Our knowledge about Implementing, Maintaining, Scaling Up and Sustaining (IMSS) programs and approaches gas been accumulating. We just came across this 2015 realist review that illuminates and substantiates our recent efforts to summarize the available knowledge. (See our summary and other information on this page in the Schools-for-All web site. Pearson et al (2015) "conducted a realist review to identify the conditions and actions which lead to the successful implementation of health promotion programmes in schools. We used the international literature to develop programme theories which were These theories were "then tested using evaluations of school health promotion programmes conducted in the United Kingdom (UK). developed four programme theories (preparing for implementation, initial implementation, embedding into routine practice, adaptation and evolution); these were then refined using the UK evaluations in the review. This enabled us to identify transferable mechanisms and enabling and constraining contexts and investigate how the operation of mechanisms differed in different contexts. We also identified steps that should be taken at a senior level in relation to preparing for implementation (which revolved around negotiation about programme delivery) and initial implementation (which centred on facilitation, support, and reciprocity—the latter for both programme deliverers and pupils). However, the depth and rigour of evidence concerning embedding into routine practice and adaptation and evolution was limited."
Although this review examined only health & life skills education programs delivered by teachers, its findings and theories offer insights and application to other programs and approaches. Go to the full text (free) article. Go to our IMSS summaries. 

The recent February 2nd, 2021 open web meeting of the FRESH Partnership discussed why UN agencies had apparently dropped Health & Life Skills (H&LS) education from the list of core subjects they are monitoring as part of Target 4.7 of Goal #4 (Education). (You can access the recording and documents on the FRESH webinars page). One of the reasons why this important gap in UN monitoring has occurred is our collective failure to advocate strongly and clearly for including health & life skills as an important subject. Instead, most advocacy, research and program development is focused on many, many specific topics such as nutrition, drugs, bullying or HIV/AIDS rather than a core curriculum. (Thereby frightening decision-makers and educators away from monitoring it as a core curriculum.)We have not defined a list of generic student outcomes and we have not defined clearly how much instructional time is needed since 1985. Although it is one of the core components of the FRESH and other multi-component approaches, no global agency, donor or research group reports regularly on the status of H&LS curricula in countries. (This lack of data will be addressed in an upcoming fact-finding survey and curriculum/policy analysis.)

Two recent reports illustrate how we, collectively, have not been clear about what we want. Is it Health and Life Skills education? Or is it Health education alone? Or is it Life Skills education alone? Greater clarity  is urgently needed if we are to make a stronger case. And there are different networks and sectors making the case separately for one or the other. Our cause has suffered by the competition among topics as the focus. We cannot allow for similar confusion between health and life skills.

The school health program of the Centers for Disease Control has just published a report on how health education and other school nutrition components on (nutrition) can support social & emotional learning (SEL) which is a large part of life skills education. The student learning outcomes being emphasized are items such as self awareness, self-management and other skills. Nutrition or other health topics are the vehicle for learning these life skills. Almost at the same time, the school health program of the World Health Organization published a School Handbook on Life Skills education. In the WHO guide, the student learning outcomes are focused on preventing NCDs, with nutrition knowledge, skills & attitudes being a risk or protective factor for NCDs.

The answer to the potential confusion in terminology is quite simple. We need a core curriculum that teaches both health and life skills. The life skills are not just skills, They are better understood to include social and emotional outcomes such as forming healthy relationships and being included in supportive families, peer groups and at school. We need to find ways to measure and monitor such skills. We also need better and more specific descriptions of the functional health literacy needed in health within different contxts and on different topics (Note: HL includes safety & security topics) 

Once we combine Health and Life Skills (H&LS), we need to add a third component, which a FRESH Working Group has called Social Inclusion.  This is where students learn universal values such as caring for others, relationships, diversity, character, ethics, social and environmental responsibility. Many countries call this Personal, Social & Health (PSH) education. 

Then we need to construct models of core H&LS or PSH curricula with well-planned scope and sequencing of generic skills, essential knowledge and universal values. If we start using coherent and clearly stated terms and concepts, we might have a better chance of being understood by decision-makers and policymakers.

The Global Partnership for Education’s (GPE) Knowledge and Innovation Exchange (KIX) thematic funding supports global and regional initiatives that use knowledge exchange, evidence and innovation to help developing countries solve critical educational challenges. A GPE discussion paper,Improving teaching and learning. A knowledge and innovation exchange (KIX) discussion paper was published in July 2019. The purpose of this paper is to describe the current landscape in improving teaching and learning and spark discussion and debate around potential areas for GPE/KIX investment. The "describes the challenges facing developing country to improve learning levels and reviews existing efforts to address those challenges through global goods. It identifies remaining knowledge and innovation gaps and offers a set of areas in which GPE could invest.
"focus on teachers and their work,and on three important sets of challenges that affect them:
1.The quality of support to teacher development. This includes weak content and pedagogical knowledge and classroom skills (including instructional practices) among teachers, often because of low quality of pre-and in-service teacher training. This is related to inadequate standards and accreditation for teachers and a lack of ongoing support and coaching from head teachers and other administrative leaders.
2.Teaching methods and learning materials.This includes a lack of textbooks and other learning materials;language issues, particularly around mother-tongue teaching; and teaching that is not aligned with children’s current level of understanding.
3.Systems for recruiting, managing and engaging teachers.This includes attracting and retaining the most qualified individuals to the teaching profession, deploying teachers to areas of the country with the greatest need, reducing unauthorized teacher absences and maximizing instructional time, and engaging teachers in policy dialogue and reform.
The GPE paper reviews several global and regional initiatives currently underway from UNESCO, GPE and other organizations that aim to improve the quality of teaching. A notable item in that list is the Breadth of Learning Opportunities initiative led by the Brookings Institution and Education International that includes physical health and emotional/social well-being.
The paper concludes by identifying five areas for investment. These include "sharing what works" to (a) improve data on teachers and teaching, enhance teacher recruitment, selection & retention, (c) improving accountability, incentives & rewards, (d) scaling up high quality teaching in early childhood and primary grades (e) enabling school and system level factors that support teaching (f) aligning budgets, planning and workforce changes to increase the number of teachers and transparency. 
Read more.... 

The written submission from the committee responsible for monitoring the achievement of SD Goal #4 (Education) to the UN High Level Political Forum in July 2019 cause concern for those seeking to ensure that the educational objectives described in Target 4.7 of the Goal include attention to health and life skills education as per the 2015 Incheon Declaration which includes health and life skills as essential parts of a high quality education (See below). Most of the SDG committee's submission does a good job of calling for more investments in equity/access and in describing how Goal #4 (education) is connected to other goals such as #10 (inequalities), #5 (gender), #8 (employment), #16 (peace, good government), #13 (climate action) and the role of education sector in coordination (#17), Notably, Goal #3 (health), #6 (water, sanitation) and #2 (hunger) are missing from this discussion. The exclusion of these goals from the submission needs further explanation given that the theme of the HLPF was "Empowering people and ensuring inclusiveness and equality".

The submission from the SDG committee does not directly address the content/learning objectives that should be part of Target 4.7 but it does refer to the Brussels Declaration (see below) which was published subsequent to a series of UNESCO-led consultation in December 2018. It is disappointing to note that the work done by FRESH Partners in adding the concepts of health and life skills to the Incheon Declaration continues to be ignored or misunderstood. We are not opposed to adding new elements to the definition of quality student learning content but surely it is easy to understand that sexuality education is part of health education and at least equal in importance to physical education. And surely life skills, a key concept in most curricula around the world deserve more attention. 
     
These two documents underscore the importance of the work of the FRESH Working Group on Health Literacy, Life Skills and Social Inclusion which is building the case and demonstrating how Health, Personal & Social Development (HPSD) education is already a core subject in most countries and should be considered and monitored by the SDG committee monitoring progress in Goal #4 and Target 4.7.

The 2015 Incheon Declaration included this wording: "Quality education fosters creativity and knowledge, and ensures the acquisition of the foundational skills of literacy and numeracy as well as analytical, problem-solving and other high-level cognitive, interpersonal and social skills. It also develops the skills, values and attitudes that enable citizens to lead healthy and fulfilled lives, make informed decisions, and respond to local and global challenges through education for sustainable development (ESD) and global citizenship education (GCED)." as well as this reference tolife skills "We further commit to ensuring that all youth and adults, especially girls and women, achieve relevant and recognized functional literacy and numeracy proficiency levels and acquire life skills, and that they are provided with adult learning, education and training opportunities. We are also committed to strengthening science, technology and innovation.". These statements define the content for a holistic, high quality education that meets the needs of the whole child.    .

The 2018 Brussels Declaration defines the content of a high quality education. Health and Life Skills education are absent from the statement, ignoring the foundation provided by Incheon Declaration but adding pieces such as sexuality education and physical education.  "we commit to supporting lifelong learning opportunities for all to ensure necessary competencies for personal development, decent work and sustainable development, with attention to climate change, adaptation and mitigation. Additionally, education institutions must provide children, youth and adult learners with the competences to be active citizens in democratic and sustainable societies. This includes efforts to promote education for sustainable development and sustainable lifestyles, democracy and human rights, gender equality, age-appropriate comprehensive sexuality education, physical education and sports, education in native language, peace and non-violence, global citizenship and active participation, appreciation for cultural diversity, multilingualism, intercultural dialogue, solidarity and more peaceful, tolerant and inclusive societies. This requires attention to pedagogy, curricula, teaching and learning materials, assessments, initial teacher training and continuous professional development, inter alia.

A special issue of the Journal of Adolescent Health in July 2019 contains several cost-benefit estimates of investing in health, education, productivity and safety in low & middle income countries. "The papers in this supplement present an important milestone in addressing this challenge, helping the international development field to move forward by focusing on the question of investing at scale for a few key components of the adolescent health agenda that are especially relevant for low- and middle-income contexts. All the empirical papers assess the effectiveness of implementing a specific set of interventions nationally at scale for their prioritized outcome of interest—health, education, productivity, safety—for a sustained period through 2030. The analyses confirm that the resulting benefits in all cases are substantial, both for the adolescents and for the economic and social progress of their nations. Four of the five empirical papers also model the costs of these interventions, and three papers further extend their analysis to calculate benefit-to-cost ratios (BCRs) of such investments. The BCRs range from 5.8 to 12.6, indicating a compelling case for national and global decision-makers to prioritize investing in adolescents."  ....

• "Sweeney et al. [10] make the case for investments to improve outcomes in adolescent sexual and reproductive health, the health of adolescent mothers and their newborn children, and adolescent relevant communicable and noncommunicable diseases. They examine investments in intervention-specific costs, program costs, and health systems costs for 40 low- and middle-income countries. For the 66 adolescent health interventions modeled through 2030, they estimate 7.0 million deaths and 1.5 million serious disabilities averted at the average cost of $4.5 per capita each year. They also estimate BCRs of 12.6 for low-income, 9.9 for lower middle-income, and 6.4 for upper middle-income countries.  
• Rassmusen et al. model the effects of a set of identified interventions on child marriage (life skills, community mobilization, and cash transfers) and education (availability and proximity of schools, teacher quality, and cash incentives) for 31 low- and middle-income countries [11]. They find that the interventions result in an 8% reduction in marriage rates for 15-17 year olds by 2050, an increase of 19.3% in school attendance and completion, and 22.7% increase in productivity by 2030. The average BCR for these interventions is 7.4.
• Wils et al. [12] find that in 44 low- and middle-income countries, school dropout among preadolescents is now very rare. Rather, dropout is mainly an adolescent effect—especially between ages 14-19 years and particularly for girls. Their analysis shows that at the cost of $10.5 per capita per annum, nine identified interventions can be sustained through 2030, increasing secondary completion rates by 25% and doubling the quality of secondary schooling as measured by the learning index.
• On a continuum to this analysis, Sheehan and Shi [13] estimate the economic returns to both the quantity and quality of education for adolescents in the context of the actual employment patterns in 72 low- and middle-income countries. They find that with sustained investment through 2030, the economic benefits of better education for adolescent cohorts lead to an increase in Gross Domestic Product (GDP) of 40% overall and 50% in low-income countries.
• Noting that in 75 low- and middle-income countries, death rates by road accidents are disproportionately high and the leading cause of death for adolescents, Symons et al. [14] provide an assessment of interventions to reduce these deaths and injuries for adolescents. Modeling of their preferred interventions results in 1 million deaths and 3 million serious injuries averted, at a cost of $1.2 per capita and a BCR of 7.6   

Read more.....

A research review reported in the July 2019 issue of the Journal of Adolescence found that "Greater density of same race/ethnic peers led to better mental health for all youth" and that ".No overall mental health advantage in schools with increased diversity was found."A range of mental health outcomes were assessed (e.g., internalizing behaviors, psychotic symptoms) in order to broadly capture the relationship between school context on mental health and psychological wellbeing. Methods: A search across six databases from 1990 to 2018 resulted in 13 articles from three countries (United States, United Kingdom, and the Netherlands) that met inclusion criteria following a two step review of titles/abstracts and full-text."  Read more....

An article in the July 2019 issue of Pediatrics examined associations between adolescent connectedness and multiple health-related outcomes in adulthood. "We used weighted data from Waves I and IV of the National Longitudinal Study of Adolescent to Adult Health (n = 14 800). Linear and logistic models were used to examine associations between family and school connectedness in adolescence and self-reported health risk behaviors and experiences in adulthood, including emotional distress, suicidal thoughts and attempts, physical violence victimization and perpetration, intimate partner physical and sexual violence victimization, multiple sex partners, condom use, sexually transmitted infection (STI) diagnosis, prescription drug misuse, and other illicit drug use.In multivariable analyses, school connectedness in adolescence had independent protective associations in adulthood, reducing emotional distress and odds of suicidal ideation, physical violence victimization and perpetration, multiple sex partners, STI diagnosis, prescription drug misuse, and other illicit drug use. Similarly, family connectedness had protective effects for emotional distress, all violence indicators, including intimate partner violence, multiple sex partners, STI diagnosis, and both substance use indicators. Compared to individuals with low scores for each type of connectedness, having high levels of both school and family connectedness was associated with 48% to 66% lower odds of health risk behaviors and experiences in adulthood, depending on the outcome.  Read more......