School Health Promotion in Latin America and the Caribbean: A Regional Assessment www.paho.org This report presents the results of a regional assessment of the status of school health and the health-promoting schools (HPS) approach conducted jointly by PAHO, UNESCO, UNICEF, and the World Bank during 2018-2019. The objectives of the assessment were to: 1) assess the context and broader policy environment of school health in the LAC region, including legislative frameworks; 2) identify the scope and form of school health programs and services available in the region, as well as opportunities for improvement; and 3) enable countries to share with each other their best practices and the lessons learned in developing and implementing school health policies, programs, and services. The assessment results also serve as a regional baseline for the initiative, launched in 2019 by WHO and UNESCO, to make every school a health-promoting school. The results of this assessment are expected to contribute to strengthening the HPS approach in the LAC region on subnational, national, and regional levels, and to help accelerate progress toward achieving the SDGs for all children and adolescents in the region. This assessment was conducted before the COVID-19 pandemic. The impact of the pandemic has underlined the prominent role and multiple benefi ts of schools as an environment for equitable protection and promotion of the health and well-being of children and adolescents during the pandemic and in the recovery phase. Washington, D.C., 2022 School Health Promotion in Latin America and the Caribbean: A Regional Assessment School Health Promotion in Latin America and the Caribbean: A Regional Assessment © Pan American Health Organization, 2022 ISBN: 978-92-75-12592-2 (PDF) ISBN: 978-92-75-12594-6 (Print version) Some rights reserved. 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PAHO/FPL/PS/2022 Cover design: © Prographics/Emilia Palomeque Cover photo: © PAHO Design concept: © Prographics https://creativecommons.org/licenses/by-nc-sa/3.0/igo https://doi.org/10.37774/9789275125922 http://iris.paho.org mailto:sales@paho.org https://www.paho.org/en/publications/permissions-and-licensing iiiCONTENTS Contents Preface ..................................................................................................................................................v Acknowledgments .............................................................................................................................vii Abbreviations and Acronyms ............................................................................................................viii Executive Summary ..............................................................................................................................x Introduction 1 1.1 A global perspective of health-promoting schools .............................................................. 1 1.2 Health-promoting schools in the Americas ........................................................................... 5 Methodology 7 2.1 Desk review ............................................................................................................................. 7 2.2 Country assessments ............................................................................................................... 9 2.3 Stakeholder consultation ..................................................................................................... 11 2.4 Ethical considerations and limitations ................................................................................ 11 Results 12 3.1 Desk review ........................................................................................................................... 12 3.2 Country assessments ............................................................................................................. 20 3.3 Stakeholder consultation ..................................................................................................... 34 Conclusions 37 References ......................................................................................................................................... 40 iv CONTENTS Figures 1 Scoping review flow chart .................................................................................................... 12 2 The status of school health policies, strategies, and plans in participating countries ...... 22 3 Topics addressed in school health policies, strategies, and plans ...................................... 23 4 Student population, by age group, served by school health services ................................ 31 5 Estimated percentage of students covered by health services, by age group .................. 32 Tables 1 The Focusing Resources on Effective School Health (FRESH) framework ............................ 3 2 School health legislation, policies, strategies, and plans by country or territory ............. 15 3 Components addressed in the school health legislation, policies, strategies, and plans by country or territory. ........................................................................................ 18 4 Countries and territories that completed the school health survey, by subregion ........... 20 5 Coverage of school health activities by country/territory and student age group ........... 26 6 Healthy and safe learning environment components assessed in the survey ................... 27 7 Recent development or revision of time requirements for health education, certification or accreditation of HPS, and professional development by country ............ 29 8 Organization of school health services by country ............................................................. 30 9 Estimated number of school health personnel per 100 students ...................................... 32 Boxes 1 The School Health Program in Brazil – the Programa Saude na Escola (PSE) .................... 21 2 The national school health program in Argentina – PROSANE ......................................... 23 3 Health and family life education (HFLE) .............................................................................. 25 Annexes 47 Annex 1 Global standards for health-promoting schools and standard statements ..............47 Annex 2 Summary details of articles scoping review ...............................................................48 Annex 3 Existence of national standards, by country, for priority topics ...............................67 Annex 4 Development or revision, by country, of policies or standards for the content of instruction on priority topics in the past two years ................................................... 69 vPREFACE The Sustainable Development Goals (SDGs) and the Global Strategy for Women’s, Children’s and Adolescents’ Health highlight the strategic importance of young people for the success of the 2030 Sustainable Development Agenda. The essential role of the school in promoting the health and development of human capital is well-established and has gained greater emphasis in the context of the SDGs; it brings a renewed urgency to the implementation of evidence-based and multi-sectoral actions for improving the health and well-being of children and adolescents in a more effective, integrated, and equitable manner, with no one left behind. For several decades, the World Health Organization (WHO), the United Nations Educational, Scientific and Cultural Organization (UNESCO), and other partners have invested in comprehensive school health approaches using the health-promoting school (HPS) approach and other initiatives. In 2018, WHO and UNESCO launched a global initiative to “make every school a health-promoting school.” In the context of that initiative, global standards and indicators for HPS, an implementation guide, and a guideline on school health services were developed; they were published in 2021. In the Region of the Americas, the HPS approach, launched jointly in 1995 by PAHO/WHO, UNESCO, and the Organization of American States (OAS), has gained major traction. Almost every country in the Region has promulgated actions ranging from developing legislation, policies, and plans to implementing school-level actions of various scopes. In addition to the HPS initiative, a range of other regional partners, including the World Bank, the Food and Agricultural Organization (FAO), the World Food Program (WFP), UNICEF, and UNFPA, have dedicated mandates and initiatives that target school- aged children and the educational system. Latin America and the Caribbean (LAC) continues to be the most inequitable Region globally, and these inequities affect the health and development of children and adolescents. Children and adolescents from poor, lower educated, and ethnic minority groups carry disproportionate burdens of illness and preventable mortality. Mainstreaming and effectively implementing the HPS approach can significantly contribute to giving children, adolescents, their families and communities—particularly those from vulnerable groups—equitable opportunities for health, well-being, and development. Preface vi SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT In order to better understand the current status of school health and the HPS approach in LAC and to establish a baseline for scaled-up implementation, PAHO/WHO collaborated with UNESCO, UNICEF, and the World Bank in 2018–2019 to conduct a regional assessment, which is presented in this report. The objectives were: 1. To assess the context and broader policy environment of school health in the Region, including legislative frameworks. 2. To identify the scope and form of school health programs and services available in the Region and identify opportunities for improvement. 3. To enable countries to share with other countries of the Region the best practices and lessons learned from developing and implementing school health policies, programs, and services. The results of this assessment are expected to contribute to strengthening the HPS approach in the LAC Region on subnational, national, and regional levels, and thus help accelerate progress in achieving the SDGs for all children and adolescents in the Region. This assessment was conducted before the COVID-19 pandemic. The impact of the pandemic underlined the prominent role and multiple benefits of schools as an environment for protecting and promoting the health and well-being of children and adolescents both during the pandemic and the recovery phase. Dr. Andres de Francisco Serpa Director Family, Promotion and Life Course Department viiACkNOWLEDGMENTS Acknowledgments PAHO/WHO acknowledges all the following who contributed to this document: Authors: Sonja Caffe (PAHO/WHO), Gerry Eijkemans (PAHO/WHO), Fernanda Lanzagorta (PAHO/WHO), Daniel Tobon Garcia (consultant). Contributors: Betzabe Butron (PAHO/WHO), Claudina Cayetano (PAHO/WHO), Mary Guinn Delaney (UNESCO), Izola Garcia (PAHO/WHO), Amparo Gordillo (World Bank), Brigitte de Hulster (PAHO/WHO), Leendert Nederveen (PAHO/WHO), Alejandra Trossero (UNICEF), Janice Woolfort (PAHO/WHO). The extraordinary contributions from the regional partners, the 18 countries that participated in the country assessment, and the participants in the regional stakeholder meeting are also gratefully acknowledged. viii SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT AAHA! (Global) Accelerated Action for the Health of Adolescents CARICOM Caribbean Community CDC Centers for Disease Control and Prevention CNHPS Caribbean Network of Health-Promoting Schools COMISCA Consejo de Ministros de Salud de Centroamerica [Council of Ministers of Health of Central America] CSE Comprehensive sexuality education FAO Food and Agriculture Organization of the United Nations FRESH Focusing resources on effective school health G-SHPPS Global School Health Policies and Practices Study GSHS Global School-based Student Health Survey GYTS Global Youth Tobacco Survey HFLE Health and family life education HIV Human immunodeficiency virus HPS Health-promoting school(s) INABIE Instituto Nacional de Bienestar Estudiantil IUHPE International Union for Health Promotion and Education LAC Latin America and the Caribbean LANHPS Latin American Network of Health-Promoting Schools NGO Nongovernmental organization OAS Organization of American States PAHO Pan American Health Organization PROINAPSA Instituto de Programas Interdisciplinarios en Atención Primaria de la Salud PROSANE Programa Sanidad Escolar SABER System Approach for Better Education Results SDG Sustainable Development Goal SDH Social determinant of health Abbreviations and Acronyms ixABBREVIATIONS AND ACRONYMS SRH Sexual and reproductive health SRHR Sexual and reproductive health and rights STI Sexually transmitted infection UN United Nations UNESCO United Nations Education, Scientific and Cultural Organization UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund UNODC United Nations Office on Drugs and Crime WHO World Health Organization x SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT Executive Summary This document presents the findings of a regional assessment of school health in Latin America and the Caribbean (LAC). The goal was to analyze the current status of school health and the HPS approach in LAC in order to identify priorities and strategic actions that can strengthen the HPS approach to make every school in the Region a health-promoting school. The objectives: 1. To assess the context and broader policy environment of school health in the Region, including legislative frameworks. 2. To identify the scope and form of school health programs and services in the Region, as well as opportunities for improvement. 3. To enable countries to share best practices and lessons learned in the development and implementation of school health policies, programs, and services. The pillars of the FRESH and IUHPE frameworks informed the design of this regional assessment, including review checklists and tools. Based on these frameworks, the assessment focused on the following six elements: • Governance of school health programs • School health policy environment • Health education and curriculum • Healthy and safe learning environment • Student and community participation • Access to health services The assessment consisted of three main components: 1) desk review, which included a scoping review of published peer-reviewed articles and review of country legislation, policies, strategies, and plans; 2) country assessments conducted in 18 countries; and 3) a stakeholder consultation with 40 participants representing regional partners, ministries of health and education, civil society, academia, and youth. xiExECUTIVE SUMMARY The assessment results indicated that school health and the health-promoting schools (HPS) approach are firmly embedded in the fabric of the Region of the Americas, referred to by different terms—school health, healthy schools, and HPS. The term HPS has stronger resonance in Latin America than in the Caribbean, where health and family life education (HFLE) is considered the flagship school health strategy. The majority of countries have developed legislative and policy instruments related to school health, some specifically dedicated to school health and others with school health incorporated in wider governance instruments. Countries with dedicated school health legislation and/or policies were most likely to have operational plans for implementing school health programs. However, only slightly over half of the countries have mechanisms for documenting and monitoring the coverage and results of school health and HPS actions. Limited political will, insufficient funding, and lack of coordination between stakeholders were identified as major challenges in implementing school health policies, strategies, and plans. The organization, scope, and funding of school health and HPS programs and activities vary widely, from structured government-funded programs with assigned resources to fragmented, externally funded initiatives of limited duration. The scoping review of peer-reviewed literature indicated a multitude of implementation studies and projects in schools across the Region that addressed a range of topics. The majority of the initiatives ranged from short duration (a few months) to medium duration (a few years). They usually did not have a national scope, which raises the question of how extensively the initiatives improved the health of school children and adolescents beyond the interest of the study. The assessment underlined the importance for countries to develop national strategies and plans to which donors, regional partners, and researchers can contribute, rather than having school health efforts driven by external interests. The organization and package of school health services varies between and within countries and includes school-based health services, school-linked health services, and scenarios where teachers provide some services. Activities from school health teams extended beyond the clinic to public health action in the classroom and support for teachers and parents. Challenges associated with school health services included: lack of clear, supportive legislation and regulation, a shortage of personnel trained in school health, lack of funding, inadequate standardization of school health services, and limited involvement of parents and caregivers. Effective partnerships were identified as a critical challenge and condition for successful and efficient school health programs. Of primary importance are partnerships between the ministries of health and education and the private sector and civil society—including youth-led and youth-serving organizations, regional partners, and other relevant stakeholders. The assessment highlighted the importance of continued efforts to foster a common understanding of core school health and HPS concepts and essential implementation dimensions. Regional partners can play an important role through advocacy and technical guidance and support for implementation. xii SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT The assessment was conducted before the COVID-19 pandemic. The impact of the pandemic has underlined the prominent role and multiple benefits of the school as an environment for social interaction, play and learning, structure, and protecting children and adolescents. Schools have an important role in mitigating the indirect consequences of COVID-19 on the health, well-being, and development of children and adolescents during the pandemic and in the recovery phase. 1INTRODUCTION 1.1 A global perspective of health-promoting schools Childhood and adolescence are critical periods of human development in which the foundation for health and development during the life course and across generations is established. The health and education of children and adolescents are strongly interrelated. A healthy child or adolescent is better equipped to perform well in school, and a child or adolescent who is well educated is more likely to make informed and better choices for his or her health. Better educated students become healthier adults, and parents of healthier children. A global analysis of the social determinants of health and adolescence identified access to quality education as one of the strongest determinants of adolescent health (1). In addition, safe and supportive families and schools and positive and supportive peers were highlighted as crucial to helping adolescents attain the highest possible level of health and well-being in their transition to adulthood (1). Available evidence confirms the mutual benefits of investment in human development to achieve health and educational goals. In the context of the Sustainable Development Goals (SDGs), the role of the school in promoting the health and well-being of children and adolescents has gained new momentum as an equitable, cost-effective strategy for simultaneously pursuing several SDGs, particularly SDGs 3 and 4 (2). Introduction 1 2 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT Recognition of the vital role of schools in the health and development of children and adolescents is longstanding. In 1995, the World Health Organization (WHO) launched the Global School Health Initiative with the goal of increasing the number of schools that can be called “health-promoting schools” (HPS) (3-6). WHO’s Global School Health Initiative is guided by the WHO Expert Committee Recommendation on Comprehensive School Health Education and Promotion (1995) (7), the Ottawa Charter for Health Promotion (1986) (8), and the Jakarta Declaration of the Fourth International Conference on Health Promotion (1997) (9). The initiative defines a health-promoting school as one that continually strengthens its capacity as a healthy setting for living, learning, and working. It does this through: • Fostering health and learning with all the measures at its disposal. • Engaging health and education officials, teachers, teachers’ unions, students, parents, health providers, and community leaders in efforts to make the school a healthy place. • Striving to provide a healthy environment, health education, and health services in schools along with school/community projects and outreach, health promotion programs for staff, nutrition and food safety programs, opportunities for physical education and recreation, and programs for counseling, social support, and good mental health. • Implementing policies and practices that respect an individual’s well-being and dignity, that provide multiple opportunities for success, and that acknowledge good efforts, good intentions, and personal achievements. • Striving to improve the health of school personnel, families, and community members as well as pupils, and working with community leaders to help them understand how the community contributes to, or undermines, health and education. At the World Education Forum in Dakar in 2000, WHO, UNESCO, UNICEF, and the World Bank launched an interagency initiative called Focusing Resources on Effective School Health (FRESH) (10, 11) and agreed on a common framework consisting of four components and three supportive strategies (Table 1). 3INTRODUCTION TABLE 1 The Focusing Resources on Effective School Health (FRESH) framework COMPONENTS SUPPORTIVE STRATEGIES Health-related policies • Partnership between education and health • Community partnerships • Student participationSafe water and sanitation Skills-based health education Access to health and nutrition services Sources: United Nations Educational, Scientific and Cultural Organization (UNESCO). The Dakar Framework for Action: Education for All: meeting our collective commitments (including six regional frameworks for action) [internet]. Paris: UNESCO; 2000. Available from: https://unesdoc.unesco.org/ ark:/48223/pf0000121147 FRESH Monitoring and Evaluation Coordinating Group (UNESCO, Save the Children, Education International, EDC, UNODC, AIR, World Bank, WHO, UNICEF, PDC). Monitoring and Evaluation Guidance for School Health Programs. Eight Core Indicators to Support FRESH (Focusing Resources on Effective School Health) [internet]. February 2014. Available from: https://healtheducationresources.unesco.org/library/documents/monitoring-and- evaluation-guidance-school-health-programs-eight-core-indicators Health-promoting schools have been defined in different and often overlapping ways. In 2008, the International Union for Health Promotion and Education (IUHPE) provided a six-point definition of health-promoting schools (12): • School health policies and plans • A safe physical environment • Social environment that addresses safety • Individual health skills and action competencies • Community links • Health services In other literature, a simpler three-point definition is applied (12, 13): 1. Formal health curriculum: To help students develop the knowledge, attitudes, and skills needed for healthy choices, the formal school curriculum allots a specific amount of time to health education topics. 2. Ethos and environment of the school: The health and well-being of students and staff are promoted through the “hidden” or “informal” curriculum, which encompasses the values and attitudes promoted within the school and the physical environment and school setting. 3. Engagement with families, communities, or both: Schools seek to engage with families, outside agencies, and the wider community in recognition of the importance of these other spheres of influence on children’s attitudes and behaviors. https://unesdoc.unesco.org/ark:/48223/pf0000121147 https://unesdoc.unesco.org/ark:/48223/pf0000121147 https://healtheducationresources.unesco.org/library/documents/monitoring-and-evaluation-guidance-school-health-programs-eight-core-indicators https://healtheducationresources.unesco.org/library/documents/monitoring-and-evaluation-guidance-school-health-programs-eight-core-indicators 4 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT In 1999, two systematic reviews were conducted with the following objectives: a) to investigate the evidence that health-promoting schools are effective in improving health-related outcomes, and b) to determine whether health-promoting schools are more effective than other ways of delivering health- promoting interventions, and to determine their relative costs (12). The researchers concluded that descriptions of interventions and methodological quality varied greatly across the studies and that most studies were underpowered, making it difficult to draw definitive conclusions. Nevertheless, the researchers concluded that the HPS approach is promising, although continued investment and ongoing evaluation are needed to provide evidence about the effectiveness of this approach (12). Another systematic review conducted 15 years later, in 2014 (13), concluded that the HPS approach has demonstrated positive results in improving some health behaviors and outcomes, including better nutrition and physical fitness, and had reduced the uptake of tobacco use. However, the approach had not reduced alcohol or drug use, violence, depression, bullying, or being bullied by others. The researchers remarked that very few HPS studies included educational indicators. The overall conclusion was that although there is some evidence to suggest the HPS approach can produce improvements in some areas of health, there is insufficient data to draw conclusions about its effectiveness in other areas. More studies are needed to determine if this approach can improve specific aspects of health and impact academic performance. In 2015, WHO convened an expert meeting to review school-based interventions and the HPS initiative at the global level (14). The experts identified major barriers for HPS implementation: challenges with inter- and intra-ministerial cooperation and collaboration; lack of comprehensive school health policies, plans, and approaches; and limited allocated budget and human resources. The meeting identified nine key factors necessary for successfully implementing school health programs with limited human and financial resources: • Establish systems for collecting better data and for monitoring, reporting, and providing and using evidence to make policy and implementation plans. • Strengthen inter- and intra-ministerial cooperation and collaboration among all stakeholders at all levels. • Strengthen advocacy at all levels for moving from policy to implementation. • Ensure sustainable funding, better costing, and long-term financing plans and procedures. • Establish the health education curriculum as a home for all topics. • Develop an institutionalized human resource, such as pre-service and in-service training for teachers, health personnel, and government staff. • Promote a comprehensive approach. • Collaborate with all stakeholders at all levels, including the private sector. • Promote the engagement of parents, students, and teachers. 5INTRODUCTION The Global Accelerated Action for the Health of Adolescents (AAHA!), published in 2017, states that the evidence for the positive effects of school-based interventions and school health programs is compelling, and that investing in school health is a fundamental priority for intersectoral programs. The AAHA! calls on countries that do not have school health programs to consider establishing them, and for countries that already have such programs to consider critically reviewing them to align them with the evidence base and emerging priorities (15). In 2018, the HPS approach received a renewed global push with the launch of an initiative from WHO and UNESCO to “make every school a health-promoting school,” which included a commitment to develop global standards and indicators for HPS and to support their implementation (16). Through an inclusive global process, those global standards, along with a recommended list of indicators, were developed; they were officially launched in 2021 (16). Annex 1 presents the standards. The global standards and indicators are intended to provide direction to government staff, policymakers in all sectors, and to school leaders and developmental partners for implementing, monitoring, and evaluating sustainable whole-school approaches to health in education. An implementation guide was also developed to support making the global standards operational on national and local levels (17). Together with these documents, WHO published guidelines on school health services (18). These three documents provide a solid basis for updating and strengthening a comprehensive approach toward school health in the era of SDGs. 1.2 Health-promoting schools in the Americas The Region of the Americas has a long history of school health initiatives, including the regional HPS initiative, which was started in the early 1990s and officially launched in 1995 as a collaborative effort between the Pan American Health Organization (PAHO/WHO), the United Nations Educational, Scientific and Cultural Organization (UNESCO), and the Organization of American States (OAS) (19). Under the initiative, the majority of countries and schools in LAC developed school health strategies and initiatives of varying scopes, some focused on the pre-school level, others at the primary or secondary school level. Activities undertaken related to improving hygiene, water, and sanitation, and to nutrition and exercise, among other aspects. In addition, Latin American and Caribbean networks of HPS were established with the aim of providing a space for exchanging ideas and providing resources and support for sharing experiences among countries. The Latin American Network of Health-Promoting Schools (LANHPS) was established in 1996, the Caribbean Network of Health-Promoting Schools (CNHPS) was established in 2001, and the Puerto Rican Network of Health-Promoting Schools was established in 2004 (20). This assessment did not include a review of the current status and functioning of these networks. In 2003, PAHO published an HPS Strategic Plan for the period 2003–2012 (21). It presented a clear articulation of this vision and proposed six main strategies: 1) advocacy for school health programs and 6 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT dissemination of the HPS regional initiative; 2) support for institutionalization of the HPS strategy and formulating healthy public policies in educational communities; 3) increasing participation of key actors in managing school health programs; 4) strengthening the capacity of Member States in managing the HPS strategy; 5) research support for developing school health programs; and 6) mobilizing resources. The strategic plan proposed a holistic, comprehensive, and multidisciplinary approach, and it recognized that educational institutions were important in transforming local communities and sharing aspirations for human development. It aimed to develop future generations who will have the knowledge, abilities, and skills needed to promote and care for their own health, the health of their families and communities, and who will be able to create and maintain healthy physical and psychosocial environments. The HPS concept and action were carried forward through more recent regional commitments, including the Plan of Action for Women’s, Children’s, and Adolescents’ Health, 2018–2030 (20), the Strategic Plan of the Pan American Health Organization 2020–2025: Equity at the Heart of Health (22), and the Strategy and Plan of Action on Health Promotion within the Context of the Sustainable Development Goals 2019–2030 (23). The goal of this assessment was to analyze the current status of school health and the HPS approach in LAC, in order to identify priorities and strategic actions that can be taken to strengthen the HPS approach in the Region. The objectives were to: • Assess the context and broader policy environment of school health in the Region, including legislative frameworks. • Identify the scope and form of school health programs and services available in the Region, as well as opportunities for improvement. • Enable countries to share best practices and lessons learned in the development and implementation of school health policies, programs, and services. The assessment was implemented as a joint effort between PAHO/WHO, UNICEF, UNESCO, and the World Bank, and the results are presented in this report. In the context of renewed global and regional efforts to enhance the scope, coverage, and results of school health, this assessment presents a baseline and serves to inform ongoing and renewed efforts by policymakers, program managers, and other stakeholders in health and education and elsewhere to take targeted actions for making every school in the Region a health-promoting school. 7METHODOLOGY Methodology The components of the FRESH and IUHPE frameworks informed the design of this regional assessment, including the review checklists and tools. Based on the frameworks, the assessment focused on six elements: • Governance of school health programs • School health policy environment • Health education and curriculum • Healthy and safe learning environments • Student and community participation • Access to health services The assessment consisted of three main components: 1) desk review, 2) country assessments, and 3) stakeholder consultation. 2.1 Desk review The desk review consisted of two elements: a) a scoping review of peer-reviewed literature on school health and HPS implementation in LAC and b) review of country legislation, policies, strategies, and plans related to school health and HPS in LAC. 2 8 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT 2.1.1 Scoping review The purpose of the review was to gather insight into the scope and content of peer-reviewed information on school health and HPS implementation. Searches were conducted for the period 1995 and onward for English and Spanish papers, and for Portuguese papers with a full English translation or an English abstract. The search engines used were PubMed (including MEDLINE), LILACS, and Scielo. Searches were conducted in English and Spanish using the terms “school health,” “healthy schools,” and “health-promoting schools” in combination with the names of all countries and territories in LAC. Review question: what are the scope and contents of school health and HPS programs and interventions in countries in LAC? • Identification of relevant literature: – Search concepts: school health; healthy schools; health-promoting schools. – Search terms: School health AND (name of the country); healthy schools AND (name of the country); health-promoting schools AND (name of the country); salud escolar AND (name of the country); escuelas promotoras de la salud AND (name of the country); escuelas saludables AND (name of the country). • Selection of literature: – Inclusion criteria: papers in English and Spanish published between 1995 and 2019 – Exclusion criteria: articles that reported only on studies among school or school-aged children and/or were conducted in schools, and multi-country articles mentioning LAC countries without presenting country-specific information. • Data charting: two reviewers selected the articles to be included based on review of titles, followed by abstract review and finally full text review for data extraction. • Data synthesis and reporting: – The results were synthesized and interpreted according to the following main themes: - Locations (countries and subnational locations). - Definitions or concepts of school health and HPS applied: whether the article provided a definition or conceptual framework for the action, and specifically, whether this definition included or reflected the six elements mentioned above. - Health topics and scope of the programs and interventions presented in the paper. - Results and conclusions. 2.1.2 Review of country legislation, policies, strategies, and plans The objective of this component was to gain an understanding of the policy environment of school health and HPS in LAC. Searches for these documents were conducted using the Google search engine using the strategy below. 9METHODOLOGY • In the first step, a broad search was performed using the terms “school health,” “health-promoting schools,” and “HPS” with the name of each country. • In the second step, more highly targeted individual searches were performed with the terms “law,” “legislation,” “policy,” “strategy,” “plan,” “program,” used in conjunction with “school health,” “health-promoting schools,” “HPS,” and the country name. • In the third step, the same searches were performed as in the second step, but “school health” and “health-promoting schools/HPS” were replaced with “health” in one search, and “education” in the other. In instances where school-health-specific laws, policies, or strategies were not available in the country, this step broadened the search to any documents pertaining to the health and education sectors. Once located, the reviewer then verified whether such documents included a reference to school health or HPS. When it did contain a reference, the document was included in the catalog of collected materials. • In the fourth step, an even broader search was performed for countries’ policies, strategies, or plans that might not pertain directly to the health and education sectors (e.g., poverty-reduction strategies, development policy, etc.). Once these were identified, a review was performed to identify any references to school health. This step was used in instances in which no other documents had been identified in previous steps. • Finally, the lists of identified documents were shared with countries through the PAHO country offices for review and validation. During this process, countries could share additional documents not previously identified, which several did. Data extraction and analysis: The documents that were identified through the search strategy described above were reviewed for the existence and nature of school health content. A distinction was made between documents that focused on school health, and documents that did not specifically focus on school health but that mentioned or referred to school health. All the documents were categorized as pertaining to one of three areas—legislation; policy; or strategies and plans—and then reviewed for content that related to five key components: 1. governance of school health programs; 2. health education and curriculum; 3. healthy and safe learning environments; 4. student and community participation; and 5. access to health services. The results of the review are presented in the results section as descriptive results expressed in absolute numbers and percentages. 2.2 Country assessments The country assessments were conducted through two surveys—a national-level survey and a school- level survey. The survey instruments were drawn from existing instruments, including the FRESH monitoring and evaluation guidance for school health programs and tools (11), the System Approach for Better Education Results (SABER) (24), and the Global School Health Policies and Practices Study (G-SHPPS) (25). The survey instruments covered four areas: 10 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT 1. School health policies and strategies 2. Healthy and safe learning environment 3. Skills-based health education 4. Organization and delivery of health services The assessment instruments were piloted and validated in two English-speaking countries (Guyana and Trinidad and Tobago) and one Spanish-speaking country (the Dominican Republic) prior to regional implementation. The results of the pilots were used to further adjust the methodology and instruments for regional implementation. The national surveys were completed by officials from the ministries of health and education or other national institutions with responsibilities for developing, coordinating, implementing, and providing oversight for school health or components thereof. Other relevant local stakeholders, such as NGOs engaged in school health, also completed the national surveys. In the case of decentralized governance, the surveys were completed by officials at the highest decentralized administrative level, such as provincial authorities. With support from a national data coordinator, the relevant authorities at the ministries of health and education completed the questionnaire separately, followed by a consensus workshop with participation of the two ministries and relevant other stakeholders, such as NGOs and community-based organizations engaged in school health. During the consensus meeting, the initial responses to the survey questions were reviewed and discussed in order to arrive at a consensus response that could be verified with evidence (policy documents, studies, reports, etc.). The final consensus responses were entered into an online SurveyMonkey. The school-level surveys were designed to be completed by school principals, administrators, teachers, and health workers. In a process similar to that used with the national surveys, relevant school-level stakeholders received a paper copy of the survey in advance, followed by a consensus meeting for discussion and joint completion of the survey through SurveyMonkey. Only countries that conducted a Global School-Based Student Health Survey (GSHS) (26) or a Global Youth Tobacco Survey (GYTS) (27) in the two years before the regional school health assessment participated in the school-level survey; they used the same GSHS or GYTS sample of schools. Data extraction and analysis: The Excel data tables were generated by and directly downloaded from SurveyMonkey. The country responses were reviewed and quality control of entries was conducted by cross-checking related questions and comparing them with supporting documents submitted by respondents. Where needed, countries were contacted to clarify discrepancies. Countries were requested to share copies of documents reported in the survey. Univariate analysis was conducted to explore the frequency distribution of responses. Categorical variables were presented in proportions, percentages, or frequencies. In this assessment, maps, tables, and figures are used to present the findings. 11METHODOLOGY 2.3 Stakeholder consultation The final step in the regional assessment consisted of a two-day technical meeting. The main purpose of that meeting was to validate the results of the preliminary assessment, engage stakeholders in a regional dialogue about the current status of school health and HPS implementation in the LAC Region, and to articulate recommendations for strengthening school health and HPS in the Region. Meeting participants included youth, regional partners, and representatives from the ministries of health and education from selected countries. 2.4 Ethical considerations and limitations Prior to implementation, the assessment protocol was submitted to the PAHO Ethical Review Committee for approval. The assessment reflects the situation as of 2017–2018; limitations include the completeness of information provided by key informants on the country level. Additionally, attrition of any key government post can affect institutional memory, which may have influenced the information provided. 12 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT Results 3.1 Desk review 3.1.1 Scoping review A total of 516 articles were identified for possible inclusion; the number was reduced to 390 after removing duplicates and title review, and reduced to 73 after abstract review (see Figure 1). FIGURE 1 Scoping review flow chart LILACS N=155 PubMed N=341 N=516 Following removal of duplicates and title review N=390 Following abstract review N=73 Scielo N=20 3 13RESULTS Annex 2 summarizes the key content of the 73 articles according to the countries and components mentioned. The following paragraphs provide a synthesis of the results. To ensure that relevant articles were captured, separate searches were conducted using the search terms “school health,” “healthy schools,” and “health-promoting schools.” Notably, however, searches with the term “health-promoting schools” generated no results for Caribbean countries and generated only about half of the articles that were ultimately found for Latin American countries. This discrepancy may suggest that the term “health-promoting schools” is less familiar or less often used in the countries of the Caribbean than in Latin America, and that in Latin America “school health,” “healthy schools,” and “health-promoting schools” are all used in practice. Included in the review: articles reporting on studies related to a school health intervention and articles evaluating or reflecting on school health interventions and programs. Excluded from the review: articles that reported on multi-country studies but that did not provide country-specific information, and articles reporting on studies conducted in the school population but unrelated to a school health intervention. (The large number of articles in this last category illustrates that a school population—which provides a captive audience for studies related to school-aged children—is very attractive.) The 73 reviewed articles presented information from 21 countries and territories. The review generated a preponderance of articles from Brazil, Chile, Colombia, and Ecuador. There was, however, sufficient material from other countries to provide a general regional overview of peer-reviewed information on school health and HPS activities in LAC. A set of articles (28–38) presented overall reviews, evaluations of and reflections on school health programs and approaches, and implementation of the HPS approach; these were useful for extracting lessons learned from a regional perspective. A supportive policy environment for school health and HPS was emphasized by various authors, including a review by Salinas and del Vio (28) of the implementation of the school health program, Vida Chile. The authors concluded that after this nationally accredited program was canceled, a variety of unspecified actions were implemented with limited results. The authors also concluded that both a recognized authority and a coordinating mechanism are essential to effectively implement a coherent school health promotion policy (28). Among the lessons learned from implementation of HPS in Buenos Aires, Argentina: the local community and context play an essential role in the articulation of school health program priorities and interventions. Also, it is necessary to reflect on and accommodate differences between sub-groups in the same communities (29). Various papers emphasized the importance of stakeholder ownership and participation and ensuring the building of agency and autonomy in communities, families, and students. From a governance perspective, various authors also emphasized the critical importance of policy to support, guide, and enforce school health actions, and the benefit of having a clearly defined entity 14 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT that is responsible for implementation. Intersectoral articulation and collaboration, particularly between health and education, was also emphasized as an essential element for success; the importance of training and supporting teachers was also emphasized. The remaining articles (30–100) presented reports on implementing school-based interventions of varying scopes that address a range of health topics. Some articles presented simple evaluations of the interventions, while others presented studies with more rigorous designs, including quasi-experimental designs with intervention and control groups. The duration of the interventions ranged from brief (days or weeks) to longer-term (multiple years). The target populations were mostly primary and secondary school students; the scope varied widely, ranging from one or two schools to district-wide. From the information presented, it was often difficult to assess whether the interventions were implemented in the context of a larger school health intervention or HPS approach, and whether they continued after the studies were completed. The HPS elements most frequently included in the articles are health education and curriculum, as the majority of interventions consisted of health information or education presented to students in the classroom, and in some instances in after-school activities for students, parents, and communities. The second most frequently addressed element was a healthy and safe learning environment—for instance, changes in the nutritional options in the school cafeteria or vicinity, or improvements in school facilities, providing increased opportunities for physical activity. Student and community participation and access to health services were less frequently mentioned, but when they were mentioned, they were considered critical. The majority of studies focused on a single health topic. They included substance use, bullying, HIV, water consumption, oral health, ocular health, diabetes, asthma, nutrition, dengue, schistosomiasis, sexual health, mental health, and dating violence. Several articles reported on more multidimensional interventions addressing healthy habits, most frequently healthy eating and physical activity. In most studies, the topics appeared to have been chosen by the researchers; however, a few studies mentioned that the top-priority topics were evidence-informed and selected in partnership with local stakeholders. The results and lessons learned presented in the reviewed papers were predominantly positive. Notably, most studies reported on immediate or short-term results of interventions, such as improved skills and knowledge, and very few reported on how interventions affected the level of health outcomes. Studies that reported on the feasibility of interventions commented on the cost-effectiveness of school-based interventions and on the suitability of the school environment to positively influence the health of students, teachers, and the wider community. 3.1.2 Review of country legislation, policies, strategies, and plans As presented in Table 2, school health governance documents were identified for 44 countries and territories in the Americas. Of these, just 17 (39%) of the countries and territories had dedicated school 15RESULTS health legislation and/or policies; the remaining 27 had other, usually broader legislation and/or policies that explicitly mentioned school health. The school health-related legislation and policies included laws, bills, acts, presidential and ministerial decrees or resolutions, and formal policy documents. About a third of the countries had legislation and policies dated from before the year 2000, another third from the period 2000–2010, and the remaining from the period 2011–2018. Typically, the school health legislative and policy documents articulated a vision and goal, reiterating the right to and importance of children’s health, and the important role that schools have in maintaining and promoting students’ health. The documents also specified key implementation responsibilities. In the vast majority of cases, that implementation is to be shared with the ministries of health and education; in some cases, it is shared with other partners, such as the ministry of social protection; and in a few cases, it is shared with designated school health institutes, such as the Programa Sanidad Escolar (PROSANE) in Argentina and INABIE (Instituto Nacional de Bienestar Estudiantil) in the Dominican Republic. Several countries have adopted school health policies that address one or more specific topics, such as Dominica’s and Haiti’s school nutrition policies and Guyana's public health immunization act. Country legislation and policies that were not specific school health policies but included or referred to school health include national child and youth policies, education policies, physical education and health policies, health promotion policies, sexual and reproductive health policies, and family planning policies. TABLE 2 School health legislation, policies, strategies, and plans by country or territory COUNTRY/TERRITORY SCHOOL HEALTH LEGISLATION AND/OR POLICY SCHOOL HEALTH/HPS STRATEGY OR PLAN Caribbean 1 Anguilla 2 Antigua and Barbuda 3 Aruba 4 Bahamas 5 Barbados 6 Belize 7 Bermuda 8 British Virgin Islands 9 Cayman Islands 10 Cuba 16 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT COUNTRY/TERRITORY SCHOOL HEALTH LEGISLATION AND/OR POLICY SCHOOL HEALTH/HPS STRATEGY OR PLAN 11 Curaçao 12 Dominica 13 Dominican Republic 14 Dutch Caribbean municipalities (Bonaire, Saba, Sint Eustatius) 15 French Territories (French Guiana, Guadeloupe, Martinique) 16 Grenada 17 Guiana 18 Haiti 19 Jamaica 20 Montserrat 21 Saint Kitts and Nevis 22 Saint Lucia 23 Saint Vincent and the Grenadines 24 Sint Maarten 25 Suriname 26 Trinidad and Tobago 27 Turks and Caicos Islands Central America 28 Costa Rica 29 El Salvador 30 Guatemala 31 Honduras 32 Nicaragua 33 Panama South America 34 Argentina 35 Bolivia (Plurinational State of) 36 Brazil 37 Chile 38 Colombia 39 Ecuador 40 Paraguay 41 Peru 42 Uruguay 43 Venezuela (Bolivarian Republic of) 17RESULTS COUNTRY/TERRITORY SCHOOL HEALTH LEGISLATION AND/OR POLICY SCHOOL HEALTH/HPS STRATEGY OR PLAN North America 44 Mexico Countries/territories with dedicated school health legislation, policies, strategies, plans Countries/territories with school health included in other legislation, policies, strategies, plans No information As presented in Table 2, 41 countries and territories had operational school health programs, albeit at varying degrees. In total, the literature review found designated school health strategies or plans for 20 countries and territories (49%) of those in the literature review. These included 15 countries with designated school health legislation and policies and five without. The remaining countries had school health activities incorporated into other strategies and plans. For instance, Aruba, Bermuda, and Suriname had plans for reducing overweight and obesity; Sint Maarten had a national mental health plan; the British Virgin Islands had national health and safety school strategies; and several countries included school-level activities in their HIV strategies and plans. These results underline the important role of policy, as countries with defined school health legislation and policies were more likely to have a strategy or plan for implementing school health programs. As a next step, all school health legislation, policies, strategies, and plans identified through the dedicated desk review were reviewed for five school health components: a. Governance of school health programs – specifically, whether they defined and assigned implementation responsibilities, and if so, to whom. b. Health education and curriculum – specifically, whether they mentioned a structural, curriculum- based approach to health education. c. Healthy and safe learning environment – specifically, whether a healthy and safe learning environment for students and faculty was acknowledged as important. d. Student and community participation – specifically, whether participation of students, parents, and communities was called for. e. Access to health services – specifically, whether there was mention of the importance of linking to health services and increasing students’ access, and if so, using which methods. 18 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT TABLE 3 Components addressed in the school health legislation, policies, strategies, and plans by country or territory COUNTRY/TERRITORY GOVERNANCE OF SCHOOL HEALTH PROGRAMS HEALTH EDUCATION AND CURRICULUM HEALTHY AND SAFE LEARNING ENVIRONMENT STUDENT AND COMMUNITY PARTICIPATION ACCESS TO HEALTH SERVICES Caribbean Anguilla Antigua and Barbuda Aruba Bahamas Barbados Belize Bermuda British Virgin Islands Cayman Islands Cuba Curaçao Dominica Dominican Republic Dutch Caribbean municipalities (Bonaire, Saba, Sint Eustatius) French Territories (French Guiana, Guadeloupe, Martinique) Grenada Guyana Haiti Jamaica Montserrat Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Sint Maarten Suriname Trinidad and Tobago Turks and Caicos Islands 19RESULTS Central America Costa Rica El Salvador Guatemala Honduras Nicaragua Panama South America Argentina Bolivia (Plurinational State of) Brazil Chile Colombia Ecuador Paraguay Peru Uruguay Venezuela (Bolivarian Republic of) North America Mexico Countries with school health legislation, policies, strategies, plans Countries with school health included in other legislation, policies, strategies, plans Elaborated in the school health legislation, policies, strategies, and plans Not elaborated in the school health legislation, policies, strategies, and plans No information As presented in Table 3, all five components were found in the policies, strategies, and plans of only five countries (Colombia, Cuba, Dominican Republic, Mexico, and Peru). Twelve more countries addressed three or four of the components; the majority of these were countries with school health legislation or policies. In general, the component most frequently included was a healthy and safe learning environment. While the international school health frameworks define a healthy and safe learning environment as both a physical and psychosocial environment, most of the policies, strategies, and plans referred to a physically safe environment—in particular, to water and sanitation issues. It also appears that countries in South America and Mexico have more comprehensive school health policies than countries in Central America and the Caribbean. 20 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT 3.2 Country assessments Through the PAHO country offices, 35 PAHO Member States in LAC were invited to participate in the country assessments; 18 accepted the invitation, a response rate of 51%. In informal follow-up, Member States that declined to participate provided the following reasons: a) recent government change; b) limited staffing to allocate to the assessment, and c) absence of an articulated school health program in the country. A total of 18 countries, including three pilot countries, completed national assessments. Following the validation, the three pilot countries were given the opportunity to revise their assessment results and provide additional information, as needed. Because the school-level survey was completed by only three countries, it was decided to exclude that survey from the data analysis and report. As presented in Table 4, nine (50%) of the participating countries were from the Caribbean. Nevertheless, the participating countries reflected a variety of contexts in the three LAC subregions. TABLE 4 Countries and territories that completed the school health survey, by subregion CENTRAL AMERICA SOUTH AMERICA CARIBBEAN Honduras Mexico Panama Argentina Bolivia (Plurinational State of) Brazil Colombia Paraguay Peru Antigua and Barbuda Barbados Belize British Virgin Islands Dominican Republic Guyana Haiti Suriname Trinidad and Tobago 3.2.1 School health policies, strategies, and plans Existence and scope of school health policies, strategies, and plans The survey responses corroborated the results from the desk review and provided more specificity. From the 18 countries that completed the national school health survey, eight reported having a current national school health policy, strategy, and/or plan; one reported having an expired national 21RESULTS school policy; one reported having a draft school health policy; four reported having school health as a dedicated section in a broader policy, strategy, or plan; and the remaining four reported not having a school health policy, strategy, or plan at the time of the assessment but reported that school health was mentioned in other policies, strategies, or plans (Figure 2). Nine of the 14 countries with a school health policy, strategy, or plan (either dedicated, expired, a draft, or a dedicated section in another policy) indicated that these governance tools applied to both public and private schools. The remaining four countries (Bolivia [Plurinational State of], Brazil, Guyana, and Panama) indicated that they only applied to the public schools. In response to questions about how these policies, strategies, and plans were developed, Panama and Paraguay reported using existing data on the health situation of school-aged children to establish priorities; two countries (Brazil and Haiti) reported conducting stakeholder consultations; and seven countries (Argentina, Bolivia [Plurinational State of], Colombia, Dominican Republic, Guyana, Honduras, and Mexico) reported conducting situation analyses as well as stakeholder consultations. Box 1 provides some details on the school health program in Brazil and Box 2 on the program in Argentina. BOX 1 The School Health Program in Brazil – the Programa Saude na Escola (PSE) The intersectoral health and education policy guiding the PSE was developed in 2007 with a limited number of municipalities and is now implemented on the state, provincial, and municipal level; all municipalities in a country are eligible to join and participate. The program was conceived as a strategy for fostering citizenship and developing healthy children and adolescents. It articulates priority actions to be taken by the health and education sector as well as relationships between the sectors, and includes preschools and day care centers. Participation in the PSE requires establishing an intersectoral working group for joint stakeholder planning, execution, monitoring, and evaluation. Working group members of PSE must include the ministries of health and education and encourage the inclusion of stakeholders who represent public policies and social movements—stakeholders representing culture, leisure, sports, transportation, urban planning, NGOs, and civil society. Sources: Brasil EGM, Silva RMD, Silva MRFD, Rodrigues DP, Queiroz MVO. Adolescent health promotion and the School Health Program: complexity in the articulation of health and education. Promoção da saúde de adolescentes e Programa Saúde na Escola: complexidade na articulação saúde e educação. Rev Esc Enferm USP. 2017;51:e03276. doi:10.1590/s1980-220x2016039303276 Monteiro PH, Bizzo N. A saúde na escola: análise dos documentos de referência nos quarenta anos de obrigatoriedade dos programas de saúde, 1971–2011 [Health in school: an examination of the reference documents for the forty years of compulsory health programs, 1971–2011]. Hist Cienc Saude Manguinhos. 2015;22(2):411-428. doi:10.1590/S0104-59702014005000028 22 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT FIGURE 2 The status of school health policies, strategies, and plans in participating countries A. Current dedicated school health policy, strategy, or plan B. School health included with a dedicated section in another policy, strategy, or plan C. School health mentioned in another policy, strategy, or plan D. Expired school health policy, strategy, or plan E. Draft school health policy, strategy, or plan A: Argentina, Brazil, Dominican Republic, Haiti, Honduras, Mexico, Panama, Paraguay B: Barbados, Bolivia, Colombia, Guiana C: Antigua and Barbuda, Belize, British Virgin Islands, Suriname D: Peru E: Trinidad and Tobago 0 1 2 3 4 5 6 7 8 N u m b er o f co u n tr ie s A: Argentina, Brazil, Dominican Republic, Haiti, Honduras, Mexico, Panama, Paraguay B: Barbados, Bolivia (Plurinational State of), Colombia, Guyana C: Antigua and Barbuda, Belize, British Virgin Islands, Suriname D: Peru E: Trinidad and Tobago Ten of the countries with school health policies, strategies, or plans indicated that these documents had not been widely disseminated and were therefore probably not available at the district or school level. Participants were asked which topics were included in the school health policy, strategy, or plan. The most frequently mentioned topics: healthy and safe learning environments, skills-based health education, and health services. The next most frequently named topics: skills-based health education and nutrition. Other topics mentioned were social participation, student empowerment, and peaceful coexistence (Figure 3). 23RESULTS FIGURE 3 Topics addressed in school health policies, strategies, and plans 0 2 4 6 8 10 12 E. Other D. Nutrition C. Health servicies B. Skills-based health education A. Healthy and safe learning environment A: Argentina, Barbados, Bolivia (Plurinational State of), Colombia, Dominican Republic, Guyana, Haiti, Honduras, Mexico, Panama, Paraguay. B: Argentina, Barbados, Bolivia (Plurinational State of), Colombia, Dominican Republic, Guyana, Haiti, Mexico, Panama, Paraguay. C: Argentina, Barbados, Bolivia (Plurinational State of), Brazil, Colombia, Dominican Republic, Guyana, Haiti, Mexico, Panama. D: Argentina, Brazil, Dominican Republic, Haiti, Mexico, Panama, Paraguay. E: Bolivia (Plurinational State of), Brazil, Colombia, Mexico, Panama, Paraguay. BOX 2 The national school health program in Argentina – PROSANE The “Programa Nacional de Salud Escolar” (PROSANE) is coordinated by the national directorate of maternity, children, and adolescents at the Ministry of Health and Social Development. The national program was created in 2008 through Resolution # 439/2008. Because the country is of a federal nature, the program’s implementation depends on local regulations. Its mission is to develop and strengthen integrated care policies between health and education, actively respond to the health needs of school-age children and adolescents, promote actions and polices that prevent disease and promote health, and strengthen the articulation between the country’s Ministry of Health and its Ministry of Education. At least 19 provinces have developed corresponding provincial regulations to support implementation of PROSANE, which was conceived as a primary health care strategy where teams that provide first-level care help identify and implement priority actions in schools. The program works closely with relevant national and provincial programs, including the adolescent health program, the national comprehensive sexual education program, and the national program for education and prevention of drug use. It is estimated that each year PROSANE reaches more than 200,000 children and adolescents in more than 2,500 schools across Argentina. Source: Codarini G, Andracchio M, Viggiani F, González P, Lev D. Programa Nacional de Salud Escolar: una política de cuidado de niñas, niños y adolescentes en edad escolar de Argentina. Rev Argentina Salud Publica. 2018;9(35):38-41. Available from: https://rasp.msal.gov. ar/index.php/rasp/article/view/560 https://rasp.msal.gov.ar/index.php/rasp/article/view/560 https://rasp.msal.gov.ar/index.php/rasp/article/view/560 24 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT 3.2.2 Planning, coordination, supervision, implementation, and budgeting Sixteen countries responded to the questions regarding coordination, supervision, and implementation of school health actions. The arrangement most frequently reported is shared, coordinated responsibility between the countries’ ministries of health and education (10 countries). One country (Barbados) listed its ministry of health as the lead responsible agency; two countries (Guyana, Antigua and Barbuda) listed their ministries of education. One country (Peru) indicated that school health activities are independently determined by the health and education sector, with each sector responsible for coordinating and implementing their activities. One country (Bolivia [Plurinational State of]) identified its municipal authorities as the entities responsible for planning, coordinating, and supervising school health activities. Another country (Belize) cited an inter-ministerial mechanism that coordinates school health action. Five countries reported they had a formal mechanism for coordinating school health activities, i.e., the ministries of health and education; four of those countries also included other government partners, and two countries mentioned NGOs and UN partners as members of the school health coordinating mechanism. Planning and budgeting for school health activities occurs either exclusively on the national level (six countries) or primarily on the national level, with limited planning and budgeting on the local level (seven countries); occasionally it is shared equally between the national and local levels (three countries). When it comes to implementation, 17 countries confirmed that they are implementing school health activities; 10 countries indicated they are implementing HPS strategies, and 7 Caribbean countries reported that their main focus for school health is HFLE (Box 3). One remaining country, Suriname, indicated that it is not currently implementing regular school health actions. The most frequently reported target group for school health actions were children ages 5–12. When asked about coverage, nine countries confirmed they had a national register or mechanism to track school-level implementation of school health activities. 25RESULTS All responding teams were asked to report on the coverage of their school health activities, either based on their registry or their best estimate. The results are presented in Table 5. BOX 3 Health and family life education (HFLE) HFLE is classroom education that seeks to empower children and young people by imparting knowledge and skills necessary for healthy living and prepare them to cope effectively with life’s many challenges. The expectation is that a combination of life skills, knowledge about health, and a supportive environment will enhance young people’s potential to become healthy, productive, contributing citizens. In 1994, the Caribbean Community (CARICOM) Standing Committee of Ministers of Education passed a resolution supporting the development of a comprehensive approach to Health and Family Life Education (HFLE) by CARICOM and the University of the West Indies (UWI). The commitment gave rise to the CARICOM/ UN Multiagency Health and Family Life Education (HFLE) Project which was endorsed in 1996 by the Standing Conferences of Ministers of Health and Ministers of Education. The HFLE curriculum focuses primarily on five core areas or themes: 1) health and human life; 2) developing oneself and developing interpersonal relationships; 3) appropriate eating and fitness; 4) managing human sexuality, and 5) managing the environment. HFLE has been adopted and implemented in most Caribbean countries and territories at various scales and continues to be a health and education priority for CARICOM. Sources: PAHO & CARICOM. Preparing teachers to implement HFLE in schools of the Caribbean Community (CARICOM). https://caricom. org/documents/11871-revised_curriculum_guide_for_caribbean_teachers.pdf UNESCO/ECD, UNICEF, CARICOM. Health and Family Life Education. Regional curriculum framework for ages 9–14. http://www.hhd.org/ sites/hhd.org/files/HFLE%20Curriculum%20Framework_Merged.pdf https://caricom.org/documents/11871-revised_curriculum_guide_for_caribbean_teachers.pdf https://caricom.org/documents/11871-revised_curriculum_guide_for_caribbean_teachers.pdf http://www.hhd.org/sites/hhd.org/files/HFLE%20Curriculum%20Framework_Merged.pdf http://www.hhd.org/sites/hhd.org/files/HFLE%20Curriculum%20Framework_Merged.pdf 26 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT TABLE 5 Coverage of school health activities by country/territory and student age group AGE/COUNTRY 5–8 YEARS 9–12 YEARS 13–15 YEARS 16–18 YEARS > 18 YEARS Antigua and Barbuda 76–100% 76–100% 51–75% < 25% < 25% Argentina 26–50% 26–50% 26–50% 26–50% < 25% Barbados 76–100% 76–100% 76–100% 76–100% < 25% Belize 76–100% 76–100% 76–100% Don’t know Don’t know Brazil Don’t know Don’t know Don’t know Don’t know Don’t know British Virgin Islands 26–50% 26–50% 51–75% 51–75% 51–75% Bolivia (Plurinational State of) 76–100% 76–100% 76–100% 76–100% Don’t know Colombia Don’t know Don’t know Don’t know Don’t know Don’t know Dominican Republic Don’t know Don’t know Don’t know Don’t know Don’t know Guyana 51–75% 51–75% 51–75% 51–75% 51–75% Haiti Don’t know Don’t know Don’t know Don’t know Don’t know Honduras 26–50% 26–50% < 25% < 25% < 25% Mexico 51–75% 51–75% 26–50% < 25% < 25% Panama 26–50% 26–50% 0% 0% 0% Paraguay < 25% < 25% < 25% 0% 0% Peru < 25% < 25% < 25% 0% 0% Trinidad and Tobago < 25% < 25% < 25% < 25% 0% Countries with registration systems Countries without registration systems The data presented in Table 5 indicates low to average coverage of school health activities in several countries. Antigua and Barbuda, Barbados, Belize, and Bolivia (Plurinational State of) stand out as reporting coverage of over 75% in the age group 5–15 years. key challenges mentioned by countries regarding implementation of school health policies, programs, and services: 1. Lack of political will and low prioritization of school health. 2. Limited understanding and appreciation of the usefulness of school health actions. 3. Lack of a legal basis to ensure that policies and programs will have continuity. 27RESULTS 4. Lack of designated and secure funding to implement school health programs and activities, especially in remote areas. 5. Lack of adequate infrastructure for implementation of school health activities, particularly in rural areas. 6. Insufficient coordination and partnership between different stakeholders interested in the topic, and at times potential conflict of interest. 7. Initiatives do not trickle down to the local levels, particularly to remote areas. 8. Lack of systems that ensure quality and timely data to evaluate school health initiatives. 9. Limited human resources to dedicate to school health activities. 10. Lack of school health training opportunities for health and education human resources. 3.2.3 Healthy and safe learning environment Survey questions related to a healthy and safe learning environment focused on 24 topics that can be divided into five broad areas (Table 6). TABLE 6 Healthy and safe learning environment components assessed in the survey PHYSICAL ENVIRONMENT SUPPORTIVE ENVIRONMENT PROTECTION FROM HARM PREVENTION OF RISK BEHAVIORS PARTICIPATION Drinking water quality Gender equality Bullying prevention Tobacco use prevention Parent and family participation Sanitation Non-discrimination Violence prevention Alcohol use prevention Community involvement Safety of buildings Classroom management Use of positive discipline methods Illegal drug use prevention Physical accessibility (disability) Cultural diversity Injury prevention and safety Hygiene Waste management Faculty and staff health promotion Emergency and natural disaster preparedness Nutrition/dining and/ or food kiosks Spaces for sports and physical activity Protection from (road) traffic 28 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT The survey asked countries a) whether they had national standards to guide schools on these topics, b) whether they had procedures to formally assess if schools met the standards, and c) to estimate the percentage of schools that met the standards. Countries that said national standards were in place were asked to share the standards documents for review. As illustrated in Annex 3, most countries reported the existence of national standards on the 24 topics. However, only a few countries provided documentation required to verify the existence and contents of those standards, and reviews of that documentation indicate that the standards were mostly generic principles and guidance contained in laws, policies, and plans related to a specific topic—for instance, principles on gender equality in the national gender policy, national nutrition guidelines, etc. Very few standards specific to a school context were found. Examples of school-specific standards shared during the assessment include national and subnational standards pertaining to school food programs, including restrictions on food with high sugar and fat content, menus, portion sizes, storage, sanitation, equipment, and building and infrastructure. Of the 17 countries responding to the question about the existence of a mechanism for formal assessment of standards, 10 (59%) confirmed the existence of such a mechanism, five indicated there is no mechanism, and two did not know. Overall, the responses and the review of country documents did not provide an impression of clear, school-specific and measurable standards on key subjects, suggesting that education systems and schools may construct actions in the absence of standardized and evidence- based guidance. 3.2.4 Skills-based health education For this component, the survey asked about recent policies or standards (developed in the two years preceding the survey) related to a) time requirements for health education; b) certification or accreditation standards for health-promoting schools; c) professional development or continuing education programs on health education; d) instructional content on priority topics; and e) incentives for schools and teachers to provide skills-based education. As shown in Table 7, nine countries reported having recently developed or revised the time requirements for health education, and eight countries had made those changes for professional development or continuing education programs for health education. In addition, six countries reported having recently developed or revised the standards for certification or accreditation of health-promoting schools. 29RESULTS TABLE 7 Recent development or revision of time requirements for health education, certification or accreditation of HPS, and professional development by country NUMBER OF COUNTRIES COUNTRIES REPORTING RECENT DEVELOPMENT OR REVISION Time requirements for health education for children ages 5–8 9 Barbados, Belize, Dominican Republic, Haiti, Honduras, Mexico, Panama, Peru, Trinidad and Tobago Time requirements for school health education for children and adolescents ages 9–12 9 Barbados, Belize, Dominican Republic, Haiti, Honduras, Mexico, Panama, Peru, Trinidad and Tobago Time requirements for school health education for adolescents ages 13–15 9 Barbados, Belize, Dominican Republic, Haiti, Honduras, Mexico, Panama, Peru, Trinidad and Tobago Time requirements for school health education for adolescents ages 16–18 9 Belize, Dominican Republic, Haiti, Honduras, Mexico, Panama, Peru, Trinidad and Tobago Time requirements for school health education for adolescents and young people older than 18 3 Haiti, Mexico, Peru Certification or accreditation standards (or the equivalent) for health-promoting schools 6 Belize, Haiti, Mexico, Panama, Paraguay, Trinidad and Tobago Professional development or continuing education programs on health education 8 Argentina, Barbados, Belize, Bolivia (Plurinational State of), Dominican Republic, Honduras, Mexico, Trinidad and Tobago Annex 4 presents an overview of countries’ responses to questions about recent revisions to policies or standards pertaining to the content of instruction for priority health topics. The responses indicate a mixed result: some countries have made recent revisions to the content of all or almost all 24 topics; others have not made revisions to any health education topic. Finally, countries were asked about the existence and characteristics of incentives to provide skills-based education content in class. Of the 18 participating countries, seven reported having incentives in place, nine reported not providing incentives, and one was not sure. The incentives mentioned were: • Certification of schools. • Recognition of schools; grants for promising intervention models. • Opportunities for knowledge exchange with peers. • Sports kits for schools that meet physical activity standards. • Opportunities for capacity building, training, salary increases, and public recognition. • Scholarships for specialized training. 30 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT 3.2.5 Organization and delivery of health services This section of the survey explored the organization of school health services provision, the target age groups, package, and coverage of services. As presented in Table 8, the organization of school health services to students varied between and within countries, and includes all four major scenarios included in the survey: 1. School-based health services 2. A distinct structure for school health services, but not based in schools 3. Certain health services offered to pupils in primary health care facilities 4. Certain health services provided by teachers TABLE 8 Organization of school health services by country DESCRIPTION COUNTRIES School health services are “school based” (i.e., a school-based health care provider is either on permanent or part-time basis, and there is usually a special room for consultations). Argentina, Brazil, Dominican Republic, Haiti, Honduras School health service is a distinct entity/structure in the health system, but school health services personnel are not based in school(s) and they make visits according to existing plans/ schedules. Antigua and Barbuda, Argentina, Barbados, Belize, Brazil, British Virgin Islands, Colombia, Dominican Republic, Guyana, Suriname, Trinidad and Tobago Certain health services for pupils are offered by health care provider(s) based in primary health care facilities. (Services are based in primary health care facilities with a clear link between the primary care providers and the school.) Argentina, Brazil, Colombia, Guyana, Haiti, Mexico, Panama, Peru Certain school health services are provided by teachers. Guyana, Honduras No school health services in the country. Bolivia (Plurinational State of), Paraguay Bolivia (Plurinational State of) does not provide school health services and respondents suggested that those services would cover a significant gap in pupils’ opportunities to seek care and receive age-appropriate services. In contrast, in Paraguay, where there are also no school health services, respondents indicated that they believe the country’s health system and service delivery models provide adequate opportunities for pupils to seek care and receive services; they felt that school health services would not add value to what is already in place. 31RESULTS Seven countries indicated that the school health services system is largely homogenous across the country and that it follows the national structure and regulations. Another seven reported that variations exist due to decentralization and the local autonomy of regions, provinces, or municipalities. The age of students served by school health services also varied across countries. The most frequently reported group is students ages 5–12, followed by the group of students ages 13–15 (Figure 4). Coverage also varies significantly (Figure 5). FIGURE 4 Student population, by age group, served by school health services 0–4 years: Argentina, Barbados, Brazil, Colombia, Dominican Republic, Guyana, Mexico, Peru. 5–8 years: Antigua and Barbuda, Argentina, Barbados, Belize, British Virgin Islands, Brazil, Colombia, Dominican Republic, Guyana, Haiti, Honduras, Panama, Mexico, Peru, Suriname. 9–12 years: Antigua and Barbuda, Argentina, Barbados, Belize, British Virgin Islands, Brazil, Colombia, Dominican Republic, Guyana, Haiti, Honduras, Panama, Mexico, Peru, Suriname. 13–15 years: Antigua and Barbuda, Argentina, Barbados, British Virgin Islands, Brazil, Colombia, Dominican Republic, Guyana, Haiti, Honduras, Mexico, Peru. 16–18 years: Antigua and Barbuda, Argentina, Barbados, British Virgin Islands, Brazil, Colombia, Dominican Republic, Guyana, Haiti, Mexico, Peru. >18 years: Antigua and Barbuda, British Virgin Islands, Colombia, Haiti, Guyana. The countries reported various mechanisms to cover the cost of school health services: paid by the government, with no cost to students (seven countries); paid by health insurance, parents, or caretakers (three countries); and a combination of different payment mechanisms (six countries). Figure 5 presents the estimated percentage of students, by age group, covered by health services. 0 2 4 6 8 10 12 14 16 18 N u m b er o f co u n tr ie s Age in years 0-4 5-8 9-12 13-15 16-18 >18 32 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT FIGURE 5 Estimated percentage of students covered by health services, by age group The health teams that are based at or linked to schools consist of school nurses (six countries), physical education officers (six countries), dentists (five countries), psychologists (four countries), health assistants (three countries), social workers (three countries), physicians (two countries), and nutrition specialists (one country). In total, nine countries responded to the questions related to provider–pupil ratios. Most countries commented that these ratios differ across districts and schools, and that their answers were rough estimates (Table 9). TABLE 9 Estimated number of school health personnel per 100 students COUNTRIES NUMBER OF NURSES PER 100 STUDENTS NUMBER OF DOCTORS PER 100 STUDENTS NUMBER OF OTHER PROFESSIONALS PER 100 STUDENTS Antigua and Barbuda >1 >1 Don’t know Argentina 0.75 0.75 0.75 Barbados 0.1 0.1 Don’t know British Virgin Islands Less than 1 Don’t know Don’t know Dominican Republic <1 0.000037 0.3 (psychologist or counselor) Guyana 4 4 Don’t know 0 1 2 3 4 5 6 >18 years16-18 years13-15 years9-12 years5-8 years N u m b er o f co u n tr ie s Age groups covered by school health services 26-50%1-25% 76-100%51-75% 33RESULTS COUNTRIES NUMBER OF NURSES PER 100 STUDENTS NUMBER OF DOCTORS PER 100 STUDENTS NUMBER OF OTHER PROFESSIONALS PER 100 STUDENTS Honduras 0.01 0.08 0.03 Panama <1 <1 <1 Suriname 0.16 Don’t know Don’t know Three countries indicated that students are in contact with the school health team as often as needed; two countries reported that students are in contact with the health team more than once a year; five countries reported that contact averaged once a year; and four countries reported that the contact averaged less than once a year. Except for Brazil and Haiti, all participating countries indicated that their school health teams are generally unable to meet students’ health care needs due to staff shortages and, more specifically, a shortage of staff trained in school health and in providing health services from a rights and gender- based perspective to adolescents. Only four countries (Belize, Guyana, Haiti, Suriname) reported that training was available for school health personnel. The most frequently mentioned services included in school health services were vaccinations, health education, sexual health counseling, dental care, and screening. Screening services included vision, hearing, dental, and height and weight. Some countries also listed screening for anxiety, depression, suicide risk, and behavioral and developmental disorders. The least frequently offered screenings were for blood pressure and sexually transmitted infections (STI). Only Argentina includes blood pressure in its school health screening, and Honduras is the only country that includes STI screening (specifically, syphilis testing for students 16 and older). Additionally, a few countries mentioned providing services for students with chronic illnesses; providing care for acute illness or injury; and providing diagnostic services and referrals for additional care. According to countries’ responses, the health teams’ activities extend beyond the clinic and include the larger school community, i.e., teachers and parents. Activities mentioned include: • Health promotion for the group/classroom that includes education about sexuality, tobacco, alcohol, drugs, physical activity, nutrition, and mental health. • Promotion of a healthy school environment. • Support for teachers. • Support and counseling for parents. • Management and control of infectious disease outbreaks. 34 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT • Emergency response. • Monitoring school facilities for sanitary and hygienic conditions. 3.2.6 Record keeping, monitoring, and evaluation Eleven countries indicated having a formal responsibility and process for record keeping on school health services provided to students. In addition, six countries (Argentina, Colombia, Dominican Republic, Guyana, Haiti, Peru) conducted a review of the scope and content of their school health services in the five years prior to the survey; two countries (Antigua and Barbuda and Brazil) did likewise between five and 10 years before the survey; and five countries (Barbados, Mexico, Panama, Suriname, and Trinidad and Tobago) did likewise more than 10 years ago. 3.2.7 Country perspectives on school health services The main challenges countries reported in relation to school health services: • Lack of standardization of services. • Unequal access to school health services across the country. • Shortage of personnel and insufficient involvement of families/caregivers, teachers, and/or communities. • Inadequate training for school health services staff. • Lack of funding. All participating countries except Brazil indicated a need for revising the scope and content of school health services in their countries. key areas for revision and strengthening include: Defining and clarifying the most appropriate models and types of services to include in a package of school health services. Defining and guidance for the composition, job descriptions, and roles of members of the school health team and optimal personnel-to-pupil ratios. Strengthening the evidence base for the impact of school health services in order to support advocacy and increased investment. 3.3 Stakeholder consultation In June 2019, PAHO/WHO organized a consensus meeting in collaboration with UNICEF, UNESCO, and the World Bank. The goal of the meeting was to jointly identify critical actions for strengthening school health in the Americas. Objectives: • Joint review of the status of school health in the Americas, both challenges and achievements. • Identification and discussion of lessons learned and opportunities for improvement. 35RESULTS • Consensus on regional and country-level strategies and action to strengthen the organization and results of school health in the Americas. Forty participants attended. They included representatives from WHO, PAHO/WHO, UNICEF, UNESCO, the World Bank, OAS, UNFPA, the World Food Program, FAO, SE-COMISCA, and CARICOM, and representatives from ministries of health and education for various countries (including Colombia, the Dominican Republic, Guyana, Haiti, Honduras, Mexico, and Paraguay), Johns Hopkins University, the Instituto de Programas Interdisciplinarios en Atención Primaria de la Salud (PROINAPSA), and youth leaders. The meeting agenda included presentations on global, regional, and country-level experiences and developments related to school health and health-promoting schools. During small group work, participants discussed current school health policies; healthy physical environments; health-promoting ethos and culture; school health and nutrition services; participation by parents, students, and community; and governance and financing of school health programs. The presentations and discussions illustrated the range of school health and HPS actions being implemented by regional partners and the differences in mandate, interest, and approaches from partners related to school health. In general, stakeholders agreed that the LAC Region has a strong history of school health and HPS, both at the regional and country levels, and suggested that this history and the lessons learned should be analyzed, documented, and shared within the Region and beyond. In this respect, the discussion illustrated marked differences between Latin America and the Caribbean. In Latin America, the experience focused on implementation of HPS. In contrast, in the Caribbean, the terminology HPS has less resonance; the HFLE initiative is considered the flagship Caribbean school health initiative and has been implemented with strong CARICOM involvement and leadership. In addition to promoting an HFLE curriculum and teacher training, various linked initiatives have been developed in the Caribbean, including a school-based initiative on violence prevention, and initiatives for youth participation and school health clubs. The stakeholders highlighted the importance of better definition, clarification, and alignment of core HPS concepts and dimensions; they felt there is no uniformity between and even within countries in the way the terminology pertaining to school health and HPS was defined, interpreted, and applied. Another cross-cutting issue discussed during the meeting was the appropriateness of a regional approach to HPS versus a country-driven approach. Participants agreed that a strong regional approach or strategy is essential and requires a component of strong advocacy to foster high level commitment to HPS and facilitate common understanding. The regional strategy should include technical and operational guidance for implementing HPS, help generate evidence about what works, and document 36 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT and share good practices and promising examples. The regional strategy should have sufficient flexibility for adaptation to different country contexts. On the country level, the HPS approach must entail formal partnerships between, primarily, the ministries of health and education; it must also include broad-based partnerships with civil society, the private sector, and other relevant partners. The partnerships with the private sector should, at a minimum, focus on reduction of harm (i.e., reducing sugar content in food products served in school), and should ideally be based on principles of social entrepreneurship that engage the private sector to become active partners in creating, implementing, and funding solutions to the main challenges in health and development that affect children and adolescents. Engagement with civil society was proposed as a strategy to better reach vulnerable and under-served groups, and to enhance the accountability of school health programs. The meeting also provided an opportunity for gathering input from the LAC Region in the early stages of the development of the global HPS standards. This was made possible because of an additional half- day agenda about HPS standards that was facilitated by WHO and UNESCO. 37CONCLUSIONS Conclusions This regional assessment on the status of school health and implementation of the HPS approach in LAC benefitted from information generated through various methods, including a desk review of school health policies and legislation, a scoping review of journal articles, a country survey with 18 LAC countries, and a regional stakeholders meeting. This multi-dimensional approach allowed for triangulation and consolidation of findings that led to these conclusions: • School health and the HPS are firmly embedded in the fabric of the Region. The majority of countries have developed legislative and policy instruments related to school health, some specifically dedicated to school health, and others with school health incorporated in wider governance instruments. Countries with dedicated school health legislation and/or policies were most likely to have operational plans for implementing school health programs. The HPS approach has strong resonance in Latin America, more so than in the Caribbean, where HFLE is considered the flagship school health strategy. However, only a little over half of the countries have mechanisms for documenting and monitoring the coverage and results of school health and HPS actions. Limited political will, insufficient funding, and lack of coordination between stakeholders were identified as major challenges in the implementation of school health policies, strategies, and plans. The assessment highlighted the importance of continued efforts to foster a common understanding of core school health and HPS concepts and the importance of a broad policy framework that promotes a culture of school health and considers a wide range of issues. Issues to be considered 4 38 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT should include the placement and location of school buildings and take into account elements such as air quality, sound pollution, traffic, access for students with disabilities, the concentration of vectors (e.g., mosquitos, rats, venomous snakes), and neighborhood problems such as violence and gang territory. Such policies go beyond health and education and include other sectors—for example, public works and public transportation, infrastructure, development, and police. A holistic approach to school health and HPS should consider and try to address the social problems affecting youth, such as family violence and poverty. • Governance and financing of school health programs. The assessment illustrated variations in the governance and financing of school health programs, ranging from national mechanisms and programs with dedicated staff and budget to countries with limited school health initiatives that are mostly dependent on external funds. Even in countries with dedicated school health staff and budget, resources may not be sufficient to cover all needs and may not be distributed effectively enough to reach the entire population. Therefore, an important dimension of the regional and country-level efforts must be the development of costed strategies and plans, allocating national and local resources, and mobilizing additional resources as needed and when feasible. It was emphasized that school health programs must not exclusively be donor-driven, because depending on external resources can contribute to fragmentation. Rather, interests and priorities from donors and external partners must be folded into a comprehensive country strategy or plan. • The organization and scope of school health and HPS programs and activities vary widely. They range from structured, government-funded programs with assigned resources to fragmented, externally funded initiatives of limited duration. The scoping review of peer-reviewed literature indicated a multitude of implementation studies and projects in schools across the Region, addressing a range of topics. Most of these initiatives were of short (a few months) to medium (a few years) duration and usually did not have a national scope, which raises the question of how extensively, beyond the interest of the study, the initiatives improved the health of school children and adolescents. School food programs are probably the most consistent component of school health activities in the Region, providing essential nutrition to children who may be vulnerable to malnutrition, and it was recommended that these programs should serve as important entry points for broader, more comprehensive approaches to school health. Stakeholders emphasized the importance of a healthy physical environment and a health-promoting ethos and culture, and highlighted the importance of proper water and sanitation as essential conditions for every school in addition to elements such as good lighting and appropriate seating arrangements. The importance of a healthy psychosocial environment was highlighted, too; it should include addressing and preventing all forms of emotional and physical violence, including bullying and corporal punishment. It was emphasized that a health promoting ethos and culture can only be established with the full participation of teachers, students, and parents. The assessment underlined that it is important for countries to develop comprehensive national and subnational strategies and plans to which donors, regional partners, and researchers can contribute, rather than having school health efforts be dependent on fragmented external interests. Evidence-based and standard-driven approaches to school health must be strengthened to increase effectiveness of interventions and programs. 39CONCLUSIONS • The organization and package of school health services varies between and within countries. It includes school-based health services, school-linked health services, and scenarios where teachers provide some services. Activities from school health teams extended beyond the clinic to public health actions in the classroom and support for teachers and parents. Among challenges associated with school health services that participants cited: a lack of supportive and clear legislation and regulation; a shortage of health personnel trained in school health; inadequate funding and standardization of school health services; and the limited involvement of parents and caregivers. Discussions on school health services concentrated on questions about engaging the educational system with health services and the feasibility of countries offering school-based or school-linked health services. Meeting participants agreed upon the importance of health services for the school-age population, and that the form and scope of health services should be determined by the local context. • Effective partnerships were identified as a critical challenge and a condition for successful and efficient school health programs. First and foremost, partnerships with the ministries of health and education are crucial and should extend to encompass the private sector and civil society—including youth-led and youth-serving organizations, regional partners, and other relevant stakeholders. There was strong agreement on the importance of genuine and optimal participation by students, parents, and the community. However, stakeholders raised concerns about the scarcity of effective models for meaningful engagement with students and parents. In this context, it was suggested that digital technology (where the technology and connectivity permit) was a way to facilitate and galvanize student engagement. The youth participants in the consensus meeting expressed strong opinions on the structural elements that discouraged young people from participating on issues that affect their health and development, and they called on stakeholders to intensify efforts to engage students in designing, implementing, and evaluating school health programs and interventions. • Regional partners can play an important role in strengthening comprehensive school health approaches through advocacy and by providing technical and implementation guidance and support. There is a need to better align school health mandates and partners’ interests. Organizing the various mandates, interests, and initiatives under the umbrella of HPS would contribute to greater efficiency in using available resources and would improve results, and the partners discussed the possibility of establishing an interagency regional mechanism on HPS, similar to the Inter-American Task Force on NCDs. 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Factores asociados con la implementacion de la estrategia educative nutricional “El sabor del saber”: perspectiva docente. Revista Salud UIS. 2009;41(1). 91. Florez AL, Hewitt RN. Acciones de Reforzamiento de la Competencia Social (ARCOS): un programa de salud escolar fundamentado en conceptos de autodeterminación humana. Psychol Av Discip. 2013;7(2):117-22. 92. Cardenas Cardenas LM, Suarez Cardenas CC, Agudelo NA. Implementacion de la estrategia escuela saludable. Una alianza intersectorial. Invest Educ Enferm. 2010;28(3):428-34. 93. Pérez Cueto MD, Sánchez Álvarez MD, Cueto Montoya GA, Mayor Puerta AM, Fernández Cárdenas N, Alegret Rodríguez M. Intervención educativa y parasitismo intestinal en niños de la enseñanza primaria. Revista Cubana Medicina General Integral. 2007;23(2). Available from: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0864- 21252007000200010&lng=es&tlng=es 94. Torres I, Simovska V. Community participation in rural Ecuador’s school feeding programme: A health-promoting school perspective. Health Educ. 2017;117(2):176-92. doi:10.1108/HE-02-2016-0009 95. Torres I. Policy windows for school-based health education about nutrition in Ecuador. Health Promot Int. 2017;32(2):331-9. doi:10.1093/heapro/daw037 96. Ávila Montes GA, Araujo R, Leontsini E, Herrera GO, Cerna EF. Un programa escolar para el control del dengue en Honduras: del conocimiento a la práctica. Rev Panam Salud Publica. 2012;31(6):518–22. 97. Alvirde-García U, Rodríguez-Guerrero AJ, Henao-Morán S, Henao-Morán S, Gómez-Pérez FJ, Aguilar-Salinas CA, et al. Resultados de un programa comunitario de intervención en el estilo de vida en niños. Salud Publica Mex. 2013;55(Suppl 3):406-14. Available from: http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0036- 36342013000900007&lng=es&tlng=es http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0864-21252007000200010&lng=es&tlng=es http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0864-21252007000200010&lng=es&tlng=es http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0036-36342013000900007&lng=es&tlng=es http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0036-36342013000900007&lng=es&tlng=es 46 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT 98. Abril-Valdez E, Rascón-Loreto C, Bonilla-Fernández P, Hernández-Pérez H. Promoción de hábitos saludables en escolares de Hermosillo, Sonora, México. Rev Cubana Hig Epidemiol. 2012;50(3):354-64. Available from: http://scielo. sld.cu/scielo.php?script=sci_arttext&pid=S1561-30032012000300010&lng=es&tlng=es 99. Ríos-Cortázar V, Gasca-García A, Ordóñez AR. Reducción de la obesidad infantil a través del componente de nutrición de una iniciativa de Escuela Promotora de Salud. Salud Publica Mex. 2013;55(Suppl 3):S431-3. Available from: https:// saludpublica.mx/index.php/spm/article/view/5144 100. Choque-Larrauri R, Chirinos-Caceres JL. Eficacia del programa de habilidades para la vida en adolescentes escolares de Huancavelica, Peru. Rev Salud Publica. 2009;11(2):169-81. http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S1561-30032012000300010&lng=es&tlng=es http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S1561-30032012000300010&lng=es&tlng=es https://saludpublica.mx/index.php/spm/article/view/5144 https://saludpublica.mx/index.php/spm/article/view/5144 47ANNExES Annex 1 Global standards for health-promoting schools and standard statements 1 Government policies and resources There is whole-of-government commitment to and investment in making every school a health-promoting school. 2 School policies and resources There is commitment to a whole-school approach to being a health-promoting school. 3 School governance and leadership There is a whole-school model of school governance and leadership to support being a health-promoting school. 4 School and community partnerships There is engagement and collaboration within the school community, including with students and between the school and local communities, for health-promoting schools. 5 School curriculum supports health and well-being. The school curriculum supports physical, social-emotional, and psychological aspects of student health and well-being. 6 School social-emotional environment The school has a safe and supportive social-emotional environment. 7 School physical environment The school has a healthy, safe, secure, and inclusive physical environment. 8 School health services All students have access to comprehensive school-based or school-linked health services that address their physical, emotional, psychosocial, and educational health care needs. Source: World Health Organization and the United Nations Educational, Scientific and Cultural Organization. Making every school a health-promoting school: global standards and indicators for health-promoting schools and systems. Geneva: World Health Organization and the United Nations Educational, Scientific and Cultural Organization; 2021. Available from: https://apps.who.int/iris/bitstream/handle/10665/341907/9789240025059- eng.pdf Annexes https://apps.who.int/iris/bitstream/handle/10665/341907/9789240025059-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/341907/9789240025059-eng.pdf 48 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT Annex 2 Summary details of articles scoping review AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 1 Martin TC, Josiah-Martin JA, Roberts CW, Henry HåP. (2001) Toward effective school-based substance abuse prevention “breaking the cycle” programme in Antigua and Barbuda Antigua and Barbuda 5,571 third-grade students aged 8–9 years, from 46 schools Health education and curriculum Substance use A curriculum-based life skills intervention using interactive teaching methods to teach on drug harm use, community values, decision-making, and peer resistance training. Uptake of the intervention was good. At a cost of US$ 7 per student, the program was considered cost-effective. 2 Rossi ML, Antun MC, Casagrande ML, et al. (2019) Evaluacion de la intervencion del program Mi Escuela Saludable en una cohort de escuelas que ha participado durante 2016–2017 Argentina Buenos Aires Healthy and safe learning environment Health education and curriculum Healthy habits Physical activity Eating habits Screen hours A two-year nutritional intervention that engaged teachers and students to seek healthy alternatives and improve nutritional habits. The intervention reduced unhealthy food intake. There was no favorable difference in the habitual consumption of fruits and vegetables, nor in physical activity or screen hours. 49ANNExES AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 3 Kornblit AL, Mendes Diz AM, Di Leo PF, Camarotti AC. (2007) Entre la teoria y la practica: algunas reflexiones en torno al sujeto en el campo de la promocion de la salud Argentina Buenos Aires Governance of school health programs School health policy environment NA Lessons learned from implementation of HPS in Buenos Aires. This article reflects on conceptual aspects of HPS and their implications. Key conclusions include: the need for opportunities to adapt the HPS guidance to the local context; the importance of accommodating and fostering acceptance and solidarity for differences between sub-groups in the school communities, particularly related to the most vulnerable groups; the risk assessment of young people (the sense that others may be at risk but that they personally are not) is a challenge that needs to be overcome to effectively achieve results for improved health; fostering critical thinking with regard to what the market offers and what is healthy is critical. Key elements of HPS must be: stimulate the autonomy of subjects, favor the collective above the individual, work with and not for, seek institutional transformation that generates autonomy. 4 Esandi ME, Panizoni E, Schernuk- Schroh J, et al. (2018) Factibilidad de implementar una intervencion compleja para prevenir la intimidacion entre pares en el ambito escolar Argentina Bahia Blanca City 1,182 school children aged 8–12 years Healthy and safe learning environment Bullying A bullying-prevention intervention in schools, using locally designed solutions, included teacher training, improved listening skills, social media, workshops, etc. The evaluation showed mixed results in terms of acceptability and impact. 5 Codarini G, Andracchio M, Viggiani F, Gonzalez P, Lev D. (2018) Programa nacional de salud escolar: una politica de cuidado de ninas, ninos y adolescentes en edad escolar de Argentina Argentina National Governance of school health programs School health policy Access to health services Health education and curriculum NA Description of the Programa Nacional de Salud Escolar (PROSANE) and 10 years implementation. The target population of PROSANE are grades 1–6 of primary school. The program is implemented in an intersectoral collaboration between the Ministries of Health and Education. 50 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 6 Franken SCM, Smit CR, Buijzen M. Promoting water consumption on a Caribbean island: an intervention using children’s social networks at schools Aruba National level Children aged 11 years Student and community participation Water consumption A social network-based intervention (SNI) using students as peer influencers. Promoting water consumption as opposed to sugary drinks showed promising results for health behavior change. 7 Stanton B. (2015) Teachers’ patterns of implementation of an evidence-based intervention The Bahamas National level Grade 6 and 7 students Health education and curriculum HIV Program fidelity is important. In this program, the quality of the booster session a year after initial implementation was critical for success. 8 Wang B, Stanton B, Deveaux L, et al. (2017) Multi-year school-based implementation and student outcomes of an evidence- based risk reduction intervention The Bahamas National level Elementary and middle schools Health education and curriculum HIV An HIV prevention program, Focus on Youth in the Caribbean (FOYC), implemented in 80 government elementary and 34 middle schools. Teacher attitudes had a direct positive effect on student outcomes. 9 Wang B, Stanton B, Deveaux L, et al. (2015) Fidelity of implementation of an evidence-based HIV prevention program among Bahamian sixth grade students The Bahamas National level Grade 6 and 7 students Health education and curriculum HIV Teachers taught on average 16.3 out of 30 core activities, 24.9 out of 46 total activities, and 4.4 out of 8 sessions. Prior training of teachers in the intervention curriculum, teacher perception of the importance of the intervention, and fewer years as a teacher are associated with implementation fidelity, which is associated with improved student outcomes. 10 Lwegaba A. (2005) Field trial to test and evaluate primary tobacco prevention methods in clusters of elementary schools in Barbados Barbados 31 primary schools Health education and curriculum Tobacco use prevention After the program, the occurrence of experimental smoking in the last 30 days dropped from 9.2% to 1.2%. 11 Paz FM, Teixeira VA, Pinto Ro, et al. (2017) School health promotion and use of drugs among students in Southern Brazil Brazil Healthy and safe learning environment Substance use The effects of the school environment on the use of drugs were not significant separate from the individual and family conditions of the students. 51ANNExES AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 12 Goncalves Maia Brazil E, Magalhaes da Silva R, Rocineide Ferreira da Silva M, et al. (2015) Adolescent health promotion and the school health program: complexity in the articulation of health and education Brazil Fortaleza, Ceara Governance of school health programs NA School professionals’ lack of knowledge about the program and a lack of intersectoral planning between education and health contributed to poor articulation and implementation of the school health program. 13 Moyses ST, Moyses SJ, Watt RG, Sheiham A. (2003) Associations between health- promoting school policies and indicators of oral health in Brazil Brazil Curitiba 1,823 12-year- old students from 33 primary schools Health education and curriculum Oral health Schools with a comprehensive curriculum were more likely to have a higher percentage of caries-free students. 14 Bechara GM, Castelo Branco F, Rodrigues AL, et al. (2018) Kids and diabetes in schools project: experience with an international educational intervention among parents and school professionals Brazil 5 primary schools with 42 parents and school staff Health education and curriculum Student and community participation Diabetes The school staff and family members acquired new knowledge about diabetes and felt more confident in supporting children with diabetes. 15 Oliviera FPSL, Vargas AMD, Hartz Z, Dias S, Ferreira EFE. (2018) Elementary and lower secondary school students’ perceptions of the health at school programme: a case study in Belo Horizonte, Brazil Brazil Belo Horizonte Students 11–14 years Governance of school health programs NA Students assessed the program as positive, as an opportunity to gain information and knowledge, and as a way to access health services. 16 Souza EF, Soares M, Paolo TR, Brandao MV, Freitas Junior IF. (2018) Constructing a logical model in school health: experience on the lower Amazon Region Brazil Parintins, Amazonas Secondary school students Governance of school health programs Health education and curriculum Physical activity Healthy eating habits A systematic structure for implementing the school health program on the municipal level is important for its effective implementation. 52 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 17 Medeiros E, Pinto ES, Paiva AC, Nascimiento CP, Camila PA, Reboucas DG, et al. (2018) Facilidades e dificuldades na implantacao do programa saude na escola em um municipio do nordeste do Brasil Brazil Rio de Janeiro 120 schools participating in the HPS strategy Governance of school health programs School health policy environment Health education and curriculum Student and community participation NA Factors that facilitated implementation of the school health program were intersectoral articulation and professional satisfaction. Shortage of material and financial resources, lack of intersectoral articulation, and excessive workload were mentioned as limiting factors. 18 Becker D, Edmundo K, Bonatto D, Do Nascimento GF, dos Santos Silva C. (2005) Problem solving for better health (PSBH) and health- promoting schools: participatory planning and local action in the Rio de Janeiro program Brazil Rio de Janeiro 120 schools participating in the HPS strategy Governance of school health programs School health policy environment Health education and curriculum Student and community participation SRH Drug use interpersonal relationships Schools and stakeholders prioritized topics and issues to be addressed. The most frequently selected issues included violence in school, improvement of learning, self-esteem of students and teachers, smoking, and HIV. Key factor for success was direct participation of the school community, from the definition of the main needs and priorities to the development and evaluation of interventions. 19 Batista M da SA, Mondini L, Jaime PC. (2017) Actions of the school health program and school meals in the prevention of childhood overweight: experience in the municipality of Itapevi, São Paulo State, Brazil Brazil Itapevi, São Paulo 21 public primary schools of the first cycle Healthy and safe learning environment Nutrition High presence of ultra-processed foods in the breakfast and afternoon snacks. 30.6% of the students were overweight. The assessment suggested the need for adjustment of the school menus. 20 Favre TC, Pereira APB, Beck LCNH, Galvao AF, Pieri OS. (2015) School-based and community-based actions for scaling up diagnosis and treatment of schistosomiasis toward its elimination in an endemic area of Brazil Brazil Student and community participation Schistosomiasis The assessment concluded that actions targeting vulnerable communities should combine school-based and community- based interventions. 53ANNExES AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 21 Monteiro PH, Bizzo N. (2015) Health in school: an examination of the reference documents for the forty years of compulsory health programs, 1971–2011 Brazil Governance of school health programs NA Through review of relevant documents and stakeholder interviews, including with students, the researchers try to articulate and assign meaning to school health. The study concluded that the school is a suitable environment for health practice, considering the active participation of its peers, emphasizing the significance of “school-life world” for the adolescent, and the importance of aligning adolescents’ actions to their life plan and health project. 22 De Barros MVG, Nahas MV, Hallal PC, de Farias Junior JC, Florindo AA, Honda de Barros SS. (2009) Effectiveness of a school-based intervention on physical activity for high school students in Brazil: the Saude na Boa project Brazil Recife and Florianopolis Ten schools in each city, targeting students ages 15–24 years Health education and curriculum Healthy and safe learning environment Physical activity The intervention was effective at reducing the prevalence of physical inactivity. 23 Sanchez ZM, Sanudo A, Andreoni S, Schneider D, Pereira APD, Faggiano F. (2016) Efficacy evaluation of the school program Unplugged for drug use prevention among Brazilian adolescents Brazil 2,185 students from 16 middle schools in 3 Brazilian cities Health education and curriculum Drug use prevention There was no evidence that the program affected the students ages 11–12, but it showed some results in students ages 13–15, specifically related to marijuana use and binge drinking. 24 Cyrino EG, Pereira ML. (1999) Integration of health into the school curriculum in Botucatu, São Paolo Brazil Botucatu, Sao Paulo Governance of school health programs Health education and curriculum Access to health services NA This article documents the integration of health activities in the elementary school curriculum in Botucatu through training of personnel from the health and education sector, fostering of interdisciplinary teamwork, and working with teachers to develop and implement innovative measures to address health issues and meet the health needs of the students and the community. 54 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 25 Cordeiro KCC, Gomes NP, Estrela FM, Silva AF, Magalhães JRF, Lírio JGDS. (2019) Strategies by educators within the school setting to prevent and cope with the experience of domestic violence by adolescents Brazil Salvador, Bahia Access to health services Domestic violence This study explored the role of the school in preventing and addressing domestic violence experienced by students in the home, and concluded that the following five actions can contribute: Activate the Guardianship Council in case of suspected abuse; create reception and listening spaces for students; strengthen bonds between the school and family; promote educational actions; and articulate knowledge through partnerships between the school and other professionals. 26 Barria von B, Guzman MP, Villaseca CI, Von Bischhoffsahsen AC. (2005) Programa nacional de JUNAEB en salud escolar oftalmologica en Chile: analisis de sus resultados Chile Access to health services Ocular health The ocular school health program in Chile resulted in significant numbers of school children being diagnosed with astigmatism and prescription of glasses. 27 Kain J, Concha F, Salazar G, Leyton B, et al. (2009) Obesity prevention in preschool and school children attending public schools from a district of Santiago, Chile: pilot project 2006 Chile Santiago 7 public primary schools Governance of school health programs Health education and curriculum Obesity Nutrition Physical activity The five-month intervention demonstrated a decrease in obesity in the younger children and improved fitness. The evaluation also indicated a trend toward decreasing BMI and increasing levels of physical activity in teachers. It was concluded that more time should be given to training teachers for successful program implementation. 28 Kain J, Concha F, Moreno L, Leyton B. (2014) School-based obesity prevention intervention in Chilean children: effective in controlling, but not reducing obesity Chile Santiago 9 elementary schools Students ages 6–8 years Health education and curriculum Obesity Nutrition Physical activity Teachers were trained to deliver nutrition contents and improve the quality of PE classes. The study documented a non- significant decrease in obesity in girls from intervention schools and an increase in control schools. It was concluded that the intervention was effective in controlling obesity, but not in preventing it. 55ANNExES AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 29 Mardones F, Vega MP, Pemiean U, Bustamante RC. (1998) El programa chileno de alimentacion escolar 1965–1997 Chile Governance of school health programs Access to health services Nutrition Evaluation of 32 years’ implementation of the school feeding program indicates that the program has contributed to health improvement. Challenges were identified with the selection and weighted assignment of resources to the most vulnerable schools and populations, and the lack of an individualized focus on recipients and groups and their needs, in line with their stage of puberty and development. 30 Guzman J, Kessler RC. (2015) Evidence for the effectiveness of a national school- based mental health program in Chile Chile Governance of school health programs Student and community participation NA The two most important factors that contributed to the success of the Vida Chile program were the participation of community and societal groups, and an adequate budget for local activities. 31 Kain J, Uauy R, Concha F, et al. (2012) School-based obesity prevention interventions for Chilean children during the past decades: lessons learned Chile Casablanca Macul Governance of school health programs Health education and curriculum Student and community participation Obesity Nutrition Physical activity Lessons learned: parent participation is limited, obesity is not recognized as a problem, increasing physical activity and implementing training for teachers is difficult due to inflexible curriculum and lack of teachers’ time. 32 Salinas C, Vio del RF. (2011) Programas de salud y nutricion sin politica de Estado: el caso de la promocion de salud escolar en Chile Chile Governance of school health programs School health policy environment NA Since the cancellation of the nationally accredited school health program Vida Chile, multiple unspecified actions have been carried out, with limited results. The article concludes that it is necessary to create a national institution responsible for implementing a coherent public school health promotion policy. 33 Morales A, Garcia-Montano E, Barrios- Ortega C, et al. (2019) Adaptation of an effective school- based sexual health promotion program for youth in Colombia Colombia Adolescents aged 15–19 years Student and community participation Sexual health HIV STI A Spanish sexual health intervention (COMPAS) was adapted for implementation in schools in Colombia. The adaptation included cultural and linguistic changes, and active participation of adolescents in the adaptation process. 56 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 34 Campos AC, Robledo- Martinez R, Arango-Soler JM, Agudelo- Calderon CA. (2012) Evaluacion de la politica publica de escuela saludable en Colombia: fase de formulacion (1999–2006) Colombia School health policy environment NA The study analyzed the public policy cycle related to healthy schools and concluded that healthy schools have not been a policy priority during 1999–2006 in Colombia, in spite of a stated commitment. 35 Hernandez J. (2007) Estrategia escuelas promotoras de la salud en instituciones de basica primaria de Bucaramanga Colombia Bucamaranga 33 elementary schools School health policy environment Health education and curriculum Student and community participation Access to health services NA Evaluation of the implementation of the strategy: Estrategia Escuelas Saludables (EES) in 33 elementary schools. The evaluation focused on: 1) the establishment of institutional policies for development of EES; 2) establishment of a coordination team; 3) participation of teachers and directors in the implementation of EES activities; and 4) development and implementation of action plans. The evaluation highlighted the importance of an integral approach, ensuring the participation of the various stakeholders, the importance of political leadership, technological innovation, participatory identification and formulation of priorities, and the availability and effective use of information and resources. 36 Perez R, Aya DH, Prieto F, Pinzon-Rondon AM. (2012) Disminucion de las prevalencias de desnutricion mediante la promocion de la salud en grupos de escolares en una localidad de Bogota Colombia Bogota Students from 6 public schools in Bogota Health education and curriculum Access to health services Nutrition The evaluation of the program “Salud Escolar Integral” targeting students ages 5–8 years was conducted to assess the levels of acute and chronic malnutrition in students. In the period 2001–2005, both acute and chronic malnutrition were significantly reduced. 57ANNExES AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 37 Hernandez J, Constanza Concha S. (2009) Factores asociados con la implementacion de la estrategia educative nutricional “El sabor del saber”: perspectiva docente Colombia Santander 82 teachers from 36 municipalities and 56 schools Health education and curriculum Nutrition Evaluation of the implementation of the intervention “El sabor del saber” highlighted the important role that teachers serve as mediators and facilitators for learning about nutrition and, in general, about the health and well-being of their students. This role requires that the teachers acquire the necessary knowledge, skills, and conviction. 38 Florez Alarcon L, Hewitt Ramirez N. (2013) Acciones de reforzamiento de la competencia social (ARCOS): un programa de salud escolar fundamentado en conceptos de autodeterminaacion humana Colombia Middle and high school students Health education and curriculum Universal prevention Protective factors Development of the intervention “ARCOS,” based on results of previous interventions with similar underlying concepts, benefitted from a research design with analysis at every stage of the development and adaptation, as needed, based on the lessons learned. 39 Cardenas Cardenas LM, Suarez Cardenas CC, Agudelo Cely NA. (2010) Implementacion de la estrategia escuela saludable. Una alianza intersectorial Colombia Nuevo Colon, Boyaca Governance of school health programs Health education and curriculum Healthy and safe learning environment Student and community participation Water and sanitation Nutrition Headaches Gastrointestinal problems Skin problems Description of the process for participatory design and implementation of an HPS program in a school in Nuevo Colon. The program resulted in an intersectoral set of interventions that included individual, family, and community-level actions and required collaboration between the education and health sectors and the municipal authorities. 58 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 40 Carvajal Rodríguez C, Torres Cuesto GMA. 2007 Estrategia metodologica para desarollar la promocion de la salud en las escuelas cubanas Cuba Governance of school health programs Health education and curriculum School health policy environment NA The paper analyzed the implementation of health- promoting schools in Cuba. The analysis concluded that the program does not take full advantage of the potential of the Cuban education system to promote the health and well- being of its students. The results contributed to strengthening the implementation of this approach in Cuba, including fostering shared values regarding health and health care, social participation, and a culture of health. 41 Perez Cueto, MC, Sanchez Alvarez ML, Cueto Montoya GA, Mayor Puerta AM, Fernandez Cardenas N, Alegret Rodriguez M. (2007) Intervencion educativa y parasitismo intestinal en ninos de la ensenanza primaria Cuba Los Sirios, Santa Clara Health education and curriculum Student and community participation Access to health services Intestinal parasites An intervention in which intestinal parasites were diagnosed, followed by educating parents, treating the children, and post-intervention diagnosis. The intervention resulted in a significant reduction in the burden of intestinal parasites in the children in the participating schools after 6 months. 42 Andrade S, Lachat C, Ochoa-Aviles A, et al. (2014) A school-based intervention improves physical fitness in Ecuadorian adolescents: a cluster-randomized controlled trial Ecuador Health education and curriculum Physical fitness A two-year, school-based program improved the physical fitness in the intervention group. 43 Andrade S, Verloigne M, Cardon G, et al. (2015) School-based intervention on healthy behavior among Ecuadorian adolescents: effect of a cluster- randomized controlled trial on screen-time Ecuador Adolescents of grade 8–9 from 20 schools Health education and curriculum Screen time Diet Physical activity The multi-component school- based intervention was able to mitigate the increase in screen time only when it included specific components or activities that focused on reducing screen time. 59ANNExES AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 44 Andrade S, Lachat C, Cardon G, et al. (2016) Two years of school- based intervention program could improve the physical fitness among Ecuadorian adolescents at health risk: subgroups analysis from a cluster- randomized trial Ecuador Cuenca 1,440 adolescents from grade 8–9 Health education and curriculum Healthy and safe learning environment Student and community participation Physical activity A multi-component program, called ACTIVITAL, with individual and environmental interventions improved the speed and strength aspects of physical fitness in low-fit and overweight/obese adolescents. 45 Bustamente G, Andrade MS, Mikesell C, et al. (2019) “I have the right to feel safe”: evaluation of a school-based child sexual abuse prevention program in Ecuador Ecuador Children aged 7–12 years from six public elementary schools Health education and curriculum Child sexual abuse A 10-week educational program to teach children self-protection strategies showed they had increased knowledge six months after the intervention finished. 46 Torres I, Simovska V. (2017) Community participation in rural Ecuador’s school feeding programme. A health-promoting school perspective Ecuador Governance of school health programs Student and community participation Nutrition The meaningful participation of parents and community members in small rural schools in a low- to middle-income country such as Ecuador can be linked to an empowered stance toward school feeding programs. School leadership, geographical characteristics, and internal community organization seem to influence participation, what shape it takes, and how it is valued. 47 Torres I. (2016) Policy windows for school-based health education about nutrition in Ecuador Ecuador Governance of school health programs School health policy environment Student and community participation Nutrition A biomedical perspective and norms resulted in schools being viewed as settings for interventions rather than as sites for generating change. A holistic understanding of health facilitated critical participation of stakeholders and the community, addressing the broader determinants of health through critical, democratic, and collaborative processes anchored in and supported by the local community. 60 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 48 Kulis SS, Marsiglia FF, Porta M, Arevalo Avalos MR, Ayers SL. (2019) Testing the Keepin’ it Real substance use prevention curriculum among early adolescents in Guatemala City Guatemala Guatemala City Health education and curriculum Substance use The intervention group reported changes, both pre-test and post- test, in desirable directions on behaviors related to substance abuse and attitudes, and acquisition of skills relevant to resisting drug use. The comparison group generally showed changes in undesirable directions. 49 Eustache E, Gerbasi ME, Severe J, et al. (2017) Formative research on a teacher accompaniment model to promote youth mental health in Haiti: relevance to mental health task-sharing in low-resource school settings Haiti Four secondary schools in Haiti’s Central Plateau 120 secondary school students aged 18–22 years Health education and curriculum Mental health This was a school-based mental health model aimed at providing psychosocial support and facilitating linkages to clinical resources; key elements included teacher training, school-based mental health screening of students, and regular teacher- student meetings. The results indicate that the program has conceptual appeal and potential utility for both students and teachers. 50 Avila Montes GA, Martinez M, Sherman C, Fernandez Cerna E. (2004) Evaluation of an educational module on dengue and Aedes Aegypti for school children in Honduras Honduras Comayaguela Four public elementary schools Health education and curriculum Student and community participation Dengue Evaluation of a special course on environmental health and dengue for primary school students was implemented during 2005–2010, aimed at promoting a behavior change related to the mothers’ safe handling of water, adequate disposal of trash, and controlling vector breeding sites. There was significant increase in student and teacher knowledge with respect to dengue, and it helped encourage participation of family members in reducing breeding sites in the home. 51 Avila Montes GA, Araujo R, Orellana Herrera G, Fernandez Cerna E. (2012) Un programa escolar para el control del dengue en Honduras: del conocimiento a la practica Honduras Health education and curriculum Student and community participation Dengue This intervention, implemented during 2005–2010 in primary schools in various cities in Honduras, was based on positive results that showed increased student knowledge and improved prevention measures by students’ families. 61ANNExES AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 52 Larsen CD, Larsen MD, Kim M, Yang E, Brown N, Cunningham RP. (2014) Sequential years of dental outreach to Jamaica. Gains toward improved caries status of children Jamaica Saint Ann Parish One primary school Health education and curriculum Oral health Four years of dental outreach, consisting of dental health promotion, education, and prevention, showed positive benefits in the caries status of the children. 53 Guzder J, Paisly V, Robertson- Hickling H, Hickling FW. (2013) Promoting resilience in high-risk children in Jamaica: a pilot study of a multimodal intervention Jamaica 30 children from an inner- city primary school Access to health services Mental health A multi-modal after-school and summer psychotherapeutic intervention consisting of creative arts therapies and remedial academic support implemented over 2.5 years; it targeted academically underachieving children with severe disruptive disorders. The intervention group made significant improvements in school social functioning. 54 Brissett D, Griffiths-Irving J. (2008) Speak up! Speak out! Building HIV and AIDS awareness among Jamaican school children Jamaica 91 primary schools Governance of school health programs Student and community participation HIV/AIDS This was a partnership between the private sector (Scotiabank), the Ministries of Health and Education, and schools to address HIV. While communication between partners was at times challenging, the feedback indicated the debates were a valuable strategy for building awareness and developing student potential and unity around a common cause. 55 Sosa-Rubi SG, Saavedra- Avendano B, Piras C, Van Buren SJ, Bautista- Arredondo S. (2017) True love: effectiveness of a school-based program to reduce dating violence among adolescents in Mexico City Mexico Mexico City Two urban, low-income high schools Health education and curriculum Dating violence A 16-week intervention consisting of school- and individual-level components on dating violence (Amor. Pero del Bueno). The study measured a reduction in perpetrated and experienced psychological violence. 56 Gomez SA, Badillo AR. (2014) Educacion para la salud, desde la teoria de la accion, en educacion primaria del Estado de Mexico Mexico 1,451 primary school students and their parents Health education and curriculum Physical health Mental health The evaluation concluded that, even though there are health topics in the curriculum, the content of physical and mental health is insufficient. 62 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 57 Safdie M, Levesque L, Gonzalez- Casanova I, et al. (2013) Promoting healthful diet and physical activity in the Mexican school system for the prevention of obesity in children Mexico Mexico City Students aged 9–11 from 27 elementary public part- time schools School health policy environment Health education and curriculum Student and community participation Healthy and safe learning environment Obesity Nutrition Physical activity A two-year multi-factorial intervention with a communication/education component and intervention components on physical activity and nutrition, including increasing the availability of healthy food and beverages, reducing opportunities to eat, and increasing opportunities to engage in physical activity. The study aim was to promote energy balance in the school children. It was concluded that more comprehensive approaches that include families and modification of the food available in and around schools are necessary for optimal effectiveness. 58 Lopez-Nunez B, Aleksejuniene J, Villaneuva- Vilchis MDC. (2019) School-based dental education for improving oral self-care in Mexican elementary school- aged children Mexico 408 students from four elementary schools Health education and curriculum Student and community participation Oral health This was a lecture-based educational intervention in one group and education by trained peer educators in another group. Outcomes of oral self-care knowledge and practices improved in the two intervention groups but not in a control group at 6-month follow-up. 59 Alvirde-Garcia U, Nut MSC, Rodriguez- Guerrero AJ, et al. (2013) Resultados de un programa comunitario de intervencion en el estilo de vida en ninos Mexico Tenango del Valle Two elementary schools Health education and curriculum Student and community participation Nutrition Cardiovascular health Evaluation of three-year implementation of the program CATCH (Child and Adolescent Trial for Cardiovascular Health) showed positive but moderate results in reducing obesity, illustrating the complexity of interventions to address this health problem. 60 Carriedo A, Bonvecchio A, Lopez N, Morales M, Beltran Mena C, Theodore FL, et al. (2013) Use of social marketing to increase water consumption among school-age children in Mexico City Mexico Health education and curriculum Healthy and safe learning environments Nutrition Obesity A three-month social marketing intervention, which included promoting and providing water to the intervention group, resulted in decreased consumption of sweetened beverages. 63ANNExES AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 61 Abril-Valdez E, Rascon-Loreto C, Bonilla- Fernandez P, Hernandez- Perez H, Cuevas-Bahena S, Arenas- Monreal L. (2012) Promocion de habitos saludables en escolares de Hermosillo, Sonora, Mexico Mexico Hermosillo, Sonora Health education and curriculum Hygiene Self-esteem Tobacco Addictions Culture of peace Care for the environment Weekly one-hour educational sessions with the students. Students’ knowledge increased on these topics, and their self- esteem increased. 62 Rios-Cortazar V, Gasca-Garcia A, Fanco-Martinez M, Tolentina- Mayo L. (2014) Narrativa infantil en entornos escolares: una estrategia de promocion de la salud Mexico Mexico City A public elementary school Health education and curriculum Student and community participation Healthy lifestyle A participatory approach towards HPS, consisting of participatory planning, implementation, and evaluation, and based on a model of shared and collaborative learning. It was applied in a community in the south of Mexico City that was characterized by high levels of unemployment, vandalism, theft, alcoholism, and drug sale and use. In the first phase, stakeholders analyzed and identified the key health challenges affecting the children, by grade level, through small group discussions. In the second phase, objectives and targets were identified, followed by jointly formulating strategies to achieve the targets. Narratives were identified as a priority strategy for the children to organize and negotiate their experiences and knowledge of the world. This was implemented through students developing, presenting, and discussing their stories and drawings. The evaluation concluded that the narrative approach illustrated that children are able to reflect on their health and identify solutions, and strengthened them as individuals as well as their collective capacity to address health challenges. 64 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 63 Rios-Cortazar V, Gasca-Garccia A, Ordonez AR, Vera ME, Franco-Martinez M, Tolentino- May L. (2013) Reduccion de la obesidad infantil a traves del componente de nutricion de una iniciativa de Escuela Promotora de Salud Mexico Mexico City A public elementary school with students from 1st-6th grade Governance of school health programs Health education and curriculum Healthy and safe learning environment Student and community participation Nutrition Overweight and obesity A three-year, school-wide intervention consisting of education and skills-building for students on healthy nutrition and physical activity. Students’ mean body mass index (BMI) reduced each year following implementation of the intervention. Important elements in the intervention were strengthening individual and collective capacities and values related to healthy living, including healthy nutrition and physical activity. 64 Ravindran AV, Herrera A, da Silva TL, Henderson J, Castrillo ME, Kutcher S. (2018) Evaluating the benefits of a youth mental health curriculum for students in Nicaragua: a parallel-group, controlled pilot investigation Nicaragua Leon High school and university students aged 14–25 years Health education and curriculum Access to health services Mental health Pilot implementation of a curriculum-based mental health literacy intervention in Nicaragua. At 12 weeks, intervention students reported significantly greater mental health knowledge, less stigma, more adaptive coping, better lifestyle choices, and less perceived stress compared to control groups. 65 Allen P, Meadows-Oliver M, Ryan-Krause P. (2008) Establishing a school-based clinic in Managua, Nicaragua Nicaragua Managua Access to health services NA Although the Ministry of Health theoretically provides health care for all, resources are often limited and difficult to access. A school-based clinic helped meet the day-to-day needs of the children and established health care contacts for more serious needs. 66 Sharma B, Kim HY, Nam EV. (2018) Effects of school- based health promotion intervention on health behaviors among school adolescents in North Lima and Callao, Peru Peru North Lima Callao Two secondary schools Health education and curriculum Access to health services Healthy lifestyle Nutrition Mental health Violence This was an intervention consisting of health education, screening, and psychological counseling for vulnerable individuals; it resulted in significant improvement in the consumption of vegetables. Suicide attempts, television- watching, video game use, internet use, consumption of chips and sugary drinks, and being in fights did not decrease in the intervention group, but increased in the control group. 65ANNExES AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 67 Choque-Larrauri R, Chirinos- Caceres JL. (2009) Eficacia del programa de habilidades para la vida en adolescentes escolares de Huancavelica, Peru Peru A high school in Huancavelica Health education and curriculum Life skills Evaluation of the one-year implementation of a life skills program in the context of HPS demonstrated results in improved assertiveness, communication, self-esteem, and better decision-making in the intervention group. 68 Escobar-Chaves SL, Shegog R, Moscoso- Alvarez MR, et al. (2011) Cultural tailoring and feasibility assessment of a sexual health middle school curriculum: a pilot test in Puerto Rico Puerto Rico Seventh grade students Health education and curriculum Sexual health The article describes the process of adapting an existing program, “It’s Your Game: Keep it Real” (IYG), to the local context, through pilot sessions with students and measurement of acceptability, understandability, credibility, ease of use, and motivational appeal. 69 Fernandez- Santos DM, Miranda-Diaz C, Figueroa-Cosme WI, et al. (2015) Impact of ASUMA intervention on HIV risk behaviors among Puerto Rican adolescents Puerto Rico 135 public and private junior high school students Health education and curriculum Student and community participation HIV/STI An intervention consisting of workshops with students and parents. During the final year of the three-year invention, a higher proportion of students in the control group reported using alcohol and cannabis and having sexual intercourse compared to the intervention group. 70 Francis M, Nichols SDS, Dalrymple N. (2010) The effects of a school-based intervention programme on dietary intakes and physical activity among primary- school children in Trinidad and Tobago Trinidad and Tobago Sangre Grande district 12 primary schools Health education and curriculum Healthy and safe learning environment Nutrition Physical activity A short-term, multi-component intervention consisting of education, screening, and increased physical activity was associated with higher knowledge scores and lower intake levels of fried foods and snack foods high in fat, sugar and salt and sodas. But the intervention was not significantly associated with changes in physical activity. 66 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT AUTHORS (YEAR) TITLE LOCATION AND POPULATION DEFINITIONS AND CONCEPTS OF SCHOOL HEALTH AND HPS HEALTH TOPICS RESULTS AND CONCLUSIONS 71 Nichols SDS, Francis MP, Dalrymple N. (2014) Sustainability of a curriculum-based intervention on dietary behaviors and physical activity among primary school children in Trinidad and Tobago Trinidad and Tobago Sangre Grande district 579 students from five primary schools Health education and curriculum Nutrition Physical activity A brief curriculum-based intervention on dietary behavior, physical activity, and knowledge to assess the effectiveness of such an intervention for improving long-term knowledge, attitudes, and behaviors related to better dietary and activity habits. The intervention showed effects in improving knowledge and awareness; lower levels of intake of fried foods and soda were noted. There was no significant long-term effect on the level of physical activity. 72 Springer AE, Harrell MB, Martinez Gomensoro L, et al. (2019) Activate Ya! Co- learning about school-based tobacco prevention and physical activity promotion in secondary school students in Uruguay Uruguay 654 students from 16 secondary schools Health education and curriculum Healthy and safe learning environment Tobacco This was a one-year intervention that included a classroom-based curriculum, activity breaks, and an after-school program. Although positive intervention effects were found for selected psychosocial outcomes, follow-up measurements found no impact on prior-year smoking and smoking susceptibility. 67ANNExES Annex 3 Existence of national standards, by country, for priority topics MEX COL HON PAN PER PAR ARG BOL DOR BAR ANT SUR BVI T&T GUY BRA BEL HAI Classroom management Bullying prevention Violence prevention Gender equality Non- discrimination Cultural diversity Use of positive discipline methods Parent and family participation Community involvement Injury prevention and safety Tobacco use prevention Alcohol use prevention Illegal drug use prevention Drinking water quality Faculty and staff health promotion Sanitation Safety of buildings 68 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT MEX COL HON PAN PER PAR ARG BOL DOR BAR ANT SUR BVI T&T GUY BRA BEL HAI Physical accessibility (disability) Hygiene Waste management Spaces for sports and physical activity Emergencies and natural disasters Protection from road traffic Nutrition/ dining and/or food kiosks Country has standards No standards Not sure No response 69ANNExES Annex 4 Development or revision, by country, of policies or standards for the content of instruction on priority topics in the past two years MEX COL HON PAN PER PAR ARG BOL DOR BAR ANT SUR BVI T&T GUY BRA BEL HAI Alcohol and/ or drug use prevention Tobacco use prevention Nutrition and dietary behavior Physical activity and fitness (classroom instruction, not a physical education class) Pregnancy prevention Human immunodeficiency virus (HIV) prevention Other sexually transmitted disease (STD) prevention Human sexuality Addressing stigma (HIV, orphans, disability) Emotional and mental health Suicide prevention Violence prevention (e.g., fighting or dating violence) Bullying prevention Injury prevention and safety Ocular health Oral health 70 SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT MEX COL HON PAN PER PAR ARG BOL DOR BAR ANT SUR BVI T&T GUY BRA BEL HAI Infectious disease prevention Immunization Hygiene Accessing health information Life skills (e.g., interpersonal communication, decision-making, goal-setting, advocacy) Physical activity and fitness First aid Yes No Not sure No response SCHOOL HEALTH PROMOTION IN LATIN AMERICA AND THE CARIBBEAN: A REGIONAL ASSESSMENT School Health Promotion in Latin America and the Caribbean: A Regional Assessment www.paho.org This report presents the results of a regional assessment of the status of school health and the health-promoting schools (HPS) approach conducted jointly by PAHO, UNESCO, UNICEF, and the World Bank during 2018-2019. The objectives of the assessment were to: 1) assess the context and broader policy environment of school health in the LAC region, including legislative frameworks; 2) identify the scope and form of school health programs and services available in the region, as well as opportunities for improvement; and 3) enable countries to share with each other their best practices and the lessons learned in developing and implementing school health policies, programs, and services. The assessment results also serve as a regional baseline for the initiative, launched in 2019 by WHO and UNESCO, to make every school a health-promoting school. The results of this assessment are expected to contribute to strengthening the HPS approach in the LAC region on subnational, national, and regional levels, and to help accelerate progress toward achieving the SDGs for all children and adolescents in the region. This assessment was conducted before the COVID-19 pandemic. The impact of the pandemic has underlined the prominent role and multiple benefi ts of schools as an environment for equitable protection and promotion of the health and well-being of children and adolescents during the pandemic and in the recovery phase.