Global School-based Student Health Survey (GSHS) 





2005 Item Rationale          


For more information:
www.cdc.gov/gshs or 
www.who.int/chp/gshs/en/  





Global School-based Student Health Survey (GSHS)
2005 Core Questionnaire Module Rationale




Respondent Demographics


Questions:

* How old are you?
* What is your sex?
* In what grade/class/standard are you?


Rationale:

The questions in this module measure the age, gender, and grade/section/level/form of the respondents.  These characteristics are related to the health risk behaviours and protective factors assessed by the GSHS survey.  Data describing how health risk behaviors and protective factors vary by demographic characteristics can help guide policy and program planning and implementation.  

Alcohol and Other Drug Use

Questions:

* During the past 30 days, on how many days did you have at least one drink containing alcohol?
* During the past 30 days, on the days you drank alcohol, how many drinks did you usually drink per day?
* During the past 30 days, how did you usually get the alcohol you drank?
* During your life, how many times did you drink so much alcohol that you were really drunk?
* During your life, how many times have you ever had a hang-over, felt sick, got into trouble with your family or friends, missed school, or got into fights, as a result of drinking alcohol?
* During your life, how many times have you used drugs such as COUNTRY SPECIFIC EXAMPLES?

Rationale:

The questions in this module measure current alcohol use, how students get the alcohol they drink, episodes of heavy drinking, problems associated with alcohol use, and lifetime drug use.

Worldwide, alcohol use causes 3% of deaths (1.8 million) annually, which is equal to 4% of the global disease burden. Across sub-regions of the world, the proportion of disease burden attributable to alcohol use is greatest in the Americas and Europe ranging from 8% to 18% of total burden for males and 2% to 4% of total burden for females. Besides the direct effects of intoxication and addiction, alcohol use causes about 20% to 30% of esophageal cancer, liver disease, homicide and other intentional injuries, epilepsy, and motor vehicle accidents worldwide.1  In most countries, alcohol-related mortality is highest among 45- to 54-year-olds, but the relationship between the age of initiation of alcohol use and the pattern of its use and abuse in adulthood makes the study of alcohol consumption among adolescents important.2 

While adverse health consequences from long-term chronic alcohol use may not cause death or disability until fairly late in life, acute consequences of alcohol use, including intentional and unintentional injuries, are far more common among youth and young adults.  Unintentional injuries are the leading cause of death among 15- to 25-year-olds and many of these injuries are related to alcohol use.3 Young people who drink are more likely to use tobacco and other drugs and engage in risky sexual behaviour, than those who do not drink.4  Problems with alcohol can impair adolescents` psychological development and influence both the school environment and leisure time negatively.5

Although scientific evidence on the efficacy of educational programmes conducted in schools is limited,6 such programmes have been designed to help reduce risks associated with alcohol use among young people.  School health programs can help students acquire communication, critical thinking, refusal, and other life skills needed to avoid problems associated with alcohol and other drug use. 
 
Dietary Behaviours


Questions:

* How tall are you without your shoes on?
* How much do you weigh without your shoes on?
* During the past 30 days, how often did you go hungry because there was not enough food in your home?
* During the past 30 days, how many times per day did you usually eat fruit, such as COUNTRY SPECIFIC EXAMPLES?
* During the past 30 days, how many times per day did you usually eat vegetables, such as COUNTRY SPECIFIC EXAMPLES?


Rationale:

The questions in this module measure self-reported height and weight, frequency of hunger, and fruit and vegetable consumption. Data on self-reported height and weight will be used to calculate body mass index and provide a reasonable proxy measure of whether students are overweight or underweight.7

During adolescence, overweight is associated with hyperlipidemia, hypertension, abnormal glucose tolerance, and adverse psychological and social consequences.  Overweight acquired during childhood or adolescence may persist into adulthood and increase risk later in life for coronary heart disease, diabetes, gallbladder disease, some types of cancer, and osteoarthritis of the weight-bearing joints.  Nutritional deficiencies (protein-energy malnutrition, iron, Vitamin A, and iodine deficiency) affect school participation and learning.8  

Fruits and vegetables are good sources of complex carbohydrates, vitamins, minerals, and other substances important for good health.  Dietary patterns that include higher intakes of fruits and vegetables are associated with several health benefits, including a decreased risk for some types of cancer.9

As part of a school health program, school meal programs can be a source of healthy foods to students (who may not have other regular sources of food) and can promote daily attendance, class participation, and academic achievement.  In addition, schools can teach nutrition education as part of health education curricula to help students develop the knowledge, skills, and behaviors needed to foster lifelong healthy eating habits. 10,11,12,13


Hygiene


Questions:

* During the past 30 days, how many times per day did you usually clean or brush your teeth?
* During the past 30 days, how often did you wash your hands before eating?
* During the past 30 days, how often did you wash your hands after using the toilet or latrine?
* During the past 30 days, how often did you use soap when washing your hands?

Rationale:

The questions in this module measure frequency of tooth-cleaning, hand-washing, and hand-washing with soap.  

Dental caries are one of the most common chronic childhood diseases.14  Dental caries and other oral disease can affect the ability to eat, appearance, communication, overall health status, and the ability to learn.  In both developed and developing countries, many children do not have access to water fluoridation or professional dental care.  Daily tooth cleaning or brushing can help prevent some dental disease.

Diarrhoeal diseases kill 2 to 3 million children in developing countries every year.  Hand-washing with soap alone could cut deaths in half.  Removing excreta and cleaning hands with soap after contact with faecal material prevents transmission of the bacteria, viruses, and protozoa that cause diarrhoeal diseases.  UNICEF reports one of the major problems faced by hundreds of millions of school-age children is infection by parasites and flukes.  These parasites consume nutrients from children they infect, bringing about or aggravating malnutrition and retarding childrens physical development.  They also destroy tissues and organs in which they live causing pain and various health problems.  Water and sanitation related diseases affecting children include diarrhoea, trachoma, schistosomiasis, scabies, and Guinea worm.  All of these compromise childrens attendance and performance at school and, not uncommonly, can result in death.15

Schools can help improve child and adolescent health by providing and maintaining sanitary conditions. Hand washing, toilet or latrine, and other sanitation facilities and safe water are either non-existent or inadequate in many schools in both rural and urban areas in developing countries.16  By providing well-maintained and adequate numbers of sanitation facilities and safe water as part of the school health program, schools can reinforce the health and hygiene messages delivered in health education and serve as a model to both students and the broader community.






Mental Health


Questions:

* During the past 12 months, how often have you felt lonely?
* During the past 12 months, how often have you been so worried about something that you could not sleep at night?
* During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing your usual activities?
* During the past 12 months, did you ever seriously consider attempting suicide?
* During the past 12 months, did you make a plan about how you would attempt suicide?
* How many close friends do you have?


Rationale:

The questions in this module measure feeling of loneliness, loss of sleep due to worry, sadness and hopelessness, suicide ideation and attempts, and attachment.

Anxiety disorders, depression and other mood disorders, and behavioural and cognitive disorders are among the most common mental health problems among adolescents.  Every country and culture has children and adolescents struggling with mental health problems.  Most of these young people suffer needlessly, unable to access appropriate resources for recognition, support, and treatment.  Ignored, these young people are at high risk for abuse and neglect, suicide, alcohol and other drug use, school failure, violent and criminal activities, mental illness in adulthood, and health-jeopardising impulsive behaviours.  Depression during adolescence and young adulthood is recognized increasingly as an important public health and social problem. Worldwide, about 4 million adolescents attempt suicide annually, resulting in at least 100,000 deaths. 17,18,19

As part of a school health program, school mental health and social services can play a critical role in fostering healthy social and emotional development among students.  To help students develop positive mental health, school mental health and social services can teach life-skills such as problem-solving, critical thinking, communication, interpersonal relations, empathy, and methods to cope with emotions and crises.  In addition, school mental health and social services can include prevention, assessment, treatment, and case management for students either directly or through referrals to community-based programs.20,21


Physical Activity


Questions:

* During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day?
* During a typical or usual week, on how many days are you physically active for a total of at least 60 minutes per day?
* How much time do you spend during a typical or usual day sitting and watching television, playing computer games, talking with friends, or doing other sitting activities such as COUNTRY SPECIFIC EXAMPLES? 
* During the past 7 days, on how many days did you walk or ride a bicycle to and from school?
* During the past 7 days, how long did it usually take for you to get to and from school each day?  

Rationale:

The questions in this module measure participation in physical activity and sedentary leisure behavior and travel to school.

Participating in adequate physical activity throughout the life span and maintaining normal weight are the most effective ways of preventing many chronic diseases, including cardiovascular disease and diabetes.22  The prevalence of type 2 diabetes is increasing globally and now is occurring during adolescence and childhood.23 Participating in adequate physical activity also helps build and maintain healthy bones and muscles, control weight, build lean muscle, reduce fat, reduce feelings of depression and anxiety, and promote psychological well-being.24  However, a sedentary lifestyle has increased rapidly in most countries around the world, developed and developing.  It is estimated that in a great number of countries, both industrialised and developing, less than one third of young people are sufficiently active to benefit their present and future health and well-being.25

As part of school health programs, schools can offer physical education and opportunities, both during and outside the school day, for all students to participate in physical activity and sports.  Schools that offer intensive physical activity programs see positive effects on academic achievement, even when the time spent on academics is reduced to allow for these programs, including increased concentration; improved mathematics, reading, and writing scores; and reduced disruptive behaviors.26,27,28

Protective Factors


Questions:


* During the past 30 days, on how many days did you miss classes or school without permission?
* During the past 30 days, how often were most of the students in your school kind and helpful?
* During the past 30 days, how often did your parents or guardians check to see if your homework was done? 
* During the past 30 days, how often did your parents or guardians understand your problems and worries?
* During the past 30 days, how often did your parents or guardians really know what you were doing with your free time?


Rationale:

The questions in this module measure school attendance, perceived social support at school, parental regulation and monitoring, and parental bonding and connection.  

For most adolescents, school is the most important setting outside of the family. School attendance is related to the prevalence of several health risk behaviors including violence and sexual risk behaviors.29,30,31  Students perceptions of the school environment are associated significantly to their health and well-being.32,33  Perceived high-level support from fellow students is related to subjective health complaints, satisfaction with school, and increased physical activity. Conversely, students who feel that they are not supported by fellow students are more likely to report a much lower quality of life. 34,35 

One of the most reliable and powerful findings in research on adolescence and their families is the importance of adequate regulation of adolescents, measured in terms of supervision, monitoring, rule-setting, and other forms of behavioral control.36,37,38 Without adequate regulation and monitoring, children do not learn to self-regulate, tend to be impulsive, prone to risk taking, more susceptible to peer influences, and more likely to engage in various health risk behaviors including alcohol use and sexual risk behaviors.39  Parental bonding and connection is associated with lower levels of depression and suicidal ideation, alcohol use, sexual risk behaviors, and violence.40

School health programs can help create a supportive and caring school environment and provide  students with knowledge and skills they need to develop positive and supportive relationships with their peers and families.  
      
Sexual Behaviours That Contribute to HIV Infection, Other STI, and Unintended Pregnancy


Questions:

* Have you ever had sexual intercourse?
* How old were you when you had sexual intercourse for the first time?
* During your life, with how many people have you had sexual intercourse?
* During the past 12 months, have you had sexual intercourse?
* The last time you had sexual intercourse, did you or your partner use a condom or [COUNTRY SPECIFIC SLANG TERM FOR CONDOM]?

Rationale:

The questions in this module measure the prevalence of lifetime and current sexual intercourse, age at first intercourse, number of sexual partners, and condom use.

Since the epidemic began, more than 60 million people have been infected with HIV.  In 2001 alone, an estimated 5 million people became infected with HIV.41  More than half of those newly infected with HIV today are between 15 and 24 years old.  Each day, nearly 6,000 become infected.  An estimated 11.8 million young people aged 15 to 24 are living with HIV and AIDS.42  HIV infection and AIDS is by far the leading cause of death in sub-Saharan Africa and the 4th leading cause of death worldwide.  In 2001, the epidemic claimed about 3 million lives.  In many countries, HIV infection and AIDS is reducing average life expectancy, threatening food security and nutrition, dissolving households, overloading the health care system, reducing economic growth and development, and reducing school enrollment and the availability of teachers.43

Sexually transmitted infections (STI) are among the most common causes of illness in the world and have far-reaching health consequences.44  For example, untreated STI can lead to cervical cancer, pelvic inflammatory diseases, and ectopic pregnancies.  STI also are a major public health problem because they facilitate transmission of HIV.  Of the estimated 333 million new STI that occur worldwide each year, at least 111 million occur in young people under 25 years of age.

School health programs can play an important role in helping students reduce their risk of pregnancy, STI, and HIV infection and AIDS. 45  Based on community norms and preferences, school health education can help students develop the knowledge and skills they need to avoid or reduce sexual risk behaviors, school health services can provide or refer to reproductive health services, and school health policies can protect students and staff infected with HIV and foster a safe and respectful environment for everyone.

Tobacco Use


Questions:

* How old were you when you first tried a cigarette?
* During the past 30 days, on how many days did you smoke cigarettes?
* During the past 30 days, on how many days did you use any other form of tobacco, such as COUNTRY SPECIFIC EXAMPLES?
* During the past 12 months, have you every tried to stop smoking cigarettes?
* During the past 7 days, on how many days have people smoked in your presence?
* Which of your parents or guardians use any form of tobacco?


Rationale: 

The questions in this module measure current cigarette use, age of initiation of cigarette smoking, attempted cessation of cigarette smoking, current use of other tobacco products, exposure to second-hand smoke, and tobacco use by parents/guardians (i.e., role models).

About one in three or 1.1 billion people worldwide smoke.  Among these, about 80% live in low- and middle-income communities.46  By 2020, the tobacco epidemic is expected to kill more people than any single disease.  By 2020, tobacco use will cause about 18 percent of all deaths in developed countries and about eleven percent of all deaths in developing countries.  Tobacco use is a known or probable cause of about 25 diseases including heart disease; cancer, stroke, and chronic obstructive pulmonary disease.  Smokeless tobacco use causes oral cancer in the lip, tongue, mouth, and throat areas and digestive system cancers.  Most people who use tobacco initiate use prior to age 18.  Exposure to tobacco smoke in the environment 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.47   Family members, film stars, and sports heroes who use tobacco influence whether children and adolescents choose to use tobacco.48

School health programs can reduce tobacco use by implementing and enforcing policies to prevent tobacco use among students, faculty, staff, and visitors on school property and at all school events at all times; by providing tobacco use prevention education; and by offering tobacco cessation programs for faculty, staff, and students.49,50



Violence and Unintentional Injury


Questions:

* During the past 12 months, how many times were you physically attacked?
* During the past 12 months, how many times were you in a physical fight?
* During the past 12 months, what were you doing when the most serious injury happened to you?
* During the past 12 months, what was the major cause of the most serious injury that happened to you?
* During the past 12 months, how did the most serious injury happen to you?
* During the past 12 months, what was the most serious injury that happened to you?
* During the past 30 days, how were you bullied most often?


Rationale: 

The questions in this module measure how often students have been physically attacked, how often they have participated in a physical fight, the circumstances surrounding serious injuries, and the nature of bullying. 

Injuries are a major cause of death and disability among young children.51,52  Each year, 750,000 children die from injuries. Another 400 million children are hurt seriously.  In 2000, an estimated 190,000 youth homicides (9.2 per 100,000 population) occurred globally. For every youth homicide, approximately 20 to 40 victims of non-fatal youth violence receive hospital treatment.  Many injuries lead to permanent disability and brain damage.  Victims of bullying have increased stress and a reduced ability to concentrate and are at increased risk for substance abuse, aggressive behaviour, and suicide attempts.53

School health programs can help reduce violence and unintentional injuries in schools by establishing social and physical environments that promote safety and prevent injuries and violence; implementing health education that teaches students knowledge, attitudes, and skills they need to adopt safe lifestyles; establishing crisis response mechanisms; providing mental health and social services to meet the needs of students; and providing safe physical education and extracurricular physical activity programs.54,55




References

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2Poikolainen K, Tuulio-Henriksson A, Aalto-Setala T, Marttunen M, Lonnqvist J.  Predictors of alcohol intake and heavy drinking in early adulthood: a 5-year follow-up of 15-19 year-old Finnish adolescents, Alcohol and Alcoholism. 36(1): 85-88, 2001.

3Facy F. La place de llcool dans la morbidite et mortalite des jeunes[Place of alcohol morbidity and mortality of young people] in Actes du colloque les jeunes et Llcool en Europe. Navarro F, Godeau E, Vialas C. eds,  Toulouse, France:  Universitaires du Sud, Toulouse, 2000.

4Hibell B, Andersson B, Ahlstrom S, Balakireva O, Bjarnason T, Kokkevi A, Morgan M.  The 1999 ESPAD  Report:  Alcohol and Other Drug Use Among Students in 30 European Countries. Stockholm, Sweden:  Council of Europe, 2000.

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6Paglia A, and Room R. Preventing Substance Use Problems Among Youth: A Literature Review and Recommendations.  Toronto, Addiction Research Foundation, 1998.

7Brener ND, McManus T, Galuska DA, Lowry R, Wechsler H.  Reliability and validity of self-reported height and weight among high school students.  Journal of Adolescent Health  (in press).

8Vince-Whitman C, Aldinger C, Levinger B,  Birdthistle I.  School Health and Nutrition.  UNESCO: International Consultative Form on Education for All, 2001.

9US Public Health Service.  The Surgeon Generals Report on Nutrition and Health.  Washington, DC: US Department of Health and Human Services, US Public Health Service, 1988.  (DHHS publication no. (PHS) 88-50210)

10Powell C. Walker SP, Chang SM, Grantham-McGregor SM. Nutrition and education:  a randomized trila of the effects of breakfast in rural primary school children.  American Journal of Clinical Nutrition. 68(4):873-879, 1998.  

11Murphy JM, Pagano ME, Nachmani J, Sperling P, Kane S, Kleinman RE.  The relationship of school breakfast to psychosocial and academic functioning.  Archives of Pediatric Adolescent Medicine. 152(9):899-907, 1998.

12CDC.  Guidelines for school health programs to promote lifelong healthy eating.  MMWR.  45(RR-9):1-40, 1996.

13WHO.  WHO Information Series on School Health  Healthy Nutrition:  An Essential Element of a Health-Promoting School.  Geneva, Switzerland: WHO, 1998.

14Department of Health and Human Services.  Oral Health in America:  A Report of the Surgeon General.  Rockville, MD:  US Department of Health and Human Services.  National Institute of Dental and Craniofacila Reaserch, National Institutes of Health, 2000.

15Burgers L.  School Sanitation and Hygiene Education: Background and Rationale for School Sanitation and Hygiene Education.  Available on-line at www.irc.nl/sshe/rationale/rationale.html.

16Burgers L.  School Sanitation and Hygiene Education: Background and Rationale for School Sanitation and Hygiene Education.  Available on-line at www.irc.nl/sshe/rationale/rationale.html.

17http://www.who.int/child-adolescent-health/New_Publications/ADH/mental_health_factsheet.pdf

18Annan KA.  We the Children: Meeting the Promises of the World Summit for Children.  New York, NY:  UNICEF, 2001.

19WHO.  The World Health Report 2001  Mental Health: New Understanding, New Hope.  Geneva, Switzerland: WHO, 2001.

20Mental Health: A Report of the Surgeon General.  Rockville, MD:  US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Mental Health Institute, 1999.

21Adelman H. School counseling, psychological, and social services.  In Marx E, Wooley SF, Northrop D, eds.  Health is Academic:  A Guide to Coordinated School Health Programs.  New York, NY:  Teachers College Press, 1998.

22WHO.  Diet, Physical Activity and Health: Report by the Secretariat.  Fifty-fifth World Health Assembly, Provisional agenda item 13.11, 2002.  

23Silink M.  Childhood diabetes: A global perspective. Hormone Research.  57(suppl 1):1-5, 2002.

24Physical Activity and Health: A Report of the Surgeon General.  Atlanta: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996.

25WHO, Noncommunicable Diseases and Mental Health Cluster, Department of Noncommunicable Disease Prevention and Health Promotion. Promoting Active Living In and Through Schools: Policy Statement and Guidelines for Action, 1998. (WHO/NMH/NPH/00.4.)

26Shepard R. Curricular physical activity and academic performance.  Pediatric Exercise Science. 9:113-126, 1997.  

27Sallis J, McKenzie TL, Kolody B, Lewis M, Marshall S, Rosengard P. Effects of health-related physical education on academic achievement:  Project SPARK.  Research Quarterly for Exercise and Sport.   70(2):127-134, 1999.

28CDC.  Guidelines for school and community programs to promote lifelong physical activity among young people.  MMWR. 46(RR-6):1-36, 1997.

29Dearden K, Hale C, Woolley T.  The antecedents of teen fatherhood:  A retrospective case-control study of Great Britian youth.  American Journal of Public Health. 85(4):551-4, 1995. 

30Westall J.  Poor education linked with teen pregnancies.  British Medical Journal.  314(7080):537, 1997.

31Halcon L, Beuhring T, Blum R.  A Portrait of Adolescent Health in the Caribbean.  Minneapolis, Minnesota:  WHO Collaborating Centre on Adolescent Health, Division of General Pediatrics and Adolescent Health, University of Minnesota, and Pan African Health Organization, Population Program Adolescent Health and Development, 2000.

32Health and Health Behaviour Among Young People Health Behaviour in School-Aged Children:  A WHO Cross-National Study International Report. Currie C, Hurrelmann K, Settertobulte W, Smith R, Todd J, eds.  Copenhagen, Denmark:  WHO Regional Office for Europe, 2000.

33Eccles JS, Midgefield C, Wigfield A, Buchanan CM, Reuman D, Flanagan C, Iver DM.  Development during adolescence:  The impact of stage-environment fit on young adolescents experiences in schools and in families.  American Psychologist. 48:90-101, 1993. 

34Samdal O, Dur W. The school environment and the health of adolescents.  In Currie C, Hurrelmann K, Settertobulte W, Smith R, Todd J. (eds.)  Health and Health Behavior Among Young People  Health Behaviour in School-Aged Children:  A WHO Cross-National Study International Report.  Copenhagen, Denmark:  WHO Regional Office for Europe, 1998.

35Health and Health Behaviour Among Young People Health Behaviour in School-Aged Children:  A WHO Cross-National Study International Report. Currie C, Hurrelmann K, Settertobulte W, Smith R, Todd J, eds.  Copenhagen, Denmark:  WHO Regional Office for Europe, 2000.

36Barber BK, Olsen JE, Shagle SC.  Associations between parental psychological and behavioral control and youth internalized and externalized behaviors.  Child Development.  65:1120-1136, 1994. 

37 Dishion TJ, Loeber R.  Adolescent marijuana and alcohol use:  The role of parents and peers revisited.  American Journal of Drug and Alcohol Abuse.  11:11-25, 1985.

38Patterson GR, Stouthamer-Loeber M. The correlation or family management practices and delinquency.  Child Development. 55:1299-1307, 1984.

39Barber BK, Adolescent socialization in context  The role of connection, regulation, and autonomy in the family.  Journal of Adolescent Research.  12:5-11, 1997.

40Barber BK. Regulation, connection, and psychological autonomy:  Evidence from the Cross-National Adolescen Project (C-NAP).  Paper presented at the WHO-sponsored meeting Regulation as a Concept and Construct for Adolescent Health and Development.  WHO Headquarters, Geneva, Switzerland, April 16-18, 2002.

41UNAIDS.  Report on the Global HIV/AIDS Epidemic.  Geneva, Switzerland, 2002.

42UNICEF, UNAIDS, WHO.  Young People and HIV/AIDS  Opportunity in Crisis.  New York, NY:  UNICEF, 2002.

43UNAIDS.  Report on the Global HIV/AIDS Epidemic.  Geneva, Switzerland, 2002.

44WHO.  Young People and Sexually Transmitted Diseases  Fact Sheet No. 186, 1997.  

45WHO, UNAIDS, UNESCO, Education International.  WHO Information Series on School Health  Preventing HIV/AIDS/STI and Related Discrimination:  An Important Responsibility of Health-Promoting Schools.  Geneva, Switzerland: WHO, 1998.

46WHO.  What in the World Works?  International Consultation on Tobacco and Youth.  Singapore, September 28-30, 1999

47WHO, UNESCO, Education International.  WHO Information Series on School Health  Tobacco Use Prevention:  An Important Entry Point for the Development of Health-Promoting Schools.  Geneva, Switzerland: WHO, 1999.
 
48US Department of Health and Human Services.  Preventing Tobacco Use Among Young People:  A Report of the Surgeon General.  Washington, DC:  US Government Printing office, 1994.

49WHO, UNESCO, Education International.  WHO Information Series on School Health  Tobacco Use Prevention:  An Important Entry Point for the Development of Health-Promoting Schools.  Geneva, Switzerland: WHO, 1999.

50 CDC.  Guidelines for School Health Programs to Prevent Tobacco Use and Addiction.  MMWR.  43(RR-2): 1-8, 1994.

51WHO.  World Report on Violence and Health.  Geneva, Switzerland: WHO, 2002.

52 UNICEF.  Injury Prevention.  2003.  Available on-line at www.unicef.org/ffl/12/index.html. 

53Anti-Bullying Centre.  School Bullying:  Key Facts.  Trinity College, Dublin:  Anti-Bullying Centre, 2002.  Availabe on-line at www.abc.tcd.ie/school.htm. 

54WHO, UNESCO, Education International.  WHO Information Series on School Health  Violence Prevention:  An Important Element of a Health-Promoting Schools.  Geneva, Switzerland: WHO, 1999.

55CDC.  School health guidelines to prevent unintentional injuries and violence.  MMWR. 50(RR-2):1-73, 2001.






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Final GSHS Item Rationale - 2005	
For more information: www.cdc.gov/gshs or www.who.int/school_youth_health/gshs   
Last Updated: March 11, 2005