| Abstract|| |
Background: Cardiovascular diseases (CVDs) are one of the most common causes of morbidity and mortality. Most of the risk factors of CVDs develop early in childhood. Schools immensely influence the thinking pattern of students and can thus shape their behavior. However, no amount of knowledge and awareness can change health behaviours of students until they get support from enabling environment in the schools. The Ottawa charter has also emphasized on building healthy public policy and creating supportive environments for health promotion in schools. Materials and Methods: The present study was conducted in 10 schools in Delhi, India. School policies, environment, community participation and approach of school health agency were assessed by interviewing authorities, review of related documents and direct observation in schools. Results: It was found that none of the schools had any written health policy. Environment in most of the schools was not conducive for cardiovascular health promotion. Conclusion: The study highlights that the schools lack health policies and environment for cardiovascular health and also points out the approach of school health agency, focusing on medical check-ups and treatment of minor illnesses.
Keywords: Cardio vascular diseases, environment, health policy, health promotion, schools
|How to cite this article:|
Kaur R, Mishra P, Taneja DK. Cardiovascular health promotion in schools of Delhi, India: A baseline evaluation of environment and policies. Ann Trop Med Public Health 2012;5:114-8
|How to cite this URL:|
Kaur R, Mishra P, Taneja DK. Cardiovascular health promotion in schools of Delhi, India: A baseline evaluation of environment and policies. Ann Trop Med Public Health [serial online] 2012 [cited 2020 Feb 21];5:114-8. Available from: http://www.atmph.org/text.asp?2012/5/2/114/95965
| Introduction|| |
Cardiovascular diseases (CVDs) are a major cause of morbidity and a leading contributor to mortality worldwide. In 2005 noncommunicable diseases accounted for 53% of all deaths in India, out of which 29% were due to CVDs.  Besides this, coronary heart disease in Indians has been shown to occur at least a decade or two earlier than their counterparts in developed countries. 
CVDs have multiple risk factors like unhealthy diet, physical inactivity, tobacco and alcohol use. Most of these are determined by patterns of behavior established in childhood. , Hence, these cardiovascular risk behaviors may be easier to modify in younger age rather than at later ages.
Schools have profound influence on thinking patterns and behavior of children and their families. The school environment and policies affect the behavior of children in the formative years of their personality that directly influence their lifestyles later in life. Applying the principles of health promotion in school children can lead to decreased burden of CVDs.
The Ottawa charter released in 1986 was a major milestone in the direction of health promotion. It focused on health promotion actions like building healthy public policy, creating supportive environments, strengthening community action, developing personal skills and reorienting health services.  Based on these principals the health promoting school concept was adopted by the World Health Organization (WHO) in 1995.
In India, there is lack of studies based on the aspects of health promotion in schools. Therefore the current study was carried out with objectives of evaluating school health policies, school environment, approach of school health agency and community participation towards health promotion in relation to cardiovascular health.
| Materials and Methods|| |
The present study was carried out in central district of Delhi, the capital of India. Central district was selected for the study because of proximity to the research institution. All schools, government and private in central district of Delhi were included in the sampling frame. Five government and five private schools were randomly selected from the list of schools.
Exclusion Criteria: Schools involved with WHO's 'School Health Promotion Project' were excluded from the study, as the project could have affected the school environment and policies.
In the beginning, permission from the Delhi Government School Health Scheme was taken for government schools whereas for private schools permission was sought from the concerned authorities i.e., Principals, Vice Principals or Members of the managing trust (in one school). A suitable date and time was fixed for the interview. On the prefixed days Principals or Vice Principals were interviewed using a semi structured questionnaire to get information on school health policies, participation of parents, teachers and students in health issues and approach of school health agency in cardiovascular health promotion. Class monitors were also interviewed to get information on meetings of parents, teachers and involvement of parents in health issues. They were also enquired about periods of physical activity per week, availability of sports equipments, guidance by physical education or yoga teacher and use of tobacco or alcohol by any staff member in the school.
Observations regarding display of any school health policy, availability of play ground, type of food in the school canteen and outside the school as well as approximate distance of outlets for sale of tobacco products from the school, were made by the investigators and recorded on the proforma.
Ethical considerations: The study was approved by the ethical committee of the institution. The objective and procedure of the study was explained to the school authorities. Written informed consent was taken from the school authorities. Address and the phone numbers of the investigators were made available to the school authorities and students for further communications if required.
After completion of the study, students and teachers in these schools were given health education regarding risk factors of CVDs and how to avoid modifiable risk factors of these diseases.
| Results|| |
School Health Policies
None of the10 schools studied had any written health policy. No school, government or private, had policy for regulation of food stuffs sold in the canteen or vendors selling food products just outside school premises. None of the schools had written policy for prevention of tobacco and alcohol use. Only in one private school a board indicating 'Selling of Tobacco Products within 100 Yards of School is Prohibited' could be found. In another private school a board saying 'No Smoking Zone' was displayed.
Five schools (two government and three private) had informed the investigators that they were following some regulations, like prohibition of tobacco and alcohol use in the school campus, but these were neither documented nor displayed.
All the schools studied except one had a play ground for outdoor games and physical activities along with equipments for playing games like volleyball, football, cricket, etc. [Table 1] Students had free access to these equipments during games period in all these schools except for one government school where these were available to students of senior classes only and that too not always.
Most of the schools had two or more games teachers, except for one private and two government schools which had only one teacher. Two of the government schools also had one yoga instructor with them.
Only one government and one private school had three or more games period per week for each class.
Effects of physical activity and obesity were included in curriculum in one government and one private school only. Extracurricular activities in the form of plays, skits, mono acting competitions, poster making competitions, etc. for promotion of physical activity and prevention of obesity were held in one government and two private schools.
All the private schools and two government schools had canteen in their campus. Canteens both in government and private schools were serving fast foods like burger, patties, fried savory snacks, aerated drinks, chips, etc. Only two private school canteens had healthy food items (like fruits, rice and pulses, fruit juices, etc.) along with fast foods.
All the government schools had vendors/hawkers selling junk food outside the school where as three out of five private schools had such vendors. The food items sold by these vendors were chhole bhature, kachauri (fried Indian snacks), chips, ice candy, etc. Only two government schools had vendors selling fruit chat but it was not hygienic.
Out of 10 schools, seven (two government and five private) covered the effects of fruits, vegetables and fast foods in the school curriculum during the last 1 year. Extracurricular activities covering good dietary practices like intake of fresh fruits and vegetables, avoidance of fast foods and carbonated drinks were held in two government and two private schools.
Tobacco and alcohol
Outlets selling tobacco products were present within 100 yards of all government schools and four of the five private schools studied [Table 2].
In one government and two private schools students had reported use of tobacco products like Khaini, paan, gutkha (forms of chewable tobacco commonly available in India) by school staff during school hours. Use of alcohol by any staff member during the school hours was not reported by students in any of the schools.
Only half of the schools studied had covered effects of tobacco and alcohol on health in their curriculum. Extracurricular activities highlighting effects of tobacco and alcohol were held in two government and two private schools.
Involvement of parents in health issues
Parents- teachers' meetings were held in all the schools. In government schools these meetings were held only 3 - 4 times a year. The frequency of such meetings was more in private schools, every 2 -3 months. While private schools made it compulsory for parents of every student to attend such meetings, it was optional in government schools. In most of the schools, the main focus of these meetings was to discuss academic performance of the students. In none of the schools these meeting addressed health issues nor did the teachers send any health-related messages to parents though the students.
School health agencies
All government schools were provided health services by Delhi Government's School Health Scheme. The health services were provided by a team of one Medical Officer, one pharmacist and two other supporting staff. The services provided were mainly limited to periodic examination and screening of the students annually along with T.T immunization, treatment of minor illnesses and referral of students requiring higher care. These services were accompanied by occasional extra-curricular activities addressing health like Health Mela, etc.
In private schools health services were provided by different health agencies from private sector. The staffing pattern varied in different schools with visiting doctor for periodic medical examination and screening in all these schools. Two schools had one permanent nurse each for treatment of minor illnesses. In rest of the private schools there was no health staff permanently posted in the school and the responsibility of treating minor injuries and illness had been given to one of the teachers. All the schools had linkages with nearby hospitals/nursing homes for emergencies.
The approach of school health agencies of all the schools studied was mainly focused on routine medical examination and treatment of minor illnesses and referral services. None of the school health agencies were involved in health education through extracurricular activities or in advocacy to school authorities for health promotion. There was also no participation of school health agencies in PTA (Parent Teacher Association) for health promotion in any of the schools studied.
There were no school health team/committee in any of the school comprising of representatives of students, teachers and parents.
| Discussion|| |
CVDs, one of the most common causes of mortality, are life style related and associated with a number of risk factors that begin in childhood. Schools can play a prominent role in developing health promoting behaviors among school children. It has been well realized that schools have to move from the simple classroom-based topic focused old style health education to the whole settings approach and the broad-ranging, comprehensive actions for developing healthy behaviors among students. 
School health policies have a very important bearing on health of students. The Ottawa charter of "Health Promotion" also mentions health policies as an integral part of health promotion in any setting. In the current study, none of the schools evaluated had any written and displayed school health policy. Our results are consistent with the results of an evaluation done in two government and two private schools in Delhi by a voluntary organisation HRIDAY-SHAN which also reported no health policies in all four schools studied by them.  This finding from Indian setting is different from that of the developed countries since many of them had already implemented comprehensive health promotion in schools. According to SHPSS 2006 (School Health Policies and Programs Study) which is a national survey periodically conducted in US to assess school health policies and programs at the state, district, school and classroom levels, 63.6% of total schools studied had health policies.  This could be due to early and widespread implementation of health promotion in schools with most of the schools already labelled as "Health Promoting Schools" in US where as this concept is relatively new in India.
Studies conducted in Philadelphia and Scotland have shown that healthy eating policies in schools have resulted in healthy eating behaviors among students. ,
School environment directly influences the behavior and practices of students. Students need supportive environment to practice the knowledge gained in classroom teaching about healthy behavior. Many of the studies have demonstrated change in students' health behavior and practices with improvement in environment. A study conducted in 287 schools in US had shown that changing the type of food available in the school campus from sugar sweetened beverages and low nutrient energy dense foods with fruits and vegetables and other healthy options significantly reduced the calories intake by school students. 
Although there are not many studies on evaluation of school environment conducive for health, our findings are consistent with the findings of evaluation done by HRIDAY-SHAN which also reported only one of the private school in Delhi having environment supportive for good dietary practices. 
Only two out of 10 schools in the current study had environment supportive for physical activity. A study done by Russel et al, in 22 high schools in US had shown that change in school environment along with instructional practices for physical activities had resulted in significant increase in physical activity among students. 
In India sale of tobacco products within 100 yards of any educational institution is strictly banned according to law. In spite of that sale of tobacco products was found within 100 yards of 9 out of 10 schools studied.
In the present study alcohol use was not reported by any of the school staff/teacher during school hours. Thus all the schools studied had environment conducive for prevention of alcohol use by students.
None of the schools studied involved parents in health issues of students. Similar findings were confirmed by HRIDAY-SHAN in their study, where only one private school out of four schools somewhat involved parents by providing them information on healthy diet during parents teacher meetings and also sending health messages through the school diary, containing guidelines for encouraging the students to bring cost effective healthy food in their tiffins. 
Parent's involvement is crucial for the implementation and maintenance of new health behaviors in younger children. Studies like "Healthy Start" project in New York have documented improvement in health behavior and practices of school children by involving parents in health issues of students. ,
In the current study school health agency was not involved in health promotive activities in any of the schools.
No comparable studies evaluating approach of school health agencies toward health promotion were available. However, a study conducted among dental nurses regarding knowledge and perception of oral health promotion in schools showed that majority (60%) of dental nurses did not perceive oral health promotion to be important. Nearly 25% of them did not think they had a role to play in providing healthy food choices in school canteens. 
The result of our study also shows the lack of comprehensive approach of school health agency toward health promotion.
| Conclusion|| |
The present study highlights that the schools lack health policies and supportive environment conducive for cardiovascular health. There is no involvement of parents in health issues of students in the schools studied. The current study also points out the narrow approach of school health agency, focusing mainly on medical check-ups and treatment of minor illnesses instead of comprehensive health care including health promotion.
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H. no 3, Opp. Manak Bhawan Staff Quarters, Bahadur Shah Zafar Marg, New Delhi-110 002
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]