Health Promoting Schools—a complex approach and a major means to health improvement

Development of health promoting schools in the European region The health promoting school (HPS) approach was developed and introduced during the 1980s. Its development was inspired by the Ottawa Charter presented at the first international conference on health promotion in 1986, which helped changing the context for health promotion significantly. The Ottawa Charter (WHO, 1986) states that health promotion is a process about enabling people, meaning that people can actively acquire competencies to create more control over their own health and over their environment. Until then, the more traditional approach to health education in schools was, and often still is, focused on gaining knowledge about diseases and healthy behaviour based on a narrow concept of health. The new paradigm which provided a basis for the health promoting school approach, includes health education and is viewed as any activity undertaken to improve and/or protect the health and well-being of all school users, including students, teaching and non-teaching staff. It includes provisions and activities relating to health promoting school policies, the school’s physical and social environment, the curriculum, family and community links and health services at the school (SHE, 2014). It therefore focuses on promoting health and well-being through increased health literacy, on lifestyles and living conditions, and on the absence of diseases. This approach also takes into account the health and well-being of those working in the school, teachers and non-teaching staff. The underlying concept of health is more than the traditional WHO definition: ‘a complete state of physical, mental and social well-being, and not merely the absence of disease or infirmity’. It uses a more open concept of health, in which children and young people should be involved in defining their own health. Huber et al. (2011) proposes a new definition of health changing the emphasis towards the ability to adapt and self manage in the face of social, physical, and emotional challenges. The Schools for Health in Europe network (SHE network, www.schools-for-health.eu) was initiated by the World Health Organization for the European region (WHO EURO) in 1992, together with the Council of Europe and the European Commission. In each member country the Ministry of Health and the Ministry of Education appointed a SHE national coordinator who is responsible for the national health promoting school programme (if one such existed). Currently there are 45 member countries in the European region, as well as six autonomous regions (from Italy, Spain and the Netherlands). Researchers are organized in the SHE research group with over 85 researchers from 25 countries, each with an interest and commitment in research in school health promotion. The SHE network has developed into an important platform for school health promotion in the European region. This was confirmed in December 2016 at the WHO high level conference ‘Working together for better health and well-being’ in Paris, where school health promotion as well as the SHE network were explicitly mentioned in the draft declaration on promoting the health and well-being of every child and young person in the European region (WHO, 2016). In the SHE network a health promoting school is defined as ‘a school that implements a structured and systematic plan for the health, well-being and the development of social capital of all pupils and of teaching and non-teaching staff’ (SHE, 2014). This is characterized as a whole school approach (or ‘whole of school approach’) to health and well-being; in different European countries similar terms are used such as ‘healthy schools’, ‘good and healthy schools’, but they all have a similar intention. Schools, being part of their surrounding community, are designated as one of the settings to help reduce inequalities in health. Collaboration with other relevant policy areas, for example youth, social and environmental policies and sustainable development is essential. Partnerships and networking are key tools that have been developed and used in the health promoting school approach. The members of the Schools for Health in Europe (SHE) network use a positive concept of health and well-being and acknowledge the UN Convention on the Rights of the Child. They recognise the whole school approach to health well-being with an active participation of all members of the school community. Health promoting schools support schools in achieving their educational and social goals. Healthy students learn better, healthy teachers work better. The SHE network has demonstrated progress on a European and an international level, emphasising the role of schools in improving the health of children and young people. Members of the network have indicated that their membership contributes to the national development and implementation of school health promotion. They have expressed their commitment to the further development, expansion and/or improvement of their national health promoting school programmes (SHE, 2013; Buijis et al., 2014). During the school year 2012–2013, 34 000 schools were identified as health promoting schools in the European region (SHE, 2013). These include preschools, primary, secondary and other types of schools, including vocational schools. The age groups of students range from 3 to 20 years old. The level of implementation of health promoting schools varies widely between member countries and even within countries. Some countries have a formal national health promoting school policy while others don’t. These national health promoting school policies can be integrated into other national education policies. Some countries have a long history in implementing health promoting schools while other countries just recently initiated a national health promoting school programme and joined the SHE network. Depending on individual countries, health is not taken into account in educational policies in the same way. The political organisation, priorities, degree of decentralisation, organisation and goals of education systems differ from one country to another. In 2013, a survey was conducted among the national coordinators of the SHE network in Europe to gain an overview of current health promoting school policies. Nearly two in three countries (62%) have a formal health promoting school policy, in most cases as part of their education policies, followed by inclusion in their public health policies, or a combination of education and health policies (SHE, 2013). The perspective is intersectoral since the core business of schools is focused on educational outcomes, rather than the reduction of health problems. From an educational point of view, the school’s contribution to health includes a reference to citizenship and healthy living with a dual purpose: a) to create conditions for pupils’ achievement (such as school environment, school climate, nutrition services, policy and planning, staff competencies, access to social and health services, partnerships) and b) acquiring health competencies for empowerment for healthy decision making (Jourdan, 2011). Nowadays, the political context is favourable since there is an increasing awareness of the close relationship between health, physical and cognitive development, school participation and educational achievement which led to a whole of government and intersectoral policies. An intersectoral approach is now widely recognized as a condition for all schools to make a difference for health and well-being of all pupils and of teaching and non-teaching staff by strengthening school’s capacity as a healthy place in which to live, learn and work. The health promoting school approach has been adapted in many European countries, Australia and New Zealand. Also in the United States and Canada the ‘Comprehensive School Health Program’ and more recently the ‘Whole School, Whole Community, Whole Child’ model are used more frequently. While countries may differ in nomenclature and structure to varying degrees, similar underpinning principles apply to all and the definition of a Health Promoting School (HPS) provided by the World Health Organisation (WHO 2015) encapsulates these well: ‘a school that is constantly strengthening its capacity as a healthy setting for living, learning and working’. The whole school approach to health has six essential components; (i) healthy school policies, (ii) physical environment of school, (iii) social environment of school, (iv) individual health skills and action competencies, (v) community links and (vi) health services (Moynihan et al., 2016). The whole school approach used in the SHE network rests on five core values (equity, sustainability, inclusion, empowerment and action competence, democracy) and five pillars (whole school approach to health, participation, school quality, evidence base, involvement of schools and communities). The evidence base related to the contribution of the school setting to the improvement of children’s health and well-being is strong. For example, WHO’s work, led by Suhrcke and Paz Nieves (2011), showed the negative influence of ill-health (obesity, sleep problems, anxiety and depression) and potentially harmful health behaviours (alcohol consumption, cannabis and tobacco) on academic performance of children and adolescents. OECD’s work (2010) highlights the contribution of education, both in improving health, well-being and quality of life and strengthening civic and social engagement. It also stresses that families and the community should be involved (see Sormunen et al., 2013). There are still many epistemological and methodological issues in relationship to evaluation of health promotion effectiveness. Nevertheless, the authors of the Cochrane review on ‘Assessment of the HPS framework on students’ health and well-being and their performance at school’ found that interventions using the HPS approach were able to reduce students’ body mass index (BMI), increase physical activity and fitness levels, improve fruit and vegetable consumption, decrease cigarette use, and reduce reports of being bullied. However, they found no evidence of effectiveness on fat intake, alcohol and drug use, mental health, violence, and bullying others (Langford et al., 2014). The authors of a Cochrane review called ‘Interventions for preventing obesity in children’ (Waters et al., 2011) considered the following promising leads for effective interventions in schools: interventions targeting school curricula, physical activity sessions throughout the school week and healthy food supply in schools. In addition, environments and cultural practices should support and encourage children and young people to eat healthier foods and also support them in being active throughout each and every day. Capacity-building activities for teachers and other staff, and parental involvement were also important. A systematic review of studies on the effectiveness of school health promotion efforts, further concluded that programmes that account for contextual factors and emphasize multidimensional approaches are more likely to be effective in terms of health outcomes (Stewart-Brown, 2006). Three main factors for the success and the quality of these initiatives were identified: (1) involvement of the school community as a whole and addressing all the aspects of school life; (2) addressing the school social environment (relationships between pupils and staff, among pupils, among staff and between parents and schools); (3) development of children’s life skills. A collaborative work coordinated by the International Union for Health Promotion and Education (St Leger et al., 2008) summarises what has been shown to work well and are prominent features of effective schools. These are: developing and maintaining a democratic and participatory school community; developing partnerships between the policy makers of the education and health sectors; ensuring students and parents feel they have some sense of ownership in the life of the school; implementing a diversity of learning and teaching strategies; providing adequate time for class-based activities, organisation and coordination, and out of class activities; exploring health issues within the context of the students’ lives and community; utilising strategies that adopt a whole school approach rather than primarily a classroom learning approach; providing ongoing capacity-building opportunities for teachers and associated staff; creating an excellent social environment which fosters open and honest relationships within the school community; ensuring a consistency of approach across the school and between the school, home and wider community; developing both a sense of direction in the goals of the school and clear and unambiguous leadership and administrative support; providing resources that complement the fundamental role of the teacher and which are of a sound theoretical and accurate factual base; creating a climate where there are high expectations of students in their social interactions and educational attainments. The papers published in this special edition of Health Promotion International focus on health promoting schools from many different points of view. The papers include original studies and conceptual analyses from different parts of the world representing the topical issues related to health promoting school globally. The themes discourse basic pillars related to health promoting schools from theoretical, practical, policy and methodological perspectives focusing on participation in HPS and implementation of HPS. In addition, several methodological papers are presented including new instrument development, an innovative data collection method as well as analyses of complex system science in relation to HPS. Pike and Iannou describe the processes, and specifically the experiences of participation in a project (‘Shape Up’) that aimed to create health-promoting environments in seven primary schools in Cyprus. The findings suggest that the schools have a lot of potential to act towards healthier communities, if the individuals are engaged to the processes in a sustainable way. Especially the children’s responsibility, innovativeness, and sense of achievements were respected, and together with adults, they formed a collaborative team. As the authors conclude, schools are more than physical settings where healthy activities are carried out; they can be the agents of change. Participation continues as a theme in the Griebler and colleagues’ article. 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