Supporting the implementation process

In an effort to address these fundamental planning and implementation issues, some initiatives have developed (or recommended) specific strategies to support the health promoting school process. For instance, Inchley and colleagues (2006) have argued that a clear structure of management and roles along with the structured involvement of the wider community in all stages of design, planning and implementation are key to the sustainability of health promoting school -related school improvements. More specifically, a number of authors have found that the setting up of school-based health promoting school steering groups/committees provides a useful framework for schools in planning and designing health promoting policies, procedures and activities (Lee, St. Leger, & Moon, 2005; Leurs et al., 2005; Senior, 2012). These committees aim to engage with various stakeholders and work towards developing all components of a health promoting school ethos. Perhaps unsurprisingly, this kind of shared responsibility amongst school staff and indeed amongst all stakeholders (e.g. the creation of health committees) has been identified as crucial to the success of this type of initiative (Mitchell, et al., 2000).

3.4.2.1 Importance of HSP support staff

At the same time, these kinds of groups/committees/teams can be difficult and time- consuming to develop, especially when time and resources are limited. It is also often the case that one or two champions are required to drive the initiative forward (e.g. Gleddie, 2011; Weare & Nind, 2011). For this reason, the appointment of a health promotion coordinator to support schools in taking responsibility for the planning and implementation of health promoting school work has been recommended (e.g. Cushman, 2008). Almost 15 years ago, a British author called Weare (2000) was among the first to identify the need for such a role to ensure primarily that any initiatives put into practice are based, not only on the needs of any school, but on the priorities

68 identified by the entire school community, thereby ensuring a bottom-up approach. In this way, where appointed, HSCs can have the capacity to guide and encourage democracy, participation and collaboration amongst the entire school community with the aim of incorporating a health promoting school ethos into the daily school environment (Cushman, 2008).

Indeed, one evaluation of a HSC-led coordinated school health programme in the US suggested that the provision of a HSC as an additional staff member (coordinating less than three schools) was linked to an improved health education curriculum as well as greater improvements in the development, implementation, and sustainability of health related policies (O’Brien et al., 2010). Likewise, Inchley and colleagues (2006) reported that the appointment of a senior member of staff as a school-based coordinator of a health promoting school initiative was important in gaining enthusiasm and support by the school community for the work. This suggests that the role of the HSC may still be effective in leading and supporting the implementation of a health promoting school ethos even if it is assumed by an existing member of the school community.

However, according to Leurs and colleagues (2005), a regional coordinator should also be involved as an external support to schools, thereby reflecting the importance of fostering broader support at a national level for health promoting school plans. For example, HSCs are provided at a regional area as part of the UK National Healthy School Standards and are involved in supporting schools in developing and implementing health promoting school initiatives as well as collaborating with schools to evaluate progress (UK National Healthy Schools Standard, 2000). The findings of a recent evaluation of this service suggest that this ‘link person’ played an important role in helping schools to progress the implementation of health promoting school procedures and practices (Arthur et al., 2011). The kind of support provided varied from one-to-one support for staff on issues such as implementing an audit as well as delivering group level training and guidance. This work highlights the intrinsic value of a national level health promoting school structure.

3.4.2.2 School ownership and staff buy-in

Whilst external guidance is clearly important, school ownership and ‘buy-in’ from all staff is also essential for a successful and sustainable initiative and, again, this appears

69 to be inextricably linked to the development of an effective health promoting school ethos/culture. Turenen Tossavainen, Jakonen, and Vertio (2006) also point out that a bottom-up approach involving all members of the school community is essential. Leurs and colleagues (2007) identified, for instance, that teachers’ enthusiasm for health promotion initiatives was associated with positive pupil feedback on the initiatives. This suggests the wider influence on school-level buy-in in terms of the acceptance of health promoting school practices by the school community. Gleddie (2011) argued in favour of both top-down and bottom-up processes are necessary for successful implementation of a health promoting school approach. Thus, the way in which the programme is coordinated and managed at senior level is important, as is the buy-in from everyone ‘on the ground’. Interestingly, Gleddie’s (2011) case study evaluation of a Canadian health promoting school initiative noted the importance of the involvement of different staff members from the beginning of the programme who participated in developing goals and organising health related activities. A further related aspect was the ‘readiness’ of the school community for change and their willingness to address and improve how health is addressed in their school. Furthermore, the significance of principal buy-in cannot be underestimated. The principal’s role as both a leader and a key influence on other school staff in terms of their enthusiasm for driving innovative projects like a health promoting school approach has been highlighted by a number of studies (Aggleton et al., 2000; Deschesnes, Trudeau, & Ke´be, 2010; Lindahl, 2010; St. Leger, 1998). For example, Valois and Hoyle (2000) reported, perhaps unsurprisingly, that when a principal shows an interest in the values and objectives of a health promoting school approach, more positive changes are likely to occur. This highlights the importance of programme administrators/funders engaging with key staff members and ensuring buy-in prior to the implementation of these kind of initiatives.

3.4.2.3 Additional key components facilitating the establishment of a health promoting school approach

In addition to the involvement of staff and the establishment of an in-school steering committee, the IUHPE (2009) highlight a number of additional key factors that facilitate the capacity of the school to effectively address health in an health promoting school way. These include: the development of agreed objectives between different stakeholders and how to achieve them; the establishment of a health promoting school philosophy statement and charter approved by all stakeholders; and the development of

70 self-audit processes to identify areas of health to be prioritised at a school level. Senior (2012) provides an example of this in a previously mentioned evaluation of a health promotion initiative in Australia. In an agreement of terms between schools and a local service, the health services agreed to provide school support via a health promotion officer whilst the schools agreed to set up a committee of school members to complete an audit of health practices and also to engage with a health promoting school evaluation. In this way, a close partnership between health and education was established from the outset and stakeholders’ responsibilities were clearly defined (Senior, 2012). Pre-implementation training by the health services as well as ongoing opportunities for discussion and relationship building also helped to establish a meaningful partnership between key education and health stakeholders. These findings suggest that some kind of pre-implementation work is important in providing a strong foundation for any health promoting school initiative.

Senior (2012) also emphasises the value of conducting a school-led audit in establishing a health promoting school ethos. Indeed, the completion of a needs audit by schools at the outset of any initiative is highlighted across the health promoting school literature (e.g. Arthur et al., 2011; Leurs et al., 2005; Leurs et al., 2007; St. Leger & Nutbeam, 2000). These are important in identifying the needs of a school in order to focus planning and design as one of the first steps in the implementation of a health promoting school (Leurs et al., 2007). If conducted effectively, schools themselves identify which areas of health should be prioritised and in this way, the nature of health promotion work is relevant to the needs of each individual school. As a result, the school community is more likely to get involved, thereby increasing the possibility of sustainable and manageable improvements in how schools address health in an inclusive way. This flexibility to adapt a programme to the needs of any individual school is a central component of the health promoting school model, although it is important to note that this should be followed up by a structured plan of action (Mitchell, Palmer, Booth, & Powell-Davies, 2000). It is this aspect, perhaps, which is more challenging in terms of practical implementation and maintenance.

On a related point, several studies in the literature have identified workload concerns amongst some school staff involved in health promoting school programmes. Understandably, endeavouring to implement a health initiative in an environment where staff are already under pressure to maintain and often improve upon academic

71 standards, may raise some concerns and a perception amongst teachers of an additional burden (Aggleton, et al., 2000; Rowe & Stewart, 2009). According to St. Leger (1999),“it may be unrealistic to expect teachers to adopt the agenda of the health sector

and involve themselves in more direct interventions outside the classroom which seek to improve the health of their students” (p66). Therefore, it is important to establish the

link between learning and health from the outset and ensure that the education sector is aware of how a health promoting school approach can support both educational and health outcomes (Rissel & Rowling, 2000; IUHPE, 2009). This might also involve developing the perception that this approach is a ‘way of being’ for schools rather than a discrete add-on whilst also building a momentum amongst the school community (Inchley et al., 2006).

3.4.2.4 The role of cross-discipline collaboration

Another key challenge, in this respect, is convincing the health sector that it should embrace the concerns of educationalists and address health promoting school in a way that facilitates academic achievement whilst also addressing the health needs of children. This kind of inter-agency thinking and working is notoriously difficult and not least when the goals of each sector may be perceived as ideologically different and very distinct from each other (Weare, 2007). Arguably, however, improvements in one area will support improvements in the other (Barnekow et al., 2006), whilst an effective school is one in which children’s overall development is supported (Guldbrandsson & Bremberg, 2005). The findings of the systematic review conducted by Murray Low, Hollis, Cross, and Davis (2007) on the impact of a health promoting school approach on academic achievement, helps to clarify, at least to some extent, how such initiatives can address the educational outcomes of children and how health and education are intertwined. For example, whilst the evidence is somewhat mixed, the authors suggest that additional health and nutrition services, as well as psychological health initiatives, in the school setting may contribute to positive educational outcomes (Murray et al., 2007).

Inchley, Muldoon, and Currie (2006) identified in their evaluation of the national framework for HPS in Scotland, that the involvement of the Education Department had benefitted participating schools in a number of ways including, in particular, the provision of professional guidance in the areas of policy change, staff training and

72 curriculum, all of which are considered important positive supports for schools in implementing a health promoting school ethos. Increased governmental support and involvement are also needed to facilitate greater efforts towards joined-up thinking on how both the health and education sectors can support schools effectively, thereby increasing the likelihood of a shared understanding of a health promoting school ethos and its objectives (Bruce, et al., 2012; Stokes & Mukherjee, 2000). However, several studies have also noted that staffing, time and other resource constraints are important factors in predicting the extent to which schools do/do not adopt a health promoting school approach and thus whether the health promoting activities can be sustained over time (e.g. Bruce, et al., 2012; Deschesnes, Trudeau, & Ke´be, 2010; Leurs et al., 2007; Senior et al., 2012). Not surprisingly, Deschesnes, Trudeau, and Ke´be (2010) highlights for example that constraints faced by schools mean that some schools may resist such initiatives unless adequate support and commitments are provided at a national government level.

Warwick and colleagues (2004) further highlight the importance of allowing adequate time for the establishment of a successful health promoting school initiative and, in a more recent study undertaken in Britain, Senior (2012) reported that it took nearly a year for the initial planning of the initiative to be completed. Thus, the comprehensive implementation of these kind of initiatives may take years to fully bed down and lead to meaningful changes in children’s health. As mentioned earlier in this chapter essential elements at the outset might include agreeing the terms between education and health stakeholders, completing a school audit and establishing key health promoting school structures (such as the steering committee), and all of these may require considerable resources. The way in which funding is provided is an also important contributory factor in the sustainability of these types of initiatives. Not surprisingly perhaps, Mukoma and Flisher’s (2004) review identified that the provision of funding had a significant positive impact on the implementation of health promotion activities. Interestingly however, where schools progressed the health promoting school initiative by focusing on initiatives already established in schools - instead of developing new health promotion initiatives and activities - external funding was not perceived as essential to the success of the initiative. Other schools reported providing new activities as a result of funding, in which case funding was deemed to be essential to the successful roll-out of the health promoting school programme of work (Mukoma &

73 Flisher, 2004). In the same way, Inchley, Muldoon & Currie (2006) found in their evaluation, that whilst financial support was important in initiating changes, it was not, in itself, an essential component for successful implementation. Importantly, respondents in this study indicated that where schools were provided with their own small budget, this led to a sense of responsibility and empowerment around the implementation of the health promoting school work. This suggests that, although important, health promoting school -related funding should be incorporated into the existing plans of individual schools rather than provided as an ‘add-on’ resource.

3.5 Conclusion

The available evidence suggests that health promoting initiatives which involve longer term, multilevel integrated approaches, provide more evidence of effectiveness than short curricula-based topic specific approaches (Senior, 2012; Stewart-Brown, 2006; St Leger, 1999; St Leger & Nutbeam, 1999; Wells et al., 2003). The World Health Organisation (1997) further maintains that the health promoting school approach, if implemented effectively, is potentially the most efficient method to comprehensively address the health needs of children in an educational setting. The literature reviewed in this chapter indicates that, whilst improvements in health outcomes are mixed, health promoting school initiatives can indeed improve, albeit to varying degrees, how schools address health in various ways. It is apparent, though, that both the implementation and evaluation of health promoting school initiatives is still very much evolving and that a number of challenges still exist in implementation including in particular: developing a shared understanding of the principles and application of health promoting school practices; implementing a school-led approach; building effective collaboration; and tackling broader issues such as adequate support and resources.

All these factors may both support and inhibit the progress of health promoting school initiatives. However, an examination of these through rigorous evaluation should help to inform the planning and implementation processes underpinning health promoting school programmes and to identify and tackle barriers going forward. To date, however, there are very few mixed method studies which comprehensively evaluate health promoting school initiatives as defined by WHO (Deschesnes, Martin, & Jomphe-Hill,

74 2003; Dooris, 2005; Lister-Sharp, 1999) whilst several authors over the years have also called for further studies of the facilitative and inhibitive factors which influence effective implementation (e.g. Deschesnes, Trudeau & Ke´be, 2010; Inchley, Muldoon & Currie, 2006; Lister-Sharp, 1999; Mukoma & Flisher, 2004; Stewart-Brown, 2006; Clarke et al., 2010).

In terms of psychological health more specifically, and as indicated earlier, there are numerous studies examining universal and targeted school-based mental health promotion initiatives, but only a small number have evaluated how psychological health is addressed by health promoting school programmes as conceptualised by the WHO (e.g. Levin, et al., 2012). Some of these studies have provided evidence on psychological well-being and emotional health, but the results thus far have been mixed. Furthermore, it would appear that exploring the effects of a health promoting school approach on psychological health using only health outcome measures, may not be sufficient to comprehensively determine the value of these types of programmes. As with all aspects of health, a more in-depth analysis of health promoting school initiatives and the extent to which they address psychological health is needed in order to explore the broader process of implementation. Again, less concrete and tangible factors such as the school ethos, health policies and collaboration with external agencies (and parents), as well as the numerous facilitators and inhibiting factors within initiatives, all need to be considered when evaluating any health promoting school initiative in terms of how such initiatives can address children’s health needs and in particular (in the context of the current study), their psychological health. In addition, broader implementation issues such as programme design and implementation fidelity and quality all need to be explored in the context of process evaluations. Whilst a small number of more recent evaluations have used mixed method approaches, more are needed, whilst few of these have focused on psychological health specifically.

There are a number of reasons for the lack of comprehensive evaluations. In addition to various resource limitations, there are differing perceptions in the research literature surrounding even fundamental elements of a health promoting school. This has led to variation regarding what constitutes such programmes (e.g. examples of different kinds of studies which have different focus) and consequently how each should be evaluated (St. Leger, 1999). Evaluations of the processes inherent in health promoting school

75 initiatives in general are also difficult and complex as, in contrast to pre-designed topic specific interventions, the outcomes are often less tangible (Moon, 2000). The ecological model addressing all aspects of the school community is a complex shifting one which creates difficulties for many traditionally framed evaluation methods (e.g. Nutbeam et al., 1993; Weiler, Pigg, & McDermott, 2003). The idiosyncratic school-led nature of the health promoting school also creates obvious difficulties in the replication of initiatives and evaluation studies. This may explain why the many earlier evaluation studies examining their efficacy are often exclusively outcome motivated and tend to concentrate on a subset of the primary pillars of a health promoting school. Indeed the practical difficulties in achieving adherence to such a holistic and multifaceted model have been highlighted as a factor in many health promoting school initiatives of reverting to the traditional topic-specific individual-based intervention model (e.g. Dooris, 2004; Dooris, 2005).

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