(An item from the ISHN Member information service)  University-school district partnerships in the implementation of comprehensive school health programs proved to be effective in Taiwan. An article in Issue #4, 2015 of Health Education Research examined whether expanding the support for this initiative was effective in advancing HPS implementation, perceived HPS impact and perceived HPS efficacy. "In 2011, the Taiwan government expanded its support of school–district/university partnership programs that promote the implementation of the evidenced-based Health Promoting Schools (HPS) program. In 2011 and 2013, a total of 647 and 1195 schools, respectively, complemented the questionnaire. Univariate analysis results indicated that the HPS implementation levels for six components were significantly increased from 2011 to 2013. These components included school health policies, physical environment, social environment, teaching activities and school–community relationships. Participant teachers also reported significantly greater levels of perceived HPS impact and HPS efficacy after the expansion of support for school–district/university partnership programs. Multivariate analysis results indicated that after controlling for school level, HPS funding and HPS action research approach variables, the expansion had a positive impact on increasing the levels of HPS implementation, perceived HPS impact and perceived HPS efficacy." Read more>>

(An item from the ISHN Member information service)  With debates about the purposes of schooling now underway in several countries such as England, the US and others, we note that several blogs are adding useful commentaries suggesting that a holistic education, aimed at developing the whole child, are also adding to those debates. Watch these pages for ongoing reporting of the education reform paper in England and the renewal of the Education Act in the US. Both countries are deciding whether health education will be part of their core subjects. Read more>>

(An item from the ISHN Member information service)  An analysis of coordination the Dutch Healthy School Approach (HSA) is reported in the July 2015 Issue of BMC Public Health. "HSA targets demand-driven practices based on the epidemiological data, a prioritization of needs, an assessment of important/modifiable determinants, the drafting and implementation of a multi-year plan, and its evaluation. All this is done jointly with multiple stakeholders. At school level, implementation is assisted by a ‘HPS advisor’, who represents various public services and providers in individual contacts with schools. At local and regional levels, the public health services (PHSs) function as a coordinator between the education, health and other services stakeholders. Their coordinating role derives from a legal responsibility for the implementation of local public health policy and youth health care financed by the municipality". The study "reports on the longitudinal quantitative and qualitative data resulting from a two-year trajectory (2008–2011) based on the DIagnosis of Sustainable Collaboration (DISC) model. This trajectory aimed to support regional coordinators of comprehensive school health promotion (CSHP) in systematically developing change management and project management to establish intersectoral collaboration. Multilevel analyses of quantitative data on the determinants of collaborations according to the DISC model were done, with 90 respondents (response 57 %) at pretest and 69 respondents (52 %) at posttest. Quantitative data showed major improvements in change management and project management. There were also improvements in consensus development, commitment formation, formalization of the CSHP, and alignment of policies, although organizational problems within the collaboration increased. Content analyses of qualitative data identified five main management styles. Read more>>

(An item from the ISHN Member information service)  An article in Volume 76, 2015 of Preventive Medicine reports on a review of studies using the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate physical activity interventions aimed at youth. "A systematic search for controlled interventions conducted within the last ten years identified 50 studies that met the selection criteria. Based on Reach, Efficacy/Effectiveness, Adoption, Implementation and Maintenance criteria, most of these studies focused on statistically significant findings and internal validity rather than on issues of external validity. Due to this lack of information, it is difficult to determine whether or not reportedly successful interventions are feasible and sustainable in an uncontrolled, real-world setting. Areas requiring further research include costs associated with recruitment and implementation, adoption rate, and representativeness of participants and settings. This review adds data to support recommendations that interventions promoting physical activity in youth should include assessment of adoption and implementation issues". Read more>>

(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>>

(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’:

• A discrete, developmental and responsive PSHE education programme at the centre of the school curriculum, providing  opportunities to teach concepts, knowledge, language, strategies and skills that enrich the wider curriculum.
  
• PSHE education managed by an experienced, central co-ordinator with a genuine passion for the subject in their school. This co-ordinator should be supported by a ‘whole school’ commitment to PSHE education, and be part of a single data-driven system under which pupil personal development and pastoral care are provided.
  
• A senior leadership committed to monitoring the quality of PSHE teaching with the same rigour and expectations as other subjects. This also helps to ensure that any PSHE lessons observed during an Ofsted inspection can contribute positively to the overall judgment.
  
• Active involvement from members of the senior leadership team in teaching PSHE. Senior leadership team members’ involvement  - for example through heads of years teaching certain modules -  raises the profile and status of the subject with staff and pupils.
  
• PSHE education built around clear learning objectives and expected learning outcomes. Robust teacher, pupil and peer assessment allows schools to demonstrate pupils’ immediate learning from a single lesson and their progress over time. Schools should gather data to focus, evaluate and evidence the impact of the school’s PSHE provision. This ‘data rich’ environment also provides a strong evidence base for Ofsted inspections.
  
• PSHE education treated with the same regard as other subjects on the school’s curriculum. PSHE should be given appropriate curriculum time and a developmental scheme of work, have lessons observed and ensure that pupils’ work and progression is subject to scrutiny.
  
• Clear learning objectives which differentiate PSHE education where it is ‘blended’ with other subjects.  Some secondary schools ‘blend’ PSHE education, citizenship and RE whilst others separate them out as discrete timetabled subjects. Regardless of the model there should be clear learning objectives and outcomes for each element.
  
• Scope for flexibility and creativity to change the direction of lessons in response to pupil need.  This flexibility should take place within a wider framework ensuring that pupils would return to the planned learning at a later date.
  
• Recognition by schools that PSHE education helps to develop transferable skills that support academic success and success in life beyond school.  Schools should recognise PSHE education’s role in developing interpersonal skills such as listening, questioning, team-working and risk identification and its impact on pupils’ academic achievement, behaviour and success beyond school, including employability.
  
• A single ‘unifying framework’ or philosophy that focuses the entire school’s curriculum, making it clear to staff how the content and pedagogy of PSHE education contributes to this ethos.
  
• External visitors used within the context of a planned PSHE programme. Carefully selected external visitors can be used to enrich learning, provide expert input and act as role models with pre and post learning  offered through the regular planned PSHE programme.
  
• Active involvement of governing bodies. As part of their scrutiny of the curriculum, governing bodies should be provided with reports of pupils’ progress in PSHE and intended developments in the subject. Strong links with the student council should also be encouraged.

The Center for Disease Control & Prevention in the USA also provides excellent advice in their review of several Characteristics of an Effective Health Education Curriculum:

1. Focuses on clear health goals and related behavioral outcomes
2. Is research-based and theory-driven.
   
3. Addresses individual values, attitudes, and beliefs
4. Addresses individual and group norms that support health-enhancing behaviors
5. Focuses on reinforcing protective factors and increasing perceptions of personal risk and harmfulness of engaging in specific unhealthy practices and behaviors.
6. Addresses social pressures and influences.
7. Builds personal competence, social competence, and self efficacy by addressing skills
8. Provides functional health knowledge that is basic, accurate, and directly contributes to health-promoting decisions and behaviors
9. Uses strategies designed to personalize information and engage students.
10. Provides age-appropriate and developmentally-appropriate information, learning strategies, teaching methods, and materials
11. Incorporates learning strategies, teaching methods, and materials that are culturally inclusive.
12. Provides adequate time for instruction and learning.
13. Provides opportunities to reinforce skills and positive health behaviors
14. Provides opportunities to make positive connections with influential others
15. Includes teacher information and plans for professional development and training that enhance effectiveness of instruction and student learning.

The Glossary Term on Health Personal and Social Development Education being developed by the International School Health Network on its Wikipedia style web site has listed these important student learning outputs as part of its description of effective health and social development education.
There are several types of learning objectives that can be achieved in effective HPSD curricula and programs. These include:

• Focusing on functional or practical knowledge rather than simply presenting facts about health/social issues (eg too much detail on how STI are transmitted and not on enough on the fact that a person can have an STI and still look healthy)
• Developing and practicing general social, decision-making, life, media and decision-making/reasoning skills as well as practice and rehearsals in skills for specific situations (such as refusing alcohol)
• Promoting specific, practical age-appropriate behaviours (e.g. how to discuss/negotiate/refuse sex with partner) and providing specific pre-planned situational options (e.g. having a back-up drive home from parties) that can be sustained by the students rather than general and unrealistic calls for abstinence, alarmist messages contrary to prevailing social norms (alcohol is bad for you in communities where most adults drink)
• Addressing social pressures and influences through media literacy education, instruction about puberty, relationships with peers and peer pressure, how to communicate with parents and other adults
• Influencing normative beliefs, perceptions and attitudes through deconstructing mis-perceptions and providing factual information and investigation of collective behaviours of their peers/fellow students
• Personalizing information and risks about health and social problems and behaviours through inquiry-based learning, reflective journalling, role plays and other activities
• Developing behavioural intentions or personalized action plans through class discussions, buddy-based projects, external presentations
  
• Increasing self-awareness and awareness of the values and expectations of their parents, schools and communities
• Developing stronger empathy with others and greater social responsibility for promoting the health and welfare of others
  
• Learning how to access and use health services by visiting physicians offices, health clinics
  

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>>

(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.

1. Requiring collaboration: Law can create legally binding duties for departments to collaborate around health. This can be required at the national, state or local agency level.
   To our knowledge, there is no government that requires such cooperation by law for SH promotion. Many appoint officials and some even huave joint SH progrrams or committees, but this is not done in legislation. 
2. Authorizing collaboration. Even when law does not require cross-sector collaboration around health, it may permit it. This permission may be direct and explicit. Or, Law may also authorize collaboration around health implicitly, through broad grants of public health authority. -- Many governments authorize their health ministry staff and local health authorities to cooperate with school systems. But often the funding and staffing for this cooperation is not provided to the SH team. Usually funding for prevention and promotion work is delivered through other sections of the health ministry rather than the SH team or any other teams that have responsibility for working with the other sectors/settings. 
3. Establishing institutions for collaboration. Law can organize and implement collaboration by formalizing relationships through task forces, boards, commissions, or other institutions. -- To our knowledge, there is no government that has established an inter-ministry SH structure by law, although several exist by administrative decisions. These administrative structures often are changed when a new elected or appointed official decides to re-structure the huealth ministry to address new priorities, often focused on urgent health issues rather than ongoing relationships with other ministries. We have seen some structures on child or family health established by law but often they are not successful and often they are focused on urgent problems rather than long term solutions such as SH or on inter-ministry, inter-sectorial relationships. 
4. Prescribing a collaborative process. Governments can go beyond generally requiring or authorizing collaboration to prescribe specific collaborative processes. 
   Again, to our knowledge, there is no government that requires that a collaborative process within the health ministry, across ministries or among local agencies to promote health through schools. In many cases, there are committees, but their existence and use by the various ministries and agencies is always voluntary. Often such committees seldom meet. There are no requirements for ministries or agencies to cooperate in order to receive funding. There are few jointly appointed staff teams or coordinators. There are seldom any joint reporting requirements.
5. Assigning responsibility. The law can be used to assign responsibilities for cooperation and joint action. Often there are SH coordinators assigned within the health ministries or local health authorities. Sometimes these coordinators are assigned within the education system. However, often these coordinators are responsible for other duties. Often any funding that they have available to work with are focused on specific health issues or programs other than school health. 
6. Prioritizing a public health issue. Law can elevate a particular public health issue and focus the efforts of different agencies on that issue. 
   In our view, this suggestion  reflects a health sector bias, one that is most often focused on a disease or specific health problem. We recognize that this is how the health sector really works, but this tendency to ignore overall "health" to focus on the "absence of disease" will prevent any long-term cooperation with and within other sectors. If the health sector is unable to moderate this tendency and modulate its activities with other sectors to help them meet their respective goals and primary concerns, then all of the health checklists newly dressed up and prepared as part of a HiAP strategy will not be sustained. 
7. Coordinating government efforts. For a complex problem (or solution) such as homelessness (or healthy schools), requiring attention from several agencies, law can encourage agencies to work in concert and in consistent and complementary ways. -- The research on school health and other forms of health promotion and social development is now clearly recognizing the complexity involved in working within and across sectors. The authors note that " By requiring each participating agency to assign a representative responsible for homelessness (school health) with authority to bind the agency to the Council, use standard data, and contribute resources,the statute promotes consistent and complementary work. It also encourages working in concert by requiring the Council to survey available resources, provide and coordinate state services, improve information flow, establish a resource and information center, and develop monitoring guidelines." To our knowledge, there are few, if any SH councils in the world mandated by law in this manner. 
8. Providing for funding. Collaboration or executing collaborative recommendations may require funding. Law can create public finance infrastructure and provide and incentivize funding through appropriations, grants, or social impact bonds.
   In school health promotion, there are many, many bits and pieces of project funding, often offered to schools in short term competitions. But there are no funding incentives of the scale that would encourage federal departments, state ministries or even local health and education ministries to work together over the long term on school health promotion. 
9. Fostering informal relationships. Laws formalizing collaboration around any issue can improve relationships and create opportunities for future collaboration by requiring the participation of senior leaders within ministries (rather than program level staff), requiring a minimum number of meetings or reports. -- As noted above there are often such committees, but they are often have low level participation and few requirements about their joint work. 

This article on how HiAP strategies can be implemented through legislation is both useful and revealing. The many suggestions, illustrated by practical examples in the United states, are very applicable to school health promotion. The analysis also reveals a fundamental challengre to the successful implementation of HiAP in any jurisdiction. If it is used as a sledge hammer to require other sectors to work on then many urgent health problems of the day, rather than a way to re-establish long-term relationships and joint approaches that help those other sectors achieve their priorities (such as school health promotion) with other sectors, its shelf-life as a viable whole of government strategy. Read more>> 
 

(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) 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)   An article in the April 2014 issue of BMC Public Health discusses a longitudinal study and knowledge development project in Canada (The COMPASS Study) that will enable researchers to assess the cumulative impact of several school health policies and programs on multiple issues over time. The authors describe the study as "COMPASS is a prospective cohort study designed to annually collect hierarchical longitudinal data from a sample of 90 secondary schools and the 50,000+ grade 9 to 12 students attending those schools. COMPASS uses a rigorous quasi-experimental design to evaluate how changes in school programs, policies, and/or built environment (BE) characteristics are related to changes in multiple youth health behaviours and outcomes over time. It is the first study with the infrastructure to robustly evaluate the impact that changes in multiple school-level programs, policies, and BE characteristics within or surrounding a school might have on multiple youth health behaviours " The researchers note that "In Year 1 (2012–13), data were collected from 43 Ontario schools and over 24,000 grade 9 to 12 students. In Year 2 (2013–14), the cohort was increased by 47 additional schools to reach our target of 90 schools (79 in Ontario and 11 in Alberta), with more than 50,000 grade 9 to 12 students participating. Given the hierarchical longitudinal nature of the data, the cohort of 90 secondary schools are being followed over time through annual school data collection of the program and policy environment within each school, the built environment characteristics within each school, and the built environment characteristics in the community immediately surrounding each school. At the student-level, the cohort of grade 9 to 12 students within the 90 schools are followed over time using annual surveys that assess obesity, healthy eating, physical activity, sedentary behaviour, tobacco use, alcohol and marijuana use, school connectedness, bullying, and academic achievement using scientifically supported measures.COMPASS can evaluate the ‘real-world’ effectiveness of evidence-based interventions that are implemented in COMPASS schools throughout the course of the study. Considering that schools also often implement innovative and unique programs or policies that are not yet evidence-based, 
COMPASS can start to generate practice-based evidence by evaluating those natural experiments throughout the course of the study." In order to help foster health promoting schools to develop stronger links and engagement with participating schools, and track knowledge use as it unfolds from inception through decision-making, adoption, adaption and implementation in participating schools, the COMPASS study developed the COMPASS School Health Profile (SHP) and connects participating schools with a COMPASS knowledge broker.The hierarchical longitudinal nature of the COMPASS data allows for a number of different analytical strategies for examining each of the outcomes in COMPASS. For instance, both cross-sectional and longitudinal core analytical approaches to examining the data will be used. Cross-sectional analyses include, but are not limited to: 1. Identification of high-risk individuals or high-risk school environments; 2. Examination of between-school variability in the different student-level outcomes among students; 
3. Examination of the co-occurrence of different outcomes; and,4. Hierarchical analyses examining the student- and school-level characteristics associated with each outcome. Longitudinal analyses include, but are not limited to: 1. Examination of the temporal sequence for the development of individual outcomes or the co-occurrence of outcomes; 2. Hierarchical examination of how changes in school-level characteristics (programs, policies, or built environment resources) are related to changes in school-level prevalence or individual student-level outcomes over time; 3. Evaluation of how the different knowledge exchange strategies impact the provision of school-level prevention activities or resources; and, 4. Examining how the trajectories of different outcomes are predicted by other outcomes (e.g. declines in physical activity over time impact obesity) and the available sociodemographic characteristics of students and/or schools.
The authors conclude that "In conclusion, the COMPASS study is among the first of its kind internationally to create the infrastructure to robustly evaluate the impact that changes in school-level programs, policies, and built environment resources might have on multiple youth health behaviours and outcomes over time. Determining the school-level characteristics that are related to the development of multiple modifiable youth health behaviours and outcomes will provide valuable insight for informing the future development, tailoring, and targeting of school-based prevention initiatives to where they are most likely to have an impact [46], and will provide the opportunity to understand how the school environment can either promote or inhibit health inequities among subpopulations of at-risk youth. Such insight could save valuable and limited prevention/promotion resources. Developing the ability to evaluate natural experiments that occur within schools will substantially add to the breadth of our understanding of what interventions work, for which students, and in which context." Read more>>

(From the ISHN Member information service)  A 2014 review of the effectiveness of a multi-intervention approach to promoting health and learning found that "The results of this review provide evidence for the effectiveness of some interventions based on the HPS framework for improving certain health outcomes but not others. More well-designed research is required to establish the effectiveness of this approach for other health topics and academic achievement." The review included "cluster-randomised controlled trials where randomisation took place at the level of school, district or other geographical area. Participants were children and young people aged four to 18 years, attending schools or colleges. In this review, we define HPS interventions as comprising the following three elements: input to the curriculum; changes to the school’s ethos or environment or both; and engagement with families or communities, or both. We compared this intervention against schools that implemented either no intervention or continued with their usual practice, or any programme that included just one or two of the above mentioned HPS elements.". The reviewers reported that they "found 67 trials, comprising 1345 schools and 98 districts, that fulfilled our criteria. These focused on a wide range of health topics, including physical activity, nutrition, substance use (tobacco, alcohol, and drugs), bullying, violence, mental health, sexual health, hand-washing, cycle-helmet use, sun protection, eating disorders, and oral health." The reviewers reported that "We found that interventions using the HPS approach were able to reduce students’ body mass index (BMI), increase physical activity and fitness levels, improve fruit and vegetable consumption, decrease cigarette use, and reduce reports of being bullied. However, we found little evidence of an effect on BMI when age and gender were taken into account (zBMI), and no evidence of effectiveness on fat intake, alcohol and drug use, mental health, violence, and bullying others. We did not have enough data to draw conclusions about the effectiveness of the HPS approach for sexual health, hand-washing, cycle-helmet use, eating disorders, sun protection, oral health or academic outcomes. Overall, the quality of evidence was low to moderate. We identified some problems with the way studies were conducted, which may have introduced bias, including many studies relying on students’ accounts of their own behaviours (rather than these being measured objectively) and high numbers of students dropping out of studies. These problems, and the small number of studies included in our analysis, limit our ability to draw clear conclusions about the effectiveness of the HPS framework in general"   Read more>>

(From the ISHN Member information service) The Healthy Schools program in British Columbia, Canada is among the Canadian and international leaders in school-based and school-linked prevention of specific health problems and in promoting overall health.  A visit to their content rich web site will reveal that the schools program is part of an overall settings-based approach and a "whole of government" strategy called Act Now BC. The province provides funding for a number of excellent initiatives and activities, all of which have used a long-term, systems-based strategy.  Multi-intervention approaches are used regularly as the basis for strategies on physical activity, healthy eating, addictions and mental health. The province has mandatory health/personal planning as well as physical education curricula from kindergarten to senior high school grades. The province funds a network of over 150 schools per year as innovators and leaders in school prevention and promotion. Regular conferences bring the school health community together. Excellent learning resources are identified and promoted. The Healthy Schools program has funded the development of a number of generic school health resources that encourage good planning school self-assessments, the use of multiple interventions, effective teaching and student assessment practices and more. Indeed, the province has been both a pioneer and a leader.
However, like all other jurisdictions, British Columbia struggles to truly maintain a focus on improving the overall health of the school environment (policies, practices, social interactions, physical conditions, family problems and strengths, relationship with the community etc) rather than being fixated on a selected set of health or social behaviours or conditions. The list of priority topics on the BC education ministry web page for its healthy schools program is typical of most jurisdictions; healthy eating, physical activity, tobacco/drugs. If one reads the list of "generic" school health planning guides and tools from BC (and most other jurisdictions) one will find that the generic principles and practices are almost entirely focused on or applied to only these health problems or behaviours. We will struggle to find references to to child abuse, sexual health, poverty, indigenous students, LGBT students, violence, crime and many other issues confronting youth and families today in those planning documents. The BC Healthy Schools web site does maintain a list of educational and other resources addressing a broader list of issues. And it does list its 150+ school success stories according to this broader list of topics. But, again, if we examine these stories, we find almost no examples of schools trying to build their overall capacity to implement and maintain school health promotion programs (3/159) but we do find an overwhelming number of stories on healthy eating and physical activity. We also find very few stories from schools addressing topics like substance abuse, child abuse and other more difficult social issues.   
If we turn our attention to the current dominant thinking in the health sector these days, we will find out why so many of the "healthy schools" programs have actually become "school prevention" programs rather than "school health promotion" programs. As funding has been leeched from the health sector overall, we find that health authorities have retreated back to their protection and prevention functions and away from their health promotion function. The work done by health professionals in schools simply reflects this larger trend. Indeed, if one were to examine health ministries around the world and even the WHO, we would find that they are structured, staffed and funded more favourably around "non-communicable diseases" than around "health promotion".   
The danger in this trend to reduce the focus and fixate on a selected number of health issues means that the healthy schools programs become vulnerable when a new issue such as cyber-bullying emerges to capture the attention of the public, parents and decision-makers. Resources are quickly devoted to this new problem and if the healthy schools movement is not ready to address it, they will be by=passed. Or, if other multi-intervention approaches/programs such as safe schools or community schools are available and compete with each other for such new resources, then we will soon see new infrastructure, new documents, new research, new leaders emerge, often repeating or over-lapping with work that has already been done. We will also see educators and school systems having to yet again adjust to a new set of requests and demands from a new set of stakeholders, often without aligning with existing initiatives. This is what happened in BC and several other Canadian and western countries. New laws, new coordinators, new professional development  activities and much more, all focused on bullying, cyber-bullying and to a lesser extent on LGBT students have been brought into BC (and other jurisdictions) in separate strategies
If the healthy schools movement and its related government, agency and school level programs do not move towards a school health promotion rather than prevention approach, it may very well find itself bypassed by new initiatives focused on the topt topic of the day rather than a long term developmental, systems-based approach. This is not to say that the HS movement should try to compete with such specific emerging concerns. Indeed, that is the way the health system has always been funded, by disease, rather than health. But the proponents of healthy schools need to always include all of the many aspects of health, wellness, development and its connection to learning in its mandate, maintaining links with the advocates, experts and practitioners focused on these 25+ issues and concerns and being ready to work with them as attention is turned to their issue. 
This is also not to say that the healthy schools movement should try to be the primary or over-arching paradigm for addressing many of these issues. Instead, the healthy schools movement, linked most effectively to the health sector,  and programs should be ready and willing to work with the many other multi-intervention approaches that work with other systems and sectors. These include the safe schools movement working with law enforcement, community schools working with social services and community development sectors, social/emotional learning and PBS models grounded in the school systems, the relief aid/emergencies in education movement working in countries facing disasters/conflict, school health & nutrition programs working in low income countries and many others. 
But if the healthy schools movement focuses too much on prevention and too little on promotion, it will not be able to either meet its mandate in addressing all aspects of health nor will it be able work effectively to work with other movements/sectoes in addressing the needs of the whole child.                      

(From the ISHN Member information service)  In the ASCD-ISHN global discussion of the need to better integrate health and social programs within education systems, it has been strongly suggested that authorities take a holisitc, whole child approach to education rather than trying to carve up children into specific health/social behaviours or conditions to to compete with the academic purposes of schooling. With the October 2013 release of its Education Renewal and Innovation Framework: Directions for Change, the Government of the Northwest Territories in Canada illustrates how this can be done from the ground up, while using a distinctly indigenous and rural set of values and principles. The news release announcing the framework identifies several challenges that require changes in the schools, the nature of which illustrate how the new directions see school as part of their respective social and economic contexts and communities. "The framework is one of several initiatives developed by the Government of the Northwest Territories to address challenges like poverty, mental health, addictions, early childhood development, safety, the legacy of residential schools and school attendance.  Other challenges within the school system, like authentic learning, staff recruitment, training and retention and transitions to work or learning after high school will be met primarily through school programming and policies themselves, preparing children for a prosperous and healthy future." The foundations of the reforms are equally holistic in their approach to education. The executive summary of the document says it this way: "Thinking around teaching and learning is undergoing a major shift world-wide. The current education system is a model off a system similar to the factories of the Industrial Age. Subject areas are separated, students are sorted by age, and the end goal is a very specific set of skills and knowledge. Research now points to a more ecological understanding of the needs of learners and the factors that benefit learning."  These foundational statements are intended to guide the initiative. These statements, especially the first few, are born of indigenous worldviews and experiences where relationships with the land, ecology, and identity are very powerful.     

1. Relationships: Meaningful relationships with self, others, ideas, and the land are the foundation for all learning. 
   
2. Ecological Understanding: Education in the NWT is a living system of connections, each affecting an individual’s relationships and well-being. 
   
3. Identity: A positive sense of identity is actively supported. 
   
4. Development of Self: Each person has multiple needs that must be met in order to grow and become a capable, contributing person. 
   
5. Learning Together: People construct knowledge and learn individually and together. 
   
6. Diversity: Diversity is recognized and valued in the education system. 
   
7. Strengths and Growth: The ongoing growth of learners is nurtured. 
   
8. Competencies: The development of competencies is supported in all learners
   

The proposed directions for change reflect the holistic understanding and the set of coherent values. They include commitments on the part of government to  (1) "ensure that the school and community work together to build and renew positive 
relationships", (2) "e that student wellness and the development of a positive sense of identity are promoted and embedded in school experiences, programming, and environments", (3)  "ensure that educators have access to experiences and resources that enhance their wellness in order for them to focus on excellence in teaching" (5) "that the strengths and realities of small communities are recognized and built upon in order to ensure equitable, quality education in all NWT communities" and (9) "work with Aboriginal governments to be successful as they draw down jurisdiction over the education of their people".
The document does include other directions that will be more familiar to those working in school systems based on competition, traditional rote style learning and even narrow, behavioural modification approaches to promote health. These include research-based curriculum, better data and use of those data in decision-making, and more monitoring/reporting to provide better accountability. However, these traditional, more industrial approaches to education are firmly based and and linked within this indigenous, holistic, whole child approach, that in turn, is rooted in a deep understanding the indigenous and rural, northern communities served by the schools in this system.  To read more about the NWT education renewal, start at this web page.