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Unformatted text preview: 269079_health_omslag2_ny:269079_health_omslag2_ny 19/12/06 13:16 Side 1 Developing a health-promoting school A practical resource for developing effective partnerships in school health, based on the experience of the European Network of Health Promoting Schools European Network of Health Promoting Schools http://www.euro.who.int/ENHPS Developing a health-promoting school A practical resource for developing effective partnerships in school health, based on the experience of the European Network of Health Promoting Schools Authors: Gay Gray Ian Young Vivian Barnekow Unedited Version International Planning Committee (IPC) 2006 All rights in this document are reserved by the IPC of the European Network of Health Promoting Schools, a tripartite partnership involving the WHO Regional Office for Europe, the European Commission and the Council of Europe. The IPC welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the IPC or its participating members concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the IPC in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The IPC does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. The views expressed by authors or editors do not necessarily represent the decisions or the stated policy of the IPC. Printing: Kailow Graphic Acknowledgements We would like to thank the following people for their contribution to the development of the European Network of Health Promoting Schools: Katherine Weare, University of Southampton Bjarne Bruun Jensen, the Danish University of Education Karsten Sørensen, Centre for Higher Education, Southern Jutland Børge Krogh, Centre for Higher Education, Southern Jutland This document is partly based on experience and documentation they have provided. Contents ABOUT THIS RESOURCE ..................................................................................................................1 WHO IS IT FOR?..................................................................................................................................... 1 WHAT IS IN THIS RESOURCE? ................................................................................................................1 PARTICIPATION AND PARTNERSHIPS .....................................................................................................1 IF YOU WANT MORE DETAILED INFORMATION.......................................................................................2 THE EUROPEAN NETWORK OF HEALTH PROMOTING SCHOOLS .....................................3 WHAT IS THE SETTINGS APPROACH AND WHY DOES IT MATTER? ..........................................................3 PARTNERSHIPS......................................................................................................................................4 HOW DO WE KNOW THE APPROACH IS SUCCESSFUL?.............................................................................5 EXAMPLES ............................................................................................................................................5 DEVELOPING A SCHOOL HEALTH POLICY ...............................................................................7 CRITERIA FOR A HEALTH POLICY ..........................................................................................................7 A CONCEPTUAL FRAMEWORK FOR A HEALTH POLICY ...........................................................................8 REFLECTION AND COHERENCE............................................................................................................10 BASING THE HEALTH PROMOTING SCHOOL ON CLEAR PRINCIPLES AND VALUES11 EMPOWERMENT AND ACTION COMPETENCE .....................................................................................12 WHAT IS HEALTH?...........................................................................................................................13 WHO VIEW OF HEALTH .....................................................................................................................14 WHAT IS YOUR VISION OF A HEALTH-PROMOTING SCHOOL?........................................16 THE CURRICULUM AND METHODS OF TEACHING AND LEARNING...............................19 THE IMPORTANCE OF HEALTH EDUCATION .........................................................................................19 INTEGRATED ACROSS THE CURRICULUM.............................................................................................19 TAKING A LONG TERM, DEVELOPMENTAL APPROACH .........................................................................19 ACTIVE METHODS ...............................................................................................................................19 AVOID SCARE TACTICS .......................................................................................................................20 ENCOURAGE PUPILS TO DEVELOP ACTION COMPETENCIES ..................................................................21 STAFF’S OWN HEALTH AND COMPETENCES..........................................................................23 THE NEED FOR TEACHER EDUCATION .................................................................................................23 THE TOTAL PHYSICAL ENVIRONMENT OF THE SCHOOL........................................................................24 TEAMWORK, INSIDE AND OUTSIDE OF THE SCHOOL .........................................................26 TEAMWORK IN THE SCHOOL ...............................................................................................................26 USING EXPERTS AS PART OF A WHOLE SCHOOL APPROACH .................................................................26 HOW TO INVOLVE PARENTS AND THE COMMUNITY..........................................................28 THE IMPORTANCE OF PARENTS ...........................................................................................................28 THE IMPORTANCE OF CONSULTATION .................................................................................................28 INVOLVING THE COMMUNITY .............................................................................................................28 CASE STUDY ......................................................................................................................................29 SO WHERE DO YOU START AND WHICH THEMES DO YOU CHOOSE?............................31 JUSTIFICATION FOR THEMES ...............................................................................................................34 EVALUATION .....................................................................................................................................35 WHY EVALUATE? ...............................................................................................................................35 HOW TO EVALUATE ............................................................................................................................35 COLLECT BASELINE DATA BEFORE YOU BEGIN ...................................................................................35 REFERENCES .....................................................................................................................................39 i About this resource Who is it for? It is intended above all to be of practical help to schools and those working with schools on becoming more effective in health promotion and therefore ultimately more effective in meeting their educational goals. A health-promoting school (HPS) aims to reach everyone in the school, pupils and staff alike, and also to develop good links with the community and families it serves. To be successful there is a need for all stakeholders to have a sense of ownership and involvement in the process. The resource is aimed mainly at school managers and teachers, but it is also of use to other staff in schools, particularly in countries where health professionals (such as psychologists or school nurses) are based in a school. If you work at local level and are involved in decision-making and guidance on school development and practice, this resource is also relevant for you. Some schools in Europe are already implementing many of the ideas in this resource but we are confident that at least parts of the resource will be helpful in stimulating the thinking of anyone working to make schools more effective in the promotion of health. What is in this resource? A brief description of the programme which informs it – the European Network of Health Promoting schools (ENHPS) The concepts and ideas that underpin the health-promoting school Examples of what schools have done in relation to those ideas Ideas for activities that you might carry out with staff, parents and pupils Practical case studies Suggestions for evaluation processes The ideas here are the result of many years of practical experience in working with schools in the ENHPS. Participation and partnerships Participation, ownership and an approach based on democratic decisions are key to the success of developing a health-promoting school. The resource therefore aims to encourage discussion and activities with all the main stakeholders: staff, parents, pupils, health and health promotion specialists and others concerned in the local community. Collaboration and bringing teams together is often not as easy as it sounds. People from differing professional backgrounds may have different values and attach a range of meanings to terms. The resource helps stakeholders to clarify what they mean by terms such as health and the health-promoting school, as well as the overall goals of education. 1 If you want more detailed information This practical resource is targeted at individual schools and their communities. It sits alongside Health-promoting schools: a resource for developing indicators, also available from the Technical Secretariat of the European Network of Health Promoting Schools. Whilst the latter may also be of value to individual schools, it is targeted more at national policy makers and others with an interest in measuring the effectiveness of health-promoting schools. 2 The European Network of Health Promoting Schools The ENHPS is a strategic programme for the European Region, supported by the Council of Europe, the European Commission and the WHO Regional Office for Europe (Barnekow et al, 1999). It has been developed in more than 40 European countries, reaching several thousand schools and hundreds of thousands of pupils. In the ENHPS, each country has been encouraged to develop the health-promoting school idea in a way that seemed most appropriate for their needs and specific context. Clear ideas have emerged about how a health-promoting school differs from a traditional approach to school health, and some clear principles for action have evolved (Barnekow,2006). The challenge for any school starting on this path is to see how the concepts and ideas can best be developed to suit their specific needs and circumstances. The ENHPS has a conscious and planned strategy based on a settings approach to health, developed by the WHO in the 1980s. (Young I and Williams T, 1989). This also applies to other settings for health promotion for example Healthy Workplaces, and Healthy Cities. (Dooris M, 2006) (Whitelaw S et al, 2001). What is the settings approach and why does it matter? The settings approach recognizes that health is not just a matter of what individuals do to look after their own health, through healthy habits and lifestyles: health is shaped by the context in which they find themselves, where not only the physical environment but the surrounding ethos and relationships can support, or indeed undermine, health. The essence of the approach is not to ‘blame the victim’ for their own problems. Instead it attempts to prevent problems and promote well-being through providing environments that facilitate health development and influence the visions, perceptions and actions of all in that particular setting. Activity Ask partners to tick which of these aspects they think would be involved in developing a health-promoting school, taking a settings approach The taught curriculum The school ethos The values and norms of the school Relationships Management structures The physical environment Staff health and well-being Student health and well-being Teachers’ educational competencies Cooperation with the community Yes No Don’t know 3 In fact all these aspects of school life are relevant and inter-related, and there needs to be consistency between them. To give an example, if we review opportunities for physical activity in the school, we should not only consider the curriculum provision but also other aspects of school life such as safe and active routes to school and providing secure areas for bicycle storage. At the heart of the model is the young person. Creating a positive climate can influence how young people form relationships, make decisions and develop their values and attitudes. It can also have a very positive effect on their learning and educational attainment. Furthermore, healthy, well-educated young people can help to reduce inequities in society, thus contributing to the health of the population at large. (West P et al, 2004) However, in the settings approach the health of everyone in the school is important: the staff as well as pupils. Looking even more widely, the school is seen as part of its community, reaching out to and supported by parents, local health services, and other agencies, involving them in programmes and interventions, while in turn contributing to the life of the community. Importantly, a settings approach to health promotion should support the overall aims of education and of building an effective school, of helping young people to learn to participate in society and to develop to their full potential. The next section explores this further. Partnerships The ENHPS programme depends on a partnership and collaboration between three major European agencies. Nationally, the programme’s success had also depended on effective partnerships between the health and education sector. The importance of partnerships was highlighted at a Conference, held in 2002 at Egmond-am-Zee in the Netherlands. Delegates from 43 European countries considered the progress made in the health-promoting schools programme and identified the practical steps essential in building successful national health-promoting schools programmes. This resulted in the Egmond Agenda with three main components: Conditions: a situation analysis concerning the status of HPS development, partnerships within and between all players, advocacy for investment in HPS programmes and a sound theoretical base. Programming: deciding the content and objectives of a national programme, long-term planning and teacher education and professional development. Evaluation: providing evidence of effectiveness and to inform future developments All these components also apply to some extent at school level as well as at the regional and national level. 4 How do we know the approach is successful? The need to take such an approach is well supported by evidence from research on school effectiveness. Studies have consistently shown that multi-dimensional approaches, which work on several inter-related areas, are markedly more effective in producing long term changes to pupils’ attitudes and behaviour across a wide range of issues than are specific, limited, unidimensional programmes. To give some concrete examples, empirical evidence from a range of studies has shown: Examples The importance of supportive relationships to learning. It has been shown that pupils learn more, have higher attainments, enjoy learning, are more motivated, and attend better if their teachers are understanding and helpful. It is also evident that young people do not learn effectively if they do not respect their teacher. Poor relationships between pupils and staff and between teachers and their colleagues is one of the most commonly cited causes of staff stress, while high levels of support, particularly from the head teacher have consistently been shown to reduce the likelihood of teacher ‘burnout’. The level of democratic participation that the school encourages is a key factor in producing high levels of both performance and satisfaction in both teachers and pupils. Pupils learn better, including in their academic subjects, and are happier at school, if the goal for them is to think for themselves and to work as independently as their age, stage and personality allows. The importance of good relationships for staff morale. The principle of democratic participation. The importance of autonomy. Where health is concerned, it has been shown that school is hugely important as a source of both risk and protection. The World Bank says that in the poorest countries of the world teenage pregnancy falls by 7% per year from age 12-13 where children stay in school. There is a body of research that shows strong associations between young people’s views of school and health-related behaviours. Young people who feel connected to school are less involved with every risk behaviour. For example, it has been found (Nutbeam D et al, 1993) that pupils most engaged in school are more likely to succeed academically and to display positive health behaviours. The corollary of this is that pupils who are most alienated are more likely to engage in high-risk behaviours. This is supported by another study (Currie et al, 1990) which shows that young people who have problems at home are less likely to engage in certain high risk behaviours if they feel good about school. It seems that schools’ rules on cigarette smoking, (Gordon J and Turner, K, 2003) drugs or sexual behaviour do not by themselves have much impact on levels of risk behaviour. The type of school they go to also does not seem to make much 5 difference, nor does classroom size. What makes a difference is having well run, democratic schools, where everyone feels involved. Classrooms where teachers set high academic expectations and give out two messages to every child - ‘You can succeed’ and ‘I will help you do that.’ A recent international review of the evidence of effectiveness of school health promotion (Stewart-Brown, 2006) concluded that school programmes that were effective in changing young people’s health or health-related behaviour were more likely to involve activity in more than one domain (curriculum, school environment and community). Research has shown that in building resilient young people, families matter, schools matter and community connections matter. It matters that young people believe that others see their potential and that the young people feel they have a future. 6 Developing a school health policy An integral part of developing a health-promoting school is creating a health policy that underpins the work. It follows that with a settings approach, a school health policy should include all the aspects of school life mentioned previously. It also needs to be developed locally so that it reflects local issues, interests, problems and priorities. One school may consider bullying and well-being to be most important, whilst another may consider that food provision is the highest priority. It cannot be stressed enough that local commitment and ownership are needed for a health policy to be relevant and meaningful. It should also be an on-going process, with strategies and tools that enable pupils, teachers and parents to continually review, develop and sustain the policy. Everyone in the school, including pupils, needs to have ownership, so that it is embedded into people’s consciousness, practice, action and behaviour at school. The main conclusion from health-promoting schools is that more participation leads to more ownership. This idea is also explored in the section on values. One way that pupils can contribute to a health policy is through their own education. If education on health and social matters results in them drawing up proposals for action to change the school’s social environment, these can be an important input to the development of the school’s health policy. Obviously there are certain issues that pupils cannot change directly. There may be existing legislation (such as smoke free environments) or a local policy that has to be adhered to, but pupils can still be informed and the policy can be debated. It is important to discuss and justify how different stakeholders might be involved. What is appropriate and desirable may vary depending on the issue. What can be discussed and what cannot and why? What is merely information, what is open to discussion, what can be decided collectively and with what justification? Criteria for a health policy A school’s health policy must reflect the following three dimensions: Developing a policy takes attention, time and resources, if it is to be taken seriously. It needs to be on the educational agenda in the school and given priority as an important theme. It must also be integrated into the educational process. A policy presents visions of what we want in future, both regarding the type of school and society. Visions are subject to public discussion in a democratic society, with people arguing for what they consider valuable and why. A policy also defines problems and sets out a framework to solve problems. Defining problems answers the question of which problems are most important and investigates the reasons and causes for the problems arising. Solving problems includes principles, guidelines and proposed action to counteract, prevent and solve problems. 7 A school health policy should: contribute to the implementation of the schools’ educational mission; promote the health and well-being of all school users; include factors related to both lifestyles and living conditions; promote a clear vision and provide a framework for solving problems; contribute to pupils developing skills and action competences; be monitored and reviewed regularly. A conceptual framework for a health policy The conceptual framework given here illustrates all the components needed in developing a health policy. They all influence one another and all need careful consideration. If any are missed out it is likely to be ineffective, but a school may choose to start at any of the places in the framework and can address the components in any chronological order. Nevertheless, a ‘theme’ or a ‘challenge’ is a good place to start. This framework should be used in a dynamic way: with each component being assessed in relation to the others. This ensures continual assessment of whether the components are in accordance and coherent and makes the justifications for the ‘who, what, how and when’ of the health policy explicit and clear. 8 A conceptual framework for developing a school health policy Planning and coherence questions What do we want? Who should participate? How should we do it? When should we do it? What justification do we have for what, who, how and when? How do we want visions, values, objectives and action to interact? The values of the policy and the school (such as pupil participation in decision making and concepts of health) The vision of a health-promoting school Themes in the policy (such as bullying, transport and traffic, food and physical activity) Justification for the themes chosen (why this topic is important to the school) The vision for the themes that have been chosen and justified (such as ensuring a high level of well-being for everyone at the school) Specific objectives: what do we want to promote? Action plan (such as what we should do specifically to achieve the objectives) 9 Case study Three schools in Denmark selected different themes as the basis for developing a health policy. They are all members of the Network of Health Promoting Schools in the County of Southern Jutland. Guderup School focused on their general classroom teaching based on their experience with health education; Løjt Kirkeby School mainly emphasized environmental factors and relationships, and Kværs School focused on both health education and environmental factors. Guderup School had already developed, tested and evaluated several educational programmes. These included peer educational programmes in which older students taught younger students. The evaluation indicated that this had a great effect especially on the older students’ knowledge and attitudes towards health. The school decided to discuss the experience gained through this with teachers in order to generalize from the learning. As a result nine criteria were agreed that would apply to the whole school, These included ‘students should be equipped to take action that leads to development and change’ and ‘parental participation in teaching should be increased.’ Students were asked their views on all the criteria and these were fed into meetings of the Educational Council. The school then used the criteria as a basis for joint theme weeks. In Løjt Kirkeby School, following an investigation into bullying, the Health Committee agreed to focus on initiatives to improve the general working environment of the school. They adopted a vision, including that ‘a good social culture is promoted at the school’ and that ‘habits and norms are investigated to determine the barriers to a good social culture.’ Based on this vision, an educational values game was designed in collaboration with teachers to explore: mutual support, solving conflicts and consistency. The game was played by staff and the School Board and resulted in possible actions or measures being identified to address different problematic situations. The next step would be to develop a game to be used in each class. The Educational Council of Kværs School decided to strengthen playing and physical activity in the school’s teaching and daily activities. The justification for this was that teachers had noticed that students had inadequate motor skills and also considered that learning potential and physical competence are closely related. Following a seminar on the theories of playing and games and their significance for learning, the Educational Council decided to investigate the play culture at the school. Two questionnaires were designed – one for students and one to investigate how teachers used playing and games in their teaching. Informed by the results, the Council decided that they would strengthen play and physical activity during breaks and in teaching. The class teachers were asked to present the results of the survey to their classes and to elicit ideas from students on how to strengthen playing and physical activity. An action plan has been drawn up for future work. The values of the health-promoting school have been instrumental in both the processes and results for all three schools. The values include WHO’s definition of health, the principle of pupils’ active participation in the learning process, the settings perspective and the objective of developing empowerment and action competencies among the pupils Reflection and coherence Looking back on what we have done, what changes are needed in practice and in visions, values and objectives? 10 Basing the health-promoting school on clear principles and values In the past it has been assumed that promoting health is an obvious activity, but we are now realizing that it is more complex than that, and cannot be ‘value free’. In fact the act of saying that the promotion of health is important is in itself a value statement. We need to decide from the outset the principles on which we wish to base our work, and decisions about this are connected with values, morals and political judgments. There has been much discussion of what principles should underpin the healthpromoting school approach. For example, at an International Conference in Thessoloniki-Halkidiki, in Greece in 1997, (ENHPS, 1997) a conference resolution was drawn up, which reflected the views of a wide range of professionals from 43 countries. It urged governments to create the conditions for 10 principles or values to be put into practice to support the ENHPS. These principles were Democratic practices and participation Equity and access Empowerment and action competence Sustainability Curriculum based health promotion Provision of teacher training The school environment Collaboration and partnership Involving communities Measuring success Four of these are more fully explained in the table below. The others are explored in more detail in later sections. Values underpinning a health-promoting school approach Democratic practices and participation Health promotion is defined by the Ottawa Charter (WHO, 1986) as ‘the process of enabling people to increase control over, and to improve, their own health’. It aims to ensure that an action or process is done with, rather than to, people. The principle of democracy is important in education as well as in health, as the overall purpose of education in many countries is to educate pupils to participate actively in their society. A key strategy for a health-promoting school is to ensure that its organization, the way decisions are made, the management structures and ethos are all democratic, empowering and encourage genuine participation by pupils, staff and parents. Key elements include consultation of staff and pupils and open communication. The task of a teacher is to enable and facilitate pupils to help themselves, rather than determine the process for them. Pupils' parliaments, parents' councils, and school planning groups that include members of the local community are just some of the ways in which democratic intentions can become reality. 11 Equity and access The principle of equity should be enshrined within the educational experience. This guarantees that everyone in a school is free from oppression, fear and ridicule. The health-promoting school is genuinely socially inclusive and provides equal access for all to the full range of educational opportunities. Everyone needs to benefit from school, not only academic achievers, but also children, with special needs and those from all ethnic groups. The aim of the health-promoting school is to foster the emotional and social development of every individual, enabling each to attain his or her full potential free from discrimination. For this, each person needs to feel that they belong, feel cared for, valued and safe. Empowerment and action competence The health-promoting school improves young people’s abilities to take action and generate change. It provides a setting within which they, working together with their teachers and others, can gain a sense of achievement. The goal of empowerment is autonomy, by which is meant self determination and control of one’s own work and life, thinking for oneself and being critical and independent, while being able to take full responsibility for the effects of one’s own actions. Young people’s empowerment, linked to their visions and ideas, enables them to influence their lives and living conditions. This is achieved through quality educational policies and practices, which provide opportunities for participation in critical decisionmaking. Autonomy is a vital issue for teachers as well as pupils. The degree to which teachers have control over their own work, and can make their own decisions has been shown to be fundamental to their emotional and social health and to their performance in general. (Moos, 1991; Shaw and Riskind, 1983;) Higher levels of staff autonomy have a wide range of benefits, including decreased stress levels, lower absenteeism and higher morale Sustainability Any initiative planned must be sustainable, long-term and adequately resourced. It needs to be embedded in the on-going educational process. The last six principles are covered in more detail in the following sections of this resource. Activity: deciding on values for your school Schools have implicit or explicit values that influence daily school activities and classroom teaching. It is important to discuss: What values are important currently in your school? Are there other values which you would like to see given priority in a health policy? How would this fit in with the current ethos of the school? How would this fit in with the current values of society? How would people know that these values are important? 12 What is health? Before you can think about how to make your school more health-promoting, you first have to be clear about your concept of ‘health.’ Concepts of health have changed dramatically in recent years, and in any society, community or school you may find many different views. Before you start to plan for change, it is worth spending time trying to build a consensus on what you mean by ‘health’ and a ‘healthy person.’ Activities on ‘what is health?’ There are various ways of opening a discussion, some of which are creative whilst others are more traditional. They can be useful to bring to the surface the fact that different sectors, such as health and education, may hold different views on health and have different values underpinning their work. It is also useful to think about whether any of the activities could be used with pupils. Brainstorm what comes into people’s heads when they hear the word ‘health.’ Write down all their words on a blackboard. Look with them to see: how many are positive/negative? how many are to do with illness rather than wellness? whether the words refer to physical, mental, emotional or social health? Draw an outline of a healthy child on flipchart. Ask each person to write on a “postit” what they understand by ‘healthy.’ Invite them in turn to stick their “post-it “ somewhere on the flipchart and tell the group what they have written. A quiz: ask staff and others involved to quickly complete a quiz such as the one that follows. You can then compare and discuss answers. Draw a picture of a healthy person, and write round that person what helps to keep them healthy. Any or all of these activities can be carried out individually or in small groups, and followed by discussion to bring out the areas of agreement and disagreement. 13 Quiz: different views about health! How far do you agree with the following statements? Please put a cross on the answer which reflects your opinion. YES! 1. If I’m free of diseases, then I’m healthy. 2. Mental and physical health are dependent on one another. 3. A healthy person is able to make and maintain relationships with others. 4. People living beyond seventy years of age are proof that they are healthy. 5. The health issues in our country are no different to what they were 50 years ago. 6. People have a right to choose for themselves whether or not they wish to be healthy. 7. The major health concerns of today can usually be solved by legislation rather than education. 8. Responsibility for health lies mainly with the medical profession. 9. It is difficult to be healthy if you live in a deprived and polluted environment. yes ? no NO! WHO View of Health In some cultures health has traditionally meant the absence of illness, but now broader and more positive models of health are developing and re-emerging. Given WHO’s well-known definition of health as 'a complete state of physical, mental and social well-being, and not merely the absence of disease or infirmity', which has stood for sixty years now, the WHO has always preferred to take an approach which starts from a positive basis, sometimes called the ‘salutogenic’ or wellness model. The Ottawa Charter suggested that health is ‘a positive concept, emphasizing social and personal resources, as well as physical capabilities,’ (WHO, 1986). This approach to health involves more than diagnosis and treatment, or even prevention of illness, but is essentially concerned with the promotion of positive wellness. 14 When it comes to promoting health, we are now generally aware that peoples’ health is not primarily determined by their knowledge, but that beliefs, emotions and their social environment are at the root of behaviors affecting their health. People choose whether to look after their health through, for example sensible eating, taking appropriate physical activity and avoiding harmful substances. However, whether they take these actions is influenced by other factors such as; how they feel about themselves; whether they think they are worth looking after; whether they think they have a future; whether they believe that they can change; their assessment of what others think of them. They are motivated to take care of the health of others according to how they feel about the group they are in and their place within it. People can be prevented from taking healthy action by their own negative attitudes and feelings, and restricted through a lack of skills; they can also be disempowered by social or environmental circumstances which they feel they cannot change. The table below outlines the key differences in definitions of health. Traditional approach to health The absence of disease. Physical well-being. Positive well-being. World Health Organization view of health Physical, mental and social - about the body, mind and the surrounding context. The concern of everyone. Includes educational approaches e.g. learning knowledge, attitudes and skills Includes social change. The concern mainly of doctors. The goal is a perfect state of health. The goal is to help people be as healthy as they want to be – health as a resource for living, not an end in itself. Health is influenced by our environment and people need to be supported and given opportunities to be healthy. Health is improved mainly through health promotion, helping create social and physical environments that support health, and empowering people to take their own decisions to help them to be as healthy as they want to be. It involves action for social change, increasing social equality, and increasing democratic participation. Health is a matter for individuals – it is entirely up to each of us how healthy we are and if we are not it is our own fault. Health is improved mainly by medical intervention and lifestyle changes by individuals. 15 What is your vision of a health-promoting school? Do you have an overall vision of a health-promoting school? It is important to clarify what you hope for in the future as well as a vision of how you want the school to develop in relation to a selected theme. What comes into your thoughts when you hear the words ‘health-promoting school?’ Perhaps you have already been involved in work related to health promotion. Maybe you are involved in health screening in your school. Would different people in your school have different views on what we mean by a health-promoting school? As with health, it is important to spend time reaching an agreement on what the term means and deciding the principles and criteria on which your initiative will be based. If you do not do this, you may find that people may start to pull in different directions. Activities to use with staff, parents or pupils to clarify your vision of a healthpromoting school. Ask people to work on their own or in small groups to draw and label a picture of a school that is trying to promote the health of all who work and learn there. If they do not want to draw they could make a list of the features of a health-promoting school. After this you could ask: - How would you know that the school they have drawn is health-promoting? - Are there similarities or differences in their drawings? - What makes a school health-promoting? - Is there any difference between a health-promoting school and an effective school? If you do the same activity with different groups the results could then be compared. Their own experience – an activity that could be used with pupils but also with parents and staff Ask people to think about their own experience of being at school. To what extent do they think it helped them to be healthy? To what extent did it make them more unhealthy? How could it have been made more health-promoting? Encourage them to think about what aspects of health they have considered. Have they thought mainly about physical health, or also emotional and social health? What aspects of school life have they mentioned? Do they think things have changed since they were at school? Looking at the table below, do they think most schools in their locality have a traditional, moralistic approach to promoting health or a broader, more democratic approach. What about your school? 16 The table below shows the main ways in which the health-promoting school concept, as it has developed through the ENHPS differs from a traditional model of school health in some countries. Traditional, moralistic approach to school health Concept of health Focus on individuals e.g. on their health problems, on his or her ‘healthy habits’ and lifestyles. Focus mainly on physical health. Physical activity seen as linked only to sport. Health as the absence of disease and problems. Focus on illness, diagnosis and treatment. Health education seen as a value free approach. Short term response to events, often ‘crisis management’. Concept of health education The focus is changing behaviour, developing healthy habits and lifestyles: conformity and obedience. Health education taught as separate lessons. Curriculum aims to teach knowledge. Health-promoting school approach according to the ENHPS A ‘settings’ approach - focus on the totality of the school as an organization in its community, all staff and all pupils. Developing a school health policy. Focus on mental, emotional and social health as well as physical health. Physical activity seen as beneficial for all, and as being fun and enjoyable. Health as positive well-being. Focus on the quality of life, on prevention of health problems and promotion of positive mental, social and physical health. Health promotion based on explicit principles e.g. democracy, equity, participation. Long term, developmental approach which starts early, for all children and meets their stage of development, needs and interests. The focus is on autonomy and decision makingpeople decide for themselves how and to what extent they wish to be healthy. Health education integrated across the curriculum. Curriculum aims to help pupils learn skills and attitudes as well as knowledge. The objective is increasing action competence. Student participation in decisions. The focus is on learning rather than teaching, and on active methods involving group work, discussion, games, simulations, problem solving, taking action etc. Emphasis on positive methods, the advantages of being healthy, choice and decision making. Moralizing: the teacher decides. Teacher-centred methods, often with lectures on ‘good health’. Pupils generally passive. Emphasis on negative “messages”, warnings and inducing fear. 17 The whole school Teachers not part of the process or seen as role models in a moralistic sense. Only certain parts of the physical environment of the school seen as related to health e.g. gymnasiums, sanatoriums. Teachers’ mental, emotional and social health are as important as pupils. Teacher support and training is essential. Whole physical environment – classrooms, corridors, playgrounds, toilets, healthy eating, routes to school - seen as affecting health. Links with the community Experts from the community are involved The school and pupils participate in society and in the school or class. function as partners in dialogue; pupils take action and are taken seriously. Outside agencies used for referral of Outside agencies actively involved with whole children with problems and difficulties. school work. Parents and community ignored or asked to ‘support’ the school. Evaluation Measuring pupils’ behaviour related to smoking, alcohol etc. Action based on ’what has always been done’. Parents and the wider community actively involved e.g. in decision making, and there is a programme of out of school activities. Measuring pupils’ action competence (thinking, commitment and vision). Action based on evidence of what is more likely to work and on evaluation. The settings approach has already been outlined on page 3. Other ideas in the above table will be explored in more detail in the following sections of the resource. A vision must promote commitment and be measurable. To be committed, everyone concerned must feel some ownership of it and an obligation to contribute towards it. A vision is measurable if a school can formulate indicators that show whether the school is developing in the direction desired. Activity Schools could discuss the following questions. What do we want in the future and why? Which problems do we want to prevent and solve? How can we see, hear and feel whether we are moving in a desirable direction? What are the signs? 18 The curriculum and methods of teaching and learning The importance of health education Although the health-promoting school focuses on all aspects of school life, the learning and teaching in the curriculum is a still a key part of this approach. Integrated across the curriculum If health education is to be of high quality and effective, it should not be taught as a series of separate lessons, although there may be room in the curriculum for some core teaching. It is vital that health promotion be integrated right across the curriculum, throughout a whole range of subjects, all of which have something to contribute. Furthermore if programmes are to succeed they need to be based on the best available evidence on what works, the best and most appropriate resources and materials, and be systematically planned, structured and evaluated. Such a wellorganized approach will not happen by chance, it demands that schools appoint health promotion coordinators with the training, status, time and resources to make their role effective. Taking a long term, developmental approach Taking a developmental approach means tailoring the approach to the learner, for example their age, stage or emotional state. Younger, less mature and more introverted and anxious pupils need higher degrees of structure, concrete experiences of demonstration and organization but they can still benefit from being given as much autonomy as possible, and by being gradually encouraged to work with more independence. As pupils grow older they are increasingly able to reflect consciously on processes and use more complex and abstract ideas and principles. As they become more mature and more confident, they can handle higher levels of individual choice and autonomy and programmes can increasingly become pupil led. If we want to devise appropriate projects and assess their impact, we need to find out where pupils are starting from in terms of their knowledge, attitudes and skills. Once we know this, we can use that information to develop projects that starts where they are, and build from there in small steps. A wide range of qualitative and quantitative methods to do this have been devised, including questionnaires, inventories, discussion, interviews, focus groups, and ‘draw and write’ techniques. Some of them will be discussed later in this resource under evaluation, but they are just as useful for programme development. It is important as well that health promotion is continuous. Work should not just be one lesson, or triggered by particular ‘crises’, or restricted to a particular age or other target group, or have long gaps in between. All of these have been shown to have little long term effect. Active methods It is important to think about appropriate learning and teaching methods as well as what is taught. Schools need to use a wide range of methods, with the emphasis on 19 those that are active and participatory. If the health-promoting school is about empowerment, participation, democracy and open communication, then these principles must be reflected in classroom methods. Those involved in education and training at all levels are coming to realize the importance of actively involving people in their learning, through group work, discussion, project work, games, and simulations. Active learning methods give the student more of a say in the content and offers them more responsibility for their own learning. It is particularly important in the affective domain as it allows the learner an opportunity to reflect on their own beliefs, values and attitudes in a way that traditional teaching does not. Case Study Eight classes from eight countries have participated in a project called Young Minds. The countries included are: Czech Republic, Denmark, England, Finland, Hungary, Ireland, Slovenia and Spain. It is an Internet-based project in which young people communicate and explore links between youth, culture, health and environment. It was initiated in 2000 and there have been several “phases” of the projects since then. The students present their countries online, to get to know each other across the physical borders. Then, depending on the topics in focus, such as the school and the environment in 2004, the students access information online provided by the Young Minds team, which they then further research and explore. Finally, the students take specific actions in their class, school, community or even internationally. Key features of the project Student participation: students are genuinely involved in dialogue and decision making about specific aspects of the topics they are working with. Action and change orientation: the student project work is directed towards action and change. Students’ ideas and visions have a crucial role in deciding about actions to be taken with regard to improving the environment and health in their schools and communities. The use of ICT: students use the internet and other technologies to investigate the topics, exchange and discuss ideas, present their findings and reflections and initiate a broader debate. Cross-cultural collaboration: students cooperate in order to explore differences and similarities with regard to the environmental and health concerns, with an emphasis on global interconnectedness and social responsibility. The project is linked to the ENHPS and coordinated by the Research Programme for Environmental and Health Education at the Danish University of Education. For more details, visit web site: http://www.young-minds.net Avoid scare tactics There is overwhelming evidence that negative approaches, which attempt to use ‘scare tactics’ to frighten learners into a healthier lifestyle are not only ineffective, but are often counterproductive. Young people will probably block out horrific images, as the mind has a useful defense mechanism of forgetting such things quite quickly. In addition some young people can find the suggestion that an activity is risky adds to its 20 glamour and attraction. We know that many young people believe that they are themselves strong enough not to succumb to, for example, addiction to nicotine or heroin, and can see taking it as a challenge. So, however morally gratifying it may feel, and however much their pupils may believe that it is a good idea, teachers should shy away from using negative messages, and find ways to teach in more positive and participative ways. Encourage pupils to develop action competencies Acknowledging that there is a great deal more to health education than transmitting knowledge, brings us to models of teaching and learning that have wider goals than the acquisition of information. Health-promoting schools tend to prefer the concept of 'competency', which includes skills and attitudes as well as knowledge. More recently the word ‘action’ has tended to be added, to remind us that competences need to provide people with the ability to make a difference in real-life situations and to effect change. Health-promoting schools are moving on from treating traditional health education topics, such as healthy eating, substance use, physical activity, or sexuality in isolation from one another and are starting to teach generic competences that underlie specific health issues. The topics are not discrete entities in reality. For example, an issue such as sexuality and relationships and alcohol use are closely related in many western countries as is evidenced from the role of alcohol and other substances in unintended teenage conceptions. There is a wide range of action competences that can be seen as underpinning learning related to health, and indeed learning across the whole curriculum. This is a more efficient way of teaching because there is never going to be enough time in the curriculum to cover all the possible health topics that might impinge on a young person’s life. Personal action competences include selfawareness, realistic self-evaluation, managing emotions, self motivation, decision making, assertiveness and goal setting. Social action competences include listening and responding effectively to others, reading and interpreting social cues, being cooperative, and knowing how to resolve conflicts, mediate and negotiate. Of course, all of these competencies are not only important in relation to health issues but to all of life. If it is possible to develop these skills and competencies relating to health and they prove to be transferable then health education will be making an important contribution to the educational and social aims of the school. A model for developing pupils’ action-competence, which originated in Denmark, (Jensen B and Simovska V, 2005) has been disseminated and applied in schools in several countries. The overall objective is to develop pupils’ critical and visionary competencies so that they can act to create health-promoting change. Called the IVAC approach, it has distinct stages: • • Investigation and significance: pupils explore the relevant theme or topic and attempt to determine its significance and value for their own lives. Visions and alternatives: pupils attempt to develop their own dreams, values and visions for how they would like to change and develop the conditions within the relevant theme or topic. 21 • Action and Change: the pupils develop proposals for specific action that brings them closer to their own visions. They choose action and try it in practice. They then compile the results of their action, assess them and perhaps adjust the action and initiate new action. Testing specific forms of action is considered an important contribution to pupils’ learning and developing action competence. Case Study In the Macedonian Network of Health Promoting Schools, one school established a health-promoting team, consisting of 35 students aged 12 to 15 to work on improving the school’s psycho-social environment. They were supported by five teachers, the school health promotion coordinator and two consultants. Their participation was structured according to the IVAC approach, mentioned above. Work carried out in each phase by students included: In the Investigation phase: an exploration of their concept of health and relating this to their own school environment; what they liked and disliked about certain aspects of the school environment and how these aspects related to health; a survey in the whole school to find out what improvements students thought should be made to the school environment. During the Vision phase: supported by their teachers, developing the students’ vision of the ideal school – for example, what the environment would look like, what would happen in teaching, what would school relationships with parents and the community look like. In the Action and Change phase: changing the school time schedule, shortening lessons from 45 to 40 minutes. This allowed more time for sports in the middle of the school day and better possibilities for relaxation and socialising during the lunch break. On the basis of their previous exploration of the concept of health and the view of other students at the school, the students were able to relate these changes to health and health promotion, to articulate their position and convince their teachers that the change was worth the effort because it would have an impact on the school atmosphere and on the health of the whole school. 22 Staff’s own health and competences Schools have traditionally focused on pupils, taking the health and well-being of their staff for granted. This has never been a sensible assumption. Teachers and other staff cannot be expected to be enthusiastic about health promotion if they do not feel their own health, both mental and physical, is being promoted. They need constant support, from staff development programmes, from positive and helpful appraisal, and most of all by having a voice in school management and organization. They need to be strongly valued, and to be given active and positive help to promote their own health and well-being. (Monaghan et al, 1997) Activity: staff stress It can be a great help to teachers to identify and share with one another the things that are stressful in their professional lives. The causes of stress might be from a range of sources: - at a personal level (e.g. poor time management, inability to delegate, inability to say no) - interpersonal (e.g. lack of respect from others, not being involved in decisionmaking, aggressive or intolerant colleagues) - organizational (e.g. inadequate equipment and resources, timetables, poor management) - community, cultural (e.g. high levels of unemployment, poor roads) - national and international (e.g. low pay, federal policies) Ask people to work in small groups to each think about a different source and write down all the many causes of stress for teachers from that source. Share results. At the end it is important to think of constructive ways that people know of dealing with stress. Draw on the skills of the group by asking each person one thing which they do to manage stress. Teachers play a central role in a health-promoting school. The example they set and the ways they relate to pupils can have a tremendous impact on a child’s self-esteem, confidence and emotional health. Consultation with teachers and education about health promotion is a vital component of the HPS. You need to take steps to educate all staff about what the HPS involves and their role in the project, and to promote their health. The need for teacher education Teachers’ competence in educating for health is one of the most important factors influencing school health education. They do not automatically possess all of the competences to explore health issues with young people, nor to make the kind of personal adjustments needed to cope with the changes involved in these new demands. So teacher education has a particularly central role to play in the healthpromoting school concept, helping teachers to equip themselves, experience new teaching methods, gather new ideas, feel more confident and competent, and adjust to change. In-service training in the form of courses, links to external consultants, 23 teacher team cooperation and supervision by colleagues are important aspects of this. Joint in-service training with potential partners in the community is a relevant initiative. The total physical environment of the school Schools attempting to become more health-promoting often concentrate on making the school environment more attractive, ecologically sound, civilised and “user friendly”. They might do this by dividing up the large spaces, and using colour, displays, art, plants, and softer furnishing. Classrooms and staffrooms are made more personal and more comfortable, with quiet areas with rugs, soft chairs, and books for browsing. Some schools have taken away the strident bells and buzzers that abruptly end lessons, and some teachers have taken the opportunity to add music, usually of a soothing kind, believing that most of their pupils do not need livening up! Pupils are more likely to be allocated areas to call their own and have some say over their appearance. The school’s architecture and furnishing can also limit or break down barriers in the development of flexible forms of teaching and small group work. This attempt to encourage a feeling of 'ownership' is being extended to secondary school pupils who have traditionally wandered the corridors to visit teachers in their specialist classrooms, but who are now more likely to have a 'home base'. Walls are more likely to be covered in pupils' work, and ideally from a range of pupils, not just the most able. Many schools have been attracted by the idea of becoming a 'green school' and used the space outside to make a garden or wildlife area, often tended by the pupils, sometimes with the help of parents to do the heavy work in the early stages. Other concerns about the environment are more fundamental and relate to hygiene, ventilation, sanitary conditions and safety. The toilets in particular have often tended to be 'black holes' in many schools, a haven for germs, dirt, and where there is sometimes no soap, hot water, or toilet paper, and where there may be no locks on the toilet doors. 24 Activity The following questionnaire was used by schools in Novosibirsk, Siberia, to find out people’s views on the school environment. You could put the same questions to a small group of parents, pupils, teachers and managers and compare their results. 1. To what extent do the classrooms contribute to promoting + pupils’ and teachers’ health? 2. To what extent are general-purpose school areas (hall, vestibule, corridors) used to improve pupils’ health? 3. To what extent do toilets meet hygienic and ethical requirements? 4. To what extent do temperature requirements to school premises meet climatic seasonal conditions? 5. How well are school premises aired (i.e. whether temperature requirements meet the existing standards)? 6. To what extent does food provision in schools contribute to pupils’ health? 7. To what extent is clean drinking water available to pupils? 543210 543210 543210 543210 543210 543210 543210 25 Teamwork, inside and outside of the school Teamwork in the school The whole school approach is necessarily based on teamwork. An initiative like the Health-promoting school cannot be carried out by one person alone. The support of the school director or head teacher is crucial, as is having someone who is clearly designated as the coordinator of the programme. One of the first steps is identifying who should be in the group to take the initiative forward. You also need to ensure that you have people from both health and education working in partnership. Teamwork is also essential to ensure that you make the best use of everyone’s skills and strengths. Activity: teamwork It is important to identify what is happening already in your locality that might support the programme. There may be local agencies available, and activities being already carried out that can be continued, extended or adapted. Brainstorm everyone who could be involved from within the school and from outside. Then think about what their role would be, what might be in it for them, and what barriers they might have? Who would it be useful to involve on a central team? Remember in creating a team you do not want too many people or it becomes unmanageable. Would it be useful to have sub-teams that connect with the central team and focus on a particular issue? Using experts as part of a whole school approach When planning the curriculum, it can be very useful to elicit the help of specialists. However, experience across Europe has shown that it is often unwise or unsustainable to use specialists or experts in a particular issue experts to teach pupils directly (for example doctors or police to teach about drug education. Outsiders may ‘lecture’ the pupils in ways they find boring and off-putting, or sensationalise a problem. This is often the case with drug education, which has the potential to do more harm than good if not developed in a sensitive, targeted and educationally sound manner. One other way that experts can be used is if they are invited into the classroom as ‘visitors’ with the pupils setting the agenda. This should be part of an on-going programme. It needs careful preparation and follow-up with the pupils and for the teacher to be present throughout. The Activity below outlines the process 26 Activity: Involving visitors One useful way of involving ‘experts’ is to spend at least one lesson before their visit, asking pupils what they want to ask the visitor, deciding who will brief the visitor, who will ask the questions, who will record the answers and who will thank the visitor. Similarly, the visitor needs to be told the kind of questions that the young people will ask. You may find it useful to invite several people to get different viewpoints. Following the visit, spend time discussing the learning involved. The main difference to this approach is that the focus is on the young people’s needs and interests, rather than a set talk on what the specialist assumes will be interesting. 27 How to involve parents and the community The importance of parents The vital role of parenting in children’s early development is well established and the evidence for the supportive role of parents within the health-promoting school is also accumulating. Where parents are actively involved in their children’s health promotion, good outcomes are more likely. There are many positive examples of this, such as in healthy eating initiatives in schools. Where parents were involved it led to: more impact on pupils’ behaviours in relation to food preparation; influencing food policies in schools through involvement in school nutrition action groups; co-operatives to provide healthy food for pupils in the middle of the school day. The importance of consultation This active involvement needs to be encouraged through consulting with parents and the wider community. This does not just mean holding meetings to inform them about the health-promoting school, but seeking their advice on what they feel is important. In particular, schools need to make special efforts to reach out to and welcome parents whose own experience of school may have been an unhappy one or who feel alienated from school. Schools need to explain their approaches to parents and achieve their active support, consult with them about the running of the school, and link the goals and culture of the school with that of the range of home backgrounds from which their pupils come. If parents are to remain engaged they need to get regular feedback about what changes as a result of their suggestions and to have opportunities to contribute to those changes. Involving the community The health-promoting school concept needs be widely understood by all in the community, including those agencies which are directly concerned with the school, and embedded in their philosophy and practice. It is especially important to get support from local health and education authorities, and from formal and informal local networks and groups. Often representatives from different groups in the community can be a very useful asset, contributing to the various school boards and committees that plan activities related to health promotion, as to other aspects of school life. If the local media are supportive of positive initiatives this can also be a very useful partnership and an excellent way of spreading good news and progress about the work of the school. As the report from the Thessaloniki conference suggests (ENHPS, 1997), healthpromoting schools are starting to see themselves as a main focus for community development and action. They may stay open well outside of normal school hours for a wide variety of educational and social local activities. They can provide education for adults returning to study, perhaps out of interest, or for new qualifications to overcome unemployment or to help them to improve their job prospects in a society 28 where people need to be flexible and need to retrain many times in their lives. They can become a meeting point for many disparate local groups and agencies. Community involvement and collaboration is a two way process, and schools have much to contribute as well as receive. Practical examples of supportive community initiatives include: facilitating safe and active routes to schools; restricting the sale and advertising of unhealthy products near the school entrance and within the school e.g. in vending machines; the provision of ‘drop- in’ centres for young people where they can raise issues on a confidential basis. Case Study In North Presentation Primary School in Cork City, Ireland, the health-promoting schools working group, (consisting of school staff, parents and students) identified promoting the health of the whole school community, particularly parents, as their action area for the school year 2003/2004. In consultation with the Health Promotion Department, the idea of a strollers walking group (parents walking while pushing their young children in prams, buggies, strollers or pushchairs) for parents was suggested and agreed upon as a result of the need for parents to get involved in physical activity while also caring for their children. Parents and especially women often state that, before they had children, they were very active, played sports, were part of teams and exercised regularly. Child care is not the only barrier identified for women continuing an active lifestyle, but it is a significant one. The objectives of the project were: • to promote walking as a mother and baby-friendly form of physical activity; • to increase the awareness of the benefits of physical activity and develop an appreciation for • walking among new mothers; • to reduce concerns associated with physical activity in the postpartum period; • to build a support network for new mothers; • to reduce the feelings of social isolation; • to teach techniques for breathing and walking correctly, stretching and pelvic floor exercises. How it was developed Health promotion officers who had completed the Irish Heart Foundation walking leader training join with the health-promotion school coordinator in interested schools and design and lead a route, with a teacher taking the role of the sweeper (staying at the back of the walking group). After the five-week course, two members within the group were encouraged to become leaders to sustain the project. The group of parents and children began with a 10-minute warm-up consisting of full body movements to raise the heart rate gradually and mobilize the joints before the walk. They then spent 30–60 minutes walking with a pram, pushchair or stroller at a pace suitable for each individual and all abilities. After the walk, which started and ended at the school, a parents’ room was made available for the 15-minute cool down, which consisted of some gentle exercises to help to bring heart rates back to normal. Children could watch a suitable video, play with toys or sleep after all the fresh air! Healthy snacks were made available following the cool down. This allowed parents time to talk, which helped to create social support and valuable interaction. Each week a different health topic such as smoking cessation, healthy eating, posture, breathing and toning was introduced. The successes The evaluation was very positive from the parents who participated. Most parents commented that the most useful part of the project was the opportunity to meet and walk with others. 29 The health-promoting school takes its community responsibilities seriously: pupils are likely to be found outside the school, engaged on community projects, contributing to and learning from the outside world, as well as in the classroom. Examples of ways of doing this have been: caring for elderly people and receiving lessons in oral history from them; clearing refuse and learning about recycling; creating havens for wildlife and learning about ecology in the process; creating herb gardens or health gardens In developing action competences this is taken still further with pupils investigating what is needed in the community and taking action to bring about change. In doing this they may not only build relationships with people in the community, but may also find that their actions can have an impact on their families and communities. 30 So where do you start and which themes do you choose? How do you choose the themes on which you are going to concentrate? You could be influenced by guidelines for education on health, sexuality and family studies laid down by the Ministry of Education. Locally rooted problems or issues can be a source of inspiration that can be relevant to the pupils. Case Study In the Austrian Network of Health Promoting Schools, a healthy diet and exercise have become the focal points of interest for the following reasons: Unhealthy diet and/or lack of physical activity may influence performance at school through unrest, fatigue, and lack of concentration; Many students are clearly overweight; A rising number of students are encountering eating disorders; Inappropriate eating and exercise habits manifested in the early years of childhood may later trigger many causal illnesses. In one primary school, in Schwaz, Tyrol the subject of diet and exercise has been firmly incorporated within the school programme, and the following measures have been tackled: healthy snacks comprising indigenous products from local farmers: central to this is increasing awareness of the positive effect of a healthy diet on efficiency and productivity; the introduction of a fruit break; consideration of the environmental aspects of diet, for example using the slogan “a snack box instead of aluminum foil”; drinking water during class and in the break; physical activity in classes. The themes should reflect a positive and broad concept of health as described in the previous section. Plans and policies should not focus solely on treating and preventing disease and illness but also include objectives and proposals for action to promote mental, social and physical well-being and to influence and change lifestyles and living conditions. However, if your focus is a perceived health problem you will need to have a grasp of the health trends in your community, region and country as a whole. The healthpromoting school model will help you to look beyond the lessons in the classroom to the wider social environment of the school and the role of parents and the community. 31 Case Study WHO, in collaboration with local institutions, are currently implementing a programme of activities in Kosovo (Serbia) which aims to decrease exposure from environmental pollution caused by lead and other heavy metals and to raise awareness of the population to take appropriate action. This programme of capacity-building includes health risk assessments, a public awareness campaign and the development of a health strategy (screening, diagnosis and management protocols) and environmental remediation activities. The health-promoting school approach has been chosen by the public awareness working group, as a main tool for raising the awareness of the population on how to live more safely in a contaminated environment. The public awareness working group includes officials from different sectors such as health, education, environment and women’s associations. This multi-sectoral method of implementation not only aims to improve the environment of schools through environmental health risk management activities (cleaning and greening activities). It involves nutrition education in the schools to minimise the risks of anaemia associated with the heavy metal poisoning. It also aims to raise awareness in the community to environmental problems, their health effects and methods to decrease exposure. Health promoters from the Main Family Health Centre undertook family to family visits (home visits) in the most affected neighborhoods, giving information to families specifically to mothers. To quote health promoters after the visits conducted in the families they said: “It is amazing how much school is influencing awareness raising, as we find often that mothers already have information about lead and ways of lead poisoning prevention, and when we ask them where do you know it from? - they tell us from children and their teachers - and then they show us brochures they have read” (These were brochures their children received at school.) The schools organized practical activities where parents, pupils and others were included in order to improve the school environment and reduce the risk of lead poisoning (painting classrooms, greening activities and providing means for improved personal hygiene). By organizing parents classes on lead poisoning prevention (which includes importance of screening, follow up, hygiene and nutrition). Through the health-promoting schools approach there was the provision of good opportunities for intersectoral collaboration and the setting of the school was seen as a key environment as children are particularly vulnerable to the effects of heavy metal poisoning and it provided the structural links to mothers, families and the wider community. The themes chosen may differ according to whether you ask staff or pupils. Children often identify well-being and relationships with family and friends as most important in relation to health. In the early development of the health-promoting school model twelve criteria were developed to assist schools in their development work (Young and Williams, 1989) 32 These can form the basis for selecting themes for your own school policy and you can amend and add to them as appropriate. In the European Network of Health Promoting Schools, participating schools are offered the following twelve criteria for a health-promoting school: 1. Active promotion of the self-esteem of all pupils by demonstrating that everyone can make a contribution to the life of the school. 2. Development of good relations between staff and pupils and among pupils in the daily life of the school. 3. Clarification for staff and pupils of the social aims of the school. 4. Provision of stimulating challenges for all pupils through a wide range of activities. 5. Use of every opportunity to improve the physical environment of the school. 6. Development of good links between school, home and community. 7. Development of good links among associated primary and secondary schools to plan a coherent health education curriculum. 8. Active promotion of the health and well-being of school and staff. 9. Consideration of the role of staff as exemplars in health-related issues. 10. Consideration of the complementary role of school meals (if provided) to the health education curriculum. 11. Realization of the potential of specialist services in the community for advice and support in health education. 12. Development of the education potential of school health services beyond routine screening towards active support for the curriculum. Activity: setting your own criteria Looking at the WHO criteria, discuss with colleagues what would be important in your school? Why is the theme/criterion selected important? For whom is it important? Who has defined it as being important? 33 J Justification for themes You need to discuss the reasons for the themes you have selected and incorporate this justification in your health policy, as this defines the school’s values and make them visible. There are usually several types of justification for example: preventing negative effects and promoting health, such as when a school justifies strengthening playing and physical activity with the objectives of preventing disturbances in the classroom, promoting pupils’ physical, mental and social well-being and promoting creative processes in teaching and learning. promoting values and solving problems; for example, if a school justifies focusing on social interaction at the school by the desire to promote a positive culture for interaction and a desire to initiate specific measures to break down the barriers to this interaction. 34 Evaluation Why evaluate? We need to evaluate interventions to make sure they are not based on false assumptions, and to convince the sceptical of the value of work in this area. For this we need hard and objective evidence that the interventions have made a difference. Stakeholders at all levels, from classroom teachers and school principles to administrators and decision makers, need to have evidence of the range of benefits which the health-promoting school can provide. How to evaluate The evaluation process must be in line with the principles of the health-promoting school. This can differ from the approach used to evaluate public health initiatives as illustrated in the table below Public health approach Measures health behaviours, health status etc. Often uses diagnostic tools, questionnaires, tests – quantitative rather than qualitative. Sometimes imposed without participants having ownership of the process. Systematic and rigorous. Health-promoting school approach Evaluates educational outcomes. Often uses multi-dimensional instruments that involve a range of people and data. Empowering of all stakeholders, such as teachers, parents, pupils, and community members. Ideally, participants are involved at every stage, consulted before it begins, involved in the data collection and interpretation and in the implementation of any outcome. Can be used as part of the teaching and learning process. Often small scale. May provide useful qualitative data. Often large scale. Helpful for gathering statistics through which to compare, for example, the impact of different initiatives on a population. Certain basic procedures need to be followed in both approaches if they are to stand up to scientific scrutiny and persuade people that the innovation in question was worth doing. Collect baseline data before you begin Without baseline data you cannot know whether anything has changed. In an ideal experimental model you would have a control group, as without this you cannot be sure whether it was the ‘intervention’ that made the difference rather than some other 35 influence. However, using controls is expensive and may be beyond the reach of small initiatives. In fact experimental comparative designs are difficult to justify in schools because they are complex communities and controlling all the variables requires a very sophisticated design. It may be more realistic to look at the changes that occur in a school in terms of the added value they provide rather than the experimental controlled based studies more favored by public health medicine. Deciding on objectives and indicators Having decided on the themes you are going to pursue, you need clear and jointly agreed objectives if you are to succeed. Without this there is no focus, no sense of ownership, and no hope of evaluating success. Objectives answer the question: what would we like to achieve? They can be used to assess the effects of a health policy and might relate to: teaching in a selected theme the school’s environmental factors the interaction between teaching and environmental factors and the impact on the community Objectives can be quantitative (targets) for measuring the degree of fulfilment or qualitative, requiring indicators for assessing whether trends are moving in the desired direction. Activity Schools could discuss the following questions. How does the school’s vision influence the school’s objectives for both teaching and environmental factors? How can we measure whether we are fulfilling the objectives or targets? How can we see, hear and feel whether we are fulfilling the objectives or targets? 36 Methods to use to collect evaluation data Discussion You could bring groups of staff, parents and pupils together (in separate groups, it is probably best not to mix them) to discuss their views. Draw and write/ bubble dialogue There is a growing body of knowledge about the use of what are sometimes called ‘illuminative techniques’, which have been used extensively in developing the HPS approach. Illuminative approaches involve presenting children with an invitation to which they are asked to respond in some way. ‘Draw and write’, and ‘draw and talk’ invite children to draw plus writing or talking, depending on their age and stage of development. ‘Bubble dialogue’ asks them to fill in the dialogue over the heads of cartoon figures. Examples of these techniques are: Ask pupils to draw a picture of their school and ‘what this school does to help us be healthy and keep us healthy’. You could compare the results before and after the project. Give staff, pupils or parents a cartoon of two people talking with speech bubbles over their heads. Tell them that these two people are good friends who are having a private conversation with no-one listening. You could tell them they are parents, or staff or pupils. One person is saying: ‘I hear that this school is a health-promoting school. What does that really mean in practice?’ The person filling it in is asked to write what the other person is replying in their speech bubble. Again this could make an interesting comparison, before and after. Illuminative techniques can tell us a great deal about what people think, know, feel and do, and at quite a deep level, but without frightening them with a formal checklist or putting ideas into their heads with a set of pre-set questions. The techniques are quick to administer, fun to do, and can gather a great deal of data, in a manageable form, from a lot of people in a very short time. They can be repeated later in a process to see whether and how their responses have developed. They are, however, time consuming and rather challenging to analyze. Questionnaires Questionnaires, in other words a series of written questions to which people respond in writing, are an obvious way of evaluating. They need to be appropriate in language level for their target audience and require being pre-tested to sort out problems before use. 37 Tips for using illuminative techniques Keep replies anonymous, but make sure you know whether it is a member of staff, parent or pupil who filled it in. Make sure the issue is one people can relate to in real life and which they find it fairly easy and natural to explore. Take an indirect approach, for example asking children what ‘someone of your age’ would do or say rather than quizzing them about themselves. Make sure people feel that any response is acceptable, and that there is no right answer. Usually ask people to complete illuminative techniques individually so as to ensure a spread of opinion. Tips for developing questionnaires Keep them as short as possible. Make sure the wording of the questions is clear and not ambiguous. Do not ask two questions in one. Make sure the questions are interesting to participants. Thank people for completing them, and make sure they are told of any results. 38 References Barnekow, V (2006) The European Network of Health Promoting Schools – from Iceland to Kyrgyzstan. Promotion and Education xii, 3-4, IUHPE, Paris Barnekow Rasmussen V, Rivett D, Burgher MS (1999). The European Network of Health Promoting Schools: the alliance of education and health. Copenhagen, WHO Regional Office for Europe. Clift, S. and Jensen, B.B. (Eds.). (2005). The Health Promoting School: International Advances in Theory, Evaluation and Practice. Copenhagen, Danish University of Education Press. Currie, C., Todd, J., and Wijckmans, K. (1990) Health Behaviours of Scottish Schoolchildren: Report 2 Family, Peer, School and Socioeconomic Influences. University of Edinburgh. Dooris, M (2006) Healthy settings: challenges to generating evidence of effectiveness. Health Promotion International, 15, 169 – 178. ENHPS (1997). First Conference of the European Network of Health Promoting Schools. The Health Promoting School – an investment in education, health and democracy: conference report, Thessaloniki-Halkidiki, Greece, 1-5 May 1997. Copenhagen, WHO Regional Office for Europe Gordon, J. and Turner, K, (2003). School staff as exemplars-where is the potential? Health Education 101:6 pp 283-291, London International Planning Committee (2002). Education and Health in Partnership. a European conference on linking education with the promotion of health in schools.: conference report, Egmond aan Zee. Netherlands, 25-27 September 2002. Copenhagen, WHO Regional Office for Europe. IUHPE. (1999) The Evidence of Health Promotion Effectiveness. International Union of Health Promotion and Education. Jensen, B.B. and Simovska, V. (2005) Involving students in learning and health promotion processes – clarifying why? what? and how? Promotion and Education xii 3-4. IUHPE, Paris. Moos, R. (1991) ‘Connections between school, work and family settings’. B. Fraser and H. Walberg (eds) Educational Environments. Oxford: Pergamon. Monaghan, F., McCoy, M.,Young,I. and Fraser, M. (1997) Time for teachers: the design and evaluation of a personal development course for teachers. Health Education Journal 56, pp 64-71. 39 Perry, C. et al (1988) Parental Involvement with Children’s Health Promotion: The Minnesota Home Team. Amer. Journal of Public Health 78:9, pp 1156-1160. Sammons, P, Hillman, J. and Mortimore, P, (1994) Characteristics of Effective Schools. London, OFSTED. Scheerens, J. (2000). Improving School Effectiveness. Fundamentals of Education planning No. 68. Paris, UNESCO Shaw, J. and Riskind, J. (1983).’Predicting job stress using data from the position analysis questionnaire’. Journal of Applied Psychology, 68, 253-61 St Leger, L. (1999) in The Evidence of health promotion effectiveness. A report for the European Commission by IUHPE, Part two, 110-122. Brussels and Luxembourg, The European Commission. Stewart-Brown, S. What is the evidence on school health promotion in improving health or preventing disease and specifically, what is the effectiveness of the health promoting schools approach? Health Evidence Network, WHO, Copenhagen Weare, K. and Markham, W. (2005). What do we know about promoting mental health through schools? Promotion and Education xii, 3-4. IUHPE, Paris. West, P, Sweeting, H. and Leyland,A. (2004) School effects on pupils health behaviours:evidence in support of the health promoting school. Research papers in Education 19: 3. Routledge, London. Whitelaw,S, Baxendale,A., Bryce,C., MacHardy, L.,Witney,E., and Young,I., (2001) Settings based health promotion: a review. Health Promotion International, 16, 339-353. Williams, T., Wetton, N . and Moon, A.(1989) A picture of health-what do you do that makes you healthy and keeps you healthy? HEA, London. Young, I. and Williams, T. (1989). The Healthy School. Scottish Health Education Group/ WHO regional office for Europe. Young, I (2005) Health Promotion in Schools – A historical perspective. Promotion and Education xii, 3-4, IUHPE, Paris ADDITIONAL RECOMMENDED READING Deakin University, VicHealth and Department of Education, Employment and Training Health (2000) Promoting Health Promoting Schools In Action: A Guide For Schools, Deakin University, Melbourne. B 40 A Boddington, N. and Hull, T. (1996) The Health Promoting School: Focusing on Health and School Improvement. Forbes. Denman, S., Moon, A., Parsons, C. and Stears, D. (2001) The Health Promoting School: Policy, Research and Practice. London: Routledge/ Falmer. Elias, M., Zins, J., Weissberg, R., Frey, K., Greenberg, M., Haynes, N., Kessler, R., Schwab-Stone, M., and Shriver, T. (1997). Promoting Social and Emotional Learning. Alexandria, Virginia: ASCD. Goleman, D. (1996) Emotional Intelligence. London: Bloomsbury. Gray, G. Ed. (1995) Promoting Health in Second Level Schools in Europe, ENHPS Practical Guide Europe against Cancer, World Health Organization Regional Office for Europe. Gray G Ed. (1999) Whole School, Healthy School, a guide to the Health Promoting School, Health Education Authority. Olweus, D. (2001) Olweus’ Core Program Against Bullying and Anti-Social Behaviour: A Teacher Handbook. Bergen: Hemil Research Centre for Health Promotion. Weare, K. and Gray, G. (1994) Promoting Mental, Emotional and Social Health in the European Network of Health Promoting Schools. World Health Organization Office for Europe: Copenhagen. Weare, K. (2000) Promoting Mental, Emotional and Social Health: A Whole School Approach. Routledge. Weare, K (2003) Developing the Emotionally Literate School. Sage. Wetton, N and McCoy, M (1998) Confidence to Learn. Health Education Board for Scotland , Edinburgh. WHO (1986) Ottawa Charter for Health Promotion. WHO, Geneva. WHO (1996) Regional Guidelines: Development of Health-Promoting Schools – A Framework for Action. WHO Regional Office for the Western Pacific: Manila, the Philippines. Young I and Williams M Eds (1993) Promoting the Health of Young People in Europe: a European Manual, European Community and World Health Organization, 1993. pp 105 - 132. 1993 Young I Ed. Promotion and Education xii, special edition of journal devoted to school health promotion, IUHPE, Paris 41 ...
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