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Important Notice

This notice is not to be erased and must be included on any

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School

Health

Promotion

Towards Health

Promoting Schools

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N a t i o n a l H e a l t h a n d M e d i c a l R e s e a r c h C o u n c i l

N

H

M

R

C

Effective school

health promotion

Towards health promoting schools

NHMRC Health Advancement Standing Committee

1996

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© Commonwealth of Australia 1996 ISBN 064227228X

This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of an acknowledgement of the source and no commercial usage or sale. Reproduction for purposes other than those indicated above, requires the written permission of the Australian Government Publishing Service, GPO Box 84, Canberra ACT 2601.

The strategic intent of the NHMRC is to work with others for the health of all Australians, by promoting informed debate on ethics and policy, providing knowledge based advice, fostering a high quality and internationally recognised research base, and applying research rigour to health issues.

Publication approval number 2114

This document is sold through the Australian Government Publishing Service at a price which covers the cost of printing and distribution only.

National Health and Medical Research Council documents are prepared by panels of experts drawn from appropriate Australian academic, professional, community and government organisations. NHMRC is grateful to these people for the excellent work they do on its behalf. This work is usually performed on an honorary basis and in addition to their usual work commitments.

Publications and Design (Public Affairs, Parliamentary and Access Branch) Commonwealth Department of Health and Family Services

Produced by the Australian Government Publishing Service

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Contents

Preface vii Executive summary 1 Introduction 11 Rationale 11 Terms of reference 11 Methods 11

The approach to assembling the report 12

1 Background 15

1.1 Introduction 15

1.2 The health of young people 15

1.3 Health and education 16

1.4 Schools and the health sector 18

1.5 Current international influences on school health programs 19 1.6 Developments in school health programs in Australia 20

1.7 Concluding remarks 21

2 Curriculum-based school health programs—what works?

...The evidence 23

2.1 Scope of the review 23

2.2 Curriculum 24

2.3 School environment 27

2.4 Health services 29

2.5 Partnerships 30

2.6 Concluding remarks 31

3 Contemporary approaches to school health programs in Australia 33

3.1 Introduction 33

3.2 An overview of the current situation across Australia 33

4 The health promoting school 37

4.1 Introduction 37

4.2 The health promoting school – a promising framework 37 4.3 The health promoting school versus the traditional approach 39

5 Monitoring school health programs 41

5.1 Introduction 41

5.2 The current situation 41

5.3 A proposed framework for monitoring school health programs 42

5.4 Concluding remarks 42

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6 Recommendations 47

6.1 Achieving effective practice 47

6.2 The role of the health sector 48

6.3 Education and training 48

6.4 Research priorities 48

6.5 Monitoring 49

Appendices

1 Public consultation 51

2 Curriculum-based school health programs 57

References 77

Glossary 85

Figures

1 The health promoting school framework 38

Tables

1 Comparisons between traditional school health program approaches and that of the

health promoting school 39

2 Proposed indicators for monitoring school health promotion 43 3 Curriculum-based school health programs 58

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Comittee Membership

Health Promoting Schools Working Party

Professor Lawrence St Leger Working Party Chair, Faculty of Health and Behavioural Sciences, Deakin University

Dr Derek Colquhoun Faculty of Education, Deakin University

Mr Gawaine Powell Davies School of Community Medicine, University of NSW Ms Yvonne Robinson Public and Environmental Health Service, South Australian

Health Commission

Dr Louise Rowling Faculty of Education, University of Sydney

Health Promotive Environments Working Party

The NHMRC Health Advancement Standing Committee’s health promotive environments work agenda is overseen and co-ordinated by the Health Promotive Environments Working Party, whose members are: Professor Don Nutbeam Working Party Chair, HASC member, Department of Public Health

and Community Medicine, University of Sydney Ms Billie Corti Department of Public Health, University of WA Ms Sophie Dwyer HASC member, Queensland Health Department

Professor Lawrence St Leger Faculty of Health and Behavioural Sciences, Deakin University Dr Rae Walker HASC member, School of Health Systems Sciences,

La Trobe University

Ms Marilyn Wise Department of Public Health and Community Medicine, University of Sydney

Acknowledgements

Other individuals provided valuable and timely assistance at various times throughout the development of this report. Dr Rob Irwin was contracted as a research consultant to undertake the preliminary literature review, while Dr Kimberley McClean and Ms Jennie Lyons undertook the technical editing of the report and provided additional research support. This initiative was very ably and efficiently supported

throughout by Ms Shelley Maher, research assistant, and Ms Sandra Twist, Secretary to the Health Promotive Environments and Health Promoting Schools Working Parties.

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Preface

This Report of the National Health and Medical Research Council is intended to inform debate and to further the progress of health promotion in schools in Australia. The Report has been prepared, in part, to provide advice to State and Commonwealth Health Ministers and their Departments on the best

approaches to health promotion through schools at this point of time. The health sector makes a considerable investment in school health programs of different kinds, and this Report provides clear recommendations concerning the types of investments likely to lead to measurable health outcomes. The Report also recognises the fact that schools have a wider set of goals concerning the education and social development of young people, and that health promotion may be seen as contributing to these goals as well as leading to measurable health outcomes. This wider set of educational goals may not be fully reflected in the way in which information has been assembled and presented in this Report. This is an inevitable consequence of the terms of reference for the Report, and the NHMRC mandate. It is not intended to reflect a lack of recognition of the importance of these goals to individual schools and the education system more generally.

As well as providing clear advice to the health sector, the Report offers schools a wide range of information and advice on the likely effectiveness, in terms of improved health outcomes, of different approaches to health promotion. It also summarises contemporary thinking on the health promoting school concept, and indicates ways in which schools can interact most successfully with the health system. Some recommendations are more specifically directed at schools and the education system, particularly

concerning teacher education, and the allocation of curriculum time. In each of these examples, the Report is intended to be used as a resource by the health and education sectors for further debate and to guide action directed towards improving the health and welfare of young people using the school as a health promoting environment.

Professor Don Nutbeam Professor Lawrence St Leger

Chair, Health Promotive Environments Working Party Chair, Health Promoting Schools Working Party

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Executive summary

Introduction

This report is a summary of the available evidence concerning what constitutes effective practice for promoting health in the school setting, and identifies what is needed to fill the current gaps in knowledge. The report also proposes a framework for comprehensive school health programs which incorporates both their behavioural and organisational elements.

The NHMRC Health Promoting Schools Working Party developed the report by researching the following content areas:

• national and international developments in school health promotion programs; • schools as settings for health promotion;

• evidence from evaluated programs to ascertain the elements required for successful programs; • the current situation of school health programs in Australia; and

• frameworks and key indicators for improved delivery of school health promotion programs.

The research was undertaken through a comprehensive review of the international literature, consultation with internationally-renowned researchers, and a survey of state and territory education sectors to determine current activities in relation to school health programs. This research was analysed by the Health Promoting Schools Working Party, which also took responsibility for drafting this report. A draft report was widely distributed to educational and health interests for comment, and was the subject of consultative workshops in three states and at the National Health Promoting Schools Conference in late 1995.

The case for promoting health through schools

In Australia, it is compulsory for all children to attend school between the ages of five and 15 years, with the majority of students completing 12 years of schooling. The contact between individual students and their teachers is close, especially in primary school, and occurs at a formative stage of a child’s development. The school years are a time of rapid individual and social development, where many elements of attitude and behaviour, health literacy and skills which impact on future health are formed.

The interaction between schools and young people, and the overall experience of attending school, provides unique opportunities for health promotion which can be sustained and reinforced over time.

The broad reach of schools is also important from a social justice perspective. The school is the one setting where all children can be reached – irrespective of their socioeconomic status, ethnicity, or location – and through which their health concerns can potentially be addressed.

Available evidence indicates that school health programs which are comprehensive and integrated, and include the curriculum, the environment and the community, are more likely to lead to advancements in the health of school children and adolescents. Such a concept – the health promoting school – is proposed in this report. Improved collaboration between the health and education sectors, and the development of methods for monitoring progress and evaluating health outcomes are also suggested.

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Health and education

Health and education are closely linked, for instance:

• young people with poor vision or hearing often have learning difficulties; • those who are tired or malnourished have poorer concentration skills;

• those with poor resistance to infections, or whose chronic conditions are inadequately managed, suffer significantly higher school absences; and

• mental health problems or substance use can undermine the capacity of students to learn. Good health and educational achievement are not ends in themselves, but rather means which provide individuals with the chance to lead productive and satisfying lives.

There are, however, limits to schools’ capacity to address health issues. The education sector has undergone significant changes in recent years, which have led to increased responsibilities for schools. At the same time, support services have been reduced, in particular, curriculum consultancy and professional development for teachers. All of this places great pressure on time and resources in schools. Health is up against strong competition for curriculum time, teacher attention and resources. This places a premium on supporting health promotion through the mainstream organisational structures of the school (e.g. the school welfare system), rather than relying exclusively on special purpose initiatives, which are often the first to go when resources are scarce.

Schools and the health sector

The health sector and schools in Australia have worked together for 90 years towards improving and sustaining the health of children and adolescents. Health sector involvement in the promotion of health in schools occurs at all levels – nationally, state-wide, regionally and locally. In general, the most common roles for the health sector in schools appear to be:

the provision of screening and treatment services – either routine (e.g. school screening) or as required,

especially for young people at risk, or in need of special care (e.g. a backup service to school counsellors);

consultancy, advice and advocacy to school personnel (e.g. teachers, administrators), students and

parents, either on specific health issues or on more general approaches to school-based health promotion;

policy development, either concerning specific issues (e.g. asthma, critical incident management), or

relating to the broader issues of school health promotion; and

the provision of technical support for education and training of teachers to improve their health

knowledge and skills, both within the health curriculum and in the other domains of school health programs.

These are all contributions from the health sector to school health programs which are unique, valued and easily recognised as legitimate.

Current policy influences in support of school health programs

International and inter-governmental organisations alike have identified the school as an appropriate setting in which to improve youth health. Most recently, the World Health Organization established a School Health

Initiative, building upon the evidence gained from school health programs worldwide. This identifies the school

as a key setting for improving the health of young people, and provides a framework to mobilise and strengthen health promotion and education activities at the local, national, regional and global levels to improve health through schools.

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At the Australian governmental level, Commonwealth, State and Territory Education Ministers, through the

1989 Hobart Declaration, identified health as a crucial part of schooling, in order “to provide for the physical

development and personal health and fitness of students, and for the creative use of leisure time”. This

sentiment is reflected in the ‘national curriculum statements and profiles’, in which health is identified as one of the eight key learning areas. Curriculum statements and frameworks on health from the different Australian states and territories make explicit the educational goals of the health curriculum area.

However, while there is an expectation that schools will address health as one of the eight national key learning areas, there are no demands made on them by the education sector to change specific health behaviours or to improve the health status of their students. Nevertheless, most schools encourage healthy behaviours through the implementation of policies and regulations, such as non-smoking schools, ‘no hat, play in shade’ policies, and encourage healthy practices, for instance, through healthy canteens.

Essential elements of school health programs

It is reasonable to expect that schools should be able to provide suitable conditions for healthy living and growth for their students. This report examines school health programs and attempts to identify the necessary criteria for successful health promotion in schools as gauged from reported evaluations of these programs. In so doing, it examines the impact, in terms of improved health and education, and the characteristics of school health programs in the major areas in which such programs focus, namely the curriculum (the formal taught health program which is usually classroom-based), environment (the geographical, physical and psychosocial environments where the students learn and live), health services (the medical, dental, nursing, guidance and counselling services which are provided in schools to prevent or treat ill-health), and partnerships (the formal and informal relationships which exist between some or all of schools, community, parents and private or government organisations). Importantly, each of these elements need to be integrated within supportive school

policy structures to reinforce the efforts of the school health programs and, therefore, to maximise health and

educational outcomes.

Curriculum-based programs incorporate health education into the school’s formal curriculum, and are usually

taught by teachers in the classroom. Many focus on specific topics – particularly HIV/AIDS and sexual education, nutrition and exercise, oral hygiene, drugs and alcohol, but some concern personal development and growth and life skills education.

This analysis of curriculum-based health programs revealed several factors which determine the success of curricula-based school health interventions. These factors include:

Content-related factors:

comprehensive health promotion programs, i.e. the evidence reveals the importance of developing

well-planned, designed and trialed, comprehensive programs;

life skills acquisition, e.g. transfer of social, lifestyle, negotiating, problem-solving, decision-making and

coping skills, as well as self-esteem training, rather than the passive giving of knowledge;

Teaching and learning issues:

teaching and learning strategies, e.g. nutrition programs which incorporate food preparation and

‘cook-off’ competitions, role plays, hands-on demonstrations, audiovisuals, skits and plays, student discussion and peer presentations;

time allocation, i.e. more than 50 hours per year of classroom instruction alone are required for

significant achievements in knowledge gain;

team approach, e.g. involving students, all teachers, school staff, parents, local community members and

agencies, as well as expert technical organisations;

Preparation and resource support requirements:

adequate resources, i.e. well-designed and developed educational, rather than biomedical, curriculum

and training materials;

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teacher training and support, e.g. pre-service training, ongoing professional development, in-service

training and support;

involvement of local community, i.e. parents and relevant community interests; and

environmental support, i.e. curricula-based health education conducted in conjunction with changes to

the school’s physical and psychosocial environment and within a supportive infrastructure and school policy.

The environment in which students learn and live should be one which supports the health promotion objectives of school health programs. In schools, this environment includes the:

physical environment, e.g. playground layout and structures, building and classroom layout and

appearance, special facilities such as healthy canteens, provision of shade for sun protection, equipment, wall posters, photographs and artwork;

psychosocial environment, e.g. the relationship between staff, students, parents, and the traditions and

values which are adopted; and

organisational structure, e.g. infrastructure, health policies and regulations, school and staff

organisation, administration, health budget, planning and methodologies.

In summary, the evidence clearly indicates that improved health behaviours can be fostered through the adoption of a whole school, broad-based, integrated, and comprehensive team approach involving the participation of the local community (particularly the parents).

The role of health services in the context of school health programs in Australia has not been well evaluated. Part of the problem arises from the ways in which health services are connected to schools. In most cases, these services are completely external, based on visiting clinical services. In ideal circumstances, such services would be school-based, providing comprehensive health, welfare, and local government services. This is rarely the case.

There is increasing interest in both the health sector and schools alike in using clinical practitioners to address school groups on health issues. This review of the literature found little evidence to support the provision of one-off talks by general practitioners, or any other health practitioners, to school children.

Partnerships fostered between schools and outside bodies have led to the successful implementation of several

school health programs. Such partnerships include parents (either as part of an organised committee or individually), local community, and government and non-government organisations, particularly health organisations.

Involvement of parents may occur in the setting of school health policies and strategies, as well as in the implementation, support and reinforcement of school health programs. Parental support enables students to relate the health messages learnt at school to a broader living context. Partnerships with agencies and persons, particularly parents, in the community appears to form an integral part of programs which are comprehensive, holistic and broad-based. Such programs typically combine curriculum-based activities with modifications to the school environment.

The existence of school health policies, such as ‘no hat, play in shade’ or the structuring of outdoor sport activities to reduce sun exposure, and their application within the school provides a mandate for action and legitimises the promotion of health within the school setting. As such, policies play a major role in supporting and reinforcing all of the educational and structural elements of school health programs. Where possible, health should be promoted through mainstream school policies as well as those which are directly concerned with health issues.

Criteria for effective school health programs

The preceding analysis identified several key factors essential for optimal school health program outcomes. These include:

a comprehensive approach, which covers many aspects of health, and is broad-based rather than

categorical;

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program relevance, and attention to reinforcement of program messages inside and outside of the school

(which, in turn, relies on strong community partnerships); • integration of health into other subject areas in the curriculum;

a focus on programs which provide conditions for the empowerment of students to acquire healthy life skills, and utilise a variety of teaching and learning strategies performed, with attention to timing, and the adequacy of time allocated;

the integration of the school health program within a supportive school policy framework;

ensuring the maintenance of a healthy physical and psychosocial environment for students, which is compatible with the school health program themes;

ensuring that teachers are well-trained and supported with adequate resources;collaborative involvement of teachers and students;

the involvement of health services; and

ensuring that the program has been subjected to adequate evaluation, and a mechanism for monitoring progress and outcomes is in place.

Conversely, school health programs which have proved less successful may be characterised by the following elements:

• they were largely problem-focused (often accompanied by scare tactics and preaching); • broader school involvement was spasmodic and unfocused;

• they were based primarily on external resources with little involvement of school staff; and • teachers received little or no training, support or additional resources.

In summary, the evidence points overwhelmingly to the adoption of comprehensive and integrated approaches to teaching and learning, which foster teams within the school and in the local community, and which support healthier behaviours by addressing the physical and psychosocial environment of the school, through

supportive policies and practices. Above all, teachers need adequate preparation and support to carry out and maintain the effects of such programs.

The current situation across Australia

‘Health and Physical Education’ is one of eight key learning areas of the national curriculum statements and profiles, to which all Australian states and territories are signatories. In turn, each jurisdiction has developed its own curriculum guidelines or frameworks to guide curricular activities in their state or territory schools, and which better reflect local requirements.

It comprises a compulsory part of the curriculum in almost all states, often with a minimum time allocation established for class contact time for the subject. In most cases, however, individual schools retain the right to teach the subject as they see fit and in line with local requirements. There is a general tendency for school health education and promotion to be accorded a low priority in what is an increasingly crowded curriculum. In almost all cases, state education departments have developed and promoted policies on significant health-related issues for use in schools. These are particularly in relation to smoking in schools, sun protection, bicycle and other safety, first aid, HIV/AIDS, violence in schools, harassment, and blood spills. Many schools have used their centralised state policies in the development of individual school-based policies. Schools and departments alike note the value of such documents in providing a policy mandate and impetus for action to promote school health.

Three major areas of interest emerge about current involvement of health services in schools, namely, the provision of policy support and guidance (for instance, on health promoting schools approaches), the provision of funding for resources, programs and infrastructure (such as health promotion officers to support schools and

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teachers), and professional development activities (particularly running short courses and providing access to information resources).

The potential to develop school initiatives in the health curriculum and in the schools’ broader environment is substantially limited by the paucity of pre-service training about health for those teachers not specialising in health education, and also comprehensive, ongoing professional development programs. These are needed to equip teachers with the knowledge and skills required to develop and deliver the quality school health programs associated within an integrated health promoting school framework.

A considerable gap exists between what is known to be most effective in school health programs and the current conditions prevailing in many schools in Australia. By using the ‘conditions for success’ indicated previously as a benchmark, several important actions appear necessary to move school health programs towards achieving their optimal health and educational outcomes. These include:

adopting a comprehensive approach – through wider promotion and adoption of established guidelines

for comprehensive school health programs;

learning from success – by recognising ‘best practice’ in relation to the design, implementation and

evaluation of school health programs;

allocating time – by recognising the need to allocate sufficient time in the school curriculum for health

programs, and to allow teachers sufficient time to work in partnerships with significant others; • allocating resources wisely – to educating and training teachers;

maximising the contribution of health services – by achieving better co-ordination in contacts with

schools; and

acknowledging others’ circumstances – for instance, by recognising that the core business of schools is

in the education of students, and that the achievement of health behavioural goals may only be peripheral to this core business.

Monitoring school health programs

The main purpose of monitoring school health programs is to assess progress toward creating the conditions needed to support improved health and learning outcomes. In order to be effective, processes to monitor such conditions in the school setting requires:

• demonstrable relationships between health outcomes and the conditions which affect them; • access to appropriate and valid indicators with which to measure change; and

• the availability of co-ordinated data collection systems.

While there is evidence to demonstrate causality between certain determinants and health and learning outcomes (e.g. excessive exposure to the sun and skin cancer), in many cases, such strong empirical evidence does not exist (e.g. a supportive psychosocial environment and mental health).

While it is not possible at this point in time to describe a definitive set of measures either to monitor progress or to characterise a school as ‘healthy’, there is scope to develop appropriate indicators around the evidence presented above on effective school health programs. Such indicators would need to address the following key domains: curriculum, teaching and learning; school organisation, ethos and environment (incorporating the physical and psychosocial environment); school-home-community interaction; and interaction with health services.

Importantly, it would be inappropriate for the National Health and Medical Research Council, or indeed the health sector in general, to attempt to impose any indicators or standards upon schools. Any developmental work on indicators or data collection systems in this area must be undertaken in conjunction with both health and educational interests.

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Recommendations

1

Achieving effective practice

Evidence from this review indicates several essential elements required to achieve the best education and health outcomes from school health programs.

1.1 It is recommended that Commonwealth, state and territory education and health authorities, together with individual schools, examine current school health programs in the light of the conditions for success indicated below:

1.1.1 School health programs should be comprehensive in concept

This includes attention to school policies which impact on the physical and psychosocial environment of schools, the extent and appropriateness of connections with the wider community, including those with parents, health services, and other community agencies, and to the integration of health issues across the school curriculum. (Refer to Sections 2.2-2.5)

1.1.2 School health programs should be comprehensive in content

Such programs should not merely focus on categorical health problems, but also include elements of personal and social development, life skills education relevant to student needs, and attention to the positive aspects of health as a resource for life. (Refer to Section 2.2)

1.1.3 School health programs should be based on partnerships

They should involve effective partnerships between teachers and students, and the school community and parents, health practitioners, and relevant agencies. (Refer to Section 2.2)

1.1.4 School health programs should be adequately resourced

Adequate resources should be provided, both in terms of material and human resources, and in the time allocated. In the latter case, a minimum of fifty hours per year of classroom contact is indicated, supplemented by a further allocation of fifty hours per year for out of class activities (including the development of effective partnerships with parents and community agencies external to the school). (Refer to Section 2.2)

1.1.5 School health programs should adequately utilise appropriate teaching and learning strategies

This includes encouraging the active participation of students in classroom teaching and learning, and a particular emphasis on the development of life skills. (Refer to Section 2.2)

Progress towards achieving effective practice will be facilitated by the wider dissemination of existing guidelines to support comprehensive school health programs, including the recently published World Health Organization (WHO) guidelines on the development of health promoting schools.

1.2 It is recommended that individual states and territories and also individual schools support the development of adapted versions of the WHO guidelines to meet local needs and circumstances, and to provide a benchmark against which developments at both state and school levels may be assessed. (Refer to Sections 1.5-1.6)

2

The role of the health sector

2.1 It is recommended that the health sector continues to play an active role in supporting and advocating comprehensive school health programs. To this end, the primary role of the health sector should be to provide appropriate health services to students, technical advice and also resources to support specific initiatives. (Refer to Sections 1.4, 2.2-2.5, 3.2)

2.2 It is also recommended that, where necessary, the health sector advocates action by education authorities and individual schools to promote and protect the health of young people. (Refer to all Sections)

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2.3 It is further recommended that health agencies pursue these opportunities for collaboration with the education sector and with individual schools with due regard to:

the core educational goals of schools; (Refer to Sections 1.3, 1.7, 3.4)

the need for investment in teacher development, alongside the production of curriculum and other material resources; (Refer to Sections 2.2, 3.3)

avoidance of a narrow focus on the ‘health’ curriculum and consideration of the opportunities provided for school health programs through other subject areas in schools (e.g. Science, English, Mathematics, etc.); (Refer to Sections 2.2, 3.2)

the need to achieve a more integrated approach to communication with the education sector, particularly avoiding the current procession of unconnected, project-based contacts with schools; (Refer to Section 2.2)

the ineffectiveness of one-off, unsupported interventions with schools, especially talks to students by health practitioners; (Refer to Section 2.4)

the limitations of schools in achieving health behavioural goals; (Refer to Section 3.3) and

the need to develop school health services in ways which are well connected to other elements of comprehensive school programs. Such services have a special role in meeting the needs of high risk students, and students with special health needs. (Refer to Section 2.4)

3

Education and training

Achieving future progress in the adoption of comprehensive school health programs will depend upon the quality of the workforce, especially the capacity of teachers to participate fully in both the curriculum, and non-curriculum activities implied in comprehensive school health programs.

3.1 To this end, it is recommended that:

3.1.1 All teachers in training should have an introductory course in health education, and opportunities

should be available for some teachers in training to specialise in health education as a major discipline. (Refer to Section 2.2)

3.1.2 Education and health authorities in collaboration with tertiary institutions and key health

advancement agencies, provide on a continued basis, in-service education of teachers in health education. (Refer to Section 2.2)

3.1.3 Adequate investment needs to be made by health authorities in the education of those health

practitioners in regular contact with the education system to ensure that they are fully prepared to contribute in an appropriate way to the development of comprehensive school health programs. (Refer to Section 2.4)

4

Research priorities

Evidence from the literature highlights the complexity of evaluating the outcomes of school health programs. However, there are many promising studies which indicate that, with careful planning, such evaluations can be successfully completed. The available evidence indicates the potential of comprehensive and integrated school health programs to achieve both positive health and educational outcomes. For the future, it is recommended that emphasis shifts from demonstrating effectiveness, to research which helps improve understanding of how to create conditions for success in ‘normal’ school circumstances. (Refer to Sections 2.1 and 5.2 for the majority of the Recommendations below)

4.1 It is recommended that the National Health and Medical Research Council, Australian Research Council, state and territory health promotion foundations and other relevant research funding bodies encourage research and development in the areas of:

• identifying what teachers do in to support of comprehensive school health programs, both in and outside the classroom;

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• identifying the core competencies that teachers need to operate effective school health programs; • understanding how schools establish comprehensive health programs, what facilitates this, and the major

barriers to implementation;

• clarifying the most appropriate roles for the health sector, and especially the contribution of school health services to comprehensive school health programs; (Refer to Section 2.4) and

• the development of useful, relevant and accepted indicators for comprehensive school health programs. (Refer to Chapter 5)

5

Monitoring

The development of indicators and data collection systems for monitoring school health program activity needs to be undertaken within an integrated framework which incorporates curriculum, teaching and learning; school organisation, ethos and environment (incorporating the physical and psychosocial environment); school-home-community interaction; and interaction with health services. However, any developmental work on indicators or data collection systems in this area must be undertaken in conjunction with both health and educational

interests. (Refer to Section 5.4 for the Recommendations below)

5.1 It is recommended that Commonwealth health and education agencies, including the Australian Institute of Health and Welfare, fund the development of indicators and monitoring strategies in the areas of health literacy and life skills development, the health of children and their access to services, changes in the physical and psychosocial school environment, health policies and practices and other aspects of school organisation which support comprehensive school health promotion, and partnerships with parents and other community agencies.

5.2 It is further recommended that a national system for monitoring these indicators be developed, based on nationally consistent data. Consideration should also be given to the development of a state-wide or national accreditation process using the agreed indicators, modelled on the Community Health Accreditation and Standards Program, and related to the WHO health promoting school guidelines.

5.3 Formal relationships will need to be established with relevant health and education agencies to enable the collection of data which is relevant to both sectors, and to report on progress in ways that are beneficial to all those sectors involved.

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Introduction

Rationale

Given that health has formed a part of the school curriculum in many countries for the past 20 years, it is not surprising that considerable information exists in relation to school health programs. However, evaluations of these programs are limited, and the literature is patchy. Government and non-government agency reports have generally been limited to describing programs and their implementation, while few have included rigorous program evaluations. Curriculum guidelines and school health policies on the whole have not been systematically evaluated to determine their effect on the knowledge, behaviour and health of students. Thus, the limited availability of reliable research and evaluations of school health programs provided the impetus for this report, which seeks to summarise the available evidence and identify what is needed to fill the gaps. This report also seeks to develop an appropriate framework which incorporates both the behavioural and organisational elements of school health programs.

Terms of reference

The Health Promoting Schools Working Party was established by the NHMRC Health Advancement Standing Committee in 1995.

Its terms of reference were to:

• review and assess methods for the development of healthy environments through the school setting, having due regard to the existing policies developed and endorsed by the NHMRC and other relevant health advisory bodies, and to the structures and mechanisms which govern the settings;

• use these reviews to identify opportunities for effective intersectoral action for improved health; • recommend appropriate strategies to build organisational capacity to promote health in schools; • clarify the role of the health system in supporting the development of health promoting schools; • identify measurable health-related indicators which are relevant to the school setting and can be used to

monitor progress over time;

• identify significant gaps in knowledge, particularly concerning effective environmental and public policy interventions, and recommend priorities for future research;

• explain the major benefits of the activities and actions which are proposed; and • advise on strategies to implement the recommendations.

Methods

Literature review

A comprehensive review of the international literature was undertaken. The sources included only refereed journal articles, books and major international and national published reports.

Public consultation

The NHMRC Health Advancement Standing Committee (HASC) invited public submissions on its preliminary work program in April 1995. Advertisements appeared in The Australian newspaper and the Public Service

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Gazette, and were distributed through HASC’s mailing list. A total of 44 submissions were received. Of these,

17 submissions contained comments which were relevant to the Health Promoting Schools Working Party. An informal second stage public consultation process was undertaken during October 1996. The draft report was sent to approximately 120 representatives of the health and education sectors, and 16 submissions were received. Appendix 1 lists the submissions and a summary of their key issues.

Consultation with key researchers

Several key international researchers were contacted and their advice sought on the most definitive studies concerning school health promotion programs.

Survey of state education systems

Education departments in all Australian states and territories were surveyed to determine the status of health education/promotion in schools. The resulting information is outlined in Chapter 3. The respondents are listed at Appendix 1.

The writing team

Five people formed the Health Promoting Schools Working Party (listed on p.iii), which took responsibility for drafting this report. This writing team also consulted with members of the Health Promotive Environments Working Party of the NHMRC Health Advancement Standing Committee (also at p.iii).

Consultative workshops

The first draft of the report was distributed to 46 health and education professionals across Australia, who met with members of the writing team to discuss the report’s content and findings, in workshops in Sydney, Adelaide and Melbourne in 1995. Participants represented schools, health departments, education departments, non-government organisations, universities and the private sector. A further workshop was held prior to the National Health Promoting Schools Conference in September 1995. Details of workshop participants are at Appendix 1.

The approach to assembling the report

Areas investigated

The following content areas were investigated:

• national and international developments in school health promotion programs; • schools as settings for health promotion;

• evidence from evaluated programs as to the criteria required for successful programs; • current situation of school health promotion in Australia; and

• frameworks and key indicators for improved delivery of school health promotion programs.

Report structure

This report is structured in a way which seeks to develop a case for higher quality school health promotion programs which are based on sound theory and practice.

It sets the scene in Chapter 1 by identifying key issues affecting the health of young Australians and by providing an overview of recent international and national developments in school health promotion. The place of the health sector in school health promotion is made explicit. This chapter goes on to explore the potential of schools as settings for preventive health initiatives.

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The report then presents a critical review of the evidence of what works and what is less likely to work in school health promotion (Chapter 2).

Chapter 3 maps the current situation in Australian schools from the education system’s perspective, and then assesses current activity in relation to the evidence presented in the preceding chapter.

Chapter 4 proposes a framework for the Health Promoting School, and discusses the differences between this approach and traditional approaches to school health promotion.

Information-related issues are outlined in Chapter 5, along with proposed model standards for monitoring health promotion activities in schools.

Recommendations have been developed, drawing upon the findings presented in the preceding chapters. These recommendations are listed in Chapter 6.

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1

Background

1.1 Introduction

The health of children and adolescents is of paramount importance to the growth and development of Australia. This chapter explores the role of schools in promoting and maintaining the health of young people. It also explains the various interactions between health status and education, and the health and education sectors in promoting health.

In Australia, it is compulsory for all children to attend school from the age of five to 15 years, with the majority of students completing 12 years of schooling.1 The contact between individual students and their teachers is

close, especially in primary school where each class has the same teacher for most of the day. Teachers know the children personally, and are often aware of their life circumstances. This interaction and the overall experience of attending school provides unique opportunities for health promotion which can be sustained and reinforced over time.

This contact occurs at a formative stage of a child’s development. The school years are a time of rapid individual and social development, where many elements of attitude and behaviour, health literacy and skills which impact on future health are still forming. These include the ability to develop friendships, manage conflict, relate to authority, make decisions and carry through tasks. This contact also occurs at a time when adolescent students may be exposed to specific health-compromising behaviours such as smoking, alcohol and other drug use, sexual activity and other risk taking behaviour in general. Along with the family, the school is one of the main settings in which this individual and social development occurs. The contact with teachers and peers through school is a major influence in this process.

This broad reach of schools is also important from a social justice perspective. There is strong evidence that children from less advantaged families are more likely to suffer poor health.2 Many children have limited

access to other mainstream organisations and activities due to language, cultural barriers or poverty.3

The school is the one setting where all such children can be reached, and through which their health concerns can potentially be addressed.

Schools clearly have the potential to be major settings for maximising the health of Australia’s children and adolescents. Schools also have the policy mandate to support action to promote the health of young people and, importantly, they have the opportunity (and often the capacity) to do so.

In Europe, North America and the Western Pacific region there have been significant developments in the promotion of children’s health involving schools. The World Health Organization (WHO) has fostered many of these initiatives, supported by health and educational bodies and a variety of non-government organisations.4-6

This report explores the potential of utilising the school as a setting for promoting the health of school-age children. An examination of the literature concerning health promotion in schools (presented in Chapter 2) clearly demonstrates the gains that can be achieved when health is on the agenda in schools. This evaluation indicates that programs which are comprehensive, integrated and holistic, and which embrace aspects across the curriculum, the environment and the community, are more likely to lead to advancements in the health of school children and adolescents. Such a concept – the health promoting school – is proposed in this report (see Chapter 4). Improved collaboration between the health and education sectors, and the development of appropriate methods for monitoring progress and evaluating health outcomes are also suggested.

1.2 The health of young people

Children and young people represent a country’s future. Their health needs are vital, and they share an entitlement to good health and quality health services with the rest of the community.7

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Australia is committed to developing the health of its children and adolescents. Recent reports7-9 have clearly

argued the case for investing in the country’s future by ensuring that the health of young people is protected and promoted. The World Bank10 has recognised that achieving improvements in young people’s health is

dependent, in part, on literacy levels and, in turn, on access to educational opportunities, especially for girls. The report makes explicit the strong relationship between levels of education and the achievement of improved health and economic productivity.

Additionally, the 1991 Geneva Consultation Conference, auspiced by WHO, UNESCO and UNICEF,11 argued

strongly for greater attention to child and adolescent health and identified a number of appropriate strategies to attain substantial improvements in the health status of children and adolescents. This conference identified schools and their local communities as the key partners for achieving better health and preventing disease. Children and adolescents have been accorded the right to knowledge and skills about health in the Universal Declaration of Children’s Rights.12 Adequate knowledge about health and the ability to use that knowledge and

make appropriate decisions which promote health is not something which is gained and developed from one source. Clearly the peer group, families, media and the school all have a role to play. Yet it is only the school which provides the setting for establishing and achieving certain health targets and providing the framework which permits the inter-connections and partnerships between the home, peer group, local community (including health services), and the physical and social environments in which young people live.3

It is recognised that aspects of the Australian lifestyle impact significantly on health status. Hence, opportunities exist to reduce premature illness and death through lifestyle modification.13

Much can be done to develop healthy lifestyles for young people, to enhance their health environment and to ensure that the health care system is appropriate to their needs. The Health of Young Australians Policy3

recommends attention to schools as health enhancing environments for children and young people. The current health status of children and adolescents in Australia is high in comparison with many other countries. However, on closer examination of the data, there is substantial scope for improving Australia’s youth health status, particularly in some of the less advantaged sectors of the community.

The 1994 Health of Young Australians Draft Report7 identified five areas of concern:

(i) Child abuse – the number of deaths due to child abuse is twice that of Canada.

(ii) Children living in poverty – Australia has the third highest number of children living below the

UNICEF – defined poverty line amongst industrialised countries.

(iii) Measles immunisation – Australia has one of the poorest records for immunisation against measles in

the industrialised world (ranked 27th from 28 countries).

(iv) Infant mortality – in Australia, the infant mortality rate is 8.2 deaths per 1,000 live births, compared

with 4.6 deaths per 1,000 live births in Japan.

(v) Youth suicide – the youth suicide rate is unnecessarily high compared to almost all other countries.

Many other reports2-4,14-17 have identified education – through both the level of schooling attained and its

processes of furthering skills and knowledge – as crucial indicators of a young person’s present and future health status. Therefore, the school is a key setting where the health and education sectors can jointly take action to improve and sustain the health of Australia’s young people. The school is a setting which provides scope to develop health knowledge and skills which lead to healthy behaviours, which enables support and care to be given to specific population groups, and which provides a structure to address morbidity and mortality issues in a supportive environment.

1.3 Health and education

There is a significant body of evidence which demonstrates that education is paramount in achieving better health for children and adolescents.

At the most basic level, schools have an interest in their students’ health in so much as poor health can interfere with learning.

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For instance:

• young people with poor vision or hearing often have learning difficulties; • those who are tired or malnourished have poorer concentration skills;

• those with poor resistance to infections, or whose chronic conditions are inadequately managed, suffer significantly higher school absences; and

• mental health problems or substance use can undermine the capacity of students to learn.18

At a more fundamental level, there are strong links between the goals of health and education, and therefore between the interests of the two sectors. Good health and educational achievement are not ends in themselves, but rather means which provide individuals with the chance to lead productive and satisfying lives. As such, they are interdependent. Good health contributes to educational outcomes by removing the kinds of barriers to children’s learning described above. Conversely, educational achievement contributes to health outcomes by developing the knowledge, skills and attitudes that are required for health literacy. Thus the goals of the health and education systems are closely linked.19,20

A meta-analysis of 25 reports concerning child and adolescent health published in the United States of America between 1989 and 1991 highlighted five critical issues:21

(i) Education and health are interrelated:

• Well planned, school-based education concerning health issues contributes substantially to improving the health of students.

• A young person’s health status constitutes a major determinant for their educational achievement. • Children in good health are able to achieve higher educational levels.

(ii) ‘Social morbidities’ are the greatest threats to the health of children and adolescents:

• Social morbidities were seen as the result of poor social environments and/or behaviours (e.g. suicide, drug use, injury in risky situations, violence).

• To illustrate this, the meta-analysis reports clearly showed that children and adolescents who experience violence, hunger, substance abuse, unwanted pregnancies and depression have poorer health indicators than those who do not experience these. It is worth emphasising that the factors which influence these social morbidities are largely external to the school environment.

(iii) Integrated approaches are needed to address the underlying causes of health problems:

• Particularly as these relate to combined health service and education interventions. (iv) Schools are the best setting for health promotion and education initiatives for young people:

• School health interventions achieve the best outcomes if the programs are holistic and contain partnerships between different sectors which together address child and adolescent health issues. (v) Health education and promotion strategies are cost-effective:

• The meta-analysis cited a range of economic studies which demonstrated that appropriate health and education programs saved significant amounts of money in the long term. For example, each additional year of secondary education attained reduces the probability of public welfare

dependency in adulthood by 35 percent; and most teenagers who give birth are on welfare within two years.21

Schools clearly have the opportunity to promote the health of their students. They also have much of the capacity to do so. Teachers are trained in both education and child development, but have little or no training about health issues and a limited number are also trained in health education. Broader school systems provide support to individual schools and teachers in the form of in-service training, educational materials and

supportive policies. These include continuing support from health consultants and others within the system, and special state and national projects. Non-government organisations such as the Cancer Councils and the Heart Foundations also provide professional support, programs and resources.

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Schools also have substantial control over the physical and psychosocial environment of their school, with authority to determine policy and enforce rules. This enables them to develop a school ethos which reinforces what is taught in the classroom, and which provides a safe and supportive environment for students.

Additionally, schools enjoy a high community profile. Many schools openly encourage active parental involvement in the school, and may also maintain links with government departments (particularly health and community services), local businesses and community organisations. This provides opportunities for co-ordinating action across departments and organisations on issues which impact on the health of students. There are, however, limits to schools’ capacity to address health issues. The education sector has undergone significant changes in recent years which have led to increased responsibilities for schools. However, support services have been reduced, in particular, curriculum consultancy and professional development for teachers. Increasingly, schools are expected to address many issues affecting the health and wellbeing of young people, and this is largely as a result of the health sector’s growing acknowledgement of the importance of the school setting for promoting health. However, these increased expectations and demands usually occur without additional support or resources. As a result, the amount of time and energy that schools and their staff can devote to innovations in school health are limited. At the same time, schools have been subjected to demands from other sectors, such as environment, science and technology, as well as increased attention to literacy and numeracy programs. All of this places great pressure on time and resources in schools. Health is up against strong competition for curriculum time, teacher attention and resources. This places a premium on supporting health promotion through the mainstream organisational structures of the school (e.g. the school welfare system), rather than relying exclusively on special purpose initiatives, which are often the first to go when resources are scarce.

1.4 Schools and the health sector

The health sector and schools in Australia have worked together for 90 years towards improving and sustaining the health of children and adolescents. The health sector is involved in the promotion of health in schools at a number of levels - nationally, state-wide, regionally and locally. At the Commonwealth and state levels, most governments have developed policies (e.g. in relation to youth health, juvenile justice, and drug and alcohol), which explicitly involve schools in health promotion activities and programs, and contribute resources to school health programs.

Where health and education services are organised on a regional basis, there is often contact between the two services on such activities as the establishment of policy, development of protocols and collaboration on joint projects. Health staff may also participate in training and resourcing education staff. Finally, regional health services may also provide a service to individual schools. These include referral services such as child and adolescent psychiatry services, drug and alcohol services, HIV counselling and testing, and health promotion units.

At the local level, involvement of the health sector in schools varies across Australia. Sometimes health staff, particularly community nurses and dental therapists, are based in schools. These practitioners develop strong links with their particular school, and may become involved in its operation (for example, through membership of the school welfare committee). They may also use the school as a base for services to the wider community (such as baby health clinics set in schools), as well as having other roles outside the school.

Other health services are based in the locality of the school, and provide services either at the school or at a health service location. The largest group is government community health services, such as youth health services, child and family health services, speech pathology and services for children with special needs. Some general practitioners are also beginning to play a role in schools, particularly since the advent of Divisions of General Practice and divisional project grants.

In many cases, non-government organisations such as the Heart Foundations and the Cancer Councils have also developed programs and projects which involve schools. These range from fundraising activities through to the development of curriculum materials, and provision of educational experiences such as Life Education Centres. In general, the health sector plays a number of different roles in improving the health of children and

adolescents in schools. These include:

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• involvement in particular health or social issues (e.g. child abuse, homelessness); • providing technical advice to teachers in developing health promotion strategies;

• addressing the needs of particular students (e.g. students referred to a youth health service by a school counsellor); and

• involvement in prevention (e.g. immunisation), early detection (e.g. screening for developmental problems), and treatment of disease (e.g. asthma management), as well as rehabilitation and integration of students with special needs.

Within this range of possibilities, the most common roles for the health system appear to be:

the provision of screening and treatment services – either routine (e.g. school screening) or as required,

especially for young people at risk, or in need of special care (e.g. a backup service to school counsellors);

consultancy, advice and advocacy to school personnel (e.g. teachers, administrators), students and

parents, either on specific health issues or on more general approaches to school-based health promotion;

policy development, either concerning specific issues (e.g. asthma, critical incident management), or

relating to the broader issues of school health promotion; and

education and training of teachers to improve their health knowledge and skills, both within the health

curriculum and in the other domains of school health programs.

These are all contributions from the health sector to school health programs which are unique, valued and easily recognised as legitimate.

1.5 Current international influences on school health programs

Schools have been identified in numerous reports from international and inter-governmental organisations as appropriate settings to improve the health of children and adolescents.3,6,11,13-14,22-30 Most recently, the WHO

established a School Health Initiative in 1994, which built on the experience and evidence gained from school health programs worldwide. This document identifies the school as a key setting for the improvement of the health of children and adolescents. It ‘ provides a framework for mobilising and strengthening health promotion and education activities at the local, national, regional and global levels to improve health through schools’ .31

The main goals of this initiative are to promote:

a healthy school environment – not only good hygiene, water and sanitation facilities, but also adequate

space and working conditions for students and teachers;

comprehensive school health promotion which treats health holistically, and addresses the

inter-relationship between health problems and the factors that influence health;

a comprehensive health service for all students and staff, and which addresses priority health conditions

such as sight and hearing problems, poor nutrition, lack of immunisation and psychological stress; • optimal use of scarce health and education resources through intersectoral planning at national and

international levels, training programs for teachers, and networking between schools;

a positive approach to health promotion, adapted to the local environment, and which includes

education in life skills, counselling on self-care and the prevention of illness, injury and substance use, and which makes use of the successful child-to-child approach;

equity in education and health, using the enhanced influence of the school to raise the level of education

and the status of girls and women in the community; and

outreach to parents and the community, in which the school, as an institution, plays an essential role.31

The WHO Western Pacific Regional Office (WPRO) has developed a health framework for all member states, including Australia, entitled New Horizons in Health.32 WHO WPRO has also produced a set of guidelines for

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