Since the 1970s, the Chinese government has placed emphasis on prevention and control of common diseases among students, mainly including vision impairment, trachoma, caries, ascariasis, anemia, and malnutrition. In recent years, the incidence of some of these common diseases among students, such as anemia, ascariasis, and trachoma significantly decreased. Malnutrition also declined in Beijing because of improvements in nutrition and environment. However, by contrast, obesity has shown an increasing trend. Unintentional injuries and some health problems related to smoking and lack of exercise also are becoming more frequent.
School provides one of the main settings for children and adolescents to learn and to live. It also offers a resource for promoting their health and development. School can transmit prevalent cultural values to children and adolescents through organized learning experiences. School also serves as an agent of cultural change by providing instruction in line with changing knowledge, social needs, and values. (1) A report from the WHO Expert Committee on Comprehensive School Education and Promotion suggested schools should constantly strengthen their capacity as a healthy setting for living, learning, and working. (2) School nurses, as health care providers, play a crucial role in assisting children and adolescents to form positive health values, to develop skills, and to share resources for solving health problems.
In China, primary health care for children aged 6 to 15 years in full-time compulsory education is provided mainly by school nurses under the guidance and coordination of the government departments of education and health at the national and local levels. In 1990, the National Education Commission and Ministry of Health of China jointly issued the document Regulations on School Health, (3) which stipulated that the tasks of school nurses should include supervising student health status, providing health education, improving the school environment, and controlling common diseases among students.
The principal of a school can decide how many nurses the school can hire in keeping with local education authorities regulations on personnel, and the number of students in the school. According to Regulations on School Health, at least one nurse should be employed in schools with more than 600 students.
At present, the system of service provision by school health workers, including both full-time school nurses and other, part-time health workers, has been established in middle schools throughout China. An estimated 60,000 school health workers currently are employed.
The project sought to ascertain school nurses' perceptions about their existing responsibilities and scope of services, to investigate attitudes of school nurses toward health care services for students for whom they are responsible, and to understand barriers they encounter in providing these services in school. The project also examined the strengths and weaknesses of existing training provided to school nurses as part of their career development.
The project used in-depth interviews for data collection, conducted in two different kinds of middle schools: key schools and nonkey schools. The former have better resources, such as more experienced teachers and better teaching appliances. Schools were selected in urban districts in Beijing, and 30 full-time school nurses from these schools were selected randomly as interviewees. Each interview was conducted by two trained interviewers and lasted one hour on average.
The interview guide included background information on school nurses, scope of their daily work, training prior to taking up work, and perceptions of and attitudes toward student health care. Observations of medical equipment used in the school clinic were done after each interview to understand working conditions of the nurses. Records from notes and tape recorder were transcribed and coded.
School nurses play an important role in student health care. In line with government regulations, their routine tasks can be classified into appraisal, prevention, and remedial aspects.
Control and prevention of common and infectious diseases. This important task for school nurses is mainly performed through the conduct of regular check-ups for students, including height, weight, and vision tests annually to evaluate the status of nutrition and vision of individuals and groups. Nurses also monitor lighting and other environmental conditions in the classroom, and encourage students to do exercises in intervals between lessons to decrease the incidence of sight problems. They also monitor sanitation in school dining rooms, and they give students and their parents advice on diet to prevent anemia and other diseases related to nutrition. School nurses are responsible for immunization of students to control the spread of infectious diseases, including measles and influenza.
Health education and counseling. Some 22 schools had developed a regular health education curriculum for students in the seventh and eighth grades. Contents included growth and development during adolescence, control for some common diseases, and other contents based on requirements of the Guidelines for School Health Education issued by the Ministry of Education in 1992. (4) About one-third of the nurses were responsible for teaching the course. Other nurses were not directly involved in teaching health education classes, but most still were responsible for transmitting messages related to health, including advice on how to eat well, and how to prevent influenza. This task was accomplished through school radio and bulletin boards. Reasons for not teaching the health education curriculum included:
* Lack of time.
"We have a lot of routine duties in student health care and are so busy that we have no extra time to give health education lessons for students or do other things."
* Lack of qualifications.
"Generally speaking, a teacher who can teach a course should have the right qualifications. I am only a school health worker and not qualified to teach. That is the reason why we school nurses should not teach health education courses."
* Lack of extra pay.
"It (teaching health education or not) is decided by school principal. A teacher will get paid by the number of teaching hours. If they let school nurses teach health education, the principal must pay them. So health education courses are usually arranged for the biology teachers."
Counseling services should be part of a coordinated school health program. Eight schools have established a formal counseling room that focuses mainly on mental health problems of students, and 14 opened a telephone hotline for the same purpose. School nurses were not commonly part of the counseling service, but students often visited them because of physical health problems, and students wanted to ask questions related both to physical and psychological aspects of health. The number of students seeking counseling from nurses increased from just a few persons to more than 100 every term. Female students were more likely to seek help than were males. The scope of counseling for students included the following:
* Reproductive health issues, such as nocturnal ejaculation, menstruation, dysmenorrhea and other menstrual problems, and HIV prevention.
* Physical growth and development, such as height and overweight.
* Health and diseases, such as sleeping problems and nutrition.
* Problems related to learning, such as heavy work loads and stress, and anxiety about examinations.
* Personal relationships including how to communicate with members of the other gender, teachers, and parents.
School nurses thought students were willing to seek their help.
* "Most students trust me and think I can help solve their problems. I have a good attitude toward them and they do not feel pressure. For these reasons, they like to talk with me."
* "They (students) think of our school nurses first when they have health problems, because it is convenient for them to come here." "I think there are two reasons why students like to talk with me. The first is that I am a doctor. They think I have more knowledge of medicine than others. Second, I am not a teacher in charge of a class. I never tell tales to other students and teachers, so students trust me."
Students accept and actively use medical services only when convenient and when they trust the provider of these services. Perceptions of safety and trust depend on the health service providers' professional qualifications as well as their attitude toward students, and confidentiality. Health service providers must show sensitivity to the special problems of adolescents, and demonstrate a friendly attitude and good communication skills with adolescents as well as having medical qualifications.
Dealing with routine health problems. Unintentional injuries has become a major cause of illness for students in Beijing. School nurses often deal with injuries, such as cuts and trauma caused in the classroom or playground. School nurses also provide students with referrals to hospitals. School nurses organize "Red Cross teams" among students to assist the development of self-care skills and to enable students to help each other when accidents occur. In addition, school nurses are responsible for health problems of school staff.
The attitudes of school administrators and teachers toward the school health program differed among schools. About one-third of nurses indicated they had a supportive environment for work, and that their administrators provide opportunities and financial support for training, health activities, and improvement in clinic facilities. They also reported that other staff understood the significance of the school health program in promoting health. However, other school nurses thought the administrators in their schools attached lesser importance to the school health program than to math, language learning, and cognitive development.
According to regulations issued by the Ministry of Health and the Ministry of Education, (4) at least one school nurse should be employed for every 600 students. However, only one-fifth of schools in this project met the criterion. In seven schools, one school nurse was responsible for more than 1,200 students. Lack of school nurses in middle schools remains a serious problem. More than one-half the nurses complained of heavy work loads.
Quality of health care in school depends on school nurses' knowledge and skills, and training plays an important role in promoting capacity building among school nurses. Several nurses interviewed had been provided with different kinds of training after taking employment, including regular training and some short courses. Content of training was diverse, including not only school health but some clinical information. Duration of and costs for training also varied. The amount of training undergone in the year preceding the interviews ranged from three to four days to more than one month.
The estimated cost for training every year per teacher ranged from 100 to 1,000 yuan renminbi ($12 to $120 US dollars). These costs were mainly supported by the school itself or the local government of the administrative district where school nurses were employed. However, nurses still expressed dissatisfaction with training. For example, many reported that they attended some training on counseling skills, but they did not feel able to use these skills. Most wanted more training in this area.
School nurses were interested in training areas, such as adolescent health care, mental health and counseling skills, nutrition and food balance, and so on. They thought these areas provided them new and useful information and knowledge for their work. However, some who received clinical training were less satisfied because they felt these areas were weakly associated with their routine work.
* "I am not satisfied with some training that I receive at present. I think the content is mainly associated with hospital clinics and are far away from school health. It makes me bored."
* "Topics of some workshops and training are too old to keep pace with the time. We want more information about modern trends in school health."
School nurses wanted to master more practical and effective methods and skills for school health education, and for psychological guidance and counseling. They hoped to receive training on specific issues, such as how to reinforce students' abilities to avoid smoking or other substance abuse; how to design health education classes related to nutrition or safety; how to provide counseling around sexuality; and how to use computers in analyzing data on students' health problems.
Some nurses also felt that training often was not organized well, that is was not sufficiently long, that some trainees were not well selected, and that classrooms for training were too small.
Project results indicated that most school nurses interviewed had a positive attitude toward their job, despite different education backgrounds, duration of employment, and motivation for choosing the job. They play an important role in promoting student health, particularly appraisal, prevention, assessment of growth and development of children and adolescents, and control of common diseases among students in middle schools.
Only a few school nurses participated in teaching health education classes and providing formal counseling services, but their role should not be ignored. School nurses had many strengths in understanding students' physical and psychological health problems. Many school nurses also transmitted health information through ways other than formal health education courses. In addition, school nurses were frequently more accessible to students than other sources of information. Students could talk with nurses without making an appointment in advance, and school nurses often were perceived by students as more confidential. The role of school nurses in providing health information should be expanded. Problems encountered by the school nurses included:
* Heavy workload. Most nurses were responsible for the health care of more students than stipulated in government regulations. This load reduced their ability to participate in a wider range of health activities.
* Access to training. More than one-half of nurses indicated training they attended was not targeted to their specific role or activities. Thus, they did not feel qualified to participate in a broader range of tasks such as teaching or providing counseling services.
(1.) Jenne FH, Greene WH. Turner School Health and Health Education. 7th ed. CV Mosby Co; 1976.
(2.) World Health Organization. Global School Health Initiative: Health Promoting Schools. Geneva: World Health Organization; 1998.
(3.) National Education Committee and Ministry of Health of China. Rules of School Health. Beijing: 1990.
(4.) National Education Committee and Ministry of Health. Guidelines for Health Education in Primary and Secondary Schools. Beijing: 1992.
Xiaoming Yu, MD, MPH, Institute of Child and Adolescent Health, Peking University Health Science Center, Xueyuan Road #38, Haidian District, Beijing 10083 P.R. China. The article was submitted April 17, 2001, and revised and accepted for publication September 25, 2001.…