(An item from the ISHN Member information service) A traditional approach to evaluating the effectiveness of school health promotion programs was used in a small scale study reported in Issue #4, 2015 of Health Promotion Practice. The authors report that "SH interventions are evidence based and integrated into the curriculum, while embedded in complementary healthy school policies and environment. This study evaluates the effects of such an intervention on Dutch high schools. Methods. Two Dutch high schools and two controls were followed to evaluate the intervention’s effects on health behaviors, body mass index, and psychosocial problems after 1 year (N = 969) and 2 years (N = 605). Outcomes were measured via self-report surveys and analyzed with mixed methods regression analyses. To complement information on intervention effects, structured interviews were held with a representative sample of teachers per intervention school to map their respective whole school approach implementation success. Results. After 2 years, one intervention school showed significant improvements: Body mass index and excessive screen time use were reduced. In the other intervention school, priority targets did not improve. These findings reflected their respective success in intervention implementation, for example, differences in intervention integration and tailoring." The challenges associated with this type of study, beyond the short term measurement of behavioural effects, is that we are no informed about why implementation worked in one school but not the other. Read more>>
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(An item from the ISHN Member information service) An education ministry funded evaluation of the effectiveness of the Taiwan Health Promoting Schools Network, the mechanism used to implement school health in that country since 2001 was summarized in the July 2015 issue of the Journal of School Health. The survey of 800 randomly selected schools found that "Respondents were most satisfied with consultants and schools' recognition of responsibilities and rules and their interactions with HPSSN administrators. They were least satisfied with the extent of their HPSSN consultant interaction and believed HPSSN provided insufficient resources to establish HPS. Respondents' consultant partnerships and satisfaction with HPSSN administration significantly predicted HPS implementation. Additionally, the predictive values of healthy policies and school-community relationships were greater than the other 6 HPS components." In other words, capacity and relationships were critical. Read more>>
(An item from the ISHN Member information service) With UNESCO and other UN agencies in the midst of developing indicators for student learning outputs as part of the new 2015-2030 Social Development Goals, our attention has turned to sources of advice about high quality HPSD education and curricula. Here are some good sources.
The association representing Personal-Social-Health-Economic Education (PSHE) in the UK provides an excellent summary in a blog posting on the characteristics of effective health and social development curricula. The list includes " some common elements of good practice, summarised here and available in greater detail in our ‘Case study key findings document’:
There are several types of learning objectives that can be achieved in effective HPSD curricula and programs. These include:
Health literacy is a newer concept in health promotion that has not yet been applied extensively to school health education. We have always been trapped into developing health education by health topics (rather than generic skills or even basic skills/knowledge as in HL) so we do not have an evidence-based, experience-tested set of student learning outputs for all topics that can be developed in context relevant sets as a realistic, minimal output for schools. Linking health instruction inextricably with health services and other components of a comprehensive school health approach. There are a number of models of health education, particularly from sex education that has linked instruction with convenient, accessible services, or ensuring nutrition education goals are reflected in the school cafeteria are examples. The IVAC model developed in Denmark and used widely in Europe has flipped the instructional paradigm by using a student action learning framework as its basis rather than the traditional behavourist model. (An item from the ISHN Member information service) Formative evaluation results of eleven pilot schools participating in the ASCD Healthy Schools program (detailed planning and assessment guide, technical advice, networking) identifies "nine levers of change: principal as leader of the HSC efforts; active and engaged leadership; distributive team leadership; effective use of data for continuous school improvement; integration of the HSC process with the school improvement process; ongoing and embedded professional development; authentic and mutually beneficial community collaborations; stakeholder support of the local HSC effort; and creation or modification of school policy related to HSC that increased the likelihood that school improvement via health promotion would be pursued and sustained." The study was based on "Pre- and post-site visits along with in-depth interviews with school teams, teachers, students, administrators, community stakeholders and other involved individuals, school site report reviews, Healthy School Report Card results and school improvement plans were used for evaluation purposes. " The article concludes that "integration of health and education can become a sustainable and integral part of a school’s culture." Read more>>
(An item from the ISHN Member information service) Happiness is a publicly stated and authorized goal as well as a cultural tenet in Thailand, so it is not surprising that the model of school health promotion is built around happiness as the central organizing principle. An article in Volume #186, 2015 of Procedia - Social and Behavioral Sciences, reporting on the proceedings of 5th World Conference on Learning, Teaching and Educational Leadership, describes how this Thai model for school health promotion can be developed from several national comprehensive and issue-specific projects. "The first group are system-based projects that aim to help the school management and healthy learning management systems, such as the Healthy Schools Network (HSN), Healthy Literacy for Children, Youths, and Family Educational Network (HL). The second group are issues-based projects for students both in the classroom and outside the classroom, such as
the Development of Integrated Learning Systems: Life Skills and Sex Education (LS), Health Promotion for Thairath Wittaya School (HPT), Non-smoking Schools Network (NSN), Youth Justice (YJ), and Empowering Children and Community (ECC). The project defined the Components and common characteristics of a Healthy School as follows: There are 5 components of a Healthy School including 1) happy students, 2) happy organization, 3) happy environment, 4) happy family and 5) happy community. All five components are related and affecting each other as a Healthy School aims to achieve “happy students” through adjustment, risk factors reduction, structure and system management for the school, environment, family, and community as a safe place and promotion of student health and well-being in both social and physical, mental, intellectual fields. And there are 30 common characteristics in these five components. The authors conclude that: "The target of healthy development in school context shows a substantial part of the definition of “health” that the Thai Health Promotion Foundation has tried to explain: that it must have a broader meaning that bypasses the traditional definition of health being “diseases-free” and diseases are “germs" that can be eliminated with vaccines and drugs only”. It supports a new definition of health as being “a comprehensive and integrated health and social dimensions of body, mind and soul into a lifestyle linked and interrelated to the human relationship with the physical and social environment”. In these days where many health ministries and even WHO are retreating from a health promotion (health asa resource for living" to a prevention only approach (absence of diseases), this newly developed Thai model is to be welcomed. It portrayal of the school as part of the community and linked to the family also is a strong reminder for us all. Read more>> (From the ISHN Member information service) An article in Issue #1, 2015 of Public Health Reports discusses how governments can implement a Health in All Policies (HiAP) approach to inter-sectorial cooperation by using their legislative, regulatory leadership and funding levers. The article makes several practical suggestions on how governments can use the law to prescribe, authorize, structure and fund inter-sectorial cooperation. The article provide several state and local agency examples for each of these suggestions. Most of these cited legally required cooperative actions in the article are focused on responses to specific health issues rather than long-term inter-ministry or intra-ministry cooperation or long term approaches such as school health programs. However, the article can be used as a litmus test of government commitments to requiring and supporting their health ministries to work within other ministries and sectors who deliver their programs in settings such as schools, municipalities, workplaces etc.
In this ISHN comment, we extract the suggestions from the article to determine if there is a commitment to the inter-sectorial approach that we call school health promotion. The article reviews the HiAP approach: "The U.S. Centers for Disease Control and Prevention, Institute of Medicine (IOM), European Union, and World Health Organization all recognize the potential of HiAP to address the social determinantsof health, and through them, upstream contributions to morbidity and mortality.Sometimes called “healthy public policy”14 or described as a component of “horizontal government,” “joint-up government,” or “whole-of-government,”15 HiAP is an approach that integrates health considerations into non-health sectors; it recognizes that “corporate boardrooms, legislatures, and executive branches” make choices that profoundly affect health.11 Additional research is critical to determine whether HiAP leads to decisions that are more likely to consider health16 and, ultimately, improve it.Nonetheless, HiAP is a promising approach consistent with solving complex social problems through the “collective impact” of multiple sectors collaborating around a common agenda.19 These sectors include transportation, agriculture, housing, employment, planning, business, education, and energy, and in federal, state, and local government, they are often connected to agencies charged with regulating or facilitating their work." The article goes onto suggest that legislation is a good way to implement HiAP. " But how do governments implement HiAP? Consistent with law’s contributions to improving the public’s health,law can be “an important tool for institutionalizing an infrastructure for HiAP and for requiring agencies to ensure that the policies they pursue serve . . . health.” Governments use law to integrate health into other sectors.They also use legal mechanisms to further cross-sector collaboration around health, which is a critical component of HiAP. Since an effective HiAP strategy will require practical applications to inter-sectorial work, we suggest strongly that any introduction of an HiAP strategy will require the health sector to go to the venues or settings where the other sectors actually deliver their services and programs such as workplaces, municipalities, schools and other places. In other words, the health sector will need to return to a settings-based health promotion strategy if it expects ongoing cooperation from the other sectors. Otherwise the HiAP strategy runs the risk of being perceived as the health sector dumping its work onto the other sectors and they will resist, delay or simply not cooperate. The articles suggests that government levers can be used in several ways. Let's take a quick look at how many of these strategies are used to promote intersectorial cooperation through comprehensive, whole of government approaches to school health promotion.
(From the ISHN Member information service) The WHO released its 2013-2020 Action Plan on Non-Communicable Disease (NCD) prevention in January 2015. This commentary looks into the document from the perspective of the latest knowledge we have on school health promotion.
The action plan states "The action plan provides a road map and a menu of policy options for all Member States and other stakeholders, to take coordinated and coherent action, at all levels, local to global, to attain the nine voluntary global targets, including that of a 25% relative reduction in premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 2025. 6. The main focus of this action plan is on four types of noncommunicable disease—cardiovascular diseases, cancer, chronic respiratory diseases and diabetes—which make the largest contribution to morbidity and mortality due to noncommunicable diseases, and on four shared behavioural risk factors—tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. It recognizes that the conditions in which people live and work and their lifestyles influence their health and quality of life" It is in this last sentence where the action plan fails. quite badly. In this analysis, we look more closely at the words in the document and then discuss one aspect drawing from the recent evidence and experience in school health promotion. The vision described on page 12 of the document is revealing. it begins with the goal " A world free of the avoidable burden of noncommunicable diseases". Nowhere does the document contain the WHO vision of health, which, as we know, is "more than the absence of disease". The vision contains several nice concepts, including human rights, equity, national multi-sectorial action, life-course approach, empowerment, and managing potential conflicts of interest with food companies and others. But the implicit nature of the document becomes clearer when we note that the words population health, public health u or health promotion are not used. As well, the agenda becomes clearer when we note that of the five functions of public health (protection, promotion, prevention, services and surveillance) only universal health services is mentioned. The WHO intent in this document is clearly to galvanize action in countries in a disease prevention strategy. The first objective of the action plan (p. 5) is to "raise the priority accorded to the prevention and control of NCD's". This action plan really is about disease, and building the case for for access to universal health care. In our view, the document is part of and reflects a world wide trend for the health sector to retreat back to a medical model and move away from the principles of the Ottawa and ensuing charters related to health promotion and social development. We will come back to the vision statement about evidence-based strategies later in this analysis. As proponents of school health promotion and settings-based work, we were hopeful when we read on page 5 of the objective stating " to reduce modifiable risk factors for noncommunicable diseases and underlying social determinants through creation of health-promoting environments." If there is any chance that WHO and the health ministries in countries are to secure the cooperation of other sectors in the Health in All Policies (HiAP) initiatives, then the health sector will need to "go to where those sectors do their work, ie in the settings where people live, learn, work and play. However, when we got to pages 29-37, we found no mention of healthy cities/communities, schools, workplaces, hospitals, universities and other settings. We found only recommended actions such as legislation on second-hand smoke, warnings on cigarette packages, controls on food marketing, promotion of physical activity guidelines and limitations on alcohol sales. These are all good things but they are also all "prescriptions" (medical pun intended) for behaviour change. This medical model has long been discredited in the research on behaviour change and, more recently, even more so on our growing understanding of ecological and systems-based approaches. The document does suggest that the WHO Secretariat should provide technical assistance to countries through settings such as schools, cities, recreation etc but the investment (or re-investment) by countries in these settings-based strategies as the means to deliver the NCD prevention strategy is clearly not included as part of the recommended action by countries. Further, when we know that the current total investment of the global WHO office for working with all of these settings is one staff person, we must question the feasibility of the intent to provide such technical assistance. In closing, we will pick out one aspect of the action plan that further illustrates how the WHO action plan is actually more of a medically-inspired, bureaucratic creation rather than being based on research evidence and professional experience in the real world. On page 33, we find recommendations that suggest countries should promote "active transportation" and "Improved provision of quality physical education in educational settings (from infant years to tertiary level) including opportunities for physical activity before, during and after the formal school day." If you are a reader of this blog you will recall that we have been tracking the research and reports on physical activity, particularly in regards to its connection to obesity/overweight. Based on several research reviews and articles, we now know that increased physical activity alone, has little effect on body weight. We also know that increased PE time does little to increase actual moderate/vigorous activity unless PE classes are transformed. We know that extensive school-based obesity prevention programs have not reduced obesity levels. We know that we can squeeze out more minutes of activity for some students through active recess, after-school and in-class activities but these efforts do not always engage the naturally less active or uncoordinated students. We know that walking and biking to schools is the best way to accumulate activity minutes. But we also know that structural barriers (perceived safety, parent work schedules, existing neighbourhood designs all prevent significant change in transportation patterns. We also know that these economic and social barriers to active transportation to school may actually illustrate the more fundamental, deeper analysis that is missing throughout the WHO action plan. For example, a recent analysis of active school transportation in California notes that poor children are the ones most walking to school and they are also the ones that are more obese and overweight. As well, these poor children, who now comprise over one-half of the school children in the United States, actually have more urgent and important health problems. If we retreat to a medical, prescriptive model, one that ignores what we have learned about behaviour and ecological influences in the past two decades, then all of the words in documents like the NCD plan will be much less useful in the real world. (From the ISHN Member information service) The WHO fact sheet describing the response of health ministries to prevent and control NCDs indicates the collective, global intentions and strategies. The ideas and actions not mentioned on the page and in the action plan are as important as the ones that are highlighted. WHO summarizes the actions needed as follows:
" To lessen the impact of NCDs on individuals and society, a comprehensive approach is needed that requires all sectors, including health, finance, foreign affairs, education, agriculture, planning and others, to work together to reduce the risks associated with NCDs, as well as promote the interventions to prevent and control them. An important way to reduce NCDs is to focus on lessening the risk factors associated with these diseases. Low-cost solutions exist to reduce the common modifiable risk factors (mainly tobacco use, unhealthy diet and physical inactivity, and the harmful use of alcohol) and map the epidemic of NCDs and their risk factors. Other ways to reduce NCDs are high impact essential NCD interventions that can be delivered through a primary health-care approach to strengthen early detection and timely treatment. Evidence shows that such interventions are excellent economic investments because. The greatest impact can be achieved by creating healthy public policies that promote NCD prevention and control and reorienting health systems. Lower-income countries generally have lower capacity for prevention and control. Countries with inadequate health insurance coverage are unlikely to provide universal access to essential NCD interventions". Our initial comments: (1) The WHO is clearly medical, focused on health services rather than health promotion. (2) The absence of disease is the goal rather than overall health. (3) Other sectors are expected to be partners but a settings-based approach, essential to these partnerships, is neglected and forgotten. Read more>> (From UCLA School Mental Health Project) A new book in January 2015 by the UCLA School Mental Health Project makes a cogent argument for transforming the fragmented delivery of various support services so that they truly support student learning and equitable educational opportunity. The authors begin with this " external and internal barriers to learning and teaching have continued to pose some of the most pervasive and entrenched challenges to educators across the country, particularly in chronically low performing schools. Failure to directly address these barriers ensures that (a) too many children and youth will continue to struggle in school, and (b) teachers will continue to divert precious instructional time to dealing with behavior and other problems...Transforming student and learning supports is key to school improvement. To this end, this book incorporates years of research and prototype development and a variety of examples from trailblazing efforts" They go on to say "Mapping a school district’s existing efforts to address problems yields a consistent picture of many practices and fragmented, piecemeal, and usually disorganized activity (as illustrated below). The range of such learning and student supports generally is extensive and expensive". They also go on to describe the cause and this is where we might disagree: "Underlying the fragmentation is a fundamental policy problem, namely the long-standing marginalization of student and learning supports in school improvement policy and practice. Thus, most efforts to directly use student and learning supports to address barriers to learning and teaching and re-engage disconnected students are not a primary focus in school improvement planning. " In our view, a major cause of the fragmentation is that the mandates and funding of the various health, social and other services is done in a sporadic, competitive and disjointed manner. Part of the transformation will require that health and other ministries re-organize their work so that they are accountable for providing consistent support for students most at risk, rather than always worrying about the optimal health of all students in universal programs. There have often been attempts to insert health outputs and outcomes into school system accountability. In our view, this should be a two-way street, with health and other systems being accountable for a reasonable number of educational outputs, particularly for more vulnerable students. Read more>>
(From the ISHN Member information service) An article in Issue #1, 2015 of the American Journal of Public Health describes the new strategic priorities of the US National Institutes of Health. That article led us to investigate by briefly reviewing them and the NIH web site. We found that the 2014 priorities were sensible, although more operational rather than strategic in nature. (They include monitoring investments and impacts, identifying new areas, promoting best methods, promoting cooperation and coordination, promoting evidence-based interventions, implementation and dissemination, and increasing the visibility of research). In our brief review, we looked for the concepts that are driving health promotion practice in recent years. These include ecological approaches, systems change/thinking, social determinants, promoting health in all polices, population health, contextual/situational analysis as well as more traditional ideas such as settings-based health promotion and even the words health promotion. We were disappointed. We found a dated definition of primary & secondary prevention, a narrow conception of prevention research and an overriding focus on diseases and disorders rather than health. Since the priorities were for the Office of Disease Prevention, which is situated within the Research Coordination division, we looked, in vain, for a parallel office on health promotion. Among the various NIH Institutes, we found three on populations (child health, aging, disparities/minority populations) two on medical/health care delivery and the rest (16) on diseases. We looked at the child health institutes and found that their mission was focused on funding studies that explore "health processes; examines the impact of disabilities, diseases, and defects on the lives of individuals". Many years ago, the concept that health was more than "an absence of disease" was established. Maybe NIH should catch up. Read more>>
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