Health-promoting school development in Zhejiang Province, China
1 Health Education Institute of the Zhejiang Province Center for Disease Control and Prevention, Hangzhou, China 2Provincial Department of Education, Zhejiang Province, Hangzhou, China 3Health and Human Development Programs, Education Development Center, 55 Chapel Street, Newton, MA 02458, USA 4 China Center for Disease Control and Prevention, Shanghai, China 5 Formerly of World Health Organization/Headquarters, Geneva, Switzerland
* Corresponding author. E-mail: caldinger{at}edc.org
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SUMMARY |
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In 2003, after three pilot projects successfully implemented WHO's Health-Promoting Schools (HPS) concept, officials in Zhejiang Province, China, expanded to additional 51 schools (93 000 students and their families and 6800 school personnel). Each school identified a health issue to begin HPS development, followed by conceptual orientation, resource mobilization, teacher training, surveys, interventions, outreach and evaluation.
This study focused on the extent to which participating schools implemented the HPS concept and improved their psycho-social environments (PSEs). Forty-nine of the 51 schools met China's HPS criteria. Schools with fewer resources and with substantial resources, i.e. schools in both rural and urban areas, met the criteria. Schools’ PSEs, as measured by the PSE Profile, improved as they became HPS. Findings from interviews and observations identified strong encouragement and support from officials, school personnel, students, parents and community leaders, and consistency of HPS with the national policy on quality education, as success factors.
Key words: health promotion; school health; psycho-social environment; health-promoting schools
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INTRODUCTION |
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In 1995, the World Health Organization (WHO) launched the Global School Health Initiative (GSHI) to improve health through schools (WHO, 1998
) by developing Health-Promoting Schools (HPS). WHO worked with international partners to produce WHO's Information Series on School Health (WHO, n.d.) to help schools become HPS. The WHO Regional Office for the Western Pacific (WPRO) also published regional guidelines for HPS development (WHO, 1996).
Officials from China played key roles in developing the GSHI and regional guidelines. The director of the Institute of Child and Adolescent Health (ICAH), Peking University served on the WHO Expert Committee on School Health Promotion and Education which served as the basis for the GSHI (WHO, 1997). ICAH, in collaboration with China's health and education ministries, also hosted a national conference on school health and provided support for the technical consultation that developed regional guidelines.
With endorsement of the health and education ministries, several of China's health and education agencies then began applying the HPS concept in selected schools. In 1996, a HPS pilot project successfully reduced parasitic helminth infections in rural schools (XU et al., 2000). In 1998 and 2000, two HPS projects in Zhejiang Province successfully addressed tobacco use prevention and nutrition, respectively (Ma et al., 2002; Xia et al., 2005).
In 2003, health and education officials in Zhejiang Province launched an expansion of HPS to improve health and support the policy of ‘quality education’ advocated by the Chinese government (State Council of the People's Republic of China, 1999). Zhejiang Province, in southeastern China, has 47 million people, 9530 primary and secondary schools and 6.3 million students aged 6–18 years. Officials noted that health and quality education are essential to the well-being of their students, province and nation.
As part of the expansion, Zhejiang officials applied WHO's Psycho-Social Environment (PSE) profile to assess and improve their schools' environments. The PSE profile was designed to support health and quality education by fostering friendly, rewarding and supportive learning environments, measured by seven quality areas (Box 3) (WHO, 2003).
Thus, the Zhejiang Province HPS expansion aimed to help schools become HPS, support the national policy on quality education and obtain additional evidence about the feasibility and effectiveness of HPS in China.
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METHODS |
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Expansion
With joint endorsement, Zhejiang Provincial departments of education and health expanded HPS development to all 11 prefectures of the Province. The expansion included 51 schools (at least four schools from each prefecture), representing about 93 000 students and 6800 school personnel. Twenty-nine schools were located in resource-poor areas, 20 were in areas with adequate resources, 12 were rural and 37 were urban.
Intervention
Interventions to expand the development of HPS in Zhejiang Province took place between October 2003 and November 2005. Interventions to build school health program components are listed in Box 1, reported in more detail elsewhere (Aldinger et al., 2008a); interventions to influence health and related knowledge, attitudes and behaviors are listed in Box 2, reported in more detail elsewhere (Aldinger et al., 2008b), and an intervention to create awareness of the importance of a healthy PSE and to help school personnel and students find ways to improve it are described in Box 3.
| Box 1: Interventions to build the components of a health-promoting school Pre-implementation processes included: • Gaining leadership support • Motivating willingness to take part • Learning the HPS concept • Choosing an entry point • Setting up a special HPS committee • Developing a work plan • Setting up policies and systems of operation Implementation processes included: • Prioritizing health • Being guided by rules and obedience • Holding a start-up or mobilization meeting • Popularizing the HPS concept • Cooperating with governmental departments • Ensuring community cooperation and participation • Obtaining input from students, parents, and teachers • Being a role model • Choosing interventions • Providing training • Conducting study visits • Utilizing the Internet • Choosing class topics • Using new teaching and learning methods • Teaching social skills and life skills • Choosing textbooks and adapting materials. Evaluation processes included: • Carrying out process evaluations • Conducting baseline, mid-term and final evaluation
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| Box 2: Interventions to influence health and health-related knowledge, attitudes and behaviors Classroom-based activities included: • Integrating health into regular teaching • Holding class meetings • Providing individualized instruction and care School-wide activities included: • Adding extracurricular activities • Creating wallboards and bulletins • Holding competitions • Sponsoring signature activities • Launching arts days and other festivals • Providing psychological consultation and care • Offering physical examinations and health services • Checking students' appearance • Encouraging physical exercise • Broadcasting through school radio stations • Providing nutritious food • Instituting safety measures • Forming unique student support groups Outreach activities included: • Disseminating information to parents • Disseminating information to communities • Conducting social research • Engaging in social practice Activities to change the school environment included: • Improving facilities • Enhancing cleanliness and beautification • Assuring a harmonious psycho-social school environment • Maintaining a caring atmosphere
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| Box 3: The psycho-social environment profile The PSE profile is an intervention composed of a series of questions about seven quality areas of a school's environment. It is designed to: • Create awareness among teachers, other school personnel and students about the importance of a healthy psycho-social environment • Help school personnel and students identify the positive characteristics of the school's environment and the characteristics which can be improved School personnel and students use what they learn to engage the school and community in determining priorities, developing strategies and taking action. To administer the PSE, school personnel are encouraged to: • Review the PSE profile to become acquainted with the questions and determine if it needs to be adapted • Decide who should fill out the PSE profile • Hold a meeting with all PSE profile users to discuss the purpose of using it • Clarify how the results will be used and give the instructions for completing it • Tabulate the score of each completed PSE profile and summarize the scores for all the PSE profiles completed in the school • Circulate the results to all members of the school • Hold an open school conference (or series of meetings with different groups in the school) to review the findings and plan actions for change Quality Areas Number of questions Providing a friendly, rewarding, supportive environment: 18 Supporting cooperation and active learning: 8 Forbidding physical punishment and violence: 20 Not tolerating bullying harassment and discrimination: 18 Valuing the development of creative activities: 10 Connecting school and home life through involving parents: 13 Promoting equal opportunities and participation in decision-making: 13
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The HPS expansion was launched with a training workshop for headmasters and teachers from each participating school. Health educators from the Chinese Centers for Disease Control (CDC), education officers of the prefectures and other experts spoke on issues, including the HPS concept, psychosocial environment, dental health, injuries, nutrition, tobacco, parasites and skills-based health education. School personnel involved in earlier pilot programs participated in the training and later provided consultation to the schools to share their experiences.
Following this training, each school chose a health issue, based on surveys, observations and/or perceptions, that was important to their school or community and identified it as their ‘entry point’ for developing the HPS concept. After mobilizing interest and resources within the school and community, every school formed a working group comprised of headmaster and teachers, and in some instances also students, parents and community leaders. The working group planned and implemented interventions including teacher training, materials distribution, curricular or extracurricular health education, modification of the school's physical and PSEs, new or reinforced school health policies, opportunities for physical activity and health checkups, outreach to parents and community, and composition and drawing competitions. Provincial and municipal CDCs provided further training throughout the year, including training on measurement tools.
Evaluation
The HPS expansion included various levels of evaluation. This article focuses on two parts of intervention evaluation: the extent to which schools met HPS criteria and the extent to which schools improved their PSEs. This is supplemented with findings from group interviews to triangulate the data.
Health-promoting schools bronze level
During the training, school personnel learned about the criteria (Table 1) to reach the first level of becoming a HPS (Bronze level). These criteria were adapted from the WHO/WPRO regional guidelines (WHO/WPRO, 1996) and were published in a special issue of the Journal of Chinese School Health (Zhou et al., 1997). The criteria were further refined to the Chinese context as HPS experience was gained (Tian, 2005). Criteria included key health promotion components: school health policies, schools' physical and PSEs, school community relationships, personal skills and health services (Table 1). Schools were required to meet a number of checkpoints. For example, of the five items for the component ‘school health policy,’ schools might be required to meet two items to achieve the HPS Bronze level. If the school met two more of the other three items, it was eligible for the Silver level.
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A mid-term evaluation using the criteria was conducted after the first year, and a final evaluation after the second year. For the final evaluation, all schools were trained by the Prefectural CDCs to make self-assessments following these criteria. The self-assessments were reported to the health education section of the Prefectural CDC, which then sent a team of education/health officers to the schools to check if the school met the HPS criteria. The Prefectural CDC reported results to the Provincial CDC's Health Education Institute which then made an assessment of one randomly selected school in each prefecture.
Psycho-social environmental profile
Each school administered the PSE profile at baseline (generally within the first 3–6 months of operation) and at the end of the second year.
The PSE profile was developed by WHO in collaboration with international education and health organizations (WHO, 2003) and contains questions about seven ‘quality areas’ (Table 2), each of which represents an important element of a healthy PSE. The number of questions ranges from 8 to 20 among the quality areas (Box 3). School personnel and secondary students (about 5% of boys and girls) used the PSE Profile to assess psycho-social qualities of their school. Respondents considered the elements of each quality area and expressed how much they were like ‘their school’. The score for each question was from 1 (not at all) to 4 (very much). The data were analyzed by calculating means, standard deviation and t-test scores at the Provincial CDC.
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Additional assessments
Qualitative evaluation in the form of 1 h group interviews was conducted with school administrators, teachers, students and parents, respectively. Interviews were carried out at baseline, mid-term and final evaluation in a total of nine schools with a total of 191 participants to inquire about the development, implementation and evaluation processes. Interviews were carried out by a team of 3–5 people from WHO and a WHO Collaborating Center, accompanied by staff from the Health Education Institute and an interpreter. Schools in which interviews were conducted were selected in order to examine HPS development in primary, secondary and vocational schools in areas that were urban, rural, resource-adequate and resource-poor. Illustrative examples of responses are included here while most of the results are reported elsewhere (Aldinger, 2007
).
Quantitative data on health knowledge, attitudes and behaviors were collected using the WHO Global School-based Student Health Survey (GSHS) and content-related questionnaires from former HPS pilot projects in China. These results were reported elsewhere (Provincial HPS program coordinating group, 2005).
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RESULTS |
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Success in becoming health-promoting schools
Based on China's HPS criteria (Tian, 2005
), 49 of the 51 schools achieved HPS Bronze level. Of the two schools which did not achieve HPS status, one withdrew because school personnel were ‘too busy,’ and the other participated in the whole process but did not meet the criteria. This school was located in a resource-poor area. The high level of compliance might show the urgency and interest of the schools to address health issues and participate in an international effort, and might also be related to cultural values and to the government's mandate for ‘quality education’. Table 1 lists how many schools from resource-poor, resource-adequate, rural and urban areas met the various items of the criteria.
Qualitative data showed that strong encouragement and support from provincial officials, willingness of local leaders, parents, students and school personnel to participate, and availability of school personnel from the pilot schools to work with new schools contributed significantly to the expansion's success. The development of HPS began to be viewed as co-responsibility by school personnel, students, parents and community members.
On-site evaluations by provincial health and education officials confirmed that school facilities including kitchens and dining halls, toilets and grounds were cleaned and renovated.
Psycho-social environment profile
The total number of respondents was 5703 (staff 79% and students 21%) and 4730 (staff 71% and students 29%), respectively, for baseline and final surveys.
Table 2 shows that average scores in all seven quality areas were significantly higher in the final evaluation than at baseline (P < 0.01). Analyzed by role/status and gender of respondents for baseline and final surveys, the scores given by teachers were higher than those from students (P < 0.01) and scores from females were higher than males (P < 0.01, P < 0.05), both in baseline and final survey, except in two quality areas by gender (Table 3).
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DISCUSSION |
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Development of HPS infrastructure
The expansion of HPS in Zhejiang Province has been successful. The vast majority of schools met at least minimum level of China's HPS criteria. The expansion demonstrated that it was feasible to implement the HPS concept in rural and urban schools in resource-poor and adequately resourced areas.
However, as data in Table 1 show, some schools in rural areas were more likely than schools in urban areas not to meet some of the specific criteria. For instance, only 5 out of 12 rural schools had at least 1 health worker recruited for every 600 students, while 31 out of 37 urban schools had done so. Also, while all schools implemented a number of tobacco use prevention policies, none of the poorly resourced and rural schools had implemented efforts to help smoking students quit.
The development of HPS involves building ‘health promotion’ infrastructure. The expansion demonstrated that given technical support, encouragement and attention, schools can make health supportive modifications of the physical environment, PSE, policies and services—all key components of health promotion called for in the Ottawa Charter (WHO, 1986):
- The physical environment. Table 1 shows all participating schools had ‘school kitchen and canteen in accordance with hygienic norms and requirements,’ maintained a ‘hygienic environment to meet requirements of the "law for infectious disease control" and disinfection,’ and all but one school reported ‘attendance of students in maintaining cleanness of environment.’
- The psycho-social environment. All schools reported no physical punishments and insults, a school motto expressing good spirit, and plans and measures to support students with difficulties. Interviews in various schools confirmed a caring attitude and showed various examples how teachers helped students with difficulties with individualized approaches.
- School health policies. All schools reported health promotion activities in the annual plan of the school, one of the school headmasters responsible for health promotion, and measures for communicable diseases such as routine vaccinations and emergency procedures.
- School health services. All schools reported periodical medical checks for teachers and students at least once every 2 years and health files established for at least 95% of the teachers and students.
) and recently (Stewart-Brown, 2006) revealed that none of the schools implemented all components of the Ottawa Charter or HPS approach. In light of these reviews, compared to the findings of this study in which 49 of the 51 schools implemented all of the components recommended to become a HPS, the efforts of the schools in Zhejiang Province are remarkable.
Psycho-social environment
This effort demonstrated that the development of HPS can enhance qualities conducive to quality education, as well as emotional and social well-being. Attention to psycho-social issues is important in China because of unexpected personality developments as a result of the ‘one couple, one child’ policy, excessive competition and academic examinations, and impact from social changes.
In general, PSE scores by teachers were higher than those by students. Teachers may perceive the school environment as socially and emotionally supportive and pressures coming more from outside than inside the school. As interviews revealed, students perceived the school environment as a strong source of pressure due to the importance of achieving high grades, high expectations of parents for their one child and competition among students, especially competition for university entrance.
The higher ratings on the final assessment of the schools’ PSE were consistent with numerous examples of positive change given during interviews. Students described ‘treating teachers like friends’ and ‘sharing their life experiences’ and teachers described ‘feeling like big brothers’. Research has also shown that students who feel fairly treated by teachers and close to people at school are more likely to succeed: they engage in less health risk behaviors and do better in school (Blum et al., 2002).
Among students, girls generally scored PSE qualities higher than boys. Girls may be more comfortable about school regulations while boys may associate regulations with bounds of discipline. Thus, girls may better adapt to regulations and consequently perceive and score the schools’ environment more positively than boys.
Recommendations and way forward
Schools that obtained the HPS Bronze-level can continue their effort to reach higher levels as HPS—silver or gold levels. One criteria of a silver achiever is that the school help another school develop as HPS. This is a sustainable model for HPS development and expansion. The accomplishments of resource-poor and rural schools should give confidence to policy- and decision-makers throughout China that the HPS concept is a feasible and effective means of supporting health and quality education. In 2006, health and education officials in Zhejiang Province launched HPS in additional 125 schools.
The results of the PSE profile have not been as fully utilized as expected. Results should inform school administration, teachers, Youth Leagues and parents of health supportive and unsupportive qualities of their school's environment. They could be requested to discuss the results and provide advice to headmasters about recognizing positive achievements and making improvements as needed. School personnel may need to be encouraged and further trained to make full use of the PSE profile.
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The program received partial financial support from the World Health Organization.
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Acknowledgements |
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The program received technical support from the World Health Organization.
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REFERENCES |
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