School textbooks are an essential part of health education. They are the primary tools for transmitting educational content and guiding the classroom activities [21]. School textbooks have been considered as important as teachers, students, and the classroom itself in achieving educational goals [22]. The role of school textbooks as a reliable source of information becomes even more important when access to other sources of information is limited [23]. The Organization for Economic Cooperation and Development (OECD), World Bank and United Nations Educational, Scientific, and Cultural Organization (UNESCO) have acknowledged the importance of textbooks for health education in developing countries [24].
A 2011 systematic review conducted in the United states and Spain, evaluating the content of school textbooks in relation to health lessons, concluded that the lessons in these textbooks are inadequate, inaccurate, or out of date, and hence need improvement [25]. In a study in Spain, Irala et al. reported that sexual and reproductive education in school textbooks are inaccurate [26].
Two studies about the status of health education in school textbooks from Iran showed that the content of textbooks, according to the age of children and their vulnerability, is poor and quantitatively limited [27, 28]. However, these studies only evaluated a few aspects of health and many important health topics, including oral health have not been evaluated yet.
Nearly 100% of the Iranian children receive primary education. Primary education in Iran up to the year 2012 included five years for children six to 11 years old studying in grades one through five. Children take part in educational programs in schools for 24 hours a week for about nine months each grade. In this period they mainly receive lessons in mathematics, Farsi, arts, physical education, religious studies, natural sciences, and social sciences.
Among the textbooks of different grades, the prevalence of health-related lessons was the highest in the textbooks of the third grade with 144 lessons and the lowest in the textbooks of the fourth grade with 26 lessons (Figure 1). The number of lessons in each topic in the third grade books was as follows: environmental health: 33, nutrition: 28, oral and dental health: 27, safety and accident prevention: 25, physical education: 13, personal health: 10, prevention of high-risk behaviors: six, and introduction to diseases: two. For the textbooks of the Fourth grade, the total number of lessons (26) comprised of the followings: physical education: 10, personal health: eight, environmental health: five, safety and accident prevention: two, and nutrition: one.
As it appears in this figure, among the five grades, science textbooks with 210 messages and religious studies textbooks with seven messages contained the highest and the lowest number of health messages, respectively.
With regards to oral and dental health, the textbooks of the first three grades contained the most number of lessons, with 15 lessons in the first grade books, 24 lessons in the second grade books, and 27 lessons in the third grade books. There were no lessons in the fourth grade books, and only one lesson in the fifth grade books (Figure 1). The lessons contained messages about using a toothbrush and brushing teeth regularly, dental hygiene, visiting a dentist on regular basis, exfoliation of primary teeth and eruption of permanent teeth, functions of different types of teeth, and tooth decay in the form of pictures or text.
Furthermore, according to the statistics of the UNICEF, the number of children who attend primary schools in Iran is exceptionally high, even larger than the number of students in secondary schools [32]. This led us to evaluate primary school textbooks as an important source for presenting health information to children.
The results of the present study show that in a total of 3598 pages of primary school textbooks, just 502 health related messages are presented. This relatively small number of health lessons is not adequate for effectively presenting a broad range of health concepts to the students and shaping their beliefs and attitudes towards healthy choices throughout life.
Another important point is the way in which messages are presented. In the first grade books, 72% of messages are presented visually while that decreases to 30% in the fifth grade. This is in line with the results of a study showing that images and diagrams are associated with improved learning [33]. This is especially the case in early school years, when kids are not able to read.
In all five grades of primary school, science textbooks had the most contribution in delivering health messages. Farsi literature textbooks, which comprise a big proportion of education time in primary school, have an important role in teaching health concepts as well. On the other hand, the textbooks of social sciences, religious studies, and mathematics were very poor in presenting health concepts, despite having a great potential for delivering health messages considering the total time devoted to these topics. Health concepts could be presented in these textbooks very successfully if combined with social and religious subjects, or Intellectual activities.
Personal hygiene is one of the most important aspects of health education. Unless measures are taken to cleanse the body on regular basis, the body is at risk of catching infections [34]. To this end, personal hygiene had the highest number of messages among the nine health related categories in primary school textbooks. The basic hygiene behaviors such as using a personal cup, using soap and hand washing, taking a bath, appropriate dressing, adequate sleep, and proper attitude towards hygiene, have been properly emphasized in primary school textbooks. It has been reported that health knowledge and attitudes of students significantly improve after receiving education [35].
There was a dearth of lessons about prevention of high-risk behaviors in the studied textbooks (only eight lessons in 27 books). Results of a few published studies have previously shown the low level of knowledge with regards to preventative measures and high-risk behaviors among Iranian students [44,45]. While lessons about prevention of high risk behaviors such as smoking, alcohol and drug abuse, and high risk sexual behaviors may be unnecessary in early school years (i.e. grades one through three), it is imperative to educate students in the fourth and fifth grades who are in transition period from childhood to adolescence and probably experience puberty, about such high risk behaviors.
This meteoric rise in costs has passed to individual students and school districts. This is especially true for post-secondary classes where professors have created textbooks and force students to purchase them for single classes.
This concept is close to how public school districts adopt textbooks. Because the district is footing the bill (instead of the student), textbook suppliers have an incentive to lower prices and sweeten deals for their customers.
The District has implemented an Integrated Library and Textbook System in all schools named Destiny Manager. Part of the process is to inventory and barcode all textbooks; therefore, all surplus textbooks must be transferred to the District Warehouse. Surplus core textbooks are defined as number of textbooks in excess of 10% over the number of projected enrollment.
The District's policy requires that each student, including English Learners and those in special day classes, have a State/District-adopted, standards-based textbook/application for use in the defined subjects of reading-language arts, history-social science, mathematics, science, health (Grades 6-7, 9) and foreign language (Grades 9-12). Students must be assigned a single textbook/application in each subject that they can use both at home and in class. District policy does not allow the use of State textbook funding for the purchase of class sets in addition to the books issued directly to students.
The first textbooks Sarvarzade and Wotipka studied were published in 1980, when Afghanistan was under communist rule. Here, female characters reflected progressive ideals: Women were portrayed as professionals and skilled laborers; girls demonstrated ambitions to advance their education and enter the workforce. Male and female characters appeared in equal measure, both inside and outside the home. Notably, younger women were pictured in nontraditional dress and mostly without hijab (head scarves).
These books, which were developed in large part with funding from the U.S. Agency for International Development (USAID), reflected a militant ideology that devalued women and girls, the researchers found. In the very rare instances where female characters appeared, they were relegated to domestic settings, doing chores and staying home while male characters went to school or to war.
After the Taliban regime collapsed in 2001, women and girls reappeared in new textbooks issued under a democratically elected administration. But with the continued threat of Taliban forces looming over the nation, female characters are far more passive and less ubiquitous than they were in the Soviet-era textbooks. While men are seen in a variety of professions, female workers are shown only as teachers. Conforming to the practice of conventional Islam, most girls are depicted in hijab.
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