Report of the ‘Health in All Policies’ Focus Area Group on: EDUCATION & HEALTH ppt

Contents 1.1 Health in All Policies – intersectoral working 4 HiAP overview Nursery Nutrition and Food Provision in Liverpool Smoke and Mirror Initiative HiAP overview Model for Heal

Report of the ‘Health in All Policies’ Focus

Area Group on:

EDUCATION & HEALTH

2

Title: Report of the ‘Health in All Policies’ focus area group on education &

health

Date: July 2011

Authors: Noëlle Cotter (Institute of Public Health in Ireland), Owen Metcalfe

(Institute of Public Health in Ireland), David Ritchie (NHS North West Health,

UK)

Contents

1.1 Health in All Policies – intersectoral working 4

HiAP overview Nursery Nutrition and Food Provision in Liverpool Smoke and Mirror Initiative

HiAP overview Model for Healthy Lifestyle in School National School Nutrition Programme

HiAP overview Smoking Prevention Programme in Kindergartens & Schools Health Promotion Pilot Project against Segregation

LOGO – Complex Youth Service System

HiAP overview Joyful School ‘Radosna szkoła’

I know what I eat ‘Wiem, co jem’

HiAP overview Food Dudes: A primary education initiative to promote healthy eating Green Schools Ireland: Focus on Active Travel

HiAP overview Integrated educational package on the prevention of AIDS and STIs in secondary schools

National Project for the Promotion of Physical Activity (NPPPA)

Health in all Policies (HiAP) is an approach which ensures that all policy considerations, in particular those outside of the immediate remit of health and healthcare policy, take account of the potential

to contribute to population health A HiAP approach demonstrates an understanding that determinants of health are principally controlled by sectors other than health Dahlgren and Whitehead’s diagram (figure 1 below) is frequently cited to demonstrate the multi-faceted nature of influences on population health

Figure 1: Dahlgren, G Whitehead, M (1991) Policies and strategies to promote social equity in health, Institute of Futures Studies, Stockholm

1.1 Health in all Policies and inter-sectoral working

Recognising that ‘health’ goes beyond ‘health care’, and that health is often determined in sectors outside of health has taken time within European policy-making but incremental progress is being achieved, in particular with regard to the links between education and health (Grossman, 1975; Lleras-Muney, 2006; cited in Suhrcke et al, 2011) and the work of the World Health Organisation and the Marmot Review have made significant contributions in this regard However, in accepting this approach in theory, or acknowledging it as a good idea does not mean that the HiAP approach is diligently followed The implementation of Health Impact Assessments (HIA) in several European jurisdictions to health-proof policies during formulation shows some improvements in this area However HIA is generally not a statutory requirement but health impacts are taken into consideration within other statutory impact assessment processes, for example Strategic Environmental Assessment (European Directive 42/EC/2001)

The intent of ‘Crossing Bridges’ is to progress this and explore what exactly is it that ensures a HiAP approach, or indeed what are the barriers The method used was to explore case studies across Europe in the areas of transport and planning, and education where health was explicitly or implicitly addressed during the policy-making process and was an intended outcome or unintentional by-product Stahl et al (2006) have outlined what is needed for a HiAP approach and

‘Crossing Bridges’ intends to learn more about embedding this action

Action and implementation of HiAP is dependent on the availability and existence of human resources and knowledge of public health issues, health impacts and social determinants Focus on HiAP therefore needs to be set in a long-term and institutional context This requires a sufficient basis

of training and research on matters of public health, health policy and determinants of health It also requires that action on HiAP has sufficient priority and a critical mass of support within the government and among policy-makers, including nongovernmental organizations (NGOs) This is of particular importance in the context of tackling more complex and long-term problems and policy- level issues (Stahl, T et al (2006: 17) Health in All Policies: Prospects and potentials Ministry of Social

Affairs and Health, Finland)

‘Closing the Gap’ and ‘DETERMINE’ both worked towards increased awareness, knowledge and willingness to implement a HiAP approach ‘Crossing Bridges’ intends to drive this forward through capacity building knowledge Thus far it is known that there are six principal areas of capacity building and awareness-raising to encourage a HiAP approach as identified in the ‘DETERMINE’ process:

At a grassroots level, such as among the community and voluntary sector, there has been a greater move towards inter-agency cooperation and inter-sectoral working Himmelman (2004) developed a matrix to demonstrate the differences between various levels of inter-sectoral working using definitions from a healthcare setting; ranging from a more informal basis to full integration However, this is frequently reliant on a ‘champion’, a person who wants to drive forward multi-sectoral and integrated working, or alternatively is reliant on a top-down instruction Use of a

‘champion’ or a direct top-down order to implement integrated working may also be less complex to implement in terms of direct service provision than at the policy-making level where there are more complex competing interests; in particular ‘champions’ of other issues working in diverse directions

to HiAP

Box 1 Matrix* of Coalition Strategies for Working Together

Definition

Exchanging information for mutual benefit

Exchanging information for mutual benefit, and altering activities to achieve a common purpose

Exchanging information for mutual benefit, and altering activities and sharing resources to achieve a common purpose

Exchanging information for mutual benefit, and altering activities, sharing

resources, and enhancing the capacity of another to achieve a common purpose

Characteristics Minimal time

commitments, limited levels

of trust, and no necessity to share turf;

information exchange is the primary focus

Moderate time commitments, moderate levels of trust, and no necessity to share turf;

making access to services

or resources more user-friendly is the primary focus

Substantial time commitments, high levels of trust, and significant access to each other’s turf; sharing

of resources to achieve a common purpose is the primary focus

Extensive time commitments, very high levels of trust and extensive areas of common

turf; enhancing each other’s capacity

to achieve a common purpose is the primary focus

Resources No mutual

sharing of resources necessary

No or minimal mutual sharing

of resources necessary

Moderate to extensive mutual sharing of resources and some sharing of risks, responsibilities, and rewards

Full sharing of resources, and full sharing of risks, responsibilities, and rewards

Source: Himmelman (2004)

*Himmelman states that in reviewing this chart, it should be borne in mind that these definitions are developmental and, therefore, when moving to the next strategy, the previous strategy is included within it None is superior; rather, each may be more or less appropriate

In a similar vein to the Crossing Bridges project, the Public Health Agency of Canada published Crossing Sectors – Experiences in intersectoral action, public policy and health (2008) This was prepared in collaboration with the Health Systems Knowledge Network of the WHO’s Commission

on Social Determinants of Health and the Regional Network for Equity in Health in East and Southern Africa (EQUINET) This, and an associated publication Health Equity through Intersectoral Action: an Analysis of 18 Country Case Studies (2007), intended to similarly identify what ensures intersectoral action to promote health equity through an analysis of case studies from high, middle and low income countries Their results are parallel to those found in this report focussed on EU member states There is no over-riding paradigm transferrable to each context; rather there are a series of strategies based on the existing situation that appear to facilitate intersectoral action These identified strategies will be further discussed in the final section to combine the evidence for proposals for developing HiAP

Norway has been particularly progressive in attempting to ensure a HiAP approach and in 2009 the World Health Organisation (WHO) published an outline for how this HiAP process was developed (see Strand et al, 2009) What can be learned from the Norwegian experience is that the political, policy, and problem streams merged to progress a HiAP approach The mechanisms that appear key and potentially universal to this positive HiAP outcome, that could be applied elsewhere are:

 Development of a strong evidence-base, coupled with clear communication of the outcome messages

 A willingness among the policy developers and makers to partake in this process based on

national policies of social inclusion and equity

 Cooperation without cynicism between research, NGO and civil service actors

 Formal structures to make the links and communicate the health inequity perspective in seemingly unrelated policy arenas

 Despite the creation of these new structures and ‘policy entrepreneurs’, existing infrastructures and budgets to be used to ensure embedding of the HiAP process, rather than as an add-on

The common theme across these five points is the need for seamless sharing of knowledge and skills across the policy spectrum which includes an abandonment of silos and breaking down the barriers between esoteric knowledge What also potentially contributed to this relatively rapid uptake of a HiAP approach in Norway was political willingness Although this may not be present in all countries, this can be developed by highlighting that HiAP is a sensible approach to ensuring other key manifesto and policy promises are fulfilled Demonstration of financial savings that could potentially

be made by health equity is controversial; there are moral reasons for health equity and the arguments should not be reduced to cost benefit analysis However, in the absence of interest in health equity and particularly in light of the current straitened times financial savings may be the most appealing method to encourage interest

2 Executive Summary

The influence of education on health status has been well-documented; particularly in the context of the social determinants of health Educational attainment can frequently be used as a proxy for socio-economic status which both in turn can be used to predict health outcomes A recent WHO systematic review (2011) also noted the influence of health on educational outcomes, however causality cannot be assumed In addition to the relationship being complex, it can also be difficult to state definitively the impact or correlation of education or health interventions on each other It can

be a challenge to measure or evaluate the long term effects of, e.g early years interventions, and rather measurement focuses on the more narrow immediately apparent indicators Despite these limitations, it is accepted that education plays a significant role in the social determinants of health and that the relationships between health and education are inherently linked

Eight countries/regions submitted seventeen ‘health and education’ case studies to the ‘Crossing Bridges’ project with the intent of providing policies/projects/initiatives as examples to inform capacity-building for a ‘health in all policies’ agenda Central to this was the question of what made a

‘health in all policies’ approach succeed or prove challenging in an educational policy context Case studies were diverse; seven dealt with nutrition and/or physical exercise, five with early years developmental health (including neglect of children and breastfeeding) and five dealt with risk behaviours such as school drop-out, sexual activity, tobacco and other substance misuse These could be divided into two principal categories; encouraging healthy lifestyles and positive health outcomes for young children, and avoiding risk behaviours that would impact on older children’s health These case studies are summarised in the main report, and a separate annex provides the original case studies sources These case studies do not claim to be representative, and identification

of case studies did not involve systematic country/region reviews but rather deferred to the local knowledge of work group partners A diverse and rich body of data was gathered and key points to develop a health in all policies agenda are outlined below:

 Political expediency: getting buy-in at the highest levels of policy formation may be ideal if

it is not already present If not present, the importance of health to multiple policy agendas should be highlighted

 Established regulations and relationships: Frameworks for inter-sectoral work are very important to facilitate this process, however relationship-building within these frameworks cannot be legislated for – this may be where higher ranking staff can play a role in ensuring cooperation Shared budgets and agendas facilitate flexibility and much successful inter-sectoral collaboration There is a need to move beyond rhetoric to systematic action

 Communication: Learning to utilise other stakeholders’ knowledge and expertise may require engagement on their own territory using language they are familiar with in their own domains The complexities of other sectors and systems must be recognised and not shied away from The usefulness of new technologies for information dissemination, sharing ideas and attracting attention should not be under-estimated

 Implementation: Implementation is needed at all levels and although an impetus may originate from the top-down or bottom-up, engagement and buy-in at all stakeholder levels

is needed and useful for tapping in to expertise

 Evidence and evaluation: Having an evidence-base for the policy, project or programme assists the strength of the argument for implementation and ongoing monitoring and evaluation not only ensures constant vigilance and a strong evidence-based, but also keeps the project in the spotlight

 Sustainability: Keeping the costs low, reinvention and expansion, and ensuring the least disruption to staff assists the sustainability of programmes

3 Health and Education

In 2011 the WHO published a systematic literature review of the impacts of health and health behaviours on educational outcomes in high-income countries This review noted that much of the literature available in this area focuses not only on developing countries, but also on the impact of education on health This review intended to look at evidence from developed countries as well as the relationship from the opposite direction; if better health leads to a better education Specifically the authors focussed on the following:

 Does poor health during childhood or adolescence have a significant impact on educational

achievement or performance?

 Does the engagement of children and adolescents in unhealthy behaviours determine their educational attainment and academic performance?

Based on the evidence reviewed, some of the principal findings included the following:

 Overall child health status positively affects educational performance and attainment For example, reviewed studies turned up evidence that good health in childhood was linked to more years in education, that sickness significantly affected academic success and sickness before age 21 decreased education on average by 1.4 years

 There are negative effects on educational outcomes of smoking and poor nutrition that may

outweigh the negative effects of alcohol consumption or drug use

 There appears to be a significant positive relationship between physical exercise and

academic performance

 Obesity and being overweight are negatively associated with educational outcomes

 Sleeping disorders, anxiety and depression may impact on educational outcomes

The WHO systematic review outlines that there are significant links between education and health, but these can often be difficult to definitively establish and causality frequently cannot be assumed These authors also outline elsewhere (2005) that the direction of a relationship can move in both directions – better health can lead to better educational outcomes, but in addition better education can lead to better health

Given the rigorous nature of academic research and problematic research artefacts such as reported health, causality and unknown and unquantifiable influences, it can be difficult to establish clear links between health and education although it may be otherwise apparent that there is a logical correlation Therefore, research and advocacy is in a bind of wishing to remain loyal to a rigorous academic process which may only be achieved by focus on variables with very clear relationships to health while wanting to move away from these clear measurable correlations For example, the clearest way of showing links between health and education may be through evaluation of an intervention and that intervention will have a clear, defined and measurable relationship to health However this will generally mean a focus on a lifestyle factor rather than a more abstract policy ‘intervention’ that appears to have little in common with health policy, and in fact may have multiple other positive impacts on health that are not apparent within the formal educational spectrum

self-In formulating the research question for ‘Crossing Bridges’ work group partners, certain factors had

to be taken into account; the resources available, as well as the necessity for a clearly formulated question This ensured a greater focus on policies from across Europe that had apparent links between health and education rather than these more obtuse policies However, work group

partners have provided a wealth of case studies which will inform the capacity-building process These include:

 Nutritional programmes

 Physical exercise and developmental programmes

 Mental and physical well-being programmes

 Tobacco and alcohol control programmes

4 Overview of Research Process

Partners were asked to submit abstracts of potential case studies for review and comment; case studies could be amended or rejected as well as accepted The case studies had to clearly demonstrate a ‘health in educational policy’ measure and policies that did not work as well as those deemed successful were welcomed Details of the case studies are outlined below, but in sum, many could be classified as health promotion measures that happened to occur in educational settings, and overall the focus was on improving health outcomes for children Once a case study was accepted, partners were asked to arrange interviews with at least one individual involved in the case study development/implementation and complete a reporting template (see accompanying document Annex 1) This reporting template also included an overview of the ‘health in all policies’ specific to the partners’ countries/regions A preliminary analysis and overview of these case studies was presented to partners for verification and opinion In addition, drafts of the final reports were circulated among partners for further verification and correction

These case studies were identified by focus area group partners with regard to their countries/regions and therefore there was not a rigorous and uniform selection process across the project group However, the intent was to defer to the knowledge and expertise of the focus group partners to identify case studies that they considered worthy of inclusion, and it must be acknowledged that there may be many more potential examples not identified by partners

5 Case Studies

In total, there were 15 ‘health and education’ case studies; seven dealt with nutrition and/or physical exercise, three case studies dealt with early years developmental health and five further case studies dealt with risk behaviours such as school drop-out, sexual activity, tobacco and other substance misuse Therefore the focus fell into two areas – encouraging healthy lifestyles and positive health outcomes for young children and avoiding risk behaviours that would impact on older children’s health These case studies are outlined below, alongside an overview of each country’s/region’s experience of HiAP.1

5.1 The Netherlands

The M@ZL project

This project developed from schools’ concerns about the growing problem of children’s absences from school; the Netherlands has legislation with regard to non-excused absenteeism but not for excused absenteeism which is often related to medical reasons and infrequent attendance at school

is associated with school drop-out The M@ZL project was developed as a close partnership of youth health care, secondary school boards and the municipal education attendance service When a significant number of schooldays are missed the secondary schoolchild has a compulsory consultation with a physician and if this is not fulfilled a school attendance officer undertakes further action The school attendance officer provides the legal framework within which the physician can intervene and provide any necessary additional advice to the child’s parents and school Physicians receive training and peer-support for these roles, and development, implementation and evaluation was received from Maastricht and also Tilburg universities

Developed by: Youth health care, secondary school boards, municipal education attendance

 Information was made available to children and their parents

 Training and peer support for physicians has also been key to success

 M@ZL has been included in a national intervention database for others to follow

 To maintain interest, short term results can be seen which can encourage staying with an intervention beyond the availability of data on long term outcomes

Evaluation: By two universities

submitted a case study however the Netherlands experience of HiAP is not available

5.2 Germany

HiAP overview

In Germany there is no universal strategy on Health in all Policies but many of the other German ministries, alongside the Ministry of Health, have included health promotion and prevention into their programmes and activities Inter-sectoral cooperation taking health aspects into account has gained importance recently and there are a variety of good practice examples in Germany regarding successful inter-sectoral cooperation to include health impacts However HiAP tools, like Health Impact Assessment (HIA), are not regularly used and there is little explicit reference to HIA in Germany.2

However Germany’s Environmental Impact Assessment process (regulated under German law since 1990) includes health impacts as part of its evaluation

In 2005 a coalition agreement was made for the development of an early prevention system by better interlinking health services, children and youth services and other relevant actors In 2007, the National Centre on Early Prevention (NZFH) was established by the Federal Ministry for Family Affairs, Senior Citizens, Women and Youth (BMFSFJ) within the framework of the action programme

“Early Prevention and Intervention for Parents and Children and Social Warning Systems”

“National Centre on Early Prevention (NZFH)”

This initiative is provided by the Federal Centre for Health Education in Germany (BZgA) and the German Youth Institute (DJI) and is a nationwide programme to improve the protection of children against neglect and/or abuse; the programme in general addresses all parents-to-be and parents with small children but has a specific target on troubled families living in adverse social settings The NZFH supports interdisciplinary cooperation between health services, the Child and Youth Support Service and other institutions like the Pregnancy and Parenting Advisory Services or women’s support institutions Close cooperation improves the access to families in need, the early identification of risks and the motivation of these families to accept help A top-down approach was found to work best for developing networks, while implementing the initiative successfully used a central coordinating office and binding cooperation agreements

The NZFH has developed an information platform on early childhood intervention, transfers this knowledge into action and informs the public A central part of the programme is the support and coordination of the evaluation of pilot projects in early childhood intervention

Developed by: In 2007 the National Centre on Early Prevention (NZFH) was established by the

Federal Ministry for Family Affairs, Senior Citizens, Women and Youth (BMFSFJ)

Ongoing responsibility: The responsibility of the NZFH belongs to the Federal Centre for Health

Education (BZgA) which belongs to the portfolio of the Federal Ministry of Health (BMG), the German Youth Institute (DJI), a non-university research institute that is mainly funded by the BMFSFJ The central office of the NZFH is situated at the Federal Centre for Health Education in Cologne

Context: Heightened public awareness of child abuse and neglect

[http://www.liga.nrw.de/_media/pdf/service/vortraege/fehr_mekel_101110_hia_poster.pdf accessed 4th April 2011]

Conceptual approach: social determinants of health

 A top-down approach was successful in implementing community networks, while a central coordinating office and public relations work also proved useful

 Evaluation and updating of the programme as required

 The NZFH developed a workbook for inter-sectoral cooperation of children and youth

welfare services and the health sector which proved to be a useful tool (Werkbuch Vernetzung)

Evaluation: By external evaluators, and also some self-evaluation

5.3 North West England

HiAP overview

The North West of England is working towards developing sustained approaches for reducing health inequalities and is actively engaging leaders and policy makers across the region to secure a health and well-being component to policy development North West England recognises the drivers required for the implementation of HiAP and is working to create strong alliances and partnerships; ensuring joint decision making and enabling consultative approaches to stakeholder endorsement and advocacy North West England has developed and co-produced with a wide range of people and organisations across the region, a response document to the Marmot Review on Health Inequalities

in England called ‘Living Well in the North West’ As a partner in the Marmot Review the North West has recognised that its efforts to address health inequalities need to be refocused with more emphasis on prevention across the broader social determinants of health ‘Living Well in the North West’ is not a framework with solutions as these are for local partners and communities to work through, rather it is a long term approach that promotes a way of working locally to bring about improvements in health and wellbeing

This includes:

 building on the strengths, assets and resilience of individuals and communities to bring about change

 local partnership working, and community development and empowerment that devolves

power to neighbourhoods and local people to influence policies and practices

 the need to have a greater focus on the social determinants of health and on fairness and

social justice

 the focus on health as a positive outcome of wellness, not just absence of mortality, disease

or health-damaging behaviour

 the need to recognise better the casual factors of lifestyle choices (i.e from what people do

to why they do it) and taking holistic approaches to tackle these

HiAP is implemented, albeit to different levels across the North West with different terminology being utilised, for example, ‘Healthy Cities’; Preston in Central Lancashire celebrated its Healthy City status in January 2010 Preston as a spearhead local authority has experienced significant health inequalities between the North West and the UK generally Most of these inequalities show Prestonians at a disadvantage on key health indicators compared to other regions of the UK There are also inequalities between Prestonians depending upon where they live in the city The Healthy Cities movement provides Preston with an impetus to systematically tackle health inequalities The Preston Healthy City programme links to well-being projects in terms of healthy lifestyles and healthy urban planning, and enables the development of formal structures to allow health and well-being to be a mainstream undertaking for all key organisations, agencies and partners

Recent developments in Blackburn with Darwen (BwD) include ways to embed HiAP utilising the transition of the NHS reforms as the driving force Working and aligning public health within local government is an option being pursued to promote a cross departmental approach This is via a multi-agency approach with the strategic direction being driven from the Health and Well-Being Board via the Local Strategic Partnership

Nursery Nutrition and Food Provision in Liverpool

This case study developed from the Liverpool First for Health and Wellbeing Partnership belief that there was scope to examine nursery and pre-school nutrition across Liverpool A review to assess and evaluate pre-school nutrition across public and private early years settings was undertaken using a self-reported questionnaire and a full nutritional menu analysis General findings demonstrated that while most nurseries understood the importance of good nutrition within their settings, many did not have adequate food policies, relevant training or know where to find current

or specific guidelines for children under five Phase two of this project provided for training for nursery workers to improve nutrition in their workplace settings and outcomes were evaluated This phase of the project was overseen by a multidisciplinary steering group, of whom the majority had a background in health

Initiated by: Liverpool First for Health and Well-Being Partnership

Developed by: Multidisciplinary nursery nutrition steering group, the majority of whom have a

health background – key staff in the areas of public health, nutrition, early years, environmental health, academics from Liverpool City Council, Liverpool Primary Care Trust, Heart of Mersey, Liverpool John Moores University and University of Liverpool

Other engagement: by other policy areas due to the impact of the programme on their areas of

work, for example increasing the skills and knowledge of the workforce Health sector professionals linked with early years professionals (regulatory bodies)

Context: A need to offer support in food and nutrition to early years setting was identified in the

context of the Liverpool First for Health and Well-Being Partnership’s role in delivering the Health and Well-Being outcomes identified in the City Vision

Conceptual approach: Health Promotion – early years as critical for growth and development;

 The training, evaluation and resource elements of the programme are transferable

 Also impacted on the staff’s own nutritional intake

Evaluation: Self reported evaluation of the impact of training and resources

Smoke and Mirror Initiative

Smokefree North West, a collaborative region-wide tobacco control programme, has since 2009 operated the Smoke & Mirrors project as a method of contributing to a reduction in youth smoking uptake in the North West, on behalf of the regions 24 Directors of Public Health Inspired by Florida’s Truth campaign, the initiative is now linked into the EU Help campaign and has recently been awarded the 2010 Council of Europe Pompidou Drugs Prevention Prize Smoke and Mirrors aims to encourage young people to ‘see through the illusion’ created by the tobacco industry in targeting young people as potential future customers and encourages young people to take action Young people have a significant lead role within the project, steering strategic direction and developments,

as well as undertaking their own self directed anti-tobacco industry projects Key outputs of the initiative include media and campaigning actions as well as delivery of an intervention in schools and youth work settings A film competition and a campaign weekend for 100 young people engaged international spokespeople in the field, respected third sector campaigners and local MPs Production of three winning film ideas engaged young people in the film making process and linked

to campaign actions online Films were broadcast in cinema and virally A Resource Pack aimed at 14-18-year olds was initially distributed to 670 Schools and 270 youth groups in the North West The pack has been academically evaluated and will be further rolled out in July 2011 In addition, young people have been supported to express their views at the EU and UK Parliaments, a national tobacco control event and through protests at Tobacco Industry AGMs (www.seethroughtheillusion.co.uk)

Initiated by: Smokefree North West (Public Health)

Developed with: Our Life (third sector), North West Regional Youth Work Unit (education) and

young people as the target audience to include young people over age 18 as role models

Context: 24% smoking prevalence of people (age 11-17) in the North West of England which is

higher than the national average

Conceptual approach: Health Promotion – risk behaviours

Keys to success:

 Involvement of young people in the development, delivery and evaluation

 Collaboration – expertise was used across sectors to meet multiple needs for each sector

 The approach was broadened to the formal education sector by tying the approach to National Standards in Education and to the National Curriculum The latest resource pack also has potential to link with documents such as the UK’s policy guidance ‘Every Child Matters’ (2002)

 Based on successful programmes in the USA

 Evaluation by Lancaster University and feedback from this has led to the development of an online resource for teachers and youth workers delivering the resource pack

 Moved the anti-tobacco message away from a conventional health message and reframed and broadened the issue

Evaluation: As stated above by a local university, Lancaster University on the educational pack and

the anti-tobacco approach is also being independently evaluated by Liverpool John Moore University

5.4 Republic of Slovenia

HiAP overview

The baseline for HiAP is given in the Slovene health care and health insurance law3 and this follows

directions given by the WHO The general spirit of the HiAP approach is defined in article 5 “Republic

of Slovenia creates conditions for health promotion and health care by economical, ecological and social policy measures and coordinates activities in all sectors to achieve optimal health.” Such

legislative developments in Slovenia were possible from 1992 (after separation from Yugoslavia) because multi-sectoral work was quite well developed in the former state In the area of health and education there was a well-functioning multi-sectoral body to harmonise the policies in both areas However, there may be some discrepancies between legislative commitments and HiAP implementation Between 1992 and 1997 Slovenia had a Health Council which had good potential but was wound-up before it had reached its full capabilities (human resources, specific knowledge and multidisciplinary competences, organisational capacity)

More recently, Slovenia has been very involved with the WHO’s health promoting schools network, and in general there is good cooperation and shared consultation with particular regard to the domain of school nutrition Although sectors are cooperating, the levels of cooperation are not necessarily very demanding and often policies are developed by one lead sector and checked by the other relevant sectors Policy preparations do involve coordination to include adjustment during preparations but policies are not fully integrated A HiAP working group was established by the National Institute of Public Health in 2011 It is expected that this project will produce an overview

of the literature and information on HiAP approaches in other countries, and an analysis of HiAP in Slovenia is expected in 2012

Model for Healthy Lifestyle in School

In 2008 the Ministry of Education and Sport invited the National Institute for Public Health to take part in a project to develop model school hours in the following areas: nutrition, physical activity, mental health, alcohol and tobacco education These model hours were integrated into existing subjects across primary school classes However, it is at the teacher’s discretion to use these model hours and therefore implementation is not uniform The purpose of developing this programme was

to tackle the identified growing problems among Slovenian schoolchildren of overweight and obesity, spinal deformities, psychosomatic problems and early onset of alcohol use This programme was developed through meetings with experts and with schools (focus groups with pupils, teachers, parents), reviews of the curriculum, evaluation of pilot lesson plans, guidelines for implementation and manuals for pilot lessons and physical activities New lessons are being developed for a 2011 pilot, and for eventual roll-out to other Slovenian primary and secondary schools

Initiated by: Ministry of Education and Sport

Developed by: Health and education sector experts; National Institute of Public Health (NIPH),

teachers from 4 health promoting schools and external experts in the Faculty of Sport, the National Education Institute of the Republic of Slovenia

Context: Health has been increasingly integrated into the education system since the active

involvement of Slovenia in the health-promoting schools network A joint cooperation agreement on

http://www.uradni-list.si/1/objava.jsp?urlid=19929&stevilka=459

children and adolescent health was signed by the National Institute of Public Health, Ministers for Health, Education and Sport, and Labour, Family and Social Affairs in 2007 But it was not until 2008 that the Ministry of Education and Sport invited the NIPH to be part of an ESS call to develop this programme In addition, research data had demonstrated growing problems of overweight and obesity, spinal deformities, psychosomatic problems, early onset of alcohol use among Slovenian young people

Conceptual approach: Health promotion

Keys to success:

 Political will and support

 Began with the needs of the children and teachers

 Embedded in the curriculum

 Sustainability – new pilot lessons have been developed and rolled-out for 2011 and in November 2011 there will be a conference on children and adolescent health in Slovenia and NIPH intend to use this opportunity to strengthen inter sectoral cooperation in this regard However, a drawback has been the voluntary nature of implementation

 Widespread support among the media, public, educators and state officials

 Success enhanced by the cooperation between the schools and health experts (however a barrier to success was the lack of resources made available by decision-makers)

Evaluation: Questionnaires and discussions with pupils and teachers at the pilot stage, and again at

the end of the pilot phase with teachers and the NIPH

National School Nutrition Programme

Slovenian primary schools provide food during the school day, and in 2008 this was rolled out to secondary schools to include a subsidised meal per day Additional subsidies are also available for children who would otherwise not be able to afford the subsidised food and vending machines in schools have been banned

This process began with a policy 2005-2010; Resolution on Food and Nutrition New guidelines for healthy nutrition in schools were launched in 2005 by the Ministry for Health and harmonised with the Ministry for Education with the main objective of provide support to schools in the area of nutrition The issue of school meals became a political issue in the 2008 elections, and this policy was developed against the backdrop of changing working hours in line with European hours and high levels of female involvement in the labour force Changing working hours and the unavailability of women to prepare food for children has encouraged this policy, and while there has been criticism

of the implementation of the standards, these are currently being addressed and evaluations have demonstrated consistent improvements

Developed by: Ministry of Education with strong consultation and support from the Ministry of

Health

Context: Primary school meals have been available since the 1960s, and there was mounting

pressure to extend this since 2000, and it became an election issue in 2008 Secondary school nutrition was defined as an important goal within the Slovene Food and Nutrition Action Plan 2005-

2010

In addition, Slovenian working hours have become increasingly harmonised with the rest of Europe, and with a very high percentage of women in the workforce the typical providers of meals are not available at eating times as they would have been two decades ago (6/7am-2/3pm)

Conceptual approach: Health promotion

Keys to success:

 Timing of the NIPH in publicising this issue during a pre-election period

 Healthier nutritional habits and status of children and better school performance – the drawbacks are fewer meals eaten together as a family and children are not as exposed to cooking

 A common understanding of the problems, awareness and enthusiasm

 Considerable support was available to schools where implementation was very difficult

 Nutritional guidelines for schools were already available since 2005

 The Ministry of Education were courageous in following the advice of the health promotion sector in banning vending machines in schools The advice of the health promotion sector was strongly supported by WHO recommendations on marketing food to children

 The strength of the evidence and advice of experts – and the willingness of the Ministry of Education to take these on board

Evaluation: The NIPH and nine regional public health institutes regularly monitor the quality and

organisation of school meals and annual reports are produced Self-evaluation tools are also available for school meal providers to use

5.5 Hungary

HiAP overview

In Hungary HiAP has not been fully implemented and inter-sectoral cooperation needs improvement However, since the new government’s election (May 2010) steps were taken to increase inter-sectoral cooperation; the Ministry of National Resources was established in 2010 by merging the portfolios of sport, education, culture, social affairs and health, and in 2011 government offices at county level were formed These offices are local public administration bodies, consisting

of administrative departments of different sectors Former bodies of the National Public Health Service operate in these offices within the Public Health Administrative Departments The government offices are legally and financially supervised by the Ministry of Public Administration and Justice, and the Public Health Administrative Departments are under the professional leadership

of the Office of the Chief Medical Officer These structures (ministry, government offices) provide good prerequisites for inter-sectoral cooperation and a health in all policies approach in theory, but

it is not yet fully implemented in practice However, good examples of implementing a HiAP approach can be found at local level, for example in city health plans and health promoting workplaces

The Public Health Programme (2003-2013) has inter-sectoral cooperation as a core principle but financial resources for implementation were scarce and the programme needs updating and rethinking In June 2011, the government adopted the “Semmelweis Plan” for health care reform With regard public health it undertakes to develop a new public health action plan which reflects a paradigm change and reacts to identified problems The action plan aims to renew the public health system, to provide sustainable financial resources and to involve the whole population in public health activities It necessitates intersectoral cooperation to tackle health inequity and it explicitly mentions HiAP as an important tool for this

Health Impact Assessments, as a way of implementing HiAP, are not common practice However, the current Hungarian legal system provides the necessary prerequisites for HIA (for example, calls for compulsory impact assessment of draft legislative provisions and there is an ongoing practice of Environmental Impact Assessment)

Development plans for the EU Structural Funds also build a good platform for inter-sector cooperation Measures on health are mainly integrated to the Social Renewal Operational Programme Most of the tenders are focused on the different settings in health promotion, like schools, workplaces and local governments, with special focus on deprived areas and socially excluded populations

Smoking Prevention Programme in Kindergartens and Schools

This programme developed from the evidence that basic behaviour patterns regarding smoking are imprinted in early life Experts at the Hungarian Focal Point for Tobacco Control developed an effective kindergarten (pre-school environment) and school smoking prevention programme to influence children’s current and future health behaviours The aim of the kindergarten and school smoking prevention programme is to generate long-term changes in the attitude towards, and knowledge about smoking, to develop smoke-free lifestyles, and skills to reduce exposure to passive smoking Several age-specific, entertaining tools and methods of the kindergarten and school programme promote the implementation by teachers, and make the learning process of the programme exciting and interesting for children The program is cost effective and innovative owing