**3. A critical glance at the concept of health**

risk-taking behaviour such as aggression and violence, unsafe sexual activity, unhealthy eating, physical inactivity and substance use are associated with low scholastic performance [1]. Considering that health problems have a significant influence on the overall performance of students, there is a need to look at the various health determinants and how they affect students. Identifying health factors that impact student performance is essential because of the relationship between health and academic performance. This chapter therefore will analyse the complex relationship that exists between the various health problems and academic achievement.

To understand the relationship between health and academic achievement, it is worthwhile to understand the concept of health. Most school-based health intervention strategies have been informed by a limited perspective of health as a concept. Health intervention strategies have tended to focus on the so-called 'pathogenic' approach by emphasising on the treatment of diseases. This is evidenced by a proliferation of school-based clinics that focus mainly on treating diseases. However, the World Health Organisation (WHO) asserted that health is not merely the absence of diseases, but a complete state of well-being. To this effect, various theories and models have been postulated in trying to define health as a complex concept. One interesting theory is the theory of Salutogenesis postulated by Antonovsky in 1917 and later advanced by Lindstrom in 2010. The theory hypothesises that health is a continuum that focuses on the relationship between health, stress and coping [2]. The theory comprehends health holistically; that is, health is more than the absence of illness. This chapter looks at the concept of health from this broad view in establishing the link between the various aspects of

The World Health Organisation in 1986 asserted health is created and lived by people within the settings of their everyday life; where they learn, work, play and love. This argument was also raised during the Bangkok Charter for Health Promotion where the setting-based approach to health promotion was advocated [3]. Therefore, schools need to come up with health intervention strategies and provide healthy environments for students. School health services, which comprise components such as health services, health education, healthy environment, physical activity programmes, counselling, psychology, social services, nutrition services, improving employee well-being and family-society involvement approaches, are said to contribute to the academic performance of students in various ways [4]. In this regard, the Institute of Medicine concluded that there is a need to '*strengthen schools as the heart of health*' [5]. School-based health interventions are essential in offering better outcomes in both health and academic achievement. In light of the need for school-based health interventions, this chapter examines the various health interventions that influence academic performance.

The search was done in three stages. Firstly, the researchers did an intuitive search on the Internet using keywords that include student health, academic achievement, health interventions, health promotion, universities and colleges. The search was done via the Health InterNetwork Access to Research Initiative (HINARI), PubMed, Scopus, MEDLINE and Google Scholar. The authors also did a manual search on specific peer-reviewed medical journals that focus on health promotion

health and scholastic performance.

144 Health and Academic Achievement

**2. Methods**

Health is arguably one of society's most important values and has been prioritised as one of the key objectives of the sustainable development goals. Many people have regarded health as one of the most precious values in life. Health therefore should be protected and enhanced as much as possible. Achieving health is important because when people are healthy, their families, communities and countries benefit. Society should make the health of especially young people a priority because they are the future workers and leaders. There is need for an understanding of the various factors that influence health when addressing health concerns of society. However, health is a complex and elusive concept, and there has not been an absolute consensus on the definitions of health. It is one is the concepts which has often been taken for granted. One of the reasons why health is difficult to define is that it permeates different disciplines (e.g., medical sociology, health psychology and medical demography) and it is imbued with political, medical, social, economic and spiritual components.

Health is an old-age concept that has been evolving over time. The concept of health first appeared in Old English literature as *haelen* and the literal meaning was 'to heal'. The word appears in Middle English as *helthe*, referring to the sound status of an individual in body, mind and spirit. Between the seventeenth and nineteenth centuries, the words *health* and *restoration* and *hygiene* featured in the literature [6]. The word health resurfaced after the Second World War with the formation of the World Health Organisation in 1948, which defined health as 'a state of complete physical, mental, and social well-being and not merely the absence of disease of infirmity' [7].

However, the definition that was proposed by WHO in 1947 has come under a lot of criticism due to several reasons; chief among them being that health cannot be considered to be a state due to its dynamic nature, for instance, a person's health can change at any moment in time. A person can suddenly develop a headache at any time and they can heal a few minutes later. The definition also does not address the spiritual aspect of health. The spiritual aspect is also an important component of health because it incorporates five dimensions of health that are values and beliefs, sense of fulfilment, wholeness in life, human spiritual interaction and God or some form of controlling power. Another criticism stems from the fact that the issue of *well-being* is subjective and difficult to measure. It can also be argued that the definition views health as an end product, whereas health can be viewed as a means to an end in achieving something valuable, for example, students want to be healthy so that they can pass examinations. Moreover, health should not be looked at from an individual perspective as suggested by the definition; health needs to be looked at from a community or societal level because it is highly influenced by family values and societal norms. All these criticisms point to the elusive nature of health as a concept and how it has been viewed from a limited perspective. There is therefore a need to view health from a broader lens, especially when it pertains to the younger generation living in today's complex world.

#### **3.1. A broader view of health**

There have been modifications on the original definition that was proposed by WHO in 1948. WHO made some modifications on the definition during its first International Conference on Health Promotion held in Ottawa, Canada, in 1986, which saw the drafting of the Ottawa Charter for Health Promotion. WHO redefined health from a broader perspective:

**3.2. Emphasis on wellness**

**Figure 1.** Dimensions of health.

tion of accomplishments for their life.

Institute are: • spiritual, • emotional, • intellectual,

• physical,

It is interesting to note that the issue of well-being or wellness features a lot in the proposed definitions of health. It seems there is now more emphasis on wellness than health. However, the difference between health and wellness has not been adequately clarified in literature. In fact, the terms health and wellness have been viewed as near synonymous and have been used interchangeably in most instances. It is therefore important to provide clarity on the relationship between these concepts, especially considering the increasing popularity and use of the term wellness in designing school-based health interventions. Most school-based health promotion initiatives today often prefer to use the term wellness instead of health, hence the

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Wellness can be defined as a lifestyle that promotes health. This entails that for one to achieve total well-being, they have to lead a lifestyle that promotes physical, mental and social health. The Pacific Northwest Foundation believes that wellness is much more than just a state of physical health and it encompasses emotional stability, clear thinking, the ability to love, create, embrace change, exercise intuition and experience a continuing sense of spirituality [11]. This entails that health is an active process of becoming aware of and making choices towards a more successful existence. These choices mean that individuals have considered a variety of options and select those that seem to be in their best interest. Academic achievement and general success in life is therefore determined by each individual to be their personal collec-

Wellness is multidimensional. A popular model adopted by many university, corporate and public health programmes encompasses various dimensions that include social, occupational, spiritual, physical, intellectual and emotional. The National Wellness Institute recognises eight 'dimensions', or essential life areas which collectively comprise the wellness (well-being) of all human beings. The eight dimensions of wellness proposed by The National Wellness

popularity of the term 'wellness centres' in schools and universities.

*Health has been considered less as an abstract state and more as a means to an end which can be expressed in functional terms as a resource which permits people to lead an individually, socially, and economically productive life. Health is a resource for everyday life, not the object of living. It is a positive concept emphasizing social and personal resources as well as physical capabilities* [8].

This is a more helpful definition which resonates with recent theories that attempt to define health. One of the most interesting theories that offer helpful solutions in defining health is the theory of Salutogenesis that has been also evolving over time. The theory was postulated by Antonovsky in 1987 and later advanced by Lindström in 2010. The term Salutogenesis was coined by Antonovsky to describe health as a holistic concept. It posits that health is a continuum that focuses on the relationship between health, stress and coping. The theory comprehends health holistically; that is, health is more than the absence of illness. In the health promotion context, the term Salutogenesis is used to describe approaches which focus on factors that support human health and well-being, rather than those that focus on factors that cause disease. Fundamentally, the theory forms the opposite to the hitherto dominating concept of pathogenesis, which examines the causes of illness. The theory emphasises that quality of life or well-being is determined by various factors such as cure, protection, disease prevention, health education and health promotion. Lindstrom used the *Health in the River of Life* metaphor to argue that individuals should learn how to swim in the river of life. In other words, individuals should be equipped with requisite life skills so that they can thrive in the 'river of life'. Lindstrom also emphasises that quality of life or well-being is determined by various factors such as cure, protection and disease prevention [9].

The World Health Organisation proposes three dimensions of health, which are mental, physical and social health (see **Figure 1**). This view of health has been adopted by many professional organisations. For example, the American Occupational Therapy Association (AOTA) defines health as:

*'...the absence of illness, but not necessarily disability, a balance of physical, mental and social wellbeing attained through socially valued and individually meaningful occupation; enhancement of capacities and opportunity to strive for individual potential; community cohesion and opportunity; and social integration, support and justice, all within and as part of sustainable ecology'* [10].

**Figure 1.** Dimensions of health.

something valuable, for example, students want to be healthy so that they can pass examinations. Moreover, health should not be looked at from an individual perspective as suggested by the definition; health needs to be looked at from a community or societal level because it is highly influenced by family values and societal norms. All these criticisms point to the elusive nature of health as a concept and how it has been viewed from a limited perspective. There is therefore a need to view health from a broader lens, especially when it pertains to the younger

There have been modifications on the original definition that was proposed by WHO in 1948. WHO made some modifications on the definition during its first International Conference on Health Promotion held in Ottawa, Canada, in 1986, which saw the drafting of the Ottawa

*Health has been considered less as an abstract state and more as a means to an end which can be expressed in functional terms as a resource which permits people to lead an individually, socially, and economically productive life. Health is a resource for everyday life, not the object of living. It is a positive* 

This is a more helpful definition which resonates with recent theories that attempt to define health. One of the most interesting theories that offer helpful solutions in defining health is the theory of Salutogenesis that has been also evolving over time. The theory was postulated by Antonovsky in 1987 and later advanced by Lindström in 2010. The term Salutogenesis was coined by Antonovsky to describe health as a holistic concept. It posits that health is a continuum that focuses on the relationship between health, stress and coping. The theory comprehends health holistically; that is, health is more than the absence of illness. In the health promotion context, the term Salutogenesis is used to describe approaches which focus on factors that support human health and well-being, rather than those that focus on factors that cause disease. Fundamentally, the theory forms the opposite to the hitherto dominating concept of pathogenesis, which examines the causes of illness. The theory emphasises that quality of life or well-being is determined by various factors such as cure, protection, disease prevention, health education and health promotion. Lindstrom used the *Health in the River of Life* metaphor to argue that individuals should learn how to swim in the river of life. In other words, individuals should be equipped with requisite life skills so that they can thrive in the 'river of life'. Lindstrom also emphasises that quality of life or well-being is determined by various factors such as cure, protection and disease

The World Health Organisation proposes three dimensions of health, which are mental, physical and social health (see **Figure 1**). This view of health has been adopted by many professional organisations. For example, the American Occupational Therapy Association (AOTA)

*'...the absence of illness, but not necessarily disability, a balance of physical, mental and social wellbeing attained through socially valued and individually meaningful occupation; enhancement of capacities and opportunity to strive for individual potential; community cohesion and opportunity; and social* 

*integration, support and justice, all within and as part of sustainable ecology'* [10].

Charter for Health Promotion. WHO redefined health from a broader perspective:

*concept emphasizing social and personal resources as well as physical capabilities* [8].

generation living in today's complex world.

**3.1. A broader view of health**

146 Health and Academic Achievement

prevention [9].

defines health as:

#### **3.2. Emphasis on wellness**

It is interesting to note that the issue of well-being or wellness features a lot in the proposed definitions of health. It seems there is now more emphasis on wellness than health. However, the difference between health and wellness has not been adequately clarified in literature. In fact, the terms health and wellness have been viewed as near synonymous and have been used interchangeably in most instances. It is therefore important to provide clarity on the relationship between these concepts, especially considering the increasing popularity and use of the term wellness in designing school-based health interventions. Most school-based health promotion initiatives today often prefer to use the term wellness instead of health, hence the popularity of the term 'wellness centres' in schools and universities.

Wellness can be defined as a lifestyle that promotes health. This entails that for one to achieve total well-being, they have to lead a lifestyle that promotes physical, mental and social health. The Pacific Northwest Foundation believes that wellness is much more than just a state of physical health and it encompasses emotional stability, clear thinking, the ability to love, create, embrace change, exercise intuition and experience a continuing sense of spirituality [11]. This entails that health is an active process of becoming aware of and making choices towards a more successful existence. These choices mean that individuals have considered a variety of options and select those that seem to be in their best interest. Academic achievement and general success in life is therefore determined by each individual to be their personal collection of accomplishments for their life.

Wellness is multidimensional. A popular model adopted by many university, corporate and public health programmes encompasses various dimensions that include social, occupational, spiritual, physical, intellectual and emotional. The National Wellness Institute recognises eight 'dimensions', or essential life areas which collectively comprise the wellness (well-being) of all human beings. The eight dimensions of wellness proposed by The National Wellness Institute are:


Some dimensions of health can be measurable at a specific point in time. For example, blood pressure, depression and sugar levels can be measured at specific intervals to determine someone's health. However, an unhealthy individual can achieve well-being. For example, someone with HIV, chronic cancer or diabetes can be well if they practise a healthy lifestyle. Conversely, an individual does not have to be well to be healthy. For example, an HIV-free individual can engage in unhealthy lifestyle such as smoking or excessive alcohol intake.

of knowledge and understanding in a specific intellectual domain such as numeracy, literacy, science or history, among others. Academic achievement, therefore, should be considered to

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Academic achievement is commonly measured by examinations or continuous assessment. There is, however, no general agreement on how it is best tested or which aspects are most important. Some of the yardsticks that have been used to measure academic achievement include procedural knowledge such as skills or declarative knowledge such as facts. Among the many criteria that indicate academic achievement, there are very general indicators such as knowledge acquired in an educational system, more curricular-based criteria such as grades or performance on an educational achievement test, and cumulative indicators of academic

Individual differences in academic performance have been linked to differences in intelligence and personality. Students with higher mental ability as demonstrated by IQ tests and those who are higher in conscientiousness (linked to effort and achievement motivation) tend to achieve highly in academic settings. Although the primary goal of educational institutions is to achieve higher standards in terms of academic performance, research shows that academic achievement is influenced by multiple factors. Factors such as learning environments, parent's academic socialisation and extra-curricular activities have a positive relationship with academic performance. Health has been seen as one of the key factors that influence academic performance. The importance of health on academic achievement was emphasised by the Centers for Disease Control and Prevention (CDC) by stating that 'CDC recognizes that the academic success of … youth is strongly linked with their health. In turn, academic success is an excellent indicator for the overall well-being of

youth, and is a primary predictor and determinant of adult health outcomes' [14].

Research evidence reveals that students with poor health have a higher probability of school failure, grade retention and dropout. Previous studies found that the health services provided at school can alleviate the problem of absenteeism, late-coming and undisciplined student behaviour, and increase graduation rate. However, the relationship between student health and academic success is complex because health is a broad concept which is complex to define. Previous research has found some significant relationship between specific attributes of health and academic achievement. For example, previous research found an association between nutrition and physical activity with higher academic performance [15]. Overweight and hypertension are associated with decreased cognitive function, and overweight is associated with poorer school performance [16]. In contrast, higher levels of physical activity have been associated with better cognitive function, such as enhanced concentration and memory [17]. Results of a randomised control trial carried out in 2011 demonstrated that overweight students randomised to a 13-week exercise program exhibited dose-response benefits of exercise on executive function and mathematics achievement as well as preliminary evidence of enhanced brain activity measured via functional magnetic

In a longitudinal study carried out in the United States of America, the findings revealed that after accounting for family characteristics, adolescents with poorer general health were found to

be a multifaceted construct covering multiple domains of learning [13].

achievement such as educational degrees and certificates.

resonance imaging (MRI) [18].

The issue of wellness is emphasised in the definition by WHO and in the Salutogenesis theory. Therefore, it is clear that wellness is an emerging concept within the health promotion context and it is an important attribute of health. It is also clear that the concept of health has been evolving over time. Previously, there has been a medical dichotomy separating health from illness, and health was seen from a traditional pathogenic approach. This view saw health as the absence of diseases or other infirmities. The World Health Organisation attempted to change this line of thinking by proposing that health is a complete state of well-being. However, as discussed previously in this chapter, this definition was also criticised, and as a result, WHO came up with a broader definition that has been authenticated by theory. This broader view of health from the definition proposed by WHO and the Salutogenesis theory by Antonovsky and Lindstrom will be helpful in determining the various health dimensions that affect students' academic achievement. As mentioned earlier on, it seems learning institutions are using a narrow approach in promoting health among student. Most schools especially in the developed world do not have comprehensive health promotion strategies and they tend to employ the 'pathogenic' approach which is more reactive than proactive. This is characterised by the presence of student clinics for the treatment of diseases, injuries and other forms of ailments. As discussed later in this chapter, there is a need to come up with school-based interventions that address the overall health and wellness of students. Moreover, these interventions should be more proactive in addressing students' health needs.
