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Dra. Nora Salazar
Diciembre 1995
Case study: Justification Diagnosis of the peruvian school Health and school sanitation program Educational package "the school and ourselves,
promoters of hygiene and health" Achievements In Peru, 47% of the population have less than 19 years; 68% are children and 32% are teenagers. If this trend continues, by the year 2000 Peru will have 11 million of children. The 1991 survey on living standards detected that 54% of the population live in poverty and 22% under extreme poverty.
From 8.5 million of children under 14 years, 43% are women. Six out of ten children live in urban areas and 4 in marginal areas. Only 46% of these children live in homes where their basic needs are met. It explains their low levels of health, nutrition, hygiene and education.
With regard to health, 25% of the country mortality correspond to infectious diseases that affect especially the infant population. Mortality of children under 5 is 70/1000. Mother's educational level affects positively the reduction of mortality. While 102 out of one thousand children of illiterate mothers die before their first year of life, the number diminishes to 21 when mothers are better educated.
The leading causes of child morbidity are respiratory diseases (49%) and infectious and parasitic diseases (22%). Chronic malnutrition affects 48% of the students (6 to 9 years) attending first grade. In rural areas malnutrition prevalence is 64%.
These health and nutrition problems are associated with inadequate environmental sanitation conditions. In Peru, only 78% of the urban population and 22% of the rural population have access to water services including those of easy access but in both cases, quality is not always guaranteed. In addition, only 71% in the urban area and 17% of the rural sector have excreta disposal systems, although not always sanitary, maintaining a generalized practice of defecation in the open air.
On the other hand, environmental degradation is inducing the death of many children. Countries with fragile agricultural sectors, eroded soils and contaminated water, have the highest indexes of child malnutrition. Air pollution contributes to the spread of respiratory infections which cause the death of more than 4.2 million children under 5 years old in developing countries.
Toxic chemical products, heavy metals, radiation and harmful substances cause more harm to children than to adults, for example, lead effects include convulsions, behavior alterations, mental impairment, irritability, coordination problems and lack of dexterity, thus affecting children school performance.
The 1993 census indicated that only 80% of the children under school age are registered and only 60% complete four grades of elementary school; only 5.6 out of 10 students finish elementary school.
Secondary school is attended only by 44% of teenagers (12-16) who completed their elementary education.
Although in average the population reaches 6 grades of schooling, which means that they complete elementary education, they take more than six years to complete it. For example, in the segment of children under 12 years old, at that age they have completed only three grades of schooling.
The census identified 520 thousand children of 6 to 9 years that did not know how to read nor how to write, they constitute 24% of this group. This figure reveals that in Peru there is a delay in the initiation of school life. The high rate of students who repeat the academic year (1 out of 3 in the first grade and 1 out of 5 in the second grade) shows that nine years are required to complete elementary education. In summary, only 56% of the children of 6 to 12 years old who start elementary school conclude it.
The lesser cultural value given to girls affects the index of feminine illiteracy. While in the age group of 15 to 17 years old, 3% of males are illiterate, in the female group it reaches 5%. It is estimated that 65% of illiterate adolescents are women.
In Peru, 1 out of 14 children and adolescents is working; the relation is higher in the rural sector. They usually work in the service sector, carrying out dangerous tasks and receiving remunerations below the legal minimum.
In Peru, the social environment of the children causes that 69% of the group of 10 to 14 years old consume alcoholic beverages and 7 out of 1,000 smoke marijuana.
This situation demonstrates the difficult living conditions children and youth have to undergo in Peru. Due to the painful conditions of the Peruvian family and despite the limitations that the school offers, it continues to be -in our concept- the best environment to implement a program to improve health and sanitation. In addition, children and youth are the best agents to promote positive changes and practices of health, sanitation and environmental protection.
Why in Peru does the school become the privileged place to change health and sanitation conditions?
Eight million students spend at school a third part of their life. Despite its deficient quality, Peru has the highest rate of school enrollment among Latin American countries. Two factors contribute to this fact: elementary education is compulsory and free of cost. With regard to preschool education, 51% of children from urban areas attend a child center, which makes it interesting to introduce at this early stage a program on health practices and hygiene.
In the Peruvian society, the school is the most important institution that contributes to the formation and development of the child. It offers coverage and continuity to fulfill a health integrated proposal linked to education. In addition, as a public institution, the school has the capacity to offer "integral care to the child."
The school is also the space where children and youth may receive attention to their diseases and health education towards promoting a better quality of individual and collective life.
The school and the educator may contribute to the curriculum diversity including health and sanitation topics as a sine qua non condition of "education for life."
It is the educator who transmits knowledge, inculcates habits, practices, and values related to health care and the environment. He can modify erroneous concepts on health care and detrimental traditional practices related to health or the environment. The teacher together with the students can generate productive projects that give sustainability to the Health and School Sanitation Program.
In addition, the school gathers together authorities, teachers, students, and parents. The school, as part of the community, is concerned with those living around and in this sense it is an organization opened to extracurricular activities to extend the principles it claims.
Working from the school, we work for the community. Training educators and children on health promotion, we form agents of change and we affect the reduction of diseases, preparing a generation for a better life and contributing to the development of the entire community. It is relevant to recall that only 50% of the educators have been trained in the traditional curricula, and there is still quite a lot to do.
According to a World Bank study, investment in education has a higher yield than investment in physical capital. Four years of elementary education tend to increase an average of 10% in agricultural productivity.
Finally, the investment cost in health and school sanitation is lower than the investment in all and each one of the school children families. In addition, in the school we may integrate educational activities with investment activities for improving school sanitary infrastructure. In this way, children may have a clean, safe and healthy environment where they could apply their knowledge of hygiene and adapt sanitary ways to resolve their vital needs demanding the same in other environments, such as their home.
It is not enough to teach or give information to the child regarding correct attitudes and practices of hygiene, but to improve school sanitary installations so that children may confirm their knowledge and information provided.
In this way, we teach children and youth other reasons to struggle for, we give them motivation to change, and we guarantee their right to demand a clean environment at school.
In addition to inducing changes in the school physical environment for a better hygiene, we can integrate to our proposal a curriculum on health and environment to meet the needs and interests of the students and design materials to support teachers activities and the children learning process. Such proposal will include the organization of microbusinesses and their management by the school community (parents, educators, authorities, and students).
It is valid to point out that only 50% of students have traditional school texts. Accordingly, there is a great deal to do regarding the preparation of materials on health and sanitation involving all actors committed to child development.
We propose a school model capable of converting students into promoters of health and hygiene, departing from the classroom and the school to be projected later to the house and the community.
For this purpose, this school archetype should rely on educators trained in health and sanitation, capable of developing processes of teaching/learning/life practice, in a permanent and systematic way.
Why are children effective agents of change?
Children and adolescents because of their vitality, creativity, mental alertness, lack of prejudices, ability to understand the interdependence of different problems, their concern about the environment, their leadership, and distance from tradition, are in the best position to be converted into agents of change.
Influenced by their mother, family and surroundings, at early age children learn values, principles and norms of conduct that elevate their conscience and create the ethical spirit of their behavior, making them more sensitive towards nature.
Children of 9 to 10 years old begin to appreciate the interaction between people and nature. They learn to recognize the implications of water and air contamination; the inadequate disposal of effluents, garbage, and excreta; oil spills, radioactive wastes and hazardous substances; the damages caused by pesticides and carbon monoxide emissions; global warming, ozone layer depletion and acid rain; loss of biodiversity, etc.
We consider that teaching positive behaviors based on the relation health-environment produces at this age long-term effects capable of creating a trend of environmental protection as a requirement to preserve life.
Only through education it will be understood that environmental health is a pre-requisite to individual and collective health. Said otherwise, students will internalize the relation between good conditions of water, air, soil and food, and the eradication of diseases associated with environmental problems that are the principal causes of child morbidity and mortality in our countries.
Finally, considering children and youth as pioneer agents for these changes will strengthen the organizations they represent, will validate their rights to a better quality of life, will control the frustrations they are exposed to and will vitalize their values and self esteem, allowing them to access adequate information about their rights, sexuality, identity and gender.
The study carried out by WHO/PAHO/IRC (1991-1992) on "Sanitation and sanitary education at school in Latin America", corroborated the aforementioned situation (see 1-d). In addition, it identified problems in the infrastructure and basic sanitation conditions at schools that necessarily should be resolved to induce changes.
Governments have limited themselves to the construction of classrooms as the only space for children, abandoning for reasons of costs, the space for recreation, for hygiene, for reflection (library) and for creativity (arts), which together make possible the integral education for life. If the hygiene space exists at school, this is precarious due to construction defects, or because it is incomplete or deteriorated.
Although in Peru the budget for elementary education is three or four times higher than the budget of the health sector, the economic crisis has had great impact on the provision of these social services. The national investment on education has declined from 20% to 13% in recent years. The budget of education is destined to remuneration payments and very little has been derived to investment. In this category, traditionally the greatest participation comes from schoolchildren parents through their grass root organizations, the APAFAS (Parents' Associations).
The contribution of the Parents's Associations in labor, materials and payment of registration fees, has been utilized for construction of classrooms, schools and hygienic nuclei, as well as for expenditures that demand their operation and maintenance.
At present, the State is concerned about school hygiene, and there is the contribution of international organizations such as IDB, AID, World Bank, and agencies of bilateral cooperation, among others.
Concerning basic sanitation, only 16% of schools have continuous service of water, sewerage and electricity. In Lima, 42% of schools lack sanitation services and where there exist (58%), they are intermittent (by some days or hours). The percentage of schools that have poor water quality amount to 63% and 21% carry out chlorination inadequately, without following WHO/PAHO standards.
The design of restrooms are based on conventional systems for urban areas, and alternative models for peripheral and rural areas. For the periurban and rural areas, slab latrines are installed, sometimes with a toilet of porcelain or concrete. Regarding technical specifications, the relation between number of units and number of students do not correspond to the actual offer of water or capacity of the water utility to provide schools enough water according to their schedules and number of students. This produces the abandonment of constructions, deterioration, early obsolescence, and vandalism by the users.
In many cases, the service is limited to the provision of water for drinking and washing hands, putting aside other needs of the children, like showers for their complete hygiene since they do not have this installation available at home.
It has been forgotten that people working at school (admin-istrative staff and teachers) also demand restrooms. At the end, they are those who benefit from the hygiene installations and the students have to defecate outside the school.
Upon checking the sanitary infrastructure it has been detected that only 40% are relatively in good conditions due to problems of intermittent service and low water quality. This deficit is aggravated by poor operation and maintenance, broken pipes, wastes, floods and incomplete installations. The scarcity of equipment, accessories, tools and materials worsen this situation. The responsibility on operation and maintenance is not defined in educational centers.
Quality material of sanitary devices versus frequency of use has not been taken into consideration at schools. Thus, the collapse of sanitary devices produces floods and loss of great volumes of water. In addition, their design is inappropriate to the body structure and cultural habits of children, which means that they are difficult to operate, especially by the smaller ones. The relation between number of sanitary devices versus quantity of students does not correspond to their needs, nor distinguishes between population of boys and girls to adapt facilities such as urinals in the case of males, optimizing the investment.
Periurban schools, attended by 70% of the school population, do not have municipal collection of garbage and both neighbors and schools just discard it in open dumps. In rural areas, garbage is burnt or dumped into courses of water, increasing levels of contamination.
Appropriate technologies have not been used despite their low cost and easy installation. Hence, it has hindered the expansion of sanitary service coverage in areas where water and electricity are scarce.
Notwithstanding these sanitary conditions, it is encouraging to find positive attitudes towards change in schools and other agents linked to their development. In Peru, every school has a parents' association and a teachers' association. Promoted by the Ministry of Education in coordination with the Ministry of Health, there also exists a Health Committee at schools. With regard to children, their participation in the decision making process is strengthened through instances such as the "parliament of children", the "health promoter", the "classroom delegate", among others.
It is necessary to train these various school agents to maximize their management capability.
With regard to the curricula, it includes subjects and aspects through which children initiate their education in hygiene and environmental health. In Peru, the 1994 educational reform considers health and hygiene topics at preschool level, first and second grades. At the other levels, health education is integrated into food and nutrition, environment, body and health, and identity. This curriculum made it possible for us to set up the Health and School Sanitation Program as a strategy of the Pan American Health Organization to promote children and youth health in Peru and other countries of the Region.
The Pan American Health Organization promotes in the Region the Health and School Sanitation Program comprised of three fundamental areas:
A healthy school environment is made up of a set of spaces that meet the affective and intellectual needs of the child. These are: the classroom or space for the thought; the recreational areas for playing games; the space for reflection or library; the space for hygiene or hygienic nucleus to meet their physiological needs; the space for creation and artistic activities; the space for nutrition or dining room; and the nursing or emergency kit as the space for health.
The hygienic nucleus is the focus of our presentation. In it children will resolve not only their physiological needs, but they will be able to put into practice the knowledge they have received about hygiene for a good health.
It is the space where children will meet their needs of safe water, cleaning, personal hygiene, and sanitary disposal of excreta. As well, they will also learn how to dispose of recyclable wastes and they will practice methods of treatment and final disposal to maintain the balance of the ecosystem.
Based on this daily experience children are going to understand that protecting the environment, they prevent diarrhea and other diseases associated with poor sanitation. Accordingly, they will become health and hygiene promoters in their communities.
To sum up, a healthy school environment will be capable of providing children the essential conditions to guarantee their intellectual, social and physical health.
Hygiene education implies innovation of the curricula to offer children "education for life." It includes the development of labor skills linked to environmental protection and management, as well as skills to fix sanitary installations (masonry, plumbing). It tries to integrate health actions, hygiene and productive projects to sustain the Health and School Sanitation Program under the management of the school community.
The curriculum innovation will result in the preparation of educational materials with topics on health and environment, directed to educators and students of different educational levels. These contents, developed progressively through active learn- ing/doing techniques, will improve children hygiene competence at classroom, school, home and community.
It involves all agents (authorities, educators, parents, and supporting organizations) as responsible for managing the Health and School Sanitation Program. It considers the child as pioneer of change.
In this way, participation is opened to all who make decisions regarding the situation of environment and health at school. Their roles are defined and committees are strengthened from the classroom level up to the school as a whole. The school community is responsible for promoting sanitation and developing productive projects to sustain the Program.
The fulfillment of the Program will improve sanitary installations making them operational and will develop educational materials and training programs in water, sanitation, health, construction techniques, maintenance of services, and management of school sanitation programs.
This educational package integrates the above mentioned aspects and forms part of the Health and School Sanitation Program. Below are defined its objective, audience, and content.
The educational package has been designed for educators and students of educational centers from Lima and Callao. It contains the Teacher's Guide and the Student's Guide targeted at the following levels: I: Initial and first grade of elementary education; II: Second to third degree of elementary; III: Forth to sixth grade of elementary; and IV: First to third grade of secondary education. The Ministry of Education, together with specialists and educators will define the specific grade in which they will be applied. Both the Teacher's Guide and the Student's Guide contain 14 subjects distributed in the following way: five on water management, seven on environmental sanitation and two on social environment.
The objective of the educational package is to convert the school and the students into promoters of the care of water and the environment in their communities.
The package develops its contents in four modules, one per each educational level. Every module has guidelines, one for the teacher and another one for the student.
In both guides the following subjects are developed sequentially:
The Teacher's Guide includes the topics (theory) and the educational techniques to promote hygiene practices and attitudes at classroom and school (intramural activities); and at home and community (extramural activities).
Each subject of the Teacher's Guide includes the following parts:
The titles phrasing help children to internalize and make theirs the concepts so as to convert them into concrete actions.
Competence to be reached at the end of every session.
Basic information to orient the educational session.
To apply knowledge into actions at classroom, school, house and community levels.
Motif that synthesizes new acquired knowledge.
Assist teachers to organize basic materials they should have at their disposal to apply educational techniques in every session.
Identifies achievements that should be reached at the end of every session and activities that should be fulfilled in the classroom, school, house and community.
The Student's Guide develops the same topics of the Teacher's Guide. It compiles 56 awarded stories from the competition promoted by WHO/PAHO/ CEPIS/Ministry of Education/ SEDAPAL in 1994. Each story develops a topic stated in the competition rules. The variety of topics covers the foreseen instruction objectives for each educational session. In this sense, the competition was not opened, but subjected to conditions concerning the argument and topic to be developed.
Pedagogically, it is considered that the story is an effective way to induce analogous situations in daily life. Accordingly, they are easy to extrapolate to behaviors, attitudes and practices that constitute excellent models to improve health and hygiene quality.
Teachers are suggested to initiate the educational session telling the story as a motivation to promote concrete actions related to the subject dealt with. After reading the story, a series of questions follows generating discussion, reflection, conclusion and action.
Afterwards, the Teacher's guide suggests the use of complementary techniques to strengthen the conclusions.
The order and number of topics may be altered by the teacher, in accordance with their needs and available time.
What is important is to ensure that at the end of each session, the students participate in activities to improve hygiene conditions at school, home and community.
Through the Health and School Sanitation Program, the Pan American Health Organization and CEPIS are achieving:
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