Healthy schools and colleges: what works, what is needed, and why?

Citation

Marks, R. (2010), "Healthy schools and colleges: what works, what is needed, and why?", Health Education, Vol. 110 No. 4. https://doi.org/10.1108/he.2010.142110daa.001

Healthy schools and colleges: what works, what is needed, and why?

Article Type: Guest editorial From: Health Education, Volume 110, Issue 4

Background: need for health promoting schools

For nearly a century, schools have played a vital role in the delivery of health services, and interventions designed to promote health (Mohammedi et al., 2010, in press). This includes reducing the vulnerability of young people to poor health behaviors and poor health outcomes in later life, thus impacting on the health of young people across the lifespan in a positive way (Centers for Disease Control, 2004). Moreover, it has been argued that as access to standard health care systems becomes more restrictive, health promotion programs in schools are likely to play an increasingly important role in determining the overall health of a nation (Winters et al., 2007). Mounting evidence shows that a significant number of young people already have one or more irreversible health condition that can impair their learning. Furthermore the health issues of most concern today are those that develop early on in life, and are likely to be exacerbated in the absence of adequate health education efforts.

As suggested by Charles Basch (2010) of Columbia University, it is imperative now more than ever health goals become part of individual school improvement plans. Accordingly, in the USA, resources are currently being allocated for a $41 million initiative focused on healthier schools. This is consistent with English public health policy that identifies schools as the key setting in efforts to achieve a healthier nation (Denman, 1999).

However, to be effective, it has been clear for some time that school-based health education must not only be comprehensive, continuous, interdisciplinary and involve adequate teacher training, but must also allow adequate instruction time, family involvement, and community support for all this (Gold, 1990; Seffrin, 1990). Furthermore the context or setting in which these lessons takes place must consistently support and reinforce such school-based health promotion efforts. There must also be strong support for partnerships that can guide the implementation of effective health promotion policies in order to optimize the health status of young people. Indeed, to be sustainable, as well as effective, school based health programs today must go well beyond simply offering information, fostering motivation, and providing the skills necessary to accomplish a given health goal (Basch, 2010).

In line with this recognition of complex and interdependent factors, for more than two decades, the World Health Organization has thus advocated for the broad all encompassing concept of the “health promoting school” (Young, 2005). According to this concept, which is an accepted approach in public health for enhancing children and adults’ health in the school setting (Denman, 1999), it is incumbent upon schools to foster the health and learning of these targeted recipients with all measures at its disposal (World Health Organization, 2010).

This approach thus stresses the importance of the entire school, rather than categorical curricula alone in fostering favorable health outcomes of today’s youth. That is, rather than relying on standardised lesson plans alone, promoting young peoples’ health in the school setting requires an appropriate school infrastructure, well trained support staff, as well as educational professionals and informed parents to work together to achieve the desired level of health of its priority audience. It also demands an organizational climate that is supportive of a carefully planned comprehensive, culturally sensitive and well-coordinated developmentally appropriate set of lesson plans, plus effective policies and policy directives, strategic planning efforts and appropriate resources. Indeed, for the youth to benefit from the health promotion efforts carried out by the school, at least three interactive elements of import must be present as follows:

1. 1.

   An effective health education curriculum.

2. 2.

   A positive school ethos or social environment and healthy physical environment.

3. 3.

   A broad-based network of support from the wider community (Denman, 1999).

Consequently, contemporary educators and others desiring to demonstrate significant reductions in risk behavior and favorable healthy lifestyle choices of our youth in the future have an obligation to work beyond their individual silos of concern and consider all opportunities at their disposal that can be mobilized to enhance the academic achievement level and healthy lifestyle choices of young people. In essence, they can no longer be content with merely developing educational topics and embedding these in health education curricula. They also have to ensure these lessons can be carried out in a positive social and physical environment that effectively links parents, youth, and the wider community in pursuit of the goal of maximizing the wellbeing and health outcomes of the youth and are strongly encouraged to advocate for such as approach on behalf of all youth.

If the school itself, which is a venue attended by millions of children daily, strives to promote health, schools as organizational entities must commit to providing a safe, healthy context for health teachers and support staff as well as young people. The school must be proactive as well in helping to inform parents about how they can support their children’s learning, and making this feasible in times of constraint. In addition to playing a key role in creating a health enhancing environment for the youth both in and out of the school setting, its educational directives must be aligned with the prevailing and future needs of young people, and must support the content and delivery of evidence based health education curricula that meet national agreed upon standards of excellence (Denman, 1999). School leaders and teachers must work together to provide a climate that respects cultural diversity as well as learning preferences and cognitive capacity, and an ethos that promotes inclusiveness in order to yield significant and sustainable positive health practices as well as health knowledge, general knowledge, life skills and positive self esteem.

The contribution of this special edition

In this special issue, some factors that speak to the complexity of the development and implementation of school-based health promotion efforts and the health promoting school paradigm are examined. These studies reveal several insights, as well as challenges that may help to account for the generally poor outcomes observed in achieving desired sustainable health changes in schools despite the strong rationale of support for the health promoting school concept and framework. A relatively understudied area, these findings may thus contribute to a better understanding of what might work, what might not work, and why. They also suggest what is needed in the future to achieve success in fostering the well being of young people across the lifespan. In particular, they stress the importance of careful planning using an ecological approach when designing or implementing school based health programs in order to maximize positive school based preventive efforts, and minimize organizational, administrative, policy, as well as social barriers that might impede the goal of creating a health promoting school.

The five papers presently selected were derived from submissions that had their origins in The Netherlands, The UK, Australia, Canada and Ireland and thus represent diverse constituents, and views, as well as some consistent common overlapping features. There were many more submissions, some of which will appear in subsequent volumes, plus several submissions and requests to submit that could not be processed due to time factors, suggesting this is a topic of high interest worldwide.

The topic areas covered in this special edition include:

• •

  A pilot whole school intervention study to improve school ethos and reduce substance abuse using the Healthy School Ethos intervention.

• •

  A study of context in the implementation of an emotional wellbeing program for primary school children called Zippy’s Friends.

• •

  A mixed method study to examine the development and impact of a college based health education course in conjunction with a healthy campus.

• •

  A study designed to garner perceptions of stakeholders concerning their understanding of the health promoting school concept.

• •

  A study that examines the role and impact of the school health promotion advisor in the context of establishing health promotion activities and policies in Dutch based secondary schools.

The papers presented here employed a range of different-approaches, and all examined different research issues, in different time periods, and geographic locations. Clearly more work from more varied backgrounds is required so that there can be more generalisability of these aforementioned ideas. However the five papers do provide considerable empirical support for the view that efforts of health educators to foster the concept of the health promoting school in all its complexity are of immense import.

The papers also suggest that, to achieve the goal embodied by the health promoting school concept, efforts must not be simplistic. First, efforts need to involve the entire school in its complexity as well as its staff members, its students and their parents. Policy makers, administrators, and appropriately trained advisors, as well as related outside community members must be on board. Mohammadi, Rawling and Nutbeam, 2010, in press, in a very insightful study using survey methodology that captured responses of school staff including principals, and teachers responsible for teaching health found considerable diversity in educational perspectives regarding the meaning and benefits of health promoting schools in an Australian context. Thus, before attempts are made to translate the WHO vision of the health promoting school into a reality, identifying how stakeholders view this concept, and making every effort to identify their core values is clearly advocated. Moreover, without a shared understanding of both the health and educational sectors of the school and what the end goal is, it is very unlikely that sustained positive health outcomes can be achieved. In particular, the authors suggest more emphasis be given to educational outcomes and the link between health and educational outcomes.

The importance of tailoring and flexibility is another related insight that is likely to impact sustainability of school health programs as outlined by Bonell et al.. This group examined the transferability of an evidence based whole-school intervention in an English context. Although successful in its previous Australian and US contexts, these authors argued for flexibility in the implementation of the desired school-based intervention to allow for local innovation. They also stressed the importance of structure to ensure implementation consistency. Thus, a curriculum that works in one venue is not necessarily transferable directly to another, and must involve the stakeholders, including the teachers and youth in the whole school process. The directives they successfully used to achieve this goal involved engaging all students, formalised student participation in all decisions, and involving staff with the capacity to ensure intervention delivery.

The salience of understanding the real life context of school and its impact on school health programmatic objectives was further studied by Clarke, O’Sullivan and Barry. This case study was conducted using a well-established emotional wellbeing program for primary school children in disadvantaged schools in Ireland. These investigators found that despite largely positive attitudes concerning the benefits of the program, there were contrasting levels of parental involvement at the two schools. This highlighted the importance of understanding the prevailing socio-economic and cultural influences that can impact program implementation and effectiveness. It also supported the conclusion of Bonell et al., that all stakeholders should be included in the process of adopting a curriculum, even if this is shown to be efficacious elsewhere. It emphasized the importance of understanding the nature of the social network and social environment in mediating health outcomes in the school arena.

In this regard, Boot et al., showed that the introduction of a school health promotion advisor trained to impact the role of health promotion agencies in structuring school health promotion might be helpful. This group evaluated the role of the school health promotion advisor in the implementation of the six steps of the Dutch “Schoolbeat” approach. Schools, which implemented this strategy adequately or even partially was reported to be more satisfied than those that had not done so.

Wharf-Higgins et al. suggest that health education curricula that are responsive to student’s needs and delivered in conjunction with a health campus environment, are promising. Using a mixed methods study conducted at a Canadian University, these researchers’ showed future recipients were desirous of attaining holistic health, feeling connected to others and the campus, achieving a scholarly degree, and balance, and that students were responsive to a curriculum based on these personal goals.

When viewed as a whole, the five papers clearly indicate the importance of active student and community collaboration in the design of health programs as well as the need to implement health programs in a systematic strategic way. They also indicate the important role of promoting shared understandings between school staff and decision makers about the value of school-based health education. Engaging health and education leaders, parents, school health policy makers and community leaders is also of import in attempts to produce an efficacious school-based health-promoting venue.

Although the health status of school-age youth is significantly associated with their school achievement, subject areas such as health education tend to receive less prominence in the school curriculum. The importance of health in the context of academic achievement needs to be reinforced among educators and parents. Groups disadvantaged due to social factors, chronic illness or loss, high-risk groups and/or those with specific language or cognitive needs must be targeted as well, rather than ignored.

Enlightened school and local policies, state policies to support healthy school environments and inclusive school-based health educational opportunities that are effectively organized and implemented are likely to have far reaching social and economic benefits for all. Creative as well as insightful programmatic applications conducted by professional educators, and/or trained advisors or community members, plus careful modifications of state of the art programmatic efforts, can similarly ensure the attainment of the desired sustainable health and quality of life outcomes anticipated by the health promoting school concept. Conducting careful needs assessments, enacting inclusive participatory processes, and fostering a positive school and community ethos is thus highly desirable:

Schools have more influence on the lives of young people than any other social institution except the family and provide a setting in which friendship networks develop, socialization occurs, and norms that govern behavior are developed and reinforced (Healthy People, 2010).

Future directions

There are indeed many topics highly relevant to school and college attendees’ well-being and development, as well as to their overall academic achievement that require attention. The health promoting school framework designed to strengthen capacity and delivery of health curricula in the school is however, a topic of potential merit, has not been extensively studied, nor evaluated (Mukoma and Flisher, 2004). The present authors support the view given in 2004 of Mukoma and Flisher that process evaluation is very important in this context, as is the understanding of the local culture, and economy, as well as identifying the local needs and perceptions of stakeholders. The relative influence of social conditions, versus school capacity, and the educational stakeholders’ interest also needs to be stressed and examined further in the context of health promoting schools. Especially needed are further studies of factors that impact schools and colleges both positively and negatively in the context of a variety of school-related policies, administrative, and fiscal situations, and organizational climate factors. Also needed is information on what programs and conceptual models should be put in place to ensure a school is health promoting, that is, one that constantly strengthens its capacity as a healthy setting for living, learning and working (World Health Organization, 2010).

The role of parents, teachers, principals, program staff, support services, advisors, community members and organizations and school boards also needs to receive more attention in the relevant literature.

Clearly, schools today may be the only venue where youth can learn those life long skills that are cross-cutting and essential in the adult workplace for ensuring economic security and high levels of mental, social and physical well-being. In this regard, early interventions that focus on the cognitive, emotional, behavioral and social needs of individuals, groups, and families are indicated. In addition, to prevent and address their most pressing health problems, it is necessary to facilitate positive learning experiences and healthy behaviors, plus related social competencies that can foster a positive attachment to the school using well planned and articulated planned sequential empirically derived curricula. Youth must also be afforded ample and consistent opportunities to practice healthy behaviors, and related social competencies and be encouraged individually and collectively to meet their highest potential (Marx et al. 1998). Inclusive, culturally sensitive practices and learning approaches that accommodate all youth are especially indicated, as are adequate teacher training, skilled advisors, resources and interactive departmental and whole community participatory collaborations in a socially and physically conducive environment. As outlined over a decade ago by Marx et al (1998), the importance of conducting, researching, and implementing effective coordinated school health programs cannot be underestimated, and fostering the practical assistance to do this is especially crucial in efforts to foster the health promoting school.

Ray Marks