 13 (20.3) 18.489 0.000 (c) Safety measures Safety patrol team 0 (0.0) 4 (13.3) 4 (6.3) *4.836 0.028 School fence 5 (14.7) 14 (46.7) 19 (29.7) 7.799 0.005 Fire extinguisher 0 (0.0) 1(3.33) 1 (1.6) *0.004 0.950 Fire alarm 0 (0.0) 0 (0.0) 0 (0.0) - - No measure(s) 29 (85.3) 11 (36.7) 40 (62.5) 16.079 0.000 (d) Health hazards Industrial population including major road/ markets Dangerous/ grazing animals 18 (52.9) 19 (63.3) 37 (57.8) 0.706 0.401 Animal droppings in 28 (82.4) 15 (50.0) 43 (67.2) 7.567 0.006 classrooms 23 (67.6) 14 (46.7) 37 (57.8) 2.876 0.009 Floods/open drainages 18 (52.9) 16 (53.3) 34 (53.1) 0.001 0.975 Vectors/pests 16 (47.1) 13 (43.3) 29 (45.3) 0.089 0.765 No health hazard observed 3 (8.8) 9 (30.0) 12 (18.8) 4.691 0.030 (e)Evidence of maintenance 10 (29.4) 13 (43.3) 23 (35.9) 1.342 0.247

* - Chi-square (ϰ2) with Yate’s correction applied

Food service area As shown in Table IX, food service area was available in 51 (79.7%) schools. These includes all the 34 public schools and 17 (56.7%) private schools. Significantly more private schools did not have food service area p=0.000.

Safety measures Forty (62.5%) schools consisting of 29 public schools and 11 private schools did not carry out any of the listed safety measures in the evaluation scale. Nineteen (29.7%) schools (5 public and 14 private) had school fence, while 4 (6.3%) schools (all private) had a safety patrol team, and 1 private school had fire extinguisher. No school had fire alarm. Significantly more private schools provided safety patrol teams and school fences p=0.028 and 0.005 respectively. This is shown in Table IX.

Health hazards/nuisance Thirty-seven (57.8%) schools were located close to major roads, markets or industrial areas. Also, 43 (67.2%) schools (28 public and 15 private) had either dangerous or grazing animals in their premises. In 37 (57.8%) schools (23 public and 14 private), there were animals droppings in their classrooms. Open drainages/ tendency to flooding were observed in 34 schools, while disease vectors like mosquito larvae and cockroaches were found in 29 (45.3%) schools. Twelve (18.75%) schools had none of the observed health hazards as indicated in the evaluation scale. Significantly more private schools did not have any of the observed health hazards compared to the public schools (p=0.03). (Table IX).

Evidence of maintenance As shown in Table IX, 23 (35.9%) schools made up of 10 (29.4%) public and 13 (43.3%) private schools had evidence of maintenance like mending of destroyed parts of school buildings, painting of classroom buildings and cutting of grasses.

Healthful living in the schools As shown in Table X, significantly more public than private schools had sport fields, sport facilities and adequate emotional climate (p=0.000, 0.028 and 0.000 respectively). Compulsory wearing of shoes, regular cleaning of toilets and classrooms were more significantly carried out by private schools p=0.000 and 0.030 respectively.

Table X: Healthful living in the schools Healthful living Public Private Total ϰ 2 P value N=34 N=30 N=64 n (%) n (%) n (%) Adequate emotional climate 21(61.8) 5(16.7) 26(40.6) 13.438 0.000 Shoes worn compulsorily 5(14.7) 21(70.0) 26 (40.6) 13.438 0.000 Sports field available 25(73.5) 3(10.0) 28(43.7) 23.620 0.000 Sports facilities available 14(41.2) 4(13.3) 18(28.1) 4.812 0.028 Toilet rolls available 1(2.9) 4(13.3) 5(7.8) 1.165 0.280 Soaps for washing hand available 0(0) 1(3.3) 1(1.6) 0.004 0.950 Washing hands basin & stand available 4(11.8) 2(6.7) 6(9.3) 0.488 0.485 Dustbins and waste paper basket available 3(8.8) 6(20.0) 9(14.0) 0.852 0.356 Regular cleaning of toilets & classrooms 21(61.8) 28(93.3) 49(76.6) 8.851 0.003 Drinking fountains bucket & cups in class 2(5.9) 1(3.3) 3(4.7) *0.000 1.000 * - Chi-square (ϰ2) with Yate’s correction applied

SCHOOL HEALTH INSTRUCTION The various scores attained in the different aspects of School Health Instruction by the schools are shown in Tables XIa and XIb.

Table XIa: An Outline of school health instruction scores for each of the public schools s/n of Time Progressive Scopes of Teaching Organization Teachers Total schools allotted teaching health methods of health preparation (max=41) to for all instruction (max=10) and safety for health health grades (max=12) trips teaching teaching (max=5) (max=5) (max=4) (max=5) 1 1 5 8 4 0 1 19 2 3 5 6 4 0 2 20 3 1 5 6 4 0 2 18 4 1 5 6 4 0 1 17 5 1 5 6 4 0 2 18 6 1 5 4 4 0 2 16 7 1 5 6 4 0 1 17 8 1 5 8 4 0 1 19 9 1 5 6 4 0 1 17 10 1 5 6 4 0 2 18 11 1 5 8 4 0 2 20 12 1 5 8 4 0 1 19 13 1 5 6 4 0 1 17 14 3 5 8 4 0 2 22 15 1 5 6 4 0 2 18 16 3 5 8 4 0 1 21 17 1 5 8 4 0 2 20 18 1 5 6 4 0 2 18 19 1 5 6 4 0 2 18 20 1 5 6 4 0 2 17 21 3 5 8 2 0 1 19 22 1 5 8 2 0 2 18 23 1 5 8 2 0 2 17 24 1 5 8 2 0 2 18 25 1 5 6 2 0 2 16 26 1 5 6 2 0 1 15 27 1 5 8 2 0 2 18 28 1 5 8 2 0 1 17 29 1 5 6 2 0 1 15 30 1 5 4 2 0 2 14 31 1 5 8 2 0 1 17 32 3 5 6 2 0 1 17 33 1 5 4 2 0 2 14 34 1 5 6 2 0 1 15

Table XIb: An Outline of school health instruction scores for each of the private schools s/n of Time Progressive Scopes of Teaching Organization Teachers Total schools allotted teaching health methods of health preparation (max=41) to for all instruction (max=10) and safety for health health grades (max=12) trips teaching teaching (max=5) (max=5) (max=4) (max=5) 1 3 5 8 4 0 1 21 2 3 5 6 6 2 2 24 3 1 5 4 4 0 0 14 4 1 5 6 6 0 1 19 5 1 5 6 6 2 2 22 6 3 5 4 4 0 1 17 7 3 5 4 4 0 1 17 8 1 5 4 4 0 1 15 9 1 5 6 4 0 1 17 10 3 5 4 6 2 1 21 11 1 5 4 6 2 1 19 12 3 5 4 6 2 1 21 13 1 5 6 4 0 1 17 14 3 5 6 6 3 2 25 15 1 5 4 6 2 1 19 16 3 5 4 4 0 1 17 17 3 5 4 6 2 2 22 18 3 5 4 6 0 1 19 19 1 5 4 2 0 0 12 20 3 5 4 6 2 2 22 21 3 5 4 6 2 1 19 22 3 5 4 6 0 1 19 23 1 5 6 2 0 1 15 24 1 5 6 2 0 2 16 25 3 5 4 6 0 1 19 26 1 5 6 2 0 1 15 27 1 5 4 6 0 1 17 28 1 5 6 6 0 1 19 29 3 5 8 6 0 1 23 30 1 5 6 6 0 2 20

Time allocated to health education/ teaching All the primary schools in Ilesa East Local Government Area carried out health instruction activities, 43 of them did so once a week (85.3% public vs 50% private schools) and 21 twice a week (14.7% public vs 50% private schools). None of the schools gave health instruction thrice a week.

Content of health instruction in schools The contents of the health instructions as shown in Table XII below are mainly on growth and development, personal health and nutrition, safety education and HIV/AIDS. Four schools included knowledge of community health or social and emotional health. There was no significant difference between the public and private primary schools with regards to the content of health education, except in the aspect of HIV/AIDS where the public schools performed significantly better (P=0.021).

Table XII: Contents/ Scope of health teaching/ in the schools Contents /scope Public Private Total ϰ 2 P value N=34 N=30 N=64 n n n (%) Growth and development 34 29 63 (98.4) 0.004 0.950 Personal health including food and nutrition 34 28 62 (96.9) 0.656 0.418 Community health including communicable and non communicable diseases 1 2 3 (4.7) *0.012 0.912 Social and emotional health 1 0 1 (1.6) *0.000 1.000 HIV/AIDS 30 18 48 (75.0 ) 5.354 0.021 Safety education including first aid and home accident prevention 19 17 36(56.3) 0.004 0.950 *- Chi- square (ϰ2) with Yate’s correction applied

Methods of health instruction As shown in Table XIII, methods of teaching health education in these primary schools were by integration with other subjects (taught under different subjects) using supplementary teaching aids. Four private schools had designated health education staff P=0.028.

Table XIII: Methods of health Instruction Methods Public Private Total ϰ 2 P value N=34 N=30 N=64 n n n (%) Direct by health education staff 0 4 4 (6.3) *4.836 0.028 Integration with other subjects 34 30 64 ( 100.0) - - Integrated with other classroom activities 0 0 0 - - By visiting medical specialists voluntary group 0 0 0 - With supplementary teaching aids 20 18 38 (59.4) 0.009 0.924 * - Chi square (ϰ2) with Yate’s correction applied

Teachers’ preparation for health teaching Table XIV shows the level of preparation of teachers interviewed for health teaching. Fifty-nine (46.1%) of the teachers interviewed claimed to have had training in personal health, 28 (21.9%) in community health and none on components of SHP while being trained in the various institutions they graduated from. Four (3.1%) of them had In-service training on health issues in the past five years.

Table XIV: Preparation of teachers for teaching health education Preparation No of respondents No of respondents Total no of ϰ 2 P value in public schools in private schools respondents N=68 N=60 N=128 n n n (%) In service training on health issues 2 2 4 (3.1) *0.000 1.000 Elementary training in personal health 33 26 59(46.1) 0.346 0.556 Elementary training in SHP components 0 0 0 - - Elementary training in community health 18 10 28 (21.9) 1.793 0.181 * - Chi-square (ϰ2) with Yate’s correction applied

Organization of health and safety trips by the schools Ten (15.6%) schools (all private) organized health and safety trips either within or outside their schools.

SCHOOL HEALTH SERVICES

The various scores attained in the different aspects of School Health Services by the schools are shown in Tables XVa and XVb.

TableXVa: An outline of the public schools scores on school health services

s/n 0f Personel Health Treatmen Emergency Control of Record Nutritional Guidance Total schools (max=10) Appraisal t Care communicable Keeping Service & score (max=5) Facilities (max=5) disease (max=3) (max=7) counseling (max=45 (max=5) (max=8) (max=2) ) 1 0 1 0 1 2 0 4 1 9 2 0 1 2 2 2 0 3 2 12 3 0 1 1 1 2 0 3 2 10 4 0 1 2 1 2 0 3 2 11 5 0 1 2 1 2 0 3 2 11 6 0 1 1 1 2 0 4 2 11 7 0 1 2 1 2 0 3 2 11 8 0 1 1 1 2 0 3 2 10 9 0 2 0 1 2 0 4 2 11 10 0 1 1 0 2 0 3 2 9 11 0 1 1 1 2 0 3 2 10 12 0 1 0 1 2 0 3 2 9 13 0 1 2 2 2 0 4 2 13 14 0 1 0 2 2 0 3 0 8 15 0 1 2 1 2 0 3 0 9 16 0 1 2 1 2 0 3 0 9 17 0 1 2 1 2 0 3 0 9 18 0 1 2 1 2 0 3 0 9 19 0 1 1 0 2 0 3 0 7 20 0 1 1 0 2 0 4 0 8 21 0 1 2 1 2 0 3 0 9 22 0 1 1 1 2 0 4 0 9 23 0 1 0 1 2 0 3 0 7 24 0 1 2 1 2 0 3 0 9 25 0 1 0 1 2 0 3 0 7 26 0 1 1 0 2 0 3 0 7 27 0 1 2 1 2 0 3 0 9 28 0 1 1 1 2 0 4 0 9 29 0 1 0 1 2 0 3 0 7 30 0 1 0 1 2 0 3 0 7 31 0 1 1 1 2 0 3 0 8 32 0 1 0 1 2 0 3 0 7 33 0 1 1 2 2 0 3 0 9 34 0 1 0 1 2 0 4 0 8

Table XVb: An outline of scores of the private schools on school health services

s/n of Personel Health Treatment Emergency Control of Record Nutritional Guidance& Total score schools (max=10) Appraisal Facilities Care communicable Keeping Service counseling (max=45) (max=5) (max=5) (max=5) disease (max=3) (max=7) (max=2) (max=8) 1 0 1 1 1 2 0 3 2 10 2 1 2 5 1 2 1 3 2 17 3 0 2 2 1 2 0 3 2 12 4 1 2 3 2 2 1 3 2 16 5 1 3 5 3 2 1 4 2 21 6 0 1 4 1 2 0 3 2 13 7 0 1 0 0 2 0 0 2 5 8 0 1 3 2 2 0 4 2 14 9 0 1 4 2 2 0 3 2 14 10 0 1 2 2 2 0 3 2 12 11 0 1 0 1 2 0 3 2 9 12 0 1 2 2 2 0 3 2 12 13 0 1 4 2 2 0 3 2 14 14 1 3 5 3 2 0 3 2 19 15 0 1 0 1 2 0 3 2 9 16 0 1 3 1 2 0 3 2 12 17 0 1 4 3 2 0 3 2 15 18 0 2 2 2 2 0 3 0 11 19 0 2 2 1 2 0 3 0 10 20 0 1 4 3 2 0 3 0 13 21 0 1 2 1 2 0 3 0 9 22 0 2 2 2 2 0 3 0 11 23 0 1 2 1 2 0 4 0 10 24 0 1 2 1 2 0 3 0 9 25 0 1 2 1 2 0 3 0 9 26 0 1 2 1 2 0 4 0 10 27 0 1 4 2 2 0 3 0 12 28 1 2 3 2 2 1 3 0 14 29 3 3 5 2 2 1 3 0 19 30 0 1 2 1 2 0 3 0 9

Health personnel As shown in Table XVI, none of the public primary schools had a designated health personnel. However, these were available in six private schools (one nurse and five health assistants). Significantly more private schools had health personnel (p=0.021). Table XVI: School health personnel in the schools Personnel Public Private Total ϰ 2 P value N=34 N=30 N=64 n n n (%) None 34 24 58(90.6) 5.33 0.021 Health Assistant 0 5 5(7.8) 6.147 0.013 Nurse 0 1 1(1.6) *0.004 0.950 Nutritionist/Health 0 0 0 - - Educator Doctor 0 0 0 - - * - Chi-square (ϰ2) with Yate’s correction applied

Health appraisals services As shown in Table XVII below, routine inspection of the pupils’ clothes, nails, teeth etc was done in all the schools by the teachers. However, five (7.8%) private schools requested for pre-entry medical screening- test (p=0.013).

Table XVII: Health appraisal services in the schools Health Appraisal Public Private Total ϰ 2 P value N=34 N=30 N=64 n n n (%) Routine inspection by teachers 34 30 64(100) - - Pre-entry screening test 0 5 5(7.8) 6.147 0.013 Periodic medical examination for staff & pupils 0 1 1(1.6) *0.004 0.950 Referral to health centres/ hospitals 0 8 8(12.5) 10.362 0.001 Supervision of health of the handicap 0 1 1(1.6) *0.004 0.950 * - Chi-square (ϰ2) with Yate’s correction applied Treatment facilities within the schools As shown in table XVIII below, forty nine (76.6%) schools made up of (24 public and 25 private) each had a first aid box. The private schools performed better in the provision of treatment facilities. Four (6.3%) of them had a health room, 12 (18.8%) had telephone services and 14 (21.9%) functional school bus (p=0.028, 0.000, 0.000 respectively). No school had an ambulance.

Table XVIII: Treatment/ Health Facilities in the schools Health facilities Public Private Total ϰ 2 P value N=34 N=30 N=64 N n n(%) Health room/dispensary 0 4 4(6.3) 4.836 0.028 School Ambulance 0 0 0 - - School Bus 0 14 14(21.9) 17.670 0.000 Telephone services 0 12 12(18.8) 14.216 0.000 First Aid box available 24 25 49(76.6) 1.443 0.230 64

Contents of First Aid box Out of the 49 (76.6%) schools with First Aid boxes, 16 (25.0%) schools had nothing in their First Aid boxes ( i.e empty). Wound dressing materials (cotton wool, plaster, bandages, disinfectants) were the most commonly stocked materials by both private and public schools. However, the private schools significantly stocked more of these items than the public schools. Drugs like: oral rehydration salts, haematinics, antimalaria and antifungal are only available in a few schools [3(4.7%), 1(1.6%), 1(1.6%) and 1(1.6%)] respectively. None of the schools stocked vitamins and anti scabetic drugs. (Table XIX).

Table XIX: Contents of the first Aid box Contents Public Private Total ϰ 2 P value N=34 N=30 N=64 n n n (%) Analgesic 0 15 15(23.4) 22.4 0.000 Vitamins 0 0 0 - - Anti-fungal 0 1 1(1.6) *0.004 0.950 Anti scabies 0 0 0 - - Haematinics 1 0 1(1.6) *0.004 0.950 ORS 0 3 3(4.7) *1.680 0.195 Cotton wool 13 25 38(59.4) 13.438 0.000 Plaster 9 20 29(45.3) 10.392 0.000 Bandage 7 12 19(29.7) 2.877 0.090 Disinfectant 11 20 31(48.4) 7.513 0.006 Anti- helminthics 12 3 15(23.4) 4.360 0.037 Anti-malaria 0 1 1(1.6) *0.004 0.950 Empty 1st aid 11 5 16(25.0) 2.092 0.148 boxes *-Chi-square (ϰ2) with Yate’s correction applied

Care of emergency illness/injury Forty- nine (76.6%) schools, comprising 23 (67.6%) public and 26 (86.7%) private, gave first aid treatment in emergency illness or injury. More private schools gave emergency care but the difference in these proportions was not statistically significant. Only four private schools recorded treatments given. Ten schools (all private) notify parents immediately and 14 (21.9%) transport the children to the nearest health post (p= 0.028, 0.001 and 0.037 respectively). This is shown in Table XX below.

Table XX: Care of Emergency illness in the schools Care Public Private Total ϰ 2 P value N=34 N=30 N=64 n n n (%) 1st aid treatment usually given 23 26 49(76.6) 0.000 0.985 Treatment given recorded 0 4 4(6.2) *4.836 0.028 Notification of parents immediately 0 10 10(15.6) 11.023 0.001 Transport child to nearest health post 4 10 14(21.9) 4.338 0.037 Convey child home after 1 2 3(4.7) *0.012 0.912 * - Chi-square (ϰ2) with Yate’s correction applied

Control of communicable diseases

Forty two (65.6%) of the 64 schools gave health talks to the children, parents or guardians of the children with communicable diseases. All the schools (100%) usually send home any child with communicable disease. Routine immunisation services was lacking in all the schools. Records keeping Sixty (93.8%) of the schools kept no record at all, whereas, four (6.2%) kept medical records of treatment, None of these schools kept records of communicable diseases and none of the records was cumulative and transferrable.

Nutrition services All the schools offered school meals. This was free for the lower classes (kindergarten-Primary 2) of the public schools. Nutritional supplements were given by 6(9.4%) of all the schools but nutrition demonstration classes were not carried out by any of them. Twelve (18.8%) of the schools had school farm (8 public and 4 private) with the public schools having relatively more farms than the private schools.

Guidance and counseling services Guidance and counseling services were offered in 30 (49.9%) schools (13 public and 17 private schools) in the form of follow up services or home visitation of ill pupils.

Factors responsible for the current status of SHP in the study area Identified factors which may be responsible for the current status of SHP in the study area include the following: None of the teachers (0%) interviewed had elementary training in components of SHP while 6 (9.4%) of the schools had school health personnel. Three (5.8%) of the schools with toilets met the recommended one toilet to thirty pupils’ ratio. Also, 27 (42%) of the schools had dilapidated buildings with very little maintenance efforts noticed in 23 (35.9%) of all the schools.

MEAN SCORES AND THEIR COMPARISON The mean scores attained by the two groups of schools in the various components of the school health programme were compared using the independent sample t- test as shown in Tables XXI and XXII below. The mean scores attained on School Health Instruction by the schools were 18.73 ± 3.05 SD for private schools and 17.62 ±1.84SD for public schools, out of a maximum score of 41 in the evaluation scale (Appendix I). Although, the private schools performed relatively better. An independent t- test for equality of these means shown on table XXII did not show any statistically significant difference between the means of public and private primary schools (t=1.795, df=62, p=0.078). The mean scores attained by the schools on Healthful School Environment were 32.00 ± 9.98SD for private schools and 30.82 ±5.39 SD for public schools, out of a maximum score of 66 (from the evaluation scale, Appendix I). Although, the private schools performed relatively better, there was no statistically significant difference in the mean scores (t=0.597, df =62, p= 0.553). The mean scores attained on School Health Services were 12.47 ± 3.53SD for private schools and 9.06 ± 1.57SD for public schools, out of a maximum score of 45 in the evaluation scale (Appendix I). The difference in means was statistically significant (t= 5.099, df=62, p=0.000), with the private schools performing better. Also, the mean scores attained by the schools on SHP were 63.23 ± 14.57SD for private schools and 57.50 ± 6.59SD for public schools out of the maximum score of 152 in the evaluation scale. The difference in means was statistically significant (t=2.068, df=62, p=0.043), with private schools performing better.

Table XXI: The mean scores attained in the various components of school health programme by group Group statistics

Components of School Scores Std. Error of SHP Type No Mean Mean ± SD Health Private 30 18.73 ± 3.051 .557 Instruction Public 34 17.62 ± 1.843 .316 Healthful Private 30 32.00 ± 9.976 1.821 School Public 34 30.82 ± 5.385 .924 Environment

School Health Private 30 12.47 ± 3.530 .645

Services Public 34 9.06 ± 1.556 .267

School Health Private 30 63.23 ± 14.574 2.661

Programme Public 34 57.50 ± 6.589 1.130

Table XXII: Independent sample t- test to compare mean scores between the private and public schools in the various components of SHP

Independent samples test

T Df 95% confidence interval P value Score on School Health Instruction 1.795 62 -0.127 2.358 0.078 Score on Healthful School Environment 0.597 62 -2.766 5.119 0.533 Score on School Health Services 5.099 62 2.072 4.744 0.000 Total SHP score 2.068 62 0.193 11.274 0.043

ACTUAL TOTAL SCORES ON THE COMPONENTS OF SHP The outlines of the cumulative scores attained by each school are shown in Tables XXIIIa and XXIIIb below. Three schools scored up to the minimum acceptable score of 19 in the school health services. These were all private schools. Also, one private school made the minimum acceptable score of 57 in healthful school environment while none of the schools scored up to the minimum acceptable score of 27 in school health instruction. No school scored up to the minimum total acceptable score of 103 when all the three SHP components scores were added together.

Table XXIIIa: Total scores of public schools in the various components of school health programme

S/N OF SCHOOL HEALTH SCHOOL SCHOOL HEALTH TOTAL SCHOOLS INSTRUCTION ENVIRONMENT SERVICES (min.acceptable=103) (min.acceptable=27) (min.acceptable=57) (min.acceptable=19)

1 19 32 9 60 2 20 37 12 69 3 18 28 10 56 4 17 33 11 61 5 18 24 11 53 6 16 37 11 64 7 17 36 11 64 8 19 27 10 56 9 17 34 11 62 10 18 26 9 53 11 20 37 10 67 12 19 33 9 61 13 17 33 13 63 14 22 35 8 65 15 18 31 9 58 16 21 21 9 51 17 20 27 9 56 18 18 37 9 64 19 18 20 7 45 20 17 23 8 48 21 19 28 9 56 22 18 35 9 62 23 17 30 7 54 24 18 35 9 62 25 16 34 7 57 26 15 28 7 50 27 18 36 9 63 28 17 33 9 59 29 15 17 7 39 30 14 26 7 47 31 17 35 8 60 32 17 31 7 55 71

33 14 34 9 57 34 15 35 8 58

Table XXIIIb: Total scores of private schools in the various components of school health programme

S/N OF SCHOOL HEALTH SCHOOL SCHOOL HEALTH TOTAL SCHOOLS INSTRUCTION ENVIRONMENT SERVICES (min.acceptable=103) (min. acceptable=27) (min. acceptable=57) (min. acceptable=19) 1 21 22 10 53 2 24 31 17 72 3 14 31 12 57 4 19 28 16 63 5 22 54 21 97 6 17 37 13 67 7 17 15 5 37 8 15 29 14 58 9 17 25 14 56 10 21 36 12 69 11 19 25 9 53 12 21 36 12 69 13 17 25 14 56 14 25 57 19 101 15 19 25 9 53 16 17 29 12 58 17 22 47 15 84 18 19 41 11 71 19 12 31 10 53 20 22 47 13 82 21 19 26 9 54 22 19 41 11 71 23 15 22 10 47 24 16 27 9 52 25 19 26 9 54 26 15 22 12 49 27 17 22 14 53 28 19 28 14 61 29 23 40 19 82 30 20 35 9 64

Table XXIV shows the mean ± SD of total scores of the schools on SHP in relation to their ages. As shown in the table, schools that were not more than 20years old had the highest mean total score (62.87 ± 13.10 SD) and the Pearson correlation coefficient r of the total SHP scores was -0.163. However, this is not statistically significant (p=0.197).

Table XXIV: Age distribution of the schools and their total mean scores on SHP.

Age group of No of schools Range of scores on SHP Mean total score ± SD schools in years n=64 (min acceptable=103) 1-20 38 37 – 101 62.87 ± 13.10 21-40 8 53 – 64 55.38 ±3.89 41-60 9 45 – 69 57.56 ± 7.67 61-80 5 39 – 60 57.20 ± 8.73 81- 100 2 47 – 62 54.50 ± 10.61 ˃ 100 2 59 – 63 61.00 ± 2.83

DISCUSSION

The importance of a good and functional SHP as a component of primary health care in the provision of quality health care to the children of any nation especially, in the developing countries have been stressed by various authors. 1-3,7,15,56,59,81,83 Despite the near equal distribution of the schools between the public and private ownerships, there was significant difference in the population of pupils enrolled in the two groups of schools, with the public schools having more pupils. This may be attributable to the free education programme being implemented in the public schools, bearing in mind that most Nigerians (including the inhabitants of the study area) are poor110 and may have taken advantage of the free education programme in the public schools to give formal education to their children. There were more female pupils enrolled in the study area with a female to male ratio of 1.04:1. This is a shade better than the National average of 0.9:1 according to USAID23 and this does not indicate marginalisation of the girl child with respect to educational opportunities in the study area. However, the area of study being semi-urban with relatively more enlightened people, this finding may not be a true reflection of the girl child enrollment status in Osun State.

All the teachers (100%) interviewed in public schools and 81.7% of those in private schools had the minimum required qualification of at least NCE for teaching in primary schools as recommended in the National Education Policy in Nigeria.91 However, that the public schools had more qualified teachers did not impact positively on their performance in the implementation of SHP. The presence of more unqualified teachers in the private schools may stem from the belief that some of them found their way into those schools out of frustration from the unemployment problems plaguing the country. It might also be a manifestation of laxity as obtained in those private schools aided by lack of adequate supervision by the appropriate government agencies.

Only 8(12.5%) schools had a school health committee that is supposed to see to the implementation of SHP. This is at variance with the situation in USA where 100% was recorded14. The relative lack of school health committee is not surprising because no such

committee existed in the local government contrary to the National School Health Policy3 recommendation for such a committee.

Functional PTA was available in 82.8% of the schools. This is close to Ezeonu’s94 96.8%. The relatively high proportion of schools with functional PTA did not impact positively on the schools’ performance in SHP. This may be due to lack of proper collaboration between the schools’ administration and the community, resulting either from inadequate advocacy by the schools` heads or nonchalant attitude of the community members themselves. The inestimable roles of a functional school health committee and PTA in the implementation of effective SHP has been highlighted by Oduntan15 and Ezeonu.94

Majority of the schools carried out extracurricular activities like cultural dancing and inter-house sporting competitions. This is commendable and in conformity with the recognition by some authors 40-42 of the role of exercise in achieving good health. However, fewer private schools did so (56.7% private vs 73.5% public) and this may be due to lack of space for such activities as some of them were using rented apartments not primarily designed for school activities as shown in picture A (Appendix VII). This calls for improvement because such activities allow pupils to ventilate their energy, diversify their interest and interact positively with colleagues, thereby allowing them to achieve total state of physical, mental and emotional health as being advocated by WHO.13

Healthful school environment

Although, 70% of the schools had at least one source of water supply, one out of every 4 schools with an identifiable water source had the source located outside their school premises, with more private schools belonging to this category. The 70% attained in terms of water supply though commendable and higher than 50% observed by Adegbenro20 in Ile Ife, 28% by Nwachukwu22 in Imo State and 46% from the national survey by USAID-Nigeria in 200723, was however less than the 100% observed in Lagos in 1981.21

When the source of water supply is located outside the school premises like was the situation in some of the schools, it’s adequacy cannot be guaranteed and this may lead to unavailability of water for various needs like drinking, hand washing and cleaning of toilets

which are very germane to the healthy living of the school community, thereby putting such community at risk of diseases associated with water shortage as highlighted by different authors.3,26

Eighty-one percent of the schools had toilet facilities. This is similar to 80% observed by Adegbenro20 in Ile Ife, and close to 73% by Ofovwe12 in Egor LGA of Edo state but higher than the values obtained from other studies across the nation, notable among them being, 46.2% by Idris, Aikhionbare, Ogala et al11 in Zaria and 25% recorded by Alex- Hart and Akani95 in Bonny LGA of Rivers state. However, the preference for pit latrine as the means of sewage disposal in this study is in tandem with findings by other authors.3,11,20,22 This may be attributed to the cost effectiveness, minimal water requirement and the ease of using this method of sewage disposal by minors like pupils in primary schools.

Gross inadequacies were noted in the toilet-pupil ratio with only 5.8% of the schools meeting the recommended ratio of one toilet to not more than 30 pupils.3 This is only a shade better than the 0% recorded in Zaria11 and 1% recorded in the 2007 USAID – Nigeria national survey.23 When toilet facilities are inadequate in schools, pupils are left with no option than indiscriminate disposal of sewage materials thereby constituting health threats which may result in outbreak of poor sanitary related diseases like gastroenteritis and cholera in the school community as was reported across the nation recently.96 Appropriately fostered school-community relationships may be the way out for lack of amenities in this locality.

All the schools (100%) practised open dumping and burning of refuse. This is similar to the 100% found in Zaria11 and Bonny LGA of Rivers State.95 The practice of open dumping and burning is at variance with the sanitary measures in the National school sanitation guidelines 31 and findings in developed countries where waste management in schools has moved to the level of turning them to wealth and monitoring their pollution effects in schools.17

Going by the findings of Onuzulike27 that majority of NCE students in Owerri had bad waste management’s habits and this is reinforced by the findings by Ekpu and Archibong28 that open dumping and burning was the preferred method of refuse disposal in

Ikot Ekpene LGA of Akwa Ibom state. The poor refuse disposal habit observed in this study may therefore be a reflection of the attitude of the larger society because school communities are miniature replica of our larger society. Schools have the propensity to generate significant waste materials which can aid the breeding of vectors of diseases15,47,68 that are major contributors to our high childhood morbidity and mortality rates. Hence, the need for concerted efforts by all stakeholders to ensure proper waste management in the study area. One feasible way of doing this is through appropriate waste management education backed up with the provision of relevant facilities in the schools.

Up to 42.2% of the school buildings were dilapidated with the public schools being more significantly affected. Example is shown in picture B (Appendix VII). This is similar to the 40% recorded by Adegbenro20 in Ile Ife but higher than 33% and 25% recorded in Zaria11 and Bonny in Rivers State 95respectively. When school buildings are dilapidated, they not only become unsightly but also negatively affect the psyche of a growing child. They may also collapse, killing and maiming the pupils. It is the duty of the LGA to establish, manage and maintain primary schools under the supervision of the state Governments1,3,87 Evidently, it does not seem to be the priority of the government at various levels to provide funds for maintenance of structures in these schools.

Sixty-seven percent of the classrooms floors have standard space with 94% of public schools significantly belonging to this group as opposed to 37% of the private schools. Thus 63% of private schools floor space were not standard going by the federal government recommendation31. This finding is similar to that in Zaria 11, in which 71.4% of public schools had adequate floor space, while in 67% of private schools, this was substandard. When classrooms space are not large enough, there is a tendency towards overcrowding as depicted in picture C (Appendix VII) with attendant risks of transmission of various infectious skin diseases described by various Nigerian authors.26,97 Also, like other studies11,20 majority of the schools(67.2%) had worn off/ broken floors ( Picture D). Broken floors have been described as potential causes of injuries32,38 and this may translate to more injuries to the school children in the study area.

Most schools (81.2%) in the study area had adequate ventilation. The ventilation was also controllable in 76.6% of the schools. This finding is similar to 85% of schools in Rivers State having adequate ventilation as obtained by Alex Hart and Akani,95 80% by Adegbenro20 in Ile Ife and close to the 94% recorded by the 2003 Federal Government schools survey.3 However, the finding that 23.4% of the schools had ventilation that is not controllable as shown in picture F (Appendix VII) calls for concern as uncontrollable ventilation makes pupils to bear the harmful effects of harsh weather conditions like rainstorms and windstorms to which they may have little defence.

In 37.5% of schools, the pupils were not completely seated while in 19.7% of the schools, not all the teachers had seats. These are similar to findings by other authors.11,20,21,95 The fact that more teachers were relatively completely seated compared to pupils may suggest that less emphasis were placed on the welfare of pupils in the study area. This is disturbing in the sense that a child needs every comfort, including that of sitting to enjoy maximum learning while teachers without seats will not give their best to the pupils in terms of supervision and teaching. Evidently, the pupils are the losers wherever such situation prevail.

The parlous state of classrooms found in this study has laid credence to the findings of the 2007 national school survey,23 where it was found that only 4% of the classrooms across the country support learning because of their lack of adequate seats, floor space and instructional materials. This abysmal performance may be attributable to the menace of general infrastructural neglect that is plaguing the country at large. This is at variance with the situation in developed countries where there are entrenched policies of constant maintenance, inspection and construction of school buildings.18

Majority of the schools (62.5%) did not carry out any of the listed safety measures in the evaluation scale. This is similar to the findings in other Nigeria studies.11,29,32 This is quite appalling, bearing in mind that accidents and risks are part of human life and schools in particular are accident prone.38 The reasons for the poor safety measures may be due to lack of appraisal of the safety and injury prevention measures in the study area in contrast to what is being done in the United Kingdom.99 Appropriate authorities can start by upgrading the

scope of safety trainings in the curriculum for the National Certificate in Education (NCE) as this represents the catchment group for the recruitment of teachers working in primary schools91 thus making them to appreciate the need for safety in the schools and implement its measures Picture G (Appendix VII).

Various forms of health hazards listed in the evaluation scale were encountered in 81.3% of the schools. This is similar to the 83% recorded in Zaria11 and a shade better than the 100% recorded by Alex- Hart and Akani95 in Bonny LGA of Rivers state using the same instrument as for this study. With respect to the types of health hazards encountered, the presence of dangerous and grazing animals was the commonest hazard as previously reported by Alex- Hart and Akani.95 Like other studies,11,95 tendency to flooding/ open drainages, location near industrial disturbance and presence of animals droppings were also common. The high presence of grazing or dangerous animals on the school premises in the study area may be attributable to the fact that more than 70% of the schools lacked perimeter fencing, thereby giving such animals’ free access to their premises to graze, defaecate or cause other health hazards. The presence of these animals may distract the pupils from concentrating on their academic activities. Also, their droppings may help transmit some diseases within the school premises Picture H (Appendix VII).

The findings that 57.8% of the schools were located close to industrial hazards like major roads, markets, concrete industries and saw mills, as shown in pictures I and J (Appendix VII) calls for concern, as activities from these places not only distract pupils from learning but can also injure them leading to either impairment or total disability. This ugly trend may be due to improper planning for expansion of schools in the study location by the town planning authorities. It is also possible that the inhabitants are not aware of the health implications of the noise or other disturbances such structures could bring to the schools when located close to them. Awesu and Okuaso100 demonstrated this lack of awareness among Ijebu Ode residents in Ogun state. Enforcement of National policy guidelines on school sanitation31 matched with punitive measures may help deter inhabitants of the study area from encroaching on school premises.

Teachers in majority of the schools (60%) complained of inadequate emotional climate. This is similar to the findings by Alex-Hart and Akani95 that none of the schools assessed in Bonny LGA of Rivers State had teachers with adequate emotional climate. Although, lack of in- service training was given by the teachers as the commonest reason for the inadequate emotional climate in this study, however, as observed by Alex- Hart and Akani,95 delayed/ inadequate salaries may also be an important factor for the poor emotional climate observed. This contradicts the recommendation of our National Policy On Education91 that, “In-service training shall be developed as an integral part of continuing teacher education and shall also take care of all inadequacies” and entirely different from the situation in the USA where evidence of such trainings are required yearly.55 When the emotional climate in a school is inadequate, all the various aspects and benefits of health promoting and child friendly schools as highlighted by various authors are threatened.1,3,14,44,85

The finding that some pupils in majority of the schools were not wearing shoes as shown in picture E (Appendix VII) is worrisome. This may be due to the inability of the pupils’ parents to buy shoes for them because of the observed high poverty rate in Nigeria.110,120 It may also stem from lack of enforcement of standard dress code by the teachers who were supposed to do so. Consequent upon this, the pupils may sustain injuries to their feet which may lead to dangerous infection like tetanus and can also encourage the transmission of other soil-borne infections like hookworm infestations and jigger disease. Some of these have been described by different authors as prevalent among school children.3,15,68,98 Ekpo, Odoemene, Umedo et al98 demonstrated a relatively higher prevalence of hookworm infestation among primary school children in Ikenne Ogun state. Hookworm infects host by direct skin penetration.98 This suggests that pupils in the study area may be at risk of contracting this disease.

There were no refuse disposal materials (dustbins and waste paper baskets) in 86% of the schools. This may be a reflection of the general poor societal attitude towards waste disposal as highlighted by Onuzulike27 and Ekpu, 28 The guidelines on school environmental sanitation31 needs to be fully enforced to curb this.

Overall, only one private school attained up to the minimum acceptable score on Healthful School Environment, thus indicating the parlous state of primary school environment in Ilesa East LGA. This may not engender maximum learning that is expected of pupils attending schools in this locality and may jeopardize the effective implementation of the Universal Basic Education programme in the study area. Provision of requisite infrastructures backed with appropriately motivated personnel and monitoring may be the way out.

School Health Instruction

No school complied with the National Education Research Development Council’s (NERC) recommendation of not less than three times per week health teaching.101 This is in keeping with findings by Agusiegbe 39 in Anambra, Eke56 in Old Bendel State, Idehen and Oshodin57 in Edo State.

Concerning the scope of health teaching, a high proportion of private schools were not teaching their pupils about HIV/AIDS despite it’s being a topical issue now and its inclusion in the middle level basic curriculum of health education in primary schools.101 This could be as a result of ignorance on the part of those concerned or from lack of supervision of the delivery of the health education curriculum contents in the study area as contained in the national 9-year Universal Basic Education curriculum.101 This is in contrast to what obtained in developed countries, where there are well entrenched policies for monitoring effective delivery of health instruction in schools.58

Only 6.3% of the schools had designated health education staff, suggesting that health instruction in most of the schools was either not given at all or given by unqualified teachers with poor knowledge on health issues as demonstrated by various authors56,57,102,104 across the country. This may account for the poor delivery of health instruction curriculum in these schools. Another interesting finding is that health instruction was being given with other subjects like physical and health education, family living and social studies. This may allow inadequate monitoring of the contents or scope of health instruction being given in these schools compared to that recommended in the schools’ curriculum.101 Of interest is the

finding that whereas in most schools the time table reflected two or three periods per week for health education as shown in picture K (Appendix VII), only one of such periods was used to teach health in most schools while the remaining period(s) might have been used for physical exercises and other activities. Though exercise is good, having adequate health knowledge is equally good. The best way to balance the two may be by having separate periods allocated to health instruction rather than lump it with other subjects.

There was lack of instructional materials like: posters, illustration charts and audiovisual aids in 41% of the schools. Presence of instructional materials not only makes passage of knowledge easy but also makes them last longer in the memory of pupils.50 According to Ogundele,50 school children tend to remember better what they hear, see and act rather than mere hearing alone. The relative lack of instructional materials in schools is not limited to this study. Authors from other parts of the country 22,23,56,57 painted similar scenarios though to varying degrees. Also, complete lack of visiting health personnel to give health instruction in the schools contradict the philosophy of primary health care in the country in which schools are targeted as one of the catchment areas for preventing childhood illnesses through SHP.56,81,83 This may suggest collapse of the primary health care system and lack of collaboration between the ministries of health and education in the study area.

Regarding teacher’s preparation for health teaching, none of the teachers could vividly remember if they had training in components of SHP. This may be attributable to their inability to properly recall the contents of their training as many of the teachers might have graduated a long time ago or a reflection of the inadequate knowledge of primary schools teachers in the country on SHP as observed by Ofovwe and Ofili12 and Agusiegbe39 in Edo and Anambra States respectively.

Only 3.1% of the teachers in the study area had engaged in in- service training on health issues in the last five years preceding this study. This is disturbing bearing in mind the identified deficiencies in the training of their counterparts elsewhere.39 In-service training could be used to remedy deficiencies in the training of the teachers and update them with recent developments on school health issues.91

The finding that none of the schools in the study area attained up to the minimum acceptable score in the aspects of school health instruction calls for concern and is a reflection that no meaningful health instruction was being given in the study area. This supports findings from other parts of the country12,39,56,57 and other developing countries59 but sharply contrast with that of developed world.58 Factors that may be responsible for this poor performance include inadequate time allocation, inadequate training of teachers and inadequate instructional materials as reported in this study and by other authors.39,56-57 It may also be due to poor health knowledge of teachers reported across the country by various authors.57,102,104,105 With the revelation by the Centre for Disease Control USA that, “for every dollar spent on health education, the society saves more than thirteen dollars in cost”.54 It is expected that health instruction in schools should be adequately supported by all the stakeholders.54 Feedbacks from the intervention by Akani, Nkanginieme and Oruamabo 102 in Rivers State and Adegbenro, Adeniyi and Oladepo105 in Ile Ife resulted in teachers having better knowledge on school health matters with positive attitudes towards implementing school health instruction. This corroborate the fact that given the right training, environment and motivation, teachers can serve as agents of change at reviving the poor state of health instruction in the schools. Hence, interventions like the seminar anchored by the researcher in the study location, should be encouraged in this locality (Picture L in Appendix VII).

School Health Services

Only 9.4% of the schools had health personnel. This is better than 0% recorded by Alex- Hart, Akani and Nkanginieme93 in Rivers State but below the national average of 17% recorded in the Federal government survey.3 It is however at variance with the situation in the United State of America where virtually all the schools (86.3%) had at least a school nurse.14 The emphasis now is on appropriate nurse-pupil ratio of not less than one nurse to 750 puplis.14 The lack of health personnel in this study may indicate that pupils in the study area are at risk of not having their minor ailments attended to early and according to Oduntan,15 these may progress to debilitating illnesses and leading to school absenteeism.

Proper collaboration between the ministries of education and health with active involvement and reorientation of the Primary Health Care (PHC) unit of the study location may help to ensure availability of health personnel in the schools.

All the schools conducted routine inspection of the pupils once or twice weekly. Areas inspected included school uniform, nails, teeth and hair. This is similar to findings by Ojugo8 and Alex Hart, Akani and Nkanginieme.93 Pre entry medical examination was carried out by only 7.8% of the schools and all these were private. This is better than the 0% recorded in Rivers State93 but lower than the national average of 14%.3 With the lack of health personnel in the study area, the relative lack of pre-entry medical screening may possibly foreclose the identification of many health problems like hearing and visual impairments that have been identified among Nigerian school children by different authors62- 64,66,106,108 and which may negatively affect learning. For example, Umar, Ibrahim and Hasan106 found a significantly poorer performance in school work by school children with visual impairment in Sokoto compared to their counterparts with normal vision.

Concerning supervision of children with special health needs and handicap, this appraisal service was very poorly done in the study area as only 1.6% of schools practiced it. This is contrary to the situation in South Africa where there are ongoing interventions on the health needs of a special category of children called albinos with the aim of meeting their special needs107 thus making their schools to fulfill the criteria of being health promoting schools.1,44

Generally speaking, the level of health appraisal services in the study area was poor. This might be reflective of the lack of school health personnel in the study area. However, it is cheering to note that some authors have demonstrated the enormous roles school teachers could play in achieving health appraisal services in schools. For example, Tabansi, Anochie, Pedro et al108 in Port Harcourt Nigeria, used primary school teachers (after training them) to diagnose vision impairments like myopia and hypermetropia in pupils with high level of precision and provided appropriate intervention to those affected. Also, teachers in primary schools were used to correctly identify 80% of eye diseases among primary school children in a rural area of Tanzania.109 Reflecting on these findings, it may therefore be reasonable to

encourage appropriate use of school teachers for health interventions in the study location given the scarcity of school health personnel in the area.

First aid boxes were found in 49(76.6%) schools but in 16(25%) of them, these boxes were empty Picture M (Appendix VII) leaving a net of 33(51.4%) schools with any content(s), majority of which were sparingly stocked as shown in picture N. That first aid boxes were found in 76.6% of the schools is similar to 80.6% observed by Ezeonu94 in Abakaliki and 60% by Nwachukwu 22 in Imo State and therefore commendable.

A look at the items stocked by various schools in their first aid boxes showed that wound dressing materials were the most commonly stocked whereas, drugs like anti- malaria, ORS, hematinics, antifungal were sparingly stocked (1.6%, 4.7%, 1.6%, 1.6%) respectively. This is similar to reports by Ojugo8, Ofovwe and Ofili12 in Edo State and Ezeonu94 in Ebonyi State. The reason for the preference for wound dressing materials in this study may be attributable to the observation that pupils are playful, adventurous and inexperienced.30,32,33,38 So, they are prone to accidents which lead to bruises and wounds33,38 requiring the use of these materials to dress them thereby preventing infection and bleeding.

Availability of anti-malaria in schools will help reduce the burden of severe malaria among school children by encouraging prompt access to effective anti-malaria within 24hours of onset of symptoms thus, helping to meet part of the targets of roll back malaria.47 Also, availability of ORS in schools will help prevent dehydration often associated with diarrhea, which together with malaria and other infections have been found to be major contributors to school absenteeism and children’s death in Nigeria.1,15,47,68

Only 6.3% of the schools (all private) had a health room although they are called by different nomenclatures e.g. healing bay, sickbay, isolation unit depending on the religious bias and belief of the owner of such schools (Pictures O and P in Appendix VII). The proportion of schools with health room in this study is similar to 9% obtained by Ezeonu94 in Abakaliki but far below 31.6% and 40% observed by Ofovwe and Ofili12 in Edo State and Nwachuwkwu22 in Imo State respectively and completely at variance with the 87.9%

recorded in the USA.79 As found in this study and others from Nigeria,12, 22,94 health rooms were virtually non-existent in our primary schools.

School telephone services were lacking in this study. It was found in only 12 (18.8%) schools compared to 40% observed in Abakaliki in Ebonyi State 94 and 100% in the USA.14 When available, it can fast track information dissemination especially in emergency situations. It may also help check the spate of kidnap of school children while at school by allowing the parents and guardians to easily track their wards.

In this study, all the schools (100%) sent home children with suspected communicable diseases. This is in agreement with findings by other Nigerian authors93,94 but at variance with 12% observed by Ejifugha69 in Enugu State. The practice of sending home children with suspected communicable disease may be borne out of the fear about spread of such diseases within the school community. It may also result from of lack of health personnel in these schools to correctly identify and sort out illnesses among school children thus, giving room for some to be sent home in error while the real culprits are left to continue to incubate and spread such infectious diseases.

No school was routinely immunizing children. This suggests that children with incomplete immunisation as well as those with missed opportunities attending primary schools in the study area may not be made to complete them while at school. This may contribute to poor immunisation coverage in the study area and Nigeria by extension. It may also, explain the domicility of tetanus (a vaccine preventable disease) in our country despite several attempts by WHO to eradicate it. The appeal by Oruamabo111 to curb its menace through effective implementation of immunisation services in SHP is therefore well placed.

Records of medical examinations, treatment of illnesses and reasons for absenteeism were not kept by most of the schools. In the few schools with any health record, these were not properly documented or tidy as shown in picture Q (Appendix VII). This finding is in keeping with other Nigerian studies 8,69,78,93,94 and the authors found in the results of their studies that lack of knowledge of the importance of proper record- keeping as well as poor attitude towards such were the reasons. 8,69,78,93,94 In the study area, the 58% schools without

health personnel cannot be expected to keep good health records. Of the six schools with health personnel, only four of them kept any form of health record. One of them had a nurse in charge of school health while the others had health assistants in charge. In lieu of appropriate health personnel, proper orientation of teachers in the study locality by health personnel from the host local government area can go a long way in helping primary schools in this area to achieve proper health records documentation like the situation in developed countries.74

In this study, only 18.8% of the schools had a school farm, in contrast to 67% reported by Ezeonu94 in Ebonyi State and 40% reported by Alex Hart, Akani and Nkanginieme.93 Like reports from Rivers State93and Ebonyi state,94 majority of schools with school farms in this study were public schools. School farms could serve as avenues to teach pupils the rudiments of agricultural practices which may spur their interest to practice large scale farming later in life, thus, helping to widen the economic base of the country rather than being a solely oil driven economy that we have at the moment.

No school was having nutrition demonstration classes despite its being included in the primary school health education curriculum.101 Nutritional demonstration classes could be used to give school children proper nutrition education and help them to make proper food choices thereby, preventing the ugly scenario of unhealthy food choices found by Ketiku46 to be rampant among Ibadan primary school children. Unfortunately, as shown in picture S (Appendix VII) children in the study area were not left out of this bad habit.

When school children are left unguided as to healthy food choices they have the tendency of choosing more attractive but less nutritive foods that may be injurious to their health and even lead to acute intoxication an example of which was the coca-cola intoxication outbreak found among Belgian students.112 While countries in Europe like Belgium may have the wherewithal to tackle such outbreak, the same cannot be said of Nigeria where according to NAFDAC,113 some foods and drinks manufacturing companies in Nigeria have untraceable addresses probably to escape being monitored by this agency and as such sources of some contaminated foods and drinks may be difficult to identify if sold in our schools.

The finding that all the schools offered school meals is better than what was found by other authors across the country.12,22,92,93 The two methods described by Moronkola70 in providing school meals were used by schools in the study location. Of interest is the fact that some cadres of pupils (Kindergarten to primary 2) received free school meals in public schools. This contrast with the findings in Rivers State,93 where no public school offered free meals. (Pictures T, U and V in Appendix VII).

The free meal given to some pupils in public schools is courtesy of selection of Osun State as one of the beneficiaries of the UNICEF- Federal Government Home Grown School Feeding Programme which was launched in September 2005,76 and is a semblance of the free fruit and vegetable programme in Europe.114 Its implementation began one year later (September 2006) in Osun State. This is a good example of the partnership being advocated by United Nations in an attempt to meeting MDG8 which is to foster development through encouragement of international partnership. According to the teachers, it has tremendously increased enrolment in the public schools as found in this study. The feeding programme has also increased community participation in school nutrition by way of kitchens solely built by the PTA of respective public schools (Picture V in appendix VII). Going by the reported relative lack of health screening of food handlers in schools across the country,3,12 repeated screening of food handlers in the study area for typhoid carrier state, tuberculosis and other infectious diseases that have been described locally2-3,15,68 and internationally,115-116 as health problems of school children should be encouraged. This screening should involve examination on body effluents as well as radiological examination of the chest as suggested by Oduntan.15 Repeated appraisals of the school meal contents and quality is suggested through quality control measures as obtainable in Europe.117 This will ensure delivery of the numerous benefits of school nutritional services as highlighted by various authors3,7,12,70,117,118 to the school children in the study area. Stakeholders in the study area can complement the free school meals further by sponsoring packages that could include free school fruits and vegetables as is done in Europe114 This can help to fulfill the proposition of Ibe119 at a recent Paediatric Association Conference in Ilorin that “even a stick of carrot per day” may suffice for our school children.

Attempts by Ibe119 and other Nigerian authors,2,3,12, 70,118 to draw attention to school nutrition may not be out of place bearing in mind the grave revelation by Oruamabo120 of the high poverty and inflation rates at 70% and 23% respectively in Nigeria and his proposition that strengthening PHC through SHP will primarily prevent malnutrition in the country. This was also stressed by the researcher in his health seminar with the school community in the study area through talks on the need to garnish school meals with fruits, some of which were actually displayed and used for the seminar (Appendices V and VI). The fact that the public schools performed poorer in the implementation of SHP may be related to the profit- making orientation of the owners of the private schools, hence, the compulsion by the later to offer quality services in order to attract more patronage. The status of SHP as being practiced in the study location was poor as none of the schools attained up to the combined minimum acceptable score on SHP. Few schools attained up to the minimum acceptable score in the aspects of School Health Services and Healthful School Environment, a finding similar to that of other Nigerian studies8,11,12,93,94 and a reflection of the poor state of SHP in Nigeria. This therefore, calls for immediate intervention. Interestingly, the outcome of previous interventions across the country were impressive and showed encouragement with great improvements.20, 102,105

Sequel to the dismal poor performance of most schools in the aspects of SHP studied, a one day seminar was organized for the primary school community in the study area by the researcher to sensitise the community and help proffer some immediate solutions to some identified areas of deficiencies in the implementation of SHP in the study location. Pictures W,X,Y,Z (Appendix VII). This may serve as a way of bringing the gown to town thus helping to fulfill the roles of paediatricians and other physicians as major stakeholders in senhancing effective SHP in Nigeria as advocated by various Nigerian authors.1-2,11-12, 68, 102,105,108,119-121

CONCLUSIONS

This study has shown a lot of deficiencies in both human and material resources needed for the provision of appropriate SHP in Ilesa East LGA primary schools. The findings are:

1. The level of school health services in primary schools within Ilesa East LGA was very poor.

2. The school environments within the local government are not healthful.

3. Health instruction activities in the schools within the LGA are poor.

4. The private schools performed better than the public schools in the overall assessment of SHP, indicating that proprietorship affected implementation of SHP in the study area.

5. Poor awareness of teachers on the components of SHP, lack of school health personnel and infrastructure contributed to the current status of the School Health Programme in the LGA.

RECOMMENDATIONS

1. Trained health personnel should be made available in all the primary schools. 2. The curriculum for training teachers should be reviewed with components of SHP given the pride of place they deserve. This should be backed with regular In- service trainings and seminars on SHP. 3. Implementation of National guidelines on School sanitation which recommends that “schools should be cited in safe area away from noise, factories, highway etc” should be encouraged. 4. There is need for an expanded and larger study to evaluate school health programme in Osun State and Nigeria by extension. 5. There is need for further studies on why and how schools’ ownership affects the implementation of SHP in the study area and other parts of Nigeria.

LIMITATION

Since only two pupils chosen randomly were interviewed, it is possible that any of them might not have had reasons to encounter some items of SHP in the school.

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APPENDIX I: SCHOOL HEALTH PROGRAMME EVALUATION SCALE SCHOOL HEALTH ADMINISTRATION DATA

1.Name of school

2.Age/date established

3.School population (i) Total no of children= Male= Female=

(ii) Teaching staff = (iii) Non-teaching staff= 4.(i) Name of head teacher/teacher /pupil (ii) Qualifications (iii) Date appointed head teacher (iv) Duration of stay in present school (v) Subject/ Area of specialization 5.School has (i) a school health committee (ii) a trained first aider (iii) a functional PTA 6.School organizes extra-curricular activities

A.HEALTH INSTRUCTION SCORES 1. Time allotted to health teaching One period/week 1 Two periods/week 3 Three periods/week 5 2.General plan for progressive health 5 instruction for all grades

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3.Scope/conducts of health education curriculum a. Growth and Development 2 b. personal health- food and nutrition, use of 2 health services, need for exercise, rest and sleep c. Community health -Major community health problems 2 (communicable and non- communicable disease, prevention and control) - Community health services-type, levels of organization d. Social and Emotional Health(Mental, Drug, Sex education) - personality and character development - use and abuse of drugs- (alcohol, tobacco, 2 narcotics etc) - family living including sex education e. AIDS (Acquired Immune Deficiency syndrome) education f. Safety education and first aid 2 - Types and causes of common accidents in Nigeria Home and community 2

4. Teaching methods a. Direct -by health education staff 2 b. Correlation with other subjects 2 c. Integrated with other classroom activities 2 d. By visiting medical specialist and voluntary groups 2 e. With supplementary teaching aids 2

5. Beyond the classroom - Organized health and safety trips -in school 2 -outside 3

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6. Preparation of teachers for health teaching -In-service training for teachers and head- Teachers of schools (Policies and recommendations of health departments 1 interpreted to teachers) - Areas included in training elementary teachers (personal health, components of school health programme, community health. 3 B. HEALTHFUL SCHOOL ENVIRONMENT A. DESIGN 1.water supply a. source- i. Pipe borne 4 ii Bore-hole/mono pump 3 iii. Wells 2 vi. Surface water 1 b. Location i. Within the school 3 ii.≤ 200metres outside school 2 iii. >200metres outside school 1 2. Refuse Disposal System a. incineration 4 b. Controlled tipping 3 c. Composing 2 d. Open dumping/burning 1 3.Sewage Disposal System a.Toilet type: i. Water closet/ septic tank 3 ii. Pit/ trench 2 iii. Bucket 1 iv. Surface (bush/water) 0 b. Toilet- Pupil ratio i. 1:≤ 30 5 ii. 1:31-45 4 iii. 1:46-60 3 iv. 1:61-90 2 v. 1:>90 1 vi. None 0

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4. School Plan a. Buildings: i. Dilapidated 0 ii. Old walls, leaking roofs 1 iii. Strong walls with minor 2 cracks iv. Strong walls, good roof 3 b. fire protection i. All buildings with fire resistant material 3 ii. Some prefab buildings 2 iii. all prefab buildings 1 c. Floor: i. Floor space- Standard 2 Not standard 1 ii. Finishing- Flat, non-glossy 3 Flat, glossy 2 Worn off, broken & dusty 1 Sandy 0 d. Ventilation: i. Adequate 2 ii. Not adequate 1 e. Ventilation i. Controllable 2 ii. Not controllable 1 f. Lighting: i. Good 2 ii. Poor 1 iii. With supplementary artificial light +1 g. Insulation from heat: i. Properly ceiled 2 ii. Partially ceiled 1 iii. No ceiling 0 h. Sitting comfort(chairs & writing tables) i. Pupils: 100% seated 2 < 100% seated 1 None 0 ii. Teachers: 100% seated 2 < 100% seated 1 no seats 0 i. Food service area: available 2 Not available 0

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j. Safety measures (each scores 1 point) i. Safety patrol team ii. School fence iii. Fire extinguisher/buckets of sand iv. Fire alarm k. Nuisance/health hazards at site +5 i. None ii. Industrial population iii. Animals grazing/dangerous wild animals iv. Faeces in classrooms v. Flood/open drainages vi. Vectors/pests B. MAINTENANCE Evidence of maintenance +2 C. HEALTHFUL LIVING (score 1 for each point) i. Adequate emotional climate ii. Shoes worn compulsorily iii. Sports field available iv. Sports facilities available v. Toilet rolls available vi. Soap for washing hand available vii. Washing hand basin and stand in class viii. Drinking fountains, buckets & cups in class ix. Dust bins and waste paper baskets available x. Regular cleaning of toilets and Classrooms

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C. HEALTH CARE SERVICES 1.Personnel(Graded scoring 0-4) a. None 0 b. Health Assistant/ Trained first-aider 1 c. Health Educator/ Nutritionist 2 d. Nurse/midwife/Health Sister 3 e. Doctor 4 2. Appraisals(each item scores 1) a. Routine inspection (Teacher observation) b. Screening tests to detect growth defect, handicaps, disabilities c. Periodic medical exams for staff and pupils d. Referrals to health centres/ hospitals e. Supervision of health of the handicapped 3.Treatment facilities within the school (each scores1) a. First Aid box b. Essential drugs and materials – analgesics, vitamins, anti-malarials, scabicides, antihelmthics, antifungals, haematinics, ORT sachets,disinfectant, cotton wool, plaster, bandage. c. Health room/dispensary/sick bay d. Ambulance/School bus e. Telephone services 4.Care of emergency illness/injury (each scores1) a. First aid treatment usually given b. Treatment given recorded (if referred, referral copy given) c. Notification of parents immediately d. Transport child to nearest health post e. Convey child home after treatment has been given

5. Control of communicable disease(graded scoring) a. No activity 0

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b. Health talks 1 c. send child home 2

d. Isolate/quarantine in a health room 3 e. Immunization 4 6. Records keeping a. No records available 0 b. Available but not cumulative 1

c. Cumulative but not transferable 2 d. Cumulative and transferable 3 7. Nutrition Services a. school farm available 1 b. nutrition demonstration classes 2 c. school meals 3 d. nutritional supplements +1

8. Guidance and Counseling services

with teachers 1

with parents 2

COLLATION OF SCORES

Component of Maximum Score Minimum Actual Score

SHP Acceptable Score School Health 41 27 Instruction School Health 45 19 Care Services Healthful School 66 57 Environment Total Scores 152 103 ?

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APPENDIX III: LIST OF PUBLIC AND PRIVATE PRIMARY SCHOOLS IN ILESA EAST LOCAL GOVERNMENT AREA s/n Public schools Private schools 1 A.T.C Demonstration School ‘A’ Oke Ooye Alpha N/P School, Irojo 2 A.T.C Demonstration School ‘B’ Oke Ooye Anointed Model N/P School 3 Baptist Pry School Ifosan Bibo Oluwa School, Breweries 4 Bolorunduro/ Irewolede Community Pry Bright Future N/P School Biladu School. 5 C.A.C Pry School ‘A’ Okesa Christ The King Academy N/P School 6 C.A.C Pry School ‘B’ Okesa Christ The Redeemer N/P School 7 Christ Anglican Primary School Ilerin Deen Ul Haq N/P School Ifofin 8 G.T.C Demonstration Pry School ‘A’ Cappa Excellent Group of Schools Ilesa Bolorunduro 9 G.T.C Demonstration Pry School ‘B’ Cappa Forward N/P School Ilesa 10 Hon. Makinwa Model Pry school Franciscan N/P School Bolorunduro 11 Ife –Oluwa C&S Oke –Eso Genius N/P School Imo 12 Irojo Community Pry School ‘A’ Golden Child N/P School 13 Irojo Community Pry School ‘B’ Great Children N/P School 14 Ido- Ijesa Community Pry School Holy Vessels N/P School Irojo 15 Ilo Olomo Community Pry School Holy Church N/P Biladu 16 L.A. Pry School ‘A’ Imo Ledeko Pry School Irojo 17 L.A. Pry School ‘B’ Imo N.U.D N/P School Irojo 18 Methodist Pry School Ogudu Olufunso N/P School Stadium Rd Ilesa 19 Methodist Pry School Oro- Ajimoko OSSCE Staff N/P School 20 Methodist Pry School Otapete Prestige N/P School Iloro 21 N.U.D Igebaye Ilesa Prince Chard N/P School 22 Oke Opo Community Pry School Progressive N/P School Imo 23 Omi Asoro Community pry School Stevel N/P School Oke Opo 24 Orire Ogedengbe United St James N/P School 25 St. John’s School ‘A’ Iloro St. Peters N/P School Isona 26 St. John’s School ‘B’ Iloro The Apostolic N/P School Oke Ooye 27 St. Theresa’s R.C.M. Pry School ‘A’ Ijofi The Rock N/P School 28 St. Theresa’s R.C.M. Pry School ‘B’ Ijofi Treasure Land N/P School 29 St. Mary’s R.C.M Ifofin Ultimate N/P School Olomilagbala 30 St. Peter’s School ‘A’ Winners Academy Bolorunduro 31 St. Peter’s School ‘B’ 32 The apostolic Central Oke Ooye 33 The Apostolic Pry School Oke Iro 34 The Apostolic School Igbaye Total Number of Schools = 64

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APPENDIX V: ELECTRONIC COPY OF SENSITIZATION SEMINAR ON SCHOOL

HEALTH PROGRAMME BY THE RESEARCHER TO ILESA

EAST LOCALGOVERNMENT PRIMARY SCHOOL COMMUNITY

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APPENDIX VII: PICTURES

(A) A Private School sandwiched between residential buildings with no space for play activities

(B) Dilapidated structure in one of the public schools 112

(D) Broken floor in one public school 113

(E) Some school children without shoes

114

(F) A school with uncontrollable ventilation

(G) Some school children crossing road without supervision

115

(H) Animal droppings within the premises of a school

(I) Block industry within the premises of a school

(J) Sawmill located just beside a private school

116

(K) Time table of lesson schedule of a school

(L) The Researcher giving lecture at the seminar he organized for primary schools in Ilesa East LGA Osun state Nigeria 117

(M) Empty First Aid box in a school

118

(N) Sparingly stocked first aid box in a school

(O) Health room called “healing bay” in a private school

119

(P) Interior of the healing bay

(Q) Scanty treatment record in a private school

(R) Phone book record in a private school 120

(S) Some private school pupils patronizing snacks seller located at the entrance of their school

121

(T) Time table for free school meals supplied by government/ UNICEF to some pupils in public schools

(U) Some Pupils queuing to receive their free school meal in a public school

(V) Recruited food handlers preparing the free school meals in a school kitchen donated by PTA 122

(W) The researcher answering questions from participants at the seminar he organized for primary school community in the study area

(X) Some guests at the seminar on SHP for primary school community in the study area

123

(Y) Some items donated by the researcher to Ilesa East Local government primary schools at the seminar

(Z)A guest presenting donated first aid materials at the seminar

124

A guest presenting donated first aid materials at the seminar

125

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