Health Promotion International Advance Access originally published online on December 18, 2006
Health Promotion International 2007 22(1):65-71; doi:10.1093/heapro/dal059
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PERSPECTIVES |
Becoming a health promoting school: evaluating the process of effective implementation in Scotland
Child and Adolescent Health Research Unit (CAHRU), The University of Edinburgh, Scotland, UK
Address for correspondence: Jo Inchley Child and Adolescent Health Research Unit The University of Edinburgh St Leonard's Land Holyrood Road Edinburgh EH8 8AQ Scotland UK E-mail: Jo.Inchley{at}ed.ac.uk
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SUMMARY |
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Increasingly, researchers are exploring alternative ways of assessing the impact of ‘Health Promoting School’ (HPS) initiatives, in recognition of the model's emphasis on achieving change that is both enduring and far-reaching. However, it is still assumed that initiatives will lead to immediate change at the individual level. This paper challenges that view and argues that potential markers of success associated with process need to be identified earlier as a means of supporting schools and teachers. Notwithstanding differences in the way the HPS is conceptualized and implemented, four themes are highlighted that have relevance beyond any one school or country. These were drawn from a process evaluation of a European Network of HPSs Project in Scotland. They highlight the ways in which schools were able to successfully adopt HPS principles and the conditions that need to be in place for the HPS concept to flourish. Such indicators need to be given greater recognition as HPS outcomes if schools are to progress beyond the early stages of project implementation.
Key words: health promoting school; process evaluation; implementation
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODSFINDINGSCONCLUSIONREFERENCES |
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The ‘Health Promoting School’ (HPS) model has become a major theme in health and educational strategy, providing a framework for school-based health promotion activity that is widely accepted (Booth and Samdal, 1997
; World Health Organization, 1998). In Scotland, HPS activity is now supported by a national HPS Unit (established 2002). Although all schools have been charged with becoming an HPS by 2007 (Scottish Executive, 2003), progress towards this target inevitably varies as schools/local authorities begin this endeavour from different starting points. Accordingly, a strong evidence base is critical to ensure that future investment and development are effective and sustainable. However, evaluation poses a challenge for researchers given the broad, multi-faceted nature of the HPS concept (Mukoma and Flisher, 2004). One key question concerns the issue of what constitutes an indicator of success or appropriate foci for evaluation (St Leger, 2004).
Existing evidence, although limited, shows that an HPS approach can provide an effective framework for health promotion practice in schools and have a positive impact on outcomes relevant to both health and education (Lister-Sharp et al., 1999; St Leger, 1999). Nonetheless, there is little discussion of how the HPS works in practice or how confident schools feel in their ability to operationalize such a comprehensive, integrated approach (Deschesnes et al., 2003). This is significant because lessons learnt about implementation at a practical level are essential for schools in the preliminary stages of their journey towards becoming an HPS. There is also a tension concerning expectations of change both in terms of what counts as a positive outcome or marker of effectiveness and exactly when results are expected to materialize. It is often assumed that initiatives will lead to immediate, measurable health gain or to improvements in educational outcomes. Indeed, a common approach to school-based health promotion/education has been to focus on specific, short-term interventions that produce ‘visible’ change in pupils' health-related behaviours. Such initiatives may fail to embrace fully the philosophy behind the HPS, which recognizes that longer-term health improvements will only ensue if initiatives are integrated into a broader, multi-faceted health promotion strategy that supports sustained change.
While children remain at the heart of the HPS model, such a strategy must move beyond the individual to encompass the school environment, structural issues and organizational practice. According to the World Health Organization (World Health Organization, 2000), ‘creating an HPS means applying a new way of thinking’ about health and the role of the school. Ongoing reflection regarding appropriate indicators of progress and success is therefore necessary. In particular, greater recognition could be made of the steps schools make towards ‘rethinking’ their practice and embracing the HPS concept. This is important in terms of recognizing and allowing for change to (i) take place, (ii) have an effect and (iii) reveal its impact on children's (and staff) health. ‘Re-culturing’ (Fullan, 1993) may be a useful term in helping to conceptualize the process that needs to take place. This involves ‘changing the norms, values, incentives, skills, and relationships in the organization to foster a different way of working together’ (p. 9) (Fullan, 1998).
The challenge for evaluators is to find appropriate methods to track the ways schools are transforming practice. For this to occur, a shift in focus is required, from individual-level outcomes to measures of success at the school/operational level. A failure to recognize these processes as valid HPS outcomes in their own right carries the risk that schools may become disheartened at a perceived lack of progress and disengage from pursuing the HPS ideology. Accordingly, the intention of this paper is to show how an exploration of the processes involved in developing and implementing the HPS at local level is critical to our understanding of how schools are progressively able, through sustained attention to HPS principles, to exert an influence on intermediate health outcomes (e.g. healthy lifestyles/environments). The findings highlight the key elements at a structural/organizational level that need to be in place to allow the HPS to work most effectively.
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METHODS |
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The findings presented in this paper are drawn from a process evaluation of a 4-year project undertaken within the European Network of HPS (ENHPS) in Scotland. Details of the other aspects of the study (i.e. baseline assessment and outcome evaluation) are reported elsewhere (Inchley et al., 2000
; Inchley and Currie, 2003). A focus on ‘healthy eating’ was employed as a means of helping schools to apply HPS principles to a real problem among the school-aged population in Scotland (Currie et al., 2000; Inchley et al., 2001). Four schools (two primary and two secondary in different local authorities) were each given a budget of £4000 to support HPS development over a 2-year period (1998–1999 and 1999–2000). The aim was to enable schools to develop and implement the HPS concept in a flexible way, responsive to locally identified needs. Current health promotion theory highlights the importance of involving all stakeholders and practitioners in a given community in the development and implementation process. Accordingly, schools did not follow a pre-designed intervention protocol. Instead, in collaboration with external agencies, they determined their own priorities for action based on the initial needs assessment. The rationale for such an approach to health promotion programme development is that it should promote a sense of ownership, enhancing sustainability through the mechanism of perceived competence or a ‘can do’ attitude towards change (Koelen et al., 2001).
A multiple case study approach was employed to evaluate the initiatives, the unit of intervention being the school (Inchley et al., 2000). In addition to a quantitative component, qualitative methods were employed to enable the evaluators to trace the process of development and implementation within each school in order to identify (i) factors that may contribute to successful adoption of HPS principles and (ii) key stages for schools in moving towards HPS status. Qualitative methods included in-depth interviews with key stakeholders (Table 1) and direct observation by the research team through visits to the schools and attendance at project meetings.
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Focus group discussions with students and teachers were also undertaken at the initial baseline stage (1997–1998) and at follow-up (2000–2001). In the latter stage, a total of 10 group discussions were held with mixed gender groups of same-age students in all four schools. A total of 25 school staff also participated in focus group discussions, with one group per participating school. All follow-up interviews and group discussions were conducted by the lead researcher (J.I.) and were tape-recorded and transcribed in full. Data were subsequently analysed thematically by hand using the HPS concept as a theoretical framework for analysis.
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FINDINGS |
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Each school implemented a number of initiatives in line with the WHO criteria for an HPS. Some examples of these activities are provided in Table 2. Little evidence of widespread changes at the individual level (i.e. in eating patterns) was found over a 2-year period. However, schools had increased the availability of healthier options in food provision, raised awareness of the importance of healthy eating and changed attitudes among staff and pupils towards healthy eating in general (Inchley and Currie, 2003
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The process evaluation also revealed changes that had taken place in the ways schools were working. Four main themes highlighted factors that facilitated translation of HPS principles into practice: ownership and empowerment; leadership and management, collaboration and integration. How these themes are fostered, why they matter and what presents a challenge for schools within these domains are key questions for evaluators, as they seek to identify the conditions in which the HPS approach can flourish. Here, we begin to address these issues by bringing to light the views of key stakeholders as they reflected on what had helped schools progress in HPS terms. It should be noted that these factors are interdependent and often develop in tandem. They are dealt with separately here simply to sustain clarity.
Theme 1: ownership and empowerment
A sense of ownership by the individual school was considered crucial to the success of the project. O'Hara and McNamara (O'Hara and McNamara, 2001) draw attention to the need to empower staff through ‘shared "ownership" of change and innovation, in a framework enabling each member to take a much fuller role in strategic planning and professional decision-making’ (p. 100). Members of staff were more likely to ‘buy in’ to the project when it was ‘rooted in the school’ and they had control over development and implementation:
...one of the strengths of the project was that it was school-based. That it was the enthusiasm of the school and what the school wanted to take forward... it wasn't simply being imposed on them by [outside agencies] as a good idea (Education Officer)The importance of ownership and empowerment was highlighted when one teacher, appointed during the course of the project, explained that she felt coerced into being involved in something she knew little about. This is particularly significant if teachers are the key ‘agents of change’ within schools (Turunen et al., 1999
; O'Hara and McNamara, 2001). A sense of ownership must extend beyond teaching staff to all stakeholders. Members of the catering team echoed this sentiment when they explained how their initial reluctance to embrace change had been overcome when they were drawn into the decision-making process. A sense of ownership was facilitated through various means. The initial needs assessment allowed schools to identify issues relevant to them and the local community. This was subsequently reinforced through the flexibility with which they were able to interpret the results, develop aims and objectives and use the allocated budget. Identifying a member of school staff as a project coordinator, as well as involving teachers, the catering team, pupils and parents helped to reinforce the message that all members of the community had a role to play. Although financial support for the project was relatively small, it proved to be of importance not just for practical reasons, but also as a means of empowerment. Schools were able to spend the money as they wished, as long as this could be shown to be instrumental in achieving the project aims. External professionals drew attention to the benefits of empowering schools through these various means, to promote a sense of ownership. In this respect, trust in their ability to spend the money wisely had been demonstrated:
I think [the money] was really important for the school... It gave them a sense of empowerment around their part in the project, that they could spend that money on how they felt it should be spent... (Health Promotion Officer)Perhaps it was this trust that led some of the external professionals to feel that it was not the funding itself that was crucial; it simply provided the impetus for change. Schools commented on its importance as a motivator to get the project going, stimulating ideas and plans: ‘It was good to have it. It kind of kick-started us really... lets use it, get everybody excited’ (Project Coordinator).
Theme 2: leadership and management
Each school was required to appoint a project coordinator and typically a head teacher or member of senior management took on this role. However, in one of the secondary schools, two principal teachers shared this responsibility. Where senior management did take the lead, it gave the project status and their involvement was considered crucial to effective implementation even if they were not participating at an operational level:
Its scary how crucial [senior management] are because it can be quite frustrating, particularly if you have enthusiastic teachers but they don't get moving anything forward because there's no support... (Health Promotion Officer)
You could hear from the other projects, when the head teacher was running with it, it makes a big difference (Health Promotion Officer)Senior management involvement/leadership helped to embed the HPS concept in the life of the school through school development planning, as well as providing benefits in terms of resourcing, delegating responsibilities to key members of staff and liaising with external agencies. Where teachers took the lead, effectiveness was dependent on their commitment and ability to convey enthusiasm to others. Nonetheless, it is important to recognize that although effective leadership is critical, and an enthusiastic ‘driver for change’ particularly so, responsibilities need to be shared among a larger group of staff. This is essential for change to be sustained as staff members come and go.
Theme 3: collaboration
Partnership working or ‘intersectoral collaboration’ is a core principle of the HPS; however, it was an underdeveloped area in relation to health in most of the schools at the start of the project. Indeed, the extent to which schools collaborated with various groups over the course of the project was variable. Schools were encouraged to establish multi-agency steering groups to bring together a range of people who could contribute to an increased understanding of healthy eating issues within a whole school approach. However, this only occurred successfully in two of the schools. Within these schools, the process of forming a group was a valuable learning experience and a number of important steps towards establishing effective alliances were made. These included identifying key players, allocating roles clearly and establishing effective communication channels.
If you're going to have a multi-agency, multi-disciplinary group... people do need to have a distinct, clear and distinct role within it. And if that's kind of thrashed out beforehand then I think it makes things easier in terms of the action plan and who's going to play what part (Health Promotion Officer)
I think communication is terribly important between all parties concerned... I think the more who get round the table and talk about these things, come up with ideas and try to introduce them, the better (Catering Manager)Establishing a common understanding of underlying principles and values and negotiating mutually agreed goals and expectations were also important elements of collaboration. Each of these actions helps to provide an overview or ‘map’ of individual involvement and clarify what each partner has to offer and what they can expect to gain from involvement. Within this study, collaboration could be understood as operating within at least three spheres: (i) partnership working with external professionals, (ii) pupil participation and (iii) parental involvement. Schools may struggle with any one of these areas more than another and support needs to be tailored appropriately. However, each of these steps towards either fostering new alliances or rethinking the ways in which existing relationships function is a sign that schools are making changes in line with HPS principles.
Partnership working with external professionals
Involving external professionals proved particularly useful. As one head teacher commented, ‘schools aren't really aware of who's out there and what's out there’. Not only were they able to provide ‘the bigger picture’, but they were also seen as sources of support and encouragement, helping to move the initiative forward. Health promotion specialists, in particular, were seen as highly significant to the progress of the project, playing ‘a crucial role in being "the glue", in keeping everything together and making contacts’.
Key individuals in the Education Department were also important in terms of sustainability, acting as facilitators, providing strategic direction and supporting school staff through training, policy and curricular guidance. With a focus on healthy eating, the involvement of catering staff working within the school, although not always easy to achieve, was also considered critical in making the school meals service a more integral part of school life. It was acknowledged that changes would be unlikely to ensue in the absence of catering staff cooperation. Accordingly, this highlighted the need for flexibility in establishing dialogue and communication to ensure their support for the project.
What we are doing now seems to be more of a sort of integral part of the school, but in a much wider sense because [Catering Manager] and I see a lot of each other and we discuss things, what we can do, whereas before we didn't really do that... it has made the dining hall and the cafeteria more of a part of the school (Deputy Head Teacher)
Pupil participation
Although school staff emphasized the importance of enthusiastic and supportive leaders and coordinators, they also felt that attention to HPS principles had prompted changes in (or at least reflection on) other relationships. In particular, schools had taken greater steps towards working with pupils. Activities in addition to those outlined in Table 2 included involving pupils in the design and implementation of the healthy vending machines and the development of new school rules. External professionals commented on the gains that had been achieved through this kind of activity. Moreover, pupils shared the perception that schools did ‘listen’ and act on their views:
The student council has got a suggestions box... for new things in the school or something to be improved... Nearly every week there was ‘better toilets’, ‘mirrors in toilets’ or something, so that has changed now (Primary pupil)
It was the student council that got the music in the café and things like that (Secondary pupil)
Parental involvement
Overall, involvement of parents proved to be one of the most challenging areas of partnership working and on the whole, parents had little direct involvement in the planning or implementation of project activities. However, schools sought to involve parents through, for example, a special meeting to discuss results from the needs assessment, project updates in school newsletters and school meal samples at parents' evenings. Improvements in relationships were demonstrated through parents' involvement in School Nutrition Action Groups. One primary school was notably successful in improving communication between the catering service and parents through the project. Members of the catering staff attended a parents' evening, providing information about the school meals service and the quality of the food they had started to supply.
Theme 4: integration
Integrating new initiatives into the ongoing life of the school is considered crucial to sustainability in the longer term. As schools can feel overwhelmed by constant reforms, they may tend to view the HPS as yet another ‘add-on’, for which staff lose enthusiasm if immediate results are not apparent. Therefore, it is important that the HPS is not seen as a discrete activity, but rather as a way of being that permeates all aspects of school life and links to the core objectives of the school (St Leger, 2001). Although project schools were asked to focus on sustainability to encourage HPS principles to become embedded, some found it more difficult than others to identify links with existing practice and priorities. Where links were perceived, the project was more likely to become a core element of the ongoing work of the school:
It fits in nicely with the type of school we want to be... . It wasn't like a foreign body being introduced, you know, it wasn't some add-on or something that we were forced to accommodate (Head Teacher)
What I have found interesting is the way [the project] has grown and it has become part of the school rather than separate from anything else (Head Teacher)In many respects, it was changes in relationships that helped with integration, particularly fostering a sense of common purpose. In addition, some schools began to add to the project budget with their own funds as they recognized the value of the improvements that had been made. Momentum can build as the school feels greater ownership and faith that their efforts will lead to positive change in the longer term. Participating in the process evaluation appeared to prompt reflection that led to the identification of successes. Recognition of such achievements will, in turn, sustain interest and motivation (Deschesnes et al., 2003
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CONCLUSION |
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TOPSUMMARYINTRODUCTIONMETHODSFINDINGSCONCLUSIONREFERENCES |
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Numerous factors have the potential to influence HPS implementation in the school setting (Greenberg et al., 2001
). Without attention to the various influences that facilitate translation of the approach into practice, the potential for real change is unlikely to be realized. Poor standards of implementation are unlikely to yield positive results and can undermine the credibility of the approach as a whole (Deschesnes et al., 2003). This is an important issue cross-nationally, but is particularly pertinent in Scotland where all schools have been set the target of achieving HPS status. When assessing schools' progress, the focus needs to extend beyond narrow behavioural outcomes. Rigorous evaluation of the ways schools put HPS principles into practice ought to be the first step (Deschesnes et al., 2003), with a focus on changing organizations and conditions rather than individuals (Wold, 1999; Greenberg et al., 2001). Not only should this affect motivation and prevent disillusionment within schools, but it should also highlight the specific areas that external professionals should target to enhance their supportive role. This must be undertaken without losing sight of the importance of refining measures to assess longer-term effects.
Irrespective of local conditions and contexts, it is possible to discern a number of common features that influence how well schools are able to adopt and apply the HPS approach. It should be noted that funding, although important, is neither the sole nor the most significant factor. Our findings suggest that ownership, leadership, collaboration and integration are all critical to ‘improving schools from within’ (O'Hara and McNamara, 2001). However, there needs to be greater recognition of the time it takes to achieve such change and the support schools need to actively engage the whole school community in pursuing the HPS ideology. Teachers lie at the heart of such efforts as key agents of change in the school setting (McBride et al., 1996; Turunen et al., 1999). Such an emphasis on changing organizations and supporting teachers should prove more productive than a narrow focus on individual behaviour in promoting effective implementation of the HPS and facilitating sustainable long-term health improvement.
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ACKNOWLEDGEMENTS |
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This study was funded by the Health Education Board for Scotland (now NHS Health Scotland) as part of the European Network of Health Promoting Schools (ENHPS) Evaluation in Scotland. However, the views expressed in this paper are those of the authors and not the funding body.
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REFERENCES |
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TOPSUMMARYINTRODUCTIONMETHODSFINDINGSCONCLUSIONREFERENCES |
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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.[ISI][Medline]
Currie C., Hurrelmann K., Settertobulte W., Smith R., Todd J. (2000) Health and Health Behaviour among Young People. A WHO cross-national study (HBSC)(WHO Regional Office for Europe, Copenhagen).
Deschesnes M., Martin C., Hill A. J. (2003) Comprehensive approaches to school health promotion: how to achieve broader implementation? Health Promotion International 18:387–396.
Fullan M. (1993) Change Forces: Probing the Depths of Educational Reform.(The Falmer Press, London).
Fullan M. (1998) Leadership for the 21st century: breaking the bonds of dependency. Educational Leadership 55:6–10 Http://home.oise.utoronto.ca/~changeforces/Articles_98-99/04_98.pdf.
Greenberg M. T., Domitrovich C. E., Graczyk P., Zins J. (2001) A Conceptual Model for the Implementation of School-Based Preventive Interventions: Implications for Research, Practice and Policy. (Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, Rockville, MD).
Inchley J. and Currie C. (2003) Promoting Healthy Eating in Schools using a Health Promoting School Approach. Final Report of the ENHPS Healthy Eating Project. Edinburgh University, Child and Adolescent Health Research Unit.
Inchley J., Currie C., Young I. (2000) Evaluating the health promoting school: a case study approach. Health Education 100:200–206.[CrossRef]
Inchley J., Todd J., Bryce C., Currie C. (2001) Dietary trends among Scottish schoolchildren in the 1990s. Journal of Human Nutrition and Dietetics 14:207–216.[CrossRef][ISI][Medline]
Koelen M. A., Vaandrager L., Colomér C. (2001) Health promotion research: dilemmas and challenges. Journal of Epidemiology and Community Health 55:257–262.
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]
McBride N., Midford R., Boland J., Lake J. (1996) Making Schools Healthy IV: Western Australian School Health Project Final Evaluation Report. (National Centre for Research into the Prevention of Drug Abuse, Perth, Australia).
Mukoma W. and Flisher A. J. (2004) Evaluations of health promoting schools: a review of nine studies. Health Promotion International 19:357–368.
O'Hara J. and McNamara G. (2001) Process and product issues in the evaluation of school development planning. Evaluation 7:99–109.[Abstract]
Scottish Executive. (2003) Improving Health in Scotland: The Challenge. (The Stationery Office, Edinburgh).
St Leger L.H. (1999) The opportunities and effectiveness of the health promoting primary school in improving child health—a review of the claims and evidence. Health Education Research 14:51–69.
St Leger L.H. (2001) Schools, health literacy and public health: possibilities and challenges. Health Promotion International 16:197–205.
St Leger L.H. (2004) What's the place of schools in promoting health? Are we too optimistic? Health Promotion International 19:405–408.
Turunen H., Tossavainen K., Jakonen S., Salomaki U., Vertio H. (1999) Initial results from the European Network of Health Promoting Schools program on the development of health education in Finland. Journal of School Health 69:387–391.[ISI][Medline]
Wold B. (1999) The European Network of Health Promoting Schools (ENHPS) in Norway: purpose, implementation and evaluation. In Wold B. and Samdal O. (Eds.). Health Promotion Among Young People: The Development of Healthy School Environments.(University of Bergen, Research Centre for Health Promotion, Norway).
World Health Organization. (1998) WHO Global School Health Initiative. Health Promoting Schools: A Healthy Setting for Living, Learning and Working WHO/HPR/HEP/98.4.
World Health Organization. (2000) Local Action: Creating Health-Promoting Schools Department of Health Promotion/NCD Prevention and Surveillance, WHO WHO/NMH/HPS/00.4.
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