Physical SCH Environment PDF

The World Health Organization’s
INFORMATION SERIES ON SCHOOL HEALTH DOCUMENT 2
The Physical School

Environment
An Essential Component of a Health-Promoting School
This document is a joint effort of the Department of Protection of the

Human Environment and the Department of Noncommunicable Disease
Prevention and Health Promotion.
It is jointly published with partner organizations working together in the

international initiative to Focus Resources on Effective School Health
(FRESH). It is also intended to support the objectives of the Healthy
Environments for Children Alliance.
WHO UNICEF
WORLD BANK
The principles and policies of each of the above agencies are governed by the relevant decisions of its
governing body and each agency implements the interventions described in this document in accordance
with these principles and policies and within the scope of its mandate.
ii CONTENTS
ACKNOWLEDGEMENTS ..........................................................................................iv
FOREWORD ................................................................................................................v
1. INTRODUCTION ............................................................................................1
1.1 Why did WHO prepare this document? ............................................................1
1.2 Who should read this document? ....................................................................1
1.3 What is a healthy physical school environment? ............................................1
1.4 Why increase efforts to improve the physical environment at schools? ......3
1.5 Why focus efforts through schools? ................................................................3
1.6 How will this document help people recognize threats and take
control over and improve their environment? ................................................4
2. CONVINCING OTHERS THAT SCHOOLS’ PHYSICAL

ENVIRONMENT IS IMPORTANT ........................................................................5
2.1 Argument: Many childhood illnesses and deaths are greatly influenced
by the environment ............................................................................................5
2.1.1 Respiratory infections..................................................................................6
2.1.2 Diarrhoeal diseases ....................................................................................7
2.1.3 Vector-borne diseases ................................................................................7
2.1.4 Injuries and poisonings................................................................................8
2.1.5 Cancer ........................................................................................................9
2.1.6 Developmental disabilities ..........................................................................9
2.1.7 Asthma ......................................................................................................10
2.2 Argument: Children are more susceptible to environmental diseases
than adults and therefore need healthy school environments ....................11
2.2.1 Water and sanitation..................................................................................12
2.2.2 Indoor air pollutants ..................................................................................13
2.2.3 Outdoor air pollutants................................................................................14
2.2.4 Ultraviolet radiation ....................................................................................14
2.2.5 Pesticides ..................................................................................................14
2.2.6 Food ..........................................................................................................15
2.2.7 Hazardous location ....................................................................................16
2.3 Argument: Implementing changes in the school’s physical
environment can improve children’s health ..................................................16
3. CONVINCING OTHERS THAT IMPROVING THE PHYSICAL

SCHOOL ENVIRONMENT WILL PROTECT HEALTH ....................................17
3.1 Argument: Children’s health can improve with low-cost interventions
to the physical environment at schools ..........................................................17
3.2 Argument: Improvements in the physical environment at schools can
increase school attendance..............................................................................18
WHO INFORMATION SERIES ON SCHOOL HEALTH

CONTENTS iii
4. PLANNING INTERVENTIONS FOR HEALTH PROTECTION IN

SCHOOL ENVIRONMENTS ................................................................................19
4.1 Procedural steps toward creating a healthy physical
environment at schools ....................................................................................19
4.2 Goals identification ..........................................................................................19
4.2.1 Substantive goals ......................................................................................20
4.2.2 Procedural goals ........................................................................................20
4.3 Participation in planning the interventions ....................................................21
4.3.1 Form a school health team........................................................................21
4.3.2 Establish a community advisory committee ............................................21
4.4 Intervention plans ............................................................................................22
4.4.1 Identify information needs ........................................................................22
4.4.2 Answer basic questions and identify key information sources ................24
4.5 Commitment and policies................................................................................24
4.5.1 Gain national political commitment ..........................................................24
4.5.2 Achieve community commitment ............................................................25
5. INTEGRATING ENVIRONMENTAL HEALTH INTERVENTIONS WITHIN

VARIOUS COMPONENTS OF A HEALTH-PROMOTING SCHOOL ................26
5.1 Skills-based health education..........................................................................26
5.1.1 Methods and materials for skills-based health education in relation to
the environment ........................................................................................27
5.1.2 Training teachers to implement skills-based health education in
relation to the environment ......................................................................28
5.1.3 The student’s role in skills-based health education in relation to the
environment ..............................................................................................28
5.2 A healthy school environment ........................................................................30
5.2.1 A safe school location and structure ........................................................30
5.2.2 Indoor school environment........................................................................31
5.2.3 Outdoor school environment ....................................................................34
5.2.4 Healthy environmental management practices ........................................35
5.3 School health services......................................................................................40
5.4 Community and family projects and outreach ..............................................40
5.5 Health promotion for school staff ..................................................................40
6. EVALUATION ........................................................................................................41
6.1 Components of evaluations ............................................................................41
6.2 Reporting progress and achievements ..........................................................42
ANNEX 1: EXAMPLES OF EDUCATIONAL STRATEGIES TO PROMOTE

ENVIRONMENTAL HEALTH ................................................................43
REFERENCES ............................................................................................................46
THE PHYSICAL SCHOOL ENVIRONMENT: AN ESSENTIAL ELEMENT OF A HEALTH-PROMOTING SCHOOL

iv ACKNOWLEDGEMENTS
This document was prepared for the World Health Organization (WHO) by John Wargo, Yale
University, New Haven Connecticut.
Eva A. Rehfuess, Department of Protection of the Human Environment, WHO, and Jack T.
Jones and Charles W. Gollmar, Department of Noncommunicable Disease Prevention and
Health Promotion, WHO guided the overall development and completion of this document.
Technical editing was undertaken by Martha Shimkin, and Caron Gibson, and copy editing
by Karina Wolbang.
This paper draws on a variety of sources in the research literature and on consultation with
experts working in the area of school health and environmental health. We wish to thank
the following organizations and persons for their technical guidance, inspiration and
generosity:
Monika Arora, HRIDAY-SHAN, India

Marie Louise Bistrup, International Research and Information Network on Children’s Health,
Environment and Safety
Amaya Gillespie, Senior Advisor, Education Sector, UNICEF
Jose Hueb, Protection of the Human Environment, WHO
Richard Helmer, Protection of the Human Environment, WHO
Kate Joicey, Gesellschaft für Technische Zusammenarbeit, Indonesia
Jenny Pronczuk, Protection of the Human Environment, WHO
Yasmin von Schirnding, Healthy Environments for Children Alliance, WHO
Merri Weinger, Environmental Health Technical Advisor, USAID
National Council on Education, Uruguay

FOREWORD v
“The children of today are the adults of tomorrow. They deserve to inherit a safer and
healthier world. There is no task more important than safeguarding their environment.” This
message is emphasized by the Healthy Environments for Children Alliance (HECA), which
focuses attention on the school environment as one of the key settings for promoting
children’s environmental health. HECA was launched at the 2002 World Summit on
Sustainable Development. This publication is intended as a tool to help schools shape
healthy environments for children.
The Physical School Environment: An Essential Component of a Health-Promoting School

focuses on the physical environment of the school and is complemented by the document
Creating an Environment for Social and Emotional Well-being: An Important Responsibility
of a Health-Promoting and Child-Friendly School. Together, these two resources can help
schools provide an environment that is supportive of the World Health Organization’s
definition of health, “… a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity”.
The Physical School Environment: An Essential Component of a Health-Promoting School

includes information to create a healthy school environment, and to identify and modify
aspects of the physical environment that jeopardize safety and health. However, physical
interventions alone will not suffice. The document also contains guidance to ensure that
positive changes in a school’s physical environment are supported, reinforced and sustained
by school health policy, skills-based health education and school health services, the core
components of an effective school health programme as called for in the international
initiative to Focus Resources on Effective School Health (FRESH).
The extent to which each nation’s schools provide a safe and healthy physical environment
plays a significant role in determining whether the next generation is educated and healthy.
Effective school health programmes, including a safe and healthy school environment, are
viable means to simultaneously address the inseparable goals of Health for All and
Education for All.
Pekka Puska Maged Younes Mary Joy Pigozzi

Director, Noncommunicable Disease Senior Advisor, Health and Director, Division for the Promotion
Prevention and Health Promotion Environment Coordinator, of Quality Education
WHO, Geneva, SWITZERLAND Occupational and Environmental UNESCO, Paris, FRANCE
Health,
WHO, Geneva, SWITZERLAND
Cream Wright Leslie Drake Cheryl Vince-Whitman

Chief, Education Section Coordinator, Partnership for Child Director, WHO Collaborating Center to
UNICEF, New York, USA Development Promote Health through Schools and
London, UNITED KINGDOM Communities
Education Development Center, Inc.
Newton, Massachusets, USA
Fred Van Leeuwen

General Secretary
Education International
Brussels, BELGIUM

1 1. INTRODUCTION
1. Introduction
Environmental challenges and opportunities vary considerably among schools around the
world, across countries and within communities. Similarly, the resources available to schools
to manage health hazards vary as widely as the threats themselves, often
creating formidable management challenges, particularly in the poorest parts of the world.
Evolving from recommendations of the Ottawa Charter for Health Promotion, The Physical
School Environment: An Essential Component of a Health-Promoting School discusses a
range of environmental conditions that exist in a variety of school environments. It presents
strategies to improve the health, education and development of children, families, and
community members and aims to help communities recognize, manage, and avoid
12
physical, chemical and biological threats that may exist in or near their schools.
1.1 Why did WHO prepare this document?
The World Health Organization (WHO) prepared this document to help individuals,
communities, school officials, and governments improve the health of children by
reducing their exposure to environmental hazards. This will be accomplished by providing
information to help people understand the relationship between the environment and
health, identify key hazards in the places where children learn, and recognize children’s
special vulnerability and exposure to environmental threats. By taking action, health-
promoting schools will send messages home to families and communities, encouraging
awareness, and building skills to last a lifetime so that protecting children from
environmental hazards becomes a way of life.
1.2 Who should read this document?
This document can be useful to:
• Members of the school community, including teachers and their representative

organizations, administrative staff, students, parents, school facility managers, and
school construction workers.
• Community leaders, local residents, health care providers, and other groups
interested in improving public health.
• Members of non-governmental agencies, institutions, and organizations interested
in working with schools to promote health.
• Government officials, policy-makers, decision-makers, planners and coordinators at
local, district, provincial, national and international levels.
1.3 What is a healthy physical school environment?
The physical school environment encompasses the school building and all its contents
including physical structures, infrastructure, furniture, and the use and presence of
chemicals and biological agents; the site on which a school is located; and the
surrounding environment including the air, water, and materials with which children may
come into contact, as well as nearby land uses, roadways and other hazards.

1. INTRODUCTION 2
WHO defines a health-promoting school as “one that constantly strengthens its capacity
as a healthy setting for living, learning and working.”3 The American Academy of Pediatrics
defines a “healthful school environment” as “one that protects students and staff against
immediate injury or disease and promotes prevention activities and attitudes against
known risk factors that might lead to future disease or disability.”4
Provision of safe and sufficient water, sanitation, and shelter from the elements are basic
necessities for a healthy physical learning environment. Equally important is the protection
from biological, physical, and chemical risks that can threaten children’s health (see Table 1).
Infectious diseases carried by water, and physical hazards associated with poor
construction and maintenance practices are examples of risks children and school
personnel face at schools throughout the world.
Table 1: Components of a healthy school environment
Provision of basic necessities • Shelter

• Warmth
• Water
• Food
• Light
• Ventilation
• Sanitary facilities
• Emergency medical care
Protection from biological threats • Molds

• Unsafe or insufficient water
• Unsafe food
• Vector-borne diseases
• Venomous animals
• Rodents and hazardous insects
• Other animals (e.g. dogs)
Protection from physical threats • Traffic and transport

• Violence and crime
• Injuries
• Extreme heat and cold
• Radiation
Protection from chemical threats • Air pollution

• Water pollution
• Pesticides
• Hazardous waste
• Hazardous materials and finishes
• Asbestos, paint
• Cleaning agents

3 1. INTRODUCTION
1.4 Why increase efforts to improve the physical environment at

schools?
The physical school environment has a strong influence on children’s health for several
reasons. First, the environment is one of the primary determinants of children’s health:
contaminated water supplies can result in diarrhoeal disease; air pollution can worsen
acute respiratory infections and trigger asthma attacks; and exposure to lead, arsenic,
solvents, and pesticides can cause a variety of health effects and even death.
Second, children may be more susceptible to the adverse health effects of chemical,
physical, and biological hazards than adults. Reduced immunity, immaturity of organs and
functions, and rapid growth and development can make children more vulnerable to the
toxic effects of environmental hazards than adults. Relative to their body weight, they
breathe more air, consume more food and drink more water than adults. Their exposure
to any contaminant in air, water, or food will therefore be higher than experienced by
adults. Children spend much of their day within school environments during critical
developmental stages.
Third, children’s behavioural patterns are distinctively different from adults and place them
at risk from exposure to environmental threats that adults may not face. These behaviours
include placing fingers and other objects in the mouth and not washing hands before
eating. Children lack the experience to judge risks associated with their behaviours.
Adolescents, in particular, are more likely to take risks, such as climbing and jumping from
unstable structures.
1.5 Why focus efforts through schools?
Most children throughout the world attend primary school. It is important to the health of
these children that they have clean water to drink, enough water to use for hygiene,
adequate sanitation facilities, clean air to breathe, safe and nutritious food, and a safe place
to learn and play. A contaminated environment can cause or exacerbate health problems.
These include short-term health effects such as infectious diseases, respiratory infections
or asthma that can reduce school attendance and learning ability. Health effects such as
cancer or neurological diseases may be delayed until much later in life.
A healthy school environment can directly improve children's health and effective learning
and thereby contribute to the development of healthy adults as skilled and productive
members of society. Furthermore, schools act as an example for the community. Students,
school employees, families, and community members should all learn to recognize
environmental health threats that may be present in schools and homes. As members of
the school community become aware of environmental risks at school they will recognize
ways to make home and community environments safer. In addition, students who learn
about the link between the environment and health will be able to recognize and reduce
health threats in their own homes.

1. INTRODUCTION 4
1.6 How will this document help people recognize threats and take
control over and improve their environment?
This document provides information that can be used to recognize and reduce
environmental health threats at school, striving to implement calls for the socio-ecological
approach to health of the Ottawa Charter. It invokes the overall guiding principle of the
Charter: to encourage reciprocal maintenance - to take care of each other, our communities
and our natural environment.5 It also provides guidance that can lead to improved health and
environmental protection. It will help schools, communities and governments:
• Create health-protective public policy: This document provides information that

could guide adoption of public policy to improve the physical environment of schools
and the overall health of children.
• Develop supportive environments: Simple, low-cost changes are suggested that
could be made in school facilities and management to create a healthier
environment for children to grow and thrive.
• Reorient health services: School administrators, teachers, and health care
providers may recognize health problems in their school environment that are
caused or exacerbated by these conditions.
• Develop personal skills: Information is provided to help students and staff
recognize health threats and identify ways to reduce these hazards.
• Mobilize community action: This document identifies actions that could be taken
by the school and community together to promote a healthy physical environment.
It also describes ways in which the school can work with the community to
implement and strengthen school health programmes. In addition, it fosters
participation by students themselves to plan and work together with school and
community representatives, drawing upon their local knowledge and ensuring
consideration of their preferences and opinions to implement the most feasible,
effective and sustainable environmental improvements.

5 2. CONVINCING OTHERS THAT SCHOOLS’ PHYSICAL ENVIRONMENT
IS IMPORTANT
2. Convincing others that schools’ physical environment is important
This section provides information that can be used to demonstrate the importance of creating
and maintaining a healthy physical school environment to protect the health of children and
others who spend time in schools. Some health and contamination problems relate to
general levels of prosperity, other health threats may only exist in certain climates or
geographical locations. Whatever the risk, children throughout the world are particularly
vulnerable to environmental health threats. It is therefore important for educators, planners,
and school administrators to be aware of specific health threats in their own school
environments. Environmental health issues facing children in developing and developed
countries throughout the world are discussed in the subsections below.
2.1 Argument: Many childhood illnesses and deaths are greatly

influenced by the environment
Leading causes of mortality in school children aged 5 to 14 years for both low and high
income countries are depicted in Figure 1.6 The higher rate of mortality in lower income
countries is primarily due to the high incidence of acute respiratory infections, malaria,
diarrhoeal diseases and injuries due to road traffic and drowning. Injuries are also
dominant causes of death in higher income countries along with congenital abnormalities
and leukaemia.
Figure 1: Leading causes of mortality in children aged 5-14 years, 2000
leukaemia
interpersonal violence
cerebrovascular disease
tuberculosis
fires
HIV/AIDS
inflammatory cardiac disease
congenital abnormalities
nephritis/nephrosis
war injuries
diarrhoeal diseases
drowning
road traffic injuries
malaria
acute lower respiratory infections
0 5 10 15 20 25
Mortality rate per 100 000
high income countries
low income countries

2. CONVINCING OTHERS THAT SCHOOLS’ PHYSICAL ENVIRONMENT 6
IS IMPORTANT
WHO estimates that between 25% and 33% of the global burden of disease can be
attributed to environmental risk factors. About 40% of the total burden of disease due to
environmental risks falls on children under the age of 5.7
Disease burden can be expressed in Disability-Adjusted Life Years (DALY), which combines
the burden due to death and disability in a single index. The DALY index allows comparison
of the impact of different diseases, and the contribution of environmental and other risk
factors to these diseases. Table 2 presents the estimated contribution of selected environ-
mental risk factors to major diseases in less developed and more developed countries.8
Table 2: Attributable DALYs by level of development (in thousands)9
High mortality Low mortality Developed

Risk factor Example of disease developing developing countries
countries countries
Unsafe water, Diarrhoeal diseases 46 183 7 150 825

sanitation and hygiene
Urban air pollution Respiratory infections 2 685 4 008 1 171
Indoor smoke from Lower respiratory infections, lung 30 393 7 595 550
solid fuels cancers
Lead exposure Cerebrovascular disease, hypertensive 5 953 5 584 1 388

disease
Climate change Diarrhoeal diseases, malaria, 5 202 294 22

unintentional injuries
While this table represents the global burden of disease in all age groups one can
surmise the relative effects of environmental exposures in children. It is important to
remember that children are affected disproportionately by environmental exposures as
compared to adults. Unfortunately, more specific data on the environmental burden of
disease in children or on additional environmental risks are currently not available. WHO
and UNICEF are co-leading a Global Initiative on Children’s Environmental Health
Indicators, launched at the World Summit on Sustainable Development, which intends to
provide richer data on children’s health and the environment in the near future.
Preventing childhood exposure to environmental hazards may prevent injuries, immediate

illnesses, such as respiratory infections and diarrhoeal diseases, and diseases with longer
latency periods, such as cancer, as discussed in detail below.
2.1.1 Respiratory infections
Respiratory infections are the most common among all diseases in children, and
pneumonia is the primary cause of childhood mortality worldwide. Indoor and outdoor air
pollution may be to blame for as much as 60% of the global burden of disease brought
about by respiratory infections.10
The most recent estimates suggest that 36% of acute lower respiratory infections,
including pneumonia, are attributable to solid fuel use.11 More than half of the world's

IS IMPORTANT
population relies on solid fuels such as dung, wood and coal for cooking and heating
needs, leading to very high levels of indoor air pollution. Exposure to such indoor air
pollution has been linked with respiratory infections in children, chronic illness such as
bronchitis and, in the case of coal, lung cancer in adults, and may be associated with low
birth weight, tuberculosis, cataract, and many other diseases. Indoor air pollution is the
fourth most important risk factor in developing countries (behind malnutrition, unsafe sex,
and unsafe water and sanitation).
Outdoor air pollution remains a serious threat to health in cities throughout the world.12
In Latin America, for example, air pollution limits are routinely exceeded in many cities
including Sao Paulo and Rio de Janeiro, Brazil; Santiago, Chile; and Mexico City, Mexico.13
Both ambient air quality and a school’s indoor air quality affect the respiratory health of
school children.
2.1.2 Diarrhoeal diseases
Diarrhoeal diseases, the second most common global illness affecting young children and
a major cause of death in lower income countries, are closely linked with poor sanitation,
poor hygiene, and lack of access to safe and sufficient supplies of water and food. Each
year, nearly two million children under the age of five die of diarrhoeal diseases caused
by unsafe water supplies, sanitation, and hygiene. Interventions such as simple hand
washing have been shown to reduce sickness from diarrhoeal diseases by up to 47%,
and could save up to one million lives.14
Although diarrhoeal diseases are most prevalent in the developing world, they are also a
significant health threat in developed countries. Salmonella and Campylobacter jejuni, tiny
organisms that spread through eggs, chicken or milk, are two of the most common
causes of diarrhoea in the developed world.15 Outbreaks of food poisoning in the United
States of America, Canada, Europe, and Japan have been linked with the parasite
Cyclospora and a new form of E. coli bacteria.16 Contaminated water can also be a cause
of diarrhoea in the developed world. The largest outbreak of diarrhoea in the United States
affected over 400 000 people when the municipal water supply of Milwaukee, Wisconsin
was contaminated with Cryptosporidium, a parasite from farm animal waste.17 School
children everywhere need to have access to safe and sufficient water and sanitation and
need to be taught basic hygiene.
2.1.3 Vector-borne diseases
Vectors are organisms that transmit diseases and include mosquitoes, ticks, flies, fleas,
triatomine bugs, worms, and rodents. Different species of mosquitoes can transmit
different diseases such as malaria, dengue fever, yellow fever, lymphatic filariasis (known
for its most dramatic symptom: elephantiasis), and Japanese encephalitis. Ticks can
transmit Lyme disease, tick-borne encephalitis, relapsing fever, and many other illnesses.
Rodents are capable of spreading the plague (transmitted from rats to humans by fleas),
and other infectious diseases. In sub-Saharan Africa, tsetse flies can cause African
trypanosomiasis (sleeping sickness).18 In Central and South America, triatomine bugs
transmit American trypanosomiasis (Chagas disease).
Malaria, the most deadly of mosquito-transmitted diseases, kills over one million people
each year; the majority of these deaths occur in African children under five.19 In endemic
areas, 60% of all school children may suffer from malaria.20 Controlling malaria requires

IS IMPORTANT
understanding the reproductive ecology, biology and behavioural patterns of mosquitoes.

Nearly 60 mosquito species transmit malaria and different species have different
ecological requirements in terms of altitude, rainfall, temperature, sunlight, humidity,
heat, quality of available surface water, and host species. Culturally determined
behaviours and environmental factors are key determinants of the increase in malaria in
many parts of the world. For example, in hot periods, people may choose to sleep out-
side rather than in their houses, unprotected by bed nets or by the effects of indoor
residual insecticide spraying. Standing water and poor waste management in schools
increase the risk of vectors breeding and spreading near the school environment.
Another mosquito species can carry dengue and yellow fever and thrive in urban settings,
where they lay their eggs in water storage containers or in discarded plastic bottles or
tires. Since the 1960s, the incidence of dengue and dengue haemorrhagic fever has
increased dramatically; about 20 million cases are estimated to occur each year.21 It is
believed that rapid urbanization, the wide use of non-biodegradable plastic packaging and
cellophane, increased travel and trade, and the lack of adequate mosquito control efforts
have contributed to the increased incidence of this disease.22
Schools sited adjacent to pools of water and wetlands are more susceptible to
mosquito-borne diseases. Agricultural irrigation and forestry practices near schools may
provide breeding places for disease-bearing mosquitoes. Children must be protected
from disease vectors at home and at school. At the same time, learning to take
precautions that help avoid contact with disease vectors can influence practices by
families and in communities.
2.1.4 Injuries and poisonings
In high income countries, road traffic injuries are the most common cause of death among
children aged 5 to 14, and account for approximately 10% of deaths in this age group. In low
and middle income countries they are the fifth leading cause of death in the same age group
behind diarrhoeal diseases, lower respiratory infections, measles and drowning.23 Schools
located near busy roads or water bodies have increased risks of these types of injuries. Falls
and injuries within the school grounds can
occur as a result of poorly maintained schools Box 1: Pesticide poisoning in Peru 25
or poor construction management.
In 1999, 24 children in the Peruvian Andes
Poisonings in children account for about 2% of died and 18 more were severely poisoned
all injury deaths in children in developed by a powdered milk substitute that had
countries, and about 5% in developing been contaminated with the pesticide
countries.24 There is potential for children to be methyl parathion. Methyl parathion is
poisoned at school by pesticides due to classified as “extremely hazardous” and
improper storage or improper pesticide acutely toxic and is responsible for a large
applications (see Box 1); lead in paint chips and share of pesticide poisonings in Latin
in water contaminated by metals; and by America. The pesticide was packaged in
chemicals in cleaning products. In addition, the the form of a white powder that
effects of long-term exposure on children's resembled powdered milk, had no strong
health and development, even to low levels of chemical odour, and was stored in small
pesticides, are suspected of having lasting plastic bags with no pictograms indicating
effects that could extend over a lifetime. danger or toxicity.

IS IMPORTANT
2.1.5 Cancer
Cancers of all types claimed more than 7 million lives in 2001.26 This figure is likely to
underestimate incidence, since disease surveillance efforts are often inadequate or
non-existent. Genetic factors in combination with a wealth of environmental factors, such
as exposure to chemical pollutants, and behavioural factors, such as unhealthy lifestyles,
are believed to cause the vast majority of cancers.27 Some environmental causes of child-
hood cancer such as ionizing radiation are well known.28 29 Other childhood exposures, such
as excessive exposure to sunlight and environmental tobacco smoke, pesticides, solvents,
radon (a radioactive gas) and arsenic may contribute to cancers that develop in adulthood.30
31
All children are exposed to ultraviolet radiation from the sun and almost half of the
world's children are regularly exposed to environmental tobacco smoke.32 Some evidence
suggests that childhood cancer may
be associated with a variety of other
Box 2: Exposures associated with the risk of
childhood cancer in the school environment products and exposures (see
Box 2).33 34 Children may be at higher
• Pesticides risk of developing cancer due to
• Ultraviolet radiation (from the sun) some exposures, such as radiation
• Metals and pesticides, than similarly
• Paints exposed adults.35 Therefore, it is
important to minimize children's
• Solvents
exposure to such agents in the
• Environmental tobacco smoke
school environment.
• Radon
2.1.6 Developmental disabilities
Developmental disabilities include a variety of conditions that occur during childhood and
cause mental or physical limitations. These disabilities include autism, cerebral palsy,
epilepsy, mental retardation, and other neurological impairments. Many researchers
believe an epidemic of learning and behavioural disabilities is occurring among children.
Developmental disabilities are believed to be a significant and frequently undetected
health problem in developing countries.36 Malnutrition and parasitosis (especially helminth
infections) may contribute to these illnesses.37 In India, undernourished rural children
10-12 years of age demonstrated a range of learning deficiencies when compared to
normally nourished children.38 Considering the estimate that a third of the world’s children
suffered from malnutrition during the 1990s39, the potential for widespread learning
deficiencies is staggering. Schools could play an important role in ensuring that students
have nutritious food to eat several times per day. Schools that offer a lunch programme
give children an opportunity for at least one safe and nutritious meal a day. This also
serves as a motivation for families to send children to school.
Exposure to toxic substances also places children at risk of developmental disorders,

particularly in developing countries where regulations are lax or non-existent. In many
developing countries where leaded gasoline is still used, lead presents a threat to more
than half of urban children.40 Populations in at least 100 countries are still exposed to air
polluted with lead from gasoline.41 Also, past use of leaded gasoline in countries that have
already phased out leaded gasoline leaves behind a reservoir of lead in the soil which will
continue to pose a hazard to human health for years to come.42
In the United States, 17% of children younger than 18 years have been diagnosed with
one or more developmental disability.43 It has been estimated that 25% of major
developmental deficits may result from a combination of environmental and genetic

IS IMPORTANT
factors.44 These estimates are based on known toxic substances. Since little is known
about the developmental effects of most chemicals, this percentage could be much
higher. Exposure to lead45, mercury46, organic solvents47, substances such as
polychlorinated biphenyls (PCBs)48, and pesticides49 (particularly organic compounds such
as organophosphates50) occur worldwide. All of these chemicals are known to affect the
nervous system and are particularly harmful to children. Schools need to reduce or
eliminate student exposures to these chemicals.
2.1.7 Asthma
Asthma and chronic respiratory illnesses such as bronchitis are growing problems,
especially in intensively developed nations. Since the middle of the 20th century, the
worldwide prevalence and severity of asthma have increased considerably, especially
among children.51 In Taiwan, the prevalence of childhood asthma has risen to around 10%
in contrast to a 1% prevalence rate in the 1970s.52 Currently, Australia and New Zealand
report the highest asthma prevalence rates in the world (>15%), and in the United States,
asthma is now the most prevalent chronic disease among children, affecting about 7% of
all American children.53 Between 1980 and 1995, the asthma prevalence rate for children
increased 75% in the United States.54 Asthma rates are increasing among all ethnic
groups, both sexes, all age groups, and in all regions of the United States but asthma
prevalence is highest among urban children55 56 and is the primary cause for childhood
hospitalization in urban areas.57
Experts acknowledge that in conjunction with genetic susceptibility, indoor and outdoor
air pollution are an important factor in the increasing incidence and severity of asthma.
Exposure to house dust mite allergens and secondhand smoke has been associated with
the development of asthma as well as the exacerbation of asthma symptoms. Other
indoor asthma triggers include allergens from cockroach, pet dander, and mold. Recently,
ozone has been implicated as a factor contributing to asthma among children who
exercise in urban settings. Common asthma triggers are listed in Table 3. By reducing
exposure to allergens and irritants, the incidence of asthma attacks can often be reduced.
Table 3: Common asthma triggers58
Allergic asthma Non-allergic asthma
• House dust mites • Tobacco smoke

• Mold or yeast spores • Pollutants
• Pollen • Natural gas, propane, or kerosene
• Cat hair, saliva, and urine used for cooking and heating
• Cockroach particles • Wood smoke
• Aspirin or other nonsteroidal • Coal smoke
anti-inflammatory drugs • Paint fumes
• Metabisulfite, used as a preservative • Viral respiratory infections
in many beverages and some foods • Exercise

IS IMPORTANT
Schools represent an important setting for effective control measures. Wood smoke,
environmental tobacco smoke, molds, and many volatile chemicals found in indoor
environments can reduce respiratory function in school children. School absenteeism
associated with these respiratory diseases can adversely affect both intellectual and
emotional development.
2.2 Argument: Children are more susceptible to environmental diseases

than adults and therefore need healthy school environments
Children under five years of age experience over 40% of all environment-related
illness.59 Children living in poor populations in rural and peri-urban areas in developing
countries are particularly affected. These children face health risks from living in an
environment that lacks clean air, water, and food, and from hazardous chemicals
associated with rapid economic and urban development.60 (see Figure 2)
Children are more susceptible to the harmful effects of chemical, biological and physical
threats in their environment for the following reasons:61
• Children are in a dynamic state of growth and their nervous, immune, respiratory,
endocrine, reproductive and digestive systems are still developing. Their ability to
detoxify and excrete toxins differs from that of adults. Exposure to environmental
toxicants during certain stages of development can irreversibly damage the normal
development of organs and systems.
• Young children breathe faster, and eat and drink more in proportion to their body
weight than adults. They drink 2.5 times more water, eat 3 to 4 times more food,
and breathe 2 times more air. Children therefore absorb more toxicants contained
in air, water or food, which makes them more vulnerable to acute and chronic effects
of environmental hazards.
• Children often have a greater exposure to environmental hazards than adults: they
are closer to the ground where many contaminants settle and young children
commonly put their hands into their mouths.
• The longer lifespan of a child increases the risk of developing diseases with long
latency periods such as cancer.

IS IMPORTANT
Figure 2: Children’s complex environment
RISKS MEDIA
SETTINGS
Biological Water - Air - Food - Soil - Objects
Home
Physical School
Chemical Transport
Recreation
BEHAVIOURS
Workplace
Eating - Drinking - Playing - Learning
Working - Scavenging
1 2
VULNERABILITY
Breathing
Body mass and height
Intestinal and skin absorption
Metabolism
Developing, immature organs
In much of the developed world, children spend roughly one third of their day for nine months of the year
within school environments. Potential risks at school include unsafe water and sanitation, contaminated
indoor and outdoor air; recreational and other facilities that are contaminated with asbestos, metals, such
as lead and arsenic, organic solvents, and bacteria; vector-borne diseases such as malaria, yellow fever,
and dengue fever; unsafe building structures; and excessive exposure to ultraviolet radiation from the sun.
Preventing childhood exposure to environmental hazards can help reduce the risk of developing diseases.
2.2.1 Water and sanitation
Around 1.1 billion people (one sixth of the global population) lack access to improved
drinking water sources.62 Even sources of water thought to be safe may be affected by
microbiological or chemical contamination. For example, where the water distribution
systems in urban areas function intermittently, contaminated water may infiltrate into the
pipelines. In Bangladesh as well as many other parts of the world, contamination of
groundwater with arsenic is a major public health problem.
The Global Water Supply and Sanitation

Assessment reported that 2.4 billion people Box 3: Potential health effects of
water pollutants
globally did not have access to any type of
improved sanitation facilities in 2000.63 These
facts indicate that billions of people around the • Diarrhoea
world, especially the poor, are at serious risk of • Cancer
contracting diseases such as diarrhoea, • Kidney failure
intestinal parasitic infections, trachoma, • Liver damage
schistosomiasis, and of being exposed to high • Birth defects
concentrations of heavy metals or chemicals
• Neurological disorders
(see Box 3).

IS IMPORTANT
2.2.2 Indoor air pollutants
For many children, much of their school day Box 4: Symptoms associated with
is spent indoors. The air they breathe inside poor indoor air quality
their school may be more polluted than out-
door air. Poor indoor air quality may increase • Headaches
rates of asthma, allergies, and infectious and
• Fatigue
respiratory diseases, and affect student
• Shortness of breath
performance of mental tasks involving
concentration, calculations, and memory.64 • Coughing, sneezing
Symptoms associated with poor indoor air • Eye and nose irritation
quality are listed in Box 4.65 • Dizziness
In many rural schools in developing countries, fuels such as dung, wood and coal are used
for heating and the preparation of school meals, exposing students to high levels of
particles and other toxic pollutants. Cooking and heating with simple fuels is likely to be the
most prominent source of indoor air pollution in developing country schools but additional
pollutants may include airborne bacteria and viruses, molds and fungal growths, and
particles from building materials.
In schools in industrialized countries, indoor air pollution may be the most prevalent of all
environmental hazards. Over half of the schools surveyed in the United States reported at
least one environmental problem affecting indoor air quality.66 Problems include molds and
toxic fungi; pesticides; volatile organic chemicals emitted from cleaning products,
photocopiers, and classroom furnishings; radon gas and outdoor pollutants entering the
school buildings; airborne asbestos from insulation, and lead released from paints and other
building materials (Box 5). Faulty heating, ventilation, and air conditioning systems can
exacerbate air quality problems. "Sick building syndrome," manifested by headaches,
nervous system effects, and respiratory problems, is routinely reported to American school
nurses.67 The syndrome became prevalent in the 1970s and continues today with the
construction of airtight buildings designed to conserve energy.
Box 5: Sources of air pollutants in classrooms
• Outdoor emissions (e.g. diesel exhaust from school buses that is pulled into
school air ventilation systems or flows through open windows and emissions from
nearby land uses such as industrial facilities, agricultural lands or transportation
corridors)
• Carpet (e.g. formaldehyde)
• Tobacco smoke (e.g. faculty lounges)
• Commercial products (e.g. paints, cleaning agents, pesticides, and air fresheners)
• Vapors from supplies and equipment (e.g laboratory chemicals, photo and art
supplies, copying and printing equipment, dry erase markers)
• Radon gas, carbon dioxide, carbon monoxide
• Lead
• Animals and insects
• Molds and fungi
• People (e.g. transmission of bacteria and viruses)

IS IMPORTANT
2.2.3 Outdoor air pollutants

Box 6: Health effects of outdoor air
In urban settings, children are exposed to pollution
outdoor air pollution from industry and traffic
exhaust fumes on their way to school, and Acute/transient effects
outdoor air pollutants may enter into the • Wheezing and cough
classroom. Box 6 68 outlines the range of • Lung function decrements
health effects associated with outdoor air • Lower respiratory tract infections
pollution. These health effects are difficult to
• Exacerbation of asthma
quantify, but WHO estimates that worldwide
about 800 000 annual deaths and 0.8% of all Potential chronic effects
DALYs are caused by outdoor air pollution.69 • Chronic obstructive lung disease
• Exacerbation of asthma
Air pollution is a global health threat to • Cancer
children. Nearly 80% of 105 European cities
surveyed exceeded WHO air quality standards for at least one pollutant.70 In Western Europe,
asthma cases have doubled in the last ten years.71 In the United States, the number of
asthmatics has leapt by over 60% since the early 1980’s and deaths have doubled to over
5 000 per year.72 In the Russian Federation, over 200 cities often exceed pollution limits and
air pollution has been implicated as a contributing factor to 17% of childhood illnesses.73
Air pollution in developing world cities is estimated to be responsible for 50 million

annual cases of chronic coughing in children younger than 14 years of age.74 In Beijing,
Delhi, Jakarta, and Mexico City, pollution levels sometimes exceed WHO air quality
standards by a factor of three or more. In some of China's major cities, particulate levels
are as much as six times the WHO guidelines. Throughout the world, as many as 1.5
billion urban residents breathe air exceeding WHO air quality standards.75
While all school children incur health risks as a result of exposure to air pollution, children
with asthma need to be particularly concerned because they are 40% more likely to have
an asthma attack on high outdoor pollution days.76 Even short-term increases in air
pollution levels have been associated with an increase in asthma symptoms in children.77
2.2.4 Ultraviolet radiation
The majority of lifetime sun exposure for most people occurs during childhood. Ultraviolet
radiation exposure and sunburn during childhood constitute an important risk factor for
several long-term health effects, among them skin cancer and cataracts. Damage is
preventable through sensible sun exposure behaviour.78 It is important to target children’s
attitudes and behaviour at a young age, particularly during primary school, when they tend
to be most receptive. Preventive health habits developed at a young age may persist into
adulthood and can enable healthy adulthood and ageing. Schools are vitally important
settings to promote sun protection, as during the first 18 years of life a significant
proportion of time is spent at school where sun exposure may occur.
2.2.5 Pesticides
Children may be particularly sensitive to the cancer-causing and other adverse effects of
pesticides, and accumulate a large percentage of their lifetime health risk during
childhood.79 80 81 Exposure to pesticides at school may result from their application both
indoors and outdoors. Children in both developing and industrialized countries may also be
exposed to pesticide residues in drinking water, food and objects such as books and toys.

IS IMPORTANT
Pesticides are widely misused due to misunderstanding of their toxicity by applicators.

Labels rarely provide a complete and accurate summary of pesticide health threats.
Pesticides like DDT have been banned or restricted in many countries, but are still widely
available in others. In a school in Costa Rica for the children of workers in a banana
plantation, health problems were reported to be overwhelmingly respiratory and eye
infections. The school was located in the center of the plantation and was regularly sprayed
with insecticide from the plantation’s aircraft.82
Several recent studies in various parts of the United States found that nearly 85% of
schools were treated with pesticides, with no notification or vacancy requirement prior to
spraying.83 Some of the pesticides used have the potential to cause short-term or long-
term health effects, including vomiting, diarrhoea, convulsions, headaches, skin irritations,
liver damage, neurological problems, and behavioural and emotional disturbances. Other
pesticides used in schools were labeled with warnings of health effects that may include
reproductive system disorders, flu-like symptoms and asthma-like problems. In addition to
using pesticides in and around school grounds, many industrialized countries use
“pressure treated lumber” that has been impregnated with pesticides to build play sets
and picnic tables. In the United States, new regulations on pressure treated lumber will
help avoid this problem in the future.
2.2.6 Food
In 2002, UNESCO estimated that nearly 5 500 children die each day from bacteria in food.
Unsafe food remains a widespread public health problem in all parts of the world.
Surveys in New Zealand, Europe, and North America suggest that each year up to 10%
of the population suffer from diseases caused by unsafe food.84
E. coli bacteria are a major

Box 7: Foods implicated or suspected to have caused
cause of diarrhoea and kidney
disease in school children or college students
failure that can be fatal in
children. The largest ever
• In 1984 in Malaysia, 114 students were infected with
outbreak occurred in 1996 in
Bacillus cereus from eating fried noodles.
Japan, affecting 6 300 school
• In 1993, 80 children aged six and under were infected by children and 92 staff
Bacillus cereus in the United States, from eating chicken members and resulting in two
fried rice. deaths. The probable cause
• Cake with cream topping infected 14 school aged was determined to be fresh
children in Saudi Arabia in 1992 with Salmonella typhi. radish sprouts (see Box 7).85
• In 1981 in the United Kingdom, 2500 children were Another large E. coli outbreak
infected with Campylobacter enteritis by drinking milk. occurred in Africa: contami-
nated drinking water and
• 8 753 children in Japan were infected in 1996 by E. coli
cooked maize infected
from eating radish sprouts
thousands of people.86
• 152 children aged 7 to 12 were infected with E. coli in
Indonesia, when they ate sweetened green-bean
porridge with coconut milk. Two deaths resulted.
In developing countries, a polluted environment, lack of a safe water supply and poor
sanitation increase the likelihood of food contamination.

IS IMPORTANT
Worldwide, most outbreaks result from improper food handling such as use of
contaminated equipment; contamination by infected persons; use of contaminated raw
ingredients; cross-contamination; and addition of toxic chemicals or use of food
containing natural toxins.87
2.2.7 Hazardous location
Lands near or directly beneath schools in many parts of the world may pose health
threats to children. Schools located near transportation corridors, bus depots, industrial
sites, abandoned lots, landfills, military bases, utility plants, and construction sites may
present health problems to the students and staff occupying the school.
New schools are difficult and expensive to site and are often constructed on undesirable
lands. One of the most famous American examples is the Love Canal dumpsite in Niagara
Falls, New York. Two schools constructed on a former industrial landfill were closed after
testing showed excessive levels of contamination. The construction of another American
school had to be halted because of the recognition that the site was an abandoned oil
field containing methane and hydrogen sulfide gases.88 In developed countries, enormous
sums of money are spent remediating schools that have been built on hazardous land.
Many schools are located adjacent to highways causing students’ and staff’s exposure to
high concentrations of vehicle exhaust, which is known to contain several cancer-causing
substances and at least 50 toxic air pollutants.
2.3 Argument: Implementing changes in the school’s physical

environment can improve children’s health
There are potentially many changes that can be implemented to improve a school’s
physical environment and, ultimately, the health of students and staff. These changes can
serve to educate students, teachers, and parents about the relationship between the
environment and health. For example, providing shade from a sweltering sun either by
planting trees or building shade structures and encouraging the use of clothes, hats and
sunglasses can reduce exposure to the damaging effects of ultraviolet radiation.
Minimizing the use of pesticides in schools while educating teachers and students about
why this is important can lead to a heightened awareness about the hazards of pesticides
in the community. Implementing changes in the physical environment to improve indoor
air quality with the goal of reducing respiratory illness and asthma will educate students
about managing their own environment to improve respiratory health. Students can, in
turn, educate their parents about these management techniques. Health education
activities brought home from school by children have been found to positively influence
parents' self-management of asthma.89

17 3. CONVINCING OTHERS THAT IMPROVING THE PHYSICAL SCHOOL
ENVIRONMENT WILL PROTECT HEALTH
3. Convincing others that improving the physical school

environment will protect health
This section provides information that can be used to convince policy-makers and other
decision-makers that improvements to the physical environment will benefit health and
school attendance, and can be achieved at little or no cost.
3.1 Argument: Children’s health can improve with low-cost

interventions to the physical environment at schools
Schools can implement policies and procedures that can improve the health of students
at little or no extra cost. Some examples include:
• Reducing risk of diseases such as malaria, dengue fever and schistosomiasis by

improving drainage to eliminate formation of puddles where mosquitoes and other
vectors breed.
• Adjusting behaviour to avoid risks. Scheduling outdoor activities during periods of
the day when air pollution and sun exposure are lowest and insects are not feeding
can reduce children’s exposure to toxic air pollution, ultraviolet radiation, and insects
that transmit diseases.
• In areas where school children cross busy roads, crossing guards or older children
can assist younger children and reduce the risk of accidents.
• Prohibiting the idling of school bus engines can minimize exposure to diesel and
gasoline exhaust fumes. Buses should not idle in areas around schools where
fumes could enter the school building.
• In the developing world, where children dip unwashed hands into a shared drinking
water source, a ladle may be used to fill cups or bowls providing a low-cost solution
to cleaner water.
• Teaching young children basic rules of food safety such as washing hands before
eating.
• Establishing safety rules in the handling and preparation of foods.
• Planting shade trees around school grounds to reduce the risk of overexposure to
the sun’s ultraviolet rays.
• Creating a health committee with a mission to ensure that classroom facilities and
grounds are safe and healthy for children.
• Sorting and recycling waste.
• Reducing respiratory infections by using improved stoves and increasing ventilation
when polluting fuels are used inside schools for cooking and heating.
• Reducing asthma attacks by improving ventilation to enhance indoor air quality.
Depending on the location of the school, ventilation in classrooms may often be
improved by simply opening a window. Where resources permit, additional options
can be considered.
• Reducing pesticide exposure and poisonings by eliminating/minimizing use of
pesticides. Schools adjacent to locations where pesticides are routinely applied
could learn about the timing of pesticide applications and keep children inside the
school with windows and doors closed.
Further suggestions on improving the physical environment at schools are provided in

Section 5.2.1.

3. CONVINCING OTHERS THAT IMPROVING THE PHYSICAL SCHOOL 18
ENVIRONMENT WILL PROTECT HEALTH
3.2 Argument: Improvements in the physical environment at schools

can increase school attendance
In the developing world, providing separate sanitation facilities for girls is an important
contributing factor in reducing dropout during and before menses. Educated girls marry
later in life, have fewer children and are more likely to seek health care for themselves
and their children. An increase in the number of girls who stay in school is likely to lead
to a reduction in childhood mortality, improved children's health and nutrition, and a
deceleration in population growth. Female education has the greatest return on the
dollar of all investments available in the developing world.90
Eliminating air pollutants that trigger asthma attacks and other respiratory illnesses can
help improve attendance in high and low income nations. In the United States, asthma is
believed to be the most common reason that students miss school.91

19 4. PLANNING INTERVENTIONS FOR HEALTH PROTECTION IN SCHOOL
ENVIRONMENTS
4. Planning interventions for health protection in school environments
The preceding sections demonstrate that children’s health and educational potential depend
on the quality of the physical school environment. Building capacity to protect children’s
health and educational potential will demand changing knowledge, perspectives, and
priorities. It will also require collective decisions to adopt new policies, and make
commitments to pursue specific plans for health risk reduction. The following procedural
steps could help guide this reform. Further information on how to implement these
procedural steps and guidance on how to mobilize resources is given in Local Action:
Creating Health-Promoting Schools (Box 8).
4.1 Procedural steps toward creating a healthy physical

environment at schools
• Participation: Organize broad participation to design and implement plans to create
healthy school environments. Participants could include school administrators;
managers of facilities, transportation and grounds; parents; students; community
leaders; and experts in public health and environmental protection.
• Threat identification: Conduct research to identify the magnitude and relative
importance of significant threats to health within the school environment. Threats
may be associated with the following: water quality, sanitation, air quality, food
safety and nutrition, vector-borne diseases, waste management, pesticide use,
hazardous chemical management, transportation, adjacent land uses, structural
integrity, renovation, purchasing, and grounds management.
• Goal identification: Establish clear and measurable goals to reduce significant
threats.
• Design of intervention plans: Design specific intervention plans to improve health-
promoting practices in the following areas: water quality, sanitation, air quality, food
safety and nutrition, waste management, pesticide use, hazardous chemical
management, transportation, facility siting, structural integrity, renovation,
purchasing, and grounds management.
• Implementation of plans and evaluation of progress: Implement the intervention
plans. Define timetables to meet goals, and assign clear responsibility and
accountability. Routinely evaluate progress in goal attainment, and the effectiveness
of interventions. Adjust policies, intervention plans, and methods of implementation
in response to evaluations, changing conditions and availability of resources.
Box 8: Local Action: Creating Health-Promoting Schools forms part of the WHO
Information Series on School Health. It offers school leaders help in developing ideas
and organizing activities to identify health problems in their school and community, and
to take steps to improve health. It provides guidance and tools for assessing local
health problems; identifying resources; defining goals, objectives and action plans; and
documenting progress.92
4.2 Goals identification
Successful protection of children from environmental threats at school requires careful

definition of problems and goals to resolve them. Goals are grouped into two categories:
substantive goals and procedural goals.

4. PLANNING INTERVENTIONS FOR HEALTH PROTECTION IN SCHOOL 20
ENVIRONMENTS
4.2.1 Substantive goals
• Hazard reduction: Reduce exposure to significant physical, biological and chemical

threats to children’s health within the school environment.
• Education: Educate school administrators, teachers, parents, health providers,
political leaders and community members about direct and indirect relationships
between the school environment and health.
• Surveillance: Create an effective system to monitor and record infectious and
chronic disease prevalence, and environmental hazards within the school environment.
• Health service delivery: Develop capacity to provide fundamental emergency
medical care within each school.
• Food: Provide safe and nutritious meals for students.
• Water: Provide safe water at schools for drinking, cooking and washing.
• Sanitation: Provide clean and well maintained sanitary facilities, separate for males
and females.
• Transport: Provide safe passage between homes and schools.
• Waste: Create a secure and effective system for waste collection, storage and
removal.
• Facilities: Ensure structural integrity of school buildings, use of safe building
materials, and health protective renovation procedures.
• Grounds: Prevent students from exposure to dangerous conditions on grounds,
such as rivers, ravines, flood prone areas, rockslides, or highways. Manage grounds
to prevent diseases carried by rodents or insects.
• Hazardous materials storage: Ensure that hazardous materials are stored safely
and securely, preferably in a structure detached from educational facilities.
Hazardous materials include fuels, solvents, some cleaning supplies, paints and
wood finishes, pesticides, and vehicle fluids.
• Pesticides: Restrict use to situations where pesticides will confer a health
protective benefit, such as reducing insects that carry diseases, and then employ
only the least toxic alternatives.
• Tobacco: Eliminate use of tobacco on school grounds.
• Green purchasing: Develop criteria to guide purchasing of products and services
that will better protect the environment and children’s health. Categories of products for
which low risk options should be identified include: food, vehicles, fuels,
furnishings, cleaning products, building materials, pesticides, paints and wood finishes.
4.2.2 Procedural goals
• Participation: Create decision-making processes that encourage broad community

participation in goal formulation, policy development, intervention design,
implementation and evaluation.
• Transparency in decision-making: Make decisions and deliberations in open meetings.
• Freedom of information: Information and records on hazards in the school
environment should be publicly accessible.
• Protection of privacy: The privacy of individual medical records should be protected.
• Fair warning of significant hazards: If school officials recognize unusually
hazardous situations, the community should be promptly warned (e.g. lead water
piping, bacterial contamination of food or water, pesticide applications, asbestos in
renovation debris).

ENVIRONMENTS
• Timely response: The community should expect a timely response by school

officials to credible evidence of health hazards.
• Equity: Implement interventions to achieve an equitable reduction in exposure to
hazards within school environments.
4.3 Participation in planning the interventions
Effective protection of health and enhancement of education require school and

community involvement in the planning of interventions. Two important groups that could
be involved in the planning process are a school health team and a community advisory
team.
4.3.1 Form a school health team
A school health team may be designated to coordinate and monitor health-promoting

policies and activities. If a school does not have a health team, planning to improve the
school’s physical environment can provide the opportunity to form one. Valuable
members of the school health team could include teachers, administrators, school
nurses, students, parents, transport managers, facilities managers and groundskeepers.
Specific task forces can be organized to focus on specific health concerns such as health
surveillance and evaluation, health service delivery, sanitary facilities, water quality, food
preparation and safety, waste management, transport, vector-borne disease
management, pesticide use, structural facilities, renovation, purchasing, and grounds.
4.3.2 Establish a community advisory committee
Planning improvements to the physical environment provides an opportunity to work outside

the school with those who have an interest and expertise in the relationship between the
environment and health. Potential partners from the community include parents, childcare
centers, local government representatives, businesses, residents, non-governmental
agencies, health service providers, environmental organizations, and experts in facility
design, construction, renovation, grounds management, waste management, transport, and
infectious diseases. The community advisory committee could:
• Identify specific problems and goals;

• Provide expertise for design and implementation of intervention plans;
• Disseminate information about environmental health issues, in particular regarding
children;
• Encourage broad community involvement and support;
• Search for financial support and voluntary contributions to meet the goals of the
intervention plans.

ENVIRONMENTS
4.4 Intervention plans
Schools could develop intervention plans that include:
• Purpose statement: A general purpose statement should address the need for
hazard reduction, environmental quality, safety assurance, education, surveillance,
and health service delivery.
• Problem identification: Problems should be identified and ranked in order of
relative significance to provide priorities given limited budgets and time.
• Goals and objectives: General goals and specific objectives should provide clear
and measurable targets for environmental improvements.
• Procedural policies: Policies should be adopted to structure participation,
transparency in decision-making, access to information, confidentiality and privacy
of medical records, warning of significant hazards, timely response to significant
threats, and equitable reduction in exposure to hazards within school environments.
• Specific intervention strategies: Specific strategies should be designed to protect
or improve the following components of the school environment: nutrition and food
safety; water quality; air quality; sanitation facilities; transportation; waste; facilities
design, construction, renovation and maintenance; grounds; hazardous materials
storage; pesticide use; and purchasing.
• Educational strategy: Each plan may also include an educational strategy,
addressing important problems through curricular and extracurricular efforts.
• Responsible parties: Specific individuals should be assigned responsibility to
develop and implement components of intervention plans.
• Financial analysis: Each plan should include a financial analysis estimating the cost
of goal attainment, and potential sources of funding or voluntary service and
materials.
• Evaluation: Each plan should include criteria for evaluating progress and goal attainment.
• Community outreach: Each plan should consider how the expertise, labour and
financial resources of community members might be helpful in achieving goals.
4.4.1 Identify information needs
Both qualitative and quantitative data are necessary for planning effective environmental
health interventions, and to establish a baseline for evaluation. Qualitative data include
perceptions, beliefs, and attitudes; quantitative data include numerical information. The
following information could help determine local needs and priorities in relation to the
school environment:
• Health trends at the national, regional, local and school level, if available.
• Environmental status and trends at the national, regional, local and school level, if available.
• Knowledge, attitudes, beliefs, values, behaviours and conditions related to the
environment and health.
• Available resources, both personnel and financial, and commitment to health within
the school and community.
• Ongoing initiatives in the community, in other schools, or in the country that may
provide support.
• Status of existing school and community programmes that might help to implement
improvements to the physical environment.

ENVIRONMENTS
Table 4: Basic questions and information sources
Basic questions Methods for data collection
What health issues are a cause of concern in the Review of local, regional, and national health data,
country, community and schools (e.g. acute respiratory mortality and morbidity rates, and disease burden;
infections, diarrhoea, injuries, infectious diseases, review of school data on absences, type of illnesses,
asthma, malaria, pesticide poisonings, lead poisoning, and medications administered. Consultations with
learning disorders, childhood cancers)? health clinics, health departments, hospitals, or
medical schools.
What physical conditions exist in schools that may Interviews with school officials, teachers, facilities
impact the health issues of concern (e.g. wood managers, general practicioners, pediatricians, primary
smoke in schools, access to clean drinking water, health professionals such as nurses, parent panels etc.
poor drainage and dampness, unsafe food preparation Surveys or questionnaires, observations, research
and storage facilities)? data.
What resources are available at the school and Interviews with school and community leaders.
community level to provide improvements in the
physical environment of schools?
Do teachers, school nurses, parents and children Observation, questionnaire/survey.

have basic knowledge about managing respiratory
infections, asthma, and diarrhoea?
Do teachers, school caretakers, parents and children Observation, questionnaire/survey.

have basic knowledge about important environmental
health risks identified in their school and community,
such as unclean drinking water, lack of sanitation, air
pollution, and pesticide exposure?
Are classrooms well ventilated? Do they receive Observation, questionnaire/survey.

adequate natural light? Are they able to control
excessive noise?
Is safe water available for drinking, washing and Interviews with school and community leaders,
cooking? What are possible threats to the school’s observation, water quality testing, inspections.
water supply?
Are safe food preparation and storage practices Interviews, observation.

followed?
Are school buildings structurally sound? Are safe Routine inspection and record keeping.
building materials being used in the construction,
renovation, and furnishing of school buildings and
play areas? Are the buildings safe, e.g. broken
stairs, broken furniture?

ENVIRONMENTS
Table 4: Basic questions and information sources (continued).
Basic questions Methods for data collection
Are schools built on “safe” land (e.g. contaminated Inspection.

site, hazardous conditions, flood prone, high water
table)?
What physical hazards exist on or adjacent to school Visual inspection.

property (e.g. water bodies, steep terrain, busy
highways, waste sites, polluting industries)?
Are relevant environmental health issues adequately Interviews with school officials and teachers,
addressed within the school curricula? curriculum review, observation.
How are hazardous chemicals stored and used on Inspection, interviews with facilities manager, staff
school grounds? What is the potential for student or members, and students.
staff exposure?
4.4.2 Answer basic questions and identify key information sources
Table 4 lists basic questions and some methods for collecting information to plan
environmental health interventions. Because the environmental hazards within schools
vary greatly among countries and even among schools within a given country, it is
important that collaboration between the school and community takes place to identify
additional questions and resources available for data collection.
4.5 Commitment and policies
Making improvements to a school’s physical environment will require understanding and

commitment from a wide range of individuals and groups, including relevant government
departments, health and education authorities, community and business leaders,
educators, parents, students, and the community.
4.5.1 Gain national political commitment
Successful reduction of environmental health threats within schools demands political

commitment at all levels of government. Political leaders will need to understand the
importance of the threat. Experience in some nations suggests that recognition of school
environmental health problems results from the educational efforts of community and
grass roots organizations. National legal authority, expertise, and financial support may be
necessary to implement change, especially within the poorest communities.

ENVIRONMENTS
Political commitment and support may occur in the form of:
• Support for research: Research to understand more fully the extent and
distribution of environmental health threats faced by children in schools is often
necessary. Although hazards may vary from classroom to classroom, national and
regional governments and universities can show commitment by providing support
and/or expertise to implement needed research. Results of such research can also
be publicly acknowledged and disseminated by national authorities.
• Authority and responsibility: National authority to set standards for physical school
improvements may be necessary to bring about significant change. This authority
could require the provision of safe food and water; attainment of sanitary standards;
and establishment of pollution limits and building standards.
• Financial commitment: Financial support for construction, maintenance, health
surveillance, medical services, and environmental hazard assessment and
intervention may all be necessary to assure sufficient health protection for children
in schools. Training, equipment, and materials may be required to enable schools to
develop and implement physical improvements. Many communities lack the
financial resources necessary to provide these services, and will need financial
commitments from provincial or national levels.
4.5.2 Achieve community commitment
A healthy school environment requires community support. Parents and community

members need to participate in the development and evaluation of interventions to improve
school health. Commitment and the support of many parties on a variety of levels are
necessary to share expertise, facilities, and resources. Community group meetings,
parent-teacher conferences, open houses, and formal presentations are all opportunities for
involving family and community members early in the development process.
Community commitment may be enhanced by:
• Public recognition of the association between health and the environment by

community leaders, local government representatives, health and education
authorities, and other relevant organizations.
• Establishment of a designated committee for coordinating efforts to improve the
physical environment of schools.
• Provision of local resources for interventions to improve the physical environment of
schools.
• Coordination of interventions with other programmes in the community (e.g.
malaria control, food safety initiatives, asthma education, pesticide awareness,
recycling initiatives, implementation of environmental management systems).
• Efforts to attract community and media attention (e.g. though printed material,
community forums, school events).

5. INTEGRATING ENVIRONMENTAL HEALTH IMPROVEMENTS WITHIN 26
VARIOUS COMPONENTS OF A HEALTH-PROMOTING SCHOOL
5. Integrating environmental health improvements within various

components of a health-promoting school
A health-promoting school draws on the school’s full organizational capacity to improve

the health of students, school personnel, families and community members by improving
the physical environment of the school and
Box 9: Components of a health- educating the school community about
promoting school environmental health threats. Physical
improvements to schools can serve as an entry
• Skills-based health education point for the development or enhancement of
• A healthy school environment policies, planning groups, and various
• School health services components that serve as a framework for a
health-promoting school. The key components
• School health policies
are listed in Box 9.
The effectiveness of interventions integrated into each of these components is influenced by

the extent to which they are supported by a variety of people, policies, and trained staff and
by the extent to which interventions in each of these components combine with other health
promotion efforts to complement and reinforce each other.
Most schools will not have the resources to address all the environmental health issues
that might be identified at once. Each school must establish its own priorities, in
collaboration with all parties concerned, to decide the extent to which identified issues
should be addressed. A health-promoting school should enable students, parents,
teachers and community members to work together to make these decisions. Schools
should start with small changes that are feasible rather than waiting until resources
become available to address all of the issues at once.
5.1 Skills-based health education
Physical changes alone will not suffice to create a health-supportive physical environment
at schools or in communities. Students, and the adults they will soon become, will need
to acquire knowledge, attitudes, values and skills to sustain improvements and address
new challenges in the environment. Skills-based health education, along with school
health policies, school health services and a health-supportive school environment are
considered the basic components of an effective school health programme. They are
complementary and reinforcing of each other. Skills-based health education should
increase awareness of environmental threats to health, generate a feeling of responsibility
for health and the environment, and improve the health of students. It should inform
students about how to avoid health risks and how to create an environment that is
conducive to healthy living. It should be designed to contribute to improvements in the
physical school environment including the school site and buildings, indoor and outdoor
air quality, and school-related activities affecting the environmental quality of schools.
Collaboration between education and health officials, the school health team, the community
advisory committee and other school and community members is necessary to identify
knowledge, attitudes, behaviours, skills and services students need to acquire to protect
themselves from illness and hazards associated with the physical environment at school or in
their communities, and to help improve environmental conditions that affect health.

27 5. INTEGRATING ENVIRONMENTAL HEALTH IMPROVEMENTS WITHIN
Skills-based health education (see Box 10) should occur sequentially from primary
through secondary levels. It can be taught as a specific subject, as part of other subjects,
or as a combination of both. It should be part of the school health curriculum, and also
integrated into a range of subject areas, as relevant. Integrating ideas on environmental
health within existing curricula on health, natural science, social science and the humanities
offers opportunities to consider environmental health problems from multiple perspectives
and within multiple contexts. For example, in science lessons, students can learn to use
scientific methods to identify environmental threats to their health and their family’s health,
and to find effective ways to reduce such threats. Even though education about the
environment can be incorporated into many subject areas, it should be a core component of
school health education classes and a prominent subject in health promotion programmes
for staff.
Educational materials and teaching strategies for environmental health-related issues are
available through some governmental and non-governmental agencies and organizations,
universities, or teachers’ unions. Supplemental materials specific to the local environment
can also be generated by teachers in collaboration with health officials, the school health
team, the community advisory committee and other school and community members who
can help identify the physical environmental conditions that affect children’s health in the
community.
Ideas for educating primary school children in developing countries about environmental
health threats are available in Food, Environment, and Health: A Guide for Primary School
Teachers published by WHO.93
Box 10: Skills for Health, Skills-Based Health Education, including Life Skills: an
Important Component of a Child Friendly/Health-Promoting School forms part of
the WHO Information Series on School Health. It provides practical guidance about
designing health education to address important public health issues, including
education to complement and reinforce interventions to create a healthy school
environment.94
Annex 1 provides some examples of education strategies that can be used to promote
environmental health in the classroom.
5.1.1 Methods and materials for skills-based health education in relation to the
environment
A variety of educational methods, including lectures, debates, discussions, experiments,

hands-on activities, audio-visual aids, and role-plays are effective tools for environmental
health education. These methods should be designed to increase knowledge, build positive
attitudes and values, dispel myths, increase skills and provide support for a healthy lifestyle.
Methods should be selected on the basis of lesson objectives. For example, a lecture is an
effective way to increase knowledge but is less effective in influencing beliefs than
discussions or debates. In educating students about the physical environment, practical
information that will enable students to reduce their exposure to unhealthy environments
and create safe and supportive environments should be emphasized.

5.1.2 Training teachers to implement skills-based health education in relation to the

environment
Teachers need to receive training and information to incorporate effectively issues

related to health and the environment in their subject area (Box 11). Teachers could be
provided with information about basic relationships between the environment and health,
and with learning materials to make the content interesting to their students. They could
also be instructed on how to generate a feeling of responsibility toward the environment.
Teachers primarily responsible for health and science education could receive training in
implementing a curriculum targeted at health issues related to the physical environment
of the school and local community. This training could be continuous and address content
and teaching strategies.
All teachers should serve as role models for students by demonstrating responsible
classroom management practices. They should be encouraged to keep their classrooms
healthy by providing adequate ventilation, cleaning them with non-toxic cleaning
products, minimizing/eliminating mold growth, disposing waste properly, and recycling
classroom materials.
Box 11: A healthy schools initiative case study: Trinidad and Tobago
The Ministries of Health and Education in Trinidad and Tobago, along with The Pan
American Health Organization (PAHO), recently produced a manual entitled "Schools'
Environmental Health and Safety Manual." The manual was written for use by school
principals, school administrators and teachers, providing them with information on
environmental health risks, together with guidelines for action for the creation and
maintenance of healthy environmental conditions in schools. There are five chapters
covering the topics of: water and sanitation, vector control, waste management, food
safety and disaster preparedness. The sixth chapter outlines the responsibilities of
other government agencies in providing support for maintaining healthy environmental
conditions. Included are the agencies' contact telephone numbers and the telephone
numbers of emergency services.
The Ministry of Health, in partnership with PAHO and major stakeholders in the
country, has also embarked on a comprehensive healthy space initiative focused on
developing a network of Health-Promoting Schools and Healthy Communities to
provide a supportive environment which targets the school population and its wider
community. The initiative builds on and strengthens ongoing interventions in order to
improve efficiency, reduce cost, and increase impact at local level. A national school
health policy has been prepared, the plan of action has been approved and more than
one million US dollars was committed by the Government to support the first phase of
the process, while it is streamlined into the regular institutional budgets.
5.1.3 The student’s role in skills-based health education in relation to the environment
Throughout the world, children are the future caretakers of the environment and will
become stewards of their own health and that of others. Their knowledge of the
environment and their understanding of the relationship between their own health and

the environment shape the attitudes children develop toward the environment. One
effective way for students to learn about their environment is for them to become active
participants in environmental health education. The child-to-child approach, developed at
the Institute of Child Health and Education, University of London is based on the
observation that children play a central role in the care of their younger siblings and that
traditional knowledge and health practices of villages are passed on from parent to child
and from child to child. In the child-to-child model, there are four fundamental ways
children can serve as health agents for their communities:95
• Older children can help younger ones. Children can be taught how to teach their
younger siblings to manage their own health.
• Children can learn from others of the same age by doing small projects together.
• Children can pass on health messages that they have learned to the larger community.
• Children cooperate to create health actions with their communities.
The child-to-child approach is an effective approach to teaching because:96
• It links what children learn with what they do;

• It links what children do in class with what they do in the home;
• The activities are not taught in one lesson and then forgotten; they are learned and
developed over a long period of time.
The training materials developed by the Child-to-Child Trust deal with environmental
issues such as community-wide water and sanitation surveys, action programmes, and
solid waste management schemes. They are available at http://www.child-to-
child.org/resources/index.html. A similar approach has been adopted by the Indian
non-governmental organization HRIDAY-SHAN (Box 12).
Box 12: Students as informed health activists
In Delhi, students aged 10 to 13 receive health education about the environment while
participating in the HRIDAY (Health Related Information Dissemination Amongst Youth)
programme. As they progress to senior grades, they are introduced to SHAN (Student
Health Action Network) programme, wherein these well-informed students learn to
identify various health problems and existing government policies linked with those
problems. They are motivated to voice their opinions and suggest action to the
government, with support from schools and communities. These intervention
programmes are particularly important for students, because children are the most
vulnerable victims of a degraded environment as well as powerful agents for remedial
social change.
The Theory and Practice of Involving Young Citizens in Community Development and
Environmental Care provides additional information about children’s participation in
environmental interventions.97 In this book, case studies of children’s participation from
urban and rural, poor and middle-class communities in both developed and developing
countries are provided. The book includes successful models, practical techniques and
resources for involving young people in environmental projects.

5.2 A healthy school environment
The preceding sections of this document have made the case that the condition of a
school’s physical environment can impact the health of both students and staff. It has
been demonstrated that all members of the school community need clean air to breathe,
clean water to drink, a safe place for recreation, a safe way to travel to school to avoid
accidents, and protection from extreme temperatures and ultraviolet radiation. A safe and
healthy physical environment requires a good location and safe buildings; protection from
excessive noise; natural light; clean indoor air and water; a healthy outdoor environment;
and healthy school-related activities including safe management and maintenance
practices, use of non-toxic cleaning supplies, careful use of pesticides, vector control, and
use of non-toxic art supplies. With the importance of children’s environmental health in
mind, this section offers actions to create a healthy school environment.
5.2.1 A safe school location and structure
Find a good school location
Before a school is constructed, planners and community groups need to consider potential
environmental risks in relation to the school’s location, e.g. the vicinity of a chemical plant
or former waste site, an area prone to flooding, or a busy, noisy road (Box 13).
Options for improving existing schools on

poor sites include hazardous waste Box 13: Guidelines for selecting a
removal, construction of footpaths or school site
bridges for getting to school, and
construction of school barriers to provide a • Include parents, teachers, and
buffer to hazardous areas. Adjustments in members of the community in the
behaviour can be made to account for poor site selection process.
environmental conditions such as avoiding
• Do not build schools within two miles
recreation activities during periods of the
of facilities that release toxic
day when air pollution is at a peak or the
chemicals into the air or land.
sun is most intense. In areas where school
children are required to cross busy roads, • Contaminated sites should not be
crossing guards or older children can assist used for school construction.
younger children. If children are required to • Schools should not be built in areas
travel to school by bus, these buses should prone to flooding, mud slides, or
be in good running order and exposure to other natural hazards.
diesel or gasoline exhaust fumes should be
minimized.
Design a safe school structure
The structure of a school building should protect students and staff, but poorly designed
school buildings and play areas may present serious health risks instead. School buildings
are often larger than traditional domestic or residential buildings. Special construction
techniques may be required to ensure safety, particularly in areas prone to natural
disasters such as earthquakes and typhoons. In addition to being structurally sound,
school buildings and play areas should be constructed without asbestos and with the
safest, non-toxic materials available.

Schools should be designed to prevent temperature extremes inside classrooms. Cold,

damp, and poorly ventilated classrooms provide an unhealthy environment for school
children, particularly poorly nourished and inadequately clothed students who are especially
vulnerable to respiratory and other infections. Extremely warm conditions may reduce
concentration and attention span, and can lead to heat-related illnesses including thermal
stress, fatigue, and heat stoke. One way to ensure protection from the elements is to plan
school holidays so that they coincide with the rainiest, coldest or hottest season.
School siting and landscaping can affect interior conditions such as temperature, humidity,
lighting, and ventilation. For example,
• Schools in heavily forested settings are often darker, cooler, and damper than those
in open areas.
• Schools in depressions, wetland, or adjacent to rivers or other water bodies are
normally damp.
Poorly maintained structures may also pose a health threat to children. Cracks in walls,
floors, or foundations provide homes for insects such as hookworms, mites and jigger
fleas. Broken windows, dilapidated steps, exposed nails, and missing stair rails present
obvious hazards and increase the risk of injury.
5.2.2 Indoor school environment
Protect school drinking water
Fecal material contaminates drinking water.

Children dipping their unwashed hands into a Box 14: Protecting a well from
shared drinking-water supply provide a contamination
typical route of contamination.98 In areas
where this occurs, providing schools with a • Locate wells upstream and at least
ladle to dip into water sources may be a 30 metres from any sources of
low-cost solution to cleaner water. A safe contamination such as sanitation
water supply is free from bacteria, parasites, facilities.
and toxic chemicals. Box 14 outlines • Do not use pesticides within 100
important considerations for protecting a metres of well.
well from contamination. Where there is
• Regularly inspect well for structural
uncertainty about the quality of the drinking
integrity.
water, it should be tested regularly. If the
water has not been chlorinated, it is • Build a raised wall or fence around
important to disinfect it through chlorination, the well to keep animals away.
boiling or any other acceptable method. Safe • Dig a drainage ditch around the well
storage of water at school and at home to prevent surface water and spilled
should also be promoted (Box 15). water from contaminating the well.
• Keep water bucket clean.
• Use a raised block on which to place
Box 15: Storing water safely the water bucket to avoid
contamination.
• Wash containers once a day or • Keep well covered.
when empty.
• Cover container tightly.
• Place the container off the floor on
a box or shelf.

Where helminth infections are a problem, store drinking water for over 24 hours and then
decant to help remove helminth eggs that may have fallen to the bottom of the
container. Boiling is an effective way to kill worms, eggs, and other germs that may have
contaminated the water. A filtration system made from stones and sand or gauze/filters in
guinea worm areas can also be used to make water safe from worms.99
In the industrialized world, water supplies at school can be contaminated by chemicals present
on-site as a result of former land-use practices, adjacent land uses, or plumbing
fixtures. Many school water fountains have lead-soldered or lead-lined tanks. Patterns of
intermittent water use from these fountains result in water standing in tanks longer than in
typical residential situations, increasing the amount of lead that is absorbed into the water from
the tanks.100 Schools need to be aware of these potential risks and have their water
tested regularly.
Provide sanitation facilities
Human excreta are the biggest source of disease-producing organisms including parasites,
bacteria, and viruses. Success in eliminating fecal material from the school environment is
dependent on: informed and responsible students; supervision of young students; a fence or
structure to stop animals from defecating in areas where children play; toilets conveniently
located, reliable, clean, odor-free, private, and well-maintained.101 Separate facilities for girls
can reduce dropout rates during or before menses. A variety of latrine systems are used in
different parts of the world depending on cultural, environmental, and economic conditions.
Education and health officials need to make sure that construction of latrines is technically
appropriate and acceptable.102
Aim for good indoor air quality
The quality of indoor air is a function of building ventilation, construction materials used,
and pollutants released inside the building (such as tobacco smoke, cleaning supplies,
pesticides, and art supplies). It is also a function of policy, as in the case of
environmental tobacco smoke.
WHO strongly recommends that schools and their grounds should be completely
tobacco free (see Box 16). Breathing environmental tobacco smoke (e.g. side-stream and
exhaled smoke from cigarettes, cigars and pipes) causes serious health problems. It can
aggravate allergies and increase the severity of symptoms in children and adolescents
with asthma and heart disease. It is also associated with lung cancer because
environmental tobacco smoke contains essentially the same cancer-causing substances
and toxic agents that are inhaled by the smoker.103
Box 16: Protection from environmental tobacco smoke104
Smoking should be legally prohibited in public places, especially in schools and places
where children may be present. Environmental tobacco smoke (ETS) is known to be
harmful, especially to children. If schools and other public places become smoke-free,
young people will have far fewer places to light up, which could go a long way in
reducing smoking. Finally, children who grow up seeing smoking permitted all around
them will wrongly conclude that smoke is not very harmful, and that it is socially
acceptable to smoke.

In developing countries, the indoor burning of dung, wood and coal for cooking and
heating within schools can cause high levels of fine particles in indoor air that can lead to
respiratory illness and trigger asthma attacks. Adequate ventilation should be provided
whenever possible and students should be educated about the health effects of poor ven-
tilation, and particles and other combustion by-products in smoke. Schools in the devel-
oping world can promote the use of improved stoves, ensure that fuel wood is dry, time
cooking activities when students are outside, and ensure that smoke is vented away from
places where students may study or play.
Box 17: Guidelines to improve indoor air quality in schools
• Open windows and doors but avoid ventilation during times when outdoor
emissions are likely to be highest.
• Do not permit smoking.
• Regularly inspect furnaces, gas water heaters, clean air conditioners, humidifiers,
and heat exchangers.
• Limit the amount of carpet used.
• Use water-based paints, wood finishes and sealants.
• Minimize use of fresheners, fragrances, deodorizers, and harsh cleansers, and
ventilate when using these types of products.
• Schedule painting, floor refinishing and renovation during seasons when windows
can be kept open and when school is not in session.
• Provide maximum ventilation when painting or using solvents or strong cleaning
solutions.
• Store cleaning supplies, pesticides and solvents in air tight and child-proof
containers out of reach of children.
• Prevent moisture problems.
• Use art supplies that are non-toxic.
• Prohibit idling of diesel school buses outside schools.
• Ensure that air intakes are not located adjacent to parking lots or exhaust vents.
A study on the causes of indoor air quality problems in schools throughout the developed
world105 found that most problems in school facilities could be avoided by:
• Providing adequate outdoor air ventilation on a continuous basis (15 cubic feet per
minute per student).
• Controlling the space relative humidity between 30% and 60%.
• Providing effective filters to remove fine particles from the outdoor air.
The guidelines in Box 17 can also help improve the quality of air inside classrooms.
Reducing dampness and improving ventilation can help prevent the growth of molds and
fungi (see Box 18).

Box 18: Mold prevention tips106
• Fix leaky plumbing and leaks in the building as soon as possible.

• Watch for condensation and wet spots. Fix source(s) of moisture problem(s) as
soon as possible.
• Prevent moisture due to condensation by increasing surface temperature or reducing
the moisture level in air (humidity). To increase surface temperature, insulate or
increase air circulation. To reduce humidity repair leaks, increase ventilation (if
outdoor air is cold and dry), or dehumidify (if outdoor air is warm and humid).
• Keep heating, ventilation, and air conditioning drip pans clean, flowing properly,
and unobstructed.
• Vent moisture-generating appliances, such as dryers, to the outside where possible.
• Maintain low indoor humidity, below 60% relative humidity, ideally 30-50%, if possible.
• Perform regular building inspections and maintenance as scheduled.
• Do not let foundations stay wet. Provide drainage and slope the ground away from
the foundation.
5.2.3 Outdoor school environment
Seek high quality outdoor air
The probability that children with asthma will have an attack is estimated to be 40%
higher on high outdoor pollution days,107 and research indicates that children that play
active sports are more likely to develop the disease in polluted cities.108
Many schools should be concerned with outdoor air quality. Equipped with some
knowledge about air quality in their area, schools may choose to avoid involving students
in intensive outdoor exercise during periods of high air pollution. Ozone levels usually
peak between midday and evening. Avoiding outdoor activities during high pollution
periods and in areas adjacent to highways or near other sources of air pollution will help
to minimize asthma attacks in sensitive children and other short- and long-term health
effects associated with exposure to air pollutants.
Make play areas supportive of physical development
Play areas should be designed to be more than “play” areas. There is an urgent need for
children to be able to take part in regular and appropriate physical activity. Schools offer a
unique setting to promote and provide opportunities for physical activity as recreation and
sport. Regular and appropriate physical activity is an essential stimulus for children to
reach their potential of growth and development. It is necessary for optimal health and
functional capacity. It also counteracts disabilities and diseases common to ageing.
Regular physical activity helps children and adolescents develop strong muscles and bones,
normal body weight, efficient function of the heart and lungs, and skills of movement.
To provide an environment that encourages and enables children to engage in regular and
appropriate physical activity, schools should:
• provide play areas that are safe and have facilities for physical activity;

• establish and enforce policies and standards for the use of equipment and grounds
to prevent physical activity-related injuries;
• provide time during the day for children to have access to play areas for unstructured
physical activity;
• provide access to community recreation areas when insufficient space prevents
children from regular physical activity on the schools grounds.109
Children need to be protected from injuries that could occur outside the school buildings,
and areas where children play or exercise should be free from hazards. Busy roadways,
water bodies, waste sites, rockslides, and ravines should be considered threats to
children. Play areas should not be located near these areas.
When selecting wood for playgrounds or outdoor furniture that children and staff will use,
avoid lumber treated with chromated copper arsenic, creosote and pentachlorophenol.
Potentially toxic levels of arsenic can leach from the wood to the hands of children and
contaminate the soil below where children play. Existing treated play sets can be sealed
with polyurethane or painted to reduce exposure to toxic wood preservatives.
Protect children from ultraviolet radiation
Planting shade trees around school grounds can reduce the risk of overexposure to
ultraviolet radiation for students and staff, particularly when the sun is at its peak. In
countries such as Bangladesh, an open-air classroom with a roof may be sufficient to
protect students from the sun while enhancing light and ventilation. However, reflection
of ultraviolet radiation from light surfaces may still lead to significant exposure. In
Australia, where skin cancer incidence is the greatest in the world, the SunSmart Schools
programme of the The Cancer Council Victoria emphasizes a sun protection policy that
involves the whole school community. Students in SunSmart schools wear sun-protec-
tive clothing, hats and sunglasses, apply sunscreen, avoid outdoor
activities when the sun is at its highest, plant trees for shade, and study ultraviolet
radiation levels at different times of the day. Such schools can apply for accreditation as
a SunSmart school and receive a large metal SunSmart School sign. Over 70% of
Victorian primary schools have become SunSmart Schools since the programme started
in 1994. Data indicate significant improvements in policy and practices in the seven years
since the introduction of the programme.110
5.2.4 Healthy environmental management practices
Schools can provide a role model for responsible environmental management and health
protection. Other documents in the WHO Information Series on School Health provide
additional information on some of the management practices discussed below and are
referenced where appropriate.
Dispose of waste quickly and properly
Waste generated in schools should be properly disposed to avoid spread of communicable

diseases, discourage the presence of pests and other vectors, and prevent human contact with
potentially hazardous material (see Box 19).111 Appropriate practices of recycling and
waste disposal in the community should be identified, and students and other members

of the school community should follow these practices. Schools should promote
methods to eliminate, conserve or recycle hazardous materials to decrease the volume
of hazardous waste generated. A hazardous waste management plan should be
developed to promote the identification, collection and proper disposal of all hazardous
waste generated by the school.112 Many schools in developed countries use mercury-
containing products such as thermometers, fluorescent lamps and some batteries,
possibly placing students and faculty at risk from toxic effects of mercury (mercury is
toxic to the central nervous system, digestive system, kidney, liver and skin). Some
communities hold annual Household Hazardous Waste Collection Days and school
personnel may bring hazardous materials such as batteries and pesticides to these
collection events.
Box 19: Tips for waste management in schools
• Identify hazardous and non-hazardous waste generated.

• Store hazardous wastes in a safe area located away from students.
• Inspect obsolete equipment prior to disposal for hazardous components that need
to be recycled or disposed of as hazardous waste (e.g. batteries, ballasts, mercury
switches, computer components, lamps).
• Develop hazardous waste management procedures and educate staff about these
procedures.
• Promote methods to eliminate, reduce or recycle hazardous materials to decrease
the volume of hazardous waste generated.
Students should be involved in the management of non-hazardous waste at their school

to create a sense of responsibility (Box 19). Students can be involved in collecting waste
in the classroom and throughout the school. They can also help to separate waste that
can be composted, re-used or recycled. If a system is clearly established to manage
waste, the entire school community will be a cleaner and safer environment.
Reduce use of cleaning supplies around children
Clean schools have healthier indoor air, a lower risk of spreading contagious diseases, and
provide a more pleasant learning environment for both students and teachers. Adequate
cleaning requires that areas of responsibility are clearly defined and understood by all
members of the school community. Students should be involved in keeping their school
clean to create a sense of responsibility and pride in their school environment. Skills
learned in school may be carried into other environments, hopefully for many years.
Schools are easier to keep clean if properly designed. In designing a school, or in

upgrading one, clean and dry pathways should lead to the entrance of the school
building. If walkways are muddy, students and other visitors to the school will track in
mud, dust and outdoor contaminants, increasing the amount of dust in the school and
contributing to unhealthy indoor air.
Only products that are safe for use around children should be used to clean classrooms.
Natural cleansers commonly perform as effectively as harsh detergents and solvents.
Use alternatives to products labelled ‘caution’, ‘warning’ or ‘danger’ and use the minimum
amount of the product recommended to complete the job.

Carefully manage the use of chemicals
Managing the use of chemicals within a school is an important issue in industrialized

countries. An inventory of chemicals used and stored at school should be maintained, and
teachers and staff should understand the risk associated with improperly handling and
disposing these chemicals. Chemicals should be stored in a centrally located, secured
and ventilated area.
In science labs, teachers should eliminate the most toxic chemicals and implement micro-
scale experiments to reduce the volume of materials used or generated. The following
factors should be considered when choosing a science experiment:113
• Hazards associated with the activity.
• Potential impact on indoor air quality.
• Protective equipment required.
• Generation of hazardous waste.
Art classes may be another location for chemicals. Asbestos, heavy metals, organic
solvents, and other toxic ingredients have been found in some art and craft materials and
may present risks to the health and safety of students using them (see Table 5).
Protection from exposure to toxic materials can be achieved by:
• Safely storing and properly labelling art and craft supplies.
• Keeping dust to a minimum by damp mopping rather than sweeping.
• Thoroughly cleaning up after use of art and craft materials.
• Not allowing students to eat or drink while engaged in art projects.
• Washing hands thoroughly when finished with an art project.
• Providing proper ventilation in the art classroom.
• Premixing dry materials with water and firing ceramic products when students are
away from the kiln area.
Table 5: Art and craft materials to avoid and recommended substitutes114
Avoid Substitute
Products that may generate an inhalation hazard Wet or liquid non-aerosol products. If dry products
(e.g. dry clay, powdered paints, glazes, pigments, are used, they should be mixed while children are
wheat paste, aerosols in spray paints or fixatives). not present.
Hazardous solvent-based products (e.g. rubber Water-based glues, paints, markers.

cement and its thinner, turpentine and other paint
thinners, and solvent-based markers).
Materials that contain lead or other heavy metals Products that do not contain heavy metals.
(e.g. some paints, glazes, and enamels).
Cold water dyes or commercial dyes. Vegetable dyes.
Instant papier-mâché, which may contain asbestos Papier-mâché made from black and white
fibers, lead or other metals from pigments in newspaper and library or white paste (or flour and
coloured printing inks. water paste).

Practice safe use of pesticides
Indoor use of pesticides leaves residues that may persist long after schools are sprayed.
Many nuisance problems can be controlled physically rather than chemically. Screening
doors and windows and minimizing food crumbs, spills and scraps that attract insects will
discourage insects from entering buildings.
Schools adjacent to farmland, golf courses, recreational areas or other land uses where
pesticides are routinely applied should learn about the timing of application and keep
children inside the school with windows and doors closed during periods of spraying.
Schools could also encourage nearby pesticide applicators to use alternatives to
pesticides.
In areas where insect-borne diseases are a problem, schools should employ integrated
pest management methods, including the control of water bodies, and develop a
pesticide reduction strategy (Box 20). If these measures are insufficient, the lowest-risk
pesticide should be used and guidelines regarding re-entry intervals must be followed.
Box 20: A school pesticide reduction strategy
• Adopt the least toxic pest management policies and practices to reduce/eliminate
pesticide use and exposure, and select the least toxic pesticides in situation where
pesticide use is deemed to be essential.
• Put pest management policies in writing and make these policies public.
• If pesticides are used, schools should notify school staff, teachers, administrators,
students and their parents.
• Before and after pesticides have been applied, warning signs should be posted
around the treated area.
• Only certified applicators should apply pesticides at schools.
• Maintain detailed information about what pesticides are being applied, where,
how, why and by whom.
• Do not use pesticides containing known or probable carcinogens for merely
aesthetic purposes, such as lawn care.
• Do not spray or apply pesticides while children are in school.
Ensure safe school food services
School food services should be integrated into a school’s effort to manage its
environment. It could be coordinated with health and nutrition education and with other
components of the health-promoting school to reinforce lessons on healthy eating and
ensure nutrition support. If food is provided, the school should offer a variety of healthy
food choices and promote healthy eating and food safety.116
Food-borne disease prevention should be a priority of school food services. Most

food-borne diseases are preventable with proper food preparation and handling. It is
important to educate school children and food handlers so that they can take specific
measures to make food and water safe. Educating school children about food safety gives

them knowledge to be selective about the foods they choose to eat. Young children in
particular should therefore be taught basic rules of food safety such as washing hands
before eating.117 Basic principles for the preparation of safe food for children are provided
in Box 21.
Box 21: Basic principles for the preparation of safe food for children118
• Cook food thoroughly. All parts of the food must become steaming hot, reaching a
minimum temperature of 70ºC.
• Avoid storing cooked food.
• Avoid contact between raw ingredients and cooked foods. Cross-contamination
can occur when raw foods come into contact with cooked foods or through hands,
flies, utensils or unclean surfaces. Hands should be washed after handling
high-risk foods such as poultry. Utensils used for raw foods should be carefully
washed before they are used again for cooked foods.
• Wash foods and vegetables.
• Use safe water.
• Wash hands repeatedly.
• Protect foods from insects, rodents, and other animals.
• Store non-perishable foods in a safe place.
• Keep all food preparation premises meticulously clean.
Control hazardous vectors
If rainwater or floodwater is allowed to stand in puddles, mosquitoes and other insects

may be encouraged to reproduce, leading to transmission of diseases. Accumulated
waste can cause similar problems in addition to attracting flies, rodents and dogs.119
Modifying the environment to deprive insects and other vectors of the requirements for
survival (e.g. places for breeding, resting, and feeding) will reduce contact with such
organisms and create conditions less conducive to transmission of diseases such as
malaria, dengue fever and schistosomiasis.120
Locating schools away from major breeding sites and promoting and supporting the design
and construction of schools to reduce contact between humans and insects or other
disease-causing organisms can minimize the risk of vector-borne diseases. Incomplete
schools with open walls, wide or unscreened eaves, open windows and doors and no
ceilings encourage the entry of mosquitoes. Mud or unplastered walls with cracks and
crevices and thatched roofs or walls also provide resting sites for mosquitoes.121
Effective malaria control has led to dramatic declines in malaria death rates in Asia.
Prompt and effective treatment of malaria can reduce death rates by 50% or more.122
School health services can help identify and treat malaria cases in school children.

5.3 School health services
School health services help to treat health problems and to prevent, reduce and monitor
them. In a health-promoting school, health services work in partnership with and are
provided for students, school personnel, families and community members. School
health services should be coordinated with members of the school and community to
recognize and treat health problems resulting from exposure to environmental threats.
These threats vary from community to community.
School nurses can help raise awareness of health problems among students, teachers and
staff, and play an important role in referring students to specialists. They are
responsible for "de-worming" at regular intervals, managing health outcomes such as an
asthma attack or injury, and recognizing severe diseases such as malaria, severe diarrhoea
and respiratory infections for correct referral. Ideally, they should receive training in
environmental health issues prevalent in their community. School nurses should be
responsible for tracking illnesses among students to help identify potential environmental
health problems within the school.
5.4 Community and family projects and outreach
A health-promoting school should involve students, school staff, families, and community
members in efforts to improve health in the school. Children who participate in efforts to
create a cleaner and safer environment learn about protecting themselves and their
environment, and can acquire the knowledge, attitudes, values and skills needed to adopt
healthy lifestyles as adults. Family and community members can serve on the school
health team or community advisory committee; participate in activities and services
offered through the school such as helping to build a safe play structure for children or
helping to clean up school grounds; or provide support and resources by offering financial
or technical assistance to improve a school’s building structure or ventilation system.
It is important for parents to understand the relationship between their child’s health and
their environment both at school and at home. A health-promoting school can help to
educate parents about potential environmental health threats in the home. This can be
accomplished at a school health fair or at a health-related workshop for parents on
environmental health threats to children. In addition to learning about maintaining a
healthy environment for children to thrive, parents can contribute their services or
resources to the school to make improvements in the school’s physical environment.
Both the school and the community can benefit from working together to create a safe
physical environment at schools. For example, a school can use the services of a local
company to improve its ventilation system. Parents may subsequently utilize their
services to improve the indoor air quality of their own homes.
5.5 Health promotion for school staff
Heath promotion and training school staff to understand and recognize the relationship
between the environment and health is necessary if staff are to be positive role models
for students. Additionally, well-trained school staff will be able to recognize problems
in their school environment that may be contributing to poor health in both students
and staff.

41 6. EVALUATION
6. Evaluation
Evaluation provides information about the extent to which the programme is being
implemented and provides feedback to those involved in project planning. Information
obtained from the evaluation process can be used to make improvements in the programme,
and to document experience gained from the project so it can be shared with others.
6.1 Components of evaluations

Two types of evaluation are most relevant to evaluating school health programmes:
Process evaluation assesses how well the interventions have been taken up by schools,
and identifies factors that hinder or promote their implementation. Outcome evaluation
measures whether and to what extent objectives have been achieved, and whether the
intervention has been able to influence the knowledge, attitudes and behaviour of
students and staff. Outcome evaluation can demonstrate the benefits of a healthy school
environment or show further need for intervention. Evaluation results can be brought to
the attention of the community and can be used to convince others to become involved.
Examples of topics that might be addressed in conducting the two types of evaluations
are presented in Tables 6 and 7.
Table 6: Process evaluation
Basic questions Method of measurement
Does the school have policies to improve and Interviews with school officials or programme
maintain a healthy physical environment? coordinator.
Are policies implemented and enforced?
Do policies address all aspects of the physical
environment (e.g. air, water, sanitation, waste,
location, hazardous chemicals, transport, food,
disease vectors)?
Are goals and objectives well defined and do they Interviews with school officials or programme
establish criteria to measure and evaluate coordinator.
intervention activities and outcomes?
Are students, teachers, school health personnel, Interviews with programme coordinator, school
food service personnel, parents and community health officials, food service personnel, parents,
members involved in the planning of interventions and community representatives.
that are directed toward them?
Is environmental health education integrated into Interviews with programme coordinator and
the curriculum and extra-curricular activities? teachers.
Is in-service training provided for educators
responsible for implementing environmental health
education? Do teachers feel comfortable
implementing the curriculum?
Do school health services periodically screen for Interviews with programme coordinator and school
environmental health problems? health officials.

6. EVALUATION 42
Table 7: Outcome evaluation
Basic questions Method of measurement
What do administrators, teachers, students, and Questionnaire; interviews; focus group

parents think of the school’s policy to improve the discussions.
physical environment at schools?
Has the environmental health status of the target Interview with health service providers.
group(s) improved?
What percentages of students, parents or other Interviews with educators and school officials.
relevant groups have been reached by
environmental health interventions?
Does environmental health education foster the Questionnaire; interviews; focus group
knowledge, attitudes, beliefs, and skills needed to discussions.
adopt healthy behaviours or create conditions
conducive to health?
Frequently used methods of evaluation include classroom discussions, questionnaires,

focus groups, observations, and interviews. Medical screenings provide measurements
of specific health indicators such as asthma or respiratory infections, and oral or written
tests can provide information on educational achievements.
6.2 Reporting progress and achievements
An evaluation is complete when its results are reported and communicated to those
responsible for managing the school environment. Evaluation reports could be designed
to contain interesting and easily understandable material for many individuals and groups.
Evaluation results can be used as a basis for discussion to develop further and support
efforts to improve the physical environment of schools.

43 ANNEX 1: EXAMPLES OF EDUCATIONAL STRATEGIES TO PROMOTE
ENVIRONMENTAL HEALTH
Examples of educational strategies to promote environmental

health
Health is missing from the curriculum of many schools. Environmental health may be
incorporated within curriculum units of any discipline including: history, science,
mathematics, geography, social studies, literature, art, etc. Although it is not the purpose
of this document to develop or present curricula, the following topical examples might be
adapted to grade level and subject matter.
Environmental health
• Explain how specific illnesses are related to poor environmental quality.

• Identify key environmental threats to health within your school and community.
Older students could compare threats among nations, and different regions of
their country.
Air
• Identify possible sources of indoor air pollution.

• Identify sources of air pollution within schools. These could include wood smoke
cooking fumes, pesticides, and volatile chemicals.
• Discuss practical options to improve air quality within the school.
• Identify sources of air pollution within the community. These might include: motor
vehicles, industrial activity, construction equipment, and agricultural practices.
• Consider how pollution levels might be reduced, or how exposure may be
minimized.
• Explore how pollution may vary by time of day.
• Research whether indoor air is cleaner than outdoor air, and the implications for
ventilation.
• Keep track of rates of respiratory illness within the school through the year. Use this
as an opportunity to teach mathematics and graphing of data.
Water
• Identify sources of water in the community.

• Identify contaminants that may threaten the local water supply.
• Explore how land use practices may affect water quality in your community.
• Discuss ways to keep the water supply safe from dirt, bacteria, parasites, or other
contaminants that could make the water supply unhealthy.
• Explore ways of promoting safe water storage and disinfection practices in the
home.
• Research how human illness may be related to water pollution.
• Have older students design a water quality sampling strategy that would capture
different types of pollution, and its variability throughout the year.
• Keep track of the use of pesticides within your community, and learn about the
potential of pesticides to contaminate water supplies.

ANNEX 1: EXAMPLES OF EDUCATIONAL STRATEGIES TO PROMOTE 44
Food
• Discuss types of food contamination in the community including the possibility of

contamination by human or animal waste, manure, pesticides used on crops, or
other chemicals accidentally or intentionally added to the local food supply.
• Have older students design, conduct and analyze a dietary survey.
• Explore how dietary patterns among students compare with recommended
nutritional guidelines.
• Identify the sources of all foods and drinks consumed during a single day or meal.
• Discuss proper food handling procedures.
Waste
• Discuss types of wastes generated in the community, categories may include:

chemical waste (pesticides, industrial waste), solid waste (household trash), and
liquid waste (animal/human urine, feces, waste water).
• Identify common practices of disposing waste, including excreta, in the community.
• Discuss risks associated with improper waste disposal.
• Younger children could make posters showing different types of waste in the
community and how they should be disposed.
Disease vectors
• Students can identify key disease vectors in their community (mosquitoes, ticks,
worms, rodents, etc.).
• Have local vector-borne diseases become a curriculum unit within science classes
to study vector behaviour, reproduction, habitat requirements, and the lifecycle of
the illness in humans and other species.
• Identify ways students may be exposed to vectors. Have older students research
diseases associated with vectors using available research methods.
• Discuss methods to reduce vector populations. Organize efforts to reduce the
vector population, such as clearing brush away from the school.
Hazardous materials
Older students can:

• Develop an inventory of hazardous substances on school properties. These may
include pesticides, fuels, solvents, some cleansers, paints and wall finishes.
• Explore how use of these substances could be reduced, and search for less toxic
substitutes to meet intended purposes.
• Research proper containment, storage and disposal practices to minimize the
potential for human exposure and illness.

45 ANNEX 1: EXAMPLES OF EDUCATIONAL STRATEGIES TO PROMOTE
Transit and transport
Older students can:

• Develop a transportation inventory for the school.
• Document the methods of transit between home and schools for students and staff.
• Examine vehicle use, distance travelled, fuels consumed, and idling behaviour of
vehicles.
• Identify accidents associated with transport by type, severity, location and outcome.
• Evaluate routing and control alternatives to reduce vehicle-pedestrian and
vehicle-bicycle conflicts.

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on School Health. Available at http://www.who.int/hpr/gshi/helminths.pdf and Helminth
Control in School-Age Children: a Guide for Managers of Control Programmes. Geneva: WHO, 2002.
100 United States Department of Health and Human Services. Preventing lead poisoning in young
children. October 1991. Available at http://aepo-xdv-www.epo.cdc.gov/wonder/prevguid/
p0000029/p0000029.asp.
REFERENCES 50
103 WHO. Tobacco – Health Facts. Fact Sheet. Available at: http://www.who.int/
inf-fs/en/fact221.html.
104 Adapted from WHO. Tobacco Use Prevention: An Important Entry Point for the Development
of Health Promoting Schools. WHO Information Series on School Health. Geneva: WHO, 1998.
105 United States Department of Energy. Causes of indoor air quality problems in schools.
Summary of scientific research. Revised Edition. 2000. Available at: http://www.eere.
energy.gov/buildings/documents/pdfs/iaq-rpt.pdf.
106 Adapted from: United States Environmental Protection Agency. Mold remediation in schools
and commercial buildings, 2001. Available at http://www.epa.gov/iaq/molds/prevention.html.
107 United States Environmental Protection Agency. The EPA children’s environmental health year
book 1998. Office of Children’s Health Protection, EPA 100-R-98-100, 1998.
108 McConnell R, Berhane K, Gilliland F, et al. Asthma in exercising children exposed to ozone. The
Lancet 359(9304):386-91, 2002.
109 WHO. Promoting Active Living in and through Schools. Policy Statement and Guidelines for
Action. Geneva: WHO, 1998.
110 WHO. Sun Protection: an Essential Element of a Health-Promoting School. WHO Information
Series on School Health. Geneva: WHO, 2001.
111 Dresser, T. A case study of environmental, health and safety issues involving the Burlington,
Massachusetts public school system. United States Environmental Protection Agency, Region
7. Available at http://www.epa.gov/region07/kids/dresser9.htm.
112 Dresser T. A case study of environmental, health and safety issues involving the Burlington,
113 Dresser T. A case study of environmental, health and safety issues involving the Burlington,
114 Adapted from: Office of Environmental Health Hazard Assessment. Guidelines for the safe use
of art and craft materials. California, 2002. Available at http://www.oehha.org/education/art/art
guide.html.
115 Adapted from: Attorney General of New York. Pesticides in schools: reducing the risks
(Revised). New York State, Department of Law, Environmental Protection Bureau, 1996.
116 WHO’s advice for developing national or regional dietary guidelines for children. Available at:
http://www.who.int/hpr/nutrition. Current advice is based on the Report of the Joint
WHO/Food and Agricultural Organization Expert Consultation on Diet, Nutrition and the
Prevention of Chronic Diseases, (2002). Additional information about nutrition, food services
and the physical environment is available in Healthy Nutrition: An Essential Element of a
Health-Promoting School. WHO Information Series on School Health. Available at:
http://www.who.int/hpr/gshi/nutri.pdf.
118 WHO. Basic principles for the safe preparation of safe food for infants and young children.
Geneva: WHO, 1996. In: WHO. Food-borne Disease: a Focus for Health Education. Geneva:
WHO, 2000.
120 WHO. Vector control for malaria and other mosquito-borne diseases. Report of a WHO study
group. Geneva: WHO, 1995.
121 WHO. Vector control for malaria and other mosquito-borne diseases. Report of a WHO study
group. Geneva: WHO, 1995.
122 WHO. Roll Back Malaria: Increasing the Momentum. Fact Sheet. Available at
www.who.int/inf.fs/en/fact203.html.

51 NOTES

This document is part of the WHO Information Series on School Health. Each
document in this series provides arguments that can be used to gain support for
addressing important health issues in schools. The documents illustrate how selected
health issues can serve as entry points in planning, implementing, and evaluating health
interventions as part of the development of a Health-Promoting School.
Other documents in this series include:

· Local Action: Creating Health-Promoting Schools (WHO/NMH/HPS/00.4)
· Strengthening Interventions to Reduce Helminth Infections: An Entry Point for the
Development of Health-Promoting Schools (WHO/HPR/HEP/96.10)
· Violence Prevention: An Important Element of a Health-Promoting School
(WHO/HPR/HEP/98.2)
· Healthy Nutrition: An Essential Element of a Health-Promoting School
(WHO/HPR/HEP/98.3)
· Tobacco Use Prevention: An Important Entry Point for the Development of a
Health-Promoting School (WHO/HPR/HEP/98.5)
· Preventing HIV/AIDS/STI and Related Discrimination: An Important Responsibility
of Health-Promoting Schools (WHO/HPR/HEP/98.6)
· Sun Protection: An Important Element of a Health-Promoting School (WHO/PHE
and WHO/NPH, 2002)
· Creating an Environment for Emotional and Social Well-Being: An Important
Responsibility for a Health-Promoting and Child-Friendly School (WHO/MNH and
WHO/NPH, 2003)
· Skills for Health: Skills-Based Health Education Including Life Skills (WHO and
UNICEF, 2003)
· Family Life, Reproductive Health and Population Education: Key Elements of a
Health-Promoting School (WHO/NPH, 2003)
· The Physical School Environment: An Essential Component of a Health-
Promoting School (WHO/PHE and WHO/NPH, 2004)
Documents can be downloaded from the Internet site of the WHO Global School Health
Initiative (www.who.int/school-youth-health) or requested in print by contacting the
School Health/Youth Health Promotion Unit, Department of Noncommunicable Disease
Prevention and Health Promotion, World Health Organization, 20 Avenue Appia, 1211
Geneva 27, Switzerland, Fax: (+41 22) 791-4186.
In an effort to provide you with the most useful and user-friendly material, we would
appreciate your comments:
· From where did you receive this document, and how did you hear about it?
· Did you find this document useful for your work? Why or why not?
· What do you like about this document? What would you change?
· Do you have other comments on any aspect of this document, for example,
its content, design, or user-friendliness?
Please send your feedback to:

School Health/Youth Health Promotion Unit
Department of Noncommunicable Disease Prevention and Health Promotion
World Health Organization
20 Avenue Appia
1211 Geneva 27
Switzerland
Thank you. We look forward to hearing from you.

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The World Health Organization’s

INFORMATION SERIES ON SCHOOL HEALTH DOCUMENT 2

The Physical School

This document is a joint effort of the Department of Protection of the

It is jointly published with partner organizations working together in the

2. CONVINCING OTHERS THAT SCHOOLS’ PHYSICAL

3. CONVINCING OTHERS THAT IMPROVING THE PHYSICAL

WHO INFORMATION SERIES ON SCHOOL HEALTH

4. PLANNING INTERVENTIONS FOR HEALTH PROTECTION IN

5. INTEGRATING ENVIRONMENTAL HEALTH INTERVENTIONS WITHIN

ANNEX 1: EXAMPLES OF EDUCATIONAL STRATEGIES TO PROMOTE

THE PHYSICAL SCHOOL ENVIRONMENT: AN ESSENTIAL ELEMENT OF A HEALTH-PROMOTING SCHOOL

Monika Arora, HRIDAY-SHAN, India

WHO INFORMATION SERIES ON SCHOOL HEALTH

The Physical School Environment: An Essential Component of a Health-Promoting School

The Physical School Environment: An Essential Component of a Health-Promoting School

Pekka Puska Maged Younes Mary Joy Pigozzi

Cream Wright Leslie Drake Cheryl Vince-Whitman

Fred Van Leeuwen

THE PHYSICAL SCHOOL ENVIRONMENT: AN ESSENTIAL ELEMENT OF A HEALTH-PROMOTING SCHOOL

1.1 Why did WHO prepare this document?

1.2 Who should read this document?

This document can be useful to:

• Members of the school community, including teachers and their representative

1.3 What is a healthy physical school environment?

WHO INFORMATION SERIES ON SCHOOL HEALTH

Table 1: Components of a healthy school environment

Provision of basic necessities • Shelter

Protection from biological threats • Molds

Protection from physical threats • Traffic and transport

Protection from chemical threats • Air pollution

THE PHYSICAL SCHOOL ENVIRONMENT: AN ESSENTIAL ELEMENT OF A HEALTH-PROMOTING SCHOOL

1.4 Why increase efforts to improve the physical environment at

1.5 Why focus efforts through schools?

WHO INFORMATION SERIES ON SCHOOL HEALTH

• Create health-protective public policy: This document provides information that

THE PHYSICAL SCHOOL ENVIRONMENT: AN ESSENTIAL ELEMENT OF A HEALTH-PROMOTING SCHOOL

2. Convincing others that schools’ physical environment is important

2.1 Argument: Many childhood illnesses and deaths are greatly

Figure 1: Leading causes of mortality in children aged 5-14 years, 2000

WHO INFORMATION SERIES ON SCHOOL HEALTH

Table 2: Attributable DALYs by level of development (in thousands)9

High mortality Low mortality Developed

Unsafe water, Diarrhoeal diseases 46 183 7 150 825

Urban air pollution Respiratory infections 2 685 4 008 1 171

Lead exposure Cerebrovascular disease, hypertensive 5 953 5 584 1 388

Climate change Diarrhoeal diseases, malaria, 5 202 294 22

Preventing childhood exposure to environmental hazards may prevent injuries, immediate

2.1.1 Respiratory infections

THE PHYSICAL SCHOOL ENVIRONMENT: AN ESSENTIAL ELEMENT OF A HEALTH-PROMOTING SCHOOL

2.1.2 Diarrhoeal diseases

2.1.3 Vector-borne diseases

WHO INFORMATION SERIES ON SCHOOL HEALTH

understanding the reproductive ecology, biology and behavioural patterns of mosquitoes.

2.1.4 Injuries and poisonings

THE PHYSICAL SCHOOL ENVIRONMENT: AN ESSENTIAL ELEMENT OF A HEALTH-PROMOTING SCHOOL

2.1.6 Developmental disabilities

Exposure to toxic substances also places children at risk of developmental disorders,

WHO INFORMATION SERIES ON SCHOOL HEALTH