1

Preface

Message from The Nippon Foundation

This school health textbook, “School Health for All - A Step to a Better World,” is the first full-fledged

I am delighted at the completion of the textbook for school health teachers, [School Health for All – A

school health textbook to be published for teacher education in Cambodia, corresponding to thestep to a better world].

Memorandum of Understanding (MoU) between the Ministry of Education, Youth and Sport and Tokyo
Gakugei University. This textbook has been developed under the financial support as a generous grant

The outbreak of Covid-19 spread throughout the world in no time and our daily lives have changed

from the Nippon Foundation to enable student teachers to teach school health classes in response to thedrastically from what we knew since before the outbreak. Infection prevention methods such as obligatory

decision of the Royal Government of Cambodia to introduce school health education to primary andmasks, thorough washing of hands, alcohol disinfection, and maintaining distance from one anotherlower secondary schools under the School Health Policy. The school health textbook consists of an

have been recommended. On the other hand, there were quite a number of cases of infection arising fromintroduction and 16 chapters with selected topics necessary for learning the fundamentals of schoola lack of awareness of the importance of infection prevention measures.

health education. Furthermore, these chapters are comprehensive and can contribute to Cambodia's
efforts to achieve the Sustainable Development Goals (SDGs).
The textbook was developed by school health experts from Tokyo Gakugei University (representative)

Today, with diverse information surrounding us related Covid-19 it is even more important forindividuals to further pursue and be equipped with correct health and hygiene knowledge.

and Ibaraki University, Jumonji University, Saitama University, and Yokohama National University. The
experts worked in close collaboration to complete a draft in Japanese, which was then translated into

This textbook [School Health for All- A step to a better world] comes with important information

English. The Khmer version of the textbook was later developed with the great support of lecturers fromnecessary for leading a healthy life. It is my hope that this textbook will be useful to all the young futureboth Teacher Education Colleges in Phnom Penh and Battambang, with regard to the accurate use ofschool health teachers in gaining thorough knowledge of correct health and hygiene and that they will,

Khmer terminology. The school health textbook in Khmer was finalized after a review by the Schoolin turn, pass on that knowledge to the younger generation.

Health Department of the Ministry of Education, Youth and Sport of the Kingdom of Cambodia. Tokyo
Gakugei University Cambodia Office coordinated the Khmer translation, illustration creation, and layout
work of the textbook.

The Nippon Foundation has implemented a number of teacher training programs since 2004 to
rebuild the Cambodian education infrastructure, which was devastated by the catastrophic civil war thatThe English edition of the school health textbook was created in parallel with the Khmer edition.

continued for about 20 years. We have great expectations that this school health project will also

It is strongly hoped that this textbook can be used to contribute to the enhancement of student

contribute to produce excellent school health teachers. I would like to express my gratitude to theteachers’ capacities in the field of health education in the Cambodian teacher education colleges. As a

Cambodian Ministry of Education, Youth and Sports, Phnom Penh Teachers’ Training College,

result, they will be able to effectively teach school health subjects when they become teachers upon

Battambang Teachers’ Training College, Tokyo Gakugei University and members of Social Compass,graduation. This will have a positive impact on school students, resulting in healthy human resources forand the NGO Education Support Center Kizuna.

Cambodia.

Yohei Sasakawa
Takashi Asakura

Chairman, The Nippon Foundation

Representative, Ph.D.,Professor Emeritus, Tokyo Gakugei University

Sam Chanphirun
Ph.D, Deputy Director, Phnom Penh Teacher Education Collage

2

3

Contents
Message from The Nippon Foundation 3

Characteristics of school health:
How are they learned and taught? 16

1. What does it mean for people to live a lifetime in good health? 16
2. Significance of learning and teaching school health 17
3. Characteristics of health as a school subject 18
4. Sustainable Development Goals (SDGs) and school health 19
Chapter 1(1) Circulation 36(2) Blood pressure regulation 37

3) Respiratory system 38

Preface 2

Introduction2) Circulatory system 36

Health 21

1. Aspects of health 21
2. Health is a human right 23
3. Health during the developmental period 23
4. Health promotion 24
1) Background to the concept of health promotion 24
2) The Ottawa Charter for Health Promotion 24
3) The Bangkok Charter for Health Promotion in a globalized world 25

5. School health initiative 261) School health objectives and initiatives 262) Significance and importance of health education in schools 273) The link between education and health 27

6. Cambodian initiatives Focusing Resources on Effective School Health 27
7. The future of school health in Cambodia 284) Nervous system 38(1) Central nervous system 39(2) Peripheral nervous system (somatic nervous system and autonomic nervous system) 40

5) Digestive system 416) Urinary system 427) Endocrine system 428) Sensory system 439) Reproductive system 44(1) Male reproductive system (structure and functions) 45(2) Female reproductive system (structure and functions) 45

10) Immune system 46

3. Mechanisms that support human activities in daily life 471) Homeostasis of internal environment and its regulatory mechanism 472) Thermoregulation 47(1) Body heat production and dissipation 48(2) Thermoregulation mechanism 48(3) Diurnal fluctuation 49

Chapter 3

Children’s growth and development 54

1. Human development 54
2. Principles of growth and development 55
1) Most children follow a certain developmental order 552) A certain direction is observed in growth and development 56
3) Continuity of growth and development and difference in growth velocity by organ and tissue 56
4) There are critical periods and sensitive periods in a child’s growth and development 57
5) Individual variability of growth becomes significant with age 57

3. Growth and developmental periods by age 58
1) Growth and development during early childhood 58

Chapter 2

How your bodies function(Mechanisms and functions of your body) 32

1. Structure and functions of the human body 32
1) Basic structure of the human body (cells, genes, tissues, and organs) 33

2. Structures and functions of organs 35
1) Motor system 35(1) Skeleton 35(2) Muscle 35

4(1) Physical growth 58(2) Motor development 58(3) Cognitive development 59(4) Emotional and social development 592) Growth and development during the middle childhood period 59(1) Physical growth and development 59(2) Motor development 59(3) Cognitive development 60(4) Emotional and social development 60

4. Factors that influence children’s growth and development 61
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Chapter 4

Cleanliness, hygiene and health 65

1. Personal and environmental cleanliness and hygiene (home, school, town/community) 65
1) Personal cleanliness and hygiene 652) Home cleanliness and hygiene 673) School hygiene 684) Town and community hygiene 71(1) Waste disposal 71(2) Drinking water and wastewater treatment 71

2. Tips for creating a clean and hygienic personal environment 73
1) Preventing food poisoning 732) Cleaning 73

3. Good hygiene practices 74
1) Effective handwashing technique 74

Chapter 5

Lifestyle habits and health 78

1. Children’s lifestyle habits and health 78
1) Growth/development and lifestyle habits 782) Establishment of basic lifestyle habits 80

2. Diet/nutrition and health 81
1) What it means to human health to eat 812) Characteristics of dietary effect 813) Healthy diet 82(1) Nutritional significance of carbohydrates 83(2) Nutritional significance of lipids 84(3) Nutritional significance of proteins 84(1) BMI-mortality relationship 101(2) Obesity and underweight 102(3) Anemia 103

3. Prevention of lifestyle diseases and diet/nutrition 104
1) Acquiring desirable lifestyle habits 1042) Importance of healthy proteins 105

4. Acquiring a better rhythm of everyday life 106
1) Maintenance of biological homeostasis 1062) Biological clocks 1073) Lifestyle habits to maintain a normal biological rhythm 107

5. Improper diets and health problems 108
Chapter 7

Infectious diseases and their prevention andprotection 112

1. Definition of infectious diseases and three major factors for the establishment of infection 112
1) Definition of infectious diseases 1122) Pathogens 1133) Infection routes: vertical and horizontal transmissions 1144) Host susceptibility 114

2. Biological defense mechanisms 114
1) Physical defense 115
2) Chemical defense 1163) Immune system 116(1) Natural immune system 117(2) Acquired immunity 118(4) Nutritional significance of minerals 85(3) Immunological tolerance 119(5) Nutritional significance of vitamins 85

3. Prevention of infectious diseases 119(6) Nutritional significance of dietary fibers (nondigestible saccharides) 86(7) Recommended dietary allowances of nutrients 864) Habit of choosing foods with safety and security assured 88

3. Exercise and health 90
4. Rest/sleep and health 92
5. Health habits of adults and life expectancy 92
Chapter 6

Prevention of lifestyle diseases 96

1. Common lifestyle diseases among Cambodians 96
2. Lifestyle diseases and other conditions related to lifestyle habits 98
1) Lifestyle diseases 98

62) Other health issues related to lifestyle habits 101

1) What can individuals do? 120
2) What are schools expected to do? 121
3) What is society expected to do? 121

4. Common infectious diseases in Cambodia 122
1) Dengue fever 122
2) Malaria 1233) Tuberculosis 1234) Rabies 1255) Parasitic infections 125(1) Trematode infections 125(2) Nematode infections 126

6) Enteric infections 126(1) Food poisoning caused by pathogens 1277

(2) Prevention of food poisoning 127

5. New challenges with infectious diseases 128
Chapter 8

Eye and dental health 131

1. Eye health 131
1) Importance of eye health 1312) How we can see an object 1323) Eye diseases that can cause visual impairment 132(1) Cataracts 132(2) Glaucoma 133(3) Diabetic retinopathy 133(4) Trachoma 133(5) Vitamin A deficiency 133(6) Refractive errors (hyperopia, myopia, and astigmatism) 134(2) Evaluation of eyesight 157

3) Hearing test 158(1) Hearing test method 158(2) Evaluation of hearing 158

4) Recording 159

3. Practice 160
1) Flow of health checkups 160
2) Let’s practice for measurement 160

4. Use of records 161
5. Implementation at schools 163
1) Importance of creating a school health organization 163
2) Example of implementation (Plan-Implementation-Evaluation) 164

Chapter 104) Correction of refractive errors 136(1) Glasses 136(2) Contact lens 136

5) Protecting your eyes 137(1) Posture 137(2) Brightness 137(3) Rest eyes frequently 138

2. Dental health 138
1) The roles and development of teeth 1382) Dental caries 140(1) Mechanism of the development and progression of dental caries 1403) Gingivitis and periodontal disease 142
4) Prevention of dental caries and periodontal disease 143(1) Toothbrushing 143(2) Dental floss 144(3) Eating habits to maintain dental health (how and what to eat between meals) 145

Health effects of tobacco use, alcohol
consumption, and drug abuse 172

1. Tobacco use and health 172
1) Health effects of tobacco use 172
2) Harmful chemicals contained in tobacco 173

2. Alcohol consumption and health 174
1) Health effects of alcohol 1742) Alcohol dependence 1753) Social impacts caused by alcohol 176

3. Harm of tobacco use and alcohol consumption by minors 176
4. Drug abuse and health 176
1) What is drug abuse? 176
2) What is drug dependence? 178
3) Spread of drugs in the Western Pacific region 179

5. Spread of tobacco use, alcohol consumption, and drugs in Cambodia 180
1) Tobacco use in Cambodia 180

Chapter 9

Significance of health checkups andtheir methods 148

1. Significance of health checkups 148
2. Health checkup methods 149
1) Height measurement and weight measurement 149(1) Height measurement method 149(2) Weight measurement method 151(3) Assessing height and weight 1522) Eye test 155(1) Eye test method 155

82) Alcohol consumption in Cambodia 182
3) Drug abuse in Cambodia 183
4) Psychological/social factors related to tobacco use, alcohol consumption, and drug abuse 184

Chapter 11

Mental and physical changes during adolescence 189

1. Characteristics of mental and physical growth and development in adolescence 189
1) Physical changes 189(1) Significance of adolescence as a period of transition from childhood to adulthood 189(2) Secondary sexual characteristics 189(3) Functions of the male reproductive system 191(4) Functions of the female reproductive system 192

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(5) Sexual desire 195

2) Mental and social changes 195(1) Understanding mental development and problem behaviors during adolescence 195

2. How pregnancy and childbirth work and the current situation around them 197
1) Pregnancy 197(1) Somatic changes 197(2) Changes to the uterus 198

2) Childbirth (delivery) 198(1) First stage of parturition (dilation stage) 198(2) Second (expulsion) stage to third (placental) stage of parturition 198

3) Today’s circumstances surrounding pregnant and nursing mothers 199
4) Contraception 200(1) Methods of contraception 2005) Youth sexual health and its challenges in today’s Cambodia 201(1) Child marriage 201(2) Youth pregnancy and childbearing 201(3) Use of contraception during sexual intercourse 202

6) Reproductive health and rights 204

3. Sexually transmitted infections 205
1) AIDS 205(1) Causes and routes of transmission 205(2) Symptoms and course of the disease 205(3) Issues surrounding sexually transmitted infections (prejudice/discrimination against people with HIV/(3) Development of the mind in the social aspect 222

3) What is mental health? 223
4) Adolescents in the world and mental health 223

2. Stress in daily life and mental health 224
1) Mechanism for protecting the mind 224
2) Relation between mind and body, and psychosocial stress 225(1) Hans Selye’s stress theory 225(2) Mechanism of the mind-body connection 227(3) Coping behavior toward, social support for, and a sense of control over stress 229

3. Mental health challenges in Cambodia 231
1) Externalizing problems and internalizing problems 231
2) Post Traumatic Stress Disorder (PTSD) in relation to the Khmer Rouge and 2nd generation PTSD 231
3) Bullying, violence, and harassment 233
4) Loneliness, anxiety, and depression 235
5) Suicide attempts, suicide 236
6) Addiction and dependence 238

4. Common mental diseases (schizophrenia and epilepsy) 239
1) Schizophrenia 239
2) Epilepsy 239

5. Mental health care 2401) Help-seeking behavior 2402) Counselling, mental health services 241

AIDS) 206
2) Other sexually transmitted infections 208

4. Social challenges and solutions surrounding sexual health 209
1) Handling information concerning sex 209

Environment and health / Ecohealth 244

1. Importance of environmental health 244

2) Sexual violence 210

2. What is an environment? 245

3) Sexual norms in Cambodia 210

3. Human survival and the Earth’s environment 246

4) Comprehensive sexuality education 211
5) Menstrual hygiene management 213

5. Sexual diversity 214
1) Gender 2142) Gender identity 215
3) Sexual orientation 215

Chapter 12

Mental health 218

1. Concept and development of the mind and mental health 2181) Three viewpoints on the mind 2182) Development of the mind 219(1) Mental development in the biological aspect 219(2) Mental development in the mental/psychological aspect 221

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Chapter 13

4. Health and environment 247
1) Host-environment interaction 247
2) Dose-response relationship 250

5. Ecosystem health and human health 252
1) What is an ecosystem? What is an ecological health approach? 253
2) Economic growth and social development in Cambodia 254
3) Environmental issues in Cambodia 254(1) Coastal development and loss of mangroves 255(2) Deforestation 255(3) Soil degradation 256(4) Water pollution and water shortages 256(5) Climate change and natural disasters 256(6) Land mines and unexploded ordnance (UXO) 257(7) Urban environment and health issues 259

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Chapter 14

School safety and crisis management 262

1. Concepts of safety and danger 262
1) Concept of safety 262
2) Disasters and accidents 263

2. Characteristics of accidents involving children from the standpoint of developmental
stages 263
1) Characteristics of the mind and body and behavior in early childhood 264
2) Characteristics of the mind and body and behavior of elementary school students 264(1) Challenges in the safety education of elementary school students 265

3) Characteristics of the mind and body and behavior of junior high school students 266(1) Challenges of the safety education of junior high school students 266

3. Causes of injuries in accidents involving minors 267
4. Traffic safety and the prevention of traffic accidents 268
5. Prevention of criminal damage 269
1) Hardware aspect of crime prevention measures (facilities/installations) 270
2) Software aspect of crime prevention measures 270

6. School safety 273
7. Crisis management in schools 274
1) Concept of crisis management in schools 274
2) Actual practice of crisis management in schools 275

3. First aid procedures 291
1) Observation 291
2) Assessment 291
3) Action 292

4. Appropriate first aid care for different situations 292
1) First aid for injuries 292(1) Head trauma 292(2) Facial trauma 292(3) Chest or abdominal trauma 293(4) Limb trauma 293(5) Burns 299

2) First aid for illnesses 300(1) Abdominal pain / diarrhea 300(2) Headache 301(3) Fever 301

Chapter 16

Disability and special education needs 305

1. Aspects of disease, impairment disability, and handicap 305
1) Disease 3052) Impairment, disability, and handicap 306(1) Definition of impairment, disability, and handicap 306

2. Models of disability 306(1) Prevent incidents/accidents from occurring [Prevention] 276

1) The medical model of disability 306(2) Prepare for the occurrence of incidents/accidents [Preparation] 277

2) The social model of disability 306(3) Promptly respond to incidents/accidents [Response] 278

3) International Classification of Functioning, Disability, and Health (ICF) as an integrated model of(4) Subsequent response to incidents/accidents and restoration [Restoration] 278

3) Experience of an incident/accident and mental health care 280(1) Mental health care provided immediately after the occurrence of a crisis 280

8. Roles of school personnel in creating safe schools 282

disability 307

3. How does Cambodian society view disease and disability? 308
4. Special education needs for disabled children in Cambodia 309

9. Safety education of schoolchildren 282
1) Development of the ability to predict and avoid danger 283
2) Use of human resources/resources in communities 283

Chapter 15

Index 311
The contributors 320

First aid at school 286

1. Necessities for learning first aid 286
2. Vital signs 287
1) Consciousness 287
2) Respiration 288
3) Pulse 289
4) Blood pressure 289
5) Body temperature 2901213Column List
Introduction- Diseases, disabilities, and the concept of eugenics
18

Chapter 1- What is the WHO? 23- National School Health Policy 2019 is promulgated29

Chapter 2- Why do elderly people fall easily? (Aging of bones
and muscles) 36- Autonomic nerves referred to as “fight or flight”
and “rest and digest” 40- Why can we see in the dark? (Mechanism allowing
to see in the dark) 44- Body temperature rhythm of women during andafter puberty 49

Chapter 3
None

Chapter 4- Vector insects 67- Drinking water in Cambodia 67- Best-before and use-by dates 68- School environmental hygiene in Japan 70- Disinfectants by efficacy 74

Chapter 5- Things to consider when using dietary
supplements 83- Food allergy 84- Prevalence of underweight, overweight and obesity
in Cambodian children and adolescents aged 5-19
years 88
- UN WFP (United Nations World Food Programme)
89

Chapter 6- What is inflammation? 100- Plaque and tartar 100- Health information obtained based on body height
and weight 102- Cambodians and anemia 103- Environmental stimuli, homeostasis, andautonomic function 108- Dietary habits that prevent lifestyle diseases will
also help prevent infectious diseases 110

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Chapter 7

Chapter 12

Chapter 8

Chapter 13- Vaccines and immunization 120- Fighting smallpox 120- A new lifestyle 121- What are complements? 123- Carries (asymptomatic carries) 124- Zoonosis 125- What is invert soap? 128- Preventing discrimination and prejudice from being
induced by infectious diseases 129- Eye and ophthalmus 132- Asians and myopia 134- Fashionable contact lenses caused eye disorder!!
137- Causes and prevention of bad breath 142- A variety of toothpaste 144

Chapter 9- Health checkup is “Screening.” 149- What is standard deviation? 153- Situation of thinness and obesity in children in
Cambodia 154- Single eye chart 156- Example of activities of Children’s Health Club 163

Chapter 10- Emergence of heated tobacco products, a new
type of tobacco 173- What is a conflict of interest (COI)? 174- Is cannabis legal or illegal? 177- What is drug tolerance? 179- What are narcotic drugs? 180- Most At Risk Young People (MARYP) Survey at Hot
Spots 183
- Global strategies regarding tobacco and alcohol
185- How to use pharmaceuticals 186

Chapter 11- Factors contributing to the onset of menstruationand health consequences of age for menarche 191- Keep track of your menstrual cycle 194- What is ambivalence? 196- Traditional culture that supports childbirth (Ang
Pleung) and changes in childbirth 199- Sexual behaviors among university students intoday’s Cambodia 204- Harmful practices performed around the world 211- Ingenuities for lessons and guidance on sex at
school 215- What are the prefrontal cortex and synapses? 220- Various emotions and the control of emotions 225- Mental health of Cambodian people 227- Stress hormones and happy hormone 228- Psychosomatic disease 228- Manic defense 228- The Western mind and the Asian mind 230- Whole school approach 237- Loss and grief, and grief care 238- Environmental pollution of methylmercury and thehealth of people 247- Environmental risk factors in low-middle income
countries 251- Truth behind banana plantations 252- Ecohealth and systems thinking 253- Community-based tourism and ecotourism 257

Chapter 14- Hazard risk model 263- School commuters’ situations and the challenge ofhelmet use in Cambodia 269- Children living in the digital age 271- Natural disasters that frequently occur around theworld 272
- Response to lightning 272- Anniversary reaction 281- Measures related to land mines in Cambodia 283

Chapter 15- What is orientation? 288- Non-contact body thermometer 291- What is shock? 292- Management of nosebleeds 293- Special considerations when treating bleeding 295- Management of outdoor injuries caused by animals
or insects 295- Preparedness for injuries at school 298- First aid in school 298- Care for injuries provides an opportunity for healtheducation 300- Disposal of bodily waste / vomit 300- Responsible self-medication, self-care and selfhealing mechanisms 301- Cardiopulmonary resuscitation and AED 302

Chapter 16- Inclusive education for children 309- Child-friendly schools 309- What is UNICEF? 310

15

Introduction

Characteristics of school health:
How are they learned and taught?

life, and eventually have a family. A healthy man and healthy woman produce healthy sperm and healthy
eggs in their respective reproductive organs, and pass on the life information in their DNA to the next
generation. Life repeats this cycle.
When people reach maturity and healthy adulthood, they undergo the aging process according to thelaws of human life. They age healthily towards the end of their lives. They live healthily in their own
unique way in their last days, and finally die with human dignity. The afterlife is an unknown world.

Learning objectives

There is a sacred world that differs with each religion. Some may not believe in the existence of such a

You will be able to gain proper understanding and explain:world.

- What it means for people to live healthy lives, in terms of their life cycle.
- The characteristics and importance of school health as a school subject.

2. Significance of learning and teaching school health- Health as a personal matter.
- The link between the 17 Sustainable Development Goals (SDGs) and school health.
- Why it is significant for students aspiring to be teachers to study school health and teach it toIf people could live in perfect “health,” as shown in this diagram, it would be a miracle and this ischildren, and increase students’ interest in the contents of this textbook including 16 chapters.

practically impossible. The pursuit of perfect health without considering the limitations of human beingsand society leads to the concept of eugenics, which may result in the social exclusion of all but those

Targeting students in the teacher training course who use this textbook to study school health and will

who can be considered “healthy.” Since there is no such thing as a perfect human being, we must not fallteach it to children in the future, this book discusses the characteristics of the subject of school health,

into the trap of healthism (the pursuit of health as the most valuable attribute).

how to study and teach it, and the points that should be understood.

At some point in the life cycle, everybody experiences situations, environments, and conditions thatadversely affect their health, as well as suffers health challenges such as illness, injury, disability, and

1. What does it mean for people to live a lifetime in good
health?

ill-health to some extent. No matter how early or late, there is no escaping the fate of being human, or
death. In other words, while the timing of death may be unequal, we are all equal in the sense that noneof us can escape death.
However, most people want to live as long as possible in good health, and lead as abundant andWhat does it mean for a person to live a lifetime in good health? A healthy human life begins when ahappy a life as possible. What can education and schools do to achieve this? School health is an initiative

healthy sperm meets a healthy egg, resulting in healthy fertilization (Figure 0.1). The healthy fertilizedthat brings together teachers and staff, families and relatives, and community members to work together

egg divides and eventually forms a fetus, which grows and develops healthily in the healthy womb of

to realize the wish to live a healthy life, by focusing on the health of school-aged children. The role ofthe healthy mother and is born healthy through a healthy delivery upon reaching full term. The healthy“perfect health” as defined by WHO (see Chapter 1) can be seen as a guide to how we should survive

baby grows and develops healthily and eventually matures sexually. A healthy adult will work, enjoy

and lead our daily lives, just as the ancients sailed across the sea at night toward their destination byfollowing the North Star and the Southern Cross. The destination may be a feasible “better health” that

Healthy egg

Healthyfertilization

Healthy sperm

Grows anddevelops
healthily inthe womb

Borns healthy(Healthy delivery)

Continuity/transmissibility between generations

Grows and develops
healthily andeventually maturessexually

Works healthily andmatures into adulttakes into account the limitations of human beings and society.
Given the diversities of the physical body, development, sexuality, and socioculture, it isimportant to note that “health” is not a single event, but a spectrum that comprises various degrees ofhealth, and a concept with diverse dimensions of value. Depending on the culture, history, religion,
ethnicity, gender, etc., of a country, society, and region, various views of health can exist.
In today’s society, it is necessary to teach health based on the knowledge that has accumulated
through scientific methods, and simultaneously consider these diversified ways of thinking about health.
Accordingly, to live a healthy life means to combine rich wisdom about health rooted in our experiences

Unknown(religious
sacred world)

Dies withhuman dignity

Lives in his/her own
unique way towards
the end of his/her live

Figure 0.1 Human life cycle and health

16

Ages healthily

and daily life (for examples, self-care, self-medication, self-protection, and herbal medicine) withaccurate scientific knowledge about health, and to practice and confirm it in our daily lives, and to
improve our lives and ways of life by ourselves. At times, it is necessary to seek assistance from thecommunity and others in order to live a healthy life.
Introduction

Characteristics of school health: How are they learned and taught?

17

Nevertheless, the scope of what humans know about the mysteries surrounding health is limited.

pupils. Since scientific health knowledge is universal, it may not necessarily correspond to each person’s

Therefore, the attitude of being conscious of our ignorance and modestly putting into practice theindividual health, lifestyle, or environment (for example, consider traditional food cultures and how

wisdom and knowledge of health in our daily lives is the mindset that allows us to think of health asingredients are procured in a region). This is why the wisdom of health that exists in our daily lives is so

our own, and is the stance required of those who study and teach school health.

valuable. It may actually serve practical purposes because it is an accumulation of experiences that areThis textbook discusses the contents of the newly introduced elementary school health course.

appropriate to each person’s physical and personality characteristics, local lifestyle, and living

Specifically, it comprises 16 chapters that university students should study to become teachers qualified

environment. Of course, there are some practices that need to be changed from the SDGs perspective,

to learn and teach school health. These 16 chapters contain the essence of school health, which will notincluding Cambodia’s traditional sexual norms and childbirth culture, as well as child marriage andonly be useful for you when you become a teacher, but will also help you to understand your own health,female genital mutilation seen around the world (see Chapter 11).

the health of your family and friends, and the health of the people of Cambodia. It is important that you

Therefore, health education requires you to well understand and respect the traditions, customs,

approach the contents of each chapter as your own experience and something to reflect on, and study

wisdom, and ideas of the local communities, as well as to communicate by translating scientificthem as a personal matter, not that of others. You can work on the EXERCISE at the end of each chapter

knowledge in a way that is easy to understand and practice in daily lives. This may involve using

and discuss it in class to deepen your learning.

scientific, technical terms, or translating technical terms into the language used in daily life, requiring
flexibility to accommodate the circumstances.

Column: Diseases, disabilities, and the concept of eugenics

The health education in Cambodia should be aimed at exploring a healthy way of life that benefits
from the health and welfare systems and services that will be domestically developed in the future, andEugenics is a field of academic study that believes that there are two types of human beings: thosefrom a body of scientific knowledge of health and medicine emerging around the world, while preserving

with good biological characteristics and those without. It seeks to improve the quality of humanas much as possible the culture and ecology of living in the regions where economic development will

beings by retaining those with superior genetic characteristics and eliminating those with inferior

take place.

genetic factors. Against the background of this discipline, the concept of eugenics is the belief thatIn this way, health education in school seeks to cultivate the ability of students and children to live

there are people with qualities worthy of living and those without. It assigns superiority and inferiority

healthily, as well as to create a society and environment in which everyone in the community can live

to human lives. The most significant criteria used to determine superiority and inferiority, in the past

healthier life.

and present, are disabilities, diseases, race/ethnicity, and age.

3. Characteristics of health as a school subject
To teach and learn health in schools, one should comprehensively understand human health in relation
to the body, psychology, behavior, social environment, and natural environment, and apply what has
been learned to daily lives. In particular, teaching and learning about health in schools means conveying
scientific knowledge about health and right living skills to students to help them practice healthy living.
The key to achieving this is communication between those who teach and those who learn (including

Academic world where teachers exist(world of specialists)
World of professional and scientificknowledge (educational andscientific knowledge)

Teach scientificknowledge and life skills

Learn wisdom of health andinventive ideas from everyday
health practices

Everyday world where students/
pupils exist (world of general public)
World where people live based on
general health-related knowledge
such as common sense andtraditional wisdom

Figure 0.2 Two-way health education communication in school healthteaching methods, i.e., how to teach health). In fact, there are two worlds: the one where teachers belong
and the other where students, children, and the general public live. The knowledge and common sense
about health differ between these two worlds. The languages being used are also different.
The two worlds of life, of course, overlap. Teachers are familiar with both worlds: the one using

4. Sustainable Development Goals (SDGs) and school
healthprofessional and scientific knowledge and the other one depending on everyday common and traditional18

wisdom. They play a vital role in bridging the two (Figure 0.2). This role, in other words, is that of a

The final topic is the connection between SDGs and school health. SDGs are the successor to thehealth education-communicator.

Millennium Development Goals (MDGs), set out at the United Nation (UN) Summit in 2015, as goals

In health education, it is essential to convey specialized knowledge to students, children, and theor challenges to achieve a sustainable and better world by 2030. In essence, the SDGs are a set of goals

general public in an easy-to-understand manner that can help them change their behavior and thinking.

that the entire world should work towards, regardless of economic or development level, in order for

However, this by itself will only result in teachers unilaterally imposing their knowledge on students andhumanity to survive and prosper sustainably on this planet. Of course, Cambodia is also trying to address
Introduction

Characteristics of school health: How are they learned and taught?

19the SDGs.

Chapter 1

1

The SDGs consist of 17 goals and 169 targets under these goals. The 17 goals are as follows:
Goal 1: End poverty in all its forms everywhere
Goal 2: End hunger, achieve food security and improved nutrition and promote sustainable

Healthagriculture
Goal 3: Ensure healthy lives and promote well-being for all at all ages
Goal 4: Ensure inclusive and equitable quality education and promote lifelong learning
opportunities for all

Learning objectives
You will be able to gain proper understanding and explain:

Goal 5: Achieve gender equality and empower all women and girls- The deﬁnition and aspects of health.

Goal 6: Ensure availability and sustainable management of water and sanitation for all- The importance and beneﬁts of health education programs in schools.

Goal 7: Ensure access to affordable, reliable, sustainable, and modern energy for all- The signiﬁcance of implementing school health activities.

Goal 8: Promote sustained, inclusive, and sustainable economic growth, full and productive- School health policies and initiatives adopted in Cambodia.

employment, and decent work for all
Goal 9: Build resilient infrastructure, promote inclusive and sustainable industrialization, andfoster innovation

This chapter provides basic knowledge necessary to understand human health and school healthinitiatives. First, we introduce basic health concepts and a few new ideas, and underscore that health isGoal 10: Reduce inequality within and among countries

a basic human right. Next, we explain the concept of child health based on the characteristics of child

Goal 11: Make cities and human settlements inclusive, safe, resilient, and sustainable

development. We also outline the global trend towards health promotion and building healthy societies,

Goal 12: Ensure sustainable consumption and production patterns

and describe the importance of school health initiatives, their four pillars, and school health policy in

Goal 13: Take urgent action to combat climate change and its impacts

Cambodia.

Goal 14: Conserve and sustainably use the oceans, seas, and marine resources for sustainable
development
Goal 15: Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage

1. Aspects of healthforests, combat desertification, and halt and reverse land degradation and halt
biodiversity loss
Goal 16: Promote peaceful and inclusive societies for sustainable development, provide access tojustice for all, and build effective, accountable and inclusive institutions at all levels
Goal 17: Strengthen the means of implementation and revitalize the global partnership forsustainable development“Health” is a term that encompasses the physical, mental, psychological, and social state of humanbeings in a single word.
The constitution of the World Health Organization (WHO), signed by representatives of 61 nationsin 1946, describes the most desirable and ideal conditions for health with the following statement:“Health is a state of complete physical, mental and social well-being and not merely the absence of

The terms in bold in the list of 17 goals are those that are discussed in this textbook in relation todisease or inﬁrmity.”1 The WHO Constitution also declares that “enjoyment of the highest attainable

health and well-being, safety, and hygiene. They show that school health is not just about health education

standard of health is one of the fundamental rights of every human being.”1 This right must be guaranteedin schools, but that it plays a vital role in working towards the SDGs and can make a significant

regardless of race, ethnicity, religion, political belief, or socioeconomic status.1

contribution to Cambodian society. Furthermore, as stated in the Cambodian School Health Policy
2,3

The WHO Constitution warns that inequalities exist in the areas of health promotion and infectious(2016, 2019) , university students, pupils, and teachers who have studied school health are expected todisease control, depending on respective levels of socioeconomic development among nations. Suchbecome human resources who can contribute to a Cambodian society that grows sustainably and isconditions are described as a threat shared worldwide, not just among developing nations.1

peaceful and healthy.

More recently, global climate change as well as the spread of lifestyle-related diseases accompanying
changes in people’s ways of life and the rise in average human life expectancy have had a conspicuous
impact, prompting new ideas about health. One such example is to seek lifestyles that are in harmony

References

20

1

Cambodia Sustainable Development Goals. https://www.csdgs.org/km/

2

Ministry of Education, Youth and Sport. SCHOOL HEALTH POLICY. 2006.

3

Royal Government of Cambodia. National Policy on School Health. 2019.

with the environment and ecosystem. For instance, the Ecohealth concept is rooted in awareness thathuman beings are also part of the ecosystem (Figure 1.1). This approach to human health stresses theimportance of maintaining a balance among the environment, the ecosystem, socioeconomic development,
peoples’ livelihoods, production activities, and lifestyles.2
Chapter 1
Health21

Therefore, health is a multidimensional concept including at least five aspects (Figure 1.2), which

nomic develop
eco
me
cio
nt
o
S

are often interdependent.

man health
Hu

LivelihoomandHuColumn: What is the WHO?

ECOHEALTH

The WHO was established as the directing and coordinating authority on international health within
the United Nations system in 1948. The WHO mission is to promote health, keep the world safe, andserve the vulnerable. Now more than 7,000 people from over 150 countries work in 150 national

E cosyst e moffices, 6 regional offices, and at our headquarters in Geneva.

Figure 1.1 Ecohealth is a health concept that says socioeconomic development influences

the ecosystem and human livelihood, and thus human healthWith the advancing age of populations in many nations, the world is moving into an era in whichmost people will have to deal with lifestyle-related diseases and physical, cognitive, psychological, and(Cited from: https://www.who.int/about/who-we-are/our-values, and https://www.who.int/about/
who-we-are )2. Health is a human rightsocial dysfunction. Such trends have encouraged people to accept and deal with health challenges.
Rather than eliminating disease and impairment, for example, greater emphasis is being placed on the

Health is considered a basic right for all people, regardless of their race, ethnicity, religion, politicalability to achieve decent living conditions despite illness or impairment, which involves controlling thebeliefs, or socioeconomic status.1 True to this principle, it is vital for the nation of Cambodia to ensure

lifestyle impact of such negative conditions while receiving the social support necessary to cope withthat all of its citizens enjoy access to the highest attainable standard of health.

such circumstances.

3

Healthy development, particularly for children, is a fundamental right in all nations. With that goal

In 1998, the WHO Executive Board approved a proposal to add “spiritual health” to the categories

in mind, the WHO Constitution emphasizes the importance of nurturing children who can liveof physical health (e.g., physiology, morphology, and body structure and function), mental healthharmoniously in a changing total environment.1 In this regard, school health initiatives play a vital role(e.g., intellectual and cognitive function), psychological health (e.g., emotional, behavioral, andin efforts to ensure that children attain sound development within the changing environment.

psychological development), and social health (e.g., participation, engagement in activities, and socialrole).4 While that proposition has yet to be officially adopted, spirituality is a vital dimension in thehealth and happiness of the people in the Buddhist nation of Cambodia. Spirituality has no ties to

3. Health during the developmental period

specific religions. Rather, it describes the universal spiritual nature surrounding our origins as humanbeings. It is the state of mind in which we experience sensations, such as harmony, goodness, beauty,

Human growth and development commence from encounters between sperm from a male and an ovum

sacred tranquility, and eternity beyond life and death. That inner state is brought about by feeling a(egg) in the female, with the fertilized egg(s) growing in the woman’s womb. The growth and development

connection with entities that transcend human beings through our mental activity, such as praying or

cycle follow a process of maturation that continues after a child is born, with various capacities andexpanding our minds to connect with nature and the universe.

characteristics peaking during adulthood. After attaining this peak, human beings experience the natural
phenomenon of aging. This phase is characterized by gradual decline and loss of capacities, eventually
Biological
Mentalresulting in death.
Within the course of human life, kindergarten, elementary, junior high, and high school students—
the targets of school health education—are in an age bracket defined by steady growth and development.
As they mature into adults, their minds, bodies, and social relationships evolve and change daily. The

Health

Psychological
SocialSpiritual

Figure 1.2 Multidimensionality of health22

term “developmental health” is used to express the changing reactions of such children during thisperiod to various experiences, the surrounding environment, and other factors.5“Developmental health” is thus a term used to express the process leading toward maturity that
schoolchildren follow. They experience various things (e.g., friendship, commitment to learning, leisureactivities, support from others, and mutual help) within social environments (e.g., school, family, andcommunity) and acquire numerous qualities (e.g., indulgence, honesty, trust, collaboration, curiosity,
Chapter 1
Health23

sense of justice, and aspiration) through interactions with their environment that steadily increase their

4.

food

intellectual, physical, and emotional capacities to their full potential.

5.

income6.

a stable eco-system

7.

sustainable resources8.

social justice and equity

4. Health promotion
1) Background to the concept of health promotion

To inspire good health, it is vital for society to fulfill each of these conditions.
Six areas are identified as pillars of the health promotion movement.8 The key points of these pillars

Research in the 1970s and 1980s made it increasingly clear that certain aspects of personal lifestyles andare summarized below.

daily habits—including diet, exercise, rest, sleep, smoking, alcohol consumption, and work styles—are
primary factors in causing disease. The first work to bring about this change was A New Perspective on
the Health of Canadians by Marc Lalonde, published in 1974 and often referred to as the “Lalonde
6,7report”.

Lalonde also emphasized the role of physical and social environments as determinants ofhealth that are out of individuals’ control. However, this evidence strengthened the trend towards viewing
disease as a matter of personal responsibility, and efforts to both prevent disease and improve health1.

Build Health-focused Public Policy
Health promotion puts health on the agenda of policymakers in all sectors and at all levels,
directing them to be aware of the health consequences of their decisions and to accept their
responsibilities for the people’s health.

2. Create Supportive Environments

have focused on individuals, with little attention paid to social elements or social environments that

Health promotion creates living and working conditions that are safe, stimulating, satisfying,influence people’s daily habits.

and enjoyable.

Naturally, not everyone can freely determine their own daily habits, lifestyle choices, and other

3. Strengthen Community Actions

aspects of life. Key factors in this context include the quality of education received, work performed and

Health promotion works through concrete and effective community action in setting priorities,

level of income earned, quality of housing and co-habitants, foods consumed, and how leisure time ismaking decisions, planning strategies, and implementing them to achieve better health.

spent. Such factors are heavily affected by circumstances such as the communities in which people live,

4. Develop Personal Skills

their workplaces, cultural and economic conditions at provincial, district, and national levels, and social

Health promotion supports personal and social development through providing information,

stability and policies. Thus it is essential for communities and nations to collectively support the healthhealth education, and enhancing life skills.

of their citizens.8 The concept of health promotion evolves from this background.

5. Reorient Health Services
The role of the health sector must move in a health promotion direction, beyond its responsibility
for providing clinical and curative services.

2) The Ottawa Charter for Health Promotion

6. Moving into the Future
Caring, holism, and ecology are essential issues in developing strategies for health promotion.

The First International Conference on Health Promotion took place in Ottawa, Canada, on November

Holism is the idea that every part of a whole is intimately intercorrelated.

21, 1986. The conference featured the declaration of the Ottawa Charter for Health Promotion. This
charter contained the following definition: “Health promotion is the process of enabling people toincrease control over, and to improve, their health.”8 Health, meanwhile, was defined as follows: “Health3) The Bangkok Charter for Health Promotion in a globalized world8

is a positive concept emphasizing social and personal resources, as well as physical capacities.” Asstated, health was clearly perceived as a resource and capacity for pursuing everyday life, rather than

The Bangkok Charter for Health Promotion emerged from a meeting of WHO member states

being defined as an objective.

convened in Bangkok, Thailand, in August 2005. The meeting was held as globalization advanced

The charter also mentions the following eight areas as prerequisites serving as a foundation forrealizing good health:8

around the world, and reflected the growing impact of that trend on human health.9 The following
declaration was issued at that time: “Health promotion is based on this critical human right and offers apositive and inclusive concept of health as a determinant of the quality of life and encompassing mental

24

1.

peace

and spiritual well-being.”9 This charter emphasizes that health promotion must be the focus of2.

shelterdevelopment planning worldwide, with health also to incorporate spiritual aspects.

3.

education
Chapter 1
Health25

5. School health initiative2) Significance and importance of health education in schools

According to the WHO, approximately 2.3 billion school-age children worldwide spend about a third of

There are various interpretations of the significance of school health education. Dr. Didier Jourdan

their time each day at school. Schools are environments unique in their ability to foster a positive(Professor, Dean of the Faculty of Education at the University Blaise Pascal of Clermont-Ferrand,

outlook on life and establish healthy lifestyles.

10

To achieve these objectives, schools work to

independently formulate various types of health services (e.g., health education, health check-ups, firstFrance) offers two distinctive perspectives.13 The first has to do with security, and the second with thewell-being of the individual and society.

aid, mental health counseling, and school lunches). It is also their mission to collaborate with social

In the first perspective, “security” signifies concern when increasing numbers of young people

resources available in their communities to contribute to the health not only of children, but also of

engage in unhealthy lifestyles and risky behavior due to inadequate knowledge about health. Such aschool personnel, children’s guardians, and local residents. The types of health services that schools

trend could result in damage to one’s own health, injuries to others, and behaviors that raise the economic

furnish and the approaches they use to supply those services—as well as the laws, policies, and ideas

burden on society. Public order could also deteriorate, leading to societal instability. In the interest of

regulating them—differ from country to country.

maintaining the security of society and avoiding such risks, providing young people with health education
at their schools is therefore believed essential.  

1) School health objectives and initiatives

Dr. Jourdan’s second perspective on the significance of school health education, “well-being,”
reflects the moral and ethical obligations of modern nation-states.13 This refers to expectations anddemands for a heightened sense of well-being by the individual and society. In other words, because theLet us look at the examples of the United States and Japan. Below is a summary of the seven school

health of individuals and society in general amounts to well-being, it is vital to make concerted efforts

health approaches and services supplied in the US, as presented by the American School Healthto maintain and improve the health of both individuals and society through school-based health education

11

Association.

School health support in the United States consists of three pillars: the environment,

and health promotion.

services, and teacher training.
• Environment:

3) The link between education and health

A healthy and safe environment, including the physical, psychosocial, and learning environments• Services:

According to Dr. Fiona Brooks (Professor, the Faculty of Health, University of Technology Sydney,

Services and opportunities, including meals, physical activities, and health education as well asAustralia), “research evidence shows that education and health are closely linked. So promoting thecounseling, social work, and nursing

health and wellbeing of pupils and students within schools and colleges has the potential to improve• Teacher training:
Knowledgeable teachers and competent staff for health education and health services

their educational outcomes and their health and wellbeing outcomes.”14
In the “Annual Report of the Chief Medical Officer 2012” issued by the Department of Health, UK,
Dr. Brooks also mentioned that promoting physical and mental health in schools creates a virtuous

In Japan, the Ministry of Education, Culture, Sports, Science and Technology defines the objectivesof school health activities as follows: ensuring that schools strive to maintain and improve the health ofcircle, reinforcing children’s attainment and achievement, which in turn improves their wellbeing,enabling children to thrive and achieve their full potential.15

students and other parties (e.g., teachers and school office staff); giving careful consideration to thehealth and safety requirements for school education activities as a form of group learning; and cultivating
abilities needed to maintain and improve the health of oneself and others.12 To achieve these goals,
schools provide on-site health administration and health education.

6. Cambodian initiatives Focusing Resources on
Effective School Health

Health administration comprises health initiatives such as conducting health checkups and improving
school environments based on the School Health and Safety Act. Health education aims to instill

The Cambodian government has set four goals in its quest for school health: 1) improve the health of all

knowledge and capabilities necessary for healthy living through all school education activities, including

people; 2) improve the capacities and skills needed to prevent sickness and avoid the dangers of accidents

subjects such as physical education and special activities.

in everyday life; 3) supply and encourage opportunities for school health promotion; and 4) ensure equal
access to health education services. These goals cannot be achieved through the efforts of the health andeducation sectors alone; they also require the cooperation of numerous related organizations (e.g., theprivate sector, community organizations and women’s groups, and non-government organizations).

26

Chapter 1
Health27

Based on that understanding, the program has been advanced through the Focusing Resources on

physical health, while promoting sanitation, cleanliness, and comfort in the interests of greater

16

Effective School Health (FRESH) framework.

safety and peace of mind in schools, communities, and public spaces- Participation, collaboration, and coordination of wide-ranging groups, organizations, and

FRESH was first proposed in 2000 as a framework for addressing comprehensive school health. The
program was based on the results of deliberations by the WHO; the United Nations Educational,

agencies

Scientific and Cultural Organization (UNESCO); the United Nations International Children’s

Participation and collaboration by all concerned parties (e.g., schools, local governments, health

Emergency Fund (UNICEF); and the World Bank. Those discussions addressed how best to integrate

workers, community groups, religious groups, and NGOs) to advance school health promotion

the effects of human, financial, and other resources in activities that would have positive effects on

programs

school health.17
In 2019, the Cambodian government introduced a new policy setting out future vision based on the

Under FRESH, the following four areas are considered core components for integrating such

School Health Policy 2006.18 Achieving effective school health in Cambodia based on the new policy

activities:

requires all students, teachers, guardians, and other concerned parties to actively participate and1.
2.

Health-related school policies

collaborate in healthcare services, health education, and environmental enhancement, and to join in

Strategic positioning of health in school administrative policies

efforts to help schools serve as health promotion hubs.

Safe water and sanitation—the essential first steps toward a healthy physical and learning
environment
The true foundation of safe and healthy school environments lies in safe water and sanitation

3.
4.

Column: National School Health Policy 2019 is promulgated

Skills-based health education

Under School Health Policy 2019, by improving the quality of education, the government will engage

Health education positioned to cultivate the attainment of specific skillsin the following challenges; providing health knowledge based on scientific knowledge of mental

Access to health and nutrition services

and physical development, providing basic health services, encouraging the learning of skills for

Supply of outstanding health and nutrition services

preventing infectious and non-infectious diseases, fostering values and behaviors for attaining full
health (mind, body, and spirituality), and enhancing a sense of responsibility for behaviors.

As described above, FRESH serves as a framework for effectively achieving Cambodia’s drive torealize better, more child-friendly schools by prioritizing the aspects of school health expected to produce

Furthermore, the new school health policy has the goal of creating an inclusive learning environment
and fostering a culture of care in school personnel, family, and community.

positive effects.
The new policy has the following eight pillars, of which we list some examples.

7. The future of school health in Cambodia

1

Improve fundamental health of learners and educational personnel- equipping health rooms- providing health examinations and physical measurements, first aid, and vaccination

Since 2006, the School Health Policy has enabled fundamental understanding of Cambodia’s pillars of
17

school health. It consists of the four pillars listed below, which are shared with school health schemes--preventing infectious diseases, food poisoning, and mental health insufficiency
2

Promote nutrition provision

adopted in the US and Japan. Pursuing better school health initiatives in keeping with these schemes is- implementing a school vegetable garden

therefore likely to lead to a brighter future for school health in Cambodia.

- setting environmental hygiene standards- monitoring food sales in educational facilities- Basic healthcare services- setting food safety and hygiene standards

Supplying basic healthcare services that children need to equitably attain physical, mental, spiritual,and social development- providing nutrition education for parents
3- Health education- setting the guidelines of the minimum requirements for water, hygiene, and cleanliness

Promoting behavioral changes in children to achieve well-being and safety (via information supply,- enhancing facility cleanliness and hygiene, and sanitary behavior

knowledge, skills, and changes in attitude to this end)

- strengthening the concept of cleanliness, safety, and hygiene behavior- Environment
Pursuing initiatives to improve facilities and equipment that support learning environments and28

Improve supply of clean water, sanitation, and hygiene

4

Improve safe, inclusive, comfortable and friendly learning environment- creating an environment to support health, happiness, and comfort of children and personnel,
Chapter 1
Health29

including exhibiting educational materials and works- equipping garbage disposal- holding school events- providing education to prevent tobacco, alcohol, and illegal drug use- as accident prevention, setting up signs to inform of danger, traffic signs, and teaching traffic
safety rules
5

Promote security and order in educational institutions- setting “One School, One Harmonious zone” principle- prohibited bring in dangerous materials and weapons- strengthening traffic safety education- installing school fence to ensure safety- teaching accident prevention (drowning accident)- appointing a vice-principal in charge of school health- implementing extracurricular activities for children and teachers in collaboration with healthorganizations and communities

6

Promote health education- making a health education curriculum to introduce health education into teacher training andordinary education- training health education specialists at teacher training institutions- providing in-service training to school teachers and training to teacher training institutions

References
1

World Health Organization Constitution. https://www.who.int/about/who-we-are/constitution

2

Asakura T, Mallee H, Tomokawa S, Moji K, and Kobayashi J. The ecosystem approach to health is a promising strategy ininternational development: lessons from Japan and Laos. Global Health. 2015; 11: 3. doi: 10.1186/s12992-015-0093-0.

3

Huber M, Knottnerus J A, Green L, et al. How should we define health? BMJ 2011;343:d4163. doi: 10.1136/bmj.d4163.

4World Health Organization 101st Session Agenda item 7.3. Review of the Constitution of the World Health Organization: report of5

Australian Medical Association. Developmental Health and Wellbeing of Australia’s Children and Young People - revised 2010.

the Executive Board special group. EB101.R2, 1998. https://apps.who.int/gb/archive/pdf_files/EB101/pdfangl/angr2.pdf
https://ama.com.au/position-statement/developmental-health-and-wellbeing-australia%E2%80%99s-children-and-young-people-- disseminating information on disease/risk prevention- appointing health education managers- fostering a health education role model
7

Promote the implementation of health skills- changing behavior for health, environmental health, and social well-being- learning first aid skills- building a gymnasium- implementing systematic hygiene and cleanliness measures

8

Promote the participation of all stakeholders in improving school health- promoting engagement of relevant agencies, parents, communities, aid partners, monks, andcommunity leaders in school health(Source: Royal Government of Cambodia. National Policy on School Health. 2019)revised6

Lalonde M. A New Perspective on the Health of Canadians -a working document. Minister of Supply and Services Canada, 1981.
https://www.phac-aspc.gc.ca/ph-sp/pdf/perspect-eng.pdf

7

Lalonde report. https://en.wikipedia.org/wiki/Lalonde_report.

8

World Health Organization. Health Promotion: The Ottawa Charter for Health Promotion. https://www.who.int/healthpromotion/
conferences/previous/ottawa/en/

9World Health Organization.  Health Promotion: The Bangkok Charter for Health Promotion in a Globalized World (11 August 2005).
https://www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/

10 World Health Organization. Maternal, newborn, child and adolescent health: School health services. https://www.who.int/maternal_
child_adolescent/adolescence/school-health-services/en/
11 American School Health Association. What is School Health? http://www.ashaweb.org/about/what-is-school-health/12 Ministry of Education, Culture, Sports, Science and Technology. Promotion of School Health. https://www.mext.go.jp/a_menu/
kenko/hoken/index.htm
13 Jourdan D. Health education in schools: The challenge of teacher training. Saint-Denis : Inpes, coll. Santé en action, 2011 : 144 p.
https://pdfs.semanticscholar.org/677b/09068a6de93acdc7cde3dce98881b78a667a.pdf
14 Brooks F. The link between pupil health and wellbeing and attainment: A briefing for head teachers, governors and staff in education
settings. Public Health England 2014. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/

Exercises for further thought and research[1-1] Think about what health and the conditions for being healthy mean to you.
[1-2] Consider why school programs need to teach children about health and diseases.
[1-3] Examine how Cambodian society views diseases.
[1-4] Conduct group discussions on what Cambodian schools can do to promote children’s health,reflecting on your own experiences.
30

file/370686/HT_briefing_layoutvFINALvii.pdf
15 Brooks F (2013). Chapter 7: Life stage: School Years, in Chief Medical Officer’s annual report 2012: Our Children Deserve Better:
Prevention Pays, ed. Professor Dame Sally C Davies. London: Department of Health, UK. https://assets.publishing.service.gov.uk/
government/uploads/system/uploads/attachment_data/file/252657/33571_2901304_CMO_Chapter_7.pdf
16 UNESCO, UNICEF, WHO, World Bank and Education International Inter-agency flagship programme in EFA. FRESH acomprehensive school health approach to achieve EFA. 2002. https://www.paho.org/hq/dmdocuments/2016/2002-FRESH-eng.pdf
17 Ministry of Education, Youth and Sport. School Health Policy. 2006. https://www.moeys.gov.kh/index.php/en/policies-andstrategies/1986.html
18 Royal Government of Cambodia. National Policy on School Health. 2019.
Chapter 1
Health31

Chapter 2

body (Figure 2.1). Functions for motion and regulation include seeing, hearing, and moving joints.

How your bodies function

Organs inside and outside the body are involved in these functions.

(Mechanisms and functions of your body)1) Basic structure of the human body (cells, genes, tissues, and organs)

Learning objectives

The human body is made up of cells as minimum units. A cell is composed of a cell nucleus and the

You will be able to gain proper understanding and explain:cytoplasm surrounding it. The cell’s basic function is to produce proteins based on the information- The mechanisms and functions of a body that supports life.

possessed by the cell nucleus. Each cell nucleus contains 23 pairs of chromosomes (46 in total), and one- The regulatory mechanisms of the human body in supporting daily activities, in relation to yourchromosome contains hundreds to thousands of genes. Genes correspond to the blueprint of the humanbody and form a part (region) of deoxyribonucleic acids (DNAs), which holds specific genetic

own daily activities.

information such as “what kind of protein to make. DNA is a chain of small units called nucleotides
In this chapter, you will learn about the basic structure (structure and morphology of organs) andcomposed of sugar, a nitrogenous base, and a phosphate group. It usually has a double-helix structure infunctions (roles and functions of organs) of the human body; organs and tissues functioning while

which two strands of nucleotides running in opposite directions are bound to each other. Long-pitchinteracting with each other; and functions of the body that maintain a stable internal environment.

filamentous double-helix DNA is connected to histones (protein) to form chromosomes, and is locatedin the nucleus of a cell. There are four types of DNA bases, namely adenine (A), guanine (G), thymine

1. Structure and functions of the human body(T), and cytosine (C), where A binds to T and G binds to C (Figure 2.2). Sequences in which the fourtypes of bases are arranged (base sequence) provide encoded (symbolized) genetic information. There
are many areas in DNA whose functions have yet to be understood.

The human body carries out various functions. These functions are broadly grouped into those that

There are many types of cells in the body, such as heart, liver, and muscle cells. They vary in size

sustain life and those that actively use life for motion and regulation. Examples of functions that sustain

and shape by their functions. For example, red blood cells (erythrocytes) are disc-shaped and are able tolife include eating food to obtain nutrition, breathing to take in air, and circulating blood throughout thechange shape easily. This allows them to squeeze through narrow blood vessels and transport oxygen
throughout the body. Derived from a single fertilized egg, all cells essentially have the same DNA.
However, different genes are expressed in different cells (or at different times in the same cell), which is

Thyroid gland
Trachea
Superior vena cava
Lung
Liver
Inferior vena cava
Gallbladder
KidneyUreterVermiform appendix

Aorta
Heart
Esophagus
Diaphragm
Aorta

Figure 2.1 Anatomy of the human body (Organs)32

chromosome

chromatin

2nm

nucleosome

10nm

StomachhistonePancreas

Sugar
CH2base phosphate

Small intestine
Large intestineDNA

1400nmSpleenBladder
Urethrawhy cells are able to acquire diverse appearances and functions.

nucleotide

nm = nanometre, 10-9 (m)RectumFigure 2.2

DNA structure
Chapter 2

How your bodies function (Mechanisms and functions of your body)33

A collection of specifically differentiated cells is called a tissue. Tissues work together to create anorgan that performs a specific function. A group of organs with similar functions is called an organsystem, which can be classified as shown in Table 2.1:

Main functions

Motor system(Bone, and muscle)

Bones form the skeleton (strut) that supports the body.
The body is able to move simply by moving bones withjoints. Bones also protect internal organs and thehematopoietic function.

Main organs

Bones, cartilage, joints,
muscles

34

23, spinal column 26, thorax 25, upper limbs 64, lower limbs 62), with five types of bone shapes (long,for air.

CardiovascularsystemHeart, blood vessels(arteries, veins), blood,
lymph vessels

Respiratory system

The respiratory system takes in oxygen necessary for
activities into the body and discharges carbon dioxide. It
also functions to produce sound waves (pharynx) andresonate in the oral cavity to produce voice.

Nose, pharynx, trachea,
lungs
Brain, spinal cord(central nervous system)

Nervous system

The nervous system can be divided into the central
nervous system (which processes collected informationand sends out instructions) and the peripheral nervous
system (which conveys instructions from the central
nervous system to various parts of the body and conveys
systemic information to the central nervous system).
The digestive system functions to chew, swallow, digest,
and absorb the beneficial parts of food into the body.

Oral cavity, esophagus,
stomach, small intestine,large intestine, rectum,
liver, pancreas

Autonomic nerve,
somatic nerve (peripheral
nervous system)

Urinary system

The urinary system excretes unnecessary substances inthe blood as urine. It adjusts the amount and composition Kidney, urinary tract,of urine to maintain the constant composition and osmotic bladder, urethra
pressure of body fluids.

Endocrine system

The endocrine system secretes substances (hormones) that
Pituitary gland, thyroid
circulate throughout the body along with the blood flow
and work on specific organs. It regulates the functions of gland, adrenal gland,pancreas, gonads
those organs.

Sensory system

The sensory system mainly collects information outside
the body to regulate and control the body’s activity.

Eyes, ears, tongue, nose,
skin

Reproductive
systemThe reproductive system produces sperms and eggs andfunctions to preserve species (create future generations),from the binding (fertilization) of sperms and eggs todelivery.

[Male] Testis, seminal
duct

Immune system

The skeleton is the base tissue shaping the human body. It includes a total of about 200 bones (cranial
short, flat, irregular, and pneumatized bones). Pneumatized bones (hollow bones) are filled with space

The cardiovascular system consists of the heart (acting as
a pump to circulate blood) and blood vessels (acting as
pipes for supplying blood), and functions to deliver therequired nutrients and oxygen to cells throughout thebody, as well as carry carbon dioxide and other waste
products away for disposal.

The immune system functions to eliminate foreign
substances invading the body and abnormal cells in the
body. The body is affected if its function deteriorates orreacts excessively.

and other connective tissues. It functions to move and support the body.

(1) Skeleton

Skeletal muscles are able to contract and change theirlength to move each part of the body.

Digestive system

1) Motor system
The motor system consists of the bones (making up the skeleton), muscles, joints, ligaments, cartilage,

Table 2.1 Main functions and types of organ systems

Organ system

2. Structures and functions of organs[Female] Ovary, uterus
Lymphatic vessels, bonemarrow, spleen, thymus,
blood, skin, tonsils

The roles of bones are as follows: (1) supporting the head, internal organs, and trunk, (2) supporting
movement, (3) protecting key organs, (4) storing minerals (calcium, phosphorus), and (4) creating bloodin the bone marrow (red blood cells, white blood cells, and platelets).

(2) Muscle
Muscles can be grouped into skeletal, cardiac, and smooth (visceral) muscles based on their differencesin shape and function. Skeletal muscle can be consciously moved through the somatic nerve (voluntarymuscle). Its roles include (1) moving the body by contraction and relaxation of skeletal muscle, (2)maintaining posture, and (3) producing body heat. Through muscle contraction, the skeleton moves at
joints. The axis and range of joint movement are mainly determined by the shape of the joint. During
movement, the muscles that mainly work are called prime mover (agonist muscles), the muscles thatwork together to move the body are called synergist muscles, and the muscles that perform opposite
movements are called antagonist muscles. For example, both flexors and extensors are antagonisticmuscles (Figure 2.3).

Biceps brachii

Humerus

Triceps brachii

Ulna
RadiusFigure 2.3 Muscle structure (agonist and antagonist muscles)
Chapter 2

How your bodies function (Mechanisms and functions of your body)35

AortaThe myocardium is the muscle forming the heart wall. It is the same striated muscle as the skeletal
Superior vena cava

muscle, but unlike the skeletal muscle, it cannot be moved consciously and is regulated by the autonomic

Pulmonary trunk
Left pulmonary artery

nerves (involuntary muscle). It differs from the skeletal muscle in that it does not get fatigued no matter
how much it continues moving, and in that myocardial cells do not have the ability to divide, whichmeans that these cells will not be regenerated once they are damaged or undergo necrosis, for example,
due to events such as myocardial infarction.

Right pulmonary arteryLeft pulmonary veins

Right pulmonary veins

Smooth muscles are also involuntary muscles, which are controlled by the autonomic nerves in theLeft atrium

Right atrium

same way as myocardium. They serve as the internal organ walls and blood vessel walls of the digestive
tract, airways, etc. Their ability to contract is not as strong as skeletal or heart muscles, but they can

Right ventricle

continue to move without getting tired.

Left ventricle
Interventricular septum

Inferior vena cava

Aorta

1

Column: Why do elderly people fall easily? (Aging of bones and muscles)

Figure 2.4 Heart structure and blood flow

With aging come many changes in the skeleton and muscles. For example, sarcopenia, a phenomenon
in which muscle mass decreases with age, begins around 30 years of age and progresses throughout
life. During this process, the amount of muscle tissue and the number and size of muscle fibers(2) Blood pressure regulation

gradually decrease. As a result, muscle mass and strength gradually decrease. This mild weakness

The pressure of blood on the walls of blood vessels is called blood pressure. The blood pumped byincreases the load on some joints (e.g., knee joints), thereby increasing susceptibility to arthritis andcontraction of the ventricles generates blood pressure. Blood pressure decreases as distance from the left

falls. Although physical inactivity (lack of exercise) is assumed to be the main cause, its mechanism

ventricle increases or elasticity of the vascular wall (vascular resistance) changes while blood moves in

has yet to be fully understood.

the vasculature from arteries through arterioles, capillaries, and venules to veins (Figure 2.5).
Vascular resistance is defined by: (1) inner diameter of the blood vessels, (2) viscosity of blood, and2) Circulatory system(3) total length of the vessels. The smaller the inner diameter of the blood vessel, the greater the resistanceto blood flow. Generally, physiological changes in the vessel diameter of the arterioles affect bloodpressure. Blood pressure lowers during vasodilation and rises during vasoconstriction. Blood pressure

The circulatory system consists of the heart, blood vessels, blood, and lymphatic vessels. It sends

rises when the viscosity of blood, which is regulated by the amount of red blood cells and plasma,

oxygen and nutrients to cells throughout the body and takes back carbon dioxide and waste products that

increases, and falls when it falls. Blood pressure is maintained relatively constant at rest. In adults,

are no longer needed by the cells.

normal values are approximately 120 mmHg for systolic blood pressure and 80 mmHg for diastolic(1) Circulation
The heart acts like a pump and is slightly larger than the fist (weighs about 250–300 g in adults). It is
located slightly to the left of the center of the chest in the mediastinum space in the thoracic cavity,
surrounded on its right and left sides by the lungs, and connected to the diaphragm at the bottom.
The heart is composed of four chambers (left ventricle, left atrium, right ventricle, and rightatrium). The atriums receive blood to the heart, and the ventricles pump out blood from the heart(Figure 2.4). Blood from the left ventricle flows throughout the body to supply oxygen and nutrients toblood pressure.
bloodpressure(mm Hg)

140
120
100
80
60

somatic cells, receives waste from those cells, and returns to the right atrium. This circulation is called

40

systemic circulation. On the other hand, blood from the right ventricle passes through the lungs, where20

it undergoes gas exchange (exchange of oxygen and carbon dioxide), and then returns to the left atrium.

0This is called pulmonary circulation.

mean arterial pressure

aorta

large
arteries

arterioles
venules large
venae
venules cavae
capillaries

right
ventricle

Increasing distance from left ventricle

Figure 2.5 Changes in blood pressure along systemic circulation2

36

Chapter 2

How your bodies function (Mechanisms and functions of your body)373) Respiratory system

The nervous system can be divided into the central nervous system (brain and spinal cord, thecenter of functions of the nervous system) and the peripheral nervous system (somatic and autonomic

The respiratory system consists of the upper respiratory tract (nasal cavity, pharyngeal pharynx,

nervous systems). Peripheral nerves cover every corner of the body and play a key role in connecting

larynx), lower respiratory tract (trachea and bronchus), and lungs. It works to take into the bodyeach part of the body to the central nervous system (Figure 2.7).

necessary oxygen and excrete carbon dioxide outside of the body (Figure 2.6).
The function of taking oxygen (O2) from the air (outside air) into the blood and excreting the carbon
Brain

Cerebrum, Diencephalon (Thalamus,
Hypothalamus), Cerebellum, Brainstem (Midbrain, Pons, and Medulla
oblongata)

Spinal cord

Medulla oblongata, Thoracic spinal
cord, Lumbar spinal cord, andSacral cord

dioxide (CO2) generated in the body from the blood to outside the body is called external respiration.
The O2 and CO2 that enter and leave the body through breathing are collectively called respiratory

Central nervous
systemgases, and O2 and CO2 gas exchange is performed in the alveolis.
After emitting CO2 and taking in O2 by external respiration, the blood returns to the heart as arterial
blood, and is pumped out from the left ventricle to the entire body. This blood reaches the periphery,
enters the capillaries, and exchanges gas with body tissues. The direction of inflow and outflow of
respiratory gas at this stage is opposite to those in external respiration in the lungs, i.e. O2 is released
from the blood and taken in by tissue cells, while CO2 generated by cell metabolism is released from

Nervous systemcells and moves into blood. Such gas exchange at peripheral tissues is called internal respiration.

Somatic nervous
systemPeripheral nervous
systemNasal cavity
Pharynx
LarynxAutonomic nervous
systemTrachea

Right lungLeft lungSensory nerve (afferent nerve)
Conveys information from different
distal parts of the body to thecentral nervous system.
Motor nerve (efferent nerve)
Conveys information from thecentral nervous system to different
distal portions of the body.
Sympathetic nervous system
Parasympathetic nervous system

Figure 2.7 Structure of nervous system classification(1) Central nervous system3, 4
The central nervous system comprises the brain and spinal cord. Located in the cranial cavity, the brain
Diaphragm
Figure 2.6 Respiratory organs

4) Nervous systemweighs approximately 1,300–1,400 g in adults. It can be divided into four main parts (cerebrum,diencephalon, cerebellum, and brain stem). The cerebrum is the most developed part of the brain andoccupies 80% of the whole brain volume. Its functions include identifying information and instructing
movements accordingly (primary functions), as well as advanced mental functions such as memory,emotion, motivation, and cognition (higher functions). Under the cerebrum lies the cerebellum (motor
regulation). Between the left and right sides of the brain is the diencephalon (sensory information38

Neurons are the basic developmental, morphological, and functional units of the nervous system. They

processing, and integration of the autonomic nervous system). The brain stem is the center of theare excited by stimuli, and the excitement is transmitted to other neurons by synapses. Neuronal

functions supporting life, namely respiration, circulation, digestion, and thermoregulation. The medulla

excitement generated by the stimulation of receptors in various parts of the body is transmitted to the

oblongata at its lower rear is connected to the spinal cord. The spinal cord is located in the spinal canal

central nervous system by ascending neurons, while excitement of the central nervous system isand is approximately 40–45 cm long in adults. Each nerve of the peripheral nervous system runs fromtransmitted to peripheral effectors by descending neurons. The nervous system covers the entire bodythe central system and branches repeatedly toward the target organs under its control. If the spinal cord

like a mesh and controls the functions of organs and tissues through the conduction of excitement

loses its function, all sensations will be lost, and you will become numb. Furthermore, motor functions

generated by impulses of nerve fibers and conduction of excitement to effectors and other neurons.

are also lost, and you will not be able to move.
Chapter 2

How your bodies function (Mechanisms and functions of your body)39

(2) Peripheral nervous system (somatic nervous system and autonomic nervous system)

breathing becomes fast and deep, your palms get sweaty, and you get thirsty. These are due tohyperactivity of the sympathetic nervous system. On the other hand, the parasympathetic nervous

Somatic nerves control the skin and muscles. The sensory information can reach consciousness easily,

system works when relaxed to encourage you to rest for storing energy. The parasympathetic

and often motor commands are consciously sent from the cerebrum.

nervous system also plays an important role in regulating the function of the digestive system, which

The autonomic nervous system controls most of the complex communication networks thattogether makes its function referred to as “rest and digest.”

regulate body functions. It works without human consciousness, and you almost never notice that it isfunctioning. Substances called neurotransmitters transport messages in different parts of the nervous
system, or between the nervous system and other organs. There are two types of autonomic nervous

5) Digestive systemsystems: sympathetic nervous system and parasympathetic nervous system. They control processes
such as blood pressure, heart rate, body temperature, digestion, metabolism, sweating, excretion, andThe digestive system has four roles: food intake and digestion, nutrient absorption, and excretion ofsexual response. Many organs are regulated by both sympathetic and parasympathetic nerves. These two

unwanted substances. It is composed of a single gastrointestinal tract, which extends 9 m from the mouthtypes of nerves work antagonistically. For example, signal input to the sympathetic nerve increases theto the anus, and several organs attached to it (Figure 2.9). Specifically, these organs include the mouth

heart rate, while signal input to the parasympathetic nerve decreases it (Figure 2.8). They also play a(oral cavity) , pharynx, esophagus, stomach, small intestine, large intestine, and anus for moving

major role in regulating blood pressure via hormones.

and absorbing food, as well as the pancreas, liver, and gallbladder, which are responsible for making
digestive enzymes, removing toxins, and storing substances needed for digestion.

Sympathetic nerve
ExciteParasympathetic nerve
Brain

Relax

Widen pupil

Iris of eye

Constrict pupil

Reduce saliva

Salivary gland

Increase saliva

Promote sweating

Sweat gland

DilateTracheaConstrict

Increase heart rate
Constrict
Increase blood pressure

Heart

Decrease heart rate
DilateDecrease blood pressure

Blood vessel

Food taken from the mouth is digested by the actions of digestive enzymes in the digestive juice
secreted into the digestive tract while the food is transferred to the stomach and small intestine. The
digestive juice is secreted not only from the cells in the digestive tract such as the stomach and small
intestine, but also by the salivary glands, pancreas, and liver.
Digested nutrients, water, and various electrolytes are mainly absorbed from the wall of the small
intestine into the cell, then into the blood. Most of the absorbed nutrients are sent to the liver. There, they
are synthesized, decomposed and detoxified, and converted into a form that can be used by cells
throughout the body. What is not absorbed is subjected to water absorption in the large intestine and thenis excreted as stool. Gastrointestinal motility and secretory functions are regulated by autonomic nerves,
intestinal plexus, and gastrointestinal hormones secreted into the blood from the gastrointestinal wall.

Blood pressure
Increase glycogenolysis

Liver

Suppress the activity

Gastro-intestine

Decrease urination(urine retention)

Bladder

Increase glycogen synthesis
Promote the activity

Mouth

Pharynx
Esophagus

Increase urination

Diaphragm

Figure 2.8 Actions of sympathetic and parasympathetic nervous systems

StomachLiver

Pancreas

Gallbladder
4

Column: Autonomic nerves referred to as “fight or flight” and “rest and digest”

Generally, the sympathetic nervous system works when you are stressed or taken by surprise. For

Large intestine
Small intestine
Rectumthis reason, it is referred to as “fight or flight,” as sympathetic nerves work to either counteract (fight)Anusagainst or escape (flight) from the situation in order to adapt to the circumstances. This explains, forexample, why when you are taken by surprise, your heart beats intensely, your pupils dilate, your40

Figure 2.9 Digestive organs
Chapter 2

How your bodies function (Mechanisms and functions of your body)416) Urinary system

mainly affects the growth of bones andHypothalamus

skeletal muscles, determining the size andPineal gland

As you live, many waste products, excess salts, and non-volatile acids are produced in your bodies as aheight of the body. Growth hormone isresult of metabolism. The urinary system functions to produce urine in the kidneys so as to efficiently

secreted during exercise and sleep, that’s

remove these substances from the blood and excrete them from the body through the urine. By adjusting

why they say “children who sleep (andthe amount and concentration of urine produced, it maintains the amount of circulating blood and its

exercise) adequately grow well.” Reduced

chemical composition.

secretion from the pituitary gland during

The urinary system is comprised of the kidneys and urinary tracts (ureters, bladder, urethra)childhood causes short stature. The pancreas(Figure 2.10). The kidneys filter and concentrate blood to make urine. The kidneys are located on the left

secretes insulin and glucagon into the blood,and right sides of the spinal column. Each is about 10 cm in length, 6 cm in width, and 3 cm in thickness.

hormones involved in the regulation of blood

They are slightly larger than the fist, protrudes like a bow on the outside and indents on inside, giving

sugar levels (glucose levels in the blood).

them their bean-shape. By regulating urine

Insulin is the only hormone produced in the

production, the kidneys keep fluid volume, osmotic

body that can lower blood sugar levels.

pressure, and pH (acid-base balance) constant,

When insulin does not function properly,

excrete unnecessary metabolites and drugs, andblood sugar levels spike, leading to themaintain the homeostasis of the fluid environment.

possible onset of diabetes.

The kidneys also have the endocrine function of

Pituitary gland
Thyroid gland
Parathyroid glands
Thymus gland
Adrenal glands
Pancreas

TestesGonadsOvariessecreting renin, which is involved in blood pressure
regulation, and erythropoietin, which has ahematopoietic effect, as well as activating vitamin
D for calcium metabolism.

KidneyUreterFigure 2.11 Endocrine organs

The bladder is a stretchable sac-like organ that
temporarily collects urine. The amount of urine

Bladder

produced per day is about 1.5 L, but the capacity ofan adult bladder is 250– 600 mL. You feel a light

UrethraSensation is awareness and consciousness of sensory information input from the outside or inside of theurinary urge when about 150 mL is collected and astrong one with about 250 mL.

8) Sensory system4

Figure 2.10 Urinary organs

body. For example, when you say “Ouch!” it means that you have become aware of pain stimulus. For
humans to carry out actions and follow their will, they need to carry out a series of actions by swiftly7) Endocrine systemgrasping various information from the outside, making judgments based on the information, and working
on the surroundings. The sensory system detects internal and external information and conveys that
information to the central nervous system.

The endocrine system consists of endocrine glands that are found widely throughout the body (Figure

Receptors are parts of the body that are sensitive to physical and chemical stimuli such as light,

2.11). It produces chemical substances (transmitters) according to purpose. These substances are

sound, body posture and movement direction, temperature, taste, and smell of things. On the other hand,collectively called hormones. The endocrine system regulates various functions of the body by secreting

sensory organs have a series of structures that transmit these stimuli to the afferent nerves (Figure(releasing) hormones directly into the blood. Hormones work as messengers responding to instructions

2.12).

from the brain, and act on specific organs (target organs) in cooperation with the nervous system to

There are general senses and special senses. Receptors for the general sense, also called somatic

control the activities of each part of the body such as metabolism, growth/development, and reproduction.

sense, can be found all over the body, specifically in the skin, muscles, joints, and internal organs. The

Excessive secretion or deficiency of hormones leads to serious health consequences, with excessive

general senses include the senses of pain, touch, pressure, temperature, and proprioception (sensory

secretion possibly causing hyperfunction, and reduced secretion causing hypofunction.

function to feel the relative positional relationship of each part of the body, which forms the body-

Major endocrine glands include the pituitary gland, thyroid gland, pancreas, adrenal glands, andgonads. For example, growth hormone, one of the representative hormones from the pituitary gland,
42

image). Special senses include vision, hearing, taste, smell, and parallelism. Receptors for these senses
are located in specific organs such as eyes, ears and semicircular canals, tongue, nose, and skin.
Chapter 2

How your bodies function (Mechanisms and functions of your body)43

(1) Male reproductive system (structure and functions)
Sight

The male reproductive organs consist of (1) testes; (2) epididymises, sperm ducts, and ejaculatory ducts(for maturation of sperms, transport path, and ejection); (3) seminal vesicles and prostate (attached

Hearing andequilibrium

gland); and (4) penis and scrotum (extrinsic region) (Figure 2.13). Reproductive functions include (1)Centralnervous
SystemSmell

Afferent
neuronsperm formation in the testes, (2) sexual response (various physical and mental changes that occur whensexually stimulated), and (3) regulation of reproductive functions by hormones.

(2) Female reproductive system (structure and functions)
The female reproductive organs consist of (1) ovaries; (2) fallopian tubes, uterus, and vagina (forHear and cold,
pain, touchtransportation route); and (3) mons pubis, clitoris, labia majora, labia minora (Figure 2.13). Reproductive

Tastefunctions are (1) conception and preparation for pregnancy, (2) pregnancy, and, similar to male, (3)sexual response, and (4) regulation of reproductive functions by hormones.

Figure 2.12 Sensory organ system (exchange of signal information)

2

Column: Why can we see in the dark? (Mechanism allowing to see in the dark)

In “vision,” which is the mechanism by which you can see things, sensitivity to light constantly
changes according to the intensity (brightness) of light so that you can obtain appropriate light andcolor information. When you suddenly go to a bright place after being in a dark place for some time,
you feel it is very bright, but that glare disappears in a relatively short time (light adaptation). This isbecause photoreceptor cells rapidly reduce their photosensitivity, and miosis occurs due to the

Urinary bladder
Seminal vesicle

Vas deferens

Prostate gland

Urethra
Penis

Anus

contraction of the iris sphincter muscle (pupillary light reflex), which also reduces the inflow of light.
On the other hand, if you move from a bright place to a dark place suddenly, at first you will not

TestisScrotum

be able to see anything, after which you will gradually be able to see things (dark adaptation). In
dark adaptation, mydriasis is caused by the dilator muscle of the pupil. Vitamin A deficiency causes
failure to adapt to darkness and this is called “night blindness.” Vision is discussed in detail in

Body

Chapter 8.

9) Reproductive system

Fallopian tube

Ovary
Endometrium

Reproduction is the act or process by which male and female germ cells, namely eggs and sperms are
fertilized, to create new beings with the genetic information of each cell. The reproductive system has
two functions. The first is production, development, and transport of eggs and sperms, and the second is
the secretion of hormones. There are two types of reproductive organs, primary reproductive organs
and secondary reproductive organs. The primary reproductive organ, which is the gonad (ovary infemales and testes in males), has two functions: secretion of hormones and production of egg and sperm.

Myometrium
Perimetrium

Cervix

UterusVaginaDuring growth, the functions of the reproduction system change significantly, the details of which are
discussed in Chapter 11.
44

Figure 2.13 Reproductive system (top: male reproductive organs, bottom: female)
Chapter 2

How your bodies function (Mechanisms and functions of your body)45

First line of defense

10) Immune system5

Chemical barriers

Immunity is a self-defense mechanism in which immune cells in the body prevent the entry of foreign

Mechanical barriers
Tears

invaders or pathogens, such as bacteria and viruses, and eliminate harmful substances produced in the
body. Many types of immune cells work together to play the roles of discovering, transmitting
information about, and attacking foreign invaders. There are two main types of immune functions that

Reflexes

Skin and mucous
membranes

Acid

Sneezing

eliminate foreign substances entering the body: innate (natural) immunity and adaptive (acquired)immunity.
Innate immunity is a mechanism that identifies a wide range of characteristics common to pathogens
and acts swiftly. It includes phagocytosis (action of taking foreign substances into cells and digesting

Second line of defense

Nonspecific
Immunitythem) by neutrophils, monocytes, dendritic cells, and macrophages to eliminate foreign substances,

Natural killer (NK)Cells

inflammatory reactions, and attack by natural killer (NK) cells. On the other hand, adaptive (acquired)immunity works against foreign substances that cannot be eliminated by innate immunity. In this case,lymphocytes act specifically on foreign substances. It can be divided into humoral immunity, in which

Phagocytosis

B cells produce antibodies from the actions of lymphocytes, and cellular immunity, in which killer T
cells directly attack cancer cells and infected cells (Table 2.2).

Inflammation

The immune system works to identify what is in the body as its “self ” or “nonself,” and to eliminate
the latter. To do this, the immune system coordinates innate immunity and adaptive (acquired) immunity

Fever

Protective proteinsto deal with disease-causing microorganisms (pathogens). On the other hand, because the immune

Copyright © 2017, Elsevier KK. All rights reserved. Translated and modified with permission.

system may overreact to your “self ” and cause diseases (autoimmune diseases), there is a system that

Figure 2.14 Immunity functions (innate immunity)4

adjusts the immune system to maintain the immune homeostasis of the living body in a balanced way.
There are many types of organs that contribute to immune cells and immunity (Figure 2.14). For
example, almost all immune cells are produced in the bone marrow. Immature T cells produced in the

3. Mechanisms that support human activities in daily life

bone marrow gather and mature in the thymus. The thymus, consisting of left and right parts, is locatedin such a way that it covers the heart. During puberty, the thymus reaches a maximum weight of 30–40

Mechanisms maintaining defense functions and regulatory mechanisms for sustaining life and theg. After puberty, the thymus begins to atrophy. The details of immunity are discussed in Chapter 7.

homeostasis of the human body

Table 2.2 Types and functions of human immunity and defense

Type

Main functions(1) Physical/chemical defense

Phagocytotic elimination, inflammatory
reactions, NK cell attack(2) Innate immunity(3) Adaptive immunity(Acquired immunity)

Skin, mucous membranes, saliva, sweat, tears,
runny nose, gastric acid

HumoralImmunity
Cellular
Immunity

TargetVarious foreign
substances(Nonspecific)

Antibodies produced by B cells react specificallywith the antigens to eliminate themSpecific foreign
matter(Specific)
Killer T cells and B cells eliminate cancer andinfected cells

1) Homeostasis of internal environment and its regulatory mechanism
What happens to your bodies in your daily lives? Living things have functions that help them staybalanced and maintain a similar state with their surrounding environment. This is called homeostasis(see also Chapter 6). To maintain homeostasis, the mechanism of information transmission in the living
body is crucial, and two systems serve this purpose: the nervous system that transmits information
by electrical signals and the endocrine system that transmits information via chemical substances.

2) Thermoregulation
The system that keeps the body temperature constant is very important for the brain and for sustaining
life. For example, hyperthermia such as heat stroke causes brain dysfunction, and can be life-threatening.

46

Chapter 2

How your bodies function (Mechanisms and functions of your body)47

This reduces the amount of blood flowing to prevent heat dissipation, and inadvertent muscle contraction(1) Body heat production and dissipation

causes heat production. Exceeding the limit of the thermoregulation range may lead to consciousness

Your body temperature differs by location. The temperature at the core of the body is called core

disturbance or death.

temperature and cannot be measured directly. For this reason, rectal temperature, oral temperature, and(3) Diurnal fluctuation (see also Chapter 6)

axillary temperature are used. The rectal temperature is the closest to the core temperature. Even if theenvironmental temperature fluctuates, it remains more or less constant at about 37°C, which is 0.4–0.7°C

Body temperature drops to the lowest level during sleep in the early morning, starts rising as you wakehigher than axillary temperature. The temperature of the skin and muscles is called outer shellup, and sharply rises after breakfast. After that, it continues to rise gradually and peaks in the evening,temperature, and it differs according to the body part and outside temperature.

after which it starts dropping. This change in body temperature in the cycle of one day is called diurnal
fluctuation (circadian rhythm). Circadian rhythm is present in many vital activities such as body(2) Thermoregulation mechanism

temperature and blood pressure and affects sleep and dietary patterns. If disturbed, sleep rhythm will be

The temperature regulatory center in the hypothalamus (diencephalon) works on cutaneous blood

disrupted, for example, resulting in sleep disorders. It is said that a good way to regulate this rhythm

vessels, sweat glands, and arrector pili muscle to regulate temperature. Thermoregulation in humans isnormally is to receive sunlight in the morning.

controlled by the sensitivity of skin temperature receptors and temperature receptors in the hypothalamus.
(Figure 2.15).

Column: Body temperature rhythm of women during and after puberty

When the body temperature rises, the sympathetic nerves work less, the blood vessels passively

6

dilate, and sweating dissipates heat from the skin to regulate the body temperature within the normal

In women during and after puberty, the body temperature fluctuates due to the effects of hormone

range. Meanwhile, when the body temperature decreases, the sympathetic nerves constrict blood vessels.

secretion according to the menstrual cycle. From menstruation to preovulation, body temperature islow (normal body temperature). After ovulation, the body temperature rises. The difference between

Thermostat

the low and high temperature periods is about 0.5°C. This fluctuation is due to the progesterone(secreted from the corpus luteum formed in the ovaries during the secretory period) acting on the

Hypothalamus

hypothalamus in the temperature regulatory center.

Exercises for further thought and research
Increased Temperature:

Blood vessels dilate, giving flushed
appearance.
Sweat glands become more active.

[2-1] Use information about the body: Challenge the quiz!

Decreased Temperature:

Blood vessels constrict, heat istrapped in deeper tissues.
Sweat glands become less active.
Skeletal muscles contract, causing shivering.

(1) Does the number of times you blink change when using a smartphone?
		(i) Increases(ii) Same(iii) Decreases(2) How much do you breathe in one day? (In terms of 500 mL plastic bottles)(3)	How much blood is sent from the heart to the entire body in one minute? Measure your pulse
for one minute and make a prediction based on it (see Chapter 15 for how to measure yourpulse).

References
1

Ministry of Health, Labor and Welfare: e-Health Net.
https://www.e-healthnet.mhlw.go.jp/information/dictionary/exercise/ys-087.html

Copyright © 2017, Elsevier KK. All rights reserved. Translated and modified with permission.

Figure 2.15 Mechanism of body temperature regulation

48

4

2

Atsushi Fujimoto (sp.), Mamoru Fujita, Yoshiaki Doi (ed.): Visual Anatomical Physiology. Nouvelle Hirokawa, Tokyo. 2007.

3

Anatomical Physiology: Structure and functions of the human body (1). Igaku-Shoin, Tokyo. 2018.

4

Human Body Original 5th Edition: Anatomical Physiology for Understanding the Body. Elsevier Japan, Tokyo. 2017.

5

Tadashi Ueda, Katsumi Maenaka (ed.): Pharmaceutical Immunology. Revised 3rd Edition. Nankodo, Tokyo. 2018.

6

Mechanisms and Functions of the Human Body, Asakura Publishing Co. Ltd., Tokyo. 2015.
Chapter 2

How your bodies function (Mechanisms and functions of your body)49

Supplemental materials (Suppl.)
Answers[2-1] Use information about the body: Challenge the quiz!

Cranium(1) Does the number of times you blink change when using a smartphone?
A. (iii). You blink less when concentrating on something such as when looking at the screen ofyour smartphone. When you blink less, tears do not spread on the surface of the eyes, causing theClavicle

Mandible

Scapulaeyes to dry. It can also cause “dry eye which leads to subjective symptoms such as dryness anduncomfortable sensation and damage (scratches) on the surface of the eyes.

Sternum(2) How much do you breathe in one day? (In terms of 500 mL plastic bottles)

HumerusA. About 11,520 L (taking the amount you breathe each time to be about 0.5 L)

Ribs

Vertebral column(3) How much blood is sent from the heart to the entire body in one minute?
A. Approximately 5 L. For adult, approximately 60–70 mL of blood is pumped out by one

Ulnacontraction of the heart. The heart beats 60–80 times per min. Normally, your heart rate is equal

RadiusCoxal (hip) bone

to your pulse rate. For example, 60 mL × 80 times = approx. 5 L volume of blood is sent to theentire body in 1 min. The volume of blood pumped out per minute varies depending on theindividual’s age, body size, gender, health condition, and exercise experience.

Carpals
Metacarpals

SacrumPhalanges

Femur

PatellaTibia
FibulaTarsals
Metatarsals
Phalanges

Calcaneus

Suppl 2.1 Skelton. Axial skeleton (pink) and appendicular skeleton (tan).

50

Chapter 2

How your bodies function (Mechanisms and functions of your body)51

Frontalis
Orbicularis oculi

Trapezius

Buccinator
Orbicularis oris

MasseterSternocleidomastoid

Trapezius

Pectoralis major

Deltoid

Deltoid
Biceps brachii
Brachialis

Serratus anterior
Triceps brachii

Rectus abdominis
Latissimus dorsiInternal oblique
External oblique
Gluteus medius

Brachioradialis

Iliopsoas
Quadriceps femoris
Rectus femoris

Sartorius

Vastus lateralis

Tibialis anterior

Biceps femoris
Semitendinosus
Semimembranosus

Vastus medialis
Vastus intermedius(not illustrated)

Gluteus maximus

Quadriceps ligament

Hamstring group
Gastrocnemius

SoleusAchilles tendon(calcaneal tendon)

Suppl 2.2 Major muscles of the body. Anterior view.

52

Suppl 2.3 Major muscles of the body. Posterior view.

Chapter 2

How your bodies function (Mechanisms and functions of your body)53

Chapter 3Children’s growth and development(ii)

Believe in the innate power to grow that every child is born with. Treat each child as having strong
vitality.

(iii) Understand, believe, and help develop the child’s innate abilities. Newborn babies already havevarious abilities at birth. We need to believe in such abilities and support the fulfillment of theirpotential.
(iv) View the child from a life-course perspective to support his or her future. A life-course perspective

Learning objectives

involves understanding the child’s health based on his or her past, present, and future. We also

You will be able to gain proper understanding and explain:need to bear in mind that the health impacts of childhood conditions may not become apparent- The principles of growth and development.

until adulthood.

- The characteristics of physical and physiological growth and development from infancy to earlyadolescence.
- What is necessary for the healthy growth and development of children in light of circumstances in
Cambodia.

Teachers can instruct children according to their growth and developmental stages by learning aboutchildren’s growth and development. Teachers can also help to build environments that promote healthy
growth and development by removing factors that have adverse effects on growth and development andby instructing children and their families to avoid such factors. Furthermore, by learning the normal
patterns of growth and development, teachers can assess whether a child is developing appropriately

This chapter defines the concepts of growth and development, then provides an exposition of the common

within normal ranges and help to start addressing problems at an early stage if any abnormalities or

principles of children’s growth and development and explains the characteristics of physical and mental

problems are suspected.

growth and development from infancy to early adolescence. Lastly, we describe factors that affectgrowth and development.

1. Human development

2. Principles of growth and development
Human growth and development are considered to result from synergy between a biological maturation
process regulated by genes and a developmental process influenced by the environment and learning

The process of humans maturing from birth to adulthood is expressed in various words including

experiences of the individual. Individual variability in human growth and development results from“growth,” “development,” and “maturity.” Growth refers to the maturation process of a living organism

differences in the biological maturation process and developmental process influenced by theincreasing in quantity through cell division, in other words quantitative change in morphology orenvironment. However, there are common principles of growth and development that apply to mostbody growth. Body height and weight are representative indicators of growth. Development, on theindividuals.

other hand, is a process through which biological structures and functions undergo division anddiversification to become more complex. Through this process, latent functions emerge over time. It isa phenomenon of qualitative change also influenced by the additional effects of experience, practice,1) Most children follow a certain developmental ordertraining, education, and environment. In other words, development refers to structural and functional
growth centered on mental aspects.1

Body growth and development of motor functions progress in a certain order.

Children are still in the process of growth and development. Their minds, bodies, and social relations

For example, most children become able to hold their heads up steadily when they are 3-4 months

change daily toward maturity. It is critical for children to have healthy childhoods in order to develop

old, roll over from tummy to back when 5-6 months old, sit unsupported when 7-8 months old, start

their intellectual, physical, and emotional capacities to their full potential. Children’s healthy growth andcrawling and stand holding furniture when 9-10 months old, and by the time they reach 12 months, somedevelopment not only enrich the child’s own personal life but also lead to enrichment of society as astart to walk alone. Although there is a wide variation as to when a child reaches a certain stage of motor

whole. Since children spend much of their time at school, teachers who engage with children have a duty

function development, they mostly follow a certain order of development (Figure 3.1).

to support children’s healthy growth and development. To this end, it is important for teachers to bear
the following four points in mind and take an integrated view of the holistic health of each child,rather than a fragmented view of children’s growth and development.2(i)View the child as a whole person. Understand the unique characteristics of each child and take aholistic approach to assessing his or her health.

54

Chapter 3

Children’s growth and development

55

process). The growth velocity, however, differs by age, sex, and function of the tissue (genetic factors).
For example, body height increases from infancy to adolescence. Furthermore, the period when bodyheight increases rapidly differs between boy and girls. Neural tissue develops rapidly during infancy and
In Mother’s womb

Birth

Lifting head

Rolling overSitting with Support

early childhood, while lymphoid tissue develops throughout middle and late childhood. Note, however,that Scammon’s growth curve only gives an image of growth and development after birth and that thesize and functions of each organ and tissue are not zero at the time of birth. Let’s work on “Exercise [33]” here.

Crawling

Standing up

Walking with support

Walks alone

Figure 3.1 Stages of growth and development in babies

2) A certain direction is observed in growth and development

4)	There are critical periods and sensitive periods in a child’s growth anddevelopment5
In the biological process of growth and development, there are critically important periods for the

3,4development of certain physical and mental skills and acquisition of new patterns of behavior. If a childdoes not receive the appropriate environmental stimulus or experience to acquire a given skill during

Body growth and development of motor functions progress in a certain direction. For example, motorthat period, it becomes difficult for the child to develop the associated functions or behavior later in life.

skills develop from holding the head erect, rolling over, sitting up without support, then standing up

This period is called the critical period. In the case of sensory and motor development, for example, thealone. As seen in this order, body functions develop in the direction from head to tail (cephalocaudal

environment and experiences during infancy have a large impact on the development of binocular vision

direction), and from the center or middle to peripheral portions of the body (proximodistal direction).

(the ability to see things using both eyes) and hearing acuity. The critical period for the ability to acquire

When we look at the process of how children become able to grasp an object, they first touch things, thenlanguage is said to be up to 12 or 13 years of age, meaning that if a child grows up in an environment

start grasping things using their fingers and palms (palmar grasp), and finally become able to grasp or

where he or she cannot receive proper language input during early childhood, it becomes very difficult

pick things up with their fingers (pincer grasp) (simple to complex, general to specific). As seen here,

for the child to acquire language proficiency after reaching adolescence.

body functions develop in the direction from gross to fine motor functions (Figure 3.2).

A sensitive period is when the child is most sensitive to certain environmental stimuli effective foracquiring a new pattern of behavior, which means that the period is most suitable for acquiring thatbehavior or skill. For example, Dr. Maria Montessori (described by the American Montessori Associationas "an Italian physician, educator, and innovator, acclaimed for her educational method that builds on the(i)From head to tailway children learn naturally") advocated that the sensitive period for acquiring cognitive skills and(ii)

From center to peripheral portionssocial aspects of life is from infancy to early childhood.6,7(iii) From gross motor to fine motor functions

Although the path of individual growth and development is not completely determined biologically,
we are not endowed with unlimited plasticity while we grow up. In fact, human growth and development
is an intermediate of both, determined through the influence of both biological characteristics and growth

Figure 3.2 Directions of body growth and development3)	Continuity of growth and development and difference in growth velocity
by organ and tissue

environment.

5) Individual variability of growth becomes significant with age
The biological variability of newborn babies is rather small, but as babies grow older, individual
variability becomes larger through the influence of genetic factors and the growth environment

As seen in Scammon’s growth curves (Scammon,1930), which show the growth of various tissue types(individual difference).

over time, while there are ups and downs in the curves, growth and development of organs and tissues
continue uninterruptedly until they reach the size of the adult level represented by 100% (continuous
56

Chapter 3

Children’s growth and development

57

3. Growth and developmental periods by age

meaning that they can learn to write letters by moving a pen with the tip of their thumb, index finger, andmiddle finger. They will also become able to hold a paper cup without crushing it by applying the right

Human growth and development periods can be roughly divided according to age groups: newborn (upto 4 weeks from birth); infant (until the age of 1); early childhood (until entering primary school) divided
into toddler (1-3 years) and preschool (3-6 years); middle childhood (during enrollment in primaryamount of force as appropriate to the object.

(3) Cognitive development

school; school age, 6-12 years); and adolescent or late childhood (from secondary school to adulthood,Children at the ages of two to three start developing abstract thinking skills, the ability to form an image

or until height growth ceases; approximately 12-18 years) (Figure 3.3). Here, we will investigate theof something through perceptual experiences, and imagine things that are not being directly experienced.

details of physical growth, motor and cognitive development, and emotional and social development

When they reach the ages of four to six, they become capable of sorting and associating objects. They

during the early and middle childhood periods (Table 3.1).

also understand left and right with reference to their own body. When drawing a picture of a person, they0
1start drawing hands and feet, though not in sufficient detail.
Dramatic language development can be seen during the toddler period. After 18 months to two years

Infants
Early childhood(Toddler and preschool)

6from birth, children start joining two words in a sentence and their vocabulary rapidly expands. It is said
Enters kindergaten
Enters primary school

Middle childhood
1218Adolescence(Late childhood)

Enters secondary school

Figure 3.3 Children’s growth and development periods by age

1) Growth and development during early childhood(1) Physical growththat by the age of two children typically have a vocabulary of more than 300 words. At the ages of fourto six (i.e., preschool age), they understand that a “cat” is an “animal” and “banana” is “food.” Thismeans that they understand the definition of those words and can categorize words that represent a
concrete object into a category of abstract meaning.

(4) Emotional and social development
Emotional and social development during the early childhood period is closely associated with humanrelations, basic lifestyle habits, and play that the child experiences. Children start developing selfconsciousness and show their desires. For example, children two to three years old play individually,
doing their own things, even when there are other people around, but as they grow older, they graduallylearn to engage in the same play and interact with others. By the time they reach five to six years of age,they can share common goals and rules while playing. They develop the ability to understand other

Body height and weight steadily increase during these periods. By the time a child reaches the age of

people’s feelings from around age four and become capable of thinking from another person’s point of

five, body height and weight will increase 2.2-fold and 6-fold respectively from the time of birth. Body

view.

shape becomes more slender, approaching the shape of an adult, and the head-to-body ratio reaches
around 1:6 at the age of six. A child’s permanent teeth start to grow from around this time, with someindividual variability.

(2) Motor development(1) Physical growth and development

Gross motor skills development: a child typically starts walking around 12 months after birth, becomesPhysical growth and development are steady and gradual during the earlier half of the middle childhood

able to walk steadily by 18 months, and by the age of three, can jump and kick a ball. At ages five to six,

period. Once children enter the latter half, however, genital functions develop rapidly with somemost children become able to make complex and coordinated movements using hands and feet like

individual variability. Development of genitalia begins earlier in girls than in boys. Girls start to develop

standing on one foot, skipping on both feet, and jumping rope.

breasts and pubic hair.

Fine motor skills development: a child from 12 to 18 months old has typically mastered basic skills
like reaching out for an object, grabbing, and letting go. As children grow older, they become capable of582) Growth and development during the middle childhood period(2) Motor development

coordinated motions using tools with both hands. At ages three to four, they become able to use scissors

Children develop muscles and acquire basic motor skills over the middle childhood period. They becomeor button and unbutton clothes, which require different movements between the two hands, but still inable to jump, throw, and perform other motions much more skillfully than during the early childhood

an awkward manner. From around age four, children start showing a tendency to consistently use theirperiod. They learn how to combine basic motions using hands and feet, and attain temporal and spatial

dominant hands. By the ages of five to six, they become capable of skillfully moving finger joints,

movement skills.
Chapter 3

Children’s growth and development

59Children form groups based on a sense of unity fostered by playing together and sharing the same(3) Cognitive development

experience. This period is called the “gang age” and peer groups take on a social significance. TheseIn the cognitive aspect, children start thinking logically about specific things. By ages nine to ten, theygangs or peer groups are prominently characteristic of boys.

become able to recognize equal amounts of a substance even if it is placed in different containers. This
indicates that they have acquired the concept of “preservation” and are ready to understand such concepts
as numbers, weight, volume, and time. From ages eleven to twelve, children start to think systematicallyand infer a conclusion based on a hypothesis.

4. Factors that influence children’s growth anddevelopment

The main form of communication for children is speech during the early childhood period, but asthey grow up and attend school, they acquire other forms of communication: writing and reading. During

Historically, children’s health was defined in the same way as adult health and was hardly given special

the earlier half of the middle childhood period, children tend to write only short sentences, but willconsideration. However, it has recently been recognized that a developmental perspective needs to beeventually learn to write longer sentences using conjunctions in the latter half of this period.

incorporated into the concept of children’s health. It is becoming increasingly clear that children’s healthis determined through the interaction of many factors different from those of adults. Against this(4) Emotional and social development

background, the Committee on Evaluation of Children’s Health (National Research Council and Institute

The middle childhood period is a time when children develop social emotions such as sense of self andof Medicine, US) issued a report that proposes to define the concept of children’s health as follows to

empathy within the social framework of school. Self-consciousness can be observed from the early

include growth and development and sheds light on the factors that influence developmental health.8

childhood period, but children start to recognize and sense themselves as beings (i.e., experience their“Children’s health is the extent to which individual children or groups of children are able or enabled

own existence) through social interrelations with their peers when they enter the middle childhoodto (a) develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities that allow

period. They develop feelings of capability as well as inferiority through comparison with others, andthem to interact successfully with their biological, physical, and social environments.”8

gradually establish their feelings of self-esteem. Peer-to-peer relationships also undergo change in thelater part of the middle childhood period. The peer group with which a child engages grows larger.

Table 3.1   Summary of development indicators during the early and middle childhood periods

Dimension of Development

Infancy and early childhood period

Age

0-1

Body height

1.5 times birth height

Body weight

3 times birth weight

Gross motor skills

1-2

60

4-5

5-6

4 times birth weight

6-7

Catches a ball with hands

5 times birth weightStands holding furniture Walks

Runs

Drops a ball and follows Throws a ball toward a
it with eyestargetKicks a ballSkips on one footSkips on both feet

Draws a circle

Draws a square

Draws a triangle

Fine motor skills

Emotional and social skills

3-4
Twice birth height

Draws and copies lines

Language skills

2-3

Middle childhood period

Builds a tower withblocksUses scissors

Produces first
intelligible words

Expands vocabulary

Asks questions using
interrogatives

Understands and obeys
prohibition

Plays alone apart fromparents

Plays with friends

Repeats the same
behavior when praised

Imitates phone
conversation

Likes to care foryounger children

Capable of holding a
conversation

Reads, writes, andacquires basic academic
skillsPlays in groups of threeor moreRational and theoreticalthinking

Can make inferences in
the mindAsks for permission

Can move from concrete
to abstract thinking

Chapter 3

Children’s growth and development

61

Table 3.2   Organization of Influences on Children’s Healthconditions such as water sources and toilet facilities, violence against children and child labor, andChildren’s biology

socio-economic disparity between urban and rural households. Therefore, in order to promote the healthyChildren’s behavior

development and growth of Cambodian children, it is necessary to clarify the risk factors and factors

Physical environment

promoting development and growth by targeting a wider age range of children and to address suchchallenges as school health initiatives under the national policy.

Prenatal exposures
Childhood exposures

Table 3.3   Examples of community or ecological risk factors and individual risk factors

Home, school, and work settings

among preschool children in developing countries

Child injury and the provision of safe environments

Community or ecological risk

The built environment

Individual

Poor sanitation

Repeated infections

FamilyFamineUnder-nutrition

Community

Endemic violence

Abuse and neglect

CultureLack of accessible services: preschools, schools,
libraries, health services

Very low family income

Lack of commitment to child development

Low birthweight

Social environment

Discrimination
Services
PolicyLow maternal education9

Large family size

Cited from “Committee on Evaluation of Children’s Health. Children’s health, the nation’s wealth: Assessing and improving child health.”

Short intervals between births
Low levels of developmentally enhancing parenting
practices

According to the report, there are biological, behavioral and (physical and social) environmental
factors that affect a child’s developmental health (Table 3.2). From this report, we can understand acomprehensive list of factors that affect children’s health. Biological influences include genetic

11

Cited from “A brief review of risk-factors for growth and developmental delay among preschool children in developing countries”

expressions, prenatal influences, and perinatal and postnatal events. Behavioral influences include thechild’s emotions, beliefs, attitudes, behaviors, and cognitive abilities. Environmental influences are

In light of this situation, the Cambodian Government developed the five-year National Action Plan

wide-ranging and include influences from the biological environment (e.g., infectious agents such as

on Early Childhood Care and Development, 2014-2018, which aims, as a priority, to increase school

malaria and intestinal helminths in Cambodia) and physical environment (e.g., water pollution andenrollment rates and enhance protection of all young children under six years of age, especially children

exposure to metals and pesticides in Cambodia) and social factors such as loving interactions withfrom poor families and indigenous minority groups and children with disabilities, who were mostcaregivers (e.g., domestic violence, abuse, and maternal mental health in Cambodia), socioeconomic

marginalized from early learning opportunities. Through this action plan, the Cambodian Government

resources in the family and community (e.g., income and job opportunities in Cambodia), and peer

commits to extending support and improving the quality of early childhood care and development

9

relationships and the availability and quality of services (e.g., health services in Cambodia).

throughout the nation.13

In a survey of factors affecting early childhood growth and development based on the current
situation in Bhutan, the following five main factors have been identified as contributing to growth anddevelopment in early childhood: nutrition, environment, parent’s behaviors, parenting, and social andcultural practices.10 Table 3.3 shows risk factors for growth and developmental delay in developing
countries, listing influence of both community or ecological factors and individual factors on preschool
11

children.

The issue of healthy growth and development in children is a focus of interest in Cambodia, too. The
health status of children in Cambodia largely improved in the period from 2000 to 2010: infant mortality(deaths per 1,000 live births) dropped from 95 to 45 and under-five mortality (deaths per 1,000 live
births) from 124 to 54.12 On the other hand, consistent with the risk factors noted in Table 3.3 and the
Bhutan study, there are still challenges to be resolved, such as improvement of nutritional status, hygiene
62

Exercises for further thought and research[3-1] Think of a child you are familiar with (a younger brother or sister, a child in the neighborhood,etc.) and check the child’s growth and development status according to the dimensions ofdevelopment in Table 3.1.
[3-2] Consider the potential benefits and significance for a school teacher of learning about children’s
growth and development processes.
[3-3] Check the patterns of Scammon’s growth curves on the Internet and their characteristics. Next,
think about why these pattern differences occur.
Chapter 3

Children’s growth and development63[3-4] Consider events and phenomena that are, or are likely to be, a threat to the growth and developmentof children in Cambodia.

Chapter 4

Cleanliness, hygiene and health
Learning objectives
You will be able to gain proper understanding and explain:- The principles of cleanliness and hygiene.
- With examples, diseases and conditions that arise from unsanitary and unhygienic behavior.
- With examples, good hygiene behavior and behavior to keep our bodies clean.
- With concrete examples, unhygienic environments (home, school, town/community).
- With multiple examples, diseases and conditions that arise from unhygienic environments.
- With examples, what can be done to improve unhygienic environments.
- Ideas on how unhygienic and unclean behaviors can be changed.
In this chapter, we learn about cleanliness and hygiene in relation to children, homes, schools, andcommunities. The speciﬁc learning topics are hand washing, bathing, clean water, hygienic foodpreparation, cleaning, waste separation, and water and sewage systems.

References
1

Edited by Emiko Fukuda, (Ed.) “Ningen hattatsugaku (Human development)” 5th edition, Tokyo: Chugai-Igakusha, 2019.

2

Edited by Goro Kono and Etsujiro Takahashi, (Eds.) “Hoikuno nakano hoken – Yochien/hoikusho denohokenshido no riron to jissen(Health as part of nursing – Theory and practice of health guidance in nursery schools),” revised edition, Tokyo: Houbunshorin,
2010.

3

Ruffin N.J. Human growth and development – A matter of principles. Virginia Cooperative Extension. Virginia Tech. 2019. https://www.pubs.ext.vt.edu/content/dam/pubs_ext_vt_edu/350/350-053/350-053 (FCE-134 P).pdf

4

Dhaker R. Growth and development. https://www.slideshare.net/rdhaker2011/growth-and-developmentppt

5

Schaffer H.R. Key Concepts in developmental psychology, 58-61, Los Angeles, Sage, 2006.

6

Montessori M. Six “Sensitive Periods.” https://www.montessoritrainingusa.com/sites/montessoritrainingusa.com/files/Six%20
Sensitive%20Periods.pdf

78

To lead healthy lives, we need to keep our own bodies clean and hygienic. “Cleanliness” refers to thestate or habit of keeping yourself and your surroundings free from dirt. “Hygiene” means the practice ofpreventing illness or the spread of disease by keeping yourself and your home, workplace, and community

Who-Was-Maria-Montessori

environments clean. Key behaviors in maintaining cleanliness and hygiene are washing your hands,

Committee on Evaluation of Children’s Health. Children’s Health, the Nation’s Wealth: Assessing and Improving Child Health. p.4,

brushing your teeth, and bathing.

Committee on Evaluation of Children’s Health. Children’s Health, the Nation’s Wealth: Assessing and Improving Child Health.
p.45-90, Washington DC, The National Academies Press, 2004. https://www.ncbi.nlm.nih.gov/books/NBK92200/#ch3.s1

10 Pem D. Factors Affecting Early Childhood Growth and Development: Golden 1000 Days. Journal of Advanced Practices in Nursing,
1:1, 2015. DOI:10.4172/2573-0347.1000101.
11 Ali S.S. A brief review of risk-factors for growth and developmental delay among preschool children in developing countries.
Advanced Biomedical Research. 2:91.2013 doi: 10.4103/2277-9175.122523.
12 National Institute of Statistics, Directorate General for Health, and ICF Macro, 2011. 2010 Cambodia. Demographic and HealthFirst, to prevent infectious diseases, it is important that your hands are clean (not dirty) and hygienic(no cause for disease to take effect). Hands need to be washed with water and well-lathered soap toremove dirt attached to the surface of the hands (cleanliness), while also removing the viruses andbacteria that are the cause of disease (hygiene), blocking this infection route. As explained in detail in
Chapter 7, the three main factors in the transmission of infectious diseases are pathogens (for example,
bacteria and viruses that cause disease), transmission routes (the routes whereby bacteria and viruses

Survey: Key Findings. Phnom Penh, Cambodia and Calverton, Maryland, USA: National Institute of Statistics, Directorate General

are communicated), and hosts (people’s resistance and immunity to bacteria and viruses). Transmissionfor Health, and ICF Macro. https://www.nis.gov.kh/nis/CDHS/CDHS_2010_Key_Findings.pdf

routes include direct contact, droplets, and airborne transmission. To prevent direct contact

13 The National Committee of Early Childhood Care and Development. National Action Plan on Early Childhood Care andDevelopment 2014-2018. https://planipolis.iiep.unesco.org/sites/planipolis/files/ressources/cambodia_early_childhood_national_
action_plan_2014-2018.pdf

641) Personal cleanliness and hygiene

American Montessori Association. Who Was Maria Montessori? https://amshq.org/About-Montessori/History-of-Montessori/

Washington DC, The National Academies Press, 2004. https://www.ncbi.nlm.nih.gov/books/NBK92198/#ch2.s3
9

1. Personal and environmental cleanliness and hygiene(home, school, town/community)transmission in particular, it is important to maintain cleanliness and hygiene by washing your hands,
sterilizing your ﬁngers, and sterilizing surfaces that are touched by multiple people.
Chapter 4

Cleanliness, hygiene and health65

Next, cleanliness and hygiene are also the foundation for preventing tooth disease and keeping teeth

and after using the toilet. On the other hand, around 20 percent of children had taken time off school in

healthy. If teeth are not brushed correctly, food particles are not completely removed, and the particles

the last 12 months because of toothache, which shows that cavities and periodontal disease prevention

attach to the tooth surface. Bacteria then flourish, forming a sticky white substance called plaque. Plaquethrough correct brushing is clearly an issue in school health care.

can grow within approximately eight hours of your last meal. Many bacteria live in the plaque adhering
to your teeth, with mutans streptococci (‘cavity bacteria’) and lactobacilli converting the sugar fromfood particles into acid that begins to dissolve the teeth. To prevent tooth disease and keep teeth healthy,2) Home cleanliness and hygiene

it is therefore vital to keep teeth clean so that food particles don’t remain on the teeth, and to maintainoral hygiene by removing the clumps of bacteria and bacterial metabolites that make up plaque. ThisA clean and hygienic home environment is closely related to your health. For example, cleaning yourmeans, firstly, brushing your teeth correctly every day. Brushing using a fluoride toothpaste and using

house and separating your household waste properly prevents vector insects and environmental

dental floss or an interdental brush for interdental care are also effective methods. Fluorides encourage

pollution. Make sure that you use the right disposal methods for waste and recycling resources. Organic

tooth recalcification, repairing the tooth damage caused by decalcification and restoring the teeth towaste (food scraps) should be placed in a polythene bag for disposal, or, if you are burying it, covered

health. Fluorides also inhibit the production of acid by plaque (see Chapter 8 for details).

with a good layer of soil. Glass bottles, cans, and plastic bottles should be put out for recycling.

Cleanliness and hygiene are also fundamental in preventing infectious diseases and dermatitis (skindisease) (Figure 4.1, Figure 4.2). After you have washed dirt from your body in a shower or tub using coldor hot water and soap and then dried yourself, your skin needs to be moisturized. Brushing and washing

Column: Vector insects — Insects causing direct harm to people, including lice, mites, cockroaches, and flies

your hair and trimming your nails so that your skin is not scratched also help to maintain personal

Ensuring clean water with no pathogens helps to prevent food poisoning and the intestinal infectious

cleanliness. Washing dirty clothing and towels prevents diseases and the bad odors caused by thediseases which are so common in Cambodia. Dirty water contains pathogenic microbes such as

reproduction of the bacteria and mold feeding off sebum and protein in the stratum corneum (hygiene).

pathogenic Escherichia coli (E. coli), Salmonella enterica, Staphylococcus aureus, viruses, and1

A survey on the cleaning practices and hygiene behaviors of Cambodian children aged 13–17 found

Entamoeba histolytica that cause infectious gastroenteritis. For drinking water, buy mineral water or,that most brush their teeth at least once a day and are in the habit of washing their hands before meals

if none is available, drink boiled tap water. In the countryside, when using water from wells, rivers,
lakes, and springs, remove any dust and dirt first by straining the water through clothing, a
handkerchief, or a towel and then boil the water to kill bacteria and viruses, which cannot be simply
strained out. The boiling time must be at least five minutes.
You can prevent food poisoning by acquiring fresh food ingredients, storing them appropriately,
preparing them hygienically, and storing food appropriately after cooking. In particular, raw fish andWashing your face

Brushing your teeth

Washing your hands

Washing your hairmeat that have been purchased at the market should be cooked immediately or, if you have arefrigerator, stored in the refrigerator. If you don’t have a refrigerator, use all the fish or meat at once.
If there are best-before or use-by dates on food packaging, make sure you consume that foodcompletely before the given date.

Changing your clothes

Brushing your hair

Using the toilet

Washing your body

Figure 4.1 Practicing personal cleanliness and hygiene

Column: Drinking water in Cambodia

The World Health Organization (WHO) defines drinking water as including all water used in daily life,
breaking this up into three levels. ‘Improved drinking water sources’ comprise ‘piped water on thepremises’ (from a household well, for example), while ‘other improved drinking water sources’
comprise public wells and rainwater tanks, etc. All of these have lids to prevent contamination by
fecal matter and are relatively hygienic, but they can still be contaminated with bacteria, so care isneeded. ‘Unimproved drinking water sources’ comprise sources that are not protected from theexternal environment and could be contaminated by fecal matter, etc. (https://www.who.int/water_

Dermatitis

Stomachache

Fever and coughToothachesanitation_health/monitoring/water.pdf).

Figure 4.2 Disease caused by unhygienic behaviors

66

Chapter 4

Cleanliness, hygiene and health67

According to a study on the drinking water used by Cambodian children aged six to 36 months,

It is also important to make the classroom a good learning environment. Not only do classrooms

more than 90 percent of city children use relatively hygienic water, including 34.8 percent who useneed to be clean and free of waste but care also needs to be taken with the air quality (temperature,bottled water and 58.1 percent who use piped water on the premises. In rural areas, however, thehumidity, dust), brightness (natural light and artificial light), and noise levels (Figure 4.4). Natural andtotal was only around 30 percent, including 23.6 percent who use bottled water and 7.9 percent who

artificial light should be used to ensure that classroom brightness is right for learning, and the air in theuse piped water on the premises. Around 40 percent of rural drinking water comes from unimproved

classroom should be kept at a normal level by bringing in fresh air from outside and expelling stale air.

drinking water sources, making securing safe and hygienic drinking water a key challenge in healthprotection (Poirot et al, “Water quality for young children in Cambodia: High contamination atcollection and consumption level,” Maternal and Child Nutrition, 2019; e12744. doi.org/10.1111/

Refresh air

Bring in light

Prevent glareand flickeringmcn.12744).
Reduce noise
Column: Best-before and use-by dates

The food that you buy in stores only tastes good and can be consumed safely for a certain length of

Clean desktops
and floors
Separate waste

time. Food packaging and containers are usually marked with a best-before or use-by date. The
best-before date is the date up to which, if the packaging or container around the food remains
unopened, the food will taste good and have lost none of its quality. The use-by date is the date up
to which, if the packaging or container around the food remains unopened, the food may have lost
some of its quality and not taste as good but is still safe to eat. Food stored at high temperatures andFigure 4.4 How to keep classrooms healthy and hygienic

humid conditions tends to spoil more quickly than the indicated date. Once the packaging or container
has been opened, the product should be consumed as quickly as possible regardless of the date.

Table 4.1 Examples of necessary conditions for the school environment in Cambodia

Category

3) School hygiene

Requirement

Example• All students have safe drinking waterin schools.

All students have safe drinking
water at least 500 ml per shift bybringing from home or from othersources.

• All students can use functional andclean latrines in both shifts.

The school has 1 latrine for boys
and 1 latrine for girls.

Hand Washing Facilities• All students can use hand-washingfacilities with water and soap.

A basic hand washing facility isnext to each latrine or/andclassroom.

Environment and Safety• All students participate in dailycleaning of school premises,classrooms, latrines and hand-washingfacilities.

Drinking Water

Because many people gather at schools, they can become places for disease transmission. Schools alsoneed to provide a good learning environment to promote children’s growth and development. Care
therefore needs to be taken to ensure a clean and hygienic school environment. First, toilets must be used
for all urination and defecation, and children must be taught to wash their hands with well-lathered soap

Latrines and Urinals

after using the toilet (Figure 4.3). Classrooms must be kept clean and food debris and waste placed inwaste bins, not left lying around.

• No waste in school premises andclassrooms.

School has at least one waste bin
per classroom and latrine, and they
are used.

Created from Minimum Requirement Guidelines on Water, Sanitation and Hygiene in Schools (2016)

4

Cambodia has set the target of having hygiene facilities installed in all schools to create a healthy
Beforedefecation

Defecating

DefecatedAfterdefecation

Figure 4.3 Hygienic behavior at school(left: how to use the toilet, right: placing waste in waste bins)

68

Dustbinand safe learning environment and enable children to practice desirable health behavior.2,3 In 2016, theSchool Health Department created the Minimum Requirement Guidelines on Water, Sanitation andHygiene in Schools (WinS) that stipulate necessary school conditions in relation to (a) drinking water,(b) toilets, (c) hand washing facilities, and (d) environment and safety (Table 4.1), as well as mechanisms
for the improvement of hygiene facilities and for health and hygiene activities.4
Chapter 4

Cleanliness, hygiene and health69

In 2019, the School Health Policy was upgraded into a National Policy on School Health,5 of which
one of the strategies is to “strengthen the concepts of cleanliness, safety and good hygiene practiceregularly in the workplace and in educational institutions.” In other words, in addition to creating

4) Town and community hygiene(1) Waste disposal

mechanisms for health and hygiene activities and improving hygiene facilities, Cambodia has now

In Cambodia, rapid socioeconomic development and the advance of the tourism industry have madereached a stage whose aim is to introduce clear standards for cleanliness, safety, and hygiene.

waste disposal a huge social problem. Throwing waste on roads and into empty lots makes your town
look ugly, and people are offended by the putrid smell. Not only that, discarded waste makes the living
environment unhygienic. Piles of waste provide breeding grounds for mosquitoes, flies, and other insects

Column: School environmental hygiene in Japan

harmful to human health, for example, as well as generating toxic gases, and when it rains, waste-

In Japan, the School Health and Safety Act requires regular school environment hygiene

clogged drainage ditches flood the town with dirty water. In rural areas, rain falling on piles of waste

inspections based on the school environmental hygiene standards.6 These regular inspections

creates polluted water that then flows into farmland and pollutes the crops. Waste is not a problem

check whether schools are maintaining appropriate learning environments. For example, theycreated solely by Cambodians, but also by tourists visiting the country. At the same time, mountains ofmeasure carbon dioxide, temperature, relative humidity, floating dust, air flow, carbon monoxide,

waste can also be a source of revenue supporting people’s lives in some poor regions and regions withnitrogen dioxide, volatile organic compounds, mite allergens, illumination, glare, and noise levels.

little industry. We need to recognize that waste is a complex issue in which social development,

The inspections are conducted by experts or by teachers under the guidance of experts.

environmental and ecosystem pollution, and people’s livelihoods and health are all interwoven.
To address the waste issue in daily life, it is important to start by learning about the necessity ofIn addition to the inspections, there are also several items that must be checked daily (Table 4.2).
Teachers can conduct these checks every day either visually or using simple instruments.

waste separation and recycling, including setting up boxes and containers so that waste can be divided
into recyclables, non-recyclables, and organic waste when it is thrown out. Ideally, social mechanisms
will be developed for collecting and processing the separated waste.

Table 4.2 Examples of school environmental hygiene items subject to daily checks in Japan

Item(1) Ventilation

Classroom
environment

Standard(4) Noisemosquitoes, and other disease vectors carrying the pathogenic microbes that cause infectious diseases is(2) Appropriate ventilation

number of people affected increases during the rainy season. Certainly, people should take personal care

(1) Sufficient light to be able to clearly see letters and diagrams on
blackboards and desktops(6) Vermin andinsect pests

also important to create an environment that prevents mosquitoes from breeding, such as removing old
tires, empty cans, and plastic bottles where water could collect and provide a home for mosquito larvae(3) No light reflections on the blackboard

created in the first place will be critical for Cambodian society in addressing the waste problem.

Students can easily hear what the teacher is teaching.

In addition to developing social mechanisms for waste disposal, reducing the amount of waste(2) Drinking water and wastewater treatment
The public facilities that supply potable water are called waterworks, while the facilities that purify
rainwater and sewage (the generic term for human waste) and then release it into rivers and seas are(3) Toilets and toilet facilities are clean, functional, andundamaged.

called sewers. Waterworks send water to households and factories via (a) water tanks in which waste(4) No mud or sand has built up in drainage ditches and theirsurrounds, and there are no foul odors.

are mixed in thoroughly to have the water purified; (c) flocculation tanks which use chemicals to(5) Rubbish collection points, waste bins, and their surroundings
are clean.

tanks that filter the impurities; and (f) reservoirs for adding chlorine and storing clean water). The water

There are no mice, wild dogs or cockroaches inhabiting schoolbuildings or school grounds.

Created from Ministry of Education, Culture, Sports, Science and Technology, School Environmental Hygiene Management Manual,
2018 revision 6

70of themselves to avoid mosquito bites, such as using insect repellant and mosquito nets. However, it is(see Chapter 7).

(2) Sports grounds and sandpits are clean and free from waste andanimal fecal matter.
(5) Schoolcleanliness

just as important. For example, because dengue fever and malaria are transmitted by mosquitoes, the(2) No glare interfering with the visibility of blackboards,
desktops, and surroundings(1) School facilities and classroom equipment are clean andundamaged.

School cleanliness,vermin, and insect
pests

other vector insects, so the waste must be disposed of hygienically. The elimination of cockroaches,(1) No irritants or foul odors are detected on entering theclassroom from outside

The classroom is at a temperature conducive to learning (in Japan,(2) Temperature
stipulated at 17°–28°C).

(3) Brightness
and glare

If not dealt with, organic waste in particular becomes a breeding ground for flies, cockroaches, andand sand is precipitated from water taken from rivers; (b) mixing tanks where microorganisms and air
flocculate impurities; (d) sedimentation tanks that settle the suspended particles of impurities; (e) filter
purification system at the Phnom Penh waterworks is shown in Figure 4.5.7
Ensuring safe drinking water and preventing infectious diseases require installing combined septic
tanks and sewage systems to process town and community sewage. Sewage is the generic term for the
Chapter 4

Cleanliness, hygiene and health71human waste from toilets as well as domestic wastewater from cooking and laundry, along with theindustrial wastewater from business operations (stores, hotels, and workshops through to large factories).
Waterworks are gradually being installed in Cambodia, starting with Phnom Penh and other cities.
However, there are still few sewage systems, with sewage passing from septic tanks through drainage

2. Tips for creating a clean and hygienic personalenvironment1) Preventing food poisoning

canals out into lakes and wetlands where it is purified by natural processes. Given the issues related to
sewage treatment as shown in Table 4.3, Cambodia clearly needs to install combined septic tanks andsewers.

8

To prevent food poisoning, hygiene needs to be maintained at each stage of consumption, from buying
and storing food to preparing and cooking it, eating it, and storing the leftovers. Key points in relation
to each of these are shown in Figure 4.6. First, when buying food (point 1), choose fresh ingredients,

Hydraulic Mixing Tank

Flocculation Tank

PAC Chlorine

check the use-before dates (see Column: Best-before and use-by dates), and get your groceries home as
quickly as possible. Store raw fish and meat and perishable ingredients in the refrigerator (point 2), if
one is available, to protect the food from perishing or being contaminated by flies. At the preparation
stage (point 3), don’t use the same chopping board and knife that you used for raw fish and meat foryour vegetables, wash your cooking implements thoroughly afterwards, and wash your hands afterRiver
Rapid Sand Filters

Sedimentation

handling raw fish and meat. Avoid undercooking by heating food to the point that it reaches a sufficienttemperature even right in the middle (point 4). Wash your hands before eating and use clean tableware(point 5). Store remaining food and ingredients in the refrigerator and throw out old food (point 6).

Chlorine
Commercial Consumers
Clean Water Tank

Point 1: Buying food
• Choose fresh ingredients• Check the use-before date

Point 2: Storing food
• Use the refrigerator toprevent food from spoiling

Point 3: Preparing food
• Wash your hands first• Use clean cooking implements
and wash them well afterwards

Point 4: Cooking food• Cook your food rightthrough (raise thetemperature sufficiently)

Point 5: Eating food
• Wash your hands before
eating• Use clean tableware

Point 6: Store leftovers• Use a fly net or a fridge• Throw out old foodDistribution Station
Domestic Consumers

Figure 4.5 Water treatment process7

Table 4.3 Sewage treatment issues in Cambodia81

Because septic tanks have not been installed, untreated sewage percolates underground or isreleased directly into drainage canals and rivers.

2

Even when septic tanks are installed, they have insufficient capacity.

3

Only human waste is treated in septic tanks, with domestic wastewater directly released to theenvironment.

4

Septic tank sludge is not properly scooped up, so septic tank treatment efficiency is low.

Tidying and cleaning your environment contributes to safe and healthy living by helping to prevent

5

Households along rivers and waterways release their sewage directly into the water.

infectious diseases and allergies as well as injuries from falling. Engage in cleaning activities, including

Figure 4.6 Actions to prevent food poisoning

2) Cleaning

using a dustpan, broom, or vacuum cleaner to remove dust from floors, wiping desks with a cloth, andputting the accumulated waste in waste bins (Figure 4.7). Particularly when infectious diseases are goingaround, use disinfectants to sterilize surfaces that many people touch (Figure 4.8) and engage in cleaning
activities to block infection routes (for more on infection routes, see Chapter 7).
72

Chapter 4

Cleanliness, hygiene and health73

The coronavirus (SARS-CoV-2), and infectious disease caused by them (COVID-19) has been
sweeping the world since January 2020, and effective treatments and vaccines to increase immunity
against the virus are still in development. The virus is transmitted via droplets and fingers, so it is vitalto follow cough etiquette when coughing, and to wash your hands carefully and thoroughly for at least
30 seconds. Cough etiquette means using your sleeve, a tissue, a handkerchief, or a mask to cover yournose and mouth when coughing or sneezing to avoid spreading the virus to others (Figure 4.10).

Figure 4.7 Classroom cleaning

Figure 4.8 Examples of disinfectants

Column: Disinfectants by efficacy

There are many types of disinfectant with varying efficacies, so the right disinfectant needs to be

1 Wet hands

2 Squirt hand soap

with wateron to palm

used for the right job. Ethanol is used to sterilize fingers and objects such as doorknobs and tables.

3 Rub palms

together tocreate a lather

4 Use palm to rub

5 Interlace fingers

9 Rinse under

10 Dry well withback of other
hand, then swap

and rub between
them

However, there are some viruses on which ethanol has little effect unless it is very concentrated. It
also has no sterilizing effect on spores, which are the special cellular structures that form when somemicrobes are placed in an environment in which they cannot reproduce. Spores are highly resistantto heat, desiccation, and drugs, and cannot be sterilized using ethanol.
Sodium hypochlorite is usually found in bleach and has powerful disinfecting properties. Unlike
ethanol, it should not be used on the skin, but it can be used to soak clothes and dishes or applied
directly to vomit for sterilization (see also Chapter 15). Check the product label for the appropriate

6 Clasp thumbwith other hand
and rotate

concentration. For skin applications, people who are allergic to alcohol can use povidone iodine
also work on spores given a long disinfection period. The area of skin to which it is applied will turn

3. Good hygiene practices
1) Effective handwashing techniqueInfluenza and many other infectious diseases can be spread by human fingers, so making it a habit towash your hands effectively using water and well-lathered soap increases the chances of preventing
infectious disease. The specific method (Figure 4.9) is to wash hands with running water, pick up thesoap and lather it well, and then wash your hands for around 30 seconds in the following order: palms,
palm side of fingers, back of hands, back of fingers, between fingers right down to the base, thumbs andon opposite
palm

8 Rub each wristwith opposite
handrunning watera paper towel

Figure 4.9 Washing hands with soap

(isodine) instead. Povidone iodine is sometimes used to sterilize wounds and injection sites. It canbrown, but this will wash off with water.

7 Rub fingertips

Table 4.4 Effect of handwashing by duration and no. of times

Handwashing method

No. of viral flora remaining (survival rate)

No handwashing

Approx. 1,000,000

Wash 15 seconds under running water

Approx. 10,000 (approx. 1%)

Rub with hand soap for 10 seconds, then rinse under
running water for 15 seconds

Several hundreds (approx. 0.01%)

Rub with hand soap for 30 seconds, then rinse under
running water for 15 seconds

Several hundreds (approx. 0.01%)

Rub with hand soap for 60 seconds, then rinse under
running water for 15 seconds

Several dozen (approx. 0.001%)

Rub with hand soap for 10 seconds, rinse under
running water for 15 seconds, then repeat

Several (approx. 0.0001%)

cushion at the base of thumbs, fingertips, and wrists. Then rinse thoroughly with running water to wash
off the soap. After washing your hands, wipe and dry your hands using a clean towel or paper towel.
Please do not use a shared or dirty towel, as the effect of hand washing can be lost as a result. Disinfecting
your hands with alcohol once you have wiped away the water is also effective. Washing your hands withsoap using the correct method increases the chance of eliminating bacteria and viruses (Table 4.4).974

Chapter 4

Cleanliness, hygiene and health75

and health. Draw a diagram of how these elements are related.
[4-6] Discuss your experiences of food poisoning and think about how they could have been prevented.
[4-7] Discuss how to ensure that there is always soap in school bathrooms when schools have such tightbudgets.

Wear a mask

Cover your mouth andnose with a tissue or
handkerchief, etc.

Cover your mouth and nosewith the inside of your jacket
or your sleeve

Figure 4.10 Cough etiquette

Exercises for further thought and research[4-1] Try an experiment on effective handwashing.
You will need: Starch, iodine solution (or another disinfectant containing iodine), basin.
Method (Figure 4.11):(1) Rub the starch over your hands and wrists like hand cream.
(2) Let it dry.
(3) Wash and dry your hands using your usual method.
(4) Place the iodine solution in the basin and soak your hands into it.
(5) The iodine solution will react with any remaining starch by turning purple.
(6) Discuss those areas easily missed when washing your hands.

References
1

Global School Based Student Health Survey 2013. https://www.who.int/ncds/surveillance/gshs/Cambodia_2014_GSHS_Report.pdf

2

Ministry of Education, Youth and Sport (2006), School Health Policy. https://www.moeys.gov.kh/index.php/en/policies-andstrategies/1986.html

Figure 4.11 Experiment on effective handwashing

3

Ministry of Rural Development (2011), National Strategy for Rural Water Supply, Sanitation and Hygiene 2011-2025

4

School Health Department, Ministry of Education, Youth and Sport (2016), Minimum Requirement Guidelines on Water, Sanitation andHygiene in Schools. https://www.washinschoolsindex.com/storage/articles/zaEGjjZVB2WzMWY7UOommy58UP0AZdWq5zQLecNp.

[4-2] Identify an unhygienic environment close at hand and discuss in groups how it could be improved.
[4-3] Identify unclean or unhygienic actions by people around you and discuss in groups how thoseactions could be changed.
[4-4] Discuss in groups problems related to using and cleaning school toilets and cleaning classrooms
and school grounds, as well as possible solutions to these problems.
[4-5] Research waste treatment problems in developing countries and discuss why these problems are
occurring and what impact they are having on the environment and on people’s lives and healthfrom the perspectives of social development, the environment and ecosystems, and people’s lives
76

pdf
5

Royal Government of Cambodia Council of Ministers (2019), National Policy on School Health6

Ministry of Education, Culture, Sports, Science and Technology, Japan (2018), Manual for Management of School Environmental
Health. https://www.mext.go.jp/component/a_menu/education/detail/__icsFiles/afieldfile/2018/07/31/1292465_01.pdf

7Phnom Penh Water Supply Authority, Water Treatment Process. https://ppwsa.com.kh/en/index.php?page=water-treatment-process

8

Global Environment Department, Japan International Cooperation Agency (2018), Detailed Evaluation Report on Capacity Building
Project for Sewerage System Management in Phnom Penh, Cambodia. https://openjicareport.jica.go.jp/pdf/12320883.pdf

9Mori Kōji, Hayashi Yukinao, Noguchi Yayoi, Kai Akemi, Ohe Kyōko, Sakai Sachi, Hara Motonobu, and Morozumi Satoshi (2006),“Effects of Handwashing on Feline Calicivirus Removal as Norovirus Surrogate,” The Journal of The Japanese Association for
Infectious Diseases 80, no.5: 496-500. http://journal.kansensho.or.jp/Disp?pdf=0800050496.pdf
Chapter 4

Cleanliness, hygiene and health77

Chapter 5

Lifestyle habits and healthrest/sleep. Where exercising is concerned, this is a phase when development of the nerve system occurs,
which prompts a child to try a variety of different body movements, such as those that require control ofbody balance (i.e. standing, sitting, or spinning), those that move the body from one place to another (i.e.
walking, running, or climbing), and those that involve the maneuvering of tools (i.e. throwing, kicking,or pedaling)1.
School-age years: The first half of this phase is when a child undergoes relatively stable growth, andLearning objectives

it is important that a child should not only establish habits of healthy diet, exercise, and rest/sleep, but

You will be able to gain proper understanding and explain:also learn and gain an understanding and sense of right and wrong, language and cognitive abilities, and- What makes heathy lifestyle habits.

self-affirmation, as well as developing social skills2. Following infancy and early childhood, school-age- Healthy lifestyle habits at different stages of children’s development.

years will continue to see development of the nerve system; in addition to body movements that require- How malnutrition and overnutrition affect the human body.

control of body balance, moving the body from one place to another, or which involve the maneuvering- How lack of sleep and physical inactivity affect the human body.

of tools, a child during this period will try body movements that test their body strength (for example,- What relationship diet, exercise, and rest/sleep have with health, and then think about healthy

two children carrying another child, tug-of-war) or those that combine more than one basic bodylifestyle behaviors.
- What should be improved in terms of healthy lifestyle behaviors by reviewing your life on a
specific day (from the previous week).
- What should be improved in terms of healthy diet and balanced nutrition by reviewing your dieton a specific day (from the previous week).

movement3. In the latter half of the school-age years, meanwhile, a child will experience significant
growth of their body, and it is essential that they lead a healthy life to promote body growth. This is aperiod when a child’s body will come to change to that of an adult’s, although growth varies significantly
among individual children. In terms of exercising, it is important that a child practice sustained, lowintensity exercise that helps them become better at keeping skilled movements, such as jumping ropeand standing on one foot.

In this chapter, you will learn about the relationships between one’s health and lifestyle habits (lifestyle

Adolescence: A child will undergo dramatic changes to their body such as menarche or spermarche.

behaviors), with a focus on diet, exercise, and rest and sleep. Specifically, we will cover topics that

These are called secondary sex characteristics. During this phase, a child will experience certain

include children’s growth/development and lifestyle habits, lifestyle habits and health, basic lifestylephysical issues associated with body growth and development, including anemia due to deficiencies ofhabits, diet/nutrition and health, exercise and health, rest/sleep and health.

nutrients, especially iron, as a result of muscle growth and menstruation, or dizziness and fatigue due tounstable autonomic function.

1. Children’s lifestyle habits and health1) Growth/development and lifestyle habits

In psychological and behavioral development, a child may develop sexual interest and rebel against
adults. It is therefore necessary to pay attention to any sign of risky sexual activities, smoking, drinking,Learning of body movements

Mental and physical changes in children are known to include growth and development. The former(qualitative) changes. While children’s growth and development vary among individuals, they may be
divided into the following stages according to their nature: neonatal (first four weeks after birth);
infancy (birth to 1 year); early childhood (preschool years); middle childhood (primary school years);
and adolescence (junior high school years to young adulthood, or until one stops gaining height) (seeAnnual gain

includes quantitative changes in factors such as height and weight, and the latter refers to functional

HeightEndurance

Chapter 3 for details on the topic of children’s growth and development). Here we discuss the relationship
Body strength

between lifestyle habits and health in the following phases: infancy and early childhood; school-age
years; and adolescence.
Infancy and early childhood: This is a phase when a child will become able to do things on their

0
5

6

7

8

9

10

11

12

13

14

15

16

17

78

19 (Years of age)
(Miyashita, 1986)

own, such as eating, using the toilet, and dressing and undressing themselves, as well as learn patternsof everyday life. It is therefore important that a child should acquire habits of healthy diet, exercise, and18

Figure 5.1 Child growth/development patterns4
Chapter 5

Lifestyle habits and health79

or drug abuse. Socially, a child will need to acquire control of their social life so that they remain true tothemselves and live their own way while fulfilling their social responsibilities in interactions with friends
and adults in school, the local community, and at home. In terms of exercising, this is a period when the

2. Diet/nutrition and health

6-81) What it means to human health to eat9

load on children increases so that they acquire abilities (endurance) and body strength to performsustained exercise that helps them become better at skilled movements4 (Figure 5.1).

Humans need to take in nutrients from the external world in order to maintain life activities. Humans
fulfill this need by eating. Eating has the following three primary functions:2) Establishment of basic lifestyle habitsi. Supplying nutrients to sustain life and support living activities
ii. Providing a sense of security and satisfaction, bringing about psychological fulfillmentiii. Building a basic unit of social community

Basic lifestyle habits refer to a set of lifestyle habits with well-balanced nutrition, exercise, and rest/

The function of “supplying nutrients to sustain life and support living activities” is an important one

sleep that are important for the promotion of a child’s growth. Sections 3, 4, and 5 below discuss diet/for the purpose of maintaining homeostasis in the body of a living person. The body of a living person

nutrition, exercise, and rest/sleep, respectively. They are not independent of one another, however, but

has biological clocks that regulate the cycle of circadian rhythms. Maintaining one’s circadian rhythm

are mutually interrelated. As Figure 5.2 shows, for instance, reduced quality of sleep affects breakfast

is strongly associated with maintaining their health in a favorable condition. When the body of a living

habits, skipping breakfast affects daytime activities, and physical inactivity during the day reduces

person develops a memory of the timing when nutrients are supplied, regulatory functions such as

quality of sleep, thus creating a vicious cycle.5 Rather than focusing on one element only, it is critical tohormone secretion and enzyme reaction are synchronized properly. While nutrients may be pooledestablish healthy and regular lifestyle habits in which all of the elements are well-balanced, and thus aim

within the body of a living person to a certain degree, they are basically supplied with each meal.

for a virtuous cycle based on good rhythm of everyday life.5

Regular supplies of nutrients are essential for sustaining life and supporting living activities. Eating
regularly everyday therefore forms a foundation of desirable lifestyle habits, which in turn helps prevent

Example of good rhythm of everyday life

lifestyle-related diseases.
The function of “providing a sense of security and satisfaction, bringing about psychologicalMorning- Gets up early- Wakes up feeling refreshed- Eats breakfast- Passes a bowel movement

At school- Can focus on studying- Plays well with friends, fullof energy- Eats lunch

fulfillment” helps one avoid a sense of danger to life and remain emotionally stable. If the body of a

Evening- Enjoys supper- Seldom has late-night snacks- Goes to bed early

At home- Plays outdoors, full of energy- Does household chores- Does schoolwork and reads
books

that they will always obtain food at regular times or when they feel hungry. Eating food that is delicious

Example of poor rhythm of everyday life
Morning- In bed until last moment- Hard to wake up- Skips breakfast- Fails to pass a bowel movement

At school- Cannot focus on studying- Behaves restlessly- Feels ill after physical activity- Skips lunch

living person senses a state of starvation, it will trigger a variety of chemical reactions, including
preferential activation of the system that supplies glucose to the brain and nerve cells. During infancy
and early childhood, in particular, meals have the significance of giving children a sense of security inor which is something they like can also give them a sense of satisfaction or a zest for life.
The function of “forming a basic unit of a social community” is, in other words, a tool forcommunication to form connections between people. This is because people form human relationshipsthat will become basic units of a community through interactions among themselves as they share ameal, giving children an opportunity to acquire social-mindedness from adults such as their food culture,
table manners, and ceremonial rituals. Furthermore, the same group of people sharing the same time andplace regularly will be able to check in on the safety and health of one another. It has been reported thatthose in middle childhood and adolescence who share family meals three or more times per week are
more likely to stay in a normal weight range and have healthy dietary and eating patterns compared tothose who do so less than three times per week10.

Evening- Eats supper at later hours- Has late-night snacks- Stays up late at night

At home- Plays video games indoors- Attends many after-school
programs

Adapted from Ministry of Education, Culture, Sports, Science and Technology,
Learning materials on eating habits (for 5th and 6th graders)

Figure 5.2 Examples of good and poor rhythms of everyday life5802) Characteristics of dietary effect
The body of a living person will not fall out of form immediately after the external supply of foodceases. This is because various mechanisms come into play to maintain the homeostasis of the body. For
Chapter 5

Lifestyle habits and health81

instance, mineral or vitamin deficiencies will not immediately cause pain or other problems; in many

the body; and to coordinate the chemical reactions that occur in the body. Carbohydrates, lipids, andcases, by the time a mental or physical symptom does manifest itself, the problem will already haveproteins serve as the sources of energy, and proteins and minerals (i.e. the 16 essential minerals

fairly progressed. Dietary effects have the following three characteristics:

including calcium, iron, and sodium) form components of the body, while minerals, vitamins, and dietaryi. Diet has gradual effects on the body of a living person

fibers are required to coordinate the chemical reactions in the body.

ii. Adequacy of content of meals does not become clear to them immediately in generaliii. One must take in nutrients repeatedly and indefinitely

Nutrients

The effects a diet has are characterized by their slow and gradual nature. While pharmaceuticalproducts in general produce effects rapidly, food produces effects little by little, which often makes it
impossible to evaluate its effects promptly. Imbalance in diet results in inadequate nutrient intake, leading
to malnutrition. In many cases, people recognize the fact that they have an inappropriate diet only after
a state of malnutrition persists for a while and they themselves or others around them notice their mental

Carbohydrates

at an early stage, it is important to conduct a diet survey and physical examination. If malnutrition is
manifested as mental or physical symptoms, testing must be performed, including biochemical andphysiological tests such as blood tests (e.g. white blood cell count and hemoglobin levels) and urine tests

Primary dietary sources

Energy sources

Starchy food, cereal, fat

Building components ofthe body

Fish, meat, eggs, beans, milk

Coordination of chemical
reactions in the body

Whole small fish, milk, dairy
products, fruits, vegetables

LipidsProteinsor physical changes. Figure 5.3 illustrates what characterizes dietary effects and how they may beevaluated. In order to detect any imbalance in nutrient intakes and a poor nutrition due to improper diet

Major roles

Minerals
Vitamins
Dietary fibers(e.g. urine protein, occult blood, and urine glucose level), and functional and morphological tests (e.g.

Figure 5.4. Nutrients, and their major roles and primary dietary sourcesheight/weight measurements, athletic performance, pulmonary function test, hearing, and eyesight).
Diet

Body

Body

Body

Factors

Nutrients

Nutrition status

Biochemical/
physiological changes

Functional/
morphological changes

Evaluation
methods

Diet survey

Physical examination

Blood/urine testing

Function testing

Subclinical/asymptomatic
Mild

Clinically evident
SevereFigure 5.3 Dietary effects and methods for their evaluation

3) Healthy diet

Whole grain, beans, seeds,
vegetables, seaweeds

With the exception of granulated sugar and refined oils, very few food items contain a single nutrient;food contains a variety of nutrients. In order to minimize imbalance in nutrient intake, it is important totake in as many types of food as possible. In reality, however, it is difficult to have every type of food in
one meal and such an attempt can even result in excessive intake. It is therefore important to focus on
daily total or weekly average intake to keep a well-balanced diet. In the following, we will briefly
discuss the nutritional significance of the nutrients shown in Figure 5.4. It is important that you gain
understanding of where these nutrients exist and what roles they serve in the body of a living person.
Column: Things to consider when using dietary supplements

A large variety of dietary supplements are marketed for use to supplement inadequate intake ofminerals, vitamins, and amino acids. It is important that you should review your diet rather thantaking such dietary supplements without careful consideration. Some dietary supplements may

In order to stay healthy both mentally and physically, one needs to take in energy and nutrients in acontain ingredients that are different from those found in plant- or animal-based food products. It ismanner that is appropriate for their individual physical build, behavioral patterns, state of health, andimportant that you acquire correct knowledge about dietary supplements in order to stay in goodliving environment. When one “keeps a well-balanced diet,” it means that their dietary intake of energy

health.

and nutrients closely match those they need, with very little excess or shortage.
Figure 5.4 shows major nutrients and their roles, as well as their respective primary dietary sources.

Nutrients may be divided roughly into the following: carbohydrates, lipids, proteins, minerals, and

82(1) Nutritional significance of carbohydrates

vitamins. They are called the five essential nutrients. In recent years, it is recommended that dietary

Saccharinity is also called “available carbohydrates,” which are high in polysaccharide starch. Starchfibers (nondigestible saccharides) should also be taken in addition to these five. There are three major

is the main source of carbohydrates in our diet and is composed of hundreds to thousands of basicroles of nutrients: to provide energy required for physical activity; to become building components ofcarbohydrate molecules. This basic molecule is a monosaccharide, of which glucose, fructose, andChapter 5

Lifestyle habits and health83

galactose are important for our body. Our body uses digestive enzymes to decompose many of the“available carbohydrates” in our diet into monosaccharides, absorbs, and then uses them as an energy(4) Nutritional significance of minerals

source. The cells in the brain and nerve tissues, red blood cells, as well as skeletal muscles during

Minerals are divided into macrominerals and microminerals, depending on the amount needed; thedepletion of energy, can only use glucose. Because depletion of glucose can result in a collapse offormer are needed in relatively large amounts, while the latter are needed in trace amounts. There are six

homeostasis and even death, the level in the blood (blood glucose levels) is maintained even during amacrominerals: calcium, phosphorus, sodium, potassium, chloride, and magnesium. They are required

fasting state. The liver and muscles store glucose temporarily in the form of glycogen, which is afor the control of pH and osmotic pressure of body fluids as well as for nerve impulse transmission andpolysaccharide of glucose. Glycogen in the liver is readily used as an energy source to maintain the levelmuscle contraction. Of the six macrominerals, calcium, potassium, and magnesium are essential for theof blood glucose concentration. Excessive amounts of glucose are stored as triglycerides, which may be

development of bones and teeth. Microminerals, meanwhile, include 16 types of minerals, such as iron,used as another source of energy in the future. When energy taken in from food is not entirely consumed

zinc, and iodine. They are involved primarily in metabolism. Some microminerals, including arsenic andand leaves an excess, triglycerides are carried in the bloodstream to become subcutaneous or viscerallead, can cause harm to health and trigger poisoning symptoms when taken in large amounts, so caution

fats, which promote the development of arteriosclerosis.

is required against excessive intake.

(2) Nutritional significance of lipids(5) Nutritional significance of vitamins

As a source of energy that is readily stored in the body of a living person, lipids are stored primarily in

Although not a source of energy for the living body, vitamins are an essential nutrient that serves

the form of triglyceride. They are constituents of hormones, cell membranes, and nuclear membranes.

significant physiological roles even with a trace amount of intake. They can be either water-soluble

In the form of subcutaneous fats, they serve to protect internal organs and tissues against injury and cold.

(such as vitamin C and B vitamins) or fat-soluble (such as vitamin A and vitamin D) (Table 5.1). Water-

They also promote absorption of fat-soluble vitamins.

soluble vitamins are excreted in urine and not readily stored in the body, making them prone to deficiency.

(3) Nutritional significance of proteins

Fat-soluble vitamins, meanwhile, are stored in the liver, and may cause poisoning symptoms in case ofcontinuous excessive intake.

Proteins are an important nutrient that supports cells’ life activities. The muscles, organs, skin, hair, nail,
Table 5.1 Types of vitamin and symptoms of their deficiencies

hormones, enzymes, and antibodies are built with proteins. While proteins are broken down into aminoacids before being absorbed, proteins that are absorbed without having been broken down into amino

Types of vitaminacids can become allergens (which trigger allergic reactions.)

Deficiency symptoms

Vitamin B1 (thiamin)

Beriberi, anorexia, edema

Vitamin B2 (riboflavin)Impaired growth, oral ulcer

Vitamin B3 (niacin)

Dermatitis, diarrhea, brain damage

Vitamin B6 (pyridoxine)

Impaired growth, arteriosclerosis, dementia

Vitamin B7 (biotin)

Hair loss, dermatitis, impaired growth

Vitamin B9 (folic acid)

Anemia, arteriosclerosis, dementia, fetal neural tube closurein which the reaction occurs shortly after the intake of the offending food. They are mediated by aVitamin B12 (cobalamin)

Anemia, neuropathy

protein found in the living body called immunoglobulin E (IgE antibody). Typical symptoms of food

Vitamin C

Gum or skin bleeding

Vitamin A

Night blindness, impaired immunity

Vitamin D

Impaired bone formation, osteomalacia

Vitamin E

Infertility, miscarriage

Vitamin K

Excessive bleeding (intracranial hemorrhage in newborns
and infants), impaired bone formation

Column: Food allergy

The immune system is a biological defense mechanism that protects our body by ridding the bodyof invading pathogens or other substances that are harmful to the body (See Chapter 7). A food

Water-soluble
vitamins

allergy occurs when the immune system mistakenly treats a certain protein in food that entered the
body as an antigen and overreacts to it. Many food allergies produce immediate allergic reactions,allergies include hives, eczema, vomiting/stomachache/diarrhea, coughing/sneezing, and breathingdifficulties. Intense allergic reactions that cause a drop in blood pressure, lowering of consciousness,or fainting are called anaphylactic shock, which can be life-threatening. It is necessary that school
teachers and staff are aware of whether or not their pupils have any food allergies, and they have aform to keep tabs on them (https://schoolsequella.det.nsw.edu.au/file/d6b6621f-7036-4d2a-a84c0cc740cbe946/1/anaphylaxis-appendix-1-khmer.pdf).This form provides a space to check as toFat-soluble
vitamins

whether a child has an EpiPen prescribed. It is preferable that teachers familiarize themselves with
first aid and use of an EpiPen in the event of anaphylactic shock (https://allergy.org.au/images/
stories/anaphylaxis/2018/Khmer_ASCIA_PCC_Anaphylaxis_First_Aid_2018.pdf).

84

Chapter 5

Lifestyle habits and health85

(6) Nutritional significance of dietary fibers (nondigestible saccharides)
Dietary fibers are a type of carbohydrate. They are also called nondigestible saccharides because they
are not broken down by digestive enzymes. They are fermented by intestinal bacteria, and work toregulate the functions of the intestines and maintain gastrointestinal function. One needs to take indietary fibers to maintain and improve health.

(7) Recommended dietary allowances of nutrients

Table 5.2 Definition of 6 food types and standard of serving

Food type

Standard of serving

1 small bowl ore 10 spoons of cooked rice (140 g)
2 changvay (set) of Khmer noodle (165 g)
Cereals and Starchy
1 serving is 40 g of carbohydrate 1/2 of corn (65 g)
foods
1 loaf of baguette (70 g)
2 1/2 pieces of sandwich bread (80 g)
1 serving is 30 g

2 spoons of green vegetable (30 g)
3 pieces of pumpkin (30 g)
1/2 or 4 pieces of cucumber (30 g)

1 serving is 100 g

4 pieces of water melon (100 g)
3 pieces of guava (100 g)
4 pieces of papaya (100 g)
1 1/2 of banana (100 g)
4 pieces of ripe mango (100 g)

1 serving is 6 g of protein

2 spoons of chopped or slice meat (20 g)
4 pieces of fish meat (30 g)
1 chicken egg (50 g)
3 spoons of mungbean (60 g)

Calcium-rich foods

1 serving is 100 mg of calcium

2 spoons of small fish (40 g)
7 small dried fish (10 g)
1 cup of yoghurt (100 g)
1/2 glass of milk (100 ml)
5/9 pieces of tofu (60 g)

Fat and oils

1 teaspoon of butter (5 g)
1 teaspoon of oil/fat (5 g)Try to choose vegetable oil rather than animal fat.
Fat is also contained in other food types.
Limit your fat intake by 2-3 teaspoons (10-15 g) per day only.

Vegetables

In Cambodia, the Government discussed the recommended dietary allowances (RDA) for children aged
between 6 and 17 years in collaboration with FIDR, and established the RDA for different nutrientsusing a reference body weight for each age group of school-aged children11. In addition, the Food-Based
Dietary Guidelines (FBDG) were proposed; the recommended food intakes are visually illustrated for

Fruitssix food types in the Cambodian Food Pyramid (Figure 5.5). The definition of 6 food types and standardof serving (Table 5.2) provides the standard of serving and the portion size of serving for each of the six
food types, while the following seven key messages are proposed for the healthy growth of children(Figure 5.6)11. In school health education, it is necessary to actively teach and disseminate these messages

Protein-rich foodsby using a handbook based on these guidelines.

Salt, Sugar, Fat and Oil

Calcium rich foodPortion size of serving

Protein rich foodi. Eat food from all food types with a well-balanced diet* everyday

Fruitsii. Consume calcium rich-food such as whole small fish, milk, and milk products.
Vegetablesiii. Eat protein-rich food such as fish, meat, eggs, or beans at least 2 or 3 times a day.
iv. Eat plenty of fruits and vegetables regularly.
v. Eat cereal and starchy food such as rice, noodles, breads, and its alternatives in an
adequate amount.

Cereals and Starches

vi. Reduce food high in salt, sugar, and fat.
vii. Measure your body weight and height regularly and track your growth.
11

Figure 5.5 Cambodian food pyramid*Balanced diet is to eat from all types in proper amounts and in line with physical activity.
Figure 5.6 Seven key messages11

86

Chapter 5

Lifestyle habits and health874) Habit of choosing foods with safety and security assured
We take in nutrients required for the maintenance of homeostasis in the living body in the form of food.
For this reason, we need to take in a wide variety of food. The intake of contaminated or spoiled food may
modify the homeostasis of the body and lead to diseases. It is therefore important that we gain knowledgeof food safety and sanitation, and acquire the habit of choosing safe food. Such a habit not only

Prevalence(%)

50.0

maintains and improves our health but also promotes environmental health and safety (see Chapter 4).

Obesity(BMI>2SD)

40.0

Overweight(BMI>1SD)

30.0
20.0

Underweight(BMI<1SD)

10.0

Food safety and sanitation must be evaluated in a careful and wide-reaching manner, from each

0.0

process of food production/harvesting, processing, distribution, preparation, and sales, to the stages

5

6

7

8

9 10 11 12 13 14 15 16 17 18 19

Agewhere consumers purchase, cook, and eat the food. In the agriculture, dairy, forestry, and fisheryindustries, the safety of soil, sea water, and air is important. Using safe seeds and seedlings, fertilizers,

Figure 5.7 Nutrition status by age (Boys, 2016)

and feedstuff helps ensure environmental safety. It is also desirable that consistent views on food safety
are introduced to the processes of food processing, distribution, and sales, as well. It is also important to50

It is important for consumers to acquire knowledge of food safety and sanitation, and choose safe
and sanitarily prepared food on an everyday basis. It is therefore necessary for pupils/students to learn
in school health education about contamination and other risks that may occur anywhere between the
production and consumption of food. It is also important to provide opportunities for them to learn
through first-hand experience, which may include, for instance, growing edible plants from seeds orseedlings, raising animals, observing parasites in fish, and visiting a market or a shop in person. Keeping
school vegetable gardens may also offer an opportunity for pupils/students to learn about and improve
nutrition.

Obesity(BMI>2SD)

40

Overweight(BMI>1SD)30
20

Underweight(BMI<1SD)

10
0

5

6

7

8

9 10 11 12 13 14 15 16 17 18 19

Moderate and severe
underweight(BMI<2SD)

Age
Figure 5.8 Nutrition status by age (Girls, 2016)

Column: Prevalence of underweight, overweight and obesity in Cambodian children andadolescents aged 5–19 years

88

Prevalence(%)

establish regulations and standards concerning the genetic engineering, irradiation, and preservatives,and for consumers to gain correct knowledge of these.

Moderate and severe
underweight(BMI<2SD)

Column: UN WFP (United Nations World Food Programme)

When you look at the nutrition status of boys and girls in Cambodia in their middle childhood andUN WFP (United Nations World Food Programme) won the Nobel Prize for Peace in 2020. This wasadolescence, aged between 5 and 19 years, based on the Global Nutrition Report (https://in recognition of WFP members’ fighting hunger in all corners of the world and helping to improveglobalnutritionreport.org/resources/nutrition-profiles/asia/south-eastern-asia/cambodia/)itsconditions to bring peace to the people, as they go anywhere on the planet if needed, even war zones

data (https://ncdrisc.org/data-downloads-adiposity-ado.html), percentages of boys who are(https://insight.wfp.org/world-food-programme-chief-pays-tribute-to-front-line-staff-and-partners-

underweight are high for all ages, with approximately 40% being underweight between 11 and 17

after-nobel-peace-prize-fc406608d60).

andyears of age (Figure 5.7). This shows that many in this age group have problems in their nutrition

In Cambodia, the WFP Cambodia Country Strategic Programme - 2019-2023 started in February

status. While the percentages of boys who are overweight are relatively large between 5 and 11

2019. At the top of the Executive Summary, the challenges in food security are described as follows:

years of age, they decrease with age.

“Cambodia has achieved sustained economic growth over the past two decades, attaining lower

Compared to boys, girls overall show lower percentages of being underweight, although about

middle-income country status in 2016. Despite substantial progress, socio-economic and gender

40% are underweight at around the age of 10 years, which is comparable to boys (Figure 5.8).

inequalities persist, hampering access to a nutritious diet. Food security and nutrition face challenges

Percentages of girls who are obese are also small, at about one-third of those of boys. Based on

caused by shocks, a rapidly changing food environment, and inefficiencies in the food system.”these findings on excessively low or high body weight, the nutrition status seems to present larger(https://docs.wfp.org/api/documents/WFP-0000112436/download/?_ga=2.261728648.484506432.

problems with boys than with girls.

1604280209-264903587.1595213932)

Chapter 5

Lifestyle habits and health893. Exercise and health

Physical inactivity can cause lifestyle diseases such as obesity, arteriosclerosis, and diabetes. In
Cambodia, while some children were physically active for a total of at least 60 minutes per day on five

Exercising promotes growth and development of children’s organs, and benefits their health. Stimulation

or more days, many were not so physically active (Figures 5.10 and 5.11)12. For instance, nearly 40% of

to epiphysis as a result of exercising promotes bone growth. Moderately loaded exercise that involves

the children said they had not been physically active for a total of at least 60 minutes per day on any ofmuscle contraction, such as strength training, enlarges muscles and improves muscle strength. Aerobic

the preceding seven days, while around 35-43% had been attending zero physical education classes per

exercise that sends oxygen throughout the body, such as walking and swimming, strengthens the heart

week. The fact that physical education class is not common poses a challenge for ensuring that children

and lungs, and helps reduce the risk of lifestyle diseases. Exercise that improves flexibility, such as

acquire exercising habits in Cambodia. Styles of living vary among individual children, and it isstretching, increases the range of motion in joints, which helps reduce the risk of injuries (Figure 5.9).

important that a child should choose what suits them from among different varieties of exercises, andAerobic exercises

enjoy doing it. In doing so, they should incorporate activities that improve muscle strength and postexercise activities that improve flexibility, in order to prevent injury. Care should be taken to avoid

Aerobic exercises

excessive exercise, for it can cause injury, which may hinder a child’s growth and development.
(%)

50

National

40
Rural

30

Do exercises that would make you sweat and huff and puff, for a duration of 30 minutes,
three times a week.

Exercises to improve muscle strength

Urban

20
10
0

0 days1 days2 days3 days4 days

5 days6 days7 days

Source: 2013 Global School – Based Student Health Survey Results -Cambodia Survey
Public Use Codebook (https://extranet.who.int/ncdsmicrodata/index.php/catalog/220)

Figure 5.10 No. of days with a daily total of ≥60 minutes of physical activity during thepreceding seven days

Do exercises such as standing on tiptoes, sit-ups, and push-ups to an extent that does
not put strain on you.

(%)

50

National

Exercises to improve flexibility

40
Rural

30

Urban

20
10
0

Extend body part(s) without recoil, stop where they feel stretched, and take deep breaths.

Figure 5.9 Examples of physical activities to build health90

0 days1 days2 days3 days4 days

5 days ormore days

Source: 2013 Global School – Based Student Health Survey Results -Cambodia Survey
Public Use Codebook (https://extranet.who.int/ncdsmicrodata/index.php/catalog/220)

Figure 5.11 No. of days with a physical education class per week
Chapter 5

Lifestyle habits and health91

4. Rest/sleep and health

The relationship between health habits and health has since been explored in a variety of different
combinations. In a study15 that examined five lifestyle factors, for instance, the authors found that those

Sleep not only helps one recover from fatigue caused by various activities they have performed during

who adhered to more of the following factors: never smoked cigarettes; physical activity of ≥3.5 hours/

the day, but also promotes growth and development in children. The growth hormone produced during

week with moderate to vigorous intensity; high diet quality (e.g. a diet rich in whole grains, nuts,

sleep, in particular, helps repair damaged tissues and promotes child growth.

legumes, and vegetables, and low in red and/or processed meats, refined grains, sugar-sweetened

Sleep is a part of lifestyle habits, and good sleep is a product of a regular sleeping pattern. Humans

beverages, and sodium); moderate alcohol intake of 5–15 g/day for women or 5–30 g/day for men; andhave a body clock, which not only determines the timing of sleep but also regulates hormone secretion

normal weight (body mass index <25) had a longer life expectancy from age 50 free of diabetes,and other physiological activities in advance to prepare one for sleep. Keeping regular hours helps one’s

cardiovascular diseases, and cancer.

body clock work properly and facilitates sleep.

Past studies such as these have shown that life habits related to exercise, diet, smoking, alcohol use,

In modern life, however, use of electronic devices such as smartphones and PCs is on the increase.

and weight control are important factors of health habits. Health habits are influenced by society andExposure to blue light, or intense light from a smartphone or PC, before bedtime is believed to affectculture, however, and it is important that Cambodia should pursue health habits that are rooted in its own

the quality of sleep and sleep rhythm in a negative manner. In order to improve the quality of sleep, one

society and culture. To promote school health education, in particular, it is necessary to clarify how

should aim to get the right amount of exercise during the day, keep a well-balanced diet, and do things

lifestyle habits and living activities are associated with health, growth, and development of young people

that relax the body, such as stretching and avoiding the use of electronic devices that stimulate the brain

in Cambodia.

before bedtime.

Topics for further thought and research

5. Health habits of adults and life expectancy[5-1] List up as many types of play as you can think of that would involve children being physically
active.

We have so far looked at the relationships between lifestyle habits and growth/development and health[5-2] Think of what teachers can do to secure playtime for children to be physically active.

by focusing on exercise, diet/nutrition, and sleep/rest. We will now take a look back at past studies to see

Do research on foods in Cambodia that can cause food allergies (see the column on Food Allergy).

what lifestyle habits or kinds of lifestyles have an influence over our health and life expectancy. The[5-3] Recall and write down what you have eaten in the past few days, and discuss with others as toterm “health habits” here refers to lifestyle habits that are associated with health. In a study initiated inwhether or not you are keeping a well-balanced diet based on a good variety of food, by using the1965, Breslow, L., et al.13,14 surveyed 7,000 residents of Alameda County, California, United States on

Cambodian food pyramid (Figure 5.5) and the Seven key messages (Figure 5.6) as references. If

a variety of health practices and levels of their physical health, and found that seven health practices

your diet lacks certain foods, think of what you should eat to make up for it.

were strongly associated with physical health levels. When a 45-year-old man who was practicing 6-7[5-4] Ask an elderly person (Cambodians have an average life expectancy of approximately 69 years)of the seven health practices was compared with another 45-year-old man who was practicing only 0-3,

who is active and healthy without suffering any major illness about what health habits they keepfor instance, the two had a gap of approximately eleven years in their life expectancy. This was the firstin their everyday life (such as diet, physical activity, smoking, drinking, and stress-relief habits).

study that demonstrated that one’s habits have an influence on their health.

[5-5] Identify unhealthy lifestyle behaviors of people around you, and think of what should be done tohelp them change such behaviors.

The seven health habits identified by Breslow, L., et al. 13,14 are as follows:
1. Getting 7–8 hours of sleep at night regularly[5-6] Check on your lifestyle habits using the checklist in Table 5.3. Based on the results, review yourlifestyle habits by using the examples of good and poor rhythms of everyday life (Figure 5.2).

2. Eating breakfast nearly every day
3. Eating between meals once a day or less frequently
4. Not drinking habitually, or having four drinks or less at one time
5. Not smoking habitually
6. Performing moderate to vigorous physical activities*1 frequently, and
7. Keeping a proper weight*2*1 Vigorous sports activities, long-distance walking, hunting, gymnastic exercises, gardening*2 BMI of around 22 (see Chapter 6)

92

Chapter 5

Lifestyle habits and health93

Table 5.3 Lifestyle habit checklist

Item / Date
What time did you
get up in themorning? (Rest/
sleep)
Did you get up
feeling refreshed?
(Rest/sleep)
How many hours of
sleep did you have?
(Rest/sleep)
Did you havebreakfast? (Diet)
Did you pass abowel movement?
(Diet)For how long did
you do sports orother exercises on
the day in question?
(Exercise)
For how long did
you walk getting toand from school, or
do light exercises?
(Exercise)

/

/

/

/

/

/

/

) (

) (

) (

) (

) (

) (

)

H: 6

H:

H:

H:

H:

H:

H:

H:

Min: 30

Min:

Min:

Min:

Min:

Min:

Min:

Min:

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

8 hours

hours

hours

hours

hours

hours

hours

hours

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No
References

90 min

min

min

min

min

min

min

min

Ministry of Education, Culture, Sports, Science and Technology. Why is the use of various body movements important? Childhood
pdf

2

60 min

min

min

min

min

min

min

min

Ministry of Education, Culture, Sports, Science and Technology. Characteristics and important challenges in children for different
developmental stages. https://www.mext.go.jp/b_menu/shingi/chousa/shotou/053/gaiyou/attach/1283165.htm

3Ministry of Education, Culture, Sports, Science and Technology. Exercises that produce a range of body movements (plays). https://www.mext.go.jp/a_menu/sports/jyujitsu/__icsFiles/afieldfile/2009/12/28/1247477_1.pdf

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

Did you use asmartphone, etc.
before bedtime?
(Rest/sleep)
Did you do things
that improve sleep
like stretching andtaking a bath?
(Sleep/rest)

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

What time did you
go to sleep? (Rest/
sleep)

H: 21

H:

H:

H:

H:

H:

H:

H:

Min: 30

Min:

Min:

Min:

Min:

Min:

Min:

Min:

Did you eat between
meals? (Diet)

1

Exercise Guidelines. 2012. https://www.mext.go.jp/component/a_menu/sports/detail/__icsFiles/afieldfile/2012/05/11/1319748_4_1.

Yes

Did you eat at
regular hours? (Diet)

94

8/23/2021( Mon ) (

No

No

Yes

No

Yes

No

No

Yes

No

No

Yes

No

No

Yes

No

No

Yes

No

Yes

No

No

4

Miyashita M., et al.: Pediatric sports medicine, Nankodo, 1986.

5

Ministry of Education, Culture, Sports, Science and Technology. Learning materials on eating habits (for 5th and 6th graders) Think
about your eating habits: Keeping physically and mentally healthy every day. https://www.mext.go.jp/a_menu/shotou/eiyou/06050810/001.pdf

6

Oku T, Yamada K: Basic learning of biochemistry. Rev. Ver. 2. Nankodo, Tokyo. 2014.

7

Oku T, Yamada K: Basic learning of biochemistry. Rev. Ver. 3. Nankodo, Tokyo. 2019.

8

Oku T, Shibata K. s.b. National Institute of Health and Nutrition, Incorporated Administrative Agency. Basic nutrition. Rev. Ver. 3.
Nankodo, Tokyo. 2010.

9

British Columbia Health LinkBC. The Benefits of Eating Together For Children and Families.https://www.healthlinkbc.ca/healthyeating/eating-together#:~:text=People%20of%20all%20ages%20eat,and%20how%20to%20communicate%20better.

No

10 Hammons AJ., Fiese BH. Is frequency of shared family meals related to the nutritional health of children and adolescents?

Yes

11 Federation for International Development Relief. Development of recommended dietary allowance and food-based dietary guidelines

No

Pediatrics. 127(6), e1565-e1574. 2011. https://pediatrics.aappublications.org/content/127/6/e1565
for school-aged children in Cambodia. 2017. http://www.fao.org/3/I9704EN/i9704en.pdf
12 Preventive Medicine Department Ministry of Health. Global School-based Student Health Survey (GSHS) CAMBODIA, 2013
COUNTRY REPORT 2014. https://extranet.who.int/ncdsmicrodata/index.php/catalog/220/related_materials
13 Belloc NB, Breslow L.: Relationship of physical health status and health practices. Prev Med. 1(3):409-21.1972.
14 Breslow L, Enstrom JE.: Persistence of health habits and their relationship to mortaliy. Prev Med. 9(4):469-483.1980.
15 Li Y, Schoufour J, Wang DD. et al. Healthy lifestyle and life expectancy free of cancer, cardiovascular disease, and type 2 diabetes:
prospective cohort study. British Medical Journal 2020;368:l6669 doi: 10.1136/bmj.l6669.
Chapter 5

Lifestyle habits and health95

Chapter 6

specifically, factors related to lifestyle habits such as diet and exercise, rest, and labor, and abnormal
health conditions (e.g. smoking, diet, alcohol use, obesity, occupational risks, fasting hyperglycemia,

Prevention of lifestyle diseases

hypertension, and high cholesterol) have become problematic (Figure 6.3)2.
2007 ranking

Learning objectives
You will be able to gain proper understanding and explain:- The current situation surrounding lifestyle diseases in Cambodia.
- How obesity affects a person’s health.
- The importance of diet/nutrition in the prevention of lifestyle diseases.
- Factors to help one acquire healthy lifestyle habits.
- Health problems that stem from an improper diet.
In this chapter, you will learn about the relationship between lifestyle diseases and lifestyle habits.
Specifically, we will cover lifestyle diseases that are common in Cambodia, and basic lifestyle habitsand diet/nutrition as contributing factors to the diseases.

1. Common lifestyle diseases among Cambodians
Around 30 years ago, Cambodia had a high mortality rate caused by infectious diseases. While thecountry has since seen declines in the proportion of infectious diseases-related mortality thanks to

Lower respiratoty infection

1

1StrokeStroke22Lower respiratoty infection

Cirrhosis

33

Cirrhosis

Ischemic heart disease44Ischemic heart disease

Neonantal disorder

55Neonantal disorder

HIV/AIDS

6

6

Road injuries

Tuberculosis

7

7

Mechanical forces

Road injuries

8

8

COPD

Mechanical forces

99Tuberculosis

Congenital defects

10

10 Diabetes

Communicable,maternal, neonatal,
and nutritional diseases

COPD

12

13 Congenital defects

Non-communicablediseases

Diabetes

13

18 HIV/AIDS

Injuries

Source: Institute for Health Metrics and Evaluation. Cambodia -What causes the most deaths? http://www.healthdata.org/cambodia

Figure 6.2 Changes in causes of deaths over time in Cambodia (2007–2017)2

improved hygiene and nutrition, the proportion of non-communicable diseases (NCD)-related

2007 ranking

mortality has surpassed 60% (Figure 6.1)1. In particular, what are known as lifestyle diseases, such as

Malnutrition

1

1

Malnutrition

stroke, liver disease, heart disease, cerebrovascular disease, malignant neoplasms (i.e. cancer), andAir pollution

2

2

Tobaccodiabetes, are now among the leading causes of death (Figure 6.2). Among the risk factors for death andTobacco3

3

Dietary risks

disability due to such diseases, factors related to human behaviors and metabolism figure largely;

Dietary risks

44

Air pollution

Alcohol use

55High fasting plasma glucose

High fasting plasma glucose

66

Alcohol use

High blood pressure

77High blood pressure

Unsafe sex

88

Occupational risks

WaSH

9

9

High body-mass index

Occupational risks

10

10 High LDL

1990

2017
Non-communicablediseasesAccidents, etc.

8.3%

Non-communicablediseasesAccidents, etc.

10.7
34.8%

56.9%

Infectious diseases

%

26.6%

62.7%

Infectious diseases

Source:Ministry of Economy, Trade and Industry. “International Healthcare Development Country Report: Cambodia”1

Figure 6.1 Changes in causes of deaths over time in Cambodia (1990–2017)

962017 ranking

2017 ranking

High LDL

11

12 WaSHHigh body-mass index

13

13 Unsafe sex

Metabolic risks

Environmental/
occupational risks
Behavioral risks

Source: Institute for Health Metrics and Evaluation. Cambodia - What risk factors drive the most death and disability combined?
http://www.healthdata.org/cambodia

Figure 6.3 Changes in risk factors for death and disability over time in Cambodia(2007–2017)2

Chapter 6

Prevention of lifestyle diseases97

2. Lifestyle diseases and other conditions related tolifestyle habits

Normal blood vessel

1) Lifestyle diseases

Buildup of cholesterol forms due tosmoking or obesity

Table 6.1 shows a list of common lifestyle diseases and their symptoms. Cerebrovascular disease is a
Buildup in inner walls causes narrowingof the vessel, reducing blood flow

collective term for diseases caused by abnormality of arteries in the brain, with stroke being a commonly
known form. Liver disease (hepatitis) involves inflammation of the liver, and possible causes include
hepatitis virus infection, alcohol use, and obesity. Heart disease includes angina and myocardial

A blood clot blocks blood vessel

infarction, which are caused by reduced blood flow or the formation of a blood clot in coronary arteriesof the heart. A malignant neoplasm is an out-of-control growth of diseased cells (cancer cells) withina human body. Cancer cells are a mass of diseased cells, which were originally normal cells that turn into

Figure 6.4 Development and progression of arteriosclerosis

cancerous cells when their genes are damaged. Diabetes is a disease in which the bodily function that
Normal cells

Table 6.1 Common types of lifestyle diseases and their symptoms

Type of lifestylediseaseSymptoms

CerebrovasculardiseaseA collective term for diseases caused by abnormality of arteries of the brain. Stroke is acommonly known form. Stroke has two main types: diseases caused by a blockage or
rupture of the brain blood vessels. The former refers to cerebral infarction, in which a
blockage of a blood vessel prevents blood from flowing into the brain, depriving the brainof oxygen and nutrients. This leads to the necrosis of neurons in the brain, which may cause
a range of damage. The latter form of cerebrovascular disease includes subarachnoid
hemorrhage and brain hemorrhage, in which a rupture of an artery in the brain causes
bleeding into the brain. The blood that leaks out puts pressure on the neurons in the brain
and causes damage. Symptoms include headache, paralysis of limbs, speech difficulty, anddecreased level of consciousness.

Liver disease(hepatitis)

Liver disease (hepatitis) involves inflammation of the liver. Its possible causes are hepatitis
virus infection, alcohol use, and obesity. Symptoms include loss of appetite, malaise,nausea, vomiting, and jaundice.

Ischemic heartdiseaseIschemic heart disease includes angina and myocardial infarction. Angina is a condition
where arteriosclerosis narrows the coronary arteries of the heart and obstructs the bloodflow (Figure 6.4), resulting in repeated seizures accompanied by transient pain.
Myocardial infarction refers to a condition where formation of clots in a blood vessel of theheart due to arteriosclerosis causes occlusion of the blood vessel, resulting in necrosis of
myocardial cells. Delays in treatment can be fatal, and prompt medical attention is required.

A malignant neoplasm (cancer) is a disease in which normal cells turn into diseased cells(cancer cells) and grow in an out-of-control manner (Figure 6.5). Cancer cells may form in
Malignantdifferent organs including the lungs, liver, uterus, and breast, and may grow, expand andneoplasm (cancer)
spread to other organs, a process called metastasis. Symptoms vary depending on the site of
the cancerous organ.

Diabetes

98

Diabetes is a disease in which the insufficiency or impaired action of insulin, which
reduces blood sugar, causes a decline of the bodily function that suppresses the elevation ofblood sugar levels, leading to chronic high blood sugar. There are type 1 and type 2
diabetes. Type 1 diabetes involves destruction of insulin producing cells due toautoimmune diseases and requires self-injection of insulin. Type 2 diabetes develops due tocertain genetic factors combined with certain lifestyle habits such as overeating andphysical inactivity. It may worsen without subjective symptoms, and raise risks for thethree main complications, namely retinopathy, nephropathy, and neuropathy, as well as for
progression of arteriosclerosis in larger vessels which may lead to heart diseases or stroke.

Cancer cells form

Normal cells destructed

Cancer cell growCancer develops

Figure 6.5 Process of carcinogenesis

suppresses the elevation of blood sugar levels is reduced, leading to chronic high blood sugar and causing
a number of complications.
Another lifestyle disease is periodontal disease. Periodontal disease is an inflammatory diseasecaused by bacterial infection of the gums (Figure 6.6). When the gap between the teeth and gums iscleaned insufficiently, plaque may build up, allowing numerous bacteria to linger. The margins of thegums may be reddened or swollen due to inflammation, although pain is absent in many cases. If it
progresses, the gap between the teeth and gums, called a periodontal pocket, becomes deeper, and thefoundation of the teeth (alveolar bone) breaks down, ultimately requiring tooth extraction. Furthermore,
toxic substances that form as a result of inflammation can enter into general circulation via blood vesselsof the gums, causing various diseases or worsening pre-existing conditions.
Risk factors for periodontal disease include oral environments such as plaque, tartar, misaligned
teeth, and smoking, as well as lifestyle habits that may decrease the body’s resistance to diseases suchas poor eating habits, stress/fatigue, physical inactivity, and lack of sleep. To prevent periodontal disease,
Chapter 6

Prevention of lifestyle diseases

99

Healthy

Periodontal disease2) Other health issues related to lifestyle habits

PlaquePocket

Healthy gum

TartarInflammation of gum

Healthy bone
Bone destruction

Figure 6.6 Periodontal disease(1) BMI-mortality relationship
In all causes of death, the BMI-mortality relationship among Japanese men demonstrates a reverse
J-shaped curve when plotted on a graph (Figure 6.7.1).3 This graph shows that when men whose BMI
are between 23 and <25, their mortality risk is assumed to be 1.0 (the reference value), and then shows
how many times the mortality risk increases for those who have lower or higher BMI than the reference
value. For example, the mortality risk of men with BMI of 30 or higher is 1.42 times higher than thosewith BMI of 23 and <25. Japanese men whose BMI are between 23 and less than 30 are shown to have
low risk of mortality from all causes compared those with other ranges of BMI. That is the optimal range

it is therefore important for one to reduce or refrain from alcohol and tobacco use, keep regular hours,of BMI for Japanese men.

avoid stress, and keep a balanced diet, as well as brushing one’s teeth properly every day to keep the

The BMI-mortality relationship among Japanese women demonstrates a U-shaped curve (Figure

surface of the teeth clean and free of plaque. It is also effective to have one’s teeth cleaned by a dental

6.7.2).3 This graph indicated that, taking into account mortality risk from all causes, the optimal range

specialist on a regular basis to maintain the health of one’s teeth, as it will remove tartar completely, evenof BMI for Japanese women is between 21 and less than 27.

inside the gums, and clean the dental root, making the surface smooth and ridding it of bacteria that

It should be noted, however, that BMI, or body mass index, is calculated based on a person’s heightcause inflammation. In addition, the treatment of damaged gums and bone will help restore the gums

and weight, and does not tell whether the person is muscular or has excessive fat. “Latent obesity,” orclose to a healthy state. For details on dental health, see Chapter 8.

normal BMI combined with a high body fat percentage, is found among young women. Although there
are body fat scales available for purchase, different models may employ different methods of estimation

Column: What is inflammation?

or criteria, which makes it difficult to take an accurate measurement of body fat percentage. You can use
trends in body fat percentage as one indicator for obesity, keeping in mind that it has a margin of error.

Inflammation is a bodily reaction to damage to biological tissues or cells caused by an injury, disease,or noxious stimulation, as a means of removing the damaged parts and helping regeneration. It is areaction necessary for a human body to restore its health. Major stimuli (causes) of inflammation
1.8

1.5

BMI with
low risk for
mortality

1.4
1.3
1.2
1.1
1.0
0.9

Plaque is a sticky substance, white or yellowish white in color, that is found on the surface of a tooth.

0.7

It is a mass of numerous bacteria, as many as 100 million per 1 mg. A cavity-causing bacterium

14-<

Tartar is a calcified form of plaque. It is a mass that is hard as a stone and tends to form between
teeth and the gum ridge. It often contributes to the development of cavities, halitosis, and periodontal
disease.

1.4

BMI with
low risk for
mortality

1.3
1.2
1.1
1.0

Reference

Column: Plaque and tartar

Reference

0.9

0.8

BMI

BMI

Figure 6.7.1

Figure 6.7.2

40

30

30
-<

27

27
-<

25

25
-<

23

23
-<

21

21
-<

40

30

30
-<

27

27
-<

25

25
-<

23
-<

23

21

21
-<

19

0.8

19
-<

called Streptococcus mutans is prone to adhere to teeth, forming stiff plaque.

Hazard ratio

Hazard ratio

pain, and the inability to move the affected part. Inflammation may be acute, meaning it subsides inare at play in the chronic phase (See Chapter 7).

1.5

1.6

19

chemical stimuli such as acid and alkali. Common symptoms include reddening, swelling, fever,is dominated by a type of white blood cell called neutrophils, while lymphocytes and macrophages

1.6

1.7

19
-<

Chapter 7); physical stimuli such as ultraviolet, light radiation, or high or low temperatures; andJapanese Women

1.7

14
-<

include: biological stimuli due to the invasion of a pathogen (bacteria, viruses, parasites, etc.; seea short period of time, or chronic, when the symptoms are prolonged. The acute phase of inflammation

Japanese Men

1.9This figure is created using the data published in Sasazuki S. et al. Body Mass Index and Mortality From All Causes and Major
Causes in Japanese: Results of a Pooled Analysis of Large-Scale Cohort Studies. Journal of Epidemiology. 21(6) 417-430. 2011.
http://doi.org/10.2188/jea.JE20100180

Figure 6.7 Association between Body-Mass Index and Risk of mortality from all causes3

100

Chapter 6

Prevention of lifestyle diseases

101(2) Obesity and underweight(3) Anemia

Obesity is a condition in which a person’s body has an excessive accumulation of body fat. Because it

Anemia is a condition in which the amount of hemoglobin and the number of red cells in a given volume

constitutes a risk factor for respiratory, cerebrovascular, liver, and heart diseases, as well as for diabetes,of blood fall below standard levels. When one has anemia, they may experience symptoms such as facial

prevention and control of obesity plays an important role in building health. Body mass index (BMI) is

pallor, fatigue, general malaise, headache, palpitation, shortness of breath, loss of appetite, and in theused to determine the level of obesity.

cases of children, the impairment of intellectual development as well as learning or motor problems due

Being underweight, meanwhile, is a condition in which a person’s body has low body fatness. Manyto poor concentration. This is because a primary role played by red blood cells, which are a component

young women may have an unbalanced diet or repeat extreme dieting despite the fact that they do notof blood, is to transport oxygen and nutrients throughout the body, and any impairment to this functionneed to lose weight, and this raises health risks associated with dieting. An unbalanced diet owing to theaffects the brain the most out of all organs. A key to the delivery of oxygen is hemoglobin, which is a

wrong eating habits, in particular, may cause iron deficiency anemia or osteoporosis, which arecomponent of red blood cells. Hemoglobin is rich in iron, and it carries oxygen when iron binds todetrimental to one’s health. When it becomes serious, it may lead to anorexia or bulimia. Both anorexia

oxygen.

and bulimia are forms of eating disorders. The former is estimated to affect in many cases people in

Adolescence in particular is a phase when one’s consumption of iron increases as one goes throughtheir adolescence and early adulthood, when they avoid eating for fear of becoming fat, which causes

growth or menstruation, which often causes iron deficiency anemia due to a lack of iron as a component

them to become extremely thin. The latter involves repetitive episodes of overeating a few times a weekof hemoglobin. Poor nutrition also causes iron deficiency anemia. Dietary iron is found in two forms:

over a period of months combined with inappropriate compensatory behaviors to avoid gaining weightheme iron, which is present in large amounts in animal-based products such as meat, and fish, and non-(i.e., vomiting, use of a laxative). If such eating disorders become chronic, they may cause a number ofheme iron, which is present in vegetables and grains (Figure 6.8). Heme iron is known to be more well-forms of health disturbance, including amenorrhea, hypotension, and arrhythmia.

absorbed than non-heme iron. For the prevention of iron deficiency anemia, it is recommended that one
takes animal products that are rich in heme iron. Vegetables, legumes, and other common plant-based

Column: Health information obtained based on body height and weight

BMI is calculated based on a person’s height and weight. According to the WHO standards, aproducts that are rich in non-heme iron, meanwhile, can also have better iron absorption when combinedwith vitamin C-rich vegetables and fruits. One therefore needs to take both heme and non-heme iron ina balanced manner.

normal BMI is 22.0 for both men and women, and those with a BMI of below 18.5 are classified as
being underweight, and 30 and above, obese (Table 6.2). BMI is an indicator meant for adults; theHeme ironNon-heme iron

Kaup index and the Rohrer index are used for infant and school children, respectively (See Chapter
9 to learn about the calculation).

BMI = weight (kg) / height (m) 2

Meat

Liver

Green/yellow vegetables

Chicken eggs

Fish

Shellfish

Legumes

SeaweedTable 6.2 BMI and Nutritional status

BMI
Below 18.5

Nutritional status

18.5–24.9

Normal weight

25.0–29.9

Pre-obesity

30.0–34.9

Obesity class I

35.0–39.9

Obesity class II

Above 40

Obesity class III

Underweight4

Source: WHO region office for Europe, Body mass index-BMI.
https://www.euro.who.int/en/health-topics/disease-prevention/nutrition/a-healthy-lifestyle/body-mass-index-bmi

Figure 6.8 Main dietary sources of iron

Column: Cambodians and anemia

Anemia represents a serious health issue in Cambodia. Prevalence of anemia in the country isapproximately 56% among children under 5 years of age, and approximately 45% among women
15-49 years of age5. Possible causes of anemia in Cambodians, other than simple iron insufficiency,
may include deficiencies of zinc or folic acid deficiency, parasite or malaria infection, and pregnancy.
Anemia caused by these factors may not be improved by the intake of dietary iron or iron102

Chapter 6

Prevention of lifestyle diseases

103supplementation alone (Table 6.3)6. While use of the Lucky Iron Fish7 and fish sauce fortified with
8

A balanced diet is a diet that allows one to take in just the right amounts of nutrients they need toan iron compound have been known to improve dietary iron deficiency anemia, the Lucky Iron Fish

maintain their health. To maintain homeostasis, it is important for one to acquire a habit of eating a

was reported to have been ineffective in the cases of anemia due to non-dietary causes such asbalanced diet. However, it takes some time for us to see whether or not our diet is right as the latter9

genetic hemoglobin disorder . It is therefore important that one keep a balanced diet. Other possible

manifests in the form of abnormal physical conditions. In other words, people are not quick to realize it

approaches to alleviate or prevent anemia include parasite control using vermicides, proper malaria

when their diet is not appropriate. This is what makes dietary habits one of the factors for lifestyle

prevention and treatment measures, and family planning that suits individuals.

diseases. Continuation of an inappropriate diet exposes a human body to an inadequate supply ofnutrients for a prolonged period of time. Many cases of type 2 diabetes, dyslipidemia, and hypertension,

Table 6.3 Non-iron-related causes of anemia in Cambodia

for instance, are attributable to inappropriate dietary habits. Development of these diseases constitutes

Deficiency of zinc makes the erythrocyte membrane more
vulnerable to damage, which causes the red cell count to
decline.

risk factors for ischemic heart diseases and cerebrovascular diseases.

Folic aciddeficiency

Folic acid is essential for hematopoiesis, and its deficiency
inhibits production of normal red blood cells.

different groups according to their characteristics. When using the Cambodian Food Pyramid to track

Parasite infection

If hookworms are attached to the intestinal mucosa for a
prolonged period of time, it causes chronic blood loss,
resulting in anemia.

Zinc deficiency

Malaria

Pregnant women

To help one take in the right amounts of necessary nutrients, it is effective to use the Cambodian
Food Pyramid (see Chapter 5) as a guide to appropriate food intake. The pyramid classifies foods into
one’s dietary nutrient intake, it is preferable to do so over the span of one week or similar, rather thanjudging whether or not the intake is appropriate based on a meal-by-meal or day-by-day basis.
In addition, it is critical to have children acquire good dietary habits in their infancy and earlychildhood, and children need to learn about the Cambodian Food Pyramid and the Seven Key
Messages during their school-age years (see Chapter 5). Since lifestyle habits of school-age children

Malaria parasites proliferate inside the body and infect andeventually destroy red blood cells. (See Chapter 7 to learn
more about malaria)

depend largely on parent education, it is also important to communicate with parents and guardians. In
school education, it is desirable to have students/pupils gain understanding of the characteristics offoods that are consumed frequently in each region of Cambodia, and have them acquire knowledge on

Expecting mothers require iron and other nutrients in greater
amounts than normal. Short inter-pregnancy interval puts
greater strain on a mother, raising the risk for anemia.
Pregnancy and delivery by a teenager, who is still in a periodof growth herself, can also be more susceptible to anemia.

nutrition, such as what to eat and how much to eat to maintain an appropriate nutrition status. To thisend, it is effective to provide opportunities to try actual food and meals by offering experiences such as
observing foods being sold at a market or store, eating at a restaurant, growing crops at school or home,and cooking the crops they have grown by themselves, or making use of audiovisual learning materials.

3. Prevention of lifestyle diseases and diet/nutrition

2) Importance of healthy proteins

10-121) Acquiring desirable lifestyle habitsProteins are found in nearly all foods, regardless of whether they are plant- or animal-based. They are
degraded by multiple digestive enzymes in the digestive tracts into amino acids for absorption. Onceabsorbed, the amino acids are converted into a variety of different substances based on genetic information

A normal rhythm of everyday life often means that one eats three times a day. It is desirable that one

and biological state, and serve as an energy source or building material for biological structures. In

acquires a habit of eating a regular and balanced diet, keeping lifestyle disease prevention in mind as aaddition, amino acids play important roles to synthesize proteins, which produce enzymes, hormones,

part of daily life. Being mindful of one’s every meal every day helps maintain healthy lifestyle habits.

neurotransmitters, immune cells and antibodies, various receptors, or transporters. Thereby, the proteins

The human body is inherently equipped with a system that works to maintain homeostasis. For

regulate bodily functions and maintain immune function, contributing to preserve bodily resistance (seeinstance, if one eats snacks that are high in sugar and fat, levels of sugar and triglyceride or cholesterol

Chapter 5).

in the blood increase. Such increases are a normal bodily response, and they return to the levels before

While there are 20 amino acids that are body constituents, nine of them cannot be synthesized in thethe intake of such snacks. If undesirable lifestyle habits or disturbance to a rhythm of everyday life

body. These nine are called essential amino acids, and humans must take them in the form of dietary

harms the system that maintains homeostasis, however, it may cause a situation where the blood sugar

protein. If one’s diet consists predominantly of a single type of food, it is difficult for them to cover allor triglyceride levels elevated by food intake take much longer to return to normal, with these levels

essential amino acids. It is therefore necessary for one to maintain a balanced intake of meat, seafood,remaining high even when one has not eaten.

eggs, and legumes, in addition to grains as a staple food.

104

Chapter 6

Prevention of lifestyle diseases

105

4. Acquiring a better rhythm of everyday life2) Biological clocks

1) Maintenance of biological homeostasis

The earth rotates once every 24 hours approximately. Living organisms on earth have bodily systems
that reflect changes in photoenvironment that repeat in a 24-hour cycle. This is called a circadianHomeostasis is a bodily function, or a process of biofeedback, with which a living body maintains arhythm, in which their biological clocks regulate sleep, hormone release, body temperature, blood

constant internal environment and sustains life activities by responding to environmental changes (seepressure, and enzymatic reactions (i.e., chemical reactions such as digestion, degradation, absorption,

also Chapter 2). A living body has mechanisms that maintain homeostasis, such as regulation of bodyand metabolism induced by enzyme activity). If a circadian rhythm is out of form or is disrupted, it has

temperature, body fluid osmolality and pH, the concentration of glucose in blood, and blood pressure.

mental and physical consequences; if the rhythm is not restored, it may induce sleep disorders, lifestyle

For instance, the body temperature of a healthy human being is maintained at 36–37 degrees Celsius

diseases, or psychiatric illness (see also Chapter 2).

regardless of external temperatures. Likewise, a person’s concentration of glucose in blood is maintained

Humans eat and are active during the light period (i.e., when it is light during daytime) and sleep

within the normal range even right after meals or when they have not eaten. By having these mechanisms

during the dark period (i.e., when it is dark during nighttime, etc.). The chemical reactions and hormone

work in concert to keep an optimal condition for the individual, a living body is able to sustain life

releases in the body are regulated according to this shift of behaviors. Regular hours and desirable

activities.

lifestyle habits accord with this innate biological rhythm and play a role in preventing diseases.

Figure 6.9 shows the main composition of a human body. Approximately two-thirds of a humanbody is water, of which two-thirds is the intracellular fluid and the remaining one-third extracellular
fluid. Intracellular and extracellular fluids normally have the same fluid density because homeostasis is3) Lifestyle habits to maintain a normal biological rhythm

at work to induce osmotic transport of water. In addition, intracellular and extracellular fluids contain anumber of substances required for a living body to sustain life, and they exchange substances via cell

To maintain the inner environment of a living body, many organs work in coordination, including themembrane to ensure the cells work properly. For instance, key substances found in extracellular andimmune autonomic, and endocrine systems. For instance, the concentration of glucose in blood is

intracellular fluids are electrolytes, including sodium ions (Na ), chloride ions (Cl ), and phosphate ions

regulated to be always within the normal range. This is achieved by the pancreas releasing insulin in(HPO42‒) in the former, and potassium ions (K+), calcium ions (Ca2+), and magnesium ions (Mg2+) in the

response to elevation of blood sugar, with insulin promoting the cellular uptake of glucose. Diabetes islatter.

a condition in which insulin fails to work properly, leaving the blood sugar level out of control and+–increasing beyond the normal range, which results in an excessive amount of glucose in urine. There are
LipidsProteins

30%

Elderly (age 75 years)

Minerals

Intracellular
fluid

Extracellular
fluid

5%

33%

20%

12%

two causes for insulin to fail to work: reduced insulin secretion, and insulin resistance. The former may
occur when insulin output by the pancreas is already low to begin with, or it becomes lower as a resultof aging or genetic reasons. The latter means that insulin has become less active even when its output issufficient. If a person becomes obese due to irregular dietary habits and physical inactivity, insulin
becomes less active.

15%

Adult male (age 25 years)

17%

6%

42%

To maintain homeostasis, daily lifestyle habits play an important role. Not only does eating at regular

20%

hours sate one’s hunger and supply the body’s need for nutrients, but it is also an activity that is necessary
to regulate enzymatic reactions and maintain homeostasis. Besides diet, regular bowel movements and15%

Infant (age 3 months)

11% 4%

40%

desirable sleep habits are also important. Some hormone release and enzymatic reactions may subside

30%

when the body is resting and energy consumption is low, while others may increase. Growth hormones
are important during periods of growth, and their secretion is promoted during sleep at night. While

0

20

40

60

80

100 (%)

sleeping, one’s hormone release and enzymatic reactions associated with the digestion and absorption ofThis figure is a modification of the original in “Oku T, & Yamada K (Eds.), Badic biochemistry, 2nd ed. Nankodo, 201410 and its
3rd ed. published in 201911.”

nutrients are reduced, so that the body stores the nutrients and saves energy. This well-orchestrated

Figure 6.9 Composition of the Human body

habits are important activities in order for a living body to maintain a normal biological rhythm andregulation allows a living body to sustain life activities without running out of energy. Regular lifestyle
maintain biological homeostasis.

106

Chapter 6

Prevention of lifestyle diseases

107Column: Environmental stimuli, homeostasis, and autonomic function

enzymes, and hormones.
Overweight and obesity, meanwhile, were observed in 3.2% of students. Prevalence of overweight

Humans are exposed to various environmental stimuli, including physical stimuli such as heat,was 2.1% among urban students13. Among students, 86.6% consumed junk food at least once a week andultraviolet light, and noise, biological stimuli such as those caused by bacterial infection, chemical

21.9%, every day; 84.3% consumed soft drinks at least once a week and 11.8%, every day. One of thestimuli caused by drugs, and psychological distress such as stress from peer relationships, hardships

Seven Key Messages advises against excessive intake of salt or fat, and this helps prevent non-of life due to financial reasons, and violence (see also Chapter 12). When one is exposed to such

communicable diseases from developing. While child overweight and obesity are not an issue of highstimuli for a prolonged period of time, their biological homeostasis may become imbalanced, putting

priority in Cambodia at present, it will become important to educate students on what diets help prevent

their health at risk. As discussed in Chapter 2, the autonomic nervous system has two divisions,non-communicable diseases.

namely the sympathetic and parasympathetic nervous systems, and they control the blood pressure,heart rate, body temperature, digestion, metabolism, perspiration, excretion, sexual arousal

Table 6.4 Comparison of nutrition statuses (age 6–17 years)

processes. When the body is continuously subjected to environmental stimuli, this autonomic

Urban

Rural

Stunting

20.4%

36.4%

Wasting

10.4%

16.1%

Underweight

22.1%

38.1%

regulation may be disturbed, potentially resulting in homeostatic imbalance. This causes certain
symptoms to manifest in mental and physical ways, such as tiredness, constipation or diarrhea,
headache, dizziness, palpitation, and feeling of depression. It is therefore necessary to pay ample
attention to stimuli from the environment in addition to keeping regular lifestyle habits, in order tomaintain homeostasis and good health.

Source: FIDR, 201713

5. Improper diets and health problems
In many cases, the health impact of a proper or improper diet may only be noticed when one is aware of
subjective symptoms and the illness is advanced. Where infants are concerned, a mother may experiencea low milk supply or become unable to breastfeed a child at all due to poor nutrition or health, or childneglect. In their early childhood and school-age years, children may experience an imbalance in energy
and nutrition intake that is necessary for them due to picky eating, unbalanced eating, or allergy.

Egg
Legumes,
nuts and seeds

According to an FIDR report13, the prevalence of stunting in Cambodia was approximately 20%
among children of age 6 years, peaked at over 40% in those of age 10–12 years, and was still higher than
30% in 13–15 years. Wasting accounted for 10% in age group 7–9 years and approximately 20% in
10–15 years. As for malnutrition, the prevalence increased significantly at the age of 10–12 years. In a
comparison of children’s nutrition status between urban and rural areas, malnutrition was severe among
rural children (Table 6.4). See Chapter 9 to learn about the definitions of stunting, wasting, andunderweight as indicators of malnutrition.
For normal growth of children, intake of protein as well as energy is important. In Cambodia, theMeat andmeat products

Others5%

16%

Cereal

37%

5%
16%

Fish andshellfish

21%

Source: FIDR13

Figure 6.10 Sources of protein for children

largest source of students’ protein intake was cereal, followed by fish, meat, eggs, and legumes (Figure6.10)13. The most common meal pattern in Cambodia was “rice with soup or sweetened soup,” followedby “rice with soup and deep-fried/grilled dish.” To ensure normal growth of children, it is important toimprove nutrition status through a smart approach to supplying good-quality protein. Meat and eggs, forinstance, contain iron on top of quality proteins, which helps prevent anemia. In Cambodia, people
consume more soy milk than regular milk, and soy milk serves as their source of protein intake. Proteins,which are an important composition of a human body, are building blocks of the immune system,
108

Chapter 6

Prevention of lifestyle diseases

109Column: Dietary habits that prevent lifestyle diseases will also help prevent infectious

diseases

they content to remain as they are? And what are their reasons? Explore answers to these questions.
[6-4] Examine dietary habits of people who are very thin. Explore the reasons behind them and discuss
what may be done to improve them.

Dietary guidelines implemented in Cambodia including the Cambodian Food Pyramid not only help

[6-5] Cases of eating disorders are on the rise among young women in Western countries as well as

prevent lifestyle diseases but infectious diseases as well. WHO has published “Nutrition advice forsome Asian countries, including Japan and South Korea. Discuss if there are women who suffer

14

from anorexia or bulimia in Cambodia.

adults during #COVIT-19 ” (Table 6.5), emphasizing the importance of food: “Proper nutrition isvital. Eat a well-balanced diet every day to get the vitamins, minerals, dietary fiber, protein and[6-6] Identify health problems among children and young people around you that are likely to be a

antioxidants your body needs to be healthier with a stronger immune system and to lower your risk

result of an improper diet, and discuss as many factors as possible that may explain why they eatof chronic illnesses and infectious diseases.”as they do.
[6-7] Discuss what health impacts there may be when the body fails to maintain homeostasis.
14

Table 6.5 Nutrition advice for adults during the COVID-19 outbreak

Eat fresh and unprocessed food such as dark green leafy vegetables, orange/yellow colored fruit andvegetables, legumes (e.g., lentils, beans), nuts and whole grains (e.g., unprocessed maize, millet, oats,
wheat, brown rice or starchy tubers or roots such as potatoes), and proteins (e.g., meat, fish, eggs,milk).
Drink 8-10 cups of water every day. Water is the best choice, but you can also consume other drinks(e.g., lemon juice diluted in water and unsweetened, tea and coffee – not too much), and eat fruits andvegetables that contain water (e.g., cucumber, tomatoes, spinach, mushroom, melon, broccoli, Brussels
sprouts, oranges, apples, blueberries).
Eat healthy fats found in white meat (e.g., poultry), fish, avocado, nuts, olive oil, soy, canola,
sunflower and corn oils, rather than fats found in fatty meat, butter, coconut oil, cream, cheese, ghee
and lard. Avoid fats found in processed food, processed meats, fast food, snack food, fried food, frozen
pizza, pies, cookies, margarines and spreads.
Limit your salt intake. When cooking and preparing food, limit the amount of salt and high sodium
condiments (e.g., soy sauce, fish sauce). Limit your daily salt intake to less than 5 g (approximately 1
teaspoon), and use iodized salt. Avoid snack foods that are high in salt.
Limit your sugar intake. Choose fresh fruits instead of sweet snacks (e.g., cookies, cakes, chocolate).
Limit your intake of soft drinks or sodas, still drinks and other drinks that are high in sugar (e.g.,sweetened fruit juices, fruit juice concentrates and syrups, flavored milks, yogurt drinks).
Avoid eating out. Eating out during this COVID-19 pandemic increases your contact with otherpeople and your chance of being exposed to the virus. So eat at home. Home-cooked food is the best
choice, and is healthier and more nutritious for you than calorie-filled food from outside the home.
Reach out for help. During this COVID-19 pandemic, you may need support with your mental healthand diet to ensure you keep in good health, especially if you are living with a chronic illness and havesuspected or confirmed COVID-19. If you feel overwhelmed, seek help from trained professionals andthrough other trusted sources (e.g., digital, social, print and broadcast).

References
1

Ministry of Economy, Trade and Industry. International Healthcare Development Country Report: Cambodia. https://www.meti.
go.jp/policy/mono_info_service/healthcare/iryou/downloadfiles/pdf/countryreport_Cambodia.pdf

2

Institute for Health Metrics and Evaluation. Cambodia. http://www.healthdata.org/cambodia

3

Sasazuki S, Inoue M, Tsuji I, Sugawara Y, Tamakoshi A, et al. Body Mass Index and Mortality From All Causes and Major Causes inJapanese: Results of a Pooled Analysis of 7 Large-Scale Cohort Studies. Journal of Epidemiology. 21(6): 417–430. 20114

WHO. Body mass index - BMI. https://www.euro.who.int/en/health-topics/disease-prevention/nutrition/a-healthy-lifestyle/bodymass-index-bmi

5

USAID, Strengthening Partnerships, Results, and Innovations in Nutrition Globally(SPRING), Cambodia National Anemia Profile.
https://www.spring-nutrition.org/sites/default/files/publications/anemia-profiles/spring_nap_cambodia.pdf

6

Wieringa FT, Dahl M, Chamnan C, Poirot E, Kuong K, et al. The High Prevalence of Anemia in Cambodian Children and Women
Cannot Be Satisfactorily Explained by Nutritional Deficiencies or Hemoglobin Disorders, Nutrients 2016, 8, 348; doi:10.3390/
nu8060348. https://www.mdpi.com/2072-6643/8/6/348

7Charles CV, Dewey CE, Hall A, Hak C, Channary S, et al., A Randomized Control Trial Using a Fish-Shaped Iron Ingot for the
Amelioration of Iron Deficiency Anemia in Rural Cambodian Women. Tropical Medicine & Surgery 3(3):2015.
https://www.longdom.org/open-access/a-randomized-control-trial-using-a-fishshaped-iron-ingot-for-the-amelioration-of-irondeficiency-anemia-in-rural-cambodian-women-2329-9088-1000195.pdf

8Longfils P, Sowath S, Nakanishi Y, Chavait V, Monchy D, et al., Daily Consumption of Iron Fortified Fish Sauce Improved Iron
Status of Iron Deficient Anemic School Children in Cambodia. Trace Nutrients Research 24:59-64 2007. http://www.jtnrs.com/
sym24/24_059.pdf

9Rappaport AI, Whitfield KC, Chapman GE, Yada RY, Kheang KM, et al., Randomized controlled trial assessing the efficacy of areusable fish-shaped iron ingot to increase hemoglobin concentration in anemic, rural Cambodian women. The American Journal of
Clinical Nutrition, 106(2), 667–674, 2017. https://academic.oup.com/ajcn/article/106/2/667/4557630

Exercises for further thought and research[6-1] Review and assess your own lifestyle habits.
[6-2] Discuss issues of lifestyle habits with your group members, and offer advice to one another.
[6-3] Examine lifestyle habits of people who are obese. What makes them different from those of people
who are not obese? Do they wish to change their lifestyle habits and overcome obesity? Or are110

10 Oku T, & Yamada K (Eds.), Basic biochemistry, 2nd ed. Tokyo: Nankodo, March 30, 2014.
11 Oku T, and Yamada K (Eds.), Basic biochemistry, 3rd ed. Tokyo: Nankodo, August 20, 2019.
12 National Institute of Health and Nutrition, Oku T, and Shibata K (Eds.), Basic Nutrition, 3rd ed. Tokyo: Nankodo, February 25,
2010.
13 Federation for International Development Relief, Development of recommended dietary allowance and food-based dietary guidelines
for school-aged children in Cambodia. 2017.
14 WHO, Nutrition advice for adults during #COVIT-19. http://www.emro.who.int/nutrition/nutrition-infocus/nutrition-advice-foradults-during-the-covid-19-outbreak.html
Chapter 6

Prevention of lifestyle diseases

111Chapter 7
Human host
(Entity)

Infectious diseases and their prevention
and protection

Onset ofinfectious diseases

Learning objectives
You will be able to gain proper understanding and explain:

Source of infection(Pathogen)- The three major factors for the establishment of infection and the definition of infectious diseases.
- Common infectious diseases in Cambodia and their causes, symptoms, and treatment.
- Common infectious diseases in Cambodia and workable preventive measures by taking into

Infection route(Hands, etc.)

Figure 7.1 Three major factors for establishment of infection: agent, infection route, and hostaccount the three major factors for the establishment of infection.
- Discrimination and prejudices that may occur with an infectious disease, and then develop ways
to prevent them.

2) Pathogens2,3- The functions of how the skin and mucous membranes as well as perspiration, tears, and saliva
work to prevent foreign substances from invading the body from outside.
- The types of defense mechanisms your body has to eliminate foreign substances that have invaded
the body.

Pathogens in general are small organisms that cause diseases. As shown in Table 7.1, pathogens may be
divided into different categories depending on their size and structure, including viruses, bacteria,
fungi, and parasites, each with different characteristics and causing different infectious diseases. Other
transmissible diseases include prion diseases, which are caused by abnormal proteins called prions.

This chapter illustrates infectious diseases, which represent important disease control issues in countries
around the world. Specifically, we will consider basic knowledge of the pathogenic mechanisms ofinfection, how biological defenses and immune systems protect our health against infection withpathogens, characteristics of major infectious diseases, and measures to prevent infectious diseases.

Table 7.1 Major pathogen categories and their characteristics3–5

Pathogencategories

Sexually transmitted diseases will be discussed in Chapter 11.
Viruses

1. Definition of infectious diseases and three major
factors for the establishment of infection1) Definition of infectious diseases1

Biologicalclassification

Characteristics

A virus consists of nucleic acid
(DNA or RNA) and protein.
Nonliving things
Viruses are incapable of selfMeasure approx.
replication; They bind to living
1–10 nmcells and get taken up, then use
those to copy themselves.

Influenza virus, Ebola virus, coronavirus,
human immunodeficiency virus, hepatitis
virus, rabies virus, measles virus, rubellavirus, chickenpox virus, rotavirus,
norovirus, adenovirus

Bacteria do not have a nuclear
membrane but do have a cell
membrane.

Staphylococci, Streptococcus viridans,
Clostridium tetani, Klebsiellapneumoniae, Chlamydia psittaci,
Legionella pneumophila, Clostridium
botulinum, campylobacter, Escherichia
coli, Vibrio cholerae, Shigelladysenteriae, Salmonella enterica, Vibrio
parahaemolyticus

Bacteria

Prokaryotic
Approx. 1–10
μm

Fungi

Fungi include yeasts, molds,
Eukaryotic
Approx. 10–100 and mushrooms.
μm

Infection refers to the invasion and growth of a pathogen inside or on the surface of the body of a host.
A pathogen is a cause of infectious diseases, such as bacteria, viruses, and parasites that can produce
diseases. A host is an entity such as a person or animal that is infected by bacteria or viruses. A disorderin vital functions of a host that results from infection is called a symptom, while the manifestation ofsymptoms or onset of disease refers to a state in which symptoms are present. Diseases that are causedin this manner are collectively referred to as infectious diseases.
How infection occurs can vary depending on the time, place, and individual characteristics.
Infection requires three factors to be established, namely, pathogens, infection routes, and hostsusceptibility (Figure 7.1).

112

Parasites(protozoa)

ExamplesEukaryotic

Protozoa are a type of parasitethat are single-celled.

Candida, aspergillus

Malaria parasite, liver fluke,
schistosome, Trichomonas vaginalis,
Toxoplasma gondii

Note 1: The pathogens underlined are major causes of food poisoning.
Note 2: Units: 1 nm (nanometer) = 10-9 m; 1 μm (micrometer) = 10-6 m.
Note 3: The Pathogens in italics are academic names.

Chapter 7

Infectious diseases and their prevention and protection

113

Those that affect cows include bovine spongiform degenerative encephalopathy (also known as Mad

1) Physical defense

Cow Disease), while human prion diseases include Creutzfeldt-Jakob disease (CJD).
A living body is in contact with the outside world through the skin and mucous membranes. The skin3) Infection routes: vertical and horizontal transmissions

and mucous membranes have physical defense systems that prevent foreign substances from invading
the body.
The stratum corneum, which is found on the side of the skin that comes in contact with the outside

There are roughly two routes of infection, or ways through which a pathogen can enter a living organism:

world (i.e. the outermost layer), functions as a barrier. The stratum corneum barrier consists of corneocytes

vertical transmission and horizontal transmission. Vertical transmission is the transmission ofand stratum corneum intercellular lipids that fill the space between the cells. It functions to protect thepathogens to a fetus or newborn that occurs during pregnancy or childbirth. It is commonly known asbody against the invasion of foreign substances and plays the role of retaining water in the body.

mother-to-child transmission. This can occur across the placenta, through the birth canal, or by breast

The digestive system, including the mouth, esophagus, and digestive tract, and the respiratory
system, including the trachea, are separated from the outside world by membranes. The lumen of themilk.
Horizontal transmission is the spread of pathogens from the source of infection, such as people ordigestive system is covered with membranes, which work to protect against the invasion of pathogens

objects, to others. It may take forms of contagious transmission (oral, mucosal, or sexual transmission),and other foreign substances. Living organisms have approximately 60–70% of their immune system indroplet transmission, airborne transmission, and fomite (vector) transmission. Fomite transmission

the digestive system, which protects the living organisms against infection with pathogens.

includes infection through blood, secretions, ingestion, and vectors. According to WHO6, over a million

The respiratory tract is lined with hair-like projections called cilia, which move the mucous layer

people die every year from infection via vectors such as mosquitoes, freshwater aquatic snails, ticks, andupward to eliminate foreign substances. The mucous layer captures foreign substances so as not to allow

fleas. Waterborne transmission is a form of oral transmission and is a leading cause of diarrhea due toany pathogens or atmospheric particles to reach the lungs during breathing.

infection to the digestive tract, which can cause explosive outbreaks regardless of age and sex, particularly
in developing countries7. It is responsible for 2.2 million deaths globally every year, and most of thevictims are children in developing countries7.
1 Physical and chemical

defense4) Host susceptibility

1

When the same pathogens enter into living organisms, they may or may not develop symptoms. This isdue to the differences in the amounts of invading pathogens and host resistance, or activities of theimmune system. When a host is susceptible to pathogens, the activities of their immune system are

2 Natural immunity (non-specificimmunity) defense

3 Acquired immunity (specificimmunity) defense

3

2

Pathogencompromised, and the host may develop symptoms if infected. On the other hand, when the host is not
susceptible to the pathogens, which means that he/she has strong immune resistance, the immune systemeliminates the pathogens that have invaded his/her body and prevents him/her from developing
symptoms.

2. Biological defense mechanisms

8

Living organisms have biological defense mechanisms, which help them protect themselves against
pathogens and other foreign substances (i.e. substances that are not normal constituents of the body)Invasion of body

Onset ofdiseaseCopyright © JAPAN BLOOD PRODUCTS ASSOCIATION. All Rights Reserved.
Translated with permission.

Figure 7.2 Three defense mechanisms to protect the body

(Figure 7.2).

114

Chapter 7

Infectious diseases and their prevention and protection

1152) Chemical defenseline of defense”; also called the adaptive immune system). They work in stages: first the natural immune
system, followed by the acquired immune system. The natural immune system represents primitive

Chemical defense is included as a part of the physical defense mechanism. Perspiration, tears, and saliva

defense mechanisms that humans are born with, and it works to eliminate invading pathogens throughcontain an enzyme called lysozyme, which breaks down cells of pathogens (“bacteriolytic activity”).

phagocytosis. The defense provided by the natural immune system has limits, however, which is why

Sebum and gastric acid have acidic pH conditions. This helps suppress the growth of pathogenic bacteria,

the acquired immune system plays an important role.
Such immune responses involve a number of cells and organs, and white blood cells play a central

which are not highly resistant to acids.

role. White blood cells come from their precursor cells known as hematopoietic stem cells that arepresent in the bone marrow. When matured, they become cells such as granulocytes (neutrophils,3) Immune systemeosinophils, and basophils), monocytes (which leave, or “migrate” from, the bloodstream into tissues
that are invaded by foreign substances, and differentiate into dendritic cells and macrophages),If foreign substances such as pathogens have broken through the physical and chemical defense systems

lymphocytes (B cells, T cells — helper T cells and killer T cells —, and natural killer (NK) cells) (Table(the “first line of defense”), they are inside the living organism. The system that eliminates invading

7.2). Note that some other types of blood cells, such as platelets and red blood cells, also differentiate

pathogens that have entered the body is called the immune system. The immune system consists of thefrom hematopoietic stem cells. Of these types of white blood cells, those responsible for natural immunity

natural immune system (the “second line of defense”) and the acquired immune system (the “third

are neutrophils (which account for 40–70% of white blood cells), monocytes (dendritic cells andmacrophages; approx. 5% of white blood cells), and NK cells, while acquired immunity involves T

Table 7.2 Types and functions of key white blood cells involved in the immune system

Type of white blood cell

Major roles

Neutrophils

Phagocytic and bactericidal; cause
inflammation.

Dendritic cells (differentiatedfrom monocytes migrating fromthe bloodstream to the tissues)

Phagocytic; communicate antigen
information (“antigen
presentation”).

White blood cells

Type ofimmunity

Killer T cells (differentiated fromT cells which mature in thethymus gland)

NaturalLymphocytes
B cells (differentiate and maturein the spleen)

Natural killer (NK) cells

116

macrophages migrate from the bloodstream and gather in the invaded tissues to take these bacteria intoand “heterologous” or other components. Phagocytes digest and break down foreign substances thathave been taken up with cellular enzymes. This process is called the phagocytic mechanism.
In the case of virus infection, unlike bacterial infection, phagocytosis has limits on its own. This iswhere NK cells come in, directly attacking and destroying the virus-infected cells. NK cells, too,recognize autologous and heterologous components, and usually do not attack uninfected or normal
cells (see Immunological tolerance).

b. Inflammation
Acquired

When natural immunity provided by phagocytosis has caused substantial damage to the body (such as
mass cell deaths), macrophages recognize it and gather neutrophils in the bloodstream, causing a
localized inflammatory response. As the capillaries relax and dilate, the blood flow is increased locally,

Proliferate, become activated, anddifferentiate into antibodyproducing cells (plasma cells) to
produce antibodies that are specificto the antigen; present antigen;become memory cells to prepare
for invasion of the same antigen.
A potent killer; directly attack andeliminate virus-infected cells andautologous cancer cells.

When bacteria have entered into a living organism, cells such as   neutrophils, dendritic cells, andthe cells. Known as phagocytes, these cells recognize “autologous” or normal components of the body,Receive antigen information fromdendritic cells and become
activated, promoting proliferation
and activation of B cells, whichhave the same antigen information;some become memory cells to
prepare for invasion of the same
antigen.
Receive antigen information fromdendritic cells, and attack andeliminate infected cells; somebecome memory cells to prepare
for invasion of the same antigen.

responsible for the immune function that protects the body against parasitic infection.

(1) Natural immune systema. Phagocytosis

Macrophages (differentiated from Phagocytic and highly bactericidal;
cause inflammation; present
monocytes migrating from theantigen.
bloodstream to the tissues)
Helper T cells (differentiatedfrom T cells which mature in thethymus gland)

cells (helper T cells and killer T cells) and B cells. These are the typical immune cells. Eosinophils arewhich in some cases causes a plasma leakage, accompanied by tumefaction and rubor. Macrophages
release substances into the bloodstream that work on the hypothalamus of the brain (i.e. interleukins),
thereby increasing the body temperature (i.e. fever) and activating the immune cells. In other words, an
inflammatory response is proof that the immune system is given a boost.
Natural

Chapter 7

Infectious diseases and their prevention and protection117

(2) Acquired immunity
a. Communication from the natural to the acquired immune system (Figure 7.3)

In acquired immunity, upon invasion by the pathogens or other foreign substances that have the same

The acquired immune system is characterized by its specific activity against a specific kind of foreign

information as that is stored in memory cells, B cells promptly differentiate into antibody-producing

substance. An antigen is a substance that induces acquired immunity. In general, exogenous pathogens

cells (plasma cells) to produce antibodies. In general, they produce antibodies in a larger amount andare recognized as antigens. First, dendritic cells and macrophages, which work as a part of natural

more quickly than when the first infection occurred and eliminated the pathogens. As a result, an

immunity, digest and break down the foreign substances such as pathogens through phagocytosis. Then

individual may have relatively mild symptoms or may not manifest symptoms at all in a second or

they take up the foreign substances (antigens) and move to lymph nodes, where they present the antigen

subsequent infection.

information on the cell surface, and deliver the antigen information to T cells (helper T cells and killer
T cells), which work as a part of acquired immunity that follows. The mechanism in which antigen
information is transferred from the natural to the acquired immune system is called antigen presentation.

c. Secondary immune response(3) Immunological tolerance
Immunological tolerance is the body’s mechanism that prevents the immune system from wrongly
recognizing normal autologous cells and tissues as antigens and attacking them. On rare occasions, thisNatural immunity
Neutrophil

Macrophage

Acquired immunity
T cellAntigenpresentationum

normal autologous cells and tissues as antigens and attacking them. This is called autoimmune diseases,
which include type 1 diabetes and rheumatoid arthritis.

3. Prevention of infectious diseases

B cellPathogens

immunological mechanism fails to work properly, resulting in the immune system wrongly recognizing

Antibody

Figure 7.3 Antigen presentation from natural to acquired immune system

b. Cell-mediated and humoral immunity

To prevent infectious diseases, it is necessary to cut off the chain of three major factors for theestablishment of infection described earlier in 1. Specifically, it is necessary to eliminate pathogens(source control), block the routes of infection (control of infection routes), and boost the host resistanceto diminish susceptibility to pathogens (susceptibility control) (Figure 7.4). By cutting off one of thefactors of the three principles, an epidemic of infectious disease may be prevented after an outbreak. In

The acquired immune system has two mechanisms, namely cell-mediated immunity and humoral

addition, the practice of preventive behavior by individuals and improvements in the social system are

immunity. In cell-mediated immunity, upon recognizing antigen presentation by dendritic cells andrequired for the prevention of infectious diseases.

macrophages, helper T cells and killer T cells proliferate and become activated, and move to the infectedsite. There, killer T cells capture and destroy the infected cells in a specific manner. At the same time,
proliferated helper T cells activate neutrophils, macrophages, and B cells. Even after the elimination of
the antigen, helper T cells and killer T cells promote the differentiation of the activated B cells intomemory cells (i.e. memory B cells), which remain in the body for a long time to prepare for any

Keys to prevention measures
Cut off the sourceof infection

Cut off the routeof infection

Boost immunity

There are different ways
for sterilization anddisinfection dependingon the pathogens.

Keep skin/clothes clean; clean
house; maintain water system;
ensure hygienic distribution/storage
and refrigeration of foodstuffs.

Keep a balanced diet;appropriate level of exercise,rest and sleep; immunization.

subsequent infection. Meanwhile, some of the T cells become memory T cells (memory helper T cells
and memory killer T cells) to prepare for any subsequent infection.
In humoral immunity, first proliferated helper T cells activate the B cells that have recognized thesame antigen. Then the B cells differentiate into the antibody-producing cell (plasma cells), andproduce antibodies. Antibodies are made up of proteins called immunoglobulin, and they deactivate
the invading antigen by binding specifically to it (“antigen-antibody reaction”). The deactivatedantigen is eliminated through phagocytosis by neutrophils and macrophages. Once the antigen has
attenuated in the living body, normally the antibodies also disappear in two to three weeks, but asdescribed above, some of them remain in the body as memory cells to prepare for any subsequent
infection.
118

Figure 7.4 Keys to prevention measures to cut off the three major factors

for establishment of infection

Chapter 7

Infectious diseases and their prevention and protection

1191) What can individuals do?

the leadership of the WHO. For the purpose of ensuring the quality of the vaccine, a manual on
vaccine production was created and guidance given on its production, while a simplified technique

We will discuss measures an individual can take that are based on the three principles of infection.

for vaccination was developed. As a result, following the case of a young Somali man in 1977, noSource control measures may include proper management of food to prevent pathogens from growing,cases of smallpox have been reported. In 1980, the WHO announced the global eradication of theand disinfection and sterilization of pathogens. An important measure for the control of infection routes

disease. The eradication of smallpox demonstrates that it is essential for countries to work together

is hand washing. While the routes of infection vary among different pathogens, many of the pathogens

across national boundaries to control infectious diseases.

that affect humans tend to adhere first to a hand; as the hand touches mucosal membranes of the nose,
mouth, and eyes, the pathogens can be introduced into the body. Moreover, as a person’s hands carrying
pathogens touch many objects and other people touch such objects with their hands, the infection spreads.

2) What are schools expected to do?

Washing hands thoroughly with soap is an effective way to prevent infection that anyone can do. For
infectious diseases that are caused through droplets produced by coughing and sneezing, it is effective

Since schools are where children learn in large groups, they are prone to the prevalence of droplet

in reducing droplets by having infected individuals wear masks and maintain cough etiquette (e.g. covertransmission and contagious transmission. For this reason, it is necessary to implement infectious

your mouth and nose with a handkerchief or sleeve when you don’t have a mask), and ventilating indoor

disease control measures based on the three principles of infection prevention. Source control measures

spaces as well (see Chapter 4). As a susceptibility control measure, one can boost their immunity. For

include improvement of the school environment. Drinking water stations and toilets, in particular, should

people to protect themselves from developing an infectious disease, and to keep it from becoming serious

be kept clean. It is preferable to inspect drinking water routinely to ensure that it meets safety standards

if they do develop one, it is important for them to boost their immunity. Specifically, they should form a(See Chapter 4 for drinking water standards).

healthy lifestyle based on a balanced diet, adequate sleep, and an appropriate level of exercise (seeHealth education of pupils and students is important for the implementation of control measures for

Chapter 5). Vaccination (immunization) is another effective measure for preventing infectious diseases.

infection routes and susceptibility. Children should not only be given knowledge in class, but also learn

From the standpoint of preventing waterborne infectious diseases, changing from open urination andto be mindful of preventive behaviors against infection in their school life, such as those concerning thedefecation to the use of toilet facilities can prevent contamination of water lines, and thus help in theuse of toilets, hand washing after using the toilet, and cough etiquette. In Cambodia, prevention of

prevention of infectious diseases.

infectious diseases represents an important challenge. For Cambodians to learn basic knowledge on
infectious diseases and prevention skills at school helps them protect not only their own growth andColumn: Vaccines and immunization

Infectious diseases are caused by pathogens such as bacteria and viruses. However, the humanbody memorizes pathogens that once invaded and maintains a defense system that prevents thehealth, but the health of their families and communities, as well.

3) What is society expected to do?

onset of diseases or alleviates symptoms caused by the second infection and thereafter. That is theimmune system. Vaccination is a medical application of this mechanism. Vaccines contain weakened

Because infectious diseases spread from person to person, it is necessary to ensure not only the practiceor detoxifyed pathogens. Vaccination helps not only to protect you from infectious diseases, but alsoof preventive behaviors by individuals but also the improvement of social systems. Specifically, thishelps prevent infections to those around you. However, vaccines are attenuated or detoxified

means improving public health systems such as water and sawage systems in order to prevent infectious

pathogens, and the possibility of side reactions cannot be eliminated.

diseases, implementing quarantine in order to prevent infectious diseases from getting into the country,
and promoting immunization to give the population acquired immunity as prophylaxis. It is also

Column: Fighting smallpox

Humanity has fought many infectious diseases. The first infectious disease that humanity eradicatedimportant to develop a monitoring system to check on infection in the country, communicate appropriate
information to the people, and make use of the information gathered in studies for future measures to be
implemented.

was smallpox. Extremely contagious, smallpox was feared as a fatal disease since pre-Christiantimes. At the end of the 18th century, noticing that milkmaids did not catch smallpox while they did
catch cowpox, which is not fatal, an English physician named Edward Jenner developed immunization

120

Column: A new lifestyle(the smallpox vaccine). Although the introduction of the smallpox vaccine dramatically decreased

In the wake of the outbreaks of the novel coronavirus infectious disease (COVID-19) in 2020, a shift

smallpox deaths, the vaccine was potent only for a few days at room temperature and could not be

is called for to a new lifestyle, represented by mask wearing and maintaining a distance of at least 1

delivered to all corners of the world. In 1967, an initiative to eradicate smallpox was launched underm between one another. These measures not only change the way we live our daily lives, but will lead
Chapter 7

Infectious diseases and their prevention and protection121to changing how we work and how we live. We all feel reluctant to change the lifestyles we are

These symptoms disappear in about a week, and patients usually recover without sequelae. The severefamiliar with. It is not all a bad thing, however. As we have gained the habit of washing hands toform of dengue fever, namely dengue hemorrhagic fever, causes a patient to experience a sequence ofprevent COVID-19, morbidity due to influenza and food poisoning has also declined. As long as we

dengue fever symptoms, but before recovery, they experience bleeding, hypotensive shock, and multiple

are part of nature, there will always be infectious diseases caused by viruses. What we should aimorgan failure. It is noteworthy that severe symptoms tend to appear when a fever recedes and thefor is not to overcome viruses but to co-exist with them while minimizing the damage they cause.

temperature begins to return to normal. Pleural effusion and ascites occur at very high rates. Patients
may also experience enlargement of the liver, activation of complements, platelet depletion, and/or

4. Common infectious diseases in Cambodia

prolonged blood clotting. In addition, as the name “hemorrhagic fever” implies, 10–20% of the patients
experience nasal and/or gastrointestinal bleeding. Treatment for dengue fever is symptomatical.
For the prevention of infection, it is important to take measures to avoid mosquito bites. Specifically,

An outline of infectious diseases commonly seen in Cambodia is given below.

one shoud wear long-sleeved shirts and long pants, apply an insect deterrent, and sleep under a mosquito
net. It is also important for the purpose of prevention to make community-wide efforts to exterminate
mosquitoes and suppress breeding of mosquitoes (e.g. eliminating puddles, cutting grasses).

1) Dengue fever
According to a WHO report9, a total of 9,108 dengue cases with 14 deaths had been reported in Cambodia

Column: What are complements?

by September 2020. This number of cases is only 15% of the 61,198 cases in the same period last year.

Complements are a collective term for proteins that mediate immune response to eliminate antigens

Dengue fever is still one of the most serious infectious diseases in Cambodia, which has a tropical climate.

such as pathogens invading a living organism. They are so named because they complement the

Dengue fever is an infectious disease caused by the dengue virus and spread by the yellow feverfunction of antibodies.

mosquito (Aedes aegypti) and the tiger mosquito (Aedes albopictus). The dengue virus is of the family
Flaviviridae, and has four serotypes (DENV 1–4). The dengue virus forms a human-mosquito-humantransmission cycle (Figure 7.5). It is believed that most of the cases of dengue virus infection end up

2) Malaria

being inapparent or subclinical.
Malaria is an infectious disease that results from the transmission of a malaria parasite into the humanbody via female anopheles mosquitoes. After 1–4 weeks of incubation, a malaria parasite proliferates

Humanin the hepatic cells and red blood cells, and causes symptoms such as fever (which has cyclicity of
repeating febrile periods followed by afebrile ones), headache, joint pain, nausea, anemia, and spleenenlargement. Few patients develop all of the symptoms from the beginning; many follow atypicalcourses. There are four types of malaria that affect humans depending on the species of the parasites:
Mosquito

Mosquito

Plasmodium falciparum (P. falciparum), Plasmodium vivax (P. vivax), Plasmodium ovale (P. ovale), andPlasmodium malariae (P. malariae). Incubation periods, fever cycles, and treatment methods varydepending on the type of the parasites. Treatment is provided by antimalarial drugs; the choice of drug
depends on the type of the parasites. There is no immunization for malaria. For prevention, it is importantHuman

to take measures to avoid mosquito bites (see Dengue fever).

Figure 7.5 Transmission cycle of dengue virus

3) Tuberculosis
For those who do manifest symptoms, there are two types: a relatively mild form of dengue fever
and dengue hemorrhagic fever, which is a severe form. Dengue fever manifests as a sudden onset ofTuberculosis is an infectious disease caused by inhalation of tubercle bacilli. It is the leading cause offever 3–7 days into infection, often accompanied by a headache (especially orbital pain), muscle pain,

death linked to a single pathogen worldwide, followed by AIDS10. According to WHO statistics10,

and joint pain. It may also be accompanied by a loss of appetite, stomachache, or constipation. Three toapproximately 10 million (range: 9–11 million) patients contracted tuberculosis in 2018; the numbers

four days into infection, a red rash appears on the chest and trunk and then spreads to the limbs and face.

have remained constant for the last few years. While tuberculosis affects people regardless of sex and122

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Infectious diseases and their prevention and protection123

age, it was most prevalent in men aged ≥15 years, accounting for 57% of all the patients. It was estimated4) Rabiesthat women accounted for 32% and children of age <15 years, 11%. Geographically, most tuberculosis
cases were found in India (27%), China (9%), Indonesia (8%), the Philippines (6%), Pakistan (6%),

Rabies develops when a person is bitten or scratched by a dog, cat, bat or other wild animal that is

Nigeria (4%), Bangladesh (4%), and South Africa (3%); these eight countries accounted for 67% of theinfected with the rabies virus, and the virus invades the body through the wound. The duration ofworld’s patients. Cambodia is among the 30 countries with the highest tuberculosis burden, with 49,000

incubation after infection, while it may vary depending on the site of the bite, is usually 1–2 months.

11

patients and an incidence of active tuberculosis of 302 patients per 100,000 population . This is

Symptoms of a common cold may develop, including fever, headache, lethargy, muscle pain, tiredness,

approximately 2.3 times the average among the WHO Member States of 132 patients per 100,000

poor appetite, nausea/vomiting, sore throat, and dry cough. It may be accompanied by pain at the bite

population, which warrants tuberculosis control measures12.

site and loss of sensation or muscle spasms around the site. Symptoms of encephalitis appear, starting

While tuberculosis is a systemic infectious disease, pulmonary tuberculosis, which causes lungwith excitement, anxiety, and mania, followed by delirium, hallucination, aggressiveness, and muscle

lesions, accounts for as much as approximately 80% of the cases. As the tubercle bacilli start to movespasms such as hydrophobic fits. Patients eventually progress to coma and die of respiratory arrest.

hematogenously in the body, lesions form in a number of organs, including the pleura, lymph nodes,

Rabies, once developed, has a mortality rate of almost 100%. Due to its long incubation period, its onset

kidneys, and bones, and symptoms appear at each site. If the tubercle bacilli enter the lungs through the

can be averted by continuous vaccination starting immediately after any events that may cause infection

respiratory tract and cause a small initial focus of infection, it is regarded that initial infection is

to happen. Since rabies is a zoonosis, wild dog management and immunization of domestic dogs are

established (first infection). However, many such patients do not manifest symptoms and become

important for prevention.

carriers. They may spend years as carriers with the tubercle bacilli being established in the lung alveoli
and may manifest symptoms only after several years to decades when they become seniors or become
ill and have weaker immunity (second infection). Children often become infected through household

Column: Zoonosis

transmission, in which most cases are primary tuberculosis (first infection). Common treatment for

A zoonosis is a disease that can be transmitted from animals to humans and vice versa. Zoonotic

tuberculosis is a combination of anti-tuberculosis drugs. There are concerns over the emergence ofdiseases make up for approximately 50% of all infectious diseases, and include a number of diseases

multi-drug-resistant tuberculosis, however, and WHO

13

recommends Directly Observed Treatment,

other than rabies, such as avian influenza, SARS, clonorchiasis, and plague. For this reason, theShort-Course Chemotherapy (DOTS), where healthcare professionals, health nurses, and family

concept of One Health, which means that human health and animal health are interdependent, ismembers directly check on patients’ compliance to help them avoid missing doses. Immunization is

advocated primarily among veterinarians.

14

effective, and Cambodia recommends immunization of infants within the first 12 months after birth .
Column: Carriers (asymptomatic carriers)

5) Parasitic infections

Some people may be infected with a virus and carry it inside their bodies, but do not manifest

There are many parasitic infectious diseases found in Cambodia. Of these, those that are particularly

symptoms. This is a state where the strength of the pathogens and the person’s immunity are wellcommon, namely trematode and nematode infections, are discussed in this chapter.

balanced, and which suppresses manifestation of symptoms. Even though they do not show any
symptoms, such people still shed bacteria and viruses, and thus risk infecting others around them.

(1) Trematode infections

Such people are called bacterial or virus carriers for bacterial or virus infection, respectively, andTrematodes bear two suckers, one at the end of the body and the other on the ventral surface, and are flat

those who do not show particular symptoms are called asymptomatic carriers. In the spread of aand symmetric. For them to grow, trematodes always require intermediate hosts, in which larvae

new coronavirus, tuberculosis, and HIV, such carriers play a significant role, and it is important for

multiply by division. They grow inside a first and second intermediate hosts, and eventually become

people to exercise preventive measures and get tested even if they are not aware of any symptoms.

adult in the definitive host. Common trematodes include schistosomes, which are transmitted via a
percutaneous route and live in the host’s blood vessels, and trematodes that settle in organs through oraltransmission. Depending on the type of trematode, various symptoms develop. Particularly problematicin Asia are four species of foodborne trematodiases (Table 7.3).
Trematodes infect freshwater aquatic snails as a first intermediate host. A second intermediate host
may vary depending on the type of trematode; freshwater fish for clonorchiasis and opisthorchiasis,and crustaceans for paragonimiasis, while fascioliasis does not require a second intermediate host. The
definitive hosts are always mammals. Humans become infected by trematodes by eating raw fish,

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Infectious diseases and their prevention and protection125

Table 7.3 Epidemiological characteristics of foodborne trematodiases

DiseaseAcquired throughconsumption of

Infectious agent

Food poisoning is a foodborne illness caused by intake of naturally occurring toxins, chemical
substances, or pathogen found in food. Adverse health effects of exposure to naturally occurring toxins

Natural definitive hosts of
the infection

may be caused by an intake of wild mushrooms or plants, poisonous fish such as pufferfish, or molds.

Clonorchiasis

Clonorchis sinensis

Fish

Dogs and other fish-eating
carnivores

Opisthorchiasis

Opisthorchis viverrini, O.
felineus

Fish

Cats and other fish-eating
carnivores

Fascioliasis

Fasciola hepatica, F.
gigantica

Aquatic vegetables

Sheep, cattle and otherherbivores

Crustaceans (crabs andcrayfish)Cats, dogs and othercrustacean-eating carnivores

Paragonimiasis Paragonimus spp.
Note: Infectious agents in italics are academic name.

Food poisoning is commonly caused by pathogens. Other causes include chemicals, such as metal
poisoning caused by copper pots or dishes for eating or lead in canned food, and histamine poisoning
caused by raw fish or processed fish.

(1) Food poisoning caused by pathogens

15

Source: World Health Organization

A common form of food poisoning is that caused by pathogens, which can be roughly divided into
bacterial food poisoning and viral food poisoning. In general, bacterial food poisoning is common in
an environment suitable for bacterial growth, namely when it is warm and humid. Viral food poisoning,on the other hand, tends to be more common when it is cold with low humidity.

crustaceans, or vegetables contaminated with larvae. According to estimations by the WHO Foodborne
Disease Burden Epidemiology Reference Group (FERG) (2015)15, the leading four species of foodborne

a. Bacterial food poisoning

trematodes cause physical disorders in an estimated total of 200,000 people and more than 7,000 deaths

Common forms of bacterial food poisoning include cholera and dysentery, as well as infection withper year. For treatment, patients take an anthelminthic (such as praziquantel) orally.

campylobacter living in the intestines of poultry. While many types of food poisoning occur as a result(2) Nematode infectionsof infection with 100,000 to 1,000,000 viable bacteria, dysentery and Campylobacteriosis require amuch smaller number of bacteria for infection. In many cases, predominant symptoms of food poisoning

Nematodes have a cylindrical body. There are approximately 500,000 species known, of which some 50

are vomiting, diarrhea, and fever, but some may be accompanied by a headache or neurologicalparasitize human bodies. They do not always require an intermediate host, and some may repeat cycles

symptoms. Particular caution is required with infection with verotoxin-producing Enterohemorrhagicof growth and reproduction inside the definitive host. Many nematodes are transmitted orally, but someEscherichia coli (EHEC), O-157, O-26, O-111, and O-128. In addition to a high fever and severe

are transmitted via a percutaneous route. In this chapter, we discuss the roundworm (Ascaris

diarrhea, they may cause hemorrhagic enteritis and hemolytic uremic syndrome, which may progress tolumbricoides) and the human pinworm (Enterobius vermicularis). With ascariasis, a person becomes

kidney failure or encephalopathy resulting in death.

infected through ingestion of the worm’s eggs with food. They typically show digestive symptoms, andmay cause acute abdominal conditions in the case of erratic parasitism in the biliary tree. Enterobiasis isb. Viral food poisoning

caused when a person happens to take stools or food contaminated with stools in the mouth, or eats with

Viral food poisoning occurs as a result of intake of a virus carried by shellfish or virus-contaminateda hand that has touched a person or object contaminated with stools. It is particularly prevalent inwater or food. Common forms include norovirus and rotavirus infections. While bacterial foodchildren. The worms lay eggs around the anus, which causes itchiness around the area. Infection can also

poisoning is caused by bacteria that are attached to the surface of foodstuff and grow in the food, viruses

be transmitted orally via fingers that have scratched the area around the anus. It may lead to urethritis,

do not grow in food but inside the body or cells of a host.

vaginitis, or hepatitis. For treatment, patients take anthelminthic (e.g., pyrantel pamoate) orally for both
the roundworm and human pinworm.

(2) Prevention of food poisoning
A key to the prevention of food poisoning is the exercise of the “three principles of food poisoning

6) Enteric infections

prevention,” which ensures that we “do not allow pathogens to come in contact with food,” “do notallow pathogens to multiple,” and “destroy all pathogens.” Heat kills many of the bacteria responsible
for food poisoning. Bacteria such as campylobacter die when the contaminated food is heated at a center

Enteric infections refer to a group of diseases characterized by the manifestation of symptoms such astemperature of 75°C for 3 minutes or longer. Meanwhile, toxin-producing bacteria are more heat

diarrhea, vomiting, and stomachache caused by bacteria, viruses, and protozoans. Since there are a large

resistant. A toxin from Staphylococcus aureus will not die even after heating at 100°C for 30 minutes,

number of causative pathogens and their symptoms are similar, their diagnoses are challenging. It isbut will be killed at 200°C for 30 minutes or longer. It is therefore common to use antibacterial agents.

however important to identify the cause as precisely as possible because the treatment varies depending

Many pathogenic bacteria multiply by binary fission every 20–30 minutes. One E. coli bacterium,on the type of pathogen. In this chapter, we discuss the most important type of enteric infection, namely

for instance, becomes eight after an hour, and 1022 after 24 hours. When food contaminated withfood poisoning.

pathogenic bacteria is left at room temperature, the bacteria multiply in a short period of time. They do

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Chapter 7

Infectious diseases and their prevention and protection127not die even in the refrigerator; they simply multiply at a slower rate. While antibacterial agents areis a growing demand for enhanced public health systems based on international cooperation, for example,

effective against bacterial growth, they are not against viruses. Vaccines are effective against viruses, yet

supported by WHO.

not all viruses have vaccines, and everyday exercise of preventive measures is important.
It is possible to prevent food poisoning by means of disinfection with 70–80% alcohol and invert
soap. In the case of norovirus, however, alcohol is not highly effective, and disinfection with sodium
hypochlorite is necessary.

Other than those mentioned above, challenges we are facing include the rise of multidrug-resistantorganisms, which are pathogens resistant to newly developed drugs, and animal-derived infectious
diseases due to increases in imported pets and changes in how people interact with them.
Furthermore, infectious disease control measures always face discrimination and prejudice.

Even when causative bacteria or viruses for food poisoning find their way into the body, how

Misconception, fear, and anxieties concerning an infectious disease can give rise to discrimination. Withsymptoms manifest can vary depending on the immune strength of the person infected. Because evenleprosy and HIV infection (AIDS), there were cases where national governments implemented control

asymptomatic carriers can spread infection through their hands or bodily waste, hand washing ispolicies such as isolation of patients, even though the risk of transmission was low in everyday settings.

extremely important.

Preventing infectious diseases is important, yet it is necessary to take into account the human rights of
the infected when implementing measures, so as not to let them become a target of discrimination.

Column: What is invert soap?

Although called “soap,” invert soap has properties that are opposite to those of regular soap. It is
not capable of removing dirt or stain but has bactericidal and sterilizing properties to destroy the

Column: Preventing discrimination and prejudice from being induced by infectious

diseases

cells of molds and bacteria. It is not effective against viruses, which do not have cells. It is used forYear 2020 saw a global outbreak of novel coronavirus infectious disease (COVID-19). COVID-19

sterilizing fingers and dishes for eating, laundry, and cleaning. To sterilize fingers, one should firstis an emerging infectious disease, and we are faced with the challenge of responding to infectionwash hands thoroughly with regular soap to remove any dirt, then disinfect with invert soap.

prevention. In the course of our tackling this crisis, prejudice against infected people occurred. This
was nothing new. As the cases of AIDS and Ebola hemorrhagic fever are still fresh in our minds,
infectious diseases and pandemics have historically induced prejudice and discrimination. Behind

5. New challenges with infectious diseases

such discrimination are people’s anxieties over the illness. Prejudice and discrimination pose apublic health threat. They not only cause damage to physical and mental health and welfare of theThroughout human history, we have fought many infectious diseases, and successfully overcome somepeople who are subjected to prejudice, but they also make it difficult to contain the infectious

by improving healthcare standards and public health. On the other hand, we are facing new challenges.

disease. WHO recommends that governments, citizens, media, key influencers and communities

16

One example is emerging infectious diseases. WHO defines emerging infectious diseases as “thoseshould do their part to prevent prejudice and discrimination from spreading20. Steps suggested todue to newly identified and previously unknown infections which cause public health problems either

achieving this are: “Spread the facts”; “Engage social influencers”; “Amplify the voices of people

locally or internationally.” While not all emerging infectious diseases are fatal, their causes and routes

with lived experience with the coronavirus”; “Portray diversity of ethnicity in public informationof transmission are unknown at the beginning, which can cause a quick spread of infection. One of thematerials”; “Promote ethical journalism”; and “Correct myths, rumors, and stereotypes thatcauses behind these diseases is the increasing proximity between wild animal and human populations byencourage purejudice”21.

such activities as forest development. As there are more opportunities for humans to enter wildlife
habitats, humans may contact viruses carried by wild animals, or a virus that should originally infectonly animals may undergo the mixing of other viral genomes inside the cells of the animal and mutate
into a new type of virus that may prove extremely pathogenic when transmitted to humans. Because it
takes time to develop a new vaccine or therapeutic drug, emerging infectious diseases can pose challenges
on the prevention and treatment front.

Exercises for further thought and research[7-1] Do research on the laws and measures concerning infectious diseases and those concerning
hygiene management in Cambodia and give a presentation about them.

A second example is pandemics. A pandemic is defined as an epidemic of an infectious disease[7-2] Choose one infectious disease that is common in Cambodia and summarize the measures against

occurring across different countries and regions. With globalization comes greater movement of people,

it. In doing so, list up measures by the following categories: the three principles of infectious

and this can cause an infectious disease in one area to rapidly spread to multiple countries and regions,diseases; what individuals can do; what schools can do; and what society should do.

resulting in a global outbreak. WHO declared the H1N1 pandemic in 2009

17,18

, and the COVID-19

19

pandemic in March, 2020 . Because it is not possible to prevent a pandemic from occurring throughindividual countries’ efforts alone in implementing thorough infectious disease control measures, there
128[7-3] Create a poster promoting the prevention of food poisoning. Discuss as to where it should be
posted for it to be effective, keeping your target audience in mind.
[7-4] Discuss in groups what brings about discrimination and prejudice related to an infectious disease.
Chapter 7

Infectious diseases and their prevention and protection

129Plan a lesson on the theme of infectious diseases and human rights.
[7-5] Propose a new lifestyle for a new era of people living with the novel coronavirus in Cambodia.

Chapter 8

Eye and dental health
Learning objectives
You will be able to gain proper understanding and explain:- How we can see an object and why refractive errors occur, and explain how we can prevent eye
diseases.

References- The function of a tooth, the causes of dental caries, gingivitis, and periodontal disease, and explain
how we can prevent them.

1Center Hospital of the National Center for Global Health and Medicine, Antimicrobial Resistance Clinical Reference Center. Basics

2

Tokyo Food Hygiene Association. A guide to prevention of food poisoning as a threat to your family health. 2019. https://www.

This chapter explains the mechanisms of the eyes and the teeth, diseases related to them, and prevention

fukushihoken.metro.tokyo.lg.jp/shokuhin///pamphlet2/files/r1july_guide.pdf

of those diseases. Eyes and teeth, which are organs familiar to children in that they can easily observeof infectious diseases: What is an infectious disease? http://amr.ncgm.go.jp/general/1-1-1.html

3

Kitasato H, et al. Viruses and bacteria: Illustrated. Tokyo: Gijutsu Hyoronsha, 2020.

4

Hatanaka M and Shimada J, Ed. Microbiology. Tokyo: Bunkodo, 2004.

5

Yamazaki S, et al, Ed. Companion guide to infectious disease prevention. Tokyo: Japan Public Health Association, 2001.

make them realize the outcomes of health learning easily. Therefore, eye and dental health is one of the

6

World Health Organization. Vector-borne diseases. https://www.who.int/en/news-room/fact-sheets/detail/vector-borne-diseases

teaching and learning materials of school health familiar to all members of a class.

7

World Health Organization. Water sanitation hygiene. https://www.who.int/water_sanitation_health/diseases-risks/diseases/

them, provide them with opportunities to experience, for example, preventive measures in practice anddiarrhoea/en/
8

Byoki ga mieru: Vol. 6, Immunology, Collagen Diseases and Infectious Diseases (2nd ed). Medic Media, 2018.

9

WHO Western Pacific region. Update on the Dengue situation in the Western Pacific Region. Dengue Situation Update Number 610.
2020. https://www.who.int/docs/default-source/wpro---documents/emergency/surveillance/dengue/dengue-20201105.pdf?sfvrsn=
fc80101d_42

10 World Health Organization. Global Tuberculosis Report 2019: Executive Summary. https://www.who.int/tb/publications/global_
report/tb19_Exec_Sum_12Nov2019.pdf?ua=1
11 World Health Organization. Global Tuberculosis Report 2019: Annex2 Country Profile For 30High TB Burden Countries. https://www.who.int/tb/publications/global_report/tb19_Report_country_profiles_15October2019.pdf?ua=1
12 World Health Organization. Global Tuberculosis Report 2019: Annex 3 Regional and Global Profile. https://www.who.int/tb/
publications/global_report/tb19_Report_regional_global_15October2019.pdf?ua=1
13 World Health Organization. Tuberculosis: What is DOTS (Directly Observed Treatment, Short Course). http://origin.searo.who.int/
tb/topics/what_dots/en/
14 Cambodia Demographic and Health Survey 2014, 14. Child Health-Immunization of Children, P.152. National Institute of Statistics(Cambodia), Directorate General for Health (Cambodia) and The DHS Program (USA), 2015. https://dhsprogram.com/pubs/pdf/
FR312/FR312.pdf
15 World Health Organization. Foodborne trematode infection. 2020. https://www.who.int/news-room/fact-sheets/detail/foodbornetrematode-infections
16 World Health Organization. Emerging Infections Diseases. World Health Day 97.1. https://www.who.int/docstore/world-health-day/en/documents1997/whd01.pdf
17 Doshi P. The elusive definition of pandemic influenza. Bulletin of the World Health Organization 2011;89:532-538. doi: 10.2471/
BLT.11.086173. https://www.who.int/bulletin/volumes/89/7/11-086173/en/
18 WHO declares influenza A(H1N1) pandemic. https://www.youtube.com/watch?v=10Nfk0zcTAk
19 Coronavirus outbreak: WHO declares COVID-19 a global pandemic. https://www.youtube.com/watch?v=xKPWngYf2Wk

1. Eye health1) Importance of eye health
Eye and dental diseases signiﬁcantly affect our health not only during school age but also in adulthood.
Loss of sight in particular is a serious issue. Cambodia implemented the national strategic plan to prevent
loss of sight (2008–2015) with a focus on the National Program for Eye Health, and achieved the goalof making the rate of blindness 0.5% or lower.1 Nevertheless, an estimated 28,800 people still sufferfrom loss of sight or visual impairment. The leading cause of loss of sight and visual impairment iscataracts (approx. 19,000 people), but they can also be caused by leaving refractive errors that occur
during school age untreated. It is said that 80–90% of these causes are preventable or treatable.2
Meanwhile, about 20% of children have missed a class due to a toothache over the last 12 months,
indicating that dental health is an issue that should be given priority for school-age children.3 The school
age is a period in which milk teeth (deciduous teeth) are replaced by permanent teeth, and leaving dental
caries or periodontal disease untreated during this period can invite exacerbation later and result in lossof teeth in adulthood.
Therefore, it is very important to learn eye and dental health in school health classes during schoolage.

20 IFRC, UNICEF, WHO. Social Stigma associated with COVID-19: A guide to preventing and addressing social stigma. https://www.
who.int/docs/default-source/coronaviruse/covid19-stigma-guide.pdf
21 American Psychological Association. Combating bias and stigma related to COVID-19: How to stop the xenophobia that’s spreadingalong with the coronavirus. https://www.apa.org/topics/covid-19-bias

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Chapter 8

Eye and dental health1312) How we can see an object

dermatitis, cases caused by a traumatic injury like perforation or the contusion of the eyeball, and casesof congenital cataracts. There are drug therapies and surgical treatments. Drug therapy can slow theThe ophthalmus is an intricate organ that allows us to clearly see things in the outside world and is often

progression of the disease but cannot remove the crystalline lens opacity. Recovery of sight requires

compared to a camera. The cornea and crystalline lens, which correspond to camera lenses, pass andsurgery in which the opaque crystalline lens is removed and replaced with an artificial lens.

refract light. The retina corresponds to camera film. An object in the outside world can be clearly seen
when the image refracted by the cornea and crystalline lens is focused on the retina surface (Figure 8.1).

(2) Glaucoma

The ciliary muscle surrounding the crystalline lens focuses an image on the retina by becoming tense or

Glaucoma is a disease in which increased intraocular pressure and the fragility of the optic nerve impair

loose according to the distance to the object that is seen. Whether an image can be focused on the retina

the optic nerve, resulting in visual impairment. Intraocular pressure is the pressure inside the eyeballsurface depends on the refractive power of the lens and the distance from the front surface of the lensand has the role of maintaining the shape of the eyeball. Symptoms of glaucoma are reduced vision andto the retina (the axial length of the eye).

visual field defects, but often, no symptoms are developed in the early stage. If the state of increased
intraocular pressure continues, it impairs the optic nerve and results in loss of sight. Although glaucoma
is mostly primary (cases in which there is no original disease or the cause is unknown), there are also

Column: Eye and ophthalmus

cases that occur secondary to other diseases. There are drug therapies and surgical treatments, one ofwhich is selected depending on the pathological condition (state of the disease).

The eye covers a region that is larger than the region of the ophthalmus. The eye refers to the entire
eye as a part of the face, including the eyelid, the inner corner of the eye, the outer corner of the eye,(3) Diabetic retinopathy

and the eyeball. Meanwhile, the ophthalmus, which is a term in medicine and physiology, refers to
the eyeball.

Diabetic retinopathy is a disease in which persistent hyperglycemia weakens vessel walls in the eye,causing angiopathic lesions of the retina. It is one of the three major complications of diabetes andoccurs several to ten-odd years after the person is affected by diabetes. There are often no symptoms in
the early stage, and retinopathy has already significantly advanced by the time symptoms are noticed.
Symptoms are misty vision (the whole vision is blurred), myodesopsia (a symptom in which a small

Retina (film)

flying object like an insect appears in the vision), reduced vision, and visual field defect, which eventually

Optic nerve

result in loss of sight. Depending on the symptom, surgery to coagulate retinal tissue using a laser, or
surgery on the vitreous body is performed. It is important to control blood glucose along with theCornea(first lens)Crystalline lens(second lens)Ciliary bodytreatment of diabetes.

Optic nerve head(4) Trachoma

These two are used to focus

Trachoma is conjunctivitis caused by repeated infection with Chlamydia trachomatis. In severe cases,
a lot of conjunctival vessels enter the cornea and make it opaque, resulting in loss of sight. It is common

Figure 8.1 How we can see an object (Structure of the eyeball)in preschool children. To treat the disease, new quinolone antibiotic eye drops or eye ointment are used,or a tetracycline or macrolide antibiotic is taken orally. Not sharing towels and bedding, as well as3) Eye diseases that can cause visual impairment

washing hands and faces frequently can help prevent home infection.
The real situation and magnitude of trachoma is still unknown. However, it is assumed that in

As diseases that can cause reduced vision or loss of sight, which are common in Cambodia, we can cite

Cambodia trachoma still remains a major public health problem, though no nationwide surveys have1

cataracts, glaucoma, diabetic retinopathy, trachoma, vitamin A deficiency, and refractive error.

ever been carried out. Cambodia is a member of the WHO Global Alliance for Elimination of Trachoma.

Described below are the outlines of these diseases.4

A rapid assessment of trachoma and its risk factors is planned in 3 provinces with objectives to determine(1) Cataracts
Cataract is a disease in which the crystalline lens becomes opaque. The opaque crystalline lens impairs

the occurrence of blinding trachoma, measure its magnitude, and the severity of the problem.2(5) Vitamin A deficiency

light transmission, resulting in visual impairment and eventually loss of sight. The leading cause of

Vitamin A is a nutrient that is related to the reception of photic stimulation as well as the differentiation

cataract is aging, but there are also cases associated with systemic disease such as diabetes and atopic

and functional maintenance of epithelial cells (see Chapter 5). Deficiency in vitamin A can cause night132

Chapter 8

Eye and dental health133blindness or make the conjunctiva and the cornea dry enough to cause visual impairment. Nightin Japan (Tokyo).6 The high prevalence of myopia in school children is a major issue of school healthblindness is a disease characterized by a significant reduction of vision in the dark, caused by impaired

and public hygiene in Asian countries.

rod cells that usually function in the dark (see Chapter 2). When the conjunctiva is dried, moving the

The causes of myopia are thought to be related to genetic factors and the environment. It has

eyeball may make wrinkles in the conjunctiva, or show dull, dirty white spots (Bitot spots) in the

been reported that seeing objects at a short distance for long hours during the growth period canpalpebral conjunctiva. If the symptoms progress further to dry the cornea, an ulcer is formed, and in

affect the prolongation of the axial length of the eye, indicating that the use of mobile games andsevere cases, a hole in the cornea may have been developed resulting in loss of sight. To treat the disease,

SNS could progress myopia; therefore, attention needs to be paid to lifestyles. Meanwhile, there isvitamin A is administered. Intake of a proper amount of vitamin A is also effective in prevention.

another survey of Chinese elementary school and junior high school children that reported that tasks(6) Refractive errors (hyperopia, myopia, and astigmatism)

performed at a short sight distance had no influence on myopia while a longer time of participationin outdoor activities was associated with a lower incidence of myopia in elementary school children.5

Uncorrected refractive error is major cause of visual impairment. An estimate of prevalence of visual

Moreover, it has been confirmed that increasing the time for outdoor activities at schools reduced

impairment due to refractive errors accounts for 52.8%. In children refractive errors affected

myopia. Increasing the time for outdoor activities is not only good for eye health but also expected1

to be effective in preventing lifestyle diseases including obesity, and therefore, it is a good effort in2

about 70% of refractive errors in children were myopia, indicating the importance of early detection

school health.7 However, in Southeast Asian countries including Cambodia, where sunlight is strong

and prevention of exacerbation of refractive errors, particularly myopia, during school age.

and temperatures are high, it is difficult to increase the time for outdoor activities and someapproximately 10% in urban areas and 1.5% in rural areas. Meanwhile, there is also a report stating that

Normal refraction refers to the condition of the ophthalmus in which parallel rays are correctly

consideration is needed.

focused on the retina when an object is seen in the non-accommodative state (state in which nothing isbeing done). The condition in which they are not correctly focused is called refractive error. There arethree types of refractive errors: hyperopia, myopia, and astigmatism (Figure 8.2).

a. Hyperopia

c. Astigmatism
Astigmatism is a condition in which parallel rays are not focused at a single point on the retina. This iscaused primarily by an unequal curvature, instead of a spherical surface, of the cornea. In astigmatism,

Hyperopia refers to the condition of the ophthalmus in which parallel rays are focused posterior to thehow objects are seen is different from, and more complicated than that in myopia and hyperopia. Objects

retina in the non-accommodative state, thus producing an unfocused, unclear image on the retina. The

look blurred regardless of the distance.

causes of this include a short axial length of the eye and weak refractive power of the cornea or the
crystalline lens. In hyperopia, it is difficult to clearly see both far and near objects, and particularly near
objects. Consultation with a specialist is required depending on the severity, but leaving it untreated maylead to reduced vision or cause amblyopia or esotropia.

Emmetropia

Focused on the retina

Myopia

Focused anterior to the retina

Hyperopia

Focused posterior to the retina

Astigmatism

Non focused on a single point(shifts up and down, and to
the left and right)

b. Myopia
Myopia refers to the condition of the ophthalmus in which parallel rays are focused anterior to the retina
in the non-accommodative state, thus producing an unfocused, unclear image on the retina. The causesof this include a long axial length of the eye and strong refractive power of the cornea or the crystalline
lens. In myopia, it is not possible to clearly see far objects but possible to clearly see near objects. School
children with myopia may find it difficult to see letters on the blackboard. In addition, as they have tonarrow their eyes, or knit their brows to see objects, they may experience headaches.
Column: Asians and myopia

The prevalence of myopia in schoolchildren has been reported to be higher in Asian countries thanin Europe and other regions (20–30%), with the rate of myopia being 45.7% for high school students
in Korea, 70.3% for those aged between 12 and 19 in Taiwan, 78.4%5 for those aged 15 in China(Guangzhou), and 76.5% for those aged between 6 and 11 and 94.9% for those between 12 and 14

134

Figure 8.2 Emmetropia and refractive errors
Chapter 8

Eye and dental health1354) Correction of refractive errors

In both types of contact lenses, attention needs to be paid to complications that may be caused byputting the lens on the surface of the cornea. Such complications include corneal infection, which is(1) Glasses

caused by damaging the cornea, conjunctivitis, which is caused by allergens attached to the contact

Glasses are used to correct refractive errors. There are the two types of lenses for glasses: a convex lenslens, and corneal epithelium disorder, which is caused by decreased oxygen supply to the surface layer

and a concave lens. The convex lens is used in a magnifying glass, and its shape is round in the centerof the cornea that is covered. To reduce these complications, it is important to properly manage and use

and tapered in thickness toward the periphery. Meanwhile, the concave lens is thin in the center andcontact lenses. First of all, pay attention to how many hours per day. Depending on the type of lens andthickens toward the periphery.

the condition of the wearer’s eye, generally 12 to 16 hours per day is seen as a guide. Second, contact

Since myopia is a condition in which rays converge anterior to the retina, glasses with concave

lenses should be kept clean, and contact lenses other than single-use lenses should be cleaned after use

lenses are used. The concave lenses converge rays posteriorly, thus adjusting the focal point to focus theand stored in a clean container. Also important is having an eye examination at an ophthalmologicalimage on the retina. In hyperopia, meanwhile, rays converge posterior to the retina, glasses with convex

clinic on a regular basis.

lenses are used. The convex lenses converge rays anterior to focus the image on the retina, making it
possible to see the object clearly (Figure 8.3).
Type

How rays travel

Column Fashionable contact lenses caused eye disorders!!

How the image is focused on the retina
Convex lensConvex lens(for hyperopia)

colored contact lenses to change the color of the iris as well as circle contact lenses to make thepupil look larger. As with contact lenses for visual correction, contact lenses for fashion may also
cause eye diseases if they are not properly used. Some people developed an eye disease by sleeping

Rays froma close distance

RetinaCrystalline

Converge rays

These days, some people use contact lenses not for visual correction but for fashion. They use

Concave lens

while wearing contact lenses, or borrowing/lending contact lenses from/to a friend. Avoid carelessuse, adhere to the same usage hours, and properly maintain the lenses. In addition, take care not topurchase inferior goods that use harmful substances to color the lenses. The abnormality of the eyeor an uncomfortable feeling that people experience while wearing colored contact lenses is a sign oftrouble in the eye.

Rays froma far distanceConcave lens(for myopia)
Diverge rays

Correction of myopia(rays are diverged by the concave lens before entering
the ophthalmus)

Figure 8.3 Mechanisms of visual correction by glasses(2) Contact lens

5) Protecting your eyes
Because myopia often occurs during school age, the prevention of myopia is discussed here. Preventing
the onset and progression of myopia can lead to the prevention of visual impairment in adulthood. The
progression of myopia due to “environmental factors” can be prevented by reviewing daily life.

(1) Posture

A contact lens, which is a medical device placed directly on the cornea, can be used for various eye

It is said that sitting in a bad posture during class, or watching television or reading books while lying

disorders, including myopia (nearsightedness), hyperopia (farsightedness), astigmatism, and presbyopia

can exacerbate myopia. Pay attention to posture during class. Sit straight up, and allow a fist-size space(poor focusing with reading material and other near vision tasks occurring typically in middle and oldbetween the desk and the belly. It is desirable that the height of the chair allow the bottoms of the feet toage). According to the material, it can be divided into hard contact lenses and soft contact lenses. The

reach the floor entirely. If that is not possible, adjust the height of the chair or use a stool (Figure 8.4).

hard contact lens is made of a hard material and generally used for a long period while receiving
maintenance such as cleaning. The soft contact lens is made of a material that softens with water and(2) Brightness

comes in different types: a single-use type, a type that is replaced every two weeks to one month, and aClassrooms and equivalent facilities require a brightness of 300 lux or more. Vertical TV and computer

type that is used for a long period of time. The soft contact lens is slightly less effective in correction

monitors should ideally give off 500–1000 lux (lux is a standard unit of measurement of light level

than the hard contact lens but has the advantages of giving the wearer a less uncomfortable feeling andintensity). In Japan, the “School environmental hygiene standards for environment of classrooms, etc.”

causing less slipping and dropping.

stipulate that when classrooms are used for learning, they are required to have a brightness of 300 lux or136

Chapter 8

Eye and dental health137

these, the functions of “eating” and “talking” that are acquired in infancy as the teeth and the mouth
develop are fulfilled by keeping those functions healthy throughout life. Therefore, keeping the teeth andDistance between the desk
and the bodythe mouth healthy will improve the person’s quality of life (QOL) throughout their life. Although QOL
Give a fist-size spacecan be interpreted variously depending on context, one popular understanding is that QOL represents theextent to which a person obtains satisfaction from life.
The number of teeth is 20 for milk teeth or deciduous teeth and 32 for permanent teeth. However,
eruption of the third molars (the wisdom teeth) varies among individuals. Without the third molars, theHumpback

number is 28. At around six months after birth, babies start teething with milk teeth and finish when they
are around two and a half to three years old. The order of teething varies among individuals. The firstpermanent tooth to grow is often a mandibular central incisor or a mandibular first molar. Teething of
permanent teeth is completed at 12 to 13 years old, with variations in the order of teething among
Feet do not reach the floor

individuals greater than those for milk teeth. Childhood is a period in which milk teeth are replaced by

Back: Straight
Bottoms of the feet: Entirely reachthe floor
Belly: Fist-size spacepermanent teeth (Figure 8.5).11 Because dental caries may affect how permanent teeth grow as well as
the tooth alignment, childhood is viewed as an important period also from the standpoint of developing
the characteristics, alignment, and occlusion of permanent teeth.
Individual teeth have shapes suitable for their roles concerning the function of eating. Incisors cut

Figure 8.4 Bad posture and good posture during classfoods. Canines play a role in tearing foods into pieces. Molars play a role in grinding foods to change
their shapes so that they can be easily swallowed. A tooth is comprised of the outside of very hard8

more for the entire classroom and a brightness of 500 lux or more for the blackboard surface.

enamel, the body of dentine, and the root surface of cementum (Figure 8.6).

During class, students repeatedly look at the blackboard, a book, and a notebook. Therefore, a large
difference between the brightness of the blackboard and that of the classroom causes eyestrain. In
addition, attention should be paid to any direct sunlight from the window or a light source that interferes

8-9 y.o. 7-8 y.o.

with the field of vision, as it can disturb visibility even if the intensity of illumination meets the standards.

(3) Rest eyes frequently
Staring at a close object for long hours will keep the ciliary muscle tense and likely exacerbate myopia.
Recently, there have been increasing opportunities to look at small screens of devices such as smartphones

17-18 y.o.
10-15 y.o.

12-14 y.o.

it is important to deliberately look away from the screen and look into the far distance to rest the eyes.

17-18 y.o.

followed in order to prevent eyestrain caused by continuing to stare computers or smartphone screens inparticular. The rule is to take at least a 20-second break to view something 20 feet (approx. 6 meters)
9away every 20 minutes.

2. Dental health
1) The roles and development of teeth
The functions of the teeth and the mouth are significantly related to vital functions including “eating,”“talking,” “creating expressions,” and “supporting movement and keeping a body in balance.”10 Among138

8 y.o. 7.5 y.o.

6-7 y.o.

and tablets. Small letters and screens make us particularly short-sighted and are likely to cause eyestrain;
The American Optometric Association (AOA) recommends that the 20-20-20 rule should be

Teeth newly added(accessional teeth)

10-11 y.o10.5 y.o10.5 y.o.
11.5 y.o.

Timing of teething of
permanent teeth

Timing of losing milk teeth

17-18 y.o.

11 y.o.

11-13 y.o

10 y.o.
9.5 y.o6-7 y.o.

7 y.o. 6 y.o.

10-12 y.o.
9-11 y.o.

9-10 y.o.
7-8 y.o. 6-7 y.o.

Nemes ofpermanet teeth
Third molar(wisdom tooth)Second molarFirst molar
Second premolarFirst premolar
CanineLateral incisor
Central incisor

Figure 8.5 Timing of losing milk teeth and timing of teething of permanent teeth11
Chapter 8

Eye and dental health139

caries.

Cementum Enamel Dentine(vii) Dental caries starts in enamel. Dental caries developed in enamel does not cause symptoms
such as toothache or a pain sensitive to cold water or sweet foods. If left untreated, dental caries
extends to dentine and the dental pulp (nerve). If dental caries extends to the dental pulp, a

Crown
Gum

Nerve

Tooth root

Periodontal membrane
Alveolar bonesevere pain develops. Leaving this condition untreated results in the death of the nerve, anddissipation of the pain. Further progression of dental caries causes the crown to collapse andleaves only the tooth root. Because conservative treatment is impossible for this condition of atooth, the tooth will be extracted.
Memo: Sucrose and sugar

ArterySucrose is the most common food sweetener. Industrial products mainly composed of sucrose areVeincollectively called sugar.

Figure 8.6 Structure of a tooth
PlaquePhosphorus2) Dental caries

Acid

EnamelDental caries is a disease in which enamel or dentine is destroyed by acid produced by the activity ofCalciumbacteria (mutans streptococci) and lactic acid bacteria in the mouth (see Chapter 4). Dental caries does
not heal on its own, nor does a tooth with caries return to the original health even if it is treated. The

DentineCambodia National Oral Health Survey, conducted in 2011, reported that the prevalence of dental caries
is 93% for children aged six, and 80% for those aged 12 and 13 and aged between 35 to 44, indicatingthat dental caries is a major health issue not only for children but also for adults in Cambodia.12(1) Mechanism of the development and progression of dental caries
Figure 8.7 Mechanism of the development of dental caries

Dental caries develops when the conditions of three factors, that is, bacteria, tooth quality/shape, andcarbohydrate (sucrose or sugar) are met, and time passes. Described below is the mechanism of thedevelopment of dental caries (Figure 8.7).
Infection with mutans streptococci (formal name: Streptococcus mutans) is established.

deciduous incisors as well as maxillary and mandibular deciduous molars are susceptible to dental(ii) Mutans streptococci in the oral cavity uses carbohydrate taken as food to produce sticky glucan

caries. Among permanent teeth, the maxillary molar region is the most susceptible to dental caries. The

from sucrose. The glucan attaches to the surface of the tooth and produces plaque (see Chapter

regions that are likely to cause dental caries are grooves in molars, gaps between the teeth, and boundaries

4) with other oral bacteria. Thus, the plaque is an aggregate of various bacteria.

between the tooth and the gum (Figure 8.8). In these regions, food particles tend to remain and the(i)(iii) Bacteria in the plaque further proliferate to produce acids using carbohydrates (sucrose) taken
as food.

cleaning effect of saliva is difficult to reach physically. Thus, the adhesion of plaque (see Chapter 4) islikely to occur.

(iv) When acidity in the plaque becomes pH ≤ 5.5, enamel on the tooth surface begins to decay

In addition, newly grown teeth are likely to develop dental caries. When a tooth comes in contact(decalcification; the dissolution of calcium and phosphoric acid from the enamel of the teeth).

with saliva, enamel absorbs calcium in the saliva to promote the crystallization of enamel, thus making(v) Acidity in the plaque returns to the original pH level thanks largely to the effect of saliva,

the tooth resistant to dental caries. But this is said to take two to four years in general. Given thatcausing remineralization (restoration by the activity of saliva).
(vi) Eating foods containing saccharides without a break leads to the disruption of the balance
between (iv) and (v), which makes decalcification greater than restoration, resulting in dental
140

There are teeth and regions that are likely to cause dental caries. Among milk teeth, maxillarypermanent teeth start to grow at six years old and complete growth by 12 or 13 years old, the school age
is a period in which the development of dental caries is rather common. This is also a reason why
establishing dental and oral health practice is necessary during school age.10
Chapter 8

Eye and dental health141

Gaps between teeth

Boundaries between teeth and gum4) Prevention of dental caries and periodontal disease10
The school age is a period in which milk teeth are replaced by permanent teeth and a lifestyle isestablished. It is therefore important to learn dental and oral health during school age. Establishingdental and oral health practice is a daily, common subject, in which it is easy to find challenges and see
the process of solving such challenges. For this reason, dental and oral health is a valuable teaching andGrooves in molars

learning matter that enables the direct observation of the body condition and its changes. Here, brushingteeth and diet are discussed as preventive measures against dental caries and periodontal disease.

Figure 8.8 Regions that are susceptible to dental caries(1) Toothbrushing
Toothbrushing is effective in removing plaque (an aggregate of living bacteria) that can cause dental

3) Gingivitis and periodontal diseasecaries and periodontal disease. Plaque is milk white, a color similar to that of a tooth, and rough when it
is tongued (see Chapter 4). Plaque tends to attach to gaps between the teeth, boundaries between thetooth and the gum, and the occlusal surface. Therefore, brush the teeth along the tooth alignment by

Periodontal disease is a general term for conditions where periodontal disease bacteria have caused

brushing one area at least 20 times and keeping the following three tips in mind: (i) properly place

inflammation of the periodontia around the tooth (e.g., the gum, periodontal membrane, alveolar bone,bristle ends of the toothbrush against the boundary between the tooth and the gum as well as gaps

and cementum). The condition in which inflammation is only caused in the gum is called gingivitis, andbetween the teeth, (ii) move it with light force that does not allow bristle ends of the toothbrush to

the condition in which inflammation extends to the alveolar bone and the periodontal membrane isbroaden, and (iii) wiggle the toothbrush within a range from approximately 5 to 10 mm, and brush one

called periodontitis. Having no subjective symptoms, gingivitis is often left untreated and progresses

by one (Figure 8.9). Brushing the teeth in a predefined order will enable uniform, complete brushing.

silently. By the time the disease is noticed, even the alveolar bone supporting the tooth has decayed due
to a toxin from periodontal disease bacteria and inflammation. This is called the resorption of the alveolarbone, and in this condition, the tooth is wobbly, chewing foods becomes difficult, and eventually the
tooth comes out.

Angle

How to move

Behind the front teeth

Place the toothbrush at an angleof 45 degrees against a gap
between the tooth and gum.

Wiggle the toothbrush.

Place the end of the toothbrushvertically.

Grooves in molars

Gaps between teeth

Properly place bristle ends
against grooves and brush them.

Place the tip of the toothbrush.

Inflammation of the gum is caused by plaque that attaches to the boundary between the tooth and thegum and then increases. Plaque is an aggregate of various types of bacteria, and periodontal disease
bacteria in particular, which like places where the amount of oxygen is small, enter the space between
the tooth and the gum (a periodontal pocket) and destroy periodontal tissues with a toxin and acid (seeChapter 4). While periodontal disease affects many adults, gingivitis starts during elementary and juniorhigh school age. Adolescent hormonal imbalance (particularly, changes in female hormone levels),stress, lifestyle habits such as smoking, and lifestyle diseases including diabetes are risk factors that can
exacerbate periodontal disease.

Bad example

Column: Causes and prevention of bad breath

Bad breath is a very common issue of oral hygiene. In most cases, causes are in the mouth; the two
major causes are coating of the tongue and periodontal disease. Bad breath is caused by systemic
diseases (metabolic diseases) such as diabetes, uremia, hepatic cirrhosis, liver cancer, andtrimethylaminuria.13 The best way of making sure you do not have bad breath is to keep your teeth,
tongue, and mouth clean. Preventive measures include twice-a-day gentle, careful brushing of the

Do not apply excessive force as
it can damage the gum.

teeth, the gum, and the tongue, removing food particles from the space between the teeth, notsmoking, and not taking in high-sugar drinks.14

142

Figure 8.9 How to use a toothbrush
Chapter 8

Eye and dental health143

Make it a rule to brush the teeth after eating breakfast, lunch, and dinner in order to prevent the acid state

10-15 cmof the oral cavity from lasting for a long time after meal ((iii), (iv), and (v) in the development andprogression of dental caries described above). Brush the teeth particularly carefully before going to bed
because, while sleeping, the amount of saliva secretion becomes small and the self-cleaning function
decreases.

1-2 cmColumn: A variety of toothpaste

What kind of toothpaste do you use? What standard do you apply to choose it?
Toothpaste contains various components. They include a polishing agent to remove stains(calcium carbonate, sodium bicarbonate), a refrigerant like mint, a forming agent to improve theCut floss to a length ofabout 40 cm (length froma fingertip to the elbow).

feeling of brushing, and fluoride to prevent dental caries (sodium fluoride, sodium monofluorophosphate).
It is only fluoride that has been shown to be effective in scientific studies. Although the foam ofWind floss around both
middle fingers (forefingers)
several turns lightly. Winda longer section aroundyour non-dominant hand.

Adjust floss to make thespace between both
middle fingers 10-15 cm
when floss in taut.

Hold floss with thumbs
and forefingers andhandle it while keeping aspace of 1-2 cm.

Figure 8.11 How to hold dental floss

toothpaste makes us feel the teeth have been cleaned, foaming agents are not effective in preventing
dental caries. The most important thing to prevent dental caries is to brush the teeth properly. It is
recommended that you should start brushing without toothpaste and finish brushing with toothpaste.
When you use toothpaste containing fluoride, it is also important to keep gargling to a minimum inorder to allow the component to spread over and coat the teeth.

Let’s experiment

Experiment for effective toothbrushing

Preparation: Plaque disclosing tablets, toothbrush, mirror, cotton swab, towel, clothespin, waterbottle (water for gargling), container to spit out water, etc.

(2) Dental floss

Experimental method (Figure 8.12)

It is difficult to remove plaque between the teeth with a toothbrush because bristle ends do not always(i)reach between teeth. Dental floss is made of thin bundled fiber (Figure 8.10). This allows it to pass(ii) Brush your teeth.

through a narrow gap between the teeth to scrape off plaque that cannot be completely removed with a(iii) Chew one plaque disclosing tablet firmly into small pieces. Apply them to your teeth with yourtoothbrush. Figure 8.11 shows the proper method for using dental floss.
Dental floss comes in two types: wax type and non-wax type. The wax type slides well and is easy

Put a towel around your neck and fix it with a clothespin.

tongue with the aid of a mirror, then spit them out.
(iv) Rinse out your mouth one or two times.

to insert into gaps between the teeth; it is thus recommended for novice users. The non-wax type can(v) Observe areas that have been stained red in the mirror.

scrape off plaque more efficiently because its fiber is not fixed with wax and thus can fit the surface of a(vi) Discuss regions that tend to remain uncleaned.

tooth when it sticks to it.

Figure 8.12 Staining experiment steps(3) Eating habits to maintain dental health (how and what to eat between meals)
Among carbohydrates, sucrose (sugar) can be a primary cause of dental caries because “it is used as amaterial to produce plaque” and “it is used as a material for acid production by bacteria.” At the same
Figure 8.10 Example of dental floss

144

time, sucrose is an important nutrient source. Therefore, the important thing is not just cutting the intake
of sucrose but taking it in a wise way. Specifically, it is important not to take foods containing it frequently
Chapter 8

Eye and dental health145

or irregularly (not to eat without a break) because the constant presence of sugar in the oral cavity creates
an environment in which acid is constantly produced and thus decalcification progresses (Figure 8.13).
In addition, eating sticky foods such as snack foods should be discouraged because carbohydrates
persistently remain in grooves in molars, which is a condition that is likely to cause dental caries.
Three meals a day

pH 7.06.5
6.0
pH
5.5~5.7 5.5
5.0
4.5
4.0
3.5
3

Remineralization Return to normal

Decalcification The teeth lose calcium

Frequent drinking and eating

pH 7.06.5
6.0
pH
5.5~5.7 5.5
5.0
4.5
4.0
3.5
3

Because saliva and/or toothbrushing clean
bacteria and acid, the period of normal pH
levels is lengthened.

Remineralization Return to normal

Decalcification The teeth lose calcium
The period of normal pH levels is limited.

Figure 8.13 Relationship between diet and oral cavity pH (Stephan curve)

References
1

Report of eye care activities in Cambodia 2011. http: //www.npehcambodia.com/filelibrary/Report_of_PBL_Activities_in_2011.pdf

2Sogbesab E, Yutho U. Cambodia’s National Eye Care Programme and VISION 2020: The Right to Sight. Community Eye Health13(36) : 57-59,2000. https: //www.ncbi.nlm.nih.gov/pmc/articles/PMC1705982/

Exercises for further thought and research[8-1] The prevalence of myopia among school children is said to be lower in Cambodia than in other3

Report.pdf
4Institute of Medical Information Science ed. Byoki ga mieru VOL12 Ophthalmology. Medic Media, 2019.

5

Lin Z, Vasudevan B, Jhanji V, Mao GY, Gao TY, et al., Near work, outdoor activity, and their association with refractive error.
Optometry and Vision Science. 91(4) : 376-382. 2014. https: //www.researchgate.net/publication/260874694_Near_Work_Outdoor_

Asian countries. Find reasons for that. Predict whether or not the number of children with myopia
will increase in the future by sharing views.
[8-2] Assume that you give an eye health class to elementary school students, consider the content andmethod, and give a mock class.

Activity_and_their_Association_with_Refractive_Error/link/5d0dabc092851cf44040e5b0/download
6

measures can be taken to increase time for outdoor activities for children.
[8-4] Investigate the habit of toothbrushing among elementary school students. Consider benefits andchallenges based on the section of “Toothbrushing.”[8-5] Consider an effective method for teaching toothbrushing taking into account ages at which teeth
are replaced by new growth.

Yotsukura E, Torii H, Inokuchi M, Tokumura M, Uchino M, et al., Current Prevalence of Myopia and Association of Myopia With
Environmental Factors Among Schoolchildren in Japan. JAMA Ophthalmology. 137(11) : 1233–1239. 2019.

7

Dolgin E. The Miopia Boom. Short-sightedness is reaching epidemic proportions. Some scientists think they have found a reason
why. Nature. 519: 276-278. 2015. https: //www.nature.com/news/polopoly_fs/1.17120!/menu/main/topColumns/topLeftColumn/[8-3] It is difficult to increase time for outdoor activities in Southeast Asian countries including
Cambodia, where the sunlight is strong and temperatures are high. Consider what kinds ofGlobal School Based Student Health Survey Cambodia 2013. https: //www.who.int/ncds/surveillance/gshs/Cambodia_2014_GSHS_

pdf/519276a.pdf
8

Ministry of Education, Culture, Sports, Science and Technology. School environmental hygiene standards: 2018. https: //www.mext.
go.jp/a_menu/kenko/hoken/__icsFiles/afieldfile/2018/05/28/1403737_02_1.pdf

9

American Optometric Association. 20/20/20 to Prevent Eye Strain. https: //www.aoa.org/AOA/Images/Patients/Eye%20
Conditions/20-20-20-rule.pdf

10 Ministry of Education, Culture, Sports, Science and Technology. School dental health reference material, Establishing dental andoral health practice at school to foster “zest for living,” Chapter 1 Introduction. https: //www.mext.go.jp/component/a_menu/
education/detail/__icsFiles/afieldfile/2011/06/23/1306939_03.pdf
11 Tsuchiya M. Children’s teeth: 2. Survey on children’s health and environment Eco & Child Miyagi Unit Center. http: //www.ec-muc.
med.tohoku.ac.%AD%90%E3%81%A9%E3%82%82%E3%81%AE%E6%AD%AF%E3%81%AB%E3%81%A4%E3%81%84%E
3%81%A6%E3%83%BB2%E3%80%91/
12 Chher T, Turton BJ, Hak S, Beltran E, Courtel F, et al. Dental Caries Experience in Cambodia: Findings from the 2011 Cambodia
National Oral Health Survey. Journal of International Oral Health 8(1): 1-7. 2016.
13 Ministry of Health, Labour and Welfare. e-healthnet: Causes and realities of bad breath. https: //www.e-healthnet.mhlw.go.jp/
information/teeth/h-07-001. html#:~:text=%E5%8F%A3%E8%87%AD%E3%81%AE%E5%A4%A7%E9%83%A8%E5%88%86%
EF%BC%8880,3) 2S%5D%E3%81%A7%E3%81%99%E3%80%82
14 National Health Service. Bad breath. https://www.nhs.uk/conditions/bad-breath/146

Chapter 8

Eye and dental health147

Chapter 9

Significance of health checkups andtheir methods

Cambodia do not conduct health checkups. However, all schools in the country are called on to conduct
health checkups to ensure the sound growth and development of children (see the National School
Health Policy 2019 in chapter 1). Some countries include clinical medical tests such as electrocardiography,
radiography, and urinalysis in health checkups. This chapter will focus on easy and effective measurements
and tests that are feasible in Cambodia: height measurement, weight measurement, eye test, and hearing
test.

Learning objectives
You will be able to gain proper understanding and explain:- The significance of health checkups and learn to conduct health checkups correctly.
- Based on the results of health checkup, how to identify health issues of children, screen them, andconsider appropriate measures at school.
- The importance of creating a system for conducting high-quality and continuous health checkups
at schools.
In this chapter, you will learn about the significance of health checkups; specific procedures for measuring
and recording height, weight, eyesight, and hearing; how to utilize these data; and how to plan andColumn: Health checkup is “Screening.”

Screening means to group people into those who may have problems and those who do not throughtests. Health checkups are a form of screening, not a diagnosis of illness. If a child is suspected ofsome possible health problems in a health checkup, it is important to refer the child to the appropriate
health service.

2. Health checkup methods

prepare for health checkups at the school.
This section explains procedures for height measurement, weight measurement, eye test, and hearing

1. Significance of health checkups

test, and for evaluating the measurement/test results. Screening can be performed properly without
specialized equipment. Check the physical growth and health conditions of children with materials
available at your school.

There are two objectives for health checkups (health examinations and physical measurements):
The first is to check and evaluate whether children are growing steadily, and if abnormalities are
discovered, refer to health services. The second is to identify the health issues of children as a group, andlink to appropriate responses and health education at the school.
The primary goal of school health is for children to grow and develop soundly. As discussed in
Chapter 3, the growth and development of children is promoted or interfered with by various factors

1) Height measurement and weight measurement(1) Height measurement method
a. Items for use: Measuring tape, triangle ruler, adhesive tape (Figure 9.1)

(i.e., biological, behavioral, and physical/social environmental factors). Hence, it is important to regularly
check, evaluate, and screen whether children are growing and developing soundly. If children are left ina state where their growth/development is inhibited, it can cause a negative spiral that interferes withlearning and daily life and further inhibits growth/development. If the growth and development of achild is not smooth, it is vital to investigate the factors and make necessary improvements. Examples offactors that inhibit growth and development may include serious illnesses, nutritional conditions,unfavorable living environments, daily rhythm, and psychological stress.
Health checkups aim not only to evaluate the individual growth and development of children, but toidentify and improve collective health issues. For example, suppose a school has discovered that manyof its children have poor eyesight through a health checkup. To improve this, the school can propose toadjust the brightness of the classrooms, provide health education to the children regarding their postureand eye health, and take other measures on a schoolwide basis to improve the eyesight of the children.

Figure 9.1 Items for measuring height (triangle ruler, tape measure, and adhesive tape)

In this way, it is important to connect the health checkup to health education and school health activities.
Health checkup systems and programs vary from country to country. At present, most schools in
148

Chapter 9

Significance of health checkups and their methods

149

b. Set up the place for measuring height (Figure 9.2)(i)(v) Have them hang their arms down the side of the body.

Look for a level floor and wall. Even a pillar will work.

(vi) Have them look straight forward.

(ii) Hold the tape measure to the wall, making sure it is perpendicular to the floor.

(vii) Lower the triangle ruler(iii) Mark the floor where the child’s feet should be.

straight down along thetape measure, read, andnote it down the value atthe corner of the triangle
ruler (Figures 9.4 and 9.5).
d. Tips- Make sure that the postureof the child is correct
during measurement.
- Measurement may not be
accurate for children who
tie their hair near the topsof their heads. Ask them

Figure 9.2 Setting up the place for measuring heightfor consent to untie or

ruler

Figure 9.5 Scene ofmeasuring height

lower the knot.

c. Procedure(i)Figure 9.4 Lowering triangle

Call the names of the children one at a time.

(2) Weight measurement method(ii) Have them remove their shoes.
(iii) Have them stand upright with both heels touching the wall.

a. Items for use: Scale(iv) Make sure both heels, buttocks, and back are touching the wall.

b. Set up the place for weighing

Be sure that the back of the head touches the wall. (Figure 9.3)

Find a level floor.

(i)(ii) Position the scale.
c. Procedure (Figure 9.6)

Back of head(i)Call the names of the children one at atime.

(ii) Have them remove their shoes. Havethem take off their jackets and weigh
To measure accurately, open
toes 30-40° wide so that you
can stand stably and knees
stretch naturally.

without carrying anything unnecessary,

Backsuch as mobile phones or watches.
(iii) Have them stand gently on the middle

Buttocks

30 -40°Line connecting the infraorbital
margin with the superior marginof the external acoustic meatus.

of the scale.
(iv) Ensure that they do not move while on
the scale, and read and note down thenumber on the scale.

Figure 9.6 Scene of measuring weightd. TipsHeels- The method for turning on and using the scale differs for each scale. Check these methods
before starting. For analog scales, make sure that the needle is pointing to 0. For digital
instruments, check the batteries.

Figure 9.3 The correct posture when measuring height

150- Avoid weighing immediately after eating, as this can affect body weight considerably.
Chapter 9

Significance of health checkups and their methods151Column: What is standard deviation?

(3) Assessing height and weight
Reference values for comparing measurements are essential for checking the growth and development

The standard deviation is an indicator of how much the distribution of data varies from the overall

conditions of an individual, in order to determine if there is any illness or growth bias such as obesity or

mean. Assuming that there are data measuring the height of 100 children, it means that about 68%¹

thinness, and to know the position within the group. Physique indices are used for evaluating growth(68 children) of the height data are between +1SD and -1SD. About 96% of the data are included

based on height and weight. In addition to the body mass index (BMI) discussed in Chapter 6, they

between +2SD and -2SD. This means that children outside the range of + 2SD to -2SD are either

include the Rohrer index, Kaup index, the degree of obesity, and various other indices. BMI is used forvery short or very tall and may have health issues.

adults worldwide while the degree of obesity and Rohrer index are also widely used for childhood
assessment (Table 9.1).
However, note that BMI and Rohrer index must be used carefully. First, the formula for calculating
BMI is universal, but the criteria for judgment differ by country. For example, BMI ≥ 30 is obese

Table 9.1 Physique indices used for children

Physique index

Calculation method

Suited toAppropriate values

according to the WHO international standard² while ≥ 25 is obese in the Asia-Pacific region.³ Generally,

3 mo to <1 y :16 to <18

the Rohrer index can be used for children who are 125 cm or taller. However, considering that heightchanges are complicated during growth from elementary school age to puberty, the Rohrer index may
come out higher for children who are short.

1 y to <1 y 6 mo : 15.5 to <17.5
Kaup index

Weight (kg) / Height (m)²

3 mo to 5 y
1 y 6 mo to <3 y : 15 to <17

Furthermore, given individual differences in childhood growth and development, just measuring
how many centimeters a child has grown and how many kilograms the child has gained are not sufficient

3 y to ≤5 y : 14.5 to <16.5

for appropriate evaluation of growth. For example, a sudden increase in height tends to be welcomed inmost children but it may be a sign of precocious puberty (after an early growth spurt where there is atemporary sudden increase in height, growth stops with the body remaining extremely small) or abnormal

Rohrer index

Weight (kg) / Height (m)³× 10

Elementary school
children - Junior highschool students

115–145

Body massindex (BMI)

Weight (kg) / Height (m)²Senior high school
students and above

18–22

growth where the body stops growing completely after such sudden growth, both of which require
treatment.4 For this reason, it is important to not only evaluate the height and weight by simply comparing
the previous data, but also to continuously observe changes, so as to ensure the sound growth anddevelopment of the child without overlooking any abnormal changes.

mo=month, y=year

In the case of physique indices, the reference value differs depending on the age and is useful only
for evaluating growth at a single point in time. This means that the value is not an index of continuous
Table 9.2 Appropriate height and weight of children in Cambodian

growth. Consequently, the use of growth curves is recommended for continuously evaluating the growth5and development of children. A growth curve is a graph drawn by collecting measurements of height

Appropriate Value for Height (cm)Appropriate Value for Weight (kg)and weight of many children of various ages by gender, and connecting the average values of each age

Age (y)Boy

Girl

Age (y)Boy

Girlwith a curve. Growth curves of +2SD (SD: standard deviation), +1SD, -1SD, -2SD (or percentile) of the6

113–117

109–113

6

19–21

16–19

average values are also shown. By entering the measured data of the child in the standard growth curve,7

116–120

116–120

7

20–23

19–22

you can see how tall or short, how heavy or light the child is. Furthermore, by entering values over time,8

121–124

119–123

8

21–24

20–23

9

124–128

123–127

9

22–25

22–25

10

128–132

127–131

10

25–28

25–28

11

132–136

134–138

11

27–30

28–31

on the height and weight of children in the future, it will be possible to create growth curves for children

12

136–140

142–146

12

29–32

32–35

in Cambodia.

13

142–146

147–151

13

32–35

35–38

14

151–155

150–155

14

38–41

39–42

15

157–161

152–156

15

43–46

44–47

the growth pattern of the child can be obtained and the progress of growth can be confirmed.
Although there are no currently available growth curves for children in Cambodia, the Foundation
for International Development / Relief (FIDR)6 has proposed the appropriate height and weight ofchildren (Table 9.2). With the spread of health checkups across the country and the accumulation of data

Source: FIDR, 2017

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Significance of health checkups and their methods

61532) Eye test9

Column: Situation of thinness and obesity in children in Cambodia

In Cambodia, height and weight are used to evaluate the nutritional status of children. Specifically,malnutrition (nutritional deficiency) or the state of lacking balanced nutrition for healthy growth
are classified into stunting, wasting, being underweight, and being overweight (Figure 9.7).
Stunting is assessed by “Height-for-age” and is an indicator of long-term chronic nutritional status.

(1) Eye test method
a. Items for use: Eye chart (see Exhibits for E chart), eye shield (Figure 9.8, if no eye shield, gently
cover one eye with your own hand or paper)

6,7

Wasting is assessed by “Weight-for-height” and is often used to evaluate short-term acute nutritional
status. Being underweight is assessed by “Weight-for-age,” and being overweight is assessed by“Weight-for-height,” as is done for wasting 8
According to the Cambodia Demographic and Health Survey 2014,8 the nutritional status ofCambodian children has been improving since 2000 with a downward trend in all stunted, wasted
and underweight children. However, results of every category differ by state significantly, suggesting
contributions of differences between urban and rural areas and between rich and poor. In this way,although the number of overweight children is surging in urban areas, the problem of stunting issignificant in Cambodia as a whole. Physiological tests are required for a detailed assessment of
nutritional status. However, given that height and weight can be easily measured without discomfort,
they can be considered an effective means for evaluating the growth and development status of

Figure 9.8 Eye shieldchildren.

b. Set up the place for performing the eye test
(1) Find a bright room that provides a distance of at least 3 m (turn on the light / open the window).
Normal height for age(2) Fix the eye chart on a wall or pillar with the big E at eye level. Mark the position 3 m from theeye chart to indicate clearly where to stand when taking the eye test.
(3) If the test is taken sitting down, prepare a chair that is 3 m from the eye chart.
c. Procedure (Figures 9.9, 9.10, and 9.11)(1) Before the test, explain to the children how to take the eye test in the classroom.
(2) Have several children line up at a time for the eye test to wait quietly for their turn.
(3) Call out their names one by one.
(4) Have those wearing eyeglasses to take the test with their eyeglasses on.
(5) Have the children stand or sit at a position 3 m from the eye chart (Figure 9.9).
(6) Have the children point their finger in the direction that E faces. Have them reply “can’t see” or“don’t know” if they cannot see (Figure 9.11).

NormalWasting
Low weight for height

Stunting
Low height for age

Figure 9.7 Different types of undernutrition

Underweight
Low weight for age(7) Testing the right eye. Tell the children to use an eye shield or something similar to gently hide
the left eye. (Figure 9.11)(8) Ask the direction of each large E (6/60). Record children who get all four directions (up,down, left and right) correct as Pass and all the other children as Fail. Those who fail in thelarge E test are not eligible for the test using the small Es.
(9) For children who passed the test using the large Es, ask which directions the five small Es facein row (6/12). Record children who could see 4 out of 5 as Pass, and 3 or less as Fail.
(10) Do the same for the left eye.

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155

Figure 9.9 Scene 1 of the Eye test

Figure 9.10 Scene 2 of the Eye test

Figure 9.12 Example of the Single eye test chart(2) Evaluation of eyesightRefractive errors and diseases of the eyes cause weakening of eyesight. The difficulty in viewing faraway
objects reduces concentration and limits activity. Some children may drop out of school because theycannot see the blackboard clearly and fail to keep up with their classes. In Cambodia, many children do
not wear eyeglasses. Some children themselves or people around them do not even know that they havepoor eyesight because they have never had their eyes tested before.
Eye tests are designed to check eyesight conditions. Examining children’s eyesight by eye tests andtaking the required action are important for promoting the growth and development of children. In the Echart method introduced in this chapter, it is desirable to be able to see both large Es (6/60) and small Es(6/12). If the children cannot see small Es, it means that their eyesight has deteriorated and a visit to
Figure 9.11 Scene of a student answering which way E is facing

basic eye care services available at 331 health centers (that is, 30% of the total health centers) inprovinces, or ophthalmological services available in 21 referral-based hospitals (that is, 23% of the totalreferral-based hospitals) for an eye test and visual correction if necessary is recommended. If children

d. Tips- The eye chart is a tool for measuring human eyesight that can be measured using numbers,letters, and symbols. Here, a method using the E chart is introduced.

cannot see a large E, they may have a very serious eyesight impairment and need to consult a medical
specialist. However, at present, only 40% of the people in Cambodia have access to eye care services in- If you do not have an eye shield, you can use your palm or paper.

10 out of the 25 provinces. Therefore, expanding eye care services and training ophthalmologists are- The description in this section is based on the Guidelines for Vision Testing in School

future issues to work on.10(Department of School Health, Ministry of Education, Youth and Sport, Cambodia 2016).9

Eye tests do not reveal the nature of refractive problems such as myopia or hyperopia or the presenceof illness. Detailed ophthalmology tests are required. For children with poor eyesight, it is necessary to

Column: Single eye chartadjust their learning environment, for example, by setting their seats in the front row of the classroom.
Please refer to Chapter 8 for details on eye structure, refractive errors, and diseases.

This chapter introduces how to test eyesight using an eye chart fixed on a wall or pillar. Sometimes,
a single eye chart is used according to age and the level of eyesight (Figure 9.12). Since only one
symbol is drawn on a single eye chart, children with low vision and/or who are young can answer
them without confusion. A single eye chart is also convenient in that it can be hand held and does
not require walls or pillars.
The teacher holds the eye chart and measures eyesight as he/she turns it around, but the basic
procedure is the same.

156

Chapter 9

Significance of health checkups and their methods

1573) Hearing tests11

Outer
ear

(1) Hearing test method

Middle
ear

Inner
ear

Auditory ossiclea. Item for use: Chair

Auditoryb. Set up the place for performing the hearing test
Find a quiet room because measurement cannot be performed correctly in a noisy place. Takemeasures such as closing windows and doors.
Position the chair.

Ear canalc. Procedure(i)

CochleaCall out the names of the children one by one in turn.

(ii) Have a child sit on the chair.

Basement
membrane(iii) Perform a voice test. Ask the child for their name and grade and check if there is any problem

Auditory tube

with answering. If the answer is good, record it as “Pass.” If there is any problem, record as

Eardrum“Fail.”(iv) Perform a hearing test (Figure 9.13). Tell theSound conduction systemchild to close their eyes and raise their handSound-sensing system

Figure 9.14 Structure of the earon the side where they hear the sound of
fingers rubbing together.
(v) Rub your fingers together about 5 cm away

outer and middle ears play the roles of transmitting sound while the inner ear plays the role of sensing

from the child’s ear. Repeat it on the left andand transmitting sound to the brain. Deafness can be divided into two types: conductive deafness caused

right sides twice each. Record as “Pass” ifby poor sound transmission due to disorders of the outer and middle ears, and sensory deafness caused

they can hear and “Fail” if they cannot.

by problems with the inner ear that make it difficult to sense sounds. Conductive deafness is caused byotitis media, otitis externa, and cerumen impaction. Sensitive deafness often develops naturally(congenital deafness). It also includes noise-induced deafness caused by exposure to factory mechanicalsounds or construction sounds at work and acoustic deafness caused by listening to loud sounds overheadphone, etc., for long hours.
WHO warns that 1.1 billion young people around the world are at risk of acoustic deafness caused
Figure 9.13 Scene of the hearing test

d. Tipsby listening to portable music players and smartphones.12 Deafness caused by ear disease may progress
slowly. In such cases, hearing is not lost overnight, and hence it is difficult for the person and others to
notice the condition. Deafness in a child can be suspected not only from the results of hearing tests but- Use the Voice test to check if children have any problems in daily conversation, and the hearing
test to check if they can hear weak sounds.
- Now smartphones have apps for simple hearing tests, which can be used to produce weaksounds in the hearing test.

(2) Evaluation of hearing

also from other symptoms: the child always listens with one ear, turns up the TV volume, sits near theTV, and does not notice people who are out of sight talking. If hearing is poor, the child must see anotolaryngologist or an audiological clinic for a detailed examination.

4) Recording
Keep records carefully and correctly as omissions or mistakes will disable correct evaluation and

Deafness is the condition of not being able to hear sounds or words clearly or at all. It is a serious

appropriate screening. To accurately record the measurement results, set up a stand for writing in thedisorder that interferes with daily life, language development, and knowledge acquisition. Hearing tests

recording sheets at each measurement location and deploy a recorder. Use standardized units, such as

are intended to check for the presence of deafness and its degree if any. It is extremely important toheight in cm (e.g., 156.5 cm) and weight in kg (e.g., 45.5 kg). Regarding height and weight measurements,

detect deafness and take early measures.

read to the first decimal place and record it. Be careful not to mistake the left and right sides for vision

The structure of the ear is divided into the outer ear, middle ear, and inner ear (Figure 9.14). The
158

and hearing results.
Chapter 9

Significance of health checkups and their methods

159

The record table (see Supplemental material 2) must have fields for filling out the child’s name,Step 2: Let’s measure children

gender, age, and date of measurement in addition to the field for entering the measurement results. To(i)facilitate data organization, it may be a good idea to include fields for the child’s date of birth, grade/(ii) Give prior instructions to children. In order to conduct health checkup smoothly, it is recommended

class, and school name. It would be ideal to prepare copies of the records for feedback to children andthat a prior lecture be given to the children on the purpose and method of health checkup and how

their families and for storage at the school. It is important to accumulate the results of health examinations

to answer the eye test. In particular, explain carefully to children who are taking the measurements/

not only for screening or cross-sectional evaluation but for longitudinal evaluation. For example, by

tests for the first time and younger children.

using recording sheets that can keep records for 6 years of elementary school, you can understand theDecide the roles (person measuring, person recording, and person giving instructions).

(iii) Precautions for measurement

trajectory of the growth situation and characteristics of each student. The analysis of the accumulated- Use signboards to indicate where the measurement is carried out. Also show notes on a poster.

data allows you to identify health issues in classes and schools. For details on using recording sheets,- During the eye test, make sure that the children waiting in the vicinity do not tell the answers to
the child being tested.

please refer to “4. Use of records” in this chapter.
Supplemental materials in the end part of this chapter show some examples of recording sheets. Edit
them to a format that is easy to use or create your own recording sheets according to the situation of each

- During the hearing test, make sure that the children waiting in the vicinity are not noisy.
- During the eye and hearing tests, if it is difficult to judge whether the child cannot see/hear ordoes not know how to answer, ask the child directly.

school.

- During the eye and hearing tests, do not laugh or get angry as it is not wrong to be unable tosee/hear.

3. Practice

4. Use of records

1) Flow of health checkups (Figure 9.15)
Preparations

Measurement/
Recording- Allocate roles- Prepare necessary equipment
and materials- Measure byappropriate method- Record accurately

Check- Check formeasurementomissions/recording
mistakes- Prior instructions to children- Check that everyone
has completed
measurement- Fill in required information on the- Check absentees- Set up a measurement location

recording sheet

Keeping records of each child over time enables tracking of growth longitudinally. The recording sheets
should include the height, weight, and other numerical data not only at a single measurement but overtime in a graph, and be bound into a healthcare notebook of the records for six years. By providing
sections for the children, families, and school to make comments, and having the children bring thehealthcare notebook home for families to write comments and then returning it to the school, the children
will be able to visually understand their growth, and both the school and family members can keep trackas well. Furthermore, by keeping records on eyesight and hearing, comparison of results can be madewith those of the last year, consequently the school can provide families with advice on points to note ineveryday life, and recommend medical consultation.

- Check clothing and belongingsat measurement

Records can not only be kept for saving individual growth but can also be used to statisticallyanalyze the health status of children throughout the school. By comparing the height, weight, and obesity

Figure 9.15 Flow of health checkups

of one’s school with national and regional values by age and sex, the health issues of one’s school can
be clarified and utilized for health education.
Figures 9.16 and 9.17 show the average and standard deviation for height and weight development

2) Let’s practice for measurement

among boys and girls through ages 6 to 12 years in Kandal Stueng County, Kandal Province, calculated
from data collected from nine schools that cooperated in the health checkup conducted by NGO Udon
House in 2019. For example, the left side of Figure 9.16 shows that between the +1SD and -1SD intervals,

Step 1: Let’s measure each other

there is approximately 68% of the boys in the sample for each age. In the same way, between +2SD and

Decide the roles (person measuring, person recording, and measured children) and measure alternately-2SD, approximately 96% of the boys in the sample are counted.

so that everyone has the chance to play all roles. After the measurement, discuss which part was difficult
and which should be improved.

160

Chapter 9

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161

(cm)

Height-Boy(Average and standard deviation)

170.0

170.0

160.0

157.7
152.0

150.0
140.3

120.0

136.8
129.7

132.1

124.2

113.1

120.8

118.1
114.6

100.0 102.0
6

160.0

130.0

106.4

7

121.1

137.0

9

Age

128.0

10

11

12

+SD

+2SD

126.9

123.5
116.9
114.7

118.6

117.0

It is hence important to build a framework within the school. Ideally, teachers should be able to shareroles based on a common understanding, and the school should run the system for health checkups as awhole to ensure that checkups are conducted smoothly in a limited amount of time. It is also effective to

132.7

123.1

hold an internal training program for the significance and methods of health checkups or position healthcheckups as a school event.
It is necessary to draw up an implementation plan according to the size and situation of the school.
If the school has only a few teachers or many children, it is not necessary to take all the measurements

109.9

100.0 101.4
8

137.7

128.0

110.0

90.0

141.8

141.4

112.2

109.4

The understanding of managers and cooperation between teachers are indispensable for health checkups.

148.4

120.0

117.2

156.7

156.8

140.0

127.5
123.1

110.0

90.0

136.4

139.4

5. Implementation at schools
1) Importance of creating a school health organization

150.0

147.1

140.0
130.0

(cm)

Height-Girl(Average and standard deviation)

105.8

of all the children at once. The implementation plan should be reasonable and continuously implementable
at least once a year at the same time every year. Alternatively, by setting up a permanent health checkup

6

7

Average

8

9

Age

10

11

12

area in the Health Room, which is expected to become widespread in Cambodia, health checkup will
become more familiar to the children as a habit for them to check their own growth whenever they want.

-2SD

-SD

Health checkups serve an important health education opportunity for children to face and understandFigure 9.16 Average and standard deviation for height development among boys and girls

their bodies and should therefore be made good use of.

through ages 6 to 12 years -9 elementary schools in Kandal Stueng County, Kandal ProvinceColumn: Example of activities of Children’s Health Club (Figure 9.18)(kg)

Weight-Boy(Average and standard deviation)

60.0

(kg)

Weight-Girl(Average and standard deviation)

60.0
54.0

50.0

47.3

50.0

40.6
34.3

30.0
20.0

26.1

30.3

28.3

10.0
0.0

12.0

6

12.5

7

8
+2SD

24.9

13.6

9

Age

15.8

11
+SD

12

0.0

Average

Members have fun measuring the height and weight of friends and younger children, and test

22.9
18.2

16.7

10.0

10

Through repeated practice, they learn how to take measurements and perform tests correctly.

28.4

11.6

19.9

11.5

14.9
12.9

In neighboring Laos, there are elementary schools that actually operate children’s health clubs.
Children selected as members of the health club are taught by teachers about health checkups.

25.5

20.0
15.3

31.6

28.4

25.0

20.4

11.6

34.9

32.9

30.0

teachers, but also heighten the children’s interest in health, encouraging voluntary learning. For

the health of others and also make new discoveries.

36.5

32.0

27.9
23.0

19.1

40.0

how to conduct health checkups and doing it themselves, it will not only reduce the burden onclassmates and younger children how to take measurements provides the opportunity to think about

41.8

36.4

schools. One solution is to teach children to run the health checkup program together. By learning

example, having older children at the school organize a Children’s Health Club and teach their

48.4

44.7

40.0

Since there is a shortage of teachers in Cambodia, it is difficult to conduct health checkups in some

14.8

15.8

14.5

their eyesight and hearing. If a younger student of an ethnic minority who does not understand theLao language has difficulty taking the measurements and tests, an older student of the same ethnic
group will explain the tests thoroughly in the ethnic language, helping the younger student understand

6

7

8
-SD

9

Age

10

11

12

-2SD

Figure 9.17 Average and standard deviation for weight development among boys and girls

the procedure and take the health checkup smoothly.
For the Children’s Health Club to work, teachers must first understand the significance andmethods of health checkups. Teaching children and getting them involved in activities takes a lot oftime. But once these efforts take root, it will be a meaningful initiative that facilitates the managementof health checkups and deepens children’s learning.

through ages 6 to 12 years -10 elementary schools in Kandal Stueng County, Kandal Province162

Chapter 9

Significance of health checkups and their methods

163

Date/Implementation stage

Main details

ExampleImplementation
Preparation►Prepare required
items●Prepare the necessary items formeasurements and check if they
can be used without problems.
●Print the recording sheets.

►Provide priorinstructions●Check the purpose and methodof the health checkup, andpoints to note in measurements.
By practicing how to take theeye tests in advance, the test on
the day will proceed smoothly.
●Instruct children to fill in therequired information on therecording sheet. In the lower
grades, teachers can fill in themon their behalf beforehand.
●Check clothing and belongings
when taking the health checkup.

►Set up the place
to carry out
measurements/
tests●Use posters and signboards toindicate where the healthcheckup place is according to
the situation of the school.

Figure 9.18 Scene of a children’s health club (Laos)

2) Example of implementation (Plan – Implementation – Evaluation)
When you conduct health checkup in your school, you can refer to an example of the procedure forhealth checkup in school described in Table 9.3.
Table 9.3 The flow of from planning to evaluation of health check-up in school

Date/Implementation stage

Main details

Example●Consider the date and time andimplementation method.
Examples of methods include
measuring by grade or type over
several days, or measuring all
children over one day.
●Check the roles of teachers on
the day.
●Check the equipment and items
required on the day.
●It is advisable to set aside a day
to train teachers about healthcheckups, and/or a day to giveprior instructions to children,
apart from the day of themeasurement/test according to
the school situation.

●Date and time: HH:MM to
HH:MM on MMDD, HH:MM
to HH:MM on MMDD.
●Implementation method:
Perform all four measurements/
tests on all grades.
●Role: 6 persons carrying out
measurements, 6 to record
values, and two guides●One place each for measuring
weight, measuring height, andperforming hearing test
respectively. Two places for
performing eye tests as it takes
time.
●Give prior instructions tochildren on the day before.

●Find a suitable place formeasurements. Pick a place
where the health checkup canproceed smoothly.

●Appropriate places wereselected assuming that themeasurements will be carriedout in the order of weight →height → eye test → hearing
test.

Plan
►Prepareimplementation
plan

More than 1
week before►Decide place for
performing
measurements/
tests

164

Measure/record
Day before–
day ofmeasurement/
test►Performmeasurements●Precautions on height●Measure according to anmeasurement: Have children
appropriate method.
adopt a hairstyle suitable for●Call children’s attention if
measurement.
necessary.
●Precautions on weight●Prevent confusion among thechildren by having them line up, measurement: Have children
take off their jacket and take out
calling their names first before
everything from their pocket.
measurement, and placing●Precautions on eye test: Make
guides.
sure that children waiting in thevicinity do not tell those who
are taking the test the answers.
●Precautions on hearing test:
Make sure that children waitingin the vicinity do not makenoise.

►Take records●Write the results in the correct
fields.
●Be careful not to make errors inwriting.

●Record weight in “kg” andheight in “cm.”

Check►Check●Check for omissions or errors inmeasurements entered.
●Check that everyone has beenmeasured/tested.
●Make arrangements forabsentees to take the healthcheckup on a later day.

Chapter 9

Significance of health checkups and their methods

165

Date/Implementation stage

Main details

Example►Perform
screening●Based on the results of healthcheckups, identify student withhealth problems.
●Continue to keep records andcreate graphs for futureevaluations.

●Height / Weight: Evaluate
physique and growth.
●Eye test: Check for refractive
problems and visual
impairment, and the degree ofinterference with daily life.
●Hearing test: Check for hearing
loss or impairment, and thedegree of disability in daily life.

►Follow-up●Support for students with
●Support at school: Improve
weakening eyesight: Set theirlearning environment, provide
seats in the front row in thefollow-up, provide healthclassroom. Check their posture
education, and report to parents.
during class. Check if they can●If necessary, advise parents tosee writing on the blackboard
consult a health center, or aclearly during class. Provide
clinic.
health education on the use ofsmartphones. If school support
is not enough, encourage
parents to make eyeglasses fortheir children or visit basic eye
care services at provincial
health centers or
ophthalmological services inreferral-based hospitals.

Evaluation

Next day andafterwards

Exercises for further thought and research[9-1] Use your height and weight to calculate your BMI.

References[9-2] Share what you found difficult or noticed when measuring children. Also, calculate the average

1height and weight from the measurement results and compare them with the appropriate values
indicated by FIDR (Table 9.2) and the average value of Kandal Stueng County (Figures 9.16 and9.17). Calculate the Rohrer index with the children.

[9-3] Make a preliminary guidance plan for children. How can you convey the purpose and significanceof health checkups, measurement methods, and precautions to children in an easy-to-understandKobayashi M. Physical growth and development. New School Health. eds. Tokuyama M, Takehana Y, Mimura Y, Hiroko K. pp.120–
134. Higashiyama Shobo, 2019.

2

WHO. Obesity: preventing and managing the global epidemic. 2000. https://www.who.int/nutrition/publications/obesity/WHO_
TRS_894/en/

3

WPRO. The Asia-Pacific perspective: redefining obesity and its treatment. 2000. https://apps.who.int/iris/handle/10665/206936

4

The Japanese Society for Pediatric Endocrinology. Precocious puberty. http://jspe.umin.jp/public/sishunnki.html

5Japanese Society of School Health. Utilization of growth curve. In Health examination manual for schoolchildren. Supervised by
School Health Education Division of Sports and Youth Bureau, MEXT. 2015 revised edition: 68-71. https://www.gakkohoken.jp/

manner?

book/ebook/ebook_H270030/index_h5.html#%E8%A1%A8%E7%B4%99
6

FIDR. Cambodian Food-based Dietary Guidelines Brochure. 2017.

7

Japan Association for International Health. Anomalotrophy (Malnutrition). In International Health Glossary. https://seesaawiki.jp/w/

8

Cambodia Demographic and Health Survey 2014. 16 Nutrition of Children and Women 16.1 NUTRITIONAL STATUS OF

9Department of School Health, Ministry of Education, Youth and Sports, Cambodia. Guideline for Vision Testing in Schools. 2016.

jaih/d/%B1%C9%CD%DC%BC%BA%C4%B4%A1%CA%B1%C9%CD%DC%C9%D4%CE%C9%A1%CB
CHILDREN. p.173-178. https://dhsprogram.com/pubs/pdf/FR312/FR312.pdf
10 Sogbesan E, Yutho U. Cambodia’s national Eye Care Programme and VISION 2020: The Right to Sight. Community Eye Health13(36):57-59. 2000. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1705982/
11 USAID, Cambodia–All Children Learning. Hearing and Vision Disability Screening Report. 2019. https://ierc-publicfiles.
s3.amazonaws.com/public/resources/Cambodia%20Screening%20Report_Approved.pdf
12 WHO. 1.1 billion people at risk of hearing loss. 2015. https://www.who.int/mediacentre/news/releases/2015/ear-care/en/

166

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Significance of health checkups and their methods

167Supplemental materials (Suppl.)
Health Checkup Recording Sheet (For individual data)

Name

Sex

Sample…No problem

Date of BirthMale

12/25/2009

Academic Year

2015-20162016-20172017-20182018-20192019-2020

2020-2021

Grade and Class

Grade 1A

Grade 2A

Grade 3A

Grade 4A

Grade 5A

Grade 6A

Month

Nov

Apr

Nov

Apr

Nov

Apr

Nov

Apr

Nov

Apr

Nov

Age

6

7

7

8

8

9

9

10

10

11

11

Height

115.0

118.5

121.5

124.0

127.5

130.0

133.5

136.0

140.0

143.0

145.5

Weight

20.0

22.0

23.5

26.5

28.0

29.0

32.5

33.5

35.0

36.5

37.5

R



















L























R























L























GlassesGlassesGlasses

Small E Small E

Apr

Nov

Apr

Eyes

Ears

Suppl 9.1 E chart

Other

Health Checkup Recording Sheet (For class)Academic Year:
Grade and Class:

Health Checkup Recording Sheet (For individual data)

…No problem

No .

Name

Sex

Age

Date of BirthEx

SampleF1112/24/2009

Height (cm)Weight (kg)

Eye(R)

Eye(L)

Ear(R)

Ear(L)

Nov

Apr

Nov

Apr

Nov

Apr

Nov

Apr

Nov

Apr

Nov

Apr

140.5

145

35.0

37.5







Small E

QS test…No problem

Other

Name

Sex

Date of Birth1
2

Academic Year

3
4

Grade and Class

5
6
7

Month

Nov

Apr

Nov

Apr

Nov

Apr

Nov

Apr

Nov

Apr

Nov

Apr

Nov

Apr

8
9

Age

10
11

Height12
13

Weight

14
15

R

16

Eyes

17

L

18
19

R

20

Ears

21

L

22
23
24

Other

25

Suppl 9.2 Recoding sheet for class168

Suppl 9.3 Recording sheet for individual data
Chapter 9

Significance of health checkups and their methods

169

13

14

Date of Today:
Name:

Age:

Date of Birth:

Grade and Class:
CM

Male

FemaleWeight:KG

12Height:

Sex:

11

Eyes:

10

Ears:

Large E

<Right>NormalImpaired		<Left>

NormalImpaired

Small E

<Right>NormalImpaired		<Left>

NormalImpaired

Voice T

<Right>NormalImpaired		<Left>

NormalImpairedHearing T<Right>NormalImpaired		<Left>

NormalImpaired

9

Cutting off

7

8Date of Today:
Name:

Age:

Date of Birth:

Grade and Class:
CM

Male

FemaleWeight:KG

6Height:

Sex:

5

Eyes:

50
49
48
47
46
45
44
43
42
41
40
39
38
37
36
35
34
33
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14

Ears:

Large E

<Right>NormalImpaired		<Left>

NormalImpaired

Small E

<Right>NormalImpaired		<Left>

NormalImpaired

Voice T

<Right>NormalImpaired		<Left>

NormalImpairedHearing T<Right>NormalImpaired		<Left>

NormalImpaired

Weight (kg)Cutting off

12

13

14

Date of Today:
Name:

Age:

Date of Birth:

Grade and Class:

Height:

11

Eyes:

10

Ears:

CM

Sex:

Male

FemaleWeight:KG

Large E

<Right>NormalImpaired		<Left>

NormalImpaired

Small E

<Right>NormalImpaired		<Left>

NormalImpaired

Voice T

<Right>NormalImpaired		<Left>

NormalImpairedHearing T<Right>NormalImpaired		<Left>

NormalImpaired

9

Cutting off

6

7

8

Date of Today:
Name:

Age:

Date of Birth:

Grade and Class:

Height:

5

Eyes:

160
159
158
157
156
155
154
153
152
151
150
149
148
147
146
145
144
143
142
141
140
139
138
137
136
135
134
133
132
131
130
129
128
127
126
125
124
123
122
121
120
119
118
117
116
115
114
113
112
111
110
110
109
108
107
106
105
104
103
102
101
100

Ears:
Height (cm)Suppl 9.4 Recoding sheet for graphing

170

CM

Sex:

Male

FemaleWeight:KG

Large E

<Right>NormalImpaired		<Left>

NormalImpaired

Small E

<Right>NormalImpaired		<Left>

NormalImpaired

Voice T

<Right>NormalImpaired		<Left>

NormalImpairedHearing T<Right>NormalImpaired		<Left>

NormalImpaired

Suppl 9.5 Recoding sheet: brief version
Chapter 9

Significance of health checkups and their methods

171

Chapter 10

Health effects of tobacco use, alcohol
consumption, and drug abuse
Learning objectives
You will be able to gain proper understanding and explain:- The health effects of tobacco use.
- The health effects of alcohol consumption.

smoking, and therefore, breastfeeding is recommended.
In young people, there are health risks, including the effects on physical activities and sports,
contracting respiratory disease, progression to nicotine dependence, an increased risk for using alcoholand drugs such as cannabis and cocaine, and the fact that the younger they start tobacco use, the higher
the risk for developing lung cancer becomes.3
Nasal cavity/ Sinus cancer
Oral/ pharyngeal cancer

StrokeLaryngeal cancer

Periodontal disease
Ischemic heart disease

Esophageal cancer- The health effects of drug abuse.
- Why some people begin tobacco use and alcohol consumption while knowing that they are harmful
to their health.
- Why it is difficult for people to stop tobacco use, alcohol consumption, and drug abuse.

Nicotine dependence

Lung cancer

Peripheral arteriosclerosis

Liver cancer

Development ofType 2 diabetes

Gastric cancer

In this chapter, you will learn the health effects of tobacco use, alcohol consumption, and drug abuse,and the factors underlying them. Specifically, you will learn about the spread of tobacco use, alcohol
consumption, and drugs in Cambodia as well as what you can do to protect the health of young people

Figure 10.1 Health effects of tobacco use

from tobacco use, alcohol consumption, and drug abuse by understanding drug dependence, relationships
between tobacco use and health, and relationships between alcohol consumption and health.

1. Tobacco use and health
1) Health effects of tobacco use

12) Harmful chemicals contained in tobacco
Tobacco smoke contains approximately 5300 types of chemicals, of which approximately 50 to 70 types
are shown to be carcinogenic. Among its gas components, carbon monoxide competes with oxygen tobind to hemoglobin in erythrocytes, decreasing the amount of oxygen carried by erythrocytes. If thestate of oxygen deficiency chronically persists, red blood cell count may increase to maintain the delivery

When lit by flame, tobacco generates various components (i.e., gas and particulate components). If theseof oxygen, which increases blood viscosity and raises blood pressure. Tar, a particulate component, is acomponents are inhaled, they circulate around the body through the blood and do harm to many organs

complex mixture that contains chemicals having carcinogenic effects, meaning they turn healthy cellsof the human body (Figure 10.1). The smoke inhaled by a smoker is called the mainstream smoke, andinto cancer cells, as well as cancer-promoting actions, which grow cancer cells. Nicotine, a type ofthe smoke coming from the end of the tobacco is known as the sidestream smoke. The sidestream

alkaloid (a substance that neutralizes acid to form salt), is a deadly poison with strong neurotoxicity.

smoke contains more harmful chemicals than the mainstream smoke that is inhaled through a filter. This

After being taken into the body through tobacco smoke, nicotine rapidly spreads throughout the body.

is why tobacco use has serious health effects not only on smokers but also on their children and partners

Because of the dependency on nicotine, it becomes difficult to give up the habit of smoking. In addition,

who live with the smokers and are subject to passive smoking.

it has a strong vasoconstrictor effect, which constricts capillaries and increases blood pressure. Although2

In pregnant women, smoking and passive smoking can increase the possibilities of miscarriage andpremature delivery. The chemicals of tobacco inhaled by a pregnant woman affect her fetus through the

nicotine itself is not shown to be carcinogenic, nitrosoamines, which are produced when nicotine isbroken down / metabolized in the body, are known to be carcinogenic.

blood, increasing the risk of her delivering a low-birth-weight baby (with a birth weight of less than2500 g) or delaying the development of the fetus. Attention should also be paid to smoking and passive
smoking by breastfeeding women. The mother’s milk, which contains harmful substances in two to

4

Column: Emergence of heated tobacco products, a new type of tobacco

three times higher concentrations than the mother’s blood, can do harm to the infant (the lung and theHeated tobacco products (HTPs) are tobacco products that produce aerosols containing nicotine

brain in particular). Furthermore, smoking has been shown to decrease the amount of mother’s milk

and other chemicals, and inhaled by users through the mouth. They contain the highly addictive

secretion. Note that the benefits of breast-feeding are considered to outweigh the risks of mother’schemical nicotine. They also contain additives and are often flavored. They also make people mimic

172

Chapter 10

Health effects of tobacco use, alcohol consumption, and drug abuse

173the behavior of smoking a conventional cigarette. The products include iQOS from Philip Morris

such as vomiting, a depressed level of consciousness, and worsening of respiratory status. In the long

International, PloomTECH from Japan Tobacco International, Glo from British American Tobacco,term, meanwhile, it has effects on the liver, which bears the burden in breaking down alcohol, and on theand PAX from PAXLabs. These products use a battery-powered heating system to heat tobacco up

whole body (Figure 10.2). Examples of the long-term effects include increased susceptibility to alcoholic

to 350°C in order to generate vapors containing nicotine.

hepatitis, cirrhosis, hypertension, cancer, diabetes, and cerebral atrophy.

Currently, there is no evidence to show that HTPs are less harmful than conventional tobacco
products. However, some studies sponsored by the tobacco industry have claimed that theysignificantly reduce the formation of and exposure to harmful and potentially harmful components

Alcohol dependence

relative to standard cigarettes. Presently, there is no evidence suggesting that reduced exposure to

Cerebral atrophythese chemicals leads to reduced risk in humans. Therefore, in order to verify the claims of reduction

Cardiomyophathyof risks and harm, additional studies without conflicts of interest are needed. In addition, there isHypertension

insufficient evidence regarding the effects of passive smoking caused by HTPs. Further studies areneeded to assess the risk of being exposed to emissions released from HTPs.

Fatty liver

All forms of tobacco use are harmful, including HTPs. Tobacco is inherently toxic and contains
carcinogens even in its natural form. Therefore, HTPs should be subject to policy and regulatory
measures applicable to all other tobacco products in line with the WHO Framework Convention on

Pharyngeal cancer
Laryngeal cancer
Esophageal cancer
Gastric ulcer

Alcoholic hepatitis

Gastric cancer

Cirrhosis

Development ofType 2 Diabetes

Liver cancer

Tobacco Control (FCTC).5

Oral cancer

The Phnom Penh Post reported in March 2021 that the National Authority for Combating Drugs
Figure 10.2 Effects of alcohol consumption on the body

(NACD) of Cambodia has directed all relevant ministries and agencies as well as organizations to
6take action to immediately stop the commercialization and use of HTPs.
Column: What is a conflict of interest (COI)?

2) Alcohol dependence8

Take a study sponsored by the tobacco industry as an example. If a relationship based on interest is

Chronic consumption of large amounts of alcohol will develop dependence on alcohol, resulting in asuspected between the company and a researcher who conducts the sponsored study, it will leadpersistent or chronic disorder of mental/physical function. Symptoms of dependence consist of psychic

to a situation in which third parties may have doubts about the neutrality, objectivity, and scientificallydependence and physical dependence. In psychic dependence, symptoms that may appear include arigorous procedures that are required in the study of HTPs and health effects. That is, they may raisestrong desire to consume alcohol, inability to control drinking behavior through one’s own will (e.g.,questions about the possibilities of data being falsified or fabricated to deliberately produce study

time and quantities), and a tendency to consume alcohol to cope with feelings of frustration, tension, andresults that support the interest of the tobacco industry. This situation is called a conflict of interest,

depression from daily stress. If psychic dependence progresses further, it leads to harmful behaviors,

and researchers are required to disclose relationships based on interest to ensure that public trust inincluding spending most of a day consuming alcohol and sobering up by disregarding pleasures otherthe study will not be lost.

than alcohol consumption, and not abstaining alcohol even though mental/physical problems haveworsened. Thus, psychic dependence is a condition in which the habitude has changed in such a way that

2. Alcohol consumption and health
1) Health effects of alcohol7

the person is driven by a strong desire to re-experience a pleasant sensation that can be obtained whenalcohol activates the reward system of the central nerve, and this condition is the nature of dependence.
In physical dependence, withdrawal symptoms appear, including trembling hands and fingers andsweating, when alcohol is cleared from the body. These symptoms can lead to alcohol consumption at
the workplace, a decline in work performance and absence from work, and human-relation problems at

Alcohol is a central nervous depressant and has a relaxing effect if consumed in small amounts. However,

the workplace, causing difficulties in work. In addition, people who consume alcohol in the daytime canbefore consuming alcohol, we need to understand that it has short- and long-term health effects. In thedestroy their family lives for reasons including being unable to engage in housework or childcare, using

short term, it suppresses the brain function and has psychological effects, such as impaired judgment,

violence toward family members, and borrowing money for alcohol consumption. In the case of students,

and physical effects, including slower body movement. Moreover, consuming a large amount of alcohol

they will not be able to continue their studies for reasons such as absence, poor academic performance,

in a short period of time can cause acute alcohol intoxication, resulting in life-threatening conditions,and dropping out.

174

Chapter 10

Health effects of tobacco use, alcohol consumption, and drug abuse

175

Table 10.1 Types of drugs and examples of symptoms

In this way, if psychic and physical dependence are developed, social lives in one’s workplace,family, school, and community can be destroyed.

Type

Symptom

Stimulant (central nervous
excitation)

Exhibits a neuroexcitatory action for several hours. Then, severe weakness,fatigue, and malaise occur. Hallucinations and delusions appear. Results indeath if consumed in large amounts. Likely to develop toxic psychosis. May
cause flashbacks even after stopping use.

Cocaine (central nervous
excitation)

Alkaloid contained in coca. Gives the experience of extreme euphoria and afeeling of being full of energy. Hallucinations and delusions appear. A large
amount of consumption causes generalized seizure and difficulty ofbreathing, resulting in death.

MDMA (Ecstasy) (central
nervous excitation)

A type of synthetic narcotic. Changes perception. Increases a feeling of wellbeing and a sense of closeness to others. On the other hand, increases
sleeplessness and uneasiness. Gives a strong psychic dependence. A large
amount of consumption results in hyperthermia and death.

Heroin (central nervous
depression)

A drug made from poppy. Causes severe withdrawal symptoms, including
severe pain, chill, vomiting, and fainting. A large amount of consumption
results in difficulty of breathing, and coma followed by death.

3) Social impacts caused by alcohol9
A drunken condition (drunkenness) is a condition in which emotional control and judgment are impaired.
It can cause social issues and problems such as traffic accidents resulting from drunk driving, accidents
including falls, and high-risk behaviors such as unprotected sexual behavior and self-injurious behavior,as well as violent incidents, domestic violence/abuse, and involvement in crimes.

3. Harm of tobacco use and alcohol consumption byminorsTobacco use and alcohol consumption by minors are said to cause greater health damage and are more
likely to cause dependence. This is because the organs of the growing body are undergoing maturation,
thus making them more susceptible to harmful chemicals and alcohol. Particularly, the period between
10 and 24 years of age, defined by the World Health Organization (WHO) as young people, correspondsin the reward system circuit, and produce pleasure. Both of them affect the brain and may result into puberty/adolescence, which is not merely a period for becoming sexually mature and physicallydeath if consumed in large amounts at one time.

developing into an adult, but is also a transitional period toward psychosocially developing into an adult

Note that besides tobacco, alcohol, and the drugs listed in Table 10.1, there are other drugs andby achieving the developmental tasks of the relevant age group through brain development andchemicals that may be abused, such as volatile organic solvents (e.g., lacquer thinners and toluene for10

maturation.

Although the accomplishment of physical, cognitive, and psychosocial developmental

tasks are affected by other factors mentioned in Chapters 3 and 11, alcohol has influences on thepainting, and adhesive bond) and pharmaceuticals (e.g., analgesics, purgatives, antitussives, sleeping
pills/antianxiety drugs, and cold medicine), which are easily available and thus require attention.

development of the brain of young people and is considered to have impacts on the accomplishment ofdevelopmental tasks as well.
This is why many countries define the minimum ages for tobacco use and alcohol consumption. In

Column: Is cannabis legal or illegal?

Japan, the legal minimum age is 20 years old for both. In Cambodia, the minimum age for tobacco use

The possession and use of cannabis have been illegal for many years. It is also true, however, that itis 18 years old. Although the minimum age for alcohol consumption is not established as of 2020, there

has historically/traditionally been used as medicine and food materials.

is a movement to it at 21 years old.

In recent years, there have been growing movements to legalize cannabis in some countries andregions. Cannabis is used for recreational, medical, and industrial purposes. It is used for personal,

4. Drug abuse and health
1) What is drug abuse?

recreational enjoyment, to provide analgesia/sedation as a medicine, and to process clothes,cosmetics, and foods in industry. Cannabis for industrial use does not have euphoric effects and issaid to pose little risk of being abused as a drug.
Currently, cannabis for recreational use is legalized nationwide in Uruguay, Canada, and Mexico.
In the United States of America, it is prohibited by the federal government but legalized by some

Drug abuse refers to the use of illicit drugs and the use of pharmaceuticals for purposes other than theirstate governments. The aims of legalization are to conduct proper management by setting the legal

intended use. Drugs that may be abused include stimulants, cocaine, the synthetic narcotic MDMAage for cannabis use and the maximum amount that can be possessed, and to cut off funding(methylenedioxy-methylamphetamine, known as Ecstasy), and heroin (Table 10.1). Among drugs, there

sources for criminal organizations by restricting the cannabis trade on the black market.

are central nervous system stimulants (uppers) and central nervous system depressants (downers).

There are arguments for and against the legalization of cannabis, and it has been discussed at

Despite their different actions, they eventually increase dopamine activity in the brain, excite nerve cells

the WHO and the United Nations as well. Cannabis is said to be a gateway drug (drugs that serve

176

Chapter 10

Health effects of tobacco use, alcohol consumption, and drug abuse177as a gateway to the use of other substances with stronger dependence and adverse reactions, suchas stimulants, heroin, and cocaine). This is because those who become unsatisfied with cannabis

Repeated abuse and tolerance

will begin to use other drugs for a stronger stimulus. The legalization of cannabis use may promote
the abuse of other drugs.
It has been pointed out that cannabis use would affect the health of young people, including

Drug effect wears off

cognitive distortion, impairment of concentration, mental disease, excessive vomiting, anddependence. In puberty and adolescence in particular, it may affect the development of prefrontal
cortices as well as the neural circuit and neural structure of the hippocampus, having negative
effects on brain functions to control attentiveness, thinking, and behavior as well as on memory; it isconsidered that the earlier they begin to use cannabis, the greater the effect becomes. Therefore,

Drug seeking behavior

regardless of whether it is legal or illegal, cannabis should not be used during the ages in which the11brain develops, as in the case of alcohol consumption and tobacco use.

For adults, in whom the period of brain maturation has finished, societies will consider how theyshould deal with cannabis use from various perspectives, including risks, traditional / medical values,

Mental/physical pain

and impacts of legalization on communities.

Figure 10.3 Cycle of drug dependence

2) What is drug dependence?
has since spread to more than 130 countries around the world, proposes The Twelve Steps as a guide to
Drug dependence refers to a condition in which people cannot give up using a drug on their own as arecovering from alcohol dependence. The first step is a “powerless declaration” saying: We have admitted

result of the continued use of the drug since stopping makes them feel unpleasant (Figure 10.3). Because

we are powerless over alcohol—that our lives have become unmanageable. Al-Anon has a base in

obtaining the drug becomes the highest priority in their daily life, they may have difficulty leading a

Phnom Penh, while Alcoholics Anonymous (AA), a likeminded mutual self-help group, holds meetingsnormal life, or may try to obtain the drug without a thought for how they look. Using a drug as a one-in Phnom Penh, Siem Reap, and Battambang. Mutual self-help groups aiming for recovery from drug

time experiment may result in drug dependence, or some cue may prompt a person who stopped the use

dependence are also expected to play an active role in Cambodia.

of a drug to begin it again.
Drug addicts have a strong desire to use a drug when its effect wears off. As a result, money to buy
the drug becomes necessary, and they even commit crimes, such as shoplifting, robbery, and prostitution,

Column: What is drug tolerance?

to obtain the drug. They cannot control their desire by themselves even if they think that they do not

Tolerance to a drug develops when the body gets used to the drug by taking it repeatedly, and thus

want to use the drug or they want to give it up after using a certain amount. Stopping drug use may leadthe amount of the drug necessary to get the same effect increases. One of the physiologicalto sleeplessness/hypersomnia, depression, anxiety, fretfulness, hallucination/delusion, muscle/joint

mechanisms that develops tolerance is a faster excretion of the drug from the body, as a result of

pain, convulsive seizure, hyperphagia, weakness, vomiting, diarrhea, abnormal sweating, and withdrawal

increased metabolic efficiency of the drug or the creation of a new metabolic pathway (metabolism

symptoms. The habitual use of a drug builds up tolerance to the drug, increasing the amount necessarylevel). In addition, decreased sensitivity to the drug in the bodily tissues can also be raised (bodily

to gain pleasure.

tissue level).

No specific medicine or therapeutic method is available for curing drug dependence. The only
possible way is to continue to live without using a drug. Receiving appropriate advice from experts andcontinuing to live without using drugs will make it possible to return to social life. This is called recovery.

3) Spread of drugs in the Western Pacific region12

In order to effectively achieve this recovery, people suffering from dependence on alcohol or illicit
drugs, such as stimulants, should accept that they cannot voluntarily control their behavior and try to

The Golden Triangle, an area covering Myanmar, Thailand, and Laos, is known as a production/

keep themselves away from drugs through ties with people who have also suffered from drug abuse by

distribution area for opium (Figure 10.4). Myanmar in particular has become famous for its abundantjoining a mutual self-help group.

poppy fields. In recent years, the types of narcotic drugs produced in this Golden Triangle have changed

In this connection, Al-Anon, a mutual self-help group that started in the United States in 1951 and178

from opium and heroin, which are made from poppy, to stimulants (synthetic narcotics). Stimulants are
Chapter 10

Health effects of tobacco use, alcohol consumption, and drug abuse179

prevalence of smoked tobacco standing at 16.6% for the entire group, 32.9% for men, and 2.4% for

China

women. Meanwhile, the use rate of smokeless tobacco (chewing tobacco) among people aged 15 years

Golden Triangle

and older is 0.8% for men and as high as 8.6% for women.15 The material that is mainly used as smokelessVietnam

Myanmartobacco is betel quid, which generally refers to a mixture of betel nut / Areca catechu and slaked limeLaoswrapped in a betel leaf (Figure 10.5). It has been shown that one out of ten rural women uses this typeof smokeless tobacco, with the use rate increasing with age.15 Although smokeless tobacco has beenThaiculturally/traditionally regarded as medicinal in some cases, it is considered to have an adverse effectCambodia

Malaysia(the risk of oral cancer) on the human body, like smoking.

Distribution
channelFigure 10.4 Golden Triangle

not only consumed in Myanmar, Thailand, and Laos, but also smuggled into the surrounding countries:
Cambodia, Vietnam, Bangladesh, India, and China. Moreover, they spread to the entire Asia-Pacificregion, including Japan, Korea, Taiwan, Indonesia, Malaysia, Singapore, the Philippines, Australia, and
New Zealand. Besides the Golden Triangle, there are many areas where narcotic drugs are produced

Figure 10.5 Betel quidaround the world. Drugs including narcotics, which are smuggled across borders, are threatening thehealth of people around the world.

Concerning the use of tobacco products by the younger age group, 6.4% of children aged 13 to 15
years old have used tobacco products (smoked and/or smokeless), with 2.4% presently using tobacco
products.16 There are many advertisements in urban districts that encourage people to smoke, and theColumn: What are narcotic drugs?

media report scenes in which tobacco is used. In addition, cheap tobacco prices may be another reason

Narcotic drugs originally referred to various substances that numb sensation to reduce pain. Today,that the younger age group can easily begin using tobacco.

opium, opium derivatives, and opioid medications synthesized from opium extracts are called

On the other hand, there are many adults who think tobacco use can cause heart disease and lungnarcotic drugs. However, because narcotic drugs can refer to other drugs, they are collectively

cancer, and support restricting tobacco use in public places and increasing the tobacco tax.15 Like adults,

called opioids for clarification. Opioids are a class of drugs that include heroin, morphine, andchildren also understand the impacts of tobacco on their health and the importance of restricting tobacco

codeine13

use in public places (Table 10.2).16
Table 10.2 Students’ knowledge and attitudes toward smoking

5. Spread of tobacco use, alcohol consumption, anddrugs in Cambodia

Knowledge and Attitudes

1) Tobacco use in Cambodia
The WHO’s Report on the global tobacco epidemic 2019-Cambodia Country Report-14 states that thelatest surveys of tobacco use in Cambodia are the National Adult Tobacco Survey of Cambodia (2014)15

and the Global Youth Tobacco Survey (2016).16 Described below is the present situation of tobacco use%

Students who definitely thought other people’s tobaccosmoking is harmful to them

78.50%

Students who favored prohibiting smoking inside enclosed
public places60.70%

Students who favored prohibiting smoking at outdoor public
places60.80%
16

Source: WHO. Global Youth Tobacco Survey Cambodia 2016

in Cambodia based on these reports.
According to the National Adult Tobacco Survey of Cambodia (2014), as of 2014, 22% (approx.
1.68 million) of Cambodian people aged 15 years and older use some form of tobacco product, with the180

Chapter 10

Health effects of tobacco use, alcohol consumption, and drug abuse

1812) Alcohol consumption in Cambodia

20

Column: Most At Risk Young People (MARYP) Survey at Hot Spots

As for Cambodian peoples’ alcohol consumption, the annual per capita consumption of alcohol among
17

A survey of socially vulnerable young people aged 10 to 24 years who engage in high-risk behavior

drinkers aged 15 years and older is 21.7 liters (Table 10.3). This represents the consumption converted

was conducted in 2010. The aim of the survey was not to understand the situation of general young

to pure alcohol; the annual consumption is equivalent to 434 liters in the case of beer with an alcohol

people but to identify the behavior and consciousness of MARYP, who manifest high risk behavior

content of 5%.

related to alcohol, drugs, and sex and flock to “hot spots” (e.g., bars, karaoke places, massage
salons, and game centers), in eight states where high-risk behaviors for HIV infection have spread.

Table 10.3 Total alcohol per capita consumption, drinkers only (in liters of pure alcohol)

Among those aged 10 to 19 years who were surveyed, 81.4% of men and 57.6% of women

CambodiaJapan

ThailandMyanmarVietnamLao PDR

responded that they have experienced alcohol consumption. Of these people, 2.3% of men (1.9%

21.7

14.1

20.3

17.6

22.8

25.9

The awareness of high alcohol consumption differs between the sexes, and the difference is evenof the total) and 18% of women (10.4% of the total) are aware that their alcohol consumption is high.

17

Source: WHO. Global Status Report on Alcohol and Health 2018

greater in the age group of 20 to 24 years old. This is probably because young women who work at
karaoke bars and night clubs have many opportunities to consume alcohol with their customers.
The survey shows that reasons for alcohol consumption by MARYP include curiosity to experience

According to the results of the 2013 Global School-based Student Health Survey (GSHS),18 among

something new; coping with stress and depression; coping with events that occurred at school (i.e.,boys and girls aged 13 to 17 years old, the percentage of those who consumed at least one drink offailure in the exam, pressure of deadlines, altercations with friends, and love relationships); alcohol

alcohol in the last 30 days was 12.5% (N=1250) for boys and 4.4% (N=1526) for girls. The percentage

consumption by family members; frequent encounters with alcohol consumption/drug use/tobaccoof those who have ever consumed alcohol was 28.7% for boys and 12.7% for girls. The percentage ofuse in the neighborhood or community; avoiding ostracism from friends; and psychosocial reasons

those who have had problems resulting from alcohol consumption, including problems with familysuch as peer pressure. It also indicates that they think, from their point of view, that education does

members or friends, absence from school, and brawls, was 2.6% for boys and 1.6% for girls.

not guarantee success in life, and stylish appearance is very important, with alcohol consumption

Currently, Cambodia has a minimum level of legal restrictions on alcohol without the establishedseen as a stylish behavior.

minimum age for alcohol consumption or restrictions on advertisements for alcohol. Although there areblood alcohol concentration limits for driving, it is unclear whether a crackdown on drunk driving isproperly carried out on the basis of the limits. There are also cases in which unofficial manufacturers’3) Drug abuse in Cambodia

19

tax payment is evaded because of lax restrictions (Table 10.4). To solve these challenges, there is amovement to revise the law. Restricting accessibility to alcohol leads to not only the prevention of healthAs described in “Spread of drugs in the Western Pacific region” in this Chapter, Cambodia is not included

damage and dependence but also the prevention of incidents and accidents, including drunk driving,in the Golden Triangle, but drugs come into the country for trafficking from neighboring Thailand, Laos,

brawls, domestic violence, and sexual deviancy.

and Vietnam. In Cambodia, stimulants (methamphetamine tablets and crystalline methamphetamine),
Ecstasy, heroin, and ketamine are abused. Since 2017, because of the launch of the anti-drugs campaign
by the government, a crackdown on drugs has been intensified and the amount seized has increased year

Table 10.4 Issues in legal restrictions on alcoholby year (Table 10.5).21 However, drug dependence remains a challenge, and it is said that more than

1. Inadequate age restrictions

20,000 people are in rehabilitation facilities under the control of the Ministry of Health. Drug abuse isspreading particularly among young people, and 49% of the people admitted to drug treatment centers

2. Inadequate restrictions on the hours for sales of alcohols

are reported to be young people aged 18 to 25 years old (Figure 10.6).21,22

3. Emasculated blood alcohol concentration limits for driving

Drugs pose a threat to children as well. A survey of children between 13 and 18 years of age23 has
shown that 15.9% of the children have seen the trading of drugs in the area where they live. The

4. Inadequate restrictions on advertisements

percentage of children who have seen someone abusing a drug was 18.9%, of which 70.2% said theysaw it in the area where they live. The percentage of children who have been offered drugs by a friend

5. Lack of laws regulating sponsors and sales promotion

or a neighbor was 4.9%. It has been reported that children who have seen the trading of drugs in the area

6. Non-mandatory inclusion of warning messages in packages and advertisements

where they live and those who have been offered drugs by their friends or neighbors tend to feel anxious
19

Source: The Asia Foundation (2016)

182

when staying at home alone or dislike going to school or public places. For healthy growth andChapter 10

Health effects of tobacco use, alcohol consumption, and drug abuse

183

Table 10.5 Seizures of selected drugs in Cambodia 2014-2019 -UNODC 2020

Many young people were worried that they might be excluded from a group if they refused such offers,

Unit

2014

2015

2016

2017

2018

2019

and accepted the offers to maintain friendships. In all of these cases, they intended to try just once but

tablets

87,000265,760

490,689

371,556

77,000483,402

came to use habitually.20,24

kg

29

72.9

66.3

80.1

306.6

384.9

It is thought that there is a relationship between alcohol consumption and tobacco use: men who

tablets

10,53370

5,509

83,533599,200

382,728

smoke are more likely to consume alcohol than men who do not smoke. Although the relationship is not

Cannabis herb

kg

19.9

1,511.5

37

116.3

74.0

102.8

as clear as in men, women who use smokeless tobacco are said to be more likely to consume alcohol.25

Cocaine

kg

7.9

5.3

14

12.8

5.4

61.1

In order to change interrelated risk behaviors, that is, alcohol consumption, tobacco use, drug abuse,

Heroin

kg

1.8

2.5

6.2

22.5

1.3

47.9

and unprotected sexual acts, it is necessary to reduce social stress as well as steadily carry out health

Ketamine

kg

0.0

0.1

1.1

6.3

36.3

33.1

education and social policy to change values.

Drug type

Methamphetamine tablets
Crtstalline methamphetamine
Ecstasy

Source: United Nations Office on Drugs and Crime (UNODC) : Synthetic Drugs in East and South-East Asia: Latest developments andchallenges. 2020

>46 years 1%
36-45 years

7%

10-17 years

8%

Column: Global strategies regarding tobacco and alcohol (Figure 10.7)

As a global tobacco strategy, the Framework Convention on Tobacco Control 5 was adopted at
the 56th World Health Assembly in 2003 and entered into force on February 27, 2005. The objectiveof the Convention is to protect present and future generations from the harmful health effects of
tobacco use, etc. To achieve this objective, the Convention includes “Protection from exposure to26-35 years

35%

tobacco smoke,” “Ensuring that tobacco product packaging and labelling do not promote tobacco
18-25 years

49%

products by any means that are false, misleading, deceptive or likely to create an erroneous
impression, and health warnings shall be no less than 30% of the principal display areas,” “A
comprehensive ban or restrictions on all tobacco advertising, promotion and sponsorship,” “Taking
measures to eliminate illicit trade in tobacco products, including requiring unit packets and packages

Source: UNODC: Synthetic Drugs in East and South-East Asia: Latest developments and challenges. 2020

Figure 10.6 Drug treatment center admission in Cambodia by age group -UNODC 2020of tobacco products to carry effective marking indicating the final destination,” “Implementing
effective measures to prohibit the sales of tobacco products to minors,” “Establishing the Conferenceof the Parties that keeps under regular review the implementation of the Convention and takes
decisions necessary to promote its effective implementation,” and “Each Party shall submit to thedevelopment of children, it is important to have a drug abuse prevention program aimed at creating a

Conference of the Parties periodic reports on its implementation of this Convention.”5

safe community, in which social norms are developed to enhance a sense of unity in the community andto refuse drug use. To achieve this, it is necessary to improve the community’s socioeconomic andcultural environments, such as addressing the community’s poverty, unemployment or lack of
employment, social unrest, and high density of shops that sell alcohol and tobacco.

4)	Psychological/social factors related to tobacco use, alcohol consumption,and drug abuse
Column: As touched on in the section on the Most At Risk Young People (MARYP) Survey at Hot Spots,
triggers for high-risk young people to begin tobacco use, alcohol consumption, and drug abuse arecasual curiosity such as “I just wanted to try something new,” or “I just gave it a try,” or the influenceof family members/friends or advertisements such as “they looked cool,” “they looked tasty,” and “I saw
advertisements.” Some young people began when they become depressed because of a problem with afriend, lover, or family member. In addition to these, offers or pressure from friends is another factor.
184

Figure 10.7 Social measures (warning messages on tobacco packages)

Chapter 10

Health effects of tobacco use, alcohol consumption, and drug abuse

185

Meanwhile, “the global strategy to reduce the harmful use of alcohol”26 was unanimously adopted

High

and mortality related to alcohol as well as the resulting social impacts, and to improve the health ofindividuals, families, and society, in order to significantly curb the use of alcohol, which is the thirdlargest factor adversely affecting health and societies in the world. To achieve this objective, thestrategy calls for a broad range of measures, including restrictions on advertisements, bans or
restrictions on bargains and all-you-can-drink offers, and alcohol price increases through taxationand minimum price systems.26

Dangerous
range

Drug level in the bloodat the 63rd WHO general assembly in 2010. The objective of this global strategy is to reduce morbidity

Effective
range
Ineffective
range

Column: How to use pharmaceuticals

Although pharmaceuticals are originally designed to alleviate or cure human diseases and disorders,

Source: Risk/Benefit Assessment of Drugs - Analysis and Response. Kusuri Guidebook.
Copyright ©RAD-AR Council, Japan. All rights Reserved. Translated with permission.

they need to be properly used because even beneficial pharmaceuticals can have adverse effects
on health if used in the wrong way. Pharmaceuticals have, by nature, “main effects,” which are to

Figure 10.8 Drug levels in the blood and drug efficacy 27

achieve the intended purposes of easing and curing the symptoms of disease, and “side effects,”
which are adverse influences on the body resulting from the use of the pharmaceutical. Side effects
can occur with any pharmaceutical as well as in people with certain predispositions or conditions.

Exercises for further thought and research

Pharmaceuticals are drugs designed to be used for the diagnosis, treatment, or prevention ofhuman and animal diseases. They have the components and forms (e.g., liquid, semisolid, and solid)[10-1] As restrictions on advertisements for alcohol consumption, there are “bans on advertisingthat are suited for the effect and efficacy (e.g., easing pain). In addition, usage (dosage andappealing to minors” in Canada, and “bans on advertising on television and movies” in France.

administration, and timing) is established so that pharmaceuticals can properly exhibit effect andConsider what kind of social measures can be taken in Cambodia to create an environment for

efficacy.27 However, even pharmaceuticals can cause side effects if used in the wrong way. For

preventing tobacco use and alcohol consumption among children.

example, if you miss a dose of a drug that needs to be taken three times a day and take a double[10-2] Smokers say that they feel refreshed after smoking tobacco and that they cannot help smoking

dose of the drug at one time, drug levels in the blood can rise to a dangerous degree, possibly

tobacco when they feel stressed. Present your counterarguments against these opinions.

causing anaphylactic shock. Or, if you adjust the dose of a drug and take a subtherapeutic dose,[10-3] Consider what you need to create a society in which drugs have no place.

drug levels in the blood will be too low to be efficacious (Figure 10.8). Therefore, in using drugs, it is[10-4] Understand the relationships between risk behaviors related to tobacco, alcohol, and sex, andconsider why young people display those behaviors.

important to carefully consult a physician, pharmacist, or pharmacy personnel about the usage of27

the drug, and to follow the dosage and administration stated on the package.

Low-quality pharmaceuticals and counterfeit medicines, which include those with false[10-5] Consider what should be done to encourage children to refuse drug offers.
[10-6] Consider how a teacher should act if a child reports that he/she witnessed a person abusing
alcohol or a drug, or trading drugs in the area where he/she lives.

labeling of contents and ingredients, those not meeting quality standards or specifications, andthose that have not been assessed or approved by regulatory authorities, are rapidly increasing
28

mainly in Asia, South America, and Europe. The WHO’s survey[10-7] Research cannabis restrictions in Cambodia. Study how cannabis has been historically andculturally used in Cambodia.

reports that low-quality

pharmaceuticals and counterfeit medicines account for approximately 10.5% of available
phamaceuticals in low- and middle-income countries. It also reports that these pharmaceuticals
particularly affect pneumonia and malaria in children. There is a concern that the spread of theinternet may increase the online sales of low-quality pharmaceuticals and counterfeit medicines.
In Cambodia, the estimated percentage of these pharmaceuticals widely varies from 4% to90%. Particular attention should be paid to drugs that community stores sell in loose form as they
contain many low-quality pharmaceuticals, counterfeit medicines, or unapproved drugs.29
Pharmaceuticals should be obtained at reliable places, such as hospitals and pharmacies.

References
1
2

186

Ministry of Health, Labour and Welfare: e-healthnet “Health effects of tobacco use.” https://www.e-healthnet.mhlw.go.jp/
information/tobacco-summaries/t-02
CDC. Smoking, Pregnancy, and Babies. https://www.cdc.gov/tobacco/campaign/tips/diseases/pregnancy.html
Chapter 10

Health effects of tobacco use, alcohol consumption, and drug abuse

187

Chapter 113

WHO: Health effects of smoking among young people. https://apps.who.int/tobacco/control/populations/youth_health_effects/en/
index.html

4

WHO: Heat-Not-Burn tobacco products information sheet. https://apps.who.int/tobacco/publications/prod_regulation/heat-not-burnproducts-information-sheet/en/index.html

56

WHO: WHO Framework Convention on Tobacco Control. 2003. https://www.who.int/fctc/text_download/en/
Chheng N. New tobacco device banned. The Phnom Penh Post. March 21, 2021. https://www.phnompenhpost.com/national/new-

Mental and physical changes duringadolescence

tobacco-device-banned
7

Ministry of Health, Labour and Welfare: e-healthnet “Health effects of alcohol.” https://www.e-healthnet.mhlw.go.jp/information/
alcohol-summaries/a-01

8

Ministry of Health, Labour and Welfare: e-healthnet “Alcohol and dependence.” https://www.e-healthnet.mhlw.go.jp/information/
alcohol-summaries/a-05

9

Ministry of Health, Labour and Welfare: e-healthnet “Alcohol and social issues.” https://www.e-healthnet.mhlw.go.jp/information/
alcohol-summaries/a-06

10 WHO Western Pacific Region Office. Young People and Alcohol: A Resource Book. 2015. https://apps.who.int/iris/bitstream/
handle/10665/208202/9789290616849_eng.pdf?sequence=1&isAllowed=y
11 Dharmapuri S, Miller K, Klein JD. Marijuana and the Pediatric Population. Pediatrics. 146 (2) e20192629. 2020. https://pediatrics.
aappublications.org/content/146/2/e20192629
12 Global News View: “The Golden Triangle—Rapidly increasing stimulants.” https://globalnewsview.org/archives/9905
13 United States Drug Enforcement Administration. Drug Fact Sheet: Narcotics. https://www.dea.gov/sites/default/files/2020-06/
Narcotics-2020.pdf
14 WHO: Report on the global tobacco epidemic 2019 -Country report Cambodia-. https://www.who.int/tobacco/surveillance/policy/

Learning objectives
You will be able to gain proper understanding and explain:- The mental and physical changes and the issues associated with growth and development duringadolescence and how to handle them.
- Pregnancy and childbearing and sexually transmitted infections in youth.
- The social challenges regarding sexual health in Cambodia and discuss their solutions.
In this chapter, you will learn about the following three topics: characteristics of mental and physicalgrowth and development in adolescence in the context of sexual health; basic information about
pregnancy/childbearing and sexually transmitted infections, and the current landscape and challenges in
Cambodia concerning these issues; and the current state of sexual health and its handling in Cambodia.

country_profile/khm.pdf
15 National Institute of Statistics, Ministry of Planning, Cambodia: National Adult Tobacco survey of Cambodia, 2014. https://
untobaccocontrol.org/impldb/wp-content/uploads/cambodia_2018_annex-1_national_adult_tobacco_survey_report_2014.pdf
16 WHO: Global Youth Tobacco Survey 2016 -Country Report Cambodia-. https://extranet.who.int/ncdsmicrodata/index.php/
catalog/690/related_materials
17 WHO: Global Status Report on Alcohol and Health. 2018. https://www.who.int/substance_abuse/publications/global_alcohol_report/
gsr_2018/en/
18 WHO Cambodia - Global School-Based Student Health Survey 2013. https://extranet.who.int/ncdsmicrodata/index.php/catalog/220/
data_dictionary
19 The Asia Foundation. The Alcohol Industry in Cambodia -A Study of Taxation, Regulation, Distribution, and Consumption of
Alcohol-. 2016. https://think-asia.org/bitstream/handle/11540/7313/The-Alcohol-Industry-in-Cambodia_report.pdf?sequence=1
20 Ministry of Education, Youth and Sports, Cambodia: Most at Risk Young People Survey Cambodia. 2010. https://
healtheducationresources.unesco.org/library/documents/most-risk-young-people-survey-cambodia-2010
21 UNODC: Synthetic Drugs in East and South-East Asia: Latest developments and challenges. 2020. https://www.unodc.org/
documents/scientific/ATS/2020_ESEA_Regonal_Synthetic_Drug_Report_web.pdf
22 AIPA Council on Dangerous Drugs: Country Report of Cambodia-. 2019. https://www.parliament.go.th/ewtadmin/ewt/aipa2019/
download/article/AIPACODD/Annex%20J%20-%20Country%20Report%20of%20Cambodia.pdf
23 Good Neighbors Cambodia: Survey Report -The Child’s Reporting on The Situation of Drug Use in Community-. 2019. http://www.
gncambodia.org/wp-content/uploads/2019/11/GNC_Drug-Survey-Reported-by-Voluntary-Grassroots-Youth-EN.pdf
24 Peltzer K, Pengpid S, Tepirou C. Associations of alcohol use with mental health and alcohol exposure among school-going students
in Cambodia, Nagoya Journal of Medical Science. 78(4): 415–422.2016. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5159467/
25 Banta JE, Addison A, Job JS, Yel D, Kheam T, et.al. Patterns of Alcohol and Tobacco Use in Cambodia. Asia Pac J Public Health.
25(5 Suppl): 33S–44S. 2013. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5043075/
26 WHO: Global strategy to reduce the harmful use of alcohol. 2010. https://www.who.int/substance_abuse/alcstratenglishfinal.pdf
27 RAD-AR Council, Japan. KUSURI GUIDEBOOK. https://www.rad-are.com/downloads/kusurigb-pdf02.pdf
28 WHO: WHO Global surveillance and monitoring system for substandard and falsified medical products. 2017. https://www.who.int/
medicines/regulation/ssffc/publications/GSMS_Report.pdf
29 Khan MH, Okumura J, Sovannarith T, Nivanna N, Nagai H, et al. Counterfeit Medicines in Cambodia—Possible Causes.
Pharmaceutical Research 28:484-489. 2010. https://www.researchgate.net/publication/47157896_Counterfeit_Medicines_in_
Cambodia-Possible_Causes

188

1. Characteristics of mental and physical growth anddevelopment in adolescence (Table 11.1)
1) Physical changes(1) Signiﬁcance of adolescence as a period of transition from childhood to adulthood

1

Adolescence is a period when a child undergoes dramatic changes biologically, physically, and socially.
During this period, one experiences the appearance of secondary sexual characteristics due tohormonal changes in the body, while mentally, one goes through rapid cognitive and emotional
development. The human brain continues to develop until around the age of 25; during adolescence, one
becomes able to control their impulses and make more rational judgments as they grow older.
The ﬁrst half of adolescence is a period during which, as one grows, one becomes increasingly more
susceptible to the inﬂuence of people of the same age group, while becoming less dependent on theirparents. What you should keep in mind when addressing adolescence is the fact that the duration ofadolescence is growing “longer.” Speciﬁcally, most men and women today are experiencing theappearance of secondary sexual characteristics earlier in life, while entering into a period in life when
they assume social roles expected of adults, such as those connected to marriage, later, compared to what
they used to assume.
2(2) Secondary sexual characteristics

During the second half of adolescence (ages 15–19), one experiences sexual development andmaturation following the growth spurts in the ﬁrst half of adolescence. Physical growth and sexual
Chapter 11

Mental and physical changes during adolescence189

Table 11.1 Physical, cognitive, social, and psychological development in adolescence1■ Physical changes• Start of puberty (typically ages 8–14 in females)• Muscle acquisition and growth spurts• Menstruation and breast growth (females)• Voice change and facial hair growth (males)■ Cognitive, social, and psychological changes• Appearance of self-consciousness and low selfesteem

related to one another. As early as the 19th century, the physical maturation of girls was considered
to be influenced by climate (especially the mean annual temperature), ethnicity, social status, place• Susceptible to peer pressure (influence byfriends and peers)inheritance, and health status.3 The 20th century saw further additions to the list of factors that affect• Tendency to focus on the present rather than the
futureChanges during late adolescence (ages 15–19)• Continued physical growth, especially for males

The age of onset of menstruation is influenced by heredity and environment, which are intricately• Feelings of awkwardness or discomfort related
to physical changes• Improved ability to engage in abstract thinking
and introspection■ Physical changes

Column: Factors contributing to the onset of menstruation and health consequences ofage for menarche

Changes during early adolescence (ages 10–14)■ Cognitive, social, and psychological changes• Increased independence and feelings of
invincibilityof residence (urban or rural), physical activity, level of education, sexual stimulation, housing,the onset of menstruation, including season and month of birth, physique (e.g., BMI), dietary habits,
position in sibship, family income, education and occupation of parents, and family size. A recent
review pointed out that, while the onset of menstruation was now known to be controlled by acomplex neuronal network as well as genes, it was also influenced by factors other than genetics,
including socioeconomic and environmental factors, BMI, exercise, dietary habits, and geographicalfactors, and that more studies were needed.4
In the context of health implications, early menarche is associated with increased risks of• Tendency to seek out novel and varied
experiencescardiovascular diseases and breast cancer mortality, and higher susceptibility to health issues of a

• Increased interest in opposite-sex friendships
and romantic relationships

menarche, meanwhile, has been associated with an increased risk of osteoporosis and bone

• Continued improvements in abstract thinking
and introspection• Improved decision-making, critical thinking,planning skills, and moral development
Source: Skolnik R. Global Health 101 Third Edition. Jones & Bartlett Learning, 2016 (Kihara M and Kihara M, Trans., and Ed.
Gurobaru herusu: Sekai no kenko to taishosenryaku no saishin doko [Global Health: Latest Trends in World’s Health and HealthStrategies]. Medical Science International, 2017).

psychosocial nature, such as anxiety, depression, premature intercourse, and violence. Latefracture.4 Further research is needed in order to find out what consequences early menarche may
have on women’s health later in their lives.

(3) Functions of the male reproductive system
This section gives an overview of the functions and anatomy of the reproductive system and sexual
response in males.5

maturation are considered to be based on different mechanisms from one another. However, when you
consider the onset of menstruation, which is a typical occurrence that represents sexual maturation ina) Anatomy and function

girls, one does not experience the onset of menstruation until after she has reached a certain level ofSperm is a cell that consists of a head of 4–5 μm in diameter and a long, thin tail, with an overall length

physical growth (see Column: Factors contributing to the onset of menstruation and health consequencesof approximately 60 μm. Sperm produced in the testes do not move at all at first; as they leave the testesof age for menarche).

and move through the epididymis, sperm start swimming and gain fertilizing capability. Sperm swim at

The most representative changes during adolescent sexual development are the onset of menstruationa rate of around 1–4mm per minute. Sperm production begins as a male reaches puberty, and it continues

for girls and spermarche for boys. These occurrences of sexual maturation are caused by the actions ofmostly throughout the rest of his life. The two testes of an adult male produce over 120 million sperm

sex hormones; there are also other changes such as the growth of pubic hair, voice changes, andevery day, but the number significantly declines as one reaches old age. Around 100–400 million sperm

enlargement of breasts. These are collectively referred to as secondary sexual characteristics. As theare released in a single ejaculation. Once expelled, sperm can live only for 24–48 hours at human body

appearance of secondary sexual characteristics is one of the most characteristic features of adolescence,

temperature. Yet, they may be preserved for years if frozen at −100°C. Low sperm count, abnormal

it is generally common to refer to ages between 15 and 19 years as “adolescence.” In the second half ofsperm morphology, or low sperm motility can be a cause of male infertility.

adolescence, the development of secondary sexual characteristics is nearly complete, as adolescentscome close to sexual maturity, and the physical build of their bodies is nearly that of an adult.
Such occurrences of the adolescent growth spurt (the dramatic increase in height during adolescence)

See Chapter 2 for the anatomy of the male reproductive system (i.e., a cross-section).

b) Sexual response

and secondary sexual characteristics are not random incidents, but sequentially ordered by the genetic

The male penis becomes erect in response to sexual stimulation. Penile erection is a phenomenon inprogram.

which the firmness and size of the penis increase, and it occurs as the corpora cavernosa fill with blood.

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Mental and physical changes during adolescence191

Upon receiving sexual stimulation, the pelvic parasympathetic nerves send stimulation to the penis,
causing arterioles to dilate. This allows blood to flow into the corpora cavernosa, but as the venous
outflow is restricted, the corpora cavernosa fills with blood and becomes firm, which results in penile
erection. If a man is exposed to further sexual stimulation and becomes highly aroused, the ejaculationof seminal fluid out of the urethra occurs. The seminal fluid consists mainly of fluids secreted from theseminal vesicles, prostate glands, and bulbourethral glands, and contains sperm produced in the testes.

Luteinizing hormone(promotes secretion of estrogen andmaturation of follicles)

Follicle stimulating hormone(Promotes secretion of
estrogen, which promotematuration of follicles)

Folliclestimulating
hormoneFigure 11.1-a

The volume of seminal fluid ejaculate is 2.5–3.5 mL, and the sperm count is 100 million per 1 mL ofseminal fluid.
When either ejaculation occurs or sexual stimulation is interrupted, the sympathetic nervous system
becomes dominant. This removes the restriction of venous outflow, allowing the blood retained in thecorpora cavernosa to flow out, which ends erection.

Remains of follicle (post-ovulatory follicle) turn into
corpus luteum, secreting progesterone and estrogen

Ovarianfollicle

Ovulation

Follicle matures

Degenerates into a
corpus albicans if no
fertilization occurs

Figure 11.1-b(4) Functions of the female reproductive system
Corpus luteum regresses,
ovarian hormones decrease,and menstruation is triggered.

The female reproductive system functions in two different periods: the preconception period with ainvolves two reproductive cycles: the ovarian cycle, which refers to a series of periodic changes that
occur in the ovaries; and the menstrual (uterine) cycle, which occurs due to periodic changes in thevolumes of the hormones secreted by the ovaries.

OvarianHormones
Figure 11.1-c

EstrogenA female has 1–2 million oocytes (immature ova) in her ovaries at birth; the number decreases

Progesterone

down to 300–400 thousand by the time one reaches puberty. Each oocyte is surrounded by a layer offollicular epithelial cells, forming an ovarian follicle. Once a female reaches puberty, one of the follicles
becomes mature, and ovulation (the follicle ruptures at the surface of the ovary and releases ova) occurs
every 28 days. Supposing a female has menarche at age 12, ovulates 13 times in each of the successive
years, and has menopause at age 50, the number of ova ovulated over her lifetime would be around 500.
The remaining oocytes reduce by the hundreds or up to one thousand every time ovulation occurs;

Low temperature phase

Basal bodytemperature

Day ofovulation

reproductive cycle of 28 days on average; and the period of pregnancy. A preconception periodHigh temperature phase

Figure 11.1-d(Temperature becomes on andafter the day of ovulation)

following menopause, there is no oocyte remaining in her ovaries.

a) Ovarian cycle (Figures 11.1-a, b, and c)
The ovarian cycle is divided into the follicular phase and the luteal phase.
During the follicular phase, a number of ovarian follicles begin maturing, but only one of themcontinues to mature while the rest regress. Follicle stimulating hormone (FSH), secreted by theEndometrium

pituitary gland, stimulates the maturation of follicles. Mature follicles within them produce estrogen,Figure 11.1-e

which works on both the follicles and the uterus; it stimulates follicles to mature further while promoting

Ovarian hormone levels become lower,
causing endometrial blood vessels to
shedding of endometrium exept for its
basal layer

Estrogen levels become higher,
triggering restoration of endometrium,with the thickness increasing to 4-10 mmand blood vessels becoming longer

Endomentrium becomes
12-18 mm thick, preparing for
implantation of fertilized ovum

the proliferation of the endometrium. On the 14th day after the start of the follicular phase, the secretionof luteinizing hormone (LH) sees a spike, causing ovulation.
Ovulation is followed by the luteal phase. After the release of the ovum, follicular epithelial cells
luteum releases small amounts of estrogen and progesterone. Progesterone is involved in the maintenanceof the proliferated level of the endometrium and the preparation of the uterus for implantation of a
fertilized ovum.
Female body temperature undergoes periodic changes on a cycle of around 4 weeks. It is lower
192

Proliderative
phase

Menstruation

remain on the surface of the ovary, and these cells form the corpus luteum. Stimulated by LH, the corpus

Day

1

7

Secretory phase

14

21

Menstrutaion

28

The period from the first day of the start of menstruation to the day before the start of
the next menstruation is called the menstrual cycle, and one cycle is about 28 days.

Figure 11.1 Reproductive cycles
Chapter 11

Mental and physical changes during adolescence193

during the follicular phase (i.e., after menstruation) and higher during the luteal phase (i.e., before
menstruation), with a fluctuation of 0.2–0.4°C. In addition, it dips during ovulation, then becomes higher
from the day of ovulation onward (Figure 11.1-d).

6(5) Sexual desire

As a child reaches adolescence, the release of the sex hormones leads to the development of secondary
sexual characteristics, and their body matures into an adult body capable of reproduction. During thisb) Menstrual cycle (Figure 11.1-e)period, it is natural for adolescents to realize their interest in sexuality is heightened and that their desire

The menstrual cycle is divided into the menstrual phase, the proliferative phase, and the secretory

for a closer relationship with someone of the opposite sex is strengthened. It has been said that men havephase. The duration of each of the phases varies among individuals; Figure 11.1 is based on a 28-day

a stronger sex drive than women do. Considering that male sex hormones are responsible for sexual

cycle, which is a typical duration.

desire and that they are found in women’s blood at a level around one-tenth of that found in men, it may

During the menstrual phase, the secretion of female sex hormones, i.e., estrogen and progesterone,

be reasonable to say that men may indeed have stronger libidos and sexual desire. This, however, varies

from the corpus luteum decreases, causing the endometrium to degenerate and eventually be shedconsiderably among individuals, and it does not remain constant but fluctuates greatly depending on

through the vagina along with blood. An unfertilized ovum dies and is shed during menstruation. The

factors such as one’s physical condition or the situation they are in, their values, experience, environment,

menstruation phase lasts from 5 to 7 days, with the first day of menstruation being Day 1.

and personal relationships.6

The proliferative phase sees the maturation of the follicles, which results in increases in the secretionof estrogen and significant proliferation of the endometrium. As a result of the proliferation of the basal
layer and the development of the glands and blood vessels, the thickness of the endometrium increases
from 1 mm at the beginning to around 5–6 mm. The proliferative phase lasts until Day 14.
As the corpus luteum develops after ovulation, progesterone secreted from the corpus luteum puts

2) Mental and social changes7(1) Understanding mental development and problem behaviors during adolescencethe uterus into the secretory phase. The glands and blood vessels develop further, and the glands secrete

Adolescence is a period when one comes to establish an identity as an adult human being while alsoa fluid containing glycogen. A number of folds appear on the surface of the endometrium, whichbeing influenced by others around them. Peer groups have a substantial role to play in this process, andfacilitates the implantation of a fertilized ovum.

peer problems can have consequences on the adolescent’s mental development and any problem

If pregnancy occurs, the corpus luteum will be sustained. As progesterone will also be produced bybehaviors. In addition, in order for you to understand, and take action to address, adolescent problem

the placenta, the endometrium will be kept at its secretory phase. If, on the other hand, no pregnancy
occurs, the secretion of progesterone will decline, and the endometrium will degenerate in around 12days, leading to the start of another menstrual phase.
6

Column: Keep track of your menstrual cycle

Are you female readers keeping proper track of your menstrual cycle? If you know your cycle, you
won’t need to feel worried if you have irregular menstruation, and you can detect irregular menstruation
early should you have it. Irregular menstruation may affect any future pregnancy; if you keep
experiencing irregularities years after your first menstruation, it will be reassuring to determine thecause. If you are not pregnant but experiencing amenorrhea, or the absence of menstruation, andthat lasts for six months or longer, you should see a doctor (or consult an expert) at an early date.
You should also be aware that extreme diets, stress, or irregular/unhealthy lifestyles can also be
the cause of amenorrhea. Your menstrual cycle provides important information to understand yourphysical condition and when you are more likely to get pregnant. For these reasons, and to know
precisely when your due date will be if you do become pregnant, it is important that you always keep
track of your menstrual cycle. If your menstruation lasts only for 1–2 days or for 8 days or longer, it
may potentially be due to amenorrhea or some other factors; in such a case, you are advised to talkto your doctor or an expert first.

Social- Social system- Values- Trends ... etc.

BackgroundPeer (ego)Group- Regional characteristics- Scool culture- Peer groups ... etc.

Family environment- Socioeconomics status- Parents’ child support
capacity- Parents’ personality
tendencies ... etc.

Developmental- Physical characteristics- Cognitive characteristics- Developmental tasks ... etc.

Egodevelopment

Peer (ego)Background

Developmentof identity(physical/sexual)

Source: Kiyota, Akio. Understanding mental
development and problem behaviors duringadolesc ence. e-Health Net.
https://www.e-healthnet.mhlw.go.jp/information/
heart/k-03-002.html
Ministry of Health, Labour and Welfare. (2021)

Figure 11.2 Adolescent mental development and relevant factors7

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Chapter 11

Mental and physical changes during adolescence195

behaviors, you need to understand what their aims are and the diverse factors behind their behaviors.7

drinking and smoking) in order to conform to peers out of fear of rejection or isolation from their peers,

One of the keys to understanding adolescence is “ambivalence.”or by peer pressure. How peer relationship dynamics work among children of these ages has a significant

Mental development during adolescence involves a number of physical, psychological, and social

impact on their mental development and socially deviant behaviors.

factors. In terms of development, at an individual level, adolescents experience significant physical andBy the time they are in high school and have developed a sense of “I am me, and they are them,” theymental changes, including secondary sexual characteristics, and as they undergo sexual development

become able to accept others who are different from themselves in some ways.7 In this phase, the peer

and maturation, levels of sexual energy become higher. Meanwhile, the values, trends, and institutions

relationships develop into those in which adolescents accept one another’s differences as autonomousof the groups to which one belongs, such as their school, peer groups, and family, as well as society at

individuals, both inside and outside. Through the experience of such relationships, they gain a sense oflarge, have a psychosocial influence on one as a member of these various societies as they explore how

self-contentment and security, which helps their mental development and builds a base for achieving

they want to live their lives and gradually form their own identity as an adult individual. Adolescence isself-identity.

a period in one’s life when they “achieve a self-identity” like this, but some of the influence put on themduring this process may lead to problem behaviors (Figure 11.2).

b) Understanding symptoms and problem behaviors observed in adolescence
Adolescence is also a period for a child who has not successfully accomplished the developmental tasks
for school-age to return to the past developmental tasks and redo or re-experience them. For instance, aColumn: What is ambivalence?

middle-school child who has not fully experienced a sense of unity or intimacy with peers mentioned

Ambivalence is one of the key concepts in addressing adolescence.7 Ambivalence is to have and/or

above may resort to self-harming or truancy out of anxiety or lowered self-affirmation. It is not uncommon

express two contrasting emotions or attitudes towards a certain object simultaneously, such as thefor adolescents to demonstrate different problem behaviors or physical/mental symptoms, but these maykind of affection and aversion that an adolescent girl and her mother may have towards one another.

be interpreted as signs for such children to have another chance to go through developmental challenges

Adolescence is a time when one often feels conflicted over the gap between justice or idealism andthey have yet to accomplish.

reality, or about autonomy from, and dependence on, parents, and this means that they experience

To handle such symptoms or problem behaviors in an appropriate manner, it is important that you

stronger ambivalence and tendencies of extreme behaviors. It is the role of adults who are around a

understand which developmental task(s) the child needs to try again. You also need to explore underlying

child to help the adolescent contain such swings to a state that will not interfere with their social life.

developmental factors to find out why the task(s) have been allowed to remain unaccomplished up toWith proper support from others around them, and through the twists and turns of life, an adolescentnow. Simply looking at the problem behaviors or symptoms that manifest on the surface will not be

will achieve a healthy self-identity and grow into an adult.

7

If, however, ambivalent emotions or attitudes in adolescence manifest in the form of drug abuse,enough to remedy the situation. In order for a teacher to provide support to these children, a teacher
needs to understand child development (see Chapter 3).

eating disorders, violence/delinquency, truancy, or certain physical symptoms, it will become
necessary to consult school staff, experts, or specialist organizations. In Cambodia, human resource
development in school counselors, social workers, and other specialists providing support tochildren, their parents and guardians, and teachers, remains a challenge that needs to be addressed.
And adults who are close to children, including teachers, families, and relations, as well as theirelders, will play a large role in such endeavors.

a) Autonomy and peer relationships

2. How pregnancy and childbirth work and the current
situation around them
51) Pregnancy
Pregnancy brings significant changes to the physiology and shape of the mother’s body. While manysuch changes are designed to prepare the body as an ideal environment for the fetus’s growth, maturation,

In adolescence, while one’s desire to become autonomous from parents becomes stronger, they also feeland delivery, there may also be secondary changes that result from pressure from the enlarging uterus oranxiety and a sense of loss or sadness over being more distant from parents. As if to compensate for thethe changing hormone balance.

unstable emotions, adolescents associate themselves with their peers in an attempt to have a sense of
security and approval of being accepted by their peers and a sense of belonging to peer groups. For a(1) Somatic changes

child in the last years of primary school up to middle school, in particular, what plays a significant role

Physiological weight gain during pregnancy is approximately 8–10 kg. This is partly due to the growing

is groups of peers of one’s own sex, those that are characterized by a sense of unity and closeness based

body of the fetus itself, but other factors also account for the gain, including the enlargement of theon inner similarities. Although this allows adolescents to act autonomously from parents, it may also

uterus and increasing volume of extracellular fluid including blood due to the body’s tendency forlead them to take on socially deviant behaviors (e.g., crime and bullying) or health risk behaviors (e.g.,

fluid retention as a part of physiological changes caused by pregnancy. Other changes include increased

196

Chapter 11

Mental and physical changes during adolescence197

insulin resistance, increases in postprandial hypertension and fasting hypoglycemia, decreased tubular

3) Today’s circumstances surrounding pregnant and nursing mothers11

reabsorption of glucose, which can all often lead to a diabetic state. In addition, increases in serum lipid
levels may also be observed; the levels can be markedly high, especially in late pregnancy.

Cambodia’s maternal and child health situation, despite the large amount of foreign aid it had received,
used to fare poorly on such indicators as maternal mortality and infant mortality until as recently as the(2) Changes to the uterus

beginning of the 2000s. To address this, the Cambodian Ministry of Health positioned maternal health

The most notable pregnancy-related changes are naturally found in the uterus. In a woman who is not

as one of the key issues in its Health Strategic Plan 2003–2007 and set a goal to promote perinatal

pregnant, the uterus is approximately 7-cm long, 5-cm wide, and 3-cm thick. Towards the end ofcheckup by healthcare professionals and skilled birth attendance. As part of this, it established apregnancy, the measurements can increase to 35 cm × 25 cm × 22 cm. This is due to the enlargement of

midwifery training program and had all regional centers employ midwives. Thanks to these efforts,

uterine smooth muscle, as well as the enlargement and growth of connective tissue. Uterine blood flow

maternal mortality in particular saw dramatic declines, with the rate per 100,000 live births down fromalso increases to around 500 mL per minute at the end of pregnancy.

472 in 2005 to 161 in 2015.
Besides medical issues, there are more fundamental issues such as regional differences in infrastructureand disparities in wealth. Data from 2010, for instance, showed stark differences in child mortality (per2) Childbirth (delivery)

100,000 live births), with 13 in the capital Phnom Penh on the one end, compared to 95 in two northeastern
provinces of Preah Vihear and Stung Treng on the other, the worst in the country. The absence of a health

By around the 270th day after implantation, the uterine cervix becomes softer, and the uterine muscle

insurance system is one of the reasons people hesitate to seek medical attention or have surgery; inlayer’s oxytocin sensitivity is increased, making it ready for delivery (childbirth).

addition, there are a number of regions where people lack physical access to a health center, are situatedfar away from a provincial hospital that provides surgery, and/or have no means of transportation in case

The course of parturition (childbirth) is divided into three stages.

of an emergency that requires surgery.

(1) First stage of parturition (dilation stage)

While a mountain of issues still remains, there are signs of change in parts of the rural areas that are

Once regular uterine contractions (labor) have started, and the uterine cervix has extended to the pointclose to urban areas. One such sign is receiving skilled birth attendance at home by calling in a midwife

the external os of the uterus is open to the full dilation (10 cm), the release of oxytocin increases, andaffiliated with a healthcare institution, in place of aging traditional birth attendants. Maintaining thelabor intensifies. Labor intervals gradually become shorter until eventually the amniotic sac breaks, andpractice of home birth helps to preserve its beneficial aspects, such as the traditional healing procedure

the amniotic water is released (water breaking).

known as Ang Pleung (see Column: Traditional culture that supports childbirth (Ang Pleung) andchanges in childbirth), and for an expecting mother to have her family and neighbors around her during(2) Second (expulsion) stage to third (placental) stage of parturitiondelivery. In addition, it also provides secondary benefits through contact with a midwife, such as more

These stages represent a period from the full dilation of the external os until the fetal expulsion. The

people acquiring family planning knowledge, and families getting sound advice, including a switch tofetus is gradually expelled toward the birth canal. The force to expel the fetus (expulsive force) graduallyfacility birth if necessary. This may be an example of coexistence, or harmony, between traditional

becomes stronger, and when it reaches its peak, the fetus is pushed out of the mother’s body, and takes

wisdom and modern medicine.

its first breath. A fetus commonly comes out head-first; if however, its buttocks and/or legs are to comeout first, it can make for a difficult delivery. Following the expulsion of the baby, fetal appendages,
including placentas are expelled, to complete the delivery.
There are no national data available on weight and length at birth for children in Cambodia. However,Column: Traditional culture that supports childbirth (Ang Pleung) and changes inchildbirth

statistics on 4,991 newborn children born in health facilities (in a five-year period between 2010 and

Takahashi11 reported that “there is a traditional healing procedure in Cambodia called Ang Pleung,2014) show that the average birth weight was 3,100 g, with the prevalence of low birth weight being

in which a postpartum mother rests on a delivery bed with charcoal fire underneath her to warm her

8around 7% on average. For reference, data from a Lao hospital showed the average birth weight among
9

body over several days. It is believed to be practiced widely in rural areas. The mother as a rulenewborn children born at the hospital in 2013 to be 3,049 g (in 3,912 children). While average birth

sleeps and eats in an area separated from others throughout the period of the procedure. Ang

weight and length varies among different nationalities, ethnicities, socioeconomic statuses, and sexes,

Pleung is completed on the day the fire is put out, and the newborn and the new mother for the first

typical birthlength and birthweight are approximately 48–50 cm, and 2.9–3.5 kg, respectively.10

time leave the enclosed area and undergo a ritual presided over by Kru Khmer, or a practitioner of
traditional medicine.” However, hospital checkups and delivery are becoming mainstream in many
parts of the country, especially urban areas, where Ang Pleung is no longer practiced; the situationis very different from that of rural areas where access to modern medicine is often difficult.

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Mental and physical changes during adolescence199

According to a recent study12, the percentage of women seeking support from health facilities

5) Youth sexual health and its challenges in today’s Cambodia

during delivery increased from 8% in 2000 to 82% in 2014, showing that more women are deliveringbabies at facilities, both in urban and rural areas. While the increases are more rapid in rural areas,

This section outlines the circumstances that surround youth sexual health in Cambodia and its

the number of facility deliveries is greater among those in urban areas, as it is in more highly educatedchallenges.13, 14

and economically advanced populations, which shows that regional and socioeconomic disparities
remain unresolved. As a health facility delivery has beneficial influence on the child’s future health(1) Child marriage

outcome, improvements in maternal and child health services targeting women and children areChild marriage in Cambodia has been in decline over the years. In 1989, 28% of women aged 20–24

hoped for.

were married before the age of 18, compared to 19% in 2014 (Figure 11.3). The marriage of girls under
the age of 15 declined from 7% in 1989 to 2% in 2014. However, the overall number of child marriages

4) Contraception

was comparable to that of 2009. The median age at first marriage among women in Cambodia hasremained largely unchanged at 20–21 years over the past two decades.
Child marriage is known to be widespread among certain ethnic groups and in certain parts of thePregnancy can threaten or damage a woman’s health. Can you say that your knowledge of contraception

country. The percentage of young women aged 20–24 years who were married before the age of 18

is accurate? Have you been able to talk about contraception with your partner? An unexpected andvaries pretty widely by region, ranging from 36% in Mondulkiri and Rattanakiri to 5% in Phnom Penh.

unwanted pregnancy may lead to abortion, and birth resulting from an unexpected pregnancy is a highrisk factor for child abuse. Contraception is a means for you to determine the interval between pregnancies

Married/in union after age 15
but before age 18

on your own, and it protects the human rights of women and children born as a result of an unexpected
pregnancy. Unwanted pregnancies are avoidable, and we should ensure that pregnancy does not change

Married/in union
before age 15

the course of a woman’s life against her will.6(1) Methods of contraception

28%

30%

30%
25%

Although there are periods of time when a woman is more likely to become pregnant and those when
she is not, there is no true “safe day.” And considering how pregnancy works, the window of fertility is

19%quite wide. Whenever one has sexual intercourse, they should be aware that there is always a possibility

19%

of pregnancy. Men, in particular, should recognize that theirs is the sex that can cause a woman to
become pregnant, and make sure they use a secure form of contraception where necessary.
One of the male-based contraceptive methods, for instance, is condoms. They are inexpensive andreadily available, free of adverse reactions, highly effective when used properly, and effective inpreventing sexually transmitted infections as well. However, cases of contraceptive failures are common
due to improper use. Oral contraceptive pills are a female-based method. They contain female sex
hormones, which inhibit ovulation when taken orally. While proper use of these pills is highly effective

7%
1989

5%

5%

4%

3%

2%

1994

1999

2004

2009

2014

Source: UNICEF Cambodia and Division of Data, Research and Policy, UNICEF New York, A Statistical
Profile of Child Protection in Cambodia, p.11, United Nations Children’s Fund, New York, March 2018.

Figure 11.3 Child marriage today13

for contraception, they can be expensive, and some women cannot use them depending on theirconstitution or pre-existing conditions. Unlike condoms, they have no effect against sexually transmitted
infections.

(2) Youth pregnancy and childbearing

There are multiple methods of contraception, yet none is 100% reliable. Even so, using a combination

In Cambodia, roughly one in eight girls aged 15–19 experiences childbearing. The percentage of girlsof contraceptive methods can boost contraceptive effectiveness. One needs to understand the advantages

aged 10–19 varies across regions, with the provinces of Battambang and Pailin being the lowest (4%)

and disadvantages of each method, and have thorough discussions with one’s partner to choose methods

and Mondulkiri and Rattanakiri, the highest (34%). The percentage of girls aged 10–19 who experiencethat are best suited to them.

childbearing decreases with urbanization, household wealth, and education (Figure 11.4).

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Chapter 11

Mental and physical changes during adolescence201

Table 11.3 Use of condoms by socioeconomic status (%)

12%

Total

2010

2014

Poorest

8.3

10.1

4

Poorer

11.2

8.4

8.7

Middle

16.4

14.5

16.9

Richer

29.1

43.1

17.6

Richest

63.3

52.4

44.9

8%

Age 17 years

4%

Age 16 years

1%
13%

Rural

6%

Urban

20%

No education or primary education

14

Source: Based on Reference

8%

Secondary or higher education

Household wealth

2005

18%

Age 18 years

Age 15 years

Socioeconomic status31%

Age 19 years

18%

Lowest quintile

Table 11.4 Comprehensive knowledge about HIV and AIDS by place of residence (%)

7%

Highest quintile

Source: UNICEF Cambodia and Division of Data, Research and Policy, UNICEF New York, A Statistical
Profile of Child Protection in Cambodia, p.6, United Nations Children’s Fund, New York, March 2018.

Figure 11.4 Youth pregnancy and childbearing today13

Place of residence

2005

2010

2014

FemaleMale

FemaleMale

Female

Male

Urban

62.5

58.6

54.9

67.1

55.3

64.7

Rural

48.1

43.2

42.1

38.1

34.2

43.6

(3) Use of contraception during sexual intercourse

Source: Based on Reference14

The percentage of people who use condoms during sexual intercourse in Cambodia, as shown below,
varies depending on the place of residence, socioeconomic status, and level of education.14
The percentage of males aged 15–24 who use condoms varies by the place of residence, and it has
been consistently higher among those who live in urban areas than in rural areas (Table 11.2).
The use of condoms varies by socioeconomic status, as well. The percentage is higher in wealthier
populations than in poorer ones (Table 11.3). While the percentage declined from 2005 to 2014, it
remained largely unchanged in the middle class.
Whether or not one has a comprehensive knowledge of HIV and AIDS varies by place of residence,and the percentage of those who have a comprehensive knowledge has been consistently higher among
those who live in urban areas than in rural areas (Table 11.4). The percentage is also higher among thosewith higher levels of education (Table 11.5).

Table 11.5 Comprehensive knowledge about HIV and AIDS by the level of education (%)

Level of education

2005

2010

2014

FemaleMale

FemaleMale

FemaleMale

No education

19.7

21.9

16.2

9.7

17.9

20.1

Primary

42.1

30.3

33.4

28.5

25.7

31.0

Secondary

72.0

60.7

54.2

51.0

42.5

53.7

Higher

89.9

87.9

71.5

84.3

74.6

76.2
14

Source: Based on Reference

Table 11.2 Percentage of use of condoms (males aged 15–24) by place of residence (%)

Place of residence

2005

2010

2014

Urban

57.7

50.8

57.2

Rural

23.3

9.5

10.3
14

Source: UNFPA, Sexual and Reproductive Health in Cambodia, 2016

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work together on equal terms. For this reason, it is important for a couple to be able to have serious

Column: Sexual behaviors among university students in today’s Cambodia

conversations about contraception and build a relationship of mutual cooperation before they have a

A 2015 study conducted on sexual behaviors among 1,359 university students in Cambodia (mean9, 15age: 21.3 years; 690 males and 669 females)sexual relationship.

reported the following results. The subjects included

a small number of those married and/or cohabitating (2.1%).
● 144 subjects (10.6%) had sexual intercourse; the figures showed sex differences, with 119 malestudents (17.3%) compared to 25 female students (3.7%).
The results of detailed analyses of those who had experience of sexual intercourse are as follows:

3. Sexually transmitted infections
1) AIDS● Age at first sexual intercourse was 20.7 years for males and 20.2 years for females; no gender

Acquired immunodeficiency syndrome (AIDS) is a condition caused by the human immunodeficiency

difference.
● Condom use during the most recent sex among those who had experience of sexual intercourse

virus (HIV). If not treated properly, severe systemic immunodeficiency can lead to opportunistic
infections or malignancies. With dramatic advancements in the development of medications in recent

was 57.6%; the rate was lower among females at 32.0%, compared to 63.0% in males.
● 9.2% had had sex in exchange for money/gifts, and all were males (11.2% of males).

years, it is now possible for a patient to lead a normal life without weakening their immune system if● 7.1% had had a sexually transmitted infection in the previous 12 months.

they start taking medicine at an early stage. It is therefore critical that a patient takes tests and detects the● The percentage of the subjects who had ever made someone pregnant/been pregnant was

infection early, receives proper treatment, and continues proper medication as instructed for life.
Meanwhile, as of the end of 2019, 38 million people worldwide were living with HIV, 1.7 million

12.7%, with 12.0% for males and 16.0% for females.
These results, which indicate that many of the male students had experience of sexual intercourse

had become newly infected, and 690 thousand people had died a year.17 This shows that HIV remains

and that around 40% had sex without using a condom, point to the importance of sex education

one of the most severe infectious diseases that humankind is faced with today. In Cambodia, however,among male students.

HIV infections among those aged 15–49 have declined, from 2% in 1998 to 0.7% in 2013 and 0.6% in
16

According to Sexual and Reproductive Health of Adolescents and Youth in Cambodia (2016),

Cambodia has a large youth population with the percentage of those aged between 15 and 24 years
among the highest in Southeast Asia. And this young population has issues such as sexuallytransmitted infections, unwanted pregnancies, and unsafe abortions, whose likely causes include

2014. The estimated number of people living with HIV is 74,298, and an estimated ten thousand people
do not know they are infected with HIV.

(1) Causes and routes of transmission

the lack of information on sex, poor educational attainment and high school dropout rates, and rural-The pathogen is the human immunodeficiency virus (HIV-1 and HIV-2). The primary route of

to-urban migration for employment. The study subjects referred to in this column are students of two

transmission is sexual contact, in which the virus contained in seminal or vaginal fluids of a patient isuniversities who had received a certain level of education. Taking these results into consideration,transmitted via mucous membranes (of the urethra, vagina, or anus). Other routes include mother-to-

one may surmise that high-risk sexual behaviors may be even more prevalent among young people

child transmission (transmission during pregnancy, birth, or breastfeeding) and bloodborne

who have received lesser degrees of education or those in rural areas.

transmission, which includes needlestick injuries and needle sharing.

(2) Symptoms and course of the disease6) Reproductive health and rights6

The natural course of HIV infection has three stages: primary HIV infection (acute stage),
asymptomatic HIV infection, and AIDS (Figure 11.5). Throughout the infection, patients sustain

The concept of reproductive health and rights was proposed at the International Conference on

progressive destruction of the immune system, which leads to immunodeficiency in most of those

Population and Development held in Cairo in 1994 and has been widely supported across the world. The

infected.

concept recognizes the basic human right (a right to which a person is inherently entitled as a humanbeing) of people to: have a safe and satisfying sex life; freely decide whether or not to bear a child, whento have one, and how many to have; and have information and the means to do so.

i.

Primary HIV infection (acute stage): 2–3 weeks after infection, the level of HIV in the blood
rapidly reaches its peak. During this period, patients develop influenza- or mononucleosis-like

Although it is a woman who becomes pregnant and gives birth, or undergoes an abortion, it is thesymptoms, such as fever, sore throat, muscle aches, rash, lymphadenopathy, or headache. The

responsibility of a couple, both the man and the woman, to not cause or have an unwanted pregnancy. It

intensity of the symptoms varies widely; some may feel virtually no symptoms, while others

is difficult for a couple to ensure contraception unless they have accurate knowledge, care about their

may suffer from aseptic meningitis. Early-stage symptoms may last for around ten weeks, andsex lives and the lives of one another, and have a relationship in which they respect one another andmay subside on their own.

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Mental and physical changes during adolescence205

abuses, such as people having job offer withdrawn due to HIV infection or facing discriminatory attitudes
or refusal of care by healthcare facilities.
There are only three routes of HIV transmission, namely transmission through sexual contact,

CD4 lymphocyte countbloodborne transmission, and mother-to-child transmission. HIV does not spread through ordinary
everyday contact, such as shaking hands, sharing everyday items, or going into a pool or bath together

HIV RNA level(Table 11.6). It is not transmitted through coughing or sneezing, either. In other words, one does not

Set point

not experience many symptoms even when infected with HIV, there are cases where an infected person

1 Primary HIV infection(acute stage)

HIV RNA levelCD4 lymphocyte count

2 Asymptomatic

HIV infection

contract HIV through everyday activities, but only through sexual contact. However, because one may
passes it on to others through sexual contact, etc., without knowing about their own infection. In this
3 AIDS

Indicator of rate of HIV progression
Indicator of immune status of patient

All Rights Reserved. Copyright © 2021
RESEARCH GROUP FOR THERAPY OF HIV INFECTION. Translated with permission.

Figure 11.5 Course of HIV infection19

regard, HIV infection is not someone else’s problem but is something that can happen to you or someone
close to you. It is, however, preventable by using condoms correctly.
In addition, HIV infection does not equal AIDS, and there may be a long latency period before one
develops AIDS if at all. Today many medicines have been developed, and more are coming; early
detection of HIV infection and early start of treatment makes it possible to suppress the development of
AIDS. This means that even if one is infected with HIV, one can go on with their social life by receiving
proper treatment.
In the United States, the Red Ribbon campaign started in the 1990s when AIDS was becoming asocial issue to commemorate people who lost their lives from AIDS and show understanding and support
for those who are suffering from it. The campaign has since spread across borders and grown into a

ii. Asymptomatic HIV infection: As a result of the immune responses following infection (suchas Cytotoxic T Lymphocytes (CTLs) induction and antibody production), the viral load, after

global movement. The red ribbon conveys that you do not have discriminate against people living with
AIDS. See Chapter 7 to learn more about prejudice/discrimination against infectious diseases.

reaching its peak, decreases to a certain level after 6–8 months and reaches a steady state.
Patients may then be asymptomatic for several years or up to ten or more years; after this period,
they are likely to develop symptoms such as fever, tiredness, and lymphadenopathy, as well as
shingles. During this period, few symptoms characteristic of HIV infection occur.
iii. AIDS: If a patient does not receive anti-HIV treatment following infection, the HIV infection
further progresses, and CD4-positive T cells are rapidly depleted. If a patient’s CD4 lymphocyte
count falls below 200/mm3, they become susceptible to opportunistic infections such as
Pneumocystis carinii pneumonia; if the CD4 lymphocyte count drops further and falls below 50/
mm3, a patient may develop opportunistic infections that are rarely seen in people with a normal
immune status, such as cytomegalovirus infections, atypical mycobacterial infections, andmalignant lymphoma of the central nervous system, as well as malignancies. Symptoms such as
loss of appetite, diarrhea, malnutrition, and debilitation also become marked.
(Source: Yoshimura K. What is AIDS (Acquired Immunodeficiency Syndrome)? -ClinicalSymptoms. National Institute of Infectious Diseases website.18)(3) Issues surrounding sexually transmitted infections (prejudice/discrimination against
people with HIV/AIDS)
Since the world’s first reporting of cases in 1981, HIV/AIDS has spread throughout the world. In its

Table 11.6 Common misconceptions and assumptions about HIV infection and AIDS andcorrect knowledge20

Common misconceptions/assumptions• It spreads by shaking hands or talking• You catch it by going into a bath or pool with aninfected person• It spreads through coughing or sneezing• You catch it by sharing everyday items, such as atoilet seat, dish, or towel• You catch it through the bite of a mosquito or tickthat has consumed infected blood

Correct knowledge• There are only three routes of HIV transmission,
namely transmission through sexual contact,
bloodborne transmission, and mother-to-childtransmission; it does not spread through ordinary
everyday contact• The development of HIV medicines has made it
possible to suppress the development of AIDS
among people infected with HIV through early
detection of infection and early start of treatment• Recently, cases of HIV transmission through sexual
contact are on the rise; even steady partners cannot
be ruled out for risk of transmission. HIV is an
issue that can affect anyone

Source: Japanese Government Public Relations Online, Eliminating Prejudice and Discrimination against HIV and Leprosy.
https://www.gov-online.go.jp/useful/article/201108/3.html

early years, there was no treatment for AIDS, and media reports would emphasize the dangers of thedisease alone. This created misconceptions and prejudices among people, which led to human rights
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Mental and physical changes during adolescence207

4. Social challenges and solutions surrounding sexual
health2) Other sexually transmitted infections1
Table 11.7 provides a list of sexually transmitted infections that are common around the world. One

should take particular note of the fact that women are more susceptible to sexually transmitted infections.

1) Handling information concerning sex

This is due to biological factors such as that women have more exposed mucosal surfaces and that theyoften show no symptoms of those diseases; as well as social factors such as that women are forced into

Today’s highly advanced information society provides an environment where we have constant accessa disadvantageous position, which makes them less likely to receive treatment for sexually transmitted

to an internet connection, and children are exposed to staggering amounts of information in theirinfections than men.

everyday lives. They also have easy access to information concerning sex. This is leading to instances

If a woman has a sexually transmitted infection other than HIV and does not receive treatment in atimely and appropriate manner, it can have a number of long-lasting effects on her health, such as pelvic
inflammatory disease, chronic pain, ovarian abscesses, ectopic pregnancies, and infertility.

where children who do not possess information literacy are sexually victimized through the Internet
and social media. It can also become their first contact with drugs.
Social media can have an impact on the values about, attitudes to, and norms for sex. We should aim
to ensure that children can acquire basic knowledge about sex and help them develop capabilities ofgathering information they need on their own and making the right decision or choosing the right action(i.e., sexual health literacy).

Table 11.7 Types and overview of sexually transmitted infections 21

Pathogen

Syphilis

Treponema pallidum

Route of transmission

Direct contact with skin or
mucosal lesion via sexual
contact

Latency period

Approx. 3 weeks

Symptoms• Red and hard lumps or sores appear on the original site of infection (e.g., genitals, mouth), accompaniedby swollen lymph nodes in the vicinity (primary stage). Around 3–12 weeks later, systemic symptoms
such as fever and general malaise appear along with various types of rash on the skin (secondary stage). It
affects the heart, blood vessels, or brain over the next 10–30 years (latent and tertiary stages). If left
untreated, the disease gradually progresses from primary to secondary, latent, and tertiary stages. It cancause neuropsychiatric symptoms and can even be fatal.
• A newborn may have congenital syphilis when the mother with syphilis has passed the infection on to thebaby.
• Pain when urinating and pyuria for men, and vaginal discharge and vaginal bleeding between periods;
however, symptoms may often be too mild for patients to notice.

Gonorrhea

Neisseria gonorrhoeae

Direct contact with mucosal
2–7 dayslesion via sexual contact• May cause infections in the rectum and throat, but patients often have no symptoms and may therefore failto notice the infection.
• May result in infertility if left untreated.
• A baby born to a mother infected with gonorrhea may develop gonococcal conjunctivitis.

Chlamydia

Candida infections

Condyloma acuminatum

Chlamydia trachomatis

Direct contact with mucosal
1–3 weekslesion via sexual contact

Candida yeasts

Candida yeasts aretransmissible via sexual
contact, but may notnecessarily lead to disease

VariesDirect contact with skin or
mucosal lesion via sexual
contact

3 weeks
Up to 8 months

Human papillomavirus(often types 6 and 11)• Pain when urinating and itchy urethra for men; women may often have mild or no symptoms.
• May lead to infertility and miscarriage/stillbirth if left untreated.
• It is not common for symptoms to manifest among men with Candida infection; women may experience
itching of the vulva and increased vaginal discharge.
• People can have Candida in their body without it causing any problem.
• It left untreated, the symptoms persist, recur, or relapse; it can not be cured without treatment.
• Warts that look like a chicken’s comb appear around the genitals and anus.
• If left untreated, it resolves spontaneously within 3 months in 20–30% of the cases; some may see amalignant transformation, however.
Source: Japanese Foundation for Sexual Health Medicine. A List of Common Sexually Transmitted Infections. https://www.jfshm.org/
Copyright © 2013 Japanese Foundation for Sexual Health Medicine. All Rights Reserved. Translated with permission.

208

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Mental and physical changes during adolescence2092) Sexual violence

24

Column: Harmful practices performed around the world

According to WHO, sexual violence is defined as “(a)ny sexual act, attempt to obtain a sexual act,

Harmful practices against young girls inflict severe and lifelong trauma on them and deprive them of

unwanted sexual comments or advances, or acts to traffic, or otherwise directed against a person’s

the rights to fulfill their potential. For instance, gender inequalities and negative attitudes towards

sexuality, using coercion, intimidation, or violence, by any person, regardless of their relationship to thewomen and girls are causes of such harmful practices. According to a survey conducted in countries

22

victim, in any setting, including, but not limited to, home and work.”

Globally, sexual violence takes various forms, and they may include, but are not limited to, rape,
sexual harassment, sexual abuse/assault, forced marriage or cohabitation, genital mutilation, forcedthat account for 80% of the world population, 90% of people had certain kinds of prejudice against
women, and over 140 million females were considered “missing” as a result of sex selection at birthor child neglect (i.e., extreme son preference, which privileges sons over daughters).

prostitution, and trafficking of people for the purpose of sexual exploitation. Sexual violence may include

Today, around 200 million girls and women have experienced some form of female genital

intimate partner violence. WHO defines intimate partner violence as “(b)ehaviour by an intimate partner

mutilation (FGM). These harmful practices are being imposed on girls by their family members, andthat causes physical, sexual, or psychological harm, including acts of physical aggression, sexual

supported by discrimination and community norms. The country where FGM is most prevalent incoercion, psychological abuse and controlling behaviours.”

Asia is Indonesia, where 49% of girls aged 11 and under have experienced it. Half of the women andgirls who have experienced FGM believe the practice should be abandoned.

3) Sexual norms in Cambodia23

4) Comprehensive sexuality education

Cambodia has cultural codes of sexual conduct known as the Chbab Pros and the Chbab Srey, theformer applies for men, the latter, women. They have a significant impact on people’s perceptions,Sex education incorporating international policies is actively practiced across the world. This section

behaviors, and health. The male code of conduct says that men are strong and ambitious, serve as theprovides an outline of the International Technical Guidance on Sexuality Education, which is anhead of the household, and should be treated with respect and deference. If a man deviates from the maleinternational standard for such practice.25, 26, 27

code of conduct, it is not common for him to be subjected to sharp criticism or discrimination fromTo meet the need for education on sexual health and rights, UNESCO published the Internationalsociety, and their sexual conduct is likewise tolerated. The female code of conduct, on the other hand, isTechnical Guidance on Sexuality Education in 2009, in partnership with UNAIDS, UNFPA, WHO, andextremely strict; it forbids premarital or extramarital sexual intercourse, and directs women to care for

UNICEF. In light of the accumulation of practice implemented around the world over nine years, as well

the family, perform all household duties, not defy parents, and obey their husband once married. In

as the emergence of new concerns such as the influence of the Internet and social media, the content ofaddition, any deviation from the code committed by a woman will subject her to harsh judgment fromthe guidance was reviewed, and a revised edition was published in 2018.27 In addition to providing thesociety; in rural areas, in particular, their “value as a woman” will be questioned. It has been pointed out

latest scientific evidence, the revised edition presents an updated set of eight key concepts, topics, andthat these cultural codes of sexual conduct help conceal violence against women committed by theirlearning objectives, organized into different age groups (four groups: 5–8 years; 9–12 years; 12–15

spouses or other men. Women who have suffered premarital rape or human trafficking, in particular, andyears and 15–18+ years) (Figure 11.6). The guidance also contains the means of institutionalization for

who should be protected as victims, are often expelled from society on the grounds of the female code

implementing comprehensive sexuality education and specific recommendations on how to deliver23

of sexual conduct and become desperate as a result.

effective programs.

Such instances of gender inequalities are not limited to Cambodia but are a global issue that affects

Comprehensive sexuality education (CSE) is a curriculum-based process of teaching and learning

women’s opportunities in educational, political, social, and economic activities as well as their health.

about the cognitive, emotional, physical, and social aspects of sexuality. It aims to equip children andIn the field of international cooperation, the approach known as “gender and development” has become

young people with knowledge, skills, attitudes, and values that will empower them to: realize theirmainstream since the 1980s. A key to sustainable development in Cambodia is the type of support that

health, well-being and dignity; develop respectful social and sexual relationships; consider how theirempowers women in order to eliminate factors that threaten women’s living environment (such as

choices affect their own well-being and that of others, and; understand and ensure the protection of theirpoverty, violence, and human trafficking) and discriminatory traditions and customs that have a harmful

rights throughout their lives.

impact on women, by understanding specific needs for men and women, and securing understanding andinvolvement from men.

The fundamental components of comprehensive sexuality education are summarized in the ten
elements shown in Table 11.8. As shown here, comprehensive sexuality education regards sex education
as a sexual right. It is based on respect for human rights that is built on perspectives of gender equalityand diversity of gender. Comprehensive sexuality education has been practiced in many countries andterritories, including Thailand, China, Taiwan, South Korea, Australia, New Zealand, Canada, the United

210

Chapter 11

Mental and physical changes during adolescence211

Table 11.8 Basic learning contents of comprehensive sexuality education27

States, and the Republic of South Africa, among others.

Elements

Specific learning content

1. Scientifically accurate

The content of comprehensive sexuality education is based on facts andscientific evidence related to sexual and reproductive health, sexuality,and behaviors

2. Incremental

Comprehensive sexuality education is a continuing educational processthat starts at an early age and where new information builds uponprevious learning, using a spiral-curriculum approach

Key concept 1 :Relationships

Key concept 2 :Values, Rights,
Culture and Sexuality

Key concept 3 :Understanding Gender

Topics:

Topics:

Topics:1.1 Families

2.1 Values and Sexuality

1.2 Friendship, Love andRomantic Relationships

2.2 Human Rights and Sexuality

3.1 The Social Construction of
Gender and Gender Norms

3. Age- and developmentallyappropriate

The content of comprehensive sexuality education is responsive tochanges that accompany the child’s development

3.2 Gender Equality,
Stereotypes and Bias

4. Curriculum based

Comprehensive sexuality education serves as a guide for teachers intheir efforts to support child’s learning

3.3 Gender-based Violence

5. Comprehensive

Comprehensive sexuality education is supported by comprehensive,
deep, and iterative learning

6. Based on a human rights
approach

Comprehensive sexuality education aims to encourage people torecognize their own rights and those of others, and advocate for those
whose rights are violated

7. Based on gender equality

Comprehensive sexuality education addresses how gender norms cancreate inequality and how they can harm people’s overall health andwell-being and have an impact on sexually transmitted infections,
unintended pregnancies, and gender-based violence

8. Culturally relevant andcontext appropriate

Comprehensive sexuality education encourages learners to challenge
and practice how cultural structures and norms affect individuals’
formation of relationships of their choice, and acquire skills to build
responsible relationships

9. Transformative

Comprehensive sexuality education contributes to the formation of amore fair and compassionate society and transformation

10. Able to develop life skills
needed to support healthy
choicesComprehensive sexuality education aims to cultivate the ability to makeinformed decisions, communicate effectively, and demonstrateassertiveness1.3 Tolerance, Inclusion and
Respect

2.3 Culture, Society andSexuality

1.4 Long-term Commitments
and Parenting

Key concept 4 :Violence and Staying Safe

Key concept 5 :Skills for Health andWell-being

Key concept 6 :The Human Body andDevelopment

Topics:

Topics:

Topics:4.1 Violence

5.1 Norms and Peer Influence
on Sexual Behaviour

6.1 Sexual and Reproductive
Anatomy and Physiology

5.2 Decision-making

6.2 Reproduction

5.3 Communication, Refusal
and Negotiation Skills

6.3 Puberty

4.2 Consent, Privacy and Bodily
Integrity
4.3 Safe Use of Information andCommunication
Technologies (ICTs)

5.4 Media Literacy andSexuality

6.4 Body Image

5.5 Finding Help and Support

Source: UNESCO. Revised edition International technical guidance on sexuality education: An evidence-informed approach. 16-17. 2018https://www.unaids.org/sites/default/files/media_asset/ITGSE_en.pdf

Key concept 7 :Sexuality and Sexual Behaviour

Key concept 8 :Sexual and Reproductive Health

Topics:

Topics:7.1 Sex, Sexuality and the Sexual Life Cycle

8.1 Pregnancy and Pregnancy Prevention

7.2 Sexual Behaviour and Sexual Response

8.2 HIV and AIDS Stigma, Care, Treatment andSupport5) Menstrual hygiene management

8.3 Understanding, Recognizing and Reducing the
Risk of STIs, including HIV
Source: UNESCO. Revised edition International technical guidance on sexuality education: An evidence-infomed approach. 36. 2018https://www.unaids.org/sites/default/files/media_asset/ITGSE_en.pdf
27

Figure 11.6 An overview of key concepts, topics, and learning objectives

212

In the field of international development, menstruation has recently come to be discussed in association
with issues such as school attendance and hygiene and is now considered a matter that requires
improvement.28 In Cambodia, issues concerning menstruation that have been identified include thesexual code of conduct mentioned earlier, the cultural norms that regard secrecy and silence about
menstruation as virtuous, and a sense of shame and traditional taboos surrounding menstruation.29
Menstrual hygiene management (MHM) refers to access to the following: accurate knowledge
about health; clean menstrual hygiene materials to absorb or collect menstrual blood; space that provides
privacy for changing materials as often as necessary during a period of menstruation; soap and water for
Chapter 11

Mental and physical changes during adolescence213

washing the body when necessary; and disposal facilities for menstrual materials.29
The International Technical Guidance on Sexuality Education discussed earlier identifies the topic ofand practice, and recognizes the diversity of different national contexts in which sexuality education istaking place.”

menstruation as one of the learning objectives for the age group 9–12 years under Key Concept 6.3

The guidance also notes that “a positive school environment has been shown to facilitate the fullPuberty. The key idea is “Menstruation is a normal and natural part of a girls’ physical development andimplementation of programs, thus supporting their effectiveness.” It identifies “making the school a safe

should not be treated with secrecy or stigma,” and what learners will be able to do are as follows:

environment for the provision of [comprehensive sexuality education], for example by having zero-(a) describe the menstrual cycle and identify the various physical symptoms and feelings that girls
may experience during this time (knowledge);

tolerance policies for sexual harassment and bullying, including stigma and discrimination on the
grounds of sexual orientation and gender identity” as one of the duties of the school.

(b) describe how to access, use and dispose of sanitary pads and other menstrual aids (knowledge);(c) recall how gender inequality can contribute to girls’ feelings of shame and fear during
menstruation (knowledge);2) Gender identity30(d) recognize that it is important for all girls to have access to sanitary pads and other menstrual
aids, clean water, and private toilet facilities during their menstruation (attitudinal); andGender identity refers to the concept of personal sense of one’s own gender. It may be called(e) demonstrate positive and supportive strategies for girls to feel comfortable during their“psychological gender” or “brain gender.” While many people identify with “being a male” or “being amenstruation (skill).”female,” there are a variety of forms of gender identity, such as “not identifying with either male orfemale,” “not sure,” or “don’t want to pick.”

5. Sexual diversity
1) Gender
Gender is a social/cultural distinction, as opposed to sex which is a biological distinction, and it

Many people have a gender identity that matches their biological sex, namely, they are cisgender.
Some people are transgender, meaning they have a gender identity that does not align with their
biological sex.

3) Sexual orientation22,30

refers to differences that are born out of different roles men and women play in society (i.e., genderrole). It is used as a term that expresses social or cultural conceptions of “masculinity” and “femininity,”

Sexual orientation refers to the pattern of sexual attraction to other people. Many people are heterosexual,

such as “men work outside the home” and “women do housework and care for children.”or they are sexually attracted to people of the sex opposite to their own. There are, however, different

In the International Technical Guidance on Sexuality Education mentioned earlier, discussion of

categories of sexual orientation, including homosexuality (sexual attraction to people of the same sex as

issues that concern sexual orientation and gender identity is recommended under Key Concept 3:

their own), bisexuality (sexual attraction toward both males and females), and asexuality (the lack ofUnderstanding Gender.

sexual attraction to others).

Specifically, the guidance suggests goals such as the following:
For learners aged 5–8 years,(a) define gender and biological sex and describe how they are different (knowledge), and(b) reflect on how they feel about their biological sex and gender (skill).

To what degrees are lessons and guidance on sex offered at schools in Cambodia? Some teachers

For learners aged 9–12 years,

may find it difficult to teach the subject as they are hesitant to offer such guidance to children of(c) define gender identity (knowledge),

different sex to their own. Some teachers may not have any experience in giving guidance on sexual(d) explain how someone’s gender identity may not match their biological sex (knowledge),

diversity. If you find yourself in a situation that involves teasing of, or discriminatory comments(e) acknowledge that everyone has a gender identity (attitudinal), andagainst, a child of a sexual minority, how should you handle it as a teacher?

(f) appreciate their own gender identity and demonstrate respect for the gender identity of others(skill).
The aim is for children to acquire basic knowledge, attitudes, and skills by the time they are in thelast years of primary school, and it sets more advanced learning objectives for older learners.
At the same time, the learning objectives presented in the guidance are to be interpreted by curriculum
developers at the local level. “The guidance is voluntary and non-mandatory, based on universal evidence
214

Column: Ingenuities for lessons and guidance on sex at school

One thing you can do is to change the way of giving guidance according to the learning content.
For instance, with the topic of menstruation, it may be a good idea to have boys and girls takelessons separately or to have children take lessons from a teacher of the same sex as that ofthemselves. If the school has only male teachers, one way of going about it is to ask community
health workers or people from relevant NGOs to give lessons.
What about guidance on sexuality for boys? It has been reported that boys may feel flustered by
Chapter 11

Mental and physical changes during adolescence215

the physical and mental changes they experience when they reach spermarche, or feel repulsed orembarrassed during an ejaculation. Acquiring accurate information and correct knowledge helps
them build a good relationship with their partner and conduct appropriate sexual behaviors. Giving
guidance on sexuality for boys is important to ensure that they accept their mental and physicalchanges positively.

8

Chhea C, Ir P, Sopheab H. Low Birth Weight of Institutional Births in Cambodia: Analysis of the 2010 and 2014 Demographic and
Health Surveys. DHS WORKING PAPERS No.131. 2017. https://dhsprogram.com/publications/pdf/WP131/WP131.pdf

9Olsen SJ, Vetsaphong P, Vonglokham P, Mirza S, Khanthamaly V, et al. A retrospective review of birth outcomes at the Mother andChild Health Hospital in Lao People’s Democratic Republic, 2004–2013. BMC Pregnancy and Childbirth. 16: 379, 2016. https://
bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-1168-5

10 Villar J, Ismail LC, Victora CG, Ohuma EO, Bertino E, et al. International standards for newborn weight, length, and head circumference by gestational age and sex: the Newborn Cross-Sectional Study of the INTERGROWTH-21st Project. Lancet. 384: 857–68.
2014. https://media.tghn.org/articles/newbornsize.pdf
11 Ueda H, Okada T: Getting to Know about Cambodia in 62 Chapters. Akashi Shoten, Tokyo. 2012.

Exercises for further thought and research[11-1] How do one’s feelings towards and perception of sex change during adolescence? Take a specificexample and look into it.
[11-2] What kinds of environmental improvement or institutions are necessary to support pregnancies
and parenting? What kinds of facilities and services are available in the area where you live?
[11-3] How can one cope with the changes that happen to their feelings towards sex? Use your own
experience as a child as a sample case and discuss.
[11-4] What should one do to communicate their intentions to their partner? Think of a scenario and doa role-play.
[11-5] Pick a case of challenges associated with sex in Cambodia and discuss possible measures for
improvement.
[11-6] What are the challenges one faces when giving children guidance on sex? Give examples anddiscuss.

12 Pierce H. Increasing health facility deliveries in Cambodia and its influence on child health. International Journal for Equity in
Health. 18:67. 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6515616/pdf/12939_2019_Article_964.pdf
13 UNICEF Cambodia and Division of Data, Research and Policy, UNICEF New York, A Statistical Profile of Child Protection in
Cambodia, United Nations Children’s Fund, New York, March 2018.
14 UNFPA: Sexual and Reproductive Health in Cambodia. 2016. https://cambodia.unfpa.org/sites/default/files/pub-pdf/UNFPA_Final_Report_10_October_2016_5pm%28NRT_reformated%29.pdf
15 Sok S, Pal K, Tuot S, Yi R, Chhoun P, et al. Health Behaviors among Male and Female University Students in Cambodia: A
Cross-Sectional Survey. Journal of Environmental and Public Health. 2020. https://www.hindawi.com/journals/jeph/2020/6740236/
16 Kingdom of Cambodia Nimistiry of Planning, Minostry of health. Sexual and Reproductive Health of Adolescents and Youth inCambodia Analysis of 2000 - 2014 Cambodia Demographic and Health Survey Data. 2016.
17 UNAIDS: FACT SHEET – WORLD AIDS DAY 2020. https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf
18 National Institute of Infectious Diseases: What is AIDS (Acquired Immunodeficiency Syndrome)? https://www.niid.go.jp/niid/ja/
kansennohanashi/400-aids-intro.html
19 Research Group for Therapy of HIV Infection, Japanese Society for AIDS Research: Guide to the Treatment for HIV Infection, Rev.
24th ed. http://www.hivjp.org/guidebook/hiv_24.pdf
20 Cabinet Office, Government of Japan: Japanese Government Public Relations Online: Eliminating Prejudice and Discrimination
against HIV and Leprosy. https://www.gov-online.go.jp/useful/article/201108/3.html
21 Japanese Foundation for Sexual Health Medicine: What Are Sexually Transmitted Infections? (Types of Sexually Transmitted
Infections). A List of Common Sexually Transmitted Infections. https://www.jfshm.org/%E6%80%A7%E6%84%9F%E6%9F%93%
E7%97%87%E3%81%A8%E3%81%AF%EF%BC%88%E6%80%A7%E6%84%9F%E6%9F%93%E7%97%87%E3%81%AE%E7%A8%AE%E9%A1%9E%EF%BC%89/%E4%B8%BB%E3%81%AA%E6%80%A7%E6%84%9F%E6%9F%93%E7%97%87%E4%B8%80%E8%A6%A7/
22 WHO. World Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines.
2013. https://apps.who.int/iris/bitstream/handle/10665/85240/9789241548595_eng.pdf;jsessionid=59C1D2D5AC4F030E10B813708F946B49?sequence=1
23 Shimazaki Y: Feminization of Human Trafficking and Poverty: Structural Violence in Cambodia. Akashi Shoten, Tokyo. 2018.
24 UNFPA: Sekai Jinko Hakusho (Trans.) (State of World Population). 2020.
https://tokyo.unfpa.org/sites/default/files/pub-pdf/shi_jie_ren_kou_bai_shu_2020_quan_ye_web.pdf
25 UNESCO (Ed.): Kokusai Sekusharithi Kyoiku Gaidansu: Kagakuteki Konkyo ni Motozuita Apurochi. Akashi Shoten, Tokyo. 2020

References1

Skolnik R. Gurobaru Herusu: Sekai no Henko to Taishosenryaku no Saishin Doko (Global Health: Latest Trends in World’s Healthand Health Strategies), Kihara M, Kihara M, (Trans. and Eds.) Medical Science International, 2017.

26 Asai H: Comprehensive Sexuality Education: Focusing on Human Rights, Sexual Diversity, and Gender Equality. Otsuki Shoten,
Tokyo. 2020.
27 UNESCO. Revised edition International technical guidance on sexuality education: An evidence-informed approach. 16-17. 2018.
https://www.unaids.org/sites/default/files/media_asset/ITGSE_en.pdf
28 WHO and UNICEF: “Consultation on Draft Long List of Goal, Target and Indicator Options for Future Global Monitoring of Water,

2

Takizawa T (Ed.): Learning Basics of School Health Education, New Edition (Rev. 2nd ed.). Kenpakusha, Tokyo. 2018.

3

Heidi DH: Menarcheal age in Europe. Yearbook of Physical Anthropology, 1. 29:81-112. 1986.

Sanitation and Hygiene.” 2012.

4

Karapanou O, Papadimitriou A. Determinants of menarche. Reproductive Biology and Endocrinology, 8:115. 2010.

https://washdata.org/sites/default/files/documents/reports/2017-06/JMP-2012-post2015-consultation.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2958977/pdf/1477-7827-8-115.pdf
5Human Anatomy and Function [1]: Anatomical Physiology. Igaku Shoin, Tokyo. 2018.

6

Yamazaki Y, Asakura T (Eds.): New: Health Science as a Way of Living (Rev. 2nd ed.). Yushindo, Tokyo. 2021.

7

Ministry of Health, Labour and Welfare: e-Health Net: Heath information portal for the prevention of lifestyle diseases.

29 Akiho S. Menstrual Practices and Norms in Contemporary Rural Cambodia: Focusing on the Khmer Women’s Life Course. Journalof International Development Studies. 28 (2), 19-33. 2019.
30 Kondo Y (Ed.): Education on Life and Sexuality. Tamagawa University Press, Tokyo. 2021.

https://www.e- healthnet.mhlw.go.jp/information/heart/k-03-002.html

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Mental and physical changes during adolescence217

Chapter 12

Mental healthand interactions with the social environment. Given the fact that the brain, unconsciousness, and soulfunction in response to stimulation through interaction with the surrounding environment, the mind
appears to be something that does not work independently within the individual but rather is somethingthat functions only when relationships with surroundings are brought into the individual. It also
incorporates history and culture to shape itself. In other words, it is only in a dynamic interaction between
the individual and the surrounding environment or history/culture that the mind works. This aspect

Learning objectives

therefore assumes that mental illnesses/ disorders and poor health of the mind are greatly related to

You will be able to gain proper understanding and explain:issues of relationships or interactions with surroundings, or those of individual adaptation to the- The concept and development of the mind from biological, mental/psychological, and social

environment or history/culture.

aspects.

As a matter of course, these three aspects of the mind are not independent but linked to each other.

- Mental health, psychological conflicts and defense mechanisms, the mind-body relationship andThat is, the human mind, which is one phenomenon, is viewed from three aspects: the biological, mental/

the stress theory, and stressful events. And by taking these factors into account, you will also be

psychological, and social aspects. The mind has a totality that integrates at least these three aspects. This

able to consider ways to cope with stress and social support.

means that in considering mental health, issues need to be viewed comprehensively from the biological- Cambodia’s challenges in mental health and consider ways to address those challenges.

aspect, which mainly includes the growth/development of the cerebral nervous system and other body

- How to listen to children with a supportive and receptive attitude.

parts, the mental/psychological aspect, which focuses on individuals’ experiences and ways of life, andthe social aspect, which consists primarily of interactions of individuals with the social relations

This chapter provides an overview of mental health issues in Cambodia. It first describes ways tosurrounding them such as their family, school, local community, and nation, and the history/culture ofunderstand the mind and theories of the development of the mind that provide a basis for considering

their country or region.

mental health, then explains the definition of mental health by the World Health Organization (WHO),the stress theory, and contemporary mental health challenges in Cambodia.

1. Concept and development of the mind and mental
health1) Three viewpoints on the mind2) Development of the mind
(1) Mental development in the biological aspect
As in the case of the mind, we examine the development of the mind from three aspects, namely, thebiological, mental/psychological, and social aspects.
First, the development of the mind in the biological aspect is based on the growth/development of
the cerebral nervous system. Thus, it is supported by physical growth and development as well. According

What is the mind? Does the mind really exist in the first place? Is it an illusion created by the brain? We

to Dekaban and Sadowsky,1 the brain already weighs 360 g in a newborn girl and 380 g in a newborn

consider what the mind is by assuming three general aspects:

boy, as shown in Figure12.1. In one year from birth, it grows by approximately 1.6 times to 940 g for a

The first aspect sees the mind from the perspective of biomedical psychiatry and brain science.

girl and 970 g for a boy. The weight of the brain is known to reach 90% of that of an adult at around 6

This perspective views the mind as brain functions. It considers that each of the various actions of the mind

years old. After that, the growth rate of the brain decreases, with the brain size reaching almost its peakis controlled by the region that localizes it in the brain. It therefore assumes that mental illnesses/ disorders

at 19 to 21 years old. Due partly to differences in physical constitutions, brain weight differs between theand poor health of the mind are caused by damage to, or is a dysfunction of, a certain brain region.

sexes; it is 1310 g for women and 1450 g for men, indicating that men have a heavier brain than women.

The second aspect, which is adopted in some fields including psychoanalysis, depth psychology, andBrain weight starts to decrease in the late fifties as people age.

counselling, assumes the existence of “the mind” to be something that cannot be understood objectively

Meanwhile, concerning changes in synaptic density2 in the prefrontal cortex, which is responsible

or with natural science, such as unconsciousness and a soul. This view believes that the accumulation

for high-level human cognitive functions such as control of language and thinking, the density at 4 years

of individual life experiences shapes the mind as a subjective world. It therefore assumes that mental

after birth is known to reach double that of an adult. Synaptic pruning starts to progress slowly after

illnesses/ disorders and poor health of the mind are greatly related to matters of one’s way of life or lifearound 4 years old, and intensely accelerates at around 14 to 16 years during adolescence. While networks

experiences, or those of one’s subjective self-being.

of synapses used frequently remain, those not used are pruned and eliminated.

In the third aspect, the mind is understood as not only a series of functions within the individual’s

A higher synaptic density does not necessarily provide a better function; an overly complicatedbrain/central nervous system and inner self but also a series of functions in connections with people

network cannot process information efficiently as it can be imagined from a labyrinthine information

218

Chapter 12

Mental health

219

(g)

1600
1400

(2) Mental development in the mental/psychological aspect

Male

1200

Although there are a variety of theories about mental development in the mental/psychological aspect,

Femaletwo theories can be presented as representatives: Piaget’s theory of intellectual development and

1000

Erickson’s life span development theory.

800

a. Piaget’s theory of cognitive development (Figure 12.2)

600

According to the theory of cognitive development by Jean Piaget (a Swiss developmental psychologist,

400

1896-1980)3,4, children aged from 0 to 2 are in the sensorimotor stage, in which the knowledge of the

200
0

world around them is limited to what they can sense and touch. As the sense of their own existence
Newborn

1 year

2 years

3 years

10-12
years

19-21
years

50-60
years

81-85
years

This figure is created based on data obtained from “Dekaban, A.S. and Sadowsky, D., Changes in brain weights during
the span of human life: relation of brain weights to body heights and body weights, Ann. Neurology, 4:345-356, 1978”

Figure 12.1 Human brain weight by gender and age

begins to grow, they start to understand that things exist even though they cannot see, and also understandcausal relationships between actions and consequences. Then, children aged from 2 to 7 are in the
preoperational stage, in which they begin to think using images, and fantasies appear in their words
and play. They enjoy using animism to think of natural phenomena such as an angry mountain. Their
thinking is still self-oriented. The period from the ages from 7 to 11 is called the concrete operational

network. Rather, as synaptic pruning progresses, information transmission becomes more efficient asstage, in which children begin to think logically and become less self-centered and able to see things

it can be imagined from networks of major roads. Because this synaptic pruning occurs through thefrom various aspects. For example, they acquire the concept of conservation, that is, the amount ofinteraction between the body and the environment, the environment in which one has spent during

water remains the same even after it is transferred from one container to another with a different shape.

adolescence is important. Adolescence, during which intense synaptic pruning occurs, is a period in

After this stage, from early adolescence, the formal operational stage, in which adult thinking iswhich the brain structure is drastically reconstructed; therefore, it is considered to be a period in which

acquired, begins. In this stage, they acquire abstract thinking and begin to think about things according

mental disease is likely to develop (susceptible period) and deviant behaviors tend to occur. It is

to visions and ideals without concrete experience. For example, they can think scientifically and make aestimated that it takes about 25 years for the frontal cortex to mature to the adult level.

hypothesis for estimation and compare the result with a fact to draw a conclusion.

Column: What are the prefrontal cortex and synapses?

The brain can be broadly divided into the cerebrum, the cerebellum, and the brain stem (a collective
term for the midbrain, the medulla oblongata, and the pons). Among these, the cerebrum is separated
into four regions: the frontal lobe (with functions primarily related to thinking, judgment, and action),the parietal lobe (chiefly perception and sensation), the occipital lobe (vision), and the temporal lobe
(hearing and memory). The prefrontal cortex is more developed in humans than in any other animal,
accounting for approximately 30% of the frontal lobe and approximately 10% of the entire brain. The
prefrontal cortex is responsible for cognitive functions necessary to live humanly, including reflecting/thinking, controlling actions and emotions, communicating, controlling memory, making decisions,solving problems, and acting with long-term goals.
In the nervous system, nerve cells (neurons) are responsible for information transmission.
Nervous cells are not linked to each other but adjoin with gaps. A connection from the end of one

220

Sensorimotor stage(approx. 0–2 years)

Preoperational stage(approx. 2–7 years)

The sense of their own
existence begins to grow.
Begin to understandcausal relationships
between actions andconsequences

Think using images.
Fantasies appear in
their words and play.
Thinking is selforiented

Concrete operational
stage(approx. 7–11 years)
Think logically.
Can see things fromvarious aspects

Formal operational
stage(from earlyadolescence)
Acquire abstract
thinking.
Can think according
to visions and ideals

Figure 12.2 Piaget’s theory of cognitive development

b. Erickson’s life span development theory

nerve cell to the next nerve cell is called a synapse. A neurotransmitter is released in this gap, andErik H. Erikson (an American developmental psychologist and psychoanalyst born in Germany, 1902-

information is transmitted from one nerve cell to another. For example, when the sympathetic nervous

1994)5 divided the period of life from infancy to maturity into eight developmental stages by characterizing

system is activated, noradrenaline is released, making the state of mind and body active, while theeach stage according to specific skills acquired and behavioral tasks achieved, or developmental tasks.

activation of the parasympathetic nervous system leads to secretion of acetylcholine, creating a

They are infancy (basic trust vs mistrust), early childhood (autonomy vs shame/doubt), preschool

relaxed state of the mind and body (see Chapter 2).

(initiative vs guilt), school age (industry vs inferiority), adolescence (identity establishment vs diffusion),
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Mental health221

young adulthood (intimacy vs isolation), middle adulthood (generativity vs stagnation), and senium

19th century. Infants develop their mind by interacting with their caregiver and fostering environment(integrity vs despair).

through the body.

In Erikson’s view, if the developmental tasks of each developmental stage are successfully achieved,

The environment with which they interact is, according to a model presented in Adolescent healththe person will acquire a desirable nature, but if not, the person will emerge with an undesirable

21st century7, considered to be a social ecosystem consisting of schools, families, neighbourhood, andpersonality trait. For example, a main task for children of preschool age (about 3 to 4 years old) is to “domacro society. This social ecosystem affects human health throughout the entire life course from priorthings on their own or depend on others,” and then experience developmental crises, depending on

to birth to senium. Accordingly, the development of the human mind continues to be affected by thewhether they develop autonomy, or feel shame and doubt (e.g., a crisis over autonomous evacuation). If

social ecosystem.

they can successfully achieve the task, they will acquire the spirit of independence and the sense ofcontrol, which will develop their will, but if they fail, they will lose confidence in their ability and feelashamed of themselves. A task for children of early school age (about 4 to 5 years old) is whether they3) What is mental health?

can do things on their own initiative, and they experience a crisis in which they face initiative or feelingsof guilt about their negative attitude. If they successfully achieve it, they will develop a sense of purpose

According to the WHO, mental health is more than a condition free from mental disorder; it is theand the will to try new things, but if they fail, they will develop feelings of guilt or become passive.

ability to think and learn and understand others’ emotions and respond to them, as shown in the WHO’s

Children of late school age (about 5 to 12 years old) experience a crisis in which their ability to do things

definition of health (see Chapter 1).8 In addition, mental health is a condition in which an individual’s

well is tested. After entering school, they begin to shift the focus of their social relations from the family

physical, psychological, social, cultural, and spiritual health and other related factors are balanced, andto friends and teachers. If they play with friends, learn in class, do homework, and participate in schoolin which the individual is harmonized with the environment.8 Therefore, mental health is health with aevents well, they will come to feel confidence and pride in their ability, which will develop the industry

totality that cannot be considered separately from things like physical, psychological, and social health.

necessary to work hard in school. Meanwhile, if they feel they do not do those things well enoughMoreover, it is health that is also inseparable from the environment.

compared with their friends, they will come to feel a sense of inferiority or a lack of confidence, which

The WHO also states that it is a condition in which an individual can smoothly exhibit his or her

will increase the sense of maladjustment to school life. Through these experiences, a concept of self inability, cope with various stresses in daily life, and engage in work and studies to contribute to society.

school-age children is developed. Without question, support from parents, teachers, and friends, if

The WHO emphasizes the importance of mental health by describing that mental health is the foundation

provided to address the developmental tasks of this stage, will allow children to achieve the tasks moreof abilities of groups and individuals that enables people to think humanly, communicate with eacheasily and their minds to develop even more healthily. It will also help address developmental tasks

other, earn a living, and enjoy life.9

related to the establishment of identity in adolescence.

Given all of these things, mental health is considered to be a condition in which a person has the

In adolescence (about 12 to 19 years old), children face the question of who they are and experienceability to live with independence (or sense of agency) as a human in this world and can display thatthe major challenge of establishing identity. Once they obtain their roles in society through various

ability. Thus, mental health in the developmental stage is viewed as a condition in which children canexperiences in studies, work, and social relations, they will be able to deepen self-understanding andeffectively exercise their abilities to, for example, think, learn, communicate, control behaviors andbecome clearly conscious of themselves. Those who fail to find their roles or places to which theyemotions, make decisions, and cope with stress in daily life according to their age (see the function of

belong in society may become adults with vague self-consciousness. The development during and after

the prefrontal cortex), and at the same time, it is a condition in which those abilities can be enhanced toyoung adulthood is not discussed in detail here.

the highest levels that individuals can achieve because children are in the midst of growth and(3) Development of the mind in the social aspect
Lastly, we discuss theories about development of the mind through social relations. The individual’s
self-recognition of “who I am” does not exist without the existence of others. That is because one needs

development.

4) Adolescents in the world and mental healthanother person who is different from oneself in order to confirm one another existence. For example, fordevelopment of the mind in infancy, relationships between the infant and the caregiver and fostering

The WHO estimates that 10% to 20% of the adolescents in the world have mental health issues that areenvironment are important. Rene Spitz (an American pediatric psychiatrist and psychoanalyst born inundiagnosed or untreated.10 Furthermore, young people with mental health issues are victims of a human

Vienna, 1887-1974)6 discovered hospitalism, a phenomenon in which infants who are fostered in anrights violations as a result of social exclusion, discrimination, and stigma (a negative, discriminatory

institution away from their parents for some reason experience a delay in physical, intellectual, emotional,

attitude that sees a person’s specific characteristics as something shameful, abominable, and stained),or language development because of a lack of adequate stimulation from parents, that is, a physicaland tend to have learning difficulty, show dangerous behaviors, and have physical health issues. The

contact and emotional relationship with parents; this phenomenon had already become an issue in themost common cause of mental health issues in young people is depression.

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Mental health223

2. Stress in daily life and mental health
1) Mechanism for protecting the mind

Column: Various emotions and the control of emotions

A person has various emotions. According to the classical theory of emotional development, aperson first acquires emotions of pleasantness and unpleasantness in infancy, and pleasantness is

To maintain mental health, we must continue to protect the mind by coping with various stresses anddivided into joy and affection while unpleasantness is divided into anger and hatred; a person

conflicts in daily life. The world has entered a stage in which our health is threatened by various stresses

develops more complicated emotions with age. It has been said that the basic elements of emotions

caused by social life, which came after the threat of infectious disease and the spread of lifestyle diseases.

develop by 2 years of age and emotions become as various as those of adults by 5 years of age.

This section explains about the psychological defense mechanism that enables us to cope with various

However, recent studies point out that emotions such as joy, anger, and fear emerge as early as

frustrations and conflicts inherent to human life.

infancy.

Austrian psychoanalyst Sigmund Freud first proposed the defense mechanism, and Anna Freud (aEmotions themselves cannot necessarily be classified into good and bad ones, and there is nodaughter of Freud) developed it. Freud believed that the human mind consists of three layers: superego,need to deny any emotion. Meanwhile, positive emotions such as enjoyment, joy, affection, trust,ego, and id (es, unconsciousness). The superego is a sociocultural moral code that is internalizedhappiness, and surprise are easy to accept, but negative emotions including anger, jealousy, fear,through, for example, parental discipline, and represents the mind consisting mainly of conscience,

conflict, hatred, sorrow, and shame are hard to accept. Thus, if negative emotions become excessive,

which takes actions by judging norms, morals, and right and wrong, while the id represents the mind of

they can result in problems by causing antisocial behavior such as harming oneself or others. One

instinctive desires and drives, emotions, and the accumulation of past experiences. The ego representsof the mechanisms of the mind that controls these negative emotions is the psychological defense

the defensive function of the mind that receives moral requests from the superego (e.g., prohibition,mechanism. Coping behavior, social support, mindfulness, and meditation, which are discussed

ideals, and consideration for others), and desires and drives as well as emotions from the id (Freudlater, are also psychosocial means to control negative emotions.

attached particular importance to sexual desire and drive), experiences a conflict between the superego
and the id, and seeks for reality adaptation by coordinating with the reality of the outside world.
The psychological defense mechanism is the action of the mind to mitigate unpleasant emotional
experiences such as anxiety, depression, guilt, and shame that are caused when the ego is exposed to theinstinctive desires and drives as well as emotions of the id, and is the unconscious action of the mind by

2) Relation between mind and body, and psychosocial stress(1) Hans Selye’s stress theory13

which the ego attempts to resolve the crisis and readapt to reality.11 In general, the defense mechanism

Stress is originally an engineering term that means “pressure” applied to an object. In the late 1930’s,

is the means that the ego or the self uses to protect itself from desires that it wants to reject and unpleasantHungarian-Canadian physiologist Hans Selye found that strong demand from the outside world disturbs

emotions and notions, and is a normal action of the mind that everyone experiences. However, if thehomeostasis (see Chapter 2) and causes nonspecific, physiological responses to the living body (e.g.,

defense mechanism is excessive or inadequate, it can lead to social maladjustment, causing problematicswelling of the adrenal cortex, atrophy of the thymus, spleen, and lymph node, and gastric and duodenal

behavior or impairing the health of the mind and body.

bleeding/ulcers) in experiments with rats, and published the stress theory.13 Selye’s stress theory was

The most basic example of the psychological defense mechanism is repression. It is the action of theego that unconsciously excludes desires that it wants to reject (e.g., sexual desire), unpleasant notions

soon applied to humans, and research on the relation between stimulation from the psychosocial
environment and human response began.

and emotions (e.g., hostility), and threatening experiences from consciousness and puts a lid on them so

Environmental triggers that induce stress responses are stressors, which are largely classified intothat they will not enter the consciousness.12 The id is assumed to be an unconscious space to store these

physicochemical stressors (e.g., noise, vibration, temperature, and chemical substances) andunpleasant things through repression. Although repression can give a temporary escape frompsychosocial stressors (e.g., human relations, events in school life, duties, characteristics and atmosphere

unpleasantness, the memory of a very difficult experience may enter the consciousness as an unexplainedof organizations including school, and economic conditions). In psychosocial stressors, there are acuteanxiety later, causing damage to mental health. Or it may appear as physical symptoms such as thestressors, which are stressful life events, and chronic stressors, which are daily hassles.

inability to speak, walk, or sleep, despite no physical dysfunctions.

Stressful life events refer to events that cause changes to life and require efforts to adjust life andAnother example of the defense mechanism against unacceptable notions, emotions, thoughts, andreadapt. According to the scale that measures stressful life events,14 the stress level of changes in life

memories of experiences is isolation. It is the action of the mind that attempts to separate thoseafter marriage is set at 50 as the standard, and rates the death of a spouse at 100, which is the highest

unacceptable things from oneself and keeps them away. Unbearably difficult experiences may belevel. A survey of Cambodian university students15 reported the three most common life events that they

confined so as not to be remembered, which is called dissociative amnesia.

found difficult were as follows:

Meanwhile, the psychological defense mechanism has not only unhealthy responses but also healthyor mature ones (e.g., altruism, humour, sublimation, and suppression).
224

1. Marked decrease in your or your family’s income
2. Frequent minor illness
Chapter 12

Mental health225  3. Seeing poverty in Cambodia

aspect (psychological symptoms including anxiety, depression, and irritation), and the behavioral aspect

Meanwhile, daily hassles refer to irritating or frustrating events that occur in interactions in one’s(aggression, withdrawal, tardiness/absence, and errors and accidents) (Table 12.1).

daily life. In the daily life of university students, daily hassles may be an inability to understand classwork,
excessive examinations and assignments including making reports, insufficient daily living expenses, orconcerns about securing a job after graduation. The ten most common daily hassles for Cambodian

Column: Mental health of Cambodian people

university students15 are reported as follows:

In a study of Cambodians’ psychological symptoms, conducted by Dubois, et al.16 in the Kampong

1. Too many things to do at once

Cham province, 55% of the people reported experiences of violence and poverty related to the  2. Struggling to meet academic standards

Khmer Rouge, and 42.4% had symptoms corresponding to the diagnosis of depression according

3. A lot of responsibilities

to the DSM-4 standards while 53% and 7.3% had symptoms corresponding to the diagnoses of

4. Important decisions about your future career

anxiety disorder and PTSD (Post-traumatic stress disorder), respectively. In addition, many people

5. Poor health of a friend

had multiple symptoms. The three most common stressful life events were lack of food and water,

6. Hard effort to get ahead

access to medical care, and housing. The frequency of PTSD was 28.4% in a study by De Jong, et

7. Financial burden

al. 17 and 14% in a study by Sonis, et al.,18 showing some difference due to study populations and  8. Difficulties with transportation

periods. In addition, these studies are limited by simply applying the Western psychiatry diagnostic

  9. Social conflict over smoking

categories for PTSD, depression, and anxiety disorder to the stress experiences of Cambodian

10. Social isolation

people.19

There are two ways to harm health: one is through stressors caused by events that in turn cause major

According to Nou,15 Cambodian university students’ major stressors can be classified into fivechanges to life, and the other is through stressors attributed to accumulation of daily irritations. Bothcategories, one of which is their difficulty in getting white-collar jobs after graduation, such as non-stressful life events and daily hassles vary depending on society, culture, and living conditions, and it ismanual work, specialists, or engineering/development work. Moreover, social disparities that allow

therefore necessary to consider what constitutes stressors that harm human health by taking into accountonly rich students to get good jobs have become a stressor. The subsequent stressor is changes inthe society, culture, and living conditions of each country and region (urban areas or remote mountainous

life, including the death of or separation from family members, a decrease in income, and poverty

areas), including Cambodia’s group harmony-oriented culture, which is different from Westernand the uncertain future of Cambodian society. Others inclulde changes in society; Cambodia’s

individualism.

political and social uncertainty have affected university students’ daily life. The last is malnutrition

In any case, if harmful stressors cannot be removed and exposure to them continues, stress responses

resulting from environmental pollution (dust from unpaved roads) and poverty, which is reported to(strain) occur. Stress responses appear largely in the physical/physiological aspect (physical symptoms

be a stressor that many university students suffer from. Further studies of life stressors are needed

including elevation of blood pressure, palpitation, and headache/abdominal pain), the psychologicalin the context of Cambodian life and society in detail.
The challenge of school mental health is to identify the stressors, stress responses, coping
behaviors, supportive human relations, and a sense of control in the lives of elementary school,

Table 12.1 Examples of areas and types of stress responses

Area of stress responses

Types of stress responses

Physical/physiological aspect

Elevation of blood pressure, malaise, dyspepsia, fatigability, sweating,insomnia, anorexia, palpitation, headache, abdominal pain, diarrhea, being
prone to colds, substantial change in weight

Psychological aspect

Anxiety, tension, helplessness, depression, decrease of confidence/selfesteem, irritation, difficulty in concentrating, deterioration of memory/
judgment, being passive

Behavioral aspect226

Withdrawal, tardiness/ early leaving /absence, decrease of work efficiency
and morale, increase of aggression, being pessimistic, being suspicious,
diet refusal/overeating, tics, starting or increasing the amount of smoking/alcohol drinking/drug intake, decrease of cooperativeness, change inappearance, unsanitary behavior, increase of errors and accidents, suicide
attempt/suicidal ideation/self-harmjunior high school, and senior high school students in Cambodia.

(2) Mechanism of the mind-body connection
The remarkable points about the stress theory are that it revealed that stimulation from the psychosocial
environment can induce responses in the physical/physiological aspect and cause physical diseases, andso it created the concept of psychosomatic disease.
For example, if a human relation problem such as bullying, harassment, or discrimination occurs,
people will recognize and evaluate it. If the stimulation persists and it is determined by the cognitive
appraisal to be a threat that cannot be eliminated soon, it will become a stressor, leading to various
emotional responses, autonomic nervous system excitation, transmission of this excitation throughout
the whole body via synapses, and evoking the body’s responses (see Chapter 2 for responses of theautonomic nervous system). The cognitive appraisal of a stressor causes excitation of the sympathetic
Chapter 12

Mental health227nervous system or the parasympathetic nervous system. A body’s responses vary depending on the

anxiety, depression, loneliness, and despair that result from psychosocial stressful events such as

released neurotransmitter. Representative hormones that transmit stress information are cortisol andunpleasant or disappointing events and the experience of being hurt. However, such defense will not

adrenaline, which transmit excitation of the sympathetic nervous system. If this stress condition

last long, and in fact, the person will soon be exhausted and feel seriously depressed. To avoid thisbecomes chronic, the body will soon be exhausted and unable to maintain homeostasis, resulting in thesituation, it is important to have someone reliable who will listen to and accept.

onset of disease.
However, not all stresses are necessarily harmful. Good stress is called eustress and is conceptually
distinguished from the harmful stress distress. Eustress leads to fulfillment in life and a sense of(3) Coping behavior toward, social support for, and a sense of control over stressaccomplishment and is referred to as “the salt of life.” It is a metaphor meaning that consuming it too

As a means to protect health of the mind and body from psychological conflicts and psychosocial stress,

much will do harm to health, but we cannot live without taking it.

there are coping behaviors and social support in addition to psychological defense mechanisms.

Column: Stress hormones and happy hormone

a. Coping behavior
Stress-coping behaviors are actions and skills used to reduce threats, harmfulness, and stress

Cortisol and adrenaline are major hormones released when the human body responds to stress.

responses that result from a stressor, and include emotion-focused coping that attempts to

These hormones elevate blood pressure and prepare the body for fight or flight response (seemaintain the person’s composure by controlling emotions (e.g., vent of emotions, resignation,

Chapter 2). Cortisol is a steroid hormone released by the adrenal cortex. Depending on the amountand wishful thinking), problem-focused coping that tries to solve the problem (e.g., seekingof secretion, it increases blood pressure and blood glucose levels, resulting in, for example, a decline

for information and support and implementing solutions), and cognitive appraisal-focusedin immune function.

coping that perceives the problem differently (e.g., redefinition and denial of the problem).

Meanwhile, when a joyful or good thing (eustress) happens, dopamine, which is known as “thepleasure hormone,” is released. As a result, the person is motivated to make better things happen.

b. Social support

Besides dopamine, there are serotonin (known as “the hormone of reassurance”) and oxytocin

It is support that is provided and received in social relations. Although there are several(known as “the hormone of love”).

classification methods, it can roughly be divided into emotional support, instrumental support,
and appraisal support. Emotional support includes approaches to the emotional aspect, such

Column: Psychosomatic disease

as sympathetic understanding and sharing an experience. Instrumental support further
includes support by means, i.e. aid, which is a direct intervention or support to solve thePsychosomatic disease is a physical disease, whose onset and course are affected by psychosocial

problem (e.g., lending money and giving assistance), and informational support, which isstress, and in which organic or functional abnormalities are confirmed. To understand psychosomatic

an indirect support through advice and information provision. Plus, there is appraisal

disease, the mind-body connection is important for explaining the relation between psychosocial

support, which works to change perspectives and views on stressful events, or provides a

stress and physical symptoms or physiological abnormalities. Representative psychosomatic

positive appraisal.

diseases include irritable bowel syndrome, gastric ulcer, bronchial asthma, hyperventilation

Stress coping behaviors are the actions that people take when a stressor occurs. Social

syndrome, essential hypertension, and headaches (e.g., tension-type headache and migraine). Notesupport, on the other hand, includes various types of support, such as support related to thethat physical symptoms complained of by patients with depression or schizophrenia are not included

occurrence of the stressor and support for coping with the stressful situation. Thus, socialin psychosomatic disease.

support has the effect of preventing the occurrence of stressors, reducing stress levels whenstressors occur and people feel stressed, and providing support when stress responses occur.

Column: Manic defense

Therefore, in order to maintain mental health, it is important to establish reliable relationships
with people who can provide support (e.g., family members/relatives, friends, and teachers)

There are many types of defense mechanisms that protect the ego when the person feels

and to learn about socially provided programs and services. In Cambodia, however, thepsychological stress, ranging from immature defense mechanisms (e.g., isolation of affect,

challenge is a lack of facilities, services, and programs that can provide mental health care.

rationalization, denial, and somatization) that tend to lead to maladjustment and mental healthdisorder to mature defense mechanisms (e.g., humour and suppression).20
We introduce manic defense here. It is a behavior intended to hide from others by forcing oneself
to be cheerful, to laugh, or become excited as if nothing happened, in order to divert the mind from

228

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Mental health229

c. Sense of control21
The key to overcoming difficult situations is to have the belief that one can overcome them

3. Mental health challenges in Cambodia
1) Externalizing problems and internalizing problems

by changing the surrounding circumstances, or the belief that one can overcome them byreceiving the surrounding circumstances and adjusting them toward a solution. These senses

According to Achenbach, et al., the most common categories describing behavior disorders inare called senses of control. These senses of control are important psychological resources to

psychopathological studies are “internalizing,” in which behavioral problems appear internally, andadapt to developmental challenges and changes in each age group, and have positive effects“externalizing,” in which they are expressed externally22. The American Psychiatric Association’son aspects of life, including health, studies, and work. The former self-initiated sense ofdiagnosis manual also explains that classifying behavior disorders broadly like this is more useful thancontrol is the primary sense of control, which is emphasized in Western societies. Meanwhile,

looking at individual behavior disorders. For example, internalized problem behaviors include anxiety,the harmonious sense of control is the secondary sense of control, which is a sense ofdepression, loneliness/sorrow, despair, suicidal ideation, physical symptoms, and withdrawal, and thesecontrol widely shared by people in East Asia. In the Asian cultural sphere, in order to cope

represent a group of behaviors that are neurotic and excessively suppressed. It has been pointed out thatwith stressful events, it is important not only to aim to change the circumstances to meet one’s

these are frequently seen among girls in elementary, junior high, and high schools and increase their

desires but also to try to adapt oneself to the circumstances to reach a solution in which bothrisks of dropping out of school, using drugs and suicide23. Meanwhile, externalized problem behaviors

are harmonized.

include destructive/aggressive/antisocial behaviors (i.e., acts of violating rules and laws, such as fights,
subversive activities, thefts, and telling lies) and hyperactive behaviors, and these represent a state in

Column: The Western mind and the Asian mind

The concepts of the mind and mental health in psychology and psychiatry have been theorized on

which behavioral suppression is insufficient24. Note that externalized and internalized problem behaviors
coexist and cannot be considered separately because anxiety or depression may be hidden behind
antisocial behaviors.23,24

the basis of traditional Western social culture and modern Western science. Careful consideration

A study of Cambodian-Americans25 states that, although the use of official mental health services asmust be given to determine whether this Western concept of the mind can universally be applied towell as guidance from parents, relatives, friends, and other people are necessary to address externalized

non-Western social cultures, such as those in Asia, India, the Middle East, and Africa. Asia is divided

problems (a 14-year-old boy’s alcohol drinking in this research) and internalized problems (11-year-old

into six areas, i.e., East Asia, Southeast Asia, North Asia, South Asia, West Asia, and Central Asia,

boy’s depression), it is effective for coping with externalized problems to administer punishment, teachand includes people who believe in religions representing various tenets of Buddhism, Islam,manners, and place children in a training facility to discipline them. This view requires attention because

Hinduism, Judaism, and Christianity; therefore, it is better to think that the concepts of the mind andit can create a foundation that allows for physical punishment. To address internalized problems, meanwhile,mental health based on Western values are different from those in Asian countries.

the study recommends letting children do what they like to do and spend their time as they please. It is

Take mindfulness as an example, which has recently been a topic of discussion. It originatesfrom sati, a Pali word used in Theravada Buddhism. In Buddhism, a Western self-centered self-necessary to develop coping methods that are effective in Cambodia by promoting the understanding of
mental health through health education while taking into account Cambodian peoples’ beliefs.

consciousness, which focuses on “me” separated from others (e.g., people and the environment), isdenied, and instead of reducing all events to their elements and viewing them separately, people
recognize that all events are mutually linked to take place and value the overall harmony. They
concentrate on “the present moment” “as it is” with an unbiased mind through specific Buddhist2) Post Traumatic Stress Disorder (PTSD) in relation to the Khmer Rougeand 2nd generation PTSD

practices, including meditation, and strive to reach “a constantly calm behavior (state) of the mind.”
The concepts of the ego and the mind in Asian Buddhist thought are different from those in the West,

It is estimated that approximately one-fifth (approx. 2 million people) of the Cambodian population diedand the healthy state of the mind also widely differs from the WHO’s concept based on a demonstration

because of torture, execution, forced labour, hunger, or disease during the Khmer Rouge era (1975–

of individuals’ abilities as described above.

1979). Even today, about 40 years later, some of the survivors and their children’s generation are still

Note that there is mindfulness as a method for reducing stress, which is separated from religious

suffering from PTSD, physical symptoms, and social maladjustment. A special tribunal, which started

significance and practiced for therapeutic effects. Nevertheless, mindfulness is something that aims

in 2006, is ongoing, and there are concerns over what influences the tribunal can have on Cambodian

for not only individuals’ inner peace but also the peace of the group or the society that surrounds

people. It is suspected that the tribunal may cause the people to reexperience past hardships, retraumatizing

individuals.

those who are seized by anger and a desire for revenge, which may lead to increasing the prevalence of
PTSD among them. In previous studies, the prevalence of PTSD widely ranges from 7% to 86% among
different studies.26

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Mental health231

Hinton, et al.27 created the Cambodian Symptom and Syndrome Inventory (CSSI), a questionnaire

The 2nd generation PTSD due to transgenerational trauma is a concept that considers PTSD as asensitive to Cambodian culture to measure psychological health in order to assess the influences ofresult of traumatic events experienced by parents’ generation affects their children, who did not directly

psychic trauma experiences on Cambodian refugees who fled the massacre perpetrated by the Khmer

experience those events, thus causing psychopathological symptoms. A study of Cambodian families

Rouge (Table 12.2). It is a questionnaire that asks how much they suffered from these symptoms in thehas not clarified the mechanism of PTSD transmitted between generations but has shown that the higher

past four weeks. Respondents are requested to choose from among five ratings: 0 (not at all), 1 (a little

the level of traumatic stress that a mother experienced in her life, the higher the daughter’s PTSDbit), 2 (moderately), 3 (quite a bit), and 4 (extremely). It is shown that among these symptoms, thesymptom rating. Psychic trauma experiences in the Khmer Rouge era are transmitted from mothers tosymptom of “13. thinking too much” (kut caraeum) among the “syndromes” is a key indicator of distress,

daughters, and therefore, not only caring for mothers suffering from PTSD but also providing mental

and those with higher scores of this indicator tend to have higher DSM-IV PTSD scores. People with thishealth care for their children is an important issue for Cambodia.

symptom think too much about upsetting topics, past traumatic events, and death of/separation fromloved ones. “Kut caraeum” may lead to physical symptoms such as headaches, dizziness, “wind attacks,”
depletion of bodily energy, heart weakness, and memory loss.
Table 12.2 Contents of the Cambodian symptom and syndrome inventory (CSSI)

Somatic symptoms

  1. Dizziness  2. Standing up and feeling dizzy3. Blurry vision
4. Tinnitus
5. Headache
6. Neck soreness7. Palpitations
  8. Shortness of breath
9. Chest tightness
10. Rising sputum
11. Stomach bloating/discomfort
12. Cold hands and feet
13. Numbness in the arms and feet
14. Sore arms and legs
15. Trembling of the arms and legs
16. Weakness
17. Poor appetite
18. Feeling of lightness in the bodySyndromes

Somatic-focused syndromes
1. Khyâl attacks
  2. Standing up and feeling poorly to the point you feared
fainting, khyâl overload, or heart attack
3. Neck soreness to the point you feared the neck vessels
would burst
  4. “Heart weakness”
  5. Sputum moving upward and causing you to feel you
couldn’t breathe or might have a heart arrest
6. Khyâl hitting up from your stomach, making you fear you
might die of asphyxia
  7. Fear of “death of the hands, death of the arms” (slap day
slap ceung)  8. Excessive inner hotness (kdaw khnong)
9. Having a partial or full malaria attack
10. Out of energy to the point you feared having a khyâlattack or dying from depletion
Agoraphobia/motion-sickness syndromes
11. “Poisoned by cars” (pul laan)
12. “Poisoned by people” (pul meunuh)
Emotion-focused syndromes
13. “Thinking too much”
14. Toxique
Cognitive-capacity syndrome
15. Forgetfulness/mental distraction (phluc pheang)
16. Light in the body as if your soul was not in your body
17. Fear that someone has sent an ampuu into your body
18. Fear of having low spiritual luck (rieusuy), high bad luck
(krueh)19. “Ghost pushing you down” (sleep paralysis)

This table cited from “Hinton et al., The relationship of PTSD to key somatic complaints and cultural syndromes among Cambodian
refugees attending a psychiatric clinic: The Cambodian Somatic Symptom and Syndrome Inventory (CSSI). Transcultural Psychiatry.
50:347-370. 2013.”
Copyright@2013,SAGE Publications. All rights reserved. Translated with permission.

2323) Bullying, violence, and harassment
a. Bullying
According to the 2013 Global School-based Student Health Survey (GSHS),28 the percentages of
elementary, junior high, and high school children who were bullied at least one day in the past 30 daysin Cambodia were 22.4% for those aged 13 to 15 years and 22.3% for those aged 16 and 17 years, withno marked difference between the sexes. In this study, bullying was defined as follows: “Bullying occurs
when a student or group of students say or do bad and unpleasant things to another student. It is also
bullying when a student is teased a lot in an unpleasant way or when a student is left out of things on
purpose. It is not bullying when two students of about the same strength or power argue or fight or when
teasing is done in a friendly and fun way.”
UNICEF Cambodia29 defines these three points as characteristics of bullying: an intentional(malicious) act that causes physical or psychological pain; a patterned, repeated behavior; and an attackby a stronger child. It recommends parents and teachers observe children by paying attention to thepoints below so that they will not miss any signs of bullying.
i) Physical marks such as unexplained bruises, scratches, broken bones and healing woundsii) Fear of going to school or joining school eventsiii) Being anxious, nervous or very vigilantiv) Having few friends in school or outside of schoolv) Losing friends suddenly or avoiding social situationsvi) Clothing, electronics or other personal belongings being lost or destroyedvii) Often asking for moneyviii) Low academic performanceix) Absenteeism, or calling from school asking to go homex) Trying to stay near adultsxi) Not sleeping well and having nightmaresxii) Complaining of headaches, stomach aches, or other physical ailmentsxiii) Regularly distressed after spending time online or on their phone (without a reasonable
explanation)xiv) Becomes unusually secretive, especially when it comes to online activitiesxv) Being aggressive or having angry outbursts
Chapter 12

Mental health233

substantial damage to Cambodian society35. In response, teachers have begun to receive training to learn
Recently, cyber bullying has become an issue not only in Cambodia but also around the world. The

educational methods that do not use violence in correcting children’s behaviors and managing classes

Mobile Phones and Internet Use in Cambodia 201630 reports that 48% of people access the internet or

and how to build good relationships with children. Teachers in Cambodia are strongly required to serve31

estimates that 8.86 million (54.2%) of theas mentors of children and guide them in the right direction, build relationships in which children are

country’s population (16.83 million, as of January 2021) are internet users, indicating that about half ofrespected, and understand different characteristics of children at different developmental stages (seethe total population use the internet. The spread of social media creates new forms of bullying, violence,

Chapter 3).

Facebook. In the meantime, the Digital 2021 Cambodia

and harassment. According to a five-week public-opinion poll conducted by UNICEF, 85.7% ofCambodian youths aged 15 to 25 years are exposed to the risks of online violence, cyberbullying, anddigital harassment.32 To address this situation, UNICEF has requested the Cambodian government4) Loneliness, anxiety, and depression

develop new policies for protecting children from bullying and violence using cyber means such as SNS.
In UNICEF’s study,33 the definition of cyberbullying is as follows:

According to a study of people aged 21 and older across Cambodia, conducted using the Hopkins“Cyberbullying is bullying with the use of digital technologies. It can take place on social media,

Symptom Checklist-2536 in 2011, the percentage of people with high anxiety symptom scores (referred

messaging platforms, gaming platforms, and mobile phones. It is repeated behavior, aimed at scaring,to as “anxiety”) was 18.35% for men and 31.72% for women, which represented a statistically significant

angering, or shaming those who are targeted. Examples include: spreading lies about or posting

difference between the sexes; and the percentage of people with high depression symptom scores

embarrassing photos of someone on social media, sending hurtful messages or threats via messaging(referred to as “depression”) also showed a difference between the sexes, with the percentages being

platforms, impersonating someone and sending mean messages to others on their behalf.”

10.21% for men and 19.69% for women, indicating that the percentages of anxiety and depression are

The study points out that cyberbullying has an impact on children psychologically (feeling upset,higher in women. Interestingly, in both psychological symptoms, no difference was found between

embarrassed, stupid, even angry), emotionally (feeling ashamed or losing interest in the things youurban and rural areas, but there was a difference with regards to educational background. The percentages

33love), and physically (tired (loss of sleep), or experiencing symptoms like stomach aches and headaches).

of anxiety and depression were higher in those with lower education, and among those with no education,

Although it is not easy to prevent bullying, it is important, first of all, for children to understandthe percentages of anxiety and depression were 32.51% and 20.37%, respectively. In the general“what constitutes bullying” and not to blame themselves for being bullied. Children who are being

population, women with low education are presumed to be at high risk.

bullied as well as those around them should say that bullying has occurred and tell adults. In addition,

Meanwhile, in the results of the GSHS-2013 Cambodia, which surveyed elementary, junior high,the adults and children around them need to create a safe classroom and school environment where

and high school children, 49.0% “sometimes” feel loneliness, 4.8% feel it “most of the time,” and 0.9%

bullying is not acceptable. In the current situation of most schools in Cambodia, the awareness and“always” feel it. This indicates that 54.7% of the children feel loneliness sometimes or more frequently.

support of teachers and friends is essential as there is still no school counsellor. It is important to

A comparison of this percentage with the GSHS results of the neighbouring countries Laos (32.8%) andrecognize that not only children who are being bullied but also those participating in bullying might beVietnam (44.5%) shows that the percentage of children who feel loneliness is higher in Cambodia by

suffering from mental problems and seeking help.

10%–20%. However, there was no marked difference in the percentage of those who answered that the
number of close friends is 0, which was 5.0% for Cambodia, 4.8% for Laos, and 5.5% for Vietnam.

b. Violence against children by teachers

Loneliness itself is something that everyone sometimes feels and not a mental health issue. Nevertheless,
34

The 2013 Cambodia Violence against Children Study reports increasing violence against children in

Cambodian children, who feel loneliness more frequently than their counterparts in neighbouring

Cambodia. With regard to children aged 13 to 17 years, the percentage of those who have experienced

countries, might be at higher risk of depression, anxiety, low self-esteem, sleep disorder, self-mutilation,

physical violence was 58.2% for boys and 61.1% for girls, and approximately 68% suffered violence forand suicide.

the first time between the ages of 6 and 11 years, that is, during their elementary school age. Outside

The results of the GSHS-2013 Cambodia28 also shows that 42.4% of the children “sometimes” hadhomes, violence is used by teachers. Concerning physical violence used against girls aged 13 to 17

the experience of “being unable to sleep at night because of worries,” 5.0% had it “most of the time,”years, 58.6% of the girls suffered violence from male teachers and 20.5% from female teachers; as forand 1.0% “always” had it. This distribution is similar to that of loneliness, and 48.4% of the children

boys of the same age, the percentages were 51.7% and 18.0%, respectively.

experienced sleeplessness because of worries sometimes or more frequently. In a study conducted in

Bullying mentioned above as well as violence by adults are thought to be two of the most stressful

Laos using the same items, “sometimes” was 29.9%, “most of the time” was 3.9%, and “always” waslife events to which children are exposed. UNICEF estimates that children who experience violence will

1.1%, which totaled 34.8%. This is lower than the percentage in Cambodia by approximately 15%.

be subject to long-term negative effects on their intellectual, physical, and emotional development,

These results suggest that the mental health of Cambodian children is poorer than that of their counterparts

which can result in a decline in labor power in the future and an economic loss of US$168 million

in neighbouring countries.

(accounting for 1.1% of the GDP in 2013), and points out that violence against children will cause
234

Chapter 12

Mental health2355) Suicide attempts, suicide

how to send out an SOS and seek help, and learning the importance of life. In addition, one possible
suicide prevention measure is to provide training for teachers so that they can learn how to listen to

Suicide not only takes the life of a person but also constitutes a public health issue that can have a deep

children and have a receptive attitude. It is also important to create a system that allows children to

influence on the family and people around the person, as well as the school and the region. The suicideconsult with adults in school, the community, and through SNS as an effort of society. At the same time,

rate (the number of people who committed suicide per 100,000 population) in Cambodia for men was

adults, including teachers and guardians, must pay careful attention to the fact that SNS may include

6.2 in 2000, which slowly increased to 8.0 in 2007 and then gradually decreased to 7.0 in 2019. The rate

information that induces suicide.

37

for women, meanwhile, decreased every year from 3.9 in 2000 to 2.8 in 2019 (Figure 12.3). The 2019

In suicide prevention measures, although individual measures are also important, the key is theglobal average suicide rates are 12.58 for men and 5.68 for women, and Cambodia’s suicide rate appears

whole school approach, in which the entire school considers the health of children as a whole andto be substantially lower than the global level. However, there is a previous study that reported a highcreates a healthy and supportive school environment (e.g., curriculums, school management policies,

suicide rate of 13–44 per 100,000 population,26 and this warrants a highly accurate epidemiologicalcaring relationships, school culture and value, and the leadership of management and teachers) as

study of suicide and statistics.

explained in Chapter 1.
28

Concerning suicidal ideation and suicide attempts of young people, the GSHS-2013 Cambodia

shows that the percentage of those who seriously considered committing suicide during the past year is6.4%, those who made a suicide plan was 8.8%, and those who made a suicide attempt was 6.7%. These
children are at high risk of committing suicide in the future.
There are many possible psychological circumstances that may push children into suicide. Suchcircumstances are as follows:

Column: Whole school approach

The whole school approach is thought to be the most effective health promotion method in whichchildren, teachers and other staff of the school, guardians, and community members collaborate at
the school in order to change the present situation of the school and improve the health and well-i) loneliness and isolation, which make them feel that they cannot trust anyone and are helpless;being of all the people. The whole school approach is characterized by, first of all, its perception thatii) a feeling of worthlessness, which makes them think it is not worth living;a school is the aggregate of many systems that depend on each other. The second characteristic is,iii) unfocused intense anger because they cannot blame anyone for their sufferings and cannot

therefore, efforts by all related people, who collaboratively participate in the process for changing

solve them;iv) an assumption that their sufferings will never end and a feeling of despair; and as a result,the school to improve the health and well-being of all the people related to the school who change
the system of the school as a whole by capitalizing on the resources and strengths of everyone.

v) psychological visual field constriction, which makes them preoccupied with suicide as the only
solution.
As measures to counter suicide, there are prevention and postvention. Prevention means building(person)

9.0

relations with those who are close to children in daily life and who notice these changes; those who talkof health room teachers (like a school nurse) and school counsellors, are not in place, and therefore, it isnecessary to train general teachers to listen to children receptively and supportively, as training to
improve the quality of teachers.
Meanwhile, because one person’s suicide can trigger a chain reaction or cluster of suicide, postvention
aims to carefully observe children who are shocked by someone’s suicide and depressed, as well as those
who are feeling guilty about someone’s suicide, and to consult with them to create an atmosphere inwhich they can easily talk. A triggering suicide is the suicide of someone such as a celebrity, like anactor, a person of the same age with the same trouble, a family member, a boyfriend or girlfriend, or aclose friend. The principal and teachers are required to deal with the family of the child who committed
suicide, and students in the same school and their guardians. In dealing with these people, it is necessary
not to glorify or criticize the suicide and to be considerate to prevent the family of the deceased from
suffering the stigma of suicide.
In school classes, health education can be provided, which includes methods for coping with stress,236

mortality rate per 100,000

In many schools in Cambodia, systems that allow children to convey their worries, including allocation

Male suicide rate

8.0

to them, and who are easy to talk to about their worries; and building relationships of trust with teachers.

7.0

Female suicide rate

6.0
5.0
4.0
3.0
2.0
1.0
0.0

00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19
20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20

YearThis figure is created based on data obtained from The World Bank. Suicide Mortality Rate, Cambodia.
Male:https://data.worldbank.org/indicator/SH.STA.SUIC.MA.P5?end=2019&locations=KH&start=2000&view=chart
Female:https://data.worldbank.org/indicator/SH.STA.SUIC.FE.P5?end=2019&locations=KH&start=2000&view=chart

Figure 12.3 Mortality rate caused of suicide (per 100,000) in Cambodia
Chapter 12

Mental health237

Column: Loss and grief, and grief care

physical dependence.
For information, the number of abusers of major drugs (amphetamine/methamphetamine [stimulants],

There are various events in life that may include suicide, disasters and accidents, diseases, andcannabis, heroin, and narcotics) in Cambodia is estimated to exceed 2% of the population (for theunemployment, and we may be overwhelmed by sorrow when we lose loved ones, such as family

1998–2004 period), which makes the country one with the highest drug abuser rates in the Asia-Pacificmembers or someone close to us, or things that are important to us; or when we become ill or

region, which includes Hongkong, the Philippines, Thailand, Indonesia, Laos, and Malaysia.26

disabled and lose our health. The psychological (e.g., denial, depression, anger, sorrow, anxiety, andThose who develop dependence need to receive medical care to treat their physical symptoms instead

helplessness), physical (e.g., fatigue, sleep disorder, anorexia, and autonomic imbalance), and socialof trying to cure them on their own. A self-help group, which supports mental health, is effective at(e.g., withdrawal, isolation, and increased alcohol drinking) reactions we experience when we losechanging behaviors of dependence and addiction. Therefore, Cambodia is expected to set up self-help

loved ones are called grief reactions. These are normal reactions to loss; if we suppress sad feelings,

groups on various addictions.

we will suffer from psychological difficulties for a prolonged period, making such difficulties evenharder to overcome. Grief is a long process, from the occurrence of an event to healing, and thisprocess is called grief work. In the grief care part of this grief process, the most important thing is
to respect and sympathetically listen to, as a person, the story of the person who is suffering fromtotal (i.e., psychological, physical, social, and spiritual) pain. We must refrain from easily encouraging,

4. Common mental diseases (schizophrenia and epilepsy)
1) Schizophrenia

persuading, or curing such a person.

Schizophrenia is one of the most common chronic mental diseases, affecting 7 to 10 people per 10006) Addiction and dependence

population irrespective of differences in backgrounds such as society, culture, and ethnicity, and which
can develop severe chronic psychological symptoms. The WHO estimates that 20 million people areaffected by schizophrenia around the world.38 Since no epidemiological study of schizophrenia has been

People can be dependent on various things besides alcohol. Dependence can broadly be divided into

conducted in Cambodia, the approximate number of patients, including those untreated and treated, isdependence on chemical substances (e.g., alcohol, cigarettes/nicotine, caffeine, amphetamine, narcotics,

unknown. It has been reported that due to insufficient social understanding of the disease and psychiatricstimulants, and cannabis), which is substance dependence, and dependence on behaviors (e.g., eating

care, it takes 47 months for patients to start treatment.39

disorder/overeating, gambles, games, internet, sex, and shopping/waste), which is behavioral addiction.

Disorders resulting from schizophrenia appear in thinking, recognition, emotions, language, self-

Dependence is caused by changes in the functions of the brain, mind, and body due to the habitual use

consciousness, and behaviors, and typical symptoms include delusion (e.g., being monitored byof a chemical substance, including alcohol and cigarettes, or a repetition of a behavior, such as gamblingneighbours), hallucination (e.g., hearing someone talking when no one is there), disorders of consistency

or games. Taking alcohol or engaging in a gambling activity gives the experience of enjoyment and ain conversation and behavior, lack of emotion or motivation, disorder of ego (one’s idea is known togood feeling and stimulates a circuit in the brain called the reward system that transmits pleasure. The

others), and loss of insight into disease. Therefore, in addition to the suffering of the patient, the familybrain releases a neurotransmitter called dopamine that enhances this pleasure, creating a strong desire tomembers taking care of the patient bear a heavy burden and are likely to be discriminated against by

experience this pleasure again. The desire to repeatedly experience this pleasure is satisfied, and whenpeople around them. The disease tends to manifest in a person’s late teens to thirties, and although thethe drug use behavior is repeated, resistance develops because the same stimulus will no longer haveexact cause is unknown, a study of twins reported that the probability of a pair of twins developing

the same effect as what was previously obtained from the drug or behavior. In this way, repeating drug

schizophrenia is 50%, suggesting that it may be related to heredity, the rearing environment, and sharedingestion or gambling change the functions of the brain, mind, and body, resulting in dependence.

experience of stressful events.

Therefore, in dependence, a condition in which the functions of the brain and body have been changed,
the behavior cannot be stopped by one’s own will.
There is psychological dependence and physical dependence. The former is, for example, the

The WHO points out that schizophrenia can be treated or cured, but for that, drug therapy,
rehabilitation (e.g., life skills training, social skills training), and acceptance by the community areimportant.

behavior of searching for a cigarette to get it when the person feels tempted to smoke, and the latter is,in the case of tobacco dependence, a condition in which withdrawal symptoms, such as irritation andhand tremors, occur when the nicotine concentration in the body decreases. In the case of alcohol

2) Epilepsy

dependence, autonomic nerve hyperactivity (e.g., sweating, hand tremors, elevation of blood pressure,and tachycardia) and psychological symptoms (e.g., hallucination, irritation, anxiety, and excitation) can

Like schizophrenia, epilepsy is a general mental disease, and according to the WHO,40 approximately 50

appear. Note that not all chemical substances that cause substance dependence necessarily result in

million people are suffering from the disease around the world, with 80% living in low-middle income

238

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Mental health239

countries without receiving treatment. The prevalence of epilepsy in Cambodia is estimated at 5.82) Counselling, mental health services

persons per 1000 population and reported to be lower than that in neighbouring countries such as Laos
(7.7/1000 persons), Vietnam (10.7/1000 persons), and Thailand (7.2/1000 persons).41

Globally, mental health issues are increasing, as are needs for counselling and mental health services.

Epilepsy is a disease characterized by recurrent “epileptic seizures” that cause a person to become

However, systems are insufficient in low- and middle-income countries, and particularly Cambodia,

unconscious and unresponsive suddenly. Symptoms are transient and subside if “epileptic seizures”

where mental health services and psychiatrists suffered devastating damage during the Khmer Rouge

disappear. However, a person may be injured depending on the place where the person collapses afterera, lagging far behind in this field. Moreover, mental health receives a lower policy priority than public

losing consciousness due to a seizure, so that it is important to reduce the frequency of seizures.

hygiene challenges such as infectious diseases and lifestyle diseases; the challenge is to give a higher

The disease is said to occur at any age but is particularly frequent in children and elderly people.

policy priority in light of the present situation of mental health in Cambodia.26

The causes of epilepsy can be identified in some cases, which include a brain tumour and a posttraumatic

Meanwhile, regarding the question of whether counselling is really effective in Cambodian society,cerebral symptom, but they are unclear in other cases. Because about 70% of the afflicted can lead ait has been pointed out that building a healing relationship between an individual and a counsellor

normal social life by receiving a proper diagnosis and taking antiepileptics, there is no need to excessively

through “talking and listening” is effective in Cambodia as well. For counselling and mental healthrestrict school attendance and work. Despite this fact, many people suffering from epilepsy are subject

services to be in place, the challenges need to be addressed first, which includes the spread of education

to stigma and discrimination.

and knowledge on mental health, the human resource development of professionals (i.e., psychiatrists,
nurses, clinical psychologists, and social workers) and subprofessionals (e.g., general practitioners,

5. Mental health care
1) Help-seeking behavior

teachers, and community/health workers), as well as the improvement of the quality of training, and theimprovement of the quality of mental health services as well as the elimination of the gap between urban
and rural areas.26
Counselling basically requires active listening skills, the ability to reflect on one’s own thinking andemotions, and the power to accept human diversity. Listed below are the 11 points that teachers should

According to a survey of 391 high school students in Grades 10 and 11 in Phnom Penh and the Prey

keep in mind support children with a mind adequate to counselling. Nevertheless, teachers are not

Veng province, which investigated help-seeking behavior, the person(s)/information source(s) frommental health professionals and should fully understand their limitations.

whom/which they most frequently seek help to cope with their personal and emotional problems were,i) Do not try to elicit a solution or answer to the problem.

as a whole, their mothers (74.4%) and friends (73.9%), followed by fathers (51.4%), other relatives orii) Create a receptive and relaxed atmosphere, and accept the child’s feelings.

family members (38.9%), internet chat rooms (29.9%), teachers (28.9%), their boyfriends/girlfriendsiii) Ask open questions. Do not interrogate.

(19.2%), and information on the internet (18.7%). Mental health professionals, doctors, and telephoneiv) Wait for the child’s answer as long as possible, and endure silence.

counselling were around 8 to 11%, indicating that these are not as accessible as informal informationv) Use the child’s words to convey the message that you “understand” them.

sources. Religious figures were also chosen by about 10% of the students as persons from whom theyvi) Express a positive interest in the child.

seek help.

vii) Show a natural, reasonable empathy.

This result shows that family members, students, and teachers are likely to be chosen as persons toviii) To clarify the feelings of the student, use or appropriately paraphrase the child’s words.

whom they talk about their mental health problems, including anxiety and depression, and therefore,ix) To organize issues, summarize the story.

efforts for mental health education in communities and schools are important. In addition, since they usex) Look at the problem from the child’s perspective and seek meaning from that perspective.

the internet to search for information about mental health and persons from whom they seek advice,xi) Believe in the child’s abilities to grow and solve problems.

creating an internet website that provides accurate information about mental health is also a goal. (SeeTPO Cambodia, https://tpocambodia.org/tips-for-good-mental-health/, etc.)
High school students’ help-seeking behaviors differ between the sexes and among regions. It is

Exercises for further thought and research

noteworthy that boys are more likely to use internet chat rooms and websites to seek information and[12-1] What does it mean to have a healthy mind?

help than girls are, and that high school students in rural areas seek advice from teachers more frequently[12-2] Research the defense mechanism of the mind by referring to resources such as Britannica: Defense

than those in urban areas do. This suggests that teachers play a greater role in rural areas with poor

mechanism (https://www.britannica.com/topic/defense-mechanism). Discuss what kind of

mental health resources and thus are required to receive education/training on counselling.

defense mechanism is commonly used in Cambodia. Research mature psychological defense
mechanisms in particular.
[12-3] What is a mechanism by which the mind and the body are mutually affected?

240

Chapter 12

Mental health241[12-4] What influence does stress have on mental health?
[12-5] What are challenges in mental health in Cambodia? Discuss how they should be addressed.
[12-6] Give examples of internalized and externalized problem behaviors. Summarize what you think
about how to respond if a child seeks advice on such mental health problems, and discuss this
topic in a group.
[12-7] Discuss the reasons for and the backgrounds behind teachers’ use of physical punishment in the
education of children. How can you guide children without relying on physical punishment?
Exchange ideas for alternatives.
[12-8] Consider the person you will seek for help first when facing a personal problem, and why you
chose that person.
[12-9] Reflect on your experiences of being asked by your friends and family members about how theyshould address their problems, and review whether you practiced the points for supportive
listening.

16 Dubois V, Tonglet R, Hoyois P, Sunbaunat K, Roussaux J-P, et al., Household survey of psychiatric morbidity in Cambodia.
International Journal of Social Psychiatry. 50:174-85. 2004.
17 de Jong JT, Komproe IH, Van Ommeren M, Masri ME, Araya M, et al. Lifetime events and posttraumatic stress disorder in 4
postconflict settings. Journal of American Medical Association. 286:555-562. 2001.
18 Sonis J, Gibson JL, de Jong JTVM, Field NP, Hean S, et al. Probable posttraumatic stress disorder and disability in Cambodia:
associations with perceived justice, desire for revenge, and attitudes toward the Khmer Rouge trials. Journal of American Medical
Association. 302:527-536. 2009.
19 Agger I. Calming the mind: Healing after mass atrocity in Cambodia. Transcultural Psychiatry 52:543-560. 2015.
20 Costa RM, Brody S. Immature psychological defense mechanisms are associated with greater personal importance of junk food,alcohol, and television. Psychiatric Research. 209:535–539. 2013. https://doi.org/10.1016/j.psychres.2013.06.035
21 Rothbaum F, Weisz JR, Snyder SS. Changing the world and changing the self: A two process model of perceived control. Journal of
Personality and Social Psychology. 42: 5-37.1982.
22 Achenbach TM, Ivanova MY, Leslie A. Rescorla LA, Turner LV, et al., Internalizing/Externalizing Problems: Review andRecommendations for Clinical and Research Applications. Journal of the American Academy of Child & Adolescent Psychiatry.
55:647-656. 2016.
23 Liu J, Chen X, Lewis G. Childhood internalizing behavior: analysis and implications. Journal of Psychiatric and Mental HealthNursing. 18: 884–894. 2011.
24 Liu J. Childhood Externalizing Behavior: Theory and Implications. Journal of Child and Adolescent Psychiatric Nursing. 17: 93–103. 2004.
25 Deley TC. Beliefs about treatment of mental health problems among Cambodian American children and parents. Social Science andMedicine. 61;2384-2395, 2005.
26 Parry SJ, Ean N, Sinclair SP, Wilkinson E. Development of mental healthcare in Cambodia: barriers and opportunities. International
Journal of Mental Health Systems. 14:53. 2020.

References
1

Dekaban, AS., Sadowsky, D., Changes in brain weights during the span of human life: relation of brain weights to body heights andbody weights, Annals of Neurology, 4:345-356, 1978.

2

Myowa M., Unravelling the mystery of human development—from the fetal period to the future of humanity. Chikuma shinsho.
pp110-117. 2019.

3

Hannah K. Scott; Mark Cogburn. Piaget. https://www.ncbi.nlm.nih.gov/books/NBK448206/

4

The 4 Stages of Cognitive Development Background and Key Concepts of Piaget’s Theory. https://www.verywellmind.com/piagetsstages-of-cognitive-development-2795457

5

Erik Erikson’s Stages of Psychosocial Development. https://www.verywellmind.com/erik-eriksons-stages-of-psychosocialdevelopment-2795740

6

Spitz RA. Hospitalism: An Inquiry into the Genesis of Psychiatric Conditions in Early Childhood. The Psychoanalytic Study of theChild. 1, 53-74. 1945.

7

Blum RW, Bastos FIPM, Kabiru CW, Le LC., Adolescent health in the 21st century. The Lancet. 379: 1567-1568, 2012.
https://www.thelancet.com/action/showPdf?pii=S0140-6736%2812%2960407-3

8WHO, Mental health in the Western Pacific. https://www.who.int/westernpacific/health-topics/mental-health9WHO, Mental health: strengthening our response. https://www.who.int/news-room/fact-sheets/detail/mental-health-strengtheningour-response

10 WHO. Adolescent mental health. https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health
11 American Psychological Association. Defense Mechanism. APA College Dictionary of Psychology 2nd Eds. p.112. American
Psychological Association. Washington DC. 2016.
12 American Psychological Association. Repression. APA College Dictionary of Psychology 2nd Eds. p.391. American Psychological
Association. Washington DC. 2016.
13 Tan SY, Yip A. Hans Selye (1907–1982): Founder of the stress theory. Singapore Medical Journal. 59: 170–171. 2018.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5915631/
14 The American Institute of Stress. The Holmes-Rahe Stress Inventory PDF. https://www.stress.org/holmes-rahe-stress-inventory-pdf
15 Nou L. Investigating stress symptomatology among Cambodian university students. International Review of Modern Sociology.
29:133-164. 2013.

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27 Hinton DE, Kredlow MA, Pich V, Bui E, Hofmann SG. The relationship of PTSD to key somatic complaints and cultural syndromes
among Cambodian refugees attending a psychiatric clinic: The Cambodian Somatic Symptom and Syndrome Inventory (CSSI).
Transcultural Psychiatry. 50:347-370. 2013.
28 WHO. Global School-based Student Health Survey (GSHS). https://www.who.int/ncds/surveillance/gshs/cambodia/en/
29 Unicef Cambodia. How to talk to your children about bullying. https://www.unicef.org/cambodia/how-talk-your-children-aboutbullying
30 Phong K, Srou L, Solá J. Mobile Phones and Internet Use in Cambodia 2016. https://asiafoundation.org/wp-content/
uploads/2016/12/Mobile-Phones-and-Internet-Use-in-Cambodia-2016.pdf
31 DIGITAL 2021: CAMBODIA. https://datareportal.com/reports/digital-2021-cambodia
32 The ASEAN Post. Cambodia’s cyberbullied children. https://theaseanpost.com/article/cambodias-cyberbullied-children
33 Unicef Cambodia. Cyberbullying: What is it and how to stop it. https://www.unicef.org/cambodia/cyberbullying-what-it-and-howstop-it
34 Government Commitment to End Violence against Children. Findings from Cambodia’s Violence Against Children Survey 2013.
https://violenceagainstchildren.un.org/sites/violenceagainstchildren.un.org/files/documents/political_declarations/east_asia_and_
pacific/cambodias_violence_against_children_survey.pdf
35 UNICEF Cambodia. Ending violence against children at school in Cambodia. https://medium.com/@UNICEFCambodia/endingviolence-against-children-at-school-in-cambodia-363eb53a49cc
36 Seponski DM, Lahar CJ, Khann S, Kao S, Schunert T. Four decades following the Khmer rouge: sociodemographic factors
impacting depression, anxiety and PTSD in Cambodia. Journal of Mental Health, 28: 175-180, 2019.
37 The World Bank. Suicide Mortality Rate, Cambodia. Male: https://data.worldbank.org/indicator/SH.STA.SUIC.
MA.P5?end=2019&locations=KH&start=2000&view=chart, Female: https://data.worldbank.org/indicator/SH.STA.SUIC.FE.
P5?end=2019&locations=KH&start=2000&view=chart
38 WHO. Schizophrenia. https://www.who.int/news-room/fact-sheets/detail/schizophrenia
39 Nishio A, Horita R, Marutani T, Yamamoto M. Factors that influence delaying initial psychiatric treatment in rural Cambodia: A pilot
study. PLoS One. 13: 2018. https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0206882
40 WHO. Epilepsy. https://www.who.int/news-room/fact-sheets/detail/epilepsy
41 Preux PM, Chea K, Chamroeun H, Bhalla D, Vannareth M, et al. First-ever, door-to-door cross-sectional representative study in Prey
Veng province (Cambodia). Epilepsia. 52:1382–7. 2011. https://doi.org/10.1111/j.1528-1167.2011.03102.x

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Chapter 13

Environment and health / Ecohealthissues, and think, together with teachers, about what can be done to maintain and improve the health andquality of people’s lives in Cambodia as well as other countries.
What makes it important to address environmental health? According to WHO estimates, anunhealthy or unsanitary environment was responsible for as much as 23% of total global mortality or
12.6 million deaths worldwide, and for 26% of deaths in children younger than 5 years in 2012, whichindicates that the environment has a large impact on human health.2 Of the environmental factors,

Learning objectives

environmental pollution is the largest environmental cause of diseases and premature deaths. Diseases

You will be able to gain proper understanding and explain:caused by environmental pollution were responsible for an estimated 9 million premature deaths or 16%- What makes environment important for health of humans and survival of life.

of all deaths worldwide in 2015; this is estimated to be three times more deaths than from AIDS,- What effects each has on the health and lives of humans with several examples each of physical,

tuberculosis, and malaria combined, and 15 times more than from all wars and other forms of violence.2

chemical, biological, and cultural/psychosocial environments.
- The relationship between an environmental factor and human health based on its dose-response
relationship.

It is evident that polluted environments significantly affect human health.
Among the different forms of environmental pollution, those of particular concern are outdoor andindoor air pollution, water pollution, soil and food contamination by pesticides and other chemicals,- Through group work, and giving presentations, what impacts Cambodia’s social and economic

and toxic/hazardous occupational exposure. It should be noted that, compared to high-income

development has on the health of ecosystems, people’s lives and main occupations (livelihood),

countries, pollutants cause greater harm to the environment and human health in low- and middle-

and human health.

income countries, particularly pregnant women, fetuses, and infants, poor and minority populations, andresidents of rural areas who make a living from agriculture and fisheries.2 As a result of globalization,

This chapter will discuss the effects environment has on human health, focusing on each of the following:

foreign capital seeking to secure food is making inroads into the agricultural and fishery industries ofcategories of environmental factors as health risks; health effects of environmental pollution; thelow- and middle-income countries, causing pollution of soil and waterways/groundwater through coastal

relationship between exposure levels and biological reaction; and environmental health issues ofdevelopment, deforestation, and use of pesticides/insecticides. In recent years, many countries are

Cambodia addressed using an ecological health approach (loss of mangroves, deforestation and declining

experiencing a concentration of population in cities, bringing global attention to the deterioration of

biodiversity, soil degradation, water pollution, vulnerability to climate change and natural disasters,

urban environments such as vehicular exhaust and greenhouse gas emissions, domestic sewage pollution

landmines and unexploded ordnance, and deteriorating urban environment).

of rivers, and treatment of large quantities of waste. Cambodia is no exception. Though different
countries and regions may face different pollutants, environmental pollution presents a major risk to the

1. Importance of environmental healthhealth of humans.
In low- and middle-income countries, including Cambodia, however, environmental monitoring
systems are not well established yet, and few data are available on environmental pollution and otherFirst, we will look at what environmental health is and why it is important for human health. There areenvironmental issues. Building a system to gather and analyze environmental data is an undertaking thatdifferent definitions of “environmental health;” according to WHO:1

is necessary to promote effective environmental health measures. In the context of school health,providing environmental health education and Ecohealth education is a key to ensure understanding“Environmental health comprises those aspects of human health, including quality of life, that areof the relationship between environment and ecosystems, human health, and social development.

determined by physical, chemical, biological, social, and psychosocial factors in the environment. It also
refers to the theory and practices of assessing, correcting, controlling, and preventing those factors in theenvironment that can potentially affect the health of present and future generations adversely.”

2. What is an environment?

Human health and quality of life are determined by physical, chemical, social, and psychosocial

What does environment refer to, exactly? Living organisms are surrounded by many different conditions,factors that are present in the environment. The prevention of illnesses and disabilities, therefore, calls

objects, or circumstances of the external world, which are what constitutes the environment.3 For thefor theories and practices to assess, correct, and control these environmental factors.

purpose of this chapter, “environment” refers to that for humans, namely the conditions, objects,

This means that, in the context of school health, environmental health provides educationalorganisms, and circumstances of the external world that surround humans. While the external world that

opportunities for children to gain a deeper understanding about the environment, learn about risk factors

surrounds humankind is a limitless expanse, like outer space, we primarily discuss the biosphere (i.e.,in the environment that cause human illnesses and disabilities and about present-day environmental

the life-supporting parts that extend around the Earth including the layers on and under the ground, the244

Chapter 13

Environment and health / Ecohealth245

atmosphere, and the hydrosphere; a sum of ecosystems where living and non-living things interact), andlimit our discussion at most to the extent to which humankind has thus far reached into outer space. That

Column: Environmental pollution of methylmercury and the health of people

being said, we may need to take certain other things into consideration, such as the sun and meteorites;

Minamata disease describes the poisoning from methylmercury compounds that affected thehumankind has not reached the sun, and yet it has tremendous influence over the Earth, while a meteorite

Minamata area along the coast of the Yatsushiro Sea in Kumamoto Prefecture, Japan. The cause of

can cause major climate or environmental change or disasters if it hits the Earth, which makes meteorites

the environmental pollution was the release into the sea of methylmercury compounds, a by-productsomething that we may not be able to ignore for their influence over our environment and health.

that occurs during the production of acetaldehyde, in the industrial wastewater from a factory owned

Of the biosphere that is the Earth’s environment, environments and ecosystems relevant to theby the Japan Nitrogenous Fertilizer Company. The methylmercury compounds polluted thequality of life and well-being of human will be discussed in this chapter (see Chapter 1 for a definition ofenvironment of the Yatsushiro Sea, where fish and shellfish consumed the methylmercury compounds

health).

and passed them along the food chain in the ecosystem. This led to bioaccumulation of thepollutant, bringing about central nervous system disorders among humans and cats that ate polluted

3. Human survival and the Earth’s environment

fish and shellfish due to mercury poisoning (see the Dose-Response Relationship section in thischapter to learn more about these symptoms).
The first patient identified was a young child who, in April 1956, exhibited severe symptoms,

Now, why is the Earth’s environment important for us? As we all know, it is because it is the environment

including difficulty speaking, walking, or eating. It was not until twelve years later in 1968 that thethat possesses all the conditions that have made it possible for life (including humans) to begin, evolve,

national government finally officially recognized Minamata disease as a pollution disease. During thisand prosper as humankind does today. These conditions, for instance, include at the very least: thetwelve-year period, the nation experienced a plethora of social issues: various different theories andatmosphere; water; food; stable climates; protective layers that shield against harmful cosmic rays andmisunderstandings concerning the cause of the disease; counterarguments made by the company;

radiation; biological diversity; and adequate supply of thermal energy from the sun. These are theprejudice, discrimination, and stigma against the patients and the local communities; lawsuits overconditions that are indispensable for life activities of organisms, which means that if these conditions ofpatient certification; medical researchers making judgments in favor of the government and thethe Earth’s environment are disrupted, it poses a threat to the health, or even the survival, of humans.

company, and so on. It surfaced only recently that people inland had also suffered central nervous

One grave issue that have faced in recent years is the fact that human activities can cause environmental

system disorders due to mercury poisoning after eating fish and shellfish from Minamata Bay, yet

destruction, which threatens human health and survival. In particular, it is our short-sighted activities inheld back from seeking patient recognition for fear of discrimination, and that such inland sufferers

pursuing immediate economic interest and social utility. In fact, it has been pointed out that some ancient

had not received relief as the government would only certify coastal residents as Minamata diseasecivilizations collapsed as a result of serious environmental issues. One example is Easter Island, known

patients. More than 60 years on, Minamata disease is still an issue.

for its giant stone statues. It has been established that the civilization on the island collapsed because its

Environmental pollution of mercury has raised concerns not only in Japan but in many countries.

inhabitants harvested its scarce forest resources to build roads to transport the stone statues to various

For instance, pollution of metallic mercury used for the refining of gold has been detected in theritual platforms across the island, which resulted in soil sliding and erosion, making it impossible to

Brazilian Amazon basin, the Philippines, Tanzania, and Indonesia. In Cambodia, too, mercury was

4produce enough food to sustain its population. Japan, in its effort to bounce back from its defeat infound at high concentrations in the hair of people who were living in fishery villages and who

World War II, pursued a ten-year plan to double its national income starting in 1961 and promoted rapid

consumed large quantities of fish and shellfish, or those who were sorting waste at landfill sites.6

industrialization, ultimately achieving spectacular economic growth. Behind these accomplishments,

Increasing environmental pollution and resulting health hazards caused by mercury are of great

however, the nation suffered a tragedy; hazardous substances spewed from factories and polluted theconcern in Cambodia.

environments and ecosystems, which destroyed the health of people in the communities, as represented
by what are known as the four big pollution diseases of Japan, namely Minamata disease, Yokkaichi
asthma, Itai-itai disease, and Niigata Minamata disease.5
What conditions, circumstances, or substances that are present in environments affect human health,including our quality of life and well-being? And what human or social behaviors cause what forms of

4. Health and environment1) Host-environment interaction

ecosystem degradation and again affect human health, including our quality of life and well-being? Weneed to learn about these issues and consider what we can do to achieve ecological health, where

Broadly speaking, there are two ways to understand the relationship between our health and theenvironments/ecosystems are in harmony with human and social behaviors and human health (seeenvironment. One is to find out what kinds of health issues and diseases occur as a result of exposure to

Chapter 1 to learn more about ecological health approaches).

the conditions, objects, or circumstances in the environment. The purpose is to identify hazardous
substances or conditions in the environment and eliminate or improve them in order to secure health and246

Chapter 13

Environment and health / Ecohealth247

safety. This is an important and fundamental approach in environmental health and hygiene for thetheir work site had COVID-19, they would have a higher likelihood of catching the virus, which is a

purpose of protecting the safety and health of workers, especially in work settings where workers arebiological environmental factor, as a close contact. Furthermore, at their workplace they may be

exposed to substances and environmental conditions that are different from those they are faced with ininfluenced by cultural/psychosocial environmental factors, including working conditions (such as long

their everyday lives. This approach concerns the relationship between environmental exposure andworking hours, working at high places, and uncertain employment contacts), stress from work

human health.

relationships, and social norms of the employee population. Such diverse working environments are

For instance, the WHO Regional Office for the Western Pacific (where Cambodia is one of the nonPacific Islands Countries and Areas) regarded unsafe water, poor sanitation, air pollution, hazardous
chemicals and poisons, occupational hazards, and extreme weather as being examples of environmental
determinants of health.7
With this approach, the relationship between humans and the environment may be understood as
Biological environment

Cultural/psychosocial environment

environments, such as physical, chemical, biological, and cultural/psychosocial environments (Table

constitution as its internal environment, namely a human (i.e., host), comes in contact, through their

y (h

beh

ost/huma vio rs (l

a

ife

st

Physical/chemical environment

lifestyle behaviors, with environments (physical/chemical, biological, and/or cultural/psychosocial) of
by the results of such interactions.

yle

e

st

lifestyle activities and environment, in which an entity that has certain genetic characteristics andthe external world, and as the two influence each other, the health condition of the human is determined

tit

En

Lif

such (Figure 13.1). Figure 13.1 shows a model that illustrates the relationship between humans and their)

they form the environment in combination and exert influence over the health and lives of humans ases13.1). In the real world, these environmental factors do not exist independently from one another; rather,

n)

Gene/
constitution
Internal
environmentylhost-environment interaction, with environmental factors organized according to a category of the

Figure 13.1 Model for the relationship between humans and their lifestyle behaviors andenvironment

Take a working environment at a building construction site as an example. A worker who has certain
genetic characteristics, constitution, and lifestyle would be exposed to physical factors such as vibrations,noise, high temperatures, ultraviolet light, and dust from building construction work. They may also be
exposed to chemical factors such as organic solvents used for painting and adhesion, and if they smoked
during a break, they would inhale various chemicals contained in the cigarettes, as well. If someone at

Category of environment

PhysicalVibrations, noise, electromagnetic waves, high temperatures, lowtemperatures, high voltage, humidity, radiation, ultraviolet, airborne
particulate matter

ChemicalDioxins, asbestos, organic solvents, mercury, lead, arsenic, pesticides/
insecticides, food additives, pharmaceuticals, cosmetics, cigarettes andalcohols, illicit drugs, and other synthetic chemicals

Biological

Pathogenic microorganisms and parasites such as Escherichia coli O157,
SARS, HIV (AIDS), and SARS-CoV-2, venomous snakes, wild animals,
hygiene pests, mosquitos, plants

Cultural/psychosocial

Social systems and social organizations, political regimes, social norms,
legal systems, values, discrimination/stigma, human relationships(including violence/abuse and bullying), overcrowding, family/kinships,
religions, working conditions, financial situation, science and technology,
academia, art

Gene/Constitution
Internal environment
Hostaviors (L
ife
beh
le

248

Life
st
y

Examples of environmental factors

Cultural/psychosocial
environment

)
yle
st

Table 13.1 Categories of environment and examples of environmental factors as health risks

Biologicalenvironment

Physical/chemical
environment

Figure 13.2 Human-environment relationships. A case of construction workers
Chapter 13

Environment and health / Ecohealth249

believed to interact with a worker’s biological and psychosocial characteristics, defining the health of

poisoning, such as impairment of sensory functions, including seeing, hearing, smelling, tasting, andthe worker (Figure 13.2).

touching, and impaired ability to control the movements of limbs. In a case of a chemical used as a

In a school environment, children’s physical, mental, and social health is influenced by physicaltreatment, ED50 (effective dose 50) is used instead as an indicator of its efficacy, referring to the dose

environment (e.g., light, sound, electricity, and temperature), chemical environment (water, air, andthat produces a therapeutic effect in half of the population. In either case, the dose-response relationshipdisinfectants), and biological environment (bacteria, viruses, and animals), which are explained insuch as the one illustrated in Figure 13.3 is used to evaluate levels of harm, therapeutic effect, and safety.

Chapter 4 in the discussion of school environmental health, as well as cultural/psychosocial environment,
including children’s relationships among themselves and with teachers, and classroom culture, which
may involve issues such as bullying.

Column: Environmental risk factors in low-middle income countries

In the category of cultural/psychosocial environment, psychosocial stress has become an important

The disability-adjusted life year (DALY) is a summary measure of the overall impact of disease on

issue as a factor that damages health. The health effects of life stress that people experience in their

the health of a human population. This measure is used to assess the impact of a disease on

working, family, or school environment are addressed in Chapter 12 in the discussion of mental health.

humans in a population level, based on the number of years of life lost due to premature mortality
caused by the disease and the number of lost years of healthy life due to disabilities caused by thedisease. The number of years “lost” used to be calculated using the life expectancy (i.e., the average2) Dose-response relationshipnumber of additional years that a person of a given age is expected to live) of the Japanese as thestandard, as Japan has historically had the longest life expectancy in the world. Recently, however,

One of the ways to determine what kinds of health issues or diseases humans may develop as a result ofdifferent approaches have sometimes been taken, such as the use of national life tables for individual

exposure to a condition, object, or circumstance in the environment is to analyze its dose-response

countries.

relationship (Figure 13.3) and show the related levels of harm and margin of safety. These provide abasis for establishing environmental safety standards or permitted levels for it.
This is a method to assess what kinds of health effects may result from what amount of exposure toa physical factor in the environment, such as radiation, or by taking in what amount of a chemical factor,

Note that one DALY represents one year of healthy life lost in life expectancy because of adisease. A higher DALY value indicates a greater burden posed on human health and life by theparticular disease or health risk.
Using DALYs as a measure, the Global Burden of Disease Study 2019 estimated the 20 leadingrisk factors for countries grouped according to the levels of their social and economic development.8

such as organic mercury.

Percentage of individuals responding

Thanks to its recent economic progress, Cambodia was now included in the group of low-middleincome countries.

100%

For the group of these development levels, the leading environmental risk factors to health forfemales were8:
Household air pollution (5th);50%

Ambient particulate matter (7th);
TD50 (toxic dose 50; dose that produces
toxic reactions in half of population) or ED50
(effective dose 50; dose that produces
effects of medication in half of population)

Unsafe water (8th);
Unsafe sanitation (14th); andHandwashing (17th).
For males:
Ambient particulate matter (6th);0%
Dose of hazardous or therapeutic

Figure 13.3 Sample dose-response curveHousehold air pollution (8th);
Unsafe water (12th);
Unsafe sanitation (14th);
Occupational injury (16th); andFigure 13.3 illustrates how this may look using TD50 (toxic dose 50). Take methylmercury poisoning

as an example. It is a form of health hazard caused by mercury contamination of the environment/
ecosystem that is represented not only by Japan’s Minamata disease but seen widely across the globe. Its

Handwashing (18th).
These data show that environmental pollution represents a significant health risk and that males,in particular, are exposed to occupational risk factors.

TD50 refers to the dose at which half of the population exhibit the symptoms of methylmercury
250

Chapter 13

Environment and health / Ecohealth2515. Ecosystem health and human healthAs an approach to understand the relationship between health and the environment, we discussed theapproach of looking at exposure to environmental factors and human health in the previous section.

have been seen in the Philippines, Mexico,11 and Ecuador.12

1) What is an ecosystem? What is an ecological health approach?

Another approach is that of environmental health, focusing on impacts of economic development on
ecosystems based on the development-ecosystem-life or main occupation (livelihood)-healthAn ecosystem is a concept of seeing all the organisms that live within a certain area, together with therelationships. To help understand the social and economic development-ecosystem-life and main

abiotic environment, as one cohesive system, focusing on energy flows, food chains, and geochemical

occupation (livelihood)-health relationships, we use examples of banana plantations in the column

cycles (cycles of earth materials). Multiple layers of micro-ecosystems form one large ecosystem that is

below.

the Earth.
In the case of humans, for instance, ecosystems exist at multiple levels, from individual to family,
neighborhood, school, and workplace, municipality, county, and province, nation, and the world; acrossColumn: Truth behind banana plantations

these levels are cycles or flows of energy, materials, information, cultures, politics, and economy. In

It is believed that over a thousand kinds of bananas of different colors, shapes, and sizes areother words, all these levels, from individual to global, are linked together and influence one anotherproduced and consumed around the world. However, the Cavendish type makes up 47% of global

through such cycles and flows.

production and 99% of exports. Cavendish bananas are all genetically identical clones, andApplying the concept of ecosystems to human health is known as the ecological health approach.

overdependence on a single cultivar, or monoculture, poses the risk of disease spreading globally

According to these approaches, the health and healthy behaviors of humans are influenced by factors at

and causing tremendous damage to crops.9

various different ecological levels, while the behaviors and lives of humans exert influence over andWhile it is difficult to cite exact statistics on annual banana production, records show it was 114

bring about changes to ecosystems at various different levels. This means that the health and healthy

million tonnes in 2017. The world’s largest producer of bananas is India (29 million tonnes produced

behaviors of children who live in a given area of Cambodia are influenced by, and have influence over,annually), followed by China (11 million tonnes) and the Philippines (7.5 million tonnes), with Ecuador

ecosystems at different levels on a global scale, albeit to varying degrees.

and Brazil tying for 4th place (7 million tonnes). A majority of bananas produced in India and China

When it comes to defining different levels of ecosystems, an article titled Adolescent health in theare for domestic consumption with very little left for export; Ecuador, the Philippines, Costa Rica,

21st century, for instance, suggests the following levels (from smaller to larger): individual adolescents;

Colombia, and Guatemala are the large exporters. India and China have seen expansions in domestic

school/friends; family; neighborhood; and macro-level society.13 The US Centers for Disease Control

demand as a result of population growth, and between 2000 and 2015, they had an increase in

and Prevention (CDC), meanwhile, as a framework for the prevention of violence, presents a social-

9

ecological model, which comprises the following levels: individual; relationship; community (schools,

production by 48% and 83%, respectively.

Issues that surround banana plantations include the use of large quantities of chemicals, including

workplaces, and neighborhoods), and societal (i.e., a larger society that forms norms and cultures

pesticides, insecticides, and chemical fertilizers, to prevent diseases in banana crops and increase

concerning violence, or a society that has common politics, social policies, economy, and educational

productivity, which can create soil and water pollution, exposing workers and residents tosystems in it), which surround the lower levels.14

environmental pollution. In addition, the development of plantations may result in deforestation orland acquisition or leasing, which causes farmers to lose their land.
In Laos, for instance, many Chinese companies began arriving around 2010 and started operatingbanana plantations in the mountainous northern parts of the country, such as the provinces ofUsing an ecological health approach, we can rearrange the health risk factors in the environment thatare shown in Table 13.1; they exist in each level of an ecosystem, and they influence one another withina given level as well as across different levels, determining the health, healthy behaviors, and lives ofindividuals.

Oudomxay and Luang Namtha. Bananas produced there were all for export to China. While thesebanana plantations generated jobs and income for the poor areas, they also brought about pollutionof the local ecosystems and health hazards. Pollution of nearby rivers also killed large quantities offood fish, causing fisherfolk to lose work.10

A system is a dynamic and complex whole, within which different elements influence one another.

In the summer of 2016, flooding led to massive spills of chemicals, polluting the ecosystems andAn ecosystem is a typical system where cycles or flows of energy, information, and materials occur

environment of the region, and affecting the lives and health of the residents. This forced the Laoamong various elements that constitute the ecosystem. Systems thinking that is based on an

10

government to issue a ban on Chinese-owned banana plantations.

252

Column: Ecohealth and systems thinking

ecological health approach is a concept that holds that, in an ecosystem which comprises multiple

Similar cases of soil and waterways/groundwater pollution and health hazards to residents

levels, different elements influence one another within or across levels, thereby defining the health ofcaused by large-scale pesticide spraying and extensive use of insecticides and chemical fertilizers

the ecosystem and that of humans. In cases of health issues such as dizziness, headaches, andChapter 13

Environment and health / Ecohealth253

diarrhea among residents living near a banana plantation, for instance, issues of ecosystems andeconomic growth and social development, and they arise in a complex, interconnected manner. If suchthose of human health may be rising out of a complex web of elements influencing one another,

an impact exceeds ecosystem resilience, even if economic growth and social development bringincluding: the decisions made by the local authority to accept the company; standard of living, state

economic wealth to people’s lives in the short term, ecosystem degradation will produce health hazards,of employment, and land use in the area; background factors for the company’s entry into the area;

which ultimately makes any such growth or development not worthwhile in the long term for people

operating policy and safety and health measures at the plantation; amounts of fertilizers andwho live in the ecosystem. In other words, we cannot call it sustainable development.

pesticides/insecticides used for banana plants and their levels of harm; geographical conditions of
the rivers as sources of water; ways of life and main occupations of local residents; and levels of(1) Coastal development and loss of mangrovesfinancial hardships of the residents. Ecohealth employs systems thinking to analyze and map such

Mangroves are communities of plants that grow in intertidal zones (i.e., brackish water where freshwater

relationship, clear up complex issues, and find solutions.

and seawater mix, primarily in coastal areas or estuaries) in the tropics and subtropics. In addition toabsorbing CO2, mangroves help protect fishing grounds and biological diversity, and mitigate damage
from cyclones and high tides. Cambodia’s coastline (443 km), which makes up 14.7% of the country’s2) Economic growth and social development in Cambodia

borders, is on the Gulf of Thailand. A large portion of the coastline is found in the province of Koh Kong,which used to be the country’s largest home to mangroves, accounting for 75% of all mangroves in

Cambodia is one of the more natural resource-rich countries in Southeast Asia, with resources including

Cambodia in 1992. However, illegal logging of mangroves by local inhabitants for the purpose of

farmland, water/fishery/forest resources, minerals, oil, and natural gas. Putting these resources to good

charcoal production destroyed the mangrove forests over a vast area. Over the course of around 30 years

use promotes economic progress; in fact, the country has achieved steady economic growth over the past

between 1973 and 2002, 40% of the mangrove areas were lost. Although reforestation efforts through20 years at an annual rate of 7.6%. Further economic progress may potentially reduce poverty.15

replanting of mangroves have been made since 2000, the loss of mangroves has not been curbed, with

Cambodia is a country of great opportunities.

as much as 45% of the mangroves lost by 2016/2017 compared to 1973.

What we need to take into consideration here is that a prerequisite for economic progress based on

Shrimp farms, which were introduced in 1989 and started expanding in 1991, also stimulated

natural resources is social development. Depending on the kind of development that is carried out, it canmangrove deforestation. Shrimp farming is practiced in four provinces, namely Kampot, Kep, Preah

produce impacts not only on economic progress but also on the environment and ecosystems where theSihanouk Ville, and Koh Kong, where large ponds were created close to or within mangrove forests.17

resources exist. It is therefore important to continuously monitor any impacts on the natural environment

For that purpose, large swaths of mangrove forests were cut down. In Cambodia, the rapid destructionand ecosystems produced by development that is made for the sake of economic progress, because someof mangrove forests has caused soil and water degradation, adversely affecting the lives of residentsof these impacts may have negative effects on the lives and health of people (see Column: Truth behindliving on coastal fishing (i.e., livelihood). Furthermore, organic matter and chemicals, phytoplankton,

banana plantations). In addition, whether or not economic progress leads to a reduction in poverty also

and bacteria that are present in the effluent from shrimp farms may potentially degrade the ecosystems

depends on social systems, such as redistribution of wealth and social security, as well as the national

along the coast.17 If these issues cause the yields of fish to decrease and lead to declines in fisheries, it

political system that is in place. Poor people and rural and remote areas where poverty rates are high andmay result in food problems for Cambodia.15,17

building an economic base is challenging are also the people and areas that are more vulnerable to issues
related to natural environment and ecosystems.

In addition, there are concerns that large-scale port development projects, offshore oil and natural
gas drilling, and other development projects by the hotel business and tourism may also lead to mangrove
deforestation.15(2) Deforestation

3) Environmental issues in Cambodia

Forests provide people with a place to preserve their traditional culture and gather food and fuelwood.
What kinds of environmental issues face Cambodia today? We will address this by referring to two
15

In the context of the environment, forests help regulate climate at local levels, filtrate water, retain water

reports, one by the University of Gothenburg in Sweden, and the other by the Ministry of Environment

to control river volumes, or prevent floods or mudslide disasters.16,18 Degradation of such forests is one

of Cambodia, titled Cambodia Environment Outlook.16

of the environmental issues facing Cambodia.

The primary environmental issues in Cambodia identified by the two reports include: loss of

The percentage of Cambodia’s total land area covered by forest (forest area) was 75% in the latemangroves; deforestation and declining biodiversity; soil degradation; water pollution;

1960s, but it declined to 60% in 1993, 59% in 2006, and was down to 47% in 2018. It has been pointed

vulnerability to natural disasters (floods, droughts, and windstorms); climate change; land minesout that this rate of reduction in forest area in Cambodia is considered to be greater than those in its

and other unexploded ordnance; waste pollution; and deteriorating urban environment.

15,16

These

issues represent impacts on the ecosystems that are produced in ways that are connected to Cambodia’s
254neighboring countries or international standards.16
Causes for deforestation include rubber tree plantations and logging for timber or charcoal
Chapter 13

Environment and health / Ecohealth255

production.18 They also include constructing roads or securing land for residential use to accommodate

damage and health hazards. Mudslides caused by soil degradation/erosion can deprive people of theiran increasing population. Illegal logging is thought to account for 90% of deforestation, attributable tohouses or farmland, which may force them to relocate.15

the lack of a forest management system, absence of rules and laws on land ownership, and the corruption
15,16,18

In addition, if global warming brings about sea-level rises and mangrove forests are no longer inbrackish water, it may also affect the ecosystems in the coastal areas.15

that surrounds logging.

Health effects of concern produced by climate change or extreme weather events that are not natural(3) Soil degradation

disasters include vector-borne diseases (e.g., malaria, dengue fever), food security (malnutrition,

Cambodian soil tends to be of low fertility, and land productivity is low. According to 2001 statistics,

famine), water-borne infection, food poisoning, rodent-borne infection, and non-communicableagriculture accounts for only 21% of the total land area.16 To make matters worse, deforestation promotes

diseases.21

soil erosion, while excessive use of pesticides to increase crop yields creates pollution of soil, water, andcrops. These forms of pollution can ultimately threaten the safety of food and the health of humans.
Agricultural practice that involves excessive use of pesticides is not sustainable.

Column: Community-based tourism and ecotourism

The annual sum of pesticides imported to Cambodia was around 37,500 metric tonnes in 2019. It

Tourism is a growing industry globally. In 2014, it generated revenues of US$7.6 trillion, which

was approximately 3,300 metric tonnes for Laos, one of its neighbors; this means that, while theiraccounts for 10% of global GDP, and 277 million jobs. In the past, however, tours would be organizedpopulations and land areas differ widely, Cambodia is importing, and presumably using, approximatelyby travel agents both small and large, and such companies would take most of the profits, leaving

ten times more pesticides than Laos. The sum was approximately 48,000 metric tonnes for Myanmar,

very little to local communities. Tourism has also been responsible for environmental issues. As an

19alternative to such traditional tours, various types of community-based tourism (CBT) recently

while it was approximately 199,000 metric tonnes for Vietnam, which makes it a large importer.

emerged in many countries, including Cambodia. With CBT, tours are organized and operated by(4) Water pollution and water shortages

members of the community. This makes their tours more aligned to the preservation of the local

Cambodia is generally considered a water-rich country. However, around 3.4 million people, many of

natural environment, society, and culture, while profits are given back to the community, which helps

whom live in rural areas, lack access to safe water, and 5 million people have no access to improved

raise the standard of living of community members and empower the community. Compared towater (see Column: Drinking water situation in Cambodia in Chapter 4). In five of thirteen provinces,conventional styles of travel, CBT may also minimize damage to the local environment, society, andnaturally occurring arsenic has been detected in 9% of the groundwater sources at levels above the WHO

culture.

15

standards, which makes the water hazardous for drinking. Furthermore, pesticides, when used in large

Community-based ecotourism that utilizes Cambodia’s nature as an environmental resource

volumes as mentioned earlier, are released not only into soil but into groundwater and rivers as well,

may help improve the well-being and economic life of people while protecting the society and culture

polluting the water sources. Securing safe water in sufficient quantities is a challenge for Cambodia.

of the community as well as the well-being of ecosystems. People of the local community can earn

Meanwhile, the construction of impounding dams upstream in the Mekong River may have impacts

income, which allows them to live in a manner that helps protect forest resources and valuable

on the flood pulse, fish resources and fisheries, agriculture, and downstream water supply. So far, theecosystems such as mangrove forests. Tourists, meanwhile, can experience the true Cambodian

15

nature, society, and culture. Hopes are high that community-based ecotourism will grow into a new

impacts of industrial effluents on water quality have been small, owing to slow industrial development.

(5) Climate change and natural disasters
Cambodia is not yet highly industrialized and therefore has very low emissions of CO2 and otherstyle of tourism that is in keeping with the philosophy of Ecohealth, which promotes a harmonious
balance among development, ecosystem health, life, the main occupations of people, and theirhealth.

greenhouse gases, which are contributing factors to climate change, with a per capita CO2 emission of
0.97 metric tonnes in 2019,20 compared to 4.14 metric tonnes for Thailand, 4.58 metric tonnes for Laos,
0.49 metric ton for Myanmar, and 2.57 metric tonnes for Vietnam.

(6) Land mines and unexploded ordnance (UXO) (Figure 13.4)

The country has been less affected by climate change so far. Potential future increase in volume and

It is estimated that there are 100 million mines buriel in the ground globally. As a result of the Vietnam

frequency of rainfall and intensity of windstorm as a result of climate change, however, may lead to

War followed by a civil war that went on for around 20 years, Cambodia may have four to six million

unseasonal floods, which, combined with soil degradation/erosion due to deforestation, may produce

mines and over 2.4 million pieces of unexploded ordnance (UXO),22 leaving 40% of arable land

mudslide disasters. Such events may well produce extensive damage, given Cambodia is not highly

inaccessible (see Column: Measures related to land mines in Cambodia in Chapter 14).

resilient to natural disasters. Flooding itself has served to make the soil more fertile and produce benefits,

Between 1979 and 2015, land mines and UXO caused approximately 65,000 casualties. The number

and people have adjusted to dealing with seasonal flooding over the ages. Floods that come at unexpected

has been on the decline; according to the Cambodian Mine Action and Victim Assistance Authority,

times of the year due to climate change are difficult to respond to, however, potentially causing flood

Cambodia recorded 111 casualties (18 killed; 93 injured) of mines and UXO in 2015. According to the256

Chapter 13

Environment and health / Ecohealth257

(7) Urban environment and health issues
As a result of population growth, many countries are seeing a migration of population from rural tourban areas, which is creating a concentration of people in cities, thus giving rise to various environmental
and health issues that are unique to cities.
In Cambodia, population was growing at an annual rate of 2.2% up until 1970, when it reached 6.8
million. It then saw a sharp drop due to genocide under the Khmer Rouge. The population then recovered
to its pre-genocide levels, and from 2010 onward, it grew at a rate of around 1.5% to reach 16.25 million
in 2019. People in rural areas would depend on the use of natural resources in the environment for their
Photos provided by NGO JMAS (Japan Mine Action Service)

Figure 13.4 Mines and unexploded ordnance (UXO) in Cambodia

livelihood; as a result of resource decline, however, there arose a trend of migration to urban areas tosearch for employment.15,16 According to estimates in World Urbanization Prospects,26 the rate ofurbanization (i.e., percentage of people living in urban areas) in Cambodia was 22.0% in 2020,
compared to 78% of the population living in rural areas. The rate is estimated to reach only 36% byrecorded cumulative total of casualties, 30% were killed, 56% were injured, and 14% had legs amputated.

2050. For reference, the 2020 estimate was 36% and 31% for Laos and Myanmar, respectively. Japan’sCasualties are unevenly distributed across the country, with Battambang being most heavily affected,

rate of urbanization is approximately 92%.

23

followed by Bantey, Meanchey, and Siem Reap.

While the advancement of urbanization is slow in Cambodia as a whole, Phnom Penh does have

The effects of land mines and UXO span a broad range, from local economic activities such as

some concentration, with a population of 2.13 million (2019), which accounts for 14% of the overall

agriculture and tourism to people’s everyday lives, access to medical treatment, mental and physicalpopulation of the country. This is even higher than the proportion of Japan’s national population living

health, and burden on families caring for victims. Specifically, mine injuries leave the victims and theirin metropolitan Tokyo (9%). The urbanization of Phnom Penh brings about levels of concentration offamilies emotionally traumatized, negatively affecting their mental health; people who live in the area

population that are comparable to those of capitals in European and North American countries. Phnom

cannot feel safe; and mines and UXO restrict access to land that may be used for food production

Penh’s social infrastructure, however, is said to be not adequate to accommodate such a large population.

through farming or stockbreeding, other facilities, services or markets, or safe drinking water. These

The city’s unemployment rate is twice as high as that of rural areas, at 9.2% versus 4.7%.15 The

constraints, in turn, give rise to issues such as the following: food production, distribution, and supply

vulnerability and insufficiency of infrastructure in Phnom Penh is reflected in issues of waste treatment,

are affected, causing food shortages and ultimately malnutrition; as the number of injured people

drinking water, and wastewater treatment discussed in Chapter 4.

increases, medical care, which is poor to begin with, becomes even more strained; financial burdens

Urban environmental issues, unlike those of rural areas which concern natural environment andbecome greater due to medical fees for the treatment of casualties and a loss of earnings because theynatural ecosystems, are issues of the built environment (Figure 13.5), which is created by people; it

are unable to work; municipal governments have to divert funds for clearance of mines and UXO awayfrom other local public services, including healthcare and education.23 On the flip side, clearance ofmines and UXO will resolve these issues; this is why international cooperation and aid for clearance ofmines and UXO are important.
However, the area of land that was cleared of land mines and UXO during a five-year period between
2014 and 2018 was 190.52 km2, compared to 890 km2 of remaining contamination, which is 4.7 times
as large as that of the cleared area.24 At this rate, it will require another 25 years to rid Cambodia ofmines and UXO.
In order to help keep people from falling victim to land mines and UXO, it is important to provide
mine risk education in school health.24 According to statistics, youth under 18 account for 11% of
casualties, and a majority are boys (9%). What should we teach? A Japan-based international NGO25 thatis active in Myanmar, Afghanistan, and Uganda teaches the following:(i)

The colors, shapes, and sizes of mines and UXO(ii) The typical locations where mines and UXO are found(iii) What to do if one encounters a mine or UXO
258

Figure 13.5 The urban environment in Phnom Penh
Chapter 13

Environment and health / Ecohealth259

involves many elements, including buildings, neighborhoods, streets, parks, transportation systems

3

Merriam-Webster Dictionary online. environment. https://www.merriam-webster.com/dictionary/environment(including cars), housing, water supply and sewage disposal, energy grids, recreational facilities,

4

Diamond J. Collapse: How Societies Choose to Fail or Succeed. Penguin Books. 2011.

5

Asakura T, Mallee H, Tomokawa S, Moji K, Kobayashi J. The ecosystem approach to health is a promising strategy in international

distribution systems, information systems, industrial facilities, and commercial facilities (Figure 13.4).27

development: lessons from Japan and Laos. Globalization and Health. 11: 3. 2015. https://www.ncbi.nlm.nih.gov/pmc/articles/

Built environments, therefore, have large impacts on the urban ecology and human health. Human
health may be determined by the following dichotomies, for instance: if one’s physical activity is
promoted or hindered; whether or not one can obtain health-promoting food; if one enjoys good or poor
indoor or outdoor air quality; if one is socially excluded or isolated, or has smooth social relationships;
whether or not one has access to safe water; whether or not there is a safe transportation system; whether
or not one can get a job; whether or not one has elevated opportunities to become infected due to
crowding, and so on.27 It is necessary to monitor how Phnom Penh’s built environments affect humanhealth.

PMC4340288/
6

Honda S, Kamiya M. Environmental issues in Cambodia -with Field survey of mercury in biological samples-, Research reports of
the Kogakuin University, 108: 37-43, 2010.

7

WHO Regional Office For the Western Pacific Bureau. Environmental Health. https://apps.who.int/iris/bitstream/
handle/10665/259292/WPR-RC067-07-Environmental-health-2016-en.pdf?sequence=1&isAllowed=y8

Supplementary appendix 2a (Part 1 of 2) (GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries
and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet 396: 1223–49, 2020).
https://ars.els-cdn.com/content/image/1-s2.0-S0140673620307522-mmc2a.pdf

9Food and Agriculture Organization of the United Nations. Banana facts and figures. http://www.fao.org/economic/est/estcommodities/bananas/bananafacts/en/

10 Cash and chemicals: Chinese banana boom a blessing and curse in Laos. The Straits Times MAY 16, 2017. https://www.straitstimes.
com/lifestyle/food/cash-and-chemicals-chinese-banana-boom-a-blessing-and-curse-in-laos

Exercises for further thought and research[13-1] Name environments that are important for the health of humans and survival of life and discuss
why they are important.
[13-2] Give one example each of physical, chemical, biological, cultural/psychosocial environments,and look into how they are related to human health.
[13-3] Look for a case where Cambodia’s social and economic development produces impacts on thehealth of ecosystems, people’s lives and main occupations (livelihood), and human health.
Review the case and draw a chart that illustrates what links lead to health issues.
[13-4] Pick up one issue associated with urban built environments in Phnom Penh and look into how it
is related to lives and health of humans.
[13.5] Have a group discussion about which of the SDG 17 goals (Cambodia Sustainable Development
Goal: https://csdgs.org/km/) the environmental health and ecological health issues correspond to.
[13-6] Do research on organizations that are engaged in the protection of the environment or ecosystems
and report the results.

11 Geissen V, Ramos FQ, Bastidas-Bastidas PJ, Dı´az-Gonza´lez G, Bello-Mendoza R. et al., Soil and Water Pollution in a Banana
Production Region in Tropical Mexico. Bulletin of Environmental Contamination and Toxicology, 85:407-13, 2010.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2952104/
12 Svensson O, Bellamy AS, den Brink PJV, Tedengren M, Gunnarsson JS. Assessing the ecological impact of banana farms on water
quality using aquatic macroinvertebrate community composition, Environmental Science and Pollution Research. 25:13373-13381,
2018. https://link.springer.com/article/10.1007/s11356-016-8248-y
13 Blum RW, Bastos FIPM, Kabiru CW, Le LC. Adolescent health in the 21st century. 379: 1567-1568, 2012. https://www.thelancet.
com/journals/lancet/article/PIIS0140-6736(12)60407-3/fulltext
14 CDC. The Social-Ecological Model: A Framework for Prevention. https://www.cdc.gov/violenceprevention/about/socialecologicalmodel.html
15 Wingqvist GÖ. Cambodia Environmental and Climate Change Policy Brief. 2009 University of Gothenburg. https://sidaenvironmenthelpdesk.se/digitalAssets/1683/1683319_cambodia-env-and-climate-change-policy-brief-2009.pdf
16 Ministry of Environment. Cambodia Environment Outlook, 2009. https://wedocs.unep.org/handle/20.500.11822/8689
17 Lang O, Sothea M. Current Status of Shrimp Farming and Diseases in Cambodia. Addressing acute hepatopancreatic necrosis
disease (AHPND) and other transboundary diseases for improved aquatic animal health in Southeast Asia. 33-36. 2016.
https://repository.seafdec.org.ph/handle/10862/3086
18 Kajiyama T. Forest Resources and Their Transformations. In Waragai T Ed. Study on Cambodia: Its Nature, Culture, Society,
Politics, and Economy. 111-131, Bunshin-do, 2019.
19 Food and Agriculture Organization of The United Nations. Fertilizers indicators. http://www.fao.org/faostat/en/#data/EF/visualize
20 Ritchie H, Roser M. CO2 and Greenhouse Gas Emissions. Published online at OurWorldInData.org. 2020. https://ourworldindata.
org/co2-and-other-greenhouse-gas-emissions
21 WHO. Climate Change and Health in Cambodia: A Vulnerability and Adaptation Assessment. 2010.
https://www.who.int/globalchange/mediacentre/events/2010/costa_rica_consultation_200710/CAMBODIA_va.pdf
22 JICA. What is Cambodia Mine Action Centre? https://www.jica.go.jp/project/cambodia/0701732/outline/ku57pq0000231j8w-att/
cmac_01.pdf
23 Geneva International Center for Humanitarian Demining. ‘Finishing the Job’ An Independent Review of the Mine Action Sector in
Cambodia. 2016. https://www.gichd.org/fileadmin/GICHD-resources/rec-documents/Cambodia-Sector-Review-Final-ReportGICHD.pdf
24 Landmine and Cluster Munition Monitor. Landmine monitor 2019. http://www.the-monitor.org/media/3074086/Landmine-Monitor-

References

2019-Report-Final.pdf
25 AAR Japan. Mine Action. https://www.aarjapan.gr.jp/english/what_we_do/landmine/

1

Skolnik R. Global Health 101 4th Edition, pp.189-218, Jones & Bartlett Learning, Burlington, MA, 2020.

26 United Nations. World Urbanization Prospects 2018. https://population.un.org/wup/Country-Profiles/

2

Landrigan PL, Fuller R, Acosta NJR, Adeyi O, Arnold R, et al. The Lancet Commission on pollution and health, Lancet, 391:

27 Dannenberg A, Capon AG. Healthy Communities. In Frumkin H Ed. Environmental Health-From Global to Local. Third edition.

462–512, 2018.

260

377-411, Jossey-Bass, San Francisco, 2016.

Chapter 13

Environment and health / Ecohealth261

Chapter 14
Column: Hazard risk model

School safety and crisis management

To achieve safety, multiple basic safety theories have been developed from the standpoint of accident
prevention. A hazard risk model, one of these theories, is explained in this chapter.
A hazard risk model is a theory on safety that has recently become common understanding in
the fields of safety engineering as well as occupational safety and health.1 This theory basicallyLearning objectives

divides the concept of danger that can lead to the occurrence of harm (damage actually incurred)

You will be able to gain proper understanding and explain:

into hazard and risk. The methods for estimating risks vary among fields and disciplines, and the- The concept of safety as well as the theory and method of crisis management.

definition below is adopted for the prevention of accidents in the concept of crisis management in- The present situation and characteristics of accidents involving children.

nursery/educational settings.

- The concept of, and measures for, school safety (i.e., daily life safety and traffic safety) that shouldbe pursued in the future.

Risk = Gravity of hazard × Probability of occurrence of damage caused by the hazard
Even when a hazard exists and its seriousness understood, if the probability of the hazard

This chapter explains the basic concept of, and measures for, school safety. First, the outlines of thecausing harm to people is zero or close to zero, then the risk will also be zero or close to zero.

concept of safety, the psychological and physical traits of children, and the characteristic of their

Examples of hazards include bicycles, steps, doors, desks, and raised playground equipment.

accidents are given. Then, explanations are provided about the present situation of traffic safety and theThese are hazards that can cause collisions, stumbles, and falls. For the prevention of accidents, theneed for traffic safety education in Cambodia, and the basic concept of safety management and safety

viewpoint of environmental improvement is important, which includes eliminating hazards andeducation in schools that should be pursued in the future.

taking effective measures to keep children away from hazards (e.g., attaching cushioning material tothe corners of desks).

1. Concepts of safety and danger

2) Disasters and accidents
1

First, an explanation is given about the basic concepts of safety and danger.

A disaster refers to the occurrence of some kind of injury or damage to the lives, bodies, or property of1) Concept of safetypeople, which is caused by a danger resulting from a natural phenomenon or a human factor. Disasters
can be divided into natural disasters (e.g., meteorological disasters and earthquakes) and man-madedisasters (e.g., life disasters, traffic disasters, industrial accidents, criminal damage, and war damage

Safety refers to “a condition in which the lives and property of people are protected without beingthat are caused in daily lives). Most man-made disasters are brought about by accidents. Accidents can

exposed to natural or unnatural harm in daily lives,” while “a factor or condition that can undermine thebe divided into traffic accidents in a broad sense (i.e., car, railway, airplane, and marine accidents) andsafety of people” is called a danger or hazard. A thing that can be evaluated with probability as alife accidents caused in various situations in daily lives in general, including schools, homes, andproduct of the seriousness of the hazard (the magnitude of the hazard and damage) and the probability

communities (unexpected accidents that occur in daily lives, including suffocation, and stumbles/falls).

of occurrence of the hazard is called a risk (see Column: Hazard risk model). A thing that cannot beLife accidents that occur in schools, including falling down stairs and injuries caused by aging playgroundevaluated with probability is an uncertainty, which is distinguished from a risk. A condition in which aequipment, can occur even during a break (see “6. School safety”).

risk has actually caused some kind of damage to the lives or property of people is called an accident,
and damage to the human body caused by an accident is referred to as an injury.
For people who have undergone a certain level of development, it is easy to avoid “visible danger(explicit danger)” but difficult to avoid “invisible danger (latent danger),” which often causes

2. Characteristics of accidents involving children fromthe standpoint of developmental stages

accidents. The basic measure to prevent accidents comes down to the detection and removal of danger
before an accident occurs.

What kinds of accidents and injuries can occur from early childhood to adolescence? This section
explains the characteristics of accidents and injuries that can occur from early childhood to adolescence,as well as the factors behind them.2 Because the growth and development of the mind and body are

262

Chapter 14

School safety and crisis management263

immature in these periods, it is necessary to deepen children’s understanding of safe behavior while

their field of activities, which is markedly different from early childhood, during which they lived underimproving the safety management of their surroundings.

the protection of their parents. Accordingly, the possibility of encountering danger increases, which
requires them to choose safe behavior on their own.

1) Characteristics of the mind and body and behavior in early childhood

In the upper grades in particular, their inability to solve psychological problems can cause unstableconditions, which may then lead to a major accident/disaster; therefore, guidance, management, andconsideration by adults around them are important. In addition, basic lifestyle habits centered around

Early childhood is a period in which both mind and body significantly grow and develop. It is also aeating, exercise, and rest tend to become irregular as the child ages. After returning home on weekdays,

period in which the ability to communicate with others develops. Major physical characteristics in early

elementary school students spend more time watching screens, including TV, games, and smartphones,

childhood are as described below:

except for the time spent on their assignments and chores. This kind of lifestyle pattern is likely to break
the regularity of children’s lifestyle habits and involves the risk of having consequences on their healthi) Early childhood is a period in which relatively stable physical growth is seen.

(see Chapter 5). Although this does not have direct effects on safe life, it may cause distractions in dailyii) It is a period in which visual and auditory functions develop toward completion.

life or lead to dangerous behavior, which is mentioned later; thus, it cannot be ignored from the standpointiii) The nervous system significantly develops, and coordination between multiple functionsof safety education as well (see life accidents mentioned earlier).

develops.
From the standpoint of behaving safely by avoiding danger, there are characteristics of growthand development that need to be taken into consideration. For example, immaturely developed visual

Table 14.1 Psychological, social, and behavioral characteristics of elementary school

students

School age

and auditory senses may cause a delayed perception of danger. Although eyesight significantly develops• Become able to understand theconsequences of their behavior.

in infancy, it is only when children turn five or six years old that it stabilizes to visual acuity of 1.0 or
above. Binocular stereopsis is said to fully develop at around five years of age.
For auditory function, the important ability related to safety is the ability to determine soundPsychological, social

Lower grades• Come to have their own opinion andsometimes rebel against their parents.

localization (the position of a sound source), which also develops throughout early childhood. To avoid

Behavioral• Impulsive behavior decreases.
• Activities in a group consisting only ofchildren increase.
• Become able to show appropriate
behavior by understanding theconsequences of their behavior.

danger by quickly detecting the position of a car, it is essential to precisely determine the position of the• Psychological problems increase, suchas feeling stress and being unable tocontrol their emotions.

sound source. However, even if visual and auditory functions have developed, the detection of danger
may be delayed in cases where children are short in stature and have difficulty detecting things aroundthem or in cases where children have little experience of danger. Because the adults’ perspective alone• The inability to appropriately cope withproblems may cause a psychologicallyunstable state and result in violenceagainst people or destruction of things.

is likely to overlook danger, sufficient attention is needed from the children’s perspective.
The development of exercise capacity is another important factor to avoid danger. In exercise,coordination between the visual observation of the target and body movements is important. The rapid
development of this coordination is a characteristic of early childhood.

2)	Characteristics of the mind and body and behavior of elementary
school students• Tend to attach greater importance torelationships with friends than to thosewith adults (teachers, parents).

Upper grades• Come to show the behavior of losing
control.
• Come to exhibit a breakdown in basic
lifestyle habits.
• Spend more time on screens (TV,
games, and smartphones) after
returning home.
2

During the six years of elementary school, major changes are seen in growth and development. In
particular, children from 10 to 12 years of age are in the secondary rapid growth period and show a spurtof growth, which is represented by height growth. In this period, exercise capacity also develops,
establishing the physical foundation needed to behave safely.

Source: Adapted from Reference(1) Challenges in the safety education of elementary school students
Psychological development associated with the cause of behavior and the prediction of its consequences

However, from the standpoint of safety, psychological/social or behavioral changes are characteristics

is an important factor from the standpoint of predicting and avoiding danger. Elementary school childrenthat are more important than physical growth (Table 14.1). Elementary school students greatly expand

come to easily understand this kind of causal relationship from the lower grades, allowing for effective

264

Chapter 14

School safety and crisis management265safety education in elementary schools. In elementary schools, students are required to start with thefor behaving safely.

creation of an awareness of dangers around them through experiences and then gradually increase their

In addition, students need to learn in safety education not only the risk of becoming a victim of an

knowledge of dangers and disasters. Particularly in the upper grades, it is effective to use information

incident/accident but also the potential risk of causing damage to others. For example, riding a bicyclefrom mass media (TV, radio, and newspapers/magazines) and the internet to help students understandrecklessly or without a light can cause a collision with a pedestrian and may even take a person’s life inand consider safety in safety education.

the worst case. Even junior high school students need to be fully aware of their responsibility for traffic

Elementary school students are in a period in which they have a high normative consciousness andsafety as citizens.

are willing to accept the guidance of adults; this period is considered suitable for safety education.
However, in addition to providing safety education, it is also important for adults to serve as models ofsafety behavior. It is the basis of safety education for adults to set an example first, such as complying

3. Causes of injuries in accidents involving minors

4with regulations. Moreover, it is also important to gradually add consideration for the safety of others,
particularly the safety of their family members, juniors, and elderly people, to the contents of teaching.

Traffic accidents in Cambodia account for the largest percentage of injuries due to accidents, with
71.8% of those who were injured in the past 12 months being related to road accidents (Table 14.2). Of

3)	Characteristics of the mind and body and behavior of junior high school
students

the injuries, falls and stumbles accounted for 9.7%, followed by snake or animal bites at 5.1%, violence
at 2.4%, severe burns at 1.2%, and guns, drowning, and poisoning at less than 1% each. Others or
unknown causes accounted for 9.2% of the injuries.
For the injuries in those aged 0–9 years, the leading cause was traffic accidents at 48.7%, followed

Reaching puberty in this period, students move toward being mentally independent from their parents,

by falls and stumbles at 22.5%, snake or animal bites at 13.5%, severe burning at 2.0%, violence ator they rebel against their parents and school more often than before. In junior high schools, the number

1.5%, and other or unknown causes at 11.7%.

of incidents of bullying and violence is larger than that in elementary and senior high schools, indicating

Among injuries of those aged 10–19 years, the leading cause was traffic accidents at 67.8%,

that it is also a period in which the possibility of dangerous behavior, including problem behavior,followed by falls and stumbles at 9.2%, snake or animal bites at 5.1%, violence at 3.7%, severe burns atincreases (see Chapter 11).

2.0%, and others or unknown causes at 12.1%.

The decline in normative consciousness is cited as a factor for dangerous behavior. Junior highschool students tend to be more permissive about acts against social rules. Such examples include
crossing a road by ignoring the traffic light and using a mobile phone/smartphone while walking. The

Table 14.2 Causes of injuries by age

decline in compliance with social norms does not directly lead to problem behavior, but as its relationshipType of accident

to drug abuse, for example, has been pointed out,3 it constitutes one of the important background factors.
Susceptibility to peer pressure is also a characteristic of this period. Students begin to show aAgetendency to be afraid of being left out of the group and thus dare to do something dangerous in order toattract attention from peers and enhance a sense of belonging to the peer group.

Fall
from
Road
accident tree/building

Snake/
animalbite

Violence

Severeburns

Gunshot

Poisoning
Drowning Others(chemical)

Don’t
know/
missing

Injured

0-9

48.7

22.5

13.5

1.5

2.0

0.0

0.0

0.0

6.6

5.1

The tendency to try to engage in dangerous behavior is not limited to particular children. Instead, it is

10-19

67.8

9.2

5.1

3.7

2.0

0.0

0.0

0.0

12.1

0.0

generally seen in young people’s normal process of development and plays an important role, good or

20-39

79.4

6.1

3.3

2.7

1.1

0.7

0.4

0.0

6.3

0.0

40-59

73.1

11.1

4.5

1.6

0.9

0.1

0.6

0.0

8.2

0.0

represented by school rules. This triggers various dangerous behaviors. It is thought that most dangerous

60+

60.3

13.1

6.4

1.1

0.0

0.0

0.0

0.0

17.6

1.4

behavior in this period is exploratory behavior (attempts), with only some leading to significant deviations

Total

71.8

9.7

5.1

2.4

1.2

0.3

0.3

0.0

8.6

0.6

(1) Challenges of the safety education of junior high school students

bad, for their growth into adulthood. Dangerous behavior is a means of become independent fromparents and get peers. Conversely, it may lead to a decline in the sense of compliance with social norms

and continuous dangerous behavior.
However, if it is a behavior that may lead children to damage themselves or others and possibly

Percentage of the population injured in an accident in the past 12 months by type of accident according to age, Cambodia 2014
4
Source: Adapted from Reference

cause them to die, teachers are required to correctly tell their students the importance of respecting theirown lives and those of others as well as the consequences of reckless behavior, and to provide justification
266

Chapter 14

School safety and crisis management267

4. Traffic safety and the prevention of traffic accidents

Table 14.3 Contents of traffic safety education

Traffic accidents are problems that we all face. In Cambodia, the mortality rate associated with traffici) Understanding dangers associated with walking on a road and crossing a road, and how to behavesafelyaccidents is increasing every year (Figure 14.1).5 It is characterized by a large number of deaths associatedii) Inspection/maintenance of bicycles and proper ways of riding themwith motorcycles and tricycles. The prevention of traffic accidents requires the establishment ofiii) Understanding the characteristics of motorcycles and tricycles, and their safe use

relevant laws and regulations, the creation of a safe traffic environment (i.e., building road networks andiv) Understanding the characteristics of cars and how to behave safely in a driving car

improving the quality of existing roads), the inspection and maintenance of vehicles, and activities tov) Correctly understanding and complying with traffic regulations

educate people through traffic safety education.

vi) Understanding drivers’ obligations and responsibilities, including cases where a bicycle is used

The challenges in Cambodia include drivers’ low awareness of the safety of vulnerable road users(i.e., children, elderly people, and pedestrians) and low awareness of compliance with laws (e.g.,vii) Understanding and considering the traffic safety of children, elderly people, disabled people, the sickand wounded, and pedestrians

compliance with traffic regulations, helmet use, and particularly, not committing speed violations orviii) Understanding the importance of creating a safe traffic society through active participation/
cooperation

driving under the influence of alcohol).

ix) Functions of related organizations such as police and firefighters

The contents of traffic safety education (Table 14.3) in schools include understanding dangers in

6

Source: Created using Reference

various traffic situations as well as learning safe walking practice and the safe use of bicycles,
motorcycles, and tricycles. In addition, it is important to be able to practice safe behavior by learning topredict and avoid danger. The major goals of traffic safety education are for children to behave inaccordance with traffic rules and to take proper actions to protect themselves on their own, that is,

Column: School commuters’ situations and the challenge of helmet use in Cambodia7“stop,” “watch,” and “check.”6 At the same time, these goals serve as the basis for the creation of a

In Cambodia, the most common means of transportation is motorcycles. They account for more

safe traffic society.

than 80% of the officially registered motor vehicles, with deaths caused by motorcycle accidents
making up 67% of annual traffic fatalities. On top of that, the death toll is rising. Cambodia’s law
requires drivers to wear helmets but does not require passengers to do so. When both the driver and

(%)

20.0

the passenger use a helmet, deaths can be avoided. The prevention of motorcycle accidents is an
important challenge in Cambodia’s traffic safety education.

19.5

Moreover, although the law allows people aged 16 years and older to drive motorcycles, this19.0

regulation is not strictly enforced. For example, we see students who live in areas far from their

18.5

to school every day. There are often two or three students, sometimes even more, on a motorcycle,

schools and who have difficulty commuting on foot or by bicycle, driving motorcycles to commuteand they rarely wear helmets. This is a challenge for school attendance and safe commutes.

18.0
17.5

5. Prevention of criminal damage

17.0

With rapid urbanization and computerization, protecting against criminal damage, such as abduction

16.5

and injury, has become an important challenge in school safety. The number of criminal damage cases
through the use of the internet, which is related to the spread of smartphones and SNSs (social networking

20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
20
18
20
19

16.0

Source: Adapted from Reference5

Figure 14.1 Mortality rate caused by road traffic injury (per 100,000 population)

services), has increased, and the prevention of criminal damage involving schoolchildren has become an
extremely important global challenge (see “Column: Children living in the digital age”). However, thischallenge cannot be solved only through measures taken by schools; it should be addressed by the wholesociety.
This section explains how to respond to the presence of suspicious persons, which schools in
Cambodia will also need to address in the future.2

268

Chapter 14

School safety and crisis management2691) Hardware aspect of crime prevention measures (facilities/installations)persons into the school are shown in chronological order (Table 14.4). It is important to give the highest
priority to the lives of people in all items.

As a crime prevention measure from the aspect of facilities/installations, the principles of “Securingvisibility and territorial reinforcement/maintenance” and “Controlling access and entry” areimportant. These mean eliminating blind spots by improving visibility (Securing visibility and territorial
reinforcement/maintenance) and preventing those attempting to commit crimes from accessing/entering
the school premises and school building (Controlling access and entry). To this end, what can be done
first in Cambodia is to place a fence around the premises and post a security guard. With a fence, it will

Table 14.4 Crisis management flow in case of entry by a suspicious person

Item

Response

Early detection andchecking of a suspicious
person• As a rule, ask the purpose of the visit before allowing a person into the school
premises.

also be possible to prevent entry by stray dogs and domestic animals, such as goats, and to prevent• Ask a person without a proper reason to exit.

damage to the premises caused by unsanitary excretions as well as damage caused by wild dog bites.
Moreover, as the national and local economies develop, it may become possible to introduce security
installations one by one, including security cameras and interphones, automatic lock systems at gates,

Prevention of humandamageThese installations are not expected to be highly effective without the software aspect of crisis• If someone is injured, give first-aid to the person and promptly check thesafety of all people.

management, which is mentioned later. Even with security cameras, if the system for intentionally
easily gain entrance. It must be noted that hardware will be effective only when there is software• When school personnel sense danger or suspicion, promptly contact other staffof the school as well as police and related organizations.
• If the person tries to use violence, take appropriate protective measures while
promptly evacuating and guiding schoolchildren.

and emergency alarm systems.

monitoring them is inadequate, or the notification system has been cancelled, suspicious persons may• When there is a suspicious person in the school premises, say something to theperson.

Appropriate subsequent
response• Promptly build an organization for post-incident response.
• Grasp the situation of the incident and organize information.
• Contact guardians.

enhancement.

• Take measures to prevent recurrence.

2) Software aspect of crime prevention measures
It is important to establish a crisis management system in schools, and to devise and apply effective
measures based on the system, and to devise and apply a crisis management manual. The points to• Create a system for providing post-incident mental health care toschoolchildren, school personnel, and guardians.
Common matters• Gather information at one place (e.g., the principal) and record it accurately.
• Check one by one whether the critical situation was appropriately addressed
and that nothing has been overlooked.

achieve this are described below.
i) Create a crisis management system by clarifying the roles of managers and the persons incharge of safety.
ii) Collect information on suspicious persons around the school while collaborating with families
and related organizations in the community.

Column: Children living in the digital age

8

The United Nations International Children’s Emergency Fund (UNICEF) states in its report “Children
in a digital world (2017)”8 that digital technology has already significantly changed the lives and lifeiii) Take feasible and effective measures depending on the various situations.

chances of children. It points out the advantage of this technology by saying that if the technologyiv) Collaborate with related organizations/institutions in the community, and seek cooperation

becomes equally accessible all over the world in the right way, children will be able to connect to life

from guardians and community residents.
v) Create a crisis management manual suited to the situations of the school and the community.
In this process, clarify the priority of responses in case of an incident/accident.

chances around the world and gain skills and knowledge from a variety of learning resources by
overcoming disadvantages due to poverty, race, ethnicity, gender, and geographical conditions.
Meanwhile, digital technology has negative aspects as well as positive prospects. One examplevi) Conduct training to effectively apply the crisis management manual.

is the digital divide, by which poorer countries and remote areas within those countries are leftvii) On the basis of challenges obtained through training, improve the crisis management manual

behind in terms of “global” information because of their underdeveloped internet infrastructure. In

to make it more functional.
viii) Actively provide crisis management training for school personnel to enhance and maintaintheir awareness of crisis management.

addition, there is harm that can be caused to children’s online lives, such as the amplification ofexisting harm like cyber bullying, the occurrence of new forms of sexual abuse and exploitation, andwebsites containing information that could induce children to commit suicide and crimes. There has
been damage that is serious and less visible from people who are around children. UNICEF cautions

Items that should be included in the crisis management manual for coping with the entry of suspicious
270

that particularly in areas in which the internet has recently spread, such as Africa and Southeast
Chapter 14

School safety and crisis management

271

Asia, inadequate safeguards are exposing children to major risks on the internet.
As a matter of course, guardians are concerned about children’s health issues, including effects
on eye health, internet addiction disorder, depression, and obesity.

≥5 m
≤30 m

Column: Natural disasters that frequently occur around the world2

Natural disasters frequently occur and cause heavy damage around the world. Flooding alone
accounted for 47% of all weather-related disasters (1995-2015), affecting 2.3 billion people, themajority of whom (95%) live in Asia. It has been reported that about 90% of the people who lost theirlives lived in low-income countries.9

45˚

45˚

4m

In the international community, the 1990s was designated as the “International Decade for
Natural Disaster Reduction,” and since then, the United Nations Office for Disaster Risk Reduction

Figure 14.2 Response to lightning10(UNDRR) has taken the initiative to promote international cooperation aimed at reducing damage
caused by natural disasters.
It is necessary to provide disaster prevention education in schools and communities, andconsider what schools can do to protect the lives of children and community residents in case of a

6. School safety

natural disaster.

This section explains the concept of safety at school.6 School safety should be addressed with school
Column: Response to lightning10

health in an integrated manner in order to ensure the health and safety of schoolchildren, and to develop
the basic knowledge that enables them to nurture mental and physical health and remain safe throughout

Lightning occurs as follows: Static electricity is generated when light air warmed by sunlight during

their lives. School safety is aimed at developing schoolchildren’s qualifications/skills to behave safely

the day ascends while the upper cool air descends. This static electricity is built up in clouds, andon their own and contribute to the safety of others and society on the basis of respect for their own lives

electricity that the clouds cannot hold any longer is discharged as lightning. The effects of lightningand those of others, as well as at creating an environment to ensure the safety of schoolchildren.

on the human body are the direct lightning stroke and the side flash. The direct lightning stroke islightning that strikes the human body directly from the cloud. In this case, 80% of victims lose their

School safety has three fields: Daily Life Safety, Traffic Safety, and Disaster Safety (disasterprevention) (Table 14.5).

lives. Areas surrounded by open space, such as flat areas and mountaintops, are dangerous. The

Accidents that can occur during school time include accidental falls from stairs, a landing, a veranda,side flash is lightning that rebounds off a tree or other tall object struck by the lightning to a person

or a balcony, which require sufficient attention in safety management in schools. In addition, accidents

staying near the tree; or receiving an electric shock through the ground from a tree struck by lightning.

caused by the deterioration or lack of proper maintenance of building structures and facilities/installations

Evacuating to a safe place before lightning is generated is important. When you notice signs ofin schools cannot be overlooked.

lightning, such as black clouds approaching or the sound of thunder, shelter in a house, building, or

In recent years, there has been concern about critical events that take advantage of changes in thecar. Removing metals from the body or wearing an insulator like rubber boots will not protect aenvironment surrounding schoolchildren, such as the spread of smartphones and SNSs, and which target

person from a lightning strike.

schools (see Column: Children living in the digital age). Since critical events surrounding schools change

If there is no building that can serve as a shelter, shelter under a tall object that is at least fivemeters high (i.e., a utility pole, chimney, or steel tower). In doing so, keep a distance of four meters

as the times and society change, the way school safety operates needs to be flexibly reviewed to respondto the emergence of new critical events that were not considered in the past.

or more from the object while staying within a zone that allows you to look up at the top of the object

Activities for school safety consist of three major activities, namely, safety education, which is

at an angle of 45 degrees or greater. Staying close to the object will increase the risk of receiving a

aimed at developing schoolchildren’s abilities to safely behave on their own and contribute to the safety

side flash. Facing down or lying on the ground will also increase the risk of receiving a side flash. Itof others and society by predicting various dangers latent in their own behavior and environment, safety

is advisable to crouch and keep your head as low as possible (Figure 14.2).

management, which is aimed at making the environment surrounding schoolchildren safe, andorganizational activities, which facilitate both activities.

272

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School safety and crisis management273

Table 14.5 Major contents of school safety

Field

be correlated. The document that specifically provides necessary matters and procedures to properly
respond to the process from the occurrence of the accident to emerging from the crisis and restoring

Contents• Injuries and accidents while studying or during school time

Daily Life Safety• Incidents and accidents in family life

own crisis management manuals and share a common understanding among all school personnel so that

• Prevention of crime damage (e.g., abduction, bodily harm,
theft, and abuse of the network)

they can properly respond every day as well as in emergencies. In addition, it requires continuous• Dangers in school routes, safe way to commute to school• Safety of the school environment (facilities/installations),
creation of a safe environment• Danger, safety, and the prevention of accidents in various
traffic situations

Traffic Safety• Inspection/maintenance of bicycles, understanding thecharacters of motorcycles, tricycles, and cars, and safety whileriding them
• Correct understanding of , and compliance with, traffic
regulations

verification and improvement.

2) Actual practice of crisis management in schools10
Crisis management in schools is divided into preventing incidents/accidents through early detection ofdanger (risk prevention), ensuring the safety of children and school personnel (risk management), andpreventing the spread of damage through a prompt and proper response to incidents/accidents as well as
subsequent measures (crisis management). Crisis management in schools is chronologically classified
into the four phases below (Table 14.6). The content and flow of these phases are specifically explained• Creation of a safe traffic society based on new scientifictechnology

Disaster Safety(Disaster prevention)

safety is called a crisis management manual. On the basis of these matters, schools need to create their

below.

• Understanding the dangers of natural disasters (i.e., wind andflood damage, drought and famine, lightning, earthquakes,
tsunamis, forest fire, and volcanos)• Understanding dangers in case of a fire or disaster, and how tobehave safely• Use of information on disasters and preparedness for disasters

Table 14.6 Crisis management in school

Phase

Crisis management item

1 Prevention

Prevent incidents/
accidents from occurring

2 Preparation

Creation of a crisis management system,
collaboration with related organizations/Prepare for the occurrence
institutions, support from guardians andof incidents/accidents
community residents, creation of the crisis
management manual, carrying out training

3 Response

Promptly respond toincidents/accidents

Security of children and school personnel,
grasping the situation, emergency medicalcare, prevention/mitigation of the spread ofdamageSubsequent response toincidents/accidents andrestoration

Communication/explanation to guardians
and related people, preparation to resume
education, measures for preventing therecurrence of incidents/accidents, mental
health care, review of the crisis
management system• Mental health care during and after a disaster
1,2,11,12

Source: Created using references

7. Crisis management in schools
1) Concept of crisis management in schools6
Crisis management in schools must reflect the realities of schools, families, communities, and relatedorganizations. In addition, it needs to assume various situations, including learning time both in and outof school, during commutes, breaks, lunch time, school events, and during the absence of a principal,
vice-principal, or person in charge of safety, and requires drawing up a plan that can cope adequately
with a variety of incidents/accidents. The most important aspect is to give the highest priority to the

4 Restoration

Specific activity

Safety inspection, development ofchildren’s ability to predict and avoid
danger

Source: Created using rerence10

security of schoolchildren. The document that states these matters for the purpose of their implementation
is called a school safety plan.
To conduct proper crisis management, it is necessary to prepare a detailed school safety plan inadvance. In considering a school safety plan, the three activities, that is, activities related to safety
education, activities related to safety management, and organizational activities related to safety, need to274

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School safety and crisis management275

(1) Prevent incidents/accidents from occurring [Prevention]

occurrence.
ii) Analysis of schoolchildren’s behavior

Inspecting facilities/installations and apparatuses in school as well as the safety of school routes is one		The occurrence of multiple accidents is linked to schoolchildren’s behavioral characteristics.

of the important aspects of crisis management to prevent schoolchildren from getting involved in

Observe how schoolchildren behave in dangerous spots in school and on school routes, andincidents/accidents. Efforts to “isolate,” “analyze,” and “manage” dangerous spots in the environment

obtain concrete images of possible accidents. After that, determine the environmental conditionsof school life, including going to and from school, need to be systematically made based on the Plan-

and challenges in guidance that should be improved.

Do-Check-Act/Action (PDCA) cycle.

a) Isolating dangerous spotsiii) Survey by schoolchildren		
The analysis of dangerous spots conducted by schoolchildren is useful because it can lead tothe identification of problems from the perspective of schoolchildren as well as the safety

Use the three types of information below for reference to isolate spots where accidents are likely to

education of schoolchildren themselves. It is also effective to collect information fromoccur.

schoolchildren about their dangerous experiences and create a local safety map, then exchange
opinions with guardians and community stakeholders.
i) Information provided by school personnel, schoolchildren, guardians, and communities
Collect information from all the stakeholders, including school personnel, schoolchildren,c) Managing dangerous spots and the organizational structure

guardians, and communities, about places where they were injured at school or where they

Through the isolation and analysis of dangerous spots, consider concrete improvement plans to takeexperienced a danger on their way to or from school, and mark them on a local map. Identify

measures. It is desirable that schools, families, and communities come together as one to systematicallyplaces where many schoolchildren were injured and where a danger could have led to a major

promote discussions on activities including regular inspections.

accident, and narrow down the spots to which priority should be given in taking measures.
ii) Information about the occurrence of past accidents
		 For example, places where abductions or a suspicious approach incident occurred in the past,(2) Prepare for the occurrence of incidents/accidents [Preparation]a) Evacuation drills

places where schoolchildren were injured, and spots where a waterway overflowed should be

Evacuation drills are held in order to confirm the roles of school personnel stipulated in the crisis

recorded as objective facts and included in priority dangerous spots.

management manual and to nurture schoolchildren’s practical attitudes and ability to evacuate safely iniii) Information about accident occurrence conditions

case of an emergency.

		 The occurrence of accidents involves typical environmental conditions. Use the viewpoints of

Evacuation activities are “activities to protect life” from dangers that may occur in the next several

a hazard map and an inspection list for reference to find the environmental conditions that canseconds, minutes, and hours. The matters below need to be clarified before an evacuation drill wherever

be linked to accidents in school or in the commuting environment, and inspect them on a

possible, by considering what kinds of dangers can threaten schoolchildren’s lives and physical healthregular/irregular/daily basis. Conducting daily inspections for suspicious objects is also

from the standpoint of protecting them.

important.
			For your information, a hazard map is a map that indicates potentially dangerous placesi) What kinds of dangers can be posed? Evacuation from what?

and evacuation sites in case of a certain disaster. The map may differ depending on the type ofii) What kinds of evacuation activities should be taken for each danger?

disaster.

iii) When should evacuation activities be initiated?

b) Analyzing dangerous spotsb) Evacuation plans in case of danger

Analyze isolated dangerous spots to obtain concrete images of possible accidents and identify

Evacuation activities in case of danger vary depending on the type and scale of the danger as well as

environmental conditions that can cause a problem.

each individual’s characteristics and situation. Assuming that evacuation activities are “security activities
to escape danger,” they can be classified into “Wait (stay at the site),” “Move vertically (e.g., move to ai) Objective analysis through the eyes of multiple persons

276

secure place on the 2nd or higher floor),” and “Move horizontally (e.g., move to an evacuation site

Carry out joint inspections with stakeholders, and observe and analyze dangerous spots throughtemporarily or for a longer time)” in terms of space. Therefore, it is important to take this into accountthe eyes of multiple persons. As needed, seek cooperation from experts to conduct a moreand consider in advance what activities should be carried out in case of danger. In addition, evacuation

detailed, objective analysis. In regard to the situation of damage when an accident occurred

activities assuming secondary disasters (i.e., a series of disasters triggered by the primary disaster) also

and the place of occurrence, identify the environmental conditions that served as factors ofneed to be considered in advance.
Chapter 14

School safety and crisis management277

In case of danger, the school must protect the lives and physical health of schoolchildren by
establishing a countermeasures headquarters to help all school personnel fulfill their roles, such as
information gathering, evacuation guidance, and relief activities. To ensure the fulfillment of these roles,

Accident
occursit is necessary to create a crisis management manual in advance and to share a common understanding
among all school personnel.
It is necessary to prepare evacuation plans and include them in the crisis management manual bydesignating evacuations sites and evacuation routes individually and specifically on the basis of the

Discoverer

topographical and geological characteristics of the school environment and its surrounding areas, as wellas hazard maps created by local governments and organizations.

Grasp the situation(3) Promptly respond to incidents/accidents [Response]OK?

In the case of an accident in school, it is essential for the body that established the school (principal) to

Check the symptoms of
the sick (wounded) schoolchild

Ar
ey
ou

take prompt and proper action by giving the highest priority to the lives and health of schoolchildren(Figure 14.3). To achieve this, it is important for the school to have a flexible system in place as anorganization, and for all school personnel to always understand and master procedures for treating sick(wounded) persons promptly and properly without hesitation (see Chapter 15).
When a sick (wounded) schoolchild is found, it is important for the first person on the scene to check

Ask for help, instructionsFirst aid

the injured or ill schoolchild’s symptoms and ask nearby staff and schoolchildren to help while preventing
the symptoms from becoming serious by providing first aid, such as immediately stopping bleeding andproviding cardiopulmonary resuscitation (CPR), depending on the condition of the schoolchild. In caseof an accident, it is required to simultaneously perform many tasks, including contacting the guardian of
the affected schoolchildren and caring for other schoolchildren, in addition to providing first aid. All
school personnel must have a common understanding of what should be done promptly so that they can
respond systematically. In contacting the guardian of the affected schoolchild, make contact as early as
possible after organizing minimum information required about the general situation of the accident andthe degree of injury (i.e., minor, moderate, and severe).
In cases requiring emergency response, such as those in which the life of the affected schoolchild isManager(e.g., principal)

School staff

PoliceMedical institution

Guardianbeing threatened, take prompt action by giving a higher priority to lifesaving treatment than to reportingto the manager. School personnel need to work to reduce other schoolchildren’s anxieties without being
emotionally disturbed by the situation of the accident or the condition of the affected schoolchild. Try toleave notes as needed regarding the occurrence of the accident, measures taken after occurrence, and theresults of those measures while giving priority to first aid, and organize the contents of records once thesituation settles down temporarily.

(4) Subsequent response to incidents/accidents and restoration [Restoration]
Concerning accidents in school, the body that established the school (principal) is required to devise andimplement recurrence prevention measures by investigating the cause and verifying the previous safetymeasures, and to provide a sufficient explanation and continued support to the guardian of the affected

Treatment

schoolchild.
Specifically, organize background information about the occurrence of the accident once the responsethat was needed immediately after the accident is completed. Collect a broad range of information on
278

Figure 14.3 Example of response in case of an incident/accident in school(first aid/emergency contact system)

Chapter 14

School safety and crisis management279

Table 14.7 Framework of PFA-S

possible causes of the accident, conduct research/verification aimed at preventing accidents in the future,and make use of the results of research to prevent recurrence.

3) Experience of an incident/accident and mental health care2,10
Encountering an incident/accident can traumatize schoolchildren because of fear or loss; they may
develop symptoms, such as repeatedly remembering the event or reproducing the event in their play, as
well as emotional instability and sleep disorder, causing serious problems in their daily lives. These
reactions can happen to everyone, and in most cases, subside over time. If this condition persists forthree days to one month after the encounter with the incident/accident, it is called Acute Stress Disorder

Activity

Objectivei) Approach sufferers and start
activities

Reach out to sufferers (schoolchildren and the staff of the school) inan empathic manner without placing a burden on them, and respondto their requests.

ii) Safety and a sense of security

Ensure immediate security so that sufferers can rest their body andmind.

iii) Stabilization

Quell the disorder of sufferers who are overwhelmed by thesituation, and give them a perspective.

iv) Collect information

Collect related information and identify sufferers’ present needs andproblems.

v) Help solve actual problems

Help sufferers address their present needs and problems in arealistic way.

vi) Promote interactions withsurrounding people

Promote sufferers’ interactions with their families/friends/teachers/
other school officials who stay close to them and with supportingorganizations in the community, and provide assistance to makethese relationships last for a long time.

vii) Information helpful to respondto the situation

Provide sufferers with information on stress reaction and a coping
method in order to alleviate their suffering and enhance theiradaptive function.

viii) Introduction and transfer

Introduce services that sufferers presently need or will need in the
future, and transfer support.

(ASD), and if it persists for one month or longer, it is called Post-Traumatic Stress Disorder (PTSD).
Therefore, it is important to provide support for schoolchildren and their guardians immediately after theincident/accident for the prevention and early detection of PTSD. It should be noted there are cases inwhich schoolchildren develop symptoms of ASD soon after the encounter with the incident/accident,
which then become chronic and lead to PTSD, as well as cases in which symptoms are not noticeable atfirst and cases in which symptoms are reduced once but recur a few months later; thus, it is important toprovide mental health care for as long as possible (see Chapter 12).
In addition, the guardians of affected schoolchildren and school personnel may ignore these signs or
become insensitive to their own physical and mental disorders, and therefore, they may require mental
health care for themselves. For the affected schoolchildren, it is important for their guardians and theschool personnel around them to be mentally stable. This is why it is important for all the people involvedin the incident/accident to understand that they need mental health care, which includes noticing their

2,14

Source: Created using references

own physical and mental disorders as early as possible and take a break or have consultations proactively.

(1) Mental health care provided immediately after the occurrence of a crisis
Like bodily injury, mental trauma requires first aid. Psychological First Aid (PFA) is globally accepted

Column: Anniversary reaction2

as a basic method of mental health care provided immediately after the occurrence of a crisis. PFA

People who were traumatized by a disaster or incident/accident may reexperience their trauma,

provides the specific contents and overall procedures of mental health care that is necessary immediately

though since healed, on the date when they experienced it first. This is called an anniversary

after the occurrence of a crisis.

reaction.

The framework of the Psychological First Aid School Edition (PFA-S)13 consists of eight major

One method to cope with this is to inform guardians and children beforehand that the previous

activities (Table 14.7). The PFA-S considers it natural that schoolchildren and school personnel show

reaction may recur as the date of the disaster or incident/accident approaches, but they don’t havevarious early responses (i.e., physical, cognitive, behavioral, and spiritual problems) after an emergency

to worry even if it recurs because this reaction can happen to everyone. By doing this, it will besituation. Care provided by experts in disaster relief assistance and mental health can help schoolchildren

possible to prevent children’s anxiety from increasing as well as enable guardians to respond calmly.

and school personnel recover from these early responses, and leading such care to assistance tailored toeach person’s needs will be able to prevent symptoms from becoming severe or persisting for a long
time.

280

Chapter 14

School safety and crisis management281

8. Roles of school personnel in creating safe schools

1) Development of the ability to predict and avoid danger

This section explains the roles of school personnel required to make schools a safe and secure place/

Schoolchildren may encounter danger in a situation in which there are only schoolchildren, such as on

8,15

environment.

School personnel are required to appropriately make decisions and take action according

their way to or from school or on holiday. In such a situation, schoolchildren need to predict and avoid

to circumstances to protect the safety of schoolchildren’s lives and physical health from danger. They are

danger for themselves by noticing potential dangers they may face, predicting what kinds of accidents

also required to fully understand the organizational structure in school as well as the importance andcan be caused by those dangers, and deciding what to do to avoid the dangers. Safety education must be

urgency of school safety, and to further enhance their safety awareness and safety response skills as wellprovided so that schoolchildren can develop their ability to think and decide on their own in allas their safety education skills. To achieve this, it is necessary to provide school personnel with practicalcircumstances.
For example, it is important to nurture schoolchildren’s ability to predict and avoid danger intraining that meets the needs of the school and the community.
Making full use of the latest safety information provided by, for example, the government,

natural disasters specific to the region, such as typhoons, tropical storms, floods, and drought, whileinternational organizations, and international aid organizations, all school personnel must be firmly

making use of materials prepared in each region and involving activities to make schoolchildren think

determined to ensure the safety of schoolchildren, understand matters necessary to protect the health andin light of specific situations as well as experimental activities.

safety of schoolchildren, and have the basic knowledge and skills on the contents and methods ofteaching. This requires the improvement of school safety training provided for school personnel. In
doing this, structures within schools also need to be improved to enable all school personnel to share the2) Use of human resources/resources in communities

latest information.
Examples of training include the items below. Concerning forms of training, simulation exercises, inIn order to ensure more effective practice in the safety education of schoolchildren, it is necessary towhich discussion is held as to what kind of action should be taken by assuming a case that can occur in

obtain cooperation from lecturers of external organizations, including NGOs, and to actively request that

school, and training by external personnel with expertise are effective, in addition to lectures/classes.

homes and communities provide teaching materials and learning opportunities. It is important to choose
and consider the contents and methods according to the actual situation of the school and the community.

i) Evacuation drills for disaster/crime prevention based on the crisis management manual

Particularly in school, where learning is pursued according to the curriculum of each subject, it isii) Drills to respond to disasters/incidents (including responses to affected or injured schoolchildren

important to effectively use external human resources by linking curriculums across different subjects

and guardians)

instead of providing an isolated, independent learning opportunity. This is one method of curriculumiii) Cardiopulmonary resuscitation including AED, and first aidiv) Matters related to the creation of a safe environment using statistics of disasters and accidents
that occurred in school as well as information on specific casesv) Matters related to the safety education of schoolchildren

management.
Examples of collaboration with communities include the items below.
i) Utilize guidance from police and disaster prevention/safety experts in safety training provided
at school.

(e.g.) Qualifications/skills related to safety that need to be developed, positioning of safety
education, common understanding of teaching contents/materialsvi) Mental health care of schoolchildren, school personnel, and guardiansii) Use community facilities and organizations related to safety (e.g., the Commune Committee
for Disaster Management, the Village Disaster Management Group16) as teaching materials.
iii) Use the region’s topography, geology, environment, and past disasters16 as teaching materials.
iv) Study and experience the contents of work of people who protect safety in communities.

9. Safety education of schoolchildren

10

To ensure the safety of schoolchildren, it is very important to provide safety education that enables
schoolchildren to predict and avoid danger for themselves, in addition to conducting thorough safetyv) Participate in safety events in communities to develop skills to ensure one’s own safety (selfhelp) and the spirit of cooperation (mutual assistance).
Column: Measures related to land mines in Cambodia

management of facilities/installations such as safety inspections. Thus, safety education throughout all

In Cambodia, as the result of its long civil war, several million land mines and unexploded ordances

educational activities (all subjects and school events) is required.

(UXO) still remain uncleared, and thus the country is called a major land mine- and unexploded
ordance-contaminated country. These land mines and UXO have caused death and injury to a large
number of civilians, most of whom were children, posing very serious humanitarian issues. In rural
areas, they threaten safety in daily life and hinder regional development and economic recovery.

282

Chapter 14

School safety and crisis management283

Anti-land mine measures in Cambodia are led by the Cambodia Mine Action Center (CMAC). The
CMAC reports that the number of land mines it removed during the period from 1992 to January
2020 exceeded 540,000.17 It carries out activities by developing long-term plans and goals forvarious issues, including land mine removal plans, compensation for land mine victims, and risk
education on land mines and UXO, while receiving support from United Nations agencies, othercountries, and NGOs. The issues of land mines and UXO still have a great impact on the health andsafety of children and Cambodia’s economic development (see Chapter 13).

Exercises for further thought and research[14-1] What can you cite as characteristics of incidents/accidents involving children? Pick one example
of an incident/accident in Cambodia, and discuss factors and the background of its occurrence aswell as prevention measures.
[14-2] Are there any dangerous places in and around school? Pick one elementary school nearby, andcreate danger prediction maps and safety check lists for (1) School premises and (2) Area aroundthe school.
[14-3] Investigate and report the actual situations at nearby elementary, junior high, and senior highschools, including whether a crisis management system is in place, whether safety education isprovided, and whether evacuation drills and training of teaching staff are provided.

References
1

Takizawa T (author and editor): [New Edition] Learning School Health from Basics [2nd edition]. Kenpakusha, Tokyo. 2018.

2

Watanabe M (author and editor): School Safety and Crisis Management Revised 3rd Edition. TAISHUKAN Publishing, Tokyo.

3

Ichimura K, Shimomura Y, Watanabe M: Drug Abuse, Smoking, and Alcohol Consumption Behavior and Normative Consciousness

4

National Institute of Statistics, Ministry of Planning, Cambodia: Cambodia Demographic and Health Survey 2014. https://

5

The World Bank. https://data.worldbank.org/indicator/SH.STA.TRAF.P5?end=2019&locations=KH& start=2000&view=chart

6

Ministry of Education, Culture, Sports, Science and Technology: Safety Education in Schools to Nurture “Zest for Living.” 2019.

2020.
Among Junior and Senior High School Students. Japanese Journal of School Health 43: 39-49. 2001.
dhsprogram.com/pubs/pdf/fr312/fr312.pdf

https://www.mext.go.jp/component/a_menu/education/detail/__icsFiles/afieldfile/2019/04/03/1289314_02.pdf
7

Ederer DJ, Bui TV, Parker EM, Roehler DR, Sidik M, et al. Helmets for Kids: evaluation of a school-based helmet intervention in

8

UNICEF: [Summary] THE STATE OF THE WORLD’S CHILDREN 2017 Children in a digital world. https://www.unicef.org/

9

UNDRR: The human cost of weather-related disasters 1995-2015. https://www.preventionweb.net/files/46796_

Cambodia. Injury Prevention. 22:52-58, 2016. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6883409/
media/48601/file
cop21weatherdisastersreport2015.pdf
10 Ministry of Education, Culture, Sports, Science and Technology: Guide to Compiling Crisis Management Manuals for Schools.
Japan Sport Council School Safety Department. 2018. https://www.mext.go.jp/a_menu/kenko/anzen/__icsFiles/
afieldfile/2019/05/07/1401870_01.pdf
11 Ministry of Education, Culture, Sports, Science and Technology: School Safety for School Personnel e-learning Basic Training
Text material. https://anzenkyouiku.mext.go.jp/learning/course1-1/pdf/Basic_1.pdf.
12 Ministry of Education, Culture, Sports, Science and Technology: School Safety for School Personnel e-learning Basic Training
Text material. https://anzenkyouiku.mext.go.jp/learning/course1-2/pdf/Basic_2.pdf
13 Brymer M, Taylor M, Escudero P, Jacobs A, Kronenberg M, et al. Psychological first aid for schools: Field operations guide, 2nd
Edition. (2012). Los Angeles: National Child Traumatic Stress Network.
14 Tanaka E: How to implement Psychological First Aid for Schools in Japan. Japanese Bulletin of Traumatic Stress Studies. 14:41-58,
2019.
15 Tajima Y, Shizuoka Prefecture Yogo Teachers’ Association. “Crisis Management” addressed by school organizations, Higashiyama
Shobo, Tokyo. 2020.
16 Information on Disaster Risk Reduction of the Member Countries. Cambodia, Asian Disaster Reduction Center. https://www.adrc.
asia/nationinformation.php?NationCode=116&Lang=en&NationNum=06
17 Cambodia Mine Action Center. https://cmac.gov.kh/en/article/progress-summary-report/cmac-s-operational-progress-report-from1992-to-january-2020.html

284

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Chapter 15

First aid at school

parents and guardians, as well as other members of the community at large.

2. Vital signs
Vital signs are basic indications (signs) of the human body’s life-sustaining (vital) functions, indicating

Learning objectives

the maintenance of basic physiological functions that are necessary for a human body to survive.

You will be able to gain proper understanding and explain:

Specifically, vital signs refer to the level of consciousness, respiratory rate, pulse rate, blood pressure,- What vital signs mean, and assess them correctly.

and body temperature. Assessment of these signs, i.e., performing a vital sign check, provides a- How to care for minor injuries and illnesses that may happen around you.

measure of a person’s physical condition.

- Rest, Ice, Compression, and Elevation (RICE) method for injuries.
- The importance of cardiopulmonary resuscitation (CPR) and Automated external defibrillators(AEDs), and practice using them.

Vital signs are affected by factors such as age and gender. They also constantly fluctuate to somedegree with daily activities such as exercise and food intake. Nevertheless, a sudden change in a vital
sign may indicate the presence of a threat to life, and knowing the correct ways of measuring vital signs
and their reference ranges is critical when you provide first aid. It is also useful to be familiar with yourIn this chapter, you will learn about injuries and illnesses that may happen around you, and how tonormal respiratory rate, pulse rate, blood pressure, and body temperature, for it helps detect any

observe and provide care. Here we will focus on minor injuries and illnesses for which children canabnormalities in your body based on your vital signs.

provide care by themselves. Specifically, we will look at injuries such as those of limbs, and illnesses
such as abdominal pain, diarrhea, headache, and fever. In addition, you will also learn about vital signs
as an important measure of the level of urgency of a particular sickness.

1) Consciousness

Since teachers are not medical experts, this chapter covers first aid for laypeople. Understanding
what is included in first aid can vary among different countries and regions. For the purpose of thisBeing medically conscious means that one is able to respond properly to stimuli from within one’s body

chapter, the International First Aid and Resuscitation Guidelines 20161 are used as a primaryor from the outside world. One’s state of consciousness is assessed based on both one’s state of alertness

reference.

and cognitive function.
To assess someone’s consciousness, you talk to the person, saying, “Mr./Ms. ●●, are you OK?”,

1. Necessities for learning first aid

gently shake their shoulder, or apply a mild pain stimulus (Figure 15.1). Because the brain is responsible
for consciousness, a decreased level of consciousness is a sign that there is a problem with the brain,
making it a medical emergency.

First aid is the immediate assistance provided to a sick or injured person until professional help arrives.
You never know when or where an injury or illness can happen. Some injuries and illnesses are time

Some injuries and illnesses are medical emergencies and require immediate care, while others are
not so time sensitive. In Cambodia, there are situations where it takes time for one to reach a hospital.

ou

respond quickly, it may save a life.

Areysomeone present (i.e., a bystander) happens to have knowledge and skills of first aid and is able toOK?

sensitive. In a time-sensitive situation, it may be too late if you wait until the ambulance arrives. If

Even if a person is not in a life-threatening situation, providing proper care can help prevent an injury orillness from becoming worse and alleviate pain. It is therefore important to learn first aid knowledge
and skills, even for the general public.

Figure 15.1 Assessing consciousness

Teachers, besides being members of the general public, are in a position to keep children safe at
school. School is a place where children of different ages learn in groups, a circumstance which can give

There are many scales used to evaluate impairment of consciousness. Here we pick one that is

rise to an unexpected injury. For these reasons, teachers need to learn first aid. In addition, school is one

commonly used globally, called the Glasgow Coma Scale (GCS).2 On the GCS, lower total scoresof the places best suited to learn about first aid, not only for teachers but for pupils/students and theirindicate lower levels of consciousness. A GCS total score of 15 or higher indicates the person is fully

286

Chapter 15

First aid at school287

conscious, while scores of 13–14 indicate mild impairment of consciousness, and 12 or lower, semicoma

60 breaths per minute or more in adults and adolescents, children, infants, and neonates, respectively) oror coma (Table 15.1).

very low (10, 15, 25, and 40 breaths per minute or fewer in adults and adolescents, children, infants, andneonates, respectively) respiratory rates.1
Table 15.1 Glasgow Coma Scale (GCS)2

Eye opening response (E)Best verbal response (V)Best motor response (M)Opens spontaneously

4

Opens to voice sound3

Opens to pain / pressure

2

None

1

Oriented

5

Confused

4

Inappropriate words

3

Incomprehensible sounds

2

None

1

amplitude, tension, and quality in addition to the number of beats. When one is in shock, it may be

Obeys commands

6

difficult to take the pulse at the radial artery. In such a case, you take the pulse at the carotid artery

Localizes pain

5

(Figure 15.2). If the pulse is not palpable, immediate cardiopulmonary resuscitation (CPR) is required.

Normal flexion / withdraws to pain

4

Reference ranges for pulse rate vary among different organizations and authorities, but they are typicallyAbnormal flexion

3

70–90 pulses per minute for children of school age, and a rate of lower than 50 pulses per minute or

Extension

2

None

1

3) Pulse
A Pulse is a palpable wave of blood that is sent into the aorta by the pumping action of the heart as theleft ventricle contracts, and which travels through the arterial system of the body (see Chapter 2). A slow
pulse rate or an irregular pattern indicate abnormalities in the heart or the circulatory system. The pulse
may be palpated through the walls of a peripheral artery. The pulse is typically taken at the radial artery(Figure 15.2). To take the pulse, you place the tips of your index, second, and third fingers on the arteryof a subject and count the beats for a period of 1 minute. While doing so, you also assess the rhythm,

120 pulses per minute and higher should be considered a medical emergency.3

Column: What is orientation?

Orientation is one’s capability to grasp and understand the situation in which they are placed, suchas the time now, and why they are there. In order for one to have good mental orientation, there
should be no significant damage done to their function in terms of consciousness, perception,
attention, memory, and thoughts, at the very least. If people have impaired consciousness or memory
problems due to organic brain disorders, they have become “disorientated.” They lose their senseof place and identity, or time and date.

radial artery

carotid artery

Figure 15.2 Points to take pulse

2) Respiration

4) Blood pressure

Respiration involves bringing oxygen, which is required to produce energy to sustain life and perform
activities, into the body through inhalation, and flushing carbon dioxide, which is generated as a

Blood pressure is the pressure of circulating blood against the walls of arteries. The pressure of blood

metabolic end product, out of the body through exhalation (see Chapter 2). Low respiratory rates andagainst the arterial walls as the heart contracts is called the systolic pressure, while that of blood as theshallow respiration indicate inadequate oxygen intake. You assess respiration based on the measurement

heart relaxes is called the diastolic pressure (see Chapter 2). The higher the cardiac output is, and theand rhythm of respiration, by looking at the movements of the chest and abdomen per minute. Poor

higher the peripheral resistance is, the higher the blood pressure becomes. Decreased blood pressure

respiration results in the face or lips turning dark purple. If one shows such symptoms (i.e., cyanosis),indicates abnormalities in the blood circulation. Meanwhile, hypertension serves as an indicator ofassess their respiration very carefully. Special attention is required in a case of very high (20, 30, 40, andprogression of arterial stiffness. As blood pressure varies depending on age, gender, ethnicity, and288

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measurement conditions, the parameters of hypertension are determined by individual organizations
and authorities.

Column: Non-contact body thermometer

WHO defines hypertension as follows:

With the onset of the COVID-19 pandemic, “non-contact” body thermometers are becoming“Hypertension is diagnosed if, when it is measured on two different days, the systolic blood pressure

increasingly more common. Such thermometers measure the amount of infrared radiation emitted

readings on both days are ≥140 mmHg and/or the diastolic blood pressure readings on both days are ≥90

by a human body and convert it into a temperature. They offer great convenience, for you can use

mmHg.”

4

one to take the body temperature hygienically and quickly. However, due to the space between thesensor and the object of measurement, temperature readings may be affected by the air condition,

Blood pressure is measured using a sphygmomanometer. There are several types ofand may not be accurate under measurement conditions. It is recommended that you follow

sphygmomanometers; they may be aneroid or digital sphygmomanometers, and sites of placement may

manufacturer’s instructions, and if the reading is not in agreement with the observed conditions

include an upper arm, wrist, or finger.

(e.g., you feel hot but the temperature reading is low), you should take another measurement using
an axillary thermometer.

3. First aid proceduresFirst aid procedures are as follows: observation, assessment, and care.

1) Observation
Figure 15.3 Examples of digital sphygmomanometers

First aid begins with observation. You make an assessment by listening (interview), looking (visual
examination), and touching (palpation). Listening means that you ask about the circumstance in which
an affected person’s injury or illness occurred (when, where, why, what, how). Looking means observing5) Body temperature

the person’s general condition and the state of injury or illness very closely. Touching means placing
your hand over the affected area and assessing any skin swelling, heat sensation, or tension. Vital signs

Body temperature refers to internal body temperature,

are also a critical part of observation.

and values vary depending on the site used formeasurement. While body temperature may bemeasured in the rectum, in the mouth, or at the
tympanic membrane, it is commonly measured in theAngle of thermometer
under the arm: 30-45°

2) Assessment

axilla. Axillary temperature is skin temperature, andBased on the information obtained through listening, looking, and touching, as well as the vital signis therefore lower than internal temperature by about

values, you make an assessment. Teachers are laypeople and not healthcare professionals, and are

1°C. When taking measurements, wipe any sweat off

not able to make a diagnosis. Nevertheless, you can infer the injury or illness, and take action accordingly.

first, then place the thermometer under the arm, angling

First, you determine the level of urgency. If the case is urgent, the affected person should seek medical

it so that its tip is in the deepest crease of the armpit, as

attention immediately. If it is not very time sensitive, then you provide care according to the symptoms.

shown in the picture (Figure 15.4). Body temperatureUrgent conditions of sickness include a lack of consciousness, stab or gunshot wounds to the head,varies among individuals, and it is important to assesschest, neck, or abdomen, fractures of the pelvis or the femur, amputations of limbs, and burns covering

the temperature by taking one’s normal temperaturea large area.3

into account. A temperature of 38°C (100.4°F) or
higher is considered a fever.1
Figure 15.4 Taking body temperature

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3) Action
Based on the assessment that has been made, take action. How to provide care according to the symptoms
will be discussed in the following section.

immediately.
Column: Management of nosebleeds

Most nosebleeds are caused by picking of the nose or scratching it with fingernails. Bleeding often
Column: What is shock?

occurs in the 1-cm area at the front of the nose (i.e., Kiesselbach’s area). To care for a nosebleed,have the injured person tilt their head down slightly, pinch the nose around Kiesselbach’s area

Shock is an acute syndrome in which an attack to a living body or the response of body to the attack

between the thumb and index finger, and press firmly towards the back of the nose (Figure 15.5).

has caused a failure to maintain blood flow to vital organs, resulting in a disturbance in cellular

Bleeding should normally stop after around five minutes. Tipping the head up may cause blood tometabolism or damage to organs, potentially threatening to the life of the person. If shock progresses,

run down the throat; tilting the head down is preferable. A nosebleed as a result of trauma may

it can cause mulfunctions and result in death; if any symptom of shock is observed, urgent action isindicate a potential fracture of the nasal bone; cool the nose with a wet towel and seek medical

needed in response. Symptoms of shock include pallor, writhing movements, cold sweat, impalpableattention.

pulse, and decreased blood pressure.

4. Appropriate first aid care for different situations
1) First aid for injuries(1) Head trauma

Kiesselbach’s
area

Head traumas vary widely depending on the site and extent of injury, ranging from severe to mild.
Examples of severe cases of head trauma include a fracture of the skull, and a concussion caused by a

Figure 15.5 Points to apply pressure

jolt to the head. Some symptoms, such as acute epidural hematoma, may appear several days later.
Common steps that should be taken are as follows. First, find out how the injury occurred. Since theinjured person may not know everything that has occurred, seek information from other people whohave been on the scene. Knowing how it occurred will help you determine the severity of the injury.

(3) Chest or abdominal trauma

Next, check the vital signs, especially the level of consciousness. If there is any vital sign abnormality,

In the case of chest or abdominal trauma, it is possible that internal organs may be damaged. Assess thetransfer the person to a healthcare facility as quickly as possible. If there is any wound, stop the bleeding

injured person’s general condition, focusing on the vital signs. It is also helpful to ask about the cause ofand protect the affected area, as appropriate for the type of trauma. If there is swelling, cool the affected

the contusion in making necessary decisions. If the injured person has any vital sign abnormality,

area. In cases of head contusion, symptoms may worsen gradually; the injured person should be placedcomplains of intense pain, or has symptoms of shock, seek medical attention immediately.

at rest for 24 hours with their conditions monitored. Symptoms to look out for during this 24-hour period
include vomiting, seizures, headache, numbness of the limbs, and vision problems. If any of theseabnormalities is observed, seek medical attention immediately.

(2) Facial trauma(4) Limb traumaa) Wounds
Wounds include abrasions, cuts, puncture wounds, and bites. An abrasion is a wound where an areaof the epidermis is damaged due to external friction. A cut is a line of damage to the skin caused as a

Features projecting from the face, such as the forehead, nose, mouth, and cheeks are more prone to facial

result of a sharp object moving on the body surface. A puncture wound is a puncture caused by the stabtrauma. One type of facial trauma that requires particular attention is ocular contusion. Cases of ocularof a sharp object into the skin. A bite is a wound caused by the teeth of an animal or a human (Figure

contusion can become severe, as it can involve damage to the retina or a fracture of the bone under the15.6).

eye, which is thin and prone to fracture. Assess the injured eye by comparing it to the other, uninjured

The basics of care are: rinse the wound, stop the bleeding, and protect the wound (Figure 15.7).

eye, focusing on any bleeding, eye movement, and change in vision. If the injured person has anything

First, rinse the wound with clean water. As any foreign matter remaining in the wound can make itwrong with eye movement, double or blurry vision, or constriction of visual fields, seek medical attention

susceptible to suppuration, rinse the wound carefully with clean water to wash off any foreign matter or

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bacteria around the wound. This may also help stop bleeding more quickly, as the cold water cause theStop the bleeding, if any. Cover the wound with a clean cloth (preferably gauze), and apply pressure

capillaries to constrict. It is preferable to use tap water to rinse the wound; if you have no access to clean

directly over the dressing. Blood has a coagulation mechanism (i.e., platelets form a plug the rupture

water, however, bottled water or tea with no sugar added may be used in its stead. In the absence of cleanof the blood vessel, followed by the action of coagulation factors, which forms a fibrin clot). Most

water, using an antiseptic may be beneficial. Do not use pooled water to rinse a wound as it may

injuries are bleeding from capillaries or small veins (i.e., blood oozing out), and this can be stopped bypotentially be contaminated with pathogens.

simply applying pressure. In the case of bleeding from an artery, however, blood spurts out and thus
cannot be stopped by direct compression alone; seek medical attention as soon as possible.

Type

Characteristics / keys to treatment

Once the wound has been rinsed clean and the bleeding stopped, apply a clean cloth (preferably
gauze) over the wound and secure it with a strip of surgical tape to keep the wound clean and prevent itfrom drying out. Change the gauze as appropriate if it is contaminated by blood or effusion.

Epidermis
DermisEpidermis
Subcutaneous
DermisEpidermis
tissueAbrasion

Epidermis
DermisSubcutaneous
tissueDermisSubcutaneous
tissueSubcutaneous
tissueAn abrasion is a wound where an area of theepidermis is damaged due to external friction. The
surface of the wound is scraped off, leaving it
irregular; this often causes foreign matter to remainin the wound, making it susceptible to infection. It
is important to rinse any foreign matter off
thoroughly.

A cut is a line of damage to the skin caused as theresult of a sharp object moving on the body surface.
A cut left open is susceptible to infection. It isadvisable to cover the wound by holding the skin on
either side of the cut so that the cut is closed, andsecuring it with a strip of surgical tape.

Cut

1 Rinse
Rinse wound withclean water

2 Stop bleeding

Cover with clean clothand apply pressure

3 Protect
Apply clean clothor bandage

Figure 15.7 Keys to caring for wounds

Column: Special considerations when treating bleeding

A puncture is caused by the stab of a sharp object
into the skin. A wound may be small in area, but if
it is deep, it may have caused internal damage. A
wound caused by a rusty or contaminated object
can result in tetanus infection, which is caused byanaerobic bacteria; check the vaccination status andseek medical attention.

Some infectious diseases, such as hepatitis B and AIDS, are transmitted through blood. When caring
for a person who is bleeding, wear vinyl gloves or use plastic bags, taking care not to come in directcontact with the injured person’s blood. In the event of having contact with blood, wash it off withwater immediately.
There is no problem for a victim to touch one’s own blood; it may be advisable to occasionallyhave an injured child try to stop the bleeding, so long as the injury is minor.

Puncture wound
Column: Management of outdoor injuries caused by animals or insects

Caused by an animal or a human. A bite with sharp
teeth in particular can cause deep tissue destruction.
In addition, animals may harbor various bacteria
and viruses in their mouth, which may result in not
only wound infection but animal-borne infection as
well. Provide first aid, and make sure the injured
person seeks medical attention without fail.

Bite● Snake bites
Squeeze out effusion (blood) from the snake bite wound, rinse it thoroughly, and cover it with a clean
cloth. Keep the wound location at a level below the heart, and keep the person still. If one is bitten
by a venomous snake, one will experience intense pain and a burning sensation immediately
following the bite, and the site of the bite will start swelling. When you are unsure if the bite has been
made by a venomous snake, yet the injured person suffers from intense pain and significant swelling,
seek medical attention without delay in case it was indeed a venomous snake bite. If you know what

Figure 15.6 Major types of wounds, their characteristics and treatment294

kind of snake it was that made the bite, inform the staff at the hospital.
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1

2

3

● Animal bites

Joint head

Animals harbor various bacteria in their mouths, and their bites may potentially cause the wound to
become suppurative or lead to tetanus. A bite by a stray dog or cat can result in rabies. In Cambodia,
there are approximately 800 deaths a year from rabies, and 40% of the victims are those under the

Joint socket

age of 14.5 In the case of an animal bite, it is important that the wound be rinsed with clean waterand protected with clean cloth (gauze), and that the injured person seek medical attention without
delay.
● Bee stings
Pinch the sting site firmly and rinse the wound, squeezing out effusion (blood). Remove the bee
stinger, if it is left behind. When doing so, exercise caution and avoid grabbing the stinger, as it may
cause the venom to be released into the body of the person stung. It is advisable to cool the sting

Ligament

SprainPeriarticular tissues
damaged.

site with a wet towel.

Fracture

1 A break in the continuity of the bone

alone.

2 Broken ends of the bone out of place,with the surrounding tissue damaged.
3 One side of the bone disarticulated
and curved.

With a person who has in the past received a bee sting and experienced symptoms such as rashand nausea, another sting may trigger anaphylactic shock. Anaphylactic shock is a medical
emergency, and a stung person should be monitored for about 30 minutes following the sting (seeDislocation

A joint head and a joint
socket are stuck inabnormal locations due
to external force.

Figure 15.8 Differences between sprains, fractures, and dislocations

Chapter 5).

Outdoor injuries caused by animals and insects are preventable. Familiarize yourself regularlyc) The RICE method for treating injuries

with information concerning areas infested with snakes, bees, etc., and avoid places where one may
potentially encounter them. Give children guidance on clothing and precautions to take when going

The basics of care for these conditions are: Rest, Ice, Compression, and Elevation (RICE) (Figure

outdoors. It is also important to take public health measures such as wild dog control and canine

15.9).

rabies vaccination.5

Rest refers to resting the affected area. It helps to reduce the movement of the injured site and relievepain, as well as reducing bleeding (internal bleeding) and swelling. Make sure the injured person movesb) Contusions, sprains, fractures, and dislocations (Figure 15.8)

or rests in a position that prevents any weight from being put on the injured site.
Ice refers to cooling the affected area. It promotes the constriction of the blood vessels in tissues ofA contusion is a condition in which a strong impact due to a fall, collision, etc., inflicts damage to thethe affected area, minimizing the progression of bleeding (internal bleeding) and reducing swelling. It

tissues beneath the skin even without a wound on the surface of the skin, causing internal bleeding. As

also helps reduce pain from the injury. It is advisable to use iced water at 0°C or so to cool deeper parts

it can occur in any area of the human body, it is necessary to have an accurate understanding of the level

efficiently. Place ice cubes and water in a plastic bag, and apply it to the affected area. Ice the area forof risk and its characteristics.

around 15–20 minutes; stop when the injured person experiences a loss of sensation on the skin, andA sprain is a condition in which force is applied to a joint, causing damage to periarticular tissues
such as tendons, ligaments, or cartilages. A sprain often occurs in the ankle. In particular, a form ofsprain where the foot turns inward, causing the damage to the outside of the ankle, called an inversion
sprain, is quite common.

resume the icing when they regain the sensation. Repeat this process for the first 72 hours after injury,
which is considered the acute stage.
Compression involves application of an appropriate level of pressure over the affected area, which
prevents cellular fluid in tissues from flowing into other areas, thus reducing bleeding (internal bleeding)

A fracture is a broken bone caused by the application of force greater than the bone strength. In

and swelling. Pay attention to the degree of pressure applied, as overly tight compression can compromise

cases of growing children, an incomplete fracture in which the bone is bent or cracked is quite common,

blood circulation. Check the color of the tips of the digits and measure their temperature as appropriate

in addition to a complete fracture in which the bone is broken completely.

to ensure that blood circulation is not compromised.

A dislocation is a condition in which the articular surface of the head of a bone and that of the socketof another have shifted from their normal locations due to external force and become stuck in abnormal

Elevation refers to keeping the injured area above the level of the heart. This facilitates the return ofblood flow to the heart, helping to reduce bleeding (internal bleeding) and swelling.

locations. A dislocation commonly occurs in the shoulder, elbow, finger, and jaw joints.
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occurred, as well as assessing children’s growth on an ongoing basis (through health check-ups)
and sharing health-related information.

(5) Burns
Rest

Ice

A burn is damage to skin tissues caused by heat. Pain may persist and worsen with time. Burns areclassified as first-, second-, and third-degree burns (I, II, III), depending on the depth of tissue damage(Figure 15.10). That said, the severity of a burn is determined not only based on how deep the skindamage is alone but in combination with how large the area affected is. The larger the affected area is,and the deeper the damage penetrates, the severer a burn is.

Compression

Epidermis

Elevation

First degree (erythema)
Superficial second degree

Figure 15.9 RICE method for treating injuries

DermisColumn: Preparedness for injuries at school

Deep second degree

Children can get injured at school. To avoid panicking in such eventualities, it is important that
schools have a response system in place in advance. Specifically, arrangements for emergencies

Sub-cutaneous tissue

should be made, including who will provide care, who will contact parents, and what to do when an

Third degree (necrotic)

injured child needs to be transported to hospital. Individual communities may or may not have ahealthcare institution, and may have different approaches to care (e.g., schools with only maleteachers may not provide care to girls, parents or guardians of children cannot afford medical fees);
it is recommended that schools work together with parents/guardians and local specialist

First degree(I)

Damage to the epidermis. The site appears red on the surface; symptoms include stinging
pains and burning sensation. Sunburn is an example of first-degree burns.

Column: First aid in school

Damage extends into the dermis. Includes two subcategories: superficial dermal burns anddeep dermal burns. The site appears red on the surface, with the presence of blisters. With
Second degree
a superficial second-degree burn, the affected person will experience the same subjective(II)symptoms as those with first-degree burns, while a deep second-degree burn is less painful
due to the damage caused to the sensory nerves.

You are advised to have a first-aid kit of basic items including thermometers, nail clippers, adhesive

Third degree(III)organizations to build such a system.

bandages, face masks, gauze, surgical dressing, and antiseptics, so that you can respond to injuries

Damage to all skin layers, involving the subcutaneous tissues. The site appears white, andpainless.
Figure 15.10 Classification of burns

or other health problems. That being said, first aid provided at school is a procedure to temporarily
keep an injury or illness from worsening and relieve pain, and is not medical treatment. As a matterof principle, a teacher, who is not a healthcare provider, should not use pharmaceuticalproducts.

298

To care for a burn, cool the affected area with water as soon as possible. For a site that cannot becooled with water, apply a cool, wet towel. Do not use ice directly on the site, as it can cause damage to

One of the pillars of the National School Health Policy 2019 is the establishment of “healththe skin. Cool the site until the pain eases. After cooling, protect the wounds with gauze or other dressing.

rooms” to provide first aid. This suggests that schools in Cambodia are slowly starting to implement

Do not break any blisters, as they serve to protect the wounds. A burst blister can lead to bacterial

school nurse’s offices (see Chapter 1). It is advisable that a health room or its equivalent be equipped

infection. Seek medical attention for a second-degree or severer burn that covers a wide area, or a third-with what they need to provide first aid, including first-aid kits, treatment tables, chairs, and cots. In

degree burn. If a person sustains a burn with clothes on, taking the clothes off may cause damage to skinaddition to providing first aid, a health room serves as a school health center as they keep a record

tissues; do not remove the clothes but cool the affected area over the clothes, and seek medical attentionof health room visits and identify when, where, and what types of injuries and health problems havepromptly.
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Column: Care for injuries provides an opportunity for health education

According to the International first aid and resuscitation guidelines 2016,1 we need to teach children
how to provide first aid not only in school health classes but also in other classes, and using a variety
of other opportunities as well. Teachers may find themselves in a position to provide care for a child
who was injured at school. Rather than stopping at simply providing care, you can instead take it asan opportunity for children to think about prevention of and response to injuries. For children, doing
so when they have just gotten injured will drive the point home to them, giving them a chance tolearn something they will be able to use in years to come.

2) First aid for illnesses

Figure 15.11 Disposing of bodily waste / vomit(1) Abdominal pain / diarrhea
Abdominal pain or diarrhea is often caused by a digestive problem. However, some may complain of
abdominal pain caused by a urinary or gynecological problem. For these reasons, it is necessary to
perform thorough assessment and vital sign checks to determine the level of severity.
First, observe the characteristics of the abdominal pain a person experiences, and ask whether or not
he/she has symptoms such as vomiting and diarrhea. Ask the person about his/her experience with(2) Headache
Headache may occur due to a variety of factors. Check the vital signs of the sick person, and ask about
the characteristics of the headache in detail (i.e., when did it start? What kind of headache? How long
has it been going on?).

meals, urination, and for females, menstruation. If the person suffers from frequent vomiting or diarrhea

First of all, check for any trauma. If the person has trauma, and experiences vomiting and impairedin addition to abdominal pain, suspect infectious gastroenteritis (see Chapter 7). If it is not an urgent

consciousness, it is a medical emergency. Headache accompanied by high fever and seizures also

case, keep the sick person at rest and monitor their conditions. If he/she is experiencing diarrhea, haverequires particular attention. Check for a runny nose and assess the condition of the throat, too, for ear,him/her replace lost water and salts (electrolytes) in small, frequent amounts to avoid dehydration.

nose, and throat problems can also be a cause of headache.
If the sick person has normal vital signs and only mild symptoms, keep him/her at rest and monitor

Column: Disposal of bodily waste / vomit

School is a place where people live their lives in groups, and it is necessary to properly dispose ofhuman bodily waste or vomit as a source of infection. Failure to dispose properly of bodily waste or

their conditions. Since headache may be caused by irregular lifestyle habits, including lack of sleep andeyestrain, it is also important to review his/her daily life.

(3) Fevervomit may potentially lead to widespread infection (such as norovirus infection). It is therefore

Fever is an inflammatory response to various virus or bacterial infections. Check the vital signs andnecessary for teachers to be able to dispose of them properly. The disposal procedures are as

observe the general condition of the sick person. In general, a fever of 38°C or higher is considered tofollows (Figure 15.11).

be high. One has the chills as their body temperature goes up. During fever, have the sick person liei) Put on protective equipment (wear a mask and vinyl gloves at minimum; single-use masks
and gloves are preferable). In the case of a closed space, ventilate the space.

quietly and replace water and salts (electrolytes) to prevent dehydration. If he/she has the chills, keep
him/her warm with blankets and towels. If sweating, have him/her change clothes. If a person has a feverii) Wipe up bodily waste / vomit with paper towels, working inward to prevent spreading.

accompanied by severe headache/abdominal pain or vomiting, seek medical attention promptly as he/iii) Put the collected bodily waste / vomit, as well as the paper towels used, immediately in ashe may be at a risk of falling into a critical condition.

plastic bag, seal tightly, and dispose of it.
iv) Disinfect the areas that have been soiled with bodily waste or vomit, using a disinfectant.
Vomit tends to spread over a wide area; disinfect a 2-meter circle from its center, working
inward. Dispose of the paper towels, mask, and gloves used in a plastic bag.
v) After completing the process, wash your hands with soap and gargle.

Column: Responsible self-medication, self-care and self-healing mechanisms

WHO, in its guidelines on the use of pharmaceutical products (the Guidelines for the Regulatory
Assessment of Medicinal Products for Use in Self-Medication), recommends the practice of selfcare and responsible self-medication, in which individuals take responsibility for their own health300

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and care for “minor ailments” of body and mind that do not require medical attention, by means of
6,7

making adjustments in their everyday lives and using non-prescription medicinal products.

CPR is a technique to restore spontaneous blood flow and the respiration of a sick person who

The

is in cardiopulmonary arrest. Chest compression promotes the flow of blood to the brain and thehuman body has innate defense and other systems, which give our body the ability to heal illness

heart by applying pressure to the area around the heart (Figure 15.12). If the person who finds a sick(self-healing mechanisms) (see Chapter 7). For instance, having a fever or inflammation means that

person performs CPR at once, the person’s chance of survival will increase.8,9

our body’s defensive response is at work, trying to rid the body of viruses and other invaders. And
in addition to using healthcare services, we can also use our wisdom to adopt everyday lifestyle● Increased access to AEDs

behaviors that are effective in helping our body restore its health, such as eating well-balanced

AED stands for automated external defibrillator. An AED is a medical device that can analyze themeals and getting adequate sleep, all based on particular symptoms we may be experiencing.

electrocardiogram and deliver defibrillation (i.e., sending an electrical shock to the heart to reset a

In some cases, however, self-care or self-medication may have a negative impact. In order tonormal rhythm), and a layperson can operate one (Figure 15.13). When you turn on the AED, it will

promote self-care and self-medication successfully, it is necessary to promote social empowerment

give voice prompts. When you attach a pair of pads to the chest area, automated analysis of theas well, with an aim to advance people’s health education, general knowledge, and socioeconomic

electrocardiogram will be performed. If defibrillation is required, instructions to do so will be given instatus.

6,7voice prompts. Press the defibrillation button to start defibrillation. Once a person falls into
cardiopulmonary arrest, their survival rate decreases by 7–10% for every minute without
defibrillation.8,9 It is therefore critical to use an AED at the first possible moment to save their life.

Column: Cardiopulmonary resuscitation and AED

In Cambodia, AED awareness is not very high yet, and there are not many AED locations,● Why is cardiopulmonary resuscitation (CPR) necessary?

although it is gradually becoming more common. In Phnom Penh, a Japanese soccer player has

If you find yourself in the presence of a sick person who requires immediate emergency medical

donated an AED to the KMH Stadium, while another has been placed at Aeon Mall, as well. It iscare, such as one who is unconscious, in cardiac arrest, or in respiratory arrest, you may be able toanticipated that there will be more AEDs accessible, primarily at locations where large crowds ofsave the sick person’s life if you can perform cardiopulmonary resuscitation (CPR). Even if you are apeople gather and accidents are prone to happen. At the same time, it is necessary to create moremember of the general public who is not a healthcare provider, if you have received training and areopportunities for as many people as possible to learn how to use an AED first-hand.

able to give CPR, the chance of the person’s life being saved will increase if you perform chest
compression while waiting for an ambulance to arrive after contacting medical services.

i) Place the heel of one hand on thecenter of the person’s chest, andplace the heel of the other handover the first.

Figure 15.13 Example of AED useii) Push straight down on the chest,
keeping your elbows straight andpositioning your shoulders overthe point of compression.

● Special considerations when performing CPR(1) If the sick person is an infant, you many need to adjust the point and depth of compression,
taking into account the smaller body.
(2) Recommended CPR steps are subject to update. You will need to check the most current

100 compressions per minutePush down by 5 cm

information.

Figure 15.12 Keys to chest compression

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Chapter 16
Exercises for further thought and research[15-1] Find out about injuries common among children in Cambodia, and discuss what to do to preventthem.

Disability and special education needs[15-2] Assuming an injury that is likely to happen to children, such as an abrasion or cut, discuss possible
ways to teach children how to treat it.
[15-3] Concerning first aid procedures that are actually performed in daily life, discuss what kinds ofLearning objectives

scientific evidence form a basis for the procedures, and whether there is anything that can be done

You will be able to gain a proper understanding and explain:

to improve on them.

- The deﬁnition of disease, impairment, disability, and handicap using speciﬁc examples.

[15-4] Look back on experiences of your own or someone close to you of injuries or illnesses in the past,and reflect on what care was given, what action was taken in response, and what you/they were
and were not able to do. Discuss what issues Cambodia has.

- The medical model of disability, the social model of disability, and the integrated model ofdisability (International Classiﬁcation of Functioning, Disability and Health: ICF).
- Challenges in education of children with disabilities in Cambodia.
This chapter ﬁrst provides basic knowledge necessary to understand disease, impairment, disability, andhandicap. Secondly, we explain the medical model of disability, the social model of disability, and theInternational Classiﬁcation of Functioning, Disability and Health (ICF) as an integrated model ofdisability. Finally, we describe the present situation of special education needs for children withdisabilities in Cambodia.
Note that in this chapter health is mainly treated as a factor of disability; that is, in terms of healthconditions such as disease or injury. This differs from the broad meaning ascribed to health in theprevious chapter (e.g. Chapter 1).

1. Aspects of disease, impairment, disability, andhandicap
1) Disease
References

Disease results from abnormalities in all or part of the physiological state of living creatures. Someone

1

The International Federation of Red Cross and Red Crescent Societies. International first aid and resuscitation guidelines 2016.

suffering from a disease is incapable of fulﬁlling normal functions, and generally experiences various

https://www.ifrc.org/Global/Publications/Health/First-Aid-2016-Guidelines_EN.pdf
2

Jain S, Iverson LM. Glasgow Coma Scale. https://www.ncbi.nlm.nih.gov/books/NBK513298/

types of pain. However, some diseases such as diabetes produce no sense of pain before growing severe.

3

Foundation for Ambulance Service Development: Report of the committee for the criteria for determining levels of severity andurgency during an emergency medical evacuation. 2004. https://www.mhlw.go.jp/shingi/2009/08/dl/s0825-6c.pdf

4WHO. Hypertension. https://www.who.int/news-room/fact-sheets/detail/hypertension

5

Pasteur Institute in Cambodia. Rabies Prevention Centers – Pasteur Institute in Cambodia (pasteur-kh.org). https://www.pasteur-kh.
org/rabies-prevention-centers/

6WHO. The benefits and risks of self-medication. WHO Drug Information. 14:1-2. 2000. https://apps.who.int/iris/bitstream/
handle/10665/57617/WDI_2000_14_n1_p1-2_eng.pdf?sequence=1&isAllowed=y7

A disease can be deﬁned as a condition in which cells suffer damage for some reason and fail to function
normally.
Diseases recognized as resulting from morphological abnormalities in cells are referred to as“organic diseases.” They contrast with “functional diseases,” in which current medical knowledge
cannot identify any cellular abnormalities. Cancer, diabetes, cerebrovascular disease, and heart disease
are considered organic diseases, while mental illnesses are placed in the functional disease category.

Bennadi D. Self-medication: A current challenge. Journal of Basic and Clinical Pharmacy. 5.19-23. 2014. https://www.ncbi.nlm.nih.
gov/pmc/articles/PMC4012703/

8

American Heart Association: Hands-only CPR. https://international.heart.org/en/hands-only-cpr

9Larsen MP, Eisenberg MS, Cummins RO, et al. Predicting survival from out-of hospital cardiac arrest: a graphic model. Annals ofEmergency Medicine. 22:1652–1658. 1993. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2600120/pdf/649.pdf

304

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3052) Impairment, disability, and handicap

by wearing artificial limbs or using a wheelchair. In such cases, the physical loss of a leg cannot bedirectly linked to a decline in capacity or suffering social disadvantage.

(1) Definition of impairment, disability, and handicap

What happens, however, if Cambodian society is unable to supply artificial legs or wheelchairs? Or
1,2,3

Impairment

if roads, homes, and workplace environments are not altered to provide proper wheelchair access? In

is physical or mental dysfunction, which may be either permanent or temporary, due to a loss of mental

such cases, the view is that the social environment is the cause of the disability. That is the basic idea ofor physical structure or function. Disability, meanwhile, is any restriction or lack of ability (resulting

the social model.

The WHO (1980) provided definitions of impairment, disability, and handicap as follows:from an impairment) to perform an activity in the manner or within the range considered normal for a

Look at the following illustration and consider where the disability exists (Figure 16.2).

human being. Handicap is a disadvantage for a given individual that limits or prevents the fulfillmentof a role that is normal.
Views on disability, however, are more complicated and can broadly be divided into two basicmodels: the medical model and the social model.

2. Models of disability
1) The medical model of disability
Under the medical model, disability is defined as conditions in which the body fails to function normally
due to disease or injury (Figure 16.1). This causes a decline in the capacities necessary for everyday life,
placing afflicted persons in socially disadvantageous circumstances. Suffering a stroke, for example,
may cause brain damage (i.e., disease) that permanently impairs numerous physical functions. This can
include paralysis in the hands and feet, speech disorders, and other problems (i.e., impairment).

Figure 16.2 A person with a disability in a wheelchair faces stairs. Where is the disability?

Numbness in the hands and feet can adversely affect mobility, the ability to grasp objects, and othereveryday life skills (i.e., disability). Victims can lose the ability to work, perform housework, and fulfill
other social roles (i.e., suffer social disadvantage or handicap).

Disease or injury

Impairment

Disability

Social disadvantage,
handicap3) International Classification of Functioning, Disability, and Health(ICF) as an integrated model of disability
The ICF is a classification of health and health-related conditions for children and adults that wasdeveloped by the WHO and published in 2001. The integrated model of disability is an attempt tomerge, or at least bring together, the medical and social perspectives.4 This model allows for people with

Cerebrovasculardisease or stroke

Partial paralysis

Difficulty walking
and other mobility
problems

Inability to work,
unemployment

Figure 16.1 The medical model of disability

disabilities to fill a number of different roles “including citizen and patient, among many others.”4,5 An
important point to note is that this model was created to be applicable to all people under any conditions,
not just persons with disabilities.
As shown in Figure 16.3, the ICF model regards disability as a state of dysfunction or disturbance ofdaily human life. Daily life is categorized into three parts: physical and mental function and structure,
activity, and social participation. For example, dysfunction or disturbance of physical and mental

2) The social model of disability

function and structure means impairment, indicating abnormality of mental function, motor nerve
function, sensory functions such as vision and hearing, vocal organs, digestive and circulatory systems,
immune system, endocrine system, or reproductive system. Limitation of activity refers to difficulty in

In contrast, under the social model, the causes of disability are considered to lie in the social environment.

performing activities such as walking, eating, taking transport, or counting money. Restriction of social

For example, even if people lose legs after stepping on unexploded land mines, they may regain mobility

participation refers to limitation or lack of involvement in any area of life such as education, gainful

306

Chapter 16

Disability and special education needs

307employment, or leisure pursuits. Relationships between health conditions, daily activity, and6environmental and personal factors are indicated by double arrows, denoting interaction.

The three types of dysfunction of daily life are influenced and affected in turn by environmental

4. Special education needs for disabled children in
Cambodiafactors (e.g., products and technology, the natural environment and human-made changes to the

According to the Policy on Education for Children with Disabilities of the Cambodian Ministry ofenvironment, services, systems, and policies), and by personal factors (e.g., age, gender, ethnicity,

Education, Youth and Sport, 68% of all children with disabilities suffer from vision-, hearing-, or

outlook on life, and lifestyle). Moreover, this figure shows that these functions of daily life interact withmobility-related issues.8 In the 5-17 age group, 2.6% of boys and 2.9% of girls do not attend school due

health conditions such as disease and injury.

to their disabilities. Unfortunately, Cambodia has a shortage of experts that specialize in educating
disabled children. As a result, the introduction of inclusive education has not progressed smoothly.
This creates challenges to guaranteeing education for children with disabilities through the

Health Condition

framework of the child-friendly school adopted in the policy. One objective of this policy is to raise(disorder or disease)awareness of the situations of persons with disabilities throughout the community, and to promote
acceptance of such individuals into society among all concerned parties.

Daily Life

Body Functions
and Structures

Activities

Participation

Column: Inclusive education for children

All children have the right to access and benefit from quality education, based on the principle of“Education for All.” Guaranteeing education is the key to sustainable development, peace, andstability among countries; thus it is an urgent issue. However, due to various conditions there arechildren who have difficulty accessing education, and are excluded from education. What kinds ofEnvironmental
Factors

Contextual Factors

children are hampered in their right to education? For example, children with disabilities, girls,

Personal
Factors

children living in remote areas, street children, child laborers, children in poor families, and childrenof minorities. These children have special needs for education. Inclusive education not only includes

Source: World Health Organization. How to use the ICF: A practical manual for using the International Classificationof Functioning, Disability and Health (ICF). Exposure draft for comment. October 2013. Geneva: WHO.3

Figure 16.3 The ICF Model: Interaction between ICF components

3. How does Cambodian society view disease anddisability?

children with these special needs in school education, but also transforms the whole school so thatchildren with diverse traits can learn equally.
Resources: Disability Action Council. Inclusive education training in Cambodia. https://www.eenet.org.uk/resources/docs/cambodia.pdf,
Education World Forum. The Darkar Framework For Action. UNESCO 2000. https://sustainabledevelopment.un.org/content/
documents/1681Dakar%20Framework%20for%20Action.pdf

Column: Child-friendly schools

All social systems and agencies that affect children should be based on the principles of the

Disease and disability can lead to prejudice, stigma, and discrimination. In Cambodia, however, aConvention on the Rights of the Child. Based on this principle, UNICEF developed the framework ofrecent report based on a survey of people living with HIV reveals interesting results. For example,

the child-friendly school, which is characterized as “inclusive, healthy and protective for all children,

instances of job discrimination or income loss due to AIDS declined from 46% in 2010 to 2% in 2019.

effective with children, and involved with families and communities - and children.”7

Those experiencing verbal harassment fell from 14% to 3% during the same period. The report also

Cited from https://www.unicef.org/french/lifeskills/index_7260.html

notes, however, that despite the decreases in such stigmas and discrimination from others, “self-stigma”(resulting from personal shame, guilt, and self-blame) had declined only slightly.
How and why have such changes occurred in Cambodia, and what types of prejudice, stigmas, anddiscrimination are directed toward other types of diseases and disabilities, for example, mental illness,blindness, or hearing loss?

308

Chapter 16

Disability and special education needs309◆ INDEX ◆Column: What is UNICEF?

The United Nations Children’s Fund (UNICEF) is an international organization established in 1946 toprovide emergency assistance to children suffering in the aftermath of World War II. UNICEF’s
missions are to save children’s lives, to defend their rights, and to help them fulfil their potential, from

28-day cycle ►194

American School Health Association ►26amino acids ►84, 105early childhood through adolescence. UNICEF staff work in over 190 countries and territories.

6 food types ►87

amounts of invading pathogens ►114

basic eye care services ►157
basic health services / basic healthcare
services ►28, 29

70_80% alcohol ►128

anaphylactic shock ►84, 296
anatomy of the human body ►32

basic human right ►204
basic lifestyle habits ►80Aabdominal pain ►300

anemia ►79, 103

Battambang ►258
bee stings ►296

abduction ►269

angina ►98

ability to predict and avoid danger ►275,
283
abortion ►200

animal bites ►296
anniversary reaction ►281

behaving safely ►264
behavioral addiction ►238
behavioral influences ►62

anorexia ►102

best-before ►67, 68

antagonist muscles / antagonistic muscles►35
anthelminthic ►126

betel quid ►181
bioaccumulation ►247

antibodies ►46, 118
antibody-producing cell (plasma cells) ►118

biofeedback ►106
biological clocks ►81, 107

achieve a self-identity ►196

anti-drugs campaign ►183

biological defense mechanisms ►114

acoustic deafness ►159

antigen ►118

biological diversity ►255

acquired immune system ►116

antigen presentation ►118

biological influences ►62

acquired immunodeficiency syndrome(AIDS) ►205

antigen-antibody reaction ►118
anus ►41

biosphere ►245, 246
birthlength ►198

Cited from https://www.unicef.org/ and https://www.unicef.org/eca/press-releases/unicefcommemorates-70-years

Exercises for further thought and research[16-1] Think about what disability and the conditions of being disabled mean to you.
[16-2] Consider why special education programs need to teach children with disabilities, reflecting on
your own experiences.
[16-3] Examine how Cambodian society views disabilities.

References
1

World Health Organization. International Classification of Impairments, Disabilities, and Handicaps. 1980. Geneva: WHO.
https://apps.who.int/iris/bitstream/handle/10665/41003/9241541261_eng.pdf?sequence=1&isAllowed=y20-20-20 rule ►138

abrasions ►293
absence ►175
absence of a health insurance system ►199
access to health and nutrition services ►28
accident ►262

Ang Pleung ►199

biochemical and physiological tests ►82

activities of the immune system ►114

anxiety ►235

birthweight ►198

acute alcohol intoxication ►174

appraisal support ►229

Acute Stress Disorder (ASD) ►280

arrhythmia ►102

adaptive immune system ►117

arteriosclerosis ►99

bites ►293
bladder ►42
blood glucose concentration ►84

adaptive immunity / acquired immunity ►46

ascending neurons ►38

adolescence /adolescent ►78, 79, 195, 222,

Asian mind ►230

223
adolescent growth spurt ►190

aspects of health ►21

bloodborne transmission ►205

assessment ►291

blue light ►92

adolescent’s mental development ►195
adrenal glands ►42

astigmatism ►134, 135
asymptomatic HIV infection ►206

BMI-mortality relationship ►101body balance ►79

adrenaline ►228
advertisements ►181

atriums ►36

body clock ►92

autoimmune diseases ►46, 119

AED ►302, 303

autologous ►117

body growth ►79
body mass index (BMI) ►101, 102, 152

aerobic exercise ►90

automated external defibrillator ►303

body strength ►79

afferent nerves ►43

autonomic function ►108
autonomic nervous system ►39, 40

bone marrow ►46

blood pressure ►37, 287, 289
blood sugar levels ►43

body temperature ►287, 290

2World Health Organization. Towards a Common Language for Functioning, Disability and Health ICF. 2002. Geneva: WHO.

3

World Health Organization. How to use the ICF: A practical manual for using the International Classification of Functioning,

aging ►23
AIDS ►206, 308

autonomy ►196
available carbohydrates ►83

brain ►39
brain hemorrhage ►98

Disability and Health (ICF). Exposure draft for comment. October 2013. Geneva: WHO. https://www.who.int/classifications/

air quality ►69

awareness of compliance with laws ►268

brain size ►219

axial length of the eye ►132
axillary temperature ►290

brain stem ►39
brain weight ►219

https://www.who.int/classifications/icf/icfbeginnersguide.pdf?ua=1

4
5

drafticfpracticalmanual2.pdf?ua=1

airborne transmission ►65, 114

Anderberg P. Making both ends meet. Disability Studies Quarterly. 25:3, 2005. https://dsq-sds.org/article/

Al-Anon ►178

view/585/762#:~:text=The%20integrated%20model%20of%20disability,%22%20(Seelman%2C%202003).

alcohol ►174

Seelman, K. D. Trends in rehabilitation and disability: transition from a medical model to an integrative model. National
Rehabilitation Conference Keynote. Tokorozawa, Japan: National Center for Persons with Disabilities. 2003. https://www.normanet.
ne.jp/~rehab/2003/seelman.pdf

6

Fitzgerald D. People living with disabilities. https://slideplayer.com/slide/13222050/

7

Cambodia sees decline in stigma, discrimination against HIV carriers: new survey. Asia & Pacific. 2019-08-28.

8brightness ►69, 137
Buddhism ►230

alcohol dependence ►238

B
B cells ►46, 116, 117, 118

built environment ►259, 260

alcohol use ►93, 97
alcoholic hepatitis ►175

bacteria ►113
bacterial food poisoning ►127

bulimia ►102
bullying ►233
burn ►299
bystander ►286

alcohol consumption ►182

Alcoholics Anonymous (AA) ►179

bacteriolytic activity ►116

Ministry of Education, Youth and Sport. Policy on Education for Children with disabilities. http://www.moeys.gov.kh/en/press-

allergens ►84
alveolis ►38
ambivalence ►196

bad breath ►142
balanced diet ►105
banana plantations ►252

releases/policy-on-education-for-children-with-disabilities.html#.XvB1EWj7SUk

amenorrhea ►102, 194

Bangkok Charter for Health Promotion ►25

http://www.xinhuanet.com/english/2019-08/28/c_138344792.htm

310

agent ►113

311

C
calcium ►85

child-friendly school ►309
children with disabilities ►309

conjunctivitis ►137

definitive host ►125

disaster prevention ►273

conscious ►287

deforestation ►255

disaster safety ►273, 274

emerging infectious diseases ►128
emmetropia ►135

Cambodia Demographic and Health SurveyChildren’s Health Club ►163

constituents of hormones ►84

delusions ►177

discrimination ►129, 223, 247, 308

emotional and social development ►59, 60

2014 ►154
Cambodia Environment Outlook ►254
Cambodia Mine Action Center (CMAC)

chlamydia / chlamydia trachomatis ►133,
208
chloride ►85

contact lens ►136

dendritic cells ►46, 116, 117, 118disease ►305, 306

emotional support ►229

contagious transmission (oral, mucosal, or

dengue fever ►71, 122

disinfectants ►73

emotion-focused coping ►229

sexual transmission) ►114, 121

dengue virus ►122

disinfection ►120, 128

emotions ►225

cholera ►127

contraception ►200

dental and oral health practice ►143

dislocation ►296

Cambodia Violence against Children Studychoosing safe food ►88

control of infection routes ►119

dental caries ►140, 141, 142disorders ►306

empty cans ►71
endocrine glands ►42►234
Cambodian food pyramid ►86, 105

chromatin ►33

controlling access and entry ►270

endocrine system ►42, 47

contusion ►296

dental floss ►144
dental health ►138

disposal of bodily waste / vomit ►300

chromosome ►33

dissociative amnesia ►224

energy and nutrients ►82

Cambodian Mine Action and Victim
Assistance Authority ►257

chronic stressors ►225

Convention on the Rights of the Child ►309

deoxyribonucleic acids (DNAs) ►33

distress ►228

energy source ►84

cilia ►115

convex lens ►136

Cambodian refugees ►232

ciliary muscle ►132

COPD ►97

dependence ►238
dependence on alcohol ►175

diurnal fluctuation ►49
diversity of gender ►211

enteric infections ►126

Cambodian School Health Policy ►20

circadian rhythm ►49, 81, 107

coping behavior ►229

dependency on nicotine ►173

dizziness ►79

Cambodian Symptom and Syndrome
Inventory (CSSI) ►232

circulatory system ►36

core temperature ►48

cirrhosis ►97, 175

cornea ►132

depression ►235
dermatitis ►66

dopamine ►228
dose-response relationship ►250

Cambodians’ psychological symptoms ►227

cisgender ►215

corneal epithelium disorder ►137

descending neurons ►38

downers ►176

campylobacter ►127

classification of burns ►299
classroom environment ►70

corneal infection ►137

determinants of health ►24
development ►23, 54, 78

drinking ►79

cancer cells ►98
Candida infections ►208
canines ►139
cannabis ►177

clean and hygienic ►65

correct posture when measuring heightclean water ►67
cleaning ►67
cleanliness ►65, 66

cortisol ►228
cough etiquette ►75, 76

development of dental caries ►141
development of the mind ►219
developmental crises ►222
developmental health ►23

droplet transmission ►114, 121
droplets ►65, 120
dropping out ►175
drug abuse ►80, 176, 183

carbohydrates ►82

climate change ►256

counselling ►241

developmental order ►55

drug abuse prevention program ►184

carbon monoxide ►173

CO2 emission ►256
coagulation mechanism ►295

counselling and mental health services ►241

environmental monitoring systems ►245

drug dependence ►178

environmental pollution ►67, 245

carcinogenic effects ►173

coastal development ►255

COVID-19 ►75, 121, 129

drug efficacy ►187

environmental safety standards ►250

cardiac ►35

cocaine ►176

COVID-19 outbreak ►110developmental tasks ►221
development-ecosystem-life or main
occupation (livelihood)-healthrelationships ►252

drug addicts ►178

carcinogenesis ►99

drunk driving ►176

environmental stimuli ►108

cardiopulmonary resuscitation (CPR) ►278,

cockroaches ►71

creating a safe community ►184

diabetes ►97, 98, 107, 175

dust ►69

epidemic ►119

289, 302
carotid artery ►289

cognitive appraisal-focused coping ►229

creation of a safe traffic society ►268

diabetic retinopathy ►133

criminal damage ►269

diarrhea ►300

carriers ►124

cognitive, social, and psychological changes

crisis management ►274

diastolic blood pressure ►37

dysentery ►127
dysfunction or disturbance of physical andmental function and structure ►307

epidural hematoma ►292

cognitive development ►59, 60

crisis management manual ►270, 275

diastolic pressure ►289

►284

cancer ►175

cataract ►131, 132►190

coronavirus (SARS-CoV-2) ►75►150

course of HIV infection ►206

drinking water ►67

Eearly childhood ►58, 78, 264

Entamoeba histolytica ►67
Enterohemorrhagic Escherichia. coli
(EHEC) / Escherichia coli (E. coli) ►67,
127
environment ►26, 28, 245
environmental exposure ►248
environmental factors ►308
environmental factors as health risks ►248
environmental health ►244
environmental health education ►245
environmental hygiene standards ►29
environmental influences ►62

epilepsy ►239
epileptic seizures ►240
EpiPen ►84
Erikson, Erik H. ►221

cause of male infertility ►191

common infectious diseases ►122

crisis management system ►270

diencephalon ►39

causes of injuries ►267

common lifestyle diseases ►98

critical events ►273

diet ►93

CD4 lymphocyte ►206
cell membranes ►84

community actions ►25
community hygiene ►71

critical periods ►57
crystalline lens ►132

diet survey ►82

earth’s environment ►246

diet/nutrition ►92

Easter Island ►246

cell nucleus ►33

community-based ecotourism ►257

cultural codes of sexual conduct ►210

cell-mediated immunity ►118

community-based tourism (CBT) ►257

cuts ►293

dietary effects ►82
dietary fibers ►82

eating ►81
eating disorders ►102

cells ►33

complements ►123

cyber bullying ►234

dietary guidelines ►110

eating habits ►145

estrogen ►192
ethanol ►74

cellular immunity ►46
central nervous system ►39
cephalocaudal direction ►56

composition of a human body ►106
comprehensive knowledge about HIV and
AIDS ►203

dietary iron ►103
Ddaily hassles ►225

dietary supplements ►83
digestive enzymes ►41, 84

Ecohealth ►21, 22, 253, 254
Ecohealth education ►245
ecological health ►246

eugenics ►17eustress ►228
evacuation activities ►277

cerebellum ►39
cerebral atrophy ►175

comprehensive school health ►28

daily hassles for Cambodian university
students ►226

digestive system ►41, 115

ecological health approach ►253

Digital 2021 Cambodia ►234

ecological risk factors ►63

evacuation drills ►277
evacuation plans ►277

cerebral infarction ►98

Compression ►297
concave lens ►136

daily life safety ►273, 274
daily lifestyle habits ►107

digital age ►271

cerebrovascular disease ►98

digital divide ►271

ecosystem ►246, 253
ecosystem resilience ►255

cerebrum ►39, 220concept of children’s health ►61

daily total or weekly average intake ►83

digital harassment ►234

ED50 (effective dose 50) ►251

Chbab Pros ►210
Chbab Srey ►210

concept of self ►222

danger ►262
dangerous behavior ►266

digital technology ►271

concrete operational stage ►221

dilation stage ►198

Education for All ►309
effective handwashing technique ►74

chemical defense ►116

concussion ►292

dangerous spots ►276

direct contact ►65

eggs ►44

chest compression ►302
child growth / development patterns ►79

condoms ►200, 207
conductive deafness ►159

dark adaptation ►44
deafness ►158

direct lightning stroke ►272
directions of body growth and developmentego ►224
ejaculation ►192

child marriage ►19, 201
child mortality ►199
childbirth (delivery) ►198

condyloma acuminatum ►208

decalcification ►140

elementary school students ►264

conflict of interest (COI) ►174
congenital deafness ►159

decline in normative consciousness ►266
defibrillation ►303

►56
disability ►306, 307
disability-adjusted life year (DALY) ►251

externalizing ►231
externalizing problems and internalizing
problems ►231

childbirth culture ►19

congenital defects ►97

definitions of environmental health ►244

disaster ►263

Elevation ►297
emergence of multi-drug-resistanttuberculosis ►124

extracurricular activities ►30
eye ►132eye chart ►155

312

comprehensive sexuality education ►211

Erickson’s life span development theory►221
esophagus ►41

essential amino acids ►105

exercise / exercising ►78, 80, 90, 92, 93
explicit danger ►262
exploratory behavior ►266
expulsion stage ►198
expulsive force ►198
external respiration ►38

313

eye test method ►155

fungi ►113

eyeball ►132

hazard ►262
hazard map ►276

homeostasis ►47, 81, 104, 106, 108

inflammation ►100

land mines and UXO ►258

Hopkins Symptom Checklist-25 ►235

inflammatory response ►117

Laos ►252

hazard risk model ►263

horizontal transmission ►114

influences on the development of the brain

large intestine ►41

eyesight ►157

G
galactose ►84

head trauma ►292

hormones ►42

Ffacial trauma ►292

gang age ►61

headache ►301

hospitalism ►222

garbage disposal ►30

health administration ►26

fatigue ►79

gas exchange ►36

health checkups ►26, 148

fat-soluble vitamins ►85

gateway drug ►177

health conditions ►308

fealthy development ►23
feated tobacco products ►173

GDP ►257
gender ►214

female anopheles mosquitoes ►123

►176

latent danger ►262

information literacy ►209

latent obesity ►101

host ►65, 112, 113

informational support ►229

leading environmental risk factors ►251

host resistance ►114

injury ►262

learning environment ►29

host susceptibility ►112

innate (natural) immunity ►46

left atrium ►36

health education ►26, 28, 121

host-environment interaction ►247, 248

inner ear ►158

left ventricle ►36

health education in Cambodia ►19

hot spots ►183

instrumental support ►229

legal restrictions on alcohol ►182

gender and development ►210

health education in school ►19

household waste ►67

insulin ►43, 107

level of consciousness ►287

female genital mutilation (FGM) ►19, 211
female reproductive system ►45, 192

gender equality ►211
gender identity ►214, 215

health education managers ►30
health education role model ►30

how to use the toilet ►68

integrated model of disability ►307

human growth and development ►58

intermediate hosts ►125level of urgency ►291
life accidents ►263

fetus ►198

gender inequalities ►210

health education specialists ►30

human immunodeficiency virus (HIV) ►205

internal bleeding ►296

life expectancy ►92, 251

fever ►117, 301
fight or flight ►40

gender role ►214
general senses ►43

health education-communicator ►18

human life cycle ►16internal body temperature ►290

health effects of alcohol ►174

human pinworm ►126

internal respiration ►38

lifestyle behaviors ►248
lifestyle disease prevention ►104

fighting hunger ►89

genes ►33
genocide ►259

health effects of tobacco use ►172

fine motor skills development ►58

health examinations ►29, 148

human survival ►246
human-environment relationships ►249

first aid ►29, 286

gingivitis ►142

health facility delivery ►200

humidity ►69

internalizing ►231
International Classification of Functioning,
Disability, and Health (ICF) / ICF Model

first aid knowledge and skills ►286

Glasgow Coma Scale (GCS) ►287, 288
glasses ►136
glaucoma ►133
Global Burden of Disease Study ►251

health knowledge ►29
health practices ►92
health promotion ►24
health room ►29, 163, 298

humoral immunity ►46, 118hygiene behaviors ►66
hyperopia ►134, 135
hypertension ►175, 290

health services ►25, 26

hypochlorite ►74

flexibility ►90

Global School-based Student Health Survey(GSHS) ►233

Health-focused Public Policy ►25

hypotension ►102

flies ►71

global tobacco strategy ►185

healthism ►17

hypothalamus ►48

floods ►256

global warming ►257

flow of health checkups ►160

glucagon ►43

health-related school policies ►28
healthy and supportive school environment

Focusing Resources on Effective School
Health (FRESH) framework ►28

glucose ►83
glycogen ►84

follicle stimulating hormone (FSH) ►192

Golden Triangle ►179, 180follicular phase ►192
fomite (vector) transmission ►114
food allergy ►84
food chain ►247

first aid/emergency contact system ►279
first infection ►124
five essential nutrients ►82
flashbacks ►177

►307, 308
International Conference on Population andDevelopment held in Cairo ►204
International first aid and resuscitation
guidelines 2016 ►300

International technical guidance on
sexuality education ►211, 212, 213

lifestyle diseases ►91, 96
lifestyle habits ►78, 92
light adaptation ►44
lightning ►272
limb trauma ►293
limitation of activity ►307
link between education and health ►27
lipids ►82, 84
listening (interview) ►291
liver ►41

intestinal bacteria ►86

liver disease (hepatitis) ►98

I
Ice ►297

Intraocular pressure ►133

local safety map ►277

inversion sprain ►296

loneliness ►235

healthy diet ►78, 82
healthy growth and development ►54

id ►224
identity ►222

invert soap ►128
invisible danger ►262

longitudinal evaluation ►160
looking (visual examination) ►291

gonad ►42, 44

healthy human life ►16
hearing ►158

illegal logging ►256
illicit drugs ►176

involuntary muscle ►36

gonorrhea ►208

iron ►103

loss of sight ►131
low-birth-weight baby ►172

granulocytes ►117

hearing test method ►158

imbalance in nutrient intakes ►82

iron deficiency anemia ►102, 103

grief ►238

heart ►36

immature defense mechanisms ►228

ischemic heart disease ►97

food culture ►81
food poisoning ►127

grief care ►238

heart disease ►98
heat stroke ►47

immune cells ►46
Immune system ►46, 116

isolation ►224
Itai-itai disease ►246

food safety and hygiene standards ►29

height ►78

food safety and sanitation ►88

grief work ►238
gross motor skills development ►58

height measurement method ►149

Immunity ►46
immunoglobulin ►118

lowintensity exercise ►79
low-quality pharmaceuticals and counterfeit
medicines ►186

food security ►89

growth ►23, 54, 78

height-for-age ►154

immunoglobulin E ►84

J
Japan ►246

lungs ►38
luteal phase ►192

Food-Based Dietary Guidelines (FBDG)►86
foodborne trematodiases ►126

growth curves ►152
growth hormone ►42, 92, 107
growth spurts ►189

helmet use ►269
helper T cells ►116, 117, 118
help-seeking behavior ►240

Immunological tolerance ►119
impairment ►306
implementation ►164

junior high school students ►266

luteinizing hormone (LH) ►192
lux ►137
lymphocytes ►116, 117

formal operational stage ►221

Guidelines for the Regulatory Assessmentof Medicinal Products for Use in SelfMedication ►301

hematopoietic stem cells ►117

importance of health education in schools

forming a basic unit of a social community►81
four big pollution diseases of Japan ►246

grief reactions ►238

►237

heme iron ►103

►27

hemoglobin ►103

incidents/accidents ►276

heroin ►176

incisors ►139

K
Kaup index ►152

lower respiratory tract ►38
lowered self-affirmation ►197

lysozyme ►116

keeps a well-balanced diet ►82
keys to caring for wounds ►295
keys to chest compression ►302

M
macrominerals ►85

Hhallucination ►177, 238

heterologous ►117

inclusive education ►309

Khmer Rouge ►231, 259

macrophages ►46, 116, 117, 118

fracture ►296

high blood pressure ►97

incomplete fracture ►296

kidneys ►42

fracture of the skull ►292

hand ►120high body-mass index ►97

individual characteristics ►112

Kiesselbach’s area ►293

magnesium ►85
main effects ►186

framework of PFA-S ►281

hand washing ►120high diet quality ►93

individual difference ►57

killer T cells ►116, 117, 118

mainstream smoke ►172

fresh ingredients ►73

handicap ►306

high fasting plasma glucose ►97

Freud, Anna ►224

Hans Selye’s stress theory ►225

high LDL ►97

individual risk factors ►63
Individual variability ►55

Koh Kong ►255
Kru Khmer ►199

malaria ►71, 123

Freud, Sigmund ►224
frontal cortex ►220
fructose ►83

happy hormone ►228

highest priority to the lives of people ►271

infancy ►78

hard contact lens ►136
harmful chemicals contained in tobacco

high-risk young people ►184
HIV ►308
home cleanliness and hygiene ►67

infection ►112
infection route ►73, 112, 113, 114

L
Lalonde report ►24

male reproductive system ►45, 191
malignant neoplasm ►98

infectious diseases ►65, 96, 112

land mines ►257, 283

malnutrition ►82, 97, 108, 154

four types of malaria ►123

functional diseases ►305

314

►173

major types of wounds ►294
malaria parasite ►123315

mangroves / mangrove forests ►255
man-made disasters ►263

mutual self-help group ►178

ophthalmological services ►157

pharynx ►41

primary reproductive organs ►44

respiratory rate ►287

myocardial infarction ►98

ophthalmologists ►157

Phnom Penh ►259

primary sense of control ►230

respiratory system ►38

maturation ►23

myopia ►134, 135

ophthalmus ►132

phosphorus ►85

prime mover (agonist muscles) ►35

respiratory tract ►115

mature defense mechanisms ►228

mysteries surrounding health ►18

opium ►179, 180

physical / chemical defense ►46

principles of growth and development ►55

response to lightning ►272

opportunistic infections ►205, 206

physical changes ►189, 190

prion diseases ►113

responsible self-medication ►301

N
narcotic drugs ►179, 180oral cavity ►41

physical defense systems ►115

problem-focused coping ►229

Rest ►297

oral contraceptive pills ►200

physical dependence ►175, 238progesterone ►192

rest and digest ►41

oral hygiene ►66

physical education class ►91

proliferative phase ►194

rest/sleep ►79, 80

memory cells ►118

National Action Plan on Early Childhood
Care and Development ►63

proteins ►82, 84, 105

restriction of social participation ►307

National Policy on School Health ►70

organ ►34
organ system ►34

physical examination ►82

memory T cells ►118

physical growth ►58

proximodistal direction ►56

menstrual (uterine) cycle ►192

National Program for Eye Health ►131

organic diseases ►305

physical growth and development ►59

psychic dependence ►175

retina ►132
reward system circuit ►177

menstrual cycle ►194
menstrual hygiene management ►213

National School Health Policy 2019 ►29

organic waste ►71
organizational activities ►273

physical health ►22
Physical inactivity ►91

psychological defense mechanism ►224

reward system of the central nerve ►175

natural disasters ►256, 263, 272, 283

psychological dependence ►238

RICE method ►297, 298

menstrual phase ►194

natural immune system ►116

orientation ►288

physical measurements ►29, 148

Psychological First Aid (PFA) ►280

right atrium ►36

menstruation ►190, 213, 214
mental health ►22, 218, 219, 223

natural killer (NK) cells ►46, 116

osteoporosis ►102
Ottawa Charter for Health Promotion ►24

physicochemical stressors ►225

Psychological First Aid School Edition(PFA-S) ►280

risk ►262

mental or physical symptoms ►82

neonatal ►78
nervous system ►47

outbreak ►119

risk factors for death and disability ►96

outer ear ►158

►197
physique indices ►152, 153

psychological health ►22

methylmercury ►247

psychosocial stressors ►225

risk factors for periodontal disease ►99

methylmercury poisoning ►250

neurons ►38

outer shell temperature ►48

Piaget, Jean ►221

psychosomatic disease ►227, 228risk management ►275

microminerals ►85

neurotoxicity ►173

PTSD (Post-traumatic stress disorder) ►227

risk prevention ►275

puberty ►266

middle childhood period ►59
middle ear ►158

neurotransmitter ►40, 228
neutrophils ►46, 116, 117
new lifestyle ►121

ovarian cycle ►192
ovary ►44, 192
overweight ►88, 109, 154
ovulation ►192

Piaget’s theory of intellectual development

middle childhood ►78

pituitary gland ►42
place ►112

pulmonary circulation ►36
pulmonary tuberculosis ►124

risky sexual activities ►79
Rohrer index ►152
roles of bones ►35

midwife ►199

nicotine ►173

oxytocin ►198, 228

placental stage ►198

pulse ►289

roles of school personnel ►282

migration of population ►259

night blindness ►133

oxytocin sensitivity ►198

Plan-Do-Check-Act/Action (PDCA) cycle

pulse rate ►287

milk teeth ►139

Niigata Minamata disease ►246

Minamata disease ►246

nitrosoamines ►173

mind ►218

NK cells ►117

P
pancreas ►41, 42, 43, 107rotavirus ►127
roundworm ►126
rubber tree plantations ►255

mind-body connection ►227

noise levels ►69

pandemics ►128

mindfulness ►230

parasites ►113
parasitic infections ►125

pollutants ►245

minerals ►82, 85

noise-induced deafness ►159
non-communicable diseases (NCD)-related
mortality ►96

plastic bottles ►71
Policy on Education for Children with
Disabilities ►309

parasympathetic nervous system ►39, 40,

polysaccharide starch ►83

minimum age for alcohol consumption

nondigestible saccharides ►86

poor academic performance ►175

►182
minimum ages ►176

non-heme iron ►103
non-recyclables ►71

220
Participation and collaboration ►29

Rrabies ►125, 296

poor nutrition ►82

rabies virus ►125

safe traffic environment ►268

parturition ►198

population growth ►259

radial artery ►289

safe water ►256

Minimum Requirement Guidelines on
Water, Sanitation and Hygiene in
Schools (WinS) ►69

normative consciousness ►266

passive smoking ►172

positive school environment ►215

receptors ►43

safe water and sanitation ►28

norovirus ►127

pathogen ►65, 112

Post-Traumatic Stress Disorder (PTSD)

recommended dietary allowances (RDA)

nosebleeds ►293

peer groups ►195

safety ►262
safety behavior ►266

misconceptions and assumptions about HIV
infection ►207

nuclear membranes ►84

peer pressure ►266
peer relationships ►196

posture ►137
postvention ►236

recording ►159

nucleosome ►33

recording sheets ►161

safety education ►266, 273
safety management ►273

moderately loaded exercise ►90

nucleotide ►33
nutrients ►81
nutrition status ►89, 102, 109

peer-to-peer relationships ►60
penile erection ►192
perinatal checkup ►199

potassium ►85
povidone iodine ►74
practice of preventive behaviors ►121

recovery ►178
recyclables ►71
red blood cells ►103

saliva ►116, 141
Salmonella enterica ►67
sarcopenia ►36

period of pregnancy ►192
periodontal disease ►99, 142

preconception period ►192
predict and avoid danger ►268

Red Ribbon campaign ►207

Scammon’s growth curves ►56

reference values ►152

schistosomes ►125

maturity ►54
medical model ►306
medulla oblongata ►39
memory B cells ►118

mine risk education ►258

modern medicine ►199
molars ►139

nematodes ►126

monocytes ►46, 117

physiological changes caused by pregnancy

►221

►276

puncture wounds ►293

plaque ►66, 99, 100, 140, 141►231, 280

Q
quality of life (QOL) ►139
quarantine ►121

right ventricle ►36

Ssafe behavior ►268
safe classroom and school environment

►86

►234
safe schools ►282

mother-to-child transmission ►114, 205

O
O-111 ►127

periodontal pocket ►99, 142

prefrontal cortex ►219

refractive errors ►134

schizophrenia ►239

motor development ►58, 59

O-128 ►127

periodontitis ►142

pregnancy ►197

refractive power of the lens ►132

motor nerve ►39

O-157 ►127

peripheral nervous system ►39

prejudice ►129, 247, 308

school cleanliness ►70
school environment ►26, 69

motor system ►35

permanent teeth ►139
permitted levels ►250

prejudice/discrimination against people with
HIV/AIDS ►206

school environmental hygiene items ►70

motorcycles ►268

O-26 ►127
obesity ►88, 102, 109

regular school environment hygiene
inspections ►70
repression ►224

school health ►16, 17

mouth ►41

observation ►291

personal cleanliness and hygiene ►66

premature deaths ►245

reproduction ►44

School Health and Safety Act ►26

mucous membranes ►115
multidimensionality of health ►22

occupational hazards ►248

personal factors ►308

preoperational stage ►221

reproductive cycle ►192, 193

ocular contusion ►292

personal Skills ►25

prevent food poisoning ►73

reproductive health and rights ►204

school health initiatives ►23, 26
school health objectives ►26

multidrug-resistant organisms ►129

One Health ►125
online violence ►234
onset of disease ►112

pesticides ►256
phagocytic mechanism ►117
phagocytosis ►46, 117preventing discrimination and prejudice

muscle strength ►90
muscles ►35, 52, 53

prevention ►236

resistance ►238
respiration ►288

mutans streptococci ►66, 140

oocytes (immature ova) ►192

pharmaceuticals ►186

primary HIV infection (acute stage) ►205

respiratory gases ►38

mosquitoes ►71

316

►129

reproductive system ►44

school health organization ►163
School Health Policy / School Health Policy
2006 ►28, 29
school health promotion ►27

317

school hygiene ►68school safety ►269, 273

sexual behaviors ►204
sexual contact ►205

source control ►119
sources of protein ►109

systems thinking ►253

tuberculosis ►123

systolic blood pressure ►37

Twelve Steps ►179

school safety plan ►274

sexual desire ►195

special needs for education ►309

systolic pressure ►289

two worlds of life ►18

school vegetable garden ►29, 88

sexual development and maturation ►189

special senses ►43

school-age years ►79

sexual diversity ►214

sperm ►44, 191

schoolchildren’s behavioral characteristics

sexual health literacy ►209

►277
scientific knowledge of health ►19sexual maturation ►189
sexual orientation ►214, 215

type 1 diabetes ►98

vulnerable road users ►268
W
warning messages on tobacco packages

type 2 diabetes ►98

spermarche ►190

T
tachycardia ►238

sphygmomanometer ►290

take pulse ►289
tar ►173U
uncertainty ►262

wastewater treatment ►71

spinal cord ►39

water breaking ►198

►185

waste disposal ►71
wasting ►108, 154

screening ►149

sexual response ►191

spiritual health ►22

target organs ►42

SDGs ►19, 20

sexual right ►211

spirituality ►22tartar ►100

unconsciousness ►224
undernutrition ►154

second generation PTSD ►233

sexual violence ►210

Spitz, Rene ►222

TD50 (toxic dose 50) ►250

underweight ►88, 102, 154

water pollution ►256
water treatment process ►72

second infection ►124
secondary disasters ►277

shock ►292

sprain ►296
standard of serving ►87

teacher training ►26

shrimp farms ►255

tears ►116

unexpected pregnancy ►200
unexploded ordances (UXO) ►283, 257

waterborne transmission ►114
water-soluble vitamins ►85

secondary immune response ►119side effects ►186

Staphylococcus aureus ►67

teeth ►66

unhealthy or unsanitary environment ►245

waterworks ►71

secondary reproductive organs ►44

side flash ►272
sidestream smoke ►172

Stephan curve ►146

secondary sense of control ►230

sterilization / sterilizing ►65, 120

temperature ►69
temperature regulatory center ►48

unhygienic behaviors ►66
United Nations Children’s Fund (UNICEF)

weight ►78
weight control ►93

secondary sex characteristics / secondary
sexual characteristics ►79, 189, 190

six food types ►86
six macrominerals ►85

stigma ►223, 247, 308
stigma of suicide ►236

territorial reinforcement/maintenance ►270

secretory phase ►194

skeleton / skeletal ►35, 51

stimulants ►176

tetanus ►296

►310
United Nations Office for Disaster Risk
Reduction (UNDRR) ►272

weight measurement method ►151

testes ►44

securing visibility ►270

stomach ►41

university students ►204

well-balanced nutrition ►80

stop the bleeding ►295
stratum corneum ►115
Streptococcus mutans ►100

thermoregulation ►47
three defense mechanisms ►115
three major factors for the establishment of
infection ►119

unwanted pregnancies ►200
upper respiratory tract ►38
uppers ►176

well-being ►27

security activities to escape danger ►277
security and order ►30

skilled birth attendance ►199
skills-based health education ►28
skin ►115
skin disease ►66

Western mind ►230
white blood cells ►116, 117seek help ►237

sleep ►92

stress ►224

three major roles of nutrients ►82

urban ecology ►260

WHO ►23security ►27

weight-for-age ►154
weight-for-height ►154

self-affirmation ►79

slow and gradual nature ►82

three principles of food poisoning
prevention ►127

WHO Constitution ►21

small intestine ►41

stress hormones ►228
stress responses ►226

urban environmental issues ►259

selfcare ►301

urbanization ►259

self-consciousness ►60

smallpox ►120

stress-coping behaviors ►229

three viewpoints on the mind ►218

ureters ►42

WHO Framework Convention on Tobacco
Control (FCTC) ►174

self-esteem ►60

smartphone ►92

stressful life events ►225

smoked tobacco ►181

stressors ►225

thymus ►46
thyroid gland ►42

urethra ►42

self-harming ►197
self-healing mechanisms ►302

smokeless tobacco (chewing tobacco) ►181

time ►112

urinary tracts ►42
use of condoms ►202

whole school approach ►237

smoking ►79, 93

stroke ►97
structure of a tooth ►140

tiger mosquito ►122

self-help group ►239
self-stigma ►308

smooth (visceral) muscles ►35

structure of the ear ►159

time-sensitive situation ►286

use-before dates ►73

wisdom of health ►19

urinary system ►42

WHO Regional Office for the Western
Pacific ►248
wisdom and knowledge of health ►18

Selye, Hans ►225

snake bites ►295

sensation ►43social development ►254

students’ knowledge and attitudes towardsmoking ►181

tissue ►34
tobacco ►97, 172

use-by dates ►67, 68
uterine contractions ►198

withdrawal symptoms ►175, 238
World Urbanization Prospects ►259

sense ►43

social disadvantage ►306

stunting ►108, 154

tobacco dependence ►238

uterus ►198

wounds ►293

sense of belonging ►196

social ecosystem ►223

sense of security ►196

social environment ►306

subarachnoid hemorrhage ►98
substance dependence ►238

tobacco tax ►181
tolerance ►178, 179sense of security and satisfaction ►81social exclusion ►223

suicide ►236

tooth ►139

V
vaccination / immunization ►29, 120

Y-Z
yellow fever mosquito ►122

sense of unity ►61, 196
senses of control ►230

social health ►22social impacts caused by alcohol ►176

tooth disease ►66

vascular resistance ►37

Yokkaichi asthma ►246

toothbrush / toothbrushing ►143

vector insects ►67

zoonosis ►125

sensitive periods ►57
sensorimotor stage ►221
sensory deafness ►159

social infrastructure ►259

superego ►224
supplying nutrients to sustain life andsupport living activities ►81

touching (palpation) ►291

vertical transmission ►114

social media ►234
social model ►306

supportive environments ►25
susceptibility control ►119

toxic psychosis ►177
trachoma ►133

vice-principal ►30
vicious cycle ►80

sensory nerve ►39
sensory organs ►43

social networking services ►269

susceptible period ►220
suspicious person ►271

traditional healing procedure ►199

social skills ►79

traditional sexual norms ►19

Vietnam War ►257
viewpoint of environmental improvement

serotonin ►228

social support ►229

sustainable development ►309

Services: ►26

social well-being ►30

Sustainable Development Goals (SDGs)

traditional wisdom ►199
traffic accidents ►263, 267, 268►263
viral food poisoning ►127

seven health habits ►92
seven key messages ►86, 87, 105

socially deviant behaviors ►196

►16
sympathetic nervous system ►39, 40, 220

traffic Safety ►273, 274

virtuous cycle ►80socially vulnerable young people ►183

traffic safety education ►268, 269

viruses ►113
visible danger ►262

severe systemic immunodeficiency ►205

social-mindedness ►81

symptom ►112

sewage ►71

sodium ►85

synapse ►38, 220transgender ►215
transmission cycle of dengue virus ►122

sewage disposal ►260
sewage systems ►72

sodium hypochlorite ►128

synaptic density ►219

transmission routes ►65

vital sign check ►287

soft contact lens ►136

synaptic pruning ►220

trematodes ►125

vital signs ►287

sewage treatment ►72
sewers ►71
sex ►214
sex hormones ►190, 195

soil degradation ►256

synergist muscles ►35

somatic ►43
somatic nerves / somatic nervous system

synthetic narcotic MDMA ►176
syphilis ►208

tricycles ►268
triglycerides ►84
truancy ►197
tubercle bacilli ►123

vitamins ►82, 85
voluntary muscle ►35

318►39, 40

systemic circulation ►36

visual impairment ►131

vitamin A deficiency ►133

vomiting ►300

319

School Health for All — A Step to a Better World [English edition]
Acknowledgements
We would like to express our sincere gratitude to all the people involved in the publication of the textbook,including the School Health Department of the Ministry of Education, Youth and Sport of the Kingdom of
Cambodia, Phnom Penh Teacher Education College, Battambang Teacher Education College, The Nippon
Foundation, Social Compass, and Education Support Center “KIZUNA”.

The Contributors
Supervision and editing
Takashi ASAKURA (Tokyo Gakugei University)
Authors (chapter; affiliation)
Naoko AOYAGI (Chap. 2, Chap. 11, Chap. 14; Ibaraki University)
Takashi ASAKURA (Introduction, Chap. 1, Chap. 12, Chap. 13, Chap. 16; Tokyo Gakugei University)
Hirofumi MONOBE (Chap. 4, Chap. 5, Chap. 6, Chap. 10; Yokohama National University)
Sadako NAKAMURA (Chap. 5, Chap. 6, Chap. 7; Jumonji University)
Chikage SAITO (Chap. 3, Chap. 7, Chap. 8, Chap. 9, Chap. 15; Saitama University)
Assistant editing and writing
Haruka SUZUKI (Tokyo Gakugei University)
Coordination and management
Yuuka MASUKO (Tokyo Gakugei University Cambodia Office)
Sokheng THAY (Tokyo Gakugei University Cambodia Office)Kalyan LY (Nagasaki University, Tokyo Gakugei University Cambodia Office)International Division, Tokyo Gakugei University
Illustration production
Social Compass
Grant
The Nippon Foundation

Publisher
Tokyo Shoseki Co., Ltd.
2-17-1 Horifune, Kita-ku, Tokyo, Japan

Printer
Livretech Co., Ltd.
1-28-1 Horifune, Kita-ku, Tokyo, JapanThe date of issue 4/1/2022
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