Key points to be considered for further promotion of school health

The promotion of research by investigators in low- and middle-income countries was suggested by Richard Smith as a concept of Global Health 4.0.1 This special issue shows that researchers in these countries are being fostered through the promotion of joint research with Japan. We agree that “reverse innovation”2 and “child rights” should be considered in school health promotion as a part of Global Health 5.0. We believe that “reverse innovation”—studying the experiences of low- and middle-income countries—will become even more important in the future, to solve the problems in Japan and other high-income countries such as increasing suicide rate among adolescent and child poverty due to income disparity. In this special issue, we discuss the research in Kenya and Indonesia as an example of “reverse innovation”.

“School returning policy” in Kenya

In an observational study in Kenya, we identified factors that contribute to the positive return to education of children who have dropped out of school, and we believe that the results could be applied to solving this problem in Japan. Dropping out of school because of poverty is not only a problem in low- and middle-income countries, but also a challenge in high-income countries, where inequality is more prevalent. Japan's relative poverty rate is over 15%, one of the highest among Organisation for Economic Co-operation and Development (OECD) countries. Child poverty in a disparate society is now a national issue. It is a particularly serious problem in Okinawa, where it has persisted since World War II. The teenage pregnancy rate in Okinawa is one of the highest in Japan. Students who become pregnant in middle and high school are still often forced to change schools, and many are expelled from school. The Kenyan study of Henzan et al. showed some of the factors that encourage a return to school to be “social norm: school for a better life”; ”linkage of the community and school”; and ”supportive environment”. In the schools studied, a supportive environment had might be fostered for teenage mothers as well as for other students with linkage of community. We believe these factors can serve as a reference for solving Japan's school drop-out problems.3 While much effort has been made in Japan to improve the quality of education in upper secondary schools, where many students are academically advanced, it is equally important to create a supportive system for students who might otherwise drop out of secondary schools. Health Promoting Schools, which do not simply provide health services, but also create a supportive environment, should be widely encouraged in Japan. Although Health Promoting Schools have not yet been promoted nationwide in Japan, we suggest that their effectiveness should be reconsidered.

“Bullying prevention” in Indonesia

The findings of Noboru et al. on bullying prevention in Indonesia can also be applied to Japan.4 The number of recognized cases of bullying in Japan increased in 2019 by 68 563 from the previous year to a record high of 612 496.5 The number of cases of bullying continues to increase in elementary schools, especially in the lower grades. In 2013, the Anti-Bullying Promotion Act was enacted, and the following measures were promoted at school level: (i) confirming the fact of a bullying incident and reporting it to the head of the school; (ii) providing support to children who have been bullied and to their guardians; and (iii) providing guidance to children who have been bullied or advice to their guardians. The strengthening of moral education has also been mentioned, but it is unlikely that it has been significantly strengthened. In Indonesia, not only is Islamic religious education thorough, but civic education is too, which is unique to the country of Indonesia. It is thoroughly carried out while recognizing the multi-religious and multi-ethnic nature of the country. In addition, cultural events are held together in the local community, and these events were found to work effectively to prevent bullying.

“Child rights” in school health

In addition to incorporating “reverse innovation” from developing countries, we recommend that the promotion of school health services be strengthened by re-consideration of the human rights of children. In the Convention on the Rights of the Child (CRC), published in 1989, Article 28, the right to education, and Article 29, the purpose of education, have already become common knowledge worldwide in the education sector, and recognition is spreading in the community as well. In the Kenya study by Henzan et al., one of the factors promoting a return to school was that the community inhabitants understood the purpose of education and recognized their right to receive it.

However, other children's rights are still not being recognized and implemented in the communities the schools are situated in in in low- and middle-income countries. School health can be a useful tool to promote awareness and implementation of the rights of the child. The roles of the education sector and the welfare sector are significant in providing not only the right to health and medical care under Article 24, but also protection from abuse and neglect under Article 19, and protection of the child from all forms of sexual exploitation and sexual abuse under Article 34. Comprehensive sex education, which is now recommended worldwide, goes beyond simply learning about reproductive body systems and the prevention of sexually transmitted diseases, and promotes education about children's rights. Protecting children from sexual abuse involves the children themselves learning about their rights and the means to protect themselves.3 To promote comprehensive sex education, it is necessary to include it in policies and modifications of curricula at the national level, and at the school level.

All teachers need to be aware of its importance, which is still a global challenge. The role of the schoolteacher in protecting children from all kinds of abuse, such as sexual and physical abuse and neglect, requires early detection and immediate reporting. This is an extracurricular activity, and if a school nurse is assigned to its management, this important role can be pursued. If no specific person is assigned, the school health promotion program will need to improve the mental health literacy of all teachers and retrain them in detecting and reporting child abuse. In either case, implementation is not possible without the strengthening of school health policies.6

With regard to the rights of children with disabilities, as stated in Article 23, the definition of disability is now broader than it was in 1989, when the CRC was declared, and more focused education is needed for children with developmental disabilities. It has, thus, become important to improve teachers’ understanding of mental health as well.7

The Health Promoting School, which is now receiving renewed attention as the most popular global strategy of school health, is a recognized way to improve mental health and prevent bullying by strengthening the creation of a better social environment. However, it is also necessary to reconsider and promote the right of children to rest and play, as stated in Article 31 of the CRC. In many high-income countries in Asia, the impact of fierce examination wars on children's mental health has become a priority issue in public health. However, this is a situation in which the right of children to rest and play may be violated. Improving academic performance is a top priority for schools that is difficult to change. Therefore, facts need to be presented to the education sector to show that children's rest and play can also lead to higher academic performance. The promotion of sports has been found to improve academic performance and Japan has promoted sports as an extracurricular activity in schools.8, 9 The ancient Japanese martial-arts-based spirituality of “Bu do” has been incorporated into Japanese school sports. Furthermore, in recent years, the importance of having fun and playing has been recognized and incorporated as a core concept. It is expected that intervention studies of Japanese-style sports, which improve not only health, but also academic performance, will be conducted and lead to a better balance between academic achievement and playing globally. Hosting the 2020 Tokyo Olympic Games had been controversial because of the coronavirus disease pandemic. However, we believe that a child's right to have fun and play sports has been recognized by Japanese society after the Olympic Games. For example, the fact that a 13-year-old Japanese girl won a gold medal in the Olympics for skateboarding will be a strong example for creating a society that affirms the child’s right to play.

Funding information

The development of the manuscript was funded by the University of the Ryukyus Research Project Toward Post-COVID Society grant and the EDU-Port Japan Project as "2021 Research Project" under Ministry of Education, Culture, Sports, Science and Technology, Japan.

Disclosure

KT reports personal fees from Novartis pharma, Japan as a lecture reward, outside the submitted work. JK declares no conflicts of interest.

Author contributions

J.K. conceived the presented idea and drafted the manuscript. K.T. provided comments and edited the manuscript. Both authors read and approved the final manuscript.