Health Promotion International Advance Access published online on November 27, 2008
Health Promotion International, doi:10.1093/heapro/dan037
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Article |
Schools for health, education and development: a call for action
1WHO, HQ, Switzerland 2 The University of Sydney, Australia 3 Education Development Center, Inc., USA 4 Deakin University, Australia 5 World Bank, USA 6 UNICEF, USA 7 UNESCO, France 8 International School Health Network, Canada 9 Schools for Health in Europe Network, the Netherlands 10 WHO, EMRO, Egypt 11 WHO, PAHO, USA 12 Ministry of Education, Thailand 13 Partnership for Child Development, UK 14 Alexandria University, Egypt 15 School Health Consultant, Uruguay 16 WHO, AFRO, Congo 17 Joint Consortium for School Health, Canada 18Convenio Andres Bello, Columbia 19 WHO, SEARO, India 20 WHO, AFRO, Congo 21 WHO, WPRO, Philippines
* Corresponding author. E-mail: tangkc{at}who.int
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SUMMARY |
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In 2007, the World Health Organization, together with United Nations and international organization as well as experts, met to draw upon existing evidence and practical experience from regions, countries and individual schools in promoting health through schools. The goal of the meeting was to identify current and emerging global factors affecting schools, and to help them respond more effectively to health, education and development opportunities. At the meeting, a Statement was developed describing effective approaches and strategies that can be adopted by schools to promote health, education and development. Five key challenges were identified. These described the need to continue building evidence and capturing practical experience in school health; the importance of improving implementation processes to ensure optimal transfer of evidence into practice; the need to alleviating social and economic disadvantage in access to and successful completion of school education; the opportunity to harness media influences for positive benefit, and the continuing challenge to improve partnerships among different sectors and organizations. The participants also identified a range of actions needed to respond to these challenges, highlighting the need for action by local school communities, governments and international organizations to invest in quality education, and to increase participation of children and young people in school education. This paper describes the rationale for and process of the meeting and the development of the Statement and outlines some of the most immediate efforts made to implement the actions identified in the Statement. It also suggests further joint actions required for the implementation of the Statement.
Key words: school health promotion; school health; education and development
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BACKGROUND |
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International development and cooperation on school health
Over the past 30 years, there have been several international initiatives to define and advance the role of schools in promoting and protecting health. In the more recent past, in 1995, the World Health Organization (WHO) facilitated a process leading to the establishment of the Global School Health Initiative. This Initiative advanced a comprehensive and integrated methodology for school health that has become widely known as Health Promoting Schools (HPS). This Initiative and the HPS concept were built upon the pioneering work and experience of many other programmes such as the European Network of HPS, established in 1992; important work by UNESCO stretching back to the late 1980s which focused on health and nutrition; the Child Friendly School Initiative by UNICEF and related programmes from the UNDP and the UNFPA (Bundy et al., 2006
). The World Bank has also played an active role in supporting school health and nutrition programmes during this period. Since the establishment of the Initiative, programmes to migrate, adapt and advance the HPS methodology have been implemented in all six WHO Regions, and HPS Networks have been established within and between the countries.
At the Education for All World Education Forum in Dakar, in April 2000, agreement was reached among major United Nations agencies to harmonize actions around common elements in each of their respective approaches to school health. UNESCO, UNICEF, WHO, the World Bank and several non-governmental organizations agreed on a common structure for school health initiatives known as the Focusing Resources on Effective School Health (FRESH) framework. Other international agencies have since joined FRESH as partners. A survey among FRESH partners in 2006 revealed that the FRESH framework has been used as the basis for school health advocacy with governments and provided practical guidance to health and education ministries, as well as bringing together partners working in different sectors. The FRESH website and toolkit have played an important role in enabling access to resources and materials to support school health programmes (Attawell, 2006). In 2006, the partners renewed their commitment to the FRESH framework and to its goals and objectives and to further strengthen collaborative work between the partners.
Evidence of progress and continuing challenges
Inspired and supported in part by these different initiatives and programmes, many countries, regions and individual schools have made progress in implementing actions to promote and protect the health of school students and the wider school community. This progress is increasingly well documented in evidence of the effectiveness of school health projects and programmes in combating a number of health issues, including malaria and worm infections, malnutrition, sexual and reproductive health, as well as hand washing and hygiene education (Del Rosso and Marek, 1996; UNAIDS, 1997; Xu et al., 2000; Vince-Whitman et al., 2001; Guinan et al., 2002; Sidibe and Curtis, 2002; UNICEF and IRC, 2005; Kirby et al., 2006; Shordt, 2006; Biddlecom et al., 2007; Jukes et al., 2007; Kirby et al., 2007; Migele et al., 2007). There is also compelling but less consistent evidence of the effectiveness of school health programmes that address non-communicable diseases and risk factors, such as unhealthy diets (Gortmaker et al., 1999; Campbell et al., 2001; Sahota et al., 2001), physical inactivity (Dobbins et al., 2001; Timperio et al., 2004) and harmful use of alcohol and drugs (Tobler and Stratton, 1997; Lloyd et al., 2000; Midford et al., 2000; National Drug Research Institute, 2002), violence and mental health (Wells et al., 2003; Browne et al., 2004; Green et al., 2005; American Counselling Association, 2006; Stewart-Brown, 2006). However, even when positive behavioural outcomes are achieved, these are not always sustained over time, or broadened in impact through dissemination. Therefore, there remains major challenges to ensure greater consistency in implementation of effective strategies, and to develop better strategies for dissemination and for maintenance of effects.
The progress to date provides some scope for optimism, but new challenges emerge with regularity (Lister-Sharp et al., 1999; St Leger et al., 2007). This constantly evolving environment requires continued research and innovation on school health promotion and the potential for school interventions to have an impact on emerging, more complex or insidious risks to health. Addressing the underlying social determinants of health and achieving success in reducing the gaps in health and academic outcomes between students of lower and higher socio-economic backgrounds is increasingly recognized as a priority in this context.
To ensure that school health programmes make a useful contribution to the wider initiatives needed to narrow social and health inequities, it remains a priority that interventions have greatest impact on the health of students from disadvantaged backgrounds. We are challenged to improve the health of the poorest, fastest.
Rationale for a technical meeting and a meeting statement
As indicated above, research and practical experience in school health programmes have grown markedly in the past 10 years. This growing body of evidence and practitioner experience on the effectiveness of these many programmes provides important testimony to the progress achieved so far. It remains important to find ways to share and migrate the lessons learned to date, and determine processes to close the gaps in knowledge, especially those related to social and economic determinants of health.
The Technical Meeting on School Health reported in this paper was organized to consolidate what has been learnt from regions and countries since the WHO Expert Committee meeting in 1995, and to consider new global factors affecting schools. The purpose of the meeting was to pool knowledge and experience so as to provide direction and leadership for future strategies to better respond to current and emerging challenges to the health of children and young people, including improved learning outcomes and health and reduced inequities in health. The meeting sought to build on existing partnerships among national and international organizations specifically by bringing together the health, education and development sectors to focus on their many common goals (St Leger and Nutbeam, 2001). The meeting also provided the opportunity to identify new priorities for research for the next decade, while also providing guidance for future policies and actions to respond most effectively to the challenges identified above.
Process
Ten months prior to the Technical Meeting WHO convened a Steering Committee with participants from all six WHO regions, as well as representatives from major UN agencies. The steering committee advised WHO on the background and the programme for the Technical Meeting. The meeting was organized along five tracks, namely:
- evidence of the effectiveness of school health promotion,
- implementation of HPS and other school community programmes,
- the role of schools in alleviating social and economic disadvantage,
- impact of the media on health behaviour of children and adolescents,
- partnerships for promoting health and education for all school-age children.
At the Technical Meeting, each track involved a plenary session drawing upon papers that were commissioned from around the world for this meeting, and several interactive parallel sessions. A drafting group for the meeting statement met several times during the meeting to finalize the joint statement.
A working draft of the meeting statement was developed by the WHO Secretariat with input from track leaders. It was then revised twice during the Technical Meeting, based on presentations in plenary and parallel sessions and discussions and in light of the comments received from meeting participants. The statement was approved by the meeting participants at the final session of the Technical Meeting.
Throughout the development and finalization of the Statement, the participants maintained the focus on setting strategic directions, guiding principles and detailing action points without going into the details of the priorities and programmes of individual organizations.
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STATEMENT |
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The full text of the Statement is set out in Figure 1.
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DISCUSSION |
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This statement is notable in the extent to which it promotes recognition of the fundamental importance of the relationship between quality education for all to the health of future generations. This relationship is most apparent in low- and middle-income countries, but observable in all countries. Achieving school participation and promoting literacy are fundamental to public health. The statement also reflects the real concern of participants at the meeting about intractable, socio-economically determined differences in vulnerability, risk and health status between and within populations. By emphasizing these issues, the statement achieves a close alignment of goals with the education, health and development sectors, and is highly compatible with the emerging WHO strategy to address the social determinants of health (Commission on the Social Determinants of Health, 2007). The major challenges reflected in the statement are to more widely implement what we know to be effective, and to achieve optimal harmony among the different partner organizations with a stake in the action necessary to achieve implementation.
Implementing the statement
In a recent editorial, St Leger asks challenging questions about the purpose of declarations, charters and statements, whether their intentions are being achieved, who uses them, whether they are right and whether they could have been developed better to facilitate more universal ownership and implementation (St Leger, 2007).
The focus of this statement is to articulate a strategic agenda of issues and re-invigorated set of directions in school health and development programmes in order to improve health, learning and development through schools. Unless the statement is implemented and evaluated by countries, professions and the voluntary sector, it runs the risk of remaining a declaration of aspirations. This has been a concern for the Statement's authors and sponsors, and a range of actions has been taken following the meeting to disseminate and to make use of the Statement.
For example, immediately after the Vancouver Meeting, the WHO Eastern Mediterranean Regional Office used the Statement as the basis for the development of strategic directions for the future institutionalization of the health promotion concept in both health and education sectors in many countries in the Region. The Eastern Mediterranean Network of Health-Promoting Schools was also established in collaboration with UNESCO, the Islamic Educational Scientific and Cultural Organization and other development partners and Member-Sates in the Region. In the Americas' Regional Office (AMRO/PAHO), the Ibero-American Technical Meeting on health and education was held by the Brazilian government with the support of PAHO and the Convenio Andrés Bello. The meeting aimed to analyse the strategic alliance of health, education and development and reflect on the HPS Initiative in the Ibero-American region within the framework of the Vancouver Statement which was translated into Spanish. The meeting was also a means to strengthen interagency collaboration. It brought together technical officers from the Ministries of Health and Education from 10 countries in the region, two UNESCO- OREALC, UNICEF as well as three WHO Collaborating Centres on Health Promotion.
UNESCO has recently committed itself to three critical and interconnected issues for 2008 and beyond. First, to tackle equity and inclusion by reaching those who have been excluded from basic education. Second, to address quality of education, and third to provide technical support and guidance to countries committed to advancing EFA. In pursuing these priorities, UNESCO will make a major direct and indirect contribution to the achievement of the priorities for action identified in the Statement.
Similarly, the World Bank which supports both the education and the health sectors has continued to work with the founding agencies and an even broader partnership to take forward the joint commitment to the countries. The Vancouver Statement reinforces and supports the original vision of the FRESH Framework.
The Joint Consortium for School Health mobilized the health and education sectors of jurisdictional governments across Canada by providing them with the Statement and related briefing materials, and encouraging them to take action in their own jurisdiction. The Consortium continues to mobilize its members to take action in full support to the implementation of the Statement.
The Schools for Health in Europe network (SHE network), formerly known as the European Network for Health Promoting Schools (ENHPS), has used the Statement as one of the sources for defining the new Terms of Reference for SHE, subsequently published at the website www.schoolsforhealth.eu.
The International School Health Network (ISHN) has convened an expert working group to develop a more culturally relevant approach to school health, basic educational achievement and social development for aboriginal schools and communities. The project will include an international Dialogue Circle to develop a more relevant HPS framework based on traditional knowledge, aboriginal/indigenous values and a strength-based approach. The ISHN has also initiated a project that will define a more comprehensive and coherent approach to alleviating disadvantage and promoting equity through school-based and school-linked programmes. Experts and representatives from several countries have defined a list of issues and programmes that are particularly relevant to low-income communities within high-income countries. The project will make use of the Community Schools approach that is similar to HPS but which places more emphasis on community–school partnerships in addressing complex social and economic problems such as poverty, social alienation and geographical isolation. Linkages with the social welfare and crime prevention sector will be emphasized as well.
The Education Development Center (EDC), a partner in the development of the Vancouver Statement and WHO Collaborating Center, has followed up on key recommendations from the Statement by entering into a contract to publish a book with case studies from around the world in school health promotion. In doing so, EDC has worked with authors from around the world to refine the case studies that were prepared for the Vancouver meeting, to add additional cases and to analyse them in regard to identifying factors that support the implementation of school health programmes. The book is planned for publication in early 2009.
Joint actions needed
Despite all of these efforts, the proper and effective implementation of the Statement requires concerted effort among national and international organizations through existing and new partnerships, organizations, networks and other collaborative mechanisms. This will require all agencies to recognize the strong coincidence of interest between their respective missions and priorities, and the strategies identified in the Vancouver Statement. Action is therefore warranted to harmonize efforts among different organizations, as each has its own priorities for action.
Effort must be made by international organizations, such as the FRESH partners, the International School Health Network, and professional organizations such as the International Union for Health Promotion and Education (IUHPE) and Education International (EI) to consider the priorities identified in the Statement as well as initiatives at the national and international levels, so models of best practice can be created and shared. There is also a need to harmonize actions among partners by achieving consensus on a set of key performance indicators to support the efforts that need to be made by key partners for practice, policy development and research globally to address the priorities. To this end, two initiatives are being undertaken. First, the Partnership for Child Development (PCD) and Save the Children US have taken the initiative urging the FRESH partners to take the lead in coordinating the development of a global monitoring and evaluation framework for School Health and Nutrition programmes. Secondly, together with other partners, the IUHPE is also in the process of organizing a series of international discussions through innovative webinars and building a website online, for example, through Wikipedia.
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CONCLUDING REMARKS |
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The Statement that resulted from the Technical Meeting in June 2007 will only be useful if it is implemented at the country level. To implement the statement, a worldwide partnership is needed and actions among key partners must be harmonized. While UN Agencies, international NGOs and professional associations are taking the lead to shape the agenda and develop common frameworks, organizations at the country level also have to develop action plans with clear and measurable outcomes and timelines, taking their social, economic and political context into account. Effort must also be made to develop mechanisms and processes to reach marginalized people and communities in all countries.
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Funding |
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Each agency funded its own contribution. WHO and the Pan Canadian Joint Consortium for School Health provided funded travel and accommodation for some of the meeting participants from various regions.
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Acknowledgements |
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The authors wish to thank all the meeting participants for their input and comments on the earlier drafts of the Statement.
Conflict of interest: This manuscript reflects the collective views of an international group of experts participants in the WHO/JCSH Technical Meeting on Building School Partnerships for Health, Education Achievements and Development (Vancouver, 5–8 June 2007). The authors are responsible for the views expressed in this manuscript. It does not necessarily represent the decisions or the stated policy of the World Health Organization or any other of the organizations represented at the Vancouver meeting.
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FOOTNOTES |
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Present address: Merit Protection Commissioner, Thailand 
Present address: Pacific LEED, University of Hawaii, USA
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