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This article was downloaded by: [Eindhoven Technical University] On: 22 November 2014, At: 18:29 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK International Journal of Health Promotion and Education Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rhpe20 Children's acquisition of health knowledge through compulsory primary schooling in Bangladesh Samir R Nath a , A Mushtaque b , R Chowdhury b & Fiona Blinkhorn c a Research and Evaluation Division , BRAC , Dhaka , Bangladesh b Columbia University , New York , USA c Salford Primary Care Trust , Salford , UK Published online: 17 May 2013. To cite this article: Samir R Nath , A Mushtaque , R Chowdhury & Fiona Blinkhorn (2004) Children's acquisition of health knowledge through compulsory primary schooling in Bangladesh, International Journal of Health Promotion and Education, 42:1, 4-9, DOI: 10.1080/14635240.2004.10708003 To link to this article: http://dx.doi.org/10.1080/14635240.2004.10708003 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions

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Page 1: Children's acquisition of health knowledge through compulsory primary schooling in Bangladesh

This article was downloaded by: [Eindhoven Technical University]On: 22 November 2014, At: 18:29Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registered office: MortimerHouse, 37-41 Mortimer Street, London W1T 3JH, UK

International Journal of Health Promotion andEducationPublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/rhpe20

Children's acquisition of health knowledge throughcompulsory primary schooling in BangladeshSamir R Nath a , A Mushtaque b , R Chowdhury b & Fiona Blinkhorn ca Research and Evaluation Division , BRAC , Dhaka , Bangladeshb Columbia University , New York , USAc Salford Primary Care Trust , Salford , UKPublished online: 17 May 2013.

To cite this article: Samir R Nath , A Mushtaque , R Chowdhury & Fiona Blinkhorn (2004) Children's acquisition ofhealth knowledge through compulsory primary schooling in Bangladesh, International Journal of Health Promotion andEducation, 42:1, 4-9, DOI: 10.1080/14635240.2004.10708003

To link to this article: http://dx.doi.org/10.1080/14635240.2004.10708003

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”)contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensorsmake no representations or warranties whatsoever as to the accuracy, completeness, or suitabilityfor any purpose of the Content. Any opinions and views expressed in this publication are the opinionsand views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy ofthe Content should not be relied upon and should be independently verified with primary sources ofinformation. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands,costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly orindirectly in connection with, in relation to or arising out of the use of the Content.

This article may be used for research, teaching, and private study purposes. Any substantial orsystematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution inany form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Page 2: Children's acquisition of health knowledge through compulsory primary schooling in Bangladesh

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Children's acquisition of health knowledge through compulsory primary schooling in Bangladesh By Samir R Nath, Research and Evaluation Division, BRAC, Dhaka, Bangladesh; A Mushtaque R Chowdhury, Columbia University, New York, USA; Fiona Blinkhorn, Salford Primary Care Trust, Salford, UK

Key words: primary schools, health education, Bangladesh.

Abstract

This paper investigates the health knowledge of children in Bangladesh completing the five-year cycle of compulsory primary education. Data were taken from a nationally representative sample survey of 2S09 children who came from 186 schools. Eight health knowledge items, available in the textbooks and corresponding to four primary level terminal competencies, were included in the assessment instrument. The analysis revealed that overall performance of the students was poor and they did not acquire acceptable levels of health knowledge. A wide variation in the knowledge of different items was also found, from 28.S to 69.1 per cent. The students who were younger in age, affiliated with the urban schools, with educated parents and access to mass media, were more likely to have better health knowledge. There was, however, no gender variation. With high and increasing enrolment at primary level, there is a strong case for more and effective utilisation of the opportunity to foster health education in Bangladesh.

Introduction

Health and education are two of the basic human rights; however, in many parts of the world there are insufficient funds to ensure that they are available to all. Increasing industrialisation and urbanisation in many developing countries has not contributed greatly to the quality oflife for the rising generations of children and young adults. For example, the under-five mortality rate has reduced from 198 in 1960 to 82 in 1999, but inequity among countries still exists (UNICEF 2001). The under-five mortality ·rate is four in Switzerland and 316 in Sierra Leone. A similar inequity can be seen in education as well: only 41 per cent of Haitian school entrants reach grade five compared with over 90 per cent in the developed countries. The lack of education can

impact on health, as lifestyle development can be compromised if an understanding of health problems is not adequately discussed and taught in schools (Tones and Tilford 1994).

In order to achieve a healthy lifestyle through the existing schooling system, the World Health Organisation (WHO) has been trying to promote school health education programmes for the past SO years. An Expert Committee on School Health Services was established in 19SO and a number of conferences were organised by WHO and UNESCO in the 1960s (WHO 19S1, 1966). The Declaration of Alma Ata in 1978 and the Ottawa Charter for Health Promotion in 1986 are two major initiatives high­lighting and shaping the health promoting schools (WHO 1978, 1986). The World Summit on Children urged the protection of child rights, improved education for children and a focus on enhancing health (World Summit for Children 1990). The Declaration for All in 1990 and 2000 emphasised the right of all populations to good-quality basic education. Such education covers not only the 3Rs (reading, writing and arithmetic) but also an improved quality of life (Inter Agency Commission for the World Conference on Education for All1990).

Bangladesh is one of the signatories to this World Declaration, and the Bangladesh constitution also recognises health and education as basic human needs; however, the country ranks S3rd in the under­five mortality rate (UNICEF 2001). The major contributors to childhood mortality, such as acute respiratory infections and diarrhoea (Mostafa et al 1999, Mitra et al1997), can be prevented with basic health knowledge. It is clear that Bangladesh has not developed effective health education/promotion programmes.

During the last decade the access to primary schooling has improved (Chowdhury et al1999), as the enrolment rate for children aged 6-10 years has increased from about 60 per cent in 1990 to 77 per cent in 1998. The primary-cycle completion rate was below SO per cent in 1990 and has increased to about 73 per cent in 1998. This improvement was due to the government's policy to encourage both state and

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Children's acquisition of health knowledge through compulsory primary schooling in Bangladesh 5

non-formal schooling. Different types of primary school are now in operation in Bangladesh; these include the state-owned schools, privately managed schools, non-formal schools, Islamic religion focused madrassas and English medium kindergartens. The state-owned schools enrol two-thirds of the children, followed by the private (15%) and non-formal schools (8.5%). Most of the schools follow the government curriculum prescribed by the National Curriculum and Textbook Board (NCTB). However, the NCTB has specified 53 terminal competencies that are expected to be achieved at the end of the five-year cycle of primary education. Of these, five are on health (NCTB and UNICEF-Bangladesh 1988).

The five health competencies included by the NCTB are: • Understanding the importance of a healthy

lifestyle; • Interest in building a healthy body through

participation in sports and physical exercise; • To know physical and environmental health norms

and to practise them; • To know about a balanced diet, understand its

importance, and establish healthy habits; • To know the causes of common diseases and how

to prevent them. In most primary schools the pupils learn about

health from teachers and textbooks. However, there are no specific textbooks for grades I and II pupils to gain information on health, whilst for grades III to IV the essential health issues are delivered under the science part of the environmental studies curriculum. Thirty per cent of the total science content of the primary curriculum is about health. The broad issues discussed in these textbooks are food and food habits, water, nutrition, general health norms, primary health care, and health related superstitions in society. The basic professional training of teachers incorporates some health issues but no specialised training on health education is arranged for them. The National Curriculum allocates 43 minutes per week for health education in grades I and II and 83 minutes for grades III to V (Primary and Mass Education Division 1995).

In 1992, plans were developed to assess the basic educational knowledge of the children aged 11-12

years and six basic health knowledge items were included (Chowdhury et al 1994). Two national surveys were carried out in 1993 and 1998, which indicated that children's health knowledge had improved over the period (Nath and Chowdhury 2001). The questionnaire used in these strokes to monitor health related knowledge was independent of the NCTB curriculum, so it was not possible to record just how much knowledge the pupils had gained from their school based lessons. This paper reports on a survey which was based on the NCTB curriculum and explores the health knowledge of pupils at the end of a five-year cycle of primary education.

Methods

The data for this paper is drawn from a nationally representative sample, which recorded the learning achievements of the students at the end of a five­year cycle of primary education in Bangladesh. The survey was carried out under the Education Watch 2000 of the Campaign for Popular Education (CAMPE). The assessment instrument used in the survey was developed by a group of national experts on the basis of 27 cognitive competencies (out of a total of 53 competencies). Schoolteachers from different streams, teacher educators, curriculum experts from NCTB, sociologists, psychologists and statisticians worked together in the development process. Of the 27 competencies, four were on health knowledge, which was assessed through eight multiple-choice questions. Four choices were given against each question item and the students were asked to circle the right one. The questions were assessed dichotomously (correct or incorrect); there was no penalty for a wrong or blank answer. The question and the correct answer are shown in Table 1.

Pupils of grade V at the end of the academic year 2000 representing three sub-systems of primary education, namely government, private and non­formal schools, were the sampling frame.

Considering the assessment procedure as dichotomous, the sample size estimate was calculated to be 392 (with 7% precision level and 95% con-

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6 Children's acquisition of health knowledge through compulsory primary schooling in Bangladesh

fidence limit, and adjusting for cluster effect) (Cochran 1997, Henderson and Sundaresan 1982). Provision of separate estimates by sub-systems and area of residence (urban/rural) were made. A three­stage sampling strategy was designed for the purpose. The rural areas of the six administrative divisions were considered rural areas, and the metropolitan cities and the pourasavas (municipalities) were considered urban areas. At the first stage 30 upazilas or sub-districts (pourasavas/thanas for urban areas) were selected from each of the areas through a systematic sampling technique with probability proportional to size (PPS) of the students of grade V. At the second stage, one union from each selected upazilas and one from each selected pourasavas/thana was chosen randomly. The third stage was to select one school from each of the three different types for each of the selected unions/wards. In each selected school seven boys and seven girls were selected through a systematic random sampling procedure. In some cases where there were fewer students than required, more than one institution had to be taken to fulfil the sampling requirement.

The data was collected in October-November 2000, i.e. immediately before the year ending examinations. A total of 2509 pupils of grade V from 186 schools were assessed; 1251 came from rural areas and 1258 from urban areas, and the gender balance was 50.3 per cent boys and 49.7 per cent girls. Socio-economic information was collected from parents.

Both bi-variate and multivariate analyses were undertaken. In order to determine the influence of the socio-economic background on each of the knowledge items, eight logistic regression models were employed (Menard 1995); and to understand the influence of selected background variables on the overall health knowledge of the students, multiple regression analysis was performed (Berry and Feldman 1985). As the strata population varied substantially, appropriate weights were used for aggregate estimates (Cochran 1977).

The content validity of the instrument is justified in three ways: it reflects the national terminal competencies; the items were drafted by a group of practitioners; and national experts did the re­validation. The external validity of the test was determined by conducting a special test on the 'best students' of ten 'best schools' of the capital. Over 95 per cent of students correctly answered the items, thus validating the test.

Calculation of Kappa statistic, during test development, ensured the reliability of each of the items (Last 1988). The reliability of the whole set of items was assessed through Kudar-Richardson formula 20 (Kuder and Richardson 1937, Carmines and Zeller 1979, Ferguson and Takane 1989). The reliability co-efficient indicated that the instrument was 92 per cent reliable.

Results

Background characteristics of the sample students

The mean age of the pupils was 11.3 years. Over 25 per cent were under ten years of age, 59 per cent were 11-12 years of age and the remainder were over 13 years. Over half of the mothers and 38 per cent of the fathers had not attended school at all. On average, the mothers had three years of schooling and the fathers 4.7 years. The household food security of 8.3 per cent of the students was 'always in deficit', 27.4 per cent 'sometimes in deficit', 39.5 per cent 'balance', and the rest 'surplus'. Nearly 23 per cent of the pupils had no access to any of the mass media. The rural school children were more deprived than those of urban schools in all socio-economic indicators.

Health knowledge: bi-variate analysis

The percentage of children correctly answering the health questions is presented in Table 2, which shows a wide variation for different items. The best performing item was the 'way of achieving good health' (69.1 %), and the worst was the 'measures to prevent skin diseases' (28.5%). Among other items, 61 per cent knew 'how to ensure safety in tube-well water', 56.3 per cent knew 'importance of carbo­hydrate', and 53.2 per cent the 'mode of spreading diarrhoea'. Nearly half of the pupils knew about 'balanced diet', 43.5 per cent knew the 'need of extra food for adolescents' and 41.3 per cent knew 'protective measures for worm infestation'. Gender differences were found in four items: way of achieving good health (p<O.OS), safety in tube-well water (p<O.OS), mode of spreading diarrhoea

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Children's acquisition of health knowledge through compulsory primary schooling in Bangladesh 7

(p<O.Ol), and prevention of skin diseases (p<O.Ol). In the first three items the boys did better than the girls but this was reversed for the fourth item.

Except for 'prevention of skin disease', the children attending urban schools did significantly better than those at rural schools in all the items (p<O.OOl) (Table 3). The children in both areas performed equally on 'prevention of skin disease'. For most of the items, the majority of the subjects from urban schools had the correct knowledge but their counterparts in rural schools showed such a performance only in four items. The boys from rural schools did significantly (p<0.05) better than their female counterparts in two items: 'way of achieving good health' and 'how diarrhoea spreads'. The girls did better than the boys on 'prevention of skin disease' (p<O.Ol). There was no gender difference in any item in urban schools.

Only four per cent of the pupils correctly answered all eight items under assessment. This was 3.5 per cent for rural and 5.7 per cent for urban students. On the other hand, 5.8 per cent of children did not answer any of the items correctly, seven per cent for rural and one per cent for urban. Mean and standard deviation of the number of items correctly answered by the students is provided in Table 4. On

average the students had correct knowledge on four items: 4.1 for boys and 3.9 for girls; 3.7 for rural students and 5 for urban students (p<O.OOl).

Mean and standard deviation of the number of correctly answered items by socio-economic background are provided in Table 5. The socio­economic characteristics are age, school type, parental education, household food security, and access to mass media. The performance of the students significantly increased with increasing education of parents (p<O.OOl), household food security (p<O.OOl) and students access to mass media (p<O.OOl), but decreased with increasing age of students (p<O.OOl). There was variation by school type. The students of non-formal schools topped the score followed by government and private schools.

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8 Children's acquisition of health knowledge through compulsory primary schooling in Bangladesh

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Multivariate analysis

The logistic regression analyses indicated that the health knowledge of the students significantly varied by socio-economic background. The students of urban schools are more likely to do better than their rural counterparts in seven items. The students of rural schools only did better in 'prevention of skin diseases'. Except for the question on 'balanced diet', students' performance varied significantly with the variation in school type in the other seven items. Mothers' education had a positive relationship with the achievement of five items, and with fathers' education with four items. The increase in the students' access to mass media increased their knowledge in five items which are: ways of achieving good health, safety in tube-well water, balanced diet, extra food for adolescents and prevention for worm infestation. The boys outperformed the girls in two items and the girls did better than the boys in one item.

The multiple regression coefficients (Beta) reveal that at the aggregate level of knowledge, the performance of the students significantly increased with the increase in parental education (p<0.001) and access to mass media (p<0.001) (Table 6). However, the performance decreased with the increase of age of the students (p<0.001). Although the students of urban schools outperformed their rural counterparts (p<0.001), the boys and the girls performed equally. Variations in the performance by school type also persisted in the analysis (p<0.001). Unlike bi-variate analysis, no variation was observed due to variation in household food security. The independent variables together explained predicting only 13 per cent of the total variations in the performance, indicating that other variables predicting children's health knowledge are un­explored.

Discussion and Conclusion

The purpose of this paper was to explore the health knowledge of Bangladeshi children completing the five-year cycle of compulsory primary education. The random sample survey of the children repr­esented three major sub-systems - government, private and non-formal schools- which comprise over 90 per cent of the primary school students in the country. A total of 2509 children from 186 schools completed the assessment, which was held immediately before the final examination. It therefore provided an indication of the cumulative achievement of five years of primary education.

The school health programme in Bangladesh is limited, however the primary school authorities did not forget the importance of health in preparing the curriculum. Of the 53 terminal competencies, five are on health, which encompass cognitive, psycho­motor and effective development of the children. This study assessed four of the competencies, which are fully or partially cognitive. Assessment of non­cognitive competencies is equally important in order to gain a fuller picture of the value of school intervention, but was not included in this study.

The findings of this study showed that the children failed to achieve adequate health knowledge through the existing system of compulsory primary education. Less than half of the assessed students correctly answered four of the eight question items, and in no item were over 70 per cent of the children correct. Only 28.5 per cent knew the preventive measures for skin diseases. A wide socio-economic variation in knowledge was also found. Those who came from the urban schools did much better than their rural counterparts. Such a finding is consistent with the findings of other studies undertaken previously in Bangladesh (Chowdhury et al 1994, Nath et al1997). Both the bi-variate and multivariate

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Children's acquisition of health knowledge through compulsory primary schooling in Bangladesh 9

analyses showed that age, parental education, school type and access to mass media are predictors of health knowledge acquisition. Tackling inequities in learning at school requires special emphasis, and the Bangladeshi government will have to revisit the way health education is taught in schools.

Access to primary schooling has increased in Bangladesh over the past decade, but this study shows that the country is not utilising such an opportunity to its best potential to increase students' knowledge on health matters. A recent national survey found that only a quarter of the adult males and females knew the messages included in Facts For Life, a communication material published jointly by UNICEF, WHO and UNESCO (Mitra and Associates 1998). More effective school health education may well prepare children to cope with the common health problems in Bangladesh. However, health monitoring may also make the health component more effective at school level.

The assessment of knowledge about health issues in Bangladesh clearly needs more research.

Acknowledgments

The authors are grateful to CAMPE and BRAC for allowing the use of data from the Education Watch 2000, and to DFID and NOVIB for funding the Watch. The members of the Advisory Board, Working Group and the Technical Committee, who worked in different stages of the project, also deserve acknowledgement. Many thanks to the pupils tested, and the parents and the teachers interviewed.

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Address for correspondence

Samir R Nath, Senior Research Fellow Research and Evaluation Division, BRAC 75 MOHAKHALI DHAKA 1212 Bangladesh Email: [email protected] +

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