Health Education Research, Vol. 14, No. 1, 51-69,
February 1999
© 1999 Oxford University Press
The opportunities and effectiveness of the health promoting primary school in improving child health— a review of the claims and evidence
Faculty of Health and Behavioural Sciences, Deakin University, Melbourne, Victoria 3125, Australia
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Abstract |
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 Top Abstract IntroductionThe development of the...The structure of the...The potential and real...What the literature tells...Issues in assessing the...References |
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School health programs have been part of schooling for most of this century. The health promoting school is a recently developed concept which seeks to provide a multifaceted approach to school health. Will it provide a better framework to assist schools address the health issues of their students? This paper examines the development of the health promoting school and identifies its structural components. It reviews the claims and evidence which have emerged from the school health research literature which focus on primary schools. Findings indicate health gains for primary school students are difficult to assess, and will most likely occur if a well-designed program is implemented which links the curriculum with other health promoting school actions, contains substantial professional development for teachers and is underpinned by a theoretical model. The paper concludes by discussing how improvements can be made in more accurately assessing the effectiveness of the health promoting primary school in improving school health
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Introduction |
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TopAbstractIntroductionThe development of the...The structure of the...The potential and real...What the literature tells...Issues in assessing the...References |
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The health promoting school has emerged in the last decade as a new framework to assist schools in addressing health issues. It has been strongly promoted by the WHO and is being implemented in many countries throughout the world. Is it a better way of approaching school health? What are its building blocks and what is the evidence that they are useful in school health initiatives?
This paper examines the potential of the health promoting school as an overarching framework for primary schools. It begins by documenting the development of the concept, details the component parts of the health promoting school, summarizes the literature for the claimed benefits (both potential and real) and concludes by examining the issues to emerge from using the health promoting school framework as a template for health in primary schools.
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The development of the health promoting school |
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TopAbstractIntroductionThe development of the...The structure of the...The potential and real...What the literature tells...Issues in assessing the...References |
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The WHO has played a key role in shaping the directions of school health.
In the last 50 years the WHO has produced many reports which have identified issues, raised awareness, detailed morbidity and mortality data, and provided policies and guidelines for governments, agencies and practitioners as they address health in their constituencies. Many of these have focused on children and adolescents.
The early genesis for the health promoting school can be traced back to 1950 when the WHO established an Expert Committee on School Health Services. The report of the committee argued for the development of more comprehensive curriculum programs in health; teaching and learning methods, which were less instructional and didactic; and more comprehensive preservice training in health for teachers (WHO, 1951). The Report of the Expert Committee on Health Education of the Public which was produced in 1954 took school health into new areas when it suggested that those engaged in both the school and non-school sectors in health education activities should work more closely together, particularly during their training (WHO, 1954). Jones et al. (1995, p. 122) state that "although this document did not use the current language of health promoting schools, many of the criteria now specified for such schools are mentioned in this early document".
In the early 1960s a number of conferences and meetings took place between the WHO and the United Nations Education, Scientific and Cultural Organization (UNESCO) to determine how school health could be improved. A publication was released in 1966 which was one of the first international documents to address pragmatically the planning and implementation of school health programs (WHO, 1966).
The WHO continued to produce reports and documents about child and adolescent health during the late 1960s and early 1970s, although there was nothing as specific as the 1966 document which focused on planning and implementing school health. Most were about summarizing the emerging international epidemiological data on the health of young people. Reference was often made to the role of schools as a useful setting to improve the health of the young.
In their detailed analysis of these documents and technical reports, Tones and Tilford (1994, p. 123) claimed
...a number of similar principles and recommendations can be seen running through the documents: the need to recognize the two-way relationship between health and education; the matching of health education programmes to local needs and problems, enhancement of the role of schools in local communities by establishing closer relationships between children, teachers, parents and community members; greater co-operation between health, education and social authorities and increasing inter disciplinary collaborative research; basic and interdisciplinary health education training for teachers, and the use of innovative teaching methods including the participation of children in community health project.
The building blocks of the Health Promoting School and Comprehensive School Health Education (CSHE) frameworks which emerged in the 1980s and 1990s had clearly been articulated a number of years earlier.
Another influential stimulus for school health is to be found in the Declaration of Alma Ata (WHO, 1978). This statement came out of a major International Conference on Primary Health Care held in Alma Ata, which called on all Governments "to formulate national policies, strategies and plans of action; to develop a multisectoral approach, to involve citizens in planning, organization, operation and control of primary health care; and to focus on education as a means of preventing and controlling health problems" (WHO, 1978, p. 5). The Declaration of Alma Ata was the first international attempt at this level to identify the myriad of factors influencing health and to provide a focus for developing strategies by the members states of the WHO.
The focus of the Declaration of Alma Ata (`Health for All by the Year 2000'), prompted a closer examination by governments and health authorities about how this could be achieved. The Ottawa Charter for Health Promotion (WHO, 1986a) was another major milestone in shaping the direction of health promoting schools.
Its five key planks, i.e.
- build healthy public policy
- create supportive environments
- strengthen community action
- develop personal skills
- reorient health services
established a clear framework for health promoting schools, and influenced how different countries and regions developed their school health initiatives.
The Ottawa Charter for Health Promotion provided an easily understood framework for the emerging settings approach, where the settings of schools, worksites and cities became the vehicles through which better health was actioned (Kickbusch, 1989; Baric, 1994
).
A major document on Health Education, sponsored by the WHO and the International Union for Health Education (IUHE)—it added health promotion to its title a few years later—was distributed and discussed at the XIV World Conference on Health Education in Helsinki, Finland in 1991 (Dhillon and Tolsma, 1991). It identified schools as a key setting where health education ought to be focused. Perhaps more importantly, it made an attempt to explore the place of education, including schools, in the context of the prime WHO statements—the Declaration of Alma Ata and the Ottawa Charter for Health Promotion. It claimed that health behavioural change or maintenance is the main outcome of all definitions of health education. However, it expanded the traditional focus on behaviour, which it suggested was about an individual's own health practices in nutrition, sexuality, drug use, etc., to behaviours that involve advocacy, empowerment and support, i.e.
- Advocacy—to heighten public awareness and interest to impel societal forces that influence public policy and resources to support health.
- Empowerment—to help people develop knowledge and skills to make positive health choices and the ability to act individually and collectively to improve health.
- Support—to foster healthful social norms, alliances and systems that are sensitive and responsive to the health needs and conscience of the people. (WHO, 1986, p. 8)
WHO further increased the momentum for school health with its School Health Initiative.
This initiative was established by the Health Education and Health Promotion Unit of the Division of Health Promotion, Education and Communication of the WHO at its Geneva Headquarters in 1994. A WHO Expert Committee on Comprehensive School Health Education and Promotion met in 1995 to examine the status of school health and
...to make recommendations on policy and action steps that WHO and its Regional Offices, other United Nations agencies, national governments and non-governmental organizations can take through schools and communities to improve the health of young people, school staff and families. (WHO, 1995b, p. 4)
The committee commissioned 34 feeder papers on various aspects of school health. Information from these feeder papers was synthesized into three background papers, i.e. (1) `The Status of School Health', (2) `Barriers and Strategies to Improve School Health Programmes' and (3) `Research to Improve Implementation and Effectiveness of School Health'.
All these actions have set the scene for and established the frameworks of the health promoting school.
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The structure of the health promoting school |
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TopAbstractIntroductionThe development of the...The structure of the...The potential and real...What the literature tells...Issues in assessing the...References |
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Health promoting primary schools have grown considerably in number during the 1990s. They have their origins in the WHO initiatives and programs developed at country level. There have been major initiatives in the European and Western Pacific Regions of WHO, and in Northern America, particularly with CSHE in the US. All these initiatives have sought to move beyond classroom lessons and to encapsulate the directions of the Ottawa Charter for Health Promotion.
In 1991 the European Network for Health Promoting Schools (ENHPS) was created in Copenhagen, Denmark. It is a project which is managed jointly by the Council of Europe, the European Commission and the WHO Regional Office for Europe. A pilot project began in 1991 in three countries, Poland, Hungary and Czechoslovakia. The President of the European Parliament announced in late 1992 that the Committee on Culture, Youth, Education and the Media had been asked to draw up a report on school health. In a major decision at government level, the European Parliament called on the Commission for European Communities and its member states to:
...[encourage] the establishment throughout the community of pilot projects which adopt a comprehensive approach to health education by involving not only schools, but also families, local communities, sports clubs, voluntary services, etc... These measures should be pursued as an integral part of the European Network of Health Promoting Schools Projects. (European Parliament, 1993
More countries joined the project in 1992 and in 1997 about 37 countries are participating to varying degrees.
Schools are selected if they meet a number of key guidelines (McDonald and Ziglio, 1994):
- A commitment to 3–5 years involvement.
- Prepared to follow the guidelines for health promoting schools.
- Allocating local resources to their initiatives.
- Identifying health promoting schools activities as a key priority.
- Establishing intersectoral partnerships with relevant local groups.
- Tackling local health issues in the context of wider European issues.
- Developing high quality practices.
- Implementing actions to improve the health of the young.
- Upholding principles of ecological and social responsibility for personal and community health.
- Effectively managing the project.
- Facilitating evaluation and disseminating results.
The WHO's (Geneva) invitation to its regional offices to adopt the concept of health promoting schools has been taken up enthusiastically by the various regional offices of WHO. The activities in two of these global areas are described briefly.
The Western Pacific Region of WHO (WPRO) has the largest population in the WHO networks. It includes countries as large as China (approximately 1.2 billion); as developed as Japan, Singapore and Australia; and as small as Nuiai (population 2000) and a number of other Pacific Island Nations. The legitimacy of health promoting schools in the region is to be found in a key policy document New Horizons in Health which was adopted by the region's 32 member states in 1995.
During 1995 a set of Guidelines on the establishment, improvement and maintenance of health promoting schools was produced and endorsed by the member states.
The framework of the guidelines consisted of components and checkpoints for health promoting schools in six areas (WHO, 1996):
- School health policies.
- The physical environment of the school.
- The school's social environment.
- Community relationships.
- Personal health skills.
- Health services.
The guidelines invited schools and their systems to develop a charter for a health promoting school through discussions
...between teachers, students, health care workers, families and key members of the local community...[which]...should be displayed prominently in the school and will serve as a signal to all about the school community's commitment to and actions towards enhancing the health of the students. (WHO, 1996, p. 17)
In the US, the Surgeon General's Report on Health Promotion and Disease Prevention which was published in 1979 placed great value on the health of children and adolescents, and how the young could be supported through more comprehensive health programs at school (USDHEW, 1979). This report was one of the major elements to have a marked effect on how school health was developed in the US during the 1980s. The American Cancer Society and the Centre for Disease Control (CDC) in Atlanta, also played very significant roles.
During the early 1980s, school health in the US was shaped by three domains—classroom health instruction, school health services and a healthy school environment (National Professional School Health Organizations, 1984). Programs appeared to focus on these areas with little attempt to integrate health themes. A significant shift occurred in the late 1980s following Allensworth and Kolbe's expansion of the CSHE model from three to eight components (Allensworth and Kolbe, 1987). The additional five components, i.e. school food services, school site health promotion programs for staff, school counselling and psychology programs, school physical education, and integrated community and school health promotion efforts, spelt out a much broader focus for school health and moved the CSHE framework further away from classroom curriculum. The map reflected the five elements of the Ottawa Charter for Health Promotion which was developed 1 year earlier, and provided schools, government jurisdictions and departments, and health organizations with a framework to facilitate an integrated approach to school health.
A series of major reviews of CSHE programs by Allensworth (1994), English (1994) and De Graw (1994) found a number of themes emerging from the developments in CSHE in the late 1980s and early 1990s. Key ones were an increased focus on the needs of students; more emphasis on integrated and co-ordinated school and community partnerships; and a more definitive documentation of outcomes. Jackson (1994) argued that a new paradigm for comprehensive school health was emerging. She highlighted the moves from:
- School-based to school-wide and community programs.
- Formal instruction to needs driven, skill based classroom education.
- An emphasis on health information to health attitude and value clarification.
- Health education to health promotion with its strategies and community-wide focus.
- School centred approach to an interdisciplinary, interagency team approach.
- Teaching skills in isolation to a focus on generic health skills (e.g. media analysis, assertiveness, coping, problem solving).
The concept of the health promoting school had now emerged internationally with considerable commonality between the structural frameworks in the different regions.
However, what is the evidence that it is a better way to approach school health programs? The paper now summarizes some key claims about the efficacy of health promoting schools and describes the available evidence which is cited to support the usefulness of health promoting schools.
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The potential and real benefits of the health promoting school |
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TopAbstractIntroductionThe development of the...The structure of the...The potential and real...What the literature tells...Issues in assessing the...References |
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The literature identifies a number of potential and real benefits of health promoting schools. Those which are identified relate to benefits which should occur if schools had a comprehensive framework for school health which encompasses skill development, physical and social environments, integrated health services, attention to equity issues, community partnerships, and closer involvement with parents. There is little attention in the literature to school health policy and it is difficult to identify evidence to support the efficacy of establishing health school-based policies.
This section summarizes the benefits of the health promoting school which are claimed in recent literature. Where appropriate, data is cited to portray what has emerged out of the research into the effects of health promoting schools. However, the data needs to be viewed with some caution as a justification for health promoting schools. It primarily relates to topic-based interventions, which largely are implemented through only one or two of the building blocks of health promoting schools.
Research into health promoting schools is only just beginning. There is some debate about the direction it should take and its philosophical basis (Kelly, 1989; Rawson, 1992; Cohen 1995; WHO, 1995a,b). There appears to be no research into discovering whether education and health outcomes are better or worse from schools with a health promoting school focus than those which primarily address health through classroom-based instruction.
The health promoting school model has been portrayed as a most promising framework which should produce better health outcomes for students, now and into the future. Those who support this view claim that by linking the curriculum with the school environment and community, a greater range of the factors which affect students' health will have a better chance of being addressed, than if only explored through classroom curriculum (Green et al., 1980; Young and Williams, 1989; Hamburg, 1990; Kolbe, 1993; Allensworth, 1994; WHO, 1994 WHO, 1996; Dommers and Ingolby, 1996; Rowling and Ritchie, 1996; NHMRC, 1997).
There are some studies which have addressed specific health issues, usually smoking, alcohol, sexuality and physical activity, which indicate major health gains for children will occur if the strategic intervention is multifaceted. Most relate to post-primary schools and are impressive in their findings, e.g. tobacco (Tobler, 1986; Vartiainen et al., 1991; Perry et al., 1992), alcohol (Ellickson and Hays, 1992; Irwin, 1993), sexuality (Vincent et al., 1987; Walker and Vaughan, 1993; Kirby et al., 1994) and physical activity (Tell et al., 1984; Kuntzleman, 1985; Vartiainen, 1991). These studies suggest the health promoting schools approach is a most promising framework to address school health.
Educational outcomes
The literature indicates that effort which is directed at improving the health of students and the settings in which they learn also appears to enrich and improve educational outcomes. Recent major reports and studies cite various forms of evidence which suggests that children learn better if they are healthy (Arya and Devi, 1991; Lavin et al., 1992; Igoe, 1993; World Bank, 1993; Levinger, 1994; WHO, 1995b; NHMRC, 1997). Common themes run through this literature which indicate learning is faster, more comprehensive and is enjoyed by students if they are healthy. The health promoting school appears to offer an approach which increases the learning capacity of students. It provides the contextual setting for learning where the individual's health is overtly addressed.
The health promoting school approach also appears to enrich classroom-based learning outcomes, e.g. knowledge acquisition, decision making. Evidence in the literature indicates that learning goals and aims expressed in educational terms are enhanced if a broader and more comprehensive focus to school health is adopted (Kalnins et al, 1992; Lavin et al., 1992; American Cancer Society, 1993; Peters and Paulussen, 1994; Allensworth, 1995; Cohen, 1995; Collins, 1995):
Healthy school policies
There is little evidence which supports the policy component of the health promoting school. It appears that few studies have been conducted which compare health outcomes in schools which have a specific health policy with those which do not. Given that many schools in Australia, for example, have implemented policies on sun protection `no hat—no play'; in bicycle safety `no helmet—no bike at school'; in bullying and violence; in canteen and food services; in equity issues, e.g. girls' accessibility to play areas; in physical activity—daily aerobics; then it is somewhat surprising that more comprehensive evaluation has not been undertaken. Some data from Victorian primary schools through the Health in Primary Schools Study (HIPS), e.g. Bates and Tacey (1992), Beardall (1992) and Purves and Sampson (1992), suggests some health gains for children were achieved where the school adopted a specific policy, but none of these studies involved control schools.
The policy component in most of the major international and national documented frameworks of health promoting schools is not supported by evidence which indicate tangible health benefits can be achieved because policies are in place. The most comprehensive attention to school based health policies is in the WHO Western-Pacific Region Guidelines for Health Promoting Schools (WHO, 1996). Here policy statements account for 11 of the 30 identified components of a health promoting school. There is no evidence offered to support the strong focus on policy as a way of improving health.
Health services
The health sector has always interconnected with schools. This has usually been to screen and/or treat children, with some attention given to preventative measures. The literature suggests that school health services could be more effective if attention was given to working collaboratively on partnerships (Shilton, 1993; Brellochs, 1995; WHO, 1996; NHMRC, 1997) and "where school health services be integrated with other components of a health promoting school" (Cohen, 1995, p.27). Kolbe (1993) argues that better partnerships are possible, but need both the education and health sectors to work more closely together to develop organizational and intervention strategies which are consistent with the needs of the school community. Again, the literature argues the potential benefits, rather than providing evidence of the real benefits.
Local community
The frameworks for health promoting schools all address partnerships with the local community (WHO, 1993b, 1995b, 1996; Dommers and Ingolby, 1996). There are few studies which show how these partnerships may be established and how they may contribute to better health outcomes for students. Those which describe, explain and evaluate actual school community partnerships suggest that (1) such arrangements are very labour intensive and involve considerable time in bringing the various stakeholders together with a shared understanding, and (2) the key participants in the education sector (school teachers and administrators) and the health sector (clinicians, counsellors and providers) have a poor understanding of what the other sector, its work sites and customs can provide to meet the goals of their own sector (Minkler, 1991; Goltz, 1992; O'Neill, 1992; Kalnins et al., 1994).
Physical environment
All major frameworks of health promoting schools address the physical environment. These range from buildings which are comfortable, ventilated and adequately lit; to drinking, washing and toilet facilities; to play space; to playground protection (trees, covered areas); to recycling of renewable resources and appropriate disposal of waste (Young and Williams, 1989; American Cancer Society, 1993; WHO, 1993c, 1995a, 1996; Dommers and Ingolby, 1996; NHMRC, 1997). They argue that if the physical environment is appropriate for children, then conditions for health are therefore established which will reduce the risk of injury and disease. There is comprehensive evidence which indicates that inappropriate physical environments will contribute to poor health. This data has been in the health literature over many years, particularly where it relates to sanitation, fresh water, pollution and physical injury (Rowe, 1987).
Studies in the architectural area have demonstrated the influence that buildings and their surrounding areas can have on the mental well-being of the occupants and their capacity to enjoy life (Orloske and Leddo, 1981; McKenzie and Williams, 1982; Wulf, 1993). Studies also show the importance of adequate illumination (Hathaway, 1982; Nkinyangi and Van der Vynckt, 1995).
Social environment
This is described in many ways in the frameworks and uses different terms such as `psycho-social environment' (WHO, 1995a; Young and Williams 1989) and `school ethos' (NHMRC, 1997). The WHO (1996) framework typifies the range of areas under this heading and identifies specific school structures and functions which contribute to the social environment, such as discipline procedures; physical and verbal violence reduction strategies; cultural, religious and tribal celebrations; and support mechanisms for students with a physical and/or learning disability. Research also indicates that the experiences children have at school are factors in determining their health behaviours during adolescence and beyond (Pink, 1989; Hawkins and Catalano, 1990; Nutbeam et al., 1993). Schools which provide a place of enjoyment and peace are more likely to produce students with enhanced health and educational outcomes (Forman and O'Malley, 1985; Zins and Ponti, 1985; Calabrese, 1987; Hoy et al., 1991; Hurrelmann et al., 1995; WHO, 1995a). The school social environment is difficult to assess but there appears to be enough substantive research to suggest it is a key plank of health promoting schools.
Cost effectiveness
Recent reports have addressed the advantages of integrated and comprehensive school health, from a financial investment perspective (World Bank, 1993; Rothman et al., 1994; WHO, 1995b). There are a limited number of studies, "rigorous cost-effectiveness analyses or models are still rare" (WHO, 1995b, p. 4); however, some studies, particularly those undertaken by Rothman et al. (1994), have shown promising results in three topic areas of the school curriculum, i.e. smoking, substance abuse and sexual behaviour resulting in unplanned pregnancy. They reviewed programs which they classified as exemplary and which met five criteria, i.e. (1) positive change in behaviour, (2) greater than 1 year of behavioural data, (3) was school classroom based, (4) results were recent (since 1982) and (5) the studies had a control group.
The exemplary programs were further restricted to those studies for which behavioural outcomes were presented as prevalence rates, i.e. change per population of risk. (Rothman et al., 1994, p.2)
They found that the benefits of an integrated, quality Comprehensive School Health Program to be 26.5 for smoking, 5.7 for substance abuse and 5.1 for sexual behaviour, where the benefits accrued are 26.5, 5.7 and 5.1 times the cost of the program, respectively. They claimed the overall cost–benefit ratio of exemplary Comprehensive School Health Programs to be 13.8, which compares favourably with other child and adolescent programs of a more biomedical nature, e.g. 14.0 for vaccination for measles, mumps and rubella; 11.1 for whooping cough vaccination; and very favourably with adult-based programs in non-school settings, i.e. blood pressure control in the work site, 2.7, and a comprehensive work site health promotion program, 3.4.
These results, whilst encouraging for the advancement of the health promoting school concept for primary schools, should not be seen as proof of the cost-benefit of health promoting schools. They only addressed positive outcomes of school health programs and ignored the large number of programs which did not have the rigorous planning, control group comparisons nor necessarily positive results. Also, the three topic areas were directed at adolescents. There appears to be no evidence in the literature which addresses a cost-benefit analysis of school health in primary schools.
Pupil skills
All frameworks for health promoting schools focus on enriching student skills. Specific comment is made in most of them, e.g. `students have opportunities to gain skills with respect to specific and relevant health issues' (WHO, 1996, p.14); "skills such as decision making negotiating and problem solving are an important part of the curriculum and should be constantly emphasized" (WHO, 1993a, p.12); and "special skills students need include techniques for problem solving, decision making, refusal skills, negotiation, media analysis, assertiveness, behaviour contracting and mediation" (Allensworth, 1993, p.16).
There is a commonality of the skills, e.g. decision making, problem solving, communication, critical thinking, etc., which are cited in the frameworks. Also, there is an emphasis on age-appropriate knowledge which is useful to sustain one's health and which forms a basis for lifelong healthy practices. The focus on knowledge has shifted from an instructional approach to reflect current understandings about how children learn. The documents and their accompanying guides and manuals, where present, place a strong emphasis on interaction and participatory learning methods, and on involving pupils in many outside class and community activities which require different approaches to the teacher-dominated classroom curriculum.
The skill component of school health has been documented extensively in the literature, and there is now a deeper understanding of what works, what does not and why, in school health than there was 20 years ago.
This paper now identifies the outcomes and learnings of a select number of health education and health promotion programs which have been implemented in primary schools.
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What the literature tells us about health promoting primary schools— a look at 11 key studies |
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TopAbstractIntroductionThe development of the...The structure of the...The potential and real...What the literature tells...Issues in assessing the...References |
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The selection of programs reported was based on the available literature which described and analysed interventions focused on young children within the primary school context. It drew on programs from the literature which were often cited in publications, and which appear to have been rigorously designed and evaluated. It also reflected the contributions of Gatherer, et al. (1979) and Peters and Paulussen (1994) in their comprehensive published reviews. It includes some studies prior to the `legitimization' of the health promoting school in the late 1980s because these studies appear to have utilized health promoting school approaches.
The data is presented in Table I and reports on
- The study description.
- Author.
- Year level.
- The focus of the program.
- Outcomes.
- Issues.
- The presence of the components of a health promoting school, i.e. school health policy (SHP), physical environment (PE), social environment (SE), community partnerships (CP), personal health skills (PHS), comprehensive health curriculum (CHC), integration with health services (IHS) and infrastructure support.
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A set of asterisks and dashes provides an overview of the focus of the program, with two asterisks indicating strong emphasis in this area and a dash indicating no apparent concentration.
The select literature review is presented to map how major primary school health studies have connected with the health promoting school framework. Nearly all these studies did not use the concept of the health promoting school as their theoretical frame of reference. It is therefore useful to check their stated successes and failures with the framework and to see if any trends emerge which might provide support to the claimed usefulness of the health promoting school framework.
The above summaries and other macro evaluations, e.g. Lavin et al. (1992), Bremberg and Arborelius (1991) and NHMRC (1997), show the health gains from school health initiatives are minimal. It is only in those programs which have been very well resourced and where the evaluation has been comprehensive that gains of some substance appear to emerge.
The studies in Table I
also indicate other trends:
- Professional development for teachers as part of a school health program was minimal. Where it was comprehensive, there appeared to be increased skills in teachers and more commitment by them to sustaining the innovation.
- Working with parents and local community groups enhanced the health gains of a program. The studies indicated this was time consuming and required additional skills by teachers.
- Health gains from curriculum materials largely depended on the engaging nature of the material, and how it involved students in independent (and family) thinking and actions. There was also rapid and significant decrease in the various gains after the curriculum program had finished.
- The most used component of the health promoting school was `personal health skills' (in all 11 studies).
- Very little attention was given to developing school health policies (four out of 11 studies).
- Intersectoral collaboration appears to facilitate the comprehensiveness of school health programs and has the potential for significant health gains. Eight of the 11 studies involved partnerships with the local community, and seven of the 11 studies demonstrated relationships between selected health services and the school.
The macro analyses of school health interventions and innovations by Bremberg and Arborelius (1991), Lavin et al. (1992) and NHMRC (1997) show additional trends:
- Less than 20% of rigorous school health evaluations address primary schools.
- Lack of preservice teacher training is a major barrier to `successful' school health programs.
- The most promising gain in health outcomes occur in programs where the curriculum is integrated with broader school and community initiatives.
- Social Learning Theory (Bandura, 1977) is the major theoretical model underpinning school health initiatives.
- The judgement of the outcomes of most school health programs is based mainly on health indicators rather than educational measures.
The paper now raises a number of issues about the purposes of school health programs in primary schools, and associated evaluation and research questions, and the usefulness of the health promoting school as an organizing framework.
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Issues in assessing the effectiveness of the health promoting primary school and the way forward |
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TopAbstractIntroductionThe development of the...The structure of the...The potential and real...What the literature tells...Issues in assessing the...References |
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The question—what should be the outcomes of school health programs?—is not discussed widely or consistently in the literature. Measures of school health programs are made on areas as diverse as knowledge, attitudes, health practices and educational gains. It is here in both the health practices and educational gains categories where the literature is confused. There is an assumption in the literature that school health in primary schools is about developing behaviours which are health enhancing, and programs should be designed and implemented to achieve these goals. It is often assumed that there are appropriate behaviours and inappropriate ones. Certainly the literature in the biomedical area makes clear links between health problems and a persons use of drugs; amount and type of physical activity; sexual practices; traffic behaviours; food purchase and eating behaviours; and the capacity to cope with life's stressors. These increasingly substantiated links have formed the basis for school health for nearly a century. However, the majority of interventions in schools about health for young children will (at best) probably not be able to produce health outcomes until later life. Skin cancer as a result of inadequate sun protection is a typical example. It does not manifest itself until well into adulthood. Yet biomedical research indicates that if children are constantly in the sun without protection they are far more susceptible to later life skin cancers than children who use sunscreen and wear protective clothing.
School health has difficulty, particularly for programs directed at young children, in clearly demonstrating the health gains at the end of a program. Some exceptions are in dental health programs, although with many countries now mandating fluoridated water, the outcomes of the traditional dental health programs are now difficult to show. The evidence about the effectiveness of physical activity programs and nutrition programs, whilst better than most health areas, is compromised by methodological difficulties, e.g. the reliability of certain physiological tests on young children. Primary schools have trouble demonstrating outcomes of sexuality and drug programs because of the legal constraints society imposes on young children. Also the development of mental health in primary schools is very much in its infancy, and would have major problems in evaluation approaches because of the difficulties associated with defining and measuring such factors as stress and coping.
It is appropriate that a closer relationship be developed between the health and education sectors around school health. The health sector have largely ignored the vast literature on school organization and improvement, teaching and learning practices, professional development, and innovation and dissemination. Many of the morbidity and mortality indicators upon which school health programs and interventions are based become the guiding beacons for health resources and topic-based interventions. However, schools are complex places and the way forward in school health requires more sophisticated theoretical models which are based on both health and educational frameworks. Similarly, a debate needs to occur about appropriate short-, medium- and long-term indicators for primary school health. Some promising work has already begun (Bruun-Jensen, 1994; Booth and Samdal, 1997) but more effort needs to be directed at understanding what actually occurs in primary schools which impacts on the health of students, and similarly a broader view of health for young children needs to emerge which is beyond that which is shaped largely by morbidity and mortality data. The Life Skills approaches as described by Botvin (1985) and WHO (1993) appear to offer some possibilities in addressing this issue.
It appears there should be further exploration of the educational outcomes of school health. Certainly these are assessed in primary schools in many countries as part of the usual evaluation of learning gains. However, problem solving, communication and analytical skills do not have the same authenticity to the health sector as demonstrable changes to health behaviours. They are rarely the subject of the studies reported in the school health literature.
A new way is required to look at school health in primary schools. The health promoting school has gained popularity in the last 8 years as an organizing framework to address the health and welfare of children and adolescents. Will it provide a more realistic construct for school health? Who is driving it and does it promise better results than traditional school health education? Are there better and more reliable measures and indicators associated with it so the proponents, workers and stakeholders in school health can have a clearer understanding of the results of their efforts?
The education and health sectors appear to have different goals for school health. Both agree on the importance of school health, with one upholding educational principles and practices in learning, and the other seeking specific changes in health behaviours and indicators. The outcomes of these different purposes are, on the one hand, classroom-based curricula directed at enriching health learning, and, on the other, guidelines and frameworks designed to improve health indicators and reduce morbidity and mortality data.
The health promoting school has been shaped by the health sector. It is explicitly designed to facilitate health gains. Its building blocks have been developed to assist schools to take a more integrated and comprehensive view of health. The framework appears to be relevant and supported by teachers (WHO, 1995b; St Leger, 1996). However, there is a long way to go before the eclectic nature of the health promoting school is used as a planned strategy by individual schools. Teachers and other school personnel need guidance, professional development and resources to embrace its components through action. In addition there will need to be substantial changes in how schools and their personnel practice school health. Also it may be unrealistic to expect teachers to adopt the agenda of the health sector and involve themselves in more direct interventions outside the classroom which seek to improve the health of their students.
The health promoting primary school, which shows great promise, will only gain momentum if it is owned and used more intensively by teachers and schools. For this to occur, the education sectors in different countries will need to reassess their core business of facilitating learning to include intervening more comprehensively in non-classroom-based initiatives which are focussed on health gains.
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