Models and Approaches of a School Health Programme (SHP): The FRESH Framework and Child Friendly Schools

1. Concept of School Health Programme (SHP)

A School Health Programme (SHP) is a planned, coordinated set of policies, services, and activities designed to promote the health, well-being, and educational achievement of school children, teachers, and the wider school community. It links the health sector and the education sector so that healthy children learn better and educated children become healthier adults. SHP is delivered through several models and approaches, of which the FRESH framework and the Child Friendly Schools (CFS) approach are the most widely adopted internationally and in Nepal.

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2. Models of School Health Programme

(a) Medical Model (Traditional/Clinical Model)

• Focuses on curative and preventive health services — medical examination, immunization, deworming, first aid, and referral.
• The school is treated mainly as a site for delivering health services.
• Limitation: Gives little attention to health education, school environment, and community participation.

(b) Health Education Model

• Emphasizes knowledge, attitudes, and life skills through the curriculum (e.g., Health, Population and Environment Education in Nepal).
• Aims to develop healthy habits and prevent risk behaviours.
• Limitation: Knowledge alone does not always translate into healthy practice.

(c) Healthy School Environment Model

• Focuses on safe water, sanitation, hygiene facilities, safe buildings, playgrounds, and a healthy psychosocial climate.
• Based on the idea that the physical and social environment of the school itself teaches health.

(d) Integrated/Comprehensive Model (Health-Promoting Schools)

• Combines health services + health education + healthy environment + community and family involvement + school health policies.
• The FRESH framework and Health-Promoting Schools (HPS) are examples of this comprehensive model.

(e) Community/School-Community Partnership Model

• Involves parents, SMCs, local health posts, NGOs, and FCHVs in planning and running school health activities.
• Ensures local ownership and sustainability.

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3. The FRESH Framework

FRESH stands for Focusing Resources on Effective School Health, launched in 2000 by WHO, UNESCO, UNICEF, and the World Bank at the World Education Forum (Dakar). It is a comprehensive, cost-effective, inter-sectoral framework built on four core components:

Key Features of FRESH

• Equity-focused: Targets poor and disadvantaged children.
• Cost-effective: Uses simple, low-cost, proven interventions.
• Inter-sectoral: Health, education, water/sanitation, and nutrition sectors work together.
• School-based but community-linked: Involves families and the local community.
• Supports Education for All (EFA) and SDGs (especially SDG 3 and SDG 4).

Illustration of FRESH in Practice

A rural community school in Nepal:

1. Adopts a written school health policy (no tobacco, no corporal punishment).
2. Builds separate toilets and hand-washing points with soap.
3. Teaches hygiene and life skills through HPE classes and child clubs.
4. Conducts deworming, iron supplementation, and growth monitoring with the local health post.

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4. Child Friendly Schools (CFS) Approach

The Child Friendly Schools approach (UNICEF, 1990s onward) is a rights-based, child-centred model that treats health as one of the essential dimensions of a child-friendly school. Its guiding principles are:

1. Inclusive and non-discriminatory — all children, including girls, disabled, and marginalized, are welcomed.
2. Academically effective — quality teaching and learning.
3. Healthy, safe, and protective — promotes physical and emotional health and protects children from violence, abuse, and exploitation.
4. Gender-sensitive — promotes gender equality.
5. Involving children, families, and community — participation in school governance and health activities.

Health Components within CFS

• Safe drinking water and sanitation facilities.
• School feeding and nutrition support.
• Health screening and referral services.
• Life-skills-based health education.
• Child clubs and peer education.
• Psychosocial support and a violence-free environment.

Illustration of CFS in Practice

A child-friendly school:

• Has ramps and separate toilets for boys and girls.
• Runs a child club that organizes cleanliness campaigns and health awareness.
• Maintains a complaint box against bullying and corporal punishment.
• Coordinates with the health post for regular check-ups and immunization.

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5. Comparison of FRESH and CFS

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5. Conclusion

Both the FRESH framework and the Child Friendly Schools approach represent comprehensive, integrated models of School Health Programme. FRESH provides a practical, low-cost structure for delivering health and nutrition services through schools, while CFS provides a rights-based, child-centred philosophy that places health within the broader goal of quality education for all. In Nepal, these models are reflected in the School Health and Nutrition Programme, child clubs, mid-day meal schemes, and child-friendly school initiatives. Together they ensure that schools become healthy, safe, and enabling environments where every child can learn and thrive.

Role of a Health Education Teacher vs. a School Nurse in Effective School Health Services

Introduction. School health services aim to promote, protect and maintain the health of students so that they can learn effectively. Two key personnel — the health education teacher and the school nurse — contribute to this service, but their roles differ in nature, focus and method of delivery. In my opinion, the health education teacher is primarily an educator and promoter of health, while the school nurse is primarily a care provider and clinical practitioner.

Role of the Health Education Teacher

1. Health instruction: Teaches health-related knowledge, attitudes and skills through the curriculum (personal hygiene, nutrition, first aid, communicable diseases, mental health, substance abuse, reproductive health).
2. Health promotion and awareness: Organises health campaigns, debates, essay competitions, wall magazines, health clubs and "health weeks" to build positive health behaviour.
3. Preventive orientation: Focuses on prevention rather than treatment — e.g., hand-washing habits, safe drinking water, balanced diet, physical exercise.
4. Skill development: Develops life skills such as decision-making, refusal skills, stress management and first-aid skills.
5. Coordination and referral support: Identifies health problems in students during classroom observation and refers serious cases to the nurse or health centre.
6. Curriculum and evaluation: Prepares lesson plans, teaching materials and evaluates students' health knowledge and practices.

Role of the School Nurse

1. Direct care and first aid: Provides first aid, dressing of wounds, management of minor injuries and care of sudden illness.
2. Screening and health appraisal: Conducts periodic health check-ups — height, weight, vision, hearing, dental, blood pressure — and maintains health records.
3. Immunization and treatment: Assists in immunization programmes, administers prescribed medicines and gives emergency care.
4. Referral and follow-up: Refers students with serious conditions to hospitals or specialists and follows up on treatment.
5. Control of communicable diseases: Detects early signs of infectious diseases, isolates cases, informs parents and takes preventive measures.
6. Counselling and confidentiality: Counsels students and parents on health matters, maintaining professional confidentiality.

Main Differences (in my opinion)

How they complement each other. The teacher creates health awareness; the nurse converts that awareness into practice through check-ups, treatment and referral. For example, the teacher teaches the importance of dental hygiene, while the nurse screens for dental caries and refers cases to a dentist. Similarly, the teacher teaches first-aid theory, and the nurse supervises its practical application. Neither can replace the other — one builds health literacy, the other ensures health security.

Conclusion. In my opinion, the health education teacher is the preventive educator and the school nurse is the curative practitioner of school health services. Effective school health services require both to work in close coordination with each other, with parents, the school administration and the community.

Appraisal Methods Used to Identify Mental Health Problems Among School Pupils

Appraisal means the systematic process of collecting, interpreting and using information about pupils to understand their abilities, interests, needs and difficulties. In the context of school health, appraisal methods are used to detect mental health problems early so that timely guidance, counselling and referral can be arranged. The major methods are described below.

1. Observation

The teacher observes pupils in the classroom, playground, canteen and during group activities. Changes in behaviour such as excessive shyness, aggression, withdrawal, crying without reason, poor concentration, absenteeism, nail-biting or sudden decline in academic performance may indicate emotional or behavioural problems. Anecdotal records and behaviour checklists are maintained for this purpose. Observation is continuous, natural and inexpensive, but it depends on the skill and objectivity of the teacher.

2. Interview

A face-to-face interview is held with the pupil, and where necessary with parents and guardians. It helps to explore the pupil's feelings, fears, family environment, peer relations and any stressful event such as death in the family, parental conflict or examination failure. A friendly, confidential and non-threatening approach is essential. Interviews give in-depth information but are time-consuming and require trained personnel.

3. Case Study

When a problem appears serious or long-lasting, all available information about the pupil is collected — family background, health history, school record, social relations and interests — and studied as a whole. This cumulative picture helps to find the real cause of the problem rather than only its symptoms. Case studies are useful for individualised planning but require much time and record-keeping.

4. Sociometry

Sociometry is used to study the social relationships and acceptance pattern within a class or group. Pupils are asked to name classmates they would like to sit with, play with or work with. The resulting sociogram reveals isolated, rejected or neglected pupils, who are at greater risk of loneliness, low self-esteem and depression. It is a useful group technique but may hurt the feelings of rejected pupils if results are not kept confidential.

5. Psychological Tests

Standardised tools such as intelligence tests, aptitude tests, interest inventories and personality or adjustment inventories are administered by trained persons. They help to identify pupils with intellectual limitations, emotional instability or maladjustment. Such tests give objective and comparable data, but they need proper training, standard conditions and careful interpretation.

6. Cumulative Record Card

The school maintains a cumulative record card for every pupil containing academic results, attendance, health records, participation in activities, awards and remarks of teachers. A careful study of this record over the years helps to trace the onset and pattern of a mental health problem. It is cheap and readily available but useful only when records are honestly and regularly maintained.

7. Health and Medical Examination

Periodic medical check-ups by the school health team help to detect physical conditions — malnutrition, anaemia, thyroid problems, epilepsy, hearing or visual defects — that may cause or worsen emotional and behavioural difficulties. Medical appraisal is therefore an essential support to psychological appraisal.

8. Self-Reporting Techniques

Pupils may be asked to write diaries, autobiographies, essays or to fill in questionnaires and rating scales about their worries, habits and adjustment. These reveal inner feelings which may not be visible through observation. They are useful for adolescents but depend on the honesty and writing ability of pupils.

9. Case Conference and Referral

Teachers, the head teacher, the school nurse, the counsellor and parents sit together to discuss a pupil's case and decide the course of action. If the problem is beyond the school's capacity, the pupil is referred to a doctor, psychiatrist, psychologist or child guidance clinic. This method ensures coordinated and expert help.

Conclusion

No single method is sufficient. A good school uses a combination of observation, interview, case study, sociometry, tests, records and medical examination. Early identification through these appraisal methods prevents minor adjustment difficulties from developing into serious mental health disorders and promotes the all-round development of pupils.

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Importance of School–Community Co-operation in Mobilizing Local Resources for Health Programmes

School and community are interdependent institutions. The school is a part of the community and the community is the larger environment in which the school functions. For the success of any school health programme, the active co-operation of the community is essential. Its importance in mobilizing local resources can be explained as follows.

1. Availability of Local Resources

The community possesses manpower, money, materials, land and local knowledge. Through co-operation, the school can obtain these resources — volunteers, health workers, local leaders, funds, halls, vehicles and equipment — which the school alone cannot afford. This reduces the financial burden on the school and the government.

2. Utilization of Local Expertise

Every community has doctors, nurses, health assistants, traditional healers, social workers and retired personnel. Their voluntary service in health camps, vaccination drives, first-aid training and health education classes enriches the programme at little or no cost.

3. Community Participation and Ownership

When local people contribute labour, money or materials, they feel that the health programme is their own. This sense of ownership increases participation, regular attendance and continuity of the programme. Programmes imposed from outside often fail for lack of such involvement.

4. Cultural Relevance and Acceptance

Local people know the customs, beliefs, language and health practices of the community. Their participation helps to design health activities that are culturally acceptable, so that pupils and parents do not resist them. For example, local mothers' groups can effectively communicate about nutrition and hygiene.

5. Effective Health Education

Health education becomes more effective when it is carried out jointly by teachers, parents and community health workers. Messages given at school are reinforced at home and in the community, leading to lasting changes in health habits such as hand-washing, use of toilets and balanced diet.

6. Detection and Referral of Health Problems

Community members, health volunteers and parents help in identifying pupils with health problems — malnutrition, dental caries, eye defects, mental health difficulties — and in referring them to health centres. This widens the reach of school health services.

7. Financial and Material Support

Local clubs, mothers' groups, youth clubs, cooperatives and local government bodies can provide funds, medicines, equipment, drinking water facilities, toilets and sports materials. Such support makes health programmes sustainable.

8. Coordination with Local Health Institutions

Co-operation with health posts, hospitals, NGOs and local government ensures regular health check-ups, immunization, de-worming and awareness campaigns. It avoids duplication of effort and makes services available to pupils free or at low cost.

9. Emergency Preparedness

In case of epidemics, accidents or natural disasters, community co-operation ensures quick help, safe shelter, transport and medical aid for pupils. The school alone cannot manage such emergencies.

10. Development of Healthy Citizens

When school and community work together, pupils learn civic responsibility, mutual help and healthy living. They grow up as responsible citizens who value community participation.

Conclusion

School–community co-operation is not merely desirable but necessary for mobilizing local resources for health programmes. It brings resources, expertise, cultural acceptance, financial support and sustainability to school health activities. Therefore, the school should maintain continuous and cordial relations with parents, local leaders, health institutions and local government to make health programmes effective and lasting.

Why Participatory Rural Appraisal (PRA) is More Effective than Top-Down Surveys for Assessing Community Health Needs

Participatory Rural Appraisal (PRA) is a family of approaches and methods that enable local people to share, analyse and plan their own living conditions. In community health, it treats the community as the expert on its own health problems rather than as a passive source of data. This is why it is considered more effective than traditional top-down surveys.

1. Community participation and ownership. In PRA, people themselves map, rank and analyse health problems. Because they are involved in generating the findings, they feel ownership of them. Top-down surveys are designed and interpreted by outsiders, so the community has little stake in the results and often no role in acting on them.

2. Local knowledge is used as valid data. PRA draws on indigenous knowledge — local terms for illness, beliefs about causes, traditional healers, seasonal patterns of disease. A structured questionnaire with pre-set categories cannot capture these. PRA therefore gives a truer picture of health beliefs and practices.

3. Better identification of real needs and priorities. Through tools such as social mapping, health mapping, seasonal calendars, daily activity clocks, wealth ranking, pairwise ranking, matrix scoring, focus group discussions, transect walks and key informant interviews, the community ranks its own problems. The result reflects felt needs, not the needs assumed by planners. In a top-down survey the priorities are decided in advance by the questionnaire designer.

4. Flexibility and triangulation. PRA is iterative; methods can be changed as new issues emerge. Findings from different tools and different groups (women, men, poor, ethnic minorities) are cross-checked against each other. A fixed survey follows one rigid path and cannot probe unexpected answers.

5. Reaches the voiceless. PRA deliberately seeks out women, the poor, landless and marginalised groups, whose views are usually missed in formal surveys that sample household heads. This makes the assessment more equitable and representative of real need.

6. Empowerment and sustainability. The process builds local capacity to analyse and act. Communities learn to diagnose and solve problems themselves, so health programmes continue after the project ends. Top-down surveys create dependence on external experts.

7. Better basis for planning and action. Because the community has already analysed and prioritised, the plan that follows is more acceptable, more appropriate to local culture and more likely to be implemented. It also costs less, since local people collect and analyse much of the information.

8. Limitations acknowledged. PRA is weaker for statistical generalisation, is time-consuming, and can be dominated by elites if not carefully facilitated. Therefore it is best used together with quantitative surveys — PRA for depth, insight and priorities, surveys for measurable, comparable data. Even so, for assessing community health needs, PRA is more effective because it produces valid, locally owned and actionable knowledge.

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Concept and Elements of a Community, and How It Differs from Society

Concept of Community

A community is a group of people living together in a definite geographical area, interacting with one another, sharing common interests, values, norms and a sense of belonging, and having some organised social relationships. The word comes from the Latin communis, meaning "common" or "shared".

Definitions:

• Kingsley Davis: "Community is the smallest territorial group that can embrace all aspects of social life."
• Bogardus: "A community is a social group with some degree of 'we feeling' and living in a given area."
• MacIver and Page: "Community is a group of people living together in a particular area, sharing a common way of life."

Elements of a Community

1. Population (people): A community must have people. They may be small in number (a village) or large (a town), but some population is essential.
2. Definite geographical area (territory): A community occupies a specific, bounded locality — a village, ward, neighbourhood or town. Territory gives it physical identity.
3. Common interests and goals: Members share interests such as livelihood, religion, education, health and security.
4. Interaction and communication: Members interact face to face or through social networks; interaction creates social relationships.
5. We-feeling (sense of belonging): Members identify themselves with the community and feel "we" rather than "they". This is the emotional bond of community life.
6. Common norms, values and culture: Shared customs, traditions, language, beliefs and moral standards regulate behaviour.
7. Social organisation and institutions: Family, school, health post, temple or mosque, cooperatives, local government and other institutions organise community life.
8. Self-sufficiency and continuity: A community meets most of its basic needs within itself and persists over time.

How Community Differs from Society

Conclusion: Every community is a part of society, but every society is not a community. Society is the wider, abstract network of relationships; community is a concrete, local, territorially rooted group within it. The community is thus the basic unit through which society expresses itself.

Option A — Appraisal of nutritional status of school children and its use in supervising the mid-day meal programme

1. Concept

Appraisal (assessment) of nutritional status means finding out whether a school child is well nourished, undernourished or suffering from a specific nutrient deficiency, by comparing the child's measurements and clinical findings with standard reference values. It is the first step of any school nutrition programme, because planning and supervision of a mid-day meal (MDM) programme must be based on evidence, not guesswork.

2. Practical techniques used

(a) Anthropometry (the main technique)

• Height — stadiometer or measuring tape fixed to a wall; child stands barefoot, heels together, back, buttocks and head touching the wall, head in the Frankfurt plane (eye–ear line horizontal); read to the nearest 0.1 cm.
• Weight — standard weighing scale placed on a level floor, calibrated with a known weight before use; child in light clothes, without shoes, standing still at the centre of the platform; read to the nearest 0.1 kg. For infants/younger children a Salter or hanging scale is used.
• Mid-upper arm circumference (MUAC) — non-stretchable tape at the mid-point between acromion and olecranon of the left arm; useful for quick screening of wasting.
• Skinfold thickness — Harpenden or Lange caliper at triceps/subscapular site for body fat estimation.
• Head and chest circumference — for younger children.
• Practical precautions: same observer, same instrument, same time of day; two readings and average; record in a class register; children weighed in small groups to avoid crowding.

(b) Clinical examination Examination of hair (sparse, discoloured), eyes (pallor, Bitot's spots, conjunctival xerosis, keratomalacia), mouth (angular stomatitis, cheilosis, glossitis, bleeding/spongy gums, dental caries), skin (dryness, dermatitis, petechiae), nails (koilonychia), thyroid (goitre), bones (bow legs, knock knees, rickets, frontal bossing), and oedema of feet (kwashiorkor). Done by the school health nurse/teacher with a simple torch and spatula.

(c) Dietary assessment 24-hour recall, food frequency questionnaire, diet history, and weighed food record; intake of energy, protein, iron, vitamin A and iodine is compared with RDA for the age group. Also note meal pattern, junk food and mid-day meal consumption.

(d) Biochemical / laboratory tests Haemoglobin estimation (Sahli's or cyanmethaemoglobin method) for anaemia, serum vitamin A, serum iron/ferritin, urinary iodine excretion, stool examination for worms, blood sugar and urine sugar in suspected cases. These are done in the school health camp or by referral to the health post.

(e) Vital statistics and ecological data School health records, morbidity and mortality registers, attendance and dropout records, socio-economic status of the family, water supply and sanitation facilities of the school.

3. Classification and interpretation

Measurements are converted into indices and compared with WHO growth reference (2007) using Z-scores:

• Height-for-age < –2 SD → stunting (chronic undernutrition)
• Weight-for-height < –2 SD → wasting (acute undernutrition)
• Weight-for-age < –2 SD → underweight
• BMI-for-age percentile < 5th → underweight; > 85th → overweight/obese
• Haemoglobin below cut-off (11 g/dl for 5–11 yr, 12 g/dl for 12–14 yr) → anaemia

Older classifications (Gomez, Waterlow, IAP) may also be used. Results are expressed as prevalence rates (%) in the class, school and block.

4. Steps of conducting the appraisal

1. Planning — define objectives, select sample (all children or random sample), obtain permission from the school head and local health office, prepare tools and formats, train teachers/nurses, arrange and calibrate equipment, take parental consent.
2. Implementation — measure, examine, test and record; maintain privacy and hygiene.
3. Analysis — compute indices, Z-scores and prevalence; prepare class-wise and sex-wise tables.
4. Reporting — report to the school, SMC/PTA and local government; refer severely malnourished and anaemic children to the health facility.
5. Follow-up — repeat the appraisal every 6 months or yearly to see the trend.

5. Use of the findings in supervising the mid-day meal programme

• Menu planning: the baseline data decide the energy and protein content of the meal. A school child needs about 1600–2000 kcal and 40–50 g protein daily; the mid-day meal should supply at least one-third of this (about 450–700 kcal and 12–20 g protein), using locally available cereals, pulses, green leafy vegetables, oil and jaggery.
• Targeting the needy: children found stunted, wasted or anaemic are given extra/double ration, iron–folic acid and vitamin A supplementation, deworming and referral; growth charts of such children are maintained.
• Quality control: supervision of cooking (fuel-efficient stove, clean utensils, safe water, covered storage), personal hygiene of cooks (nail cutting, hand washing, health check-up), hand washing by children before eating, and safe disposal of waste.
• Regular monitoring: monthly weighing and quarterly height measurement, plotting on growth charts, checking attendance, enrolment and retention, and comparing with the baseline to see improvement.
• Supervision visits: the head teacher, school health nurse, SMC members and local health/education supervisors inspect the store, stock and daily meal registers, verify the quantity served per child, taste the food, and give on-the-spot feedback and corrective instructions.
• Community participation: involvement of mothers' groups, PTA and kitchen gardening to supplement vegetables and to ensure transparency in the use of funds and food grains.
• Coordination: school, health post, local palika and the education/health ministries work together for supply of food grains, supplements and technical support.
• Documentation and evaluation: maintain daily meal register, stock register, growth charts and referral records; prepare monthly/quarterly reports; evaluate the programme by reduction in the prevalence of underweight, stunting and anaemia and by improvement in attendance and learning achievement.

Conclusion

Anthropometry supported by clinical, dietary and biochemical methods gives a reliable picture of the nutritional status of school children. When this evidence is used for menu planning, targeting, quality control, regular monitoring and supervision, the mid-day meal programme becomes not merely a feeding scheme but an effective school nutrition intervention.

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Option B — Essential technical steps in constructing and finalizing a data collection tool (brief outline)

1. Define objectives and variables — state the research question, list variables and indicators; each item must measure one objective.
2. Review literature and adopt/adapt — use standard validated tools (WHO, DHS, national survey questionnaires) and adapt to the local context.
3. Select the type of tool — questionnaire, interview schedule, checklist, observation form, FGD/IDI guide or record-review format; decide mode of administration (self-administered, interview, telephone, online).
4. Draft items — simple, short, unambiguous language; closed and open questions, Likert and multiple-choice options; avoid double-barrelled, leading, hypothetical and jargon-loaded questions; sequence from easy to difficult, general to specific (funnel), with sensitive items later; place demographic items appropriately; include skip patterns and instructions.
5. Establish content validity — expert review, item–objective congruence, clarity and relevance rating; compute content validity index (CVI); delete or modify poor items.
6. Translate and back-translate into the local language; check cultural appropriateness.
7. Pre-test / pilot on about 10% of the sample in a non-study area — check comprehension, time taken, skip logic, response options and layout; note difficulties.
8. Test reliability — test–retest, split-half or Cronbach's alpha (≥ 0.7); inter-rater reliability for observation and coding.
9. Revise and finalize — remove ambiguous or redundant items, correct wording and order, prepare the coding manual, coding frame, interviewer instructions and consent form.
10. Obtain ethical clearance and permission, print/format the final version, train enumerators, and conduct a final field trial before actual data collection.