Year: 2021
Type: article
Abstract: Ever since the concept of settings based on health promotion has entered the scene in the 1980s, schools have been in the running for one of the top settings. Health promoting settings first received attention through the Ottawa Charter for Health Promotion (WHO, 1986) which says that ‘health is created and lived by people within the settings of their everyday life’ (p. 3). The Sundsvall Statement (WHO, 1991) followed-up on this, calling for supportive environments for health with a focus on settings. The Jakarta Declaration (WHO, 1997) described settings for health as the ‘organizational base of the infrastructure required for health promotion’ (p. 6). The aim of the settings approach is to move beyond individual behavioural change towards changing organizational processes and structures that have an impact on their members’ health. Beside schools, the WHO identifies several other settings including spatially defined entities (e.g. regions, cities, villages, islands, municipalities), organizations (workplaces, universities, hospitals, and prisons) and the private sphere (homes and families). Settings are still a topic for many current publications, and the field is generally expanding (Poland et al., 2009; Dooris et al., 2018) with new settings such as libraries (Whitelaw et al., 2017), supported housing (de Leeuw, 2020; Dahl Nielsen et al., 2021 ) and Healthy Airports (Crimeen et al., 2018) being created. Schools are an ideal setting for health promotion in many ways. Most of the children worldwide and many adolescents spend a large part of their day in schools. At the same time, childhood and adolescence are crucial for the development of healthy behaviours and a healthy life course (Kelder et al., 1994; Wright et al., 2001; Galobardes et al., 2006; Sawyer et al. 2012). Turning schools into health promoting settings can therefore be considered as significantly positive social investment. It has a large impact on the lives of students and their future as members of healthy families, communities and societies. In schools, students are encouraged to follow certain norms and regulations and adhering to specific school policies, processes and structures. These can be designed in a way to promote the health of the people affected by them (Eriksson et al., 2008; Poland et al., 2009). Furthermore, schools can reach several other target groups beyond children and adolescents: school staff, parents and sometimes even the community. And lastly, health promoting schools (HPSs) also have the potential to positively influence educational outcomes of the students (Lee et al., 2006; Suhrcke and De Paz Nieves, 2011). The concept of the HPS has been developed by the European HPSs Network in the 1990s. However, it has since been taken up by other networks throughout the world. In the USA and Canada, this has resulted in the Comprehensive School Health Program, comprising similar components to the HPS framework (Deschesnes et al., 2003; Penney et al., 2018). The International Union for Health Promotion and Education (IUHPE) suggests six components of a HPS: school policies, the social and physical environment of the school, curriculum, and family and community partnerships (St Leger et al., 2010). Furthermore, HPSs build on the principles of health promotion, which are (inter alia) participation, empowerment, holism, equity, sustainability and networking (Rootman et al., 2001; Clift and Jensen, 2005; IUHPE, 2009; Tremblay et al., 2013). With such a firm historical and developmental grounding, our Journal has played a role in the generation of evidence and where necessary, critique of school-based health promotion and education. From the very launch of Health Promotion International (HPI), colleagues from around the world have chosen the journal as a platform to publish their insights. We considered it timely to take stock and provide our readership with a curated collection. To find the most relevant papers for this collection, we have combined three strategies. First, we searched for papers in HPI using the search terms ‘HPS’, ‘school health promotion’ and ‘comprehensive school health’ in the title, abstract or keyword. This resulted in a list of 88 papers that we have ranked by the number of citations divided by age [following de Leeuw’s (2020) strategy to account for the fact that older articles had more chances to be referenced than younger articles]. Secondly, we scanned the abstracts and keywords of these papers to identify the most important topics in the field of HPSs to ensure that the collection provides a comprehensive rather than potentially biased focus. Thirdly, we invited several international scholars from the field of HPSs to nominate a paper that should be included in the collection. Seven scholars nominated six different papers. Each of these strategies has its limitations. However, by combining them, we have tried to do the wide field of HPSs some justice. As a result, the final collection is made up in large part by papers that rank within the top 30 most referenced papers on HPSs in the journal, plus a few handpicked papers that were nominated either by someone from the field, or articles that represent one of the HPS topics particularly well. This collection of papers covers a time frame of 28 years (from 1992 to 2020). They cover most of the world’s regions (North America, South America, Europe, Africa, Asia and Australia) and address a wide range of health promotion topics (Table 1). Collection of HPS papers Bold papers were nominated by scholars from the field of HPSs. NA = not available. Collection of HPS papers Bold papers were nominated by scholars from the field of HPSs. NA = not available. Several of the top papers provide the conceptual underpinnings of the idea, and outline HPSs’ position in the context of broader health promotion, education and community development perspectives. The oldest paper in this collection is one of the HPS classics written by Nutbeam (1992). It provides an (historical) introduction to the HPSs framework—from theory to practice. Many of the challenges described still hold true today: teacher resistance, financial challenges, involvement of parents and, especially, the gap between the concept of the HPS and the practice in schools. Another classic HPS paper by St Leger (2001) introduces the concept of health literacy and draws the connection between the HPS and health literacy. St Leger explains that the schools’ core business concerns educational outcomes for students; however, it also shows that HPSs have the potential to support health literacy. Participation is one of the core values of health promotion, and student participation is central to the HPSs concept. Griebler et al. (2017) have carried out a systematic review to analyse the existing evidence of student participation and have found that most included studies reported an increased satisfaction, motivation and ownership among the students, as well as increased skills, competencies and knowledge and health-related effects. A second set of important papers looks at the important step of putting ideas into action. Studies on the implementation of the HPS framework investigate how a comprehensive, integrated approach to school health promotion can be translated into practice. Deschesnes et al. (2003) describe four conditions that are necessary to achieve a broader uptake—planning and coordination, intersectoral action/partnerships, political and financial support, and evaluation. Inchley et al. (2007) describe practical ways in which schools were able to adopt the HPS approach and highlight four themes: ownership and empowerment, leadership and management, collaboration and integration—overall very similar to the four conditions by Deschesnes et al. (2003). Both papers show that implementation of the HPS concept is not a linear, straight forward process but needs different kinds of support. Focussing on organizational influences on the implementation of school health promotion, Kremser (2011) adopted the perspective of complexity science. Complexity theory here helps to understand schools as systems that are self-organized and respond to changes in their own individual ways. Kremser describes four phases of implementation (namely, starting, deciding what to do, planning and doing health promotion) and the ways the school in his case study has adapted the HPS concept throughout these phases. Penney et al. (2018) have also used a complexity approach, investigating the school’s ethos as a contextual factor that supports or inhibits implementation. They have developed a score to measure the school ethos and how it relates to the HPS. Schools are organizations whose core business concerns primarily not the promotion of health but the teaching and learning, the curriculum and students’ performance (St Leger, 2001; Kremser, 2011; Turunen et al., 2017). To take the settings approach seriously, the school has to be seen as a whole system and its key processes as well as its members have to be addressed. Jourdan et al. (2011) show that school health promotion programmes need to be relatable to the schools’ mission, to teachers’ educational perspectives and to the schools’ needs. Similar conclusions were drawn in Laurence et al.’s (2007) study investigating the efficacy of HPSs to increase fruit and water consumption: effective strategies need organizational change within schools and integrated curriculum activities, amongst others. Taking this even further, Bentsen et al. (2020) describe how school health promotion can be an ‘add-in’ approach that integrates health into the curriculum—into curriculum time and into the curricular obligations of teachers. Contrastingly, if school health promotion remains an ‘add-on’ and is not properly integrated into the schools’ and teachers’ core responsibilities, a paper, drawing on data from a HPS network, shows that health promotion can have serious ‘side effects’ for teachers, such as stress and frustration (Gugglberger et al., 2017). There are several studies evaluating school health promotion interventions and investigating the effectiveness and efficacy of the HPSs concept. An early paper that provides an overview of different evaluation studies as well as some evidence for HPSs is by Mũkoma and Flisher (2004). They concluded that there is a lack of evaluations on HPSs—something that could, however, still be said today. This collection includes some examples of different evaluation studies: Laurence et al. (2007) show that the consumption of fruit and water significantly increased through an intervention within the HPSs framework; Wong et al. (2009) compared resilience scores of schools within Hong Kong’s healthy school award scheme to schools not participating in the scheme and showed that the HPS concept can be effective in building resilience in schools; Inchley et al. (2007) have evaluated the process of schools becoming health promoting; Moysés et al. (2003) have analysed the effect of HPS policies on the oral health status of children, suggesting that the oral health of children living in deprived areas can benefit from supportive schools. The papers used as examples for evaluations of HPS interventions not only show some positive results of evaluations, but can also be used as examples in two more areas: first, they give insight into the wide range of health promotion topics covered in HPSs such as nutrition (Laurence et al., 2007), psychosocial health/resilience (Wong et al., 2009) and oral health (Moysés et al., 2003). Secondly, they also provide insights into completely different contexts of HPSs: one from Australia, one from Hong Kong, one from Brazil. To round up the collection and these different contexts one last paper is a case study from a low-resourced, developing country: Heesch et al. (2020) describe how the concept of the HPS works in a rural village in Cambodia. The study concludes that key elements of implementation were—similar to earlier studies (Deschesnes et al., 2003; Inchley et al., 2007)—the building of partnerships, building local leadership and creating a culture of change and participation. This collection can only give a small glimpse into the wide field of HPSs. For further reading, Volume 32, Issue 2 of this journal is a special issue on HPSs—any of the papers in this issue could have well been included in this collection. Furthermore, in her curated collection on complexity, Keshavarz Mohammadi (2020) has included three papers on HPSs [one of them by Kremser (2011) was also included in this collection]. As focussing on HPI published papers alone gives a limited overview; however, we invite readers of this collection to look beyond these papers and beyond HPI in their studies of HPSs. Around 30 years have passed since the development of the HPSs framework. With this collection, we have tried to give an overview of the many years, many contexts and many topics of HPSs. In these 30 years, novel approaches and methods have been introduced into the field of HPSs that have been supported by some of the papers in this collection—e.g. health literacy, complexity approach, implementation science, systematic literature reviews. These approaches help to get more insight and an increased understanding and have opened the door to new perspectives. Looking at this collection, however, it becomes apparent that a lot of the challenges identified in the papers—e.g. a gap between theory and practice, lack of integration into schools’ and teachers’ responsibilities, too little evaluation of the process and outcomes—still prevail today. There is still much work to be done on the HPSs framework, including its impact on the health and education of children, the process of translating it into practice, its integration with the concept of health literate schools and the comparison between different cultures and countries. In addition to existing challenges identified in this collection, new challenges for HPSs have already been identified and will continue to arise. Since the outbreak of the COVID-19 pandemic, schools everywhere have faced new—health-related—duties and responsibilities in fighting it and keeping their staff and students as safe as possible. Health has become an issue that every school is forced to put onto their agenda. Furthermore, HPSs will have to increase their role in fighting climate change, will need to deal with increased digitalization and will have to support students’ critical thinking and dealing with fake news/facts. Many great papers on HPSs have been published in HPI. We hope that there will be many more!
Source: Health Promotion International
Author: Lisa Gugglberger
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W3137900121