Health Promotion International, Vol. 16, No. 4, 321-331,
December 2001
© Oxford University Press 2001
School and anaemia prevention: current reality and opportunities—a Tanzanian case study
1 South Australian Centre for Rural and Remote Health (SACRRH), University of South Australia, Whyalla Campus, SA 5608, Australia, 2 School Health Program, Ministry of Health, PO Box 9083, Dar es Salaam, Tanzania, 3 Tanzania Partnership for Child Development, Ocean Road Hospital, PO Box 9383, Dar es Salaam, Tanzania, 4 Deakin University, School of Health Sciences, 221 Burwood Highway, Burwood, Victoria 3125, Australia and 5 Aboriginal Home Care Program, 2 Marion Road, Brooklyn Park 5031, South Australia
Address for correspondence: Lillian Mwanri South Australia Centre for Rural and Remote Health University of South Australia Whyalla Campus Nicolson Avenue Whyalla Norrie SA 5608 Australia E-mail: lillian.mwanri{at}unisa.edu.au
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SUMMARY |
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Iron deficiency anaemia is highly endemic in rural areas of Tanzania and in many developing countries. Its prevention among school children requires greater dissemination of knowledge of anaemia among children, teachers, parents and the general community. Associated improvements in the hygienic status of domestic and school environments are also often required. One-hundred-and-thirty-one anaemic children, 90 parents and 76 teachers were interviewed to ascertain their understanding of anaemia. Most children and parents had little knowledge of the symptoms, causes and prevention of anaemia. In addition to their iron-deficient diets, more than half of the children went to school without something to eat at breakfast and during school hours. However, parents and teachers were willing to work together to provide meals for the children. Poor sanitation in the children's homes and in schools was a little recognized factor which could pose a serious risk of anaemia. In addition, inadequate sanitation facilities and poor quality of physical environment prevailed both in the children's homes and in schools. The findings suggest the need for the establishment of a health-promoting schools network to provide a comprehensive framework for health promotion in schools as well as in homes in Tanzania and in other developing countries. Schools can be an ideal setting to positively influence a community's health status. Partnerships among teachers, parents and the wider community are required to identify, prioritize and ameliorate health problems.
Key words: health-promoting schools; iron deficiency anaemia; partnerships; Tanzania
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONACKNOWLEDGEMENTSREFERENCES |
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Iron deficiency anaemia is a public health problem in most countries, especially those in Africa and Asia (World Health Organization, 2000
). In 1991, >290 million school-aged children were anaemic, of whom 150 million attended school (Viteri, 1991).
Several studies have shown that anaemia affects cognitive functioning, motor performance and educational achievements (Soemantri et al., 1985; Pollitt et al., 1989; Seshadri and Gopaldas, 1989; Soemantri, 1989; Mwanri, L., Ryan, P., Worsley, A. and Masika, J., manuscript submitted). It is also associated with behavioural deficit, cognitive dysfunction and decreased immune function.
In 1990, the World Children's Summit emphasized that better health and education are basic rights for every child (World Bank, 1993). In fact, the two are interdependent. Successful education depends in part on good health, and in turn good health requires adequate nutrition. More children than ever are attending school, and for longer periods of their lives. If children are to take full advantage of the education they are offered, their ability to attend school and to learn must not be compromised by ill health (World Bank, 1993). Unfortunately, 11% of the global burden of disease affects school-aged children, many of whom suffer from micronutrient deficiencies (World Bank, 1993).
In Tanzania, iron deficiency anaemia is a recognized public health problem. Its prevalence in some parts of the country is as high as 100% [Kavishe, 1991; The Tanzania Partnership for Child Development (UKUMTA), 1996]. Parasitic infections such as intestinal worms, schistosomiasis and malaria, low dietary intake and chronic illnesses are the commonest causes of anaemia (Kihamia et al., 1974; Stephenson, 1987). In order to be able to control and prevent these diseases, children, parents and other members of the community require sound knowledge of these conditions in order for them to take preventive measures. Prevention of these conditions will lead to the prevention of iron deficiency anaemia. Likewise, parents and children need to have sound knowledge of nutrition in order for them to be able to consume foods rich in iron, which will lead to the prevention of iron-deficiency anaemia. Knowledge is one of several factors required to promote health in order for people to increase control over, and to improve their health. As promulgated in the Ottawa Charter (WHO, 1986) the others include building healthy public policy, creating a supportive environment, strengthening community action and reorienting health services.
Parents' health knowledge has been found to be positively correlated with child health and nutrition in developing countries (Glewwe, 1999). For example, in his survey, Glewwe found mothers' knowledge to be crucial for raising children's health in Morocco (Glewwe, 1999). Similarly, Variyam et al. used USA food consumption data to examine the effects of maternal knowledge on dietary intakes of children (Variyam et al., 1999), and found that maternal nutritional knowledge influenced children's dietary pattern, which may significantly influence the probability of acquiring certain chronic diseases in the future. These examples suggest that parents' knowledge of health issues can substantially raise child health and nutrition in both developing and developed countries.
Household characteristics such as hygiene, parents' education, household income and number of children living in the same house appear to be important determinants of nutrition knowledge and dietary intake (Variyam et al., 1999). Nutrition knowledge affects health-related choices and as such may influence the probability of acquiring certain nutrition-related conditions.
Schools should provide sound nutrition education and should be an entry point for promoting children's as well as the entire community's health. In 1997, the WHO initiated the Global School Health Initiative, ‘The Health Promoting School’, which focuses on creation of comprehensive school-based activities to improve health (WHO, 1997). The initiative describes a health-promoting school as a school that strives to strengthen its capacity as a health setting for living, learning and working. Various health problems or risks may be identified and prioritized, and used as an entry point in order to effectively address important health concerns within the schools and the community. This initiative recognizes the need of the community to understand the importance and feasibility of improving health through schools.
The physical environment of the school, in particular, has been identified as an essential factor in children's learning (Long-Shan et al., 2000). For example, good sanitary facilities and a safe water supply are essential elements in promoting children's health. Schools can also develop the environment, motivation, services and support necessary to contribute to the integrated promotion of health behaviours, which can be a lifelong asset (McKenzie and Williams, 1982). Healthy behaviours are crucial for the prevention of iron-deficiency anaemia.
We had the opportunity to examine the state of the factors described above in the Bagamoyo district of Tanzania, which is quite typical of many rural regions in developing countries, where anaemia is a known public health problem. The aims of our study were to: (i) examine children's, parents' and teachers' knowledge of the symptoms, causes and prevention of anaemia; (ii) investigate children's, parents' and teachers' attitudes towards anaemia control and prevention practices; (iii) examine the environmental and living conditions, both at home and at school, which can promote health; and (iv) investigate parents' and teachers' attitudes towards school meals and their willingness to provide them.
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METHODS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONACKNOWLEDGEMENTSREFERENCES |
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Study area and population
The study was conducted in March 1999 in Bagamoyo district schools, in rural Eastern Tanzania. Most of the pupils were poorly nourished and came from the homes of subsistence farmers. They and their families subsisted on diets that were high in unrefined cereals and low in animal protein. The staple crops were maize, rice and cassava. A few families had cattle and goats, which were used as sources of cash, not foodstuff. The food supply in the study area was very limited at the time the study was conducted, due to the severe El Niño rains the previous year, which had prevented planting.
Children's survey
A questionnaire was designed to obtain information on the children's knowledge, attitudes and practices regarding anaemia. Children from three schools who met the selection criteria were the subjects of our study. They were selected according to the following criteria: (i) children in grades two to five, of both sexes, and aged 9–12 years (only non-menstruating girls were invited to participate in the study); (ii) children who had attended school for at least 2 years; (iii) children who were not using any supplements; (iv) children of parents/guardians from whom informed consent (written or verbal) to participate in the study was received; (v) children who had haemoglobin concentrations of <120 g/l (WHO, 1968) as determined by a portable battery-operated haemoglobinometer (Haemocue, Sheffield, UK), which used finger-prick blood for haemoglobin estimation. All the children belonged to rural families with similar low socio-economic status.
The questionnaire was pre-tested on children in another school that was not involved in the study. Each child was interviewed in private by a trained interviewer. The questionnaire included questions about the children's knowledge of anaemia, its causes, associated symptoms and problems, possible personal preventive measures, and sources of information about anaemia. Additional questions were asked about the children's meals and diet in order to estimate roughly the pattern and quality of diets eaten by the children at home and at school during the previous 24 h.
The data were analysed by calculating the percentages of children's responses to the various questions.
Parents' survey
A similar questionnaire was designed for parents. However, additional information was sought to ascertain their social economic status, details of foods their children ate at school, their opinions about their children's diets' while at school, and, in particular, whether they approved the provision of meals for their children at school. They were also asked about the ways in which the provision of school meals could be organized.
Parents were interviewed in person by one of the trained interviewers at the children's school. Again, the data were analysed by calculating the percentage of parents' responses to each question.
Teachers' survey
A third questionnaire was sent to the health teachers in all schools in the district. It included similar questions to those asked of the pupils, but additional questions were included to establish the number of pupils enrolled, the presence or absence of latrines (including the number of pits), the presence or absence of vegetable or fruit gardens in the school, the provision of school meals, the teachers' willingness to participate in school meal provision, and their opinions on the ways in which schools could participate in school meal provision. The data were analysed similarly to the children's and parents' responses.
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RESULTS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONACKNOWLEDGEMENTSREFERENCES |
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Children's demographic characteristics and sources of information about anaemia
A total of 131 children were enrolled in the study, consisting of 70 girls and 61 boys. The majority of children had heard about anaemia (73%) and learnt about it from school (82%). However, only 57% cited teachers as sources (Table 1
). Parents appeared to be sources of information for only 18% of children.
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The home environment, parents' literacy status and their recalled sources of information
Most of the houses were of poor quality, made of thatched roofs and mud walls (Table 2
). The majority had uncovered floors and a few had roofs made of corrugated iron sheets. Most of the community members owned latrines, most of which were uncovered. Many households shared communal taps for water supply, but a few only had shallow wells, which were not safe for drinking. Firewood appeared to be the major source of energy. Most households had a radio (73%) and bicycles (62%). The majority of parents (88%) domesticated animals, which were used for cash as well as for food. There were ~5.5 children per household (range 1–15); however, the children living in the household did not necessarily belong to the parents but they were related, for example nephews and nieces. The mean number of children living with their own parents was 3.6 per household. Twenty-one per cent of parents interviewed did not have any formal education and as such were illiterate.
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Teachers' responses and their sources of information
Teachers in 76 schools (out of 98 invited) participated in the study. Sixty-three responding teachers were males (83%) and 13 (17%) were females. Almost all (99%) of them had heard about anaemia. Their main sources of information were teachers' colleges (52%), hospitals (86%), self reading (58%) and friends (41%). All of the teachers had a sound knowledge of anaemia, and most thought it was very harmful to health. About 8% reported they had been treated for anaemia in their lifetime.
Children's, parents' and teachers' knowledge of symptoms of anaemia
The children had less knowledge than the parents and teachers (Table 3). For example, only 28% of children knew that dizziness was a symptom of anaemia compared with 72 and 78% of parents and teachers, respectively. Similarly, only 41% of children knew that tiredness was a symptom of anaemia compared with 73 and 72% of parents and teachers, respectively.
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Knowledge of causes and prevention of anaemia
The children had less knowledge of the causes of anaemia than parents and teachers (Table 4
). For example, only 14% of them knew that chronic illness was a cause of anaemia, compared with 53% of parents and 63% of teachers. Similarly, the children had less knowledge about the prevention of anaemia than parents or teachers. In general, teachers had better knowledge about anaemia than the parents (Table 5).
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Children's, parents' and teachers' dietary habits
Over half of the children (59%) had nothing to eat before coming to school (Table 6
). For the other 41%, the most commonly consumed breakfast included black tea and bread, porridge made from maize flour, black tea with cassava, and, sometimes, plain black tea only.
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During the school day, the majority of children (73%) did not have anything to eat in school. Even for those who said they had something to eat during school hours the nutrient value of what was eaten was poor, as it consisted of small locally made buns, chewable groundnuts and, in one school, ice blocks sold by teachers who owned refrigerators.
Consistent with the children's reports, 17% of parents reported that their children ate something while in school. However, only 10% provided their children with some sort of food to be eaten at school. Seven per cent provided their children with money to buy snacks from the school vendors.
The majority of parents (93%) supported the provision of meals at school. Indeed, many of them (84%) were willing to participate in providing school meals. They suggested that parents could provide assistance in meal preparation and make other contributions, such as provision of foodstuffs.
Children's meal/food consumption outside school
Vegetables, some meat and fish were consumed by the majority of children (84%) at least once a week. However, only about 6% reported daily consumption of beef and vegetables. Although all children reported eating fruits, the majority only had access to seasonal fruits (73%) (Table 7).
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All parents reported that they and their children ate vegetables or meat with their main meal (ugali), which was made from maize flour. The majority ate vegetables on a weekly basis (66%). While most (81%) reported eating meat on a weekly basis, many of them ate fruits when they were in season (77%) (Table 8
). It appears that teachers consumed fruits and vegetables more frequently than the children's families (Table 9).
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The schools' physical environment
School enrolments ranged from 50 to 1133 children. All schools but one claimed to have pit latrines for excreta disposal, but they were of poor quality. Most of the latrines were for temporary use with no cement floor. Furthermore, most of the latrines had no roofs to protect the superstructures and users from rain or sunlight. Most pits had no covers, making them places for housefly breeding, which could pose a risk for disease transmission. The walls were built of grass or coconut leaves. In most schools, there were far fewer pits than recommended by the WHO (one pit for every 25 girl students or for every 30 boys). Only seven schools (9%) met this requirement.
Forty-five per cent of the schools had vegetable gardens. However, they were activated only during the rainy season because of the lack of water during the dry season. Although 13% of schools provided school meals, this was possible only for a short time after the harvesting season. Most schools sold their produce because the amount produced was too little to feed the school population, even for a short period of time. Most of the teachers, like the parents, were ready to participate in school meal provision. They suggested ways in which school meals could be provided, including support from the parents, both financial and in kind, and assistance from the government.
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONACKNOWLEDGEMENTSREFERENCES |
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Knowledge of anaemia
The results of this survey show that the children had fairly poor knowledge of anaemia compared with parents or teachers. Common causes of anaemia such as parasitic infections and chronic illness were known by only a small percentage of school children compared with parents and teachers. Although the children were supposed to be taught nutrition from grade one, their basic knowledge of symptoms, causes and prevention of anaemia was lowest among the three groups of people interviewed. These results highlight the need for more resource allocation to programmes that would improve the health and education of school children. These resources are needed for health education materials, teachers' capacity building and training. Moreover, there is a need for the establishment of school lunch programmes in order for children to learn about health issues, as is the case in some Thai schools (Mwanri, 1994
). Even the parents' knowledge was, in some instances, questionable. For example, 35% of parents reported that use of toilets does not prevent anaemia and 13% did not know about it. That is, 48% of parents did not acknowledge the importance of toilets for anaemia prevention. This could be a result of currently available health education, which does not relate the use of latrines to the prevention of anaemia. The available public health education materials (in illustrations or radio programmes) overemphasize the use of a balanced diet as a preventive measure against anaemia and overlook other related issues such as hygiene and water supply, which can be indirect causes of anaemia (via worm infections, houseflies transmitting dysentery when they fly from uncovered pit latrines to food ready to be eaten).
Almost 50% of parents reported that drinking beer/coke would prevent anaemia, which could be the result of attractive promotion programmes held by beer and soft drink companies, which are conducted very intensively down to the village levels throughout the country. Such poor knowledge of symptoms, causes and preventive measures makes it very difficult to control and prevent anaemia effectively.
Although the teachers' knowledge of symptoms, causes and prevention of anaemia was the highest of the three groups, the reliability of their knowledge was somewhat doubtful. For example, 49% did not know whether the use of toilets would help prevent anaemia. Based on these facts, it is evident that there is a need to develop activities which will ensure that parents and children are provided with adequate education in order to raise their knowledge of anaemia. The present results suggest the need for review of current anaemia education programmes in the country.
The home physical and socio-economic environment
The environment in which children live strongly influences the learning of children (Saini, 2000). It may also be the source of health problems, which may affect how they interact and learn (Wass, 2000). Overcrowding in the homes of these children (mean 5.5 children/household) could pose a risk of health problems such as respiratory tract infections, which could lead to poor school attendance and in turn poor learning. The poor quality of their latrines and the sharing of the communal water supply are likely to pose considerable risks of diseases such as intestinal worms and recurrences of diarrhoeal diseases. Improvement of the home environment and living conditions is important in order to improve the health and learning of these children.
Better parental education, especially maternal education, has been shown to increase health and nutrition knowledge, which in turn increases the quality of children's diets (Variyam et al., 1999; WHO, 1999). Since a substantial number of parents did not read or write, there is a need for deliberate efforts to improve the parental literacy level.
Role of schools and teachers in prevention of anaemia
The importance of safe hygienic school environments, which allow children to work and play, is self evident (Long-Shan et al., 2000). Schools should be able to provide an environment that promotes health not only to children but to the entire school community. Schools could act as role models in sanitation as well as in all matters pertaining to health and education. As such, they should have a high standard of sanitary facilities, especially pit latrines, which are important for prevention of diarrhoeal conditions such as dysentery, which can lead to severe anaemia if a victim survives. The government could allocate some funds to subsidize parents' efforts for building simple but effective latrines for excreta disposal. In this regard, parents could contribute human labour, just as they provide it for building classrooms, while the government contributes building materials for such activities. The existence of such collaboration would be consistent with the WHO concept of Health Promoting Schools.
At the curriculum level, teachers should be able to teach material relevant to local situations in order for children to acquire knowledge that they can use for prevention of locally prevalent diseases. The current curriculum does not emphasize teaching children the local issues that affect their health. Teachers should be free to tailor their teaching to specific local health issues that are relevant to their pupils' well-being.
Dietary intake
The children and parents in our study appeared to have iron-deficient diets (Tables 7 and 8
). Dietary intakes of food such as meat, vegetables and fruits that are rich in iron are important in the prevention of anaemia (Underwood and Smitasiri, 1999). In addition, the frequency of food consumption is another determinant of anaemia prevention. Not only did children have poor intakes of iron-rich foods, but a substantial number of children did not have anything to eat before going to school or during school hours. This suggests that many are hungry for much of the day. The provision of meals at school would improve children's nutritional status and reduce the incidence of short-term hunger at school (Walker et al., 1998). Studies in developing countries have shown that undernutrition and hunger among school children may affect their performance in school (Simeon and Grantham-McGregor, 1989; Simeon, 1998).
In their responses, both parents and teachers acknowledged the need for children to have meals during school hours. Most were willing to participate in the provision of meals. The parents' willingness to improve the health and nutrition of their children is a resource that can be employed to achieve better health and nutrition among these malnourished children. This could be done by developing consultation strategies which would involve parents, teachers and school communities as a whole in participating in activities that would promote health in schools. For example, in China, the involvement of parents and the entire community in a deworming programme helped transform the health behaviour of school children and influenced school policy formulation that favoured not only children's health, but that of the entire school community (Long-Shan et al., 2000). This Chinese example demonstrates that governments cannot conduct children's health promotion programmes in isolation from the local community. Partnerships are required between schools, the local community and central government. The health and welfare of school children should be a responsibility of the school community (parents and teachers) as well as government. Governments have to ensure that they involve key partners in these issues and set up a policy framework for the provision of school meals, as is the case of health promoting schools.
Development of partnerships for improving school health and education
To achieve maximum community partnership and commitment, and to be able to work in partnership with local and central governments, schools should be advised by parents' boards. These would empower parents to address school meal provision and other issues related to school children's welfare. This approach had been used in the 1970s in Tanzania and anecdotal information suggests that children's health status then was better than it is now. In the above example from China, the deworming programme became successful and influenced family priorities after parents and other community members became actively involved in the programme (Long-Shan et al., 2000). This suggests that partnership with parents, local communities and the government can be developed to foster activities that will promote the health and learning of school children.
The running costs for school meal programmes can be relatively high. Partnerships between communities, local government (especially district and village councils) and central government may allow some cost sharing in a manner appropriate to the local situation. For example, in Thailand, school lunches are provided by all schools but the delivery strategies differ in different regions and schools (Mwanri, 1994). In the cities, parents contribute a certain amount of money to schools, which use the money to buy foodstuffs, and pay the cooks and other workers involved in school meal provision. In the rural areas, parents donate foodstuffs and volunteer to prepare and serve meals.
In Tanzania, the organization of these services could be adapted to local conditions. For example, communities could involve volunteers such as parents or carers in meal preparation, while other parents, who cannot volunteer their time, contribute foodstuffs. Local government might contribute additional foodstuffs and cooking utensils, while the central government could provide kitchen facilities, and in an event that some schools fail to organize community volunteers, the employment of a part-time cook. Alternatively, parents could contribute a certain amount of foodstuff, particularly maize flour, during the harvesting season, allowing the school to store it for use throughout the whole year. In addition, parents could allow their children to bring firewood to school for cooking. Since the majority of schools have gardens which are not used in most instances due to lack of water, ways of collecting rain water during rainy seasons could be devised, allowing the schools to collect water for use in the gardens in the dry season.
For all of these options, the school principals should be the accounting officers. At the central government level, school issues should be coordinated by a team of representatives from different sectors. These should include health, education, community development and agriculture. They would advise government and schools on children's health promotion. At the curriculum level, health should be emphasized from the early years of schooling, across the curriculum.
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CONCLUSION |
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Children are the future backbone of every nation, and hence their current health and education are of paramount importance. It is reasonable to expect that schools and homes provide suitable conditions for healthy living and learning. As such, there is a need to develop strategic plans to ensure the current meagre resources are used to maximum effect on the health and education of children.
Programmes should be designed to promote health and education. Consistent with the WHO's Health Promoting Schools initiative, these programmes should not only target the children, but the parents, teachers and the wider community. Processes for involving teachers, parents and local communities in planning and maintaining order are important for the sustainability of activities.
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ACKNOWLEDGEMENTS |
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We wish to extend our heartfelt gratitude to the school children and parents at the Kongo, Mataya and Kaole primary schools of the Bagamoyo District for their participation and cooperation. We are indebted to district education officers and health education teachers in the Bagamoyo district for their cooperation in this study. We are also thankful to the Principal secretaries in the Ministries of Health and Education and Culture in Tanzania, for permission to conduct the study. Finally, we gratefully acknowledge the great contributions of the staff in the Ministry of Health Tanzania for assisting in data collection.
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REFERENCES |
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Glewwe, P. (1999) Why does mother's schooling raise child health in developing countries? Evidence from Morocco. Journal of Human Resources, 34, 124–145.
Kavishe, F. P. (1991) The Control of Micronutrient Malnutrition: The Experience of Tanzania. In: Proceedings of Ending Hidden Hunger, A Policy Conference in Micronutrient Malnutrition, Montreal, Quebec, Canada, pp. 89–130. The Task Force for Child Survival and Development, Atlanta, Georgia.
Kihamia, C. M., Mgeni, A. Y., Mkumbwa, Z. M., Mtango, F. D. E. and Ramji, B. D. (1974) Epidemiological Survey of intestinal helmiths at Mlingotini, a coastal village in Bagamoyo District, Tanzania. Department of Parasitology Report, University of Dar es Salaam, Tanzania.
Long-Shan, X., Bao-Jun, P., Jin-Xiang, L., Li-Ping, C., Sen-Hai, Y. and Jones, J. (2000) Creating health-promoting schools in rural China: a project started from deworming. Health Promotion International, 15, 197–206.
McKenzie, J. F. and Williams, I. C. (1982) Are your students playing in the safe environment? Journal of School Health, 52, 284–285.
Mwanri, L. (1994) Process Evaluation of School Lunch program in North East Thailand. A thesis submitted for partial fulfilment of the degree of Masters of Community Nutrition, University of Queensland, Australia.
Pollitt, E., Hathirat, P., Kotchabhakdi, N. J., Missell, L. and Valyasevi, A. (1989) Iron deficiency and educational achievement in Thailand. American Journal of Clinical Nutrition, 50, 687–697.
Saini, A. (2000) Literacy and empowerment: an Indian scenario. Childhood Education, 76, 381–386.
Seshadri, S. and Gopaldas, T. (1989) Impact of iron supplementation on cognitive functions in preschool and school-aged children: Indian experience. American Journal of Clinical Nutrition, 50, 675–686.
Simeon, D. T. (1998) School feeding in Jamaica: a review of its evaluation. American Journal of Clinical Nutrition, 67[Suppl.], 790S–794S.[Abstract]
Simeon, D. and Grantham-McGregor, S. (1989) Effects of missing breakfast on cognitive functions of school children with differing nutritional status. American Journal of Clinical Nutrition, 49, 646–653.
Soemantri, A. G. (1989) Preliminary findings on iron supplementation and learning achievement of rural Indonesian Children. American Journal of Clinical Nutrition, 50, 698–702.
Soemantri, A. G., Pollitt, E. and Kimm, I. (1985) Iron deficiency anaemias and educational achievement. American Journal of Clinical Nutrition, 42, 1221–1228.
Stephenson, L. S. (1987) Impact of Helminth Infection on Human Nutrition. Taylor and Francis, London.
The Tanzania Partnership for Child Development (1996) Health and Education of School Children in Tanga Region. UKUMTA Report Series No. 8, Dar es Salaam, Tanzania.
Underwood, B. and Smitasiri, S. (1999) Micronutrient malnutrition: policies and programs for control and their implications. Annual Review of Nutrition, 19, 303–324.[ISI][Medline]
Variyam, J. N., Blaylock, J., Lin, B. H., Ralston, K. and Smallwood, D. (1999) Mother's nutrition knowledge and children's dietary intakes. American Journal of Agricultural Economics, 81, 373–387.
Viteri, F. E. (1991) Iron deficiency. In: Proceedings of Ending Hidden Hunger, A Policy Conference in Micronutrient Malnutrition, Montreal, Quebec, Canada, pp. 145–184. The Task Force for Child Survival and Development, Atlanta, Georgia.
Walker, S. P., Powell, C. A., Hutchison, S. E., Chang, S. M. and Grantham-McGregor, S. M. (1998) Schoolchildren's diet and participation in school feeding programs in Jamaica. Public Health Nutrition, 1, 43–49.[Medline]
Wass, A. (2000) Promoting Health. The Primary Health Care Approach, 2nd edn. Southwood Press, Australia.
World Bank (1993) World Development Report: Investing in Health. Oxford University Press, Oxford.
World Health Organization (1968) Nutritional anaemias: Report of a WHO Scientific Group. Technical report series No. 405. WHO, Geneva.
World Health Organization (1986) The Ottawa Charter of Health Promotion. WHO, Geneva.
World Health Organization (1997) Promoting Health Through Schools. Report of a WHO Expert Committee on Comprehensive School Health Education and Promotion. WHO technical report series No. 870. WHO, Geneva.
World Health Organization (1999) Programming for Adolescent Health and Development. WHO technical report series No. 886. Report of WHO/UNFPA/UNICEF Study Group on Programming for Adolescent Health.
World Health Organization (2000) WHO home page. Http://www.who.int/home/hq.html. Accessed 21 May 2000.
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