Health Promotion International Advance Access originally published online on July 5, 2006
Health Promotion International 2006 21(3):209-218; doi:10.1093/heapro/dal020
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
System-wide adoption of health promotion practices by schools: evaluation of a telephone and mail-based dissemination strategy in Australia
1 Hunter New England Population Health, Hunter New England Area Health Service New South Wales, Australia 2 University of Newcastle New South Wales, Australia
Address for correspondence: Mrs Jenny Knight, Hunter New England Population Health, Locked Bag 10, Wallsend NSW 2287, Australia E-mail: Jenny.Knight{at}hnehealth.nsw.gov.au
 |
SUMMARY |
|---|
 TOP SUMMARY INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
Schools can potentially benefit from system-wide approaches to the dissemination of health promotion practices. This intervention study undertaken in the Hunter Region of NSW, Australia, used a pre-post design to assess whether a phone and mail intervention dissemination strategy was associated with an increase in the proportion of 218 primary schools undertaking eight health promotion practices. Health promotion practices addressed the prevention of harm associated with five agreed health issues—smoking, nutrition, playground safety, asthma and infectious diseases. The study also assessed acceptability of the dissemination strategy to schools, cost and whether intervention schools’ characteristics were associated with uptake of health promotion practices. Compared to baseline a significant improvement in prevalence was observed at both 1 and 2 year follow-up for seven of the eight health promotion practices addressed. The greatest improvement occurred in the first year of the project. There was a greater uptake of the practice of providing information regarding passive smoking in urban schools. The dissemination strategy was found to have a cost per adopted practice of $A121, and to be acceptable to the large majority (>90%) of schools. The results suggest that the dissemination strategy may represent a relatively low cost method of enhancing health promotion practices in schools and of monitoring such practices. Further research addressing the methodological issues of this study is needed to confirm these findings.
Key words: computer-assisted telephone interview; health promotion; primary schools
|
INTRODUCTION |
|---|
|
TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
To improve the health of a population there needs to be widespread exposure of members of that population to effective health promotion strategies (Rose, 1992
). In efforts to promote the health of young children, the first years of schooling present a key opportunity for achieving this goal. In New South Wales (NSW), Australia, children commence their formal schooling by attending primary school for 7 years. Children start primary school between ages 4.5 and 6 years. As well as providing access to the large majority of children who spend a significant amount of their time in this setting, schools have operational characteristics that are conducive to system-wide health promotion action (NHMRC, 1996).
The potential of the school setting to promote the health of young people is recognized internationally in a number of guidelines such as the Health Promoting Schools framework in Europe (WHO, 1996) and Australia (NSW Department of School Education, 1996), and the Co-ordinated School Health Program in the United States (Marx et al., 1998). These guidelines seek to impact on child and youth health by addressing the school curriculum, ethos and environment, and links to the community and health services. Furthermore, in some jurisdictions health service resources are directed towards supporting the implementation of such practices in schools (NSW Health Department, 2000). In Australia, each of the eight states and territories has separate education systems. Since the late 1980s education sectors, in each of these jurisdictions, have acknowledged their roles in promoting the health of schools by identifying health as one of the eight compulsory key learning areas in the school curriculum (St Leger et al., 2002), and adopting policies regarding student health, welfare and safety. In the state of NSW, the Student Health Policy indicates that the department seeks to provide opportunities for students to learn about and practise ways of adopting and maintaining a healthy, productive and active life through the student welfare policies and procedures of schools, and through Personal Development, Physical Education and other key learning areas (NSW Department of Education and Training, 2005).
System-wide adoption of health promotion practices by schools in Australia and elsewhere has been limited despite the existence of guidelines and policies (Marshall et al., 2000; Everett Jones et al., 2003). Additionally, owing to relatively low levels of resource and infrastructure support, the prevalence of health promotion practices can vary between schools according to their socio-economic status (AHPSA, 1997a; St Leger et al., 2002), size, rurality and public or private status (AHPSA, 1997b; Everett Jones et al., 2003), thereby potentially exacerbating existing inequities in health status. Further, where there have been successful changes they have been difficult to sustain, resulting in limited likelihood of a population health gain (St Leger and Nutbeam, 2000).
As a consequence, the development and evaluation of alternative models for disseminating and supporting uptake of such health promotion practices has been recommended (Lister-Sharp et al., 1999; St Leger and Nutbeam, 2000).
In developing alternative dissemination strategies, barriers to the uptake of health promotion strategies in schools need to be addressed (Reniscow et al., 1993; Lynagh et al., 1997). These include competing demands on staff time, a perceived lack of staff skill and organizational support, and poor communication between the school and the health sectors (Reniscow et al., 1993; St Leger, 1998; St Leger, 2001; Lynagh et al., 1997; Ridge et al., 2002; Rissel et al., 2002). In addition, sustainable methods of monitoring health promotion practices within schools (Booth and Samdal, 1997; Marshall et al., 2000) are needed.
Limited evidence exists that describes effective methods for system-wide adoption of health promotion practices by schools. Various behaviour and organizational change strategies have been effective in changing the health promotion practices of professional groups. These strategies have included the provision of a rationale for change, setting a clearly defined target behaviour or practice, reminders for change, supportive systems, provision of reinforcement and feedback and monitoring and ongoing support (Sanson-Fisher and Cockburn, 1993; Campbell and Sanson-Fisher, 1998).
Telephone and mail-based dissemination strategies represent two potential approaches for addressing barriers to the uptake of health promotion practices and for encouraging, supporting and monitoring system-wide adoption of such practices. These approaches have been shown to be effective in increasing the adoption of health promotion practices in a range of settings including restaurants and cafés (Licata et al., 2002), workplaces (Daly et al., 2005), hotels and clubs (Wiggers et al., 2001) and general practice (Lock and Kaner, 2000).
Given the need for strategies to facilitate the system-wide adoption of health promotion practices by schools, we undertook a study to determine the effectiveness of a telephone and mail-based dissemination strategy in achieving this end. The aims of the study were to determine whether the dissemination strategy was effective in increasing the proportion of schools undertaking health promotion practices, to assess whether uptake of practices differed according to school characteristics, and establish the cost and acceptability of the strategy.
|
METHODS |
|---|
|
TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
Design
The study involved a pre-post design with three points of data collection over 2 years. A computer-assisted telephone interview (CATI) was used to collect data in March 2000 (baseline), November 2000 (follow-up 1) and November 2001 (follow-up 2). The baseline and follow-up 1 contacts were used as the basis for the delivery of the intervention to schools (referred to as intervention 1 and intervention 2).
Setting and sample
The project was undertaken in the Hunter Region of NSW, Australia. The principals of all (n = 242) public and private primary schools in the region that were not special purpose schools were invited to participate in the study.
Intervention
The intervention model and timeline is in Figure 1 and described below.
|
(1) Stakeholder support: After engaging and obtaining support from regional level school officials, an Advisory Group was formed to provide expert advice on the setting, health issues and project methods.
(2) Selection of relevant health topics, practices and resources: A review of the literature and government policies was conducted to determine those health topics that had a large burden of illness in Australian primary school-age children, and to identify relevant health promotion practices that could be effectively implemented in schools. The Advisory Group selected five health topics and eight health promotion practices (Table 1). A quality standard was specified for each practice as the basis for determining adequacy of school performance for each practice (Table 1). Supporting resources were developed to assist those schools not undertaking a practice at the specified standard (Table 1).
|
(3) Telephone and mail-based intervention: At baseline and follow-up 1, the telephone interview completed by the principal consisted of a description of the relevance of each recommended practice and questions regarding the schools implementation of that practice. Those schools reporting that they had not implemented a practice at the required standard were offered resources to assist in its adoption. Those schools reporting the adoption of the practice at the required standard were provided positive reinforcement during the CATI.
Performance feedback
Each school was mailed a summary report describing the prevalence of adoption of health promotion practices by schools of their school type and, if a government school, in their school district. The report also described the prevalence of the adoption of each practice for the whole sample of schools.
Measures
Uptake of health promotion practices
Principals were asked whether their school had adopted each specified practice (yes, no, don't know).
School characteristics
Schools were categorized based on whether they were public (administered by NSW Department of Education and Training) or private (Catholic and Independent); their size defined by numbers of students; rural/urban location based on the Accessibility/Remoteness Index of Australia (ARIA) (Department of Health and Aged Care, 1999); and the socio-economic status of the schools' postcode (high, medium and low socio-economic categories) (Australian Bureau of Statistics, 2001).
Acceptability
Acceptability measures are outlined in Table 3.
Intervention delivery costs
The costs of developing and delivering the intervention were calculated based on salaries at the relevant industrial award (excluding on-costs) and were collected by routine project budget monitoring procedures. Research costs not included in the cost analysis were computer and telephone hardware, software costs and costs relating to the collection of follow-up 2 data.
Analyses
The statistical package SAS version 8 was used for all data analysis.
Uptake of health promotion practices over time
Uptake of health promotion practices over time was calculated for those schools that participated in all three data collections. The proportion of these schools that were undertaking each health promotion practice at the specified standard at each contact was determined. Where achieving the specified standard required more than one criteria to be met (e.g. safe disposal of sharps), schools had to fulfil all criteria in order to be considered to be meeting the standard. McNemars test was used to ascertain whether there was a statistically significant change in uptake between any two contacts (between baseline and follow-up 1, and between follow-up 1 and follow-up 2), as well as over the life of the project (between baseline and follow-up 2). A value of p < 0.01 was used to determine statistical significance.
Associations between school characteristics and change in health promotion practices over time
The association between uptake of health promotion practices and school characteristics (public/private status, urban/rural location, size and socio-economic status) was calculated using a weighted least squares model with a dichotomous response outcome.
Cost
The total cost of developing and implementing the intervention was calculated on a cost per school basis. Costs were summed and then divided by the number of schools that received both intervention 1 and intervention 2. Itemized costs are detailed for intervention 1 for descriptive purposes in Table 4. Cost per practice adopted was calculated by determining the difference between the total number of practices adopted by schools at baseline and at follow-up 2, and dividing the total cost by this figure.
|
RESULTS |
|---|
|
TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
Response rate
Of the total population of 242 schools invited to participate 228 (94%) completed baseline/intervention 1 interviews. At the second phone contact (follow-up 1/intervention 2) 232 schools consented to participate and completed the interview (96%), and at final follow-up 230 schools completed interviews (95%). A cohort of 218 schools completed interviews at all three phone contacts (90%) and forms the basis of the analyses in this study.
Uptake of health promotion practices over time
Table 2 shows the proportion of schools undertaking each of the health promotion practices at each of the three contacts.
|
There was a statistically significant increase in the proportion of schools undertaking health promotion practices between baseline and follow-up 2 for all practices but one: playground safety. There was a significant improvement between baseline and follow-up 1 for six of the seven practices. For the implementation of an asthma management policy, the increase achieved a p-value of 0.05.
There was no significant increase in uptake for any practice between follow-up 1 and follow-up 2. A significant decrease in prevalence for three practices was apparent between these latter two contacts. However, an overall significant increase between baseline and follow-up 2 remained for these three practices.
Associations between school characteristics and adoption of health promotion practices over time
There were no significant associations between uptake of health promotion practices and any of the school characteristics measured with the exception of one practice (provision of information to parents regarding dangers of passive smoking). Urban schools adopted this practice at a higher rate than rural schools between baseline and follow-up 1. However, there was a greater decline in prevalence of adoption for urban schools between follow-up 1 and follow-up 2.
No comparisons could be made between schools regarding playground safety as most schools retained the same level of adoption over the three contacts.
Acceptability
Principals viewed the telephone service delivery method as acceptable at all three contacts (Table 3). The frequency at which they wished to be contacted changed from a preference for two contacts per year (64%) at baseline to a preference for one contact per year (94%) at follow-up. Most principals (92% at follow-up 1 and 91% at follow-up 2) reported that they were satisfied with all resources sent to them in terms of both relevance and usefulness.
|
Intervention cost to the health care system
The costs of the development and implementation for one intervention contact are outlined in Table 4. The total cost for the intervention over the study period was $A45 525, with a cost of $196 per school, or $98 per school per contact. The cost per adopted practice was $A121.
|
|
DISCUSSION |
|---|
|
TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
We explored a population-based telephone and mail method of encouraging and supporting a large number of schools across a geographically and socio-economically diverse area to adopt health promotion practices. The results suggest that this approach has the potential to enhance the system-wide adoption of such practices in a manner that is acceptable to schools and that is potentially cost effective.
The consistently high participation rate by schools was a strength of the project. The high participation rate and the reported acceptability of the approach further suggest a need and receptiveness among principals for support in implementing health promotion practices. Greater levels of support therefore, appear to be required if schools are to adopt existing health promotion guidelines and children are to gain the intended benefits from such guidelines (NSW Department of School Education, 1996).
The findings of the study are based on the self-reported implementation of health promotion practices. The accuracy of the reported information may have been influenced by a lack of principal knowledge of, or the ability to accurately recall the status of the schools implementation of each practice. The social desirability of reporting implementation may have resulted in an over-estimation of adoption. The extent to which either occurred is unknown. However, in a previous study using the same telephone-based dissemination approach, the accuracy of reported health promotion practice adoption was found to have high levels of agreement between reported and observed practice (Wiggers et al., 2001).
Although the overall direction and extent of changes in practice adoption are suggestive of an intervention effect, the absence of a control group makes it difficult to conclude whether the results are attributable to the intervention. The observed change in prevalence of health promotion practice may simply reflect a temporal trend, or the effect of other actions undertaken by the school systems. Although not formally assessed, discussion with the school representatives on the project advisory group reported that no specific initiatives were undertaken across both public and private schools that focussed on enhancing the targeted health promotion practices. Given the suggested benefit of the approach to schools, and potentially children, further evaluation of this approach incorporating a randomized controlled trial design appears warranted.
Despite the significant improvements in adoption of seven of the eight practices, and the large effect sizes for some, the prevalence of schools undertaking the practices remained at <50% for four and <67% for seven of the practices. These results suggest that further intervention may be needed to address the remaining barriers for ‘late adopting’ schools (Rogers, 1983). The barriers to adoption for these schools, and the types of support needed to address them, need to be identified if greater levels of adoption are to be achieved.
Similarly, the absence of continued improvement in adoption between follow-up 1 and follow-up 2 suggests that either the telephone method of support delivery, or the types of support offered, or both, may have been insufficient to encourage adoption of health promotion practices by late adopting schools. More intensive intervention may be required to achieve increased adoption by these schools. Given the limited evidence that exists about the effectiveness of dissemination methods generally (Greenberg, 2004), and even less evidence about the tailoring of dissemination strategies to the readiness of individuals or organizations to change (Prochaska et al., 2001), further research in this area is warranted if the intended benefits of health promoting schools policies are to be realized.
Behavioural and organizational change research suggests that a relapse effect is common following intervention (Weick and Quinn, 1999; Cockburn, 2004). In this study such an effect was limited. A significant intervention effect was sustained in all cases at the final follow-up (follow-up 2). Although no further improvement was evident between follow-up 1 and follow-up 2, the second intervention may have contributed to the achievement of a sustained effect. Previous research suggests that intervention programmes should include strategies that address effect maintenance and relapse prevention (Cockburn, 2004). As is the case for dissemination research generally, very limited data have been reported regarding the effectiveness of such strategies.
Despite the apparent lack of consistent improvements following each intervention contact, the findings of this study suggest that a low cost, system-wide model of supporting the adoption of health promoting schools practices may have an important role in enhancing the adoption of such practices by schools. A benefit of this approach is that subsequent, more intensive and hence higher cost intervention approaches could be applied to a much smaller number of schools.
The telephone-based dissemination method described in this study has the capacity to address the need for monitoring the practice of health promotion practices by schools (Marshall et al., 2000). This study demonstrates the capacity of the method to identify changes, both increases and decreases in the prevalence of practice adoption.
Generally, those practices with the highest level of implementation at baseline were those that addressed the acute safety of children and staff (blood spills, first aid and sharps disposal). Two of these practices (blood spills and sharps disposal) also exhibited the greatest level of increased implementation. This may be because schools prioritized their occupational health and safety obligations for staff and students. Schools also appeared to be most responsive to those practices that required the least allocation of resources, i.e. provision of information. Other reasons for differential adoption rates between practices may include ease of implementation, emotiveness of the topic, quality of the resource, differential response to protective versus promotive practices or legal obligations. However, as the factors influencing practice adoption by schools in this study were not assessed, further analysis of such factors is essential if schools are to be provided appropriate support.
With one exception, no pattern of association was apparent between school characteristics and adoption of health promotion practices. This suggests that the approach is potentially effective across a range of school types and locations, and unlikely to contribute to inequities in health. However, the small number of schools in some categories limited the ability to detect significant differences. It is not known how generalizable these findings are to schools in other geographical areas or jurisdictions. However, the lack of differentials in adoption between school groups is supported by a study of health policies and practices in 912 Australian schools that found few differences between schools in different socio-economic groups and in metropolitan and non-metropolitan areas (St Leger et al., 2002). An additional factor that could potentially influence the generalizability of this approach is health service characteristics (e.g. public or private, local or state, and commitment to prevention and collaboration with the education sector).
Within the context of this particular study, the cost of the telephone and mail method appears acceptable on a cost per school and cost per adopted practice basis. Given the significant contribution of fixed development and hardware costs, the cost per school and per adopted practice would decrease if adopted across a larger population of schools. For example, if the service were delivered to 500 schools the costs per school per contact would decrease to $132.
In summary, the telephone and mail-based dissemination method trialled in this study appears appropriate, affordable and potentially effective in supporting a large number of schools to improve health promotion activity across a range of health topics. The impact of such enhanced activity on the health, educational and environmental outcomes for children are unknown and require further investigation.
|
ACKNOWLEDGEMENTS |
|---|
The authors would like to thank participating primary schools in the Hunter region, as well as regional governing Education bodies for their support. Additionally, the advisory role of Juliana Hazell from the Hunter Community Asthma Project and Christine Page from the NSW Cancer Council (Hunter Branch) are acknowledged. Finally, thanks to additional statistical, project and interviewing staff for their assistance throughout the life of the project.
|
REFERENCES |
|---|
|
TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
Australian Bureau of Statistics. (2001) Technical Paper: Census of Population and Housing: Socio-Economic Indexes for Area’s (SEIFA). , Commonwealth of Australia, Canberra.
Australian Health Promoting Schools Association (AHPSA). (1997a) School Based Health Promotion across Australia: Background Briefing Report no 1 for the National Health Promoting Schools Initiative (AHPSA, Sydney).
Australian Health Promoting Schools Association (AHPSA). (1997b) School Based Health Promotion across Australia: Background Briefing Report no 2 for the National Health Promoting Schools Initiative (AHPSA, Sydney).
Booth M. L. and Samdal O. (1997) Health-promoting schools in Australia: models and measurement. Australian and New Zealand Journal of Public Health 21:365–370.[Web of Science][Medline]
Campbell E. M. and Sanson-Fisher R. W. (1998) Breaking bad news 3: encouraging the adoption of best practices. Behavioural Medicine 24:73–80.
Cockburn J. (2004) Adoption of evidence into practice: can change be sustainable? Medical Journal of Australia 180:S67–S68.
Daly J., Licata M., Gillham K., Wiggers J. (2005) Increasing the health promotion practices of workplaces in Australia using a proactive telephone based intervention. American Journal of Health Promotion 19:163–166.[Web of Science][Medline]
Department of Health and Aged Care. (1999) Measuring Remoteness: Accessibility/Remoteness Index of Australia (ARIA) (Commonwealth of Australia, Canberra).
Everett Jones S., Brener N. D., MCManus T. (2003) Prevalence of school policies, programs, and facilities that promote a healthy physical school environment. American Journal of Public Health 93:1570–1575.
Greenberg M. T. (2004) Current and future challenges in school-based prevention: the researcher perspective. Prevention Science 5:5–13.
Licata M., Gillham K., Campbell E. (2002) Health promotion practices of restaurants and cafés in Australia: changes from 1997 to 2000 using an annual telemarketing intervention. Health Promotion International 17:255–262.
Lister-Sharp D., Chapman S., Stewart-Brown S., Sowden A. (1999) Health promoting schools and health promotion in schools: two systematic reviews. Health Technology Assessment 3:1–207.[Medline]
Lock C. A. and Kaner E. F. S. (2000) Use of marketing to disseminate brief alcohol intervention to general practitioners: promoting health care interventions to health promoters. Journal of Evaluation in Clinical Practice 6:345–357.[CrossRef][Web of Science][Medline]
Lynagh M., Schofield M. J., Sanson-Fisher R. W. (1997) School health promotion programs over the past decade: a review of the smoking, alcohol and solar protection literature. Health Promotion International 12:43–59.
Marshall B. J., Sheehan M. M., Northfield J. R., Maher S., Carlisle R., Leger L. H. (2000) School-based health promotion across Australia. Journal of School Health 70:251–252.
In Marx E., Wooley S., Northrop D. (Eds.). Health is Academic: A Guide to Coordinated School Health Programs (1998) (Teachers College Press, New York).
National Health and Medical Research Council (NHMRC). (1999) Effective school health promotion—towards health promoting schools (Australian Government Publishing Service, Canberra).
NSW Department of Education and Training. (2005) Http://www.det.nsw.edu.au/policies/student_serv/student_health/student_health/PD20040034.shtml (last accessed 2 April 2006).
Towards a Health Promoting School. NSW Department of School Education. (1996) ISBN: 0 7310 4619 6.
NSW Health Department. (1999) Health Promotion with Schools: A Policy for the Health System (NSW Health Department, Sydney).
Prochaska J. M., Prochaska J. O., Levesque D. A. (2001) A transtheoretical approach to changing organizations. Administration and Policy in Mental Health 28:247–260.[CrossRef][Web of Science][Medline]
Reniscow K., Cherry J., Cross D. (1993) Ten unanswered questions regarding comprehensive school health promotion. Journal of School Health 63:171–175.
Ridge D., Northfield J., St Leger L., Marshall B., Sheehan M., Maher S. (2002) Finding a place for health in the schooling process: a challenge for education. Australian Journal of Education 46:19–33.
Rissel C., Dirkis H., Maloney D., Smith A., Quigley R. (2002) Health promoting schools—false starts and new directions in Central Sydney. Health Promotion Journal of Australia 13:44–48.
Rogers E. M. (1983) Diffusion of Innovations 3rd edn (Free Press, New York).
Rose G. (1992) The Strategy of Preventive Medicine (Oxford University Press, Oxford).
Sanson-Fisher R. and Cockburn J. (1993) The use of behavioural change principles to promote rational prescribing: a review of the commonly used interventions. Australian Prescriber 16:82–86.
St Leger L. (1998) Australian teachers' understandings of the health promoting school concept and the implications for the development of school health. Health Promotion International 13:223–235.
St Leger L. and Nutbeam D. (2000) A model for mapping linkages between health and education; agencies to improve school health. Journal of School Health 70:45–50.
St Leger L. (2001) Schools, health literacy and public health: possibilities and challenges. Health Promotion International 16:197–205.
St Leger L., Maher S., Ridge D., Marshall B., Sheehan M., Gibbons C. (2002) School health policies and practices in Victoria—a comparison involving socio-economic status. Health Promotion Journal of Australia 13:49–57.
Weick K. E. and Quinn R. E. (1999) Organizational change and development. Annual Review of Psychology 50:361–386.[CrossRef][Web of Science][Medline]
Wiggers J., Considine R., Hazell T., Haile M., Rees M., Daly J. (2001) Increasing the practice of health promotion initiatives by licensed premises. Health Education and Behavior 28:331–340.
World Health Organization (WHO). (1996) Promoting Health through Schools—The World Health Organisation's Global School Health Initiative (World Health Organization, Geneva).
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||