Health, well-being and education Building a sustainable future. The Moscow statement on Health Promoting Schools

Purpose –The purpose of this paper is to introduce the official statement of the Fifth European Conference on Health-Promoting Schools. Design/methodology/approach – The Fifth European Conference on Health-Promoting Schools was held on 20–22 November 2019 in Moscow, Russian Federation, with over 450 participants from 40 countries. A writing groupwas established to prepare a draft version of the statement before the conference. On the basis of an online and offline feedback process, the opinions of the participantswere collected during the conference and included in the finalisation of the statement. Findings – The final conference statement comprises six thematic categories (values and principles; environment, climate and health; schools as part of the wider community; non-communicable diseases (NCDs); evidence base; and digital media), with a total of 23 recommendations and calls for action. Originality/value – The recommendations and calls for action reflect current challenges for Health Promoting Schools in Europe. They are addressed to all actors in governmental, non-governmental and other Challenges of Health Promoting Schools © Kevin Dadaczynski, Bjarne Bruun Jensen, Nina Grieg Viig, Marjorita Sormunen, Jesper von Seelen, Vladislav Kuchma and Teresa Vilaça. Published inHealth Education. Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at: http://creativecommons.org/licences/by/4.0/legalcode This publication has received funding under an operating grant from the European Union’s Health Programme. The current issue and full text archive of this journal is available on Emerald Insight at: https://www.emerald.com/insight/0965-4283.htm Received 3 December 2019 Revised 6 December 2019 Accepted 13 December 2019 Health Education Emerald Publishing Limited 0965-4283 DOI 10.1108/HE-12-2019-0058 organisations at international, national and regional levels involved in health promotion in schools and are to be applied for the further development of the concept.


The Health Promoting Schools approach and its development
The Ottawa Charter, adopted in 1986, was a milestone in the development of a holistic and positive understanding of health that requires actions at different levels, from healthy public policy to the development of personal skills, using different strategies, such as enabling and advocacy approaches (WHO, 1986). The charter can also be regarded as marking the birth of whole-school approaches to health that have been established in Europe and internationally under the term Health Promoting Schools (Stewart Burgher et al., 1999).
A Health Promoting Schools reflects a holistic approach that moves beyond individual behaviour change by also aiming at organisational change through strengthening the physical and social environment, including interpersonal relationships, school management, policy structures and teaching and learning conditions. This approach can be seen as the result of overcoming traditional health education at school, which aimed to influence students' knowledge, attitudes and behaviour (Clift and Jensen, 2005). In accordance with a social-ecological perspective, health is considered to be the result of a complex interplay of individual, social, socio-economic and cultural factors (Dahlgreen and Whitehead, 1991). Since the early 1990, actions on school health promotion have been coordinated in national networks and the European network on Health Promoting Schools as a WHO supported Box 1. Values of the Health Promoting Schools approach Equity Health Promoting Schools ensure equal access for all to the full range of educational and health opportunities. This in the long term makes a significant impact in reducing inequalities in health and in improving the quality and availability of lifelong learning.

Sustainability
Health Promoting Schools acknowledge that health, education and development are closely linked. Schools act as places of academic learning. They support and develop a positive view of pupils' future role in society. Health Promoting Schools develop best when efforts and achievements are implemented in a systematic and continuous way. Desirable and sustainable health and educational outcomes occur mostly in the medium or long term.

Inclusion
Health Promoting Schools celebrate diversity and ensure that schools are communities of learning, where all feel trusted and respected. Good relationships among pupils, between pupils and school staff and between school, parents and the school community are important.

Empowerment
Health Promoting Schools enable children and young people, school staff and all members of the school community to be actively involved in setting health-related goals and in taking actions at school and community level to reach the goals.

Democracy
Health Promoting Schools are based on democratic values and practise the exercising of rights and taking responsibility.

Box 2. Pillars of the Health Promoting Schools approach
Whole-school approach to health There is coherence between the school's policies and practices in the following areas that is acknowledged and understood by the whole school community. This approach includes (1) Taking a participatory and action-oriented approach to health education in the curriculum; (2) Taking into account the pupil's own concept of health and well-being; (3) Developing healthy school policies; (4) Developing the physical and social environment of the school; (5) Developing life competencies and health literacy; (6) Making effective links with home and the community; and (7) Making efficient use of health services.

Participation
A sense of ownership is fostered by pupils, staff and parents through participation and meaningful engagement, which is a prerequisite for the effectiveness of health-promoting activities in schools.

School quality
Health Promoting Schools support better teaching and learning processes. Healthy pupils learn better, and healthy staff work better and have greater job satisfaction. The school's main task is to maximise educational outcomes. Health Promoting Schools support schools in achieving their educational and social goals.

Evidence
School health promotion in Europe is informed by existing and emerging research and evidence focused on effective approaches and practice in school health promotion, both on health topics (such as mental health, eating and substance use) and on the whole-school approach.

Schools and communities
Health Promoting Schools engage with the wider community. They endorse collaboration between the school and the community and are active agents in strengthening social capital and health literacy. Challenges of Health Promoting Schools network. The current work on school health promotion on a European level is organised through the Schools for Health in Europe Network Foundation (SHE), with national representatives from 36 countries. Although the concept of Health Promoting Schools in Europe has been interpreted and implemented differently in different geographical, cultural and educational contexts, its main values (Box 1) and pillars (Box 2) have remained stable and are recognised in research and policy documents and declarations (such as the Paris Declaration on Partnerships for the Health and Well-being of our Young and Future Generations; WHO, 2016, see also Figure 1 in summary and Buijs, 2009).
Since the establishment of the European network of Health Promoting Schools, four European conferences on Health Promoting Schools have been organised. The resolution of the first conference, held in Thessaloniki, Greece, in 1997, stated that every child and young person in Europe had the right to be educated in a Health Promoting Schools and urged governments in all European countries to adopt the Health Promoting Schools approach (ENHPS, 1997). The Egmont Agenda was published in 2002 as a result of the Second European Conference on Health Promoting Schools in The Netherlands and emphasised conditions, programming and evaluation as being essential to developing and sustaining Health Promoting Schools (ENHPS, 2002).
Seven years later, the Third European Conference on Health Promoting Schools was held in Vilnius, Lithuania (SHE Network, 2009). The conference and its resolution marked an important milestone in the development of the Health Promoting Schools approach by highlighting that education and health have shared interests and complement each other. Based on this, joint actions beyond sectoral responsibilities were urged.
The Fourth European Conference was held in Odense, Denmark, in 2013 and resulted in The Odense Statement, which recognised the core values and pillars of school health promotion as a strong contributor to the aims and objectives of the WHO policy framework for health and well-being in Europe, Health 2020 and the EU2020 strategy for inclusive and sustainable growth (SHE Network, 2013).

Recent societal challenges
Since the establishment of the Health Promoting School approach in the late 1980s, the world has seen constant societal change, with progressively faster dynamics during recent years. The changes have not only altered substantially the conditions in which people grow up and live, but have also affected behaviours in relation to health, social cohabitation, learning and working. Wars and violence, often rooted in cultural and religious differences or political and economic crisis, and climate change alter significantly the environmental and societal determinants of health (Mucci et al., 2016;Watts et al., 2019).
Often, it is countries that already are experiencing political and socio-economic instability that feel the effects most (Reibling et al., 2017). An increase in international migration, commonly in perilous circumstances for migrants and refugees (Silove et al., 2017), is the consequence, raising social tensions and challenges in many countries, some of which are undergoing political developments characterised by protectionism and isolationism that can partly be seen as a countermovement to the idea, values and principles of Europe (Harteveld et al., 2018).
In many cases, uncertainty has replaced political, economic, social and individual stability, raising concern and anxiety about the future in young people and adults. This has led to an unprecedented social (grassroots) movement of participation, primarily driven by young people who are demanding social, political, ecological and economic change (O'Brien, Selboe and Hayward, 2018).
These developments should not be seen as being separate from school health promotion, the aim of which is to support young people to develop healthy and self-determined lifestyles and enable them to co-create their social, physical and ecological environments and the determinants of health positively and sustainably (Clift and Jensen, 2005;Simovska and McNamara, 2015). As the conditions for growing up and living together change, the question arises of how schools, as places for health-related teaching, learning and development, need to adapt.
Where does the Health Promoting School approach stand today, more than 30 years after the Ottawa Charter on health promotion? Can the Health Promoting School, with its holistic orientation, deliver on its promise of addressing health inequalities and improving children's and young people's health, well-being and academic achievement? To what extent can school health promotion be implemented systematically in schools and be linked to local communities?
These and more questions were raised and discussed during the Fifth European Conference on Health Promoting School, culminating in recommendations for the future development of the Health Promoting School approach.

The Fifth European Conference on Health Promoting Schools
The Fifth European Conference on Health Promoting Schools was held on 20-22 November 2019 in Moscow, Russian Federation, with over 450 participants from 40 countries.
A range of topics was addressed through more than 160 contributions and nine keynote presentations focusing on conceptual aspects of the Health Promoting School approach, implementation and dissemination and current social change processes, such as digitisation and heterogeneity.
The main themes of the conference were (1) Holistic approaches to school-based health promotion and health education (such as organizational change and environmental approaches to school health promotion and strategies to promote individual and organizational health literacy in schools); (2) Implementation and dissemination of school-based health promotion and health education (facilitators and barriers to implementing interventions in schoolbased health promotion and professional development and capacity-building of, for example, teachers, non-teaching school staff, school health services, parents and external professionals); (3) Networking and intersectoral collaboration in school-based health promotion and health education (schools as part of the wider community, and multisectoral partnerships at local, national and international levels); (4) Innovative approaches to dealing with heterogeneity, inclusion and special needs (pupils' and teachers' health in inclusive schooling, school-based health promotion and education for refugees, students with special needs and innovative approaches to school-based health services); and (5) Digital media and information and communications technology (ICT) in school health promotion and health education (practical approaches to ICT use in school-based health promotion and digital devices and media as a target for interventions and a means to promote health and well-being).

Recommendations for action
As a result of the research and case studies presented and discussions among conference participants, the following recommendations for action have been developed. They are addressed to all actors in governmental, nongovernmental and other organisations at international, national and regional levels, engaging with schools and/or school health promotion.

Challenges of Health Promoting Schools
(1) We recognise and reaffirm the established values and pillars of the Schools for Health in Europe Network Foundation (SHE). Especially in times marked by uncertainties and ambiguities, the Health Promoting School stands by its inalienable democratic values. This foundation is the basis for all health-promoting activities in schools and reflects a human and social perspective characterised by openness and mutual respect. We, therefore, recommend that all actions on health promotion and health education involving young people must Be based on democratic processes and foster equal access, active involvement and participation; Take into account the needs and background of all young people regardless of their gender, geographical, cultural and social background or religious beliefs: in that sense, a Health Promoting School can be seen as an inclusive school that celebrates heterogeneity and diversity as an enriching dimension for mutual learning, respect and acceptance; Reflect a whole-school approach addressing different target groups and combining classroom activities with development of school policies, the physical, social and cultural environment of the school and the necessary capacities needed: we welcome new and established concepts and approaches within school-based health promotion, such as health literacy, salutogenesis, action competence and life skills, which should complement each other and be integrated in the holistic framework of the Health Promoting School approach; and Be systematically linked with educational goals and school quality as part of a so-called add-in approach: based on rich evidence, a Health Promoting School can be regarded as a school that not only promotes and maintains health, but also strives for successful learning for pupils and working conditions for teaching and non-teaching staff, and involves parents and families in the school's daily life.
(2) We recognize that environment, climate and health are closely intertwined and cannot be considered in isolation. Climate and environmental problems affect health, and health choices and actions affect climate and the environment. Environmental, climate and health issues are driven by the same fundamental structural determinants in societies. Health promotion and education for sustainable development or climate change have common goals and fields of action. We therefore Urge all stakeholders in health and climate/sustainability education to work together systematically to support young people to grow up and live healthily and sustainably; Urge all stakeholders to support and empower young people to raise their voice and make a lasting contribution to shaping a healthy and sustainable future for themselves and their fellow human beings; Call for actions to link planetary health and the Health Promoting School approach more explicitly by, for instance, integrating the impact of human action on the environment and its health consequences into school curricula and everyday life; and Call for realignment of health-promotion research agendas to address environmental challenges in, with and through schools.
(3) We advocate for a health-in-all-policies approach. Health should be promoted in all environments in which young people live and are engaged in daily activities. Although schools play a significant role in the lives of young people, school health promotion cannot be regarded in isolation from the surrounding community. We therefore call for All actors to move from a single-setting approach to an integrated multisetting approach that systematically links actions at school level with actions in the local community: these actions should not be implemented in isolation, but in a coordinated fashion to create synergies and avoid discontinuities; Intersectoral collaboration among different actors and professions, such as teachers, school health services and social and youth-care services: this requires professional development, and that existing local networks and their leadership capacities be strengthened to align sectoral policies and enable the development of a common vision and language; and All actors to strengthen links with existing national and regional cooperation mechanisms, such as Health Promoting School networks and healthy city or healthy region networks, by pursuing joint objectives and actions.
(4) We recognize that Noncommunicable Diseases (NCDs), including mental illnesses, are threatening the future of many countries' health and welfare systems and their economies. As emphasised in the Jakarta Call for Action on Noncommunicable Diseases from 2011, high priority should be given in national health policies and programmes to preventing NCDs. To tackle the rising incidence of NCDs, we need to start early; the Health Promoting School can serve as an appropriate setting in which to address the objectives of the WHO global action plan for the prevention and control of NCDs, 2013-2020. We, therefore, recommend that A resource-oriented intervention approach (as described in the SHE values and pillars) be taken to tackle NCDs rather than a traditional top-down and diseaseoriented approach, which normally dominates interventions related to risk factors; Young people be viewed as part of the solution and not only as part of the problem of NCDswe need to work with young people as powerful agents of healthy change and not as victims and recipients of risk factors; A school environment that promotes healthy practices in areas like healthy eating, physical activity, social and emotional well-being and good hygiene be created; and Commercial determinants are addressed by empowering young people to become critical and responsible citizens who are able to understand and critically reflect on media advertising and market mechanisms through, for instance, consumer education.
(5) We recognize that the Health Promoting School approach will be accepted and implemented more widely if it can provide evidence of its long-term effectiveness. Despite much research on various areas of school health promotion in recent years, further efforts are needed to make visible and further improve the research evidence base for the holistic Health Promoting School approach. We therefore

Challenges of Health Promoting Schools
Call for evaluation approaches that reflect the complexity of the Health Promoting School by, for example, applying mixed-methods designs and considering graded health and educational outcomes; Demand that the available scientific evidence be reviewed and evaluated using existing tools and be translated into recommendations for practical action; Urge that a one-sided focus on outcomes research be augmented by focusing also on implementation to identify the conditions under which interventions can be effective, systematically linking both research perspectives; and Call for systematic and strong partnerships between researchers and practitioners who develop and implement innovative interventions in school health promotion and those who conduct empirical surveys on child and adolescent health (such as the Health Behaviour in School-aged Children (HBSC) study) and the health of teaching and non-teaching staff. By sharing available social-epidemiological data, previously untried evaluation potential can be exploited.
(6) We clearly recognise that growing up nowadays is largely driven by high usage of digital media, and that digital devices and applications form an essential part of everyday life. The digital transformation of health systems and increasing digitalisation of everyday life mean the availability and ubiquity of health-related information has increased rapidly and substantially over recent decades. So far, school health promotion has only partially tapped the potential and challenges of digital media. We therefore Call on all actors in school health promotion to use the possibilities of digital media in the context of research, development, implementation and exchange of innovative interventions and good practice; Urge all actors to use digital media as a supplement to, and not as a substitute for, non-digital (face-to-face) school health-promotion actions; Call on all actors to ensure that the use of digital media does not lead to a step back to individual and behavioural prevention, but rather is used at organisational level to, for instance, build capacity, communicate with partners outside the school and promote low-threshold participation in change processes within the school; and Call for actions to empower individuals and whole-school systems to deal effectively with health information complexity, including its critical assessment, selection and use and to take responsibility for providing suitable and reliable health information.