Action-Oriented and Participatory Health Education in Primary Schools
  • W. Onyango-Ouma
  • D. Lang’o
  • B. B. Jensen


Kenya lies across the equator in East Africa, on the coast of the Indian Ocean. It borders Somalia to the east, Ethiopia to the north, Tanzania to the south, Uganda to the west, and Sudan to the northwest. While the last census conducted in 1999 estimated the population to be about 29 million inhabitants, 2006 estimates put the population at about 34 million. The population growth rate is about 2.6%, while the life expectancy is about 55 years and in some areas as low as 40 years. The literacy level was estimated to be about 85% in 2003; however, this varies across regions, with some regions having very low literacy levels. The GDP is about $41.36 billion (2006) with a per capita income of $1,200, while the unemployment rate is high. Although only 8% of total land is arable, Kenya is mainly an agricultural country, relying on cash crops such as coffee, tea, wheat, and a variety of subsistence crops.


Health Education School Health Mass Treatment Health Club Action Competence 
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4.1 Contextual Introduction

4.1.1 Brief Introduction to the Country

Kenya lies across the equator in East Africa, on the coast of the Indian Ocean. It borders Somalia to the east, Ethiopia to the north, Tanzania to the south, Uganda to the west, and Sudan to the northwest. While the last census conducted in 1999 estimated the population to be about 29 million inhabitants, 2006 estimates put the population at about 34 million. The population growth rate is about 2.6%, while the life expectancy is about 55 years and in some areas as low as 40 years. The literacy level was estimated to be about 85% in 2003; however, this varies across regions, with some regions having very low literacy levels. The GDP is about $41.36 billion (2006) with a per capita income of $1,200, while the unemployment rate is high. Although only 8% of total land is arable, Kenya is mainly an agricultural country, relying on cash crops such as coffee, tea, wheat, and a variety of subsistence crops.

The government is a republic, comprising a central government and decentralized administrative units, while the political system is based on multiparty democracy. The languages spoken include English (official), Swahili (national), and numerous indigenous languages.

4.1.2 Impetus and Origin of the School Health Program

The school health program was implemented at the regional level in primary schools in one district. The program was implemented under the umbrella of the Kenyan-Danish Health Research Project, an interdisciplinary project dealing with a range of health issues, including micro-nutrient supplementation, control of intestinal helminths, and maternal and child health in Bondo District, western Kenya. It was initiated following research findings that intestinal helminth infections were prevalent among schoolchildren in the district, causing substantial morbidity. Bilharzia (Schistosoma mansoni) was also found to be prevalent at different levels depending on the distance from the nearby Lake Victoria (Ouma et al., 1996).

Globally, school-aged children have both the highest rate and the highest intensity of helminthic infections. Intestinal helminthic infections are responsible for loss of blood, growth retardation, and impairment of school performance; treatment may reverse these effects with a very fast return to normality (World Health Organization, 1995). In the long term, intestinal helminth infections cannot be controlled by mass treatment alone; an integrated approach, involving behavioral, educational, and environmental factors, is required to ensure a sustainable control. As a result of international advocacy for school health education, many countries, Kenya included, are currently exploring strategies to plan, implement, and evaluate comprehensive health programs. The school health program took the foregoing issues as its starting point.

4.1.3 Overview of the School Health Program

The school health program was conducted from 1999 to 2002 in nine primary schools1 in one district. The program consisted of two main research strands or components: research in parasitology and research in health education. The two elements are closely linked in pupils' and schools' lives, as successful health education leads to an improved health status among schoolchildren, while good health conditions improve the learning possibilities in schools.

The school health education component aimed at specifying the conditions for an efficient health education leading to better health - in the short and the long run - focusing on geohelminth and schistosomiasis infections. The main concepts and principles within the health education activities developed were participation and action. Pupils' participation is considered to be the most important precondition for developing ownership among the pupils and thus also for affecting pupils' daily actions and behavior (Jensen, 1997; Simvoska, 2004).

The hypothesis is that action-oriented and participatory approaches in health education support the development of pupils' abilities to create change - their action competence (Jensen, 2000). This means that an action-oriented health education embraces pupils' own actions as important and integrated elements. The actions could be targeted at pupils' own life, the environment at the school, the pupils' families, or the local community (Onyango-Ouma, Aagaard-Hansen, & Jensen, 2005).

The key actors in the program were researchers, pupils, teachers, education inspectorate staff, trainers of trainers in action-oriented health education, and community members. The different actors played different roles that were complementary to the implementation of the program.

The program was spread out across nine schools with similar characteristics in one district. The initial implementation was limited to pupils in classes 4 and 6 in the respective schools, giving a total of 536 pupils. However, these intervention pupils engaged in health education activities that targeted the entire school population. Each of the nine schools had an average student population of about 250; thus the program reached additional pupils.

Apart from pupils, teachers were also trained as part of the project and were specifically responsible for the implementation of the intervention in their respective schools. A total of 18 teachers (two in each school) and 9 head teachers were trained in the district. The role of teachers was to teach the pupils on intervention topics and thereafter to serve as facilitators to the pupils, offering support during the implementation phase. In addition, education inspectorate staffs at the district were trained to help them understand the project objectives and potential benefits, so as to facilitate program implementation.

Although the program had an impact at the community level, the result was not documented beyond the homesteads of the 536 intervention pupils. The program aspects that were implemented in the school and home environments included improved sanitation, through construction and maintenance of clean latrines and safe water drinking practices. Although these improvements were reported in homesteads of the 536 pupils and other pupils, there was no systematic follow-up to report the figures.

4.1.4 Scope of Implementation

The school health education program comprised three interventions:
  1. 1.

    The use of flip charts as an interactive tool in the school's health education

  2. 2.

    Establishment of an extracurricular health club

  3. 3.

    In-service training in the form of continual professional support


The nine schools were divided into three groups of three, each receiving a different set of interventions. In the first group, only flip charts were used; in the second group, only health clubs were introduced; the third group received a combination of health club and flip-chart interventions. In addition, one school in each of the three groups received continual professional support in the form of fortnightly visits consisting of observations, discussion, and advice from researchers. None of the schools had previously been involved in health education programs.

Prior to interventions, a baseline study was conducted to establish pupils' level of knowledge of worms, as well as their visions, commitment, and motivation about healthy lifestyles. The baseline created a benchmark against which to conduct process and final evaluations.

Two teacher-training workshops of two days each were organized to set the ground for the implementation of interventions, by building the capacity of teachers to participate effectively in the school health program. Teachers were introduced to key health education concepts including participation, action competence, and the IVAC (Investigations-Visions-Actions-Change) approach (Jensen, 1997). They were also exposed to the school health program interventions (including treatment, flip charts, and health clubs), to help them take ownership of the form and content of the interventions. Knowledge of worms in terms of their life cycles, vectors, associated morbidity, and transmission aspects, as well as prevention and control strategies were also included in the training. Different Intervention Forms Implemented Flip Charts

This intervention activity developed flip-chart teaching materials, in collaboration with the learners. The use of the flip charts aimed at bridging the gap between folk knowledge and scientific understanding of how worms are transmitted and what could be done to reduce infections and reinfections. The flip charts also called for pupils' participation in school and in the local community. For instance, pupils were assigned to discuss what they could do, in their class and in their families, to make sure that “worms stay away.”

The teachers trained in each school used the flip charts to teach about transmission and prevention of worms during ordinary classroom lessons with pupils in classes 4 and 6 in all the nine schools. Teaching was action-oriented - as opposed to the traditional didactic approach - so as to evoke pupils' participation. Pupils were involved in investigations to find causes and sources of infection as well as actions to be taken to prevent transmission in the school and in the community. Since the charts were developed with the learners, they generated a lot of interest and fun that were key to pupils' commitment and participation. Teaching was done throughout one school term (three months). Health Clubs

The second type of intervention was the establishment of extracurricular health clubs in schools. The new, innovative approach was to link the work done in a health club to the concepts of action and participation. Health clubs stimulate and motivate pupils as they play a major role in the activities. Although the structure of the health club - via the notion of participation - was to be developed in cooperation with the partners involved (pupils and teachers), it was defined as a group of people outside the classroom situation, who have decided to come together to share ideas on health issues, with a view to promote their own health and that of their families and communities. Pupils themselves formed the health clubs and decided on the form of membership, although the teacher acted as a patron.

Health-club meetings were organized weekly in the participating schools, where they discussed health issues pertaining to transmission and prevention of worms. The meetings focused on the knowledge and identification of tangible actions that club members could take to change the health conditions in the school and at home. Club members went farther, with actions such as putting in place hand-wash facilities and ensuring that pit latrines were in a clean state. The role of the health club was to enhance the promotion of health and the prevention of diseases, at school, within the community, and at home. The major difference between a health club and the typical class situation was that pupils in a health club were the main decision-makers, while the teacher served primarily as a facilitator. Continual Professional Support

The third type of intervention was continual professional support, giving teachers focused and intensive support during the program implementation. The intent was to learn whether intensive in-service support was necessary for the introduction of new and challenging teaching approaches into the Kenyan school system to succeed. This support was provided in the form of regular miniseminars, two or three hours long, in schools, where the current developments and difficulties were presented and analyzed. The teachers kept logbooks, in which they described their own experiences, evaluations, and observations. Teachers received support from a consultant who visited the schools fortnightly to strengthen their skills and competencies for implementing the program.

Overall, teachers and pupils had the freedom to determine their implementation time frame, that is, either during or after regular school hours. Researchers observed, discussed, and recorded not only the implementation of activities either in or outside class, but also the changes effected by the school and the surrounding community, such as personal hygiene, sanitation, and environmental management. The Health-Promoting School Concept

The interventions that were implemented addressed two elements of Health-Promoting Schools - a healthy school environment (physical and psychosocial) and outreach to families and community. The interventions developed pupils' action competence through action and participation in health matters in school and home environments. With regard to a healthy school environment, the interventions addressed both physical and psychosocial aspects. Changes in the physical health conditions included actions such as making hand-wash facilities, ensuring that pit latrines were cleaned, cleaning the school compound and classrooms. These actions were aimed at maintaining the school's environmental hygiene and preventing transmission of worms. Flip-chart and health-club interventions facilitated the development of pupils' action competence to take action along these lines. Health clubs also addressed psychosocial concerns by developing life skills in children, giving them a sense of responsibility, raising their self-esteem, and recognizing their efforts.

Outreach to families and the community was achieved through children's participation and action in activities aimed at promoting hygiene and sanitation to prevent the transmission of worms in the home environment. These actions included the maintenance of personal hygiene, putting in place new latrines to improve sanitation, and environmental hygiene (e.g., appropriate refuse disposal).

The school health program also incorporated school health services. The health services involved mass treatment of pupils against Schistosoma mansoni and intestinal helminths. The mass treatment was conducted at the beginning of the project, and teachers were trained to conduct the deworming every six months. Monitoring and Evaluation

Baseline studies were conducted as a basis for future evaluation. The studies focused on potential barriers and possibilities for the development of action-oriented and participatory health education in schools. Standardized questionnaires were administered to pupils to elicit information on components of action competence, motivation for becoming involved in action-oriented health education, common knowledge regarding worms/diseases, and possibilities and motivation for collaboration between school and community.

The evaluation of the project was carried out as both process and outcome evaluation, involving quantitative and qualitative methods. During process evaluation, barriers and possibilities for developing action-oriented and participatory health education were identified through structured observations and recorded by teachers, pupils, and researchers. Simple quantitative counting of social and physical health-promoting changes (e.g., new latrines) in the schools was also done. During health-club meetings, pupils recorded their activities within the school and home environments. In the final evaluation, pupils' knowledge regarding worms as well as their visions, commitment, and abilities to take action and facilitate change were assessed through standardized questionnaires. The development of pupils' and teachers' opinions, knowledge, and commitment about participatory-learning issues were assessed through in-depth interviews. Summary of Achievements

  • Generally students possessed a high degree of action competence, that is, their ideas about how to improve health, and their commitment to taking concrete action in the health field.

  • Of the three intervention forms, the health club had the greatest impact on students' competence and knowledge, probably because the more informal climate encouraged students to participate and take ownership.

  • The other two intervention forms - the flip charts and the continual professional support - did not make any remarkable difference when they were used as the single intervention in a school.

  • The schools where health clubs were combined with flip charts had the greatest impact, probably because the use of the flip charts added more time to the projects as a whole.

  • A number of conditions were identified that facilitate participatory teaching/learning approaches:
    • A positive, creative, and explorative attitude among teachers

    • Availability of methods such as the IVAC model and materials such as flip charts.

    • Good teacher/student relationship through reduction of power imbalance by creating informal settings in the extracurricular health clubs.

  • A number of factors were identified that hinder participatory learning approaches:
    • Teacher training: From their initial training, teachers were mostly familiar with didactic, top-down approaches; so they were struggling, in spite of good intentions, to adopt the new approach.

    • Staff turnover: Frequent transfers, deaths, maternity leaves, and the like made it difficult to maintain continuity in the project.

    • Punishment traditions: In some schools, the teachers' authority was manifested through punishing students, which militated against the introduction of participatory learning/teaching approach.

    • Language: The use of English created communication barriers between students and teachers especially in the lower classes.

  • Remarkable changes were observed over time in pupils' personal and environmental hygiene choices. Hand-wash facilities (leaky tins) were placed next to the pit latrines in schools. Pupils ensured that the tins had water at any given time and were willing to spend time and energy getting water for the tins, as water is a scarce resource in the district. Compost heaps and rubbish pits were established and effectively used where none had existed before. Dish racks for drying utensils were put up in the homes near the intervention schools, indicating that pupils, either alone or in partnership with parents/guardians, translated what was learnt and practiced in school into regular, practical, health-enhancing actions at home.

  • Actions also encouraged and fostered creativity and resourcefulness among children. In all the nine schools, teachers reported that children took personal actions to manage their health, for example, burning and selling charcoal to get money to buy shoes, in order to be neat as well as to avoid hookworm infection.

Picture 1

Students participate in creating a dish rack for drying utensils on health project

4.2 Specific Aspects of Implementation

4.2.1 Vision

The program implementation focused on the development of visions and commitment among pupils. The program assessed whether pupils developed visions and commitment on how they could improve their health, learning, and school and home environments. This was considered fundamental for changes in the disease dimensions of the school health education program, such as knowledge of worm transmission and prevention. The development of visions and commitment was also considered as an important precondition for pupils' participation in the program.

4.2.2 Training

Given that action-oriented learning and teaching including student participation was new in the study district, the program provided technical assistance and training to teachers to help them implement the intervention. Two in-service training workshops were conducted for science teachers and head teachers in the selected schools, as well as for education inspectorate staff in the district. The workshops underscored the concepts of participation and action as key concepts in school health education. Apart from the two workshops, three of the nine schools also received continual professional support during weekly visits as part of the study design. The trainings and professional support equipped the teachers with skills and created the conditions necessary for successful implementation of the intervention.

4.2.3 Critical Mass

The initial in-service courses created a critical mass of teachers, head teachers, and education inspectorate staff that were equipped with knowledge and skills regarding the design and implementation of action-oriented and participatory school health education intervention programs. Teachers used the skills and knowledge they acquired during in-service to implement the interventions during ordinary classroom teaching to pupils. This process created a critical mass of pupils who had developed visions about how to improve their health, their learning, and their home and school environments. Through participation and action in everyday activities, the intervention pupils interacted with other pupils who were not part of the intervention in school and in the community, thereby creating another critical mass of knowledgeable people as regards health matters in the district. The project successfully created a critical mass of health actors within the school environment (teachers and pupils) and the home/community environment (children and adults).

4.2.4 Resources/Local Adaptation

The implementation took place in a resource-poor setting, so the program had to make do with what was available. Two major constraints in the area were inadequate reliable water supply and shortage of infrastructural facilities such as latrines. Although these were potential barriers to the implementation of the program, the challenge of dealing with them or devising alternatives was considered as a great step toward developing a vision and commitment to healthy conditions. As a result pupils brought water for drinking and cleaning latrines in schools, while in the home environments they built pit latrines and dish racks where they were lacking, in partnership with adults. Because of pupils' commitment and motivation, the project was adapted to the local situation despite the lack of resources and necessary facilities in the school and home environments.

4.3 Conclusions and Insights

The action-oriented and participatory health education strategies had impact on key variables (vision, commitment, participation, and knowledge of worm transmission and prevention); effects varied depending on the intervention strategy applied. Overall, the presence of the health-club intervention had the greatest impact, especially where it was combined with the flip-chart intervention. The combination of the health club and the flip chart gave pupils more time to engage in project activities. The content of the flip chart was more knowledge-based; during the health club sessions, children explored what they had learned earlier in flip-chart lessons, thus gaining more time to reflect on appropriate health actions.

4.3.1 Recommendations

  1. 1.
    Teacher training:
    • Teachers need to develop competence to teach with participatory approaches without feeling “loss” of their authority and control.

    • Preservice as well as in-service training of teachers should integrate action-oriented and participatory teaching and learning approaches in more systematic ways.

    • In-service training and professional support should be made available to teachers who are committed to explore and further develop more student-centered teaching and learning approaches as part of their normal practice.

  2. 2.
    Collaboration between school and the community:
    • Authentic, action-oriented teaching approaches, where pupils take action in the community as integrated parts of their teaching and learning, help to build their action competence and commitment in the health area. Consequently, closer links should be established between the school and the local community.

    • Health clubs could be valuable starting points for supporting an action-oriented approach among pupils where concrete heath problems in a community can be addressed.

  3. 3.
    Learning materials and models:
    • Materials and models (such as flip charts and IVAC-approach) with a built-in action-oriented and participatory approach should be developed and disseminated to teachers.

  4. 4.
    The curriculum:
    • The current curriculum, which is overcrowded and encouraging didactic approaches, is inefficient. A more flexible curriculum that allows students to influence the teaching processes should be developed.

    • As inspiration for future revisions of the national curriculum a number of case studies and within and between schools should be initiated. These cases should be supported, followed, and documented by trained educational researchers.



  1. 1.

    The research project came to an end in 2002. Since then, the schools have continued to work with the Health-Promoting School concept, implementing various aspects of the research project on their own. The schools have also embraced new dimensions, including HIV/AIDS, which has ably captured health promotion for staff and pupils.



This project had financial support from the Danish International Development Assistance (DANIDA) through the Kenyan-Danish Health Research Project (KEDAHR).


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Copyright information

© Springer Science + Business Media, LLC 2009

Authors and Affiliations

  • W. Onyango-Ouma
    • 1
  • D. Lang’o
    • 1
  • B. B. Jensen
    • 1
  1. 1.Institute of Anthropology, Gender and African StudiesUniversity of NairobiNairobiKenya

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