School Health in Iran

Introduction

Islamic Republic of Iran is a country with the population @ 34000000 at the end of 1977, but now until the end of 1999 according to the last census is 650000001 from which about 23500000 (27%) are young from 6 to 18. During these last years we have had an increase of adolescent students with ages between 10 to 19 and decrease of primary students (less than 10 years old).

Generally speaking, from 190000002 students of different levels in 100000 schools all over the country, more than 16000000 are the adolescents that study in guidance and high schools and the remainders, are primary students.

Even with the well-established and successful Primary Health Care (PHC) Networks, a satisfactory health condition cannot be achieved as long as people maintain passive attitudes in their approach to health, in their habits and life-style. That's why the goal of health for all by the year 2000, above all else calls for changes in attitudes and habits.

Schools, especially primary schools, are thought to be the best place for bringing on these changes. Schools are widespread, and thus a great number of pupils, families and community members can be reached, even in the rural and remote areas.

In addition, children who are the members of the future generations come to schools at an impressionable age and are motivated to learn. Also, their learning is substantially flourished because, in school they are learning as part of a group. The educational system in Iran consists of three (3) levels:  - Elementary (Primary) [5 years], - Guidance [3 years] and High school [4 years]

Table3 1 shows the number and distribution of schools and students in Islamic Republic of Iran during 2001-2002 school year. 

Table 1- The number and distribution of schools and students
(2001-2002)

The history of school health in Iran goes back to 80 years ago; during which years, it has gone through many changes.

In 1979, after the victory of the Islamic Revolution, the school health department was transferred from the Ministry of Education to (MOE) the Ministry of Health (MOHME).

One of the main achievements of this department was the training of several thousand newly developed school health technicians (Moraghebe Behdasht).

In the Ministry of Health, due to the strong belief in integrated approach of the PHC Networks, the school health technicians, who were all women, were trained for an additional six months to become family health technicians. Many years later, these people were assigned to the MOE and instead of working as multifunctional personnel are now acting just as school health technicians.

Currently, by the use of these school health technicians, the MOE is providing health education as well as environmental, disease control, and many other services in some urban schools. It should be noted that in the rural areas, there are no alternate means other than the health houses and RHC(rural health center) to provide school health services.

Moreover, the numbers of school health technicians available are not enough to fulfill the needs of all urban schools.

Therefore, the cooperation of the two ministries in provision of school health becomes very crucial.

School health was part of the family health program in the MOHME until 1994 when it became one of the seven departments under the supervision of the Undersecretary for public health. The general objective of this department is to enhance the health status of teachers, schools' personnel, students and their families.

This is achieved through increasing their knowledge and consequently, changing their conception, attitudes and habits, which is facilitated by the active participation of students and school workers in health programs and intersectional and intrasectoral collaborations.   

First priorities are rural areas and areas without any facilities.

School health department (SHD) of the Ministry of Health and Medical Education (MOHME) is responsible for all matters of health about all students over the country among 6 - 18.

Among these, education and health services are the most important issues of responsibility. 
 

School Health Activities in PHC

School health activities take place as an integrated part of the PHC Network at the National, Provincial and District levels.

National Level

Its' general activities at the national level are as follows:

• Policy making and broad planning

• Proposal of legislation and setting school health regulations

• Estimation of the needed manpower for provision of school health

• Offering continuing education for teachers and school health personnel

• Encouraging applied research

• Production of educational materials

• Cooperation with international institutions such as the Unicef and WHO, UNFPA, UNAIDS, …

• Coordinating the planning of various health activities in schools; i.e. Oral Health, Environmental Health, etc…

• Encouraging community participation

• Support and supervision of the school health activities at the provincial and the district levels

• Recommendation for inclusion of health related subjects in school books and literatures

The Provincial Level

School health experts at the provincial level are part of a team for planning and supervising school health activities as part of the PHC Networks.

The District Level

According to national and provincial guidelines, detailed planning for school health is carried out by a team at the district level that perform the following services in the rural and urban areas.

In rural areas, behvarzes visit the schools at least once a week and;

• Offer education on different health matters

• Monitor schools environmental health and propose basic steps for sanitation

• Monitor the production and distribution of food in schools

• Perform annual check-up examinations of all students, especially the first graders

• Screening and follow up of the specific cases

• Provide immunization for the first graders.

• Record and collect data pertinent to school health activities and report to the appropriate rural health center.

The health technicians at the rural health center monitor and supervise the behvarzes' activities in schools and report to the district health expert.

                As mentioned before, in the urban areas, some schools have particular school health technicians stationed in schools who perform the same tasks as behvarzes do in the rural areas.

But there are far fewer school health technicians than urban elementary schools.

Thus, the school health activities in these areas are mainly taking place by family health or other technicians of the urban health centers.

Main Ongoing Activities of School Health in MOHME

School health department activities are divided in 3 parts:

Health education

Health care services

Supervision of school environmental health and nutrition hygiene

Health Education

Target groups for education include:

1. Students

2. Students' parents

3. School staff {teachers, school health technicians (Moraghebe Behdasht), another personnel }

4. Health workers {Physicians, Health experts, Health staff, Behvarzes, another personnel }

All activities in this matter are performed by intrasectoral and intersectional collaborations [Ministry of Education (MOE) - Health deputy units of Ministry of Health and Medical Education (MOHME), health care centers & etc…]

Educational issues are variable for different groups, and education can be offered in the form of establishing contests and role playing, or educating on classes - workshops - sessions.

Health workers are responsible for these educations.

Health Care Services

These services include annual check up for screening in all grades and following up, if it is necessary, and also dT vaccination for students   between 14 - 16.

Annual Examination of Primary,Guidance and HighSchool Students
(6 - 18 yrs.)

Part of school health activities include annual examinations of students among 6 -18 yrs ., which is performed by health workers. In urban areas, these examinations are performed in health care centers or in health assessment posts by health workers and in rural areas, these are performed by behvarzes in health houses.

During these examinations, doubtful students (for any cause of disease or disorder) will be recognized and referred to health care centers for examining by physician, dentist or by specialist in professional center)

All these examinations include:

1- Measuring Height and Weight

With this measurement we can determine different indicators which are important in evaluating nutrition and health conditions of students.

This is a simple method for evaluating normal condition of students, from which we can find about nutritional difficulties, social and economic situations, and also about probability of suffering from infectious and parasitic diseases.

With these services we can help and care of any student with any problem and also we can recognize growth problems and side effects of it.

This will help us to guide students' parents about solving children's growth problems.

2- Oral and Dental Health

In Oral examinations, students with tooth cavities or gingivitis should be referred to dentist. Oral and dental health education is very important and students should be recommended for using personal toothbrushes and suitable washing teeth after each meal and especially at night before sleeping.

Another important hints which students should be learned are:

1. Preventing from breaking hard things (nuts) by their teeth

2. Preventing from drinking or eating warm and cold drinks or food at the same time.

3- Spinal Column Condition Evaluating

Spinal column deformity in children may be seen in any age especially in students and it will be seen more frequently in adolescent students.

The most important deformities are Kyphosis, Scoliosis and lordosis.

These problems may be caused by unsuitable sitting, bad conditions of tables and chairs, nutritional deficiency, vitamin deficiencies or endocrine disorders.

Side effects of these deformities are very harmful for students in future because these will be caused rib and chest discomforts, respiratory and circulatory difficulties and it also will cause severe neurotic pains because of related nerve compression.
 

4- Evaluating Nutritional Deficiencies {a: Anemia-b:Goiter }

a) Anemia: Anemic students are pale and have limited activities. In severe cases they will have respiratory problems and will also have puffy face, body and extremities.

For diagnosing anemia, inside of the mouth and lower eyelid should be examined. These parts are red in normal condition and in anemia they will be pink or disposed to white. Anemic students will be screened and referred if it is necessary.

b) Visible Goiter: Iodine deficiency is one of the causes of goiter. With insufficient intake of iodine, thyroid will not make enough hormones, which will cause important health problems.

For diagnosing goiter, concerned examining of thyroid is necessary. In normal condition it is not palpable.

When the thyroid is visible or palpable, referring to specialist is necessary.
 

5- Optical Assessment

Optical examining is just once at a year which is for the first graders of primary and guidance schools during enrollment and for another graders is during educational year.

This examination is performed via Snellen Chart (E. chart) and students with any visional problems should be referred to ophthalmologist for more professional evaluation.
 

6- Hearing Assessment

Another examination for students is for hearing evaluation, which is performed by phonometer or clock or with whispering.

After these examinations, students with any hearing problems will be referred to otolaryngologist for further evaluations.

7- Psychosocial and Behavioral Evaluation

With asking questions from students' parents and teachers, examiner will find any behavioral disorder such as stuttering, chewing nails, sequestering, quarreling and nocturia. In any doubtful cases, referral to physician should be performed.

Each mentioned disorders can cause educational loss in students. With annual examinations, doubtful students will be recognized and if it is necessary, they should be referred to physician for more evaluation and follow up.   

The National Programme of Completion dT Vaccination for First

 Graders of High School

The main objective is complete covering of vaccination for ages between

 14-16 years old students in high schools.

For the first time in January 1995, this programme was established in all over the country.

With timetable programme, near 3 million (82/72%) of these high school students were vaccinated.

There was a tremendous increase of this covering in 2nd and  3 rd  years of programme.

In the 4th year of executing this programme (1998-1999), health workers in schools also performed vaccination of school staff.  

By now, results of this programme are:

1994 --- 90%

1995 --- 82%

1996 --- 92%

1997 ---98%

1998 --- 99% @ 100% which is desirable for us.

Activities:

Organizing collaborative sessions in Main office

Sending the project with it's plan of action to all Medical universities

Providing and sending model of statistics and evaluating forms to all Medical universities

Providing and sending model of dT vaccination card

Providing and spreading required vaccines and syringes for universities with collaboration of preventive and disease control administration.

Performing vaccination of high school staff at the same time of vaccination of students.

Educating students and school staff about dT vaccination importance and other healthy issues.

This programme is continuing in all over the country.

Supervision of School Environmental Health and Nutrition Hygiene
 

This will be inspected by environmental and school health workers, and defects or deterioration will be reported to the MOE related administration [School equipment and new building administration (SEANBA)] and it will also be followed up to reform or correction by SEANBA, with cooperation and monitoring of health workers.

Executive Processes

All of these activities are integrated in PHC.

These activities are provided by behvarz in health house of village, health workers in rural health centers and by experts and physicians on urban health centers.

General activities of rural health centers are about dental health / medical assessment / providing facilities and monitoring.

In urban health centers and in health posts, technicians are responsible for school health services.

Each undercover student has a health surveillance form in school and each undercover school has a health folder in health centers (Rural and Urban)

Each health surveillance form includes all information about students.

All Medical and health services for students between 6 to 18, will be hold during annual checkup for all grades and especially for first graders of primary , guidance and high school students which will be followed up by providing and completion of health surveillance forms for them.

All these forms will be completed by health workers (behvarz in health house of villages / health technician in rural and urban health centers) and after all, form should be endorsed by physician.

These forms include past medical history of student and his/her parents and vaccination.

Also there is screening results about dental health/nutrition/hearing and vision/psychosocial/nail, hair and skin, and spinal column abnormalities. 

After examining student by health workers, if there is any doubt about severe disease/disorder, he/she will be referred to physician or dentist for entire check-up.

There is especial part in surveillance forms for diagnosis and endorsing by physician.

After a complete check-up examination, physician will report if he/she can do his/her school performance/sport or not.

If it is required, there is also a part for specialist report.

Each school health folder has separate forms on it that includes:

1. Health education form

2. Health assessment and screening form

3. Referral and following services form

4. Special services for high risk cases form

5. Vaccination and accidents form

6. Contagious diseases and their follow up form

7. Environmental health form

Any information regarding to health workers' activities in schools is held in these folders and it will be followed up if it is necessary.

Any statistics related to school health, should be collected from these folders and sent to school health office in provinces, and then to Main department in Tehran.

Collaborations

The school health department in MOHME has different collaborations and

Cooperation with other organizations:

A = GOs

B = NGOs

C = International
 

*GOs which include:

1. Consultation and School Health Administration of MOE

2. IRIB ( Islamic Republic of Iran Broadcasting): Radio, TV, Newspapers, Internet

3. MOE (Ministry of Education) Administrations such as:

    

   • Training Deputy

   • Educational Deputy

   • Especial Educational and Assessment Center Organization

   • Council of Parents and Teachers

   • International and General Relations Department of MOE

    

4. Welfare Organization

5. Imam Khomeini Relief Committee

6. High Council for Youth

7. Basij Organization

8. Nutritional Institute

9. Red Crescent Organization

10. Martyr Organization

*NGOs include:

• Psychiatric Institute

• Family Planning Association

*International includes:

• UNICEF

• UNFPA

• WHO

• UNESCO Family Planning Association and International Planned Parenthood Federation

With the national points of view and with WHO creativeness of school health and after executing child to child model project of Unicef, several projects of school health have established to encourage students and their parents to cooperate.

THE MOST IMPORTANT PROJECTS OF SCHOOL HEALTH

1. The community- oriented school project

2. The joint project of health and educational readiness assessment of preparatory students

3. The project of health assessment of first graders in guidance school

4. The project of student's participation in controlling malaria

5. The project of population concepts education

6. The comprehensive national project of pediculosis reduction

7.  

Translated by:Dr.MinooSadat MahmoodArabi(M.D)
Senior Schoolhealth Expert
Health Deputy(MOHME)