Health Promotion International Advance Access published online on November 9, 2007
Health Promotion International, doi:10.1093/heapro/dam029
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Article |
The status of health-promoting schools in Hong Kong and implications for further development
1Centre for Health Education and Health Promotion, Faculty of Medicine, The Chinese University of Hong Kong, 4th Floor, Lek Yuen Health Centre, Shatin, N. T., Hong Kong 2Faculty of Health and Behavioural Sciences, Deakin University Australia and External Expert of Hong Kong Healthy Schools Award Scheme
* Corresponding author. E-mail: alee{at}cuhk.edu.hk
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SUMMARY |
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An evaluation framework, called the Hong Kong Healthy Schools Award, has been developed to enable comprehensive collection and analysis of data reflecting the status of health-promoting schools (HPS) in Hong Kong. The key findings revealed a high prevalence of emotional problems, unhealthy eating habits, physical inactivity and risk-taking behaviours, leading to both intentional and unintentional injuries among students with higher prevalence among secondary school students. The results indicated a substantial lack of health policies in schools; it also indicated health services in schools not readily accessible to students and staff, and insufficient staff training in health promotion and education. However, most schools have made initiatives in environmental protection, established safety guidelines and strategies for managing students with emotional problems. The success of HPS depends largely on teachers' understanding of its building blocks. Evidence from the comprehensive mapping of the status of HPS in Hong Kong and from student surveys does show encouraging outcomes as well as identifying priority issues to be addressed in the next 5 years.
Key words: health-promoting schools; evaluation; model; health status
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODOLOGYRESULTSDISCUSSIONCONCLUSIONFUNDINGREFERENCES |
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The concept of the health-promoting schools (HPS) evolved in 1980s and has been regularly advocated as an effective approach to promote health in schools (Nutbeam, 1987
; Smith, 1992; Young, 1993; Lister-Sharp et al., 1999). It embodies a whole-school approach to personal and community health promotion in which a broad health education curriculum is supported by the environment and ethos of the school (Parsons et al., 1996). Such a comprehensive approach has been widely accepted by school health professionals as an effective and important method of implementing school health (Kolbe, 1986; Pigg, 1989; Nutbeam, 1992; Seffrin, 1992; Marshall et al., 2000). It has been suggested that well-developed school health promotion programmes are effective in encouraging children to adopt health-enhancing behaviours and in reducing health-compromising behaviours (Hawkins and Catalano, 1990; McKane et al., 1990; Green and Kreuter, 1991; Patton et al., 2006; Stewart-Brown, 2006).
To promote and implement the concept of HPS, Healthy Schools Award schemes became popular in European countries in the 1990s (Rogers et al., 1998). They provide a structured framework for HPS development as well as a system of monitoring progress and recognising achievements (Rogers et al., 1998). Positive changes in terms of children's health-related behaviour and the culture and organisation of the school have been shown to be related to the presence of an award scheme (Moon et al., 1999).
In 2001, the Chinese University of Hong Kong Centre for Health Education and Health Promotion (CHEP) launched the Hong Kong Healthy Schools Award (HKHSA) based on six major components of the HPS as identified by Western Pacific Regional Office of World Health Organisation (WHO) in its guidelines (WHO, 1996; Lee, 2002). Those six areas are: school health policy, school health services, personal health skills, the schools' physical environment, social environment of the school and community relationships. A set of indicators and guidelines were developed for the HKHSA based on extensive literature and documentary reviews, both locally and overseas, with a particular focus on Asia-Pacific countries. These addressed local needs and problems and provided a system for monitoring progress and assessing schools' performances (Lee et al., 2004). An evaluation framework was developed utilising a range of approaches to explore what schools actually did in their health promotion and health education initiatives (Lee et al., 2005). During the initial cycle of 3 years, 98 schools joined the HKHSA in three stages. Table 1 summarises the evaluation framework and identifies when different data were collected.
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The concept of HPS encourages schools to operate beyond the classroom, e.g. developing appropriate school health policies, building the personal health skills of students, enhancing the school environment (physical and social) and developing partnerships with relevant community organisations. The success of the widespread implementation of HPS depends largely on whether school teachers understand the building blocks of the HPS and their capacity to implement it (St Leger, 1998
). The paper reports the findings from baseline assessment of the status of HPS in Hong Kong. It is argued that such an assessment/audit of the schools' actions relevant to health assists them to identify those factors that facilitate development of realistic school-based health-promotion initiatives. |
METHODOLOGY |
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Ninety-eight schools comprising primary, secondary and special schools have joined the HKHSA in three batches at different time during the period 2001–2004 according to the time schedule as listed in Table 1. Baseline assessment of the schools' health profile in the six key areas was conducted between the months of June and July in 2001–2003 for the three batches of schools (phase 1). The instrument used was a set of indicators developed for the HKHSA based on WHO/WPRO guidelines and the details of development of the framework were reported in other papers (Lee et al., 2004
, 2005). The researchers from CHEP, who had experience in developing HPS, collected the data for the assessment. Teachers in charge of HPS in their schools identified their colleagues with the best knowledge of particular components of the school health profile to provide the information. The results reflected the status of HPS at the initial stage and also assisted schools in identifying their health profile, and facilitated an evidence base for planning their health-promotion initiatives. The data collected provided useful information for schools to develop quality and comprehensive HPS.
A student health survey was also conducted in the autumn of 2001–2003 for the three batches of schools (phase 2; Table 1). The survey was based on the six categories of youth risk behaviour adopted by Centre for Disease Control (CDC) in its Youth Risk Behaviour Surveillance (YRBS) viz: unintentional and intentional injuries; tobacco use; alcohol use and other drug use; sexual behaviour; unhealthy dietary behaviour; and physical activities (Warren et al., 1997; Kann et al., 2000). For primary schools, all students in their fourth year participated and all students in secondary schools, in their first to third years, also participated. Students from special schools were not involved in the student survey. Phase 3 was carried out by using continuous assessment by trained health-promotion co-coordinators of the CHEP who had been working previously with the schools as advisors to assist them to adopt the HPS framework and develop their own health-promotion initiatives. They kept detailed field notes of various health-related activities across the six areas of the HPS framework, (both formal and extracurricular) initiated by the 98 schools in the study.
These external data-collection processes were used to validate the responses from the schools and if school-generated data could not be authenticated, then they were not used. Focus group interviews were conducted by the CHEP staff with teachers in selected schools to seek further evidence as to whether they met the criteria of the HKHSA. Phase 4 was conducted during the period 2003–2004. It evaluated how schools had performed in the six HPS key areas to enable judgments to be made about their meeting criteria for awards. During phase 4, all the instruments used during phrases 1–3 were used to collect data on the outcomes of each school's health-promotion initiatives. Respondents were staff, students, some parents and principals.
Data analysis
In understanding the school health profile, qualitative data were categorised by existing templates. This involved trained field researchers reading through the raw data collected by observation, individual interviews, focus groups interviews and document analysis. The researchers then identified regularities and patterns. The researchers marked each unit of data (paragraph, sentence, etc.) with the appropriate coding. The researchers also made contrasts and comparisons, noting relationships between variables to seek understandings of what the data indicated. The work of Miles and Huberman (1994) and Bogden and Biklen (1998) largely shaped this approach of qualitative data analysis.
In the area of mental health, the measuring instruments included the Satisfaction with Life Scale (LIFE) and the Depression Self-Rating Scale (DSRS). The LIFE instrument was used to assess people's judgment of their quality of life (Diener et al., 1985). The Chinese adaptation has been reported with adequate reliability elsewhere (Shek, 1992). DSRS contains 18 items, which covers affective, cognitive and behavioural symptoms of depression, and was used to identify moderate-to-severe depression among young adolescents (Birleson, 1981; Asarnow and Carlson, 1985). The Chinese version had been tested on previous occasions and was found to have adequate reliability (Cheung, 1996).
This paper reports the results of phase 1 and descriptive statistics of the youth risk behaviours from phase 2. We utilised the baseline data of school health profile and youth risk behaviour surveys of the 56 schools undergoing re-assessment in 2003 (phase 4) to allow comparison when the data from re-assessment became available.
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RESULTS |
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TOPSUMMARYINTRODUCTIONMETHODOLOGYRESULTSDISCUSSIONCONCLUSIONFUNDINGREFERENCES |
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All the schools involved in HKHSA provided relevant information for school health profile assessment. Only very few students refused to participate in the student health survey. The response rate was well over 95%.
A total of 6598 students participated in the survey (2360 from primary school and 4238 from secondary schools). Data from the student health survey indicated that 31.1% of students (age 10–15) claimed to have depressive symptoms and 23.3% felt hopeless over the last 2 weeks affecting their usual activities; and 11.1% had considered suicide over the last 12 months. The median LIFE score was found to be 20.0 on a scale of 5–30, with higher scores being more satisfied with life. Over 50% (53.8%) of the students rated their health status as very good or good, whereas 15.2% of students rated their health status as excellent. However, 27.8 and 3.2% of students rated their health status as fair and poor, respectively.
Six categories of the health risk behaviours were explored and Table 2 shows the summary results. A substantial proportion of students did not have at least five servings of fruit and vegetables per day over past 30 days (92.0%). Also, about half the students were below the basic requirements for physical activity as per the Hong Kong Governments Guidelines. A significant proportion of students had planned or attempted suicide (8.0 and 2.7%, respectively).
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Table 3 summarizes the provision of various components of school health services. Most of the schools had social workers, staff trained in counselling and provided counselling referral services for students if needed.
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Although almost all schools kept student records for weight and height, special schools kept additional records of student health data (nearly 90%) with 46 and 67% in primary schools and secondary schools, respectively. With the exception of special schools, less than 30% of schools kept records of the immunization status of students. Only 21% of schools encouraged staff to have periodic health checks with a very low proportion in primary schools (8%). Less than 20% of schools informed parents of the results of the health data collection for their children (only 5% in secondary schools) and less than 10% of schools had established a comprehensive system for management of infectious diseases (none in secondary schools, 12 and 22% in primary schools and special schools, respectively). Given the large volume of learning materials carried in students' backpacks, only 8% of primary schools provided opportunities for the weight of bags to be checked and no such measures were made for secondary and special schools.
Table 4 summarises various components of the school environment (both physical and social). Nearly all schools had guidelines about safety. Only about 60% of schools had resource recycling schemes or mechanisms in place to monitor the food provided for school lunch and what was sold in the school canteen. Less than 40% of the schools engaged students in large-scale clean campus activities and environmental improvement, mainly through the ‘Green School Programme’. The proportion was higher in primary and special schools. Forty-four per cent of special schools had a committee for occupational health and 33 and 12% in primary and secondary schools, respectively.
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In the social environment component, most schools (over 95%) rewarded positive behaviours of students and acknowledged their improvement in academic performance. They also rewarded participation in community services particularly for secondary and special schools. Over 90% of primary schools prohibited verbal insults within the school as well as ensuring teachers did not use corporal punishment but less than 80% of secondary and special schools did so. The data show that most of the schools also provided leadership training and mentoring schemes for students, and measures to handle emotional problems including suicidal attempts and other traumatic events (100% for secondary schools). However, not many schools had similar measures to handle emotional problems for staff, with the figure being less than 20% for primary and special schools and 40% in secondary schools.
Just over half of the schools had established a committee for school health promotion and education (Table 5). The Hong Kong School Education Authority has clear guidelines in certain areas, e.g. disaster and crisis management, matters related to safety and injuries, and violent and bullying behaviours. It was found that schools had developed policies on those areas. However, very few schools had a smoke-free policy (only 39% in primary schools), alcohol-free policy and policy on the prevention of illegal drug use (4% in primary schools), and policies for the prevention of common infectious diseases, except special schools (89%). Few schools had explicit policies on promoting the health of staff, except special schools (78%).
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Table 5 also shows how the schools performed in various major components in building the personal health skills in their students. Just over half of the schools provided diverse health education resources for staff use with at least one staff trained or currently being trained in health education. There was a higher proportion of staff professional development in special schools of around 80%, and a lower proportion in primary schools less than 50%. Less than one-third of schools had a cross curriculum programme on health topics (only 14% in secondary schools), and just over half of secondary schools and quarter of primary schools involved students in organising health activities.
Physical education lessons of twice a week are mandatory in Hong Kong, and 76% of secondary schools reached the target of two periods per week. Fifty per cent of the primary and special schools' Parents and Teachers Associations discussed health education and health-promotion issues but it was less than 40% of secondary schools. About 40% in primary and secondary schools were active in networking with other schools for health-promotion activities with a higher proportion in special schools. Around 30% of primary and special schools involved parents as active volunteers or instructors with a very low proportion in secondary schools. About 20% of primary and secondary schools sent parent representatives to participate in local health-promotion activities. Very few schools had parents or community members involved in the planning of school health-promotion activities.
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONMETHODOLOGYRESULTSDISCUSSIONCONCLUSIONFUNDINGREFERENCES |
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What does the data tell us about the situation in Hong Kong HPS movement? What is working and what areas need to be addressed if these schools are to be more effective in their health-promotion initiatives? Three student health issues will be considered briefly: physical activity, nutrition and mental health. Indicators of the school health profile also highlight areas for improvement in the school setting to enhance health.
Our research shows that about 50% of students have less physical activity than that given the government guidelines. There is a worrying trend as the Chinese population is fast catching up with the West in terms of the prevalence of overweight and obesity (Wu, 2006). There is a comprehensive body of literature which shows that schools have a major role to play in addressing the obesity/overweight issue as well as enhancing educational outcomes (Ward et al., 2003). For example, adults who experience school-based physical activities when young are significantly more active as adults compared with those adults who did not experience a range of physical activities while at school (Dobbins et al., 2001). Research also shows that regular physical activity for students improves academic achievements (WHO, 1996; Symons et al., 1997). Also, regular physical activity programmes for 13-year-old ‘at-risk’ boys have demonstrated improvements in interpersonal interactions and reductions in resistant behaviours (Hastie and Sharpe, 1999).
The use of the HPS framework to address the issue of physical activity is more effective than if only the curriculum is utilised (Timperio et al., 2004). This and other evidence, e.g. those studies that found physical activities that linked with families were the most effective way a school could address the problem of sedentary behaviour, provide a clear option for the Hong Kong schools and the local authorities (Timperio et al., 2004).
There is a limit to the available play space in most Hong Kong schools, which are often built on a small foot-print and are frequently 6–7 stories high. It is therefore worrying that not all secondary schools provided at least two physical education lessons per week as required. Opportunities do exist with excellent contacts and relationships that schools have with parents, to be more proactive in this area, given the limits and size of playing spaces.
The data in this study showed that over a period of 1 month, over 90% of students reported not having the recommended servings of fresh fruits and vegetables. Over one-third of a student's daily energy intake is consumed in the school environment (Bell and Swinburn, 2004). Yet efforts in many countries to promote healthy eating at school have had mixed results. It appears those that work best take an integrated settings based approach, where an interconnected framework like the HPS is used (Stewart-Brown, 2006). However, health promotion interventions in Hong Kong schools to improve nutrition services and alter eating practices will need to take account for the increasing significance of advertising of foods which contain high levels of fat and sugar. Television viewing affects both energy intake and energy expenditure of students (Robinson, 1999; Diety and Gortmaker, 2001). The evidence also suggests that schools can work effectively with parents as partners in modifying the frequency of television watching by students (Wang et al., 2003; Gortmaker et al., 1999). This strongly suggests that addressing the community partnerships components of HPS is vital. Working with parents to encourage monitoring of the time and content of television watching may be more effective than merely exhorting the students to eat better. Networking with communities and other schools need be strengthened with more participation from parents especially for secondary schools. Parental involvement and networking were found to be stronger in primary schools.
Promising results from some studies elsewhere suggests that Hong Kong schools may need to be more proactive in building the personal health skills of students by teaching them how to deconstruct and analyse food advertisements (Coon and Tucker, 2002). Apart from special schools, training on health education was far from adequate and very few schools developed cross curriculum for health teaching and involved students in health-related activities.
Students with good mental health, or as it is often defined ‘social and emotional health’, achieve improved learning outcomes (Weare, 2000; Symons et al., 1997). The data from this study suggest that the schools are making concerted attempts in building the social environment of their schools by rewarding students with improvement in behaviours and established student mentorship system. Effective school based programmes in the social and emotional wellbeing area have the following attributes: a focus on building student self esteem; adopting a HPS (or whole school approach); raising the school climate; occurring over several years in programmatic rather than project form; building protective factors rather than addressing risk factors (Wells et al., 2003; Browne et al., 2004; St Leger, 2005). This evidence challenges the Hong Kong schools to continue to sustain what many have already started in their approaches, which address the whole school, are positively based and seek to build protective factors. The figures on suicide ideation, are however, cause for some concern. Further investigation is needed here. We strongly encourage this, while cautioning about adopting short term, quick fix projects to address the issue. Schools also need to develop measures to deal with emotional problems and traumatic events for staff well being as these have impacts on student health. Secondary schools tended to have more resources on student mental health and staff health than primary schools and this is an encouraging start. But the promotion of mental health for students and staff goes beyond the provision of resources. Evidence from a number of studies, e.g. Weare (2000), Stewart-Brown (2006), Patton et al (2006), suggest that schools are effective in addressing mental health issues, identify policies and priorities and commit them in an ongoing way.
Special schools provided better school health services because of extra resources from government to meet the special needs of students. Basic school health services such as keeping comprehensive health data, communication with parents of student health data, review and follow-up action for student immunization, care for students with special needs and monitoring of weight of school bags are all important in developing good health for students. Most schools, particularly secondary schools, have not fulfilled these conditions.
Policies which support health are present in most schools in developed countries (St Leger, 2004). These Hong Kong schools are no exception. This study does not report on the implementation of these policies that evidence will be available elsewhere when more data are collected after some years as a HPS. Data from other locations, e.g. Australia, suggest some dissonance between the presence of a policy and its active implementation (Marshall et al., 2000). Of current concern is the number of schools in Hong Kong 
40%, which had no healthy eating policies. Given that tobacco use and obesity/overweight are some of the biggest risk factors for many cancers and cardiovascular diseases, then it is important that the relevant authorities in Hong Kong address these issues.
The data show that Hong Kong schools give a low priority to staff health, student involvement in decision-making, on-going professional development for staff, and engagement with the local community. Many schools, although recognizing these are important, see them as a lower priority compared with curriculum programmes and facilities. Evidence from studies of successful and sustained school health promotion indicates that these four factors are in fact essential to the success of health-promoting schools over the medium to long term (St Leger, 2005, Stewart-Brown, 2006; Patton et al., 2006; Blum et al., 2002).
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CONCLUSION |
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Schools are complex and busy places. They are asked to do much to build knowledge and skills of young people, create a warm and supportive community, care for the health and wellbeing of their students, link with parents and other key members of the local community, and on regular occasions, address some of society's concerns. There is a very strong link between schools meeting, their educational goals and the health and well being of their students (Nutbeam, 2000
; St Leger and Nutbeam, 2002a,b). It is for this reason that schools need to address health, and to do it in a way that integrates it into the day-to-day structures and the functions of a school, and not as a set of discrete projects based on health problems. The HPS framework is a well accepted and strategic approach to support schools in undertaking their core responsibilities in education and health. Providing acknowledgement of their achievements through an award system such as HKHSA is a major way of affirming schools' actions and setting standards for them to achieve. This study has reported data from a very comprehensive audit and details where Hong Kong schools have started on their pathway to achieving better education and health outcomes. It highlights what is happening and points to a number of areas that need addressing in primary, secondary and special schools. It seems that secondary schools have a greater number of areas to be addressed and this would explain why certain health risk behaviours have higher prevalence in secondary schools. The ongoing research and associated publications will tell us what the schools achieve, and why it happened. The evidence reported here shows that gains are being made but that certain challenges still exist, particularly for secondary schools. |
FUNDING |
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The authors would like to acknowledge the funding support from Quality Education Fund of Hong Kong Special Administrative Region Government for the Hong Kong Healthy Schools Award project.
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FOOTNOTES |
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Mandy HO (Team Leader), Vera KEUNG, Tracy LEUNG, Nancy LI, Amelia LO, Carol SUEN, KK Wong (Statistics), Hilda YUEN (Team Leader). 
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