(From the ISHN Member information service)  In our extensive monitoring of the research, we find that the now-popular "ecological approach" is more often actually applied in the "analysis" stage, identifying the complex, multiple and multi-level influences on behaviour and practice, rather than being actually used in the "action" stage, where the approach is used to organize and deliver a planned variety of interventions to affect the multiple influences. We are pleased to read the article in the August 2014 issue of International Journal of Behavioral Nutrition & Physical Activity, which reports on a superb application of the ecological approach in 15 elementary schools in Mexico. The authors report that "Thirty-two distinct intervention strategies were implemented in one setting (i.e., school) to engage four different target-groups (students, parents, school representatives, government) across two domains (Nutrition and Physical Activity). Overall, 47.5% of the strategies targeted the school infrastructure and/or personnel; 37.5% of strategies targeted a key political actor, the Public Education Secretariat while fewer strategies targeted parents (12.5%) and children (3%). More strategies were implemented in the Nutrition domain (69%) than Physical Activity (31%). The most frequently used SCT construct within both intervention domains was Reciprocal Determinism (e.g., where changes to the environment influence changes in behavior and these behavioral changes influence further changes to the environment); no significant differences were observed in the use of SCT constructs across domains. Findings provide insight into a promising combination of strategies and theoretical constructs that can be used to implement a school-based obesity prevention program. Strategies emphasized school-level infrastructure/personnel change and strong political engagement." The complete text of the article is available. A full report on the project is also available here.  

A detailed description of the impact of intervention during its two year implementation is provided here. (Note: the results after two years are modest, with small changes in eating habits and some types of physical activity reported. In our view, this reflects the reality that complex, multi-intervention programs need several years in order to be embedded in the school culture as well as to interact with the local neighbourhood and parents/families. Larger, community, media and societal influences are also important. The study did not report any changes to obesity levels. This is consistent with other studies, not only of school programs, that obesity is a problem that is far more challenging than what can be affected by a single setting within the community.  For schools, we should adjust our expectations of the impact of even well-delivered multiple interventions such that students are truly supported by healthy factors while in school and that they graduate with the knowledge, skills, selected attitudes, beliefs and intentions that can be reasonably expected. If an entire society is obsengenic, then we should recognize the limits of the school's influence.  

The authors capture our above assessment of current efforts to implement ecological approaches as follows: " The premise underlying ecological programming is that a multilevel program is likely to be more effective than an individually focused program because it affords the opportunity to encounter the same behavioral prompts (e.g., to be more physically active) from a variety of sources (parents, teachers, coaches) in a variety of settings (home, school, community) [13]-[16]. Therefore, an intervention program that contains diverse strategies to engage several different stakeholders across a range of settings might address the health behavior in a more comprehensive way and thus yield better results than a simpler program (i.e., fewer targets, less settings). Despite its intuitive appeal and an increase in the use of ecological principles for programming to prevent childhood obesity in developed countries [17], optimal (i.e., effective, easy to implement at low cost) combinations of intervention activities to promote healthy lifestyles have yet to be identified. In addition to determining optimal combinations of intervention activities, health promotion practitioners striving to integrate ecological principles into their programs must also strive to develop programs that are theoretically informed. Challenges to theoretical integration include practitioner difficulties in operationalizing and assessing theoretical constructs [18]. The purpose of this study was to assess the integration of ecological principles and theoretical constructs in a school-based obesity prevention program that was successful in creating a supportive environment for healthy behaviors." 

The conclusion to the paper notes that "The aim of this paper was to assess the integration of ecological principles and theoretical constructs involved in a successful school-based obesity prevention program in Mexico City. We sought to unpack the intervention program along intervention domains in order to develop a map of the successful intervention program. If we compare our ecological map with recommendations in the literature [15],[17],[20], we can ascertain that this intervention program was a genuine ecological effort within a single setting since it delivered a diversity of intervention strategies involving multiple targets (POL, ORG, INT, IND), across both intervention domains. The ecological mapping showed that several different targets (PE teachers, school teachers, food vendors, parents, children and the school environment) were engaged, and that these efforts are consistent with those recommended to promote behavior change and to prevent obesity in children [7],[9],[23],[37]-[39]. Overall, our findings are consistent with existing evidence that policy intervention strategies can impact different ecological levels of influence [42]. This may be especially the case for hierarchical institutions such as school systems, where decisions are made at more than one level."


The reflections offered by the researchers are also interesting. "To our knowledge, this is the first research to document the integration of ecological principles and theoretical constructs in a school-based obesity prevention program in Mexico. The deconstruction of a successful intervention program that has documented environmental and student behavior improvements provides novel information for the implementation of multifactorial interventions in school-based health promotion programs. Although there may be a variety of successful combinations of ecological strategies and theoretical constructs, our findings provide one version that can be used as a starting point to develop even more effective combinations. Within the school setting, this ecological combination of strategies emphasizes school and political targets. Moreover, the strategies in both the Nutrition and Physical Activity domains are most commonly underpinned by the theoretical construct of Reciprocal Determinism. In a context where the school environment is considered “obesogenic” and there is compelling evidence that this environment can shape children's eating and PA patterns, the current findings provide valuable insight about the types of strategies that can be leveraged to optimal effects. It is expected that these findings will be especially meaningful to inform obesity prevention programs in Mexico and in low-middle income countries where childhood obesity is an emerging problem."  Read more>>  

(From the ISHN Member information service)   The delivery of preventive health care services in schools is effective and cost-effective, as noted in several studies and reviews. But the key role of the school nurse in engaging school participants, which leads to other health promoting opportunities within the school, cannot be overlooked. An article in Issue #36, 2014 of Vaccines reports on a Nova Scotia, Canada study which concluded that having a nurse assigned to the school, engaging parents and teachers, was related to full adherence to a voluntary HPV vaccine program. The researchers report that "HPV vaccine initiation was significantly associated with Public Health Nurses providing reminder calls for: consent return (p = 0.017) and missed school clinic (p = 0.004); HPV education to teachers (p < 0.001), and a thank-you note to teachers (p < 0.001). Completion of the HPV series was associated with vaccine consents being returned to the students’ teacher (p = 0.003), and a Public Health Nurse being assigned to a school (p = 0.025). (Note: this posting is part of a series related to the important role and investment in school nurses in schools that will appear in this blog. Read More>>

(From the ISHN Member information service)  An article in Issue #12, 2014 of the Journal of Interpersonal Violence uses "General Strain" theory to explain and understand interpersonal aggression at school. "Using data from a sample of 296 middle school students in a southwestern state of the United States, this article examined whether different types of strain and negative emotions are positively associated with psychological, physical, and general bullying. Overall findings of negative binomial regression analyses tended to be consistent with our expectations, while some aspects of GST received more empirical support than others. Strains and negative emotions were mostly related positively either to psychological or physical bullying, with negative emotions, anger and depression, partly mediating the strain-bullying relationship." This being the first encounter with strain theories for us, our quick look on the Internet found an excellent Canadian government report examining the roots of violence in response to a school shooting in Ontario. The Appendix on Literature reviews in that report has discussed several such strain theories in relation to school violence. Other sections of that report review school-based and school-linked violence prevention. Read more>>

(From National Collaborating Centre on HP Methods and Tools)  A planning tool developed in Alberta Canada for health care organizations could be adapted for use in school health and development promotion. A 2009 journal article presents the development and initial psychometric validation of the Alberta Context Tool (ACT), an eight dimension measure of organizational context for healthcare settings. Three principles guided the development of the ACT: substantive theory, brevity, and modifiability. The Promoting Action on Research Implementation in Health Services (PARiHS) framework and related literature were used to guide selection of items in the ACT. The ACT was required to be brief enough to be tolerated in busy and resource stretched work settings and to assess concepts of organizational context that were potentially modifiable. The English version of the ACT was completed by 764 nurses (752 valid responses) working in seven Canadian pediatric care hospitals as part of its initial validation. Cronbach's alpha, exploratory factor analysis, analysis of variance, and tests of association were used to assess instrument reliability and validity. The concepts that underlie the tool are very relevant to school health promotion and development. These concepts were converted to several definitions that were generally confirmed in the research study. These definitions were developed into research questions for the study and include: 

• Leadership: The actions of formal leaders in an organization (unit) to influence change and excellence in practice, items generally reflect emotionally intelligent leadership
• Culture: The way that 'we do things' in our organizations and work units, items generally reflect a supportive work culture
• Evaluation: The process of using data to assess group/team performance and to achieve outcomes in organizations or units
• Social Capital: The stock of active connections among people. These connections are of three types: bonding, bridging, and linking
• Formal Interactions: Formal exchanges that occur between individuals working within an organization (unit) through scheduled activities that can promote the transfer of knowledge
• Informal Interactions: Informal exchanges that occur between individuals working within an organization (unit) that can promote the transfer of knowledge
• Structure/Electronic Resources: The structural and electronic elements of an organization (unit) that facilitate the ability to assess and use knowledge
• Organizational Slack: The cushion of actual or potential resources which allows an organization (unit) to adapt successfully to internal pressures for adjustments or to external pressures for changes         
• Human Resources (staffing): Perceived and actual levels of staffing are sufficient 
• Time: There is sufficient time available for staff to complete knowledge related work
• Space: There is sufficient work space in the organization for staff to complete knowledge related work.  

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(From the ISHN Member information service)  As we learn more about how health and social programs can be better integrated within education systems, one of the new areas for discussion is how educator understandings, beliefs and professional identities will have an impact on their willingness to address such issues in their practice. Three articles in the July 2014 issue of Environmental Education Research provide insights on teacher, administrator/school leader and education faculty understanding of the concept of sustainable development plays out in their respective work assignments. One article shows that Swedish teachers differ in their understanding of the concept mostly according to their subject traditions. generally do not have a holistic understanding which is prescribed in the formal curriculum documents. The second article examines how a holistic, whole school approach and vision to ESD can be developed by school leaders in different ways. The third article examined how teacher educators were constrained from addressing ESD in their work due to pressing and competing priorities, even when they understood the concept. Read more>>

(From the ISHN Member information service) The National Association of Chronic Disease Directors (NACDD) has just released an easy-to-read summary of a research article (Bradley & Greene, 2013) published in the May 2013 issue of the Journal of Adolescent Health.  the relationship between health risk behaviors and academic achievement. This article, along with a recent Cochrane Review (Langford et al, 2014) of the effectiveness of multi-intervention approaches in school health promotion, has raised questions about what we know (and don't know) about such comprehensive approaches, their impact on on health and educational achievement and how new understandings based on ecological and systems-based thinking need to be taken into account as we move forward. This blog post provides a brief introduction to a discussion which ISHN will undertake this fall in cooperation with its International Discussion Group addressing healthy school models and frameworks.   

As we noted in our ISHN members weekly report on news/research in May 2013,  the connections between health status, risk/protective behaviours, health inequities and health promoting conditions and learning have been well-established by many studies and reviews. This 2013 review correlated risk behaviours such as violence, tobacco use, alcohol and other drug use, sexual behaviors contributing to unintended pregnancy and sexually transmitted diseases, inadequate physical activity and unhealthy dietary behaviors to various measures of academic achievement and found that for "all six health-risk behaviors, 96.6% of the studies reported statistically significant inverse relationships between health-risk behaviors and academic achievement.". In our view, the direct connection between health and learning is not really the issue for us to consider again today. The current question, already being discussed in several recent reviews and reports is whether multi-intervention approaches such as healthy schools affect educational achievement. The  recent Cochrane Review (Langford et al, 2014) did not find sufficient evidence to support this claim but there have been several sources who suggest otherwise, at least in part, for health and social problems that have a direct impact on school attendance and participation. These sources include a review sponsored by WHO-Europe (Suhcrke $ de Paz Nieves, 2011), our ISHN analysis (McCall, 2010), a health inequities analysis (Basch, 2010), the Centers for Disease Control and Prevention (Web page summary, nd) and many others focused on specific health/social behaviours or conditions.  A recent discussion paper from the intergovernmental consortium on school health in Canada (Hussain & Freeman, 2013) offers an interesting elaboration of the concept of "educational achievement" and starts a conversation about some indicators depicting some student and school outputs that can be jointly pursued by health and education systems. We need to sort out these claims and counter claims about whether and which types of multi-intervention approaches are most effective in promoting student achievement, student success, school and health, education and other system effectiveness.

The Langford et al, 2014 review has also caused some decision-makers to question the value of school health promotion in general. Coming at a time when public health systems and authorities around the world are withdrawing from long-term commitments to school health promotion as their resources are reduced from the economic downturn, this is an alarming coincidence. Advocates for comprehensive school health approaches need to point out that the 2014 review essentially echos the findings of a similar review done for WHO in 2006 (Stewart-Brown, 2006) insofar as concluding that the evidence supporting the use of multi-intervention programs is limited to specific health issues and behaviours,  and that  there are several other systematic reviews with findings that contradict or clarify the Langford et al review. But we also develop and argue for a new paradigm for evaluating the impact of multi-intervention approaches that is truly based on ecological and systems-based evidence. Comprehensive school health programs in which school efforts are supported by school board and other agencies as well as by several ministries of government working together take several years to develop. They require holistic understandings of health rather than measures based on the absence of disease or specific health/social behaviours. We need to be measuring realistic outputs (basic health knowledge, generic and applied life skills, mindful self-understanding and realistic behavioural plans) that can be observed as students graduate from schools. The limitations of random controlled trials that often compare specific, artificially supported programs to existing programs without much clarity or understanding of the complexity of systems needs to be challenged. We need more multi-level models and analysis and systematic reviews that use mixed method studies as their basis.     

Our ISHN May 2013 weekly report also questioned the wishful thinking in the JAH article when it suggested that a "unified (health & education) system that addresses both health behavior and academic achievement would have reciprocal and synergistic effects on the health and academic achievement". In our view, establishing such a "unified system" runs counter to the reality of government structures. Instead, ISHN and other organizations have initiated an international discussion that suggests that health and other systems need to revise their approach so that health and social programs are integrated within the core mandates, constraints and concerns of education systems. ISHN, ASCD and other organizations have initiated an international discussion group that suggests that health and other systems need to revise their approach so that health and social programs are integrated within the core mandates, constraints and concerns of education systems. A global consensus statement has prompted and international dialogue in several regions of the world leading up to a forum with UN agencies in May, 2015. International school health symposiums have already been Asia and North America on the many aspects of this integration challenge. 

Watch for the announcements of our discussions in webinars and web meetings on the evidence and experience in multi-intervention approaches to school health promotion and development in the fall of 2014 on the ISHN webinars and conference schedules foubnd at the Wikipedia style web site at www.schools-for-all.org .   

(From the ISHN Member information service)  The US Department of Education announced the winners of their research granting program on educational innovations this week. The focus of these large grants (1.5 million + for each) was on mental health issues, including resilience, social emotional learning, integrated mental health services and many more topics. The extent to which these grants are coordinated with the efforts of non-educational sectors will help to determine their ultimate impact on education and other systems. Read more>>