Evaluating health-promoting schools in Hong Kong: development of a framework

Health-promoting schools (HPS)/healthy schools have existed internationally for about 15 years. Yet there are few comprehensive evaluation frameworks available which enable the outcomes of HPS initiatives to be assessed. This paper identifies an evaluation framework developed in Hong Kong. The framework uses a range of approaches to explore what schools actually do in their health promotion and health education initiatives. The framework, which is based on the WHO (Western Pacific Regional Office) Guidelines for HPS, is described in detail. The appropriate instruments for data collection are described and their origins identified. The evaluation plan and protocol, which underpinned the very comprehensive evaluation in Hong Kong, are explained. Finally, a case is argued for evaluation of HPS to be more in line with the educational dynamics of schools and the research literature on effective schooling, rather than focusing primarily on health-related measures.     

Health-promoting schools

Chronic diseases are now the major causes of death and disability worldwide, and non-communicable diseases (NCD) account for the majority of the global health burden. About half of premature deaths are related to health-risking behaviours that are often established during youth and extend to adulthood. While these diseases might not be curable, they are preventable. Prevention is possible when sustained actions are directed at individuals and families, as well as at the broader social, economic and cultural determinants of NCD. A ‘life-course’ approach to promoting healthy behaviour should begin early in life. The aim of this article is to discuss the impact of the ‘health-promoting school’ (HPS) on improvements in youth health. HPS can be described as a holistic, whole-school approach in which a broad health education curriculum is supported by the environment and ethos of the school. HPS moves beyond individual behavioural change to consider organizational and policy change such as improving the physical and social environment of the school, as well as its curricula and teaching and learning methods. A positive culture for health would facilitate higher levels of health literacy by helping individuals tackle the determinants of health better as they build the personal, cognitive and social skills for maintaining good health. There is reasonable evidence to demonstrate that the whole-school approach using the HPS framework is effective in improving health, ranging from physical activities and healthy eating to emotional health. Schools adopting the HPS framework have demonstrated changes in culture and organizational practice to become more conducive to health improvement. These schools were reported to have better school health policies, higher degrees of community participation, and a more hygienic environment than non-HPS schools, and students in these schools had a more positive health behaviour profile. Health promotion and disease prevention is essential to reduce the healthcare burden of children and adolescents. HPS would help to combat the global burden of childhood obesity by promoting healthy eating behaviours and encouraging higher levels of physical activity. There are gaps in service provision for children and adolescents from both the health and education perspective; the HPS framework has the potential to develop a mechanism of closer integration with the primary healthcare system, making youth health services more school based and student centred. A new model of interconnection between HPS and different components of primary healthcare can be evolved to make services for disease prevention and health promotion more student friendly.     

The status of health-promoting schools in Hong Kong and implications for further development

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.     

Creating health-promoting schools in China with a focus on nutrition

This pilot project in Zhejiang Province, China, aimed at improving the nutrition and health status of students, school personnel and parents, and developing a model project for nutrition interventions for the development of health-promoting schools (HPS) in China. Three primary and three secondary schools participated. Interventions included establishing school-based working groups, nutrition training for school staff, distribution of materials on nutrition, nutrition education for students, student competitions, school-wide health promotion efforts and outreach to families and communities. Results of a pre- and post-intervention survey one and a half years apart showed improvements in nutrition knowledge, attitudes and behavior among all target groups. Primary school students at the pilot schools made the greatest knowledge gains in the areas of Chinese dietary guidelines (increased from 49.2 to 78.0%, p < 0.01) and adequate dietary principles (increased from 42.9 to 68.0%, p < 0.01). Scores of secondary school students who reported liking school lunches rose at pilot schools from 17.9 to 45.2% (p < 0.01). School staff at control schools who reported taking breakfast declined from 81.4 to 66.6% (p < 0.01), while staff who reported taking lunch at school increased in pilot schools from 87.5% at baseline to 93.9% (p < 0.01). The largest increases in nutrition knowledge among all target groups occurred among parents and guardians. At the pilot schools parents increased their knowledge in the areas of nutritional deficiencies (from 35.0 to 66.2%, p < 0.01) and nutrient-rich foods (from 38.8 to 66.8%, p < 0.01). Talks with target groups confirmed changes in attitudes and behavior, and school visits revealed improvements to school facilities and school health services, establishing of school policies and a positive school climate. This study suggests that nutrition can effectively serve as an entry point to establish HPS in China and that the HPS concept is feasible to improve the dietary knowledge, attitudes and behavior of students, parents and school personnel.     

The functional relationships of medical schools and health services

Medical schools need good functional relationships with the health systems in which their students, graduates and staff will learn and work. With increasing complexity and rising costs of health delivery the 2 types of organisation have become more interdependent but not always as collaborating partners. Recent changes in the organisation of undergraduate medical education have been reactive to re-structuring of health services. For example, traditional teaching hospitals have become more specialised and less suitable for general medical education. While this has helped to decentralise medical education into appropriate clinical environments, these and other changes have generally been adaptive to the health systems rather than being instigated by the medical schools for educational reasons. This discussion paper examines the nature of the relationships and their contributory elements. A taxonomy of functional relationships is proposed with primary categories of (i) autonomy (ii) contiguity (iii) interdependence (iv) collaboration, and (v) obligation. It is suggested that medical schools should become more assertive in application of their creative talents and educational resources throughout the environment in which their graduates will use their medical skills, and in which they will work with other health care professionals.     

Policy and provision of WASH in schools for children with disabilities: A case study in Malawi and Uganda

There is a growing body of evidence on the correlation between improving access to water, sanitation and hygiene (WASH) in schools and positive health and educational outcomes for students. Similar evidence on the impact of school WASH facilities on health, enrolment and absence for children with disabilities is not available. The limited data have revealed that children with disabilities are burdened by poor WASH in schools access, and even prevented from attending school due to inaccessible WASH facilities. We conducted two case studies of policy and provision of school WASH services for children with disabilities in Uganda and Malawi. We found a robust policy environment in Uganda and Malawi with policies and guidelines in place for WASH in schools for children with disabilities. However, provision of services and facilities are low and focused primarily on sanitation.     

Parental views about services for children attending schools for the emotionally and behaviourally disturbed (EBD): a qualitative analysis

AIM: This study examines the views of parents of children attending schools for the emotionally and behaviourally disturbed (EBD). The study aims to gain an understanding of the journey through the educational system taken by these children and to explore their families' experience of services along the way. METHODS: Thirty parents of 25 children attending primary and secondary EBD schools in three South London boroughs took part in focus group discussions. Parents were asked about their experiences of services, including educational, health and social services, as well as how they thought services should be improved. RESULTS: Qualitative analysis identified a complex web of individual, professional and organizational factors which contributed to social exclusion of children with EBD problems and their families. These factors included children receiving inadequate education because of long periods of exclusion or inappropriate placements whilst waiting for a statement of special educational needs. Parents also felt personally socially excluded because of lack of childcare provision out of school hours. Many parents felt that their children did not fit into services and were constantly being passed on to other professionals. The analysis identified aspects of services that promote social inclusion and provide support to families, including acceptance of children into EBD schools, help from voluntary organizations and support from other parents with children with EBD problems. Parents particularly stressed the value of working in collaboration with professionals to achieve shared goals. CONCLUSION: EBD schools provide a valuable resource for parents. However parents often lack emotional and practical support in coping with their children's complex needs. Agencies need to improve communication and joint working to provide effective services for these families.     

Subtainable health promotion via organisational development--a model project for teachers in professional training schools

The goal of this project is the development, implementation and evaluation of a concept designed for sustainable health promotion among occupational and trade school teachers. We assume that for sustainable health promotion -- along with a behavioral prevention program -- a change is necessary in the structure, as well as, the working and communication processes within schools. The realization of early teacher participation and self regulated cooperative groups initiates comprehensive and goal-oriented developmental processes in the project schools. The organizational development process was accomplished in the following way: At the beginning we conducted a diagnosis of school-specific and individual health risks and the resources available to the project schools. The results were reported for both the individual and for the teacher group. This was intended to clarify the potential for improvement and, thus, strengthen the teachers' motivation toward processes of change. Following the diagnosis, the teachers chose areas of stress-related strain and then worked in groups to develop and implement behaviour and working condition-oriented intervention strategies for health promotion. The diagnosis results confirm the necessity of school-specific health promotion: the schools demonstrate very different demand and resource profiles. Furthermore, is has become evident that the central success factor for health promotion in schools is the teachers' willingness for change. The individual and group reports of the diagnosis results seem to have made clear how essential individual and organisational changes are.     

Schools as social complex adaptive systems: A new way to understand the challenges of introducing the health promoting schools concept

Achieving system-wide implementation of health promotion programs in schools and sustaining both the program and its health related benefits have proved challenging. This paper reports on a qualitative study examining the implementation of health promoting schools programs in primary schools in Sydney, Australia. It draw upon insights from systems science to examine the relevance and usefulness of the concept of “complex adaptive systems” as a framework to better understand ways in which health promoting school interventions could be introduced and sustained. The primary data for the study were collected by semi-structured interviews with 26 school principals and teachers. Additional information was extracted from publicly available school management plans and annual reports. We examined the data from these sources to determine whether schools exhibit characteristics of complex adaptive systems. The results confirmed that schools do exhibit most, but not all of the characteristics of social complex adaptive systems, and exhibit significant differences with artificial and natural systems. Understanding schools as social complex adaptive systems may help to explain some of the challenges of introducing and sustaining change in schools. These insights may, in turn, lead us to adopt more sophisticated approaches to the diffusion of new programs in school systems that account for the diverse, complex and context specific nature of individual school systems.     

Developing the ‘health-promoting school’—a national survey of healthy schools awards

The concept of the ‘Health Promoting School’ has been widely advocated as an approach to enhancing public health through school based health promotion. In many areas ‘Healthy Schools Award’ schemes have been set up to support the development of this concept, but there is no information on how widespread this practice is in the UK, how standards are evaluated, and what effect Healthy Schools Awards may have on young peoples' health. This UK national survey aimed to determine the extent and nature of existing award schemes and how they were being evaluated. A postal questionnaire was sent to all 200 health promotion units in the UK; the response rate corrected for mergers of units was 78.5%. Sixty-eight respondents (51%) were involved with an award scheme and 28 (21%) were planning them. Current award schemes were mostly jointly run by the health and education sectors, encompassing 845 participating schools of which two-thirds were primary schools. The most common issues addressed were; standard chronic disease risk behaviour, the environment and health education in the national curriculum; less frequently addressed were mental health, accident prevention, staff health and developing links with the wider community. Evaluation was usually by target setting and assessment of progress over a two year period. However, evaluation was rarely external or independent, raising doubts about the standards obtained and validity of the approaches. This survey highlights the rapid growth of healthy schools award schemes and the need for wider exchange of information on good practice. In particular there is a need for more explicit and measurable standards of achievement to ensure the quality of award schemes, and further research into their effectiveness.     

Reducing the gap between the economic costs of tobacco and funds for tobacco training in schools of public health

Tobacco use costs approximately dollar 167 billion annually in the U.S., but few tobacco education opportunities are available in schools of public health. Reasons for the discrepancy between the costs of tobacco use and the creation of tobacco training opportunities have not been well explored. Based on the Behavioral Ecological Model, we present 10 recommendations for increasing tobacco training in schools of public health. Six recommendations focus on policy changes within the educational, legislative, and health care systems that influence funds for tobacco training, and four recommendations focus on strategies to mobilize key social groups that can advocate for change in tobacco control education and related policies. In addition, we present a model tobacco control curriculum to equip public health students with the skills needed to advocate for these recommended policy changes. Through concurrent changes in the ecological systems affecting tobacco control training, and through the collaborative action of legislators, the public, the media, and health professionals, tobacco control training can be moved to a higher priority in educational settings.     

Building capacity for the continuous improvement of health-promoting schools

BACKGROUND: There has been much educational verbosity over the past decade related to building capacity for effective schools. However, there seems to be a scarcity of clarification about what is meant by school capacity building or how to accomplish and sustain this process. This article describes the preexisting conditions and ongoing processes in Pueblo, Colorado School District 60 (Pueblo 60) that built capacity for the development and continuous improvement of health-promoting schools. METHODS: Capacity building strategies and a program-planning model for continuous improvement for health-promoting schools were used that included: (a) visionary/effective leadership and management structures, (b) extensive internal and external supports, (c) development and allocation of adequate resources, (d) supportive policies and procedures, and (e) ongoing, embedded professional development. RESULTS: Pueblo 60 strategically developed an infrastructure through which they successfully delivered a wide array of health programs and services. CONCLUSIONS: Through building organizational capacity at the school district and school level, additional school health programming can be developed and sustained.     

The role of the schools of public health in the development of primary health care

Starting with the assumption that the schools of public health can and should be major promoters of primary health care but that they have not fully utilized their potential, the paper reviews the different interpretations of primary health care and their implications for the recruitment policies, educational objectives, teaching methods and research orientation of the schools. Four interpretations (primary health care as a set of activities; as a level of care; as a strategy of organizing health services; and as a philosophy permeating the entire health care system) are identified. It is suggested that most industrialized countries already have a primary medical care system which has to be transformed into primary health care. A blueprint for this transformation is outlined. Many of the changes included in the blueprint are related to the concept of primary health care as a strategy. Schools of public health can play a major role in implementing the necessary strategic changes and in training their implementers. The training of actual primary care providers for leadership; increased emphasis on management in the curricula; and reorientation of research towards primary health care are underlined as particularly important elements in the new role of the schools of public health.     

Helping schools to become health-promoting environments--an evaluation of the Wessex Healthy Schools Award

The concept of the health-promoting school embodies a holistic,whole school approach to personal and community health promotion.Healthy school award schemes, which are increasing, are seenas one way of helping schools to become health promoting. Manyare based on the Wessex Healthy Schools Award scheme (WHSA)which was established in 1993. This paper outlines a 3-yearevaluation study of the effectiveness of the WHSA interventionin changing health promotion policy and practice in school,and in influencing health-related knowledge, attitudes and behaviourof pupils. The study design was quasi-experimental, and wasconducted in 11 intervention secondary and five control schools.It involved pupils, teachers, support staff, parents, schoolgovernors, health promotion officers and education advisers,using a range of quantitative and qualitative tools. The Awardprocess, which is linked to nine key areas of health, lasted15 months. Changes in school health promotion were assessedby audit; pupils' health-related knowledge, attitudes and behaviourthrough self-administered questionnaires; and attitudes andperceptions of staff, parents and governors from semi-structuredinterviews. The results showed that audit scores for all areas,except physical activity and taking responsibility for health,increased in intervention schools, indicating positive Award-relatedchanges. There was little improvement in healthy food choices,smoke-free environment and developing community links. Pupils'knowledge, high at the baseline, remained unchanged. Positiveeffects on smoking uptake and drug use were seen, but littlechange in healthy eating and physical activity. Older girlsmade greater progress in all areas. Parents and non-teachingstaff strongly supported school health promotion, perceivedmany benefits of the Award, and wished to be more actively involved.The Award positively influenced the development of a health-promotingschool, perceived as an important component of education. Furtherresearch is needed into ways of improving pupils' diet and activitylevels, how schools can implement a smoke-free environment,the development of community links, and ways in which a wholeschool approach can be achieved.     

Building bridges between school-based health clinics and schools

BACKGROUND: The 2 institutions that hold great promise in mitigating the negative cyclical relationship between poor health and educational readiness are schools and school-based health care facilities (SBHCs). In partnership with schools, SBHCs could have a profound effect on learning outcomes, which include, but are not limited to, poor concentration in school, attendance, and disturbances of normal sequential development. This article provides an overview of the role of federal, state, and local governmental agencies in the development and implementation of public educational policy and funding in an effort to provide SBHCs the foundation for building a bridge between the health and the educational lexicon. METHODS: This article reviews literature from a wide variety of sources to develop a better understanding of the complexities associated with public K-12 education and provides suggestions for initiating meaningful interactions between SBHC supporters and educational decision makers. RESULTS: Strategic reasoning between supporters of SBHCs and educational policy makers is critical because of the limitations of time and money for those delivering educational services. Additional projects (eg, SBHCs) no matter how well conceived will be difficult to promote unless officials can be convinced that collaboration in school-based health care actually enhances compliance with the No Child Left Behind Act. CONCLUSIONS: Though SBHCs and schools are both committed to enhancing the lives of children, these institutions speak different languages and are accountable to very different types of public and private bodies.     

Meeting the preteen vaccine law: a pilot program in urban middle schools

California, the most populous state in the nation, is one of many states that implemented vaccination requirements for preteens. While kindergarten requirements are well-established and accepted by parents, implementation of preteen vaccination requirements requires inter- and intra-institutional adjustments, educational and public relations efforts, and an augmentation of vaccination delivery systems. This article describes a pilot program in two middle schools in an urban school district and offers planning strategies and practical tools to assist school nurses and health providers to implement preteen requirements.     

Nutrition policies for schools

In Britain, Canada and the United States, the impetus for initiating school nutrition policies has come primarily from health, not education, agencies. These agencies define the nutrition problems of school students as both under‐ and over‐nutrition, and, to solve them, advocate the development and implementation of policies to combat health and learning problems associated with poor nutrition. Health, rather than educational, agencies are also more likely to formulate school nutrition policies; such policies commonly address the dietary principles of access, adequacy, and moderation. Within countries, the adoption of school nutrition policies varies considerably. Moreover, the degree to which such policies have been implemented is unclear, because of a lack of research to evaluate their process and impact. To enhance the successful development and implementation of school nutrition policies, greater partnership between health and education agencies is recommended throughout the policy process.     

Promoting health in schools: the German example

This paper gives an overview of research into health promotionin schools. Traditional approaches tend to focus on health educationas a means of conveying knowledge about potential health threatsor information about risks of certain forms of behaviour. Theresults and effects of these approaches are moderate. The secondpart of the paper discusses more comprehensive approaches tohealth promotion in school settings. It not only addresses children'sand adolescents' cognitive development, but also considers theentire personal, emotional, social and ecological experienceof the child. The paper elaborates on four central dimensionsof school health promotion: the curriculum, the social, theecological and the community. All four dimensions are thoughtto be an integral part of a comprehensive strategy for healthpromotion that embeds factual information on health-risk behaviourinto a context that is focused on everyday problem solving bythe child or adolescent.     

Evaluating health promotion in schools: a case study of design, implementation and results from the Hong Kong Healthy Schools Award Scheme

Health promoting schools (HPS) and Healthy Schools Award Schemes from a number of countries have demonstrated positive changes in children's health behaviours and the culture and organisation of the school. The Hong Kong Healthy Schools Award Scheme (HKHSA) aims to promote staff development, parental education, involvement of the whole school community, and linkage with different stakeholders to improve the health and well-being of the pupils, parents and staff, and the broader community, supported by a system to monitor the achievement. This concept is very much in line with the research literature on school effectiveness and improvement. The indicators examined to evaluate the success of the HKHSA reflect outcomes related to both health and education and are not limited to changes in population health status. The early results demonstrated significant improvements in various aspects of student health and also improvement in school culture and organisation. The evaluation framework described in this paper and data collected to assess how schools perform in the HKHSA scheme, provides insight into how HPSs could lead to better outcomes for both education and health.     

Health policies and procedures for medical students at US medical schools: a progress report

Summary. This paper presents the current status of school health policy at US medical schools and discusses implications for medical students with respect to physical health and occupational risks. The authors discuss the responsibility of schools to ensure that students are healthy and fit, both for their own benefit and to provide models of good health maintenance for their future patients. Schools have an obligation to monitor public safety issues, particularly in cases of chemical impairment, student mistreatment, and infection control procedures.