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Health–promoting schools in Australia: models and measurement

Health–promoting schools in Australia: models and measurement National Centrefor Health Promotion, Department o Public Health and Community Medicine, f University of Sydney Oddrun Samdal Research Centrcfor Health Promotion, University of Bergen, Norway Abstract: Schools represent a very attractive setting for health promotion. Most children and young people attend school, professional educators are in place, and most school communities are microcosms of the larger community, providing opportunities for children to develop and practise the skills necessary to support a healthy life-style. In response to this opportunity, the precepts of contemporary health promotion have been synthesised into the 'health-promoting school' model, which is guided by a holistic view of health and by the principles of equity and empowerment. Although there are different conceptions of the model, the key components are: the formal curriculum; school ethos (the social climate); the physical environment; the policies and practices of the school; school health services; and the school-home-community interaction. The health-promoting school model offers a comprehensive, systematic approach to health promotion in the school setting, which is widely accepted internationally. There have been few studies in Australia that have attempted to determine the prevalence of activities related to the model or to evaluate interventions. Unfortunately, conceptual and practical advances have far outstripped the development of research and evaluation instruments. There is an urgent need to create valid research tools to support the development and implementation of this potentially fruitful health promotion model. (Aust ATZJPublic Health 1997; 21: 365-70) HE primary responsibility of Australian schools is to provide the best possible educational experience for children and young people. As social institutions, schools also recognise their responsibility to provide that education in a safe, secure environment which protects and promotes the wellbeing of the students and other members of the school community. There is abundant evidence that those responsible for school education take these responsibilities seriously and make determined efforts to fulfil them. Unfortunately, the limits to the responsibilities of schools for the wellbeing of students and staff are often unclear and the subject of debate. However, when thoughtfully implemented, school health promotion activities do not detract from, but frequently support, the realisation of the educational and social objectives of schools.' The term enuironment is one of the buzz words of the 1990s (both in health promotion and beyond), and consequently, is attended by a range of interpretations. Many people would describe the entire school as an environment, while others describe the school as a Jetting within which exist different environments. The latter interpretation is used here. The health-promoting school concept is based on a holistic view of health which recognises the different physical, social and mental dimensions of health and is based on the fundamental principles of: equity of access to school education among different population groups, and between genders; emphasis on empowerment through the development of knowledge and skills among students; and inclusiveness, ensuring that the whole school community, parents and the wider local community are fully engaged in developing and implementing school activities. The health-promoting school concept has rapidly gained credibility over the last decade and now provides a widely accepted paradigm for the development of schools into social institutions which actively promote the health of students and staff.' Interested readers are referred to a recent World Health Organization Expert Committee publication which (together with its feeder papers) provides a very comprehensive, global perspective on health-promoting schools.' Defining and measuring the characteristics of a health-promotingschool Many of the documents on the theory and practice of health-promoting schools identify three key domains: the formal curriculum (including classroom activities and health education) ; school ethos (including the physical and social environments and NO Correspondence to Dr Michael Booth, National Centre for Health Promotion, Department of Puhlic Health a n d Community Medicine, A'27, University of. Sydney NSM' 2006. Fax (02) 9351 7420, email mikeh~puh.health.s~I.oz.au. AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1997 vot. 21 F the policies and practices of the school); and, the school-home-community interaction (including school health services). In this paper, however, we characterise health-promoting schools under six domains: the formal curriculum; school ethos (the social environment) ; the physical environment; the policies and practices of the school; school health services; and the school-home-community interaction. An essential caveat to any attempt to describe different domains within the health-promoting school concept is that, in practice, these domains of activity should be as thoroughly integrated as possible. Indeed, a central feature of health-promoting schools is that all health-related activities be integrated and coordinated. Theformal cum'culurn The formal health curriculum has several important functions. It should provide sufficient information to allow students to make informed choices about their health as young people and as adults. The formal curriculum should also foster the development of a range of skills relevant to physical and psychosocial health: cognitive (for example, decision making), physical (for example, abilities to participate in physical and other recreational activities) and interpersonal (for example, self-assertion, communication). Finally, the formal curriculum should support aspects of intrapersonal development, including personal values, positive self-concept and resilience. The characteristics of an effective curriculum are a topic of vigorous debate. There does appear to be some consensus, however, about the key features. An effective school health curriculum should offer learning experiences appropriate to the cognitive and social development of students throughout the students' school life (kindergarten to the final year). It is widely accepted that a spiral curriculum (one in which the same topics are revisited throughout school life) is also more effective than only addressing each health issue once or twice. A minimum of 50 hours of classroom-based health education per year is widely recommended and teaching should involve a mixture of teacher- and learner-centred (for example, group discussion, role play) strategies4 The formal health curriculum should address a wide range of topics, such as growth and development, interpersonal relationships, health behaviours and life-style, personal choices and safe living. A topic of particular debate is whether the syllabus should be integrated across other subjects (or key learning areas), or if health education should be presented as a separate key learning area. There are advantages to both approaches, with the greatest advantage flowing from a combination of the two. Because many teachers involved in delivering classroom health education have received little or no pre-service training in the area, comprehensive inservice training should be available and accessible. An instrument to assess the adequacy of a health education curriculum should include items on: the number of hours devoted to health and physical education in each year of school from kindergarten to the final year; the health issues or content areas of the curriculum and the time devoted to each; the time spent using teacher- or learner-centred strategies; the amount and adequacy of in-service training for teachers; and teachers' perceptions of the availability and quality of teaching resources. Although these items may appear straightforward, there are considerable problems of validity to be overcome. For example, it may be very difficult for a single questionnaire respondent to determine the time spent on each content area in an integrated curriculum or to describe accurately the adequacy of inservice training; and there may be very different perceptions of what constitutes teacher- or learnercentred strategies. It should be recognised that accurate assessment of these items simply may not be achievable and that researchers may have to settle for reasonable estimates. School ethos Within the health-promoting school model 'school ethos' is frequently used in a very comprehensive way to encompass the whole school environment, including the physical environment, social relations, organisational structure, policies and practices and daily activities in schools. In other cases it is ascribed a more limited meaning, reflecting the quality of the social interactions within the school community. The latter meaning will be employed here to emphasise the importance of school ethos as a separate area of interest. There are two separate, interrelated aspects of school ethos: school climate and classroom climate. School climate refers largely to relations among staff (for example, openness of communication, responsiveness to suggestions for change, collegial atmosphere and mutual helpfulness) whereas classroom climate refers to relations among students and between staff and students.' There is considerable evidence that a positive classroom climate is directly related to student outcomes (for example, academic achievement, inquiry skills, satisfaction).' There is also strong evidence, from the NT€O Health Behaviour among School-aged Children study, of an inverse relationship between liking school, intention to continue with further education, and self-rated school achievement and a range of health-compromising behaviours." Although the relationship between participation in health behaviours and established classroom climate measures does not appear to have been examined, the findings suggest that a positive classroom climate is related to healthier behaviour. There is a range of well-established school and classroom climate scales available and a substantial scientific literature on the measurement of climate, on the factors that influence climate and on the -,. effect of climate on educational outcomes. L',' However, this literature does not appear to have been used by those interested in school health promotion. School (and particularly classroom) climate is a potentially fruitful area for intervention to influence all aspects of student and staff wellbeing and simultaneously to improve educational outcomes. VOL. AUSTRALIAN AND NEW ZEAIAND JOURNAL O PUBLIC HEALTH 1997 F NO HEALTH-PROMOTING SCHOOLS Physical enuironment The school physical environment includes the safety and state of repair of school buildings (for example, adequate heating and lighting, absence of asbestos), adequate water and sanitation, hygienic food service, adequate play and recreation facilities and equipment, sufficient shade areas and areas conducive to quiet study or social interaction. The contribution to health of a physical environment that is safe and hygienic, and which meets (at least) the basic needs for physical comfort, for work and for play, is considered self-evident. Assessment of the quality of the school physical environment could be achieved by self-completed questionnaire, provided that clear guidelines for rating the quality of different aspects of the environment are included. The questionnaire should be validated against an examination of the environment by trained researchers between whom interrater reliability has been determined. School policies and practices School policies represent guidelines and indicators for the day-to-day activities of school life. For example, schools may have policies on wearing hats and sunscreen while outside, on the types of food available through the school food service, on the use of protective equipment while playing sport, on student involvement in decision making, and on dealing with violence or with distressed students. Policies are much more likely to be effective if they are influenced by wide consultation with all members of the school community (staff, students and parents), if they are clearly written and well-communicated, and if they are consistently enforced. The health-related practices of a school represent the actual day-to-day activities of school life, regardless of whether they are supported by policy. It would not be uncommon to find that many schools implement health-related practices in the absence of any written or widely agreed policy and that many written policies fail to be consistently implemented. The organisational structures which may foster the development of relevant written policies and encourage their consistent application are outlined below. The assessment of written policies is not expected to be difficult to achieve through the administration of a self-completed questionnaire, and the instrument may be validated against the findings of a visit to the school during which the policies are viewed. Assessment of the health-related practices of the school is more problematic. The practices may not be consistently implemented across time or by different members of school staff in different situations, making it difficult to achieve estimates of usual practice. The magnitude of these potential problems may be determined by asking several members of the same school to complete the questionnaire blind to each other. School health seruices The health-promoting schools model suggests that a broad range of services may contribute to the health of students and staff, through: prevention of infectious diseases; screening and early detection of physical diseases or disorders, intellectual dysfunction and emotional disturbances; treatment in school or referral to other practitioners or agencies; management of medications and other treatments for chronic diseases like asthma; detection of and intervention in cases of neglect or abuse; provision of critical incident care; and participation in classroom and other school activities. Most of the health professions (physicians, community or school health nurses, dentists, counsellors, social workers and public health professionals) may participate in the delivery of health services in schools and may contribute to health promotion activities in schools. Teachers play a critical role in identifylng apparent health problems and in bringing them to the attention of health specialists, but they cannot be expected to detect all significant problems. Although most departments of education (and schools) have policies and personnel for the treatment or management of health or social problems once they have been detected, they appear to have been developed on the basis of critical need, not proactive analysis and planning. The health-promoting schools model, although identifylng health services as a potentially important contributor to health in schools, has paid scarce attention to the resource implications, efficacy, cost-effectiveness or acceptability of population screening and prevention programs for many of the health problems that may confront young people. Research and development in this area, of the type exemplified by the National Health and Medical Research Council's review of screening,9is clearly needed. An instrument to assess the availability (but not the effectiveness) of school health services would comprise a comprehensive inventory of the screening, treatment and management services available in a school, and, like other aspects of a health-promoting school assessment instrument, it might best be validated by having several members of school staff respond to the instrument blind to each other. School-home-communitj interaction The attitudes toward health and the health-related behaviours of parents are among the most powerful influences over the health and the health behaviours of young people. The long-term effects of efforts by the school to encourage and support young people in making healthy choices for themselves are much less likely to be successful if parents do not actively encourage the behaviour or if they engage in less-healthy behaviours themselves. Fostering the involvement and support of parents is critical to making healthy choices easier for adolescents." There is a range of ways in which parents may support school health promotion: fund-raising and other material and practical support; advocacy in support of school health initiatives; reinforcing school health education messages; assistance in modifylng the curriculum to local cultural conditions. The provision of information on healthy lifestyles to parents through school meetings or NO. AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1997 vot. 21 F through students may also assist parents to adopt healthier life-styles for themselves and their families. There are many government agencies, nongovernment agencies and professional and community organisations which are able to provide assistance and support to schools. They may provide teaching resources, special school health promotion programs, participation in classroom activities, financial support or other material assistance. Schools may also be able to interact with community-based sport and recreational organisations to enhance the range of activities available to students. Beyond greater involvement in schools by parents and community agencies, schools may be developed as 'community centres', more intimately integrating them into the wider community. The engagement of parents in school health promotion initiatives may be determined by assessment of the frequency with which health-related information is sent home, the frequency with which healthrelated homework involving parents is set, the number of school meetings to discuss health issues (including the number of parents who attend) and the number of parents involved in planning and supporting health-promoting school initiatives. Similarly, the specific agencies or organisations and the frequency with which they interact with the school should be assessed. These questionnaire items could be validated by comparing the responses of schools against information from some of the agencies cited. Education and Health and effective collaboration between the two portfolios are invaluable. Public, ministerial commitment should infiltrate the state education department and manifest itself as policies, management practices and resource allocations that are genuinely supportive of efforts at the school level. Contributions from the health sector need to be based on thoughtful consultation with the education sector and an appreciation of the primary goals of schools and of the niany demands placed upon them. Monitoring the progress of health-promoting n schools i Australia Organisationnl structures It is necessary to consider the school both as a defined organisation and as a unit of a larger, lesswell-defined system in order to identifj the organisational structures (and the key functions they perform) that are likely to support sustained progress. Within the school, a committee or team with a responsibility for the health of the school community has been suggested as an important organisational element."-'" This team should include school staff from many, if not all, learning areas, and student representatives and parents. The functions of the team may include: identification of the health needs of staff and students; setting priorities for action based on broad consultation within the school; the development of a school health plan; delegation of responsibility for elements of the plan; communication of the plan to the whole school community; professional development of teachers; identification of required resources and sources of support; and being a point of contact with other schools in the region, local organisations (community groups, local government) and state or national organisations (National Heart Foundation, Health Promoting Schools Association). Assessment of the organisational structures may simply involve a checklist of these items. Although they are not commonly identified as an element of health-promoting schools, aspects of the broader system within which schools function may be critical to sustained progress.'-' A public commitment to healthy schools from the Ministers for The purpose of monitoring health promotion activities in schools is to assess progress toward creating the conditions supportive of improved health and learning outcomes. However, in the school setting, there exists a complex web of nonlinear causal relationships and noncausal associations between the desired health and learning outcomes and the many characteristics o f schools and school life. The nature of the relationships between these outcomes and their causes is supported by clear evidence in some cases (for example, excessive exposure to the sun and skin cancer), but there is not strong empirical evidence in many other cases (for example, a supportive social environment and mental health). Consequently, we can identify with considerable certainty some of what should be monitored, but are reduced to informed guesswork in many cases. It is not possible, at this time, to describe a definitive set of measures either to monitor progress or to characterise a school as 'a healthy school'. It is possible, however, to assemble questionnaires that will proFide reasonable and informative indicators of the development of many of the aspects of health-promoting schools. Monitoring should be undertaken against a background of research on the relationships between health and learning outcomes (including health-related behaviours) and their direct and indirect determinants. Table 1 provides a list of potential indicators of a health-promoting school. These indicators may form the basis of an instrument used in a program of monitoring the development of health-promoting schools (and in other research contexts) in Australia. We suggest that the next practical step is that a lead agency (National Health and Medical Research Council or the Australian Institute of Health and Welfare) form an expert committee to: seek national, cross-sectoral agreement on what should be measured; support a program of collaborative research to develop valid, reliable methods of measurement (paying close attention to developments internationally) ; and develop a monitoring system acceptable to the school education system. There are two alternatives to this approach. First, do nothing. Second, follow the more usual approach of allowing noncollaborating (often competing) researchers to develop incompatible instruments which have been inadequately validated and to apply them irregularly, both geographically and chronologically. VOL. AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1997 F 21 NO 4 HEALTH- PROMOTING SCHOOLS Table 1 : Potential indicators of a health-promoting school The formal curriculum Topics covered Classroom time devoted to each topic area and its distribution across years Extent of integration of health education across the curriculum Teacher training and support Quality and availability of teaching resources Teaching strategies employed Involvement of external agencies and individuals in curriculum delivery Policies and practices 0 Policy on smoking in school grounds or at school functions 0 Help to stop smoking available for students and staff 0 Use of hats by staff and students 0 Sunscreen supplied free and its use encouraged 0 Avoid sports and physical education in the middle of the day 0 Protective equipment for sports and physical education 0 Learn-to-swim programs 0 First aid and C R training programs P 0 Reduced availability of high-fat or high-sugar foods in the school 0 Increased availability and promotion of healthy foods Physical environment Availability of shade for a 1 students during breaks 1 Safe play equipment and sports equipment Shock-absorbing surfaces where appropriate Adequacy of lighting and heating Facilities for social interaction and quiet work Facilities for sports, physical education and other recreation Clean, physically attractive, well-maintained buildings and grounds, free of dangerous materials (for example, asbestos) Drinking water easily available Clean toilet facilities Social environment 0 Extent and nature of student involvement in decision making 0 Proactive programs to reduce bullying and violence Proactive programs to enhance classroom climate Proactive programs to enhance school climate Peer-support program School-home-communiiy 0 Frequency with which health-related materials sent to parents Frequency of health-related homework requiring parental involvement 0 Frequency of parent meetings and health topics discussed at those meetings 0 Nature of parental involvement encouraged by the school Frequency and nature of health promotion programs for school staff 0 Involvement with local zretailers (for example, preventing cigarette sales to minors) Frequency and nature of involvement of government, nongovernment, community and commercial agencies with school Health services 0 Management plans and other support for those with chronic disease (for example, asthma) First aid and critical-incident management 0 Screening according to National Health and Medical Research Council guidelines 0 Counselling and referral for distressed or troubled students (including those with a drug addiction, mental health problem, social adjustment difficulties) Support and referral for those suffering abuse or neglect 0 Conflict resolution for staff-staff, staff-student and studentstudent problems Support of curriculum delivery Very little has been done to monitor the current status or progress of health promotion in schools in Australia. Biennial surveys of school health education (for example, curriculum time and resources, physical education facilities and equipment, some policies) have been conducted in Western Australia since 1987.'" A recent survey of randomly selected New South Wales high schools addressed issues similar to those of the Western Australian survey and included in the questionnaire sections on the policies and practices of schools with regard to: the involvement of parents, exposure to the sun, smoking, injury prevention, involvement of communitybased agencies in the school, food services, bullying and violence, support for troubled students, and student participation in decision making (Booth ML, et al. The health-related policies and practices of NSW high schools. Unpublished report.). There do not appear to have been any other large-scale studies on the current status of health promotion activities in Australian schools. summary The health-promoting school model represents a comprehensive and potentially fruitful approach to health promotion which attempts to address (in a systematic, integrated fashion) knowledge and skill development, the physical and social environments, influential policy and practice, health services and the wider community. It is consistent conceptually with the most recent principles of health promotion and appears to be acceptable to many schools and school systems. However, conceptual development and practice have far outstripped our ability to monitor its implementation and assess its effects. One of the most significant barriers to the systematic evaluation and monitoring of health-promoting schools in Australia is the absence of reliable, valid instruments. There is an urgent need for the development of such instruments, preferably by consultation through a nationally representative group, so that comparable data may be collected within each of the states and territories. The use of widely accepted instruments will also allow more direct comparisons of the results of program evaluations. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Health–promoting schools in Australia: models and measurement

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Publisher
Wiley
Copyright
Copyright © 1997 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1467-842X.1997.tb01716.x
Publisher site
See Article on Publisher Site

Abstract

National Centrefor Health Promotion, Department o Public Health and Community Medicine, f University of Sydney Oddrun Samdal Research Centrcfor Health Promotion, University of Bergen, Norway Abstract: Schools represent a very attractive setting for health promotion. Most children and young people attend school, professional educators are in place, and most school communities are microcosms of the larger community, providing opportunities for children to develop and practise the skills necessary to support a healthy life-style. In response to this opportunity, the precepts of contemporary health promotion have been synthesised into the 'health-promoting school' model, which is guided by a holistic view of health and by the principles of equity and empowerment. Although there are different conceptions of the model, the key components are: the formal curriculum; school ethos (the social climate); the physical environment; the policies and practices of the school; school health services; and the school-home-community interaction. The health-promoting school model offers a comprehensive, systematic approach to health promotion in the school setting, which is widely accepted internationally. There have been few studies in Australia that have attempted to determine the prevalence of activities related to the model or to evaluate interventions. Unfortunately, conceptual and practical advances have far outstripped the development of research and evaluation instruments. There is an urgent need to create valid research tools to support the development and implementation of this potentially fruitful health promotion model. (Aust ATZJPublic Health 1997; 21: 365-70) HE primary responsibility of Australian schools is to provide the best possible educational experience for children and young people. As social institutions, schools also recognise their responsibility to provide that education in a safe, secure environment which protects and promotes the wellbeing of the students and other members of the school community. There is abundant evidence that those responsible for school education take these responsibilities seriously and make determined efforts to fulfil them. Unfortunately, the limits to the responsibilities of schools for the wellbeing of students and staff are often unclear and the subject of debate. However, when thoughtfully implemented, school health promotion activities do not detract from, but frequently support, the realisation of the educational and social objectives of schools.' The term enuironment is one of the buzz words of the 1990s (both in health promotion and beyond), and consequently, is attended by a range of interpretations. Many people would describe the entire school as an environment, while others describe the school as a Jetting within which exist different environments. The latter interpretation is used here. The health-promoting school concept is based on a holistic view of health which recognises the different physical, social and mental dimensions of health and is based on the fundamental principles of: equity of access to school education among different population groups, and between genders; emphasis on empowerment through the development of knowledge and skills among students; and inclusiveness, ensuring that the whole school community, parents and the wider local community are fully engaged in developing and implementing school activities. The health-promoting school concept has rapidly gained credibility over the last decade and now provides a widely accepted paradigm for the development of schools into social institutions which actively promote the health of students and staff.' Interested readers are referred to a recent World Health Organization Expert Committee publication which (together with its feeder papers) provides a very comprehensive, global perspective on health-promoting schools.' Defining and measuring the characteristics of a health-promotingschool Many of the documents on the theory and practice of health-promoting schools identify three key domains: the formal curriculum (including classroom activities and health education) ; school ethos (including the physical and social environments and NO Correspondence to Dr Michael Booth, National Centre for Health Promotion, Department of Puhlic Health a n d Community Medicine, A'27, University of. Sydney NSM' 2006. Fax (02) 9351 7420, email mikeh~puh.health.s~I.oz.au. AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1997 vot. 21 F the policies and practices of the school); and, the school-home-community interaction (including school health services). In this paper, however, we characterise health-promoting schools under six domains: the formal curriculum; school ethos (the social environment) ; the physical environment; the policies and practices of the school; school health services; and the school-home-community interaction. An essential caveat to any attempt to describe different domains within the health-promoting school concept is that, in practice, these domains of activity should be as thoroughly integrated as possible. Indeed, a central feature of health-promoting schools is that all health-related activities be integrated and coordinated. Theformal cum'culurn The formal health curriculum has several important functions. It should provide sufficient information to allow students to make informed choices about their health as young people and as adults. The formal curriculum should also foster the development of a range of skills relevant to physical and psychosocial health: cognitive (for example, decision making), physical (for example, abilities to participate in physical and other recreational activities) and interpersonal (for example, self-assertion, communication). Finally, the formal curriculum should support aspects of intrapersonal development, including personal values, positive self-concept and resilience. The characteristics of an effective curriculum are a topic of vigorous debate. There does appear to be some consensus, however, about the key features. An effective school health curriculum should offer learning experiences appropriate to the cognitive and social development of students throughout the students' school life (kindergarten to the final year). It is widely accepted that a spiral curriculum (one in which the same topics are revisited throughout school life) is also more effective than only addressing each health issue once or twice. A minimum of 50 hours of classroom-based health education per year is widely recommended and teaching should involve a mixture of teacher- and learner-centred (for example, group discussion, role play) strategies4 The formal health curriculum should address a wide range of topics, such as growth and development, interpersonal relationships, health behaviours and life-style, personal choices and safe living. A topic of particular debate is whether the syllabus should be integrated across other subjects (or key learning areas), or if health education should be presented as a separate key learning area. There are advantages to both approaches, with the greatest advantage flowing from a combination of the two. Because many teachers involved in delivering classroom health education have received little or no pre-service training in the area, comprehensive inservice training should be available and accessible. An instrument to assess the adequacy of a health education curriculum should include items on: the number of hours devoted to health and physical education in each year of school from kindergarten to the final year; the health issues or content areas of the curriculum and the time devoted to each; the time spent using teacher- or learner-centred strategies; the amount and adequacy of in-service training for teachers; and teachers' perceptions of the availability and quality of teaching resources. Although these items may appear straightforward, there are considerable problems of validity to be overcome. For example, it may be very difficult for a single questionnaire respondent to determine the time spent on each content area in an integrated curriculum or to describe accurately the adequacy of inservice training; and there may be very different perceptions of what constitutes teacher- or learnercentred strategies. It should be recognised that accurate assessment of these items simply may not be achievable and that researchers may have to settle for reasonable estimates. School ethos Within the health-promoting school model 'school ethos' is frequently used in a very comprehensive way to encompass the whole school environment, including the physical environment, social relations, organisational structure, policies and practices and daily activities in schools. In other cases it is ascribed a more limited meaning, reflecting the quality of the social interactions within the school community. The latter meaning will be employed here to emphasise the importance of school ethos as a separate area of interest. There are two separate, interrelated aspects of school ethos: school climate and classroom climate. School climate refers largely to relations among staff (for example, openness of communication, responsiveness to suggestions for change, collegial atmosphere and mutual helpfulness) whereas classroom climate refers to relations among students and between staff and students.' There is considerable evidence that a positive classroom climate is directly related to student outcomes (for example, academic achievement, inquiry skills, satisfaction).' There is also strong evidence, from the NT€O Health Behaviour among School-aged Children study, of an inverse relationship between liking school, intention to continue with further education, and self-rated school achievement and a range of health-compromising behaviours." Although the relationship between participation in health behaviours and established classroom climate measures does not appear to have been examined, the findings suggest that a positive classroom climate is related to healthier behaviour. There is a range of well-established school and classroom climate scales available and a substantial scientific literature on the measurement of climate, on the factors that influence climate and on the -,. effect of climate on educational outcomes. L',' However, this literature does not appear to have been used by those interested in school health promotion. School (and particularly classroom) climate is a potentially fruitful area for intervention to influence all aspects of student and staff wellbeing and simultaneously to improve educational outcomes. VOL. AUSTRALIAN AND NEW ZEAIAND JOURNAL O PUBLIC HEALTH 1997 F NO HEALTH-PROMOTING SCHOOLS Physical enuironment The school physical environment includes the safety and state of repair of school buildings (for example, adequate heating and lighting, absence of asbestos), adequate water and sanitation, hygienic food service, adequate play and recreation facilities and equipment, sufficient shade areas and areas conducive to quiet study or social interaction. The contribution to health of a physical environment that is safe and hygienic, and which meets (at least) the basic needs for physical comfort, for work and for play, is considered self-evident. Assessment of the quality of the school physical environment could be achieved by self-completed questionnaire, provided that clear guidelines for rating the quality of different aspects of the environment are included. The questionnaire should be validated against an examination of the environment by trained researchers between whom interrater reliability has been determined. School policies and practices School policies represent guidelines and indicators for the day-to-day activities of school life. For example, schools may have policies on wearing hats and sunscreen while outside, on the types of food available through the school food service, on the use of protective equipment while playing sport, on student involvement in decision making, and on dealing with violence or with distressed students. Policies are much more likely to be effective if they are influenced by wide consultation with all members of the school community (staff, students and parents), if they are clearly written and well-communicated, and if they are consistently enforced. The health-related practices of a school represent the actual day-to-day activities of school life, regardless of whether they are supported by policy. It would not be uncommon to find that many schools implement health-related practices in the absence of any written or widely agreed policy and that many written policies fail to be consistently implemented. The organisational structures which may foster the development of relevant written policies and encourage their consistent application are outlined below. The assessment of written policies is not expected to be difficult to achieve through the administration of a self-completed questionnaire, and the instrument may be validated against the findings of a visit to the school during which the policies are viewed. Assessment of the health-related practices of the school is more problematic. The practices may not be consistently implemented across time or by different members of school staff in different situations, making it difficult to achieve estimates of usual practice. The magnitude of these potential problems may be determined by asking several members of the same school to complete the questionnaire blind to each other. School health seruices The health-promoting schools model suggests that a broad range of services may contribute to the health of students and staff, through: prevention of infectious diseases; screening and early detection of physical diseases or disorders, intellectual dysfunction and emotional disturbances; treatment in school or referral to other practitioners or agencies; management of medications and other treatments for chronic diseases like asthma; detection of and intervention in cases of neglect or abuse; provision of critical incident care; and participation in classroom and other school activities. Most of the health professions (physicians, community or school health nurses, dentists, counsellors, social workers and public health professionals) may participate in the delivery of health services in schools and may contribute to health promotion activities in schools. Teachers play a critical role in identifylng apparent health problems and in bringing them to the attention of health specialists, but they cannot be expected to detect all significant problems. Although most departments of education (and schools) have policies and personnel for the treatment or management of health or social problems once they have been detected, they appear to have been developed on the basis of critical need, not proactive analysis and planning. The health-promoting schools model, although identifylng health services as a potentially important contributor to health in schools, has paid scarce attention to the resource implications, efficacy, cost-effectiveness or acceptability of population screening and prevention programs for many of the health problems that may confront young people. Research and development in this area, of the type exemplified by the National Health and Medical Research Council's review of screening,9is clearly needed. An instrument to assess the availability (but not the effectiveness) of school health services would comprise a comprehensive inventory of the screening, treatment and management services available in a school, and, like other aspects of a health-promoting school assessment instrument, it might best be validated by having several members of school staff respond to the instrument blind to each other. School-home-communitj interaction The attitudes toward health and the health-related behaviours of parents are among the most powerful influences over the health and the health behaviours of young people. The long-term effects of efforts by the school to encourage and support young people in making healthy choices for themselves are much less likely to be successful if parents do not actively encourage the behaviour or if they engage in less-healthy behaviours themselves. Fostering the involvement and support of parents is critical to making healthy choices easier for adolescents." There is a range of ways in which parents may support school health promotion: fund-raising and other material and practical support; advocacy in support of school health initiatives; reinforcing school health education messages; assistance in modifylng the curriculum to local cultural conditions. The provision of information on healthy lifestyles to parents through school meetings or NO. AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1997 vot. 21 F through students may also assist parents to adopt healthier life-styles for themselves and their families. There are many government agencies, nongovernment agencies and professional and community organisations which are able to provide assistance and support to schools. They may provide teaching resources, special school health promotion programs, participation in classroom activities, financial support or other material assistance. Schools may also be able to interact with community-based sport and recreational organisations to enhance the range of activities available to students. Beyond greater involvement in schools by parents and community agencies, schools may be developed as 'community centres', more intimately integrating them into the wider community. The engagement of parents in school health promotion initiatives may be determined by assessment of the frequency with which health-related information is sent home, the frequency with which healthrelated homework involving parents is set, the number of school meetings to discuss health issues (including the number of parents who attend) and the number of parents involved in planning and supporting health-promoting school initiatives. Similarly, the specific agencies or organisations and the frequency with which they interact with the school should be assessed. These questionnaire items could be validated by comparing the responses of schools against information from some of the agencies cited. Education and Health and effective collaboration between the two portfolios are invaluable. Public, ministerial commitment should infiltrate the state education department and manifest itself as policies, management practices and resource allocations that are genuinely supportive of efforts at the school level. Contributions from the health sector need to be based on thoughtful consultation with the education sector and an appreciation of the primary goals of schools and of the niany demands placed upon them. Monitoring the progress of health-promoting n schools i Australia Organisationnl structures It is necessary to consider the school both as a defined organisation and as a unit of a larger, lesswell-defined system in order to identifj the organisational structures (and the key functions they perform) that are likely to support sustained progress. Within the school, a committee or team with a responsibility for the health of the school community has been suggested as an important organisational element."-'" This team should include school staff from many, if not all, learning areas, and student representatives and parents. The functions of the team may include: identification of the health needs of staff and students; setting priorities for action based on broad consultation within the school; the development of a school health plan; delegation of responsibility for elements of the plan; communication of the plan to the whole school community; professional development of teachers; identification of required resources and sources of support; and being a point of contact with other schools in the region, local organisations (community groups, local government) and state or national organisations (National Heart Foundation, Health Promoting Schools Association). Assessment of the organisational structures may simply involve a checklist of these items. Although they are not commonly identified as an element of health-promoting schools, aspects of the broader system within which schools function may be critical to sustained progress.'-' A public commitment to healthy schools from the Ministers for The purpose of monitoring health promotion activities in schools is to assess progress toward creating the conditions supportive of improved health and learning outcomes. However, in the school setting, there exists a complex web of nonlinear causal relationships and noncausal associations between the desired health and learning outcomes and the many characteristics o f schools and school life. The nature of the relationships between these outcomes and their causes is supported by clear evidence in some cases (for example, excessive exposure to the sun and skin cancer), but there is not strong empirical evidence in many other cases (for example, a supportive social environment and mental health). Consequently, we can identify with considerable certainty some of what should be monitored, but are reduced to informed guesswork in many cases. It is not possible, at this time, to describe a definitive set of measures either to monitor progress or to characterise a school as 'a healthy school'. It is possible, however, to assemble questionnaires that will proFide reasonable and informative indicators of the development of many of the aspects of health-promoting schools. Monitoring should be undertaken against a background of research on the relationships between health and learning outcomes (including health-related behaviours) and their direct and indirect determinants. Table 1 provides a list of potential indicators of a health-promoting school. These indicators may form the basis of an instrument used in a program of monitoring the development of health-promoting schools (and in other research contexts) in Australia. We suggest that the next practical step is that a lead agency (National Health and Medical Research Council or the Australian Institute of Health and Welfare) form an expert committee to: seek national, cross-sectoral agreement on what should be measured; support a program of collaborative research to develop valid, reliable methods of measurement (paying close attention to developments internationally) ; and develop a monitoring system acceptable to the school education system. There are two alternatives to this approach. First, do nothing. Second, follow the more usual approach of allowing noncollaborating (often competing) researchers to develop incompatible instruments which have been inadequately validated and to apply them irregularly, both geographically and chronologically. VOL. AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1997 F 21 NO 4 HEALTH- PROMOTING SCHOOLS Table 1 : Potential indicators of a health-promoting school The formal curriculum Topics covered Classroom time devoted to each topic area and its distribution across years Extent of integration of health education across the curriculum Teacher training and support Quality and availability of teaching resources Teaching strategies employed Involvement of external agencies and individuals in curriculum delivery Policies and practices 0 Policy on smoking in school grounds or at school functions 0 Help to stop smoking available for students and staff 0 Use of hats by staff and students 0 Sunscreen supplied free and its use encouraged 0 Avoid sports and physical education in the middle of the day 0 Protective equipment for sports and physical education 0 Learn-to-swim programs 0 First aid and C R training programs P 0 Reduced availability of high-fat or high-sugar foods in the school 0 Increased availability and promotion of healthy foods Physical environment Availability of shade for a 1 students during breaks 1 Safe play equipment and sports equipment Shock-absorbing surfaces where appropriate Adequacy of lighting and heating Facilities for social interaction and quiet work Facilities for sports, physical education and other recreation Clean, physically attractive, well-maintained buildings and grounds, free of dangerous materials (for example, asbestos) Drinking water easily available Clean toilet facilities Social environment 0 Extent and nature of student involvement in decision making 0 Proactive programs to reduce bullying and violence Proactive programs to enhance classroom climate Proactive programs to enhance school climate Peer-support program School-home-communiiy 0 Frequency with which health-related materials sent to parents Frequency of health-related homework requiring parental involvement 0 Frequency of parent meetings and health topics discussed at those meetings 0 Nature of parental involvement encouraged by the school Frequency and nature of health promotion programs for school staff 0 Involvement with local zretailers (for example, preventing cigarette sales to minors) Frequency and nature of involvement of government, nongovernment, community and commercial agencies with school Health services 0 Management plans and other support for those with chronic disease (for example, asthma) First aid and critical-incident management 0 Screening according to National Health and Medical Research Council guidelines 0 Counselling and referral for distressed or troubled students (including those with a drug addiction, mental health problem, social adjustment difficulties) Support and referral for those suffering abuse or neglect 0 Conflict resolution for staff-staff, staff-student and studentstudent problems Support of curriculum delivery Very little has been done to monitor the current status or progress of health promotion in schools in Australia. Biennial surveys of school health education (for example, curriculum time and resources, physical education facilities and equipment, some policies) have been conducted in Western Australia since 1987.'" A recent survey of randomly selected New South Wales high schools addressed issues similar to those of the Western Australian survey and included in the questionnaire sections on the policies and practices of schools with regard to: the involvement of parents, exposure to the sun, smoking, injury prevention, involvement of communitybased agencies in the school, food services, bullying and violence, support for troubled students, and student participation in decision making (Booth ML, et al. The health-related policies and practices of NSW high schools. Unpublished report.). There do not appear to have been any other large-scale studies on the current status of health promotion activities in Australian schools. summary The health-promoting school model represents a comprehensive and potentially fruitful approach to health promotion which attempts to address (in a systematic, integrated fashion) knowledge and skill development, the physical and social environments, influential policy and practice, health services and the wider community. It is consistent conceptually with the most recent principles of health promotion and appears to be acceptable to many schools and school systems. However, conceptual development and practice have far outstripped our ability to monitor its implementation and assess its effects. One of the most significant barriers to the systematic evaluation and monitoring of health-promoting schools in Australia is the absence of reliable, valid instruments. There is an urgent need for the development of such instruments, preferably by consultation through a nationally representative group, so that comparable data may be collected within each of the states and territories. The use of widely accepted instruments will also allow more direct comparisons of the results of program evaluations.

Journal

Australian and New Zealand Journal of Public HealthWiley

Published: Aug 1, 1997

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