Module 10: Health, Schools, and Children

Education as a Determinant of Health

Many underlying physical and social factors contribute to health differences among individuals.   Social determinates of health include low socioeconomic status, limited education, insecure employment, hazardous jobs, and living in poor environmental conditions. Education is one of the most influential determinants of health for people living in low-income countries. Studies have shown that children who receive early childhood education are more likely to have better adult outcomes in terms of income, health, and general well-being.(1)(2)(3) In contrast, low educational attainment is associated with “high rates of infectious disease, many chronic noninfectious diseases, self-reported poor health, shorter survival when sick, and shorter life expectancy”.(4)

Attaining educational standards is integral to economic and social development. However, because developing countries have limited budgets and poor infrastructure, they often do not have the resources to invest in an adequate public education system. In countries with large income disparities, children from affluent households benefit from expensive private education, while children from poorer households rely on a flawed public school system. Without a functioning educational system, developing countries have limited opportunities for development. Investing in education can help low-income countries reduce the prevalence of poverty and advance their progress towards development. 

In an increasingly competitive global economy, the consequences of dropping out of high school are devastating to individuals, communities and the economy. According to the Harvard Civil Rights Project, “[a]t an absolute minimum, adults need a high school diploma if they are to have any reasonable opportunities to earn a living wage. A community where many parents are dropouts is unlikely to have stable families or social structures. Most businesses need workers with technical skills that require at least a high school diploma”.(5)

Education in the Developing World

There is ample evidence to suggest that many schools in the developing world are not performing effectively.(6)(7)(8) There may be many reasons that contribute to low-quality public education, including the lack of resources, limited number of teachers, poorly built schools without latrines, and language barriers for minority students. Rural schools are often isolated, creating transportation barriers for students to attend; it is not unusual for a school to be located twenty kilometers from a child's home. Furthermore, it is difficult to find and retain qualified teachers to work in rural areas. Additionally, in countries with many national languages and dialects, there may be students who are  not fluent in the instructional language. In urban settings, overcrowding in schools prevents students from obtaining the personal attention they need. 

Another major constraint is low school attendance due to the conflict between the school schedule and the household’s labor needs. For example, many schools in Mali start each year in the beginning of the harvest season, although the harvest season (particularly for cotton) continues through October and often later.(9)  Many students drop out of school for months or years at a time because their assistance is needed in order to support their families. A study in Peru found that the most common factors associated with the dropout rate include being the oldest child, being a farm worker, and high education fees.(10)  The factors that correlated with persistence were high levels of household expenditure, mothers’ schooling history, and the presence of a nearby secondary school. Another study of dropout rates from junior secondary schools in Ghana found that the predominant reason for dropout among girls was pregnancy, while boys were more likely to drop out to find employment.(11)

In some cases, governments are so overwhelmed by other issues that they do not know how to improve educational outcomes.(12) Although the Ministry of Education of a nation should aspire to increase educational standards, officials are often uninformed on the best ways to improve the education system.(13) One critical issue is the misguided allocation of resources; university expenditure in developing countries, for instance, typically accounts for less than 20% of the state education budget.(14) It is crucial for Ministries of Education to make positive changes that are supported by evidence. 

It is difficult, however, to generalize about the educational situation in the developing world; each particular country experiences its own combination of cultural, economic, and political factors that influence education. In West Africa, for example, school enrollment figures vary considerably by country; in Ghana, school enrollment is relatively high compared to neighboring Burkina Faso.  Ghana’s gross enrollment ratios in 1992 were 76%, with greater enrollment by boys (83%) than girls (70%); however, in Burkina Faso, the gross enrollment ratios were 38% with greater enrollment by boys (47%) than girls (30%).(15) Even within a single country, enrollment rates can vary significantly. In Ghana, there are tremendous disparities between the urban and rural areas, and between the north and south regions.

Achieving universal primary education and gender equity in enrollments across all low-income countries is an essential component of efforts to reduce poverty and transform the prospects of individuals and nations. 

School Health Programs

Schools are a central factor in healthy child development because they provide children with a comfortable social atmosphere and learning environment.(16) There is evidence that high-quality educational programs provide intellectual and social stimulation that promote cognitive development, establishing a basis for later success.(17)(18)

The school environment is also recognized as having a powerful influence on students’ nutrition.(19)(20) In the United States, many nutrition experts and public health advocates question whether the current school environment promotes healthy eating habits.(21)(22) In the United States, few of the foods offered to students are low-fat items, fruit is rarely available, and fruit juice is less prevalent than carbonated or sweetened beverages.(23)Given the increasing number of youths who are overweight and obese, as well as the emergence of type 2 diabetes mellitus in young people, the association between nutrition and school programs deserves further research attention.(24)(25)

In addition to the promotion of proper nutrition, schools can positively influence health by encouraging physical activity among youth. Studies have shown that physical activity benefits children and adolescents by increasing their aerobic fitness, bone mass, and HDL cholesterol, thereby reducing the risk of obesity and hypertension.(26) However, many children do not partake in adequate amounts of physical activity, as is evidenced by the rising rates of childhood obesity. A main source of  physical activity is from nonschool environments, such as extracurricular sports, which tend to exclude underprivileged children who cannot afford to participate.(27) Including physical activity and nutrition into school curricula has great potential to improve child and adolescent health.(28)

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(1) Campbell, F.A., Ramey, C.T., Pungello, E., Sparling, J., & Miller-Johnson, S. (2002). Early childhood education: young adult outcomes from the Abecedarian project. Applied Developmental Studies, 6(1), 42-57.

(2) Reynolds, A.J., Temple, J.A., Ou, S., Robertson, D.L., Mersky, J.P., et al. (2007). Effects of a school based early childhood intervention on adult health and well-being, Archives of Pediatrics and Adolescent Medicine, 161(8), 730-739.

(3) Muenning, P., Robertson, D., Johnson, G., Campbell, F., Pungello, E.P., et al. (2011). The effect of an early education program on adult health: the Carolina Abecedarian project randomized controlled trial. American Journal of Public Health, 101(3), 512-516.

(4) Feldman, Jacob J. Diane M. Makuc, Joel C. Kleinman, and Joan Cornoni-Huntley. 1989. "National Trends in Educational Differentials in Mortality." American Journal of Epidemiology 129:919-33.

(5) Orfield, Gary, Dan Losen, and Johanna Wald (2004). “Losing Our Future: How Minority Youth Are Being Left Behind by the Graduation Rate Crisis.” Harvard Civil Rights Project, February.

(6) Lockheed, Marlaine and Adriaan Verspoor. 1991. Improving Primary Education in Developing Countries. NY: Oxford U. Press.

(7) Hanushek, Eric. 1995. “Interpreting Recent Research on Schooling in Developing Countries,” World Bank Res. Observer 10:2, pp. 227–46.

(8) Glewwe, Paul; Michael Kremer and Sylvie Moulin. 2001. “Textbooks and Test Scores: Evidence from a Randomized Evaluation in Kenya,” Devel. Research Group, World Bank.

(9) Laugharn, Peter, Negotiating ‘Education for Many’ Enrolment, Dropout, and Persistence in the Community Schools of Kolondieba, Mali, Ph. D. Dissertation, University of London, July 2001.

(10) Ilon, L. and Moock, P. (1991) School attributes, household characteristics, and demand for schooling: a case study of rural Peru. International Review of Education, 37(4), pp. 429-51.

(11) Yokozeki, Y. (1997) The causes, processes, and consequences of student drop-out from Junior Secondary School (JSS) in Ghana: the case of Komenda-Edina-Eguafo-Abrem (K.E.E.A.) district. Education and International Development. London: University of London Institute of Education.

(12) Harbison, Ralph and Eric Hanushek. 1992. Educational Performance of the Poor: Lessons from Rural Northeast Brazil. Oxford U. Press for World Bank.

(13) Lockheed, Marlaine and Adriaan Verspoor. 1991. Improving Primary Education in Developing Countries. NY: Oxford U. Press.

(14) Psacharopoulos, G. (1982). The economics of higher education in developing countries. Comparative Education Review, 26(2). 139-159.

(15) Fentiman, A., Hall, A. and Bundy, D. (1999) ‘School Enrolment Patterns in Rural Ghana: a comparative study on the impact of location, gender, age and health on children’s access to basic schooling,’ Comparative Education, 35(3): 331-349.

(16) Shonkoff J. and Phillips D. (2000). From Neurons to Neighbourhoods. The Science of Early Childhood Development. Washington, D.C.: National Academies Press.

(17) Espinoza L.M. (2002). High-Quality Preschool: Why We Need It and What It Looks Like. New Brunswick, N.J.: National Institute for Early Education Research, Rutgers University.

(18) Masse L.N. and Barnett S. (2002). Benefit Cost Analysis of the Abecedarian Early Childhood Intervention. New
Brunswick, N.J.: National Institute for Early Education Research, Rutgers University.

(19) Centers for Disease Control and Prevention. Guidelines for school health programs to promote lifelong healthy eating. MMWR Morb Mortal Wkly Rep. 1996; 45(RR-9):1–33.

(20) Weschler H, Devereaux RS, Davis M, Collins J. Using the school environment to promote physical activity and healthy eating. Prev Med.2000; 31:S121–S137.

(21) Wechsler H, Brener NC, Kuester S, Miller C. Food service and foods and beverages available at school: results from the School Health Policies and Programs Study 2000. J Sch Health.2001; 71:313–324.

(22) Story M, Neumark-Sztainer D. Foods available outside the school cafeteria: issues, trends and future directions. Top Clin Nutr.1999; 15:37–46.

(23) School Food Service and Nutrition Operations Study. Alexandria, Va: American Food Service Association; 1999.

(24) Troiano RP, Flegal KM. Overweight children and adolescents: description, epidemiology and demographics. Pediatrics.1998;101:497–504.

(25) American Diabetes Association. Type 2 diabetes in children and adolescents. Pediatrics.2000; 105:671–680.

(26) Kemper HCG, Snel J, Verschuur R, Essen LS. Tracking of health and risk indicators of cardiovascular diseases from teenager to adult: Amsterdam Growth and Health Study. Prev Med 1990: 19:642-55.

(27) Ross JD, Dotson CO, Glibert GG, Katz SJ. After physical education: physical activity outside of school programs. J Phys Educ Recreat Dance 1985; 56(1):35-9.

(28) Sallis JF, McKenzie T. Physical education’s role in public health. Res Q Exerc Sport 1991; 62: 124-37.