mental health researches

In addition IUHPE has featured school health in an important review of effective school health promotion in the report entitled The Evidence of Health Promotion Effectiveness: Shaping Pu

REVUE INTERNATIONALE

DE PROMOTION DE LA SANTÉ

ET D’ÉDUCATION POUR LA SANTÉ

QUARTERLY TRIM ESTRIEL TRIM ESTRAL

Promotion & Education:

français page 182 español página 203

Global school health promotion

Promotion & Education, the International

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2005-Suzanne Jackson, Dawn Johnston, Bill Kane,Chuck Kozel, Ronald Labonte, Albert Lee, DianeLevin, Gordon MacDonald, Bruce Maycock,Maurice Mittelmark, Naomi Modeste, Eun-WooNam, Vivian Rasmussen, Irving Rootman,Francisco Soto Mas, Alyson Taub, Keith Tones,Isabelle Vincent

English Section

Preface

109 Promoting school health around the world through

the CDC and IUHPE Cooperative Agreement

K Weare and W Markham

123 Evaluating health promotion in schools: a case study

of design, implementation and results from the Hong

Kong Healthy Schools Award Scheme

A Lee, L St Leger and A Moon

131 Successful strategies and lessons learned from

development of large-scale partnerships of national

138 • A health promoting school approach used to

reduce the risks of lead poisoning and to establish

cross-ethnic collaboration

A Tahirukaj, I Young and G McWeeney

140 • Look after the staff first– a case study of developing

staff health and well-being

J Mason and L Rowling

142 • Empowering children for risk taking– children’s

participation as a health promoting strategy in the

“Safe Schools in a Community at Risk” project

150 Involving students in learning and health promotion

processes– clarifying why? what? and how?

B B Jensen and V Simovska

157 Health programmes for school employees: improving

quality of life, health and productivity

L J Kolbe et al.

162 Challenges in teacher preparation for school health

education and promotion

B J Smith, W Potts-Datema and A E Nolte

Case Studies

148 • Children as health promoters

B B Mukhopadhyay and P C Bhatnagar

165 • Problem Solving for Better Health (PSBH) and

health promoting schools: participatory planningand local action in the Rio de Janeiro programme

D Becker et al.

166 • Improving community hygiene and sanitation

practices through schools: a case study of thePersonal Hygiene and Sanitation Education(PHASE) project in Kenya

178 • Mainstreaming health promotion in education

policies: a Uruguayan experience

S Meresman

179 • Promoting health in French schools

S Broussouloux and N Houzelle

“My school” Latvian pupils concept of a healthyschool Zentenes primary school, Latvia

Dossier FrançaisPreface

182 Promouvoir la santé en milieu scolaire à travers

le monde dans le cadre de l’Accord deCoopération entre les CDC et l’UIPES

198 Qu’est-ce qu’un réseau ? De quoi est fait

un réseau d’écoles promotrices de santé ?

203 Promover la salud escolar en el mundo a travésdel Acuerdo de Cooperación entre los CDC y laUIPES

219 ¿Qué es una red? ¿Qué constituye una red

de escuelas promotoras de salud?

D H Rivett

220 Iniciativa Regional Escuelas Promotoras

de la Salud en las Américas

J Ippolito-Shepherd, Ma T Cerqueira y D P Ortega

Estudios de caso

231 • Transversalizar la promoción de salud en las

políticas educativas: la experiencia de Uruguay

L’Union internationale de Promotion de la Santé et d’Éducation pour la Santé est très

reconnaissante de la contribution apportée par le NHS Health Scotland (Membre

administrateur de l’UIPES) à la préparation et à la réalisation de cette publication Les

ressources tant humaines que financières investies par le NHS Health Scotland dans ce

numéro spécial ont été essentielles à l’accomplissement de ce projet en partenariat

La Unión Internacional de Promoción de la Salud y Educación para la Salud (UIPES) agradece

la amable contribución de NHS Health Scotland (Servicio Nacional de Salud de Escocia),

miembro administrador de la UIPES, en la preparación y realización de esta edición La

inversión financiera y dedicación humana por parte de NHS Health Scotland en este número

ha sido imprescindible para su fructuosa publicación

“This special issue of Promotion & Education

surely will become a landmark in the evolution of

school health programmes, and should do much to

improve our understanding and development of

such programmes around the world.” Lloyd Kolbe,

Professor of Health Education, University of

Indiana, USA

The International Union for Health Promotion and

Education (IUHPE) has been a leading organisation

in creating the ground to bring together

international experts around the subjects of child

and adolescent health and school-based health

promotion, and traces decades of relevant

experience since its inception (Modolo & Mamon,

2001) The IUHPE has organised, on three

occasions since 1987, special issues of its official

Journal, Promotion & Education, devoted to

effectiveness and quality in school health In

addition IUHPE has featured school health in an

important review of effective school health

promotion in the report entitled The Evidence of

Health Promotion Effectiveness: Shaping Public

Health in a new Europe, where the authors address

the health, social, economic and political impact of

health promotion in schools (IUHPE, 2000) In the

area of knowledge exchange, the IUHPE’s World

and Regional Conferences on Health Promotion

and Health Education frequently feature the best

practice in the promotion of health in schools It

was from these gatherings that the organisation’s

present work in the area of school health emerged

and flourished under the auspices of the IUHPE

and the CDC partnership

Martha Perry

Promoting school health around the world

through the CDC and IUHPE Cooperative

The school health programme element hasdeveloped, among its most pertinent activities,

the Protocols and Guidelines for Health Promoting

Schools (see page 145) under the leadership of

Professor Lawrence St Leger, from the Faculty ofHealth and Behavioural Sciences at DeakinUniversity, Australia The production of thisdocument is the result of on-going discussionswith renowned professionals which began at theIUHPE’s 17thWorld Conference in 2001 andcontinued in 2004 at the 18thWorld Conference,where the participants recommended theproduction of a coherent document that couldprovide a blueprint for improving the evidencebase for health promoting schools Fundamental

to this effort has been revisiting the five areasoutlined in the Ottawa Charter for Health

Promotion as they apply to school health

promotion: building healthy public policy,creating supportive environments, strengtheningcommunity action, developing personal skills andreorienting health services (WHO, 1986; Wagner,2002) To contribute to its content, input fromprofessionals was solicited and research on thepractice of international organisations, such as,WHO and CDC, has been collected Evidence ofeffectiveness has proven to contribute toprogramme implementation and funding, and thisdocument on evidence-based health promotingschools will serve as a cornerstone for policymakers and practitioners, not only in the field ofschool health, but also other health promotionsettings that influence the health of students,teachers and communities as a whole Thedocument was launched during two workshops

Martha Perry

IUHPE Project Assistant

Email: mperry@iuhpe.org

This themed issue of Promotion & Education has

received financial support from the United States’

Centers for Disease Control and Prevention

(CDC), an Agency of the Department of Health

and Human Services, under the Cooperative

Agreement Number U50/CCU021856 on Global

Health Promotion and Health Education Initiatives

Its contents are solely the responsability of the

authors and do not necessarily represent the

official views of CDC

held in October 2005 at the American SchoolHealth Association’s Annual Conference, where itwas very well received and a number of

significant recommendations were made

Dissemination avenues for this document include:

the Global Programme on Health PromotionEffectiveness (GPHPE), coordinated by the IUHPE

in collaboration with WHO, CDC and otherinstitutional partners; the IUHPE 19thWorldConference on Health Promotion and HealthEducation in June 2007; as well as throughvarious networks, such as, the informalInternational School Health Network (ISHN), theEuropean Network of Health Promoting Schools(ENHPS) and the Latin American and CaribbeanNetworks of Health Promoting Schools

Furthermore, the 2004 conference underlined theimportance of this area of work with a day-trackfocusing exclusively on health in schools Thegathering served to highlight the significantnumber of professionals working in school healthpromotion It also revealed that there is room forimprovement in sharing knowledge beyondnational networks As a result, the formation of aninformal International School Health Network(ISHN) has emerged as a means to communicateinformation and encourage the use of

comprehensive approaches to school-basedhealth promotion/health promoting schools Moreinformation on this network is provided in thisissue’s article by Douglas McCall (page 173)

The IUHPE has been an integral part of thediscussions to develop a networking strategy andenvisages to take a greater role in its coordinationtogether with other leading international andnational partners, such as WHO, UNICEF and CDC

To further advance knowledge and disseminatethe work being done around the world, theproduction of this special issue came about Theleadership role in this task has been taken on byIan Young, from NHS Health Scotland, workingtogether with IUHPE’s editorial team andLawrence St Leger, as the counterpart principalcollaborator of the school health programme inthe cooperative agreement The aim of thisedition is to give a global portrait on the state ofthe art of school health which we believe willmake the issue a defining point in thedevelopment of health promotion in schools

The approach is to push the thinking on schoolhealth promotion forward, not merely depictinterventions on what works in different settingsand for different populations, while achieving thewidest global outreach possible The value added

of this compilation of papers is a genuinereflection on the value of specific approaches.School health has been an integral component ofthe IUHPE’s work and, in particular, in theCooperative Agreement with CDC for the pastfour years The five-year work plan under thiscollaborative effort will culminate in 2007,coinciding with the 19thIUHPE World Conference

on June 11-15 in Vancouver, Canada(www.iuhpeconference.org), making thisconference the perfect setting to disseminate thework done The IUHPE’s experience gained andquality network formed, in cooperation with CDCand key internationally renowned consultants,have been invaluable in planning andimplementing the different activities Somechallenges will be overcome and other new oneswill appear Nevertheless, the IUHPE willcontinue to work with its partners in this areasince evidence of effectiveness shows that, amongothers, when it comes to schools, health is asimportant as literacy and both constitute on-goingand intertwined developments As Modolo &Mamon (2001) pointed out: “We cannot afford toleave the health citizenship of the future togenerations only casually educated about life.”

References

IUHPE (International Union for Health Promotion

and Education) (2000) The Evidence of health

promotion effectiveness: Shaping Public Health in

a New Europe A report for the European

Commission Paris: Jouve Composition &

Impression: p 110-122Modolo, Ma A & Mamon, J (2001) Children andYouth In IUHPE (International Union for Health

Promotion and Education) A Long Way to Health

Promotion through IUHPE Conferences

1951-2001 Perugia: University of Perugia, Interuniversity

Experimental Center for Health Education: 123-125.Wagner, G H (2002) Health promoting schoolsevidence for effectiveness workshops report

Promotion & Education, IX (2): 55-61.

World Health Organization (WHO) (1986) Ottawa

Charter for Health Promotion World Health

Organization, Geneva, Switzerland

Ian Young, Scotland, page 114 on

different language and concepts across

sectors–

‘‘To many progressive educationalists a

term such as health promotion is not

considered necessary in relation to

schools, because they may view the

curriculum of a school as everything a

school does and not merely the learning

and teaching of the classroom.’’

Katherine Weare, England, page 119

on effectiveness in mental health

promotion–

‘‘There have been several recent large

scale systematic reviews of the research

evidence, including evidence from

controlled studies, which have

concluded unequivocally that initiatives

that use a range of contexts,

opportunities, approaches and agencies

are more effective than more limited and

one dimensional approaches when

attempting to tackle mental health.’’

Albert Lee, Hong Kong, pag 128 on

school effectiveness–

‘‘Apart from addressing the complexity of

health promotion initiatives, the

evaluation of school health promotion

also needs to address school

improvement and effectiveness which

can be useful and meaningful for both

the education and health sectors.’’

William Potts-Datema, U.S.A., page

136 on partnership-working in

advocacy–

‘‘Like any partnership, the ability to work

and grow is dependent on the level of

trust among the partners Consciously

working to build trust is the most

significant internal work of these

collaboratives.’’

Ardita Tahirukaj, Kosovo, page 139 on

health promotion training and healing

relationships between communities–

‘‘It is clear that the development of joint

training in health promoting schools is

one small but important way in which thetwo ethnic groups can work together toimprove trust and relationships for thefuture.’’

Lina Kosterova Unkovska, Macedonia,

page 142 on the resources young

people have within–

‘‘Children in communities exposed torapid changes such as a war or refugeecrisis are forced to learn quickly - morequickly than children in more stableenvironments Marginalized and deprived

of their rights they will, counter to allexpectations, demonstrate highermotivation and persistence.’’

Lawrence St Leger, Australia, page

145 On sustaining change–

‘‘Establishing a health promoting school

is not a project It is a process of changeand development which builds a healthyschool community.’’

Bhavna Mukhopadhyay, India, page

148 On children as the educators–

‘‘The school children, who are the firstgeneration to be educated, became theagents of change Their role was topromote healthy behaviours amongstyounger children, children of same age,their immediate families and largercommunity.’’

Bjarne Bruun Jensen, Denmark, page

155 On student participation–

‘‘Inherent within the conceptualisation ofteaching and learning through genuineparticipation are issues of power andownership Genuine studentparticipation allows for studentownership of the learning process.’’

Becky Smith, U.S.A., page 164 on

teacher education and training–

‘‘The relative isolation of some universityfaculty and programmes has developed

an interesting situation in which manyadministrators and master teachers atthe K-12 level of education have a better

grasp and understanding of newteaching and learning strategies andtools than professors at the universitylevel.’’

David Wamalwa, Kenya, page 166 on

the positive outcomes of an experimental study–

‘‘An evaluation done in the year 2004

revealed that the project Personal

Hygiene and Sanitation Education in Kenya had contributed to a significant

reduction in school absenteeism andimprovement in performance in nationalexaminations.’’

Vivian Barnekow Rasmussen, page

169 on the ENHPS and its

inter-sectoral approach–

‘‘There is an increasing recognition that new forms of partnership and inter-sectoral working are required if thesocial and economic determinants ofhealth are to be addressed Investments

in both education and health arecompromised unless a school is ahealthy place in which to live, learn andwork.’’

Douglas McCall, Canada, page 175 on

the formation of a new global network–

“…there is no mechanism that bringstogether all of the national officials,researchers and associations, the healthand education sectors, as well as thenetworks concerned with health issuesand those that work in school healthpromotion in various languages That isthe niche that the International SchoolHealth Network (ISHN) can fill.’’

Sergio Meresman, Uruguay, page 178

on integrating innovation within schools–

‘‘What makes health promotionsustainable in schools is integrating itwith the existing policies aimed atimproving teaching and learning andputting it in the hands of those thatconstruct everyday life in the schools.’

14 good reasons to read on – a snapshot from the editor’s wide-angled lens

On page 51 Lloyd Kolbe suggests 14 good reasons why workplace health promotion programmes are effective and how this is relevant to school health Below you will find 14 additional examples and

quotations from across the world which explore the many dimensions of health in schools These should

stimulate your thinking and keep you informed of new developments in health promotion in schools.

Welcome to this special edition of

Promotion & Education which focuses

our wide angled lens on health

promotion in schools I was delighted

and honoured to accept International

Union for Health Promotion and

Education’s (IUHPE) invitation to write

this introductory paper and to act as

guest editor for this special edition It is

an exciting time for health promotion in

schools with the growth of international

networks and a very high level of

political and professional interest in the

issues This was clearly exemplified by

the attendance figures for events within

the schools theme at the 18th IUHPE

World Conference on health promotion

and health education held in 2004 in

Melbourne, Australia, and the interest

being shown in school health as a theme

at the next world conference in

Vancouver from June 11thto 15th, 2007

In this paper I wish to look back briefly

at the recent history of health promotion

in schools My own experience is

predominantly in the European context

and this immediately introduces an

Ian Young

Health promotion in schools – a historical perspective

element of selection and a risk of bias,although I hope that with my

international experience I haveminimised the bias if not the selectivenature of my memory! I will attempt toshow that, despite differences innomenclature in Europe and the UnitedStates, the fundamental conceptualdevelopment is convergent rather thandivergent in nature This editorial willalso look forward and introduce to youthe themes that our commissionedexperts have developed further for yourown consideration and reflection Thewhole edition also aims to be a stimulusfor more debate and networking and Iencourage you to respond to theinvitation to comment on the draft

‘Protocols and Guidelines on HealthPromoting Schools’ statement on page 145

Historical perspective

The concept that schools have a role inpromoting the health of young people isnot a new one The modern view ofhealth promotion in schools can only befully understood in the context of widerdevelopments in health promotion in thelast two decades

A move towards a general consensus onthe meaning of the term health

promotion was to a large degree theproduct of the work of Kickbusch andothers advising the World HealthOrganization Regional Office for Europe

Their original discussion paper (WHO,1984) laid out the broad concepts andprinciples of health promotion andhelped to stimulate further debate

(Green & Raeburn, 1988) In addition aground- breaking report in Canada(Lalonde, 1974) set out a model of healththat was moving from a health

care/disease-orientated one towards asocial one Over 125 years earlierreformers such as Rudolf Virchow inGermany (Virchow, 1848) and EdwinChadwick in Britain (Chadwick, 1842)had been pioneers in Europe also settingout a social model of health and ideas onthe role of the state in promoting health

Chadwick’s vision led to the PublicHealth Act of 1848 in Britain which setthe principle of state responsibility forpublic health (Acheson, 1990) In the1980’s The Ottawa Charter for HealthPromotion integrated current thinking,

particularly in Canada and in WHO(Euro) and clarified the nature of healthpromotion (WHO, 1984) The OttawaCharter defined health promotion as ‘theprocess of enabling people to increasecontrol over, and to improve, theirhealth’

This definition gave added scope andpurpose to health promotion and had thepotential to reconcile different viewpoints

on the relative roles of the individual andsociety in the process of promotinghealth (Green & Raeburn, 1988)

Some of the earlier writings on healthpromotion appeared to an extent to berather dismissive of an educationalapproach For example WHO’sdiscussion paper, referred to above,described health education as a corecomponent of health promotion ‘whichaims at increasing knowledge anddisseminating information related tohealth.’ At the time this definitionseemed narrow to educationalists and itignored the affective and action domainswhich were part of education’s frames ofreference at that time (Bloom, 1981) Inaddition it was implied that the subjectexposed to this process of education is arelatively passive recipient of

information At the time many of us from

an educational or pedagogicalbackground felt that the value of aneducational approach was in danger ofnot only being mis-represented, but thathealth education’s role could be under-valued With hindsight this is interesting,

as just prior to the birth of the modernmodel of health promotion, there werebroader, more progressive views onhealth education around For example in

1981 Kickbusch recognised theimportance of developing competencies

as well as transmitting knowledge Theview was also expressed that healtheducation had to work not only at anindividual level but had to interact withsocial, political and environmentalfactors that influence health (Kickbusch,1981)

As the new concept of health promotionemerged in 1984, the International Unionfor Health Education felt it was necessary

to prepare a paper defending what itperceived as a misrepresentation of itscore interest of health education It alsoset out health education’s role within a

Ian Young

Guest Editor

NHS Health Scotland

Email: ian.young@health.scot.nhs.uk

This Editorial is dedicated to the memory

of Noreen Wetton who died in January

2006 Noreen’s pioneering draw and

write technique, her energy and her

wisdom inspired a generation of teachers

across Europe to explore young children’s

concepts of health as a starting point for

curriculum development, learning and

teaching Please see page 147 for an

illustration of her valuable work

wider framework of health promotion

(IUHE,1986) Most practitioners now

recognise a broader concept of health

education, which, interacts with the

other components of health promotion

(Downie et al.,1990; Young & Whitehead,

1993) The IUHPE has now of course

added the health promotion dimension

to its area of interest and to its title

It is worth recounting this historical

development because it is important to

understand that the health promoting

school was born at a time when there

was a degree of scepticism that an

educational approach in general, or

schools in particular, could have much

impact on the health of the population

The important role of schools is fully

acknowledged in the United Nations

Millennium Development Goals where

one goal is specifically devoted to

providing universal primary education

and in several of the other goals schools

have an important partnership role

(United Nations, 2002)

School health education

and the health promoting school

In 1985, the Scottish Health Education

Group (SHEG) which was a collaborating

centre for the WHO (European Office)

was given the task of organising a

European symposium in 1986 at Peebles,

Scotland, attended by 150 delegates from

28 member states entitled “The Health

Promoting School” At this time Europe

was effectively a divided continent and

there were only 32 member states and

there were also restrictions on travel from

some of the eastern European countries

However with WHO assistance, senior

staff from 28 member states were able to

attend At this event the concept of the

Health Promoting School was developed

and refined (Young, 1986) In fact the

name ‘The Health Promoting School’ was

born in the planning for the event

although the concept had been evolving

for several years and the literature in

Europe had referred to the school as “a

health promoting institution” in the two

years prior to this

This symposium was significant because

it offered the WHO Regional Office for

Europe an opportunity to apply its

developing theoretical model of health

promotion to the setting of the school

From this event a report entitled ‘The

Healthy School’ was produced on behalf

of WHO (Young & Williams, 1989) Thereason the name was amended waspolitical at that time as the WHORegional Office for Europe was keen tomake links with its new Healthy Citiesproject However you can’t keep a goodname down for long, and the healthpromoting school soon bounced backinto the forefront and gradually spreadfrom its European origins to many parts

of the world including Australia, NewZealand, Hong Kong and South Africa

The report described health promotion

in schools as a ‘combination of healtheducation and all the other actionswhich a school takes to protect andimprove the health of those within it’

The health promoting school wasconsidered as having three mainelements:

• The specific time allocated to related issues in the formal curriculumthrough subjects such as Biology,Home Economics, Physical Education,Social Education and Health Studies;

health-• The ‘hidden’ curriculum of the schoolincluding such features as staff/pupilrelationships, school/communityrelationships, the school environmentand the quality of services such asschool meals;

• The health and caring servicesproviding a health promotion role inthe school through screening,prevention and child guidance

More modern ideas of the breadth of thehealth promoting school concept have

since developed and further refined thethinking about the scope of the concept

in Europe and beyond The World HealthOrganization Office for Europe (WHO,2005) has recently published a newstrategy for child and adolescent healthand development and this sets outaspects of the potential role of schools inthe context of all the sectors which canimpact on the health of young people

Comprehensive school health

In the USA and Canada the terminologyused to describe the processes relating

to health in schools was and is different,and it is important to explore these termsand to reflect on the extent to which theyreveal a different approach or if they are

in fact closely related to each other

In the United States the history of publichealth had been fundamentally differentfrom that of Europe In Britain, forexample, the medical profession hadexerted control over public health fromsocial reformers such as Chadwick in themiddle of the 19thcentury and by 1876the leading universities such as Oxford,Cambridge and Edinburgh were offeringpublic health qualifications exclusivelyfor medical specialists In the USA thefirst professors of Public Health in manyUniversities such as Yale were not from amedical background and this widerconcept of public health may have beenone factor in opening up other

educational opportunities in the USAsuch as the availability of first degrees inhealth-related subjects which were notrelated directly to nursing or medicine

Barefooted children await their healthy soup in Edinburgh nearly one hundred years ago

In the United States terms such as the

‘healthful school environment’ had been

used since the early 1950’s indicating that

there was an awareness of the importance

of wider influences on health in schools

beyond the ‘health instruction’ of the

classroom In the early 1980’s in the USA

the phrase ‘comprehensive school health

programme’ became the common term to

encompass this broader approach At that

time this concept was considered to have

the components of health instruction, the

school health services and the school

environment which was remarkably close

to the European model in the same time

period although using the different

nomenclature of comprehensive school

health programmes

In the 1990’s this broader concept of

‘comprehensive school health

programmes’ was further developed in

the USA and it was suggested the

following components were part of this

conceptual framework (Kolbe,1993)

• school health education;

• school health services;

• school health environment;

• school physical education programme;

• school food service programme;

• school psychology and counselling

programmes;

• programmes to protect and improve

the health of staff;

• integrated efforts of school and

community agencies to improve the

health of school and students

These components closely parallel the

European model set out in The Healthy

School Report (Young & Williams, 1989)

The European model emphasised pupil

participation more strongly than the USA

approach but the European report also

had some statements which now, with

the advantage of research and hindsight,

appear rather simplistic on the exemplar

role of teachers and on the unquestioned

role of self esteem in determining

health-related behaviours

The European model has further

developed to emphasise equity and

democracy at the core of its activities

(WHO, 1997) and this represents the

egalitarian approach that had its origins

in earlier European history Perhaps the

differences in terminology reflect this

separate development, it was George

Bernard Shaw who once remarked that

Britain and America were two nations

divided by a common language!

However, I would conclude that these

two models have much more in commonthan in their differences This is

interesting because to some extent theyevolved independently of each otherwith only limited cross-fertilisationcompared to the international contacts

we can utilise today through electronicmedia American school healthcolleagues such as Loren Bensley ofCentral Michigan University and the lateWarren Schaller of Ball State Universitydid visit Europe in the 1970’s and 1980’sand Tom O’Rourke of University ofIllinois and Nick Iamarinno of RiceUniversity have kept up this tradition tothis day Similarly Stanley Mitchell of theScottish Health Education Group, TreforWilliams, University of Southampton, and

Joos Van Hameren of the NetherlandsHealth Education Centre each had astudy tour to North America at this time

These early innovators were theexception rather than the norm InEurope today, with the possibleexception of The Netherlands, there hasbeen no significant adoption of theAmerican language of comprehensiveschool health when discussing wholeschool effects However, rather thanfocus excessively on the differences inapproach, of greater interest are thesimilarities in the models and the factthat to some extent they representconvergent thinking on how the totality

of the school experience can affect thehealth of young people, parents and staff

Phases of development in health promoting schools

The issue of language is also importantbetween the education and healthsectors across the world A feature of thedevelopment of health promoting schoolsand comprehensive school healthsystems is that the early innovators andproponents of change towards a wholeschool approach came from the healthsector in most countries The language ofhealth promotion and the Ottawa

Charter, or more recently the BangkokCharter, (WHO, 2005) is now familiar tohealth professionals in many countriesbut it is not the language used byeducation professionals in mostcountries To many progressiveeducationalists a term such as healthpromotion is not considered necessary inrelation to schools because they mayview the curriculum of a school aseverything a school does and not merelythe learning and teaching of the

classroom (Young, 2002) This is notinevitably a problem in partnershipworking if all partners understand theothers’ terminology and the conceptsthese terms describe However, time has

to be taken to explore these issues andthis barrier has to be addressed

An additional barrier to progress isrelated to responsibility and authority.Ultimately health promoting schools arethe education sector’s responsibility andthe experience of the last twenty yearshas taught us that if schools are merelyperceived as a convenient setting onwhich to impose a health promotingschool model from the outside, then this

is a limited and unsustainable approach

in the longer term (St Leger & Nutbeam,2000a)

Where there has been a measure ofsuccess in spreading the healthpromoting school model at a regional,sub-national or national level, certainstages and features often appear I wish

to propose that they often include some

or all of the following phases (Table 1) incountries where the concept of healthpromotion in schools has become moreestablished:

It is important to note that these phasesare not always completely separate ordiscrete and that the centre and regionsmay be at different stages at any giventime in one country It has been myexperience that some countries havereached the establishment stage wherethey have had the luxury of up to twentyyears of development Other countrieswith different levels of health problemsand more limited investment orinfrastructure in education are often inthe first phase of development Yet itwould be misleading to suggest thatprogress always occurs in a simple linearway and in steady increments It is ofcourse highly political and rapid progresscan be made when a strong political willexists When the political priorities

To many progressive educationalists a term such as health promotion is not considered necessary in relation

to schools because they may view the curriculum of a school

as everything a school does and not merely the learning and teaching of the classroom

change the process can stall or go into

reverse It is now recognised that

educational reform frequently includes

unpredictable shifts and fragmented

initiatives (Fullan, 1992)

As health promotion initiatives become

more integral to mainstream educational

practice I would predict that it will

become more and more evident that the

factors that produce effective schools

from the viewpoint of educational

achievement will be essentially the same

factors which produce schools which

promote health effectively This is hardly

surprising, in fact it is close to

self-evident and yet the riches of educational

sociology literature have not yet been

fully mined by health promoters

However this literature provides

invaluable evidence for work in health

promoting schools because of the

importance of the management and

measurement of change and innovation

in effective schools The characteristics

of effective schools have been studied

more systematically worldwide in the last

twenty years and there is evidence

highly relevant to health promotion

(Hopkins et al., 1994; Teddlie & Reynolds,

1989; Creemers et al Eds, 1989; Sammons

et al., 1994; Scheerens, 2000)

Also within health promotion today there

is an emerging body of global evidence

which supports the effectiveness of a

health promotion approach in schools

and gives us clear direction pointers for

effective ways of working (St Leger &

Nutbeam, 2000b; Allensworth, 1994;

Young, 2002; Clift & Brunn Jensen, 2005;

Kolbe, 2005) I believe that this special

edition will play a significant part in

sharing this evidence and good practice

with as wide an audience as possible

Most importantly, where there are gaps in

our understanding, the new

developments and opportunities for

global networking as set out by Douglas

McCall on page 173 will be vital in

enabling us to share ideas and to move

forward with new research and practice

Health promotion in schools

worldwide today

The papers and case studies in this

edition follow the journal’s themes of

Advancing Knowledge, Advocacy and

Networking In my view these excellent

contributions from experienced authors

reflect the diversity and stages of

development of health promotion in

schools across the world They alsoreflect the amount of sharing betweenprofessionals from diverse countries with

a unifying interest in school healthpromotion

In the Advancing Knowledge section

Katherine Weare and Wolfgang Markhamfrom England explore the growingevidence base on what schools need to

do to promote mental health effectively.

This paper shows the evidencesupporting a whole school approachand of the value of creating a supportiveclimate in schools which promotesempathy, positive expectations and clearboundaries

Also in this section Albert Lee, Lawrence

St Leger and Alysoun Moon, co-authorsfrom Hong Kong, Australia and England

respectively, describe an important

evaluation related to the health

promoting school award scheme in

Hong Kong As with the first paper, thispaper also demonstrates the linksbetween the culture and organisation ofschools and health and educationaloutcomes

Bill Potts-Datema and colleagues describemethods developed in the USA to build

links between non-governmental

organisations (NGO’s) and government policy makers They explore two

significant partnerships of public healthand education NGOs and outlinesuccessful strategies and lessons learnedfrom the development of these large-scale partnerships

In the Advocacy section Bjarne Brun

Jensen from Denmark and Venka

Phases in the roll-out of the health promoting school model

Table 1

Initial experimental phase

• Early innovators (mainly from the healthsector) raise the issue of health promotionwith colleagues in the education sector

• The education sector at first tends toperceive health in bio-medical terms ratherthan as a social model, resulting in a deficit

of partnership-working between educationand health sectors

• School Health Services are primarily in atraditional prevention model

• Non-governmental agencies work withindividual schools and individual educationauthorities on specific health issues

• Early sporadic or short term developmentsoccur which may be driven (and resourced)

by political concerns about specific topicssuch as HIV/AIDS or substance use

• Related initiatives such as CommunitySchools and Eco-Schools are not perceived

by education to have anything in commonwith health promoting schools because ofthe prevalence of the bio-medical model ofhealth within the education sector

• Adoption of some health promoting schoolterminology by education policy makers Inthe early stages this apparent adoption ofterminology may not be matched by realchanges in practice

Strategic development phase

• The education sector starts to perceive thebenefits of health promoting schools inmeeting social and educational needs intheir schools and communities Authoritiesstart to build capacity through training andstaff development

• School health services embrace a widerhealth promotion role

• More strategic approach gradually buildsthrough partnership working at national(government) level and/or educationauthority/regional level

• The health sector funds posts in theeducation sector

• By trial and error and working together, there

is a reduction in antagonism between theeducation and health sectors and a slow,gradual increase in mutual understanding ofboth sectors This includes the clarifying ofpriorities, values, language and concepts

• Some shared posts develop between theeducation and health sectors, with educationcontributing resources

• More sophisticated research and monitoring

of progress is developed as the politicalprofile and the expectations rise

• Models are developed to map links betweeneducation and health in relation to schoolhealth (St Leger & Nutbeam, 2000)

Establishment phase

• Policy statements at national level thatinitially tend to be in the health sector feedinto the education sector

• Policy statements on specific schoolinitiatives relating to health are increasinglyplaced in the context of health promotingschools, for example curriculum policystatements, food provision policy in schools

• The education sector takes on greaterresponsibility for health promotion in schoolsand integrates health promotion intomainstream education

• At the level of the individual school, healthpromotion becomes institutionalised, that is

it becomes integral to the schools corevalues and normal ways of working

Simovska, FYR Macedonia, explore the

concepts, models and practical effects of

student participation as a central tenet

of health promotion in schools They

make the case for teachers to have

flexible educational models and

resources to manage participatory

projects in health promoting schools

They elaborate the idea that a

participatory approach has to influence

all aspects of a democratic health

promoting school rather than solely the

teaching strategies

In addition, Lloyd Kolbe and colleagues

in the USA explore the importance of

health programmes for teachers and

all other school employees They

demonstrate how these programmes can

promote health and how they could have

a positive impact on the recruitment,

retention, and productivity of school

employees in every nation that has

established a formal system of education

Becky Smith and colleagues from the

USA describe the problems and

challenges of teacher education and

training for health education in schools

They make the case for the development

of educational approaches, strategic

partnerships, and securing funding to put

strong systems of teacher preparation in

place for the future

The Networking Section includes an

introduction from David Rivett of the

WHO Office in Ukraine and a description

of the European Network of Health

Promoting Schools by Vivian

Rasmussen of the WHO Regional Officefor Europe in Copenhagen This paperincludes an analysis of the factors thatare likely to support a pilot projectdeveloping into a sustainable network

Josefa Ippolito-Shepherd describes how

in 2001, the Pan American Office of WHOconducted a survey in 19 Latin Americancountries to assess the status and trends

of Health-Promoting Schools in theregion This paper illustrates how thenetwork of health promoting schools is

developing and spreading in Latin

America and the Caribbean countries.

Douglas McCall (Canada) describes the

concept of a new global network, the

International school health network (ISHN) which is in its infancy, but which

has the potential to link continentalinitiatives such as the ENHPS with otherparts of the world through electronic andother means Readers of this edition areencouraged to give feedback in theformat suggested on page 173 to thisexciting development

The Case Studies, distributed throughout

this issue, provide shorter practicalexamples of health promoting schools inaction and they also show the globalcoverage of the health promoting schoolapproach as well as the adaptability of themodel to the needs of different countries

• Ardita Tahirukaj in Kosovo explains awhole-school approach to anecological problem In this case study

the issue is dangerous levels of the

metal lead in the environment which

is being tackled by a multi-levelapproach involving the curriculum,links with mothers, and links withhealth care and environmental change

• In FYR Macedonia, Lina KosterovaUnkovska demonstrates what can beachieved through a health promotingschools approach to restore youngpeople’s feelings of safety and

belonging in conditions of continuous

community crisis caused by armed conflict.

• Jo Mason and Louise Rowling(Australia) explain the work being

undertaken in the MindMatters

mental health initiative and show

that teachers’ professional andpersonal responses are linked in thecontext of training and staff

development in mental healthpromotion This Australian initiative isbeing taken up and adapted for use inEurope and is a good example ofsharing quality resources for healthpromoting schools internationally

• Malcolm Thomas (Wales) andWenyang Weng (China) describe thefindings from a survey undertaken bythe authors in the spring of 2004 of 500urban schools within three cities inLiaoning Province, China They outline

the factors that are associated with

successful health education and health promotion programmes in

schools in China

• David Wamalwa, Kenya, describes acase study of a Personal Hygiene andSanitation Education (PHASE) project

in Kenya The success of the PHASEpilot project in Kenya has led to thereplication of similar initiatives inUganda, Zambia and South Africa, andtransformation to a national

programme by the Kenya governmentcovering all schools The initiative

demonstrates that teachers and

pupils can be effective agents of change.

• Bhavna B Mukhopadhyay and P.C.Bhatnagar (India) describe an initiative

in school health promotion where the

first generation of children to be educated became the key agents of change This school-based health

promotion programme also provided

Modern cash cafeteria at Beeslack High school, Penicuik, Scotland, today

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1482-1485

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conditions of the labouring population of

Great Britain London, Poor Law

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Clift, S & Jensen, B.B (Eds.) (2005) The

Health Promoting School: International

Advances in Theory, Evaluation and

Practice Copenhagen, Danish University of

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Eds (1989) School Effectiveness and

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Downie, R.S., Fyfe, C & Tannahill, A (1990)

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Composition & Impression: p 110-122

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the European Network of Health PromotingSchools, Thessaloniki, Greece ENHPSTechnical Secretariat, WHO Regional Officefor Europe

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an opportunity for the gradual

development of leadership within the

parent-teacher community, with a

strong sense of ownership for the

programme

• In Uruguay, Sergio Meresman explains

the importance of actively involving

the key stakeholders and change

agents, including the young people

themselves, if sustainable health

promoting schools initiatives are to be

developed He describes the success of

the EVA (Education for Life and

Environment) project in integrating

health as part of the government’s

plan to improve education in Uruguay

• Daniel Becker et al., from Brazil, report

on the programme Problem solving

for Better Health (PSBH) as part of

the health promoting school strategyimplemented in 120 schools in Rio deJaneiro The practical projects weredeveloped by each school based ontheir outstanding problems and usingonly the school’s available resources

The success of the completed 85% ofprojects lies in the cost-benefit ofimplementing an effective programmewith no external resources

• In France, Sandrine Broussouloux andNathalie Houezelle, outline thepartnership between the Health

Ministry, through the French Institutefor Prevention and Health Education(Inpes), with the Education Ministry

Their work is designed to promote

physical and mental health and well-being in schools among teachers

and students and to train personnel inhealth education

• Colleen Stanton describes the basicelements and framework of her appliedresearch project at the University of

Toronto on using a systems approach

for health promoting schools, based

on interviews with key professionalsfrom Australia, Canada, Europe and theUnited States

The school is potentially one of the

most important and effective agencies for

promoting health, including mental

health (Lister Sharpe et al., 1999; Weare,

2000; Stewart-Brown, 2005) This paper

will outline the evidence for what we

know is effective in relation to promoting

mental health through the school system

Using a whole school approach

approach

The WHO’ ‘settings’ approach has helped

focus attention on the social and physical

contexts within which health is created,

in communities, schools and other

settings where people live and work

Applying the settings approach to

schools has led to a broadening of the

traditional concerns of health education,

which have long been with the

curriculum and the individual pupil, to

one in which the totality of school life is

Katherine Weare and Wolfgang Markham

What do we know about promoting mental health

as well as the taught curriculum andpedagogic practice, so that the totalexperience of school life is conducive tothe health of all who learn and workthere Looking even more broadly, theschool is seen as part of its widercommunity, reaching out to, andsupported by, parents, local healthservices, and other agencies, andinvolving them in programmes andinterventions which support the effortsthe school is making to promote health(Nutbeam, 1992)

Definition of a whole school approach

Internationally there are many differentnames for the whole school approach,including healthy school, healthpromoting school, holistic, eco-holistic,universal, comprehensive,

environmental, multi-dimensional, andmulti-systemic However there is still alack of agreement about what it means inpractice Many examples of so called

‘whole school’ approaches are in factonly very partial accounts of what is

ideally involved It is suggested that amore ‘complete’ example of a wholeschool approach would include thefollowing features:

• It utilises a holistic model of health andrecognises the physical, social, mental,emotional and environmental

dimensions within this model

• It looks at several aspects of theschool, not just one, and not only thecurriculum Other important aspectsinclude management, ethos,relationships, communication, policies,physical environment, relations withparents, relations with community andpedagogic practice

• It looks at the underlyingenvironmental determinants ofemotional wellbeing and competence,not just its learning or behaviouraloutcomes

• It works with all relevant parties and atall levels, for example government,education authorities, and schools, andwith everyone in the school orcommunity, not just those with specialneeds or those families identified ashaving problems

Abstract:There is a growing evidence

base on what schools need to do to

promote mental health effectively There

is strong evidence that they need first

and foremost to use a whole school

approach This shapes the social

contexts which promote mental health

and which provide a backdrop of

measures to prevent mental health

disorders In this context the targeting

of those with particular needs and the

work of the specialist services can be

much more effective Schools need to

use positive models of mental health,

which emphasise well being and

competence not just illness– this will

help overcome problems of stigma and

denial and promote the idea of mental

health as ‘everyone’s business’ Themost effective programmes in schoolswhich address mental health have thefollowing characteristics:

• They provide a backdrop of universalprovision to promote the mental health

of all and then target those withspecial needs effectively

• They are multi-dimensional andcoherent

• They create supportive climates thatpromote warmth, empathy, positiveexpectations and clear boundaries

• They tackle mental health problemsearly when they first manifestthemselves and then take a long term,developmental approach which doesnot expect immediate answers

• They identify and target vulnerable and

at risk groups and help people toacquire the skills and competencesthat underlie mental health

• They involve end users and theirfamilies in ways that encourage afeeling of ownership and participation,and provide effective training for thosewho run the programmes, includinghelping them to promote their ownmental health

Using these starting points, we need todevelop a rigorous evidence-basedapproach on this issue We also requirethe facilitation of the dissemination ofsuch research findings while encouragingnew and innovative approaches

• mental health promotion in schools

• health promoting schools

• whole school approach

• It includes the care-givers (for example,

teachers) as well as the recipients (for

example, pupils)

• It ensures congruence between the

various parts, so that one part of the

picture is not undermining work that is

being carried out somewhere else (for

example, directives and advice from

education authorities conflicting with

what is happening in schools)

• It promotes coherence, teamwork,

‘joined up thinking’ and

multi-professional working

• It focuses on processes and ways of

working as well as programme content

and intended outcomes with a view to

encouraging positive attitudes towards

school

• It facilitates the acquisition of different

types of skills These skills include:

a) life skills such as self-reflection

skills, problem solving skills and

relationship skills;

b) learning how to learn skills that

facilitate greater understanding of ones

self;

c) traditional school competences

which facilitate success at school and

increased job opportunities

Evidence for the importance of

the whole school approach

There have been several recent large

scale systematic reviews of the research

evidence, including evidence from

controlled studies, which have

concluded unequivocally that initiatives

that use a range of contexts,

opportunities, approaches and agencies

are more effective than more limited and

one dimensional approaches when

attempting to tackle mental health (Wells

et al., 2003; Catalano et al., 2002)

A systematic review (Lister Sharpe et al.,

1999) concluded that whole school

approaches can be very powerful ways

of tackling a whole range of health

issues, including emotional and social

issues A review of approaches which

were designed to promote mental

wellbeing in schools (Wells et al.,

2003:221) concluded ‘the most robustly

positive evidence was obtained for

programmes that adopted a whole school

approach’.

There is clear evidence that whole

school approaches are effective, not only

for changing the behaviour and attitudes

of mainstream pupils, but also for helping

those with emotional and behavioural

problems The review by Wells et al.

(2003) on the effect of school-basedprogrammes on mental health showedthat ‘the most positive evidence ofeffectiveness was obtained forprogrammes that adopted a whole-schoolapproach, were implemented

continuously for more than a year, andwere aimed at the promotion of mentalhealth as opposed to the prevention ofmental illness’ As such, these

approaches were more effective thanthose that were limited to classroomapproaches alone This includedoutcomes for pupils with emotional andbehavioural problems Holistic

approaches have been shown to bemuch more likely to make long term

changes to pupils’ attitudes andbehaviour across a wide range of issuesthan specific, one dimensional

programmes Durlak (1995), Durlak andWells (1997) and the US Government’sGeneral Accounting Office (1995)reviewed hundreds of different types ofprogrammes designed to promote

‘prosocial’ behaviour in schools (forexample reducing alcohol, tobacco anddrug use, and violent incidents) Allthree reviews concluded unequivocallythat environmental programmes weremuch more effective than those thatused curriculum approaches alone

Various key elements which have beenshown to make a difference to theeffectiveness of schools in promotingmental health are even more powerfulwhen they work together For instance,teachers who feel supported are morelikely to set clear goals for their pupils(Moos, 1991) Many of the studies of thevarious factors have found it morehelpful to cluster them and to look atthem in combination (Hawkins &

Catalano, 1992; Solomon et al., 1992), and

some researchers have even suggestedthat we cannot understand any features

of educational organisations in isolation(Marshall & Weinstein, 1984) This points

to the essentially holistic nature of theschool context and key educationalprocesses

A backdrop of universal provision for all

Emotional, behavioural and socialproblems are widespread – they are by

no means a minority problem Forexample, estimates of clinically definedbehaviour disorder, in children andyoung people, range between 7% and 27%(Stewart-Brown, 1998) Any populationsurvey of related issues such as unhelpfulparenting (for example hitting very youngchildren), behaviour problems, worries,anxieties or experience of bullying,invariably show that emotional and socialproblems are located along a continuumand tend to affect a high percentage ofthe population

A key reason to use a whole-schoolapproach is the realisation that thosewith mental health problems are helpedmore effectively by such an approachrather than by an approach in whichonly they are targeted Mental healthproblems are widespread, and if anarbitrary percentage is targeted, themany people who suffer from a problem

to some extent will be ignored The samebasic processes that help those withemotional difficulties have been shown topromote the emotional well-being of all.These key processes include: beginninginterventions early; promoting selfesteem; giving personal support,guidance and counselling; building warmrelationships; setting clear rules andboundaries; involving people in theprocess; encouraging participation andautonomy; involving peers and parents inthe process, creating positive climatesand taking a long term, developmentalapproach (McMillan, 1992; Cohen, 1993;

Rutter et al., 1998).

The universal approach helps addressthe biggest barrier to people seeking helpwith their mental health problems,namely stigma and discrimination It alsoallows for multiple outcomes to beaddressed simultaneously, such asanxiety, depression, suicide or positivehealth and well-being

There have been several recent large scale systematic reviews of the research evidence, including evidence from controlled studies, which have concluded

unequivocally that initiatives that use a range of contexts, opportunities, approaches and agencies are more effective than more limited and one

dimensional approaches when attempting to tackle mental health

Target at risk groups

Using a holistic, positive approach does

not preclude effective targeting, and

some people will need to have a great

deal more input than is provided for

everyone Children and young people

most certainly suffer from mental health

problems, and from a surprisingly early

age According to the epidemiological

data available, the lifetime prevalence of

major depression is about 4% in the age

group 12-17 and 9% at age 18 (European

Union, 2003) The latest findings suggest

an increase in the prevalence of

adolescent depression Moreover,

population surveys show that one third

of people that have met criteria for major

depression in their lifetimes report that

the first attack occurred before the age of

21 (Andrews, 2001) Children and young

people who suffer from depression are at

greater risk for recurrence of depression

than are adults (Downey et al., 1990)

Appropriate targets include individual

young people, groups of young people,

and families at particular risk of mental

health problems These might include

young people whose parents suffer from

mental illness and or enduring physical

illness, who have experienced

particularly stressful life events, or are

suffering from post-traumatic stress, or

who have shown a tendency towards

drug abuse and /or suicide

Taking a positive approach to

mental health

The term ‘mental health’ has tended to

be synonymous with mental illness, and

to produce anxiety and denial in many

people’s minds A major shift is now

taking place right across the field of

mental health that is helping to address

this barrier, with more emphasis on a

‘salutogenic’ view of mental health as

positive emotional, social, spiritual,

physical well-being.1

Moving in this direction means that

mental health is no longer the province

of medical experts whose language may

be perceived as obscure or even

frightening It is the concern of everyone

to try to use language and terminology

that is inclusive, normalising, and avoidsstigma and discrimination For exampleusing a term such as ‘emotional andsocial well-being’ rather than ‘mentalhealth’ has been useful in Britainbecause of negative connotations aroundthe word ‘mental’ in colloquial speech

There is a desire to focus on thecompetences and strengths that underliehealth, rather than on the pathologies ofproblems and illness These

competences and strengths (Markham &

Aveyard 2003; Newman & Blackburn,2002) include optimism, coherence,resilience, ability to understand andexplore the origins of stress and theability to communicate effectively andmake mutually satisfying relationships

These skills enable us to enjoy life and tocope with pain and disappointments

Young people who have these strengthsand competencies are also able to viewpsychological distress as a

developmental process and thus, areable to prevent this distress fromhindering or impairing furtherdevelopment (NHS Advisory Service1995) Such a shift is helping to ensurethat mental health is seen as ‘everyone’sbusiness’ and is linked in with thefundamental activities of a range of socialand educational agencies

Develop coherent programmes

Effective work to promote mental healthwill not happen by chance There is aneed for explicit, coordinatedprogrammes, based on sound researchevidence and assessment of theireffectiveness

Many programmes exist, and there isclear evidence that they can be veryeffective For example, a recent review ofwhole school/whole communityprogrammes, which looked at howeffective they appeared to be in

‘promoting mental health’ found 17 which

stood up to its rigorous criteria (Wells et

al., 2003) These programmes have been

shown to reduce specific mental healthproblems, such as aggression, depressionand reduce commonly accepted riskfactors associated with mental healthproblems, such as impulsiveness, andantisocial behaviour There is alsoevidence that the programmes can helpthe development of the competences thatpromote emotional and social well-being,such as communication skills, social

skills, cooperation, resilience, a sense ofoptimism, empathy, a positive andrealistic self concept, stress managementand problem solving skills In addition tothe development of the above skills, keyfeatures of effective programmes include:

• taking a joint approach betweenagencies, with school and communitybeing a particularly effective

partnership;

• creating supportive climates thatpromote warmth, empathy and positiveexpectations and boundaries;

• promoting consistency between thevalues of the schools and values of thewider community and therebypromoting cultural stability;

• helping people to acquire the skills andcompetences that underlie mentalhealth;

• providing effective training andpromoting the mental health of thoserunning the programme;

• promoting participation in decisionmaking;

• taking a long term, developmentalapproach

Involve the young people and their families

The principles of empowerment and userinvolvement are generally recognisedacross Europe as an importantcontribution to the creation of ademocratic society, and are basic tocurrent European models of healthpromotion and health promotionevaluation (WHO, 1986) Compared withadult groups, young people are not oftenconsulted about mental health matters,often being seen as too immature or toounreliable to know what is in their ownbest interests Young people with mentalhealth problems are liable to be doublyexcluded However, there have beensome interesting efforts to ascertain theviews of young people about mentalhealth and to build them intorecommendations for action, which haveshown that young people are capable ofmaking a well informed and considered

contribution (Harden et al., 2001) It is

therefore important to build on this work,and ensure that the opinions of youngpeople themselves, including those withmental health problems, are able toinform approaches that are intended topromote their mental health

Schools can help support goodparenthood and facilitate strongparent/child relationship development

1 A powerful recent example is the ‘Mental Health Action

Plan for Europe that emerged from the WHO European

Ministerial Conference on Mental Health «Facing the

Challenges, Building Solutions» held in Helsinki, Finland, on

14 January 2005 http://www.euro.who.int/mentalhealth2005.

Reviews of emotional and socialeducation programmes, including thosebased in schools (Durlak, 1995) showedthat programmes which actively involveparents, the local community and keylocal agencies are more likely to have animpact on student behaviour and mentalhealth, as well as learning Closeattention needs to be paid to the needs

of children who have parents who aresuffering from mental health disordersand problems, including encouragingtargeted prevention programmes for thisgroup

Use a long term, developmental and differentiated approach

It is important to allow any interventiontime to work – instant results cannot beexpected Work needs to begin early inthe lives of children, before problems arewell established It is also important not

to treat this age group as a homogeneousgroup but to use a developmentalapproach Each stage in childhood andadolescence will require differentmethods and approaches towardspromotion and prevention actions, andrequires sensitivity to the needs ofdifferent groups Therefore account has

to be taken of age, gender and cultural issues when planning specific

socio-programmes (Loeb et al., 1998).

Particular efforts need to be made tosupport young people and their familiesthrough times of transition, as transitionsmay be a period of particular anxiety andstress (Furlong, 2002) These transitionsinclude the move from home to school,from one school to another, and fromschool to work or higher education (See

Kolbe et al in this issue)

Promote the mental health of professionals

A key agency is the professionals whowork with children and young people,who cannot be expected to promote themental health of others if their ownneeds are not met We need to do more

to promote the mental health of teachersand other school staff by providingproper emotional and practical supportfor their often stressful working lives,good working conditions and realisticworkloads There is a need to encouragemore training and more multi-

professional networking on mental healthissues, which can take place at manylevels, including in initial training, in

Examples of projects that use whole school approaches

European Network of Health Promoting

Schools

• Major school network, a joint venture of the

EU, Council of Europe and WHO, which

has now spread to nearly all European

countries, including Eastern and Central

Europe

• Takes a universal, whole school approach

to the promotion of health in schools, and

focuses on the community and parents as

well as children and young people

• Puts mental and emotional health at the

heart of the process

• Key emphasis on participation, ownership,

democratic action

• Concerned with the health of staff as well

as students, e.g project on teacher mental

health in Slovenia

• Strong element of concern for staff mental

health and for training, e.g Manual

‘Promoting Mental, Emotional and Social

Health in the ENHPS’ has been adopted

in many countries, especially in Eastern

and Central Europe and has led to the

training of thousands of staff across the

whole European region

• Major emphasis on evaluation, using

approaches that encourage ownership by

• A universal prevention project designed to

reduce aggression and promote social

competence

• Develop skills that are central to children’s

healthy social and emotional development:

a) empathy, b) impulse control and

problem solving, and c) anger

management

• The implementation of the project involves

teachers, children and parents

Well evaluated in the USA Now developing

major research component to evaluate its

• Uses whole community, whole school

approach – involves taught programme, a

monitoring system for student behaviour,

coordinating committee to oversee the

intervention, changes to the physical

environment, and involvement of parents

and community to work with both bullies

and victims to address this social problem

• Research based – begins with theadministration of a bullying/victimizationquestionnaire that provides informationabout the extent of the problem in thecommunity and increases awareness andinvolvement in students and schoolpersonnel

• Well evaluated - results provide support forthe effectiveness of the intervention inreducing bully/victim problems andbroader antisocial behaviour

http://www.gold.ac.uk/connect/reportnorway.html

Paths (Promoting Alternative Thinking Strategies)

• USA programme, increasingly found inEuropean countries

• Comprehensive programme for promotingemotional and social competencies andreducing aggression and behaviorproblems in elementary school-agedchildren while enhancing the educationalprocess in the classroom

• Includes parents and the community in theprogramme

• Extremely well evaluated - evaluations withcontrols have demonstrated for examplesignificant decreased anxiety/depressivesymptoms and improvements in self-control, understanding and recognition ofemotions, use of more effective conflict-resolution strategies, and thinking andplanning skills

http://www.prevention.psu.edu/PATHS/

Mind Matters

• Originally an Australian project,successfully disseminated acrossAustralia, now being adapted for use inEurope

• Specific focus on mental health incommunities and schools, including acoherent taught curriculum supported by acomprehensive teaching pack

• Prioritises teacher education – built on anational professional development andtraining strategy

• Uses a whole school approach to mentalhealth promotion and suicide prevention

The programme aims to enhance thedevelopment of school environmentswhere young people feel safe, valued,engaged and purposeful Helps schoolsand their communities including teachers,parents and students to take positiveaction to create a climate of mental as well

as physical wellbeing within schools

• Ongoing and rigorous evaluation

http://www.curriculum.edu.au/mindmattersEuropean contact: Peter Paulus,paulus@uni-lueneburg.de

service professional development and

higher education

Build the evidence base

Systematic reviews have shown that by

no means all interventions are effective,

and that promoting young people’s

mental health through the school system

is a challenging business (Harden et al.,

2001) Whenever possible new and

existing initiatives should use and build

on sound theory and evidence in order

to develop appropriate strategies and

programmes More priority should be

given to evaluation of new and existing

projects, with more resources devoted to

it, and the creation of more effective

partnerships between practitioners and

the research centres which have the

expertise in this area There is also a

need to improve the dissemination of

existing evidence to busy practitioners

In ascertaining effectiveness,

experimental studies with controls have

generally been seen as setting the

standard, and there is certainly a case for

the use of controls where this is

appropriate or feasible However there

are other valid approaches, and within

health promotion in Europe and

Australasia the emphasis is more on

multi-causal, socially focused approaches

which emphasise student involvement

and ownership with an interest in

process as well as outcomes (WHO,

1997) It is important that programmes

are not imposed on countries, regions

and agencies, but are chosen or created

by them To date almost all well

evaluated programmes have come from

the USA, but efforts are now being made

to develop programmes that are

specifically European, or adapted from

the best North American and Australian

programmes for use in Europe Within

these programmes, it is important to

allow those that use them some freedom

to adapt them to their own needs and

circumstances as long as core principles

are not compromised

We need to encourage creativity and

innovation in this area, as we have much

to learn as we build an understanding of

what is likely to be effective in this vital

area of mental health promotion

References

Andrews, G (2001) Should depression be

managed as a chronic disease? British

Medical Journal, 322, 419-421.

Catalano, R.F., Berglund, L., Ryan, A.M.,Lonczak, H.S and Hawkins, J (2002)Positive Youth Development in the UnitedStates: Research Finding on Evaluations ofPositive Youth Development Programmes

Prevention and Treatment, (5), article 15.

Cohen, J (1993) Handbook of School

Based Interventions: Resolving Student Problems and Promoting Healthy Educational Environments San Francisco:

Jossey-Bass

Downey G & Coyne, J.C.: (1990)’Children

of depressed parents: an integrative review’

Psychological Bulletin (1990), 108: 50-76.

Durlak, J (1995) School Based Prevention

Programmes for Children and Adolescents London: Sage.

Durlak, J & Wells, A (1997) ‘Primaryprevention mental health programs forchildren and adolescents: a meta—analytic

review.’ American Journal of Community

Psychology, 25 (2), 115—152.

European Union (2003) Mental Health

Promotion and Prevention Strategies for Coping with Anxiety, Depression and Stress Related Disorders in Europe:

Children, Young people and Young People

up to 24 years in Educational and other Relevant Settings Brusells: Mental Health

Europe

Furlong, A (2002) Youth transitions and

health: a literature review Edinburgh.

Health Education Board for Scotland

Harden A, Rees R, Shepherd J, Ginny B,

Oliver S, and Oakley A (2001) Young

People and Mental Health: A Systematic Review of Research on Barriers and Facilitators London EPPI-Centre.

Hawkins, J & Catalano, R (1992)

Communities That Care: Action for Drug

Abuse Prevention San Francisco: Jossey—

Bass

Lister-Sharp D, Chapman S, Stewart-Brown

S, Sowden A (1999) Health promotingschools and health promotion on in schools:

two systematic reviews Health Technology

Assessment, 3:22.

Loeb D., Markham W.A., Naidoo J & Wills J

(1998) Mental health promotion In J Naidoo

and J Wills Practising health promotion

theory and practice Bailliere and Tindall,

London

Markham W A & Aveyard P (2003) A newtheory of health promoting schools based onhuman functioning, school organisation and

pedagogic practice Social Science and

Medicine, 56, 1209-1220.

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‘Classroom factors affecting students self

evaluation: an interactional model.’ Review of

Educational Research, 54, 301—325.

McMillan, J (1992) A Qualitative Study of

Resilient At Risk Students: Review of

Literature.Virginia: Metropolitan Educational

Research Consortium

Moos, R (1991) ‘Connections betweenschool, work and family settings’ In B Fraser

and H, Walberg (eds) Educational

Environments Oxford: Pergamon.

Newman, T & Blackburn, S (2002)

Transitions in the lives of young people: Resilience factors Edinburgh Scottish

ExecutiveNHS Advisory Service (1995) Together westand: Child and adolescent mental healthservices London HMSO

Nutbeam, D (1992) ‘The health promotingschool: closing the gap between theory and

practice’ Health Promotion International,

9, 39—47

Rutter, M., Hagel, A & Giller, H (1998)

Anti-social Behaviour and Young People.

Cambridge: Cambridge University Press.Solomon, D., Watson, M., Battistich, V.,Schaps, E & Delucchi, K (1992) ‘Creating acaring community: a school based

programme to promote children’s prosocialcompetence’ In E Oser, J Patty, and A Dick

(eds) Effective and Responsible Teaching.

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St Leger, L (1999) ‘The health promoting

primary school’ Health Education

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School Safety: Promising Initiatives for Addressing School Violence Report to the Ranking Minority Member, Subcommittee

on Children and Families, Committee on Labor and Human Resources US Senate.

Washington DC: General Accounting Office

Weare, K (2000) Promoting Mental,

Emotional and Social Health: A Whole School Approach London: Routedge.

Wells J., Barlow J & Stewart-Brown S.(2003) ‘A Systematic review of universalapproaches to mental health promotion in

schools’ Health Education, 103(4):220 WHO (1986) Ottawa Charter for Health

Promotion WHO: Geneva.

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School: An Investment in Education, Health and Democracy: Conference Report First Conference of the European Network of Health Promoting Schools, Thessaloniki, Greece Copenhagen: WHO

Regional Office for Europe

Young, I & Williams, T (1989) The Healthy

School Scottish Health Education Group,

World Health Organization (EuropeanOffice), Copenhagen

The concept of the HPS was first named

at a WHO conference two decades ago

(Young, 1986) and has been advocated as

an effective approach to promote health

in schools It embodies a whole school

approach, and goes beyond the school

curriculum HPS includes those

components of schooling such as the

physical environment, school ethos,

school based health policies, linkage

with health services and partnerships

with community that would have strong

impact on the health of students (Young

and Williams, 1989; Nutbeam, 1987;

Evaluating health promotion in schools:

a case study of design, implementation and results from the Hong Kong Healthy Schools Award Scheme

Smith, 1992; McDonald and Ziglio, 1994;

Parsons et al., 1996; WHO, 1996a) The

development of HPS shifted the paradigm

of school health into a more dynamicand political domain, and aims toprovide skills in advocacy and to achieve

a sense of empowerment (St Leger,2001)

The gap between practice and “whatought to be” is greater for school healthpromotion for most other areas (Seffrin,1990) In Hong Kong, the concept of HPS

is making progress with many associated

challenges (Lee et al., 2000, Lee et al.,

2001) The Centre for Health Educationand Health Promotion of the ChineseUniversity of Hong Kong (CUHK) firststarted its contribution by offering atraining course for school educators aspart of an University ProfessionalDiploma in Health Promotion and Health

Education (Lee et al., 2003) The CUHK

also launched the “Hong Kong HealthySchools Award Schemeë (HKHSA) tofacilitate the development of school-based management and school healthpromotion practices (Lee, 2002)

HPS and Healthy Schools Awardschemes have been developed in severalEuropean countries They provide astructured framework for development aswell as a system of monitoring andrecognition of achievement (Rogers,1998) Positive award-related changes interms of children’s health behaviours,and the culture and organization of theschool have been demonstrated (Moon,1999a) However the core business ofschools is more concerned with

educational outcomes than healthoutcomes It is possible that if theoutcomes of HPS can be linked withmainstream education sector outcomes,

it increases the chance of healthpromotion being put in practice

The concept of HPS aims to sustain ahealthy school culture emphasising awhole school approach It has aninteresting parallel in models of schoolimprovement developed in the educationsector for example by the SchoolImprovement Research Group at

Cambridge University (Hopkins et al.,

1994)

It is suggested that the following factorsare associated with effective schools

(Sammons et al., 1996)

1 Good professional leadership;

2 Shared vision and goals;

Abstract: Health promoting schools

(HPS) and Healthy Schools Award

Schemes from a number of countries

have demonstrated positive changes in

children’s health behaviours and the

culture and organisation of the school

The Hong Kong Healthy Schools Award

Scheme (HKHSA) aims to promote

staff development, parental education,

involvement of the whole school

community, and linkage with different

stakeholders to improve the health andwell-being of the pupils, parents andstaff, and the broader community,supported by a system to monitor theachievement This concept is very much

in line with the research literature onschool effectiveness and improvement

The indicators examined to evaluate thesuccess of the HKHSA reflect

outcomes related to both health andeducation and are not limited to

changes in population health status Theearly results demonstrated significantimprovements in various aspects ofstudent health and also improvement inschool culture and organisation Theevaluation framework described in thispaper and data collected to assess howschools perform in the HKHSA scheme,provides insight into how HPSs couldlead to better outcomes for botheducation and health

Professor Albert Lee MB BS MPH MD

FRACGP FRCP(Irel) FFPH(UK)

FHKAM(FamMed) FHKCFP

Director of Centre for Health Education

and Health Promotion

Professor and Head of Family Medicine

Unit, Department of Community and

Family Medicine

Honorary Consultant of Family Medicine

(Head of Lek Yuen Training Centre)

During 1995, a set of guidelines on HPS

was produced and endorsed by the

member states of WHO Western Pacific

Region (WHO-WPRO) The guidelines

consisted of specific components in six

areas (WHO, 1996b):

• School health policies;

• The physical environment of the school;

• The school’s social environment;

• Community relationships;

• Personal health skills;

• Health services

Adapting these six areas to a local

perspective, CUHK launched the HKHSA

in 2001 building on the concept of HPS to

encourage educational achievement and

better health thereby supporting pupils

in improving the quality of their lives

(Lee, 2002) The HKHSA scheme also

aims to promote staff development,

parental education, involvement of the

school community, and linkage with

different stakeholders as a way of

improving the health and well-being of

the pupils, parents, staff and the broader

community The challenge is to develop

outcome indicators to evaluate the

success of a programme such as this

which also takes account of the

mainstream educational agenda of school

effectiveness and improvement

Multiple outcomes and school

effectiveness

School improvement research tends to

place an emphasis upon ‘process’ rather

than ‘outcomes’ (Teddlie and Reynolds,

2000) There are critics of school

effectiveness research which uses a

single outcome measure, in particular

academic achievement, as it is claimed to

be an inadequate method of ascertaining

the true level of effectiveness in any one

school (Harris and Bennett, 2001) It is

suggested that school improvement can

come from good leadership, school

policies, or the plan to which schools and

teachers sign up School effectiveness can

be enhanced by the organisation as a

whole, through its ethos, culture, policy

and planning (Harris, 2002) A case study

of Singapore and London schools

indicated that there is no single recipe for

turning a school around, but that there

are common elements which include the

motivation of staff, a focus on teaching

and learning, enhancing the physical

environment in and around the school

and changing the culture of the school

(Mortimore et al., 2000: 142).

Evaluation research in health promotionand education also needs to gain insightsinto the processes involved in

programme implementation and thesocial and environmental context inwhich these processes develop It shouldalso be concerned with issues related toequity, public health policy, communityinvolvement, accessibility of healthservices and social well being Takentogether these issues distinguish healthpromotion from other forms of health andmedical intervention (Whitehead, 1991;

MacDonald and Bunton, 1992; Tones andTilford, 2001) In the health sector thedominance of the “evidence of healthcare” has led to the development of a

research evidence hierarchy (Shelden et

al., 1993) where randomized controlled

trials (RCTs) are considered the ‘goldstandard’ for quantitative evaluativeresearch (Figure 1) At the bottom of thishierarchy are descriptive studies

The HKHSA has a number ofcomponents with targets for the school toachieve for each of the six key areasreferred to earlier Demonstratingpositive change in those six key areasshould contribute to health promotioneffectiveness The four different types ofoutcomes identified by Nutbeam (1996):

health and social outcomes, intermediatehealth outcomes, health promotionoutcomes, and health promotion actionsinfluenced the design of HKHSA Theseoutcomes are summarised below

Health and social outcomes

The health and social outcomes representthe end-point of health and medicalinterventions such as mortality, morbidity;

disability and dysfunction; health status;

and social outcomes such as quality oflife, life satisfaction and equity

Intermediate health outcomes

The intermediate health outcomesrepresent the determinants of healthsuch as:

• healthy lifestyles (personal behavioursthat protect or increase risk of illhealth);

• healthy environments (the physicalenvironment and economic and socialconditions that can impact directly onhealth and support healthy lifestyle);

• effective health services

Health promotion outcomes

The health promotion outcomes could

be summarised as follows:

• health literacy (the personal cognitiveand social skills for individuals tomaintain good health);

• social actions (organised effort toinfluence healthy lifestyles and healthyenvironments);

• healthy public policy andorganisational practices, e.g., healthcities, healthy schools and healthyworkplaces);

The above health promotion outcomescan modify the determinants of health

Health promotion actions

The health promotion actions can beclassified as having three main ‘domains’:

• education, facilitation and advocacy:

• education consists primarily of thecreation of opportunities for learningwhich are intended to improve healthskills;

• facilitation is action taken inpartnership or groups to mobilizehuman and material resources forhealth;

• advocacy is action taken on behalf ofindividuals and/or communities toovercome structural barriers to achievepositive health

What are the indicators for success in health promoting schools?

Young and Williams (1989) identified 12criteria which schools should consider in

a health promotion model These were

Figure 1 Research evidence hierarchy

Randomised Contolled Trial (RCT)

Controlled trial (non-randomised)

Quasi-experimental design

Cohort studies

Case control studies

Before and after studies (no control)

Descriptive studies

Adapted from Sheldon T., Gery F., andDavey Smith G (1993) Critical appraisal

of medical literature: how to assesswhether health care interventions do moregood than harm In Drummond M and

Marynard A (eds) Purchasing and

Providing Cost-Effectiveness Health Care, Churchhill-Livingstone: Edinburgh.

adopted within the European Network of

Health Promoting Schools (Parsons,

1997) They were:

• Active promotion of the self esteem of

all pupils by demonstrating that

everyone can make a contribution to

the life of the school

• The development of good relationship

in the daily life of schools

• The clarification for staff and pupils of

the social aims of the school

• The provision of stimulating challenges

for all pupils through a wide range of

activities

• Using every opportunity to improve

the physical environment of the

school

• The development of good links

between associated primary and

secondary schools to plan a coherent

health education curriculum

• The consideration of the exemplar role

of staff in relation to health

• The active promotion of the health and

well being of school staff

• The complementary role of school

meals (if provided) to the health

education curriculum

• The utilisation of the potential of

specialist services in the community

for advice and support in health

education

• The development of the education

potential of the school health services

beyond routine screening

The Western Australian School Health

Project (WASH Project) also identified

key factors for success (McBride N et al.;

1995) These key factors were organised

into three functional groupings:

negotiation with schools, working with

schools, and maintaining health

promotion in schools

In the USA Allensworth (2004) addressed

formative and process evaluation

indicative of school health promotion

initiatives to assess the design and

implementation They were:

Formative (Evaluating the design)

• Relationship of initiative to WHO

directive?

• Ability of initiative to promote/achieve?

• Education goals (knowledge, skills,

literacy)?

• Adoption of healthy behaviors?

• Improvements in health status?

• Is it comprehensive? Factual?

• Relationship of initiative to ‘best

practices’ identified in research?

Process (Evaluation of the

Programme planning approach?

• Collaboration between education andhealth? School, community agencies &

families?

• Level of participation of students?

Based on a detailed analysis and review

of evaluation frameworks adoptedworldwide, the CUHK developed theevaluation framework to measure thesuccess of a complex of initiatives withthe emphasis on practice change as well

as specific behaviour change

The framework of evaluating HKHSA

The process of the development of evaluation framework

The Award Scheme in Hong Kong coverssix key areas (health policy, physical andsocial environments, communityrelationships, personal health skills andhealth services) It is based on WHOguidelines (WHO, 1996) Each country inthe region was encouraged to developindicators to meet their local needs Theindicators and guidelines developedwere evidence-based and have a broadrange of objectives These were designed

to be relevant, adaptable, and achievable,

so they can be used to develop goodpractices (St Leger, 1999; Pattenden, 1998;

Piette, Roberts, Prevost, Tudor-Smith andTort, 2002; Centers for Disease Controland Prevention, 2002) Each key area has

a number of components with targets forthe school to achieve The componentscover school-based changes/initiatives aswell as the involvement of parents,school management committees, thecommunity and teacher training

Therefore evaluation of success wouldmean measuring the success of acomplex of initiatives

The process for the selection ofindicators for the HKHSA and also theprocess of accreditation for schools hasincorporated advice and validation by anumber of international experts in thefield CUHK then developed a practicalmanual with detailed guidelines and

indicators for each component to achievethe standard for the six key areasdocumented by WHO/WPRO (Centre forHealth Education and Health Promotion,2003a) The report of the process ofaccreditation was submitted toWHO/WPRO, and the awards wereendorsed by WHO/WPRO as meeting theWHO standards in 2002 and 2003 (Centrefor Health Education and HealthPromotion, 2003b, 2004)

The instruments used to measure outcomes

The indicators measure outcomes atdifferent stages Apart from surveyresearch methods, qualitative studieswere utilised The data collection andanalysis of qualitative studies were usedthroughout the study period withdifferent methods Heath and socialoutcomes included the measurement oflife satisfaction, self-perception of healthstatus, and emotional well-being It issuggested that these measures may bemore relevant to many of the studentsthan measurements of the prevalence ofdiseases, disability or dysfunction.Therefore data on the prevalence ofdepressive symptoms, suicidal thoughts,self-perceived physical and emotionalhealth status were collected

The intermediate outcomes measuredyouth risk behaviours, school physicalenvironment, school social environment,and accessibility to school healthservices The health promotion outcomeslooked into the development of personalhealth skills to enhance health literacy,attitudes and values towards health,school health policies, features of schoolorganisation which facilitated theimplementation of health promotion, andany actions taken to create a healthyschool environment The healthpromotion actions examined thecurriculum, partnership with community,and advocacy to overcome structuralbarriers to effective health promotion.The questionnaire utilised for theevaluation of HKHSA incorporated othertested instruments such as the Youth

Risk behaviour Surveillance (Kolbe et al.,

1993), Wessex Healthy Schools AwardScheme Students Evaluation

Questionnaire (Moon, 1999; Moon et al.,

1999b)

In the area of mental health, themeasuring instruments included theSatisfaction with Life Scale (LIFE) and

the Depression Self-Rating Scale (DSRS).

LIFE (Diener et al 1985) was translated

into Chinese and reported adequate

reliability (Shek, 1992) The DSRS was

used to measure moderate to severe

depression among young adolescents

(Birleson, 1981; Asarnow & Carlson,

1985) The Chinese version was

developed and piloted with a local

population and was found to have

adequate reliability (Cheung, 1996)

As discussed above, the CUHK had

already developed a practical manual

with detailed guidelines and indicatorsfor each component to achieve thestandard for the six key areas A systemfor monitoring progress and assessingschools’performance on HPS

questionnaires, covering the items ofthose six areas, was also produced andissued to each school beforehand Thequestionnaire was designed in templateformat to allow much of the information

to be entered as quantifiable data Thetemplate also facilitated the collection ofqualitative information A team of healthpromotion co-ordinators of CUHK visited

the school for at least one day The teamsupplemented the information byreviewing school documents, e.g.,policies, analysis of the schoolcurriculum, observing the schoolenvironment, and also interviewingschool teachers and headteachers Theassessment was conducted before theintervention, then re-assessed after aninterval to evaluate the effectiveness ofthe programme

Table 1 summarises how differentoutcomes were measured by different

instruments (Lee et al., 2005) The details

of development of rating systems andevaluation framework for HKHSA are

reported in detail in other papers (Lee et

al., 2004; Lee et al., 2005).

Analysis of data collected at the schools

The quantifiable data that were tabulated

as proportion and Chi Square statisticswere utilised for assessing the differencebetween the pre and post interventionperiod For the qualitative data, the datawas transcribed and categorised intodifferent headings and themes foranalysis A coding system was developed

to organise the data The coding systeminvolved searching through the data forregularities and patterns as well as fortopics, then writing down words andphrases to represent these topics andpatterns These words and phrasesbecame the coding categories Themeasurement instrument for the schoolhealth profile was a set of structuredquestionnaires designed in templateformat

Preliminary results of the evaluation of HKHSA

The participating schools achieved manyimportant changes in key areas whichwere indicated by the comparison of thebaseline assessment and the audit results

of 56 schools after a two year period.Some of these were:

• For school health promotion andhealth education, 98% of theparticipating schools had set up aworking group or committee for schoolhealth promotion whereas only 53% ofthe participating schools had suchworking groups as shown in thebaseline assessment (Table 2)

• In promoting healthy eating, allparticipating schools had developedthe healthy eating policy for their

Indicators and measuring instruments for the different

types of outcomes for school health promotion

i Attitudes, lifestyles andrisk behaviours

ii School environment andschool ethos

iii School health services

i Health skills andknowledge, and selfefficacy

ii School health policiesiii Networking with parents,community and otherschools to launch healthprogrammes

i School timetable forhealth educationactivities (formal andextra-curricular)

ii PTA and communityinvolvement

Measuring instrument

Validated questionnaires:

LIFE, DSRS, YRBS

Questionnaires to studentsand schools, schoolobservation, documentaryreview, interviews,ethnography

Questionnaires to studentsand schools, curriculumreview, documentary review,interviews, focus group,participant observation

Documentary review

Comparison of performance of schools in school health

promotion and healthy eating at baseline and during

audit after implementation of HKHSA

Table 2

School health promotion and health education

School has a working group or committee

Student health promoting organizations

At least one staff trained or under training

Provide diversified health education resources

Healthy eating

students whereas only 57% of theparticipating schools had this policy asshown in the baseline assessment(Table 2).

• In the maintenance of student health,there were only 5% of the participatingschools which had analysed andfollowed up students’ body weight and19% of these schools informed theparents and students of students’ bodyweight during baseline assessment.This improved markedly during auditwith 76% and 73% respectively (Table3) Schools also kept better records ofstudent health and more schoolsestablished a student healthmaintenance policy

• In crisis management, most schoolshad good measures for students butnot for staff at baseline The markedimprovement was observed forhandling crises for staff afterimplementation of HKHSA (Table 4).For addressing the needs of students,significant improvement was observed

in the development of policies toaddress violence and bullying,involvement of students in schoolpolicies, and addressing students withspecial needs (Table 4)

• The schools had made significantchanges in involving parents in schoollife in wider aspects includingformulating and reviewing the annualhealth promotion plan and healthpolicies (Table 5) Greater networkingand linkage with the community werealso observed after implementation ofHKHSA (Table 5)

At the end of the first year of theevaluation process, seven primaryschools and eight secondary schoolshad taken part in providing pre and postdata according to the above indicators.Significant improvements were observed

in various aspects of student health.Tables 6 to 8 highlight the changes inmental health and anti-socialbehaviours

Conclusion

Apart from addressing the complexity ofhealth promotion initiatives, theevaluation of school health promotionalso needs to address the schoolimprovement and effectiveness whichcan be useful and meaningful for boththe education and health sectors TheHKHSA has emphasised a healthy schoolculture with indicators that can betranscribed for both education and health

Comparison of performance of schools in student

health maintenance component at baseline and during

audit after implementation of HKHSA

Table 3

Student Health Maintenance

School informed parents and students

Comparison of performance of schools in crisis

Management addressing the needs of students at

base-line and during audit after implementation of HKHSA

Table 4

Crisis Management

Addressing the needs of students

Kept a comprehensive record of students

Comparison of performance of involvement of parents

in school life and active linkage with community at

base-line and during audit after implementation of HKHSA

Table 5

Encourage Parents’Involvement in School Life

Parents’participation in formulating and reviewing of

Proactive Linkage with Community

Involved community members or organisations in

Involved community members or organizations in

development of school’s annual health promotion

Networking with other schools in health

Participation in local health education exchange activities 21.4 75.0 < 0.05*

needs In evaluating school health, one

must not ignore the vast literature on

school organisation and improvement,

teaching and learning practices,

professional development, and innovation

and dissemination This work also

supports the view that evidence of

success in health promotion and

education can be demonstrated from data

which are derived from several different

sources such as experimental studies,observational studies and making use ofboth qualitative as well as quantitativeinformation It is argued that researchers

in health promotion and educationshould recognise the synergistic effects ofcombining different methods to answerdifferent research and evaluation

questions (Baum, 1995; Stecklen et al.,

1992)

In addition the Hong Kong study indicatesthat one need not limit effectivenessstudies on health promotion tointerventions solely concerned withchanges in population health status Theresults generated from this study shouldstimulate further debate on these issues

as well as providing valuable data abouthow the health promoting schoolapproach can enhance the health andwell being of all school users

Improvement of mental health of 820 students from

7 Primary schools one year after joining HKHSA Table 6

Baseline (%) 1 year (%)

Improvement of anti-social behaviours

of 820 students from 7 primary schools one year after joining HKHSA

Table 7

Baseline (%) 1 year (%)

Improvement of anti-social behaviours

of 2661 students from 8 secondary schools one year after joining HKHSA

Table 8

Baseline (%) 1 year (%)

*Statistical significance at level of 0.05

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This applied research project, aSystems Approach to Health PromotingSchools was completed in March 2004

Thirty five key leaders from Canada,United States, Australia and Europeinvolved in systems change towardshealth promoting schools and educationsystem reform were interviewed

Through a comprehensive literaturereview and key informant interviews aconceptual framework was developedwith the health-promoting school as the

“hub” or “centre-point” This frameworkconsists of six core elements for asystems approach to health promotingschools These elements include: sharedvision, collaborative culture, referentstructure, overarching strategy,personal/professional development,evaluation and monitoring Each coreelement is described in detail withexamples from various countries

In addition to the six core elements,there are three major cornerstones ofknowledge that have been identified tobuild a systems approach to healthpromoting schools These includeknowledge and appreciation of:

health (broad definition),systems change, andcontinuous learning and sustainability

This research brings together keylearnings from the literature and from thekey informants/system leaders in thisarea The research begins to identify howthese three knowledge areas can worktogether to contribute to long termsustainable systems change One of the

most important aspects of this approach

is the ability of the individuals andorganisations to adapt to change and tolearn on an ongoing basis

Results and final report

The final report of this applied researchstudy identifies some of the following:

• The core elements and framework for asystems approach to health promotingschools;

• The relationship between healthpromoting schools, systems changeand continuous learning andsustainability;

• The key challenges and opportunities

to creating an effective systems changeprocess towards health promotingschools;

• Areas to consider for integration ofhealth into the education system;

• Examples of how a health promotingschool framework can be integratedand “embedded” into an educationsystem at a number of levels (i.e.System Plan for ContinuousImprovement)

Conclusion

This research, while exploratory innature, provides some preliminaryinformation, analysis, expert opinionsand a review of some of literature in thearea of a systems approach to healthpromoting schools and continuouslearning The author/researcher wouldlike to take this research to a deeperlevel by examining more closely therelationship and interrelationshipsbetween health (broad definition),learning (continuous/sustainable) andsystems change through her Ph.D.studies and research at the OntarioInstitute for Studies in Education (OISE)University of Toronto She would like tothank all of the key informants from herresearch study for their time, wisdomand willingness to share their knowledgeand experience in this area

Health Promotion, Planning and Evaluation Consultant & Ph.D Student Ontario Institute for Studies in Education (OISE), University of Toronto

P.O Box 28552, Aurora, Ontario L4G 6S6 Email: C.Stanton@aci.on.ca

Improving education and health

outcomes for children and youth

involves a wide variety of partners from

the home, school, community, state, and

nation From parent to government

official, community leader to school

teacher, business person to legislator,

each partner has critical roles and

responsibilities to fulfill, valuable

resources to contribute, and important

stakes in the outcomes All of these

partners influence the behaviours that

children and youth establish and

maintain, behaviors that ultimately play a

Theresa C Lewallen, James F Bogden and Sharon Murray

Successful strategies and lessons learned from

development of large-scale partnerships of national

Two such collaborations in the UnitedStates are the focus of this discussion,the National Coordinating Committee onSchool Health and Safety (NCCSHS) andthe Friends of School Health (hereafter,

“the Friends”) This article will explore

these two significant partnerships ofpublic health and education NGOs andoutline successful strategies and lessonslearned from development of these large-scale partnerships

The National Coordinating Committee on School Health and Safety (NCCSHS)

Initiated during the administration of

President George H.W Bush, NCCSHS

first met in 1993 At present, NCCSHS is acollaboration of 64 NGOs and six U.S.government departments representingboth the fields of public health andeducation Nearly all major NGOsworking in fields related to school healthare represented, and the six primarygovernmental agencies all have at leastsome responsibility for students’ healthand safety The group is the primaryintersection of NGOs and the Federal

Abstract: National governments

world-wide work to improve education and

health outcomes for children and youth

and influence their behaviours Also

heavily engaged are national

non-governmental organisations (NGOs) in

the voluntary and non-profit sector

While individual agencies and non-profit

organisations are often concerned with

specific issues of interest related to

their charge, constituency or

membership, they often develop

allegiances with like-minded groups to

accomplish broader goals

Two such collaborations in the United

States are the focus of this discussion,

the National Co-ordinating Committee

on School Health and Safety

(NCCSHS) and the Friends of School

Health (hereafter, “the Friends”) This

article reviews these two significant

partnerships of public health and

education NGOs and outlines

successful strategies and lessons

learned from the development of these

large-scale partnerships

NCCSHS is a collaboration of 64NGOs and six U.S governmentdepartments representing both thefields of public health and education

Nearly all major NGOs working in fieldsrelated to school health are

represented, and the six primarygovernmental agencies all have at leastsome responsibility for students’ healthand safety The group is the primaryintersection of NGOs and the Federalgovernment related to school health atthe national level

The Friends of School Health (“theFriends”) is the primary school healthadvocacy coalition at the national level

in the United States Sixty-oneeducation and public health NGOsparticipate The coalition serves as acommunication mechanism and venuefor collaborative action on issues beforethe U.S Congress and state

legislatures that relate to school health

Since the coalition advocates tolegislators and other decision makers,

no government agencies participate

The paper describes the strategiesrelating to the initial development of thecollaboratives and their ongoingoperation

A common theme in development ofboth of these examples of large-scalepartnerships is trust Like anypartnership, the ability to work and grow

is dependent on the level of trustamong the partners

Both the National CoordinatingCommittee on School Health and Safetyand the Friends of School Health worktogether successfully within and acrosstheir collaborations, to improve healthand educational outcomes for childrenand youth While both experiencechallenges, and neither would indicatethat its work is near completion, theyprovide important insight into how thesecollaboratives can initially develop andsubsequently operate productively whileproviding important contributions to thepromotion of healthy schools, andultimately, healthy nations

Keywords

• coalition development

• building coalitions

• building partnerships

• school health collaborations

• school health coalitions

government related to school health atthe national level.

NCCSHS member NGOs working in thefield of education include the Associationfor Supervision and Curriculum

Development, Council of Chief StateSchool Officers, National Association ofState Boards of Education, NationalEducation Association, National SchoolBoards Association, and severalprofessional organisations ofadministrators among others A sampling

of member NGOs working in publichealth includes the American Academy ofPediatrics, American Cancer Society,American Heart Association, AmericanMedical Association, and AmericanPublic Health Association Some NGOs,such as the American Alliance for Health,Physical Education, Recreation andDance, American School HealthAssociation, National Association ofSchool Nurses, National Parent-TeacherAssociation, and Society of State Directors

of Health, Physical Education andRecreation have missions that span bothfields Constituencies of NCCSHS memberorganisations range from just over 50critical policymakers (such as theAssociation of State and Territorial HealthOfficials and Council of Chief State SchoolOfficers) to several million at the schoollevel (such as the National EducationAssociation and National Parent-TeacherAssociation) A wide range of the keygovernment departments and agenciesare represented including those relating

to education, health, agriculture, theenvironment, transport and justice

Many, though not all, NGOs are grantees

of the Health Resources and ServicesAdministration (HRSA) and the U.S

Centers for Disease Control andPrevention Division of Adolescent andSchool Health (CDC-DASH) A completelisting of members may be found atwww.healthy-students.org

As outlined in the vision and missionstatement of NCCSHS, “The primarymission of NCCSHS is to bring togetherrepresentatives of major nationaleducation, health, safety, and nutritionorganisations for collaborative activitiesthat promote policies and programmes atnational, state and local levels foradvancing the health and safety of allchildren and adolescents and promotingtheir academic success, and through theFederal Interagency Committee on

School Health (ICSH), to inform Federalagencies about current issues for the

field.” (Initially, a small subcommittee of

NCCSHS representatives and leaders ineach of the Federal agencies, known asICSH, met on an annual basis to addressthese issues and exchange ideas Due topriorities of the current government, theICSH has not been functioning Thelarger body of NCCSHS has fulfilled thoseresponsibilities in its absence.)

NCCSHS elects a chairperson for a year term in odd-numbered years Thechair is selected from the NGO members.The primary funding source is theMaternal and Child Health Bureau ofHRSA, and Dr Trina Anglin, Chief of theOffice of Adolescent Health serves aspermanent co-chair Other governmentalagencies have contributed smalleramounts from time to time There is nofee or dues for NGO members, thoughattendance at meetings is often at theirown expense

two-During 2002, the members of NCCSHSundertook a strategic planning processthat continues to inform the direction ofthe group Using that plan, the work ofNCCSHS is developed by a SteeringSubcommittee of approximately 20 NGOand Federal members, which meets everyJanuary to prepare an agenda for thecoming year Typically, two membershipmeetings are held These include a one-day Annual Meeting scheduled duringMay or June that encompasses severalcurrent topics within a general theme,and a one-day Special Issues meetingheld during September that addresses asingle priority school health issue ofinterest to both NGO and governmentconstituencies (For example, the SpecialIssues meeting in September 2005explored the challenges of translatingresearch into policy and practice.)Speakers from academia, the non-profitsector and government who havesignificant experience in an emergingschool health topic are engaged toprovide presentations addressingNCCSHS priorities A major portion ofeach meeting is set aside for groupdiscussion and member interactionrelated to the theme Participants find theopportunities to network and build newrelationships to be a valuable aspect ofthese meetings

NCCSHS also accomplishes specialprojects dependent on availability of

Corresponding author:

William Potts-Datema

(At the time of writing the article)

Director

Partnerships for Children’s Health

Harvard School of Public Health

Boston, Massachusetts

Expert Consultant, National Coordinating

Committee

on School Health and Safety (NCCSHS)

Former Coordinator, Friends of School

Division of Adolescent and School Health

U.S Centers for Disease Control and

Prevention

4770 Buford Highway NE, Mailstop K-31

Atlanta, Georgia 30341 USA

University of California – San Diego

San Diego, California

Safe and Healthy Schools Project

National Association of State Boards of

Society of State Directors of Health,

Education and Recreation

Reston, Virginia

Coordinator, Friends of School Health

Coalition

funding and staff and volunteer time.

During the past several years, an

Editorial Review Subcommittee (ERSC)

staffed by member volunteers has

functioned to advise on the development

of a web site (www.healthy-students.org)

that contains descriptions of NCCSHS

activities, member information, meeting

reports, annual summaries of work, and

a comprehensive database of resources

developed or provided by members The

ERSC worked together to identify topics

for a series of articles in development for

placement on the NCCSHS web site or

publication in member organisation

journals and newsletters An additional

major special project undertaken in 2004

and 2005 involved preparation of a series

of six articles addressing health issues

and their relationship to academic

performance (Taras et al., 2005).

NCCSHS is staffed by a logistics

contractor, who contracts with a

part-time expert consultant The logistics

contractor is responsible for securing

contracts with hotels, providing general

meeting services for participants,

maintenance of the web site, and other

duties The expert consultant provides

services related to the strategic plan,

such as assisting in preparation of

meeting agendas, securing and working

with speakers, coordinating work of the

Editorial Review Subcommittee (such as

web site and article development),

report writing and editing, member

services and recruitment, management

of elections, etc

Often, additional work is identified during

NCCSHS membership meetings

Occasionally, funding will be secured

from government sponsors to accomplish

these projects Sometimes, funding is not

necessary For example, during an issues

meeting, the membership identified two

areas of concern relating to the

re-organisation of projects at a government

agency A team of representatives was

identified to meet with the agency’s staff

to express those concerns and work

toward a positive resolution

Friends of School Health

The Friends of School Health (“the

Friends”) is the primary school health

advocacy coalition at the national level

in the United States Sixty-one education

and public health NGOs participate

Since the coalition advocates to

legislators and other decision makers, nogovernment agencies participate Thecoalition’s description summarizes itspurpose and activities:

The Friends of School Health is a partisan group dedicated to promotingcoordinated school health programmes

non-Organisations that participate in theFriends group communicate regardingschool health initiatives They alsocooperate to sponsor Congressionalbriefings, news conferences, and otherevents to educate policymakers, opinionleaders, and other decision makersabout coordinated school healthprogrammes and their value to thechildren and youth of America

Individual member organisationsadvocate for funding or programinitiatives according to their desire andability

The Friends were formally organised in

2000 after a small ad hoc group of NGOsworked together to develop a briefing forMembers of the U.S Congress on issuesrelated to coordinated school health

Since its inception, the Society of StateDirectors of Health, Physical Educationand Recreation (SSDHPER) has providedin-kind staff support by allowing use of aportion of the executive director’s salarydedicated to advocacy purposes(separate from governmental grantfunding)

Though the coalition was not originallydeveloped as an outgrowth of NCCSHS,and no formal relationship existsbetween NCCSHS and the Friends, there

is a significant overlap in organisationalmembership due to the interest of both

in school health Within an NGOmember organisation the work of theFriends is sometimes carried out by adifferent individual than the

organisation’s NCCSHS representativebecause of U.S tax laws governing non-profit organisations An NGO mightchoose a dedicated government relationsprofessional who is legally permitted torepresent the organisation’s interestsbefore legislative bodies to be itsrepresentative to the Friends, while astaff person paid from Federal funds whoworks on school health policy orprograms might serve as the NCCSHSrepresentative Decisions on

representation are determined byindividual organisations dependent ontheir policy and tax status

Rather than having a defined steeringcommittee, the Friends maintain a policythat allows any member organisation tohave a voice in setting direction Priorityissues are established for the comingyear by those attending the FriendsAnnual Meeting in November, which istwo months before the opening of thenext session of the U.S Congress.(Priority issues for 2005 included: 1) securing additional funding for statecoordinated school health programsfunded by CDC-DASH, and

2) reauthorization of the “No Child LeftBehind” elementary and secondaryeducation law administered by the U.S.Department of Education.) Planning andaction agenda decisions are

accomplished through conference callsscheduled every four to six weeks.Similar to the Annual Meeting, for thesake of efficiency only those memberorganisations with a representative onthe call are allowed to participate in thedecisions made during that call

A primary purpose of the Friendscoalition is to facilitate communicationand updates across NGOs regardingadvocacy issues Because of the fastpace and quickly changing environment

of the policy world, regular updates arecritical Time is allotted during eachconference call for this work, and Friendsoften utilise electronic communicationsbetween calls A key strength of thecoalition is its diversity of membership,and each organisation contributes thebenefits of its own existing personalrelationships and familiarity withlegislators The Friends benefit greatlyfrom the information shared acrossconstituencies

During the past six years, the Friendshave collaborated to hold nineCongressional briefings on a number ofissues related to school health, includingcoordinated school health, healtheducation, physical education, nutrition,mental health, and school healthservices Speakers have includedMembers of Congress, the U.S SurgeonGeneral, government agency

representatives, NGO executive directors,state coordinated school health

programme directors, andrepresentatives of academia amongothers These briefings attract staff fromMember offices of the House ofRepresentatives and Senate, usually staffmembers who are assigned to the health

and/or education portfolio of issues.

During the events, members of the

Friends have the opportunity to interact

with these staff and develop contacts

The Friends, in groups and individually,

often visit Congressional staff members

at their offices on Capitol Hill in

Washington, D.C to educate them on

priority issues In addition to the general

information provided during briefings,

these visits allow Friends to delve more

deeply into the issues, answer questions

and concerns, and develop ongoing

relationships The Friends have held

numerous such meetings over the past

six years Most often visited are

Congressional staff who work for those

Members of Congress in leadership

positions in the House of Representatives

or Senate or who have responsibilities

with committees that decide issues

related to Friends priorities

In April 2005, the Friends coalition was

invited to present formal testimony to a

key committee of the U.S House of

Representatives, the Subcommittee on

Labor, Health and Human Services,

Education and Related Agencies, which

is a unit of the larger House

Appropriations Committee (in the United

States, the Appropriations Committee

proposes funding levels for governmental

agencies, levels that are then considered

for approval by both houses of Congress

and the President.) A number of coalition

members contributed to the testimony

which was delivered by the Friends’

coordinator, Sharon Murray

The Friends also undertakes a number of

other activities on an episodic basis

“Sign-on letters” (correspondence to

Congress stating the position of member

organisations), are prepared on key

issues and delivered at time-sensitive

points in the Congressional policy

development process Members are

allowed to individually determine

whether they wish to sign on to (join)

the coalition’s common position, and

nearly half typically do

Smaller task groups are occasionally

developed to work on areas of special

interest For example, a current small

group is investigating ways to strengthen

development of similar and like-minded

coalitions in states, and another is

working on strategies for educating

Members of Congress on issues related

to the “No Child Left Behind” elementaryand secondary education law to assistlegislators in their deliberations when thelaw is reconsidered in 2006 and 2007

Aside from the percentage of staff timeallotted by SSDHPER to enable theexecutive director to perform thecoordination function, the Friends has noconsistent and stable funding source

When events and activities areundertaken, member NGOs contributeaccording to their desire and ability

These members receive specialrecognition during the event, but noother benefits are derived fromsponsorship At least half of the memberNGOs have provided some level offinancial support during the life of thecoalition, though all donations have been

in relatively small amounts (less thanUS$1000 per year)

Successful strategies and lessons learned

As one might expect from a large-scalecollaboration of diverse NGOs, NCCSHSand the Friends have experienced bothsignificant successes and challengesduring their development Thesesuccesses have been due to specificstrategies and related strategic decisions,some of which were planned at inceptionand some that developed over time

Where challenges occurred, lessons wereextracted that led to the creative

formulation of additional strategies

Therefore, the following points areexpressed as strategies

A few specific strategies relate to the

initial development of one or both

in significant measure ondevelopment of health-promotingschools Both believe that health isimportant for educational attainment,

and that achievement in school has animpact on future health outcomes.However, the distinction is drawn inwhat each collaborative does WhileNCCSHS strives to build collaborativerelationships among its members toimprove school health policies andprogrammes, it specifically avoidsdirect intervention with legislators due

to its incorporation of members fromgovernment agencies In contrast, theFriends exists specifically to educategovernment leaders in key decision-making positions These uniquethough complementary missionscreate a synergistic environment fromwhich both benefit

2 Secure strong leadership and a champion to lead development.

Both collaboratives have enjoyedstable leadership throughout theirgrowth and development This strongand consistent leadership has beencritical to the development of thecollaborative A lack of strong andconsistent leadership can lead todissention and eventual dissolution Inthe case of NCCSHS, Dr Anglin hasprovided stability as co-chair andchampion, and her bureau hasprovided a consistent funding source,resulting in increasingly productivelevels of activity Similarly, the Friendshave benefited from stable in-kindsupport from SSDHPER, which hasprovided a staff coordinator and,equally important, the organisationalsupport necessary to maintain thecoalition’s momentum through achange of coordinators

3 Leverage existing successful alliances and partnerships NCCSHS

began its work as an invitational group

of NGOs identified and convened bythree Federal agencies (the U.S.Departments of Agriculture,Education, and Health and HumanServices) It evolved and expanded asthose initial members invited others

to join with agreement from theFederal partners The Friends began

in a more ad hoc way, with a smallgroup of individuals interested inadvocacy The founding coordinatortook responsibility for leading a coregroup to prepare the first briefing forMembers of Congress The success ofthat initial event led to recruitment ofother NGOs from existing professionaland personal relationships, leading to

the formation of a nascent coalition of

25-30 members These existing

partnerships provided a foundation

for growth of both collaboratives

4 Intentionally diversify the

membership base Both NCCSHS and

the Friends include members that hold

the issue of health-promoting schools

as a high priority (American School

Health Association, Society of State

Directors of Health, Physical Education

and Recreation, etc.) However, both

NCCSHS and the Friends incorporate a

number of member NGOs that do not

include school health or

health-promoting schools as a first-order issue

or intervention, though they believe in

the importance of developing those

systems Several focus on specific

diseases (American Cancer Society,

American Diabetes Association,

American Heart Association, etc.),

while some focus on specific

populations or professions (National

Conference of La Raza, National

Parent-Teacher Association, American

Association of School Administrators,

Chronic Disease Directors, etc.) The

diverse constituencies bring

tremendous strength and a perspective

that broadens the vision of the group

5 Create an operating agreement or

code Development of agreement

about operations creates a sense of

trust and inclusion The style of

operation may vary, but members

must agree on how work will be

accomplished NCCSHS has a formal

operating code ratified by the

members that is reviewed periodically

to ensure relevance In contrast, the

Friends functions according to an

informal code with few overt rules

While several of the members retain

positions within both groups, the

collaboratives differ in operational

style due to the work they undertake

and the specific individuals involved

Both methods can work; the key is

broad understanding of and

agreement on the operating

guidelines

6 Determine how decisions will be

made and who will make them A

specific focus on decision-making is a

critical early step that is often

overlooked Large-scale collaboratives

thrive on trust, and decay begins

when that trust is compromised Early

and intentional discussions regardinghow decisions will be made fosterlong-term trust and create a sense ofownership within the collaborative

Again, the style may differ (NCCSHSvotes and uses e-mail to ensure thatall who wish to vote can do so; theFriends works toward consensuswhile rarely voting, and empowersonly those in attendance at in-personmeetings or on conference calls tomake decisions) The key isagreement on a process before theinevitable contentious issues areraised

7 Encourage member organisations

to utilise representatives who can both speak for the organisation and carry back information to the organisation’s leadership and membership Determining the

appropriate level of organisationalengagement is critical to success Insmaller organisations, the

organisation’s executive director isoften the most appropriaterepresentative, and that person mightserve on both NCCSHS and theFriends In larger organisations,functions may be split in ways thatrequire different representatives forNCCSHS and the Friends, such as thelegal requirements discussed earlier

Regardless, the authority to representthe NGO and the ability to

communicate with leadership andmembership are key

Other strategies relate to the ongoing

operation of these collaboratives, as

follows:

1 Attend to and respect member priorities and needs, and be intentional about providing benefits Each individual organisation

has specific priorities and needs,some of which overlap the mission ofthe collaborative and some that donot In each case, member NGOs mustreceive benefits as individual

members in order to participate andcontribute actively For many,recognition of participating incollaborative work is important andsimple steps are often sufficient (such

as preparing a general press releasethat organisations can customise toindicate their specific involvement)

Within NCCSHS, the professionaldevelopment offerings are frequently

noted as an important benefit For theFriends, accessing decision makers isoften beneficial enough, which issomething that the coalition can often

do better than individualorganisations

2 Set annual priorities and jointly prepare an annual plan of activities Inclusion in priority setting

and activity development is anotherkey step in building and maintainingtrust and ownership within suchcollaboratives Members need to feelthey play an important role in thework of the group Again, NCCSHS andthe Friends differ somewhat inpractice NCCSHS maintains a multi-year strategic plan that drivesdevelopment of annual activities TheFriends has maintained a signatureissue over many years (funding forCDC-DASH coordinated school healthprogrammes), but its other issueshave varied widely depending onissues before Congress and thecoalition’s capacity to educateCongressional staff Both approachescan work; the key is memberinclusion in priority and plandevelopment

3 Use an open process for determining specific projects that fulfill the annual plan While

members must feel included in planand project development, openness isimportant to ensure effectiveness andefficiency Any large group of NGOsexperiences a risk of duplicating orunintentionally sabotaging a member’scurrent plans or projects Ensuringthat communications and decisionmaking involve all members allowsthe collaborative to avoid potentialconflicts

4 Do projects that benefit as many members as possible Again,

members must see benefits for theirindividual organisations as well as forthe collaborative Overlaps in NGOmissions and common issues provideopportunities to develop such projectsand leverage resources in useful ways.NCCSHS meetings and special projectssuch as the web site and publicationsare planned to provide the widestpossible benefit to member NGOs Inseveral situations, the Friends havebeen able to gather small donationsfrom member NGOs that assisted

them in fulfilling their purposes (such

as Congressional briefings, which

would require a much larger

investment to implement for an

individual organisation)

5 Respect the operating code, but be

flexible in organisational operation.

Occasions may arise when the

operating code offers no guidance or

is insufficient It is also possible to

encounter situations when following

the code may hamper a necessary

process In such cases, an exception

agreed upon by the membership may

provide relief until the code can be

formally revised For example,

NCCSHS members agreed to vote

using electronic ballots to streamline

the elections process, which allowed

members from throughout the

country to participate regardless of

whether they could attend a meeting

The Friends occasionally defer issues

to get the input of a member

organisation that they believe might

provide useful insight

6 Be nimble and able to change

course if the need arises While

planning is important, both

collaboratives have found that course

changes are inevitable and often

useful NCCSHS has quickly revised

agendas for professional development

events based on emerging or

unforeseen issues The Friends

maintain an extraordinarily flexible

plan to enable the collaborative to

quickly react to new issues in

Congress

7 Be timely and responsive in dealing

with external requests, especially

from decision makers and the

media Both decision makers and the

media require and expect quick

responses to questions or inquiries

Other important requests can come

from current or potential funders and

others While both collaboratives find

media requests to be infrequent, they

differ in the frequency of potential

requests from decision makers

NCCSHS does not often receive direct

inquiries from decision makers, and

due to its involvement of government

representatives the collaborative may

defer such inquiries to the Friends

The Friends can leverage the

resources of individual member NGOs

to reply depending on the issue, andcan organise a quick conference call ifnecessary to determine the best way

to respond

8 Use whatever resources members can provide, and celebrate their contributions Financial

contributions to both collaborativeshave provided critical support, thoughneither would indicate that its needsare satisfied However, both

collaboratives benefit from the highlevel of expertise of their

membership, and individual membersoccasionally leverage their

organisation’s resources to provideassistance when an issue is closelyaligned with their work Neithercollaborative is entirely dependent onsignificant financial support tofunction, though as experienced withNCCSHS, an increase in financialresources can result in realising asignificantly enhanced scope of work

In either case, recognition andcelebration of member contributions

is vitally important

9 Obtain staff support if possible, even if the support is in-kind or a part-time volunteer Staff members

provide the glue for any organisationand large-scale NGO collaboratives are

no different Adding logistics staff and

an expert consultant led to anexpansion of the capability of NCCSHS

to do work, and also provided theFederal sponsor more time to provideguidance and oversight to thecollaborative Similarly, the Friendswould not exist without a coordinator

to keep projects moving, set andorganise meetings, and accomplishthe myriad other tasks necessary to

maintain momentum It did not existuntil a coordinator was available

10 Do regular check-ins and evaluations Keeping apprised of

member needs and interests andtheir perceptions of the success ofthe collaborative requires intentionaleffort NCCSHS provides evaluations

at each professional developmentevent, and adjustments are madedepending on the wishes expressed

by the participants A periodicevaluation is undertaken to judge theoverall satisfaction of the membersand learn their preferences for futureaction Those results guide theSteering Subcommittee in its work toset an annual plan and activities.Similarly, the Friends sets aside time

at its Annual Meeting to discuss theprevious year’s work with a viewtoward guiding the coming year’sactivities

Conclusion

A common theme in development ofboth of these examples of large-scalepartnerships is trust Like anypartnership, the ability to work and grow

is dependent on the level of trust amongthe partners Without trust, neithercollaborative organisation would be able

to function Consciously working to buildtrust is the most significant internal work

of these collaboratives Each strategypresented above contributes in someway to establishing and maintaining trustamong the members and those withwhom they relate

As the American industrialist Henry Fordnoted, “Coming together is a beginning,keeping together is progress, workingtogether is success.” Both the NationalCoordinating Committee on SchoolHealth and Safety and the Friends ofSchool Health work together successfullywithin their collaboratives, and acrosscollaboratives, to improve health andeducational outcomes for children andyouth While both experience challenges,and neither would indicate that its work

is near completion, they provideimportant insight into how thesecollaboratives can initially develop andsubsequently operate productively whileproviding important contributions to thepromotion of healthy schools, andultimately, healthy nations

Like any partnership, the ability

to work and grow is dependent

on the level of trust among the partners Without trust, neither collaborative organisation would be able to function.

Consciously working to build trust is the most significant internal work of these collaboratives

“National Coordinating Committee on

School Health and Safety Vision and

Mission Statement,“ National Coordinating

Committee on School Health and Safety,

revised June 2004, unpublished

“National Coordinating Committee on

School Health and Safety Operating

Principles,” National Coordinating

Committee on School Health and Safety,

revised September 2003, unpublished

Taras, H.(August 2005) Nutrition and

Student Performance at School Journal of

School Health 75 (6), 199-213

Available:

http://www.blackwell-

synergy.com/doi/abs/10.1111/j.1746-1561.2005.00025.x

Taras, H (August 2005) Physical Activity

and Student Performance at School

Journal of School Health 75 (6), 214-218.

Available:

http://www.blackwell-

synergy.com/doi/abs/10.1111/j.1746-1561.2005.00026.x

Taras, H & Potts-Datema, W (September

2005) Sleep and Student Performance at

School Journal of School Health 75 (7),

248-254

Available:

http://www.blackwell-1561.2005.00033.x

synergy.com/doi/abs/10.1111/j.1746-Taras, H & Potts-Datema, W (September2005) Chronic Health Conditions and

Student Performance at School Journal of

School Health 75 (7), 255-266.

Available: synergy.com/doi/abs/10.1111/j.1746-1561.2005.00034.x

http://www.blackwell-Taras, H & Potts-Datema, W.(October2005) Obesity and Student Performance at

School Journal of School Health 75 (8),

291-295

Available: synergy.com/doi/abs/10.1111/j.1746-1561.2005.00040.x

http://www.blackwell-Taras, H & Potts-Datema, W (October2005) Childhood Asthma and Student

Performance at School Journal of School

Health 75 (8), 296-312.

Available: synergy.com/doi/abs/10.1111/j.1746-1561.2005.00041.x

http://www.blackwell-Various unpublished documents of theFriends of School Health Coalition,including the organisational statement andmembership list

HPS in action

ENHPS study tour, Ferruza Mamanazarova demonstrates Uzbek dance to pupils from Longniddry primary school Scotland, one of Scotland’sactive primary schools

Context

Kosovo is a United Nations Administered

Province with Provisional Institutes of

Self-Government (PISG) and is divided

into 5 administrative regions

encompassing 30 municipalities

The conflict in the Balkans in 1999 and

also the gradual deterioration of

conditions left Kosovo with severe

problems in relation to its infrastructure,

local capacity and relationships between

the main ethnic groups Associated

environmental pollution has left severe

contamination in industrial areas which

are heavily populated

As a response to the environmental

degradation and it’s impact on human

health, WHO, in collaboration with local

institutions, is currently implementing a

comprehensive programme of activities

to raise awareness and decrease

exposure to the metal lead and other

poisonous heavy metals by establishing

sustainable structures that will address

all aspects of this complex problem

Industrial pollution from heavy metal

mining activities is one of the main

sources of this pollution Lead in soil

analyses taken by WHO in Mitrovica/ë

and Zvecan municipalities have shown in

over 90% of samples to be over a limit set

by Dutch researchers (Dutch List, 1999)

Kosovo has a population ofapproximately 2 million people and avery high proportion (approximately 50%)are of school age and pre-school age

Addressing the lead pollution that affectsboth the Albanian and Serbian

communities is considered as one of thepractical ways of unifying the efforts ofthe two communities in the divided city

of Mitrovica/ë

The problem

Mitrovica/ë had the largest metallurgicand mining complex (Trepca) in Europe,which commenced activities in 1939 withthe extraction of lead, cadmium and zinc

Many industrial plants existed in thecomplex: a huge lead smelter, fertilizerproduction plant, refinery, batteryfactory, zinc electrolysis facility and asulphuric acid plant The highconcentration and wide range ofpollutants released by these industrieshave produced associated health risksfor all the population and particularlychildren and pregnant mothers

The complexes were shut down in July

2000, however, lead and other heavymetals (cadmium, nickel, arsenic andzinc) from the abandoned sites andcontaminated soil from the decades ofmining and smelting activities havecontinued to contaminate theenvironment, and pose a health threat tothe population

A survey carried out during and after theclosing of the plant in 2000 showed highlevels of blood lead in the children,adults, and pregnant women in the area

( Molano and Andrejew, 2000)

Preliminary assessments carried out byWHO in 2002/3 of environmental samplesshow excessive levels of lead and otherheavy metals in soil, dust, paint andsome locally grown vegetables Thedrinking water appears to be withinacceptable limits

A Risk Assessment performed by WHO

in 2004 to assess exposure pathways andongoing impact, reveal preliminaryresults of blood lead levels in childrenaged 2 –3 years to be of great concern.The acceptable level of lead in blood is10mcg/dL (WHO/CDC) In the areasassessed, 58% of those tested are abovethis level in Zvecan, 40% in NorthMitrovica and 15% in South Mitrovica This is a serious risk to the health andeducation potential of the childrenthemselves because the developing brainand nervous system is very vulnerable todamage by lead poisoning Studies havereported a strong association betweenhigh lead levels in children’s bodies andlowered IQ, impaired attention andspeech performance (Needleman, 1993).The consequences for the potential andfuture of the population and the area arealso serious because of the effects on thedeveloping foetus as well as youngchildren A pregnant woman with willpass lead directly to her foetus throughthe placenta (Groszek, 2000) and this isespecially important in a population such

as Kosovo with a high birth rate Leadcan stay in bones for 30 years and duringtimes of increased calcium needs, such

as in pregnancy, an increase in therelease of lead from the bones can occur

The response– building the health promoting school network

WHO in collaboration with localinstitutions are currently implementing aprogramme of activities in the

Mitrovica/e area with funding from theDutch and Norwegian Governments Thisaims to decrease exposure from

environmental pollution caused byheavy metals and to raise the awareness

of the population This programme ofwork through local capacity building andworking groups include health risk

Case study

Ardita Tahirukaj, Ian Young and Geraldine McWeeney

A health promoting school approach used to reduce the risks of lead poisoning and to establish cross-ethnic

assessments, a public awareness

campaign, the development of a health

strategy (screening, diagnosis and

management protocols) and

environmental remediation activities

WHO have also established four local

cross-ethnic and inter-sectoral working

groups focusing on health, health risk

assessment, a public awareness

campaign and risk management

The Health Promoting School approach

has been chosen by the public

awareness working group, as a main tool

for raising awareness of the population

on how to live more safely in a

contaminated environment The public

awareness working group includes

officials from different sectors such as

health, education, environment,

women’s associations, The Institute of

Public Health and The Trepca Institute

In addition both ethic groups Albanian

and Serbians are represented

This multi-sectoral method of

implementation aims to improve the

environment of schools through

environmental health risk management

activities (cleaning and greening

activities) It also aims to raise awareness

in the community and local institutions

to environmental problems, their health

effects and methods to decrease

exposure Building the capacity of health

and education personnel and providing

opportunities for professional

development has been shown to be an

effective strategy in the development of

health promoting schools in other

countries (Young, 2002)

It is not possible in this short paper to

outline all of the strategic work which

has been undertaken but it is important

to understand that a multi-sectoral

approach has been used and that

capacity building has been undertaken at

the national, municipal and school levels

For example at the national level, an

Inter-ministerial Committee on Health

Promoting Schools has been established

and this committee includes

representatives from Ministry of Health,

Ministry of Education, Science and

Technology, Ministry of Environment,

Institute of Public Health, Ministry of

Youth, UNICEF, IOM and WHO

A memorandum of understanding on

health promoting schools was formalized

between The Ministry of Education,

Science and Technology and The

Ministry of Health and Ministry ofEnvironment and Spatial Planning inorder to:

1 develop policy and ensure ministerial collaboration in the areas ofhealth education and health

inter-promotion;

2 promote a healthy schoolenvironment, where pupils can acquirenew knowledge and skills;

3 improve and strengthen thepartnerships between the school,parents and community, and allagencies having a positive role in theirwelfare

There has been a considerableinvestment in training For example afour day multi-ethnic training seminarwas organized for teachers, schooldirectors, representatives from TheMinistry of Health, Ministry of Education,Ministry of Environment, The Institute ofPublic Health, Women Associationrepresentatives and representatives fromTrepca Institute This event was also ofconsiderable symbolic importance as itwas the first time representatives of bothcommunities had trained together in anyeducational sphere since the conflict

The objectives of this training seminarorganized by WHO were as follows To:

• train teachers, school directors and keystakeholders in the health promotingschools approach and include specificreference to the issue related to theheavy metal contamination of theenvironment;

• raise awareness and generate thesupport of community stakeholders;

• trial the translation and adaptation ofthe training manual, Promoting theHealth of Young People in Europe (Young, 1993) and other relevanttraining materials

– As part of the capacity building of localprofessionals who were working in thepublic awareness campaign, a studyvisit to Slovenia and Poland wasorganized The purpose of the visit to

Slovenia and Poland was to developlinks with institutions in Slovenia andPoland that are involved in field ofenvironmental research, environmentalremedial actions and public awarenessprogrammes

At school level the appointed ordinators and teachers receivedtraining, which included the following:

co-• Identifying ways to includeenvironmental health in the schoolcurriculum

• Exploring methods such as ‘startingfrom where children are’ regardingtheir knowledge on environmentpollution and reviewing how theschool, children and their families cancontribute to improving the school andcommunity environment

• Helping schools to make links withparents, mothers groups and healthpersonnel

• Exploring technical issues such asnutritional approaches to reducing theanaemia which is associated with leadpoisoning

• Exploring technical issues in reducingexposure in the children’s homeenvironment and in the school and itsimmediate environment

• Improving community participation insolving environmental health

problems

Conclusions

This programme is at an early stage butconsiderable progress has been madeover the last three years The healthpromoting school model has been shown

to be suitable as a basis for developingthe approach to a highly specific problemsuch as children being exposed to anenvironmental hazard This relates toschools being an excellent vehicle toreach the at risk target groups of childrenand pregnant mothers In addition theparents, the children’s environment andthe health services are accessible throughthe schools The educational role ofschools enables initiatives to be pursuedrelating to minimizing exposure to thepollutant in the young peoples’

environment The whole school approachcan also play a part in minimizing theeffects of exposure on the body throughvarious strategies For example throughappropriate nutritional advice and foodprovision in schools, the risks of theanaemia associated with lead poisoningcan be reduced The activities in schools

It is clear that the development

of joint training in health promoting schools is one small but important way in which the two ethnic groups can work together to improve trust and relationships for the future

also generate media coverage which helps

to reach more of the general population

As a result of increased awareness,

knowledge, skills, local capacity building,

improved environmental health conditions

and increased individual and community

empowerment, Kosovo is trying to deal

with both the source of the problem and

with minimizing the effects of the existing

pollution Blood lead levels and levels of

pollution in the environment will continue

to be monitored In the interim it is clear

that the development of joint training in

health promoting schools is one small but

important way in which the two ethnic

groups can work together to improve trust

and relationships for the future

Acknowledgements

The authors wish to dedicate this paper toall those working in Kosovo to improvethe health and environmental problemswhich affect all the people irrespective oftheir ethnic origins

The WHO Office in Pristina and KosovoHPS Inter-ministerial Advisory Committeeacknowledges the valuable and extensivecontributions of Mr Ian Young indevelopment of the HPS Programme andtraining of the officials from health,education, environment sector, schooldirectors and teachers on HPS approach

WHO Office in Pristina also wishes tothank Gay Gray, Lina Kostarova Unkovskaand Katerina Sokou who with theirexpertise contributed in the training ofteachers, health, education andenvironment officials on the HPS approach

References

Groszek, B (2000) Guidelines for the

prevention and Identification of lead poisoning in pregnant and Postpartum women Report for WHO Kosovo

Molano, S and Andrejew, A (2000)

Report on First Phase of Public Health Project on Lead Pollution in Mitrovica Region Kosovo,UNMIK.

Needleman, HL (1993) The currentstatus of childhood low-level lead toxicity

Neurotoxicology 14(2-3): 161-166.

Young, I (ed.) (1994) Promoting the

Health of Young People in Europe: A Training Manual for Teachers and Others Working with Young People.

Copenhagen, WHO Regional Office forEurope

The New ‘Dutch List’ (1999) of hazardouschemicals may be accessed at

www.contaminatedland.co.uk click on the

menu heading standards and guidelines

to view the list

resources that have addressed newneeds as they emerged In the on-goingtraining and development associatedwith MindMatters from pilot stagethrough to wider dissemination, staffhave had both personal and professionalinteraction with the material Evaluation

of the professional development withover 50,000 participants has

demonstrated that: staff are equipped toplan whole school change for mentalhealth and teach young people aboutmental health; and that engaging with thetopics was having a positive effect forstaff on a personal level This has beenconfirmed by the Hunter Institute ofMental Health2and is particularly evident

in the case study school that haspurposefully engaged in training staff as aprelude to a whole school approach

Large-scale access by the school staff toMindMatters training or alternatively,curriculum reviews, are critical factors ininsuring a more successful whole schooltake up The teachers’ professional andpersonal responses are linked, and lead

in turn to more positive interactions with

students Feedback suggested that someparticular parts of the training wereresonating with staff This includesopportunities to consider their ownexperience and emotional reactions totopics such as:

• trust and safety;

• resilience;

• grief and loss;

• coping

In addition staff wanted more information

on health and well-being Feedback alsoindicated the way that training wasconducted was important Staff valuedtime for interaction, reflection andplanning Staff indicated that focusing ontheir own ways of viewing mental healthwas valuable Staff attitudes and valuesappear to be key aspects of becominguseful role models for young people andvaluable allies for help-seeking

Background

MindMatters is a suite of Australian

government-funded mental health

promotion resources for secondary

schools1piloted in 1998/1999 It is now in

a national dissemination phase in all

states and territories It has continued to

expand through the development of

International Alliance for Child and

Adolescent Mental Health and Schools

School of Policy and Practice

Jo Mason and Louise Rowling

Look after the staff first – a case study of developing staff health and well-being

1 http://cms.curriculum.edu.au/mindmatters

2 http://cms.curriculum.edu.au/mindmatters/evaluation/ evaluation.htm

Development of Staff Matters

This awareness of the crucial role of

teacher personal engagement with

mental health resulted in money being

allocated to develop training and

materials specifically for staff in

2004-2005–as part of the whole school

approach The resultant materials ‘Staff

Matters’ developed from national

consultations, are available in a section

of the MindMatters website devoted to

staff health and wellbeing The Staff

Matters Health and Well-being at Work

Model specifically designed for

MindMatters, has emerged from the three

ellipses of the health promoting schools

concept and their critical underpinnings

(Fig 1)

The model is linked to MindMatters

materials and centres on the importance

of a person’s beliefs about health and

well-being as they apply to work The

Interpersonal recognises the influence of

the relationship with others at the work

site The Professional domain has a

potentially positive impact on work

success and access to health and

well-being information The Organisational

domain has a role in formally

encouraging and supporting health and

well-being These processes operate

within the wider community context (the

School in the Community) that can also

work to confirm, inform and reinforcehealth and well-being directions in theschool Well-being for staff as individualsand as a group depends on the positiveinteraction across all the domains

Importantly these materials are provided

in the context of there being noemployment relationship between theAustralian Principals Association whoprovide the materials and the CurriculumCorporation who host the website

Materials are also available throughschool intranet links In Australia,education is a state responsibility,consequently these materials aredesigned to dovetail with interventions

by state based education authorities

The approach

The MindMatters team felt that providingmore development time looking at thefollowing issues was critical to theteachers’happiness and longevity in theirrole

• The emotional intelligence aspects ofteaching

• Teaching styles and self efficacy

• Examining attitudes and beliefstowards health and well being

The training and website material arebeing trialled through a series ofpartnerships with schools for evaluation

of materials and delivery processes.Schools can add local contacts and moreinformation that is directly relevant totheir context

The outcome

The development and trial stage with arange of schools will occur untilDecember 2005 when a further reviewwill take place The schools will beengaged in actively contributing to thematerials as they use them for all theirstaff This consultative developmentalprocess was used for the MindMattersdevelopments for students and FamiliesMatter for parents and carers

The Thriving Self Figure 1

Case study

Following a year of armed conflict, the

project “A Safe School in a Community at

Risk” was initially designed to reduce a

general feeling of insecurity in the

children and their teachers, and to

restore the lost trust of the multi-ethnic

school and community faced with the

crisis The project was carried out in

seven elementary schools in Tetovo, a

city in the northwest of Macedonia

characterized by a rich multicultural

tradition

This initiative is based on long- term

experience and practice working with

children facing adversity Children in

communities exposed to rapid changes

such as a war or refugee crisis are forced

to learn quickly– more quickly than

children in more stable environments

Marginalised and deprived of their rights

they will, counter to all expectations,

demonstrate higher motivation and

persistence They often show greater

creativity in self-protection and support

of their own development than children

in safe communities In other words,

children under risk may be more

perceptive and skilful in recognising and

dealing with changes, something rarely

noticed by the adults and even more

rarely used for children’s own benefit

and for the good of the community

And yet, despite its enormous potential,

this challenging position of children in

communities at risk cannot persist in the

long run, especially in view of the

essentially low social power of children

in all societies This case study explores

what happens in a time-span filled with

continuous changes taking place in

children’s lives and their contributions tothe life of the community It also sets outthe necessary preconditions for suchchildren to make the crucial step towardslearning for development The paperdraws on the experiences gained in the

“Safe Schools in a Community at Risk”

Project which is a key part of theMacedonian Concept of HealthPromoting Schools

• reduce the post traumaticconsequences of war in the pupils andteachers, for the purposes of theiractive involvement in the school andcommunity life;

• build sustainable networks ofassistance and support (in the schoolsand more widely) despite the adverseliving conditions

The project aimed to achieve its goals bygradually building a strategy based onthe pupils’ potential It was therefore ahighly participatory, democratic andmulti-level approach to the problem As

the project developed, it became anongoing activity of providing conditionssupportive of teachers and childrencreating and running their own schooland multi-ethnic community-buildingprojects

The project started with networking andco-operation between teachers, schoolprincipals and pupils This was based onthe principles of voluntary participation,free choice and free multi-cultural andcreative expression, in and between theschools of the post-conflict community.The subject of “violence” was a tabootopic which was not discussed openlyoutside of families and/or circles of closefriends This issue was graduallyintroduced in a sensitive way into theschools’ project activities

In the first phase of the project–

preparations, the students were asked, for

example, to make drawings of their homes,neighbourhood, friends and the route tothe school, and to mark the places wherethey felt safe and where they could playand spend time in peace with their peers.The result was an exhibition of 550drawings organised in the Home of Culture

in the centre of the town and attended byparents, local community and otherschools, in which the children expressedtheir authentic experiences, perceptionsand needs related to their feelings ofbelonging and safety

In the second phase - research, the pupils

in multi-ethnic bilingual groups ofdifferent ages and sexes attended sixworkshops on the topic of violence andaddressed, through games in a safeatmosphere and with support from

adults, the following issues: Cooperation

and Trust, Similarities and Differences, Children’s Rights, Safe People, Safe Place and Safe Schools For most of the

children this was the first experience ofcontact, play and cooperation withchildren of similar ages but from the

Lina Kostarova Unkovska

Empowering children for risk taking– children’s

participation as a health promoting strategy in the “Safe Schools in a Community at Risk” project

Lina Kostarova Unkovska

Children in communities exposed

to rapid changes such as a war or refugee crisis are forced to learn quickly– more quickly than children in more stable environments Marginalised and deprived of their rights they will, counter to all expectations, demonstrate higher motivation and persistence

different ethnic communities that coexist

side by side without knowing each other

During these discussions the pupils

defined violent behaviour in their

schools They elucidated the following as

the most important characteristics:

• violent communications between

teachers and pupils;

• violence among children (boys and

In the follow-up they conducted related

research in their own schools The

research results were presented before

the parents and teachers, as well as to

the local community Thus the topic of

violence became the subject of an open

discussion and many debates in all of the

schools as well as in the community In

addition, the perception of the children

and their competence in dealing with

risk-related issues in their everyday lives

and their environment began to change

Soon after this the children, now with a

new self-confidence and in cooperation

with young artists, produced and

performed The Ideal Safe School, a

one-day event in the “Home of Culture.”

Seven groups of children (156) from all of

the schools used seven different modes

of expression (drawings, instalations,

movement, music, graffiti, mosaics and

drama pieces) to create their own

“Visions of an Ideal School– A School

Free of Violence” This was later

performed for a broad audience from the

local community

In the final phase– action, the five

inter-school pupils’ projects demonstrated the

richness of children’s creative potential

to cope with violence The projects

defined and carried out as responses to

violence, started to relate to: Bonding,

Young People and Smoking, Game – Boys

and Girls, Me and the Other, and

Dictionary (terms and phrases related to

the school life, contributed by children

from three ethnic communities –

Macedonian, Albanian and Turkish)

Conclusion

The pupils’ projects showed that if, in the

midst of a crisis, a safe and stimulating

micro-environment is created and

safeguarded it may stimulate children’s

creative and non-violent responses Assuch, it becomes more possible to buildthese responses into permanent, positiveexperiences that will nourish the growthand development of the community

This health promoting approach tochildren in a community in crisis, isbased on the principles of democraticparticipation, the holistic concept ofhealth (well-being), and its

developmental determinants such ascreativity and play This unifyingframework may be used in the dynamicshaping of the micro-environment(group, class, school) to guarantee safetyand a feeling of belonging, in lifesituations most difficult for children

Within such a frame, children’s personalexperiences of action expressed throughtheir numerous performances as creators

or leading characters, will foster thedevelopment of children’s ownsignificance and an awareness of theirnew roles This may be also recognised

as an attempt to respond to the challenge

of transforming a dangerous environmentand threats into experiences shapingtheir own well-being and the well-being

is their hopes and dreams for the future.This health promotion approach to thecrisis, in which adults recognise andutilise children’s energy and potential,can help the community be transformedinto a landscape that nourishes

development and health for all

HPS in action

Russian-speaking pupils in health role play in school 9, Ferghana, Uzbekistan

This case study draws on findings from

a survey undertaken by the authors in

the spring of 2004 of 500 urban schools

(primary, junior secondary and senior

secondary) within three cities in

Liaoning Province of China on the basis

that the cities represented the upper,

middle and lower levels of city economy

potentials based on the GDP per person

within the province

In China, health education programmes

have existed in schools for many years

The traditional health education

programme has been characterised by

centrally-led, top-down messages and

methods (Wang, 2000), which has led to

the establishment of a health education

curriculum in primary and junior

secondary schools on the basis of the

policy jointly issued by the Ministries of

Education and Health of People’s

of teachers, developing pupils’lifeskills, school attainment by gettingpupils to achieve their best, pupilinvolvement in health policydevelopment, pupil accidentprevention (traffic/swimming/other);

• Increased focus on improving pupils’

physical, mental and social health andfitness as opposed to just addressingphysical health as was the case in thepast, thus encouraging a positiveattitude towards health;

• The promotion of a healthy lifestyle byencouraging a good relationshipbetween staff and pupils in a caringand supportive environment;

• In accordance with national andprovincial policies, the seniormanagement group (consisting ofheadmaster, deputy-headmaster andother related staff) are charged withimplementing the school healtheducation policy, thus giving it greaterstatus and importance In many cases,these senior people in schoolmanagement have receivedprofessional background training inmedical science;

• The implementation, since 1994, of anindependent health educationcurriculum to all grades within theschool timetable;

• The allocation of on average, 20minutes per week to the healtheducation curriculum, which fits inwith the 1994 National HealthEducation policy of 0.5 lesson perweek;

• The use of standard textbooks asapproved by the National EducationDepartment or Provincial EducationDepartment;

• The delivery of the health educationcurriculum by teachers who hadresponsibility for other curricula, forexample, physics or health-careteacher (school nurse) or by a full-timespecialist teacher such as the schooldoctor;

• The availability of occasional in-servicetraining for health education teachers;

• The support and involvement ofDistrict Health Education/Promotionunits in health education teaching;

• The adoption of a whole schoolapproach to health education via thetaught curriculum as well as non-timetabled school practices

Reference

Wang, R.T (2000) Critical health literacy:

a case study from China in

schistosomiasis control, Health

Promotion International, 15, 269-274.

Malcolm Thomas and Wenyan Weng

Health promotion practices in Chinese urban schools

Malcolm Thomas

Senior Lecturer

School of Education and Lifelong

Learning

University of Wales Aberystwyth

Old College, King Street, Aberystwyth

SY23 2AX, Wales

United Kingdom

Email: mlt@aber.ac.uk

Wenyan Weng

Post-doctoral Research Fellow

School of Education and Lifelong